Dr. Eric Westman – ‘Keto Medicine – The Practice Of Carbohydrate Restriction’

Dr. Eric Westman – ‘Keto Medicine – The Practice Of Carbohydrate Restriction’

November 1, 2019 71 By William Morgan


thanks Kelly for the kind introduction and thank you to the meeting organizers Jeff Gerber and Rod Taylor here at low carb Denver 2019 I’ve been to a few conferences and see a lot of familiar faces now thanks for coming out and I think that low carb Denver really has become the premier spot for medical professionals and health professionals including all all kinds and and consumers as well but let’s give a big thanks to low carb Denver the title of my talk today is Quito medicine have you heard of this before no probably not we just coined the term okay we just it’s a neologism in a new word or phrase but it’s the practice of carbohydrate restriction if you look in the medical literature carbohydrate restriction is the phrase that you use to look for the evidence to support keto medicine my affiliations are I’m still at Duke University as a associate professor of medicine happy four days a week and a clinical practice that I’ll tell you about because I can’t do it all I’ve been teaching as many people as I can and then started two new companies to scale up the availability of this information I’m the past chairman of the board of the obesity medicine Association which now has the low carb keto diet in their algorithm guideline so part of the work that we’ve done is to get the OMA the OMA not a ma but OMA for obesity now there is a national organization in the US with low-carb keto diets in their guideline so I’m a co-author on several books I get royalties from keto clarity and cholesterol clarity and want to thank Jimmy Moore for making me help him write these books so I got started in the research and medicine of the keto diet in 1998 two of my patients had done this diet and I said you know you’re doing great what did what did you do how did you do this and they said well we ate steak and eggs and you know I was skeptical they also said well I’ve read this book the Atkins diet book and I was curious a young doctor in clinical research I was curious so I called dr. Atkins Bob Atkins I said to him do you need research and he said I have all the evidence I need I’ve been doing this 30 years and have you know 60,000 patients under his belt but he did say come see for yourself so I went I returned skeptical but open-minded and didn’t start using the diet immediately I never was employed by dr. Atkins other than he wrote the check first out of his personal funds to start the research going down at Duke University and the Durham VA oh so here’s a photo and that first visit from from the Atkins yeah that’s me on that far right there Jackie ever steen I still work with today sadly dr. Atkins died in 2003 slipping on the ice in a freak snowstorm in the spring in New York City and then died of head injuries shortly thereafter so right when I was ready to go back to dr. Atkins saying you know I’ve done two studies I’m ready to learn he was no longer available but Jackie was no Jack T has been so important for so many people I want to give her a round of applause here as you can see I didn’t develop the same personal connections with dr. Jack dr. Atkins as I has I have a with Nurse Jackie so 20 years later I’m dedicated to keto medicine I’ve published 46 peer-reviewed papers on the keto diet you can search my name at PubMed MEDLINE Westman ec they’re all there I’ve tried to get as many other researchers and clinicians and other even non-medical people involved with the research I’ve been practicing keto medicine since 2006 that do wrote three books found in the two new companies and what I’d like to share with you today is a combination of the research and clinical care that we and many other doctors have done now and we’ve treated over 4,000 people at Duke within a university private practice in the insurance pay and Medicare Medicaid sort of practice and it was really important for me to maintain that connection to every man or every woman and not just be concierge medicine but we’ve treated not there’s anything wrong with that but we’ve treated metabolic and inflammatory conditions like obesity type 1 and type 2 diabetes PCOS IBS non-alcoholic fatty liver disease I have the opportunity yet the sad reality to help people who’ve already had liver transplants from fatty liver because they’re developing fatty liver again and I don’t have the heart to tell him that they didn’t need the transplant and if you’ve gone through a transfer it’s not easy especially a liver transplant that’s the reality of today heartburn almost 100% gone lymphedema lipedema these are folks who have been told there’s nothing for you keto works for them cardiovascular disease if you have any worry about heart disease the heart surgeon send me their patients when the patients are too heavy that they can’t do a heart transplant so the heart doctors are not afraid of this even when the heart has left the ventricular assist device is a pump that’s placed inside the chest with two tubes from the left ventricle to the aorta because the heart isn’t pumping anymore these are probably the sickest people who are still alive and walking around and they have no pulse because the pump is a continuous flow monitor or mechanism post bariatric surgery weight gain yes we can help there and the harsh reality is most of the people who get bariatric surgery have never done a keto diet lchf diet before the surgery there’s no requirement for this to be done before a more risky yet effective but long term probably no more effective than this kind of approach and yes weight gain inadvertently unintended caused by mental health condition or mental health medications steroids steroids up the nose for allergy that’s usually what happens this time of year you’re losing weight it stopped have you started any new medicine oh no what about the nasal spray that oh yeah it started that but is that a medicine you know so this is the keto medicine world where were at odds with a lot of the treatment that other doctors are using so in 2014 I created a heel care program with dr. Atkins Nurse Jackie a Burstein and we’ve put together over we calculated over 60,000 probably 60,000 63,000 patient contacts and I just wanna to Jack these horn a little bit because she worked with dr. Atkins for 30 years and speaks very eloquently about her experience at the Atkins Center in New York City and it was her office that I sat in in 1998 in order to dispel all of the barriers that have that came up then and still come up now and it might be that you won’t really believe this until you sit in the office of another practitioner and I’m sure the doctors from Canada the UK Australia South America they’re happy to have you visit them of course give them the heads-up that you’re coming okay so there are four key conclusions that I’d like to talk about today and this is after treating many many people in the research setting and the clinical setting Quito is safe Quito is effective for more than type-2 diabetes pre-diabetes and obesity Quito works for virtually everyone when it’s done right and Quito requires a new medical normal for laboratory tests and other other biomarkers so what about Quito is safe the body of evidence now surpasses the FDA phase three requirements for approval of new drugs for the treatment of obesity I want to just thank everyone who has contributed to the research so if it were a drug it would be FDA approved but of course there’s no requirement for a diet to be FDA approved for these things but that’s the level of evidence that I wanted I wanted before a doctor uses this I want to make sure that it’s safe and effective at least at the standard of the US FDA individuals with diabetes hypertension heart failure gout or kidney stones may require special consideration in monitoring but I’m comfortable with a modification for low sodium modification for low vitamin K other perhaps potassium citrate supplements I can pretty much treat everybody with a keto diet with monitoring keto is effective for more than type-2 diabetes pre-diabetes and obesity we already know keto treats these diseases and they’re at crome of comorbidities and it’s just tragic that so many people end up on dialysis lose their eyesight have heart disease from diabetes which is totally reversible in most cases but now the the new era of science that we have just in the last say five to ten years reducing hyperinsulinemia and blood glucose also treats other conditions of for example heart failure and is a problem of insulin resistance in many cases so it makes sense that you might use this for someone with heart failure anything that has insulin hyperinsulinemia this is the most effective dietary program other than a very low calorie program that will treat hyperinsulinemia it lowers the blood insulin very well so epilim the far-left that they’re strong enough of an evidence and a whole nother scientific domain called the ketogenic diet for epilepsy that in some cases children put on this sort of eating pattern have total resolution of their seizures overnight and now that’s been known for a hundred years of the group that Johns Hopkins Eric Asaf and the Charlie Foundation has made great efforts to teach this around the world yet it’s still not very well known among the medical mainstream and I’ve learned from their experience that you can push and push and push in the medical mainstream but if there is a solid base of doctors being trained and profiting from using medications even in that epilepsy world they’ve been unable to make a dent and the idea of just just let’s just let this child try it change in medication change in diet before using medication so it’s a kind of sobering I often thought that just publishing papers would be enough people would read them and then we changed the world that way that’s not enough but so heartburn PCOS non-alcoholic fatty liver disease the most common cause of cirrhosis now liver failure glycogen storage disease this is a story of people trying this in a relatively rare disease in finding that they would have improvements in their muscle function just on their own and it’s the grassroots patients now changing the academic researchers and I was invited to a meeting to just dispel the fear of these other academics to use a you know – a high-fat diet and someone and I assured them that would be okay to study this and I hope to see more research in those areas – but there was the people with this disease actually banding together and changing the academic researchers this is a common theme TBI traumatic brain injury neurodegenerative diseases I put these in the evolving evidence categories because not only because they’re you know you get into cancer treatment and you talk about that you’re regarded as a quack I want it remember I want to have the evidence for clinical care like you would expect as a doctor for the use of medications for example so we’re not there but to see the research on these diseases terrible diseases that we have now is really pretty exciting so should we consider Kito medicine a new medical specialty I’ve been an internal medicine specialist I’m an obesity medicine specialist and yet I still haven’t been taught all of the critical sort of sorts of information and knowledge set that someone that I’m doing needs to know so I can treat heart disease as an internist I could have done that gone into cardiology as a internist I could have gone into endocrinology sadly pretty much all well sadly the cardiologists pretty much all still are in the low-fat paradigm for diet treatment the endocrinologists are in the medication paradigm to treat diabetes and don’t even understand that it can be reversed the neurologic field really doesn’t understand that nutrition can be so powerful outside that you know childhood epilepsy thing which is huge but it gets poo-pooed gastroenterology I can treat heartburn and an inflammatory really serious GI conditions just by changing the food and you would think that a gastroenterologist who is an internist goes into subspecialty you would think the gastroenterologist would know something about food and nutrition and sadly they’re not taught so I can treat all of these things as a medicine specialists so do we need another medical specialty is a question I raised to you Kido works for virtually everyone when it’s done right so I will say just like a prescription drug if you follow this plan the one that we’ve developed it will work but I can’t make you follow it so there’s a confusion of well does it really work do I have to do it you know 24 hours a day – I can’t I have that piece of cake on the weekends everyone else at church is doing if you do it right this will work it’s no different than saying you know I’m prescribing this pill you know it’s kind of large and you know you might have to take it every day but if it’s a prescription and if you do it it will work now it took me following the science treating lots and lots of patients to have the confidence to say this so if you’re a doctor or dietitian you’ve never used this this imagine that this is an FDA approved drug being marketed by a drug company putting the information in front of your your face and it will work your patients will have better adherence they’ll follow it better because they’re not wondering in their mind is this gonna work when is this gonna fail like every other approach I’ve done so you have to be I know in its we what you have to recommend this with the confidence of a prescription drug that’s approved and I think that’s helpful from the practitioners level not all low carb diets are keto and the keto target of keto threshold is a moving target because it would used to be easy when we just had urine ketones but now we have breath blood and urine and I’m still not sure of how to practically use these so in my practice with a wide range of educational level and socio-economic level I don’t use them because I don’t feel it’s necessary if I can get everyone under 20 total carbs per day just about everyone will be in ketosis you don’t have to measure it it can be helpful for a lot of people and we’re now getting the rep creation of data of how low do you have to go to get into ketosis some people will be in ketosis at 70 grams if they’re young and active I don’t even have that in green on the list at 50 grams total grams not net for the whole day you’ll get 30 to 50 percent in ketosis depending on the medical issue that there is the healthier you are the more carbs you can eat the younger you are the more carbs you can eat the more active you are the more carbs you can eat conversely the older the more sedentary the more postmenopausal you are the less carbs fewer carbs you can eat I know sorry don’t kill the messenger please so that’s why we use the 20 gram rule because pretty much everyone will be in ketosis we don’t have to measure it understanding how to do keto can be uncomplicated it can fit on a sheet of paper affectionately known as page 4 on Pinterest now because it was the fourth page of my handout at Duke University there’s a lot of free advice out there and please use it use it safely it’s I feel like it’s giving people a motorcycle that a lot of people can ride it without guidance and and but if you have medical problems this is remember as strong as many prescription medicines and you may need help in safety prescribing taking people off medicine so I just go in and say you know eat as much as you want to meat poultry fish and shellfish and eggs oh but I know you’re not going to want much I do spend an hour doing a teaching class which is available online if you can figure out how to find it it’s not hard I didn’t know that if I said oh and I’ll email it to you to these eight people around the room that when you put it out on YouTube a fraction of the hundreds of thousands of people that have seen it email me for page four because it’s in there and I was even traveling in Europe last fall and someone at the the security said oh you’re that Kido guy and I know excuse me and yes I said what page number is it page 4 he said so I don’t think I don’t think that’s gonna be the name of my next book but it may be because it can be that simple and and this is the strategy the teaching approach that came from dr. Atkins and Jack the Ebers dean’s office actually remember that visit 1998 I said what do you do here was the basic list of foods that they used and then what we did back in Duke Durham VA and Duke University is to validate the safety and effectiveness being one of the first research teams to actually not do a study and publish it in the medical literature but what I’ve learned is that medicine it would have been taught in medical school and all is not the most important therapeutic factor the physicians or health practitioners primary role is to counsel to guide to cheerlead to detect carbs basically and then to reduce medication safely so I find I’m listening I’m understanding what’s going on encouraging supporting and now in 2019 because of the influx of lots of information on the internet especially I help people uncomplicated keep it simple this really is a holistic practice because we’re using food as medicine food is much more powerful than medication when you get it right so rather than talk about cauliflower let’s talk rather than talk about metformin let’s talk about cauliflower I don’t think that’s in any medical school yet maybe we need to create one I’m open to that maybe I let patients tell their own story and it’s nothing fancy that but the patient will come tell the story and then they’ll go away and say that dr. Westman is so great he listened to me he listened to my story and this is a you know it’s a technique maybe the psychiatrist’s understand a busy doctor in a clinic has no time to listen and that’s so important but never dwell on the past there’s no shame no guilt no embarrassment you’re always supportive people bring in their own shame and guilt and embarrassment and the the doctor the health practitioner never does that but sticking to the base of basics I find has been really important no gimmicks no continuous biomarker tracking is needed you can use the just real foods no special foods but the important thing to reassure people in this kind of lifestyle change is that every day is a new day if you have some carbs because grandma you know forced you to eat it and thought you weren’t gonna love her anymore you know it’s okay just the next day you get on and go back to the allowed food so the allowed food list the special list had 60,000 patients under its belt before we studied it at Duke University now there are a lot of ways to do it but I think part of the success of our program know most of it is the special list of foods then of course I’ll say do you need another food list have you lost it oh yes my dog ate it well here it is again yeah even five years after someone has done the program they got distracted by carbs or something shiny and they regained they’ve regained all their weight I’ll ask people do you need another food list whether it’s working or not yeah you may have to be a bit of a detective and and this is gives me a little pause to do everything remotely it can work and as long as it’s working doing remote work is fine but remember if if people do it it will work don’t confuse that it doesn’t work and people know it that means it’s not being done right for example I never told this person that she couldn’t have pineapple water and she came back having pineapple water I said well how do you make that you know I told her not to have fruit but apparently fruit doesn’t you know be pineapple water doesn’t fall under the general rubric of fruit because you know it’s in water and so she said that well I open up a can of pineapple and I pour it in the pitcher I mean like syrupy oh yeah and then I pour in the water and I say well is it sweet well yeah really up okay no not everyone has had a nutritional background and knows not even everyone in the South knows that when you drink tea it has sugar in it because that’s what they’ve always had of course we call it sweet tea but no in the southern United States you ask for tea it has sugar in it you have to ask for unsweet tea and you get that funny look of you know what’s wrong with you so a lot of the this is rolling out in an environment that’s not necessarily keto friendly I had a patient who said while I’m doing your diet you know 23 hours 59 minutes and 30 seconds a day I said well what are you doing in that last 30 seconds well you know I was getting up in the middle of night eating Oreo cookies and dipping them in milk and no you have to do it all day long probably the most common mistake is falling victim to the Oh a little bit won’t hurt a little bit won’t yes a little bit can stop the ketosis can stop the weight loss the fat burning this one gentleman swore that he was being strict and I believed him I believed him so I kept thinking how does it is it did you have an operation he said yeah what was it well I had a new prosthetic leg put on well was it different yeah I put a you know a Duke sign and then a UNC sign on the back because my wife likes UNC so it doubled the weight of the prosthetic leg and the reason he gained weight was that his prosthetic leg weighed more now I couldn’t detect that in my bioimpedance scale because it doesn’t work on him so you have to think you have to you know and sometimes I’ll look in the purse not because of the money but because these sugar things just keep popping back in their people’s lives and that we help get people back on track that way so most people fail for for psychosocial reasons not because the pill doesn’t work not because the keto diet doesn’t work they’re unrealistic expectations how if you’re a practitioner you’ve heard well I’ve only lost twenty pounds this month and I am NOT a happy and this is a huge success in any program even this one so you have to adjust expectations perhaps people may expect that you need to weigh things on a scale and and be very precise with measurements and that’s an old habit that doesn’t need to be done with this some people may be discouraged to try yet another diet and our clinic you know the clinic of last resort I’ll listen very politely and then you know did you ever do a low-carb keto lchf he said yeah and I’ll say well you haven’t done it with me so yeah but you can have that confidence when this is what you see day after day so it can be young it can be complicated by lots of different things especially with the internet and in products that teach you keto means my product not changing the food I’ve seen that mistake there’s a lot of misinformation nonsense and then the opposition by the medical establishment fortunately we’ve not had any any kind of medical legal lawsuit in the US you know knock on wood I think it’s because our environment is just very different and thank you to the doctors around the country and there are countries who get bullied by the medical establishment and I’m glad you hugging them there Evelyn Tim Noakes Garrett Becky perhaps in the u.s. the people in these boards have actually followed the science and realized that actually there’s a lot of science behind this and and that’s why I I promote this now on the public public level as well friends and family I mean it really does kind of get into this sort of feeling of food is love and you know that’s kind of a big picture item if you’re if you have a family and you don’t have to always have food for celebrations do other things stress no question stress can slow down weight loss it can make you go back to eating carbs emotional eating but it’s a temporary fix and then of course we’re just supportive like any sort of chronic relapsing condition or problem we just help people get back on track on track or help them address the stress in a different way without the food physiology absolutely there’s carbon there’s actually a new textbook on food addiction that’s out if you can search for that I met the author of the textbook on food addiction at the last low-carb USA West Palm Beach meeting cravings and hunger yeah they occur there you know what’s the difference between the mind and the body anyway it’s all connected how the body works and chases overtime so actually in the obesity medicine world the condition or the disease of obesity changes as people lose weight the metabolism changes the psychosocial issues change so there’s actually a field of obesity medicine and that’s where I’ve been teaching this and there are thousands of doctors in the US but only a couple thousand who understand that and then we constantly battle the side effects of medications that are weight promoting so I’ve come to really believe that sustained lifestyle change requires integrated coaching and you know the coach or partner being working with the practitioner not against and not giving mixed messages and the purpose really is to guide individuals toward a personalized program I once had a psychologist come to my office and he said your program is brilliant it’s totally personalized and I said well I have a list of foods and I hand it out and he said yes everyone chooses exactly what they want personalize it based on what they like and what they want to eat it’s brilliant I didn’t create it I validated it in the medical literature and I watched dietitians be very meticulous about you know do you like fish yes do you like salmon no okay do you like tilapia no do you like cod no and all I do is hand a sheet of paper and say eat what you like no time needed for that here’s some preliminary results of a program that combines a simple system of Education and personalized coaching and you can see on the left that just about every one has success when it’s done right we don’t know how to do it perfectly there’s still some stragglers but the you know like a prescription drug if you take it it will work and the medical program means they had medical problems diabetes high blood pressure the non-medical on the right is if they didn’t have those problems and they were taught just at by coaches at a distance with diabetes again special monitoring is required but absolutely you can get people off insulin and medications and this kind of program works really well Tito may require something called a new medical normal it’s a theme that we’ve heard at this conference have heard a lot we use macronutrient compositions that are quote abnormal we let people not at breakfast which is an abnormal eating behavior we have people with high ketone levels which is not normal yeah and it differs from the medical care to tell someone that you don’t have to have diabetes we can fix it it does fall into what we expect or what’s normal in terms of weight loss is achieved by lowering the caloric intake there’s no magic caloric caloric measurements are more complicated than has been mentioned in the past but there is a metabolic advantage the metabolic rate doesn’t go down as much on a keto diet the glucose and insulin levels improve lipids improve and I just wanted to spend a minute and what normal means for most laboratory tests normal is described as the middle 95% of a normal distribution and this is just basic statistics so that even if everyone is quote healthy the the extremes are going to be called abnormal and so beware of this happens on the the tests that you see from the doctor from the laboratory that you get and normal can mean commonly observed that’s conventional you know he normally goes to work at nine families normally have two children it’s normal to eat breakfast biomarker correlation this is where the rubber meets the road and why we need to collect new information because biomarkers don’t mean you have the disease it’s a prediction so abnormal you know the temperature of 102 is a fever a high LDL can predict a risk factor long-term down there it’s not like you’re on the edge of a cliff and risk factor bullying to take medicines to treat risk factors is not really good practice again this is maybe we need to teach practitioners how to do this differently and then abnormal in my mind is a port a point at which treatment does more good than harm so when you’re introducing drugs or surgeries are you at a point where on average most people will actually do better than be harmed for example what’s commonly observed what’s normal in New York may be abnormal in Tokyo this gentleman walking down the street in New York City is normal and then he’s abnormal in a country where everyone is shorter okay that was supposed to be funny were it’s just too early in the morning okay but problems with biomarker correlation and they’re books written on this there are there are papers written on this the bottom line is what carbohydrate eaters this is the normal range among laboratory tests of people what carbohydrate eaters have as normal may not be normal for those who don’t eat carbohydrates and now that you can measure blood pressure at home the the normal fluctuation of blood pressure has been confused as being abnormal now that you can measure glucose at home and ketones normal fluctuations in these levels are confused with being abnormal and this is going to keep the doctors in business for a long time in keto medicine because we reassure people that it’s yes it’s okay to have just as mildly elevated blood glucose when or after you exercise that’s what you’re supposed to do nutritional ketosis also defines normality because a high beta-hydroxybutyrate in the blood is nor is abnormal for carbohydrate eaters but is keto normal and then all these biomarkers it’s a kind of a cruel joke perhaps that the only thing that doesn’t get better is the total LDL that’s kind of a and we heard great discussions on why the total LDL is not the be-all end-all the keto normal for cholesterol ohh time’s up I’m working on that one as a talk requires an hour it’s okay if the LDL is a little bit high it’s probably okay if the LDL is really high we just don’t know that for sure yet but it’s a triglyceride an HDL or looking great every other biomarker is great you’re feeling well don’t worry about that LDL is the bottom line so in summary keto is safe and effective for obesity type 2 diabetes keto may be useful for many other conditions and I can foresee this field expanding into treating lots of different other conditions and I’ll be there when the evidence is there and published in peer-reviewed journals PETA works were just about everyone when done right so like any lifestyle change it may require behavioral support to get started and even ongoing and I’ll see people 10 years in this because they’re still waiting for it to stop working but it’s not with it’s not going to but it’s that mindset of everything else hasn’t worked so is there a new specialty of Kido medicine to train practitioners I think yes and the D prescribing of medication is a cautionary note if you’re using this and you’re on medication make sure you talk to someone who understands how to get off the medicine safely most doctors have no training in this they don’t expect people to come off insulin in one day and that’s what we see it can happen caution is required when comparing labs for those in nutritional ketosis to normal values obtained from people who eat carbohydrates that’s the normal range you see on that panel you get from the lab the new reference range for nutritional ketosis is needed to reflect this new keto normal range thank you very much [Applause]