I first met Dr. Eric Westman at a low-carbohydrate meeting a number of years ago where he discussed an extremely important and insightful human clinical trial he had conducted in which he counseled participants with type 2 diabetes to follow a very low-carbohydrate, essentially ketogenic, diet. He was almost prohibited from conducted the study because some colleagues felt it was too dangerous. Nonetheless, the study was completed and demonstrated that type 2 diabetic participants no longer needed insulin and most diabetes drugs while achieving improved blood glucose measures by engaging in a lifestyle that was the direct opposite of conventional dietary advice. As groundbreaking as this study was for its time, it is simply not talked about enough, as it is one of the most important pieces of evidence that validates the idea that limiting carbohydrates and sugars, not fats or saturated fats, is key to, in this case, improving diabetes control, even helping make many people non-diabetic. I therefore thought it would be a good idea to ask Dr. Westman to describe his rationale for the study, discuss the results, and share the lessons he has learned since then.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:06):
I first met Dr Eric Westman at a low-carbohydrate
meeting a number of years ago,where he discussed an extremely
important and insightful humanclinical trial that he had
conducted, in which he counseledparticipants with type 2
diabetes to follow a verylow-carbohydrate, essentially
ketogenic diet.
He was almost prohibited fromconducting the study because
(00:28):
some colleagues felt that it wastoo dangerous.
Nonetheless, the study wascompleted and demonstrated that
the type 2 diabeticsparticipating in the study no
longer needed insulin and mostdiabetes drugs, while achieving
improved blood glucose measuresby engaging in a lifestyle that
was the direct opposite ofconventional dietary advice.
(00:49):
As groundbreaking as the studywas for its time, it is simply
not talked about enough, as isone of the most important pieces
of evidence that validates theidea that limiting carbohydrates
and sugars not fats, notsaturated fats is key to, in
this case, improving diabetescontrol, even helping make many
(01:11):
people non-diabetic.
I therefore thought it would bea good idea to ask Dr Westman
to describe his rationale forthe study, discuss the results
and share the lessons he'slearned since then.
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Dr Westman, thank you forjoining me.
(01:57):
I have been following your workfor a number of years, ever
since we met gee maybe 15 yearsago or so and I remember you as
the one who had the courage topublish a study that was very
different in, of all things,people with type 2 diabetics.
And even though it's some yearsback, I fear not enough people
have heard about this veryimportant study.
(02:17):
Would you mind recounting whatit is you were doing and
thinking back then?
Speaker 2 (02:22):
Sure Well, and it's great to be with you.
You know, the idea that whatyou eat might affect your blood
sugar is lost upon many doctors,if not all doctors, and so when
I was, I started first lookingat low carb diets for weight
loss, but then learned veryquickly that they'd been used
(02:43):
for something else, and that wasdiabetes, type 2 diabetes in
particular.
So when I did a few studies onobesity, it showed that clearly
you could lose weight doing whatwas called at the time the
Atkins diet, atkins induction Imean.
So this is going back to theyear 1998.
After doing some research there, I thought well, what else was
(03:06):
Dr Atkins doing?
What else would make sense?
A patient of mine brought in abook from 1923 before insulin
was discovered and as a bit of ahistory buff, I'm looking at
this and the exact diet that Iwas studying now is what was
used 100 years ago to treatdiabetes, type 2 diabetes.
(03:29):
So the logical next step for mewas well, let's do a study on
diabetes, and I always wanted acomparison group in my studies
doing randomized controlledtrials.
I'm kind of known as a sticklerthat I don't really like
correlational studies and havebeen criticized for that.
I'll take that criticism.
(03:50):
I want experiments, and so wedesigned a randomized trial that
was looking at low-carb,ketogenic or today it's called
keto, but not weird keto on theinternet and then I thought by
now this was 2008, when it waspublished everyone will be using
the low glycemic diet.
(04:10):
Because you lower the carbs,the diabetes gets better, right?
Well, so we looked at low carbversus low glycemic in a
randomized trial over six monthsand, lo and behold, the group
that had lower carbs, the lowcarb keto group, did a lot
better than the low glycemicgroup.
(04:32):
And, of course, these both arebetter than what the diabetes
organizations still recommendtoday.
So it's been a bit of a headscratcher for me.
Why diabetes organizationshaven't, you know, as a rule,
said look, just don't drinksugar.
Diabetes is a problem of toomuch sugar.
So anyway, that's funny.
(04:53):
You ask about the.
You know, looking back, it's aproof of concept study.
You know it's like it's not therandomized trial in the New
England Journal.
You know, like it's not therandomized trial in the New
England Journal, you know, with5,000 people per group showing
this over.
But it sure was obvious to methen and obvious today.
(05:14):
Now, having treated people inthe clinic, I kind of look back
saying, well, you know that iskind of quaint to look at that
study because I can go waybeyond a research protocol now.
I mean so as a clinical doctor,you know that you're not
constrained by a certainprotocol.
When you're in the clinic youcan actually say, jim, I know
(05:38):
your wife and you can use leversto make things work even better
than what the clinical trialsshowed.
But even looking back I read itagain recently half the people
who were on insulin in the studywere off insulin by six months
(06:01):
and I calculated that all ofthem pretty much had an A1C
under 7% on the low-carb dietsand most of them were off their
medicines in addition.
So you know, being kind of anunderstated scientist, you know
(06:21):
today, if I would redo the titleand you can get away with
titles and papers I could neverget away with before this
low-carb diet reverses diabetesin almost every case and of
course that's what I say to mypatients who come to me who have
some skepticism about it.
And even then most people don'teven know that you can reverse
(06:45):
the type 2 diabetes.
Speaker 1 (06:48):
This is some years back, but what was the reaction
back then among our colleagues?
Speaker 2 (06:54):
You know there wasn't one.
You know, looking back and yousay that I had the courage, you
know, like most doctors I didn'tget much training about
nutrition and maybe I got totalparenteral nutrition training in
internal medicine in the ICUs,right Intensive care unit.
(07:17):
If someone's not eating youhave to figure out what to give
people.
But by the time you get outinto practice you practice.
Everyone knows back then thefood pyramid was the healthiest
thing and of course it's not.
But I didn't really know howbad the things were, how
distorted they were, until acouple of our studies came out
(07:38):
and then the kind of backlashwas not to me personally.
I have to say I've never,because we treat people and
patients and the patients getbetter that it's very rare for a
doctor to be called in front ofa board for a policy thing.
It's more a one-on-one If youmess up and someone complains
(08:03):
and we're using things thatreally work.
I mean there are evenalternatives to drugs.
That now it's in clear focus tome that the medical world has
(08:35):
been really groomed bypharmaceutical companies to
really just treat doctors whatthey need to know about
medicines and so the typicaldoctor won't know that food
really matters and even thatdrinking sweet tea here in the
South will raise your.
I had someone come up raiseyour butcher.
I had someone come up 180 unitsof insulin in two days because
(08:57):
he was drinking so much sweettea Coca-Cola like substance
that he was using insulin, andhe didn't tell me.
Can you imagine someone comingin and confessing to you that
you're drinking two liters ofsweet?
No, it was only afterwards.
I said, oh my goodness, whatwere you doing?
And he said, well, I didn'twant to tell you.
But that just shows how muchhope there is, too, though, that
(09:22):
if you're still consuming sugarin drinks or in food, and
starches get digested to sugar,so it's really the same thing.
There's hope, and it's likelythat you'll be able to reduce or
eliminate these diabetesmedicines as you stop consuming
so much sugar that the medicinesare treating.
(09:43):
So you know, then, along theway, as you have been in it a
while as well, I have to say,there are all these blogs.
Remember those blogs, and Iremember Mike and Mary.
Dan Eads, who wrote ProteinPower, had a clinic and they
(10:04):
were using it in their patients,and then he wrote just kind of
this simple mathematicalcalculation about how much sugar
is in the blood and it stuckwith me and through the years I
have used it in teaching andI've even taught it to academic
(10:25):
endocrinologists, because theywould come up to me and say you
know, I never really thought ofit that way.
There's only a teaspoon ofsugar in the entire bloodstream,
so that you can double yourblood sugar by having a teaspoon
or two of sugar.
That's it.
And this could create thesurroundings, environs, for
(10:47):
diabetes.
And so we're dealing with asituation where there's just not
much sugar, not much glucose inthe blood at a given moment,
and that's anotherunderappreciated kind of fact
that we deal with.
But again, that shows hope thatif you're not paying attention
to the carbs it's the generalterm to put all this together
(11:09):
and you haven't reduced carb yet, then you don't have to go down
to the keto level necessarily.
But if you haven't reallyunderstood that, then there's a
lot of room for improvement interms of the blood sugars and
you mentioned type two diabetes,but insulin resistance and
prediabetes room for improvementin terms of the blood sugars
and you mentioned type 2diabetes, but the insulin
(11:32):
resistance and prediabetes.
I mean you want to really takeaction before the blood glucose
goes up and the pathophysiology.
The problem is actuallyhappening with elevated insulin
levels, maybe 10 or 15 yearsbefore the glucose goes up.
So, and again, most doctorsdon't check the fasting insulin
level.
So we're endlessly trying toteach not only how to measure
(11:52):
this, but then the importance ofthe carbohydrate and the diet
and at least limiting it formost people.
Speaker 1 (12:02):
You know, I've often wondered because your practice,
your clinical research has beenso contrary to prevailing
standards what happened when youtried to present this to your
local institutional review board.
So your listeners may not knowthat in order to do a clinical
study, you just can't do it.
You got to get permission froma board of scientists,
(12:24):
physicians, ethics people,clergy a board of scientists,
physicians, ethics people,clergy sometimes who say yes, dr
Westman, it sounds reasonableor no, this is dangerous or
whatever, based on their opinion.
Speaker 2 (12:38):
What was their reaction?
Well, so this is gosh.
We started our research 25years ago and I think we
benefited from the fact thatjust most doctors aren't aware
of what nutrition does, becauseour first few studies even they
were funded by Dr Atkins and hisfoundation at first.
You know, we like any goodinstitutional review board, you
(13:01):
know there's a local and thenyou can actually pay to reach
out.
But ours was local VA, durhamVA or Duke, and part of it is
they know who the investigatoris right, so it's not like Joe
Blow is coming in to do a studyrandomly on something.
So I knew a lot of the peopleon the IRB locally.
(13:24):
For our first study I was partof that peer group of
researchers learning researchand so actually the first study
we did, the review board saidwell, this is fine.
So it was only six months ofchanging a diet, although some
people said that would kill youin a day.
Right Back then it was justkind of crazy.
(13:46):
Well, some people say thattoday even.
But during that first studythere was a dietician who
complained to the hospitaldirector about our study, and so
it wasn't the review theresearchers.
There was a dietician who gotwind of it and said look,
researchers, there was adietician who got wind of it and
(14:08):
said, look, this is unethical.
And turned out the hospitaldirector at the time was pro, or
tilted toward bias, towardvegetarianism, maybe even vegan,
and so they got upset about itand they actually lobbied the or
the IRB, the research board, tostop the study.
So again today it plays out asthe politics that are kind of at
(14:31):
play, that are going back andforth.
The science has always beenhere and solid and true, so
there will always be thatpolitical controversy.
But the research board, many ofwhom I knew, basically said well
, we're not going to tell him tostop the study, but we'll make
him do more reports.
And so that's what they did.
(14:52):
They said you know, dr Westman,you're going to have to file a
monthly report to just show thatyour patients, research
subjects, aren't dying, and soit was a reasonable compromise.
And what's kind of crazy isthat research should be testing
things that are controversial.
(15:12):
It's not like that.
We know everything aboutnutrition or even non-nutrition
concepts.
So the idea that you squelchthat investigation was a
learning experience for me,because I was naively, as a
researcher collectinginformation and doing some
(15:33):
anti-diet visit at Dr Atkins'office and I saw what happens
after years of being on the diet.
So it became almost I don'tknow obvious or petty that
something else was going on,that the clinical world even
today is so far ahead of thescientific publications and
(15:56):
that's often confusing to people.
But later in the research wedid, I didn't get any kind of
pushback.
And IRBs again are localphenomenon.
Some would be more open thanothers and say one study there
(16:17):
was one study that I know ofthat was kind of shut down and
it had to do with mental healthand they were claiming they were
mistreating these vulnerablepeople and naturally they were
probably helping them bychanging the diet but don't feed
them fat.
So I mean I laugh about it nowGoing through it.
(16:40):
It's not a great process to getout.
Give research you've worked onfor several years to a meeting
and then it just falls flat.
Right, you want other people tobe excited about it, but the
patient care that we were ableto do locally.
So I opened a clinic, basicallyusing what we had studied and
(17:01):
what other doctors had used fordecades, is really what kept me
going.
It's just so thrilling to seepeople get better and okay,
there are times when I kind ofrelish the idea that it's
rebellious and all that.
But at first I didn't know.
I had no idea what hornet'snest I was getting into.
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You know, you and I have beendoing this.
What?
25, 30 years, something likethat.
And yet you and I can go toWalmart or Target or Costco or
(20:47):
the mall and see that the vastmajority of people this has not
had any impact on their thinkingwhatsoever, like your patient
with the sweet tea.
Any thoughts on why the uptakehas been so slow, so painfully
slow?
Speaker 2 (21:00):
No, yeah, I think it's multifactorial.
Of course there are a lot ofthings, but the most prominent
reasons, I think, are themedical world is still wrapped
up in drug treatment.
It's reactive and it's reallynot preventative.
And it's been that way in ourentire careers.
(21:23):
I mean, it's nothing new.
And everyone kind of expectsthe medical world to be
proactive.
No, they're not going to be.
But over the last couple ofyears I've learned, and I guess
I was primed for the idea thatthere might be addiction going
on, because I spent 10 yearsworking on smoking cessation and
(21:43):
nicotine techniques and helpeddevelop medications for nicotine
treatment.
So their Chantix came from theresearch that Dr Jed Rose and I
did at Duke, you know 30 yearsago, and now you know, you see
Chantix out there.
So I was kind of ready, I think, to accept the idea that food,
(22:09):
sugar, starch, it could be bread, it could be addictive.
And then the idea that what Iwas teaching people a total
elimination of carbohydrates.
So I give people a sheet ofpaper and say eat as much as you
want of meat, poultry, fish andshellfish and eggs which have
zero carbs, and then a littlebit of these other things, and
(22:30):
it occurred to me that what I'mdoing is sort of a cold turkey,
if you will, for sugar andstarch, and when you quit
smoking the time-honored way isto just cut them all down.
Cold turkey, quit smoking.
So I've learned over the lastfew years applying the addiction
ideas and even into the therapyof treatment of someone who has
(22:55):
diabetes or overweight.
Using the addiction model canbe very helpful and so I think,
kind of like when I was a kid,everyone would be smoking.
We were watching an old moviefrom the 70s and they were
lighting up everywhere in thedoctor's office having a
(23:15):
cigarette.
How could you imagine thattoday?
But I think carbs, sugar, isaddictive, unfortunately for a
lot of people.
So when you see the enabling ofan addiction by the family, the
(23:35):
school system, the hospitals, Imean for heaven's sake, you can
go in for type 2 diabetes outof control at a hospital and
they feed you sugar at thehospital.
This makes no sense.
So I've learned a lot from DrVera Tarman and Dr Jen Unwin,
who have worked on this idea ofsugar and ultra-processed food
(23:59):
addiction, and I bring that intomy one-on-one teaching and then
at meetings as well, and Ithink that into my one-on-one
teaching and then at meetings aswell, and I think that explains
the widespread problem.
I mean, and those with type 2diabetes or end up with weight
loss surgery as a treatment, Ithink are the worst, hardest
(24:22):
core sugar addicts, hardest coresugar addicts.
And if you ask someone who's anaddict, to their face that
they're an addict, of coursethey'll say no right.
So, just like alcoholism orsmoking or some other drug of
addiction, most people won'treally acknowledge that they
(24:44):
have a problem with sugar,ultra-processed food being
addictive.
But you look at the almostconstant consumption of this
stuff.
It's not because they're hungryWell, it is because they're
hungry.
It's not because they lackenergy storage on their body,
right, so they're eating.
People are generally eating forsome other reason, and remember
(25:07):
the ad Bet you Can't Eat One,and it was Lay's potato chips.
You don't see those ads anymore.
They would get in trouble ifthey push that edge.
And then it's been a long timesince we saw advertising for
cigarettes on billboards, and soto me that seems like a natural
(25:28):
progression that there ought tobe some sort of limitation on
especially to children, onsugary things that to advertise,
you know, fruity pebbles, andanyway, that's getting into
things that we might do toprevent our children becoming
addicted and or at leasthabituated.
Anyway, that's getting intothings that we might do to
prevent our children becomingaddictive or at least habituated
(25:51):
to eating all this stuff.
Speaker 1 (25:53):
As you know, the natural corollary to limiting or
reducing or even eliminatingcarbs is to increase your fat
intake oils, fats, saturated fat, oleic acid, extra virgin olive
oil, butter, et cetera.
So I take it you've not seen anexplosion in cardiovascular
events?
Speaker 2 (26:09):
No, no.
And that was of course an issue20, 25 years ago and it's still
an issue today in people'sminds and I think it will be an
issue forever in some people'sminds, so that if you're taught
a certain dogma, it's hard toundo that.
In fact, someone taught me orreminded me recently that if
(26:32):
you're prejudiced, there's noamount of data that will
dissuade you of being prejudiced.
So the idea that we can livewell without carbs kind of
became clear to me.
In fact it could be therapeutic.
So cutting carbs out of thediet would help people lose
(26:53):
weight, feel better, reversediabetes, metabolic syndrome,
all these other issues.
But then there was always thisbut in fact I met a researcher
who said but Eric, I couldn't godown on the carbs anymore
because what would I do?
Raise the fat, you know.
So there was this fear in theresearch world.
(27:14):
Of course she wasn't an MD.
So we have a lot of the PhDsare taught this boundary of safe
use and these rogue.
You know Dr Atkins was vilifiedfor telling people to eat fat,
although in that context itseemed fine.
And so as a minimal like tojust stay in my lane, I'd say
(27:36):
well, you know, if you don't eatcarbs.
Eating this fat looks finebecause you're burning it for
fuel.
And so these documentary filmscame out talking about running
on fat for fuel.
And these elite athletes aredoing heroic levels of exercise,
rowing from San Francisco toHawaii running on fat for fuel.
(27:57):
So okay, so at least in thelow-carb context, fat doesn't
seem to matter.
And then you get open to thatidea.
Then you start wondering well,I wonder how bad it was really
in those other contexts and howsolid was the science that
(28:18):
eating fat was bad?
And I was heavily influenced bythe work of Gary Taubes and
Nina Teicholz, who assembled thescience on the implication of
eating fat and even ofcholesterol in the blood, and it
wasn't really good science.
But then they're not doctors,right?
So you have the investigativejournalists reading data that
(28:42):
even I bet they read morestudies than even the expert
scientists because they readoutside their own work.
So in the context of a low-carbdiet, eating fat seems fine.
You're burning it for fuel.
Even people eating carbs wasn'treally very solid in the first
(29:06):
place Gets you started to wonder.
You know, in the big pictureview, what's more important and
do you worry about fat ingeneral?
And of course, it's thecardiologists who seem to be
holding this banner of you know,still, fat in the food is bad
(29:27):
and fat on the arteries comesfrom the fat on the foods and
I'm afraid it's probably notthat solid.
And you can see I'm tiptoeingaround all this because I'm
still working with hundreds ofdoctors at a university who have
that belief system, you system.
So I have to at leastacknowledge that that might be
(29:50):
true.
And yet now we have a studythat's unfolding of people with
LDL levels the lousy, the lethalcholesterol level that are two
to three times higher than adoctor would typically accept
before treatment with a drug.
Of course this is in a low-carbcontext, but they for five
(30:12):
years self-report and by oneyear under supervision, even
with these super high CCTAtechnology, which is one of the
(30:32):
best we have, that'snon-invasive.
So I'm beginning to reallywonder if the LDL idea, if the
medication maybe, is thepleiotrophic, the
anti-inflammatory effects ofthese drugs.
But then a movie comes out thisyear called First Do no Pharm,
(30:54):
p-h-a-r-m First Do no Pharm.
And in there Fiona Godley, whois an editor, former editor of a
prominent medical journal,basically says that the industry
, medication industry, oftreating cholesterol, has never
been transparent.
And they've tried, they'veasked and I don't even know if
(31:15):
it's gotten to a court order orthat level of, but they've asked
to have transparency to be ableto see the data from these
studies.
And at a recent meeting with acouple of cardiologists you may
know Nadir Ali who talks aboutLDLs being good for you and all
this we basically could onlycome up with one study that was
(31:37):
not drug company funded forlooking at these
anti-cholesterol,cholesterol-lowering medicines,
and in that study it didn't work.
So there's a lack ofindependent replication.
And then, even when Dr Godleyon film said that this industry
has never let us look at theirdata, I mean I would think if
(32:00):
someone asked to look at mypaper's data I would go back.
It's on some old computer.
It might even be printouts, butI would be happy to show it
because it works so well.
It makes you suspect and I'mnot a conspiracy theory kind of
guy, but it makes you wonder.
And so I do have a paper thathelps people look at the Mayo
(32:27):
Clinic statin decision tool,which is just a way to look at
the number needed to treat and avisualization of if I do take a
medicine, what's the likelihoodthat it will, what is my
likelihood of a heart attack andhow low will it make it go.
And the relative risk reductionit looks really good, but the
absolute risk reduction lookskind of small for a lot of
(32:51):
people, and so I think peopleshould be able to look at this
information and make their owndetermination.
Which then puts me out of lineor out of sync with the
guidelines that say youshouldn't even you know, don't
even think if the LDL is abovethis level you should treat with
a medication.
But that is a fascinating areaof kind of weak science that got
(33:20):
into drug treatment and nowkind of dogmatic point of view
that it's hard to change thiskind of thing, except if you
show a different approach can doas well.
You know, most of the timepeople will glom onto that new
approach.
I mean, who knew that we wouldbe able to take pictures with
(33:41):
our phone, you know?
And so as that new technologycomes out, you know, as people
start seeing that not eating thesame way improves their health,
and we don't have an epidemicof heart disease with these
folks, even though it waspredicted, I'm hopeful that even
(34:03):
despite the addictive nature offoods that people will end up
going in this direction.
The time lag between eating aTwinkie and having diabetes.
It's just not quick enough, youknow.
I mean, it's hard to know thatyou're really harming yourself
(34:27):
with something that tastes sogood.
Right, that's kind of theteaching that needs to happen, I
think.
Speaker 1 (34:36):
So what has this meant for your day-to-day
clinical practice?
Somebody comes, dr Westman, myprimary care doc, says my LDL
cholesterol is 212.
My primary care doc says my LDLcholesterol is 212.
So, and have you gottenpushback from hospital
administrators, other peopleinvolved in scrutinizing what
docs do and what they prescribe?
Speaker 2 (34:54):
Yeah, From other doctors and mid-levels will use
thumbscrew techniques to get mypatients to use medication.
I mean, it's the level offear-mongering.
And so if I calmly talk throughthe statin Mayo Clinic statin
(35:20):
decision aid tool, it's not myaid tool, it's from the Mayo
Clinic and I just point thesethings out and I say, well, you
know, it's really for you todecide, you, the patient, and
that's kind of my approach.
So doctors are.
No one's ever complained, youknow, knock on wood.
(35:40):
No one's ever complained, knockon wood, no one's ever
complained.
To one of my superiors becauseI think that again, the patient
is generally the approval boardsand things kind of got into it
(36:02):
too soon and nobody was harmedfrom it.
But my patient experiences ledme now to worry less about the
blood markers and worry moreabout the anatomic determination
of whether someone hasatherosclerosis or not.
So going to the calcium score,coronary, the CAC score, the CT
(36:28):
angiogram being so, I teach mypeople a small group of folks
who follow that repeat after mecholesterol is not a disease.
Now wait, you know, cholesterolis not a disease.
Atherosclerosis is the disease.
We're trying to preventAtherosclerosis.
So you have to repeat this overand over because you go into
(36:52):
the doctor's office andimmediately well, your
cholesterol is high.
But, doctor, is it a disease?
Really?
My cholesterol no, soatherosclerosis.
So you've probably been lookingat coronary calcium scores
longer than I and I'm doing thebest I can kind of piecing
(37:13):
together the knowledge of.
So, the calcium score, the CTangiogram, this will explain or,
to the best of our ability, seeif you've had damage before.
The coronary score, of course,is a bit of a Pandora's box,
because if it's zero it's veryprognostically good For the next
(37:37):
10 years you're not likely tohave a heart attack.
But it's not perfect.
So you'll see online and I'llbe trolled by someone who says,
well, I had a normal calciumscore and I had a heart attack
the next day.
Well, right, it doesn't shownon-calcified plaque.
I mean.
So we're dealing with teststhat are imperfect.
In a world that people wantperfect tests, and especially
(37:59):
the engineers who come to thebiologic system of the human
body, they just can't.
Well, but they expect the bodyto be like a computer or a
machine.
But we have adaptive responses.
And so now especially, actuallythe reason I kind of got into
this measurement through calciumscore and the CT angiograms is
(38:25):
because I felt myself defendingmy patient who had an LDL of 300
.
An LDL of 300.
This is way too high foreveryone else's comfort.
But this person was 70 yearsold, felt great, had no obvious
(38:46):
no history of a heart attack orstroke and when they got the
calcium score it was zero.
So at age 70, if you've gone 70years without any damage to
your arteries and a doctor isgoing to put you on a medicine
to prevent a disease you don'teven have, this is craziness.
An oncologist would not giveyou chemotherapy or radiation
(39:10):
therapy if they didn't havetissue diagnosis.
So I guess.
So, dr Davis, back to you.
How did our field in?
Internal medicine is my firstfield, and then obesity medicine
, my subspecialty.
But I could have been acardiologist or rheumatologist.
That was kind of what I likedbecause you treated the whole
(39:33):
body.
But so how did our field startgetting into?
Well, I don't really know, butit's likely that you have cancer
, so we'll give you thischemotherapy, you know.
But so it's likely you haveheart disease.
So here take this.
How did this happen?
Speaker 1 (39:49):
You know, I think it got started around the 1920s
when such things as penicillincame out.
If you had pneumococcalpneumonia, take penicillin.
And that paradigm seems topermeate all that we do in
conventional medical practice.
If you have high cholesterol,take a statin drug.
You have a high blood glucose,take metformin and bieta
injections.
You treat things.
(40:11):
One of the things I've beenplaying around with for at least
a decade now is this philosophy.
It's not 100, but and that is,rather than thinking about
treating these phenomena, let'saddress the factors, as you've
been doing that.
Let's subscribe by talking toyou is you and I have gravitated
down the same path, fromdifferent starting places but
(40:32):
arriving at the same place.
So I was doing CT heart scans30 years ago.
I got all kinds of crap forthat.
I can tell you.
It was one of the firstscanners in the Midwest.
But it showed me, as you pointout, cholesterol is not a
predicted.
There was no correlationwhatsoever.
In fact, we contributedpatients to the Tulane
University Bell's trial.
(40:53):
This goes back 20 some years,yeah, and we showed that if you
did nothing for a coronarycalcium score, it goes up 25%
per year.
If you go on Lipitor 40milligrams, baby aspirin, low
saturated fat, low fat dietexercise program.
It goes up 25% per year, noimpact whatsoever, with real
(41:16):
humans and they're freaking outand they're scared and, of
course, my unscrupulouscolleagues.
It's much worse in the privatesector, I think, where they're,
my colleagues, saying well, john, you're a walking time bomb, I
can't be responsible for yoursafety when you leave this
office.
I'm going to send you to thehospital for heart
catheterization.
See if you need a preventivebypass or stent.
(41:37):
As you know, this is still doneit Intentive bypass.
As you know, this is still done, it's wildly done in the
private offices and hospitals.
I refuse to do something likethat.
So I did, admittedly, zigzagand a lot of trial and error,
but found a way to reliablyreduce cardiac calcium scores,
and it had nothing to do withthe stat drugs, had nothing to
(41:58):
do with LDL cholesterol.
So that's wonderful.
You came to the same conclusionand this idea that cholesterol
is not a disease, it's a crude.
It's a lousy marker for adisease.
Let's look at the disease.
I think that's so wonderfulthat you saw that.
Speaker 2 (42:12):
Yeah, and yet to the point of a recent anecdote.
But we can learn a lot.
One of my friends had a coughand a long time, and it was
during COVID, so I hadn't seenhim in a while Finally got an
(42:32):
x-ray for the cough and he hadlymph nodes in his chest.
He had lymphoma.
Basically that was causing it.
But he also had suchcalcification of his coronaries
that you could see them on thechest x-ray.
You know this is pretty extreme.
You don't normally see theoutline of the coronaries.
(42:53):
So sadly, you know, they did acatheterization.
He had total blockages of hiscoronaries and had collaterals.
But they got to the treatmentof the lymphoma first and after
a couple of chemotherapy eventshe died, probably of a heart
attack.
That was the stress test thatyou know.
In a different world he wouldhave had the bypass done first.
(43:16):
But you know it's a toughjudgment call there.
But when I ask this and talkabout this to my colleagues they
say well, but did he havesymptoms of heart disease?
And I said well, no, thinkingthat he was totally sedentary.
In fact he was the guy whowould be there late at night
(43:37):
sound mixing.
The groups would come in andsing in his house and he'd mix
it all night long and he neverexercised at all.
So if you wait for a symptomand you're not really using your
heart much, you can developtotal blockages.
Here and in my cohort ofcolleagues it never occurred to
(43:58):
us that maybe we should justtake a look.
You know, maybe even if there'sno symptoms especially when you
know 20 or 30% of people theirfirst event is a heart attack or
sudden death that maybe weshould take a look at these
arteries, even if you'reasymptomatic.
(44:18):
Phil Ovedia, who's acardiothoracic surgeon
symptomatic Phil Ovedia, who's acardiothoracic surgeon calls it
the mammogram of the heart tohave the coronary artery calcium
score.
And I'm not quite sure it needsto go that far because even some
of the health servicesresearchers that I've worked
with that's my field that Istarted with don't think that
total screening of everyone withmammograms is a great idea.
(44:40):
But so anyway, it's a goodsoundbite at first to say well,
you know, everyone should atleast look.
You know, especially if you'rechanging from a sedentary to an
active life, and I see that alot, because someone will have
lost 50 to 100 pounds, go fromjust kind of sitting around,
going out, you know, playingpickleball and hurting their
(45:01):
elbow on the of sitting aroundgoing out.
You know playing pickleball andhurting their elbow on the
pickleball court and you know ifyou haven't had an evaluation
and you're changing, asking yourheart to do more, that might be
another proactive way to lookat the arteries.
Through one of these scans, doyou have sort of a or, like Dr
(45:22):
Ravadia, do you think everyoneshould get a calcium score or do
you have a selection process inyour mind?
Speaker 1 (45:29):
You know, the standard advice is men over 40
and women over 50, subject toalteration if there's something
extraordinary, but like ifyou're a type 1 diabetic or,
let's say, your mom had herfirst heart attack at 52.
Those guidelines have provenpretty reliable, with occasional
exceptions.
So I've been doing that too.
And then we had to develop somenew rules for people who either
(45:51):
.
So, as I mentioned, the 25% peryear is a pretty reliable
number.
That's an oversimplification,of course.
Right, if a score of two goesto four, that's 100%.
If a score of 1,000, two goesto 1,000, that's less than 1%.
So we have to use some judgmentin all this.
But I did learn some lessonsalong the way.
The first time I saw dramaticregression of coronary calcium
(46:14):
scores.
It was something like a scoreof like 780, something like that
.
Next, a scale of like 430,something like that.
Next scan was like 430,something like that, and I said
no way, come on.
So I had to pull up the scan.
This is 25, 28, 30 years ago.
Pull up side-by-side scans.
Of course you're scoringcalcium.
You can still see the contoursof softer elements, and it was
(46:35):
clear that drop in score wasaccompanied not only by a
reduction in volume of thecalcific components, but also of
the non-calcific components.
I started to see that the firsttime I saw that was with the
addition, of all things, ofvitamin d.
You know, I'm in a northernclimate so people here are
miserably sun deprived and ithad a dramatic effect on
(46:58):
coronary calcium scores.
And we used fish oil.
Thankfully the two, as you're,familiar with CT coronary
angiography, so the HEARTS trial, the EVAPORATE trial recently,
have shown that not only is ouromega-3s facilitating reduction
(47:19):
of cardiovascular events, theyfacilitate regression, which,
which is so wonderful, asopposed to progression permitted
by statin alone.
I just love that and that we dothe diet, our diets, very
similar what you've been doingall these years.
I I have factored in microbiomeissues because the process of
endotoxemia is becoming littleby little.
We're on the cusp ofunderstanding, but the process
(47:41):
of endotoxemia is clearly acontributor to insulin
resistance, visceral fatdeposition, high triglycerides,
liver conversion of carbs toVLDL, et cetera.
But that formula has beenworking very well.
You mentioned the idea ofultra-processed food addictions.
What else has evolved over the25, 30 years you've been doing?
(48:05):
What else has changed?
Speaker 2 (48:07):
Well, you know.
So my looking back, one of mycolleagues said I cheated.
I said well, what do you mean?
You use someone else's system,and that was true.
So, looking back, it just madesense to me that I would visit
(48:28):
doctors who were doing this.
I visited Dr Ease they hadclosed their practice, actually,
but Dr Rosedale was still inpractice.
I visited Dr Atkins.
I visited Dr Rosedale and DrVernon.
I visited Dr Bernstein, who isstill alive and practicing out
of his house in Mamaroneck, newYork, and after I visited Dr
(48:49):
Atkins I realized that somethingwas controversial.
In fact, they kind of playedthat up a little bit too.
But I borrowed the list that DrAtkins used in his clinic, and
so I don't teach internet ketotoday, internet keto with the
(49:10):
oils and bulletproof coffee andketo drinks and all this.
I haven't gotten into that yet,and what I teach is still what
Dr Atkins would have taught outof his office in New York City,
where it's basically zero-carbfoods, almost carnivore, except
you can have some vegetables,but it's a very limited amount.
And so when people startedcoming in saying, oh, it's too
(49:34):
expensive and all that grass-fedbeef, you know, I was like what
are you talking about?
So the Internet.
Keto blossomed and yet I'mstill teaching the old Atkins
induction the way they did itout of the office.
Dr Atkins died, I'm afraid,during our second study so I
couldn't ask him, but I was ableto ask his nurse, jackie
(49:57):
Eberstein, who's been with me asa consultant along the way or a
mentor, and she's now retireddown in Richmond, virginia, from
New York City where she lives.
So that's the deep, deep south,even though I'm in Durham,
which is south of Richmond.
So I guess what I've stuck to myguns and what I've learned is
(50:19):
that a lot of the internet stuffout there is just a distraction
and my scientific approach iswell, until you add this to what
I'm teaching, what I'm teaching, I'm not going to use it.
(50:39):
I mean in a formal way, so thatI learned that some people have
to even be stricter than what Iteach.
So there's a elimination dietfactor to what we do.
Well, if someone has a problemwith gluten, you tell them not
to have wheat.
Someone has a problem withgluten, you tell them not to
(51:00):
have wheat Duh.
So someone does a carnivorediet or a keto diet, they're not
having gluten, so it'sgluten-free.
All the dyes are gone if you doit in a certain way, and so I
guess what I've learned is thatthere is but I can't really
figure out the percentage offolks because I don't have a
denominator it's that people arecoming saying you know I did
your program, it was fine, youknow it helped, but then it
(51:22):
stopped.
And then I got rid of all ofthese vegetables and, oh boy,
everything just started to getbetter, even my stomach and my
skin, and I'm just listening tothese stories.
So I'm very intrigued about asubset of low-carb keto where
you eliminate all the vegetablesand talk about controversial,
(51:43):
you know, but adding.
So I'm very interested inlearning new things, like the
microbiome, and yet I'm struckwith we've been doing this
without talking about themicrobiome for so long.
Who really needs to add that toit?
Or maybe if we teach somethingand someone gets stuck, we add
(52:07):
that to it.
So I guess I'm sort of my VAtraining, veterans Affairs
training, kind of gave me the.
I don't want to overdo it, Iwant to try to do the minimal,
effective approach, you know.
But adding fish oil, of course,is something that Dr Atkins did
even back in the 90s, so but Ithink what he saw was the
(52:30):
dramatic triglyceride reductionfrom the fish oil.
And so I guess, to restate thatI guess I've learned that what
I learned 25 years ago is reallyeffective and kind of a safe
harbor for a lot of people whoget off on all these other
(52:53):
tangents and metformin orcoconut oil or medium chain
triglyceride or apple cidervinegar, all these things.
If someone comes in with stomachGI issues, nausea, something
like that, well, that doesn'thappen when I teach this, that
doesn't happen.
(53:13):
It's got to be one of thoseother things.
When I teach this.
That doesn't happen, it's gotto be one of those other things.
And so I can sort of helptroubleshoot something that
might that somebody that Ihaven't taught could be a
culprit, for someone recentlyhad intractable nausea, you know
, for a year, and finally shecame back and I said well, how's
(53:34):
the nausea?
Oh, it's gone.
What happened?
We talked about this a lot andshe said I stopped the coffee.
It was the coffee giving thenausea.
So you know you don't need arandomized trial or a big cohort
of trying without somesubstance yourself.
So I guess the other thing I'velearned is the end of one
(53:56):
trials.
The individualization could be.
You just go without the blankfor a couple of weeks see how
you feel.
You know if it's like a symptomof nausea or skin issue or
something like that, and that wedon't have to wait, even though
you know I got criticized being, you know, mr, randomized
(54:18):
Control Trial when I was intraining.
I want that level of evidence.
You can learn a lot about yourown body and what happens by
doing these manipulations andgetting the measurements and so
and no, you're not like at theedge of a cliff, you know, with
(54:39):
danger next door, like the otherdoctors are saying yeah, that's
and that's not appropriate.
I'm getting less tolerant ofthose doctors who are
fear-mongering.
You know what you want to do isjust measure the things you can
, and you know, measure thearteries, not the bloodering.
What you want to do is justmeasure the things you can and
measure the arteries, not theblood.
Cholesterol, if you can, andstay away from the sugar as best
(55:05):
you can, even looking at bluezones and looking at longevity,
so you could put keto over intothis.
Oh, that's a therapeutic thing,it reverses diabetes and all
that and then you'll want tostop it, right?
I don't know Even the latestresearch on cutting carbs out.
(55:25):
It doesn't have to be to theketo level.
But I think there's a signalthat keeping insulin very low is
something that will help youlive longer for longevity.
And yet the basic scientistscan't quite put two and two
together right.
It's the well caloricrestriction it's got, you know,
that works.
(55:45):
And the one meal, fasting,mimicking diet well, that works.
And then there's a study thatreviewed all of these other
studies and a keto diet and acalorie restricted diet.
They worked a little bit forlongevity and well, actually, on
a properly taught low carb orketo diet, people eat less, so
(56:08):
it's actually a calorierestricted diet compared to what
the other Americans do.
So what we teach kind ofdoesn't fit into the paradigm of
what scientists typically study.
And I'm hopeful, and it's abouttime that we have clinical
(56:30):
reviews of the data that peoplehave collected in a clinic like
this.
I'm not able to do that becauseit actually costs a lot of
money and our computer systemthe one that academic research
kind of bought into out ofVerona, wisconsin, the Epic it
(56:50):
just doesn't.
You can't just be the doctorgoing in and querying your
information.
You have to hire someone elseto go in and do it and well, or
get a medical student to do itfor you, which happened this
year.
One of the med students workingin my clinic at Duke assembled
the heart failure cases that wehad, and so now actually there's
(57:14):
a signal for ketosis and givingketones for heart failure cases
that we had.
And so now actually there's asignal for ketosis and giving
ketones for heart failurereversal.
Of course, I've seen it happenseveral times in my clinic, but
that doesn't count because theyalso lost 140 pounds during that
weight loss and heart reversal.
No, that counts.
That's part of the process.
(57:35):
So anyway, I think we're goingto hear more about the heart
failure treatment with drugsthat increase ketone levels.
No, it could actually happenwith diets that increase ketone
levels.
So I guess I was just sayingthat having our own clinical
data and audits it's about time.
(57:56):
You know, dr Jen and Dr DavidUnwin have been able to do it in
their little practice in the UKand they've even shown that
they can save the governmentmoney in their own little
practice.
And it's not just what they do.
They have a family practicethat treats lots of different
things, but it's, I think,getting to that point where, if
(58:22):
the show, we can not just onlyhelp health but also save money.
That's kind of crazy, but Iguess that'll turn the heads of
those in charge of the system.
Speaker 1 (58:35):
May I ask a personal question what's in the future
for you, and does it includeretirement?
Is that on the horizon?
Speaker 2 (58:44):
Oh, you know, I feel like I'm just getting started.
So the interest now at agrassroots level has never been
stronger, you know, even thoughit no, it's never going to, you
know kind of puncture orpenetrate through into the
(59:04):
medical world, I've kind ofthere are other agendas and and,
yeah, for a while it disturbedme or made me mildly depressed
that my other, my colleagues,didn't care, they think I'm
doing something really crazy andall that.
And yet they're gettingdepressed because nobody gets
better.
And that's why I gravitatedfrom the VA system as an
(59:28):
ambulatory care internalmedicine doctor.
We palliated people.
They really didn't get better,and now I see people get better.
So I'd like to remain at auniversity setting because I
think it allows me to teach andthe research now has been put
(59:49):
together in a textbook ontherapeutic carb reduction or
restriction.
We contributed a couplechapters in there.
There are a couple organizationsthat are teaching other people
how to do this the Society ofMetabolic Health Practitioners.
I'm on the board there and weteach non-physicians and you
(01:00:10):
know, when you think about it, Ilooked on your videos recently.
You interviewed someone andsaid is the future of healthcare
health coaches?
I'm all in.
I mean, you don't need to.
Yes, I think health coachingand the proper guidance without
a doctor's credential is goingto be critical, because doctors
(01:00:32):
get overtrained.
You don't need someone to knowhow to do, uh, appendectomy if
they're just telling you not toeat bad foods, right, so you
know.
It's kind of like when adisaster happens.
You train people to go in whatthey need to know to help in
that area.
You don't ask you know supertrained people to to go in
(01:00:55):
necessarily for relief efforts.
And that's where we are still.
Like you say, you just go tothe mall or the grocery store
and we are still in sort of acrisis situation with obesity,
diabetes, the chronic healthconditions, and so I'd like to
continue to teach and it's beenslow going.
(01:01:17):
But the people coming inshowing how they've reversed
things that doctors have beenunable to figure out for decades
, that's pretty petty stuff.
That's gratifying, and Iremember that came Dr Atkins and
(01:01:39):
Jackie Everstein 25 years ago.
I said how can you do this?
I mean, nobody respects you andall this.
We go to work every day and wesee that people are getting
better and that's enough and itjust I wish it would grow, but
that's often beyond, well beyondmy control.
Speaker 1 (01:02:03):
I was hoping that was going to be your answer,
because I thought the same thingthat we have so much to do.
There's so much yet to do.
I wish we were 25 again,because it would take at least
that long to have a biggerimpact.
But keep on wishing right.
Dr Eric Westman, thank you verymuch, truly a pleasure seeing
you again.
Speaker 2 (01:02:21):
Great, it's great to be here, great to see you too.
I first met Dr Eric Westman at a low-carbohydrate
meeting a number of years ago,where he discussed an extremely
important and insightful humanclinical trial that he had
conducted, in which he counseledparticipants with type 2
diabetes to follow a verylow-carbohydrate, essentially
ketogenic diet.
He was almost prohibited fromconducting the study because
(00:28):
some colleagues felt that it wastoo dangerous.
Nonetheless, the study wascompleted and demonstrated that
the type 2 diabeticsparticipating in the study no
longer needed insulin and mostdiabetes drugs, while achieving
improved blood glucose measuresby engaging in a lifestyle that
was the direct opposite ofconventional dietary advice.
(00:49):
As groundbreaking as the studywas for its time, it is simply
not talked about enough, as isone of the most important pieces
of evidence that validates theidea that limiting carbohydrates
and sugars not fats, notsaturated fats is key to, in
this case, improving diabetescontrol, even helping make many
(01:11):
people non-diabetic.
I therefore thought it would bea good idea to ask Dr Westman
to describe his rationale forthe study, discuss the results
and share the lessons he'slearned since then.
I'll also tell you about DefiantHealth's sponsors Paleo Valley,
our preferred provider for manyexcellent organic and grass-fed
food products, and BiotiQuest,my number one choice for
(01:34):
probiotics that arescientifically formulated,
unlike most other commercialprobiotic products available
today.
I'd like to make you aware of anew source for our favorite
microbe, lactobacillus roteri,and a skin formulation I
designed that improves skin fromthe inside out.
Dr Westman, thank you forjoining me.
(01:57):
I have been following your workfor a number of years, ever
since we met gee maybe 15 yearsago or so and I remember you as
the one who had the courage topublish a study that was very
different in, of all things,people with type 2 diabetics.
And even though it's some yearsback, I fear not enough people
have heard about this veryimportant study.
(02:17):
Would you mind recounting whatit is you were doing and
thinking back then?
Speaker 2 (02:22):
Sure Well, and it's great to be with you.
You know, the idea that whatyou eat might affect your blood
sugar is lost upon many doctors,if not all doctors, and so when
I was, I started first lookingat low carb diets for weight
loss, but then learned veryquickly that they'd been used
(02:43):
for something else, and that wasdiabetes, type 2 diabetes in
particular.
So when I did a few studies onobesity, it showed that clearly
you could lose weight doing whatwas called at the time the
Atkins diet, atkins induction Imean.
So this is going back to theyear 1998.
After doing some research there, I thought well, what else was
(03:06):
Dr Atkins doing?
What else would make sense?
A patient of mine brought in abook from 1923 before insulin
was discovered and as a bit of ahistory buff, I'm looking at
this and the exact diet that Iwas studying now is what was
used 100 years ago to treatdiabetes, type 2 diabetes.
(03:29):
So the logical next step for mewas well, let's do a study on
diabetes, and I always wanted acomparison group in my studies
doing randomized controlledtrials.
I'm kind of known as a sticklerthat I don't really like
correlational studies and havebeen criticized for that.
I'll take that criticism.
(03:50):
I want experiments, and so wedesigned a randomized trial that
was looking at low-carb,ketogenic or today it's called
keto, but not weird keto on theinternet and then I thought by
now this was 2008, when it waspublished everyone will be using
the low glycemic diet.
(04:10):
Because you lower the carbs,the diabetes gets better, right?
Well, so we looked at low carbversus low glycemic in a
randomized trial over six monthsand, lo and behold, the group
that had lower carbs, the lowcarb keto group, did a lot
better than the low glycemicgroup.
(04:32):
And, of course, these both arebetter than what the diabetes
organizations still recommendtoday.
So it's been a bit of a headscratcher for me.
Why diabetes organizationshaven't, you know, as a rule,
said look, just don't drinksugar.
Diabetes is a problem of toomuch sugar.
So anyway, that's funny.
(04:53):
You ask about the.
You know, looking back, it's aproof of concept study.
You know it's like it's not therandomized trial in the New
England Journal.
You know, like it's not therandomized trial in the New
England Journal, you know, with5,000 people per group showing
this over.
But it sure was obvious to methen and obvious today.
(05:14):
Now, having treated people inthe clinic, I kind of look back
saying, well, you know that iskind of quaint to look at that
study because I can go waybeyond a research protocol now.
I mean so as a clinical doctor,you know that you're not
constrained by a certainprotocol.
When you're in the clinic youcan actually say, jim, I know
(05:38):
your wife and you can use leversto make things work even better
than what the clinical trialsshowed.
But even looking back I read itagain recently half the people
who were on insulin in the studywere off insulin by six months
(06:01):
and I calculated that all ofthem pretty much had an A1C
under 7% on the low-carb dietsand most of them were off their
medicines in addition.
So you know, being kind of anunderstated scientist, you know
(06:21):
today, if I would redo the titleand you can get away with
titles and papers I could neverget away with before this
low-carb diet reverses diabetesin almost every case and of
course that's what I say to mypatients who come to me who have
some skepticism about it.
And even then most people don'teven know that you can reverse
(06:45):
the type 2 diabetes.
Speaker 1 (06:48):
This is some years back, but what was the reaction
back then among our colleagues?
Speaker 2 (06:54):
You know there wasn't one.
You know, looking back and yousay that I had the courage, you
know, like most doctors I didn'tget much training about
nutrition and maybe I got totalparenteral nutrition training in
internal medicine in the ICUs,right Intensive care unit.
(07:17):
If someone's not eating youhave to figure out what to give
people.
But by the time you get outinto practice you practice.
Everyone knows back then thefood pyramid was the healthiest
thing and of course it's not.
But I didn't really know howbad the things were, how
distorted they were, until acouple of our studies came out
(07:38):
and then the kind of backlashwas not to me personally.
I have to say I've never,because we treat people and
patients and the patients getbetter that it's very rare for a
doctor to be called in front ofa board for a policy thing.
It's more a one-on-one If youmess up and someone complains
(08:03):
and we're using things thatreally work.
I mean there are evenalternatives to drugs.
That now it's in clear focus tome that the medical world has
(08:35):
been really groomed bypharmaceutical companies to
really just treat doctors whatthey need to know about
medicines and so the typicaldoctor won't know that food
really matters and even thatdrinking sweet tea here in the
South will raise your.
I had someone come up raiseyour butcher.
I had someone come up 180 unitsof insulin in two days because
(08:57):
he was drinking so much sweettea Coca-Cola like substance
that he was using insulin, andhe didn't tell me.
Can you imagine someone comingin and confessing to you that
you're drinking two liters ofsweet?
No, it was only afterwards.
I said, oh my goodness, whatwere you doing?
And he said, well, I didn'twant to tell you.
But that just shows how muchhope there is, too, though, that
(09:22):
if you're still consuming sugarin drinks or in food, and
starches get digested to sugar,so it's really the same thing.
There's hope, and it's likelythat you'll be able to reduce or
eliminate these diabetesmedicines as you stop consuming
so much sugar that the medicinesare treating.
(09:43):
So you know, then, along theway, as you have been in it a
while as well, I have to say,there are all these blogs.
Remember those blogs, and Iremember Mike and Mary.
Dan Eads, who wrote ProteinPower, had a clinic and they
(10:04):
were using it in their patients,and then he wrote just kind of
this simple mathematicalcalculation about how much sugar
is in the blood and it stuckwith me and through the years I
have used it in teaching andI've even taught it to academic
(10:25):
endocrinologists, because theywould come up to me and say you
know, I never really thought ofit that way.
There's only a teaspoon ofsugar in the entire bloodstream,
so that you can double yourblood sugar by having a teaspoon
or two of sugar.
That's it.
And this could create thesurroundings, environs, for
(10:47):
diabetes.
And so we're dealing with asituation where there's just not
much sugar, not much glucose inthe blood at a given moment,
and that's anotherunderappreciated kind of fact
that we deal with.
But again, that shows hope thatif you're not paying attention
to the carbs it's the generalterm to put all this together
(11:09):
and you haven't reduced carb yet, then you don't have to go down
to the keto level necessarily.
But if you haven't reallyunderstood that, then there's a
lot of room for improvement interms of the blood sugars and
you mentioned type two diabetes,but insulin resistance and
prediabetes room for improvementin terms of the blood sugars
and you mentioned type 2diabetes, but the insulin
(11:32):
resistance and prediabetes.
I mean you want to really takeaction before the blood glucose
goes up and the pathophysiology.
The problem is actuallyhappening with elevated insulin
levels, maybe 10 or 15 yearsbefore the glucose goes up.
So, and again, most doctorsdon't check the fasting insulin
level.
So we're endlessly trying toteach not only how to measure
(11:52):
this, but then the importance ofthe carbohydrate and the diet
and at least limiting it formost people.
Speaker 1 (12:02):
You know, I've often wondered because your practice,
your clinical research has beenso contrary to prevailing
standards what happened when youtried to present this to your
local institutional review board.
So your listeners may not knowthat in order to do a clinical
study, you just can't do it.
You got to get permission froma board of scientists,
(12:24):
physicians, ethics people,clergy a board of scientists,
physicians, ethics people,clergy sometimes who say yes, dr
Westman, it sounds reasonableor no, this is dangerous or
whatever, based on their opinion.
Speaker 2 (12:38):
What was their reaction?
Well, so this is gosh.
We started our research 25years ago and I think we
benefited from the fact thatjust most doctors aren't aware
of what nutrition does, becauseour first few studies even they
were funded by Dr Atkins and hisfoundation at first.
You know, we like any goodinstitutional review board, you
(13:01):
know there's a local and thenyou can actually pay to reach
out.
But ours was local VA, durhamVA or Duke, and part of it is
they know who the investigatoris right, so it's not like Joe
Blow is coming in to do a studyrandomly on something.
So I knew a lot of the peopleon the IRB locally.
(13:24):
For our first study I was partof that peer group of
researchers learning researchand so actually the first study
we did, the review board saidwell, this is fine.
So it was only six months ofchanging a diet, although some
people said that would kill youin a day.
Right Back then it was justkind of crazy.
(13:46):
Well, some people say thattoday even.
But during that first studythere was a dietician who
complained to the hospitaldirector about our study, and so
it wasn't the review theresearchers.
There was a dietician who gotwind of it and said look,
researchers, there was adietician who got wind of it and
(14:08):
said, look, this is unethical.
And turned out the hospitaldirector at the time was pro, or
tilted toward bias, towardvegetarianism, maybe even vegan,
and so they got upset about itand they actually lobbied the or
the IRB, the research board, tostop the study.
So again today it plays out asthe politics that are kind of at
(14:31):
play, that are going back andforth.
The science has always beenhere and solid and true, so
there will always be thatpolitical controversy.
But the research board, many ofwhom I knew, basically said well
, we're not going to tell him tostop the study, but we'll make
him do more reports.
And so that's what they did.
(14:52):
They said you know, dr Westman,you're going to have to file a
monthly report to just show thatyour patients, research
subjects, aren't dying, and soit was a reasonable compromise.
And what's kind of crazy isthat research should be testing
things that are controversial.
(15:12):
It's not like that.
We know everything aboutnutrition or even non-nutrition
concepts.
So the idea that you squelchthat investigation was a
learning experience for me,because I was naively, as a
researcher collectinginformation and doing some
(15:33):
anti-diet visit at Dr Atkins'office and I saw what happens
after years of being on the diet.
So it became almost I don'tknow obvious or petty that
something else was going on,that the clinical world even
today is so far ahead of thescientific publications and
(15:56):
that's often confusing to people.
But later in the research wedid, I didn't get any kind of
pushback.
And IRBs again are localphenomenon.
Some would be more open thanothers and say one study there
(16:17):
was one study that I know ofthat was kind of shut down and
it had to do with mental healthand they were claiming they were
mistreating these vulnerablepeople and naturally they were
probably helping them bychanging the diet but don't feed
them fat.
So I mean I laugh about it nowGoing through it.
(16:40):
It's not a great process to getout.
Give research you've worked onfor several years to a meeting
and then it just falls flat.
Right, you want other people tobe excited about it, but the
patient care that we were ableto do locally.
So I opened a clinic, basicallyusing what we had studied and
(17:01):
what other doctors had used fordecades, is really what kept me
going.
It's just so thrilling to seepeople get better and okay,
there are times when I kind ofrelish the idea that it's
rebellious and all that.
But at first I didn't know.
I had no idea what hornet'snest I was getting into.
Speaker 1 (17:25):
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.
You know, you and I have beendoing this.
What?
25, 30 years, something likethat.
And yet you and I can go toWalmart or Target or Costco or
(20:47):
the mall and see that the vastmajority of people this has not
had any impact on their thinkingwhatsoever, like your patient
with the sweet tea.
Any thoughts on why the uptakehas been so slow, so painfully
slow?
Speaker 2 (21:00):
No, yeah, I think it's multifactorial.
Of course there are a lot ofthings, but the most prominent
reasons, I think, are themedical world is still wrapped
up in drug treatment.
It's reactive and it's reallynot preventative.
And it's been that way in ourentire careers.
(21:23):
I mean, it's nothing new.
And everyone kind of expectsthe medical world to be
proactive.
No, they're not going to be.
But over the last couple ofyears I've learned, and I guess
I was primed for the idea thatthere might be addiction going
on, because I spent 10 yearsworking on smoking cessation and
(21:43):
nicotine techniques and helpeddevelop medications for nicotine
treatment.
So their Chantix came from theresearch that Dr Jed Rose and I
did at Duke, you know 30 yearsago, and now you know, you see
Chantix out there.
So I was kind of ready, I think, to accept the idea that food,
(22:09):
sugar, starch, it could be bread, it could be addictive.
And then the idea that what Iwas teaching people a total
elimination of carbohydrates.
So I give people a sheet ofpaper and say eat as much as you
want of meat, poultry, fish andshellfish and eggs which have
zero carbs, and then a littlebit of these other things, and
(22:30):
it occurred to me that what I'mdoing is sort of a cold turkey,
if you will, for sugar andstarch, and when you quit
smoking the time-honored way isto just cut them all down.
Cold turkey, quit smoking.
So I've learned over the lastfew years applying the addiction
ideas and even into the therapyof treatment of someone who has
(22:55):
diabetes or overweight.
Using the addiction model canbe very helpful and so I think,
kind of like when I was a kid,everyone would be smoking.
We were watching an old moviefrom the 70s and they were
lighting up everywhere in thedoctor's office having a
(23:15):
cigarette.
How could you imagine thattoday?
But I think carbs, sugar, isaddictive, unfortunately for a
lot of people.
So when you see the enabling ofan addiction by the family, the
(23:35):
school system, the hospitals, Imean for heaven's sake, you can
go in for type 2 diabetes outof control at a hospital and
they feed you sugar at thehospital.
This makes no sense.
So I've learned a lot from DrVera Tarman and Dr Jen Unwin,
who have worked on this idea ofsugar and ultra-processed food
(23:59):
addiction, and I bring that intomy one-on-one teaching and then
at meetings as well, and Ithink that into my one-on-one
teaching and then at meetings aswell, and I think that explains
the widespread problem.
I mean, and those with type 2diabetes or end up with weight
loss surgery as a treatment, Ithink are the worst, hardest
(24:22):
core sugar addicts, hardest coresugar addicts.
And if you ask someone who's anaddict, to their face that
they're an addict, of coursethey'll say no right.
So, just like alcoholism orsmoking or some other drug of
addiction, most people won'treally acknowledge that they
(24:44):
have a problem with sugar,ultra-processed food being
addictive.
But you look at the almostconstant consumption of this
stuff.
It's not because they're hungryWell, it is because they're
hungry.
It's not because they lackenergy storage on their body,
right, so they're eating.
People are generally eating forsome other reason, and remember
(25:07):
the ad Bet you Can't Eat One,and it was Lay's potato chips.
You don't see those ads anymore.
They would get in trouble ifthey push that edge.
And then it's been a long timesince we saw advertising for
cigarettes on billboards, and soto me that seems like a natural
(25:28):
progression that there ought tobe some sort of limitation on
especially to children, onsugary things that to advertise,
you know, fruity pebbles, andanyway, that's getting into
things that we might do toprevent our children becoming
addicted and or at leasthabituated.
Anyway, that's getting intothings that we might do to
prevent our children becomingaddictive or at least habituated
(25:51):
to eating all this stuff.
Speaker 1 (25:53):
As you know, the natural corollary to limiting or
reducing or even eliminatingcarbs is to increase your fat
intake oils, fats, saturated fat, oleic acid, extra virgin olive
oil, butter, et cetera.
So I take it you've not seen anexplosion in cardiovascular
events?
Speaker 2 (26:09):
No, no.
And that was of course an issue20, 25 years ago and it's still
an issue today in people'sminds and I think it will be an
issue forever in some people'sminds, so that if you're taught
a certain dogma, it's hard toundo that.
In fact, someone taught me orreminded me recently that if
(26:32):
you're prejudiced, there's noamount of data that will
dissuade you of being prejudiced.
So the idea that we can livewell without carbs kind of
became clear to me.
In fact it could be therapeutic.
So cutting carbs out of thediet would help people lose
(26:53):
weight, feel better, reversediabetes, metabolic syndrome,
all these other issues.
But then there was always thisbut in fact I met a researcher
who said but Eric, I couldn't godown on the carbs anymore
because what would I do?
Raise the fat, you know.
So there was this fear in theresearch world.
(27:14):
Of course she wasn't an MD.
So we have a lot of the PhDsare taught this boundary of safe
use and these rogue.
You know Dr Atkins was vilifiedfor telling people to eat fat,
although in that context itseemed fine.
And so as a minimal like tojust stay in my lane, I'd say
(27:36):
well, you know, if you don't eatcarbs.
Eating this fat looks finebecause you're burning it for
fuel.
And so these documentary filmscame out talking about running
on fat for fuel.
And these elite athletes aredoing heroic levels of exercise,
rowing from San Francisco toHawaii running on fat for fuel.
(27:57):
So okay, so at least in thelow-carb context, fat doesn't
seem to matter.
And then you get open to thatidea.
Then you start wondering well,I wonder how bad it was really
in those other contexts and howsolid was the science that
(28:18):
eating fat was bad?
And I was heavily influenced bythe work of Gary Taubes and
Nina Teicholz, who assembled thescience on the implication of
eating fat and even ofcholesterol in the blood, and it
wasn't really good science.
But then they're not doctors,right?
So you have the investigativejournalists reading data that
(28:42):
even I bet they read morestudies than even the expert
scientists because they readoutside their own work.
So in the context of a low-carbdiet, eating fat seems fine.
You're burning it for fuel.
Even people eating carbs wasn'treally very solid in the first
(29:06):
place Gets you started to wonder.
You know, in the big pictureview, what's more important and
do you worry about fat ingeneral?
And of course, it's thecardiologists who seem to be
holding this banner of you know,still, fat in the food is bad
(29:27):
and fat on the arteries comesfrom the fat on the foods and
I'm afraid it's probably notthat solid.
And you can see I'm tiptoeingaround all this because I'm
still working with hundreds ofdoctors at a university who have
that belief system, you system.
So I have to at leastacknowledge that that might be
(29:50):
true.
And yet now we have a studythat's unfolding of people with
LDL levels the lousy, the lethalcholesterol level that are two
to three times higher than adoctor would typically accept
before treatment with a drug.
Of course this is in a low-carbcontext, but they for five
(30:12):
years self-report and by oneyear under supervision, even
with these super high CCTAtechnology, which is one of the
(30:32):
best we have, that'snon-invasive.
So I'm beginning to reallywonder if the LDL idea, if the
medication maybe, is thepleiotrophic, the
anti-inflammatory effects ofthese drugs.
But then a movie comes out thisyear called First Do no Pharm,
(30:54):
p-h-a-r-m First Do no Pharm.
And in there Fiona Godley, whois an editor, former editor of a
prominent medical journal,basically says that the industry
, medication industry, oftreating cholesterol, has never
been transparent.
And they've tried, they'veasked and I don't even know if
(31:15):
it's gotten to a court order orthat level of, but they've asked
to have transparency to be ableto see the data from these
studies.
And at a recent meeting with acouple of cardiologists you may
know Nadir Ali who talks aboutLDLs being good for you and all
this we basically could onlycome up with one study that was
(31:37):
not drug company funded forlooking at these
anti-cholesterol,cholesterol-lowering medicines,
and in that study it didn't work.
So there's a lack ofindependent replication.
And then, even when Dr Godleyon film said that this industry
has never let us look at theirdata, I mean I would think if
(32:00):
someone asked to look at mypaper's data I would go back.
It's on some old computer.
It might even be printouts, butI would be happy to show it
because it works so well.
It makes you suspect and I'mnot a conspiracy theory kind of
guy, but it makes you wonder.
And so I do have a paper thathelps people look at the Mayo
(32:27):
Clinic statin decision tool,which is just a way to look at
the number needed to treat and avisualization of if I do take a
medicine, what's the likelihoodthat it will, what is my
likelihood of a heart attack andhow low will it make it go.
And the relative risk reductionit looks really good, but the
absolute risk reduction lookskind of small for a lot of
(32:51):
people, and so I think peopleshould be able to look at this
information and make their owndetermination.
Which then puts me out of lineor out of sync with the
guidelines that say youshouldn't even you know, don't
even think if the LDL is abovethis level you should treat with
a medication.
But that is a fascinating areaof kind of weak science that got
(33:20):
into drug treatment and nowkind of dogmatic point of view
that it's hard to change thiskind of thing, except if you
show a different approach can doas well.
You know, most of the timepeople will glom onto that new
approach.
I mean, who knew that we wouldbe able to take pictures with
(33:41):
our phone, you know?
And so as that new technologycomes out, you know, as people
start seeing that not eating thesame way improves their health,
and we don't have an epidemicof heart disease with these
folks, even though it waspredicted, I'm hopeful that even
(34:03):
despite the addictive nature offoods that people will end up
going in this direction.
The time lag between eating aTwinkie and having diabetes.
It's just not quick enough, youknow.
I mean, it's hard to know thatyou're really harming yourself
(34:27):
with something that tastes sogood.
Right, that's kind of theteaching that needs to happen, I
think.
Speaker 1 (34:36):
So what has this meant for your day-to-day
clinical practice?
Somebody comes, dr Westman, myprimary care doc, says my LDL
cholesterol is 212.
My primary care doc says my LDLcholesterol is 212.
So, and have you gottenpushback from hospital
administrators, other peopleinvolved in scrutinizing what
docs do and what they prescribe?
Speaker 2 (34:54):
Yeah, From other doctors and mid-levels will use
thumbscrew techniques to get mypatients to use medication.
I mean, it's the level offear-mongering.
And so if I calmly talk throughthe statin Mayo Clinic statin
(35:20):
decision aid tool, it's not myaid tool, it's from the Mayo
Clinic and I just point thesethings out and I say, well, you
know, it's really for you todecide, you, the patient, and
that's kind of my approach.
So doctors are.
No one's ever complained, youknow, knock on wood.
(35:40):
No one's ever complained, knockon wood, no one's ever
complained.
To one of my superiors becauseI think that again, the patient
is generally the approval boardsand things kind of got into it
(36:02):
too soon and nobody was harmedfrom it.
But my patient experiences ledme now to worry less about the
blood markers and worry moreabout the anatomic determination
of whether someone hasatherosclerosis or not.
So going to the calcium score,coronary, the CAC score, the CT
(36:28):
angiogram being so, I teach mypeople a small group of folks
who follow that repeat after mecholesterol is not a disease.
Now wait, you know, cholesterolis not a disease.
Atherosclerosis is the disease.
We're trying to preventAtherosclerosis.
So you have to repeat this overand over because you go into
(36:52):
the doctor's office andimmediately well, your
cholesterol is high.
But, doctor, is it a disease?
Really?
My cholesterol no, soatherosclerosis.
So you've probably been lookingat coronary calcium scores
longer than I and I'm doing thebest I can kind of piecing
(37:13):
together the knowledge of.
So, the calcium score, the CTangiogram, this will explain or,
to the best of our ability, seeif you've had damage before.
The coronary score, of course,is a bit of a Pandora's box,
because if it's zero it's veryprognostically good For the next
(37:37):
10 years you're not likely tohave a heart attack.
But it's not perfect.
So you'll see online and I'llbe trolled by someone who says,
well, I had a normal calciumscore and I had a heart attack
the next day.
Well, right, it doesn't shownon-calcified plaque.
I mean.
So we're dealing with teststhat are imperfect.
In a world that people wantperfect tests, and especially
(37:59):
the engineers who come to thebiologic system of the human
body, they just can't.
Well, but they expect the bodyto be like a computer or a
machine.
But we have adaptive responses.
And so now especially, actuallythe reason I kind of got into
this measurement through calciumscore and the CT angiograms is
(38:25):
because I felt myself defendingmy patient who had an LDL of 300
.
An LDL of 300.
This is way too high foreveryone else's comfort.
But this person was 70 yearsold, felt great, had no obvious
(38:46):
no history of a heart attack orstroke and when they got the
calcium score it was zero.
So at age 70, if you've gone 70years without any damage to
your arteries and a doctor isgoing to put you on a medicine
to prevent a disease you don'teven have, this is craziness.
An oncologist would not giveyou chemotherapy or radiation
(39:10):
therapy if they didn't havetissue diagnosis.
So I guess.
So, dr Davis, back to you.
How did our field in?
Internal medicine is my firstfield, and then obesity medicine
, my subspecialty.
But I could have been acardiologist or rheumatologist.
That was kind of what I likedbecause you treated the whole
(39:33):
body.
But so how did our field startgetting into?
Well, I don't really know, butit's likely that you have cancer
, so we'll give you thischemotherapy, you know.
But so it's likely you haveheart disease.
So here take this.
How did this happen?
Speaker 1 (39:49):
You know, I think it got started around the 1920s
when such things as penicillincame out.
If you had pneumococcalpneumonia, take penicillin.
And that paradigm seems topermeate all that we do in
conventional medical practice.
If you have high cholesterol,take a statin drug.
You have a high blood glucose,take metformin and bieta
injections.
You treat things.
(40:11):
One of the things I've beenplaying around with for at least
a decade now is this philosophy.
It's not 100, but and that is,rather than thinking about
treating these phenomena, let'saddress the factors, as you've
been doing that.
Let's subscribe by talking toyou is you and I have gravitated
down the same path, fromdifferent starting places but
(40:32):
arriving at the same place.
So I was doing CT heart scans30 years ago.
I got all kinds of crap forthat.
I can tell you.
It was one of the firstscanners in the Midwest.
But it showed me, as you pointout, cholesterol is not a
predicted.
There was no correlationwhatsoever.
In fact, we contributedpatients to the Tulane
University Bell's trial.
(40:53):
This goes back 20 some years,yeah, and we showed that if you
did nothing for a coronarycalcium score, it goes up 25%
per year.
If you go on Lipitor 40milligrams, baby aspirin, low
saturated fat, low fat dietexercise program.
It goes up 25% per year, noimpact whatsoever, with real
(41:16):
humans and they're freaking outand they're scared and, of
course, my unscrupulouscolleagues.
It's much worse in the privatesector, I think, where they're,
my colleagues, saying well, john, you're a walking time bomb, I
can't be responsible for yoursafety when you leave this
office.
I'm going to send you to thehospital for heart
catheterization.
See if you need a preventivebypass or stent.
(41:37):
As you know, this is still doneit Intentive bypass.
As you know, this is still done, it's wildly done in the
private offices and hospitals.
I refuse to do something likethat.
So I did, admittedly, zigzagand a lot of trial and error,
but found a way to reliablyreduce cardiac calcium scores,
and it had nothing to do withthe stat drugs, had nothing to
(41:58):
do with LDL cholesterol.
So that's wonderful.
You came to the same conclusionand this idea that cholesterol
is not a disease, it's a crude.
It's a lousy marker for adisease.
Let's look at the disease.
I think that's so wonderfulthat you saw that.
Speaker 2 (42:12):
Yeah, and yet to the point of a recent anecdote.
But we can learn a lot.
One of my friends had a coughand a long time, and it was
during COVID, so I hadn't seenhim in a while Finally got an
(42:32):
x-ray for the cough and he hadlymph nodes in his chest.
He had lymphoma.
Basically that was causing it.
But he also had suchcalcification of his coronaries
that you could see them on thechest x-ray.
You know this is pretty extreme.
You don't normally see theoutline of the coronaries.
(42:53):
So sadly, you know, they did acatheterization.
He had total blockages of hiscoronaries and had collaterals.
But they got to the treatmentof the lymphoma first and after
a couple of chemotherapy eventshe died, probably of a heart
attack.
That was the stress test thatyou know.
In a different world he wouldhave had the bypass done first.
(43:16):
But you know it's a toughjudgment call there.
But when I ask this and talkabout this to my colleagues they
say well, but did he havesymptoms of heart disease?
And I said well, no, thinkingthat he was totally sedentary.
In fact he was the guy whowould be there late at night
(43:37):
sound mixing.
The groups would come in andsing in his house and he'd mix
it all night long and he neverexercised at all.
So if you wait for a symptomand you're not really using your
heart much, you can developtotal blockages.
Here and in my cohort ofcolleagues it never occurred to
(43:58):
us that maybe we should justtake a look.
You know, maybe even if there'sno symptoms especially when you
know 20 or 30% of people theirfirst event is a heart attack or
sudden death that maybe weshould take a look at these
arteries, even if you'reasymptomatic.
(44:18):
Phil Ovedia, who's acardiothoracic surgeon
symptomatic Phil Ovedia, who's acardiothoracic surgeon calls it
the mammogram of the heart tohave the coronary artery calcium
score.
And I'm not quite sure it needsto go that far because even some
of the health servicesresearchers that I've worked
with that's my field that Istarted with don't think that
total screening of everyone withmammograms is a great idea.
(44:40):
But so anyway, it's a goodsoundbite at first to say well,
you know, everyone should atleast look.
You know, especially if you'rechanging from a sedentary to an
active life, and I see that alot, because someone will have
lost 50 to 100 pounds, go fromjust kind of sitting around,
going out, you know, playingpickleball and hurting their
(45:01):
elbow on the of sitting aroundgoing out.
You know playing pickleball andhurting their elbow on the
pickleball court and you know ifyou haven't had an evaluation
and you're changing, asking yourheart to do more, that might be
another proactive way to lookat the arteries.
Through one of these scans, doyou have sort of a or, like Dr
(45:22):
Ravadia, do you think everyoneshould get a calcium score or do
you have a selection process inyour mind?
Speaker 1 (45:29):
You know, the standard advice is men over 40
and women over 50, subject toalteration if there's something
extraordinary, but like ifyou're a type 1 diabetic or,
let's say, your mom had herfirst heart attack at 52.
Those guidelines have provenpretty reliable, with occasional
exceptions.
So I've been doing that too.
And then we had to develop somenew rules for people who either
(45:51):
.
So, as I mentioned, the 25% peryear is a pretty reliable
number.
That's an oversimplification,of course.
Right, if a score of two goesto four, that's 100%.
If a score of 1,000, two goesto 1,000, that's less than 1%.
So we have to use some judgmentin all this.
But I did learn some lessonsalong the way.
The first time I saw dramaticregression of coronary calcium
(46:14):
scores.
It was something like a scoreof like 780, something like that
.
Next, a scale of like 430,something like that.
Next scan was like 430,something like that, and I said
no way, come on.
So I had to pull up the scan.
This is 25, 28, 30 years ago.
Pull up side-by-side scans.
Of course you're scoringcalcium.
You can still see the contoursof softer elements, and it was
(46:35):
clear that drop in score wasaccompanied not only by a
reduction in volume of thecalcific components, but also of
the non-calcific components.
I started to see that the firsttime I saw that was with the
addition, of all things, ofvitamin d.
You know, I'm in a northernclimate so people here are
miserably sun deprived and ithad a dramatic effect on
(46:58):
coronary calcium scores.
And we used fish oil.
Thankfully the two, as you're,familiar with CT coronary
angiography, so the HEARTS trial, the EVAPORATE trial recently,
have shown that not only is ouromega-3s facilitating reduction
(47:19):
of cardiovascular events, theyfacilitate regression, which,
which is so wonderful, asopposed to progression permitted
by statin alone.
I just love that and that we dothe diet, our diets, very
similar what you've been doingall these years.
I I have factored in microbiomeissues because the process of
endotoxemia is becoming littleby little.
We're on the cusp ofunderstanding, but the process
(47:41):
of endotoxemia is clearly acontributor to insulin
resistance, visceral fatdeposition, high triglycerides,
liver conversion of carbs toVLDL, et cetera.
But that formula has beenworking very well.
You mentioned the idea ofultra-processed food addictions.
What else has evolved over the25, 30 years you've been doing?
(48:05):
What else has changed?
Speaker 2 (48:07):
Well, you know.
So my looking back, one of mycolleagues said I cheated.
I said well, what do you mean?
You use someone else's system,and that was true.
So, looking back, it just madesense to me that I would visit
(48:28):
doctors who were doing this.
I visited Dr Ease they hadclosed their practice, actually,
but Dr Rosedale was still inpractice.
I visited Dr Atkins.
I visited Dr Rosedale and DrVernon.
I visited Dr Bernstein, who isstill alive and practicing out
of his house in Mamaroneck, newYork, and after I visited Dr
(48:49):
Atkins I realized that somethingwas controversial.
In fact, they kind of playedthat up a little bit too.
But I borrowed the list that DrAtkins used in his clinic, and
so I don't teach internet ketotoday, internet keto with the
(49:10):
oils and bulletproof coffee andketo drinks and all this.
I haven't gotten into that yet,and what I teach is still what
Dr Atkins would have taught outof his office in New York City,
where it's basically zero-carbfoods, almost carnivore, except
you can have some vegetables,but it's a very limited amount.
And so when people startedcoming in saying, oh, it's too
(49:34):
expensive and all that grass-fedbeef, you know, I was like what
are you talking about?
So the Internet.
Keto blossomed and yet I'mstill teaching the old Atkins
induction the way they did itout of the office.
Dr Atkins died, I'm afraid,during our second study so I
couldn't ask him, but I was ableto ask his nurse, jackie
(49:57):
Eberstein, who's been with me asa consultant along the way or a
mentor, and she's now retireddown in Richmond, virginia, from
New York City where she lives.
So that's the deep, deep south,even though I'm in Durham,
which is south of Richmond.
So I guess what I've stuck to myguns and what I've learned is
(50:19):
that a lot of the internet stuffout there is just a distraction
and my scientific approach iswell, until you add this to what
I'm teaching, what I'm teaching, I'm not going to use it.
(50:39):
I mean in a formal way, so thatI learned that some people have
to even be stricter than what Iteach.
So there's a elimination dietfactor to what we do.
Well, if someone has a problemwith gluten, you tell them not
to have wheat.
Someone has a problem withgluten, you tell them not to
(51:00):
have wheat Duh.
So someone does a carnivorediet or a keto diet, they're not
having gluten, so it'sgluten-free.
All the dyes are gone if you doit in a certain way, and so I
guess what I've learned is thatthere is but I can't really
figure out the percentage offolks because I don't have a
denominator it's that people arecoming saying you know I did
your program, it was fine, youknow it helped, but then it
(51:22):
stopped.
And then I got rid of all ofthese vegetables and, oh boy,
everything just started to getbetter, even my stomach and my
skin, and I'm just listening tothese stories.
So I'm very intrigued about asubset of low-carb keto where
you eliminate all the vegetablesand talk about controversial,
(51:43):
you know, but adding.
So I'm very interested inlearning new things, like the
microbiome, and yet I'm struckwith we've been doing this
without talking about themicrobiome for so long.
Who really needs to add that toit?
Or maybe if we teach somethingand someone gets stuck, we add
(52:07):
that to it.
So I guess I'm sort of my VAtraining, veterans Affairs
training, kind of gave me the.
I don't want to overdo it, Iwant to try to do the minimal,
effective approach, you know.
But adding fish oil, of course,is something that Dr Atkins did
even back in the 90s, so but Ithink what he saw was the
(52:30):
dramatic triglyceride reductionfrom the fish oil.
And so I guess, to restate thatI guess I've learned that what
I learned 25 years ago is reallyeffective and kind of a safe
harbor for a lot of people whoget off on all these other
(52:53):
tangents and metformin orcoconut oil or medium chain
triglyceride or apple cidervinegar, all these things.
If someone comes in with stomachGI issues, nausea, something
like that, well, that doesn'thappen when I teach this, that
doesn't happen.
(53:13):
It's got to be one of thoseother things.
When I teach this.
That doesn't happen, it's gotto be one of those other things.
And so I can sort of helptroubleshoot something that
might that somebody that Ihaven't taught could be a
culprit, for someone recentlyhad intractable nausea, you know
, for a year, and finally shecame back and I said well, how's
(53:34):
the nausea?
Oh, it's gone.
What happened?
We talked about this a lot andshe said I stopped the coffee.
It was the coffee giving thenausea.
So you know you don't need arandomized trial or a big cohort
of trying without somesubstance yourself.
So I guess the other thing I'velearned is the end of one
(53:56):
trials.
The individualization could be.
You just go without the blankfor a couple of weeks see how
you feel.
You know if it's like a symptomof nausea or skin issue or
something like that, and that wedon't have to wait, even though
you know I got criticized being, you know, mr, randomized
(54:18):
Control Trial when I was intraining.
I want that level of evidence.
You can learn a lot about yourown body and what happens by
doing these manipulations andgetting the measurements and so
and no, you're not like at theedge of a cliff, you know, with
(54:39):
danger next door, like the otherdoctors are saying yeah, that's
and that's not appropriate.
I'm getting less tolerant ofthose doctors who are
fear-mongering.
You know what you want to do isjust measure the things you can
, and you know, measure thearteries, not the bloodering.
What you want to do is justmeasure the things you can and
measure the arteries, not theblood.
Cholesterol, if you can, andstay away from the sugar as best
(55:05):
you can, even looking at bluezones and looking at longevity,
so you could put keto over intothis.
Oh, that's a therapeutic thing,it reverses diabetes and all
that and then you'll want tostop it, right?
I don't know Even the latestresearch on cutting carbs out.
(55:25):
It doesn't have to be to theketo level.
But I think there's a signalthat keeping insulin very low is
something that will help youlive longer for longevity.
And yet the basic scientistscan't quite put two and two
together right.
It's the well caloricrestriction it's got, you know,
that works.
(55:45):
And the one meal, fasting,mimicking diet well, that works.
And then there's a study thatreviewed all of these other
studies and a keto diet and acalorie restricted diet.
They worked a little bit forlongevity and well, actually, on
a properly taught low carb orketo diet, people eat less, so
(56:08):
it's actually a calorierestricted diet compared to what
the other Americans do.
So what we teach kind ofdoesn't fit into the paradigm of
what scientists typically study.
And I'm hopeful, and it's abouttime that we have clinical
(56:30):
reviews of the data that peoplehave collected in a clinic like
this.
I'm not able to do that becauseit actually costs a lot of
money and our computer systemthe one that academic research
kind of bought into out ofVerona, wisconsin, the Epic it
(56:50):
just doesn't.
You can't just be the doctorgoing in and querying your
information.
You have to hire someone elseto go in and do it and well, or
get a medical student to do itfor you, which happened this
year.
One of the med students workingin my clinic at Duke assembled
the heart failure cases that wehad, and so now actually there's
(57:14):
a signal for ketosis and givingketones for heart failure cases
that we had.
And so now actually there's asignal for ketosis and giving
ketones for heart failurereversal.
Of course, I've seen it happenseveral times in my clinic, but
that doesn't count because theyalso lost 140 pounds during that
weight loss and heart reversal.
No, that counts.
That's part of the process.
(57:35):
So anyway, I think we're goingto hear more about the heart
failure treatment with drugsthat increase ketone levels.
No, it could actually happenwith diets that increase ketone
levels.
So I guess I was just sayingthat having our own clinical
data and audits it's about time.
(57:56):
You know, dr Jen and Dr DavidUnwin have been able to do it in
their little practice in the UKand they've even shown that
they can save the governmentmoney in their own little
practice.
And it's not just what they do.
They have a family practicethat treats lots of different
things, but it's, I think,getting to that point where, if
(58:22):
the show, we can not just onlyhelp health but also save money.
That's kind of crazy, but Iguess that'll turn the heads of
those in charge of the system.
Speaker 1 (58:35):
May I ask a personal question what's in the future
for you, and does it includeretirement?
Is that on the horizon?
Speaker 2 (58:44):
Oh, you know, I feel like I'm just getting started.
So the interest now at agrassroots level has never been
stronger, you know, even thoughit no, it's never going to, you
know kind of puncture orpenetrate through into the
(59:04):
medical world, I've kind ofthere are other agendas and and,
yeah, for a while it disturbedme or made me mildly depressed
that my other, my colleagues,didn't care, they think I'm
doing something really crazy andall that.
And yet they're gettingdepressed because nobody gets
better.
And that's why I gravitatedfrom the VA system as an
(59:28):
ambulatory care internalmedicine doctor.
We palliated people.
They really didn't get better,and now I see people get better.
So I'd like to remain at auniversity setting because I
think it allows me to teach andthe research now has been put
(59:49):
together in a textbook ontherapeutic carb reduction or
restriction.
We contributed a couplechapters in there.
There are a couple organizationsthat are teaching other people
how to do this the Society ofMetabolic Health Practitioners.
I'm on the board there and weteach non-physicians and you
(01:00:10):
know, when you think about it, Ilooked on your videos recently.
You interviewed someone andsaid is the future of healthcare
health coaches?
I'm all in.
I mean, you don't need to.
Yes, I think health coachingand the proper guidance without
a doctor's credential is goingto be critical, because doctors
(01:00:32):
get overtrained.
You don't need someone to knowhow to do, uh, appendectomy if
they're just telling you not toeat bad foods, right, so you
know.
It's kind of like when adisaster happens.
You train people to go in whatthey need to know to help in
that area.
You don't ask you know supertrained people to to go in
(01:00:55):
necessarily for relief efforts.
And that's where we are still.
Like you say, you just go tothe mall or the grocery store
and we are still in sort of acrisis situation with obesity,
diabetes, the chronic healthconditions, and so I'd like to
continue to teach and it's beenslow going.
(01:01:17):
But the people coming inshowing how they've reversed
things that doctors have beenunable to figure out for decades
, that's pretty petty stuff.
That's gratifying, and Iremember that came Dr Atkins and
(01:01:39):
Jackie Everstein 25 years ago.
I said how can you do this?
I mean, nobody respects you andall this.
We go to work every day and wesee that people are getting
better and that's enough and itjust I wish it would grow, but
that's often beyond, well beyondmy control.
Speaker 1 (01:02:03):
I was hoping that was going to be your answer,
because I thought the same thingthat we have so much to do.
There's so much yet to do.
I wish we were 25 again,because it would take at least
that long to have a biggerimpact.
But keep on wishing right.
Dr Eric Westman, thank you verymuch, truly a pleasure seeing
you again.
Speaker 2 (01:02:21):
Great, it's great to be here, great to see you too.
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