It’s my great pleasure to introduce my colleague in crime – I mean, in nutrition! – at the AYLA (Adapt Your Life) membership, Amy Berger. How are you doing, Amy?
Amy Berger: I’m well. How are you doing?
Dr. Eric Westman: Good. Great. What we’re talking about tonight is so controversial that we need to be on the same sheet of music. If Amy’s giving responses, I want you to know that I’m dubbing her to be able to pass on that knowledge. In this conversation, we will first talk about vegetable and seed oils, then about artificial sweeteners.
Vegetable oils
Dr. Eric Westman: To preface all of this, I’m a critic of research. And I’m not saying this to toot my own horn; it’s just that’s my training. I’m trained in what’s called evidence-based medicine. The first society I was part of, the Society of General Internal Medicine, is known as the critics of the medical world. Way back in 1990, what’s known as evidence-based medicine today, started as how to critically appraise the medical literature. You learn how to take apart studies and tease them apart and see whether the conclusions match what they put in the paper. It can be so bad that the conclusion has nothing to do with the data they presented. Amy and I are critics of research, not promoters or pushers of the research that someone does. You have to understand, as a researcher, part of your job is to promote or advocate for your own research. If a news outlet wants to talk to you about your research in mice, you’re going to talk about your research in mice. Then the news outlet might even ask, “Does this apply to humans?” And the researcher might say, “Yes, it might.” I’m going to be the critic to say, “Not in humans. I’m really worried about this. I don’t think we can apply the keto metabolism in animals to humans because humans are very different.”
There’s something called the hierarchy of clinical evidence. You can have an anecdote – for example, Mr. Smith did a keto diet, he’s a bodybuilder, it worked for him, and now he’s teaching everyone what he did. Well, that’s okay. But you want to be careful – if he’s doing it for a different purpose, then what he’s teaching might not be for you. That’s an anecdote. Then you can follow people over time, but it’s not an experiment. That’s what we will be talking about here – animal studies that you can’t say apply to humans, and then also human studies that aren’t experiments. There are always different issues at play. They’re called confounders or other factors that might be involved. An association doesn’t mean causation. You want to look: Is it a human study? No? Well, then, it doesn’t apply. Be strict about it. Then: Was it just an association? An association does not prove causation. You can be persuaded by the smooth tongue and the orator but you want to make sure there’s data. Those are the three things: human studies, experiments, and being careful not to be hoodwinked by a great speaker. Any other thoughts, Amy, about these studies?
Amy Berger: Biochemically, looking at these oils, the reason there’s a lot of pushback against them is that their chemical structure is such that when you heat them or they’re exposed to light or air, they oxidize – meaning chemical reactions happen to the fats in these oils. Certain reactions don’t happen to a fat that’s more saturated, like lard or tallow. Every fat and oil is a mixture of fatty acids. Even beef, even bacon fat, has some polyunsaturated fats (PUFAs) in them. Even coconut oil has a teeny, tiny bit. These things are unavoidable. You can avoid seed oils, but you cannot avoid omega-6. Even grass-fed beef has some omega-6.
You’re a doctor and you’re a researcher. You emphasize, “Show me the data.” For me, I’m more like, what do I tell someone to do that’s going to get them the result I want to help them get? And you do this all the time, too, with patients. You have over two decades – I have nine years or so of experience – helping people get the results they want. I don’t know how many thousands or tens of thousands of pounds your patients have lost, reversed type 2 diabetes, reversed PCOS – all those wonderful things with no emphasis on avoiding these oils. So, whatever may be true or false about these oils, we know that you can include them on a low-carb diet and still get the results you want.
Getting back to the research, I’m not denying that maybe the rodent research does look bad, but what we do not have, what has never been done, is research comparing two low-carb or ketogenic diets – one that’s very low in these seed oils and one where nobody cares and they just eat their regular ranch dressing, their store-bought blue cheese, and they’re frying in canola oil. We never put those head to head, so we don’t know if it’s better to leave them out or not.
Going along that line, we also don’t know if adding those oils in the context of somebody who has a low-normal blood sugar, and low-normal insulin – a healthy person – versus including those oils in the diet of someone who’s hyperglycemic and hyperinsulinemic, which is over 50 percent of the US population right now. We just don’t. You say this all the time: we don’t know if what applies to regular people (on a high-carb diet) is the same is true of people on a low-carb or ketogenic diet. Maybe it is, but maybe it’s not. We don’t know.
Dr. Eric Westman: Great points. I’m not persuaded by biochemical oxidation. I’m just not. The years of telling people to lower carbs without regard to the oils works. I think the onus, the burden of proof, is on someone saying that it’s a problem to say that what we do doesn’t work or you can do better. I have to say that I am getting a little snobby; someone has to show that it will improve what we’re doing before I sign on to it. Yes, we need to be doing our research too, but this isn’t one of the big things I’m going to do to start with. One talk I attended mentioned dose-response. I’m thinking even if you do have vegetable oil or a store-bought salad dressing, it’s such a small amount compared to what a normal American eats with all the processed foods, maybe it’s not an issue for our folks because they’re not having much of it at all.
I have seen one poster where my teacher, Stephen Phinney, was arguing at the level of the membrane function and structure, that you could alter the omega-6 and omega-3 content in the food of a rat or mouse and then the biopsy membranes and the membrane content was different, therefore the function is different and it’s bad. You have to do a lot more research to take that from (animal) science to human application. And yet, I was trained in how to do drug development and how to get a drug approved for FDA trials, and that’s a high bar to reach. The information about seed oils and vegetable oils is nowhere near that. If a doctor is going to wait until you have FDA clearance for a drug, I think I need to wait until I have a lot of evidence before I say something to my patients (about these oils).
A lot of the people saying these kinds of things are not taking care of patients. They’re trying to find the best diet in the world. One doctor even at a meeting – he was not a practicing physician but he’s a doctor – said everything causes inflammation, so he doesn’t eat anything, he just fasts. That’s ridiculous because if you don’t eat anything, you’ll die. Steve Phinney says you need some inflammation, otherwise, we’d all be bleeding. You need a little bit of inflammation – not too much, not too little.
One of the best videos I saw was an interview that Dr. Bret Scher did. He interviewed three or four different people, and one of the interviewees said it’s nothing, don’t even talk about it. That’s my position. Then there are people in the middle of the road, but no one cites any high-level clinical research to say that vegetable oils and seed oils are a problem in humans. We may all be correct. This is often a solution when there’s a lot of controversy, then we’re in a “heated agreement.” When I looked at the studies themselves, these relative risks were about 1.2 and 1.1. Relative risk means how much risk there is when you look at the consumption of vegetable or seed oils compared to not consuming them. That’s such a small change that most evidence-based medicine doctors don’t think that it is real. Often, you can see what you want to see and even though they’re statistically significant, these relative risks or hazard ratios (depending on what study it is) are so small that even though the conclusion is “statistically significant,” the practical reality is it’s not clinically significant. There’s a big difference between statistical significance and clinical significance and relevance to a patient in the real world. I don’t worry about the vegetable/seed oil issue at the consumption level that we recommend, which is going to be very, very low, or you’re going to get it from natural foods, natural sources.
Amy Berger: I have a lot more to say that I think is related more to what this means for me. When I’m sitting down at the dinner table, what am I supposed to eat? You hinted at it in that just by adopting a low-carb diet, most people are going to decrease their omega-6 intake anyway because we’re not eating a lot of the processed packaged foods that contain it, like Ritz crackers. That buttery feel – that’s soybean oil. With Oreo cookies, the cream includes soybean oil. It’s all soybean oil. Cookies, crackers, pastries, all the frosting, all the pre-baked goods, even ice cream. It’s also in fried foods at restaurants, which we’re not ordering because they have breading or batter. We’re not eating any of that, the deep frying oil.
What are seed oils? We’re talking about liquid vegetable oils, things like cottonseed oil, soybean oil, corn oil, and canola oil. Some people would include olive oil and avocado in this. I wouldn’t because those oils are primarily monounsaturated fat. We’re talking about oils that are high in omega-6 fatty acids, and all animal fats are relatively low. They do contain some omega-6, but lard, tallow, and butter are relatively low in this omega-6. We’re talking about those liquid oils that you pour into the pan.
I think the main sources of this omega-6 or of these seed oils in keto the way we do it is probably going to be mayonnaise, salad dressing, maybe if you’re buying the regular salad dressing from the store, and nuts and seeds for the people who eat nuts and seeds. That’s going to be the main intake so by avoiding all that other stuff, we’re eating less omega-6 anyway.
There are two other points I want to make. You were saying that what happens in a test tube or what happens in rats isn’t necessarily what happens in humans. I think this is true of these oils, but also, what kills me is when people want to scare people away from charred meat – blackened meat or barbecued meat – that humans have been eating forever and ever, cooking over an open fire. The compounds that are supposedly harmful in the charred blackened meat, advanced glycation end products (AGEs), we know are harmful when they form in your blood vessels and in your tissues, which is not the same as eating a steak that has char on it. Ingesting it and it going through your digestive tract is not the same thing as that biochemical reaction happening in your tissues. We could probably say the same about these oils. Maybe it’s not the greatest thing to ingest these oxidized oils, but those chemical reactions are very different from those reactions happening in your body. If you want to err on the side of caution and go low in those oils, you can. If you want to pay seven dollars a bottle for avocado oil salad dressing, go right ahead.
The final point I want to make is that Durham, North Carolina is not exactly a wealthy place. There are pockets of wealth here, but you see a lot of very economically disadvantaged patients. If we set the bar at not only do you have to stop eating bread and rice and potatoes and cereal and fruit and everything you’ve eaten for the last 50 years, but you also are no longer able to eat your Ken’s ranch dressing or your Kraft blue cheese or whatever that’s $1.99 at Walmart. You now have to spend eight dollars for mayonnaise. That is a deal-breaker. It is a deal-breaker for some of the people who could benefit the most from a ketogenic diet. And they can benefit without avoiding those oils. That is putting up an unnecessary roadblock. People cannot afford that stuff.
Dr. Eric Westman: We want to only focus on things that are really important.
Amy Berger: If you don’t want to use those oils, don’t use them. But we don’t want to scare people out of even trying keto by saying they can’t have them.
Dr. Eric Westman: Just to show that our position is different from people like Maria Emmerich and Kristie Sullivan – these are not physicians, they’re PhDs or other types of researchers – it’s interesting because MDs are very practical. They do things that have to work or the patient doesn’t come back to them. A PhD often will argue the number of angels that will fit on the head of a pin. They’ll worry about things that are so minor in comparison that someone who doesn’t have the clinical training and clinical experience won’t know what’s really important.
Maybe all you want to do is teach that if someone says there’s a possible harm, you say don’t have it; our program is the healthiest diet on Earth. You can’t say that without a study comparing what you’re saying to a different type of diet. That irks me about the vegetarians and vegans who say that’s the healthiest diet when they’ve never compared it to a keto diet. You have to be aware of a promoter of their own particular approach who will take very small levels of evidence, which to me are insignificant but incorporate that into their program so that it becomes unattainable to other people or only attainable to those who have a lot of money and those who can take the time to find the darn things. (Specialty foods and expensive ingredients.) We try to teach something that is flexible across many different grocery stores and platforms of how people can get their food and eat the food so that we have a broader appeal and also practical applicability.
Someone once asked how could a doctor recommend sugar-free Jello? Well, because I get people off of sugar!
Artificial sweeteners
Dr. Eric Westman: Something people ask me all the time is if stevia is the healthiest sweetener because it’s natural. Let’s talk about non-sugar sweeteners, because stevia is not artificial.
Amy Berger: Right, but then you introduce the sugar alcohols, too, which are actually very different, so we may have to touch on that.
Dr. Eric Westman: There is a lot of controversy and fear-mongering; people who think they’re teaching the best diet on Earth who don’t have any artificial sweeteners I think suffer from the lack of proof like the vegetable oil fearmongers. There just isn’t human data with randomized trials. There might never be, which is a different issue. In the ones I found, again, the odds rate shows the relative risks are 1.5, 1.4. It’s thought that you need a difference in association studies of at least 2 or 3 to make it be clinically relevant. Smoking and lung cancer had an odds ratio of 10 and 14. The risk for cancer or these other serious medical issues of these non-sugar sweeteners just isn’t there. Even though you can say, because it was statistically significant, it’s significant – no, we want to make sure it’s clinically significant and meaningful in the real world. Even doctors don’t know that. In my field, we know that medical management of heart disease is as good as putting stents in, in our field of cardiology. If you manage people medically (without surgery), they do just as well, but those studies haven’t persuaded the cardiologist to change their mentality of just going in and opening up someone’s chest. Back to the non-sugar sweeteners: I need them to get people off sugar at least for a while. I think they actually can perform a good function initially. What are your thoughts about that?
Amy Berger: I’m going to be the devil’s advocate. I agree that they can be used for the transition. If you’re drinking a six-pack of soda, please, switch to diet! I don’t know that they have to be only a transition, because if you can include them the entire time and do fine, like I’ve been eating a low-carb diet for 20 years now, I use a sweetener in my coffee every day, one pack, but I have that and it does not trigger cravings for more and more. I have that sweet coffee and I have no desire for anything else sweet. People have to personalize that. If having the mere taste of sweet triggers cravings all day long, that’s an issue. If you can have a little cup of sugar-free jello every night, not just as a transition, but every night for 10 years and it’s fine, then I don’t know that it even needs to be just a transition.
Dr. Eric Westman: The amount is very low. If you’re having a vegetable oil, you’re not having much of it there. In typical use, the dose is going to be pretty low. I’m not concerned about consumption. The studies have been done over a long period of time and they’re very, very small associations, which is thought not to be enough to be a causal thing.
Amy Berger: Your method the entire time you’ve been doing this in your career has been looking at total carbs. This does not allow people to subtract the carbs from the sugar alcohols. All of the sugar alcohols are different. There are about five or six different kinds. Some of them do affect blood sugar and insulin more than others so it’s best to not even play that game. Don’t subtract them at all. People will say stevia spikes insulin or sucralose spikes blood sugar and I say, “Compared to what?!” Why don’t you drink a full-sugar Mountain Dew and then drink diet and let’s compare that CGM, number one.
Number two, with sweeteners, these compounds are so ultra-concentrated, it takes such a small amount to have two teaspoons of sugar. So, in order to fill the packet, they fill it with maltodextrin or dextrose or something to fill it up. Otherwise, your pack is going to be practically empty; it’s going to have two grains of sand in it. I think people are alarmed about the maltodextrin and the dextrose. But to your point, if you’re having one or two, like when you’re having a liquid, a soda or something, it’s not even in there at all, usually. If you’re having these packets, this is what you call a “carblet.” We’re talking a fraction of a gram of carbs in one pack of Splenda or one pack of Sweet n’ Low. If you’re having 84 packs a day, maybe that dextrose adds up, maybe the carbs add up. One or two packs throughout the day in a coffee, that is negligible. And again, compared to what? Compared to four sugar cubes? We’re talking about people that have type 2 diabetes. Please, have the Splenda instead!
Dr. Eric Westman: I’m still holding out for a published study or a very good anecdote of one of these non-sugar sweeteners raising the insulin level. There’s one study that’s among carb eaters. It wasn’t in the context of a low-carb diet. It was actually cited by Jason Fung as a reason that non-sugar sweeteners raise insulin. The study was not used correctly to support what he said in his book. He gets a little loose with his citations. I haven’t seen the insulin going up from these other types of sweeteners.
You made reference to the method we use and that it limits these other sweeteners because you include them in the carb count, and that’s something that’s not thought of a lot. There is a limit. Some new products, I don’t know how to handle them yet. We were just starting before the pandemic to do some research locally where we’d have 20 people drink or eat keto products and we’d check their blood glucose and ketones. With these new “keto cupcakes” out there, for instance, they add oils to it, and they have all of this allulose in there that doesn’t really impact the blood glucose, but we don’t know. Until I have a lot of patients using something, I say to stay away from that stuff. Still work with total carbs, which means those cupcakes are not allowed.
Our thinking may evolve over time. I couldn’t believe it, I just saw an interview with someone who said that there’s going to be a ketone that you can drink that gets you inebriated like alcohol, but doesn’t have alcohol in it. There’s a new world of ketones and products out there that you’ll hear about but just wait and sit tight until we see data and carefully controlled studies or lots of people with experience before jumping onto something new. You don’t want to be the first one to use a drug that’s put out there even after it’s FDA approved. There’s what’s called “phase four marketing,” where you go from thousands of people to millions of people taking a drug, and sometimes they pick up problems that they couldn’t pick up in the studies (when there were fewer people on the drug). You want to wait until something’s been out for a while.
Amy Berger: I have seen some of the research on allulose just because for one of my previous writing gigs, I read several studies. It did look good, but I agree with you. Let’s wait until a couple more million people have been using this for a while. I was fairly impressed with the lack of glycemic and insulin spikes and at least one or two of the studies were in diabetics, but in limited numbers. We’re still talking small numbers.
Dr. Eric Westman: We should flip a coin to see whether you do it or not. That’s called randomization. What that does is equalize all of these uncontrollable, even unmeasurable variables. The other thing is, you might have a one-dose study that shows allulose doesn’t impact blood glucose, but what happens when you’re using it with all the other keto foods? That’s what I really want to know, because there were some apple cider vinegar studies that were done with keto, and it cuts out the hunger so much, I had one gentleman who didn’t eat food for weeks. He thought apple cider vinegar was required to cut out his hunger, and certain studies show that, but in the context of someone trying to lose weight, you have to advise and tell people to eat real foods.
Amy Berger: That’s part of it. Just like with the seed oils, the limited research that has been done in humans is not in people on a low-carb or keto diet. But my thing, especially for our membership or anyone who’s doing your method a lot, even if allulose (which is just one example) itself isn’t a problem, what are you going to eat it in? With the keto ice cream, the keto brownie, and the keto cookies. So all of a sudden, you’ve got 74 grams of fat, and fat is not really unlimited if you want to lose weight on your program. So maybe that keto ice cream isn’t really doing you any favors, even if it has allulose in it. That’s an issue, you know? Or keto granola, which is delicious, but it’s loaded with nuts and seeds. A quarter cup is going to be 300 calories and 20 or 30 grams of fat. We’re not afraid of fat, but we know that’s one of the big roadblocks for weight loss (overdoing fat).
Dr. Eric Westman: I hope everyone’s comfortable now with the term “prescription strength” versus “over-the-counter strength.” A lot of these products are being used by people who don’t even need prescription-strength keto. They might not even need keto at all; they might be insulin-sensitive. But you know, the keto diet works even if you’re insulin-sensitive. Be careful introducing those things. There are new things coming out, and I’m hopeful that there will be things that we can introduce. But I want to systematically and gradually change rather than diving into something new.
Amy Berger: I think it’s just like the seed oils. For those people, if artificial sweeteners are not required, they don’t have to use them. If you don’t want to use them, don’t use them. But let’s not scare people away who depend on those to actually help them adhere to this long term. I don’t think we need to be afraid of them.
Someone asked about sugar-free whipped cream. I love those flavored non-dairy coffee creamers. They even have Girl Scout cookie flavored creamers. I love that stuff, but I just use regular cream. Because with that sugar-free stuff, if you look at the label, corn syrup solids are often the second or third ingredient. Don’t tell me that it’s sugar-free. The labeling laws in the U.S. are that if it’s less than 0.5 grams of sugar per serving, you can label it as zero. So maybe if you’re using a teaspoon, it’s zero, but if you’re using two or three tablespoons of that stuff multiple times a day, it adds up. My answer to all of that stuff when people ask, “Can I have X?” is: “I don’t know, can you? Why don’t you keep it in your diet for a month or so and see what happens? If you’re not happy with your results, cut it out and see what happens.” I don’t trust those labels when it says sugar-free, yet corn syrup solids or something like that is the second or third ingredient. I just don’t trust it. That doesn’t mean you can’t have it; you might be able to have it and still get the results you want, but it’s iffy.
Dr. Eric Wesmtan: Patricia says, “For me, the sugar-free Jello helped me transition. I needed to stop though, because it did trigger cravings. Listening to Dr. Tarman was extremely helpful, and I weaned off most artificial sweeteners.” It’s an individual decision, I think, partly based on your metabolism, whether it’s an addiction going on, and whether you can limit it over time. The longer you do this, the easier it gets, but for the first six months definitely and maybe even the first few holidays you go through, you want to be really careful because I see people backsliding or falling off the wagon. So many people say that when they start eating carbs again, they just can’t control it.
Watch the full video here.