Four patients who changed my life
In the early 1980s MD and I were laboring away in anonymity in our clinics in Little Rock, Arkansas. By that time I had gone through my thin-to fat-to thin again metamorphosis, and I was starting to treat patients for obesity. My own transformation had been fairly striking, a fact not lost on many of my overweight patients, a number of whom were seeking my professional advice on treating their own weight problems. I was still doing a fair amount of general primary care medicine, but more and more of my time was being diverted to helping people lose weight.
When I, myself, had gotten fat, I had tried a few diets that were then being extolled (including the Pritikin diet) and had experienced pretty much the same thing most people did with these diets: I lost a few pounds, drifted from the diet, and regained the lost weight plus a little. I then started thinking seriously about obesity as a medical problem, and, in an effort to learn all I could about it, I turned to the medical textbooks on my shelves. Unfortunately, none of them contained any information I found particularly enlightening. The texts went into great detail about the risks associated with obesity and the many diseases that it either caused or made worse, but, other than recommending caloric restriction, none really discussed the treatment. None really discussed (at least not to my satisfaction) what happens metabolically that makes people store excess fat.
I next turned to physiology texts, which didn’t help a lot, either. I then grabbed my old medical school biochemistry textbook (I hadn’t been out of med school all that long at the time, so it was fairly current) and struck gold. I started tracing out all the pathways for fat storage and noticed that in virtually every one insulin turned up somewhere. Then I started reading about all the pathways involving insulin and realized that excess insulin had to be the agent driving the storage of excess fat. I then went back to the physiology texts, reread them in light of my new found knowledge, and discovered that they reinforced what I had learned from the biochemistry text. I just hadn’t realized it, until I had made the insulin connection. (I drew out all the different pathways insulin worked through on piece of paper that we’ve saved, but I can’t lay my hands on it right now. If I find it, I’ll post it.)
This was long before the days of Google and online searches; in fact, it was at least two years before I owned my first computer. So I did what you did in those days: I trekked to the medical library at the med school, ran a search on insulin and obesity through their system, and came up with a handful of papers. The research into this field was quite new and sparse back then, but I learned about the newly proposed theory of insulin resistance, which answered my question as to why anyone would ever develop excess insulin levels in the first place.
Then I asked myself the big question: If I have too much insulin (and I was guessing I did – it wasn’t something you measured in those days unless you were in a scientific lab), how do I get it down? There were only two conclusions. Don’t eat. Or don’t eat carbohydrates. The latter seemed to make a lot more sense over the long run.
I remembered the Atkins diet. I had read his book ten years before, but that was before I went to medical school and was while I was still rail thin. (Why did I read it? Because it was a huge bestseller, much in the news, and I wanted to see what all the fuss was about.) I dug out my copy and reread it. Nowhere was insulin mentioned in the original book. He talked about some mysterious fat mobilizing substance (FMS, as he called it), which couldn’t be insulin because insulin doesn’t mobilize fat – it stores it. The references cited in the back of the Atkins book for FMS listed scientific papers written in German. But, by then, I was on to insulin, so I didn’t bother trying to seek them out.
I decided to design a diet for myself with lowering insulin in mind. What I came up with (with MD’s help) was the basis for what ultimately became Protein Power. I lost weight like crazy. Many of my patients noticed my weight loss and started clamoring for me to help them to become thin.
At the time I started treating patients with the low-carb diet, cholesterol was just starting to be demonized. For the first time, people were concerned about their cholesterol levels (and at that time, the upper level for normal for total cholesterol was 220 mg/dl, 20 units higher than it is now) It was the era Taubes discusses in his great paper The Soft Science of Dietary Fat and that Tom Naughton shows in his movie Fat Head. Low-fat diets were the rage. The 8-Week Cholesterol Cure, a book about eating giant oat bran muffins daily and taking sustained-release niacin was in the writing and destined to be a mega bestseller. The fear of fat was settling in on America.
And here I was starting to put patients on low-carb, high-fat diets to help them lose weight.
Back then I had bought into the lipid hypothesis and truly believed excess cholesterol did indeed lead to heart disease. As a consequence, I was a little squeamish about putting people who might actually be at risk for heart disease on the diet. I had read the biochemistry texts, and I knew that insulin stimulated HMG Co-A reductase, the rate limiting enzyme in the cholesterol synthesis pathway; and I also knew that glucagon (insulin’s counter regulatory hormone) inhibited that same enzyme. So, in theory, lowering insulin and increasing glucagon with diet should work to treat elevated cholesterol. But, knowing those things theoretically didn’t really give me a whole lot of solace when it came to taking care of real flesh and blood patients who were entrusting their well being to me. (The picture at the top left of this post is one of the handouts I used in my early practice to demonstrate the many effects of too much insulin.)
Stupidly, when I started on the diet myself, I didn’t check my own labs, so I didn’t really know what happened to me. The patients that I did put on the diet were typically women who were premenopausal (a group who rarely develop heart disease), so I didn’t worry about them. I checked everyone’s labwork, but no one’s was really out of whack lipid-wise at the start of the diet, so I didn’t have a lot to go on data-wise. The few who did have minimally elevated cholesterol tended to lower it over the first six weeks (I rechecked everyone at six weeks), so I figured the theoretical underpinnings of the diet were okay. But I was still uneasy.
I had visions of myself in the witness box with a sneering plaintiff’s attorney saying to me: So, Dr. Eades, are you telling the members of this jury that you put the deceased – whom you knew to have high cholesterol – on a diet filled with RED MEAT! IS THAT WHAT YOU’RE TELLING THIS JURY, SIR? YOU, SIR, CAUSED THIS MAN’S FATAL HEART ATTACK, DID YOU NOT?
But more than being worried about this scenario, I didn’t want to do anything harmful to anyone. I knew it would be difficult to live with myself if I thought I had killed someone or caused a heart attack out of pure negligence.
You’ve got to remember that at this time there was no one in his/her right mind recommending a low-carb diet. There was Atkins, of course, but he had been totally discredited in the eyes of the medical profession by that time. It wasn’t until over 20 years later in 2004 that he and the low-carb diet got even minimally rehabilitated. I was very uneasy to say the least.
Then four patients came into my clinic, one almost right after the other, who changed my life. In my actual practice, I’m kind of old school and always refer to my patients as Mr, Miss or Mrs. But for purposes of this post, I’m going to refer to them by a bogus first name just to make it easier to keep track.
The first of the four patients we’ll call Angie. She was referred to me by MD, who was working at a different clinic than I at the time. Angie came into see MD for nausea and vague abdominal pains, symptoms that, along with tenderness in her upper right abdomen, led MD to suspect gall bladder disease. Angie was a 32 year old woman who was mildly overweight and had vague abdominal pain, but no other remarkable findings. MD drew blood on her and sent her for a gall bladder ultra sound. The ultra sound came back negative, but her blood work was a doozy. Her total cholesterol was over 300, and her triglycerides were about 1900. MD called me and said “Have I ever got the patient for you.” This was what I had been waiting for. A patient who was female and pre-menopausal with terrible lipids. I figured I could treat such a patient without any risk of her developing heart disease over the short term, and I planned to recheck lipids way sooner than the normal six weeks. Since her lipids were so out of the ordinary for one so young, I asked MD to repeat them, fasting, have the results sent to me and to send Angie to see me after her repeat labs had come back.
When I got her labs, I knew the first reading wasn’t an error. In fact, they were a little worse than when MD checked them the first time.
Total cholesterol: 374 mg/dl (all values in mg/dl)
Triglycerides (TG) 2080
(There was no value for LDL because LDL is a calculated number and can’t be calculated when the triglycerides are over 400 mg/dl.)
Upon examination I found a pleasant mildly overweight young woman who had no real physical signs except for mild tenderness in the right upper quadrant of her abdomen when I really pushed on it. She had no family history of heart disease and she didn’t smoke – both pieces of information that made me feel better about what I was preparing to do.
(Not only were her lipids a mess, Angie’s liver enzymes were way abnormal as well. I now know that she had non-alcoholic fatty liver disorder, but we (the medical profession) didn’t really recognize that as a common disease back then. I’m sure her liver was inflamed to some degree, which explained the mild pain she was experiencing.)
I gave her a fairly rigid version of what became the Protein Power diet. I explained exactly what she should eat and what she shouldn’t and sent her on her way with my home phone number and my beeper number (this was before the days of cell phones). I told her to call me if she had even the slightest problem and to return to the office in three weeks for a recheck no matter what. And I gnawed my nails. I had the staff call her after a few days to see if she was doing okay. She reported that she was fine.
I got no emergency calls from her and in three weeks she returned. Her right upper quadrant pain had vanished as had her nausea. She reported that she had never felt better. She had even lost nine pounds (which was a fair amount for her since she wasn’t that overweight to begin with). I rechecked her labs and waited anxiously for them to come back from the lab the next day. When they did, I was stunned.
Total cholesterol: 292
I had hoped for a change for the better, but I hadn’t in my wildest dreams expected this kind of change. I kind of figured that her triglycerides and cholesterol would come down slowly over several months, not that they would drop like rocks in only three weeks.
The second of my life-changing patients was a casual friend of mine who came to see me about a week after my experience with Angie. He was a 55 year old guy we’ll call Lynn who worked in advertising. I had gotten to know him when his company created some brochures for our clinic. He came to see me for an insurance physical.
He arrived, we chatted, and then I looked him over. I poked and prodded and listened at all the appropriate places. He seemed fine. He was a thinnish white male who was just starting to develop a little (and I mean little) paunch. I would never have even noticed it had he not been sitting there with his shirt off.
Talk turned to my own weight loss, and he asked me if I could put him on a diet to help him lose his little pot belly. I said “Sure,” and told him about my meat, cheese, salad and green vegetable diet. I told him that I had lost my weight eating a ton of steak and had continued to do so. He was thrilled because he loved steak and had been avoiding it because of everything he had been reading about red meat and heart disease. I had our nurse draw his blood for the lab part of his physical and sent him on his way.
The next day I was going through all the results from the bloodwork that had been drawn the day before when I came upon his. I nearly dropped my teeth.
Total cholesterol: 312
(There was a note on the lab sheet that said they were unable to determine the HDL because the serum was too lipemic (cloudy with fat)?!?!)
I thought, Whoa!, a 32 year old premenopausal woman is one thing, but a 55 year old male right in the middle of major-heart-disease-risk age is something else. And here I had put this guy with totally disrupted lipids on a red-meat diet, which, according to current medical thinking, would almost guarantee to make the situation worse. I put in an immediate call to his office and was told he had left that morning for vacation for two weeks. (Why he had neglected to even mention this trip when we talked for 30 minutes the day before baffled me completely.) I asked for the number wherever he was. His secretary told me that he was on a Caribbean Island and couldn’t be contacted. I told her that if he called in to have him call me immediately.
My fears were somewhat assuaged because I figured, hey, the guy is on vacation, he’s not going to diet anyway. Why should I worry?
He called me the day he got back and before I could get a word in told me “Hey, your diet works great. I lost five pounds while I was on vacation.” As it turned out, he was on a Caribbean Island, but it was a resort of some sort. As part of his deal, all the food was provided. He had chowed down on steak just about every day.
I was mortified. I told him about his labs and told him to get into the clinic the next morning to have his blood rechecked. He came in. Here are his labs taken 15 days after his first ones.
Total cholesterol: 195
I was really stunned this time. How could these values change this much in just 15 days?
He wanted to stay on the diet, so I told him to go for it. But I kept an eye on him.
Not long after this experience I had a very nice lady, named Jesse, who was the mother of a friend of mine come to see me. She had had labwork done somewhere else and her cholesterol had come back as 735 mg/dl. Her doctor had put her on a cholesterol-lowering medicine, but she was still distressed because she had a friend who remarked to her, “I didn’t know you could even be alive with a cholesterol that high.” I examined her and found her to be a very mildly overweight 72 year old lady with no signs of anything out of the ordinary. I rechecked her blood.
Total cholesterol: 424
Along with these lipid labs, her fasting blood sugar came back at 154 mg/dl. So, not only did she have major lipid abnormalities, she had blood sugar that was in the diabetic range.
I gave her instructions on the diet and told her to stay on her cholesterol-lowering meds until we checked her again in three weeks.
Three weeks later:
Total cholesterol: 186
I was surprised this time, but not stunned. Along with these mega improvements in her lipids, Jesse’s fasting blood sugar was 90.
I told her she could go ahead and discontinue her cholesterol-lowering medications because her cholesterol was normal. She looked at me kind of funny and said, “I stopped them when I started the diet. That’s what I thought you said to do.”
The last of my four patients came along about two weeks after Jesse. This woman, we’ll call Betsy, was famous in Little Rock. Actually, she wasn’t the famous one – her husband was – but she got plenty of notoriety herself. And just in case you’re wondering, it wasn’t Hillary.
She came to see me because she had picked up a little excess weight and wanted to get it off. I went through my normal workup and found Betsy to be a moderately overweight woman with no other physical signs of ill health.
Her labs told another story.
Total cholesterol: 416
(Like Jesse’s and Angie’s labs, Betsy’s didn’t show HDL because the serum was too lipemic.)
After three weeks on the program, Betsy lost 11 pounds and came through with the following labs:
Total cholesterol: 177
By then, I was kind of getting used to these seemingly miraculous lipid improvements, so I was no longer stunned. But it did confirm that I was on the right track.
After my experiences with these four patients, all of whom came to see me over about a three month period, I became convinced that my theorizing about the potent effects of reducing insulin was based in reality. Over the ensuing years, I saw many, many more patients with disturbed lipid metabolism whom I successfully treated with low-carb, high-fat diets, but these four, coming as close together as they did in the early days of my feeling my way along in my low-carb career, gave me the conviction to press on.
I am eternally grateful to them.