Ketogenic Weight Loss: The Lowering of Insulin Levels Is the Sleeping Giant in Patient Care

In today’s challenging environment, many medical practices are contemplating various ancillary services to address the needs of their patients and practice. To be effective, these services should:

• Be welcomed by patients (be something they expect from their doctor);

• Improve patients’ health and vitality; and

• Generate reasonable profit to the practice.

If such a service could stimulate patient referrals and lift the morale of the practice and its patient base, then the time and effort required to responsibly advise practice owners of these benefits would be truly well spent. Ketogenic weight loss programs represent just such an opportunity.

The Obesity Problem

We are all aware that obesity is a growing concern that is not adequately addressed by the weight loss programs currently available to patients or by the advice doctors already offer patients for improving their diet and lifestyle.

Additionally, the various diseases associated with obesity, most notably diabetes, are reaching epidemic levels; however, the recommended approaches for treatment have limited effectiveness in reversing the disease’s progress.

Sadly, the commercially available weight loss programs (we all know their names because they seem to advertise endlessly in the media) are more focused on finding the next customer than on achieving long-term success or understanding the latest research and using it to educate patients.

Patients Want and Need Their Doctor’s Support During Weight Loss

Perhaps the single most compelling reason to incorporate weight loss into your practice is the increasing number of patients who are eager for this service to be offered through their physician’s office. Please note that I intentionally said “through their physician’s office.” Everyone knows doctors do not have time to offer weekly counseling and coaching during the course of a weight loss/wellness program; but the good news is that there are various ketogenic-diet programs and protocols that provide for the training of staff to run them within the practice thereby relieving the doctor of this burden. While the products and services available on the open market for your practice are varied, all of them involve some level of meal replacement products that are protein-/fat-centric. Services range from simply supplying educational materials to providing consultants who will actively participate in establishing weight loss within your practice.

In most cases, insurance companies will not reimburse the cost of weight loss programs. That circumstance could change over time, however, as the associated expense of treating diabetes and other lifestyle diseases drives insurers to find a cheaper way to treat them. For now, however, patients bear the costs, and the practice enjoys a cash profit equal to the difference between the wholesale price of the meal replacement products and the retail price to the patient. Typically, the practice can expect a 100% markup (50% profit margin) over the wholesale prices.

In most cases, insurance companies will not reimburse the cost of weight loss programs.

There is a growing frustration among the general public with the cost and effectiveness of the pharmaceutical approach to health and wellness. This statement is not intended to dismiss the important role that drugs play in addressing the symptoms of various diseases. That said, if your clinic were to offer a wellness option, a larger percentage of your patients than you might imagine would be likely to embrace it enthusiastically.

Compelling Evidence from the Research Community

The best way to begin a conversation with the decision-maker(s) on this subject may be simply to ask whether or not your practice should take a more aggressive position on treating obesity. You would be well served to arm yourself beforehand with a copy of a fascinating review published in the January 2015 issue of Nutrition titled Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: Critical Review and Evidence Base.(14)

In the review, 26 international co-authors, including researchers from prestigious universities such as Duke, Johns Hopkins, University of California San Francisco, Albert Einstein College of Medicine, and others, present 12 points of evidence and research in support of their position. Eric Westman, MD, MHS, who is Director of Duke University’s Lifestyle Medicine Clinic and the immediate past president of the Obesity Medicine Association (OMA), as well as one of the review’s co-authors, makes a compelling statement in the beginning: “At the end of our clinic day, we go home thinking, ‘the clinical improvements are so large and obvious; why don’t other doctors understand?’ Carbohydrate restriction is easily grasped by patients: because carbohydrates in the diet raise the blood glucose, and, as diabetes is defined by high blood glucose, it makes sense to lower the carbohydrates in the diet. By reducing the carbohydrate in the diet, we have been able to taper patients off as much as 150 units of insulin per day with marked improvement in glycemic control, even normalization of glycemic parameters.”

The 12 points of evidence presented include answers to the most compelling questions and/or objections your doctor may voice. I list them here to give you a sense of what I mean:

1. Hyperglycemia is the most salient feature of diabetes. Dietary carbohydrate restriction has the greatest effect on decreasing blood glucose levels.

2. During the epidemics of obesity and type 2 diabetes, caloric increases have been due almost entirely to increased carbohydrate consumption.

3. Benefits of dietary carbohydrate restriction do not require weight loss.

4. Although weight loss is not required for benefit, no dietary intervention is better than carbohydrate restriction for weight loss.

5. Adherence to low-carbohydrate diets in people with type 2 diabetes is at least as good as adherence to any other dietary interventions and is frequently significantly better.

6. Replacement of carbohydrate with protein is generally beneficial.

7. Dietary total and saturated fat do not correlate with risk for cardiovascular disease.

8. Plasma saturated fatty acids are controlled by dietary carbohydrate more than by dietary lipids.

9. The best predictor of cardiovascular disease in patients with type 2 diabetes is glycemic control (HbA1c).

10. Dietary carbohydrate restriction is the most effective method of reducing serum triglycerides and increasing high-density lipoprotein.

11. Patients with type 2 diabetes on carbohydrate-restricted diets reduce and frequently eliminate medication use.

12. Intensive glucose lowering by dietary carbohydrate restriction has no side effects comparable to the effects of intensive pharmacologic treatment.

The footnoted evidence provided for each of the 12 points is intriguing and compelling. Much of it is also easy to understand and speaks to us on a commonsense level. For example, if the increase in caloric intake over the last 30 years is mostly due to carbohydrates (point 2 above), and that increase corresponds with an increase in obesity and diabetes, then reducing carbohydrate consumption would seem to be a rather obvious countering response.

It’s Really About Lowering Insulin

Westman and his colleagues have published studies showing that excess carbohydrates and sugars drive high insulin levels and chronic inflammation systemically in the body. These factors play a role in almost every chronic disease that physicians are trying to treat. At a recent OMA convention, Westman commented to his colleagues, “We should not look at our obese patients and talk to them about losing weight, rather we should look at them and declare, ‘You have an insulin problem.’ The research is quite clear that when insulin rises in the body, weight is added; and when insulin is lowered, weight comes off. The only effective means for lowering insulin in the body is to limit the intake of sugars and simple carbohydrates” (personal communication).

Thirty years ago, at the beginning of the obesity epidemic, the scientific consensus was that fat needed to be removed from our diet and that waistlines were expanding because of excessive dietary fat. The problem with low-fat diets was that a lot of fat calories were replaced with sugar calories. Look at the label on a particular product in the grocery store and then compare it with that of the “low-fat” version of the same product, and you will quickly see that the low-fat version contains a higher amount of sugar and carbohydrates. An excellent review of the history of how the “fat makes us fat” belief system gained acceptance can be found in an article by Ian Leslie in the April 7, 2016, online edition of The Guardian.(15) What Leslie explains is not a particularly pretty picture.

Thanks to the work of Westman and his colleagues, science now clearly shows that excessive amounts of simple carbohydrates and sugars in the diet and their effect on insulin within the body lead to the accumulation of fat, particularly abdominal fat. Awareness of this fact is only just beginning to reach the general public, which is the reason why a ketogenic program administered within a medical practice makes good sense.

Offering Patients a Path to Wellness

Doctors who have incorporated weight loss into their practice are encouraged by the consistent results and therapeutic success of a ketogenic diet. They have found that the weight loss protocol enables them to assist and satisfy those patients who express the desire to achieve wellness.

Practices have found value in offering patients two separate pathways for treatment. Many patients prefer the appropriate pharmaceutical agent to be prescribed by their doctor. Growing numbers of patients, however, are looking for a path to wellness, having become frustrated with the limitations of traditional medicines.

For them, ketogenic weight loss is an excellent choice. As we have seen from the research outlined above, lowering insulin levels results in weight reduction and an improvement in diabetes and the risk factors associated with cardiovascular disease, in addition to other benefits. Equally important is that patients begin to feel better rather quickly, experiencing a boost in energy within 7 to 10 days. They feel empowered when they realize that their dietary choices have had a direct and positive impact on their health, having eased/relieved their disease symptoms and reduced their risk factors.

In all likelihood, the doctors in your practice have been encouraging patients for years to eat better, exercise more, and lose weight, yet they have never considered the benefits of providing a protocol in-house. The truth is that any patient can make diet and lifestyle choices that effectively lower insulin levels. In reality, however, most need a structured protocol to achieve success. And therein lies the opportunity for you to provide a much needed service and enjoy the benefits of both increased profitability for the practice and the satisfaction of watching patients get better instead of simply managing their symptoms.

Returning Joy to the Practice

Do not underestimate the value of this treatment protocol in improving morale within the office environment. Statistics indicating professional enjoyment and satisfaction among doctors are at best discouraging if not downright depressing. In a 2012 survey of over 5000 physicians, 90% said they would not recommend healthcare as a profession.(16) Providing patients with a treatment protocol that helps them feel much better and reduces their reliance on medications would return joy to the practice. Certainly, weight loss cannot address all the reasons doctors are frustrated with the profession; however, when patient satisfaction improves so does doctor and practice satisfaction.

Take time to investigate the options and companies providing this service, and open your doctors’ eyes to the possibilities that ketogenic weight loss offers. It is truly the sleeping giant of patient care.

References

1. Accurso A, Bernstein RK, Dahlqvist A et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutr Metab (Lond). 2008;5:9.

2. Westman EC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2-diabetes mellitus. Nutr Metab (Lond). 2008;5:36.

3. Dashti HM, Mathew TC, Khadada M, et al. Beneficial effects of ketogenic diet in obese diabetic subjects. Mol Cell Biochem. 2007; 302: 249-256.

4. Gannon MC, Nuttall FQ. Control of blood glucose in type 2 diabetes without weight loss by modification of diet composition. Nutr Metab (Lond). 2006;3:16.

5. Rizza RA. Pathogenesis of fasting and postprandial hyperglycemia in type 2 diabetes: implications for therapy. Diabetes. 2010;59:2697-2707.

6. Volek JS, Fernandez ML, Feinman RD, Phinney SD. Dietary carbohydrate restriction induces a unique metabolic state positively affecting atherogenic dyslipidemia, fatty acid partitioning, and metabolic syndrome. Prog Lipid Res. 2008;47:307-318.

7. Volek JS, Phinney SD, Forsythe CE, et al. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet. Lipids. 2009;44:297-309.

8. Volek JS, Feinman RD. Carbohydrate restriction improves the features of metabolic syndrome: metabolic syndrome may be defined by the response to carbohydrate restriction. Nutr Metab (Lond). 2005;2:31.

9. Tendler D, Lin S, Yancy WS Jr., et al. The effect of a low-carbohydrate, ketogenic diet on nonalcoholic fatty liver disease: a pilot study. Dig Dis Sci. 2007;52:589-593.

10. Mavropoulos J, Yancy WS Jr., Hepburn J, Westman EC. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutrition & Metabolism. 2005;2:35.

11. Yancy WS, Provenzale D, Westman EC. Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports. Alternative Therapies. 2001;7:116-120.

12. Austin GL, Thiny MT, Westman EC, Yancy WS Jr., Shaheen NJ. A very low carbohydrate diet improves gastroesophageal reflux and its symptoms: a pilot study. Dig Dis Sci. 2006;51:1307-1312.

13. Austin GL, Dalton CB, Hu Y, et al. A very-low-carbohydrate diet improves symptoms and quality of life in diarrhea-predominant irritable bowel syndrome. Clin Gastroenterol Hepatol. 2009;7:706-708.

14. Feinman RD, Pogozelski WK, Astrup A. Nutrition. Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base. 2015;31(1):1-13; www.nutritionjrnl.com/article/S0899-9007(14)00332-3/fulltext .

15. Leslie I. The sugar conspiracy. The Guardian. April 7, 2016; http://gu.com/p/4t6xc/sbl .

16. Nine out of 10 physicians unwilling to recommend health care as a profession, exacerbating anticipated physician shortage. The Doctors Company. March 1, 2012; www.thedoctors.com/TDC/PressRoom/PressContent/Nine-Out-of-10-Physicians-Unwilling-to-Recommend-Health-Care-As-a-Profession-Exacerbating-Anticipated-Physician-Shortage.