Introduction to Low Carb and Cholesterol

For this doctor talks, I have a fascinating topic. Today we are going to be talking about low carb diets. We're going to talk about the role of cholesterol.

And we are going to be talking about sick care, sort of this paradigm in the health care system, what that means, what that means for you, and to discuss all this I have with me another Colorado doctor, doctor Jeffrey Gerber, he's a board certified family physician, speaker, author, conference organizer, husband, father and owner of South Suburban Family Medicine here in Littleton, Colorado, where he is known as Denver's Diet Doctor.

He's been providing personalized health care since 1990 and continues that tradition with an emphasis on longevity, wellness, and prevention. Thank you so much for joining me. Doctor Gerber.

Thanks for having me. Carolyn. Well, you know, I invited you because when I think of sort of like low carb experts, you are one of the people who comes top of mind and I really thought it was a very important topic for us to cover in this summit.

So will you start off by telling us about the role of low carbohydrate and ketogenic diets for not just weight, but also health? Sure. Carolyn. So nutrition and wellness and aging gracefully is my, passion.

And, I became interested in, helping patients with nutrition, although I've been, doctoring for 35 years. It was 25 years ago. I learned a little bit about nutrition.

And nowadays we call it targeted, therapy because not one diet fits all. And we're really targeting, individuals that have, insulin resistance or pre-diabetes.

And in our clinical experience, what we have found is that the low carb approach, or ketogenic approach is, fits the bill perfectly.

Why Low Carb Works for Metabolic Health

And so, insulin is driven by carbohydrate, somewhat less by, by protein. And so it, it makes sense that you remove the culprit. And, there's often this debate between calories and hormones and, you know, calories.

We all understand calories. And the idea is, has always been that, if you eat less and exercise more and you have a negative energy balance, you're going to be losing weight.

But what we've come to realize is that we also have to look at the hormonal aspect of metabolism, and they're not separate. They're there. You have to consider both when you're considering, the health of the individual.

And so when the hormones come into it, you understand that, calories and and the nutrients, everything is processed differently. And so if you have a calorie of processed food versus a calorie of unprocessed food, the body metabolism, the body metabolism will handle it differently.

Plus it depends if it's carbohydrate, protein, or fat. And so therefore we focus on patients that are insulin resistant, on a more low carb diet, high in protein, lower in carbohydrate, of course, less processed food.

And to take it one step further, there's also other therapies. So addressing heart disease, we believe that heart disease is an inflammatory condition just like diabetes.

Other metabolic conditions. And so you address that with the diet that addresses inflammation and addresses the hormones. Also, in recent years we've now been looking at, addressing mental health with, targeted ketogenic diet.

And most people understand that, ketogenic diet have been around treating seizure disorders for for decades. And now the psychiatrists are taking it one step further and realizing that, metabolic health affects the brain.

And so when you're treating mental disorders, these targeted therapies can be, very helpful. Well, thank you so much for that. That overview. And I think there is a few key points that I heard from you.

One is that there's not one right diet for everyone, which always seems a little obvious to me. Like if we knew that, wouldn't everyone be recommending the same diet to like every single person on the planet?

Right. So we kind of know things need to be targeted. I think intuitively and based on our, our own experiences eating, we know that maybe what works for our best friend doesn't always work for us.

I think what I also heard you say is that not all calories are created equal, and that's what makes the calories in calories out paradigm not work, right?

Because these foods are giving our body signals of different sorts and they have different hormonal effects on our body. Yeah. So so absolutely. So at the end of the day, you do have to consider calories, but you also have to consider, the Mac, the macronutrients.

And, you can think of it in another aspect. Ultimately, if we have people that come in that need to lose weight or they want to improve metabolic health, we're trying to control appetite and we're trying to find ways to control appetite.

And so that brings in the aspect of satiety.

Defining Keto vs Low Carb

And so when you have insulin resistant individuals and by the way, it's estimated that well over two thirds of the population have insulin resistance or prediabetes.

And then targeting with a low carb diet seems to make make sense, I think. Yeah. Like the type of food matters, right? Like that's like one of the key things here.

And you actually said something that was interesting that I have heard, I think most common theme of everyone that I have interviewed is this concept of ultra processed food or processed food.

You know, being being problematic. I want to take one little step back, because sometimes I assume that when I say keto, everyone knows what that means.

But it it turns out to different people it can mean different things. What a ketogenic or a low carb diet is. Can you outline for us what a ketogenic diet is, what it looks like, and how that may or may not be the same always as a low carb diet.

Sure. So, when I think of ketogenic, I think of, a very high in fat, very low in carb diet. And basically, I break it down into the carbohydrate mix. So a ketogenic diet is under 40g of carbohydrates a day.

The low carb diet is under 80g of carbohydrate. A day. And then the upper limit of low carb is, say less than 120g of carbohydrates a day. So for somebody who's full blown diabetic and really wanting to dive in, it turns out that the higher in fat diet and this can be up to 70% of the calories from from fat can be very, satiating.

And so we can start them out at a very, high, high fat diet and, and, indeed, it'll, it'll, control appetite in a couple of weeks. And they kind of go through this, keto flu where initially they may be withdrawing off carbohydrate and that may take a couple days, but but then they start to feel great and, they have no hunger.

Their appetite is dropping. They don't think they're eating less food, but they are and they have energy. And so this is where you start out with a super high fat ketogenic diet.

But again, long term, if you have a person that needs to lose weight and is insulin sensitive on the other side of the spectrum, they're not going to respond to a diet that's high in fat, high in calories.

And so the long term approach for both these individuals, once you correct insulin resistance, or you have an individual that's already insulin sensitive and and they think they're trying to lose weight long term, is that you're you're going to back down on high fat calories.

We still believe that a higher in fat diet can be helpful to all these individuals. Increasing protein and the carb all depends. The carbon take depends on their level of insulin resistance.

Wow. Okay. Thank you for explaining that because it sounds like there's different phases. So people don't have to always stay in that really, really high fat phase.

Bacon, Satiety, and Long-Term Diet Balance

Correct. So one of the other, you know, challenges or misconceptions I see a lot with the ketogenic diet is that people when I say ketogenic, people just think bacon.

Right. Both my patients and the people who want to argue with me about a ketogenic diet. So what does, you know, what does this high fat, lower carbohydrate diet look like in an ideal world?

Yeah. So, starting out, you can eat a lot of bacon. If, again, you're a diabetic and you know, it has it has a lot of fat in it. But, where people get into trouble is that they just continue to eat a very high fat diet.

And, you know, they walk around with t shirts. I love bacon. That's great. You can, like everyone loves bacon. There's no argument on on that part. But again, long term, the calorie the calorie, the calories do matter.

And so, you we're going to tell people that you just can't eat bacon all day long, that you're going to have to reduce fat calories. Now, hopefully this will happen naturally.

And and it does indeed. People come in and see us and they said, look, you're losing weight. There's less of you. So you're not as hungry. You're eating less food.

Probably you don't need as much fat to satiate. So if it's working, if it's working properly for the individual, I just, and force what they're already doing.

Well, you know, I don't need as much bacon. I'm backing down on the fat. I'm. I'm eating more, more protein. And so, that all make sense to them? I love what you said there, too, about, like, you're having this conversation with your patients of what's working for them and what isn't right.

And that, I think, is the missing piece. A lot of time with any dietary strategy someone's trying is you need someone who can coach you along and figure out what makes sense for your body and your health, and why you may or may not be responding to what you've been doing.

We we love to say, you know, empowering our patients to make change. We're we're just their personal health coach and helping them along the way. And, it's it's not like they expect us for the answers.

They don't they don't they they don't necessarily come to us for the answers. We just support what they're what they're doing. So, another challenge that people will often have with the ketogenic diet is that they will say, you know, cholesterol goes up with these diets.

And so this this must be a really big problem. Can you explain to us the role of, of cholesterol and what people might expect on blood work and, and the role of low carb diets for potentially even improving heart health?

Sure.

Cholesterol, Heart Health, and Diabetes

So this goes way back to Framingham, back in the 40s and 50s, where, they developed this association between heart disease and, and diet and that, the operative was then, well, maybe we should lower cholesterol because that'll, reduce risk of, of heart disease.

And there was really this loose association. And when you look back at the Framingham work, they actually said LDL cholesterol isn't a current concern until it gets up to 300.

In fact, they also said that, elevated, HDL was was favorable and then we jump ahead and we look at the work of Jerry Raven, and he, he, brought to the plate, the metabolic syndrome, which were conditions including a certain pattern of cholesterol, as being unhealthy, that is, high triglyceride, low HDL.

And it had nothing to do with LDL. Also, measurement of blood pressure, your abdominal circumference, and, your analysis, spilling protein and, and, and glucose and, this is back in the 90s.

And he talked about heart health and, and metabolic syndrome, but it had nothing to do with LDL cholesterol. And so it turns out that on these low carb diets, the LDL cholesterol, or what is thought of as the bad cholesterol goes, goes up.

But, and that may be the case in some individuals. In some individuals, it doesn't change. In some individuals it goes down. But we also observed that, the HDL cholesterol, which is called the good cholesterol, goes up and the triglycerides go down.

And if you remember at the beginning of the conversation, we talked about, heart disease being, a condition of metabolic health and inflammation. And when you look at metabolic syndrome, when HDL goes up, triglycerides go down.

That tells us that, cholesterol or the lipoprotein profile is is favorable in terms of low inflammation. And that was the whole point of, the metabolic syndrome.

And so, of course, we've been looking at low carb diets for 25 years. And so if we were giving bad advice to our patients that they should go in this high fat, low carb diet, well, maybe their hearts were going to explode and they were going to have heart attacks and our patients would be dropping dead right and left.

But honestly, that hasn't been the case. In fact, we've you know, we've reversed diabetes. We've helped people lose weight. I mean, we still have patients in our in our practice that have heart attacks and cardiac events, but.

We think that we've actually prevented heart disease, prevented heart attacks and events by by recommending this to patients looking at metabolic markers.

There's also another important test called the heart calcium score, that we think is is a wonderful, test that everyone over age 45 and then 50 and women should should get because you can directly visual visualize calcium or plaque buildup in the coronary arteries rather than just simply looking at LDL cholesterol.

And we have patients that have had elevated LDL cholesterol with with again, good ratios and have had zero heart calcium scores. I'm one included. You know, I'm just an n equals one.

But you know, I've been doing low carb for 25 years and I still have a calcium score of zero. We can take that one step further. And now there's research.

Dave Feldman. Matt. Food off. Crum this year. They're now looking at, what, are called lean mass hyper responders are are hyper responders on low carb diets to see what happens, in clinical research.

And so far, it's early data, but it's looking very favorable. You know, you said a lot of amazing stuff there. And I think importantly, you know, looking at the data and there are tests we have beyond cholesterol that can also give us an idea of, of your heart health that are becoming more commonly used.

But my whole passion getting into all of this was around type two diabetes and heart disease. I had, a grandfather who had type two diabetes and ultimately died of a heart attack.

And when in med school, I learned that having type two diabetes was the equivalent risk for your heart as already having a heart attack, I became very passionate about figuring out how to resolve and treat type two diabetes.

And to me, a ketogenic diet for type two diabetes seems like it should always be offered to our patients as an option because it is a way that can often completely reverse that type two diabetes, without a medication, often, and knowing that that type two diabetes to your heart, it's like you've already had a heart attack in terms of your risk of having a heart attack was really powerful to me.

And so, you know, that's been one of the reasons I've always been so interested in the ketogenic diet, because, again, it just seems like an option that people with type two diabetes should really be given.

Yes. And, I think the the risk of insulin resistance on heart disease is probably ten x. And initially that wasn't in the wheelhouse in terms of how we were taught as, health care providers.

You know, just give them cholesterol medicine, tell them to go on a low fat diet. Oh, yeah, well, you're diabetic, but you know, maybe work on that and see your family doctor.

And it's funny, the cardiologist still doesn't know much about nutrition, although they wish.

Common Themes Across Diet Approaches

And there's now indication for, treating heart disease with some of these newer diabetic medications, whereas we think that, just working on a good, healthy whole foods diet, losing weight can work can be so much more powerful then, you know, big pharma just pushing these these medications and then, you know, anecdote wise, other just as everything is like, you know, my other grandma who's still alive, I think she just turned 94.

And, you know, she's always had like the sky high cholesterol that everyone's worried about, but she's walked every day of her life always eating a really healthy diet and and her cholesterol, probably, you know, isn't the problem.

She doesn't have the inflammation and the insulin resistance that goes with it. So yeah, I it's just so important to customize all of these things, I think to the person in front of us.

Yeah, I, you know, I would just say that there's, there's plenty of studies out there that show that, as you age, an elevated cholesterol is associated with longevity.

So, you know, individuals that are just dwindling away have very low cholesterol, and they have a lot of other medical problems. And so, you know, we we keep patients in their 70s or 80s and they, they have these healthy profiles where they have, high LDL and they have good cholesterol ratios and, and I tell them this is a sign of, thriving.

I love it. So, as you can imagine, in this summit, we have people who are talking about lots of different types of nutrition, from plant based diets to fasting, ketogenic diet.

You there's so much dietary confusion for most people. And when we try to look at the big picture, what are some of the common themes to a healthy diet that you like to point out?

Yeah, so it's certainly confusing. And, you must understand social media. I love Twitter. That's a platform for debate and argument and you can't have a debate and argument if you have common themes.

There has to be, you know, this kind of two sides to everything. And I've never been that way. I've always tried to look for common themes. So so I'm, I'm not too argumentative on social media.

They get bored because I say, well, why don't we do a little bit of both? And so that's really important to understand because it's confusing. There's so much information.

And then you have to consider the source like, who is the person giving the advice? You know, what are the credentials? What are what do they not have credentials.

And that's not necessarily a bad thing. What is their sex? What is their age? You have to, you know, consider all those things when you're taking in the information.

But so common themes are, again that the hormones and the calories all count. But I think one common theme is everyone wants to, find ways to control appetite.

So considering satiety, removing processed foods, we think that, you know, processed foods are just stimulate, the reward centers of the brain. So we just can't stop eating.

And then, you know, I talk about a low carb Mediterranean diet, long term. And it's, again, some of these principles where you, you eat enough that to fill you, you prioritize protein.

And we really make a good argument for animal based protein. And it's the primary source, and then carbohydrate intake from whole food sources again depends on the degree of insulin resistance.

So those are some common themes. But I like what you said about, you know, on social media everything has to be so polarizing, right? I've always joked that I would never be able to write a book about nutrition because I'm like you or I try to, you know, make it make sense for a person, be sustainable, you know, fit into a lot of different things.

And people don't want that a lot of times. Right? They want the extreme diets that ultimately are really hard to stick to and probably don't work well for every single person.

Sick Care vs Prevention

So thank you for sharing that approach because, you know, it sounds like there's this role for keto, but then long term using some of those principles, but maybe doesn't need to be super intense or strict forever.

Yeah. So I still work in the health care system and, you know, we do cash and insurance based, but I also try to bring in the nutrition aspect into it as well.

And one other aspect that I think is a common theme is whether or not we should use some of these new GLP one medication, semaglutide to appetite. For weight loss. And on Twitter.

Yes. No. You know, there's no in between. And so it's important to understand we've been using that class of, medications since 2005 and carefully selected patients.

And so I think there's there is a role for these newer, GLP one weight loss medications. Yeah, there's a role for all of it. Right. And that's where you meet with an expert like yourself or myself or one of the many other experts out there and say, what makes sense for me?

My goals, my health, what I've tried before, what I know does or doesn't work for me. I think that's a good, transition into this topic of sick care. What do you mean by this term? Sick care?

Yeah. So there's this there's there's there's several things about that. So, the idea that our health care system is more sick care and, and and indeed it, it is.

And, it's unfortunate, you know, health care really, was designed and you used it when you were ill. So you went to the doctor and, and and they would take care of your illness.

And and that really applies today. I think that, we're trained well as health care professionals to put out the fires. But when it comes to prevention, we, we, we're, we do a very feeble job.

And so you and myself are now in this, in this realm of helping people, in terms of, getting to ideal body weight and, and addressing prevention and wellness.

And so, you know, as much as your local health insurance company would tell you that they're, addressing wellness and prevention, you have to understand that on the other side of the health care, the sick care is the industry.

Care is another term. And I had brought up another word, investor care. And so there's kind of this, this tension between, you know, the health care system in the industry itself.

And look, it's insurance. That's how you know, insurance is designed not to pay out. And the question is, is that a system that works well for, a health care system.

And, and I, I've been at this for 35 years. And, and the answer is it's not working. And so, the insurance industry, which is backed by government policy and, and, and is really just escalating the cost of care and it's this bubble that's going to burst.

And so how do how do we resolve this. And so there's different models where, perhaps direct pay patients pay out of pocket or cash services or we need all to, to blow it up and come up with another health care system that then I personally think should be, kind of, catastrophic insurance and pay people pay out of their pockets to see providers like us and we're not rushed and we get time and we can address wellness and prevention, which is what it's all about, right?

That your insurance company is not invested in me having a 90 minute conversation with you about your health and all the different things we can do. You know, they want me to spend 15 minutes with you.

Longevity, Hormones, and Menopause

And, and if I can easily solve the problem with a medication, then that's what the system is set up for. It's not set up too well. How did you feel on that diet? You know, what does your blood work look like?

What are your goals? It's just not set up to have those conversations. Well, yes. And despite what they tell us, we still try to give patients their time.

Yes, some of us can't help but to give people the time. Right. Patients first. Yeah. Now, one of the things that sounds like you have been transitioning to is doing more longevity care, which is this, you know, practice of helping people live longer and live a better age.

Well, tell us about sort of the newest things there. What you're seeing works for your patients. Yeah. So that that's hormone therapy, bioidentical hormones.

And it really ties into the aging gracefully aspect. And so certainly, if you work on diet, lifestyle exercise, by the way, is crucial. And I I'm glad we have a second.

Just to throw that in. You have to maintain muscle mass throughout life. You want to prevent sarcopenia. And, you know, muscles process energy as, as we age.

And so, it's another organ. Some people argue that it's the major organ. And so you have to work on maintaining muscle mass. So you exercise, you eat properly, you maintain ideal body weight.

But unfortunately, you know, we age, but we're living longer. And our, women go through menopause. And you ask any female going through menopause, they immediately gain 10 pounds.

When they go right through menopause, men go through and you pause and they slow down and they gain weight. And so what we see is a drop in, hormones, including testosterone, estrogen, progesterone.

So, we now have the tools to supplement and replace testosterone in men. And yes, testosterone, estrogen, progesterone in women. Most don't understand.

And and I've learned this myself, that testosterone by blood concentration is, at a greater level than estrogen in a female. So testosterone isn't for just men is for both sexes.

And so you replace, hormones as as we age and guess what? It helps you lose fat, gain muscle. It helps with focus, concentration, libido. It's it's just, a new area that, we think can be really helpful in terms of individuals aging gracefully.

We've had a lot of actual menopause experts on, on the summit, but we have not talked about and rapports. Will you tell us a little bit about what and rapports is what it looks like and the role of hormone therapy for that.

Sure. So, men are always wanting to check testosterone. There's these TRT clinics and it, I think it can be, abused, but, you know, the men will slow down, they gain weight, they have lack of energy.

And so you check you check their levels. And I think there's different opinions as to what are normal testosterone levels. For instance, you know, the the official low testosterone level according to Medicare is, you know, three under 300 and, you know, I always tell patients, well, if you're still walking and talking at that time, well, yeah, sure, we can supplement.

But there's there's basically, you know, it's a bell shaped curve where there's quartiles of what normal testosterone levels are. So at the bottom you have the first quartile.

That'll be kind of around 300 or above. And then there's the second third, fourth quartile will be like 812 hundred. And so the idea is that if a patient has having symptoms and they're there at the bottom end of that bell shaped curve, you also look at free testosterone.

Well then you know, you supplement. And so the idea is to, to bring the level up, but you're mainly looking at symptoms. So if a patient has symptom relief, you don't have to get a level all the way up to 1200, but that's, that's kind of the range.

And so in our office we, we often different therapies we, we actually like pellet therapy which isn't as popular in men as the injection therapy. But but pellet you insert just above the waist in men in women under the waist, just under the tissue.

And, and it's a matter of convenience. So, in women, it stays there for 3 to 4 months, and in men it's 4 to 6 months. And, you get a better therapeutic level, and they don't have to be giving them shots, on, you know, weekly or biweekly.

So, you know, in addition to the nutrition and, and the fitness, this is just another tool that is helping our patients. I love it. Well, Doctor Gerber, if people want to connect with you, learn more, follow you on Twitter.

Or see you in clinic. Where can they find you? Denvers diet doctor or Jay Gerber, md.com. Wonderful. Well, thank you so much. My pleasure.

Jeffry Gerber, MD, FAAFP

Low Carb Diets, Cholesterol, And Aging Explained