BRAINERD, Minn. — Back in 2016, "healthy eating" was making Dr. Jeremiah Eisenschenk fat.
"I was always a college athlete who got by eating whatever I wanted," says Eisenschenk, chairman of hospital medicine and head of the weight management section for Essentia Health-St. Joseph’s Medical Center in Brainerd. "That all changed in medical school," he says. "I gained 30-40 pounds, all while exercising and eating what I thought was healthy. "
Eisenschenk says he got fat during medical school on a familiar list of natural, virtuous-seeming foods.
"I'd start every morning by eating granola with maple syrup, low-fat Greek yogurt and orange juice," he says. "Before my run, it would be a peanut butter and jelly sandwich with some sort of protein bar. In the evening, there would be a meat and a veggie, but also a large, large quantity of starches."
The 6-foot 4-inch, University of Minnesota and Mayo Clinic-trained physician says he put on so much weight during these years with daily runs and "eating healthy" that he soon hit 235. "When I did the duathlon (running and cycling)," he remembers with chagrin, "they put me in the stallion category."
Eisenschenk's epiphany finally arrived in fall 2016 after completing his first Twin Cities Marathon.
"I had trained all that summer," he says. "I logged 450 miles. I was eating the way I thought I was supposed to be eating. . . . I ran the marathon, got to the end of that entire period, and I think I had lost all of 7 pounds. 'I remember thinking, I can't run my way out of this.'"
Faced with a choice of running even harder and eating less, Eisenschenk turned to the growing literature describing the LCHF (low-carbohydrate, high-fat) way of eating, also known as the ketogenic diet, or keto for short.
"I started cutting carbs, increasing fats, and didn't do any exercise from November 2016 until May of 2017," he says. "I lost 25 pounds just by cutting my carbs and doing intermittent fasting. So at that point, I was like, 'I can't not utilize this as a tool for my patients.'"
Since then, the hospital medicine and board-certified obesity specialist has dropped another 15 pounds. With COVID-19 pushing the health cost of obesity and related metabolic conditions even higher, keto has now become the first tool in Eisenschenk's tool box.
"Through my own struggles," he says, "I gained a deeper understanding of nutrition and physiology, which led me to question conventional paradigms of weight, nutrition, metabolic health. It changed my clinical management with inspiring outcomes. It has also provided me the ability to educate other health care professionals while increasing my job satisfaction, countering burnout and adding joy."
The old dietary advice
For decades, the dietary status quo in the U.S. has depicted weight loss as a simple process of exercising more and eating less — fewer calories and less dietary saturated fats like butter, coconut oil or animal fat.
This calories-in, calories-out dietary belief system is reflected in the calorie counts at the counter of fast food franchises, the guidelines that control the food offered to our children in school lunches, and the fare served in hospital cafeterias, where they will gladly serve dinner rolls and vanilla pudding but only low-fat dairy.
"Health food" in this depiction has no place for savory cultural meals like pot roast, lamb, or roasted chicken with the skin on it. The so-called Mediterranean, DASH, and plant-based diets all advise better health through low-caloric diet rich in whole grains, fruits, vegetables and only small amounts of lean meat and fish, while avoiding high-fat, high-calorie, cholesterol-laden foods like cheese, butter, red meat and eggs.
This, the dietary standard of care, has been put forward as the pathway out of obesity and heart disease, adult-onset diabetes and hypertension, the same conditions mostly managed with medicines, treated as "chronic," and the same so-called underlying conditions that put patients at greater risk of bad outcomes from COVID-19.
So the answer to what we should eat is suddenly more important than ever.
Brainerd goes keto
“These are not necessarily chronic, progressive conditions — they can be reversed,” says Eisenschenk, the region’s first board-certified obesity medicine physician.
Today, he prescribes the ketogenic food pyramid to his obesity patients, and "with the same confidence as I would if I were prescribing a drug," he says. "I do it by saying 'if you do this, you'll feel better, your weight will improve, and we can probably stop some medicines."
With the help of a family member who is on board with the plan, he says, patients are usually off and running
"The first two things I hear are, one, 'I'm no longer hungry,' and two, 'I don't crave the things I used to crave.' If those become true, they have more or less transformed into eating this way, and at that point I'm more or less a counselor and coach helping to fine-tune things."
The method reduces "healthy eating" to one thing only: minimizing the release of insulin.
Insulin is a hormone released by the pancreas when fuel from dietary carbohydrates enters the bloodstream. Insulin shunts energy into fat cells. That makes you hungry again shortly after eating. In this way, insulin makes us overfed and undernourished at the same time.
To avoid insulin, the ketogenic diet promotes unlimited eating of fatty meats, cheese, plant or animal protein, nuts, seeds, and vegetables that grow above the ground.
It's possible to eat keto with a vegetarian or plant-based diet, but it's not easy. Most prepared vegan and vegetarian foods are held together with processed plant oils and carbohydrates.
Likewise, trying to eat low-carb, "high-protein" — without increasing healthy animal fats like butter, red meat and cream -- leaves a person feeling malnourished.
To ease the skepticism of colleagues who question the high consumption of saturated fat and animal protein with keto, Eisenschenk will encourage them to investigate the data showing the evidence base linking dietary cholesterol and saturated fat with heart disease, diabetes and obesity, is poor, while the data supporting LCHF to reverse adult-onset diabetes continues to mount.
For example, LCHF has been endorsed by the Obesity Medicine Association, while carbohydrate restriction is now supported by the American Diabetes Association. Virta Health, a keto coaching program in Indiana, recently published research showing two years of success reversing Type 2 diabetes with LCHF, while researchers at Johns Hopkins recently published three-month trial showing similar outcomes.
But after 100 primary care patients, and 70 obesity consults, Eisenschenk says it's his patients' results that sway colleagues the most.
"On the whole, their A1c is getting better, fasting insulin is getting better, liver function enzymes are normalizing, triglycerides down, HDL is up, weight is down, blood pressure down, reflux is in resolution, in some cases sleep apnea, and eczema no longer an issue. Occasionally their LDL changes in such a way that it may go up a bit, but if I look at the particle size, it almost always shifts to a less less-risky subtype."
"Both in primary care and the specialties, I think the thing that speaks the loudest is the patients we share . . . I get these messages from primary care doctors asking 'holy cow, what's different?' It's really powerful."
The medical center recently released the story of Katie Erickson, a 27 year-old nurse at Essentia St. Joseph's from the neighboring town of Baxter who has lost 75 pounds since July 2019 on the program, with her cholesterol and insulin levels having gone down, and her heart-health markers having improved as well. "This has been a program that actually feels like it’s sustainable," she says, "and one that I can carry forward."
Eisenschenk says young males tend to lose weight the fastest on keto, while older women lose weight but in a slow and steady progression. He feels lucky that Essentia has been supportive of his work.
"Administration leadership has been on board," he says. "Two years ago, we had the Lakes Area Low-Carb Conference, the first low-carb conference in Minnesota, and during the second one last year, 425 people showed up."
COVID and keto
The timing is good, because with COVID-19, the pressure has only intensified to find an answer for America's soaring rates of obesity and metabolic syndrome. For reasons unknown, the virus has proven far more deadly for persons with obesity and underlying conditions like heart disease, hypertension and adult onset diabetes.
"What COVID-19 has done, I think, is sort of exposed our vulnerable, baseline state of metabolic inflammation and dysregulation," Eisenschenck says. "One epidemic is exposing another."
"It's been a great talking point to say to people that, should you want to pursue lifestyle changes with us, now is a great time . . . they know that this thing is probably not going away for a while, and it could put me in a vulnerable state quite rapidly."
"In my medical school residency I was never taught these things," he says, "just like the cardiologists weren't taught them and the nutritionists weren't taught them and your average patient of course doesn't know either. But the current way we're doing things — more meds, more metabolic syndrome sequelae, unhappy patients with bigger bills and lower lifespan — we can flip that on its head."