Dr. Boz and Dr. Westman Debate on Diet Strategy – Adapt Your Life® Academy

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Adapt Your Life® Academy

Dr. Boz

Dr. Boz and Dr. Westman Debate on Diet Strategy

Introduction to Dr. Boz

Dr. Eric Westman: Dr. Annette Bosworth, better known as Dr. Boz, is a powerhouse in ketogenic health and internal medicine. Through her popular YouTube channel, she’s inspired thousands to tackle chronic health issues like obesity and diabetes through the ketogenic lifestyle. Dr. Boz is a bold advocate with a unique, uncompromising approach to health.

Dr. Annette Bosworth: When eating a ketogenic diet, what is the most important, or what comes first on that priority list? You have an answer, and I have an answer. Let’s start there.

Dr. Eric Westman: Always protein. Protein comes first.

Dr. Annette Bosworth: Why do you say that?

Dr. Eric Westman: Today, we’re going head-to-head in a debate that’s sure to spark controversy, challenge beliefs, and dive deep into the very core of what keto can mean for health.

The Debate

Dr. Annette Bosworth: Neither of us has wrestled, but a food fight? We could do that, right? Well, let’s have it.

Honestly, they don’t want to hear what we agree on. What was very evident was that most of the followers on my channel, or your channel, have been around long enough to know our histories and styles. It is those differences that, I think, help us further educate an audience that is probably better educated on nutrition than either of us was in medical school.

We continue, hopefully, to take it to the next level for our audiences as well.

Let me start with one of the easy places to see our differences. When eating a ketogenic diet, what is the most important, or what comes first on that priority list? You have an answer, and I have an answer. So, let’s start there:

Dr. Eric Westman: Always protein. Protein comes first.

Dr. Annette Bosworth: Why do you say that?

Protein Comes First

Dr. Eric Westman: Because we’re made of protein. We are mainly amino acids, fats, and cholesterol. Of course, we’re not fruit.

When I do a body composition analysis for a patient, I point out: you’re this much water, this much muscle (which is protein), this much fat, there’s no fruit. At least we agree that fruit doesn’t come first, which makes us different from every other doctor and dietitian on Earth.

Protein comes first because that’s what we’re made of. If you’re left on a deserted island or shipwrecked, or if you watch Naked and Afraid or one of these reality shows, they look for protein, because that’s what we’re made of.

I’m not saying that fat is bad or that you shouldn’t have it, but if there were one nutrient, one foodstuff to eat, it would be protein. If it’s animal-sourced, you’re also getting your fatty acids, minerals, and vitamins. You’re not going to have any malnutrition.”

The Education Gap

Dr. Annette Bosworth: I’ll respond, I’ll push back. When I look at the education gap most patients come into my space with, protein has been easily marketed. They aren’t afraid of it, and they don’t usually skimp on it.

When I look at that patient who has 15 prescription medications and is new to the ketogenic space, the key I continue to emphasize is: without fat, we can’t reset this broken endocrine system. That inflammatory rate is truly stirring up a storm of muck. The way you reduce the muck, the way your brain gets to be clear, is by focusing on fat.

Then, we can start to get into the nuances of protein. Yes, it’s important, but fat has to be a major part of that education when they first enter the ketogenic diet.

Eat Fat

Dr. Eric Westman: That’s the different angle. We may even be in more agreement than other people may think. You’re not saying people shouldn’t eat protein?

Dr. Annette Bosworth: No, that’s not it at all.

Dr. Eric Westman: That’s what I heard. That’s what my patients heard. They said, ‘She says eat fat; you say eat protein. That’s not what we’re saying, right?

Dr. Annette Bosworth: Yes.

But would you totally agree that, when I look at the part that’s the most likely for them to stay in a sustained ketogenic journey, how do I not just have a fat diet, have them come in and do what all the naysayers say, which is, “Oh, you’re just going to lose a bunch of water weight, it’s just that first little three weeks from now, you won’t be in that space”, indeed, we’ve all lost.

I don’t mean lost patients in life or death, but lost patients saying, it didn’t work for me. I give up. When they don’t feel well and that satiation, or might we say comfort to your brain, to me, that’s on a wave of fat. Their fat-based hormones have not been circulating very well, or at least they’ve been suffocated by an excessive amount of insulin.

So, by pushing that fat into the forefront of at least the first probably three to four to five months of a ketogenic diet, I believe you’re still going to be there asking me questions in four months and then moving on from there.

Keep Carbs Low

Dr. Eric Westman: So it’s interesting because of my teaching.

My teaching predates the internet keto movement. It predates the ability to measure ketones, breath, blood, or urine. My teaching was, keep the carbs super low, and your body will be in ketosis automatically for, generally, most people.

If you’re trying to lose fat weight or reverse diabetes, the main thing is just to keep the carbs low and have protein. But calories still do matter.

My patients, and, again, this may be a selection bias of the patients who come to us. People tend to go to the doctor they like, the one they want to hear from. I say, ‘Keep the carbs low,’ and most people who come to me burn their own body fat.

I had someone this past week with 200 extra pounds of body fat on her body. She didn’t need to eat fat to get into ketosis. And then my teaching was that you don’t need to add fat.

I mean, butter, bacon. Steak and Butter Girl is out here pounding the butter. But her story is not like the journey my typical patient has of losing hundreds, or a hundred, pounds of weight.

You always want to be careful whose experience you’re listening to. I’ve always liked talking to other doctors because we’re treating real people. If something doesn’t work, they’ll come back and say, ‘You know, it didn’t work for me,’ and then we find out why.

I don’t think you should say fat comes first.

High Fat Season

Dr. Annette Bosworth: Okay, here’s another place where I’ve seen the same equation. I’ve pushed patients really into a high-fat season, especially for a good several days.

When I look at the patient who’s 200 pounds overweight, and you say, ‘What is the biggest return for getting them into a state of ketosis and keeping them there?’ Yes, they’ve got plenty of fat stored, but that fat storage is hidden behind a wall of insulin.

There’s a good study, the fasting study done in the 1970s that would be illegal now, up in Minnesota. I’m going to forget the name of the trial, where they fasted people for 45 days. Those with a body mass index over, I think it was over 35, didn’t make ketones. I mean, a significant amount of ketones. They had a trickle of ketones, but not this wave of ketones. That’s the one where patients say, ‘I feel better,’ for like 10 days.

In a ketogenic state or a high-protein state, I mean, they were fasting. They should have been making ketones in 48 hours if they were healthy. But that advanced insulin-resistant patient, you’re looking for, ‘When does the ketone show up? When do they feel better? When does the keto flu pass away?’ Part of keto flu, to me, is when they finally have this wave of ketones. That wave isn’t going to last forever, but when they finally feel good. Do you ever run into this?

Dr. Eric Westman: Sure.

Insulin Medicines

Dr. Eric Westman: Let’s talk about the really difficult patient. They’re on 10 medicines, they’re on insulin, and the doctor hasn’t woken up to the fact that there are GLP-1s and other medicines that can actually help people lose weight. Insulin traps people into gaining more weight, and insulin is already high in type 2 diabetes.

It makes no sense to give more insulin to someone if they already have high insulin. They’re going to need a stronger, well, definitely under 20 total grams per day, stronger prescription-level carb restriction. It may take longer for them to see progress.

Even so, I don’t really insist on, “I’m going to get you into ketosis.” That’s not the goal. The goal is getting the blood sugars down and getting people off the medicine safely.

What I teach is kind of minimalist. It’s designed so anyone can do it. I’d love to test your method or other methods that insist on measuring ketones and all that, to see if there’s incremental benefit beyond what I teach.

There may be, actually. I’d love to hear if someone was stuck, and then the addition of ketone measurements, drinks, or something got them over the hurdle. Then you’d need to randomize people to know if it was just a matter of waiting, time passing, that would have had the same results. That’s why experimental studies are so important.

Dr. Annette Bosworth: Right.

There’s nobody better to talk to about that than you. The pedigree that comes from your teaching and where you’ve been, the place you’ve put your energy in medicine, not only do you have the astute institution of Duke behind your practice and research, but you’re also in the lineage of the Atkins teachers. Tell that story.

The Atkins Legacy

Dr. Eric Westman: Briefly, two of my patients in front of me at the VA hospital, I’m an internist, but I ended up in ambulatory care at the VA in Durham to do advanced training at Duke in clinical trials and statistics.

Two of my patients lost over 50 pounds each within a week. (NB: They did not lose 50 pounds in a week. These two patients had both lost 50 pounds over a few months and Dr. Wwestman has visits with both of them in the same week.) I saw them and asked, ‘What did you do?’ They said, ‘All I did was eat steak and eggs.’ They were basically doing the Atkins diet, and I didn’t know anything about it.

This was 26 years ago now. There was no training in nutrition. Maybe I had some TPN training in the hospital, but no outpatient nutrition training. I went to the doctors who were using this method right around the year 2000. I met Dr. Atkins, Dr. Eades, Dr. Rosedale, and Dr. Bernstein, who, by the way, is still around, known for his type 1 diabetes fame. I asked them, ‘How would you approach studying this as if it were a drug? What would drug development look like?’

So, we started with the first pilot studies, single-arm studies of what happens, and then moved to randomized trials of the low-carb keto diet. Again, this was before keto measurements, before internet keto, and before keto gummies.

Every study showed it was better than the low-fat diet, which was the diet of the day. Atkins was an influential teacher of mine. He heavily influenced my approach because I borrowed the information he had prepared and used over 30 years.

He passed away within two years of our first study, so I couldn’t learn directly from him anymore. But I learned from Jackie Eberstein, a nurse who worked with Dr. Atkins for 30 years. It turns out she was kind of the brains behind the method.

I learned that their method had worked out some of the kinks, like the overconsumption of cheese, cream, and mayonnaise. If you’re trying to lose fat weight, you don’t want to overconsume fat.

I’m really carrying the tradition of a low-carb keto diet from before there was the ability to measure ketones. Well, you could use urine ketones back then, and you still can today.

From your perspective, you might say, “That’s old stuff, and here’s why what I do is better, better, better.” But I’d say, “Let’s put it head-to-head in a clinical trial.”

Question Time

Dr. Annette Bosworth: That’s great. First of all, for those of you watching, I have my assistants gathering some of the questions you want us to answer.

I have two more topics I want to make sure we cover, and part of it is what Dr Westman just brought up.

If you have questions you think we should answer, my team will copy and paste them into the document so we’ll be able to address those.

Let me tell you, I don’t know if you remember this, but you were the first internist to help me. I was looking for a conference anywhere that I could learn from.

Dr. Eric Westman: How could I forget.

Dr. Annette Bosworth: I had gone to this place with two keto dudes. It wasn’t offering any continuing medical education, but I didn’t care. I was so hungry for someone to explain, How do you do this? It was really helping patients.

It energized me again to see I could reverse things. What a reward in medicine! I had always come from a place of a dynasty of farmers, not a dynasty of doctors. I didn’t have a network where I was practicing to answer questions like this.

Every person I went to with questions looked at me like I had an extra head. I kind of started to be quiet about it. But when I met you, I was like, “Oh, and he’s from a very renowned institution.” It was very validating for me. Between you and Dom D’Agostino, you were the two points in my education that made me say, “Just keep going. You aren’t crazy. These patients are getting better.”

In the beginning, I just used urine ketone strips. I still encourage patients: You don’t need to spend money pricking your finger in the first season. When you’re doing it right, you’re going to make ketones, and there will be a bunch of them.

As I’ve walked people through this, I’ve seen patterns. My mom had a long history of cancer. Her cancer had a strong autoimmune component, which, at the time, we didn’t know was very driven by insulin. Four years into her journey, she was doing great.

But during that journey, I realized I needed better data to know if we were on the right path. As soon as things went wrong, they went very wrong. Her gut swelled shut, and she ended up with a colostomy bag. After that mistake, I became a big proponent of checking ketone numbers to stay above nutritional ketosis.

What I saw in patients was this: They’d get benefits from the first wave of improvement, but then they’d fall out of ketosis. Even though the diet was the same, they weren’t making ketones anymore. Their insulin resistance had improved, but being in ketosis required a new stimulus, an increased metabolic challenge.

I’d love to hear your thoughts on this.

New Challenges and Community Support

Dr. Annette Bosworth: I landed in Florida after 50 years in South Dakota. It was during the pandemic, that getting a medical practice and malpractice insurance wasn’t a problem, but getting the electronic medical record (EMR) to work relied on the federal government, which was closed.

For 18 months, I couldn’t get the specific skill set on my EMR to work. I’m not made of money, so I decided to do something I’d wanted to do for a long time: teach people in the community how to manage at this advanced level.

In the past, I’d done this in the context of alcohol recovery, helping heal the brain while staying away from alcohol. You’d need a partner in recovery, like support groups.

I’ve now conducted five classes with 200 patients each. They’re all hooked up to the MyMojo dashboard, tracking their blood sugar and ketones every day: morning fasting sugars and morning fasting ketones.

What brings them into the classroom is being stuck. They aren’t losing weight. They say things like, I’m eating all protein, or I’m eating all butter. I explain that while there are skill sets I can teach them using butter, that’s not how they’ll win this game.

With the MyMojo Health data, I can see what’s happening. I think we should have a poster competition on what happens when you put patients in advanced ketosis, follow their ketones for three consecutive weeks, and track the improvements.

The transition in brain function and energy is remarkable. I don’t care how stuck they are. Across five classes with 200 students each, I haven’t had one person fail to improve.

That left that classroom with the inability to at least lose some weight, and get back on the momentum of losing weight. So, when I look at protein versus fat when they’re stuck, I need your ketones higher in order to get things moving again. It’s an endocrine issue.

Yes, the calorie, you’re going to have to eat. You’re going to want to mobilize your own fat, but when your endocrine system is so pathologic that they can’t make ketones, they’re just at 0.3 or 0.4. They just don’t go up. It’s the fat consumption that pushes them.

No Experimental Design

Dr. Eric Westman: Without an experimental design applied to this – and you don’t need one – I mean, experimental work is essential if you’re trying to say something is better than a placebo, for example, or if you’re trying to do a comparison to say, “Mine’s better than yours.”

That’s what kills me about the vegan scientists. They say it’s the best, but they never compare it against other really good diets. It’s always against the standard American diet.

An experiment doesn’t need many people sometimes. The study on citrus and scurvy, for example, was done with just 12 people. James Lind used a cross-over kind of design and figured out with just 12 people that citrus-cured scurvy. It was that strong and powerful.

We’re on our 11th cohort of about 500 people (in our Keto Made Simple course), and we don’t use any ketone measurements. All we do is keep them to this list of foods I got from Dr. Atkins, his “top-secret” list that I try to give to people.

Getting Results Without Ketones

There are a lot of moving parts, and many things change even with or without using a ketone-monitoring tool. It would be cool to get all the effective methods we practitioners and scientists have come up with onto the same racetrack, so to speak, and just see.

I think we’d find some people do better on one approach than another. What if someone can’t get a ketone monitor?

Ketone Urine Strips

Dr. Annette Bosworth: I get that question a lot. It’s not like I tell them, “Sorry, you can’t do it.” No, I tell them that ketone pee strips are not nothing. They’re not as accurate, but they are something.

Here’s a way you can make them more accurate: Your bladder is continually filling, so empty it in the morning and then check again a half-hour later. That’s probably the purest result we can get.

I think that’s another approach you’ll hear. Folks will say, “Well, Westman says this, and I say that.”

Measuring and Monitoring

I tell them to check their numbers. Look at your numbers! You can see this for yourself. I don’t need to be the one chaperoning your care; you can chaperone it. You can see if you are in ketosis or not.

Look at what your glucose and ketones are. Can we move those levers to get you into an even better state of metabolic health? That isn’t necessarily the approach you use. Tell me, how?

Medicare Medicaid Insurance

Dr. Eric Westman: Medicaid insurance days, I think you were in those at one point. The clients you get are just all over the place in terms of education and in terms of their wherewithal to purchase things.

I decided to stay in the insurance model at Duke, a private practice, and I’ve stayed in there, but it’s insurance-based. I can’t even take cash. Someone once came and said, “I’ll pay,” but we don’t have a mechanism to do it. So that’s kind of strange.

The interesting thing is, one of the patients I met, who was from the safety net clinic upstairs, learned how to just eat at McDonald’s with the information I gave him. I don’t know the last time I ate at McDonald’s; it’s not about me, but he basically ate two or three double cheeseburgers with no bun, no fries, and no sugar in the drinks.

He was only hungry once a day, so he intermittently fasted and only had one meal a day (OMAD). You could argue that’s not the ideal or optimal way to do it, but he was so much better off. He figured it out within his own context, where he eats.

We see people who either buy groceries or never purchase groceries at all. There are some grocery stores that don’t even have anything keto-friendly because everything is, “Plant-based is best.”

I try to be sort of the devil’s advocate against those who say, “You have to have grass-fed beef and go to the farmers’ market to get a cow and you name it”.

The Science and Insulin

The science is clear. Get the insulin down and get people off medications safely. That leads to my next question for you: how do we know that being in ketosis all day long is necessarily better?

One person said, “How do you know there isn’t a high ketone problem, like high glucose?” For example, with hypoglycemia, there’s hyperketonemia.

I’m not an early adopter of the idea that everyone should be in ketosis all the time and that you’ll necessarily live longer because of it. But I do know you need to be very low in carbs, maybe even on the edge of ketosis.

I heard in a video that you rely on Tom Seyfried’s work. Tom isn’t an MD, and a lot of his work is done on animals. There’s a big leap from animal studies to applying that data to humans.

Ketosis and Confidence

Right now, regarding ketosis, I can’t tell people with the confidence of an FDA-approved drug that being in ketosis all day long will make you do better. That’s a study that needs to be done.

Dr. Annette Bosworth: Absolutely. One of the questions someone wrote in with is, “What value do you, Dr. Westman, place on the GKI, the glucose-ketone index, which is where Dr. Seyfried has put a lot of his efforts?”

Evidence-Based Clinical Trials

Dr. Eric Westman: Unfortunately Seyfried’s model focuses on cancer. If you extrapolate that to other conditions, that’s fine, but I treat mainly diabetes, obesity, and other metabolic issues. Cancer is in there too.

As an evidence-based clinical trialist with a foot in the academic world at Duke University, I need a pretty high level of evidence to sign off on something. Otherwise, my colleagues would say, “That Westman guy is wacko. He’s a quack.”

There’s a textbook now on ketogenic diets that came out last year, I’m sure you have it on your shelf. I use it for show-and-tell with people. I say, “Look, here’s a textbook from last year. The science about diabetes, metabolic syndrome, and obesity is rock solid in terms of using a keto diet.”

The idea of ketosis having an incremental benefit beyond that is still relatively unknown. For cancer, Alzheimer’s, or other conditions, it seems like we’re still talking about levels of evidence.

The Levels of Evidence

There are anecdotes, clinical series, cohort studies (where we say “correlation, not causation”), and nutritional epidemiology.

When the McMaster group started doing their PURE study, they found different results showing that sugar looked bad, but it wasn’t fat. I thought, “Do I reconsider my bashing of nutritional epidemiology?” No. It’s still not like an experimental trial.

Until I get 10–20 signals of people using a product or doing a specific thing, I’m not sure. So, I’m not sure the GKI has incremental benefits beyond just keeping the carbs low.

What’s Next?

Until presented with evidence, or unless we do a study ourselves, I’m skeptical. But if we don’t do it, who will?

Advanced Metabolic Dysfunction

Dr. Annette Bosworth: I think that, yeah, you’re speaking into what pushes me to say, “Here’s why I push that. Here’s why I would say “measure this.”

I do think it is because when patients present in a state of advanced metabolic dysfunction, you can call that diabetes, metabolic syndrome, a brain that’s not working well, an autoimmune disorder, or even cancer, it reflects that the body isn’t working right. There is an excessive amount of insulin around, which is known to be linked to these cancers.

Does it mean I can guarantee the cancers will go away when you lower the insulin? No. But do I have the power of observation that shows when body mass continues to decrease, when you have a caloric deficit (and I don’t even like to use the word “caloric deficit” because it confuses people) that the body mass declines to the point where metabolic problems are removed? Yes.

And this isn’t going to happen in a three-week class. This isn’t going to happen even in a six-month class.

Cancer

Dr. Eric Westman: Part of the reason I will relent on the need for scientific, FDA drug-level approval evidence is if the disease is otherwise unfixable.

Let’s say you have cancer, and you’ve gone through all the regular treatments and nothing is working. Why wouldn’t you use a low-carb keto diet? Why wouldn’t you measure the GKI? You’re up against a really bad actor.

I’m humbled because some close friends of mine in the keto community have died of cancer. It’s not going to be a universal solution, we all die eventually.

It’s interesting, though, because a lot of the keto folks talk about how we get a hundred years, and then calculate how much time you lose, like, take away eight years if you smoked, take away more for other factors. It’s almost like a calculator for life expectancy. I don’t think we know to that degree.

Neurodegenerative Diseases

Another situation where it looks like knowing your ketones might be beneficial is in neurodegenerative diseases. If you have Alzheimer’s in the family, or if you’re at the preclinical stage with minimal cognitive dysfunction or early dementia, why not try it?

Not everyone can do it, but if you have the wherewithal, those seem like the areas where science is progressing. It looks like the more they study it, the better the outcomes appear if you have ketones.

But that’s not the garden-variety person I see. I’m still dealing with an epidemic of obesity, metabolic syndrome, cardiovascular disease, and diabetes.

Should Everyone Know Their GKI?

Should everyone know their GKI? I don’t know my GKI.

You asked me what my ketones are. I don’t know what my ketones are.

Dr. Annette Bosworth: I will tell you that usually, I start every show by showing what fasting can do. I try to do a fast once a week, and part of it is to show people that it’s possible to live off your own fat for a 40-hour window every week.

I don’t know that everybody needs to do that. It’s more to show that this is a long game.

Why would I do that? Why would I show people the GKI or Dr. Boz’s ratio? It’s simply to say that when you’re looking at the persistent health of your metabolic system, you can check how well your blood sugar drops below 100 (mg/dL).

I contend that you should be in the 80s (mg/dL) after fasting for 48 hours. If your body keeps blood sugars in the triple digits for two days without any calories going in, there is a lot more metabolic disease and insulin resistance happening, even if you don’t have a diabetes diagnosis.

Early Detection and Long-Term Insight

When you look at the years patients spend acquiring the “goo,” that grime of life that builds up for years before they ultimately receive a diabetes diagnosis, could we slide them back away from that?

Does measuring a GKI reverse that? No. But it gives me a tool, a finger on the pulse, to see how you’re doing when you stress your body.

Do I stay in ketosis at all times? I don’t think anybody does. Even my patients undergoing chemotherapy and going into a hyperbaric oxygen chamber three times a week, they are fighting for the last leg of their lives. That’s a different equation altogether.

Ketosis

Dr. Eric Westman: Ketosis matters for a lot of what we’re saying. I know that people take things out of context and want everyone to agree about everything. Sometimes we’re talking about diabetes, and sometimes we’re talking about cancer, different severities of diseases. But, you know, it could be that the commonality is being in ketosis.

I don’t know. I haven’t seen that. There’s the science, and then there’s the human aspect of this. Two of the people I’ve worked with and written a book with, Jeff Volek at Ohio State and Steve Phinney, emeritus professor out of UC Davis, are now principals at Virta Health, which is helping people reverse diabetes.

I want to be like Steve when I get to his age. He’s about 10 to 15 years older than me, and he’s in great shape. He cycles, and he knows he’s in ketosis. He was probably in ketosis when I was in high school!

But I’m still hesitant. I just want a little more evidence. That said, I don’t see any harm in being in ketosis. Have you seen that?

Jeff Volek at Ohio State, I ask him every time I see him at a public meeting, “Have you learned anything that’s bad about being in ketosis?” He says no. There’s actually never been any evidence that it’s bad.

And I look back, that’s true. With all the hoopla and prejudices, there isn’t a clinical trial with good measurements showing anything bad about nutritional ketosis.

It’s almost sacrilegious, don’t you think?

Managing Blood Pressure

Dr. Annette Bosworth: The power of that – the same thing we would be doing if we were managing someone’s blood pressure.

They come in, and you start as a resident saying, “Okay, you’re going to be seeing a doctor from now until you hit the grave because this blood pressure is never going away.”

Then, 20 years into your practice, you see patients who have lost weight, are off the prescription medications, and whose blood pressure is truly normal every time you check it.

And they didn’t get there by hiding away from ketones. They had to persistently push that metabolic motor, so to speak, enough to chip away at the problem.

We know there’s a tipping point with blood pressure where it probably won’t ever be normal again once it’s been high for so long. But if you can help them back away from the edge, that’s significant.

Proving Your Metabolic Health

When it comes to metabolic health, that “timer” is an unknown measurement in every person you’re seeing. I push patients to prove they’re working their mitochondria with a state of ketosis.

Autoimmune Diseases

Here’s another question. There are about seven of them here that my team said were worth hearing your answers to. One of them is: How does insulin impact an autoimmune disease?

If I were looking at why I’d want you to look at your ketones and glucose, it’s because when your insulin goes up, your ketones go down.

So, I think this is a reverse question. How do you advise people when they come in? There aren’t good clinical trials on autoimmune disorders and a ketogenic diet. How do you advise them?

Dr. Eric Westman: We’re in a space of grassroots change and grassroots assembly of information. That’s where anecdotes come in, credible anecdotes.

If it’s you or me, we’ll believe it because it’s us. If it’s your patient, and there are 10 of them, and you know them, they’re not lying, cheating, or stealing, then it’s credible.

I would say there’s a strong, credible anecdotal population of autoimmune diseases being reversed.

Credibility vs. Clinical Trials

They have no clinical trial publication. A lot of doctors will say, “See, it doesn’t count because you don’t have that kind of level of evidence.”

But, my understanding, and I think it’s a good story and hangs in there, is that it all comes down to the leaky gut. When you’re eating things and your gut is leaky, it lets proteins in that can cross-react with your body’s proteins. The low-carb or keto metabolism fixes it. The absence of those carbs that cause it is probably the key.

I have a poster on my wall for when people come in. All the carbs are in this red box at the bottom. I don’t teach with the red box, but I show all these carbs and I’ll just say, “You know, what do the doctors say causes the autoimmunity? What’s causing the lupus?”

And they’ll go, “Well, it’s autoimmune.”

I say, “Autoimmune to what? What’s causing it?”

Well, they didn’t know in the 1980s when I was in training, and they don’t know now. So, I look at this box of red foods, and then I’ll say, “I suspect it’s something in this box.”

I don’t know what it is. It could be the carb. It could be the preservative. It could be the artificial dye. It could be all these things.

To me, the mechanism never was so important, which may be why I’m pushing back against the ketone measurements, maybe inappropriately or too hard. But autoimmunity? Sure, there are a lot of anecdotes. The problem with anecdotes is they don’t tell you, “If you take 100 people and try this, what percentage will respond?”

For example, some people can climb Mount Everest. Just because you can climb Mount Everest doesn’t mean everyone can. Some people don’t make it, they might stop or falter along the way.

So, I explain to patients, “Why wouldn’t you try it?” The doctors haven’t told you this approach.

Now, doctors have strong medicines that cut out all the symptoms of autoimmunity, but they’re not without long-term problems. Those treatments often mask the symptoms. People are already getting cancer as a result of drug treatments for autoimmune diseases.

This is true for psoriasis and skin conditions, too.

Insulin

Dr. Annette Bosworth: Is it the insulin that causes those autoimmune issues? That is a connecting thread that makes you very suspicious. But I think we can both be even a little more confident that it’s probably something in the red box.

What you’re doing there is saying, “Go to the lowest common denominator.” We can put threads together, well, that is going to increase your insulin. Is that the cause? I think that’s a good theory.

When you’re trying to help patients in real-time, how do you, as a doctor, help the one living right now, before your clinical trial? How do I live my life? I think that’s where the art of medicine comes in.

The Art of Medicine

Dr. Eric Westman: Why not be part of the group, the team, of people where the research we see at these meetings suggests there’s never been a study showing this approach was bad? We don’t know why people think it’s bad.

I mean, we have innumerable anecdotes of vegetarian eaters where it wasn’t the right match for their metabolism and made them sick.

I don’t know if it’s the insulin, but again, my perspective is this: If there’s, for example, a dead body and a gun in the room, how did the person die? Was it the gun? Was it the hole in the heart? Was it the bullet? Was it the person?

That question never really mattered to me. If a tree makes a sound in the forest and no one’s there, I just think: give me an experiment, give me something we can work with.

Continuous Glucose Monitors

Dr. Annette Bosworth: Here’s another question. Casey Means, we both know Casey Means and her book, Good Energy. She also works for Levels Health or is part of running Levels Health.

A patient writes in and asks, “Where do doctors land on real-time tools, like continuous (glucose) monitors, as discussed in that book?”

What’s your opinion on those?

Dr. Eric Westman: They can be extremely helpful.

The CGM (continuous glucose monitor) now, you don’t even need a prescription to get one. That used to be a limiting factor, but you do need money.

You won’t get one unless you have diabetes through most insurance companies. Of course, glucose monitoring can be very helpful.

The glucose watch will one day come out, and people will say, “I can’t eat that!” That’s going to change everything.

It’ll be great when it doesn’t hurt to get your glucose reading. There was a watch recently that looked curious, but it was just hooked up to a CGM. The technology isn’t quite there yet.

Ketone measurements can also be very helpful, but my point is they’re not required.

Lowering the Barrier

I try to lower the barrier to entry. That’s the hard part, getting people to start. I try to make it look easy because it can be easy. But these tools are extremely helpful.

Do you need to live like that all the time? I don’t think so.

Living in Awareness

Dr. Annette Bosworth: What I love about doing that three-week intensive class is this: I don’t think they need to live their lives like that forever. But I think pulling back the curtain and showing what’s happening inside their system is a revelation.

It’s not so much about your doctor knowing what happens; it’s about you seeing, “Here’s the behavior that leads to this.”

These are things you can measure, get feedback on, and use to change your behavior. Hopefully, that leads you to not needing us anymore, which is the best outcome.

Comparing Tools

Dr. Eric Westman: I look to you, Dr. Boz, for the latest in tech. Are you wearing a CGM?

Dr. Annette Bosworth: I did an experiment where I wore all three of them. I had all three continuous glucose meters on and compared them.

Have you seen the new ones? Have you played with them yet?

Dr. Eric Westman: No. They’re not on my radar yet.

Dr. Annette Bosworth: Well, I’ve worn a continuous ketone meter and a continuous glucose meter. Continuous ketone meters are not allowed in the United States yet, and I don’t think they ever will be based on some of the policy decisions that have happened.

Honestly, the ketone meters weren’t very accurate. They measured continuous subcutaneous fat, just like glucose monitors measure glucose. But glucose has a much quicker equilibration.

The over-the-counter glucose monitors, you can’t calibrate them. I may be a snob, but if you prick your finger and the glucose is 15 or 20 points off, which happened more than once, you can’t reset it to match your actual glucose reading.

The prescription ones, on the other hand, can be calibrated. Studying inaccurate data isn’t just unhelpful, it’s worse because now you’re working with false information.

Glucose Watches

Dr. Eric Westman: It’s not just about a reading that says “low” or “high” or “none.” I was chatting with someone in the glucose watch world, and they can measure glucose to a certain degree. However, it’s not accurate enough for insulin administration, so it’s not being approved. My thought is, we don’t need it to be that good. We just want useful feedback.

Dr. Annette Bosworth: Here’s what I’ve learned, my summary of what patients benefit from when they wear these devices.

Fasting Numbers

The first thing is that I learn a lot from morning fasting numbers. What happens overnight when you take out the noise of all the stuff during the day? Morning fasting glucose data is very telling.

If you never take your morning fasting glucose below double digits, always in triple digits, above 100, we have work to do. That number is important to me, and it needs to be accurate.

Unfortunately, I found inaccuracies many times when using over-the-counter devices that couldn’t be calibrated.

Post-Meal Blood Sugar

However, one part that was accurate was tracking how blood sugar rises after eating. Watching how long it takes to return to baseline is incredibly useful.

For me personally, it’s valuable. I might think, “I’m healthy. I fasted yesterday. I can indulge a little.” Then I have a “deserve moment” and overeat. Watching how long it takes my glucose to go down is feedback that changes my behavior. I don’t think I’m alone in that.

Behavior and Stress

What these devices reveal to patients is the link between excess consumption, behavior, and stress. Chronic eating habits, emotional or stress-driven eating, can keep blood sugar elevated for far too long. For example, I’ve had moments of extreme stress, like when a hurricane took out my home, and I was living out of my car. Coping through food is common, and many patients rely on it as a coping skill. The amount of food they’re eating keeps their blood sugar elevated for too many minutes under the sun. A glucose watch provides valuable feedback to address this issue. Over-the-counter devices are very good for that.

Exogenous Ketones

Moving to another question. Let’s talk about exogenous ketones. Do you use them, and do you recommend them?

Dr. Eric Westman: The idea behind exogenous ketones is that you can raise ketone levels by drinking, eating, or potentially inhaling ketones. Exogenous means it comes from an external source. Endogenous ketones, on the other hand, are produced by your body when fat is metabolized in the liver. That’s how your body naturally enters ketosis, even without measuring ketones or taking supplements.

Evolution of Exogenous Ketones

Exogenous ketones have come a long way. Fifteen years ago, they tasted like jet fuel. The technology has improved, making them more palatable, and the science behind them has advanced. That said, some are being sold without robust scientific backing, relying on perceptions or anecdotal effects like appetite suppression. People may feel better, but these products are often sold without the due diligence of FDA drug approval.

Diet or Drug?

Here’s the question: Is it a diet supplement, or is it a drug?

If you drink something that cuts hunger, cures cancer, or fixes diabetes, isn’t that a drug? Exogenous ketones exist in a strange regulatory gray area.

On one hand, they’re marketed as supplements, benefiting from the lack of scrutiny many doctors place on diet. On the other hand, the manufacturers avoid regulatory oversight, which would come with tighter controls.

Clinical Perspective

In my clinical practice, I haven’t yet seen the science to fully support the use of exogenous ketones for treating diseases.

I recently spoke with Dom D’Agostino, who has developed a specific formulation. When I asked him, “Who’s studying this?” he said, “Nobody.”

I suggested collaborating on a study with real patients, but it hasn’t happened yet – primarily due to lack of funding.

Exogenous Ketones and Clinical Use

Companies aren’t going to do the studies to go through the equivalent of FDA approval for clinical settings. We’re really kind of left on our own to use them and to find out the clinical sense of whether people are getting side effects. Are they palatable?

In my world, if someone has nausea in the first week, they’re either on metformin, which causes nausea, or they’re adding oils like medium-chain triglyceride (MCT) oil, coconut oil, having butter in their coffee, or taking a ketone supplement. It’s not normal in my kind of low-carb keto program to have nausea in the first week. In fact, just about every gut problem gets better, which is great. We should really be gastroenterologists. But no, we’d be out of business because we wouldn’t be scoping people, and that’s why they make a lot of money – by scoping people.

So, I don’t use exogenous ketones yet. I have a few patients dabbling here and there, but there aren’t strong anecdotal signals, at least in my world. For example, one set of patients is trying to help their spouse with neurodegenerative disease by manipulating ketones, but those diseases are hard to know if they’re really getting better. You can impact things, there’s no question. And then, because of the SGLT2 inhibitors, which allow you to leak glucose in the urine and lower blood sugar (though not a good idea), these drugs actually develop ketosis. Drugs like Jardiance and Invokana have been found to reduce heart failure episodes, and now ketosis seems to be the mechanism.

There are researchers here at Duke giving exogenous ketones for heart failure. But it was the drug side effect, not the keto diet. I just met one of the lead investigators in those studies, and they’re not easy to conduct with heart failure patients. Some of them have sophisticated measurements, and the investigator didn’t know much about the keto diet; he’s giving exogenous ketones instead. So, there may be something to it; it’s just been very slow to get the studies done.

The Mechanism Behind Ketones

Dr. Annette Bosworth: When you think about why that would work, you have to hypothesize. Why would ketones help heart muscle?

Dr. Eric Westman: A favorable idea is that heart muscle runs on fat, and ketones are a form of fat.

Dr. Annette Bosworth: That makes sense. It should work, but it probably needs more study.

Dr. Eric Westman: I don’t use exogenous ketones in my practice yet.

Dr. Annette Bosworth: In my practice, I have found one of the best ways to use exogenous ketones is when people are falling off track.

Ketone Scams

Exogenous ketones are expensive, and I’ve been a big proponent of spending money on testing ketones after you’ve already spent money on high-quality ketones. If you swallow ketones and don’t find them in circulation, you’re being sold a scam.

Have I found that? Absolutely. There are products out there labeled “ketones,” but they contain no ketones at all and don’t raise ketone levels. You can prove this 15-20 minutes after consumption by testing for ketones, but the other place I’ve found ketones to be helpful is in the social realm.

When people fall off the wagon and binge, they often want to get back on track. I’ve said that pushing reset can be difficult, but timing matters. Sipping on ketones between the time you fall off and when you get back on track, whether that’s 48 hours or whatever, can keep appetite suppression. I’ve seen that be very powerful.

Whether it causes nausea or not, I don’t know, but I do think the distance between falling off the wagon and restarting matters. Using a supplement in the meantime to push reset, get rid of those groceries, and try again can be a valuable tool.

Safety of Exogenous Ketones

Dr. Eric Westman: To your knowledge, there haven’t been any reports of serious issues from exogenous ketones?

Dr. Annette Bosworth: Most of them are made with salts, and you can find people who, if they guzzle too much, might get diarrhea. But that’s usually a minor, temporary issue.

Research Opportunities

Dr. Eric Westman: Yes, I think this is an area that is right for research.

Dr. Annette Bosworth: If you’re willing to take my money, I’m all in.

I don’t know if you’ve Googled recently how many GLP-1s are on the market in Phase 2 or Phase 3 trials. The last Google search I did showed that 51 of them are under research right now, so they’re not going anywhere.

I was looking back to try and remember what was the first GLP-1 that we wrote. Byetta? Was that the first one or the second one? Anyway, they’ve been there.

Dr. Eric Westman: I have never written for that.

Dr. Annette Bosworth: Well, Byetta was a diabetes medication, probably around 2013 or 2014. It had this whisper of weight loss, and it came with a bunch of samples. So, I started with the samples, and it was very interesting.

And I think it does prove true as you watch forward that there were some people who just lost weight like it was some kind of magic fix. I’m like, great, I got 15 pens. I don’t know what to do with them, so you should have the samples. They did have powerful weight loss, but it was hit or miss, it was very unpredictable. I said, “You can try it. If you have appetite suppression, we’ll write you the prescription, but it’s very expensive.”

Now, as you look at the advent of several of them coming to the market, what that brings is, hopefully, competition, lowering the price, and finding better resources. So, how do you approach these drugs, not just for the ketogenic role but also for patients who are looking for a ketogenic place and need to lose weight? The weight loss part isn’t subtle, it’s very real.

Dr. Eric Westman: I also am a past president of the Obesity Medicine Association, or OMA for short. I was on the team that helped change the name from the old one to the new one, and that’s a thankless job, let me tell you. The old doctors were not happy. We’ve used a lot of medicines before. It was phentermine, and a lot of doctors are still using phentermine or Adipex. It’s like Adderall, it cuts out the hunger.

I still use a little bit of that because it’s cheap. It’s inexpensive, about $20 to $30 a month. I even joke that the organization is full of “phentermine-ers.” They just wrote phentermine, and it worked for some time.

But the GLP-1 drugs, I remember I was in a meeting with Novo Nordisk, the company in Denmark that is now massively selling this stuff. They had a pipeline of all the new medicines. This was 10 years ago, and it’s come true. The first-generation drugs are now second-generation, and there’s going to be a third generation even beyond that. The mass number of first-generation drugs will be out there, but I have to imagine that there are maybe 10 hormones that are pivotal, really important, that if you target that hormone with a drug, it’s going to, like, night and day, cut off the hunger and make people feel full.

The GLP-1 and the GIP combo, like Zepbound or Wegovy, are second-generation drugs. Maybe there are five; I don’t know how many exactly, but for some people, it’s like the “food noise” is gone, and the weight comes down. Right after Oprah did her show saying she was giving up Weight Watchers and doing the drug shilling for the drug companies, one of my patients came in and said she felt the food noise was gone.

That’s what happens on a keto diet. A keto diet targets and hits all of these hormones. It’s as if the companies should be studying the keto diet to see which hormones are changed and then target those hormones instead of combining a contrived pill that has bupropion and naltrexone and targeting the brain.

Why not target the method that really works? No one seems to want to know what really works.

I think if there’s a vendor area for obesity treatments, let’s say you walk into the meeting, and there’s a bunch of vendors with booths, lots of people in the past would come into this area through the surgery clinic. The surgeons would say, “The only thing that works is surgery, nothing else works.” And so, they would come in, and then they’d see, “Wow, there’s diet and a few drugs now.”

A lot of people are coming into this vendor area of treatments through the shots, through the medicine. It’s really important for everyone to know that other things have worked, other things have always worked, and there will be other things that work. I think it’s going to lower the bar for people to start addressing obesity and the problem.

But the tragedy, as I see it, is that doctors really don’t know how to counsel people about food. If you don’t hear the message that protein and fat and keto, which is a great diet to use when you’re on one of these shots if you don’t hear that message.

I have people coming in with just really terribly distorted eating. They’re losing muscle mass, they’re not feeling well, and they tolerate really bad gut issues. I remember back in the day, the drug companies said, “Don’t mess with the gut because no one’s going to take a drug that messes with the gut.” And now, about 30% or so of people drop out because they can’t tolerate these medicines due to gut issues. Yet, they still brought the medicines to market because so many people are around and need them.

It’s giving weight loss a bad name, and you can do it in a way that doesn’t give you nausea or make you lose interest in everything. What’s your take? I think there are a lot of people who will be helped, and I hope they will off-ramp onto a great eating program like ours.

Dr. Annette Bosworth: Before I landed in my ketogenic approach, my life was in internal medicine, specializing in peak brain performance, brain injuries, Parkinson’s, bipolar disorder, and sleep disorders. I treated all sorts of conditions in internal medicine, but that was the thread that many of the patients were referred to me for in my medical community, and I loved it. It was great.

What became a side part of that business was addiction. Do you want a brain injury? Drink alcohol for 10 years, smoke marijuana, add meth. Those brain injuries were this major subplot to an internal medicine clinic. You mentioned naltrexone, actually, one of the levers we would pull for a chronic alcoholic. Taking away that dissociative behavior that the brain really does practice makes a big difference.

You become very good at that behavior when you are abusing alcohol or opiates. Alcohol, though, was much more common, and it was a major thing I learned through patient care. So, to watch that naltrexone work, it’s the Vivitrol shot. You could give them a shot, and it would last a month. It costs $1,000. You could go to Betty Ford for $50,000 a month, or you could spend $50,000 on injections that would last at least two years and help your brain stop craving alcohol.

What I learned was that the addiction behavior for alcohol, when you could settle that noise, made it easier for people to learn how to live life without booze. We know it works faster. As much as I didn’t want to admit it, that was the reality. Yes, it’s expensive, and they come in, and if a shot goes wrong, it’s a huge hit to the bottom line of the clinic. There are all kinds of issues.

What I learned was that when patients shut down the noise, they could get back to their lives a lot faster. When I look at folks who are struggling, I want them to be able to not need us. You can say that’s bad for business, but I think the health of our country is at stake. We have an obesity epidemic, and it comes with a mental health issue that may or may not be a cause or effect of obesity. I don’t know.

It doesn’t shock me that when I look at the more you read about GLP-1 and GIP drugs and the neural modulation they do, although they don’t cross the blood-brain barrier, they definitely affect the brain. Some people have serious suicidal feelings and are haunted by past demons that they thought they buried. I’m not surprised by that.

I do think that when I’m working with somebody and I’m trying to make sure they’re in ketosis and checking those numbers and doing all the things, but they are stuck at a certain weight, even with the best ketogenic diet, they go to support groups and do all the things you and I recommend. Yet, the weight continues to creep back until they address something deeper. Something has hurt them, has broken them.

I think that’s the addiction component of medicine. I do think support groups are going to be the answer. I also think people will need a “come to Jesus” moment about how they use food, why is that coping skill the first, second, and third thing they reach for? And how can we teach them to do something different?

What I hope happens with these medications, because I don’t think they’re going away, is that they will be a tool in a toolbox I would love to have alongside a ketogenic diet for those who can’t survive or can’t seem to get the weight off. I was reading a study the other day that shows even if you have them on an anti-inflammatory diet where they lose weight, they may still have a 50-pound deficit for ideal body weight. This could increase the risk of dementia. Increased heart risk, increased risk of cancer, all these things that you and I see every day. You’re like if 50 pounds is what the cutoff is, there are a lot of people out there who’ll be on these drugs if those are the parameters they’re going to use.

What I hope happens is that it’s the smallest effective dose they can use, in hopes that, like Vivitrol, they can eventually get off of it. We don’t know that yet.

Dr. Eric Westman: Let me just echo the addiction part, and I learned a lot from Dr. Vera Tarman, who has a book called Food Junkies. She actually wrote a course for Adapt Your Life, a teaching company (Sugar & Food Addiction). But I was in a study section, meaning we reviewed grants that people wrote, with a pharmacologist for several years in a row. A brilliant person, not an MD but a PhD, and he said, “Show me a drug that’s specific, and I’ll show you a young drug. We just haven’t learned everything about it yet.”

A drug we say just targets this can end up targeting so many other things. The addictive part of food is so common. We were all taught to use food for coping. Someone comes in and I say, “What do you think causes the weight gain?” And they write “emotional eating” on the form. I’m like, “Well, of course.” I don’t say that to anybody, but everyone does.

I forgot you gave a lecture at the Society of Metabolic Health Practitioners on brain function. I remember that study or that presentation. It’s all connected. I’m actually the son of a shrink, so that’s one reason why I know the vernacular in psychiatry. I needed numbers, something other than just “How do you feel?” But yes, it’s all connected.

They say there’s more serotonin in the gut than in the brain. Even a lot of these psychiatric medicines have effects all over. It’s just amazing what changing food can do.

I was once part of an organization of doctors, 5,000 members strong, called the Obesity Medicine Association. While not all of them used low-carb or keto approaches, we taught each other how to communicate effectively, like how to measure waistlines or engage patients without making them uncomfortable.

I’ll never forget one of my friends who came up with the idea, he practices the best internal medicine of his life without drugs, we use food as medicine, good food.

In the words of Rob Lustig at the University of California, San Francisco: “Good food is medicine. Bad food requires medicine.”

It wouldn’t surprise me, in the questions tonight, that autoimmunity is caused by all these carbs in some way. While the mechanism isn’t quite known, it’s something in that red box. So many things get better, and then the advent of people who are not eating any plants, the so-called carnivore movement, is fixing people that doctors can’t fix. I’m just kind of watching this play out. The stories are really pretty amazing.

As you said, it’s so gratifying. If you came into being a doctor to help people and solve problems, what a tool we have.

Dr. Annette Bosworth: Honestly, it’s been great. I think the next time you and I overlap in person might be at Low Carb Boca. Are you going to that?

Dr. Eric Westman: Yes.

Dr. Annette Bosworth: You’re like one of the founders, one of the godfathers of these events. Are you still on the board?

Dr. Eric Westman: I am on the board.

Dr. Annette Bosworth: I knew that, but I wasn’t sure if you were still on the board or how that works if those are seasonal things you rotate off of. Do you give a lecture this year?

Dr. Eric Westman: Yes, I do. I’m not sure what I’ll talk about yet, but my interest is in what running on fat can do, because for example, a very rare orphan disease, McArdle, is fixed (by a keto diet). Yet the mainstream world would rather do research with genetic companies to try to fix the gene than just tell someone to change their food.

Dr. Annette Bosworth: That’s a great approach. When I’m trying to talk to somebody who doesn’t believe in keto, I’ll bring up McArdle. I just actually said yes to speaking at Low Carb Bocca this year. I’m doing a session on menopause brain because they’re doing a day on women’s health. So, I think we’ll get to talk. I think uric acid is what I’m covering the next day. But at least menopause brain for how that might be helpful for folks.

It’s one of the few places we get to go for continued medical education in this space. I do think it has probably the best value and return of joy for our service to patients.

Thanks again. Thanks for duking it out. I think we kept it respectable.

Dr. Eric Westman: I’ll get that food fight in the right context.

Dr. Annette Bosworth: I will say good night to our viewers.

Watch the full video here.

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