My awareness of the limits of medical knowledge began when I was diagnosed with osteoporosis at the age of 18. It peaked with a near-death experience five years later, and was heightened even further when I discovered what’s known as a ketogenic diet.
Those five years, spent far too often as a patient in some of the best medical centers in the United States and the United Kingdom, challenged my idealistic vision of medicine. Now that I am entering Harvard Medical School as a student, I find myself in an awkward predicament.
At 18, one year into a relatively successful marathon running career, I began to experience fractures due to osteoporosis, a bone-weakening condition that shouldn’t be occurring in an otherwise healthy young man. After a seemingly endless series of tests, my doctor diagnosed me with relative energy deficiency in sports (RED-S) syndrome, a condition caused by not taking in enough calories to match the calories a person burns exercising each day. RED-S is more commonly seen in women who are underweight and have hormonal abnormalities. I was on the thin side, but had a normal body-mass index, good appetite, and no hormonal abnormalities. Yet I was diagnosed with RED-S because it was the diagnosis of exclusion, which is medicalese for “none of the above.”
The treatment? I was instructed to eat more calories at all costs, and my endocrinologist prescribed the most potent bone-building medicines available. The combination improved the bone density in my spine, but not in my hip and thighbone.
At 21, I developed severe ulcerative colitis, an inflammatory bowel disease. The medications my gastroenterologists prescribed for it minimally improved my condition and I continued to experience colitis flares throughout my senior year in college. While my classmates worried about choosing the right answers on exams, I worried about having to flee the room mid-test to find a bathroom.
After graduation, I deferred acceptance to medical school to pursue a Ph.D. in metabolism and neurodegenerative disease at the University of Oxford. Not long after I arrived in the U.K., I experienced a colitis flare so severe that I lost 20 pounds in just a few weeks. The pain was so intense one night that the university called for an ambulance at 2 a.m. to take me to a nearby hospital.
My heart rate in the hospital was 28 beats per minute, a value less than half of what is considered the lower limit of normal, and one that had the doctors and nurses whispering in the hall. After three days of tests, the attending physician passed down another diagnosis of exclusion, postulating that the curcumin herbal supplement my gastroenterologist had recommended for my colitis was responsible for the low heart rate. I protested. There was no evidence that the supplement would reduce my heart rate to such an extreme extent. In addition, I had stopped taking this supplement before being admitted, and the compound lingers in the body for less than one day.
I was discharged, nonetheless, and spent the next day, my 23rd birthday, prone in my dorm room with unrelenting pain in my gut and a heart rate in the 20s.
Drained of hope, I looked for solutions outside conventional medicine. Over the next eight months I tried probiotics, supplements, meditation, and a litany of diets — gluten-free, low-FODMAP, vegetarian, vegan — none of which helped. One diet I was hesitant to try was a low-carb, high-fat ketogenic diet in which more than 70% of calories typically come from fat. I had been taught to believe that a high-fat diet would cause heart disease and kill me prematurely. Perhaps, but I had little to lose.
After one week on a ketogenic diet, my colitis symptoms began to disappear. Equally impressive, the level of calprotectin, a key marker of inflammation, dropped sevenfold to its lowest level ever and well within the normal range. Over the following months, I came off my colitis medications.
Two years later, I am still following a ketogenic diet and my colitis remains in remission. The osteoporosis has also resolved, including improved bone density in my hip and thighbone that I had not experienced while on medications alone.
So here’s my med school predicament: Within two years of starting what conventional medicine thinks of as a potentially dangerous and unsustainable diet, I went from being a patient with osteoporosis, ulcerative colitis, and a failing heart to a healthy young scholar with a renewed zest for life and great heart health to boot. From my perspective, right or wrong, conventional medicine failed me and so-called alternative medicine, in the form of a ketogenic diet, saved me.
How am I supposed to process that? To embrace the conventional thinking on nutrition I am likely to be taught in med school (assuming, of course, I’m taught anything at all about it), I have to dismiss my personal experience as a potentially meaningless anecdote.
But is it?
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In the course of writing peer-reviewed scientific papers, lecturing to physicians, collaborating with other researchers around generating international consensus statements about therapeutic carbohydrate reduction for a range of medical conditions, and working on a ketogenic cookbook, I’ve learned that several hundred clinical trials have concluded that ketogenic and low-carbohydrate diets are effective treatments for improving chronic metabolic diseases such as type 2 diabetes, metabolic syndrome, and even mental illnesses and Alzheimer’s disease. I now engage with networks of physicians and patients who share their stories of reversing metabolic diseases after adopting a ketogenic diet.
This raises more questions for me. If both anecdotal evidence and clinical trial data suggest that ketogenic and low-carbohydrate diets are effective medical interventions, why aren’t more physicians providing their patients with these options? Why are they still considered dangerous fads? Is the bias with me, because I’ve seemingly experienced the benefits of this dietary intervention, or is it with the nutritional authorities of conventional medicine because they haven’t?
For better or worse, my experience has only strengthened my resolve to pursue a conventional medical education. If nothing else, this is the best path I can imagine to challenge my biases and resolve my cognitive dissonance: Was I fooled by my experience, or is conventional medicine turning a blind eye toward an effective therapeutic option?
Nicholas Norwitz, who is pursuing a medical degree at Harvard Medical School, received his Ph.D. at the University of Oxford and is a certified metabolic health practitioner with the Society of Metabolic Health Practitioners.
Many conventional treatments seem to work only due to expectations (i.e., the placebo effect) – this seems to be true especially for continuous outcome variables (compared to a binary outcome variables) – see the following references:
Howick, J., et al. (2013). Are treatments more effective than placebos? A systematic review and meta-analysis. PloS one, 8(5), e62599.
Kirsch, I. (2015). Antidepressants and the placebo effect. Zeitschrift für Psychologie.
I am a primary care physician, recently retired after 40 years of practice. I concede that I mostly skimmed this article, so it’s possible I missed something significant. Nevertheless, I have a couple of observations. First, I encourage the author, and everyone for that matter, to better understand what “alternative” and” complementary” mean in reference to medicine. There are only two kinds of treatments — those which have been proven to work, and those which have not. “Alternative” treatments are alternative only because effectiveness has not been proven. Once its effectiveness is proven, a treatment slides into canonical status and becomes more generally used. In my experience, the only reason some treatment options have remained “alternative” is that they have never been adequately studied. The human mind being what it is, even failure to prove effectiveness by randomized double blind crossover placebo controlled study is not enough to dissuade faith among true believers. Homeopathy is probably the best example. I suspect that the failure of ketogenic diets to achieve acceptance lies with the absence of rigorous study. Our budding young doctor-author might take the hint and do that work. If his faith in the anecdotal evidence is borne out by study, he will have done something truly useful.
My second thought is that, if he is worried about how his adherence to a ketogenic diet will be received in medical school, he should simply not reveal that piece of information, and answer test questions as he knows the university wants them answered. The time to make waves is after he has a few credentials in his pocket.
Third, the words “complimentary” and “integrative” are slowly intercalating themselves into positions formerly occupied by “alternative”. They differ from “alternative” only in that they subtly imply proven effectiveness, that the integratee is adding its efficacy to an older proven treatment. These words are being pushed as replacements for the less reassuring “alternative”, and sadly have been adopted by medical schools trying to appear more hip in including these as yet unproven remedies in their curriculum.
It is truly discouraging to see all sides commit to a conclusion before any real research is done. If the medical schools and governmental institutions (NIH, CDC) would just perform rigorous studies on the most vociferously supported “alternative” treatments, then those that pass the test could be included in our armamentarium without the embarrassing qualifiers “complementary” or “integrative”. Dr. Norwitz, I sense an opportunity here.
My comment pertains to the first article addressing antibiotics and CDIFF. I have had it 4-5 times. The cases came so close. Together over a two year period that it became hard to diagnose asnew cases or a series of reactions of one sort another. I could write an autobiography regarding those frightening repetitions. But I’ll just make one comment to the authors who gave the stereotypical instructions to avoid quinones. In my cases every antibiotic caused CDIFF, ergo I am never prescribed them. This places me snd my physics s in a precarious situation for they the only treatment for some bacterial infections so I live with an underlying fear of sometime being untreatable. Re Vancomycin was
The one helpful antibiotic but eventually CDIFF would revisit. My primary care who had been an infectious disease
Specialist and infectious disease practicing only in that area and myself were Not willing to have a fecal transplant.
The one
Miracle was a biologic IV leaving CDiff behind . Unfortunately, though it was only a much longer respite than before. It did have a longer respite than before and the next time or two infections proved to be the last. It has been well over a year without this possibly fatal disease. If my experiences can help or save lives of anyone struggling with this hideous malady
I will be grateful with those patients.
Nicholas, your story is like deja vu to me, including the high protein, high fat, low carb diet. I have had Crohn’s since 1973, experienced the same painful flares in pharmacy school, surgeries galore, colectomy, revisions, etc…when Atkins came out i tried it and all my digestive issues disappeared. Now, keto is my savior, and for those of us with GI disruptive disease, at least in my case, its the easiest diet for absorption, energy and comfort…roughage is NOT for us…as to convention, screw it. BTW in 50 years of being a person with Crohn’s i never met a physician or conventional nutritionalist that knew anything about nutrition for people with IBD…a pathetic situation
Dear Paul I definitely empathize with your frustration. After spending years suffering with IBD you become hopeless and turn away from conventional medicine. If/when you find sometime else that works – for both of us a ketogenic lifestyle – you’re so happy and grateful. But then, you start meeting other people who had the same experience. Then the question arises, why did none of my doctors tell me about this? Because there is no good answer from the patient perspective, it’s easy to feel angry. I get that 100%. All that said, sometimes we need to resist saying what is cathartic to say what is productive. Would you agree? You want to grab someone and scream at them, “This will help you! Please try it!” Inside, I get that urge all the time. It’s frustrated concern, not evangelism. But sometimes the best thing to do is just share your story and lead by example. Try to gently impact the people around you who are willing to listen. As we do that, more people will catch on (there is also new science every day on ketogenics and gut inflammation, e.g. https://pubmed.ncbi.nlm.nih.gov/32437658/), and I do firmly believe IBD treatment will include a ketogenic option in my career.
Thank you for sharing this article. Hearing someone’s rough road to find Keto is extremely refreshing and reminds me a little bit of my own journey. I had struggled with an eating disorder for years, it started when I was 17. Life felt like a slow avalanche that would inevitably crush me. I decided to stop eating and realized that suddenly I had control over one thing in life. When life got a little iffy I would turn to this little secret that helped me feel in control. About a year ago I happened upon Keto, it was a rough road at first. Finding out that bacon and avacados were on the menu really drew me in and of course the occasional dark chocolate square. I was hooked. Keto was in a way a last ditch effort. The confidence I built sticking to the diet helped my self care and self love blossom. I have never been more energized and happy. Thank you Nick for sharing your story, it really meant a lot to me.
Emma, thank you for this! I know it’s not easy to be transparent about one’s struggles and I can only imagine that is doubly true with an eating disorder. The notion that a Ketogenic diet could help an eating disorder, especially anorexia, is counterintuitive to most people. I understand why. It’s perceived as a “restrictive diet,” and at some level that’s true. You are restricting carbohydrates. But I think it’s more complicated than that and, as I’ve now met seven people who overcome anorexia with a ketogenic diet, I’ve been compelled to put a bit of thought into the apparent paradox. Here’s where I stand now. I wonder what you think…
(i) Mental illnesses, including eating disorders, are metabolic disease (paper: https://pubmed.ncbi.nlm.nih.gov/32773571/). In this way they are similar to other neurological diseases and peripheral metabolic diseases, like diabetes. None of these are conditions that you can “just snap out of.” And, while medications and talk therapy do have their place, if we don’t correct metabolism with proper human nutrition, how can we really feel we are offering those struggling with eating disorders a full spectrum of treatment? As ketogenic diets have been shown to improve other neurological metabolic diseases, why wouldn’t they help with eating disorders? What I’ve seen and what you have lived seems to suggest they can, at least in some cases. (Plus the data referenced in the paper on ketogenic diets and mental illnesses, including eating disorders.)
(ii) You mentioned having “control over one thing in life.” If I’m correct, this is pretty common in anorexia. Considering that sugar and refined carbohydrates can be classified as substances of abuse (lots of literature on this), what happens when we push these foods on someone who treasures that feeling of control? Is it possible that the unease they feel by having the cravings induced by the sugar and carbohydrates backfires in the long-run? The relapse rates are at least consistent with the fact that what we are doing is not working and I hypothesize this could be just a little part of the puzzle.
(iii) People who restrict to the point of anorexia are usually incredibly intelligent and strong-willed (basically by definition) people. They also genuinely want to get better, for the most part. So when that energy can be directed towards a productive aim, e.g. learning about metabolic health/metabolism/ketogenic science, is it possible that there’s an more lasting intrinsic motivation to gain weight while focusing on other “control” metrics beyond body weight? A few of the people I’ve met shifted from looking at weight as a metric to lipid markers, endocrine markers, ketone levels, % body fat and lean mass, all while gaining weight and actually feeling good about it.
I don’t tend to be an authority on the subject, which it why I’d be interested to get your thoughts on these points. I also had an interesting conversation with Michelle Hurn, a registered dietician who herself struggled with anorexia and overcome it with the help of a ketogenic diet. Her book – the Dietitian’s Dilemma – is a must read for anyone interested in nutrition and relatively new to the space. I think you’d love it!
Be well! – Nick
What some of the commenters here forget is that some people may be fat sensitive and some carb sensitive. I believe you but there are far too many people thriving and finding their health solutions on a vegan diet (which is also considered extreme by the medical community).
However, there is one issue that you have forgotten: environmental. There is too much solid evidence that animal husbandry is a leading cause of climate change. As the human population only increases, everyone eating meat is unsustainable.
Is there not a way to go Keto without eating bacon? What about fatty fish? Coconut oil? Yes, everything has an environmental impact, but perhaps what it really comes down to is that we need to reduce our numbers. Otherwise we are heading for a nightmare.
Climate change is going to whoop our ass. If you study anything, try to study the efficacy of lab raised meat.
Brenda you need to understand THAT keto is a moderate protein not high protein diet. This means 3 to 4 oz. Per day. The majority of the diet is WHOLE foods. Salads, vegetables, fish, alternative flours like almond. Also don’t forget you are fasting so many dieters are doing 2 meals a day. You will eat less overall !! Thus conserving resources!!
Brenda, I understand where you are coming from. I’m am very much an animal loving environmentalist. When I was a kid I had a club that raised money for the World Wildlife Fund for polar bear conservation (baking for bears), I compost, never waste a speck of food (I’m a bit of a ‘food waste Nazi’ actually), etc. That said, I’m not entirely convinced plant-based is best for the planet. I’ve read that reports you’ve probably read, e.g. EATLancet, and many of them are pretty problematic in terms of their methodology and conclusions. As I’ve started to delve into the intersection among diets, the environment, and animal welfare, it seems the best way to live and eat for the world and animals involves regenerative agricultural practices that couple ruminants to plant agriculture. The result is a system that sinks more CO2 than it produces while producing meat for humans to eat as part of the circle of life (if I may quote Musfasa). In fact, regenerative agriculture beef, pound for pound, puts less CO2 into the air than Beyond or Impossible burgers because the live soil is such a great carbon sink. Plus, the animals on these farms are free to graze and live naturally. I’m entirely against factory farming myself. Furthermore, our current plant agriculture system also contributes to animal death, about 7.3 billion animal lives per year in the form of dead gophers, rabbits, field mice, etc. One also needs to consider the geography. How good is the vegan substitute for the planet if the ingredients are shipped from all over the world? Is it better than local regenerative farm meat? All that said, it somewhat misses the point because I ketogenic diet doesn’t require meat by any means. I’ve worked with many people who are vegetarian and keto. It’s perfectly complimentary. As for my part, I personally eat lots of seafood and organ meats from animals raised on regenerative farms. Thanks for your thoughts. I think it’s an important topic.