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DRF 17: Science and Practice of Low Carbohydrate, High Fat “Keto” Diets

(indistinct chattering) (uplifting music) – Good afternoon everyone, and welcome to Research Forum. Thank you for being here today. Today it is my pleasure to introduce our two speakers, Dr. William Yancy and Dr. Eric Westman, who will be telling us a little bit today about the science and practice behind low carbohydrate, high fat keto diets, which I know is a great topic of interest, especially to those of you who work in prevention of cardiovascular disease and know the difficulties of managing obesity as a risk factor. Our first speaker today is Dr. Eric Westman. Dr. Westman is an Associate Professor of Medicine and the Founder and Director of the Duke Lifestyle Medicine Clinic. He received his MD from the University of Wisconsin-Madison and his Master’s degree in Clinical Research from Duke. Dr. Westman has been at Duke since 1990 and has over a hundred peer-reviewed publications, is a past president and Master Fellow of the Obesity Medicine Association and Fellow of the Obesity Society.

He’s authored multiple books, including the New York Times best seller, The New Atkins for a New You, Cholesterol Clarity and Keto Clarity, and is a co-editor of the textbook, Obesity Evaluation and Treatment Essentials. And then after we hear from Dr. Westman, we’ll be hearing from Dr. William Yancy, who’s a General Internist and Obesity Medicine Specialist and Associate Professor of Medicine here at Duke. Dr. Yancy received his undergraduate degree from Duke and his medical degree from ECU before obtaining his Master’s in Health Sciences from Duke. He did his training in internal medicine and was chief resident at University of Pittsburgh, and his primary role is Director of the Duke University Diet and Fitness Center.

Dr. Yancy is a fellow of the Obesity Society and a diplomat of the American Board of Obesity Medicine and has over 100 scientific publications and has led multiple clinical trials investigating the safety and effectiveness and tolerability of diets and medications for weight loss. Please join me in welcoming today’s speakers, Dr. William Yancy and Dr. Eric Westman. (audience clapping) – Thank you for that introduction and it’s a pleasure to be here. I feel like I’m coming home to where I grew up. And I know you never can really go home, but we both went through the clinical research training program under a different name back in the early ’90s, and so this is back into the, at least the evidence-based home and clinical trial home. It’s great to be here. Now I also have had kids and had them go through school, and so I’d like you all just to close your eyes a moment and raise your hand if you’re following a, wait, you have to close your eyes.

(audience laughing) Close your eyes for a moment. Raise your hand if you’re doing a keto diet. Okay, I’m opening my eyes. Close your eyes, okay. So I can just tell you that, oh, close your eyes. Or wait, lower your hand. (audience laughing) I can just tell you, you’re not alone but I can’t tell you a percentage of folks. But it’s great to see that there’s some headway being made even in a house that cardiology built because you need to know that this is okay for heart disease. Now before we get to the science and practice of low carb, high fat keto diets, I need to just tell you that there are lots of ways to lose weight. Obesity medicine actually involves not only lifestyle, which is what we’re gonna talk about in the lower left hand corner here, but also medications. There are four new FDA-approved medications that I don’t use in my clinic but other obesity medicine doctors can. You can do a very low-calorie diet, which Dr. Yancy has. I don’t use that myself. And then last but not least, you can go have that down the street to, our surgical colleagues have bariatric surgery.

But in my mind, in my view, you would never have surgery before you tried lifestyle, lifestyle and medication, you try the barn shake programs, the very low-calorie diets. In our crazy world today, you can walk in and get the surgery without having tried any of those things. So just to show you in the medical obesity world, we’re talking about risk and cost. In the lifestyle medicine world, we’re just talking about changing the food.

It’s just changing the food. Just put that in context. This is from an obesity algorithm, obesityalgorithm.org or .com. You can download these slides and become an expert in obesity medicine in a minute. Looking at the nutritional slide, there are low-calorie diets, which you could restrict fat as the method of lowering the calories, or you can restrict carbs as the method of lowering the calories. These are just different ways to do it. Not wrong, not one right or wrong. They both can work. And as you’re gonna see, we’re gonna focus on the evidence behind the low carb diets. But it’s not the only way to do it. And then the very low-calorie diet on the far right is the program that Dr. Yancy has here at Duke. So when you get to the low carb diets, the science and the simplified way to look at this says that the lower in the carbohydrates you go for the whole day, the less carbohydrate you eat, the more your body has to find fuel from fat.

And so if you go to 50 grams or 20 grams of carbohydrates for the whole day, your body has to find a fuel source, and it looks too fat because generally as humans, we store fat as the fuel. And so you’re gonna start burning your own fat, you call this the ketone threshold, and now a keto diet. It’s all confused now because you can measure the breath ketones, you can measure the blood ketones, you can measure the urine ketones, and they don’t always go the same way. Well, we don’t measure ketones at all in our clinical program, we just keep the carbs low enough so we know that you’re in ketosis.

You don’t even have to measure them. How’s that for simplification, huh? So here are the other, this is the other demonstration that if you go lower on the carbs, your appetite goes down and the keto diet or low carb ketogenic diet becomes a low-calorie diet without even talking about calories. So there are good carbs, there are bad carbs. In general you can think of the vegetables, non-starchy vegetables as the good carbs. I don’t know of any popular diet program that would really recommend that you have Fritos or Cheetos or Dr. Armstrong, a couple Snickers bars? (audience chuckling) Yeah, so we’re talking about real food. That’s what we’re talking about. Dr. Yancy. – Good afternoon everybody. It’s a real pressure to talk with you all about this way of eating that we’ve been studying for almost 20 years now and we’ve been using in clinical practice for about 10 years now.

And so I’ve been charged to talk to you about the evidence, primarily evidence from clinical trials, and so I’m gonna go through a number of clinical trials that we’ve done and that others have done and just try to give you an idea of what some of the health effects of these, this kind of eating can have. So before I start with the evidence, I do wanna kind of help you to understand what we’re talking about when we talk about a low carbohydrate or a very low carbohydrate diet, particularly these ketogenic diets. So I’m gonna go through how we teach our patients and our participants in our clinical trials, first off, I just wanna point out how simplified this approach is. So if you look at these instructions, they’re pretty simple, they fit on one page. Now there are some other instructions that we give patients, but essentially this is what we tell them. And we teach them how to reduce carbohydrate intake to less than 20 grams per day, okay? 20 grams is not magical. There are some people out there that say you’re not getting to 20 grams, you have to get to 20 grams.

It’s just a starting point that we have noticed that most patients have success with if they start there and then we can add carbohydrates back into it, into their diet to a certain level where they can continue to have success. So 20 grams is really just a starting point. If you follow these instructions, you don’t even have to count the carbohydrates. You will be eating to a 20-gram per day carbohydrate diet. So pretty straightforward, notice that certain foods are unrestricted. So meat and eggs are zero carbohydrates. So you can have unlimited amounts of these foods. This is really helpful to patients who are trying to lose weight and might get hungry while they’re following a diet approach.

So you don’t have to think of this as a diet, a diet we think of as a transient thing that you do for a period of time just to lose weight. We think of this as a nutritional approach, a lifestyle, a way of eating, and we don’t want them to think of themselves being or feeling restricted. So they have foods they can eat if they need to. There are some other foods on here, cheese, several cups of vegetables, salad vegetables or things like lettuce, spinach, collard greens, parsley, things like that. And then the one cup of low carbohydrate vegetables are foods like asparagus, broccoli, cauliflower, cucumbers, mushrooms, tomatoes. So a wide variety of vegetables that are low in carbohydrate, and you can incorporate into your diet without going over 20 grams per day, okay? Notice that I don’t call this a no carbohydrate diet too.

A lot of people will say that. I’m not a no carbohydrate diet or I’m not eating any carbs. These foods, after the meat and egg, these foods do have carbohydrate in them so it’s not a no carbohydrate diet. As I mentioned with the unrestricted amounts of meat and eggs, calories are not restricted. So this means that people can eat when they’re hungry. Now the unique thing I’ll show you in a few minutes is that people end up self-restricting their calories.

They’re not hungry on this diet approach. And so they don’t end up eating as much calories as they used to eat before they’re eating this way. And as I also mentioned earlier, carbohydrate intake is slowly increased as someone reaches their goal weight. And we teach people that there’s a certain level they need to stay below in order to lose weight, and then there’s another level that’s higher than that, that they need to stay below in order to maintain their weight, okay? So one of the biggest pitfalls people run into is adding carbohydrates back into their diet too quickly or too much, and that’s when weight gain or weight regain occurs.

Most of the studies have been done with people taking a multivitamin, and so we encourage people to do that. And then as I’ll show, the diet can be dehydrating, it causes a diuresis and so we encourage people to drink lots of water. And I’ll talk about that a little more later. So we call this a ketogenic diet, and I wanna talk a little bit about ketones because as health professionals, we learn that ketones are harmful and dangerous. So we learn from Type 1 diabetes that ketoacidosis is a hazardous condition, and it is; but that’s not exactly the only role for ketones. So I wanna explain them. Ketones are simply molecules that deliver energy. So just think of them as your backup fuel source. So if you were to reduce carbohydrate intake to a certain level, then you will need to find another fuel source and that will be your fat, or the fat that you’re eating. And that fat that you have, stores in your body, is broken down into fatty acids and ketones.

And these ketones can be used to deliver energy to most of the tissues in your body. In fact, there are only a few pretty energy- not-requiring tissues that need something besides ketones. So the erythrocytes, the cornea, the lens and the retina need glucose, and there’s ample glucose left in your body to supply energy to those tissues and all the other tissues, in particular, your brain, can survive and get energy from ketones. Now notice this table, the table shows that ketones are in our bodies at any given moment.

So those of you who just finished eating your lunch, you still have ketones in your body at a very low level, but you have some. This morning when you woke up before you ate breakfast, you had them in a higher level. And then if you were to go on the induction, the most strict phase of a low carb diet, then they would be at a little bit higher level, at about one to three millimoles per liter. Now it’s not until you fast for many days or in particular, go into ketoacidosis from not having insulin if you have Type 1 diabetes that you go into a derangement where the ketones are so high that they cause acidosis, and that is harmful for your tissues and your health.

So this was obviously a concern when we first started doing our research on this nutritional approach, and so we actually wanted to look to see what happened to people following this diet, and we checked blood gases on a lot of our patients. Yes, they did agree to have me stick them in the wrists over and over again during a study, and we found out that their pH never went below 7.37. That’s actually in the normal range. So we didn’t see acidosis occur while they were in ketosis. So let’s talk a little bit about the weight effects of these diets. This table shows some of the earlier studies, including ours, that showed a weight loss effect at six months and 12 months, depending on the study. And the kind of general consensus that came from these studies is that a low carbohydrate diet has a beneficial impact on your weight regardless, but it seems to have an advantage over a low fat, low-calorie diet, particularly initially in the first six months or so. And you can see in blue here that there’s greater weight loss, and that asterisk means there’s statistically greater weight loss at six months for those four studies, whereas when it stretched out to about 12 months, the weight loss was not as clearly statistically different between the two approaches.

There was still weight loss, so both diets were creating benefit, but there wasn’t such a distinction between the two diets. So this is where a lot of people will say well, low carbohydrate diet is better for weight loss initially, but it’s not necessarily better in the long run. Well, I think we’ve got more evidence to actually argue against that, but I think it’s important for us all to know that this means that we have two approaches that can work, at least two approaches that can work and not just one. So I don’t think of this as well, which one wins? I think of this aa well, this is another approach if this works better for you. So we have two studies now that are really well done, well controlled, randomized studies that have extended the duration of follow up to two years. And in the first study down here at the bottom left was a study done in Israel, and that was actually a three-arm study. If you can’t see the three arms, one was a low fat, low-calorie diet, that’s the red line; the yellow was a Mediterranean diet; and the blue was a low carbohydrate diet.

And this again confirms what I’ve said earlier, is that a low carb diet seems to do better early on, and it seems to kind of converge as time goes on. But in this particular study, the low carbohydrate and the Mediterranean diet did better than the low fat, low-calorie diet at two years. And then in the upper right hand corner, the two diets basically paralleled the entire duration. You can see there is similar weight loss, good weight loss with both of these approaches. And if you look at meta-analysis now, and I’d like to show this one just to show you how many studies have been done, and this is not all of them, it’s not exhausted, this is just the 12-month or longer studies, we now see that a low carbohydrate diet seems to have a small advantage in terms of weight loss at 12 months or longer.

So about a kilogram, not quite a kilogram, that’s about two pounds greater weight loss with that approach. But again, both of the approaches are working. So how does weight loss occur on a low carbohydrate diet? It’s a question I get a lot. Why are people losing weight? Aren’t they just losing weight because they’re restricting calories? Well, that’s right, they are. So they’re restricting calories, but they’re not trying to. We’re not teaching them to restrict calories, we’re just saying lower your carbohydrate intake and then spontaneously they eat fewer calories. So that… they’re still losing weight because they’re eating less calories, and this is probably one of the, you know, this a good example of that. This is from one of our studies where we put people either on a low carb or a low fat diet, and the black bar is their baseline diet.

So both groups were eating over 2,000 calories a day. And then with the low carbohydrate participants, they reduced it to a little over 1,500, something around 1,600 calories per day, even though we didn’t tell them to pay attention to calories at all. And on the other side, the low fat group, we taught them specifically. We want you to reduce your calorie intake by about a 500-calorie deficit per day, and that’s what they did. So they ended up both reducing calories.

So another thing that’s out there is, could this be water loss? And yes, that is part of the equation. So with the low carbohydrate diet, there’s a diaeresis that occurs primarily in the first couple of weeks. And this is important to know for a few reasons. First of all, because that’s part of the initial weight loss that occurs. So that can come back on quickly if you start eating carbohydrates. Another reason why you should know that is because it’s really important to hydrate, especially in the first couple of weeks, okay? So you can see the lines up here that the real drop is just there in the first two weeks, and then thereafter, the water loss or the water level, this is measured by bioelectric impedance, is pretty comparable between the two diet approaches.

So we really encourage people to drink water, particularly in the first couple of weeks, and we’ll actually encourage them to make sure they increase their salt intake. I know we’re gonna talk about increasing their fat intake, now we’re talking about increasing their salt intake. This is different from all the guidelines that are out there but it is important, particularly in the first couple weeks, to get salt or broth in your diet so you can hold on to your fluids, and then you don’t have some of the symptoms that people will have early on when they’re doing a low carbohydrate diet.

Some people call it the Atkins flu or the low carb flu or the keto flu, people can feel rundown, tired, have headaches, get muscle cramps. And if they hydrate well enough and they get their salt intake, this doesn’t happen and they tolerate it quite well. Even if they do have those symptoms where they can stick with it, usually after two weeks those symptoms go away and they feel fine after that. So it’s typically in the first couple of weeks. And then one other question that we frequently get regarding the weight changes that occur regards this possible metabolic advantage. So everybody wants to know what’s the best way for me to keep up or boost my metabolic rate? And if you’re not familiar, when people lose weight, their metabolic rate goes down. That’s, if you haven’t heard the Biggest Loser study that came out a few years back, was really kind of the first study that told me, we knew this but it’s the first one that really showed us this really clearly, and this is what makes weight loss difficult and particularly weight maintenance difficult.

When people lose weight, their metabolic rate slows down and so they’re not able to continue burning energy like they used to be. But this diet wanted to see if there’s a metabolic advantage. And so it’s a randomized crossover study and they had a run-in phase where they put people on a diet and found out what their maintenance diet would be. And then they randomly assigned them to either a low fat diet, a low glycemic index diet or a low carb diet.

And that’s this part down here, I don’t know if this laser works so well, but this table right here shows you the composition of the diet. So the low carbohydrate diet was 10% carbohydrate and 60% fat and 30% protein. So participants successively randomly went to the next diet approach until they’ve done all three of the diets, and for four weeks of each each one. And they measured really carefully the resting energy expenditure using indirect calorimetry and then total energy expenditure using doubly labeled water. So these are gold standard techniques to measure energy expenditure, and they show the low fat, low glycemic index and the very low carbohydrate diet in succession in both of those graphs there. And what happened is that the energy expenditure was a little bit greater with the glycemic index diet than the low fat diet, and it was even a little bit more, a little bit higher with the low carbohydrate diet.

So this shows there might be a little bit less reduction in the metabolic rate using this particular diet during a dietary intervention. So I want to go into some of the metabolic effects that can happen too. So this is a big question that we receive. What’s gonna happen to my risk for heart disease? If this is a high fat diet, I’ve just told you it might be a high salt diet, what’s gonna happen to my blood pressure? What will happen to my cholesterol levels? We know that fat raises the cholesterol, raises your risk for heart disease, or that’s what we’ve all been told, but that’s actually probably not so accurate. And these meta-analyses I’m gonna present to you will show you a little bit about the effects on these risk factors.

So again, this confirms the weight effects that we saw in a previous slide, about a kilogram greater weight loss with the low carb versus the low fat diet, and that’s what the middle column shows you there. It actually shows you that blood pressure seems to do just a smidge better with a low carbohydrate than a low fat diet, but it wasn’t statistically significant in this meta-analysis in about, it looks like, 18 trials. And then look what happens to the cholesterol effects. And this is kind of the hallmark of the metabolic effects of a low carbohydrate diet. It’s a higher fat diet, and what fat does to your cholesterol results is it raises your HDL cholesterol. It raises your good cholesterol, okay? A lot of people know that if you want to raise your good cholesterol, you exercise more, right? Not many people know that you can do that also by eating more fat.

And it’s any kind of fat. In fact, saturated fat probably boosts it the most. But unsaturated fat will also boost your HDL cholesterol, okay? Now the difference between those two is that saturated fat also boosts your LDL cholesterol, or potentially can boost it, whereas unsaturated fat does not, okay? So this is what you see when you’re comparing low carb versus, or minus the low fat diet. You see that you get a boost in the good cholesterol, the HDL, but you also have a little bit of a boost with the LDL cholesterol. And so really, the risk is a wash, or maybe if you remember that HDL is a little bit more of a powerful risk factor, you probably get a little bit more benefit with a low carb diet just because that HDL is going up three points there. And then the other consistent effect you’ll see is that the triglycerides go down. And we actually can use this, follow this risk factor, this triglycerides, just actually to see how adherent people are. So Eric was talking about ketones being one of the ways that we can look for adherence, but triglycerides will go down when you reduce carbohydrate intake, okay? It’s really, really consistent, also not really well known, not really intuitive.

Why would the fats in my blood go down by cutting back on carbohydrate intake? But it’s what happens. So this looks just like the last slide, but it’s not, okay? So this slide actually is a different meta-analysis, and what they did in this one is we, actually I should say we did in this one, we looked at the change from before and after just in the low carbohydrate arms of these studies, okay? And I think this is useful to know. So not in comparison to a low fat diet, just what happens on a low carbohydrate diet.

And again, you can see the changes there. Now you can see how much weight loss can be expected on average, the blood pressure changes that you can expect on average on a diet like this, but I think what’s meaningful is to look at the LDL level. Notice that on a low carbohydrate diet, your LDL level doesn’t go up necessarily. It just doesn’t go down as much as it does with a low fat diet. And that’s why in the last slide, you could see a benefit going towards a low fat approach. And look how dramatic the effect where their triglycerides are. So diabetes is probably the issue that we think that a low carbohydrate diet might have the most benefit.

And so I wanna spend a little bit of time going over some day regarding diabetes. This is a systematic review. It shows you that as a number of investigators have looked at this issue and wanted to see how much reducing carbohydrate impacts our blood sugar control. So this is a little bit of confusing of a slide, but they took any trial that had less than 45% carbohydrate recommendations and followed people for at least two weeks, up to 26 weeks, and they plotted it on the horizontal access as the percentage of carbohydrates, carbohydrate and calories I should say that were recommended; and then on the y-axis, it’s what change in A1c occurred, okay? And so the line shows you that as you restrict carbohydrates lower, then there’s a greater decrease in hemoglobin A1c, or improvement in glycemic control.

So we reviewed this study, among other studies, with the American Diabetes Association in 2010 and wrote some recommendations. These are probably the first recommendations that have come out that actually supported a low carbohydrate diet for diabetes, and there’s still several guidelines out there that don’t recommend a low carbohydrate diet and sometimes caution people against using low carb, lowering carbohydrates for diabetes. But the American Diabetes Association guidelines in this year actually did support it, and it is based somewhat on what we found in the literature. We updated a literature search looking at this diet approach among other diet approaches for diabetes, and we found quite a number of studies, 11 trials done with a low carbohydrate diet compared with similar other nutritional approaches. And six of the 10 studies showed an improvement in A1c, whereas with the other diet approaches, less than half of the studies that were looked at actually showed an improvement in A1c.

And then most recently, this just came out in January of this year, they did this network meta-analysis which is pretty interesting way of looking at studies that might not have the exact same comparisons, not all necessarily low carb versus low fat, they might be comparing low carb to another diet approach or to a high-protein diet or a Paleolithic diet. And so they tried to combine all of these studies and compare each of these nutritional approaches to see what they can find. And first off, I think what’s interesting is to see that the low carbohydrate node, that’s the blue dot at the end, is one of the bigger dots, meaning that it has one of the bigger sample sizes of participants that have been studied in multiple studies.

But these are the different nutritional approaches that were studied. And their summary was the bottom bullet here, that for reducing A1c, the low carbohydrate diet was ranked as the best dietary approach in the ranking order, the sucrose statistic that they used, followed by these other diet approaches. So we think that for blood sugar control, and this makes intuitive sense, actually it’s one of the few intuitive things that we’ll talk about metabolically that happens with this diet approach, is that carbohydrates are what drive our blood sugar level. And so reducing carbohydrate intake lowers the blood sugar level. So I just wanna show just a couple of other studies that we’ve done over the years since we originally did the head-to-head kind of low carbohydrate, low fat studies.

This one was one that stemmed from, first of all, we heard or we we saw from our own research and other’s research that a low carbohydrate diet might be more effective than a low fat diet. So what about a low fat diet combined with a medicine? How would it compare against the medication? And in this study, we compared it to the one medication that was available at the time, Orlistat, and you may have heard of this as Xenical, it’s now over-the-counter as Alli, and this is the result from that study in terms of weight loss. And then you can see there’s a little bit of a benefit to the low carbohydrate diet initially, but at the end of a year, there seems to be comparable weight loss in the two approaches, one being a diet alone and the other being a diet combined with a medicine.

I’d like to show this slide also, and I don’t know how well it projects, but the blue line, the dark blue line, is the average for the Orlistat group; and the dark red line is the average for the low carbohydrate group. But you should also see in the background hopefully some lighter red and blue lines, and this shows the variability that occurs in a weight loss trial and also with our patients. There is a wide variety of response to either of these approaches, and we see this repeatedly. And I think this is something that’s really lost in a lot of the press about these clinical trials. We talked about which one works better. On average, what happens? But in any individual, somebody might actually gain a little weight during the study, and there might be people in each arm, and believe me there are blue lines and red lines down here at the bottom, people who are losing in one year more than 30% of their original body weight with diet too. This is not surgery, this is just with diet. So it can be really powerful in the right individuals or the people who are really motivated or stick to it, or maybe it’s just the right approach for them.

This last one I’m gonna talk about addresses an issue a lot of even experts have come up with after all of this information has come out, and that is well, we have a lot of nutritional approaches that work, maybe we should let people choose. Well, maybe that’s not the best idea. So we wanted to test that. So obviously, letting people choose what diet approach they follow might be beneficial because it might mean they adhere to it better. This is one they picked, it might be based on foods they prefer and therefore they might be able to stick to it longer. But it also might be the foods that have been causing the problem all along. So we tested this in a doubly randomized preference trial where we actually randomized one group to get a choice and one group did not get a choice. And then those participants who did not get a choice were randomized again to either a low carb or a low fat diet, okay? And this was a year-long study and yielded some pretty interesting results.

Turns out the control group, even though it wasn’t statistically significant, did slightly better. So it was the different direction from what we expected. So no difference between the two groups. Choosing certainly did not create a benefit and potentially could have gone the other direction. It might have actually gone the wrong direction. All right, so hopefully this is a message that you snicker at after hearing some of the metabolic benefits you can get from a low carbohydrate diet.

I see people craning their necks so I’ll read it. He says, “You went on Atkins and lost 90 pounds, “lowered your cholesterol, cured your high blood pressure, “and now you’re walking five miles a day. “But I’m warning you, “a low carbohydrate diet is bad for your health!” Something we still run into periodically. All right, I’m gonna pass the baton on to Eric, and he’s gonna take over from here and tell you a little bit about his clinical experience in our clinic, where we teach patients this approach. – Thank you, well done. And I should translate Atkins, it’s not Atkins, it’s keto now. So the first phase of Atkins is keto. And then I’m also gonna add in, “And my LDL went up 10 points, so it’s gonna kill me.” So as a joke because this is the last vestige of what has to change, is only the focus on a certain part of the lipid profile. It’s the metabolic syndrome that saved the low carb diet in terms of producing cardiometabolic risk. So about 12 years ago now, the Duke Lifestyle Medicine Clinic was founded in 2006 after what we thought was the equivalent of phase III clinical trials for FDA approval of a drug.

So oh, except there’s no requirement for a diet. But we were trying to apply that same metric. When do you start using a diet in a clinical practice? Well, when it reaches a certain level of evidence. And why not use a metric that the FDA uses for drugs? It’s something we’re all familiar with. So we opened a clinic at university, within the Duke private practice. There are two rooms adjacent to an internal medicine teaching clinic because that’s the general medicine home that we’re in academically.

There’s an obesity medicine specialist, yours truly; a clinical nurse assistant; and the payment is within the public or private insurance system. The first-line treatment is a low carbohydrate ketogenic diet. I should have said this at the beginning, I have two conflicts that may change how you hear what I say, but not what Dr. Yancy says, is that after 12 years of research in clinical care, I started two companies with other entrepreneurs, one to make low carb products and one to make a teaching company to teach doctors and health practitioners how to do this. So I’m actually owner of those two companies. But I still work at Duke full time. (audience chuckling) A busy life. So thanks to some of you who are here in the room, students, patients, colleagues. We now have over 10 years of data in the Duke system. We moved to Epic about five years ago in our outpatient clinic, so we’ve seen now 4,000 patients at the Duke Lifestyle Medicine Clinic with 28,000 clinic visits which keeps me in business and makes my paycheck.

Most of it is insurance payments, Medicare, Medicaid. The average patients we see are years old. 75% are female, half Caucasian, half African-American, which is our Durham patient mix. Most are from our area. When I visited doctors who were doing this for a living, many of them were kind of in a guru-type practice. You would go visit someone, and then you’d go home.

Actually, most of our patients live in the area here. And the payer mix, 50% private, 50% public. And over the last five years, sorry, that’s the last five years, 2,000 patients have lost 28,000 pounds in a quality assurance, quality improvement sort of data analysis we want to make this publication quality, which means I wanna replicate it again doing it in a different way. Because if you’ve used the Epic and deduced, there are some quirks to using it. But that’s pretty exciting. Someone says, do you believe in low carb diet? Do you believe in the keto diet? I’ll say something like do you believe in gravity? (audience chuckling) You didn’t see it in the back, so I do believe. So it’s science. It’s not a belief. Well, although you might argue philosophically science is just a belief system that you can replicate over and over and over.

So this is known as the clinic of last resort. I’ll have people say they’ve done everything twice. Ah, but I’ll say but you haven’t done this with me. So most doctors don’t get trained in how to help people lose weight. Anyone wanna verify that? You doctors who never were trained? We didn’t get nutrition training. It even occurs today. Medical students do not get trained. I went out to get special training. And then with Dr. Yancy, we were privy to data that no one else really had collected on the low carb diet. So we treat obesity, Type 1 and Type 2 diabetes, polycystic ovarian syndrome, irritable bowel syndrome, fatty liver and GERD. We have papers, at least proof of concept papers, published in the literature for all of these conditions in that first bullet.

We look back and we say well, okay, yeah, there were five people over six months with liver biopsies that show that fatty liver goes away, so it’s not enough to like FDA approval for that indication, but that’s pretty good evidence it’s the carbs that cause the fatty liver, not the fat in the food. It’s the carbs in the food. Think foie gras, where you feed geese carbs to make fatty liver. And that’s a delicacy in some parts of the world. Heart failure, pre-heart transplant. So I’m an old general internist from Duke who you know, we could treat anything, and now I realize there is a specialty called obesity medicine, we can’t treat everything.

But I still have that vestige, so the heart failure folks started to get wind of what I was doing without pills, without products and just changing the food and now we have over a dozen people on the heart transplant list. So the the cardiothoracic surgeons are sending us their patients because they’re too heavy to get a transplanted heart. Just last week, one of the patients came back and said, you know they’re starting an ex plant program. Oh, what’s that? Well, I’ve lost so much weight that my heart is now working at a 45-percentage ejection fraction and they’re thinking about taking out my LVAD. Well, that’s pretty good. How are they gonna do it? Well, they say they’re gonna, I’m just making it up on the fly, right? So how are you gonna do that? Well, put them in the hospital and turn off the pump. If you have any VADs (mumbles) and so you’re gonna turn off the pump and see how he does. And then how are they gonna take out the tubes and all that? I have no idea, remember I’m not a surgeon.

So I will treat anybody who is treatable, and it works better if you follow the plan, no question about it. Post bariatric surgery, weight regain. A lot of patients who never learned how to change the food, the harsh reality is perhaps even half of folks who get bariatric surgery regain their weight over time. Early on, it looks really great, but then you follow them for 10 years if they haven’t learned how to eat and live in today’s world, often they’ll regain the weight. And that 50% is kind of sad when you think about it with all of the stuff that those people went through. So this is the clinic of last resort. So this patient back in the 1980s went to…

A little trivia, does anyone know where the Roux-en-Y gastric bypass was created? (indistinct chattering) Oh no. (indistinct chattering) Will’s alma mater, it’s ECU in Greenville. Walter Pories. So this patient sought out Walter Pories back in 1984 for the Roux-en-Y gastric bypass because she wanted the best surgeon on earth. And so then the surgeons did a revision on the Roux-en-Y, you can see she lost from 280 to 200 and then they’ve actually said you’re done, you’re at 210.

And she said no I’m not. So she sought out this obesity medicine specialist, another expert but not at ECU, at Duke. And then over the next five years, she’s down to her high school weight just by using a keto diet, low carb ketogenic diet and some Lasix. And it was 54 visits over five years, we estimated about $4,000 to insurance. She didn’t pay much, it was a copay, and you can compare that to the operations that were done before. But it’s kind of a team effort here.

She’s thrilled, she’s 70 years old, going on 15 years old and just retired and now they’re moving to a mobile home. And anyway. So this is the kind of medicine you can use and do as an obesity medicine specialist. It’s exciting, it’s fun. We have great practices. We get to teach people and learn from them. This 25-year-old male at baseline had a BMI of 49. Now the younger you are, the faster it works, better it works do it now because you’re never getting younger, yeah. So he said okay, I got this, there’s a one-hour teaching class we do at the clinic, I teach the basics, like Will mentioned; and he came back losing 15 pounds a month just eating at McDonald’s. I said, well, what do you eat? He said, well you know, you’re really not very hungry. And so I have three double cheeseburgers off the dollar menu with no bun, no fries, and I drink green tea and a diet soda. And then he goes down to spring break in Daytona Beach and he drank some carbs, beer; and he didn’t lose weight, he didn’t gain weight, but he was thrilled that he didn’t, you know, he’s coming back and now he has a McChicken every now and then on the dollar menu.

It doesn’t have to cost a lot of money. You can do it within the lifestyle of someone, knowing the principle that it’s kind of like knowing how a bicycle works. You can make different kinds of bikes. So you can do it anywhere, you can do it in the mountains, you can do it on a road. So knowing the principle of carb restriction, being the… going through blood sugar and insulin, we didn’t get into the details of that, but it’s basically the control knob for dialing your appetite and your weight.

Basically, your fat burning. So this is pretty fun. And now getting to diabetes, there’s no patient more thrilled, in my experience, than those who get off insulin. And then they don’t even have to measure their blood sugars anymore because no other doctors repeatedly tell them that it’s possible. In fact, a lot of doctors will say you’re gonna have diabetes forever. Wow, that’s because they’ve never seen it! It would be like me going to Africa and saying there are these big animals with necks like this, and no (mumbles) so I’d take a picture. Here’s a picture of people coming off insulin, and it can be really fast. So I’m recalling, we were sat last night and it was kind of like a retrospective. We’ve been doing this 20 years now. And when I first showed these data to Rob Califf, it was our first 50 patients over six months and I showed him the cholesterol, he said that’s a fibrate.

And I said, no, that’s a low carb diet. So for you medication people, he was used to medications. He saw the lipid profile change and he said that’s a fibrate, the effect of a fibrate. I said no, the low carb diet. He said we need to randomize people who have heart disease, who have diabetes and follow them for two years. You’ll have an event so high that you’ll know whether it works or not. And I said wait a second, this is the first study I’ve ever done on this and you’re talking about diabetes? So here’s what we know about diabetes now that we’ve been doing this 12 years in the clinic.

It’s that you add up all the insulin, 100 units a day, cut it in half on the first day if their blood sugars are in the hundreds, fairly well controlled; and so you have to cut the insulin in half on the first day or you risk hypoglycemia. So can you imagine us 15 years ago having a couple, well, 500 people on insulin not knowing that they’re gonna have to come off half of their insulin on the first day? It would have been a disaster.

So now I’m ready to do that study though. We can monitor people, people have home monitors. We know that when the blood sugars are getting down, you’re at 120, 100, you can’t take insulin. So I tell people, don’t take insulin if your blood sugar is under 100 or 120. And I’ll have people call me that night saying my blood sugar is 90, what do I do? I said, well, I told you this morning not to take insulin. So you can tell people to do it but it’s so bizarre and unexpected, they’ll still ask for guidance. I said don’t take your insulin, you’ll go low. Oh right, if it’s 90 and I take insulin, I’ll go low. So now this person’s off 100 units of insulin in six weeks. 80 units of insulin in one day. So you add up all the insulin, this person was on 40 units twice a day here, I asked the high, the low blood sugar, insulin, the weight, and nobody knows the right way to do it.

If someone’s on 40 twice a day, I might say just take 40 once a day. Or I might say 20 twice a day, I don’t know. We need research to know how to do that best. I try to work within the insulin that a given person has. Off 60 units, now I’m trying to show that this person was on insulin, glimepiride and metformin. You could just kind of get rid of the pills. We keep people on metformin partly as a safety blanket. Security blanket, people think they’re still taking something for insulin, I don’t know, for diabetes; I don’t know really how much it helps. Add up all of the insulin, 100 units a day, off in three weeks, blood sugars are better or as good or better than before, and this is a common situation I get with endocrinologists. They’ll see this patient and say, well Dr. Westman, the blood sugars aren’t perfectly controlled. I say yeah, but they’re not on insulin anymore. Well, we need to put them on insulin to get their blood sugar better controlled. But wait, when you had them, the blood sugars were worse on more insulin.

So this is the push and pull you get with different specialists. If I don’t fix the obesity, the underlying cause of diabetes, they’re always gonna have diabetes. It’s just a different point of view. You have to treat the underlying cause, which is insulin resistance and obesity. Insulin for 10 years, it doesn’t seem to matter how long someone’s been on insulin. So be careful. Someone said oh, I’ve been on insulin 20 years, I’ve taken it everyday. No, you might not need it tonight. Off 180 units of insulin almost in one week. In retrospect, some of these patients are drinking soda they don’t tell you about. They’re drinking sugar, their insulin is treating the sugar they’re drinking and they don’t tell you about it. So you just monitor the blood sugar, it’s okay. So now we’re getting to industrial strengths of insulin here but oh no, they’re making U-500.

No, so that’s not the fixing of diabetes by using stronger insulin. The insulin is already too high in the blood. You want the insulin to go down. And anyway, so insulin for 25 years. Are you getting the picture? I mean, this is pretty reliable. Now this person’s on 40, 55, 60 units of the short-acting, 60 of the long-acting twice a day. 500 units of insulin a day. This person is still on insulin, on about 80 units now about a year and a half into it. He’s not totally off, but he has a hundred pounds of weight to lose. So the average BMI in my clinic is between 35 and 40, depending on your ethnicity.

And so if someone still has a lot of weight to lose, you might not get perfect control on the blood sugar because it’s the weight that’s causing the insulin resistance, that’s causing the diabetes. But this guy’s at high risk for seeing another endocrinologist or doctor who says look, the blood sugars aren’t perfectly controlled, I need to put them on insulin again. And so then they’re gonna go back on the insulin, gain the weight back and then go back and not have perfect control on 500 units of insulin because the problem is not insufficient insulin, it’s insulin resistance. Insulin isn’t working right. So anyway, this is pretty fun. Insulin pumps, fine, just lower the insulin and people are in less insulin. Now hemoglobin A1c is just a reflection of the daily blood sugars, in general the three months average although you can get changes pretty quickly. Here you have A1cs on the right-hand side, someone whose A1cs were not controlled. The weight is about 300 pounds, 67 year-old female, and her meds come off, her A1c is under six where it hadn’t been for 10 years off medication.

So mild diabetes. I mean, this is like yeah, it’s just kind of easy. But remember, we had all those studies about obesity, and now a growing number about diabetes. This person, this is an internist’s dream. If you like to take care of complicated patients and fix them, this person is on medicine for diabetes, high blood pressure, GERD and had A1c over seven for 10 years and now on a low carb diet within two years has a blood sugar A1c under six, off all the medications. So now Dr. Yancy has taught me, Will has taught me a lot of things, that it’s nicer, you can attract more flies with molasses than vinegar. But gosh darnit, this is fantastic! (audience laughing) When you get the emotion of people in the clinic, holy cow. I just had someone who had a renal transplant from his wife, from diabetes that he’s had for 15 years and then lost his kidneys and just had a transplant, so he’s on prednisone and now he’s off his insulin in a week.

So he’s starting to go through this, I didn’t have to have diabetes, I didn’t have to go through, this is pretty heady stuff. It’s great and it’s just changing the food. So when we get people who say, oh that dialogue there are a lot of irrational fears that we’ve been taught. You’re welcome to come to my clinic, which was the answer that Dr. Atkins gave me in 1998 because there were so many things that just didn’t compute. But what about the fat, what about this, what about the salt? So even today people come to our clinic to see it in action, to overcome all of these irrational fears that are out there. It’s fascinating. Sociologically, this is a goldmine of information. So anyway, other folks. So Dr. Yancy worked his way through the system and is now Director of the Duke Diet and Fitness Center. And by, I think popular demand, and by his reading of the science, has a low carb program there as well, I worked at the Diet and Fitness Center around 2001 and got motivated to change my life from a pill pushing internist to an obesity medicine doctor that takes away medication and then realized that well, not everyone can afford the DFC but it’s a great place, and so we opened The Lifestyle Clinic to use that model of lifestyle change.

And the DFC has been part of the Duke Health System for over 40 years. To our knowledge, it’s the only medically supervised residential-style weight management program within an academic medical center in the US. And so someone really wants the credibility of the University and then seeing the doctors often on a daily basis if needed. It’s staffed by medical providers, dietitians, exercise physiologists, behavior experts, swim instructor, certified coaches and massage therapists. It’s helped more than 50,000 clients from around the world. And if you haven’t been there, it’s just right around the corner on Douglas Street behind the VA hospital. The old metro sport, the old fitness center, turn there. So where do we go from here, and then some questions.

Let us have it. There is an ongoing two-site VA study with diabetes going on, Durham and Greenville, and Will is the PI on that 260 folks and in progress. They haven’t stopped it yet due to adverse events, Dr. Yancy? They have not stopped it yet due to adverse events according to Dr. Yancy. We’re gonna do retrospective analyses of the Lifestyle Medicine Clinic and the Duke Diet and Fitness Center. We’re happy to help and appreciate the help of students on our rotation of residents, of faculty if you have an interest here to look at what’s happened.

For example we’re gonna pull out all the people with polycystic ovary syndrome because a current student on the rotation is interested in PCOS, we’re gonna go into GYN and see what’s happened. So we have over 100 people, and I mean this is like hot off the press information as you’re on deduce right there. And then what’s really needed, and we got kind of sidetracked.

I mean, we wrote paper, we wrote study proposals 15 years ago to do the diet trial to end all diet trials. Never got funded. We have proposals sitting around, maybe it’s time to dust them off but the limiting factors, where does the money come, right? Who’s gonna fund the study that takes you off insulin? Well, not the insulin providers, right? Or not the company. So we’re still trying to fix that. There are at least two people through NIH funded, probably gonna make their careers, young investigators, K awards are a great place to start or the VA. We still need the multi-site randomized controlled trials of LCHF with clinical endpoints for heart disease, for, I’m ready to do that study with people with diabetes and heart disease who’ve had events because I think we can take people safely off the insulin now. And there was just a recent paper, a couple hundred people with diabetes, it was a single arm study done in Indiana at Purdue, and it’s fantastic. The low carb, the keto approach for diabetes, 95% of folks with insulin were taken off their insulin, something like that.

It’s so unbelievable, nobody believes it. That’s the saying that we say. So I think that’s it. So thanks so much for your attention, and we have some time for questions. (audience clapping) Yeah. Do you want to moderate or do you mind? Okay, yeah. – Thank you for the great presentation. My question is like how do you compare the low carb diet with a mini fasting diet? Mini fasting, like interval fasting? – Interval fasting? – Yes. – Yes, so I don’t think there has been a comparison of those two approaches. Most of the time that I’ve seen the intermittent fasting, it’s been compared to just a standard low calorie, usually low fat diet. And it’s a daily calorie restriction for the control diet. I haven’t seen the low carb compared to interim fasting. In terms of what’s going on, we actually think metabolically that a low carbohydrate diet is a fasting-type physiology. So there might be some benefits that people attribute to fasting, and which they also attribute to intermittent fasting that might be attributable to the low carbohydrate diet.

But at this point, the intermittent fasting has just recently been looked at in clinical trials, probably in the last three or four or five years or so. So we’re still waiting to hear more about that approach. At this point, what we’ve seen is that intermittent fasting works as well as a calorie reduction diet, not necessarily better although there is some kind of physiologic evidence to show there might be some benefits. We haven’t seen that in human clinical trials yet. – Thanks Eric and Will, this has been great. Just to go back to the story, because I think the story is so important for everyone to hear, your first trial got the American Heart Association to change their recommendations for diet. – Oh, shucks. – Yeah. (audience laughing) If you go back, remember how crazy this was when we first talked about this forever ago, the NIH turned down the first study recommendation because they didn’t wanna do a mortality study of diet. They didn’t think you needed to do that. And then go forward 15 years, over the last 15 years, we’ve seen lots of things about the harms of sugar in our diet, there’s now… when we first started, there was like six people in the country who believed what you believe.

It’s obviously much broader now. And you’ve been amazing at continuing to both practice medicine and furthering this in the clinic and doing the research studies. So it’s a huge kudos to you both to do that here at Duke. And hopefully we can finally do this trial. We also got turned down from the NIH to do the trial over mobile phones. So we tried Internet-based studies of diet, mobile phone-based studies of diet and they frankly weren’t interested in doing the clinical trial. – That would be great, thank you. – Yeah, if I was starting a new medical school or if someone asked me to help out, which I’ve never been asked, the first day would be nutrition. The most important thing for a doctor is knowing what you put in your mouth. And we get nothing. Why is that, Dr. Yancy? It’s complicated. There’s no room in the schedule. So anyway, diet is really important and that’s the kind of advice you get through our programs.

Thanks, Kevin. It’s kind of like how many times do you scale the wall and try to get in the fortress and then you fall off. But another team will coalesce, yeah. – Hello, Dr. Westman. I’m gonna put a plug in for you. If anyone has any doubts about how well this program works, I started seeing Dr. Westman a couple of months ago, 27 pounds down. It is a very easy diet to follow, but I will retract the word diet and say that it is a lifestyle change. It doesn’t matter, you have to be motivated and really stick to it, but it is so, so easy. So I thank you in front of my co-workers and colleagues. And some of the questions that I had for you, you have answered today, so thank you again. – Well, thank you for that and… (audience clapping) So we have a support group, we have one once a month, first Tuesday of the month at the Durham Hilton. And this last time, there were 80 people who came out, half had similar stories and they wanna share, they wanna help other people.

I’m curious, aren’t you? What if we looked in the database of people who came through the clinic with all the people with heart disease, with all the people who have an LDL over I don’t know, whatever you think is a bad LDL today? I’m reassured the last guideline really doesn’t have LDL in it. So triglyceride and HDL and age and whether you have hypertension and diabetes are important factors too. But if anyone’s interested in looking at the data in terms of cardiovascular events or risk or things, it’s retrospective but it’s eminently publishable because nobody else has this kind of information. Yeah? – Just a second testimony, I’m sure you don’t wanna go off in this tangent but people ask okay, is this healthy? I was 275 pounds in 2012, I am 173 pounds as of this morning. I am 61 years old, I take absolutely no prescription medicines. So it works. (audience clapping) – But you know, there are 99 things better than that one last thing. But what about the? The last vestige is kidney disease, right? It’s gonna kill your kidneys.

And what about that LDL? Yeah, so… – When do you suggest people who are on the low carb high fat diet, less than 20 grams, when do you suggest they can have an apple again or start eating some fruit or bringing that back into their diet? After they’ve reached a certain milestone? – Why don’t we both answer this? My view now from the Tampa Conference, University of South Florida, now that ketones are being studied, they actually have therapeutic effects. And we’ve gone, in my lifetime, in science from this is really bad and it’s gonna kill you, everyone. That’s what everyone thought so that you would get the pushback, don’t do this, from your doctor, your dietician, your grocery store clerk, right? So now we know that’s not true. But the studies now being done in animals, mice live 15% longer when they’re in ketosis. Holy cow. You might even prevent insulin resistance, which is the root cause of Alzheimer’s, which for some cancers they’re actually therapeutic or preventive. So now that the science is being done, now I’ve been doing keto because I like it and the science is looking good, but now oh my gosh! You might even be better by never eating carbs again to the degree of even having an apple.

Okay, now a more moderate response. (audience chuckling) – So I concur with what Eric said. I think we’ve kept patients, or we’ve followed patients who have kept at a very low level of carbohydrate intake for years. What I’ve talked to my patients about, about how to decide when to add carbohydrates back in, and first of all that should be done very slowly, like five grams a day is what we suggest to people to do that for a week; and if you’re doing okay at the end of the week then you can add another five grams and then another five grams, you do it very systematically like that. But I tell them when you’re close to your goal, if you’re close to your goal, whatever that might be, it might be your goal weight, it might be your goal blood sugar control, it might be your goal of getting off of your diabetes medicine, then that’s the time to consider it.

The other caveat to that is when you feel like you can’t do the diet any longer, if you feel like you just can’t do it anymore and I’m really convinced that they can’t do it anymore rather than like just letting them capitulate, then I’ll say well, have a little bit. Why don’t you have a little bit of some berries? They’re pretty low in carbohydrate. Add some berries if that helps you to stick to the diet better. That would be the other approach I use. – At the Low Carb Conference in West Palm Beach in January, there were a couple talks on how plants put toxins in their leaves so animals won’t eat them. This is a defense mechanism. So what do you think? We’re animals, right? So you look at these toxins that are in the vegetables, the argument that you need vegetables and then the leaves and all of that kind of is debatable. So there’s actually a subgroup of humans should be carnivores, eat nose-to-tail, make sure you get some liver, get some kidney and it’s an interesting debate.

And I think it’s a reasonable one. And I know this is changing guideline, Kevin, as you mentioned. I have all those American Heart Association, it’s the same people on the same paper without any new information and they still have the guideline that’s low fat. I think that was last year, made the national news and we’re just kind of going, oh my god, it’s not a meta-analysis. It’s just a one-sided story. I think it’s something that we need science in on that. The Nutrition Coalition is a group that is advocating to change the guidelines, started by Nina Teicholz who wrote the book, The Big Fat Surprise.

Of course, Gary Taube’s Good Calories Bad Calories is a great place to start if you’re really geeky. And then Gary came out with a book, The Case Against Sugar in January, which again, as Kevin mentioned, people are zeroing in on sugar. But we risk the pendulum, well, okay, that’s been bad so long, okay that’s fine and now sugar is bad, you know? We need science to help guide us there. You still eat carbs, Dr. Yancy, don’t you? – I’m on a maintenance carb diet is what I eat. (audience laughing) – I saw you eating carbs. (audience laughing) – I’m maintaining, I’m at my goal. – I mean, there is kind of a cult-like atmosphere, but it’s only because of the low fat cult, right? And it’s not a cult, it’s just the way our bodies work. But I think I counted seven people in this room, when you’re in the minority, you tend to kind of cluster together as a protective mechanism. I’m just kind of vamping because I don’t see any questions. (audience laughing) – Okay, we’re actually over time, but thank you so much for a wonderful and provocative talk. We look forward to having you back in 2021, 2022 with the results of the diabetes study…

(audience clapping) (uplifting music) .