Eric  Westman  presenta.on  (Vail  2016)  

I'm  going  to  talk  about  LCHF  in  diabetes,  

the  theory  and  then  the  clinical  experience.  

So  I'm  here  to  try  to  bring  together  the  clinical  and  the  research.  

We  did  cri@cal  trials  at  Duke  for  about  15  years,  

then  I've  been  in  clinical  prac@ce  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  elec@ves,  

that  teach  ketogenic  diets,  

some  medical  management  of  obesity  elec@ve  at  Duke.  

I'm  chairman  of  the  Obesity  Medicine  Associa@on,  meaning  the  past  president.  

And  if  you  ever  have  a  choice,  don't  be  the  president  of  an  organiza@on  

when  they  change  their  name.  

I'm  a  fellow  of  the  Obesity  Society  where  we  present  our  research  on  obesity  in  the  US  

and  a  fellow  of  the  Obesity  Medicine  Associa@on  as  well,  

I'm  the  author  of  the  "New  Atkins  for  a  New  You",  

also  author  with  Jimmy  Moore.  

Telling  a  professor  of  medicine  to  only  speak  for  30  minutes  is  really  tough.  

You  know  I've  goTen  into  that  point  where  I  can  speak  in  front  of  people  

when  they  are  falling  asleep  and  s@ll  go  on.  

So  let's  go  back  in  @me,  actually  about  100  years  ago,  

before  there  was  any  heart  disease.  

Heart  disease  was  a  rare  event  at  this  @me,  

but  diabetes  was  known  and  the  treatment  of  diabetes-­‐-­‐  

EllioT  Proctor  Joslin  was  one  of  the  prime  teachers  at  the  @me,  in  1893,  

he  recommended  a  low  carbohydrate  high-­‐fat  diet,  

as  shown  in  the  case  descrip@on  of  this  pa@ent  Mary  H.  -­‐  

"Diete@c  treatment  is  of  the  first  importance."  

Remember,  this  is  1893.  

"The  carbohydrates  taken  in  the  food  are  of  no  use  to  the  body  

"and  must  be  moved  by  the  kidneys  

thereby  entailing  polydipsia,  polyuria  pruritus  and  renal  disease."  

That's  lots  of  thirst,  lots  of  urine  and  itching  in  renal  disease.  

Mary  H.  was  put  on  a  stringent  diet  consis@ng  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,  buTer,  and  faTy  food  possible.  

Why  are  you  laughing?  

It's  what  I  use  today,  honestly.  

Is  not  just  EllioT  Joslin,  Joslin  clinic,  Boston,  

today,  the  clinic  is  named  a_er  him.  

Frederick  Allen  was  one  who  really  did  a  lot  of  the  research  

in  the  treatment  of  diabetes  mellitus  in  humans,  

Allen  employed  fas@ng,  then,  a  stepwise  reintroduc@on  of  macronutrients  

to  find  the  threshold  at  which  the  urine  glucose  developed  glycosuria.  

First,  the  pa@ent  was  fasted,  no  food,  un@l  glycosuria,  urine's  sugar,  

was  no  longer  present.  

Then,  carbohydrates,  in  the  form  of  green  vegetables  were  introduced,  

who  we  call  them  low  glycemic  or  non-­‐starchy  vegetables  today,  

star@ng  at  10g  per  day,  total  grams,  not  net  grams,  

no  sugar,  alcohols,  none  of  these  other  things  today.  

And  increased  un@l  the  glycosuria  threshold  was  reached,  

@ll  the  urine  was  seen...  glucose  was  seen  in  the  urine.  

They  couldn't  check  blood  glucose  at  the  @me,  so,  they  were  using  urine.  

Today  we  know  we  can  do  beTer  than  urine,  we  can  actually  check  the  blood.  

The  carbohydrate  intake  prior  to  the  appearance  of  glycosuria,  

was  considered  the  op@mal  amount  of  carbohydrate.  

This  level  was  maintained  and  then  protein  was  added  to  the  diet,  

beginning  1  to  1.5g  of  protein  today,  which  is  interes@ng,  

that's  the  recommenda@on  by  all  the  pundits  today,  

a_er  all  the  research  we've  been  doing.  

Even  when  you're  losing  weight,  1.5g  of  protein  per  day  

to  find  the  glycosuria  threshold  

for  the  combina@on  of  carbohydrate  and  protein.  

So,  it  was  known  in  the  early  1900s  that  protein  in  the  food  

would  increase  the  blood  sugar  and  increase  the  urine  sugar,  even  then.  

Finally,  fat  was  added  to  the  diet,  

to  provide  calories  for  weight  gain  or  weight  maintenance.  

And  fat  was  observed  to  have  liTle  effect  on  glycosuria,  

because  fat  doesn't  raise  the  blood  sugar,  will  raise  the  urine  sugar.  

For  some  pa@ents,  a  weekly  fast  day  was  recommended.  

Wow!  

So,  this  was  published  and  summarized  by  myself  and  Will  Yancy  from  work  in  1915.  

Serendipity,  coincidence,  whatever  you  say  it,  

I  was  given  this  book,  which  is  the  Osler  Principles  and  Prac@ce  of  Medicine,  

published  in  1923  by  a  pa@ent  of  mine,  

at  the  VA  Hospital  in  Durham  North  Carolina,  

when  I  was  doing  one  of  the  first  re-­‐studies  of  the  low-­‐carb  high-­‐fat  diets  

and  having  one  of  the  hospital  directors  

being  lobbied  by  my  die@@an  locally  to  stop  the  study,  

because  I  would  kill  people.  

So  I  had  this  pa@ent  brought  in,  you  know,  

"Doc,  I  know  you're  a  kind  of  a  history  buff"  I  was  a  history  major  at  Stanford.  

When  I  went  to  medical  school  in  Wisconsin,  that  was  my  hometown.  

I  look  in  the  book  and  I  didn't  really  know  much  about  the  treatment,  

I  didn't  know  much  about  nutri@on.  Right?  

I'm  a  doctor,  went  to  medical  school  in  the  80s,  

we  don't  have  any  classes...  What  do  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  Diabe@c  Diet  in  the  Pre-­‐Insulin  Era  

with  the  "Quan@ty  of  food  required  by  a  severe  diabe@c  pa@ent  weighing  60  kg",  

was  10g  of  carbohydrate  for  the  whole  day,  

75g  of  protein,  150g  of  fat  and  15g  of  alcohol  

And  when  I  show  this  slide,  my  pa@ents  want  to  volunteer  for  the  study  on  alcohol.  

But  the  strict  diet  was:  meats,  poultry,  game,  fish,  clear  soups,  

gela@n,  eggs,  buTer,  olive  oil,  coffee  and  tea.  

Here  are  the  research  papers  at  the  @me  and...  

I  was  really  studying  nothing  new,  

although  in  the  context  of  what  you  heard  for  about  20  or  30  years  

have  being  told  other  things,  this  had  been  forgoTen.  

And  insulin  hadn't  been  discovered,  it  didn't  make  it  in  un@l  1921,  

it  didn't  make  it  into  this  textbook,  so  there's  nothing  on  the  insulin.  

The  insulin  story  is  fascina@ng  

and  no  ques@on,  insulin  saved  lives  immediately.  

So,  a  child  like  this  who  was  emaciated,  he  couldn't  store  fat  without  insulin.  

And  that  is  a  take-­‐home  message,  

the  main  func@on  of  insulin  is  to  help  you  store  fat,  

when  you're  ea@ng  carbohydrates.  

I  think  the  main  func@on  is  actually  amino  acid  uptake  into  the  cells,  

but  that's  kind  of  a  small  player,  when  you're  ea@ng  lots  of  carbohydrates.  

So,  this  liTle  child  on  the  le_,  was  one  of  the  first  to  get  insulin  therapy.  

And  you  can  see,  he  plumped  up  really  nicely,  

a_er  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,  a  shot  of  insulin  

and  the  child  has  lower  blood  sugars,  

doesn't  have  the  disease  of  diabetes...  it's  treated  with  insulin,  however.  

Before  the  discovery  of  insulin  

an  individual  with  type  1  diabe@c  would  become  emaciated  

because  of  the  inability  to  store  fat,  

and  the  loss  of  energy  from  chronic  sugar  in  the  urine,  glycosuria.  

Despite  high  energy  intake,  no  fat  storage  would  occur.  

This  was  called  "starva@on  in  the  midst  of  plenty"  

because  the  body  would  be  thin  despite  the  large  energy  intake.  

So,  insulin  therapy  for  insulin  deficiency,  

allowed  individuals  with  type  1  diabetes  to  live.  

Miraculous.  

On  the  le_  side  of  this  panel,  type  1  diabetes,  insulin  deficiency,  

the  remedy  for  insulin  deficiency  is  to  increase  insulin.  

But  on  the  right  side  of  this  panel,  type  2  diabetes,  

especially  when  it's  associated  with  obesity,  

is  really  at  the  same  problem  of  insulin  excess  hyperinsulinemia.  

As  we  saw  the  work  like  dr.  Kra_  talk  about  and  dr.  Gerber,  

there's  too  much  insulin.  

Crea@ng  insulin  resistance  you're  able  to  store  fat,  

but  you  are  unable  to  use  the  fat  for  energy.  

You  have  a  fat  body  habitus  

and  you're  starving  due  the  glucose  swings  in  constant  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,  looking  at  the  pathophysiology  of  type  2  diabetes,  

very  different  than  type  2  

and  using  insulin  is  like  winning  the  baTle  

and  losing  the  war  in  the  long  run.  

So,  there  are  other  ways  to  do  it,  than  giving  medica@ons  to  fix  diabetes.  

If  you  look  at  the  guidelines,  what  happened  over  @me  and  you  can  read  these,  

nobody  really  knows  for  sure.  

There  was  no  pivotal  study  that  said  using  medica@ons  and  a  high  carb  diet  

is  beTer  than  a  low-­‐carb  diet.  

That  study  was  never  done  and  needs  to  be  done  again  today,  

to  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  the  associa@ons-­‐-­‐  

I  think  Ancel  Keys  was  a  part  of  the  associa@on  gejng  on  line,  

to  use  high  carb  low-­‐fat  diets  for  diabe@cs,  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,  

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  ea@ng  all  this  stuff.  

Now,  it's  kind  of  chilling  to  know  that  children  actually  are  in  this  situa@on.  

So,  what  does  the  science  say?  

I  mean,  okay,  "That's  100  years  ago,  Dr.  Westman."  

Well,  2005,  Guenther  Boden  puts  people  with  type  2  diabetes  in  a  research  work.  

We  know  exactly  what  they're  ea@ng,  what  were  the  main  limita@ons  of  our  work  

and  other  outpa@ent  work,  even  with  clinical  trials.  

If  we  don't  really  know  what  people  are  ea@ng,  

this  is  the  best  study  if  you  want  to  know  what  happens  

on  people  where  you  know  exactly  what  they  are  ea@ng.  

Annals  of  internal  medicine  2005,  you  can  see  on  the  black  bars,  

glucose  is  higher  when  they're  ea@ng  the  regular  diet  

and  the  glucose  goes  down  on  the  low-­‐carb  diet,  that  open  circles  

and  then  in  the  boTom,  insulin  levels  go  down  as  you'd  expect,  

when  you  eat  less  carbohydrate,  you  have  less  insulin.  

This  is  really-­‐-­‐  this  was  taught  in  physiology  and  then  forgoTen  

and  now  rediscovered  in  randomized  trials.  

They  are  very  costly  to  do,  but  it's  not  just  Guenther  Boden...  

When  we  had  the  first  mee@ngs  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.  

And  again,  it's  basic  physiology  that  everyone  had  forgoTen,  

but  this  is  the  replica@on  or  the  first  study.  

But,  you  know,  that's  okay,  there's  more  research  

and  if  you  want  to  make  sure  that  it's  on  a  different  con@nent  

that  humans  who  live  in  Australia  are  similar  to  the  human...  Anyway.  

So,  this  is  the  study  by  Manny  Noakes  the  CSIRO  in  Australia,  in  Adelaide.  

And  in  red,  when  you  have  no  carbs  in  the  diet,  the  red  lines,  

there's  really  no  rise  in  glucose  and  no  rise  in  insulin.  

This  study  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  given  some  of  the  low-­‐carb  diet  a  meal  that's  low  in  carb  and  see  what  happens.  

So,  we  are  using  methods  and  standards  derived  from  carbohydrate  ea@ng  

and  applying  it  to  a  different  situa@on,  which  to  me  calls  into  ques@on,  

just  about  every  theory  that  has  been  developed  from  that  world.  

But  so,  in  diet  specific  glucose  tolerance  or  meal  tolerance  tests,  

there's  no  rise  in  glucose  or  insulin,  a_er  not  ea@ng  carbohydrates.  

When  I  was  faced  with-­‐-­‐  okay,  it  works  for  obesity  

and  I  thought  the  low  hanging  fruit  would  be  less  now  uses  for  diabetes.  

100  years  ago  it's  what  they  used,  

and  the  DCCT,  which  is  the  diabetes  control  trial,  

where  they  are  using  230g  of  carbs  per  day,  

in  the  interven@on  diet,  

the  best  they  could  do  with  medica@on  in  a  high  carb  diet,  

was  an  A1c  of  8.9%  or  7.1%,  

normal  being  under  5%  op@mally  or  under  6%.  

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  who  may  or  may  not  be  following  it,  

they  were  achieving  normal  blood  sugars  off  medica@on,  

using  a  low-­‐carb  high-­‐fat  diet.  

So,  I  visited  these  prac@ces,  said  let's  write  up  ar@cles.  

And  we  did  them.  These  are  published  and  never  cited.  

I  didn't  want  to  hurt  anybody  "Primum  non  nocere."  

Did  you  see  that?  "First  do  no  harm."  

Do  people  really  need  to  eat  carbohydrate?  

World  panel  is  saying,  "You  must",  

world  panel  is  saying  "120g  are  used  by  the  brain  of  glucose,  

so  you  must  eat  120g  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  physiologists.  

I  was  presen@ng  a  research  on  low-­‐carb  diets  and  people  didn't  believe  me,  

so  I  had  to  start  following  one  myself.  

And  people  would  say,  "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  people  believe  the  science.  

I  mean,  is  there  such  a  lack  of  faith  in  the  research  that  nobody  believes  even...  

So,  it's  kind  of  crazy.  

So,  you  don't  really  have  to  have  carbohydrates.  

The  Ins@tute  of  medicine  in  the  US  

has  the  best  unbiased  source  of  informa@on  about  this.  

And  look  up  on  their  website.  

"The  lower  limit  of  dietary  carbohydrate  compa@ble  with  life  apparently  is  zero,  

provided  that  adequate  amounts  of  protein  and  fats  are  consumed."  

Even  then  you  can  see  that's  hedged  a  liTle  bit  

and  we  might  even  say  that  emerging  evidence  is  

it  might  be  even  healthier  to  not  eat  carbohydrate,  

if  we  really  updated  that  with  this  conference  in  Tampa  just  in  January  

on  metabolic  therapeu@cs  using  ketones.  

It's  fascina@ng  to  see  this.  

You  need  to  look  at  the  year  that  things  were  wriTen,  

because  a  lot  has  changed  in  the  last  two  years.  

Okay,  let  alone  10  years  to  review  the  paper  recently  

where  they  looked  at  the  guidelines  from  2004  

for  carbohydrate  restric@on  and  type  2  diabetes,  

the  daily  study  wasn't  quite  as  low  in  carbs,  down  to  110  carbs  per  day,  

the  Westman  study,  that's  Will  Yancy  and  I  really  are  the  only  ones  

who  dared  to  go  down  to  do  what  Frederick  Allen  in  Osler  did  100  years  ago  

The  20g...  it's  so  low  level...  

It's  not  so  low.  

It's  okay.  

And  what  we  found  out  in  our  2008  study  was  that  the  low  glycemic  index  diet  works.  

No  ques@on  about  it.  

Low  glycemic  low-­‐calorie  will  work  for  diabetes,  

but  the  low-­‐carb  ketogenic  diet  worked  beTer.  

So  you're  going  to  see  people  siding  things  -­‐  

Well,  it's  fantas@c.  

A  lot  of  things  work  and  there  are  a  lot  of  things  that  work  for  different  people.  

But  if  we  compare  them  head-­‐to-­‐head,  

the  lower  you  go  on  the  carbs,  the  beTer  the  glycemic  control.  

Recapitula@ng  what  had  been  known  

before  the  medica@ons  were  available  for  the  treatment  of  diabetes.  

So  there's  been  a  resurgence  of  research  on  this...  

So  Laura  Saslow,  Jeannie  Tae,  Sartori  Yamada,  

Dr.  Meyer  who  did  a  substudy  of  the  Duke  study.  

PreTy  much  the  same  theme  -­‐  

You  can  improve  diabetes,  get  weight  loss.  

The  good  news  now  that  the  pharmaceu@cal  industry  is  in  the  obesity  treatment  world,  

we  have  studies  on  using  medica@ons  to  treat  obesity  and  diabetes.  

And  diabetes  gets  beTer.  

So  if  you  want  to  use  that  informa@on,  

I  didn't  use  that  here  with  the  weight  loss...  

But  by  whatever  other  method  -­‐  surgery,  medica@on,  diet,  

you'll  get  weight  loss  and  improvement  in  diabetes.  

But  the  lower  you  go  on  the  carbs,  the  beTer  you'll  do  I  think.  

And  here  is  why.  

It's  right  in  front  of  your  face.  

And  as  a  pimp  ques@on,  

meaning  if  one  of  my  students  or  residents  are  really  kind  of  jerks-­‐-­‐-­‐  

I  say  "Okay,  how  much  sugar  is  there  in  the  bloodstream  at  any  given  moment?"  

Uh-­‐hmm,  uhh...  

You  know  the  two  Japanese  medical  students  I've  had,  taking  my  rota@on  at  two,  

knew  just  like  that.  

I  don't  know  if  it's  a  millimole  thing,  but  our  students-­‐-­‐  

I  said,  "Okay,  it's  100  mg/dL  is  a  normal  blood  sugar.  

"Remember  that  thing  now  taught  in  middle  school,  

you  take  1000g  and..."  

Whatever.  

There's  5g  of  sugar  in  the  en@re  bloodstream  at  any  given  moment.  

It's  roughly  a  teaspoon  of  sugar.  

So  basically,  when  you  look  from  the  blood  sampling,  blood  situa@on  -­‐  

5g  going  around  at  any  given  moment,  

and  you  throw  in  200g  in  one  meal...  

Or  let's  say,  the  diabe@c  recommenda@on  by  the  Diabetes  Associa@on  of  45g  per  meal,  

this  is  going  to  overload  the  blood  sugar,  you  can't  control  it.  

Your  blood  sugar  is  going  to  go  up.  

Oh,  we  actually  for  a  long  @me  taught  that  it's  normal  

to  have  an  increase  in  blood  sugar  a_er  a  meal.  

Because  that's  what  everyone  was  doing.  

But  is  that  op@mal?  

So  you  don't  have  to  have  a  blood  sugar  rise  a_er  a  meal.  

So  what  do  I  do  today?  

Research  money  drying  up...  

You  know  I  am  a  clinical  doctor,  clinical  research  Fellowship  at  Duke,  

but  my  heart  was  really  in  the  clinic  with  pa@ents.  

Let  me  go  back  to  the  clinic  and  start  using  this  at  Duke.  

We  opened  up  the  Duke  Lifestyle  Medicine  Clinic  now  about  10  years  ago  

and  teaching  that  just  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  in  the  Y  axis,  

the  more  likely  you  are  to  have  ketosis.  

And  Dr.  Phinney's  slide  -­‐  that  area  where  you  want  to  get  for  op@mal  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  @me.  

I  say,  "Let's  do  20g  or  less.  

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  polycys@c  ovary  syndrome  and  heartburn  

and  faTy  liver  and  irritable  bowel  syndrome.  

We  have  studies  published  on  all  those  things.  

Whether  you  eat  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  how  it  works  -­‐  limit  the  foods  at  the  boTom...  

2  cups  of  salad  greens,  1  cup  of  non-­‐starchy  veggie  

and  you  get  an  unlimited  amount  of  cheese,  mayonnaise,  cream,  things  like  that.  

I  think  those  are  limited  because  they  are  high  in  calories.  

You  can't  eat  too  many  calories  on  the  low-­‐carb  diet.  

It  s@ll  works  by  lowering  the  calories,  

but  we  don't  count  them  in  the  teaching.  

So  you  could  do  bacon  and  eggs  or  sugar-­‐free  yogurt  with  Berry  slices  

or  not  eat  anything.  

Like  Dr.  Fung  will  talk  about  that.  

It's  so  easy,  not  eat  anything  -­‐  it's  a  great  slide.  

It's  so  hard  not  to  eat  when  you're  out  traveling.  

I'm  star@ng  to  use  that  in  my  teaching  actually...  

I  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?  -­‐  Yes...  So  you  want  to  be  a  fat  burning  machine.  

That  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  ea@ng  two  double  cheeseburgers,  no  bun,  at  a  fast  food  restaurant.  

Jimmy  Moore  and  I  go  back  and  forth  on  food  quality  versus  carbohydrate  quan@ty  

and  the  main  factor  in  my  experience  is  carbohydrate  quan@ty.  

And  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  quan@ty.  

But  not  to  say  that  you  shouldn't  do  those  things,  

just  many  of  my  pa@ents  can't  do  it.  

So  what  can  happen  today-­‐-­‐  

It's  great  to  see  more  and  more  prac@@oners  here  using  the  low-­‐carb  ketogenic  diet  

as  we  coined  the  term  or  low-­‐carb  high-­‐fat  diet,  as  it's  coming  out  of  Sweden.  

100  units  a  day,  just  add  up  all  the  units  -­‐  

a  long  ac@ng  unit,  a  short  ac@ng  unit  counted  the  same.  

A  unit  from  your  insulin  pump  counted  the  same.  

They  are  now  units  of  insulin  that  count  500  units  per  CC.  

Used  to  be  just  100.  

So  the  medica@on  world  is  trying  to  go  up  and  up  on  the  insulin.  

There  is  already  too  much  insulin,  so  you  want  to  reduce  it.  

Cut  the  insulin  in  half  in  the  first  day,  otherwise  you  will  get  low  blood  sugars  

and  they  will  blame  you  for  the  problem  when  it  was  really  over  medica@on.  

We  have  to  be  careful.  

I  worry  about  the  spouses  and  the  family  members  of  my  pa@ents  

who  get  taught  by  me  in  an  hour-­‐long  clinic,  

because  if  they  are  on  medica@on  and  the  medica@on  becomes  too  strong,  

they're  going  to  think  that  it  was  the  diet  that  caused  it,  

when  actually  it  was  the  medica@on.  

Important  point.  

But  preTy  much  it  cuts-­‐-­‐  unless  the  glycemic  control's  way  out  of  bounds,  

cut  the  insulin  in  half  in  the  first  day.  

When  the  blood  sugar  goes  down,  you  cut  back  on  the  insulin,  

instead  of  ea@ng  up  to  meet  the  insulin-­‐-­‐  

This  person  came  off  100  units  of  insulin  in  six  weeks.  

So  this  is  a  small  mul@ply,  I'll  show  a  bunch  of  these...  

The  minimum  and  maximum  glucose  at  the  beginning  was  120  to  140,  

the  blood  sugar  is  as  good  as  before  -­‐  110  to  130.  

The  person  lost  5  pounds    over  six  weeks,  off  all  of  insulin.  

Not  bad,  huh?  

80  units  a  day  off  in  one  week.  

This  person  goes  on  insulin  Actos,  menormin,  other  oral  medica@ons.  

Blood  sugars  are  good  or  beTer  than  before  on  no  medica@on.  

Add  up  all  the  insulin  60  units  off  in  two  weeks.  

It  doesn't  maTer  if  it's  mul@ple  @mes  a  day,  

how  long  the  people  have  had  the  diabetes,  

it  seems  off  100  units  in  three  weeks...  

180  units  in  one  week,  160  units  in  four  weeks.  

This  person  had  been  on  insulin  for  25  years.  

There  is  no  happier  pa@ent  

than  the  pa@ent  who  comes  off  the  insulin,  

and  he  has  been  told  that  he  was  going  to  have  diabetes  forever.  

I've  seen  doctors'  lives  being  transformed  

because  they  were  given  tools  that  didn't  work.  

They  carried  about  their  pa@ents  and  they  started  doing  this  

and  their  lives-­‐-­‐  now  they  are  happy  going  to  work,  

seeing  people  were  happy.  

So  it's  not  just  a  pa@ent  being  happy,  it's  a  doctor  being  happy.  

What  if  a  country  could  be  happy  or  a  corpora@on  or  a  public  health  system?  

It's  just  a  maTer  of  @me,  don't  you  think?  

250  units,  300  units  of  insulin  off  in  a  month,  

500  units  of  insulin  s@ll  on  a_er  10  weeks...  

But  this  fellow  is  spending  a  lot  less  money.  

He's  in  that  area  where  the  insurance  isn't  paying  for  it.  

He's  got  to  pay  for  it  on  his  own.  

I  mean  this  person  is  injec@ng  100  units  five  @mes  a  day,  

it's  really  kind  of  obscene.  

The  way  I  see  it  is  that  the  food  contributes  par@ally  to  this,  

but  if  the  insulin  resistance,  the  underlying  cause  for  the  diabetes  is  s@ll  there,  

you  may  not  have  normal  blood  sugar  control  for  a  while.  

So  let's  see  this  person,  140  units-­‐-­‐  this  person  is  on  a  pump.  

Type  1  on  a  pump.  

No  problem  with  type  1,  you  just  need  a  lot  less  insulin,  

because  your  insulin  or  your  medica@on  is  @trated  to  the  carbohydrate  in  the  diet.  

You  lower  the  carbohydrates,  you  lower  the  insulin.  

Some  people  say,  "You  haven't  shown  me  the  hemoglobin  A1c's",  

which  is  a  measure  of  three  months  over  @me.  

Here  are  a  hemoglobin  A1c's  in  the  Y-­‐axis  under  6%,  off  medica@ons,  

when  the  person  had  an  A1c  of  9  for  10  years.  

You  really  don't  need  a  randomized  trial  to  show  that  this  is  effec@ve.  

What  you  need  is  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  an  uncontrolled  study,  

have  one  or  two  random  events  in  a  low-­‐carb  arm  

without  randomiza@on  to  know  

that  it  was  just  a  process  of  weight  loss  or  not  this  par@cular  method  of  doing  it.  

This  person  is  the  internists'  dream  for  treatment.  

Diabetes,  hypertension,  Gerd  -­‐  that's  heartburn,  

diabetes  Associa@on  diet  on  insulin  and  pills,  

checking  blood  sugars  four  @mes  a  day,  

with  an  A1c  of...  let's  say  7.  

People  say  that's  gold.  

A  straight  endocrinologist  would  say,  "This  person  is  fixed."  

On  medica@on,  hemoglobin  A1c  of  7%...  

Now  on  low-­‐carb  high-­‐fat,  low-­‐carb  ketogenic  diet  or  whatever  we  want  to  say  it,  

has  lost  40,  50,  60  pounds,  

he's  off  of  all  the  medica@on,  has  no  heartburn,  

no  hypertension,  no  diabetes.  

It's  so  unbelievable,  people  don't  believe  it.  

Honestly.  

And  that's  why  I  have  an  open  door  policy,  if  you  want  come  see  this  as  a  prac@@oner.  

And  there  are  other  prac@@oners  around  the  country,  around  the  world,  

who  would  be  happy  to  have  you  sit  in  their  office.  

When  I  look  back  -­‐  that's  how  I  learned.  

I  went  and  sat  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,  

kind  of  looking...  you  know,  we  share  pa@ents,  

and  a_er  two  or  three  pa@ents  that  I  fix  mutual  pa@ents,  

then  they  refer  everybody  to  me.  

Is  a  four  to  six  months  wai@ng  list  to  coming  to  see  me.  

I'm  sorry  about  that,  but  at  the  University  that  says,  "You're  really  in  demand."  

And  they  like  that.  

You're  so  important,  people  have  to  wait  for  you.  

Not  good  customer's  service.  

One  of  my  colleagues  down  the  hall  said,  "Gosh,  that  Westman  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  of  29  kg/m²,  

first  onset  of  diabetes  with  a  hemoglobin  A1c  of  10.5%.  

They  are  in  red.  

Looking  back  the  prior  one  was  5.9%,  you  know,  three  years  before.  

Just  cut  the  curbs  and  so  his  doc  says,  "Cut  the  carbs  and  I'll  send  you  to  Westman."  

Send  it  to  the  Lifestyle  Medicine  Clinic.  

And  the  A1c  was  normal,  5.5%,  

no  medicines  used,  just  dietary  change,  

basically  now  having  to  raise-­‐-­‐  the  bar  of  evidence  is  preTy  high  now.  

In  fact  one  might  argue,  it's  been  argued  in  editorials  

that  only  pharmaceu@cal  companies  can  afford  

the  trials  to  be  done  to  show  the  evidence.  

Or  you  could  just  come  to  one  of  our  clinics.  

Compared  to  10  years  ago  though,  the  social  climate  has  changed  in  the  US,  

so  I  get  very  liTle  pushback.  

Even  the  cardiologists,  lipidologists  who  I  speak  to  in  na@onal  mee@ngs-­‐-­‐  

And  it's  an  educa@on  barrier  at  the  moment.  

So,  in  summary,  instruc@ng  people  to  limit  carb  grams  

leads  to  spontaneous  reduc@on  in  caloric  intake,  

without  explicitly  limi@ng  the  calories.  

There's  a  loss  of  body  weight,  improvements  in  glucose,  fas@ng  lipid  profiles  

if  you  incorporate  trygliceride,  HDL  and  your  total  cholesterol/HDL  ra@o  

preTy  much  gets  beTer  in  everyone.  

Improvement  in  systolic  blood  pressure,  reduc@on  in  waist  circumference.  

A  low-­‐carb  diet  is  the  preferred  diet  for  metabolic  syndrome  and  for  type  2  diabetes.  

The  prevailing  treatment  of  medica@ons  in  a  high-­‐carb  diet  

was  never  compared  to  the  low-­‐carb  high-­‐fat  diet  in  clinical  research.  

There  is  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  those  researchers  here,  

because  their  outcomes  are  known  immediately.  

But  so  we  follow  that-­‐-­‐  very  interes@ng...  

What  I'm  telling  you  from  my  vantage  point,  

trea@ng  in  a  clinical  sejng  diabetes,  hypertension,  

across  all  socioeconomic  levels.  

Is  preTy  amazing  how  it  can  work  and  it  is  so  amazing,  people  don't  believe  it.  

What's  new?  

The  low-­‐carb  summit  happened  last  year  in  Cape  Town,  

Ketone  therapeu@cs  is  in  Tampa  in  January,  

Low-­‐carb,  Vail,  here  in  February,  

Low-­‐carb  -­‐  Cruise  is  a  place  where  like  minded  people  get  together,  

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  things.  

FoodLoose  in  Iceland  and  now  San  Diego  conference  low-­‐carb  

looks  like  it's  on  our  radar  screen.  

This  is  all  fantas@c.  

I  was  frustrated  with  people  gejng  off  track,  

because  of  all  of  the  other  foods  out  there  have  been  approached  

and  I'm  totally  conflicted  now  with  the  adapt-­‐your-­‐life  website,  

which  teaches  for  free,  but  also  sells  products  that  are  truly  low-­‐carb.  

We  are  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  preTy  cool.  

HEAL  diabetes  clinics  is  our  aTempt  to  formalize  and  scale  up  the  low-­‐carb  clinic  

within  a  sejng,  a  host-­‐doctor  sejng.  

If  you  are  interested,  this  one  is  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  am  at  HEAL.  

Because  we  just  can't  wait  for  systems  to  come  around  

with  the  evidence,  the  science  that's  there  right  now.  

Thank  you  very  much.