Eric Westman, M.D.: Update on Ketogenic Diet for Obesity, Diabetes, and Metabolic Syndrome

[Music] it's a pleasure to be here I realized that I have an hour or more on each one of these topics so I'm gonna try to give you the highlights from the science to the bedside as it's called or in science to the clinic I'm going to try to allay your fear about using a ketogenic diet if you're new to the field your ass that you're studying it you wonder you ask your doctors down the street that don't do that I want to allay your fears we need more research we at the end of the talk I hope to make you just really comfortable to use this kind of approach unless there are medical problems and I'll go into that so I started in this area not by any personal experience like many of you have had with it with a medical problem being fixed it was out of listening to my patients doing this seeing that there was a need for something different as an internist and so I became an obesity medicine specialist and just ended the presidency of the largest obesity medicine specialist organization in the world called the obesity medicine Association so it's my pleasure to be here and share with you my knowledge and I hope you have a great meeting and I hope this will again take away your fear of this approach my disclosures include some books consultant seasoned in early-stage companies and I haven't been able to quit my day job yet what is the definition of a low carb ketogenic diet or a ketogenic diet I think the first thing that came to me was is it safe to study low carb diets and to use them and so when you look at the evidence about what humans need to eat for in terms of macronutrients are carbohydrates the lower limit of dietary carbohydrate compatible with life apparently is zero provided that adequate amounts of protein and fat are consumed and this is probably the most unbiased source of information that have the Institute of Medicine the minimal amount of exogenous and endogenous carbohydrate is dependent on the brain so when you're a carb eater you're a carb burner and your brain uses carbs when you're not a carb eater you're a fat burner your brain learns how to use fat and ketones and in the third well ketones and after keto adaptation about 80% of the central nervous system energy can be derived from ketones leaving 20 to 28 grams of glucose today and per day and this is an estimate from what I'm gonna say is kind of the old old data and this needs to be confirmed with new methodology but that's the best estimate we have and because the endogenous glucose production rate is really pretty high there's really no need to ingest glucose or carbohydrate because the body can eat at all in my clinic I'll say think about the the wolf in the wild the lion in the the plane that really they're carnivores that you know carbohydrate and their metabolism is just fine so we're pretty close as humans to that kind of metabolism so how do you define low carb diets if it's okay to study them and if you can take carbohydrates down to zero for the day in the paper the American Journal of Clinical Nutrition 2007 we put out a working definition of compared to the typical American diet on the upper right hand corner of about 300 grams of carbs today a low carbohydrate diet is defined as about 50 to 150 grams per day and then when you get below the ketone Uruk threshold the 50 to 20 grams of carbs per day that's called the low-carbohydrate ketogenic diet now this is a moving playing field of definitions because now we have blood and brain blood and breath measurements of ketones and so I put down here the Steve Finney and Geoff folic say that we estimate the nutritional ketosis being 0.5 to 3 milli molar in the blood and but this is kind of a new it's evolving and so I for me I was reassured that it would be okay to study these different kinds of diets and make the macronutrient range of carbohydrate go from zero to very high without concern for the patients or the study subjects that I was having now you know enter in all the different terms and then I think the best measure in terms of ketogenesis to follow is the amount of carbohydrate grams per day in the diet and now that's the working definition so but that will give you a way to look at all these different popular diets different names and and its relationship to the ability to have ketones because carbohydrate and insulin is so potent at reducing or eliminating ketones so what is a low carb diet if you've never followed it and we talk about good carbs and bad carbs sure you know you could say there's no junk food your carbs are from vegetables as a big broad sweep you could tailor a diet toward your individual population I live in in North Carolina and have an approach that has foods that are comfort foods in North Carolina this was a study done by Jay Wortman and Stephanie and I played a smaller role in it and this was documented in the Canadian Broadcasting Company documentary called my big fat diet and you can see see in North Carolina on the upper right we don't have rabbit moose frequently but in that part of the world they did so anyway you have pretty much an unlimited amount of meats and eggs and fish and chicken is how you define all these things it doesn't matter put it on a list and people can choose it and because the hunger goes down people eat less they lose weight if they're using it for weight loss you have some salad greens and vegetables there's a limited amount of cheese mayonnaise cream things like that because those are high-calorie things we limit them explicitly so this is one way to teach a ketogenic diet people come back after a week or so and they're eating different variations on theme you might have eggs and bacon for breakfast or sugar-free yogurt with berry slices you might have chicken Caesar salad or a fast-food burger without a bun you might have snacks or you're not even hungry for snacks did you know you don't have to eat three times a day don't you know it's alright not that breakfast if you're not how do I mean these it's just a different mindset you know but I thought I had yeah okay so you have to unlearn all that stuff so individuals choose foods from a list a very low glycemic or no glycemic foods and you advise a multivitamin and you're pretty much set it's pretty easy to implement it's really nothing new it first described in 1863 by William Banting in England so we talked about the the history of using this and it was really the primary primary method to help people lose weight until the everything got messed up in the mid 1900s and that's a whole other lecture but what you'll see for weight loss is typify a typical response is kind of like this from the shine study in Israel where you have an initial weight loss and then a regain of some weight this is an intention-to-treat analysis means that you include people who aren't even following the diet and in my clinical experience what happens is actually the lower the blue line which is the low-carb group compared to other types of diets continues to go down and stays down in a clinical setting so there's a big disconnect between academic publications and the clinical world obesity medicine world where you're actually throwing out all the tools that a doctor has and I'll show a little bit about that today but this is what you'll see in the mainstream publications now not individual publications anymore here's the list of meta analyses looking at the numbers of studies for the treatment of obesity this is nothing new it's been used a long time there are lots of studies showing the 5 to 10 to 15% of weight loss at a year which is comparable to a drug my colleague will Yancey compared a low-carb ketogenic diet to a low-fat diet with orlistat which is a medication for obesity treatment and the diet was as good is the drug in the diet so the case is closed this works for obesity when I was faced with the initial concerns it was a concern about safety not I mean everyone knew it could work but is it safe and over the last thing about obesity and obesity medicine world we don't talk about weight loss we talk about fat loss so actually obesity is a disease of too much fat on the body and now with CT scan documentation and other newer modalities it's pretty clear on the upper right-hand panel that the low-carb diet and even a low calorie diet with other macronutrients leads to fat mass loss so it's pretty well documented that you can lose weight you can lose fat mass weight and having talked to many of you already many of you know that but the data shows that as well and when you're trying to talk to other doctors and and policy makers they want to see the data and so the concern about the diet really came from what does it do to the the blood cholesterol right what it but all that fat you're eating it can't be good for you so for me in 1998 that was my response but it may be the response of your doctors dieticians health policy people today instead I want to bring you through the last 18 19 years that I've seen ok so mad about the the concern about LDL cholesterol as the only thing for metabolic risk has changed for cardiovascular risk so now we talked about the metabolic syndrome and cardiovascular disease the metabolic syndrome confers a twice the risk of developing cardiovascular disease over the next five to ten years compared with individuals without the syndrome it confers a five-fold increase in risk for type 2 diabetes it's defined by an elevated blood pressure abdominal obesity insulin resistance elevated plasma glucose in the atherogenic dyslipidemia and the atherogenic dyslipidemia is elevated serum triglyceride and Apryl lipoprotein be increased small LDL small low-density lipoprotein particles in a reduced level of high-density lipoprotein or HDL cholesterol the good guy so the triglycerides are high and the good cholesterol is low that's the pattern you'll see in the blood with people who have metabolic syndrome add in the increased abdominal girth that's the extra weight or you could use a BMI as a proxy for that as well but so this was the the the saving of the low carb diet in my opinion was the shift from just looking at LDL cholesterol to all of the two at the metabolic syndrome this happened over the last 10-15 years and there's really not that well Jerry reven was talking about professor readin for a lot much longer than that the mainstream didn't acknowledge it's now being acknowledged it's even part of guidelines as a footnote but this save the low carb diet because the effect on triglyceride and HDL is unbelievable so now we're going back to one of the meta analyses not just one independent study but you line up all of them together and the recurring theme is that the low-fat diets lower LDL cholesterol that's the upper panel and low-carb diets lower the serum triglyceride better than low-fat diets and then raising HDL as well shown on this panel this is a summary by jeff lobik who with his crew from the University of Connecticut now at Ohio State University are really one of the at the forefront of collecting data on this kind of dietary pattern so if you look on the far left body mass goes down and this is comparing to the low-fat diet in the lighter color but all of the parameters of metabolic syndrome basically get better triglyceride and HDL HDL is kind of the lone one up there where you can see the orange bar going up which is the very low carb diet ketogenic diet compared to the low fat diet so the low-carb diet reduces cardio metabolic risk by raising the good cholesterol and lowering triglyceride the low-fat diet lowered cardiometabolic risk by lowering the LDL cholesterol it just works by a different method now if you're trying you're coming at this from the basic science level Geoff Bullock and his group have a great summary in the progress in lipid research 2008 which shows the liver metabolism changes the increase in ketone production the reduction in the LDL and triglyceride production in the liver in the clinic I'll talk about the foie gras effect if you want fatty liver you feed geese corn in the old days figs you feed carbs basically get a fatty liver happens in humans as well so if you want to lower fat in the liver you lower carbs in the blood or in the diet okay you'll hear a lot of people have fat in the food fat and the liver duh reduce it now it doesn't work that way now just to show the data and one one study on the HDL going up I didn't show that yet so here's a figure from the scheie paper with HDL cholesterol going up better than the other types of Dietary Approaches so in my my world I say this works as well or better than other approaches it's not that other approaches can't work and that's the best I think the political compromise when you're talking to other people who are still believers that there's only one way to do things because there's clearly not one way so in that shai study the workplace dye trial or direct study in israel this is one of the best hard endpoints that is available in a publication about the carotid Intimus going down in a longitudinal study a randomized trial it didn't matter what diet people were on if they followed the diet they lost weight and their blood pressure went down the carotid Intimus got better and this even then a subsequent analysis it was the blood pressure that was the most important thing and have you ever heard that it's important to control blood pressure yeah so maybe that the the dietary approach is not as important as the outcome of weight loss blood pressure reduction and again this is kind of the macro view again one of these I think pioneering studies with Cassandra Forsythe Jeff folic and Stephanie what what's going on in the blood so there's some evidence that saturated fat in the blood not not the diet so much but the blood is related to heart disease and so they did some had predictions but then followed it up with the data collection showing that the saturated fat level in the blood is actually lower when you're not eating carbohydrates so the higher fat diets lead to a lower saturated fat level in the blood and this well why is that well it's because you're burning it so so when you're not a car beater car burner you're a fat eater fat burner you're burning the fat on your body or burning the fat you eat the saturated fat is handled very differently and this I think is going to be one of those papers that gets cited over and over and over because everyone thought that eating more saturated fat or more fat in general would lead to worse metabolic outcomes but it doesn't even lead to the intermediate outcome that everyone said that saturated fat on the blood would be higher so this is one of those groundbreaking papers please take a look at it so what about diabetes well the hundred years ago doctors use the ketogenic diet low carb ketogenic diet the the Allen method the oser method however you want to say it they used it for the treatment of diabetes before there are any drugs before insulin was discovered and they were just checking the urine for glucose they found out pretty quickly that this is just the same information on the from the Osler textbook of medicine on the previous slide 10 grams of carbohydrate for the day I'm very curious as to why they used alcohol 15 grams a day and so are many of my patients probably because it can lower the the glucose production from the liver but so basically this is pretty similar to that list of foods you saw that I use in my clinic and careful some patients don't want to be told that this is nothing new they want to know it's something new put a new name on it but it was actually really helpful before there were any drugs hold another lecture and how that all got messed up drugs came along people need carbohydrates they love them and so that all the disk was lost the way I look at the one pathophysiologic look at diabetes is is like this so that type one which is so remember diabetes is defined by a higher blood sugar like high hyperglycemia you could have no glucose clearance out of the blood so you're putting glucose into the bloodstream absorbing it from the food and you can't clear it because you have no insulin and the treatment is to replace the insulin it took people who were starving and dying young and let them live imagine the the confusion when you actually measured it in adults and the insulin was high so now so the type-2 diabetes adult onset if you have some insulin in there it's usually associated but not always with obesity you have a high glucose input and then you have reduced clearance as well so the main things in the nutrition that lead to the high glucose input are carbohydrates protein a little bit but not much and fat has no glycemic effect if you look at the list of glycemic foods fat isn't on them on the lists because eating fat doesn't raise your blood sugar blood glucose and then so what would be the option for treating well a low or no carb diet to lower the input or adequate protein not high protein and then high fat would be perfect so this is basically the the slide from a hundred years ago you measuring the urine glucose so we can actually do better than they did I think but then the reduce glucose clearance from insulin resistance which is the term used to to explain why the blood sugar is still blood glucose remains high even though there's a lot of insulin around it's actually treated by weight loss and abdominal fat loss more specifically and exercise to a little degree but this one in a qualitative way I put a five plus on weight loss I can help people fix diabetes and Phasis not exercised at all so that's another paradigm shift everyone said you have to exercise you can't lose weight without exercise and don't even try and that's just totally wrong from the obesity medicine standpoint so this is that so type-2 is very different than type 1 and this is kind of the big picture view of what what works there's a one-two punch with a ketogenic diet because you're cutting out the carbs and people are losing weight if they have extra weight in fact that was a criticism on our early studies is you know you're doing too much we don't know the mechanism but yeah but they all got better and it doesn't matter you don't know why thank you so so it doesn't fit into a organisation that wants to know the mechanism and that's where most of the money comes to do big studies that's why it's been difficult to get these kinds of studies funded so when the old paradigm of fearing fat in the food was was prevailing the studies that were done and published about diabetes and low carb diets hit this wall of percent carbohydrate down to 25 to 50 60 so a low-carb diet was defined by 20% carbohydrate which you can't have ketogenesis at 20% of your calories as carbohydrate but in the words of separably these investigators they said well if we lower the carbs more what are you gonna do give them fat we can't do that ok so you see these studies down to 2004 which showed some improvement with lower carb diets and it's great but how much was the improvement you know so you gotta know what is the magnitude of effect and you can even do better perhaps so one of the best studies I make my students residents read this cancer Bowden did a study where inpatient ward with type 2 diabetes and knew exactly what people were eating you tell people to eat the regular food intake they have this kind of glucose and insulin pattern you let them have ad-libbed low carb so unrestricted amount of food hunger goes down they eat less and they pretty much matched what they needed to eat based on their their size which is pretty neat that was of course this is like basic physiology that had to be shown in a recent paper to just convince people who didn't get trained in Physiology I guess that if you have carbohydrate in the food and a meal the blood sugar and insulin will go up but if you take carbohydrate and in and out of the meal that you don't have a post prandial rise so I hear other domains saying we want to lower that post prandial rise of the after the meal rise a blood sugar somehow that's where the disease you know manifold find out eat less carbohydrate you know so it's just like a blind spot or or people are just in it in a different paradigm they can't understand that so now we talk about insulin reducing diets insulin keeping the insulin down as a way to induce and keep ketones around and ketogenesis I like this paper again that's the Bowden paper because they showed you know that even though we say nothing about calories people eat fewer calories on a low-carb diet this is generally true in the outpatient setting as I'll show you so it's not the calories don't matter and I just just get past that don't don't even get into that because it's just what it was - rabbit hole so calories matter would you just don't count them is the best way to teach this and really and this study what happened was people just ate less carbs ate about the same amount of protein and fat in terms of quantity and that's there's gonna be a lot of variation and in the individual what they choose to eat so our contribution to the diabetes world I thought by 2008 everyone would be prescribing a low glycemic diet for diabetes so we designed a study randomizing people to the low glycemic diet or the low carb ketogenic diet published in 2008 and so there were 49 and the low GI 48 in the low carb ketogenic diet these folks had a hemoglobin a1c a baseline of eight point three or eight point eight they were on different medications so it was medically supervised kind of diet program and in individual results here and then in average the low GI diet helped and lower the a1c by 0.5% which is good it's a drug like effect and the low carb diet works better lower the a1c by 1.5% so a lot of these approaches can work but maybe we can do even better through the years people call this a proof of concept study you know it's not enough to change policy and all that and so if you're gonna try to do that you probably need larger studies thankfully those are ongoing now and but this to me was good enough evidence for safety and also in me learning how to reduce medication so that I could start a clinical program which I did ten years ago so this is back to the study in the low GI group there were three people who had reductions in insulin and here's the so here's the insulin at baseline insulin at 24 weeks and then the a1c difference and the weight difference and that you can just see that they were the same people starting but there were only three in the low GI group that had reduction in insulin and there were one two three four five you know reduction and elimination of medicines in the low carb ketogenic diet group Willie an see my colleague at Duke who has continually funded through the VA to study low carb diets Veterans Affairs administration had to come up with a the first measurement of medication reduction because there were no treatments that really formalize that so there's a standardized questionnaire now or assessment tool that shows not only is the a1c better but we had a this much incremental reduction in medication and then the metabolic syndrome parameters in this study showed the same general theme that the HDL cholesterol goes up more than a low GI diet even among those with diabetes so since this time the last few years we have a resurgence of studies looking now carbohydrate grams per day 1958 57 76 grams per day ours was 20 grams per day over six to 12 month period and what we're seeing is that yeah lower the carbohydrate grams and the a1c is lower because a1c is a reflection of the blood glucose and you're have less you have less input into the system the Robo glucose list will be lower and this was summarized in a chapter in a book that susan Massino edited largely came from this conference last year so thank you so much for having that book done so let's go to the clinic imagine you're coming into Duke University the lifestyle medicine clinic and you're refer to patient from across the hall the internal medicine side and they tell you you know this guy's got a high just diagnosed with diabetes anyone see is 10 all the guidelines say this person should be put on insulin or some other medication my colleague and friend said you know I just told him to do your diet and now he's showing up and you're in your office okay so I'm following up tweaking and making sure he's doing a low carb ketogenic and and feeling well and losing weight and so here's his weight loss after starting the ketogenic diet he's down you know about 30 pounds and here's his a1c the this is a clinical setting so the last a one C we have was 5.9 you know four years ago four years before and he normalized his his blood glucose which is just really summarized in the a1c so we're really talking about the same thing it has a normal normal blood sugars and without any medication it goes against all the guidelines and that's okay the guidelines give you basically that what we typically see out there which is an epidemic of diabetes and obesity in my clinic wall welcome to the clinic I teach my patients to check their blood sugar and then well and I also asked them the students residents doctors and different professors how much sugar is there in the bloodstream they I don't know why would that be relevant well you know because your diabetes is a disease a disorder of a higher blood sugar how much is in there well I don't know well so you it's a plane as the you know finger stick in front of him you calculate out with what in my experience is like a middle school math so most medical students have forgotten it and and basically there's a spoonful of sugar in the entire bloodstream so this picture is on the walnut and people come back well then why would I want to be eating sugar I have diabetes and yes enough about that we got to go see these patients so here's a screenshot of my clinic panel in just the last few weeks it was before I went to another conference I thought you know I'm just going to show you what happens it's a long way there to see me and Durham and to go around so follow me okay we're gonna go see we got 25 people to see today I see some other obesity medicine specialists in the audience here pretty typical day and the obesity medicine clinic but I'm not using medications like many of the other Doc's I'm just using the low carb diet first visit here is like an internal medicine specialty you go in you talk you chat them up to develop rapport you know gosh dr. Westman doesn't have horns and everyone said he was evil and well no actually so I they come back for a teaching class it's a one-hour class that I do that's based on some handouts pretty simple people sleeping in the class and at the end I said just stated the foods on this list okay and you know and rocket scientists professors come in and they want to know why their blood sugar is 98 and not 96 and I don't know so so teaching has returned visits here in column format and we gotta go see this next patient please okay so really this is a clinic day this person lost from 302 to 258 pounds the cholesterol levels down at the bottom here the most remarkable thing that drugs cannot do the HDL went from 44 to 62 that effect is amazing and it keeps going up over time so let's see this and really didn't lose much weight so for diabetes anyone see is already 5.9 percent you know it's not a perfect sorry you people who want perfection in a in a body of imperfection you're gonna get values that that are not perfectly and please don't look at these numbers I had at last meet but no so this is a bio penis measure body composition it's not a great measure visit to visit but or for trends it is so I don't ask people to write down what they're eating at home I just have them fill out a qualitative food record when they come back make sure they're getting adequate protein they're not having many carbs and this person is off metformin with blood sugars now a minimum blood b:g blood glucose of eighty maximum 100 with home readings off medication ingest which would be usually it's about a month so within a month so pre-diabetes you know that's that's easy diabetes on pills that that's that's pretty easy this fellow with blood pressure you gotta monitor it you gotta monthly so you got to be a doctor if you're gonna handle the diet with people with doctor diseases dr. lead so be careful medications can become too strong and so this person's a1c went from eight to five point nine it's the real world he went out and got a new prosthetic limb so he could didn't didn't do any exercise he got a new limb and his weight went up three pounds that was a head scratcher because he came back as a weight was up he was doing everything right and he's got a new lower leg welcome to the real world so it's this person you know god I can scan this you know mmm not so good cricket crackers cookies chips a clinical setting how people come in there writing down at home what they're eating and they'll circle all the wrong things so a lot of this is teaching it a lot of those teaching over and over unlearning what people have learned for many years so the other thing if the weight is going up when I go in that's not a good sign although this person is still down 54 pounds from the very beginning so three years into it down 54 pounds over the holiday you give people a break so again this is the clinical application of the science that I've shown you so far just some other you know it started at 298 pounds now it has maintained it now I had a BMI of 27 a weight of 206 still losing weight over that period of time a lot of people are coming to me it's a four to six month waiting list to see me they're already starting and and I just help continue them or I just bless them to tell them yeah it's okay not to worry about what their doctor said and sometimes they'll send the doctor a valium prescription for fun because actually the nervousness of the doctors is a big impediment from the patients who are confused and and so just be ready for that you're gonna run into even today 290 pounds down to 229 and a waistline as well I should have to mention that that's part of the metabolic syndrome I mean you know don't really need exercise but it's okay if you do and this one but okay now let's get into insulin okay a little bit so here remember here's the minimum maximum blood Sugar's you can bring people in with their glucometers their Dex comms or whatever or you can just not a 1c from seven point eight to five point six off thirty units of insulin off reduced medication on meds so still on metformin you know this is four months into it now maybe ten pounds of weight loss and the blood glucoses are better or as good or better than before on less medication that's also another common mistake is they'll go back to the doctor and say well your blood sugars are still and forget that the blood Sugar's were even higher when they were on medication a year ago with them just because it's just the paradigms what doctors do they see it they try to treat it so add up all the insulin units in the class we do a total cessation of carbohydrate 220 grams or level so almost total cessation the carbs are stopped here between the first two visits you reduce the insulin by 50% if they have blood sugars and the hundreds otherwise they'll have hypoglycemia so you reduce the insulin to avoid hypoglycemia and if they're checking at home two to three times that they have the blood Sugar's under a hundred they don't take insulin okay doctors advice some of my patients don't even know what insulin does so now you apply this to a population of folks who you inherit the education and you inherit the medical treatment that someone else has initiated and basically we're taking people down from this precipice that they don't know how to get down from okay this person off hundred units of insulin in six weeks really with no weight loss this is just the effect of food just the input of food into the system treated with insulin these are all individual patients okay so 80 units off in a week blood Sugar's as good or better than before oh and by the way they lost 28 pounds by six weeks so you've you've created you you cheated people say well no it's part of the program so that the ketogenic diet there's lots of different things including glucose reduction and weight loss another patient long-acting insulin stopped in two weeks Oh down here for detail insulin can come in lots of different forms and shapes and now they've even created a 500 unit per ml as opposed to the hundred unit per ml with the idea that they give me more insulin you'll fix the underlying type 2 diabetes you can't fix insulin resistance by giving more insulin and this is the obesity medicine world you need to treat the obesity the underlying abdominal fat inflammation whatever the Meccan is okay so off insulin so you know another patient how do you know okay oh this person was on three short-acting shots one long-acting shot doesn't matter if it's Lantis or eleven Mir but Boyd you better say the exact word because patients are so scared about the medicine they need to know just that word so if you kind of just talk about leva Mir and they're on lantus I'm not unlove Amir I'm I'm like it's really pretty much the same insulin although it's the shading of all in the marketing today that you get about insulin this one's better than that just add up all the units 100 units cut it in half the first day and well this person I didn't cut in half because the blood Sugar's weren't in the hundreds but I had to reduce it so because I've seen these slides replicated without the comment here I put this on every slide so that you have to be careful to reduce the insulin immediately when you cut the carbohydrate down okay again 170 units off within a week this person had been on insulin for ten years oh and the ABA recommendation which is 45 grams of carbohydrate per meal so one of the other places where I lose patience is confidence and then they come back and I reorient them as the hospital setting they go when they're treated they're diabetic they get 45 grams per meal which you're putting into a system that has how many grams in the blood roughly 5 grams so it makes no sense it makes no sense 25 years of insulin down here on the left off in a month now I have people but it's taking so long you had it for 25 years so the other phenomenon you'll get is it's not happening fast enough well you're down 10 pounds in a month and you gained it well they're still not faster it's okay calm down that's all the the report building on it so this person about 30 pounds and 20 weeks off insulin with blood glucoses as good or better than before it's pretty amazing and 275 units stopped in 4 weeks our record is 500 units per day now off down to 75 units at 10 weeks he's still mine I've seen him since then he's still on about 50 units a day he's pretty sedentary I mean he was going around Walmart in a walker now he's walking and he's thrilled of course he's paying a lot less medicine for insulin although a lot of people pay nothing on insulin because it's paid for by their insurance so he knows white come in they're both they're doing great and they feel great and just the point being here is he's not off insulin so the insulin resistance the which we think is from the obesity abdominal obesity is still present and you know he still has a hundred pounds to lose so you'll get people who said well you had six months you didn't fixable but wait a minute this was something that took years to develop so you know just give it a chance in a world that we could send them to surgery because well even certain what MIT weight-loss surgery even now with the ten year view people regain weight if they're not taught about the lifestyle even after major area hatrocks surgery so the diet is really really important even with these other manipulations and so insulin still can be required after six months if you're just trying to get the blood sugar controlled I had someone say well but those you don't have a one sees on those slides they don't count well okay you're some a one sees the a1c here in blue going up to above seven and the weight going up to three hundred pounds now on the low-carb ketogenic diet off medications the a1c is in the fives which would be thought of as non diabetic or not requiring medication likewise this is the internists dream it treats all of these things it's the pharmaceutical companies perhaps nightmare but they don't worry about them don't worry about them because they have a lot of a lot of other irons in the fire and still selling a lot of stuff but diabetes hypertension and heartburn oh that's the other so with diabetes medicines go away heartburn medicines can reduce or eliminate them pretty quickly too checking blood Sugar's low carb ketogenic diet a1c now I'm sorry on the other side under six weight down off all medications after ten years at Duke I'm running what's known as the clinic of last resort okay I call it that people they've been on every diet you know twice and and I'll say you haven't been on this diet with me oh okay this guy seems to be confident so we've treated people who were on medications that would make everyone gain weight steroid pills steroid shots nasal steroid sprays and they lose weight we treated type 1 including people with breastfeeding mothers and type 1 grit the world changing by the internet because type 1 grit is a Facebook group with a couple thousand people with type 1 diabetes doing low carb Rd document set that up I met him last year is a great resource great place I consult on Facebook I got on Facebook with someone in the clinic and chatted with some oh yeah I can you do that Wow so I asked users of the diet with a certain disease for help in treating my patient that's pretty cool if I'm 40 bowel disease the heart failure so I people whoever sent they're on the transplant list and they have these pumps in their left ventricle because their heart doesn't work but they're denied a heart track well there's a list there's a prioritization not every we can get them and they have to be low enough and wait so the heart surgeons and cardiologists send me people to lose weight so they can get on the transplant list and get a new heart I don't use medication most other doctors for weight loss will put them on medication and the heart doctors don't want their patients on our medications so these are pretty complicated it's hard to get sicker than this especially if you had in that with to the heart failure the diabetes and all that lymphedema lipedema give me a conference talk later this spring Leslie and Keith who's a occupational therapist kitto person did a study got the award last year for lymphedema lipedema the the word on the street there's nothing works but actually that's because no one considered taking the carbohydrate out of the diet it works really well in the last couple years with these new drugs that make the urine leak out of the the kidney can cause ketosis seen actually one patient in my clinic why it was in the hospital because of ketoacidosis what happened I haven't seen this in ten years I my diabetic doctor put me on this diabetes drug it's a new drug we've got a lot of press you'll see it on TV it actually has the concern about ketoacidosis on there don't use a ketogenic diet with whey don't use this drug if someone's on the ketogenic diet it's not the diet's fault it's the drugs fault and you're going to see people blame the diet for all sorts of things it's not the diet's fault so if I can bring you up to speed from 1998 if you're just looking at this for the first time for me that was 1998 to 2017 ketogenic diets low-carb ketogenic diets keto diets paleo there are lots of different forms lead to a reduced hunger and spontaneous reduction in caloric intake that's why they're good for weight loss ketone ketogenic diets lead to improvements in obesity metabolic syndrome type 2 diabetes type 1 diabetes ketogenic diets can be used in a clinical setting by trained practitioners and be used as a healthy lifestyle ketogenic diets appear promising as a therapeutic option for many chronic medical problems many will be talked about during this conference further research is needed to determine the effect of ketogenic diets on hard endpoints of cardiovascular disease heart attacks and strokes and we're working toward those kinds of studies now the problem is just getting agencies to give them money to get that kind of study done and we're very hopeful that I'll get done from what I see in the clinic it's I pulled out an old slide I showed in May 2004 of here we are on the USS low-carb my first study I said you know I don't know where we're going but I'm on the same boat with you you know like we're on the same plane and I'm not gonna let it crash I don't want that happen so I've been looking out the crow's nest and everyone else said you we would fall off the end of the earth that hasn't happened yet and other people said that we would you know find riches and in Taj Mahal and we're hoping that happens or somewhere in between but that step that was 13 years ago when that is a slide that I gave I kind of feel like this should be the end of a computer graphics movie with the cast of thousands or not cast but the the contributors of all the people that have been involved and it's it's not the usual people you want to hear from I mean it's scientists clinical practitioners authors journalists to to get the intellectual change the mindset it's grassroots movement is people doing the change and then spreading the word in a system that just doesn't hear who can listen and then in a internal medicine world where we we don't allow drug reps into our building we're so anti Pharma anti corporations we want well however we want companies in this space because fact most medical education is funded by companies sorry but it's true that graduate education Grand Rounds things like that we need companies involved that will give money to help this area grow do more studies help with education and yes well so I assume the clapping was a you know that specific type of funding but thank you so much I hope you have a great conference you

Channel: Epigenix Foundation

Views: 157,688

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Id: WendvONj5O0

Length: 47min 50sec (2870 seconds)

Published: Sun Nov 12 2017