The first diet book wasn't about counting calories or eating less fat. It was about carbohydrate restriction, a concept that has deep historical roots.

When William Banting published his low-carb diet book in London in 1863, he documented what would take modern medicine another 150 years to confirm through rigorous science: carbohydrate restriction is remarkably effective for weight loss and metabolic health.

This historical fact might surprise those who view ketogenic diets as a modern trend. However, the evidence supporting their effectiveness against obesity and Type 2 diabetes has been building for decades, with one name consistently at the forefront of this research.

The Physician Who Broke the Scientific Taboo

Dr. Eric Westman, Associate Professor of Medicine at Duke University, has published over 45 peer-reviewed papers on the ketogenic diet and has been prescribing it for over 20 years. In 2006, he established Duke's Keto Medicine Clinic, treating over 5,000 patients.

But Westman's journey began at a time when studying high-fat, low-carbohydrate diets was considered taboo in medical research.

"Until 2002, there was a taboo on studying low-carb diets because they were high-fat," Dr. Westman explains. "You could not get a study funded. Or the scientists weren't interested in studying them because they didn't want to hurt people and cause harm."

That changed when Westman published one of the first modern clinical trials on low-carb diets in the American Journal of Medicine. This groundbreaking research helped lift the scientific embargo on studying ketogenic approaches to health.

The Evidence for Obesity Treatment

What happens when we directly compare low-carb ketogenic diets to conventional low-fat approaches for weight loss? The data is remarkably consistent.

In head-to-head comparisons across multiple randomized controlled trials with over 2,500 patients in each group, low-carb diets consistently outperformed low-fat diets for weight loss and metabolic improvements.

The first randomized trial in the modern era comparing these approaches was published in 2004 in the Annals of Internal Medicine. The results were precise, with 120 participants divided between low-fat and low-carb approaches: while low-fat diets can work, low-carb diets work better.

This finding has been replicated numerous times. In 2013, Bueno et al. conducted a comprehensive meta-analysis examining all obesity studies comparing low-fat versus low-carb diets over a 12-month duration and found that low-carb diets consistently produce better results.

Dr. Westman bluntly says, "If it were soccer, the score would be 31 to nothing, that low-carb wins. It's not even close. And it would be FDA approved if it were a drug, which is just another way to say the confidence you have in something."

Transforming Diabetes Management

The evidence for ketogenic diets in Type 2 diabetes management is equally compelling, though it represents a dramatic departure from conventional approaches.

For decades, diabetic patients were instructed to eat carbohydrates and then take medication to control the resulting blood sugar spikes. The ketogenic approach flips this model on its head: restrict carbohydrates severely, and many patients can reduce or eliminate their need for medication.

In Dr. Westman's clinical practice at Duke, approximately 98% of patients with Type 2 diabetes were able to reduce or eliminate insulin through the ketogenic diet approach.

A randomized controlled trial comparing a ketogenic diet versus a low-glycemic index diet for Type 2 diabetes found that diabetes medications were reduced or eliminated in 95.2% of patients on the ketogenic diet compared to 62% in the low-glycemic index diet group.

This evidence has become so compelling that in 2023, the American Diabetes Association published a paper supporting the use of low-carb and ketogenic diets for the treatment of Type 2 diabetes. This represents a significant shift in mainstream medical guidance.

Understanding the Mechanism

Why do ketogenic diets work so well for these conditions? The answer lies in understanding insulin's role in metabolism.

Carbohydrates stimulate insulin secretion more than any other macronutrient. For people with insulin resistance, the hallmark of Type 2 diabetes and many cases of obesity, chronically elevated insulin levels promote fat storage and prevent fat burning.

In Dr. Westman's clinical approach, insulin levels fall dramatically by drastically reducing carbohydrate intake, typically to 20 grams per day. This creates a metabolic environment that allows the body to access stored fat for energy.

The body then produces ketones, alternative fuel molecules that can supply energy to the brain and other tissues without significant carbohydrate intake. This state of "nutritional ketosis" gives the diet its name.

What's particularly notable is how this approach addresses the entire cluster of conditions known as metabolic syndrome: high triglycerides, low HDL cholesterol, increased abdominal circumference, high blood pressure, and elevated blood glucose.

Beyond Weight Loss and Blood Sugar

While obesity and Type 2 diabetes have the strongest evidence base, ketogenic diets show promise for numerous other conditions.

In a pilot study on women with polycystic ovary syndrome (PCOS), a ketogenic diet led to significant improvements in multiple parameters: body weight decreased by 12%, free testosterone by 22%, LH/FSH ratio by 36%, and fasting insulin by 54% over six months.

Two participants with previous infertility problems even became pregnant during the study period.

Dr. Westman has also successfully treated patients with irritable bowel syndrome, non-alcoholic fatty liver disease, acid reflux (GERD), and lipedema using the ketogenic approach.

Emerging research is now exploring applications for neurodegenerative conditions like Alzheimer's and Parkinson's disease, though this evidence is still preliminary.

Simplifying the Approach

Despite the growing popularity of ketogenic diets, confusion abounds. Do you need to measure ketones? Calculate macronutrient ratios. Add butter to your coffee?

Dr. Westman advocates for simplicity. In his clinical practice, he uses an approach derived from the Atkins Center in New York City, where the diet was used successfully for decades.

The most crucial factor is keeping carbohydrates low. For most people, staying under 50 total grams per day will induce ketosis, but Dr. Westman typically starts patients at 20 grams or less to ensure consistent results.

Patients are instructed to eat meat, poultry, fish, shellfish, and eggs until comfortably complete, with limited amounts of salad greens and non-starchy vegetables. There's no need for exotic supplements, expensive "keto" products, or complicated tracking systems.

The ketogenic approach's intentional simplicity is designed to make it accessible to diverse populations and increase adherence rates, providing reassurance and confidence in its practicality.

Challenging Conventional Wisdom

The success of ketogenic diets challenges several deeply entrenched beliefs in nutrition science, sparking intrigue and engaging the audience in the discussion.

First is the notion that "a calorie is a calorie," regardless of its source. The metabolic effects of different macronutrients vary significantly, with carbohydrates having unique effects on insulin and fat storage.

Second is the belief that dietary fat, particularly saturated fat, causes heart disease. Despite increased fat intake, multiple studies of low-carb, high-fat diets show improvements in cardiovascular risk markers.

Third is the idea that we need dietary carbohydrates for energy. The human body can efficiently produce glucose through gluconeogenesis and utilize ketones for most tissues, eliminating the biological necessity for dietary carbohydrates.

These challenges to conventional wisdom explain much of the resistance to ketogenic approaches in mainstream medicine. Paradigm shifts rarely occur without resistance.

The Future of Keto Medicine

As research continues to validate ketogenic approaches for various conditions, several developments are likely to shape the field.

One is the establishment of new "normal" laboratory values for people in nutritional ketosis. Current reference ranges are based on populations consuming standard high-carbohydrate diets. Specific markers, particularly lipid profiles, may look different in those following ketogenic diets without indicating increased health risks.

Another is the continued expansion of clinical applications. As Dr. Westman notes, patients often report improvements in conditions that have yet to be formally studied.

Perhaps most significantly, the integration of ketogenic approaches into mainstream medical practice continues to accelerate. The American Diabetes Association's 2023 endorsement of low-carb and ketogenic diets represents a watershed moment.

Beyond the Keto Confusion

The scientific evidence supporting ketogenic diets for obesity and Type 2 diabetes is robust and growing. What began as a medical heresy has gradually transformed into an evidence-based approach with impressive clinical outcomes.

Dr. Westman summarizes it simply: "Keto is safe and effective for obesity and type 2 diabetes and may be useful for many other conditions. When it's done right, Keto works for virtually everyone."

As with any medical intervention, the key lies in proper implementation and individualization. Not every patient will achieve the same results, and certain medical conditions may require modifications to the standard approach.

But for the millions suffering from obesity and Type 2 diabetes, the evidence suggests that carbohydrate restriction deserves serious consideration as a first-line therapeutic option, not a last resort.

After 150 years, William Banting's approach has been vindicated by modern science. The question now is how quickly medical practice will adapt to incorporate these findings.