Dr. Eric Westman - 'LCHF and Diabetes: Theory and Clinical Experience'

thank you to the meeting organizers Jeffrey Gerber and Rob Taylor it's a pleasure to be here at Lokar Vail and I'm going to in the words of Monty Python now comes something completely different okay so let's go back to diabetes not this cholesterol thing and I'm going to talk about lchf and diabetes the theory and then the clinical experience my background I approached dr. Atkins at the same time Jeff Volek did around 1998 to say why don't you do some research on this I want to thank the app concentr napkins Nutritionals and Colette Hyman wits and Jackie a pristine along the way who taught me I want to thank Ron Rosedale Mike and married a needs Steve Finney Jeff Volek all the clinical people so I'm here to try to bring together the clinical and the research we did clinical trials at Duke for about 15 years and I've been in clinical practice blissfully happy and busy like you've heard using lchf to fix lots of things today so we also have one of the only medical school electives that teach ketogenic diets it's the medical management of obesity elective at Duke I'm chairman of the obesity medicine Association meaning the past president and if you ever have a choice don't be the president of an organization when they change their name that's what gave me some humor this year Jeffrey I think I'm a fellow of the obesity society where we present our research on obesity in the US and fellow of the obesity medicine Association as well I'm an author on the new applicants for a new you also author with Jimmy Moore and thank you Jimmy Moore for forcing me to take a stance on cholesterol and ketogenic diets and so I'm a co-author on cholesterol clarity and keto clarity as well so telling a professor of medicine to only speak for 30 minutes is really tough you know I've gotten to that point where I can speak in front of people of when they're falling asleep and still go on so let's go back in time actually about a hundred years ago before there was any heart disease heart disease was a rare event at this time and the diabetes was known and the treatment of diabetes elliot Proctor Joslin was one of the prime teachers at the time in 1893 he recommended a low carbohydrate high fat diet as shown in the case description of this patient Mary H Dietetic treatment is of the first importance where this is 1893 the carbohydrates taken in the food are of no use to the body and must be removed by the kidneys thereby entailing polydipsia polyuria pure itis and renal disease it's lots of thirst lots of urine and itching and renal disease Mary H was put on a stringent diet consisting only of protein and fat the beneficial effects were seen at once she gained five or six pounds and was advised to eat all the cream butter and fatty food possible why are you laughing it's it's what I use today honestly frederica is not just le Joslin Jocelyn clinic Boston today is the clinics named after him Frederick Allen did was the one who really did a lot of the research in the treatment of diabetes mellitus and humans Allen employed fasting then a stepwise reintroduction of macronutrients to find the threshold at which the urine glucose developed glycosuria first the patient was fasted no food until glycosuria urine sugar was no longer present then carbohydrates in the form of green vegetables were introduced we would call them low glycemic or non starchy vegetables today starting at 10 grams per day total grams not net grams no sugar alcohols nor these other things today and increased until the glycosuria threshold was reached till urine was seen glucose was seen in the urine they couldn't check blood glucose at the time so they were using urine today we know we can do better than urine we can actually check the blood the carbohydrate intake prior to the appearance of glycosuria was considered the deulim amount of carbohydrate this level was maintained and then protein was added to the diet beginning 1 to 1.5 grams of protein today which is interesting that's the recommendation by all the pundits today after all the research we've been doing even when you're losing weight a gram to a gram and a half of protein per day to find the glycosuria threshold for the combination of carbohydrate and protein so it was known in the early 1900's that protein in the food would increase the blood sugar and increase the urine sugar even then a finally fat was added to the diet to provide calories for weight gain or weight maintenance and fat was observed to have little effect on glycosuria because fat doesn't raise the blood sugar won't raise the urine sugar for some patients a weekly fast day it was recommended Wow so this was published error summarized by myself and will Yancey from work in 1915 Serendip by serendipity coincidence however you say it I was given this book which is the Koestler principles and practice of Medicine published in 1923 by a patient of mine at the VA hospital in Durham North Carolina when I was doing one of the first Ries of the low carb high fat diets and having one of the hospital directors being lobbied by my dietician locally to stop the study because I would kill people so I this patient brought in the og doc I knew you were kind of a history buff I was a history major at Stanford going to medical school in Wisconsin or was my what that was my hometown I can look in the book I didn't really know much about the treatment of well I didn't know much about nutrition right I'm a doctor went through Medical School in the 80s we don't have any classes what did they know in 1923 well lo and behold this diet is the same diet I was studying in 2000 and trying to be squelched so I thought something was curious to this so the diabetic diet in the pre insulin era the quantity of food required by a severe diabetic patient weighing 60 kilograms was 10 grams of carbohydrate for the whole day 75 grams of protein under 50 grams of fat and 15 grams of alcohol and when I show this slide my patients want to volunteer for the study on alcohol but the strict iowa's meats poultry game fish clear soups gelatin eggs butter olive oil coffee and tea here the research papers at the time and so I was really studying nothing new although in the context of what you just heard about 20 or 30 years of being told other things this had been forgotten and insulin hadn't been discovered it didn't make it in until 1921 didn't make it into this textbook so there was nothing on insulin the insulin story is fascinating and no question insulin saved lives immediately so a child like this who was emaciated and couldn't store fat without insulin and that is if there's a take-home message the main function of insulin is to help you store fat when you're eating carbohydrates I think the main function is actually amino acid uptake into the cells but that's kind of a small player when you're eating lots of carbohydrates so this little child on the left was one of the first to get insulin therapy and you can see he plumped up really nicely after being able to get insulin saved his life another child couldn't store fat because of type 1 diabetes no insulin being secreted internally by the body and now you give insulin on the outside to a shot of insulin and the child has lower blood sugars doesn't have the disease of diabetes it's treated with insulin however so insulin replacement therapy before the discovery of insulin and insulin type 1 diabetic would become emaciated because of the inability to store fat and the loss of energy from chronic sugar in the urine glycosuria despite the high energy intake no fat storage would occur this was called starvation in the midst of Plenty because the body would be thin despite large entry energy intake so insulin therapy for insulin deficiency allowed individuals with type 1 diabetes to live miraculous the left side of this panel type 1 diabetes and efficiency the remedy for insulin deficiency is to increase insulin but on the right side of this panel type-2 diabetes especially when associated with obesity is really a problem of insulin excess hyperinsulinemia as we saw the work dr. Kraft talked about dr. Gerber there's too much insulin creating insulin resistance you're able to store fat but are unable to use the fat for energy you're have a fat body habitus and you're starving due to glucose swings and constant fast fat storing because you can't access the fat so the remedy is to reduce the insulin not to increase it or use it and so the looking at the pathophysiology of type 2 diabetes very different than type 1 and using insulin is like winning the the battle and losing the war in the long run so there are other ways to do it than giving giving medications to fix diabetes if you look at the guidelines what happened over time and you can read these nobody really knows for sure there was no pivotal study that said using medications and a high carb diet is better than a low carb diet that study was never done and needs to be done again today to put this on the put low carb high fat on the same randomized trial evidence of everything else we assume like drugs and I think we need to do that but all of these associations I think cancel Keys was a part of the Association getting on so teams were getting on line to use high carb low fat diets for diabetics because they die of heart disease and we all know now that fat in the diet causes heart disease around 1970 and so they stopped telling people with diabetes to reduce carbs and they told them to reduce fat without regard to the carbs and the glycemic control etc so basically a chronic disease was started called type-2 diabetes with insulin treatment and insulin resistance and this young child is saying I'm learning to manage my type-2 diabetes with insulin while he's eating all this stuff not it's kind of chilling to know that children actually are in this kind of situation so what does the science say I mean okay that's a hundred years ago dr. Westman may well 2005 Gunter Boden puts people with type 2 diabetes in on a research ward we know exactly what they're eating one of the main limitations of our work and other outpatient work even with clinical trials is we don't really know what people are eating this is the best study if you want to know what happens I'm with people where you know exactly what they're eating annals of internal medicine 2005 you can see in the black bars glucose is higher when they're eating their regular diet and the glucose goes down on a low-carb diet the open open circles and then on the bottom the insulin levels go down as you would expect when you eat less carbohydrate you have less insulin this is really this was taught its physiology and then forgotten and now rediscovered and randomized trials that are very costly to do May I had but it's not just Gunther Bowden one of the first meetings like this in 2004 we got dr. Bishop to come over from Europe to just show that if you didn't eat carbohydrate the glucose didn't go up and the insulin didn't go up again it's basic physiology that everyone had forgotten but this is the replication or the first study but now that's okay there's more research and if you want to make sure that it's on a different continent that the humans who live in Australia are similar to the human anyway so this is a study by Manny Noakes the CR si CSIRO in Australia and Adelaide and then read when you have no carbs in the diet the red lines there's really no rise in glucose and no rise and insulin and in this study with really stood out by saying let's give a diet tolerance test not a glucose tolerance test it makes no sense to give someone on a low-carb diet glucose to see what happens let's give someone on a low-carb diet a meal that's low in carbon see what's happened see what happens so we're using methods and standards derived from carbohydrate eating and applying it to a different situation which to me calls into question just about every theory that has and developed from that world but so you know in diet specific glucose tolerance or meal tolerance tests there's no rise in glucose or insulin after not eating carbohydrates when I was faced with okay works for obesity and I thought the low-hanging fruit would be let's now use this for diabetes 100 years ago it's what they used in the DCCT which is a diabetes control trial where they're using 230 grams of carbs per day in the the intervention diet the best they could do with medication in a high carb diet was the a1c of eight point nine or seven point one percent normal being under five percent optimally or under six percent so I went to visit doctors who were using this kind of diet in clinic and under the best circumstances when people are following the diet which may be you know you not people in a randomized trial where who may or may not be following it they were achieving normal blood Sugar's off medication using a low-carb high-fat diet so I visited these practices said let's write up articles and we did them these are published and never cited am I gonna back that sad but true I didn't want to hurt anybody premium no no cherry did you see that first do no harm do people really need to eat carbohydrate Worldpanel saying you must Worldpanel say 120 grams are used by the brain of glucose so you must eat 120 grams of glucose did they forget or maybe not know that the body can make glucose when you look on who's on those panels they really didn't have physiologist didn't have people like Steve Finney who did the studies were knowing so I was presenting research on low carb diet some people didn't believe me so I had to start following one myself and people would say well that can't be true people need carbs and I would say I haven't had a carbohydrate in six months and I'm here and then suddenly suddenly people would believe the science I mean is there is there such a lack of faith in the research that nobody believes even it's kind of crazy there's this so you really don't have to have carbohydrates the Institute of Medicine in the US has the best unbiased source of information about this and look up on their website the lower limit of dietary carbohydrate compatible with life apparently is zero provided that adequate amounts of protein and fats are consumed even then you can see that's hedged a little bit and we might even say the emerging evidence that it might even be healthier to not eat carbohydrate if we really updated that with this conference in Tampa just in January on metabolic therapeutics using ketones it's been fascinating to see this you need to look at the year that things were written because a lot has changed in the last two years okay let alone ten years I reviewed a paper recently where they looked at the guidelines from 2004 as the throw them out look to Sweden look to other places that have looked at data for carbohydrate restriction and type-2 diabetes the daily study wasn't quite as low in carbs down to 110 carbs per day the West Bend study that's will Yancey and I really are the only ones who dared to go down to do with Frederick Allen and Osler did a hundred years ago the 20 gram it's so low level it's not so low okay it's okay and what we found out in our 2008 study was that the low glycemic index diet works no question about it low glycemic low calorie will work for diabetes but the low-carb ketogenic diet work better so you're going to see people citing things fantastic a lot of things work and a lot of things that work for different people but if you compare them head-to-head the lower you go and the carbs the better the glycemic control recapitulating what had been known before the medications were available for the treatment of diabetes so there's been a resurgence of research for certain you know on this Saslow so Loris SOG eat a Satori Yamada and I dr. Meyer who was did a sub study of the Duke study pretty much the same theme you can improve and diabetes get weight-loss the good news now that the pharmaceutical industry is in the obesity treatment world we have Studies on using medications to treat obesity and diabetes and diabetes gets better so if you want to use that information I didn't use that here but with the weight loss by whatever other method surgery medication diet you'll get weight loss and improvement in diabetes but the lower you go on the carbs the better you'll do I think and here's why it's right in front of your face and as a pimp question meaning if one of my students or residents were in the are really kind of jerks I say okay how much sugar is there in the bloodstream at any given moment you know you can figure this out haha you know the two Japanese medical students I've had out taking my rotation at Duke knew just like that I don't know if it's a mili mole thing or but you know our students you look I say okay is 100 milligrams per deciliter is a normal blood sugar remember that thing for now Todd in in middle school or grade school where you take you know thousand grandma or whatever yeah there's five grams of sugar in the entire bloodstream at any given moment it's roughly a teaspoon of sugar I think the best written description I've seen of this Mike is at the protein power blog where you go through this in text form so basically when you look from the blood sampling or blood situation 5 grams going around at a given moment and you throw in 200 grams in one meal or let's say the diabetic recommendation diabetes association of 45 grams per meal this is going to overload the blood sugars you can't control it the blood sugar is going to go up oh we actually for a long time taught that it's normal to have an increase in blood sugar after a meal because that's what everyone was doing but is that optimal okay so you don't have to have a blood sugar rise after a meal a spoonful of sugar in the entire bloodstream so what do I do today the research money drying up you know I'm a clinical doc clinical research fellowship at Duke but my heart really was in the clinic with patients let me go back to the clinic and start using this at Duke we opened up the Duke lifestyle medicine clinic now about ten years ago and teaching it yes there are good carbs and bad carbs as we heard today everyone agrees that these bad carbs are not good the lower you go on the carbs per day on the y-axis the more likely you are to have ketosis who saw the dr. phinius line that area where you want to get for optimal ketosis I don't do that I just say let's get down low and let's see what happens most people do really well people come to me for it to work the first time I say well let's do 20 grams or lats let's just go back to what they were doing 100 years ago the science looks good not only for diabetes but for obesity and hypertension and polycystic ovary syndrome and heartburn and and fatty liver and irritable bowel syndrome we have studies published on all those things what you eat is unlimited meat poultry seafood and eggs but I know you're not going to want much eat all you want but I know you're not going to want much because you're not hungry that's the how it works limit the foods at the bottom two cups of salad greens one cup of an anon starchy vegetable imited amount of cheese mayonnaise cream things like that I think those are limited because they're high in calories you can eat too many calories on a low-carb diet it still works by lowering the calories so but we don't count them in the teaching okay so you could do it bacon and eggs or sugar-free yogurt with vari slices or or not eat anything I think dr. Fung will talk about that it's so easy they're not heed any that's a great slide it's so hard not to eat when you're out traveling in it so I'm starting to use that in my my actually you know that learned a lot from the running on fat as fuel and by the way what kind of weight do you want to lose fat weight yeah so you want to be a fat burning machine that's really helped in the teaching of this for people so you can do it I just had a gentleman young man lose 40 pounds in two months by eating two double cheeseburgers no bun at a fast-food restaurant okay to two of those burgers you know I'm Jimmy Moore and I go back and forth on food quality versus carbohydrate quantity and the main factor in my experience is carbohydrate quantity and it'd be a shame if someone thought they had to have grass fed this organic that so that therefore they couldn't do it because I see it working without regard to any of that just by lowering the carb quantity so but not to say that you shouldn't do those things just many of my patients can't do it so what can happen today and great to see more and more practitioners here using the low carb ketogenic diet is we coined the term or low carb high fat diet as it's coming out of Sweden 100 units a day you just add up all the units a long-acting unit is a short-acting unit kind of the same unit from your your insulin pump kind of the same you know they're now units of insulin that come 500 units per cc used to be just a hundred so the medication world is trying to go up and up on the insulin when remember that slide the pathophysiology of diabetes type 2 diabetes there's already too much insulin so you want to reduce it so anyway cut the insulin in half on the first day otherwise we'll get low blood sugars and they'll blame you for the the problem when it was really over medication so you have to be careful I worry about the spouses and the family members of my patients who get taught by me in an hour-long clinic because if they're on medication and the medication becomes too strong they're going to think that it was the diet that caused it when actually it was the medication important point but pretty much you cut unless the glycemic controls way out of bounds cut the insulin in half on the first day when a blood sugar goes down you cut back on the insulin instead of being up to meet the insulin this person came off a hundred units of insulin in six weeks so this is a small multiple I'm going to show a bunch of these the minimum and maximum glucose at the beginning was 120 to 140 the blood sugar has is as good as before 130 110 to 130 person lost five pounds over six weeks off all of insulin not bad huh eighty units a day often one week this person was on insulin Actos metformin other oral medications but sugars as good or better than before on no medication add up all the insulin sixty units off in two weeks doesn't matter if it's multiple times a day how long people have had the diabetes it seems off 100 units in three weeks 180 units in one week 160 units four weeks this person had been on insulin for 25 years there's no happier patient then the patient who comes off insulin and who has been told they're going to have diabetes forever I've seen doctors lives be transformed because they were given tools that didn't work they cared about their patients and they started doing this and their lives I've been now they're happy going to work seeing people who are happy so it's not just a patient being happy it's a doctor being happy what if a country could be happy or a corporation or or a public health system it's just a matter of time don't you think 250 300 units of insulin off in a month 500 units of insulin still on after ten weeks but this fellow is spending a lot less money he's in that area where the insurance isn't paying for it got to pay for it on his own and I mean this person is injecting 100 units five times a day it's a it's really kind of obscene I wish I could say words like you andreas insane this is insane now the way I see it is that the food contributes partially to this but it's insulin resistance the underlying cause for the diabetes is still there you may have to be you may not have normal blood sugar control for a while okay so let's see this person 140 unity we are this is persons on a pump type 1 on a pump no problem with type 1 you just need a lot less insulin less insulin because your insulin or your medication is titrated to the carbohydrate in the diet you lower the carbohydrates you lower the insulin and let's see some people say well you haven't shown me the hemoglobin a1cs which is a measure or three months over time it's okay here the hemoglobin a1c and the y-axis under six percent off medications when the person had an a1c of nine four and then this is now they had an a1c to nine for ten years okay so the x-axis he is here in both years so this is not you really don't need a randomized trial to show that this is effective but you need there's a randomized trial to show that it's safe and not harmful or different than other methods that you use so the terrible thing would be to have a uncontrolled study have a rant one or two random events in a low-carb arm without randomization to to know that it really it was just the process of weight loss or not this particular method of doing it this person this is the internist dream for a treatment diabetes hypertension GERD that's heartburn on the 80th a Diabetes Association diet on insulin and pills checking blood sugars four times a day with an a1c of let's see seven people would say that's goal that's straight endocrinologist would say this person's fixed on medication nema gone a1c of seven percent now on low carb high fat low carb ketogenic diet however Jana said has lost you know 60 40 50 60 pounds is off all the medications has no heartburn no hypertension no diabetes it's so unbelievable people don't believe it honestly and and so that's why I have an open-door policy if you want to come see this as a practitioner and there other practitioners around the country around the world who will be happy to have you sit in their office and when I look back that's how I learned I went and said in the office of dr. Atkins years ago to get me through all of the barriers that you've just heard about today to see the effects that can happen and then we formalized it into research now I work in a clinical group where other university professors are there and kind of looking we share patients and after two or three patients that I fix mutual patients then they refer everybody to me there's a four to six month waiting list to come in to see me sorry about that but at the University that says you are really in demand and they like that you're so important people have to wait for you not good customer service but so one of my colleagues down the hall said gosh that Westman you know says he can fix diabetes what if we get someone who's never had any treatment for diabetes this was a 64 year old male BMI body mass index of 29 kilograms per meter squared first onset of diabetes with a hemoglobin a1c of 10.5% there in red looking back the prior one was 5.9 percent you know three years before just cut the carbs and he's already says cut the carbs and I'll send you the West men you know send you to the lifestyle medicine clinic and the a1c was normal 5.5 percent no medicines used just dietary change I maybe dr. Osler and dr. Joslin are smiling looking down because we're recapitulating through years of insanity according to dr. Ian felt basically now having to raise the bar of evidence is pretty high now in fact one might argue it's been argued in editorials that only pharmaceutical companies can afford the trials to be done to to show the evidence or you could just come to one of our clinics compared to ten years ago though the social climate has changed in the u.s. so that I get very little pushback even cardiologists lipid ologist who I speak at national meetings and educating it's an education barrier at the moment so instructing people in summary and certainly people to limit carbon grams leads to spontaneous reduction in caloric intake without explicitly limiting the calories there's a loss of body weight improvements in glucose fasting lipid profiles if you incorporate triglyceride HDL and the total cholesterol HDL ratio pretty much gets better and every one improvement in systolic blood pressure or reduction in waist circumference a low-carb diet is the preferred diet for metabolic syndrome and for type 2 diabetes the prevailing treatment of medications and high carb diet was never compared to the low carb high fat diet in clinical research so the onus is really well there's equipoise now and the low-carb high-fat world wants to put this to test not only for obesity but for diabetes and as I learned in Cape Town South Africa the athletes are going to be way ahead of all of the those researchers here because their outcomes are known immediately but so we follow that very interested what I'm telling you is from my vantage point treating in a clinical setting diabetes hypertension across all socio-economic levels it's pretty amazing how it can work and it's so amazing people don't believe it what's new the low-carb summit happened last year in Cape Town ketone therapeutics in in Tampa in January Lokar Vale here in February low-carb cruise is a place where people like mining it together here lecture geeky lectures like mine when you steam from port to port you can't ski there but you can scuba dive and that sort of thing food loose in Iceland and now a San Diego conference low carb looks like it's on the radar screen this is all fantastic I was frustrated with people getting off track because of all of the other foods out there have been approached and then totally conflicted now with the adapter life website which teaches for free but also sells products that are truly low-carb they we're learning more and more and every person is different but in most people we've tested now they don't raise the blood sugar don't lower the ketone level these adapt products which is pretty cool I thank my South African team adapt team for that heal diabetes clinics is our attempt to formalize and scale up the low-carb clinic within a setting of a host doctor setting if you're interested this one is a actually something you can invest in check the website out and if you want to make a difference in any of these ways this is one way you can actually help out if enough people grassroots funds heal I'm gone and I'm at heal because we just can't wait for systems to come around with the evidence the science that's there right now so thank you very much

Channel: Low Carb Down Under

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Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, #LowCarbVail, Low-Carbohydrate Diet, Low Carb High Fat, LCHF, Diabetes, Duke University, Atkins Diet, Keto Clarity, Cholesterol Clarity, Dr. Eric C. Westman, obesity, insulin

Id: pgMizC6sQ6w

Length: 34min 23sec (2063 seconds)

Published: Thu May 12 2016