Dr. Eric Westman on the Future of Metabolic Medicine

Eric: 
But it’s all they have. So, enter in the possible- 

Bret: 
They think it’s all they have.

Eric: 
They think that’s all they have. 

Bret: 
Yeah. 

Eric: 
It’s all they were taught. 

Bret: 
Yeah. 

Eric: 
Just here’s a pill for another ill.

Bret: 
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a non-profit initiative of Baszucki Group, where we’re providing information about the intersection of metabolic health and mental health and metabolic therapies, such as nutritional ketosis as therapies for mental illness.

Thank you for joining us. Although our podcast is for informational purposes only and we aren’t giving medical advice, we hope you will learn from our content and it will help facilitate discussions with your healthcare providers to see if you could benefit from exploring the connection between metabolic and mental health.

Please remember that our channel is for informational purposes only. We’re not providing individual or group medical or healthcare advice or establishing a provider-patient relationship. Many of the interventions we discuss can have potentially dangerous effects if done without proper supervision.

Consult your healthcare provider before changing your lifestyle or medications. In addition, it’s important to note that people may respond differently to ketosis, and there isn’t one recognized universal response

Dr. Eric Westman, thank you so much for joining me. 

Eric: 
Oh, my pleasure. 

Bret: 
Here we are at the CoSci Conference, and we kicked it off last night with a exclusive screening of The The Cholesterol Code documentary, the first sneak peek. So, give us your initial impressions. What’d you think of it?

Eric: 
Of course, the evening was awesome.

Bret: 
Yeah. 

Eric: 
I felt like I was at a Hollywood gala event. But the movie itself is just really unbelievably great. And I say unbelievable because there’s science presented in the movie that people aren’t going to believe, which of course has to do with low carb diets and cholesterol. 

Bret: 
Right.

Eric: 
Thus the movie called The The Cholesterol Code. But it’s really the story of Dave Feldman and his curiosity that then gets updated with Nick Norwitz’s curiosity. And how that grows through the years is fascinating because I remember Dave Feldman coming to me showing his blood cholesterol levels multiple times a day.

Bret: 
Yeah. 

Eric: 
And I asked him, “What are you doing?” Doctors, I’m an internist like you. Doctors, we don’t look at it that way. And he said, “But look, it goes up and down throughout the day. Isn’t that interesting?” I said, “Yeah, okay. But I don’t know what to do with it.”

So, I’m glad I didn’t tell him. Now, I learned that if I had told him, “No, don’t do it,” he probably would’ve done it even further. 

Bret: 
He would’ve listened, yeah. He would’ve done it anyway, yeah. 

Eric: 
But to see that grow, he started with himself. 

Bret: 
Yeah. 

Eric: 
Self-experimenting and then grew, best I can tell, to about 30 people at a study at a meeting called KetoFest years ago.

Bret: 
Yeah. 

Eric: 
And to see Dave really be curious in this way. He then had to figure out how to fund research. 

Bret: 
Yeah. 

Eric: 
And doing a crowdsource funding because he knocked on doors of all of these academics and they said, “Your LDL is high? Don’t study this. Get off that diet.” 

And yet, he felt so good and met so many other people who were feeling good.

No, great. I mean, no, reversing disease.

Bret: 
The best they’ve ever felt.

Eric: 
Best they’ve ever felt. So, how could this one little LDL in the blood panel supersede all these other things that were getting better? 

Bret: 
So, to see that journey in the documentary yesterday was really impactful as you can tell just by your response here and the crowd’s response was very clear.

But so, you are a clinician. You’re a practicing physician. You see patients. You have colleagues who see patients. What do you think the impact of this documentary will be on those practicing physicians when they see a patient tomorrow, Monday, with high LDL?

Is it going to change the way they think? 

Eric: 
I think so. 

Bret: 
Yeah? 

Eric:
I hope so. Of course, I’ve been hoping this now for 25 years since we first did our first study. Or really, I had two patients who lost weight on their own doing an Atkins-type diet, which has different names. But basically, the worry we had then was cholesterol.

Bret: 
Yeah. 

Eric: 
But now, 25 years later, looking at the science and the balance of all the things that are getting better, including type 2 diabetes, we reverse it. And that’s not just a risk factor for heart disease. It’s basically the major cause these days. So, to ignore all those good things because of one little detraction is something to me now that seems really out of place.

It’s a misdirection of focus. And yet, in my area and in the US, most doctors, even mid-levels, will follow guidelines that say, in fact, if you have diabetes, just use medicine. Don’t reverse it, and add medicine for cholesterol. 

So, what we see in this growing number of people and in this movie is people who have LDLs that are higher than other doctors would think is okay.

And yet, they’re fine. 

Bret: 
Yeah. 

Eric: 
And not even just, “You’re fine.” They did coronary artery CT angiograms to show that they were fine. 

Bret: 
Yeah. 

Eric: 
So, this is high level. There are stories of improvement. But then, this movie is the best modern-day science to evaluate arterial disease in the coronary arteries.

That’s pretty phenomenal. 

Bret: 
Yeah, and that’s what I love about it, too. And you said it so well. It’s not just saying you’re fine. It’s let’s look as deep and as detailed as we can to show that you’re fine, which I think is so amazing. But so, there’s the LDL and the risk. But then, there’s also as physicians, we’re always having this risk-benefit analysis in our brains, and hopefully, in a discussion with the patient.

And I think maybe the benefits of ketosis are often underplayed in the general medical world. So, give me your thoughts on that and the impact this documentary may have on that side of the risk-benefit analysis. 

Eric: 
Yeah. Over the last 20 years, that’s how long I’ve been researching and using this clinically, I think there is a general acceptance that diet matters.

Does everyone have to do keto? Yeah, at least in my area, people are, doctors are tolerant of low carb and keto diets and recognize it can have beneficial effects. I think what this movie and the emerging science focuses on is, is there incremental benefit for being in ketosis all day long?

And they followed these people over a year documenting, a company gave the keto measurement tools to make sure they were in ketosis. And there may be actually extra benefit from having ketones around, which takes me from I just wanted to show this was safe for weight loss 25 years ago to the idea that ketones, the more we learn about them, they’re anti-inflammatory molecules.

They’re hormonal signals that go around with the ketones. And although, in the clinic, I still say I don’t know if you need to measure ketones all day long. I don’t know if you’re really going to have incremental benefit beyond just getting rid of all the junk and ultra-processed foods.

But I’m also optimistic that we may find some subsets of folks who actually do better in ketosis. 

Bret: 
Yeah. 

Eric: 
But we need data to support that. And data could be anecdotes, could be growing to case series and case studies. But I, so at a minimum, I hope The Cholesterol Code, the movie, will stimulate other scientists to start doing research.

Bret:
Yeah, so let’s talk about that. That’s such an impactful, or potentially impactful, part of this documentary. 

Eric: 
Yeah. 

Bret: 
And being here at the Collaborative Science Initiative talking about sort of the N of one citizen scientist, but you have the background of doing the randomized controlled trials, right?

Doing the academia research. So, they’re on opposite ends of the research spectrum, but it seems like they’re both so important and relate to each other. So, give us your perspective on that as a seasoned researcher, but still recognizing the importance of the citizen scientist and the anecdotal.

Eric: 
So, Dave Feldman’s story in the Citizen Science Foundation is let’s raise our own money. And so, you have control over what the scientific question is. 

Bret: 
Yeah. 

Eric: 
I’m afraid, even today, after 20 years of watching this happen, the investigators usually aren’t in control of what they really can study.

You have to go through study sections. You have to find mechanisms. You often are doing studies on drugs because drug companies have the money. 

Bret: 
Yeah. 

Eric: 
I have colleagues who have great lives going around speaking for obesity medicine pharma companies. And they’re great people, and they’re funded by pharmaceutical industry research.

That’s got to change. There has to be a mechanism for studying diet. 

Bret: 
Yeah. 

Eric: 
In a recent movie, called “First Do No Pharm” with Aseem Malhotra, he interviews Fiona Godlee, the former editor of the British Medical Journal. And she says, these statin companies, not only won’t they open up the data for us to see, so they’re not being transparent about data.

They could’ve,” she said this. I hadn’t thought of it, that she said, “They could have added a lifestyle component to every one of these studies.” 

Bret: 
Yeah.

Eric: 
Why don’t we have a standard diet, the placebo, the drug, and then why don’t we just try another, I don’t know, Mediterranean diet or keto or vegan or something?

Yeah. And they never did. When you step back, why would a company study anything other than their company product? 

Bret: 
Yeah. 

Eric: 
So, that would take some influence to say, “You can do a study, but you have to include a lifestyle arm.” But getting back to the idea of researchers and even established researchers, nobody wants to be the first one to stick their neck out.

Bret: 
That’s a good point. 

Eric: 
So, hopefully, The Cholesterol Code will show that actually changes are happening that you really wouldn’t predict. 

Bret: 
Yeah. 

Eric:
And you won’t be the first one. You might be the first NIH grantee to get money to it, but you’ll see actually what can happen with lifestyle change. And you won’t be the first one to risk it.

Bret: 
Yeah. 

Eric: 
Reminds me of at Duke, when I went up to visit Dr. Atkins to learn his method. There was a lot of skepticism. Why would he want to do research? And actually, they funded some of our research 10 years later when all these other studies were done. And they were all positive for low carb diets. One of my colleagues said, “You were like shooting fish in a barrel.”

I said, “What do you mean?” He said, “You cheated. You went to someone who had already worked it out, and you hadn’t worked it out.” And I said, “Wait a second. Ten years ago, you said it didn’t work.” 

Bret: 
Yeah. 

Eric: 
“And that it wasn’t worth studying.” They changed the tune. And so now, you change the tune when the science comes out.

Bret: 
Yeah. 

Eric: 
And I’m hopeful that 10 years from now, there’ll be NIH investigators, who start saying, “Of course, we always knew this was good.” 

Let them say that. There has to be someone first to stick their neck out. 

Bret: 
Yeah. 

Eric: 
And that’s Dave Feldman’s story. 

Wow. 

Bret: 
Yeah, and it’s so easy for researchers to say, “Oh, it’s just N of 1. It’s just a small group.” 

Eric: 
Yeah. 

Bret: 
“We don’t need to worry about that. It’s not real science.” But it has to start somewhere. And that’s what I think, that could be a big takeaway. And that’s going to be the snowball effect that hopefully we’ll start getting these NIH grants and getting big research institutions to look at this.

Eric: 
I hope so. 

Bret: 
Yeah.

Eric: 
But even today, having watched this movie, I can go back to my clinic and be much more comfortable saying, “Let’s not worry about that LDL. Your HDL is over 100 milligrams per deciliter. Your triglycerides are under 50. And we sent you for the anatomic tests of your arteries, and you have no disease.” 

Bret: 
Yeah. 

Eric: 
But it seems odd, doesn’t it? That I have to collect this data to convince another doctor that they won’t give a drug when they’re giving a drug for a disease that someone might not even have. 

Bret: 
Interesting perspective when you change it that way.

Eric: 
So, it’s like I’m giving people the defense to go into the other doctor and say, “Look, I have no arterial disease. Why should I take a drug?” 

Bret: 
Yeah. 

Eric: 
Even that doesn’t persuade some of the other doctors because they’re just following. They don’t think about things. They’re just following certain guidelines.

Bret: 
But I think we’re definitely in the environment where even with the documentary like this, we can’t just say, “Don’t worry about your LDL.” It’s, “Let’s take the next step to see if you have heart disease or not.” Because LDL’s not the disease. Heart disease is the disease. So, let’s monitor for that. 

Eric: 
Yeah. I’m meeting young internists, super smart young doctors who are, they’re losing faith in the drug treatment of these things. And when you really look at the absolute risk reduction of some of these medications, it’s not all that great. 

Bret: 
Yeah.

Eric: 
But it’s all they have. So, enter in the possible- 

Bret: 
They think it’s all they have.

Eric: 
They think that’s all they have. it’s all they were taught. 

Bret: 
Yeah. 

Eric: 
Just here’s a pill for another ill. But sure and in fact, I want to go back to the internal medicine ACP, the American College of Physicians.

I’m not a member now because all they use is drugs. 

Bret: 
Yeah. 

Eric: 
They manage disease. I want to go back and say, “Hey, look. We can actually reverse and prevent all of those chronic diseases.” But even my obesity medicine association that I’m past president of has now become a pharma-based sort of company. 

Bret: 
Yeah.

Eric: 
But I know that tension because now doctors get to go, and they get free dinners because the drug companies now are funded with all the obesity shots and things like that. So, that’s the competition we’re playing with the doctors at that level. That’s one reason why I am on the board of the Society of Metabolic Health Practitioners, which is a group that doesn’t require you to be a doctor to be a part of it.

You can be a coach. You can be a dietician, and you don’t have, you don’t have to know how to do an operation to be able to teach people how to change their food. So doctors really are over-trained yeah for this.

Bret: 
Good point 

Eric:
If someone’s not on medications, and then I’m a part of the American Diabetes Society on the board, which is a new organization that’s just trying to get the message out that diabetes is reversible. 

Kind of fed up with the idea the American Diabetes Association is driven by medications and let’s manage you with medicines. Let’s get the word out that actually you can reverse type 2 diabetes. And I would love to see another movie of the The Cholesterol Code with all of the case studies of the diabetes reversals.

And because actually I’m in my clinic, that’s more common where someone has reversed their diabetes, their high blood pressure, all of these metabolic issues. And yet, that remaining LDL elevation persuades other doctors to try to persuade them to not do something that fixed all these other right things. 

Bret: 
Again, that risk-benefit. 

Eric: 
So then, yeah. 

Bret: 
Such a big benefit.

Eric: 
And then, the paper that was highlighted in the movie that showed the relationship between diabetes and heart disease, obesity and heart disease, smoking and heart disease. This is like the, it’s like the smoking and lung cancer.

Bret: 
Yeah. 

Eric: 
It’s that high. 

Bret: 
Yeah. 

Eric: 
And then, the LDL cholesterol is like down here. 

Bret: 
Yeah.

Eric: 
It’s almost not even significant. So, when you take an unbiased look at everything, doctors should be trying to reverse type 2 diabetes and not worry, prattle about this cholesterol level. But sure, I don’t throw it out either.

I hedge the bet, so to speak, the anti-inflammatory effects of these medicines. And so, in my practice, I don’t tell everyone to get off their medicines for sure. 

Bret: 
Yeah. and since we’re talking about medicines, and you brought up the weight loss injections, the GLP-1s, the GLPs.

It seems like we’re in this polarized world, right? Either everybody should be on the medicines and/or nobody should be on the medicines, and it should only be diet. Do you see a world where the two can be used responsibly together for healthy weight loss, maintaining muscle mass, maintaining bone density, but still helping people who need that extra push, but still really incorporating lifestyle modifications at work, whether that’s ketogenic interventions, resistance training, whatever?

I’m sort of setting you up for the question here. Leading the witness, but what do you think about that? 

Eric: 
Yeah. I think all of these tools have a role to play. 

Bret: 
Yeah. 

Eric: 
And so I’m not, I’m a lifestyle guy. I go to the Obesity Medicine Association meetings and talk about keto diets. That’s all you need.

You don’t need these drugs. 

Bret: 
Yes. 

Eric: 
And yet the other doctors are saying, “But my patients come in and they want the shots. They want the pills.” Okay, so but then, what are you going to do when they’re off the medicines? 

Bret: 
Right. 

Eric: 
So, there’s always that they will have to reckon with the food. We saw that with weight loss surgery.

People can lose 100, 200 pounds with the surgery. But if they don’t get taught about the food, they regain the weight. That’ll still happen with the shots, unless someone teaches them here what to do when the shots are done, or they get persuaded that they always need to be on the shot. Like people are persuaded they always need to be on a statin or other. The drug companies would love that.

My patients wouldn’t really love that. So, I think there’s a balance. There’s a role for prescription strength diets. If that clicks, that’s all you need. And so that’s where I start. If someone really is entering this weight loss world, medical weight loss world, it’s not, we’re not talking internet things, like things that aren’t used by doctors in clinics. So, that’s an important distinction.

Obesity medicine has programs that really do work. Prescription strength diets, even very low calorie diets, the bars and the shakes. And now, the pills and the shots. 

Bret: 
Yeah. But it’s not all about weight loss, right? You have to, there’s still the metabolic health component. 

Eric: 
That gets better too, I’m afraid. I’m not I’m afraid. I’m fortunately, that gets better, too. 

Bret: 
Yeah. 

Eric: 
So, you can reverse type 2 diabetes now with these shots, these medications. 

Bret: 
Yeah. 

Eric: 
And actually endocrinologists are, and cardiologists are bumbling upon the right answer, which is to get the weight down. 

But they’re using the drugs, the shots to do it, which is fine with me. But at the end of the day, you don’t need any of that if you just take the time to learn how diet affects all these things.

Bret: 
Yeah. 

Eric: 
So actually, you can look at a weight loss drug outcome study and get a sense of what would happen with this kind of diet. 

Cause it’s the same sort of potency. And you actually can reverse diabetes and reverse heart attacks. So, keep in mind that it’s not just the shots that are doing that. 

Bret: 
Right.

Eric: 
It’s the weight loss. 

Bret: 
However you do it. We see the headlines, the GLP-1s reduce knee pain. There’s nothing specific that reduces the knee pain. It’s the weight loss that did it. It’s the weight loss. 

Eric: 
Yeah. Even then the diet, you cut out carbs. It’s anti-inflammatory from the get-go.

Bret: 
Yeah. 

Eric: 
And that’s one of those non-scale victories we don’t talk about. Not only the mental health improvements, but the joint pain going away. 

Yeah, so many things get better. If someone really knew, they wouldn’t believe it. And then, they would be beginning to say, “Oh, you’re just, you’re like Dr. Atkins who said everything would get better.”

He was right. 

Bret: 
Yeah. 

Eric: 
It’s just the world wasn’t ready to hear that. 

Bret: 
And when you improve metabolic health, the downstream effects are so many benefits. 

Eric: 
Even upstream. 

Bret: 
Upstream. Exactly. Well said. Well said.

Thank you so much for joining me. 

Eric: 
My pleasure. 

Bret: 
Thank you for all your work in this field. it’s a pleasure, and I look forward to hearing more from you. 

Eric: 
Thank you, Bret.

Bret: 
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