Replies

• Thank you! I have been using your page 4 to help out a lot of people.
  June 12, 2021

• I love these n=1 stories as well, thank you for sharing! Sometimes I wish I can visit some of my patients' homes and see what they're really eating day to day. I've read enough anecdotal stories online to be a believer, and I know I'm biased toward this low carb intervention. I do offer this way of eating as an option to most patients, but without strong language. It's more like, "I've heard it works, it may be worth a try if you're open to making some changes. I'll help you safely adjust your medications if needed." However for patients who are on the fence, I'd like to have stronger evidence for improved quality of life if I'm to make a strong recommendation. I feel that big changes to ways of eating is burdensome, especially in older folks. Additionally, I know I'm shy about asking patients to increase meat intake when they've spent decades not eating a lot of animal protein. Most respond that they just don't like it. Basically, is the evidence for this intervention strong enough to support the burden it takes for someone of advanced age to make big changes to their diet? This question is really meant for patients that require a bit more than a nudge; not for patients who are open to trying new things and have plenty of family support.
  June 12, 2021

• Love seeing this. It does not have to be hard or complicated. Small changes can make lasting impacts. Thanks for sharing!
  June 10, 2021

• Yes, I take "all comers." Age > 18 (I'm an internist and obesity medicine specialist.) Here are the ages one recent clinic day for me: 71, 69, 67, 76, 74, 62, 27, 67, 72, 54, 23, 66, 35. Average age in my patients; 65 y/o I think my oldest patient was 92. I'll teach anyone, as long as we can monitor the medical conditions. Those on diabetes and/or hypertensive meds need to be monitoring glucose and blood pressure at home for safe de-prescribing at home. I've taken people off 10+ medications (over time!). Pubmed us for program details: Westman EC, Yancy WS Jr Works in all populations, including Asians. See www.drwestmanonline.com for more details/info about our program Eric PS we just started a Duke Keto Clinic fundraising site--to develop our ACADEMIC program. See www.ketomedicine.org
  June 10, 2021

• Hi, I can comment my one and only successful intervention. My mother was 81 years old when we started the intervention and is living with one of my sisters, 49. My sister was doing keto but my mother doesn't sympathized too much with the way her daughter was doing. She was on Omeprazol for more than 10 year and also on one blood pressure medication (I don't remember which one). We started the intervention due of two big complaints for her side: too slow and bothersome digestions and poor sleeping. She weighted 82 Kg (180 lbs). She was doing 5 meals a day. My proposal for him was to start taking out one of the intermediate meals (morning or afternoon snacks) and checking her sensations. I explained to her that she needed to give time to her digestion to finish completely and this implied not to eat anything between breakfast and lunch and between lunch and dinner. I explained also than she needed to eat a lot more of proteins, thus his 3 meals for the day should have an important presence of eggs, meat or fish (my approach was keto/carnivore based, but self administered and without measuring or weighting ingredients). She started to take magnesium and red Himalayan salt (1/2 to 1 spoon), vitamin C 1g and vitamin D3 4000 UI daily. Also bone broth 3 times a week. She adapted well, in general. Breakfast with bread (no way to take this off) and olive oil, cured ham milk coffee. Nothing until lunch. Main course meat or fish with some veggies for lunch, no bread, potatoes or pasta. Nothing until dinner. Eggs and meat of fish for dinner, no carbs. She walked for one to two hours every day (in one to 4 times, not all of one, depending of day), and was doing for 3 months acuagym, one to 3 times a week. She lost unintendedly 14 Kg (30 lbs), ceased to need omeprazol, recovered a lot his posture, ceased a finger arthritic like pain that lasted for lasts 40 years and ceased also blood pressure medication. Had a better than before sleep quality and very puzzled with his weight loss, in her own was "I hadn't loss weight, it fell off". Main effort was to force herself to eat way more hand she was used. And also th change the way she things in what she prefers to eat. The start was really slow (as slow has she needed, for doing the project as comfortable as possible). We have learned that the body has no clue of the age. If you perform the right nutritional and behavioral ambiance then our body performs. It's never too late. It allays pays off. Sorry about my English.
  June 10, 2021

• Thank you very much to Chris fir introducing the notions advanced by Adele Hite about the proper nomenclature of therapeutic carbohydrate reduction. It is a very powerful point to coin a terminology that is not only correct but offering a semantic bridge to many health professionals that do not make out the sense of what the word keto intends to convey. I would add, though, that given the fact that carbohydrate intolerance is so idiosyncratic and dependent on the quality and degree of insulin resistance, perhaps we should think about the terminology therapeutic carbohydrate calibration to incorporate the notion of individualized approach and the need to put in context nutrition, movement, sleep hygiene and de-prescribing of anti diabetic medication. Health practitioners diagnose and prescribe therapeutic carbohydrate reduction/restriction while other metabolic health practitioners support people in how to achieve results smoothly. I would also add that other than therapeutic interventions, there are individuals that seek carbohydrate restriction/reduction for general wellness aiming at healthy weight management, increased stamina, increased self-stem, and other wellness objectives which are not sharply focused on treating a health condition but rather oriented to better health and wellness. That audience may not identify readily with the notion of a therapeutic intervention. Metabolic calibration?
  May 22, 2021

• Yes I've shared the ACC/AHA guidelines with her. She also has a lot of physician friends and family members so she is well aware of the standard of care. It is despite all the encouragement by these physician friends that she is seeking recommendations on further risk stratifying. Appreciate your input, thanks!
  May 21, 2021

• A couple of thoughts. According to current ACC/AHA guidelines this patient is in significant need of a statin. If she's not been tried on numerous statins at varying dosages, she should be (if she will allow). As for non-statin therapy, this is a must. With LDL near 190 she has a very high likelihood of familial hypercholesterolemia. CAC or lipid NMR would not really add anything to your risk stratification given her LDL and glucose intolerance, especially if high-dose statin therapy ends up being taken off the table. As for glucose tolerance, you might just consider calculating a HOMA-IR with a fasting insulin and fasting glucose level.
  May 21, 2021

• well written, so true!
  May 19, 2021

• You're right, the numbers are essentially the same. Even the history of intolerance to a statin. I think you're suggestions to the PCP are all reasonable things to do, and things that I've considered and recommended. But if the CAC comes back non-zero, how hard would you push pharmacotherapy for primary prevention? I can imagine that I won't be too happy as a patient if my CAC came back > 0 and OGTT negative. Like other imaging results, I can't "unsee" calcifications in my coronaries, yet the only other option is taking a medication indefinitely that most likely won't prolong my life. Would it be better to not see the CAC, and not take a statin, if I know that I'm someone who wouldn't want to take a life-long medication? That's why I found it difficult to make a hard recommendation for getting a CAC. At the same time, given that most doctors love statins and there is a cut-off of LDLc 190 for statin tx regardless of calculated risk, I felt like I should give it more thought. And are you considering Zetia because she was intolerant to a statin? What about trying out a different statin, and at a lower dose? And finally, I've noticed that despite all the discussion around hyperlipidemia and pharmacotherapy, I don't see much discussion around the causes of elevated LDL in patients without co-morbid conditions (e.g hypothyroidism, CKD, etoh abuse, etc). Except for "genetics", which I think many times in adult medicine is a cop-out and discourages further inquiry. The data doesn't seem strong for dietary cholesterol being a major culprit. Would you happen to know of any other mechanisms? And thanks for sharing!
  May 17, 2021