Welcome back to the DietDoctor
podcast, with Doctor Brett Scher.
Today it is my pleasure to be joined
by Dr. Robert Cywes.
Now, if you haven’t heard Dr. Cywes speak,
you’re in for a treat.
He is such a knowledgeable
and passionate individual
and that clearly comes through
in this interview.
He is a board-certified surgeon
doing bariatric and weight loss surgery,
both in adults and in children,
and he has a tremendous amount
of training and experience in this field.
He actually started in South Africa,
getting his MD and his PhD,
working with the esteemed Prof. Noakes
during his carbohydrate days.
Then he came to the United States
to train in pediatric surgery,
went to Canada to get further training
in adult surgery
and now has been here
in the United States
practicing for years in
a very busy weight loss surgery practice.
But he’s probably one of the most unique
weight loss surgeons you’re going to meet
because, there’s an old saying,
“If you go to a barber, you get a haircut.”
If you go to a surgeon, you get a surgery…
Not so with Dr. Cywes.
He wants to evaluate everybody
to see what he can do
before doing weight loss surgery,
using weight loss surgery
as either a bridge or a last resort
and focusing more on life style, specifically
focusing on low-carb, high fat nutrition.
He’s a big proponent of carbohydrate
as an additive substance
that is causing more problems
than any other addictions that are out there
and he talks a lot about that
and makes a very compelling case
for why we need to think of carbohydrates
as addictive in certain populations.
So, I really hope you enjoy this interview.
His passion, his enthusiasm
and his knowledge
really comes through in this interview.
So, without further ado
here’s Dr. Robert Cywes.
Dr. Robert Cywes, thank you so much
for joining me on the DietDoctor podcast.
Thank you. It’s great to be here
after all the good work you guys are doing.
Well, thank you,
it’s truly a pleasure to talk to you
because you’re definitely one of the most
unique surgeons that I’ve heard speak.
You talk about, emotional attachments,
about the psychological side of things
and you talk about doing what you can do
to not operate on people,
which I got to imagine
it’s going to get you kicked out
of the surgical community at some point
if you keep this up.
Tell us how you got down this road,
from being a bariatric weight loss surgeon
to then focusing on the lifestyle
to prevent the need for surgery
in some people
or to use it as an adjunct with surgery.
Thanks, I think the value of what I do, and
really can all be summarized in two words,
And I think as physician’s in general
we have lost our curiosity,
and we believe the facts and we believe–
and we are not open,
we don’t open our minds to…
hmm, maybe these facts aren’t
quite as factual as they should be.
One of the values of being a bariatric
surgeon is we have a very high-volume practice
and we started seeing certain patterns
of patients all along
and one of the myths about bariatric
surgery, is that it’s forever… It isn’t.
Everybody loses weight,
everybody loses a massive amount
of weight when you first do the surgery
for the first to two three years,
but the effective durability of weight loss
it’s like a very powerful diet.
It doesn’t last very long,
beyond two to three years,
because it ultimately is a form
of comfortable starvation.
It’s a form of intentional caloric reduction.
But if patients preserve the reason
why they became fat in the first place
then they will figure out ways
around that surgery
and most of those patients
regain their weight.
There’s an incredibly high weight regain,
whether it’s partial or complete
and most bariatric surgeons
conveniently ignore that aspect,
which we focused on very heavily,
or alternatively, probably even worse,
they can’t eat enough
and when they eat the wrong types of foods
they become malnourished
and those are the two things we’re battling
with our population, over time.
So, I looked at this group
and I looked at the group that was
successful and those that weren’t
and we looked at the changes
that they made
and that helped us to step backwards
and figure out,
okay what are the driving forces
behind causing obesity?
You see the way that surgery works is–
the way I look at obesity
is a little bit like a polluted river.
You can go down to the river’s edge
every day and take the crap out,
and if you’ve got a big net
and a lot of helpers
you can take a lot of that crap out…
But until you shut the factory down,
that’s putting the crap into the river,
you’re always going to have a polluted river.
So, more and more, with that pattern
recognition concept, we started looking at…
okay, what are the common threads,
the common pathways with these patients,
in terms of why they are eating in excess?
And the first thing we found out is that–
and I’ll put this statement out pretty boldly
and I’m 100% confident about this,
it is impossible to become fat
from eating food,
it is impossible to become fat
from eating food.
That doesn’t make sense,
but if you step back a little bit and think,
okay we’ve been a species
for a very long time,
what we eat is not trying to kill us,
it never has.
So, there must be something else
that we’ve introduced into our food system
under the label of food
that actually isn’t food.
And more and more
as I interviewed my patients,
I found that about 80-90% of the calories
that they consume
was this particular substance
and it was ubiquitous.
I’ve never met a fat person
or a type 2 diabetic
that wasn’t dominant
in terms of their consumption,
both in terms of quantity and frequency
of this particular substance.
And as I looked at the substance and put it
into the context of my research
I found that it was
one particular category
that we introduced into our food system
altruistically in the 1950s and ’60s,
but very erroneously
and we haven’t been able to let go,
and that substance is obviously
carbohydrates, sugar and starch.
And what we found is
that our patients developed this
out of control relationship with carbs
and that they eat almost in the same
pattern, as which smokers smoke.
So, we stepped back
and we looked at that
and we looked at our patients
from a variety of different perspectives
and what we found is that again,
ubiquitously every type 2 diabetic,
every obese patient has either a deficient
or a dysfunctional way
in which they handle their emotions.
So what we found, and as you–
as we again step back and look
at some of the recent history of this,
in the 1950s, physicians,
Ancel Keyes is the dominant one,
but physicians became concerned
with people having heart attacks and strokes.
At that time we had no idea
that it was related to smoking,
obviously from the ’70s and ’80s
we know that absolutely now.
However, we were concerned and
we did autopsies on patients,
we found this build-up of fat, clogging
their blood vessels with cholesterol and fat.
So, we did the simplistic
but plausible thing…
aha, it must be the fat that we’re eating
that is clogging our blood vessels.
That’s a hypothesis and you know what?
70 years later, after billions of dollars spent,
is still a hypothesis.
Right, but it’s a hypothesis that’s become
so prevalent in our society
that has been promoted as fact and yet
they don’t have the science to back it up.
And because of that we’ve seen the rise
in processed foods
and low-fat carbohydrate foods
which has stimulated this obesity epidemic
that you seem to have correctly identified
through your patients.
But what’s interesting is how do you use
the weight loss surgery
to either help people get
over that carbohydrate addiction
or do you try and use it as a last resort,
where does it fit into your–?
It, it really depends on the patient, and it
depends on the conditions of the patient.
So, the first thing that we have to have is–
and let me just back up for one second,
what we found is briefly in one sentence,
we became lipophobic as a society,
we removed fat and we went from 5%
to about 60% recommended carbs in our diet.
That’s like saying hey you know what,
water is really bad for you.
You have to drink whiskey with every meal.
Not everybody’s going to become an alcoholic,
but it certainly raises the standard,
and the question was
who is becoming that alcoholic?
So, the first thing we do now
in our practice
is we identify patients
from two different perspectives:
The first group
is obesity the primary issue,
and typically for most people if you’re 15,
20, 30, if you’re an adolescent, a child,
if you’re in your 20’s or 30’s,
it’s the dominant issue with them
is obesity– yes they are…
it’s impossible to be heavy and healthy.
So, there are health issues occurring and
some of them have profound health issues,
but around the late 30 to 40 years
and certainly 40’s, 50’s and 60’s,
obesity takes second place
and what prioritizes that are some
of the health issues, cardio vascular issues,
maybe polycystic ovarian syndrome,
we focus more and more
on the health issues.
And the way we make our decision
about the timing of intervention
I believe that 100% of patients
need a shot
at a cognitive behavioral carbohydrate
addiction program first and foremost.
Every one of them, is an expert at failing
conventional weight loss programs.
They’ve tried it all,
lost some weight,
they’ve failed the calories in, calories out
People, don’t come to you as a first step,
they come to you after they’ve tried
the liquid diets,
after they’ve tried counting the calories,
after they’ve tried the point system
they’ve done all that
by the time they get to you.
And they’ve spent thousands of dollars
and the only thing they’ve lost
is the weight out of their back pocket,
you’re absolutely right.
So the first thing is are they primarily
here for obesity
or are they a brittle diabetic
that’s now having to go on insulin?
That modifies my ideology because we have
time that we can spend with someone
who is just trying to lose weight
on the conservative side,
because the slope of the weight loss curve
When you’re a brittle cardiac patient,
as you know, or if you’re a brittle diabetic,
we want results pretty quickly,
and absolutely the surgery is the single best
form of intentional caloric reduction.
So we’ll move those patients
into the surgical category more quickly.
The other thing is that if someone
is not willing or able
to really initiate the type
of dietary approach
and has a roadblock to the understanding
of what we’re doing
I’d be more reluctant to do surgery
because the surgery will work
for a little while, but it’s going to fail.
So, that is the paradigm with which we look
at for surgery,
but there’s something else that we look at
that’s very important,
and that is what is the cause
of their emotional dysfunction.
We divide our patients
into two very distinct categories.
The first category are permissive patients,
and this is not their fault.
Nobody choses to become fat,
it’s our responsibility to address it,
but nobody chooses it,
and what we’ve found as we’ve looked
at pattern recognition
is there’s a certain sub-group of patients,
around half, maybe just less than half,
that come from a familial background
where there really is no structure.
So, let me give you
a couple of sentences on this.
In order to build an effective
emotion management system or skill,
you need to put effort into something
and the return of the investment in effort
is a wonderful sense of well-being,
a sense of pride that elevates
your self-esteem and self-confidence
and then you’re willing to put
more and more things in.
Why is that important, because when you
are putting effort into something over time,
the first thing is, that effort,
that thing that you do,
is a wonderful endorphin activator.
And the endorphin system is one
that we use to help us to relax periodically,
to help our brains to function effectively
throughout the day,
but also to handle large amounts of stress,
anxiety or depression,
and almost all the patients
that come in to our office say,
“Oh, I’m a stress eater.”
Yeah, of course, you are.
So, the first group of people are folks
who kind of should put the effort in
to develop these skillsets, but they divert.
They have a Nike problem…
they just don’t do it.
So, for example,
“You know what, Johnny?
I really want you to eat some broccoli
today, it’s healthy for you.”
“Oh, okay Mom, I’ll eat the broccoli,
but you know what?
“There’s pizza in the fridge.
I’m going to eat the pizza tonight.
And then tomorrow, I promise you,
I’ll eat all the broccoli,”
or “you know what, I’ve got
a Math test tomorrow,
“I’m going to study really hard for this,
but there’s a cool show on TV,
“and I’m going to watch that and then,
and then after the TV show,
well, I know my Math pretty well, I’ll get
a C this time and next week I’ll get an A.”
So there’s all the intent
to do the right thing,
there’s all the intent
to put effort into stuff,
but they never ever transition into a–
intent into effort,
therefore they do not build up
self-esteem and self- confidence.
And it’s so much easier for those patients
with no structure in their lives
to triangulate to some inanimate
readily available thing,
whether that’s nicotine, alcohol or what’s
now ubiquitously available carbohydrates.
-Which hits the endorphin system….
That’s where they get
their endorphin high.
So, I’ve heard you say before,
we eat carbohydrates, not for food,
not for nourishment, but for endorphins.
Right, so when I said earlier on
that food doesn’t make us fat…
Food has a very, very powerful biologic
that prevents us from overeating.
If I put a big steak in front of myself…
I may be very hungry, I’ll eat a certain amount,
as soon as my satiety system kicks in,
I stop eating steak
and I cannot 10 minutes later
or 5 minutes later eat more,
but I sure as hell can eat some ice-cream
or some chocolate or chips or…
I am not eating, I am relaxing,
I’m doing crystal meth,
and that’s that methodology.
So on the one side you have
the group of patients who have no structure,
they are the permissive or hedonistic group
of patients and it’s a parenting style.
The issue with those patients
is try as they might–
they just don’t have the skills to put
the effort it,
and that group of patients
we can often take down the surgery road
a little bit faster, or a little bit quicker,
because they’re going to keep tripping
over their own two feet.
On the other side of the equation
we’ve got exactly the opposite.
We’ve got the authoritarian families.
An authoritarian family is very rigid,
So that they are willing and able to tolerate
the austerity of putting
a lot of effort into things,
but instead of feeling the pride and
the pleasure of the accomplishment of effort,
what’s happened is they’ve set
some ridiculous standard,
some ridiculous goal or result
that there is no way they can achieve.
So no matter how much effort they put in,
they’re always falling short of that goal,
always falling short of that result,
and the very fabric of the thing
they’re doing for pleasure,
for emotional relaxation,
for endorphin release,
creates a lot of anxiety and stress
because they’re never good enough
and they’re never ever getting praise,
they’re never getting
made to feel positive and powerful.
So, it’s very erosive to their self-esteem
and those people triangulate again to some
inanimate thing that makes them feel good
that is not judgmental.
And the example there is,
“Johnny, you’ve got to eat this broccoli,
it’s good for you.”
“Oh Mom, okay,” and he sits down
and 20 minutes later he’s wrestled
that broccoli down.
“Look Mom, I finished.”
“Well that took you long enough.”
Never quite good enough,
or you know what…
“Look Mom, I studied really hard
and I got an A in my Math test
and I came second in the class.”
“Who came first
and what question did you get wrong?”
So, the whole mentality
is not good enough
and then you find something that
ubiquitously just makes you feel better.
So, just to extend that theory,
if you’ve got a second…
I’ll share this little anecdote with you.
Two people have knee surgery,
and what happens is the first woman
is really good, she’s accomplished,
she works hard, she’s got a great life,
she plays tennis, she goes to church,
she’s got a great family.
The knee surgery doctor prescribed
Percocet for three weeks
and after five days her knee pain is gone.
She gets back to her life,
she throws the Percocet away.
The second woman, very accomplished–
and doesn’t have to be a woman,
it can be a guy,
but the second person, very accomplished,
hard-working, very productive,
but is so busy working that she has no time
for rest and relaxation.
So, she’s bottled up, without knowing it,
she’s bottled up
all this emotional stress and tension
and then along comes the doctor
after he knee surgery
and gives her three weeks of Percocet,
and she takes the Percocet,
that’s very effective for knee pain
but for the first time in her life
she just develops this tranquil feeling
from the drug
that just relaxes her for the first time
and she feels in control of her life
for the first time ever.
And it’s kind of a vicarious association.
So, after the knee paid is gone,
she continues to use the Percocet,
not for the knee pain but modify
this emotional stress and tension,
because she got a deficient
emotion management system,
but the problem is then she needs more.
So, she goes from three to four or eight
to 10 to 12 to 30 or 40,
but she’s absolutely fine.
And then along comes the government–
and she’s been tranquil and absolutely fine,
functional, not perfectly functional,
but doing fine, for 10 years.
Along comes the government and says
this opiate crisis is terrible.
Laudable, I agree with that.
Doctor goes to jail,
drug companies get sanctioned,
but they fail to ask is why is this woman
taking this Percocet?
And when they take the drug
away from her, she got nothing,
she got no emotion management tools.
So, what do they do, suicide rates goes up,
alcoholism rates go up and heroin addiction
comes in, now we’ve got an opiate crisis?
Well, why I’m telling this story is because
the exact same thing happened with obesity.
In the 1950s, less than 5% of our diet
By 1977, it was entrenched
in the food pyramid at 60%,
so what happens is little baby, little Johnny,
little Jilly, whatever their name is,
as a child is told this food
is so healthy for you,
and at two to five years of age,
they don’t have–
because they come from a permissive
or authoritarian family,
they haven’t started developing
effective emotion management skills.
So, not only is this orange juice,
this apple juice or this Cheetos
or Cheerios or Goldfish healthy for them,
so called because of the food pyramid,
we know differently
but they’re getting a high from it
and they develop an attachment.
And as they get to become teenagers,
a little bit is not enough…
It’s available everywhere,
so they develop this out of control
relationship with carbohydrates
to help them to deal
with their emotional management.
Now along comes you
with your keto diet
or me with my surgery,
which is more dramatic,
and in one day, we kill their best friend.
And the challenge with that
is it plunges these patients
into anxiety, stress and depression,
because all they wanted to do
was lose weight.
And maybe they’re losing weight,
but they realize that’s not the be-all
and end-all, I’ve lost my best friend.
So, if you as a physician,
are not also making the patients aware
of the fact that that’s going to happen,
and help them to develop the skills
and the tools
that they need to mitigate against that,
they’ll either go back to eating carbs,
like a lot of people after smoking cessation,
or they find another drug.
And a lot of the bypass patients,
a lot of the bariatric patients find opioids,
because they are given that,
or they do suicide, they do alcohol,
they find another outlet.
I think that’s such a great point
to talk about a little bit more,
because there is this risk of being
in an echo chamber in a low-carb world,
that the people who are doing great
are the ones flooding
the online chat rooms
are the ones that are doing
are the ones that are promoting
but the real question is,
who is not doing so well
and why and what can we do about it?
Because those are the ones
that we need to reach.
So, it sounds like your primary message
is filling that emotional need
when you get rid of those carbohydrates,
which a lot of people don’t talk about
and don’t think about.
So, is that one of the first discussions
you have with a patient
when you talk about the ketogenic diet?
Not what you should eat,
not how many carbs,
but what you’re going to do instead,
when you get rid of that endorphin high?
Yes, so first of all, we absolutely
don’t use the word diet.
A diet is something you do
for quick weight loss,
you can go to Oprah or Doctor Oz for that.
This is a lifestyle change,
and so the very first discussion we have is
as we explain to them,
why they became heavy in the first place.
And that they need to reduce calories,
but that is vicarious.
The human body can do that
you’ve just got to reawaken those systems,
but we really talk about the fact that,
the reason that they became heavy
in the first place
is because of a deficient emotion
And anytime you get rid
of any drug,
you need to replace
the positive parts about it.
So, the first discussion we have
is get people out of the dietary
calories in, calories out philosophy
and get them into understanding that this
is a substance abuse problem
and it needs
a cognitive behavioral approach.
So, it’s removal and replacement.
And the value of removing carbohydrates,
you see the problem with carbohydrates,
because they are a drug,
and because they are a recent drug
in humans, there is no feedback control.
So, there’s very tight feedback control
when you drink water.
We’ve been drinking water
as a species forever,
so when you’re thirsty you have no idea
how much you’re going to drink.
You start drinking because your brain
says you’re thirsty
and very quickly, at some point your body
says, enough my thirst is quenched,
and you automatically stop drinking.
You don’t overdrink, although you could,
but there’s no incentive…
-You don’t crave more water once
your thirst is quenched.
But if you’re drinking alcohol, alcohol has
no negative feedback,
it’s a positive feedback system;
water for nutrition,
alcohol for pleasure or for endorphins.
So, you have to set a very specific limit
on how much alcohol you’re going to drink.
If you don’t, you’ll drink until you pass out
or get drunk
and if you do that repeatedly
you become an alcoholic.
You don’t do that with water, because
there is no feedback regulation, okay.
So, when it comes to carbohydrates,
exactly the same situation exists.
Carbohydrates are a drug that’s primarily
consumed for pleasure,
for the endorphin value,
they’re not nutritionally necessary.
We will not die
if we stop eating carbohydrates
and there is no negative feedback
when it comes to carbohydrates.
So, the reason we stop eating,
is because of the portion we selected to eat.
So, our brains, when we’re are hungry,
decide how much food we need,
or the restaurant puts food in front of us,
and because we can override
any minor satiety signals,
because carbohydrates have no feedback,
we’re able to eat
a massive amount of carbohydrates.
And we overdo it and that’s part
of the whole weight gain thing,
to get that high.
When you’re eating fat, and this is why it is
called a LCHF, a low carb high fat diet.
The human body has been consuming fat,
since we existed,
whether we were herbivores,
fat has become the thing that enters
our blood stream.
Remember, cellulose in a gorilla gets turned
into fatty acids as absorption, not sugar,
you can make a gorilla diabetic.
Be that as it may, we have always had fat
as a resource,
and therefore the human body has a very
powerful, robust, sophisticated system
of negative feedback when it comes to fat.
Let’s just use one word called leptin.
So, as you eat your meal, a little bit of fat
goes into your blood stream,
gets into the fat cells,
as the fat cells start to take up fat,
they say, whoa, I’m getting fat here,
we need to block this,
and they release a hormone called leptin.
Leptin after about five to 10 minutes goes
to your brain, and says, boom, I’m done.
You do not need to a focus portion control,
the human body does that for you,
and as soon as that leptin begins to rise,
I’m full, I’m done,
and if you overdo it,
you get a little bit queasy.
So, you learn, maybe earlier on
in a ketogenic diet or a high fat diet,
you override a little bit
because that’s your format,
but if you learn to eat sequentially,
which is another critically important part
of what we teach our patients,
instead of deciding how much you’re going
to eat depending on the portion,
take that same portion
and put it in the middle of the table
and go back and forth eating tiny amounts.
And what will happen is
as leptin becomes activated,
especially if that food
has a high fat content,
you’ll say hey,
I’ve been back two or three times, I’m full,
and you’ll recognize feedback signals
for the first time in your life.
Okay, so it has to be a conscious decision
to go get the food and bring it to you,
rather than having it there, because then
you get the psychological of…
ah it’s there, I don’t want to waste it,
I might as well eat it, it’s in front of me.
So, the psychology can override
that leptin response, to some degree.
Correct. First of all,
if it’s a high carbohydrate low fat meal,
which is the standard American diet,
there is no leptin response.
So you can finish
whatever’s in front of you
and the question is,
when do you finish?
And you typically finish
when your plate is empty.
If you’re going back and forth,
number one psychologically,
you’ve got an empty plate in front of you,
but you then have to make a decision,
whether you need more based on how
you feel, not how much you intended to eat.
So, eating carbohydrates is by intent,
whereas eating fat, ultimately,
if you understand that relationship
and you eat sequentially,
is by feedback fullness,
therefore you never have to decide
how much you are going to eat.
This whole concept of intentional caloric
reduction or portion control,
and every CICO diet is based
on some magically pseudo-scientific story
that ultimately comes down
to a very sophisticated, caloric restriction.
It’s a formula of caloric restriction,
whether it’s Nutrisystem or Weightwatchers,
the body cannot sustain that… you know why?
Because that’s called starvation.
There are times when my body needs
a huge amount
and there are times
when it needs almost nothing
and I’ve got to connect back
with my feedback pathways
and once you do,
it’s impossible to get fat from eating food.
-From real food….
Food, food by definition is something
our body needs for its nutritional value.
But drug by definition is something
we consume for pleasure.
It is not necessary for human survival.
I don’t know about you, but I certainly
don’t need heroin, except maybe on Monday’s.
Those are things we don’t need, okay,
and thirdly… excess can cause harm.
And with food,
because of the feedback systems,
it’s very rare for us
to get into harm’s way.
So, this whole concept that fat causes us
to become fat is by definition erroneous.
Yeah, so when you’re–
when you’re helping somebody,
does it have to be low-carb enough
to be into ketosis?
Is there something about ketosis
that you think helps with the weight loss,
helps with the long-term success,
or is it just low-carb enough
that you’re focusing on vegetables
rather than pasta
and processed foods and breads?
Is there a difference in the carbohydrates
and can you see the people success
with 100g of carbohydrates
if it’s from the right carbohydrates,
or is it 20g of carbs ketogenic lifestyle?
There’s two questions there.
The first thing we spoke about
a little while ago was portions,
the amount that we eat at one time.
The second issue is the driving force
Okay, so first and foremost a snack
is always an emotion event,
it is never a nutrition event,
and a snack by definition is stuff
we consume for our emotions,
that contain calories.
Right, if you’re snacking it,
usually means you’re not getting in
enough fat or calories with your meal
or protein possibly,
you’re not getting enough with your meals
if you’re feeling hungry,
or it’s the routine
of I’m just used to having something
to put into my mouth.
I don’t think it’s a lack of calories.
If a lack of nutrition,
call that a meal,
but a snack is something
we use like a smoker smokes.
About every 20 minutes,
the human brain needs to relax
and the endorphin system
is in charge of that relaxation.
What we do defines us,
the dominant thing we do defines us,
so the smokers always every 20-30 minutes,
are looking for an opportunity
to go and have a cigarette.
The obese or type 2 diabetic
are always looking for a snack
and they surround themselves
with easy access.
So a little bite here, a little bite there,
and we get, oh no, no that’s different,
that’s like saying I only smoke
five cigarettes a day,
but if you walk behind them
it’s twenty cigarettes.
Same thing with the frequency…
so, the first issue there is when
you’re snacking on carbohydrates,
and that’s what a snack usually is for most
people that are not trying to change,
it’s an endorphin event
not a nutrition event.
The second thing is that when you’re eating
your blood sugar
is continuously fluctuating,
and as your blood sugar goes up, whether
that’s two M&M’s or a whole pizza,
insulin gets produced and insulin drives
your blood sugar down,
when your blood sugar goes down,
you get hungry.
So, the problem
with a high carbohydrate diet,
is that you’re perpetually hungry,
and that is why their advice is turned
from one or two meals per day
and I talk about the post food pyramid diet.
They are now recommending
six to eight meals a day, small meals a day,
that is not the way human beings
are designed to eat.
Right, so it’s out of necessity
that they eat a high carbohydrate diet.
Correct, so the cool part about this is
that you don’t have to do this intentionally.
When you go into ketosis,
you don’t feel hungry,
because your blood sugar and
your insulin is very basal, it’s flatlining.
you’re going to get fat adapted?
But when it’s a flat line, you don’t get
those sugar highs and sugar lows.
At the same time, you still need
as fat person, a type 2 diabetic,
which is the same disease by the way,
to put something in your mouth,
like a smoker might use a piece of gum
instead of a cigarette,
to manage your emotional needs.
And that’s where we try to have patients
develop a ritualistic relationship
with something they can put in their mouth
that doesn’t contain calories.
So, in my case that’s a cup of coffee.
I don’t drink the coffee,
I sip on it throughout the day.
After every patient in my office, go back…
relax my brain, it’s an emotional relaxation,
let the stress tension of the last visit go,
have that little bit of coffee to trigger it
and when I go to my next patient,
I’m totally on, they get the best of me.
If I go patient to patient to patient,
I’m building up the stress and tension,
my brain’s going to take a break
and I’m going to lose focus.
So, understanding emotion management
as it relates and interrelates to eating
and drinking is critically important
because what we’ve tried to do is introduce
the carbohydrate addiction model,
when you remove carbohydrates,
we have to replace their role in our lives.
One role is food nutrition,
so we have to go back
to eating for the nutritional value
not the endorphin value
and secondly, we’ve got to understand
the emotion management effect that
carbohydrates had to find a replacement.
It’s a great point about the replacement
and I think that’s something
that we don’t talk enough about,
whether it’s going outside for a walk,
whether it’s just taking a minute to breath
or meditate or be mindful
or like you said the coffee.
What I find is a lot of people do like to use
a drink as a substitute,
which I think is great, unless it’s coffee
with heavy cream and MCT oil,
because then the liquid calories
are adding up,
which could be a detriment
or the caffeine is adding up if people
are drinking the whole coffee
and actually from a personal experience,
when I’m working from home,
I find myself snacking on the nuts,
more than I should,
so I started drinking more tea,
and I noticed I was getting a little shaky
from all the caffeine,
so then I went to regular water,
but regular water doesn’t quire cut it,
so I need something else,
whether it’s hot water
or some of the flavored salter waters
that are zero calories.
Are these the types
of recommendations you make?
Absolutely, so what we’re looking to do
is we understand
that obese people, like smokers
are very oral in terms
of their relaxation technique…
Some people can pray,
some people go for a walk,
some people can chat to other people,
depends on how you’re wired.
Obese and type 2 diabetics are primarily
wired to put something in their mouths,
so number one, the difference between
a snack and a bridge,
and a bridge is a term I coined,
is that a bridge bridges across that moment
of endorphin requirement
without a caloric load.
So instead of a coke, even a diet coke,
is a perfect–
no but it’s a hell of a lot better
than the coke.
So it’s a segue across,
but what the caffeine in the coffee does,
is that it needs to give you
an endorphin rush.
I find, that some people use water,
but water long term
doesn’t satisfy the endorphin need.
Now you can create a ritual around it,
and I’m not going to knock that,
but the other point you made is very valid.
In people trying to reverse type 2 diabetes
into remission or trying to lose weight,
don’t add extra calories to your–
even if it is or
because it doesn’t contain carbohydrates,
all because it’s keto,
doesn’t mean it’s okay.
So, you said the cream and the MCT oil…
when you’re trying to lose weight,
when you’re trying to get rid
of your diabetes,
give your body that intermittent fast, where
you’re not consuming those calories.
So, that’s the group that’s lowering
Once you’ve done that,
if you look at all these skinny people
in Hollywood who’s looks are their living
and they’ve adopted the ketogenic diet,
which I absolutely love,
because I think it’s a healthy way to go,
better than lettuce leaf eating,
what the MCT oil and the cream does,
those people are probably
at a slight caloric deficit,
because they were very aware of it.
So what the MCT and the cream,
or whatever it may be does,
is it keeps them in ketosis,
it keeps activating leptin
and prevents them from eating.
So, it becomes easier to adopt
an intermittent fasting pattern.
And they’re then getting
little bits of calories,
it will never make them fat, it won’t,
they don’t need to retard their weight loss,
they want to stay stable,
so the maintenance phase, we introduce
that to keep them where they are.
And remember a lot of my surgical patients
are not able to eat
a huge amount of calories at a time.
So the way to kind of stop the weight loss
on a ketogenic diet
is to increase the little bits they have,
never enough to cause weight gain
but enough to modify weight loss.
Right, I think that’s a great point
because we do have to separate
the different types of ketogenic lifestyle.
There’s a weight loss ketogenic lifestyle and
then there’s the Hollywood, Silicone valley
or the people just trying to get high, chasing
higher levels of BHB for the mental performance
and they’re not one in the same,
so I think that was a great differentiation.
So, we went through a little bit of how
you evaluate the patients that you see,
sort of their psychological make-up
in terms of who’s going to go to surgery
sooner or later,
their background health challenges, who
you’re going to use surgery sooner or later.
Let’s just say you start with the process
with the ketogenic lifestyle
and they’re progressing but not as quickly
as they would like,
and then you’re starting to think
about surgery with them as an aid.
Give us a little overview of the general
different types of surgeries…
and sort of what the potential risks are,
long term for each kind.
So if somebody out there is thinking,
“I’ve been doing this ketogenic diet
and I’ve lost 50 pounds
“but I’ve got another 100 to go,
“would weight loss surgery
be a beneficial bridge for me…
what should I be thinking about?”
Absolutely, good question
and I think that the first thing is,
I’ll never ever make a decision
on behalf of the patient.
I’ll give them my opinion and my opinion
is based on the history we’ve have had
with over 8,000 patients
that we’ve operated on.
So, we look at the range of procedures
and there’s devices and procedures, some
of them are temporary, some are permanent.
And we start
with the least amount of help.
So if somebody’s tried many times and
they’re struggling to get going,
but they are pretty authoritarian,
they are pretty good at getting stuff done,
they just can’t put it altogether
right away, that–
so for example someone who’s tried
and failed to quit smoking many times,
I would have no problem writing them
a prescription for Chantix.
In exactly the same way, an intragastric
balloon, is a very useful temporary device.
This is a balloon that occupies space
in the stomach,
fills you up with a very small amount
so you only need to eat a small amount
of food and you fill up
and secondly it partially obstructs
the outlet of the stomach,
so it keeps food in there for a long time.
So, it takes the edge off the need to eat
all the time,
both psychologically as well
as from a hunger perspective.
And the balloon stays in there anywhere
from six months to a year,
and there are a couple of different balloons
on the market, and what they do is,
if you’re working with it, you’re able
to break habits and form new ones.
One of the key things, I said before
I don’t use the word diet,
because the end point
of a diet is weight loss.
The end point of our program is habit change,
and it takes about 90 days to break a habit
or create one,
and then you want to consolidate it
and the six to nine month time period
that the balloon is in place,
up to a year or so,
if they’re effectively working this,
to not only break those habits,
but when they make mistakes,
the mistakes are not punitive.
When you’re on a diet
and you make a mistake,
you gain all the weight back
and you have to start from zero again.
With the surgery or the balloon
it’s kind of a stair step pattern,
so you’re losing weight really well
and then you screw up,
you have a Christmas party or whatever it is
and you kind of level off,
you don’t gain the weight back.
You come in,
we tweak your head a little bit,
we can maybe make some tweaks,
one balloon one balloon system,
the old balloon system
we can actually add another balloon,
it’s kind of the stair step pattern,
during which time, you’re losing weight,
so you’re seeing the success of that,
which is an important metric.
But you’re also transforming your way
of life, your self-confidence,
your self-esteem is growing and by the time
those balloons come out,
hopefully you’ve changed enough
that you don’t just go straight back.
Yes, what do you see
when the balloon comes out,
because now all of a sudden, the stomach
has gone from a small effective size
to all of a sudden,
a much larger effective size.
So does their hunger go up,
does their craving for larger portions go up,
once the balloons come out?
It depends on what the patient’s done.
There’s a group of patients that come in,
typically a wealthier Palm Beach patients,
I know exactly what to do,
I just need a tool.
They will lose a bit of weight, figure a way
around it and they fail miserably.
That’s called a wallet biopsy,
it’s a terrible way to go,
because the only thing that lasts
is the money they spent on the balloon.
That is the wrong thing
and talk as I might–
we see that group of patients,
we try to filter them out.
The other group have transformed
their way of life.
The paradox is, even after the balloon
has come in,
they continue to lose weight
and continue to get healthier,
so that’s the group
we want to buy into this.
The austerity happens
with the help of the balloon.
The success phase is pleasurable,
which is phase two,
the first phase is the divorce
getting rid of the carbohydrates
and not seeing progress,
the balloon shortens that period.
Once you get into the success phase,
when you start to succeed, see results,
you can leverage your success to do more,
and we push them
along that pathway.
So, that’s what happens
with our balloon system patients
that really engage in the process,
so they start a ketogenic diet and they use
the balloon as a tool to help them.
For patients that are either
very, very sick
or have a brittle cardiac
or diabetic or other issues,
maybe somebody who cannot deal
with the PCOS,
which is a sugar problem in the first place,
or they’re extremely heavy,
now we’re talking about
your five, six, 700 pounders
or people that have struggled
and have really failed
and finally people
from a permissive background,
that’s where the more permanent
Understand that the effect of durability,
of weight loss during that surgical time
is no more than about three years,
but as long as they follow up,
I think of our office is AA for fat people,
it’s not a weight loss office,
it really is that cognitive
behavioral therapy program.
Some just take a longer time to get it and
practice it and make it part of their lives.
So, that’s where we select the surgery.
Now, in my opinion, I do not believe
that the gastric bypass should ever be done,
as a first line operation.
The number of complications I see with it
are enormous, I fix a lot of those,
but they also have
And if you’re following a ketogenic diet,
in our program, it’s a liability.
I see them gaining weight back
as much as others,
and I see them become malnourished
far more than other surgeries.
The operation of the day right now
is the sleeve gastrectomy,
which is a pure restrictive operation.
So, what you eat, you get,
there’s really no metabolic problem with it,
but you just don’t feel very hungry.
So again it’s basically shortening
the size of the stomach.
So what we do is we turn the stomach
into this big bag
that can hold a huge amount of food
and we turn it into a tube.
It’s taking a five lane highway and turning it
into a one lane highway.
And because the traffic is slow along
they eat a small amount, they feel full
and they feel full for a long time.
So, it’s the most consistent form
of weight loss.
Obviously, if you eat ice-cream
and Oreo cookies all day long,
you’ll still lose weight in the first six months
but it will level off and you’ll gain it back.
And it’s not going to help your health.
Absolutely, so the health part of this
is to also help with health parameters,
and the paradox again is this,
is that the single most effective treatment
for type 2 diabetes is a gastric bypass.
It cures– not cures it,
but it puts type 2 diabetes
into remission, for a short period of time.
Even before the weight loss?
Even before the weight loss in the first
few weeks their blood sugars normalize,
the A1c’s come way down.
If, however the patients do not drastically
change their relationship with carbs,
it comes back.
And an NIH paper that’s just come out
said they looked at over 50% of patients
that had gastric bypass surgery for diabetes
or were diabetic at the time,
became diabetic again
at five years, five to seven years.
So, you’ll hear this about magic bullets
and it’s absolutely 100% true.
Your diabetes goes away, but it comes back
unless you do the ketogenic diet.
But the sleeve has the same effect
and it’s even more powerful
if the incentive is to augment
a ketogenic way of life,
to replace the need to do anything.
So, if someone has tried and failed
at multiple weight loss attempts
and goes to see a bariatric surgeon
and they say let’s do the gastric bypass,
would your recommendation be to say
hold on, and ask them about the balloon,
ask them about the sleeve,
ask them about these other, I guess…
you can say less drastic measures
to start with?
You know, there’s a little bit of bias,
because any time any patient
comes into me,
they’ve already failed at everything else,
and they want surgery.
Their obsession is their weight,
or maybe the diabetes
and they want a cure for that.
And I’ve got to sit down and actually hurt
myself professionally or really fiscally,
by stepping back and saying,
“Whoa, hold your horses.
It’s not going to work
the way you want it to work.”
There is no magic, there are
too many both surgeons and doctors
that prescribe diets
that are magic bullet doctors,
“Do this and you magically lose…”
and we invest in that magic.
This is hard work, it’s a lifelong process,
and, so we have to step back
and talk to the patients about this.
My job is the surgery,
all they have to do is show up.
Their job is to transform
how they handle their emotional needs,
away from a drug called carbohydrates,
toward things that they do.
That’s a lifelong job
and we have to partner together,
but I’ve got to introduce them
to that partnership.
So, I know that the majority of people
are antagonistic towards surgery
and the odd thing is, so am I, but I recognize
that there is a group of patients,
where we’ve done absolutely everything,
form the ketogenic change perspective
that just can’t make it happen,
and that as I said, is like somebody’s tired
and tried to quit smoking.
Well, we very readily write
that Chantix prescription,
and I know it’s the downside
is not as much.
I think that for people
that are recalcitrant,
that are struggling,
that are putting the effort in,
and we have to have that message in, it is
an added tool that we can really help them,
because ultimately as physicians, we want
the patients, number one, not to die,
and number two to be healthy.
And if we can mitigate
against those two things,
I believe we should use every tool we can,
but we should do it sequentially,
and a very, very small percentage
of patients, actually need surgery.
The majority of them can do that up front
with other tools
and things we can provide for them.
So, now let’s shift for a second and talk
about the long term sequence of this,
you know the– you see them,
you do a sleeve or a balloon,
they’re losing weight, but they got
10, 20, 30 years to maintain this,
and let’s be honest,
as easy as a lot of people like to say,
a low-carb ketogenic lifestyle is,
it’s still not a straight line.
People are going to slip up,
they’re going to have mistakes,
people are going to gain weight
and fall off the wagon, so to speak.
Depending on their personality type
that may be the end for some people
and they don’t get it back
and some people may jump right back in.
How do you deal with people
from an emotional side,
to help them through those failing
moments, or those weakened moments?
So, at the very first visit,
we reinforce this all the time,
we introduce the concept of failure.
Not as a failure but as a passage to doing
better, because everybody fails.
Nobody quit smoking the first time,
it’s typically three to five attempts
minimum, before they finally do,
but every time you learn a lesson
and the value of the surgery,
as I said, is that stair step pattern.
The only thing I chastise my patients for is,
if they don’t come through the door.
It’s AA for fat people.
Beyond that, we are number one
never judgmental or critical.
You have to throw that away.
These patients have beaten into submission
because they cheated,
they’re a screw up, they’re a failure,
they’re terrible, they’re–
that’s what Weightwatchers does
and what happens, they don’t go back.
When you’re struggling,
get your butt into our office.
We’re not going to kick you down,
we’re not going to push you down,
we’re going to help you back up, okay.
So, you know, part of the other problem
if you’ve been sober for a year
and you go out on a bender,
that’s not so bad, not a problem.
The problem lies in the fact that the next
morning they don’t say that was terrible,
I’ve got to get back on track,
they take three of four months
before they can get back on track.
So one alcoholic binge is not the problem,
it’s the problem with permission.
Once they grant themselves permission
to drink, they can’t stop,
and it’s exactly the same with our patients.
So, the fundamental turning point
of our practice is the word permission,
and your whole being, your–
we have this incredibly sophisticated
system of validation and trivialization
and mitigation and minimization
and rationalization the…
I know I shouldn’t be eating
this cake or this pizza,
but right now, for this very reason,
I need my shot of heroin.
So, we help the patients to understand
that the word is permission not quantity.
The world, the diet world out there
is always rewarding you
with the very drug that made you fat.
So, we build into that,
a certain amount that you can have.
Right, there’s an office party,
there’s a birthday party,
go ahead and have your couple of–
Or you save up all your points at
to have some cheesecake.
That’s like celebrating a year of sobriety
with a case of beer.
So, it’s a ludicrous concept.
That’s why the first thing we concentrate on
is zero carbs, not an allowance.
There are incidentals
that we need to cater for.
The goal is to try and be as close to zero
as possible, but you asked about failure…
the next thing is this, we tell patients,
you’re going to make mistakes,
it’s never a bad thing.
You try to create an environment where you
don’t have easy access to carbohydrates,
but when you make a mistake,
the most important thing
as I just gave the alcoholic’s analogy
is not the mistake itself,
it’s the recognition of the mistake.
And the time frame
between making the mistake
and recognizing that you’ve made it,
So, we introduce, very early on,
we reinforce, reinforce,
reinforce, the concept of OAC;
ownership, analysis, correction.
Ownership is, “Hey I made a mistake,
and I don’t care if it’s one M&M
or the whole bag”,
because it’s the word permission
and in addiction management
we can be very binary.
You either did, or you didn’t.
It doesn’t matter how much alcohol
it’s that first sip of beer that’s
the problem for the alcoholic,
it’s the first puff on that cigarette,
the first snort of heroin, it’s not how much.
The diet world is filled with restriction.
You can have a little bit,
but you can’t have a lot.
Well, you can’t tell
an alcoholic that.
Asking an alcoholic to count their drinks, or
asking a fat person to watch their portions,
it’s like telling an alcoholic
to watch their drinks, you can’t do that.
So, the word permission
So, the first step is ownership,
and it becomes much easier to recognize
when you’ve made a mistake,
if we have binary rules.
Now we don transgress them
from time to time, that’s the mistake.
The next question you want to do
is go back,
because you can’t correct the mistake,
okay, you can’t correct the mistakes.
So, the next questions
is what were the circumstances?
How did I get myself into a position
that I made that mistake?
What was the overwhelming
or what was the proximity of me
to the carbohydrates…
and where did that come from?
And the next time,
I’m in the same situation,
what tricks or tools can I do
to make it different?
And one of the things
that we teach our patients,
is they have lost
the ability to make choices.
In addiction we’ve lost the ability
to make a choice,
but we’ve retained
the ability to make a decision.
A choice is when it’s right in front of you,
should I or shouldn’t I, you’re screwed.
I can guarantee you if there’s ice-cream
in my fridge tonight, I will eat it,
and I’ll eat it all gone.
But I can also guarantee you
that I’ve made the decision
that there is no ice-cream in my fridge.
So, a decision is a pre-emptive thing.
I know what I’m going to eat
and how I’m going to eat,
what the pattern is, what’s going to happen
at the table before I walk into a restaurant.
If you look at the menu, it’s crystal meth,
crack, cocaine, marijuana,
I mean how the hell do you stay away
If you go into a store to buy stuff,
and you look around,
everything is just bombarding you
If you make a list before hand, you’ve made
a decision about what you’re going to buy.
Are you absolutely going to stick to it?
Probably, maybe not but at least
you’re more likely not to buy crap.
If you don’t have carbohydrates
in your home, you can’t have them.
If you open the fridge and say should I drink
a coke or a diet coke, you’re screwed, okay.
So, a large part
of what we train our patients,
is suing more addiction type methodology,
to protect them from themselves,
and that’s the issue, because
you can’t control your environment,
you’ve lost the capacity of choice.
So you’ve, we’ve talked a lot
and it’s a great analogy
that makes a lot of sense,
but when you talk about legal definition
or rules and regulations
around addictive substances,
are we ever going to get with carbohydrates,
processed foods, sugar
or is there just no chance,
because of all the industry
and the history and the culture
that we’ve sort of embedded ourselves?
Well, I think the first challenge
and I said this right at the beginning,
is to separate carbohydrates from food.
Absolutely food is non-addictive.
It doesn’t meet
any of the addiction criteria.
And you can’t stop eating food.
Carbohydrates, and Nicole Avena,
I think’s her name,
has done some great work on this,
but carbohydrates meet
every one of the DSM five.
If you just substitute the word carbohydrate
for the word nicotine, alcohol or heroin,
it meets every single one of the broad
spectrum of addictive substances,
from the mental alteration,
from the need to,
from the destructive lifestyles,
from every perspective,
it meets those criteria,
but we’ve got to use the word carbohydrate
not food, that’s the first thing.
So, it absolutely meets
all the addictive criteria.
The second thing on the nutritional side,
it is not necessary for human survival.
At least the consumption of carbohydrates.
Here’s the error.
Carbohydrates are absolutely necessary
for human survival,
we have to have sugar in our blood stream,
but we don’t have to put them in our face.
Our body is very well adept
at making them.
So, they are not an essential nutrient,
and while there is a survival advantage
from time to time, from a species perspective,
in small amounts at intervals.
For example Gary Fettke
does a great talk on fruit
that used to be available
seasonally for a month or two,
to help us to fatten up before winter,
Now it’s ubiquitously available
and we’re fattening up all the time.
So, you know, it’s not maligning carbs,
carbohydrates aren’t bad,
they’re not the problem,
it is our relationship with them that is.
And once you’ve lost control
of that relationship,
that’s where the abstinence part
Alcohol’s not a problem.
I drink alcohol, so do you, I think?
So, but it’s not a problem for us.
If it was, abstinence would be
the corrective pathway,
and so the issue is not the substance,
the issue is the relationship,
and it’s that addictive relationship,
and absolutely carbohydrates meet
every form of the addiction description.
They really don’t meet any
of the descriptions for essential nutrients.
The one other mistake we make,
is the world out there quantifies
carbohydrates based on the additives.
So, an apple is very healthy,
but a bowl of ice-cream isn’t,
but if you look at the carbohydrate content,
it’s about the same.
So, if you look at a glass of red wine,
very healthy, a lot of anti-oxidants.
You look at a glass of whiskey,
not so much.
But a glass of red wine is healthier for me
than a glass of whiskey.
But if you’re an alcoholic, it doesn’t matter,
it’s the alcohol content that’s important,
and that’s what we don’t understand.
So, when I talk to my adolescents,
I use the turd theory…
it’s kind of a cute little thing.
Do you eat your dog’s poop?
What happens if I ate your dog’s–?
If I took your dog’s poop and I dressed it up
really nicely and I made it look petty
and I sprinkled a few nice things on it and
made it smell good, would you eat it then?
Well, that’s what carbohydrates are
for fat people for diabetics,
carbohydrates are the turd, no matter how
much you dress them up, they’re still a turd.
You can find the stuff you dressed them up
with in other foods.
You can find your nutrients,
your fiber in other foods
that are not carbohydrate dominant.
Right, and you know I think there’s
an important differentiation to make,
you’re talking about the subset of people
who are obese
and are addicted to carbohydrates,
but just like the alcohol analogy,
not everybody is going to have that same
reaction and that same addiction.
So, part of it is for the person to identify
if they fall into that category.
But the second is
when they come to someone like you,
to be able to go down that path first before
jumping into a lifelong altering surgery,
so I really appreciate
and hopefully more bariatric surgeons
and weight loss physicians
are going down that path,
to address a lot of the emotional concerns,
before jumping into a surgery,
I think that’s very refreshing.
Yeah, I think the surgery
is so darn effective immediately
and everybody just focuses
on the immediate result.
Right, not the long term.
The first year is lovely,
and that’s the error.
It’s so darn powerful
we don’t think of the consequences,
but isn’t that why we eat carbohydrates?
Because they’re so darn gratifying
We don’t think of the consequences,
that’s the issue.
We’ve got to think long term.
Right, good analogy.
Well, I want to thank you so much
for taking the time to join me today.
If people want to learn more about you,
where can you direct them to go?
Well, I’m on Facebook
and I’m on Instagram.
It’s Robert Cywes, C-Y-W-E-S, and it’s
an open forum, but it’s nice to friend me.
My website is www.obesityunderstood.com
and we’re becoming more
and more focused on the diabetes side,
so we’re building our diabetes website.
We’re also doing a series of podcasts,
which will be turned into a book form,
looking at different chapters.
I’m recording that right now
with Doug Reynolds, from Low Carb USA,
so we’ll be producing that
in the next little while.
And if I can put one plug in there,
in terms of changing away from the diet
philosophy calories in, calories out,
I want to put a plug in
for Zoe Harcombe’s new book, The Diet Fix,
big in the UK, it’s available
by order here in the US,
and it really transforms our thinking
on the principles of diet
that we’re so welded to
and that we need to let go of.
Wonderful, thank you for that and
I look forward to seeing the podcast series
with Doug Reynolds
from low carb USA.
Thanks for taking the time.