Defiant Health Radio with Dr. William Davis
Defiant Health Radio with Dr. William Davis
Dr. Eric Westman on the Power of Limiting Carbohydrates to Reverse Type 2 Diabetes; Cholesterol is not a disease
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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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 that 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 conducting the study because some colleagues felt that it was too dangerous. Nonetheless, the study was completed and demonstrated that the type 2 diabetics participating in the study 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 the study was for its time, it is simply not talked about enough, as is one of the most important pieces of evidence that validates the idea that limiting carbohydrates and sugars not fats, not 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's learned since then.
Speaker 1:I'll also tell you about Defiant Health's sponsors Paleo Valley, our preferred provider for many excellent organic and grass-fed food products, and BiotiQuest, my number one choice for probiotics that are scientifically formulated, unlike most other commercial probiotic products available today. I'd like to make you aware of a new source for our favorite microbe, lactobacillus roteri, and a skin formulation I designed that improves skin from the inside out. Dr Westman, thank you for joining me. I have been following your work for a number of years, ever since we met gee maybe 15 years ago or so and I remember you as the one who had the courage to publish a study that was very different in, of all things, people with type 2 diabetics. And even though it's some years back, I fear not enough people have heard about this very important study. Would you mind recounting what it is you were doing and thinking back then?
Speaker 2:Sure Well, and it's great to be with you. You know, the idea that what you eat might affect your blood sugar is lost upon many doctors, if not all doctors, and so when I was, I started first looking at low carb diets for weight loss, but then learned very quickly that they'd been used for something else, and that was diabetes, type 2 diabetes in particular. So when I did a few studies on obesity, it showed that clearly you could lose weight doing what was called at the time the Atkins diet, atkins induction I mean. So this is going back to the year 1998. After doing some research there, I thought well, what else was Dr Atkins doing? What else would make sense? A patient of mine brought in a book from 1923 before insulin was discovered and as a bit of a history buff, I'm looking at this and the exact diet that I was studying now is what was used 100 years ago to treat diabetes, type 2 diabetes. So the logical next step for me was well, let's do a study on diabetes, and I always wanted a comparison group in my studies doing randomized controlled trials. I'm kind of known as a stickler that I don't really like correlational studies and have been criticized for that. I'll take that criticism. I want experiments, and so we designed a randomized trial that was looking at low-carb, ketogenic or today it's called keto, but not weird keto on the internet and then I thought by now this was 2008, when it was published everyone will be using the low glycemic diet. Because you lower the carbs, the diabetes gets better, right? Well, so we looked at low carb versus low glycemic in a randomized trial over six months and, lo and behold, the group that had lower carbs, the low carb keto group, did a lot better than the low glycemic group. And, of course, these both are better than what the diabetes organizations still recommend today. So it's been a bit of a head scratcher for me. Why diabetes organizations haven't, you know, as a rule, said look, just don't drink sugar. Diabetes is a problem of too much sugar. So anyway, that's funny.
Speaker 2:You ask about the. You know, looking back, it's a proof of concept study. You know it's like it's not the randomized trial in the New England Journal. You know, like it's not the randomized trial in the New England Journal, you know, with 5,000 people per group showing this over. But it sure was obvious to me then and obvious today.
Speaker 2:Now, having treated people in the clinic, I kind of look back saying, well, you know that is kind of quaint to look at that study because I can go way beyond a research protocol now.
Speaker 2:I mean so as a clinical doctor, you know that you're not constrained by a certain protocol. When you're in the clinic you can actually say, jim, I know your wife and you can use levers to make things work even better than what the clinical trials showed. But even looking back I read it again recently half the people who were on insulin in the study were off insulin by six months and I calculated that all of them pretty much had an A1C under 7% on the low-carb diets and most of them were off their medicines in addition. So you know, being kind of an understated scientist, you know today, if I would redo the title and you can get away with titles and papers I could never get away with before this low-carb diet reverses diabetes in almost every case and of course that's what I say to my patients who come to me who have some skepticism about it. And even then most people don't even know that you can reverse the type 2 diabetes.
Speaker 1:This is some years back, but what was the reaction back then among our colleagues?
Speaker 2:You know there wasn't one. You know, looking back and you say that I had the courage, you know, like most doctors I didn't get much training about nutrition and maybe I got total parenteral nutrition training in internal medicine in the ICUs, right Intensive care unit. If someone's not eating you have to figure out what to give people. But by the time you get out into practice you practice. Everyone knows back then the food pyramid was the healthiest thing and of course it's not. But I didn't really know how bad the things were, how distorted they were, until a couple of our studies came out and then the kind of backlash was not to me personally. I have to say I've never, because we treat people and patients and the patients get better that it's very rare for a doctor to be called in front of a board for a policy thing. It's more a one-on-one If you mess up and someone complains and we're using things that really work. I mean there are even alternatives to drugs. That now it's in clear focus to me that the medical world has been really groomed by pharmaceutical companies to really just treat doctors what they need to know about medicines and so the typical doctor won't know that food really matters and even that drinking sweet tea here in the South will raise your. I had someone come up raise your butcher. I had someone come up 180 units of insulin in two days because he was drinking so much sweet tea Coca-Cola like substance that he was using insulin, and he didn't tell me. Can you imagine someone coming in and confessing to you that you're drinking two liters of sweet? No, it was only afterwards. I said, oh my goodness, what were you doing? And he said, well, I didn't want to tell you. But that just shows how much hope there is, too, though, that if you're still consuming sugar in drinks or in food, and starches get digested to sugar, so it's really the same thing. There's hope, and it's likely that you'll be able to reduce or eliminate these diabetes medicines as you stop consuming so much sugar that the medicines are treating. So you know, then, along the way, as you have been in it a while as well, I have to say, there are all these blogs. Remember those blogs, and I remember Mike and Mary.
Speaker 2:Dan Eads, who wrote Protein Power, had a clinic and they were using it in their patients, and then he wrote just kind of this simple mathematical calculation about how much sugar is in the blood and it stuck with me and through the years I have used it in teaching and I've even taught it to academic endocrinologists, because they would come up to me and say you know, I never really thought of it that way. There's only a teaspoon of sugar in the entire bloodstream, so that you can double your blood sugar by having a teaspoon or two of sugar. That's it. And this could create the surroundings, environs, for diabetes. And so we're dealing with a situation where there's just not much sugar, not much glucose in the blood at a given moment, and that's another underappreciated kind of fact that we deal with.
Speaker 2:But again, that shows hope that if you're not paying attention to the carbs it's the general term to put all this together 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 really understood that, then there's a lot of room for improvement in terms of the blood sugars and you mentioned type two diabetes, but insulin resistance and prediabetes room for improvement in terms of the blood sugars and you mentioned type 2 diabetes, but the insulin resistance and prediabetes. I mean you want to really take action before the blood glucose goes up and the pathophysiology. The problem is actually happening with elevated insulin levels, maybe 10 or 15 years before the glucose goes up. So, and again, most doctors don't check the fasting insulin level. So we're endlessly trying to teach not only how to measure this, but then the importance of the carbohydrate and the diet and at least limiting it for most people.
Speaker 1:You know, I've often wondered because your practice, your clinical research has been so contrary to prevailing standards what happened when you tried to present this to your local institutional review board. So your listeners may not know that in order to do a clinical study, you just can't do it. You got to get permission from a board of scientists, physicians, ethics people, clergy a board of scientists, physicians, ethics people, clergy sometimes who say yes, dr Westman, it sounds reasonable or no, this is dangerous or whatever, based on their opinion.
Speaker 2:What was their reaction? Well, so this is gosh. We started our research 25 years ago and I think we benefited from the fact that just most doctors aren't aware of what nutrition does, because our first few studies even they were funded by Dr Atkins and his foundation at first. You know, we like any good institutional review board, you know there's a local and then you can actually pay to reach out. But ours was local VA, durham VA or Duke, and part of it is they know who the investigator is right, so it's not like Joe Blow is coming in to do a study randomly on something. So I knew a lot of the people on the IRB locally.
Speaker 2:For our first study I was part of that peer group of researchers learning research and so actually the first study we did, the review board said well, this is fine. So it was only six months of changing a diet, although some people said that would kill you in a day. Right Back then it was just kind of crazy. Well, some people say that today even. But during that first study there was a dietician who complained to the hospital director about our study, and so it wasn't the review the researchers. There was a dietician who got wind of it and said look, researchers, there was a dietician who got wind of it and said, look, this is unethical. And turned out the hospital director at the time was pro, or tilted toward bias, toward vegetarianism, maybe even vegan, and so they got upset about it and they actually lobbied the or the IRB, the research board, to stop the study. So again today it plays out as the politics that are kind of at play, that are going back and forth. The science has always been here and solid and true, so there will always be that political controversy.
Speaker 2:But the research board, many of whom I knew, basically said well, we're not going to tell him to stop the study, but we'll make him do more reports. And so that's what they did. They said you know, dr Westman, you're going to have to file a monthly report to just show that your patients, research subjects, aren't dying, and so it was a reasonable compromise. And what's kind of crazy is that research should be testing things that are controversial. It's not like that. We know everything about nutrition or even non-nutrition concepts. So the idea that you squelch that investigation was a learning experience for me, because I was naively, as a researcher collecting information and doing some 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't know obvious or petty that something else was going on, that the clinical world even today is so far ahead of the scientific publications and that's often confusing to people. But later in the research we did, I didn't get any kind of pushback.
Speaker 2:And IRBs again are local phenomenon. Some would be more open than others and say one study there was one study that I know of that was kind of shut down and it had to do with mental health and they were claiming they were mistreating these vulnerable people and naturally they were probably helping them by changing the diet but don't feed them fat. So I mean I laugh about it now Going through it. It's not a great process to get out. Give research you've worked on for several years to a meeting and then it just falls flat. Right, you want other people to be excited about it, but the patient care that we were able to do locally. So I opened a clinic, basically using what we had studied and what other doctors had used for decades, is really what kept me going. It's just so thrilling to see people get better and okay, there are times when I kind of relish the idea that it's rebellious and all that. But at first I didn't know. I had no idea what hornet's nest I was getting into.
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Speaker 2:No, yeah, I think it's multifactorial. Of course there are a lot of things, but the most prominent reasons, I think, are the medical world is still wrapped up in drug treatment. It's reactive and it's really not preventative. And it's been that way in our entire careers. I mean, it's nothing new. And everyone kind of expects the medical world to be proactive. No, they're not going to be.
Speaker 2:But over the last couple of years I've learned, and I guess I was primed for the idea that there might be addiction going on, because I spent 10 years working on smoking cessation and nicotine techniques and helped develop medications for nicotine treatment. So their Chantix came from the research that Dr Jed Rose and I did at Duke, you know 30 years ago, and now you know, you see Chantix out there. So I was kind of ready, I think, to accept the idea that food, sugar, starch, it could be bread, it could be addictive. And then the idea that what I was teaching people a total elimination of carbohydrates. So I give people a sheet of paper and say eat as much as you want of meat, poultry, fish and shellfish and eggs which have zero carbs, and then a little bit of these other things, and it occurred to me that what I'm doing is sort of a cold turkey, if you will, for sugar and starch, and when you quit smoking the time-honored way is to just cut them all down. Cold turkey, quit smoking. So I've learned over the last few years applying the addiction ideas and even into the therapy of treatment of someone who has diabetes or overweight. Using the addiction model can be very helpful and so I think, kind of like when I was a kid, everyone would be smoking. We were watching an old movie from the 70s and they were lighting up everywhere in the doctor's office having a cigarette. How could you imagine that today?
Speaker 2:But I think carbs, sugar, is addictive, unfortunately for a lot of people. So when you see the enabling of an addiction by the family, the school system, the hospitals, I mean for heaven's sake, you can go in for type 2 diabetes out of control at a hospital and they feed you sugar at the hospital. This makes no sense. So I've learned a lot from Dr Vera Tarman and Dr Jen Unwin, who have worked on this idea of sugar and ultra-processed food addiction, and I bring that into my one-on-one teaching and then at meetings as well, and I think that into my one-on-one teaching and then at meetings as well, and I think that explains the widespread problem. I mean, and those with type 2 diabetes or end up with weight loss surgery as a treatment, I think are the worst, hardest core sugar addicts, hardest core sugar addicts. And if you ask someone who's an addict, to their face that they're an addict, of course they'll say no right. So, just like alcoholism or smoking or some other drug of addiction, most people won't really acknowledge that they have a problem with sugar, ultra-processed food being addictive.
Speaker 2:But you look at the almost constant consumption of this stuff. It's not because they're hungry Well, it is because they're hungry. It's not because they lack energy storage on their body, right, so they're eating. People are generally eating for some other reason, and remember 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 if they push that edge. And then it's been a long time since we saw advertising for cigarettes on billboards, and so to me that seems like a natural progression that there ought to be some sort of limitation on especially to children, on sugary things that to advertise, you know, fruity pebbles, and anyway, that's getting into things that we might do to prevent our children becoming addicted and or at least habituated. Anyway, that's getting into things that we might do to prevent our children becoming addictive or at least habituated to eating all this stuff.
Speaker 1:As you know, the natural corollary to limiting or reducing or even eliminating carbs 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 an explosion in cardiovascular events?
Speaker 2:No, no. And that was of course an issue 20, 25 years ago and it's still an issue today in people's minds and I think it will be an issue forever in some people's minds, so that if you're taught a certain dogma, it's hard to undo that. In fact, someone taught me or reminded me recently that if you're prejudiced, there's no amount of data that will dissuade you of being prejudiced. So the idea that we can live well without carbs kind of became clear to me. In fact it could be therapeutic. So cutting carbs out of the diet would help people lose weight, feel better, reverse diabetes, metabolic syndrome, all these other issues. But then there was always this but in fact I met a researcher who said but Eric, I couldn't go down on the carbs anymore because what would I do? Raise the fat, you know. So there was this fear in the research world. Of course she wasn't an MD. So we have a lot of the PhDs are taught this boundary of safe use and these rogue.
Speaker 2:You know Dr Atkins was vilified for telling people to eat fat, although in that context it seemed fine. And so as a minimal like to just stay in my lane, I'd say well, you know, if you don't eat carbs. Eating this fat looks fine because you're burning it for fuel. And so these documentary films came out talking about running on fat for fuel. And these elite athletes are doing heroic levels of exercise, rowing from San Francisco to Hawaii running on fat for fuel. So okay, so at least in the low-carb context, fat doesn't seem to matter. And then you get open to that idea. Then you start wondering well, I wonder how bad it was really in those other contexts and how solid was the science that eating fat was bad? And I was heavily influenced by the work of Gary Taubes and Nina Teicholz, who assembled the science on the implication of eating fat and even of cholesterol in the blood, and it wasn't really good science. But then they're not doctors, right? So you have the investigative journalists reading data that even I bet they read more studies than even the expert scientists because they read outside their own work. So in the context of a low-carb diet, eating fat seems fine. You're burning it for fuel. Even people eating carbs wasn't really very solid in the first place Gets you started to wonder. You know, in the big picture view, what's more important and do you worry about fat in general? And of course, it's the cardiologists who seem to be holding this banner of you know, still, fat in the food is bad and fat on the arteries comes from the fat on the foods and I'm afraid it's probably not that solid. And you can see I'm tiptoeing around all this because I'm still working with hundreds of doctors at a university who have that belief system, you system. So I have to at least acknowledge that that might be true. And yet now we have a study that's unfolding of people with LDL levels the lousy, the lethal cholesterol level that are two to three times higher than a doctor would typically accept before treatment with a drug. Of course this is in a low-carb context, but they for five years self-report and by one year under supervision, even with these super high CCTA technology, which is one of the best we have, that's non-invasive. So I'm beginning to really wonder if the LDL idea, if the medication maybe, is the pleiotrophic, the anti-inflammatory effects of these drugs.
Speaker 2:But then a movie comes out this year called First Do no Pharm, p-h-a-r-m First Do no Pharm. And in there Fiona Godley, who is an editor, former editor of a prominent medical journal, basically says that the industry, medication industry, of treating cholesterol, has never been transparent. And they've tried, they've asked and I don't even know if it's gotten to a court order or that level of, but they've asked to have transparency to be able to see the data from these studies. And at a recent meeting with a couple of cardiologists you may know Nadir Ali who talks about LDLs being good for you and all this we basically could only come up with one study that was not drug company funded for looking at these anti-cholesterol, cholesterol-lowering medicines, and in that study it didn't work. So there's a lack of independent replication. And then, even when Dr Godley on film said that this industry has never let us look at their data, I mean I would think if someone asked to look at my paper's data I would go back.
Speaker 2:It's on some old computer. It might even be printouts, but I would be happy to show it because it works so well. It makes you suspect and I'm not a conspiracy theory kind of guy, but it makes you wonder. And so I do have a paper that helps people look at the Mayo Clinic statin decision tool, which is just a way to look at the number needed to treat and a visualization of if I do take a medicine, what's the likelihood that it will, what is my likelihood of a heart attack and how low will it make it go. And the relative risk reduction it looks really good, but the absolute risk reduction looks kind of small for a lot of people, and so I think people should be able to look at this information and make their own determination. Which then puts me out of line or out of sync with the guidelines that say you shouldn't even you know, don't even think if the LDL is above this level you should treat with a medication. But that is a fascinating area of kind of weak science that got into drug treatment and now kind of dogmatic point of view that it's hard to change this kind of thing, except if you show a different approach can do as well.
Speaker 2:You know, most of the time people will glom onto that new approach. I mean, who knew that we would be able to take pictures with our phone, you know? And so as that new technology comes out, you know, as people start seeing that not eating the same way improves their health, and we don't have an epidemic of heart disease with these folks, even though it was predicted, I'm hopeful that even despite the addictive nature of foods that people will end up going in this direction. The time lag between eating a Twinkie and having diabetes. It's just not quick enough, you know. I mean, it's hard to know that you're really harming yourself with something that tastes so good. Right, that's kind of the teaching that needs to happen, I think.
Speaker 1:So what has this meant for your day-to-day clinical practice? Somebody comes, dr Westman, my primary care doc, says my LDL cholesterol is 212. My primary care doc says my LDL cholesterol is 212. So, and have you gotten pushback from hospital administrators, other people involved in scrutinizing what docs do and what they prescribe?
Speaker 2:Yeah, From other doctors and mid-levels will use thumbscrew techniques to get my patients to use medication. I mean, it's the level of fear-mongering. And so if I calmly talk through the statin Mayo Clinic statin decision aid tool, it's not my aid tool, it's from the Mayo Clinic and I just point these things out and I say, well, you know, it's really for you to decide, you, the patient, and that's kind of my approach. So doctors are. No one's ever complained, you know, knock on wood. No one's ever complained, knock on wood, no one's ever complained. To one of my superiors because I think that again, the patient is generally the approval boards and things kind of got into it too soon and nobody was harmed from it. But my patient experiences led me now to worry less about the blood markers and worry more about the anatomic determination of whether someone has atherosclerosis or not. So going to the calcium score, coronary, the CAC score, the CT angiogram being so, I teach my people a small group of folks who follow that repeat after me cholesterol is not a disease. Now wait, you know, cholesterol is not a disease. Atherosclerosis is the disease. We're trying to prevent Atherosclerosis. So you have to repeat this over and over because you go into the doctor's office and immediately well, your cholesterol is high. But, doctor, is it a disease? Really? My cholesterol no, so atherosclerosis. So you've probably been looking at coronary calcium scores longer than I and I'm doing the best I can kind of piecing together the knowledge of. So, the calcium score, the CT angiogram, this will explain or, to the best of our ability, see if 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 very prognostically good For the next 10 years you're not likely to have a heart attack. But it's not perfect. So you'll see online and I'll be trolled by someone who says, well, I had a normal calcium score and I had a heart attack the next day. Well, right, it doesn't show non-calcified plaque. I mean. So we're dealing with tests that are imperfect. In a world that people want perfect tests, and especially the engineers who come to the biologic system of the human body, they just can't. Well, but they expect the body to be like a computer or a machine. But we have adaptive responses. And so now especially, actually the reason I kind of got into this measurement through calcium score and the CT angiograms is because I felt myself defending my patient who had an LDL of 300. An LDL of 300. This is way too high for everyone else's comfort. But this person was 70 years old, felt great, had no obvious no history of a heart attack or stroke and when they got the calcium score it was zero. So at age 70, if you've gone 70 years without any damage to your arteries and a doctor is going to put you on a medicine to prevent a disease you don't even have, this is craziness. An oncologist would not give you chemotherapy or radiation therapy if they didn't have tissue diagnosis. So I guess. So, dr Davis, back to you.
Speaker 2:How did our field in? Internal medicine is my first field, and then obesity medicine, my subspecialty. But I could have been a cardiologist or rheumatologist. That was kind of what I liked because you treated the whole body. But so how did our field start getting into? Well, I don't really know, but it's likely that you have cancer, so we'll give you this chemotherapy, you know. But so it's likely you have heart disease. So here take this. How did this happen?
Speaker 1:You know, I think it got started around the 1920s when such things as penicillin came out. If you had pneumococcal pneumonia, take penicillin. And that paradigm seems to permeate 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.
Speaker 1:One of the things I've been playing 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's address the factors, as you've been doing that. Let's subscribe by talking to you is you and I have gravitated down the same path, from different starting places but arriving at the same place. So I was doing CT heart scans 30 years ago. I got all kinds of crap for that. I can tell you. It was one of the first scanners in the Midwest.
Speaker 1:But it showed me, as you point out, cholesterol is not a predicted. There was no correlation whatsoever. In fact, we contributed patients to the Tulane University Bell's trial. This goes back 20 some years, yeah, and we showed that if you did nothing for a coronary calcium score, it goes up 25% per year. If you go on Lipitor 40 milligrams, baby aspirin, low saturated fat, low fat diet exercise program. It goes up 25% per year, no impact whatsoever, with real humans and they're freaking out and they're scared and, of course, my unscrupulous colleagues. It's much worse in the private sector, I think, where they're, my colleagues, saying well, john, you're a walking time bomb, I can't be responsible for your safety when you leave this office. I'm going to send you to the hospital for heart catheterization. See if you need a preventive bypass or stent. As you know, this is still done it Intentive bypass. As you know, this is still done, it's wildly done in the private offices and hospitals.
Speaker 1:I refuse to do something like that. So I did, admittedly, zigzag and a lot of trial and error, but found a way to reliably reduce cardiac calcium scores, and it had nothing to do with the stat drugs, had nothing to do with LDL cholesterol. So that's wonderful. You came to the same conclusion and this idea that cholesterol is not a disease, it's a crude. It's a lousy marker for a disease. Let's look at the disease. I think that's so wonderful that you saw that.
Speaker 2:Yeah, and yet to the point of a recent anecdote. But we can learn a lot. One of my friends had a cough and a long time, and it was during COVID, so I hadn't seen him in a while Finally got an x-ray for the cough and he had lymph nodes in his chest. He had lymphoma. Basically that was causing it. But he also had such calcification of his coronaries that you could see them on the chest x-ray. You know this is pretty extreme. You don't normally see the outline of the coronaries. So sadly, you know, they did a catheterization. He had total blockages of his coronaries and had collaterals. But they got to the treatment of the lymphoma first and after a couple of chemotherapy events he died, probably of a heart attack.
Speaker 2:That was the stress test that you know. In a different world he would have had the bypass done first. But you know it's a tough judgment call there. But when I ask this and talk about this to my colleagues they say well, but did he have symptoms of heart disease? And I said well, no, thinking that he was totally sedentary. In fact he was the guy who would be there late at night sound mixing. The groups would come in and sing in his house and he'd mix it all night long and he never exercised at all. So if you wait for a symptom and you're not really using your heart much, you can develop total blockages. Here and in my cohort of colleagues it never occurred to us that maybe we should just take a look. You know, maybe even if there's no symptoms especially when you know 20 or 30% of people their first event is a heart attack or sudden death that maybe we should take a look at these arteries, even if you're asymptomatic.
Speaker 2:Phil Ovedia, who's a cardiothoracic surgeon symptomatic Phil Ovedia, who's a cardiothoracic surgeon calls it the mammogram of the heart to have the coronary artery calcium score.
Speaker 2:And I'm not quite sure it needs to go that far because even some of the health services researchers that I've worked with that's my field that I started with don't think that total screening of everyone with mammograms is a great idea. But so anyway, it's a good soundbite at first to say well, you know, everyone should at least look. You know, especially if you're changing from a sedentary to an active life, and I see that a lot, because someone will have lost 50 to 100 pounds, go from just kind of sitting around, going out, you know, playing pickleball and hurting their elbow on the of sitting around going out. You know playing pickleball and hurting their elbow on the pickleball court and you know if you haven't had an evaluation and you're changing, asking your heart to do more, that might be another proactive way to look at the arteries. Through one of these scans, do you have sort of a or, like Dr Ravadia, do you think everyone should get a calcium score or do you have a selection process in your mind?
Speaker 1:You know, the standard advice is men over 40 and women over 50, subject to alteration if there's something extraordinary, but like if you're a type 1 diabetic or, let's say, your mom had her first heart attack at 52. Those guidelines have proven pretty reliable, with occasional exceptions. So I've been doing that too. And then we had to develop some new rules for people who either. So, as I mentioned, the 25% per year is a pretty reliable number. That's an oversimplification, of course. Right, if a score of two goes to four, that's 100%. If a score of 1,000, two goes to 1,000, that's less than 1%. So we have to use some judgment in all this. But I did learn some lessons along the way.
Speaker 1:The first time I saw dramatic regression of coronary calcium scores. It was something like a score of 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.
Speaker 1:Pull up side-by-side scans. Of course you're scoring calcium. You can still see the contours of softer elements, and it was clear that drop in score was accompanied not only by a reduction in volume of the calcific components, but also of the non-calcific components. I started to see that the first time I saw that was with the addition, of all things, of vitamin d. You know, I'm in a northern climate so people here are miserably sun deprived and it had a dramatic effect on 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 our omega-3s facilitating reduction of cardiovascular events, they facilitate regression, which, which is so wonderful, as opposed to progression permitted by statin alone.
Speaker 1:I just love that and that we do the diet, our diets, very similar what you've been doing all these years. I I have factored in microbiome issues because the process of endotoxemia is becoming little by little. We're on the cusp of understanding, but the process of endotoxemia is clearly a contributor to insulin resistance, visceral fat deposition, high triglycerides, liver conversion of carbs to VLDL, et cetera. But that formula has been working very well. You mentioned the idea of ultra-processed food addictions. What else has evolved over the 25, 30 years you've been doing? What else has changed?
Speaker 2:Well, you know. So my looking back, one of my colleagues 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 made sense to me that I would visit doctors who were doing this. I visited Dr Ease they had closed their practice, actually, but Dr Rosedale was still in practice. I visited Dr Atkins. I visited Dr Rosedale and Dr Vernon. I visited Dr Bernstein, who is still alive and practicing out of his house in Mamaroneck, new York, and after I visited Dr Atkins I realized that something was controversial.
Speaker 2:In fact, they kind of played that up a little bit too. But I borrowed the list that Dr Atkins used in his clinic, and so I don't teach internet keto today, internet keto with the oils and bulletproof coffee and keto drinks and all this. I haven't gotten into that yet, and what I teach is still what Dr Atkins would have taught out of his office in New York City, where it's basically zero-carb foods, almost carnivore, except you can have some vegetables, but it's a very limited amount. And so when people started coming in saying, oh, it's too expensive and all that grass-fed beef, you know, I was like what are you talking about? So the Internet. Keto blossomed and yet I'm still teaching the old Atkins induction the way they did it out of the office. Dr Atkins died, I'm afraid, during our second study so I couldn't ask him, but I was able to ask his nurse, jackie Eberstein, who's been with me as a consultant along the way or a mentor, and she's now retired down 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.
Speaker 2:So I guess what I've stuck to my guns and what I've learned is that a lot of the internet stuff out there is just a distraction and my scientific approach is well, until you add this to what I'm teaching, what I'm teaching, I'm not going to use it. I mean in a formal way, so that I learned that some people have to even be stricter than what I teach. So there's a elimination diet factor to what we do. Well, if someone has a problem with gluten, you tell them not to have wheat. Someone has a problem with gluten, you tell them not to have wheat Duh. So someone does a carnivore diet or a keto diet, they're not having gluten, so it's gluten-free. All the dyes are gone if you do it in a certain way, and so I guess what I've learned is that there is but I can't really figure out the percentage of folks because I don't have a denominator it's that people are coming saying you know I did your program, it was fine, you know it helped, but then it stopped. And then I got rid of all of these vegetables and, oh boy, everything just started to get better, even my stomach and my skin, and I'm just listening to these stories. So I'm very intrigued about a subset of low-carb keto where you eliminate all the vegetables and talk about controversial, you know, but adding.
Speaker 2:So I'm very interested in learning new things, like the microbiome, and yet I'm struck with we've been doing this without talking about the microbiome for so long. Who really needs to add that to it? Or maybe if we teach something and someone gets stuck, we add that to it. So I guess I'm sort of my VA training, veterans Affairs training, kind of gave me the. I don't want to overdo it, I want 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 I think what he saw was the dramatic triglyceride reduction from the fish oil. And so I guess, to restate that I guess I've learned that what I learned 25 years ago is really effective and kind of a safe harbor for a lot of people who get off on all these other tangents and metformin or coconut oil or medium chain triglyceride or apple cider vinegar, all these things.
Speaker 2:If someone comes in with stomach GI issues, nausea, something like that, well, that doesn't happen when I teach this, that doesn't happen. It's got to be one of those other things. When I teach this. That doesn't happen, it's got to be one of those other things. And so I can sort of help troubleshoot something that might that somebody that I haven't taught could be a culprit, for someone recently had intractable nausea, you know, for a year, and finally she came back and I said well, how's the nausea? Oh, it's gone. What happened? We talked about this a lot and she said I stopped the coffee. It was the coffee giving the nausea. So you know you don't need a randomized trial or a big cohort of trying without some substance yourself. So I guess the other thing I've learned is the end of one trials. The individualization could be. You just go without the blank for a couple of weeks see how you feel. You know if it's like a symptom of nausea or skin issue or something like that, and that we don't have to wait, even though you know I got criticized being, you know, mr, randomized Control Trial when I was in training.
Speaker 2:I want that level of evidence. You can learn a lot about your own body and what happens by doing these manipulations and getting the measurements and so and no, you're not like at the edge of a cliff, you know, with danger next door, like the other doctors are saying yeah, that's and that's not appropriate. I'm getting less tolerant of those doctors who are fear-mongering. You know what you want to do is just measure the things you can, and you know, measure the arteries, not the bloodering. What you want to do is just measure the things you can and measure the arteries, not the blood. Cholesterol, if you can, and stay away from the sugar as best you can, even looking at blue zones and looking at longevity, so you could put keto over into this. Oh, that's a therapeutic thing, it reverses diabetes and all that and then you'll want to stop it, right?
Speaker 2:I don't know Even the latest research on cutting carbs out. It doesn't have to be to the keto level. But I think there's a signal that keeping insulin very low is something that will help you live longer for longevity. And yet the basic scientists can't quite put two and two together right. It's the well caloric restriction it's got, you know, that works. And the one meal, fasting, mimicking diet well, that works. And then there's a study that reviewed all of these other studies and a keto diet and a calorie restricted diet. They worked a little bit for longevity and well, actually, on a properly taught low carb or keto diet, people eat less, so it's actually a calorie restricted diet compared to what the other Americans do. So what we teach kind of doesn't fit into the paradigm of what scientists typically study.
Speaker 2:And I'm hopeful, and it's about time that we have clinical reviews of the data that people have collected in a clinic like this. I'm not able to do that because it actually costs a lot of money and our computer system the one that academic research kind of bought into out of Verona, wisconsin, the Epic it just doesn't. You can't just be the doctor going in and querying your information. You have to hire someone else to go in and do it and well, or get a medical student to do it for you, which happened this year.
Speaker 2:One of the med students working in my clinic at Duke assembled the heart failure cases that we had, and so now actually there's a signal for ketosis and giving ketones for heart failure cases that we had. And so now actually there's a signal for ketosis and giving ketones for heart failure reversal. Of course, I've seen it happen several times in my clinic, but that doesn't count because they also lost 140 pounds during that weight loss and heart reversal. No, that counts. That's part of the process. So anyway, I think we're going to hear more about the heart failure treatment with drugs that increase ketone levels. No, it could actually happen with diets that increase ketone levels.
Speaker 2:So I guess I was just saying that having our own clinical data and audits it's about time. You know, dr Jen and Dr David Unwin have been able to do it in their little practice in the UK and they've even shown that they can save the government money in their own little practice. And it's not just what they do. They have a family practice that treats lots of different things, but it's, I think, getting to that point where, if the show, we can not just only help health but also save money. That's kind of crazy, but I guess that'll turn the heads of those in charge of the system.
Speaker 1:May I ask a personal question what's in the future for you, and does it include retirement? Is that on the horizon?
Speaker 2:Oh, you know, I feel like I'm just getting started. So the interest now at a grassroots level has never been stronger, you know, even though it no, it's never going to, you know kind of puncture or penetrate through into the medical world, I've kind of there are other agendas and and, yeah, for a while it disturbed me or made me mildly depressed that my other, my colleagues, didn't care, they think I'm doing something really crazy and all that. And yet they're getting depressed because nobody gets better. And that's why I gravitated from the VA system as an ambulatory care internal medicine doctor. We palliated people. They really didn't get better, and now I see people get better. So I'd like to remain at a university setting because I think it allows me to teach and the research now has been put together in a textbook on therapeutic carb reduction or restriction. We contributed a couple chapters in there.
Speaker 2:There are a couple organizations that are teaching other people how to do this the Society of Metabolic Health Practitioners. I'm on the board there and we teach non-physicians and you know, when you think about it, I looked on your videos recently. You interviewed someone and said is the future of healthcare health coaches? I'm all in. I mean, you don't need to. Yes, I think health coaching and the proper guidance without a doctor's credential is going to be critical, because doctors get overtrained. You don't need someone to know how to do, uh, appendectomy if they're just telling you not to eat bad foods, right, so you know.
Speaker 2:It's kind of like when a disaster happens. You train people to go in what they need to know to help in that area. You don't ask you know super trained people to to go in necessarily for relief efforts. And that's where we are still. Like you say, you just go to the mall or the grocery store and we are still in sort of a crisis situation with obesity, diabetes, the chronic health conditions, and so I'd like to continue to teach and it's been slow going. But the people coming in showing how they've reversed things that doctors have been unable to figure out for decades, that's pretty petty stuff. That's gratifying, and I remember that came Dr Atkins and Jackie Everstein 25 years ago. I said how can you do this? I mean, nobody respects you and all this. We go to work every day and we see that people are getting better and that's enough and it just I wish it would grow, but that's often beyond, well beyond my control.
Speaker 1:I was hoping that was going to be your answer, because I thought the same thing that 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 bigger impact. But keep on wishing right. Dr Eric Westman, thank you very much, truly a pleasure seeing you again.
Speaker 2:Great, it's great to be here, great to see you too.
