Introducing Dr. Sue Wolver
Dr. Eric Westman: I am pleased to introduce a colleague who works at a different university, Dr. Sue Wolver. Please introduce yourself.
Dr. Sue Wolver: It is my great pleasure to be here. People may not realize that I am only here because of you. You are my mentor. This May marks 11 years since I came to visit your clinic. I was blown away by what I saw, and I spent a Tuesday and a Wednesday with you. I saw more patients in those two days who lost weight than I had in the 20-plus years of my career. That very Friday, I started my clinic 11 years ago.
Dr. Sue Wolver’s work
I work at VCU Health System, but what I talk about today are my own opinions. I have been there for 21 years. For the first 20-plus years of my career, I was a primary care doctor. About 12 years ago, when I started to gain weight myself, I had an epiphany that maybe it was not that my patients were not following my advice; maybe my advice was not so good. I looked at my personal journey and figured out how to lose weight. I had tried many, many things in the past and remember thinking, if I do not feel hungry, I am not doing it right. Nothing I ever did worked; the harder I tried following my own advice, the more weight I gained. I thought let me try this Atkins thing. I looked through it and the most incredible thing was, I was able to lose weight and not be hungry. That was such a shift in thinking for me because I always thought I had to be hungry. In retrospect, knowing about how the body works, hunger makes you doomed to failure because it is not biologically plausible to have hunger and to continue on. Our brains just do not work that way. I was able to lose about 15 pounds and I have kept it off all these years. Had I not intervened, I am sure I would have at least 40 pounds to lose now. It was so easy for me; I thought let me try this with a few people, like my patients. They were very eager to lose weight. I always talked about eating less and moving more but it was not working. I said you want to try something with me? They were, we are in, we are game. After meeting you, I sat them down and I got a flip chart and started drawing some things. 11 years now, we have helped 3,000 patients, primarily with a low-carb or, for some people, ketogenic diet. I have had more fun in the last decade than I did in all my years in medicine.
I am an associate professor there; I do a little bit of research, but mostly I run the clinic and try to get the biggest team I can to help my patients.
A University allowing something radically different
Dr. Eric Westman: People often come and ask me, ‘Well, you are at Duke, how do they let you? I explained that there have been a lot of different diet programs, including the Rice Diet some years ago, which was like an Ornish diet. (Ultra low fat.) Today, there are three or four different weight loss programs that use different approaches. How did a university allow you to do something radically different from dietitians?
Dr. Sue Wolver: They did not. I just did it. I had a primary care practice, and I had patients that needed to lose weight. It was not until I thought let me see if I can do this, and started with a few patients. I did not know if I would be any good at this. They started losing weight and coming off some of their medications. I tried it with a few more patients, and I thought maybe I was good at this, and maybe I like this. Then I had my colleagues in primary care, ‘You know, if you want to send your patients to me, I can work with them.’ Then they started going to other places in the hospital and other clinics, and to date, we have never advertised our program, not once. People either Google and find out about me, but most of the time it is word of mouth by seeing one of my walking billboards – a.k.a. my patients – and they ask, “How did you lose this weight?” That is how they all come to see me.
When people started hearing about me and what I could do, some of my colleagues enquired, “Can you help this patient because they need to have this surgery? Or, can you help this patient because they need to get on the transplant list? Or, can you help this patient because they have sleep apnea? Or, can you help this patient because they need egg retrieval and they will not do egg retrieval on them with their BMI?” It just became a snowball effect.
I have to commend VCU, which is Virginia Commonwealth University, as they really have supported me. I brought them the evidence by just taking care of the patients rather than asking permission to do it because it was my primary care practice and I was helping people in the best way I knew how. Then it became a real asset for the health system to have somebody who did this because at that time nobody was doing medical weight loss. We only had bariatric surgery.
Dr. Eric Westman: That sounds similar at Duke where I am in Durham, North Carolina. I did have to ask. I chose to ask my department chair. I did not have to ask the dean or anyone super high up, but I asked for just the clinic time. He looked at me and said, “We have weight loss at Duke.” I said, “What do you mean?” He said, “We have the Duke Diet and Fitness Center.” These are rich people who come to town and it is $3,000 a week. I explained, no, I want a weight loss program within the insurance system that most people can get access to. He said, Do not lose too much money, because in a university, at least like Duke, the guys out in the outpatient area, we lose money compared to the surgeons and procedure-oriented specialties. Most universities have partnered up with surgeons and we have a very different philosophy.
11 years ago, there was no Ozempic and you were helping people lose weight.
Dr. Sue Wolver: Lose weight and come off their medications.
The experience of joy at being a doctor again
Dr. Eric Westman: We will get into medicines in a little bit because it is the buzz and what we do goes back to the 1860s, the Banting diet. They did not have apps, they did not have ketone drinks, they did not even have electricity, and it still worked. Just changing the food is so powerful. We know it helps obesity and diabetes; we published papers and you have published papers, or at least one from your clinical experience. You have a data background. I remember that you mentioned it. I would like you to talk again about the joy of being a doctor again because I see a lot of doctors who are not happy with what they do. I seem to remember that was part of the change that you liked.
Dr. Sue Wolver: No question about it. Before bringing this into my practice, I did what was called the dance. My patients would come to see me, their diabetes was not well controlled and their blood pressure was not controlled. We tweaked their medications, they would go away for three months, they would come back, their diabetes and blood pressure were not controlled. We tweaked their medicine. I would say, eat less and move more, and we would just keep doing this dance. Nobody ever got better. When I would say, we really probably need to consider insulin, no one said, great, thank you so much, I feel so much better on insulin. Now, it is every day I feel like I have cured cancer because really, obesity is like a cancer. Not only does it cause a number of cancers or is a huge risk factor for a number of cancers, but it really metastasizes into every aspect of a person’s life, their joy, their sense of fulfillment, their ability to play with their children, or get on roller coasters.
We always ask patients to tell us when they come in a non-scale victory that they have had since the last time. Some of them make me cry. Going on an airplane and not having to ask for a seat belt extender. Things that people who do not struggle with their weight take for granted.
Dr. Eric Westman: Looking around the room to try to find the chair that not only would fit but would take their weight. The ability to cross your legs. A patient looked at me and said I can cross my legs and tie my shoelaces. I can feel my bones. I also lost about 20 pounds on the low-carb diet. My patients lost weight on their own and read the Atkins book. I do not have a massive weight loss story. It might be a bit of an advantage because I am not colored by my own experience too much. Some doctors lose a lot of weight; they become advocates and zealots and obesity specialists, but there must be some inherent or unspoken bias toward the way they did it. I do not know.
Tell me a story about diabetes reversal. If you are watching or reading this and you have no idea what we are talking about, we are talking about a low-carb keto diet that has been around for a long time. It is not the ketogenic diet for epilepsy; that is very different. You help people by just changing the food. We can reverse not only obesity but also diabetes. People might say, someone has a little bit of diabetes, you put them on this.
Dr. Sue Wolver: For my first decades of practice, I never saw anybody’s diabetes get better. If I did, it was just a little bit. I precept in the resident clinic so I am working with a lot of primary care doctors.
Teaching
Dr. Eric Westman: That means that you are teaching young doctors?
Dr. Sue Wolver: Yes, I teach young doctors. Most people have given up telling patients that there is another way other than just adding medication. We have taken that choice away from them, deciding for them that this is something they do not want to do and so we will just give medication.
I try to teach my young doctors and medical students that we are all about collaborative care and agency, and letting patients make their own decisions in this day and age. We have every right and we should give them their options. For a patient that may not want to do it is not something we should be doing. Offering them a choice, we can go on this medication or we can change your diet. It is surprising how many people want to change their diet when you give it to them and then teach them how to do it. That was my other problem: I told patients to eat less and move more, which did not work, but I did not give them any true direction or guidance on how to do this thing well. I had to learn by myself. I learned to teach them a low-fat diet and exercise and everybody’s going to get better, but nobody did. Myself included.
Low fat diet fading away and food is medicine
Dr. Eric Westman: The people started with lifestyle and it is in all the guidelines. For hypertension, you start with lifestyle but they are using the wrong lifestyle. Even the medical establishment and the research establishment tied up and got together this big study of the low-fat diet with about 48,000 women and it did not work. We taught people that this was working through a study but at the end of the day, it did not work. I remember going to a researcher at Duke and asking how is the study going? Their reply was “It is going great.” What are the results? Their reply, “People are eating more fruits and vegetables.” Is there less cancer? Their reply: “It did not help with that.” So, the goalposts have been brought into the process of change without the outcome changing anymore as a requirement. The low-fat diet is fading away, don’t you think?
Dr. Sue Wolver: I do. It was interesting, you are talking about this like this was a while ago, there was something published that I came across from one of the newswires, Medscape, “Food is Medicine” is a good idea, why did it not work? I am like, “Why it did not work is because we were not teaching the right food as medicine.”
The facts about insulin reduction
Dr. Eric Westman: Rob Lustig, a colleague, and a professor of Pediatric Endocrinology from the University of California, San Francisco put it together. It was at an Obesity Medicine Association meeting. He said Hippocrates said, “Let food be thy medicine. Good food is medicine and bad food requires medicine,” which was brilliant because it allowed for the fact that doctors are using medicines because people are eating bad food. Call it junk food. Hippocrates did not have to fight the food industry. You have to be careful about the food.
Tell me a story of insulin reduction. Even if you have type 2 diabetes with insulin, you can get off it and fix the diabetes.
Dr. Sue Wolver: I helped one woman in particular. She was my primary care patient and she had been on insulin for 30 years and she’s come off of insulin.
Dr. Eric Westman: People come to me and say doc, I have been on insulin for 10 years, I can not come off it. 30 years? I have seen this too. I am saying this for emphasis. It doesn’t matter how long someone has had insulin, does it?
Dr. Sue Wolver: I recently took someone off 73 units of insulin in four days and I know you have done the same.
Dr. Eric Westman: To recap the treatment of diabetes. First, you might be told you have pre-diabetes, and you might be put on metformin. Remember, ‘medical care’ means medication care. When metformin does not work anymore, you will be put on an inhibitor or other drug, although those are fading away because it has been found that they actually make you gain weight. You might be put on another medicine like Ozempic or insulin. Once you get on insulin, you will gain weight. If weight is a contributing cause to diabetes, the doctors are basically perpetuating the diabetes by giving insulin. Insulin tells the sugar to go into the cells, it lowers the blood sugar from the bloodstream, but where does the sugar go? If you have extra food around, it turns to fat, and insulin then stops the fat burning. 70 units, you start at 20, about a unit an hour, and then you might double it to 40 and 60 and this person was on 70 units of insulin. That took months or years to get up to that and then you stop it in four days. Please explain this.
Dr. Sue Wolver: It is food. Type 2 diabetes, we should be clear about that, it takes genes and it takes food. You can not change your genes, but you can change your diet. I teach my patients that it is a bit of a carbohydrate allergy. They cannot manage their carbohydrates very well, so they can either take medication or they can stop eating carbohydrates or dramatically reduce their carbohydrates. Some people have trouble understanding this, especially patients who come to me on insulin. I might do the analogy and say to them, people who have peanut allergies, they carry around that epinephrine pen just in case they accidentally eat something that has a nut in it. Have you ever seen any of them stab themselves with the epinephrine so they could eat nuts? No, that is crazy.
Insulin and carbohydrates
Dr. Eric Westman: That is perfect, although technically it is not the same kind of reaction. It gets to the point that you are basically treating the foods. Explain how insulin is started with somebody, even in pediatrics. How do you dose insulin?
Dr. Sue Wolver: I am not a pediatrician so I would not know that.
Dr. Eric Westman: It is carbs, it is servings of carbohydrates. You dose the amount of insulin based on the amount of carbs in the food.
Dr. Sue Wolver: if you are going to be giving short-acting insulin you start with a long-acting insulin because even though you have high insulin levels, your insulin is not working very well so you have to give more insulin, so you are actually giving a patient insulin and then when their blood sugars are no longer controlled then you have to start giving them insulin for the meals that they eat. You can dose that based on how many carbohydrates they are eating for a meal.
Dr. Eric Westman: You mentioned something very quickly that I want to dwell upon for a minute. The fact that if you have type 2 diabetes, your insulin level is already high. It was in Gary Taubes’s book, Rethinking Diabetes, that came out this year. In reading that, he said, this is unusual for endocrinology. It is a field where typically if the hormone is low, you give the hormone. If the hormone is high, you give something to reduce the hormone. But when type two diabetes happens, your insulin is already high. It makes no sense to a trained endocrinologist to lower the insulin. His book Good Calories, Bad Calories is still a pioneering work. If you have any concerns about all the science that got into the low-fat diet, there was not much.
Insulin was used for type one and type two diabetes before the insulin assay was created in the early 1960s. The radioimmunoassay to detect insulin was not around. I went back to read the paper that showed that type twos had high insulin levels. In that paper, it is almost chilling because they said, do not give more insulin to these people. This was back in the 1970s. Yet doctors were trained to give insulin to people whose insulin was already too high. Does giving insulin to someone with insulin resistance fix the insulin resistance?
Dr. Sue Wolver: No, not at all. You just keep giving more and more and more insulin. I have seen patients on three to four hundred units of insulin come to me.
Dr. Eric Westman: When the U-100, which is the dilution of it, the strength of it stops, there is too much. There is not enough space to inject it. We make U-200 insulin now. The U-500 insulin, that just blew my mind. The problem is not that there is not enough insulin. The problem is that the body is not listening. Insulin resistance is like going into a noisy rock concert or any concert where there is a lot of noise. Your ears adapt and do not hear as much. That would be like sound resistance. My world record so far is taking someone off 600 units. I didn’t do it, she did it on her own. If you are on insulin or diabetes medicines, be careful. If you need to do this with someone and sometimes I have people text me their results, but this person understood it just like that. She had a glucose monitor or finger stick, I do not remember which, and by watching her own blood sugar, she came off the 600 units of insulin in eight weeks. I remember 180 units in two days from years ago when this guy was drinking Coca-Cola or Pepsi, I do not know which brand, they are sugar, he drinks liters of it and was injecting insulin and drinking sugar. How would a doctor allow that to happen?
In your old practice, did you ever ask anyone what they ate and drank? I never did.
Dr. Sue Wolver: I did a little bit, but I did not get enough detail. People would say, I am not eating much. I have a sandwich, I have some chips. But I forgot to ask, what are you drinking?
Dr. Eric Westman: In Richmond (Virginia), if you say ‘tea,’ do you assume it is sweet tea?
Dr. Sue Wolver: Absolutely.
Dr. Eric Westman: The newcomers who come from the North to train at Duke, I have to remind them that if someone says tea, it means sweet tea. Down here, we say unsweet tea, and it is usually without sugar.
What about now? Everyone is really hot on these insulin pops.
Glucose monitors and their benefit
Dr. Sue Wolver: We will talk about the insulin pop in just a second, but you mentioned something that I think we need to talk a little bit more about, and those are the continuous glucose monitors. It is such a game changer for my patients and patients who have insurance can usually get one free from the company, from their websites, and see what you eat in real-time, whether you have diabetes or not, is just an absolute game changer where you can really see, I am what I eat.
Dr. Eric Westman: It is painless. I even tried one for a month. While there is a small needle at the beginning when you inject it, it is so easy to do. You do not have to finger-stick at all, you just put your phone over it. It reads it every five minutes or so, depending on the type of monitor. It puts you, the patient, in charge of the reversal of a disease that your doctors just want to manage.
A patient came in and asked, why are doctors like salespeople for drug companies? I never thought of it that way. It is because that is all they know. Now there is a hospital in North Carolina that gives out free CGMs (continuous glucose monitors) to all of their staff if they ask for them. What an investment in a company or staff. Dr. Mark Cucuzzella did a couple of studies and published one where he just gave out continuous glucose monitors. He did not tell people what to eat, and people, on their own, reduced carbs in their food because they did not want their blood sugar to go up. I wish they were more available. I paid $100 for a month when I did not have insurance. I just went in and bought one. You still have to have a prescription, though.
Dr. Sue Wolver: There is one that is coming over the counter soon. They said it was FDA-approved. I do not know how much it is going to cost. Whether insurance is going to cover it, strictly out of pocket, how much it is going to cost out of pocket.
Insurance and sourcing of glucose monitors
Dr. Eric Westman: It is one of these things I need to put into perspective. If you have to pay a little bit out of pocket to get the information that until now has been controlled by the system, the doctors and all, it is worth a small investment now to not go down that path of diabetes.
I tragically had a recent patient who got lost out there, eating carbs again, and he came back because he lost two toes due to the management of diabetes with medication. It is not as though he is living in a third-world country or out in rural North Carolina. He is in a major metropolitan area. If you pay a few hundred dollars now so that you do not lose your toes, or kidney failure and blindness, all these things.
It is interesting, most of my insurance-paid patients assume that insurance will pay for things that are worth it. if you go outside of it, it is like you are doing something strange or not approved. When money came into the guideline process, this was in the ’80s and ’90s, when Medicare started having cost-effectiveness analyses. You had to do that. You cannot put everyone in beautiful homes. You have to figure out how much things cost.
When I explain that, it is not much cost to pay on your own for this information to reverse a disease that your doctors are only trained to manage.
How do you finesse getting CGMs for your patients? Or do you just follow insurance guidelines?
Dr. Sue Wolver: People that have insurance can pay $75 even if they do not have diabetes. I encourage them to do that. They can get maybe one or two free if they go on the site. They are loosening up the rules a little bit. It used to be that you had to, for Medicare, give four shots a day. We want to do it before you get on a single shot a day. Now if you are on insulin, Medicare will pay for it. You do not have to have four shots a day, you just have to be on insulin.
Dr. Eric Westman: Imagine if you could just get two, they last 14 days typically. If you get a month’s worth, you could get off insulin. Let’s say it is pre-diabetes because you do not qualify for the insulin payment by the insurance company. It is worth getting that information, isn’t it?
Dr. Sue Wolver: Absolutely. To pay now or pay later. It does not matter how much money it is going to cost later. No amount of money is going to preserve your health and many of these things are irreversible.
Dr. Eric Westman: The elephant in the room we have not talked about is cardiovascular disease, atherosclerosis. Diabetes is the main risk factor. If your doctor is not fixing your diabetes and they are prattling, they are worrying, obsessing about this cholesterol thing, they are missing the boat.
Dr. Sue Wolver: The weight as well.
Patient success story of insulin reversal
Dr. Eric Westman: I see diabetes and obesity together because the method that we use, the low-carb keto diet, fixes both. We were criticized in our early studies that our diet did too much.
Your success story of insulin reversal.
Dr. Sue Wolver: I saw a patient today who was on an insulin pump and within two months is completely off of insulin.
Dr. Eric Westman: I thought insulin pumps were making diabetes more manageable.
Dr. Sue Wolver: She also lost 34 pounds.
Dr. Eric Westman: Someone said to me, you cheated, doctor, you reversed diabetes. I said, yes. You also made them lose weight. Yes, that is not cheating, they go hand in hand.
How is this patient feeling now?
Dr. Sue Wolver: Completely different. She is exercising five days a week, her husband cannot keep up with her anymore. She has boundless energy and sleeps better. It affects every facet of a person’s life. She said, can I hug you? before she left. That is how grateful they are. They cannot stop expressing their gratitude. Her only disappointment was that she did not meet me 20 years ago.
Dr. Eric Westman: Time, we cannot go back. What was the introduction to that patient? Often if someone had worked hard to get the insulin controlled by a pump, they have invested so much time in this techno-system that sometimes they say they had to work hard. I reply that no, you do not need that. They reply that their other doctors worked so hard, and these other doctors are working hard, but they are misguided in not reversing it.
Did this take much persuasion on your part?
Dr. Sue Wolver: It did. You hit the nail on the head. I find some people who are doing injections of insulin are a little afraid to give them up, especially if they have good blood sugar control. They cannot imagine. They do not need that for their good blood sugar control. It takes a little bit of convincing and it was true with this patient as well. She was very reluctant to give up the pump, but now she cannot imagine ever going back.
Dr. Eric Westman: The next decade I think I want to try to percolate back into internal medicine a bit, but it has been so resistant. No one has asked my opinion. The endocrinologists, I do not understand, they are world experts in drugs and they do not understand food. At Duke, it is the NPs, the mid-levels, who send me patients from the endocrinology clinic.
Dr. Sue Wolver: I am lucky. I have a great relationship with most of the departments. Many of them are becoming obesity medicine certified and are discussing food. Yes, they do use a lot of medications, but they realize how important the food component is.
Is the diet easy or difficult to stay on
Dr. Eric Westman: Talking about other doctors, there is a bad perception that this is so difficult. Dr. Westman uses this diet, but nobody can stay on it. What is your experience?
Dr. Sue Wolver: You have to choose your difficulty. It is a lot easier to go through a drive-thru; we are all busy. Carrying extra weight is difficult, and having the disease of diabetes is extraordinarily difficult. There is difficulty in anything that is worth doing. It does not have to be difficult. It depends a lot on your psychosocial situation. If you live in a family where everybody is eating fast food and junk food and you want to do something different, it can be difficult.
You have to have some support and some resources, and hopefully, we are providing that to patients. For some of my patients, it is a lot easier, it takes the guesswork out of what do I need to eat. Here’s a simple list, these are the foods that are going to make you healthier, so for some people, it is easier and not harder. They can eat wherever they want, they can go through the drive-thru, they just make different choices going through the drive-thru.
Dr. Eric Westman: One of the things you mentioned is what I start with, which is the absence of hunger. You mentioned early on that this is a unique weight loss or diet program. Because there is no hunger, that is the way I come at it. If you cut off all the carbs, you take the band-aid off really fast and there is no hunger, and it puts you in charge. You may crave for a few days, and most people do not get the keto flu. I will spend a little time informing people on how easy it could be or in the intake process. If someone says that my knees hurt so I cannot exercise, and I do not like diet food. Do you like bacon? And then, did you know you can have pork rinds? Now I have a wall chart with the food on the wall in my office. It was a student project, and she made a research poster using the food list. I will point up to the foods that you can have, and people are surprised – I can eat that and lose weight?
Dr. Sue Wolver: Can I get a copy of that poster?
Dr. Eric Westman: Absolutely. I send it to folks and they print it out on their color printers at home and it is very helpful. It also has the no-no list on it. People now self-diagnose. I come in, and you are at the door, and I do a lot of teaching. I have this flow sheet, it is a hard copy. They wanted me to get rid of that because it was not computerized. I said, no, I need my flow sheet I teach from. If there is weight loss, two pounds per week since the last visit I know they are following it, at least some of it. If there is no weight loss, I know they are not really following it. People know they are eating carbs. It is very rare they do not, but they might not tell me or write it down, and so people look up at the wall chart, and they say, I think I know what is going on. I am having nuts. Nuts are in the no-no box. It takes time to sleuth out if they are hidden carbs. If people are honest with themselves and they do not have addiction and denial. That chart has been really helpful in having people diagnose themselves, figuring out what they are eating that is causing them not to lose weight.
Dr. Sue Wolver: I think you glossed over it a little bit. I think it is so important to reiterate that a low-carb ketogenic diet truly reduces hunger and cravings. Honestly, I do use weight loss medications in my clinic. I would say they are absolutely as effective. A ketogenic diet is an appetite and cravings suppressant as the weight loss medications.
Weight loss medicines and their side effects
Dr. Eric Westman: Without the nausea and stomach pain. Let us switch to that, because it is on everyone’s mind these days, hopefully not our patients. Although I will see people come in for the first intake, already on weight loss medicine, and they are having side effects and they say, but I am losing weight. I said, but you are sick all day long. My friend who does semaglutide in every form, he hands out a prescription for an anti-nausea pill, Zofran. That is the traditional doctor teaching. You give a medicine, and when you have a side effect of a medicine, you give a medicine to treat the side effect of the medicine.
How do you handle a first person and they do not know what to do and they are already on weight loss medicine from their doctor?
Dr. Sue Wolver: If they come to me initially and they have not been on weight loss medication, I always like to try lifestyle first with really intensive lifestyle training. I tell them, If you reduce the carbohydrates in your diet, not only do carbohydrates put weight on you, but they also make you hungrier and they make you crave more. If I put you on medicine today and you change your diet and you come back in three months and are losing weight and your appetite and cravings are well controlled, which did it now you are kind of stuck on that medicine long term. Let’s try, let’s see how you are doing. I do tell them if they have unmanageable hunger and cravings or are really struggling to stick to the eating plan, then I will consider adding medication.
Dr. Eric Westman: You mentioned the side effects. I still remember when Dr. Bob Kushner, who is at Northwestern, was like a kid in a candy store with these medicines. Finally, he’s a medicine guy. Even so, within the obesity medicine world, there are folks who focus on diet, there are people who focus on medication, and if you are a researcher, you are doing medicine research because that is where the money is. He got up for the pivotal trials for the weight loss medicines that everyone was talking about, and he said, there are a few side effects, but it was 30%, so one-third of people drop out because of side effects. I am like, I do not want to be involved in this. Imagine seeing a hundred people and a third of them are mad at you for using something that has terrible side effects. So why not try something different? I will explain that we have diets, we have prescription drugs, and we have very low-calorie diets where you just drink bars and shakes for three months. I do not have one of them, but they are available in our area. Why not start with a diet that is prescription strength, it is as strong as these other diet medications. Someone recently came back and said I just cannot do this keto thing. I need the medicine. I said, tell me what you are doing. I make people write out or ask people to write out what they are eating and drinking when I come in. It takes me one minute to know what they are eating and drinking because they took time to fill in the form, and I look at it. So it says sandwich with keto bread, and keto wrap, and keto ice cream, and I said, you are not doing the keto diet that I recommended, and remember this? And I point to the wall, I do not want you to have keto products. That is not prescription strength keto.” She looked up and said, I made a mistake, and those things are so expensive anyway. She did not do keto, not the way we teach it. The method of keto is one of the first things I ask someone who comes in. I’ll say, who are you following? What type of keto diet? What brand? What influencer are you listening to? Do they use the keto diet for what you are trying to accomplish? If someone is putting butter on their steak and they are slamming in 150 grams of fat a day and they are in the gym, they are not using it for treating obesity and diabetes.
Let’s say someone is coming in and they are on weight loss medicine and they are losing weight, but they are having side effects. How would you handle that?
Dr. Sue Wolver: It depends on what side effects they are having, and what they have done to mitigate the side effects. I will not ever hand out an anti-nausea medicine. Occasionally people have a little bit of nausea in the beginning. You want a nausea pill when I do not hand them out. But if you come back to me and say, I am having a lot of nausea right now, it is a weekly long medication, you do not want them to be nauseous for a week. But if they want a continued prescription for the nausea medicine, to be on the weight loss medicine, I said, this isn’t the right medicine for you. I am not going to accept you being nauseated. You have to feel well, otherwise it does not make sense. Not only that, losing weight is not the be-all and end-all. I think in the way we practice medicine, getting healthy is the goal. I call myself a weight loss clinic, but that is only so patients can find me. The minute they walk through the door, I tell them I am a health clinic. If I put a metabolic health clinic on the shingle, nobody would know what that means. That is my goal, to get people healthy, get their vitality back, get them to be able to exercise and live the life they want to live, and when they do all that stuff, weight loss is the side effect of that, it is the byproduct. We never want to focus on the scale. It is important to know your weight so you can gauge how you are doing and be reflective on whether you are doing the things you need to do to achieve that, but it is only one data point.
Dr. Eric Westman: We are in the same organization called the Obesity Medicine Association. These are doctors who do this for a living, and we have to use things that work, otherwise no one comes back. So I’ll explain that. If they are referred by their own primary care PCP or family doctor, I will remind them, remember, your doctor sent you to another doctor, so I am a specialist. I am using things that will work. Other approaches that I have seen come and go, the very low-calorie diets, you lose a lot of weight, but it is not sustainable. I can foresee a similar train wreck that is going to happen, that people will lose weight with the medication and then not go back, be lost to follow-up, and no one will teach them to stop eating junk food or they are addicted to the carbs and then they will regain all the weight. The response I have got from people is that we will treat them then.
I remember my teachers said, imagine someone’s lifespan and if you teach people how to lose weight and keep it off using the same method by food, by a low-carb keto diet over their lifespan, they will never have to lose the weight again because you taught them how to do it and sustain it. It might be a little slower, but in the long run, it is a more wise, rational way to do it.
Dr. Sue Wolver: I honestly think because of metabolic adaptation, which means that losing weight is not healthy if you are a caveman. Because that means something is critically wrong, you should not lose weight. So our bodies fight us to regain that weight because survival is the most important thing and we still have that same kind of brain. As we start to lose weight, our metabolism slows down, and our hunger increases. I think eventually that is going to push against a lot of these medications.
Unless you learn how to eat to reduce your hunger and cravings, and what to do when you get hungry and cravings, I consider weight loss a learned skill. It is not just about food, it is also about learning how to change your mindset, and your relationship with food. If you think of yourself as the best Ferrari that is out there, you would not want to put junk in it. We do not put junk in our cars and expect it to run, but we put junk in our bodies all the time and think, why am I breaking down?
So teaching that mindset and, you know, teaching people about, you know, people are making money off of luring you into eating this junk food, so you are lining their pockets while getting sicker. And the more you start to realize that, the more you start to look at that food in a very different light. My real goal is to get people to eat the foods they love that love them back.
Dr. Eric Westman: I love that. It is the food that is the problem. Doctors do not know much about food. It is chilling to watch this trainwreck. Companies now are doing studies that after a couple of years, they are randomizing people to placebo or regular shots and when people put on a placebo without being told how to do it by the diet, they are regaining the weight. That would just keep people on their shots forever.
Step back, that same effect is achieved by a keto diet. You do not need the drug to affect all of these hormones. I sit back and reflect on why hasn’t some researchers come and drawn the blood of our patients to figure out why it works. They are going to discover something, that studying the brain and the regular hormones that you can test, probably going to find something totally new or you will find that all of it changes favorably because the hunger goes away, you start fat burning, you are eating less, and you have more energy typically.
What are you excited about going forward about the research or areas? I am probing into other medical areas like the glycogen storage disease getting better, these orphan illnesses, the ELAD (extracorporeal liver assist device) patients that I have had, that their heart failure is so bad they have implanted pumps in their chest. You have to be very careful about the vitamin K and the anticoagulation with those folks. Any other interesting areas? You published on fatty liver.
Facts about fatty liver and the diet
Dr. Sue Wolver: One of the things that is known about fatty liver is you need more of a weight loss than you do to help start reversing some other conditions like diabetes or high blood pressure for fatty liver, especially if you have fibrosis. You need to start looking at a 7% to 10% weight loss rather than just a 2% to 5% weight loss.
Our patients we have studied with fatty liver, have had dramatic improvements and the fat in the liver seems to reverse very very quickly. Fibrosis, as you can imagine, is a more tough actual fibrous tissue. It takes longer but we do see it as well. Up until last week, there was no treatment for fatty liver other than by losing weight.
Dr. Eric Westman: I had a patient through the years who was an ultrasound tech and she had the ultrasound machine every day and she had a fatty liver so she just scanned her liver and within weeks it was gone. It was a mild form. So weight loss and especially a low-carb diet for weight loss fixes fatty liver. I am astonished it (fatty liver) is one of the main causes of liver transplantation now.
Dr. Sue Wolver: Number one in women.
Dr. Eric Westman: And it is all from the food.
Dr. Sue Wolver: Patients come to see me and they say I have a fatty liver, my liver doctor told me to come and then I tell them to eat this diet which is higher in fat than they are used to, isn’t the fat going to cause my fatty liver? It is really unfortunate that it is the same word. Then I tell them about pate and I am like you know pate – the stuff you put on the little toast? That is the fatty liver of a duck or a goose and they do not feed them fat – they feed them carbs.
Two important things. One we have not talked about is that a lot of things reverse or get better before any weight loss at all. Like my patient who was off 53 units of insulin. She hadn’t lost an ounce in four days, so it is not the weight loss that is causing the improvement in these conditions. I have had success with patients with asthma and they say the same thing. Patients with arthritis have not lost any weight, yet their knees feel better and they can walk. People say I want to learn about an anti-inflammatory diet. I am like, take out the inflammatory carbohydrates and you have got it.
Neurological diseases and cancer
Dr. Sue Wolver: You asked what else I am excited about. These low-carb ketogenic diets are where we should look for research. A lot of people are coming to me saying that they read something that maybe it is going to help with Alzheimer’s. So a lot of neurological diseases like Alzheimer’s, Parkinson’s disease, multiple sclerosis, migraines, and of course like you said one of the first use cases for a ketogenic diet was for seizure disorders, so there has always been some type of neurological signal there. We call Alzheimer’s disease “type 3 diabetes,” and so people are coming to me to try and see if this is going to help them and certainly there is emerging evidence in a bunch of neurological types of diseases. So many other indications other than just neurological diseases. Cancers love sugar. What is a pet scan? To look for cancer. We put radioactive tracers on sugar molecules and the sugar molecules go to where the cancers are. So they are using ketogenic diets as therapy along with some conventional chemotherapy to improve remission rates. A lot of this is still in its infancy but there is something very special about a ketogenic diet. There are some very active molecules that do a lot of things that we do not really completely understand at this point.
Dr. Eric Westman: It is like a smartphone – when it is low on energy it goes into safe mode. When a mammal doesn’t have energy, it starts burning its own fat. What evolutionary pressure would keep organisms from self-destructing all the time when there is no food? Alzheimer’s, best I can tell, has about a 20-year gestation period where you want to start making changes before you get symptoms. If you have a parent who has Alzheimer’s, you want to take action now. The best research, the biological research that is being done, is on the keto diet for Alzheimer’s. There aren’t clinical trials of reversal and all that yet, but insulin resistance is coming out like this strong signal for Alzheimer’s. So that would be a time to take action. I would say it is not harmful to not eat carbs ever. You do not ever have to eat carbs. Jeff Volek recently at a meeting reiterated that. He said there is no evidence that being in ketosis is harmful. That made me reflect back. The only paper I did with Jeff Volek was studies when we were trying to look for evidence for low carb diets. We published this in 1998. Reflecting back, where were the studies that showed a low-carb diet was bad? There were none. I did not even remark about that. I had a friend who said, you wear body bags if everyone is doing Atkins and it is killing you. There should be body bags in the ER, like Covid. But there were never studies. It was all just a belief system, a paradigm view, or you could say it was just a limited view. And now we have new knowledge.
For Alzheimer’s, you want to take action as soon as you can if you are at high risk for that, and for cancer. A couple of weeks ago, someone came in with a metastatic thyroid anaplastic thyroid carcinoma. He was a seeker. He had local university therapy, then went to MD Anderson Cancer Center and got onto another drug. He had a stable disease, which I had to retool on this. It is not stable, it is very aggressive. I go looking on PubMed and anaplastic thyroid carcinoma – keto came up and I clicked on it. Two studies popped up. There is a Harvard University surgeon who does an animal model and shows that there is a reduction in growth for this tumor in the animals. I emailed him the next day. He says, Dr. Westman, I have heard of you! I know your work. My wife went to a meeting, heard you talk, and went on keto. It changed my research. His area as a surgeon is this aggressive type of tumor. He said we know this tumor is very glycolytic, meaning it uses a lot of glucose. Getting back to that PET scan, labeling to find metastases for cancer with that glucose molecule, it is going to be interesting to see. I cannot keep up on all of these things, but, and that is not proof that this guy is going to be better. I will never say you do not need your traditional therapy. You always want to do traditional therapy with cancers. I do not have the evidence to say you do not need that, but I bet there will be specific tumor types where using keto as an adjuvant will be helpful. Who knows? Maybe as the only treatment, but we are not there yet. It is exciting to see. Jeff Volek is doing a lot of cancer research now. Dr. Nehs is the researcher at Harvard University. I’ll go to PubMed, the database where published papers are, to see the latest information, and I hope it is going to explode. So this tumor has been stable, they are following it, they are treating it, and Dr. Nehs said, I have some patients who seem to be outliving their prognosis for these tumors. And the first time I saw that was with the glioblastoma multiforme, the GBMs.
Dr. Sue Wolver: That is a brain tumor.
Dr. Eric Westman: There was a presentation where just about everyone had this brain tumor and, best I can tell, finally people succumbed to it. If you could add a year of life to somebody, that would be huge.
So what is your take on cancer? Have you had any patient experiences?
Dr. Sue Wolver: I get a lot of people who have had breast cancer, who are sent by their oncologists because they know obesity is a huge factor in recurrence, and actually initial breast cancers as well. I cannot say that I have studied it and say that it saved anybody from metastasis. It is hard to know the null effect. You do not know what would have happened if they hadn’t changed their diet, but most people feel better and can exercise more. Exercise is also something that helps reduce the rate of recurrence. People feel better, and isn’t that really what it is all about?
Dr. Eric Westman: I think our job is to help people have happier, healthier, and longer lives. If you live a long awful life, if we give people more terrible years, that is not my goal.
Dr. Sue Wolver: That reminds me of something that I do with patients all the time. I do not know, can you see that? The curve is going. This is the way I think most of us live our lives here, where every day you are kind of sicker than the day before. Nobody wants to live their life like that. This is the way people want to live their lives, the top line here is where you are well, every day you feel great until the day you drop dead. What is in this triangle right here as far as I am concerned, of course, genes play a role, is lifestyle, diet, and exercise, getting good sleep, managing your stress, all of those lifestyle things I feel are the difference in those two lines.
Dr. Eric Westman: When you look at other people who have had long healthy lives, you want to be the Jack LaLanne who is exercising every day in his late 90s rather than someone crouched over in a wheelchair.
Summary of experience with the low-carb diet
How would you summarize your experience with the low-carb diet? And how do people find you if you want more patients?
Dr. Sue Wolver: We always love patients, and we find some way to make it work. The low-carb diet has transformed my life, the lives of my patients, and the lives of friends and family. They see what we are doing and they adopt it as well. People feel better. I am healthier now than I have been in my life and I credit that with the way I eat and exercise.
You can do this on a budget. A lot of people think that eating a low-carb diet is so much more expensive. It doesn’t have to be. There are lots of resources on how to do this. Shopping at the dollar store. So there are definitely ways to do that. Even if you think it is more expensive, I mean, it is pay now, pay later, right? You do not want to pay with your health because oftentimes there is no going back once some of those things happen.
Where to find Dr Sue Wolver
We would love to see everybody. You can Google VCU Medical Weight Loss. I am only licensed in the state of Virginia, so I can only see people in Virginia, but we do telemedicine. We ask that people come to see us for their first visit, and then we can do telemedicine after that. We do a free informational session once a month, and if they call 804-828-0761 and get set up for the informational session, they will learn a lot. We talk about the disease of obesity and the treatments both medical and surgical.
Insurances, Medicaid and Medicare
Dr. Eric Westman: Fantastic. You are in a university system, Virginia Commonwealth University in Richmond, Virginia. This is a growing trend because it works. Back in my undergraduate days, I read a book called The Scientific Revolution and how paradigms shift. It is a slow process. Paradigm shifts is that the new way of doing things fixes things that the old way of doing things could not. Techno people like Dave Feldman who is doing the cholesterol study looks at me in disbelief and says why do doctors not change? We do something new every year, there is a new code that comes out or the computer is so evolving.
We have a select few people who will follow the herd mentality perhaps, but if you want results and want to fix people just by using food, this method is fantastic. It changed my life. I had no idea I would be prescribing pork rinds to people who reverse their diabetes.
So you are in the insurance pay system.
Dr. Sue Wolver: We are. We accept all insurance in the state of Virginia. We accept Medicaid, and Medicare. We even have a financial assistance program. That is one thing that sets us apart from many of the others is that we take insurance and we are both internal medicine doctors. And those doctors are used to taking care of very sick patients with a lot of medical problems so we are very comfortable with all of the medical problems people come to see us with.
Optimism
Dr. Eric Westman: Well said. There are some obesity medicine doctors that kind of skim. There is no medical issue that I will say is too complicated to change the food, to cut the carbs, it is you might need more monitoring. Even then I took someone off insulin watching the blood sugars on my phone. With just a text a day
Are you optimistic that the medical world will come around, so to speak?
Dr. Sue Wolver: I think it is happening and I would be remiss if I did not say that you are one of the major reasons why that is. When I met you 11 years ago I did not know that you were quite as optimistic. I think the low fat diet is dying its death. It did not work. It made people hungry. The Journal of the American College of Cardiology in 2020 came out with this big reassessment on saturated fat. I am not sure a lot of cardiologists have read it but it affirmed what I am doing and I thank you for it. Most of the world should thank you for it because there is a different way and I think the tides are turning.
Dr. Eric Westman: It does take some perspective, though. There is an old saying that in
the scientific world, things change one funeral at a time – meaning that people are entrenched in an old way. The internet and social media are both a blessing and a curse but I think effective information will be found and people will not hit against the negativity that has been there
all our lives. That is my hope. I am thrilled to see how you have been successful through the years and look forward to seeing you again very soon.
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