There are lots of things that happen early on when you start a keto diet. Carb creep is one of them. I’m learning that a lot of the long-term issues have to do more with mindset than the actual list of foods itself, so please take advantage of the ability to watch classes to help with all the mindset issues. I give people permission not to eat so much, which seems kind of silly, but that is one of the real issues that we have. We’ve been allowed to have a bounty of food around pretty much all the time.
What is Carb Creep?
Let me go back and give a little perspective, a little story. When I got involved with this (keto and low carb), a few of my patients did the Atkins diet. They lost about 50 pounds, and it was like lightning striking in my clinic office. Not many people lost weight. I was working at the Veterans Hospital in Durham, so I was curious and I followed this signal of a couple of people who had success. Like a lot of doctors, this is all new to me, even though I’ve learned that it’s been around a long time since then. What I wanted to do was to figure out a way to study this. I had concerns about safety and what would happen long term, just like a lot of doctors are having as they wake up to it today.
One of the things I decided to do was to leverage my travel for my work to visit doctors who were using low-carb diets. As you can imagine, in 1998 I went to the bookstore and it wasn’t like now where there are so many keto books. There were just a few low-carb books, and I remember Protein Power stood out to me. It was written by two doctors in a clinic in the Midwest, Mike and Mary Dan Eades. I read the book, and it was interesting. This was all new to me, I never got any training on this issue of weight loss or nutrition in my medical education, and that’s pretty much still true today. Protein Power said that you would stay to 20 grams of carbs, basically forever. When I tracked down the Eades, because I wanted to visit them, they had no clinic. They were already retired and I couldn’t visit their office. So, I went to the next book on the shelf and it was Dr. Atkins’ diet book; it was the “new” diet revolution because it was rewritten in the 1990s. (The original was published in 1972.)
I visited Dr. Atkins in New York City. I wrote a letter and he called back and said, “What do you want?” and I said, “I’m interested; your diet seems to have worked for a couple of my patients.” If you can imagine he responded to me like, “So, I’ve been doing this for 30 years!” I said, “That’s all well and good but where’s the science? Where’s the data?” He said, “It’s all in my book.” By this time I had read his book and was ready with the statement back saying, “It’s just anecdotes; it’s just anecdotal evidence.” He said something like, “Why would I want to do research? I already know what the research will find. I’ve been doing it for 30 years.” He either had a point or was overstating things. He broke the ice and said, “Why don’t you come to my office in New York City?” So, I went up for a night and told him, “This is all interesting, it seems to work fine, but you need to do some research and here’s a proposal. I’ll go back and do it at Duke.” That’s how I got started in this.
When I went to visit Dr. Atkins and when I followed up with Dr. Mike Eades (later I was able to meet him), it became clear to me that they weren’t doing what the book said. The books all said to do the first phase, 20 grams of total carbs, not net carbs – the doctors were all using total carbs, which is what I teach you and what I’ve used in my clinic, it’s what I studied. The doctors were going much longer than those first two weeks. In Atkins’ language, it’s called the induction phase. Traveling around, I met Dr. Ron Rosedale who had worked with Dr. Eades and he was in practice in Boulder, Colorado at the time. I went and reviewed charts, wrote a paper on diets and aging with him, and got it published. I visited Dr. Mary Vernon in Lawrence, Kansas, who had a low-carb practice and looked at charts and they were all using 20 grams as long as the patient needed that. The idea of a short-term induction phase was not what the doctors in the clinics were using. I just want to reiterate that there’s no concern about staying at 20 grams or less if you’re feeling well. If you still have weight to lose or diabetes to fix, staying at 20 grams or less is what the clinical doctors who used these approaches in the late 1990s did. That’s what we did in our studies and that’s what I’ve done with people at Duke.
I’ve had people on 20 grams or less now for 15 years since when we opened our clinic at Duke. I wanted to tell the story of how I had traveled around to learn and then come up with our own research proposal and then we studied over and over and over the 20 gram or less over six months or over a year to generate the evidence in scientific basis that this is a healthy thing to do. It’s therapeutic and fixes lots of different issues. It pretty much fixes all the chronic medical conditions that internists use pills and shots for. I’m an internist – internal medicine first, then obesity medicine and keto medicine doctor second and third.
In the Atkins world, I learned from nurse Jackie Eberstein, who worked with Dr. Atkins for 30 years. The Atkins language was “carb creep”. I had a research employee who spent some time deployed in the Middle East and he said there’s a saying that if a camel gets a nose underneath your tent, it’s just a matter of time before the camel’s going to get into the tent. Carb creep is the insidious creeping of carbs back into your diet. You don’t want to fall victim to the carbs creeping in and the reason for that is that one carb leads to another, which leads to another. You might even be getting into the mindset of, “I’ve seen some results, this little bit won’t hurt me,” and then you find that it does throw you off and it’s hard to get back on plan. I wanted to give you the background perspective that staying this low on carbs is fine; you don’t have to be eating carbs and sugar.
How Does Carb Creep Happen?
The way carbs can creep back can be as simple as feeling a little more confident or overconfident and not realizing that a little bit of sugar can derail you. Not keeping the house clear of the carbs; they creep in. I’ll ask people, “Who bought that?” At first, if you’re really having trouble staying away from eating sugar, just don’t have carbs in the house. If you have carb eaters in the home, you keep the carbs in a separate place up high, where they’re harder to get to. I had one couple who arranged that the husband’s carbs would be kept in the trunk of the car in the garage, so it made it more difficult for the person staying away from carbs to be able to go and access the carbs.
Other times, other people might give you the, “Oh, just a little bit won’t hurt.” We’ve learned that a keto diet works best if you’re strict 24/7. There’s no research evidence about a cheat day. I know it’s out there and people ask me about it all the time. No, when you’re fat burning, what Jeff Volek says (Jeff is a researcher at Ohio State), is that the ketogenic state is a fragile metabolism that can be thwarted or knocked off by just a very small amount of sugar or starch. Our best advice is to stay as strict as you can. If you have some carbs, you get right back on – not the next day, but at the very next meal.
It’s going to happen where you’re getting a soda somewhere and they accidentally give you the regular soda, not the diet that you ordered, or you may be tasting something and you didn’t realize there’s sugar – that’s not a big deal. Remember, it’s the total grams of carbs for the whole day. Staying under 20 will probably keep you in ketosis, and a little bit here and there is not going to derail things.
Ketosis Reduces Hunger Automatically
The other thing is to let the hunger go away, let the fat-burning relieve you of the urge and need to eat so much. This is a common thing I mentioned at first with someone who’s doing long-term, but even upfront at the beginning, I’ll see people who are still stuck in the old mindset of, “I’m supposed to eat three meals a day and I have to have this, I have to have that.” No, no, no. This is a big mindset issue. I know there’s a lot of preemptive eating; I hear, “I was going to work and I can get hungry at work, so I was going to eat something so I prevent that.” No! Bring something along. If you’re hungry later, you’ll have something with you. Eating in the morning can make you eat more in the afternoon. I know it doesn’t make sense, but this is the observation that people tell me. Let the fat-burning work well so that your hunger is now tied to the need for protein, which is really what it should be, not the sugar cravings. I want you to get over the idea of three meals a day, because the amount of weight loss, if you’re trying to lose weight, is directly related to how much you’re eating. The way this (keto) works for weight loss is there should be an automatic reduction in your hunger, so then you eat less, and that is how weight loss occurs. It’s not magic. Weight loss occurs because you eat less.
Sam Feltham is a young man in the UK who did a diet study on himself, gained weight and lost weight three different times with three different diets at over 5,000 calories each. It’s a fascinating study on himself. The main issue is that, yes, you gain weight at 5,000 calories a day, even on a keto diet. He did three different diets, but the fascinating thing is he didn’t gain nearly as much on the keto diet as he did on the vegetarian, higher carb, and then the higher carb, low-fat one. Interestingly, that’s the state of the science; there are no comparative studies like this for different diets in a weight-gaining mode. It’s been published in a journal and I hope it will stimulate other people to do that sort of study to replicate it in more and more people. The main point is that, yes, you can eat too many calories and gain weight, even on a keto diet. The food list itself is a mechanism to get the hunger to go down, to have you eat less. If that’s not happening, you’ve got to work on some mindset issues.
The other paper I encouraged someone to write that got published was the carnivore diet. Was it a nutritious approach? Interestingly, the article was good, but I’m not convinced, nor was the author, that there’s great evidence to say that it’s fine for the long term because no one has ever studied it and published papers on it. It’s interesting to see everyone glom onto the latest trend when there’s more evidence for our approach where you eat when you’re hungry, have some veggies and greens and keep the carbs low.
Substitutions
If you’re noticing carb creep, substitutions are a good thing to do. If you crave pasta, there are all sorts of different pasta substitutions. There are other kinds of rice, like cauliflower rice. There’s an interesting fried cauliflower rice dish that I saw recently with someone who wanted more Asian cuisine. If you don’t like cauliflower rice just by itself, make sure you’re adding flavoring with it to give you the rice feel.
Testimonial 1
Esther: My story began a long time ago. Around when I was eight years old, I started gaining weight. The teenage years are when I started dieting and into my 20s and that is when yo-yo dieting was pretty much the course that I went. I tried everything – the Stillman diet and Weight Watchers (a metabolic diet that really ruined my health). In May of 2018, my brother and sister-in-law introduced me to the concept of keto and that it really has worked for people in their family and other families. From there I bought Gary Taubes’s book, Why We Get Fat, and that’s how I learned about Page 4 and Dr. Westman.
I started looking at videos, reading books, and seeing if the keto diet might work for me. In June 2019, I got to go on one of the keto cruises out there and met Dr. Westman, Amy Berger, and Jackie Eberstein and got to sit in on their classes and I learned so much more. From their wisdom and all the things that I learned, I found out that keto really is the way for me to go. I have well-ingrained insulin resistance, I had PCOS until I had a total hysterectomy at age 50, I have hypertension and hypothyroidism, and have just been overweight.
On November 16 2020, I joined the Keto Masterclass. My goal at that time was getting good health, making this a lifestyle, not a diet. The things that I have learned have just been amazing. My mindset has totally changed. It’s amazing. The control and just by having the simplicity of the food plan, all the modules, and the support from the team and Facebook, have just been totally amazing. My confidence is through the roof and my husband looks over at me and says, “Who is this person?” It’s been fabulous. Since learning about keto, I’ve lost about 35 pounds and about 20 of it since November when I joined the Keto Made Simple class. Thank you very, very much for all that I’ve learned and the support. Just because of the changes in my life, my brother, sister-in-law, and sister joined the February group for Keto Made Simple. I’m very, very thankful for everything that’s been going on. I would love to know more about what happens in the brain when you get a good sugar or starch rush. How does that trigger the hormone reactions that go on in your body?
Dr. Westman: There’s a lot more known about the feeling and what happens in the behavior of repeated administration of sugar. Sugar makes you want to have more sugar. Popcorn at a movie theater doesn’t turn off your appetite – you keep eating the popcorn! Dopamine is what we talk about in terms of the pleasure center; there’s a little spot in the brain called the nucleus accumbens, and nicotine and cocaine and all the things that give reward happen there. I think there’s more to it than that. Serotonin gets changed. What’s also fascinating is that there’s more serotonin in the gut than in the brain, so people talk about the gut being the second brain. Where does food go? To the gut. We’re manipulating all these hormones by what we eat. Still today, if I get a whole bag of jelly beans, a pound of it, I could eat it. I don’t let myself do that anymore, but dopamine is what we think of as the center in the brain where you get the reward and then you want to seek it out again.
One to two pounds per week is the general amount of weight loss I see with patients, and that’s the healthiest way to do it. Over the last couple of months, 20 pounds is perfect. I know a lot of people think that it’s not enough or always want it to go faster. Everyone comes in wanting it faster, but that’s right on track and well done. Keep it up.
Testimonial 2
Marvin: I grew up on a farm, so we just ate breakfast and coffee and dinner and lunch and supper; I got on that pattern real early in my life. From my earliest days, if I could have figured out how to drink water on bread, I would have done it. I didn’t really do a lot of sugar, but bread was really my thing. When I was in my 30s, I developed fibromyalgia and kept gaining weight. I noticed that anything that I did, I’d get hungrier after I ate. That was really a pattern that I saw for decades, that it didn’t seem like there was ever an end to hunger, and so I was constantly fighting with that.
A couple of years ago, the thing that probably triggered it was that I was pre-diabetic, I had slightly elevated liver enzymes, high blood pressure, all those sort of things going on. I got in a car accident and killed a moose. I look back, now I can see that really that was the stress that put me over the top and put me into diabetes. I went through a tough fall, didn’t feel good and everything. Exactly a year ago, I had a day where things were really obviously not going well, so I waded into the emergency room. I was at 680 mg/dL blood sugar (37.8 mmol/L), 14.5 A1c. Doctors keep looking at me like, why are you still alive? I spent a few days in the hospital, still at 300 mg/dL blood sugar (16.7 mmol/L), eating the way they told me to. A nurse came and it’s kind of funny how stuff works: in the end, she was the one who convinced me to do something differently. It started with “Don’t eat any fat, don’t eat any saturated fat.” I’m going, well, this sounds kind of strange. Then, “Don’t have any salt.” Of course, they think they’re going to keep you from having that heart attack that kills all the diabetics. She goes on for a while more, and she holds out her hand and says, “Just eat a handful of corn chips.” At that point, she lost me, there was no way in the world I could only eat a handful of corn chips. I was going to go to the bottom of the bag. I don’t care if it was a super humongo family size. I’m going to the bottom of the bag.
There I was then with a chronic progressive disease but motivated to check out what’s going on. I go on the internet and I find several people, including Dr. Westman. It really only took a few days for me to be convinced there has to be a different way. Long story short, a year later, I’m not on any diabetic meds, I’m not on any blood pressure meds, I’m not on any pain pills for the first time in decades, and I don’t even take my steroid inhaler for my reactive lungs that I was going to have to take every day for the rest of my life. I’m down about 90 pounds, all while being the least hungry that I can remember in my life.
My wife’s been very supportive. She was doing this to start with about the time this all hit me anyway. She was looking at going keto. I took the masterclass to almost unlearn some things. There are so many people out there with so many different ways and so many miracle things to eat and so on that I really appreciated Dr. Westman’s quiet demeanor. It’s very straightforward. There’s not a whole lot of complicated rules. When I see people doing all these fat bombs and sweet treats and all this stuff, it seems to me that they’re almost planning on failing. They don’t want to change their lifestyle, they just want to come up with a different way to do it that they still can keep the same thing. I tried some of those things and they don’t work for me. If I start those kinds of things, I don’t even just stop losing weight – I start gaining weight. That’s what’s so attractive about this; it’s very straightforward. That’s not to say it’s easy. Life is like a gauntlet of things to try and knock you out of your keto diet.
I feel so much better. Everybody looks at the weight but it doesn’t seem to me that the weight loss comes first. It seems to me first you get better first. You get healthier first. You feel a lot better, and then the weight loss follows along behind that. It’s more a sibling of those other things rather than the parent of those other things. Insulin is the father and the father of a lot of things. We have such an epidemic going on. As a state representative, it breaks my heart because I’m representing about three-quarters of my constituents who are Native Americans. A lot of them are poor and a lot of the kids are on the WIC program. I look at the way they’re metabolically unhealthy before they’re even old enough to go to school. That’s what we’re doing to those kids. I was one of about three chubby kids out of a hundred in my class and now, today, it looks like about a third of the kids are obese by the time they get to first grade. A third of people are supposedly getting diabetes by 2050 and half of the minorities. I go around my district and I look at all the fat livers sticking outside everybody’s shirt. I don’t think we’re going to make it to 2050. The thing is, we can’t afford to do it. Something’s going to happen, either the healthcare system is going to crash, the whole economy is going to crash, or we have to change ourselves.
It’s so amazing to learn that salvation’s not in a pill, it’s just eating differently. It’s really so simple. And yet, even when you do it, it sounds so unbelievable that people don’t believe it. A lot of people have asked me, “What’s going on?” They can see the difference, they can see that I move easier and so on. I tell them. I think we’re really in the information age and it’s a matter of getting information out there. But at the same time, it’s building credibility. I see a major swing, it’s just a question to me of when. We can’t continue on the course that we’re going on. I see so many friends and neighbors who are so ill and don’t need to be. I’m trying to learn, so that if I share information, I can share solid information, I can share what actually works. Not necessarily what I think might work but actual research-based information. I appreciate that about the class and Dr. Westman as well.
Dr. Westman: Wow. Congratulations on your success.
Testimonial 3
Kyle: I was a husky kid in high school. I’ve always been heavy. I’ve always struggled with weight. There’s a whole bunch of reasons that have been posited for it. I came of age at the same time that the McGovern hearings on nutrition, which led to the dietary guidelines, became the food pyramid that you see everywhere. I’ve been low fat, I did Weight Watchers, Jenny Craig, Nutrisystem, and all that crazy stuff. I had the best results prior to Dr. Westman on Jenny Craig. I’ve already joked that those little cat-sized tin cans of whatever they mashed into those cans were one of the six meals I had a day and I was “hangry” all the time (hungry + angry). It was a real struggle. In about 2008, I had tried Atkins. I was terrified at the prospect of the fact that all this fat was going to kill me. But now I have become desperate. We’ve got a lot of anxieties that we bring to our dance on weight loss. I believe a lot of that is because we’ve been working backwards from the notion that animal products are bad in terms of saturated fat and all the things I was told to studiously avoid.
In 2016, I saw my GP and he had officially diagnosed me as obese. I was just like, that’s not me. That cannot be me. I mean, I’ve struggled my whole life, I’m desperate and I’ll try anything. I work at Duke on web development. I was going through some videos and saw one of Dr. Westman’s videos where he had given a talk that was geared towards scientists and a medical class of people well above my pay grade. I thought, look at this. This is interesting. He has his characteristic understated manner, which ironically got my interest because there are lots of shrill voices out there telling us what we should or shouldn’t do. I muscled my way in on the nine-month wait list. I got in, we had the conversation and, lo and behold, within three to four months, I had dropped the majority of my weight. I lost 60 pounds.
I know people get really wrapped around the axle on weight loss. Sorry to tell you I’m a guy and we guys lose weight more quickly. But the point isn’t just the weight loss. Other things started to happen. My skin tags went away. Things I was not expecting to get better. I thought I had arthritis in my knees and I like to run and I do exercise because I enjoy it. I’ve been able to get back to that and the pain is gone. A whole lot of issues had cleared up. I do have a special message for the people that are out there struggling. I know you want to see more weight loss on the scale, I empathize; I don’t think that’s irrational at all, but I do want to say we’re talking about a better way of living and eating. If you give it time, your body will miraculously snap together. Early on when I lost weight so rapidly I had a lot of loose skin. Now, my skin’s tightened up because I’m just giving it time. I’m going to be four years low-carb in the summer.
I started to check out other ways of doing this. I like that Dr. Westman and Amy Berger are very good about not saying do this, don’t do that. They want to hear you. They try to talk with you about what you’re thinking and why. They never say no, definitely don’t do X. But there is a protocol. I would just say, lean in there. Dr. Westman has seen over 10,000 patients, a huge number of people. Amy is very active in the community and she’s got a great non-crazy way of thinking about nutrition. We’re taking the food pyramid and we’re flipping it. We’re not having six to eight hangry meals a day. We’re just having to eat till we’re full. I am now 75 pounds lost; I range plus or minus five pounds, but I don’t weigh myself in a crazy way. Thank you, Dr. Westman, for the clarity of how you present this, your common sense, and your understated tone.
Watch the full video here.