3 Question Interview with Dr. Daniel O’Neill

3 Question Interview with Dr. Daniel O’Neill

Back in the late ’90s, when the self-published edition of How I Gave Up My Low Fat Diet and Lost 40 Pounds came out, I was interviewed by the local paper and got some book signings. At a book signing at the local Borders, a young man came up to me. He told me that his father, Dr. Martin O’Neill, was a local cardiothoracic surgeon. He, Dan O’Neill, was a type 1 diabetic who had been eating a low carbohydrate diet for years to help manage his blood sugar. His results had been so good that his father put all of his bypass patients on the Atkins diet. The other cardiologists in the local hospital were alarmed by this – the eggs, the butter, the red meat, the cheese! They were simultaneously puzzled by how much better Dr. O’Neill’s patients did than theirs. Dan had come to my book signing to get a copy of my book for his dad, who was busy performing surgery that evening.

Daniel O’Neill became a doctor himself, practicing in the Pacific Northwest. I sought him out to see if he would do a Three-Question Interview, and he graciously consented. Here is that interview with Dr. Daniel O’Neill.

How Dr. Daniel O’Neill Learned About Carbohydrate Restriction

Question 1: Dana Carpender: Dr. O’Neill, you first became familiar with carbohydrate restriction because you developed Type 1 diabetes as a kid. Can you tell us a little about how you discovered a low carbohydrate diet and what effect it had both on your health and on your life as you were growing up? (Bonus points for a few words about how it influenced your father’s practice of cardiology.)

Answer: Dr. O’Neill: I was diagnosed with type-1 diabetes in 1994 at age thirteen, around the time my family moved from New Orleans up to Bloomington, Indiana. I was a very active teenager, and balancing soccer, swimming, and theater proved very challenging at a time when counting carbohydrates was the advised approach to managing type-1 diabetes. Increased carbohydrate consumption, of course, meant using much larger quantities of insulin – resulting in more volatile swings in blood glucose and much more room for dosing errors. Not only were these frequent blood sugar highs and lows more dangerous, but they also lead to an ever-increasing consumption of carbohydrates and steady weight gain, despite my very active lifestyle. It seemed there just had to be a better way to achieve good glycemic control.

Around this time my father, Dr. Martin O’Neill – a practicing cardiothoracic surgeon – began looking into low-carbohydrate diets as an alternative to help me better manage my diabetes. He also sought to improve the health of his patients, many of whom were diabetics suffering from severe atherosclerotic disease. In his search, he came across the book, “Dr. Bernstein’s Diabetes Solution,” by Dr. Richard Bernstein, and saw great promise in this approach. Dr. Bernstein’s methods threw in the face of the prevailing high-carbohydrate, low-fat regimens for diabetes, and challenged the fat-demonizing dogma more accepted by the medical community at the time.

So while touring college campuses in late 1999, my father and I visited Dr. Richard Bernstein’s clinic at his home in New York for a several-daylong diabetes overhaul and my introduction to a new approach to managing my disease. In particular, he cut my daily carbohydrate consumption from over 200-300 grams per day to less than 20 grams. And by a stroke of coincidence, upon returning home to Bloomington, I found you – author Dana Carpender – giving a talk on low-carbohydrate diets at the local Borders bookstore.

Ever since that time, the low carbohydrate lifestyle has been my way of life and has kept my hemoglobin A1c well under control in the 6-7% range for the past 20 years. And for the remainder of his career, my father was also a strong advocate for low-carbohydrate diets for himself and his patients, especially in the period following their cardiac heart surgeries. He often found the improvement of his patients’ post-operative hyperglycemia led to far fewer complications.

After my initial meeting with Dr. Bernstein and transitioning to a lower carbohydrate lifestyle, I was well prepared to stay on track, despite the challenges around eating healthily that many new college students face in their first years away from home. I was also able to row crew and began to lose weight and feel more hopeful about my disease.

As a freshman in college, I met with Dr. Eric Westman, considered one of the preeminent researchers in low carbohydrate diets, and spent that summer working with him on one of the first randomized controlled trials of the Atkins Diet. Together we drafted a research paper entitled, “The Effects of a Low-Carbohydrate Regimen on Glycemic Control and Serum Lipids in Diabetes Mellitus,” using Dr. Richard Bernstein’s patient data, which was later published in the medical journal, Metabolic Syndrome and Related Disorders.

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Fast forward now to over a decade into practicing as a primary care physician. I am able to draw from my personal experience with diabetes and low carbohydrate diets in helping patients better manage their disease. In this process, I have often referred my patients to your [Dana’s] books for recipe ideas to improve their blood glucose and lipid profiles, as well as lose weight.

I recently passed the threshold of forty years, and as a diabetic was prescribed statin medication. However, I recently decided to discontinue because my lipid profile remained remarkably well controlled off the medication – an achievement I largely attribute to regular exercise, a low-carbohydrate lifestyle, and eating plenty of healthy fats from foods like olive oil, avocados, nuts, and fatty fish a couple of nights per week.

Does Carbohydrate Restriction Factor Into Your Treatment Of Addiction?

Question 2: Dana Carpender: One of your specialties is addiction medicine. As a person with undiagnosed ADHD, I had several addictions – I stole money to support my sugar and tobacco habits, I drank 12-18 cans of diet soda per day, and I did my level best to smoke all the dope in North America. It turned out that for me sugar was the seminal addiction. Once I quit sugar and white flour at 19, the other addictions fell away, one by one, over the next 5-10 years. Does carbohydrate restriction factor into your treatment of addiction? If so, how? If not, why not?

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Answer: Dr. O’Neill: Current primary care providers have inherited the challenge of the opioid crisis in the wake of nearly a generation of clinicians being misled about the potential harms of narcotics. In my medical practice, I have a special designation by the DEA, an X-waiver, which allows me to prescribe the medication buprenorphine to help treat opioid use disorder. Outside of my daily practice, I volunteer for Portland Street Medicine, where addiction is front and center, while providing care to our houseless neighbors. Medication-assisted treatment using buprenorphine to manage opioid use disorder has offered a unique window into the lives of those struggling with addiction. But whether on the streets of Portland or in an everyday clinical encounter, I find that addiction is almost always present to varying degrees.

Every time we glance at our cell phones – for ‘likes’ on social media, for that special someone to text us back, or for simple entertainment – it elicits a small dopamine surge in our brains that keeps us coming back for more. This same reward pathway extends to most anything in life that gives us pleasure, giving shape to the more classical addictions of drugs, alcohol, caffeine, sex, and food – sugar being one of the worst culprits. The challenge in primary care is helping patients manage their addictions if and when they veer into excess, having adverse consequences in their lives. A harm reduction approach aims to meet patients where they are at, not necessarily requiring total abstinence, but seeking incremental, accessible changes and identifying clear goals.

And while there is certainly a symbiosis between addictions, in which they amplify each other’s effects; I have found they also work synergistically in the other direction – providing momentum from one positive behavioral change to drive healthy changes in other aspects of one’s life.

While I do not feel addiction to sugar is THE seminal addiction, food is certainly central to many of our lives and identities. As such, I find in practice that cutting out refined carbohydrates is one of the first and most accessible levers to pull when starting down a path toward healthier life choices.

How Does Carbohydrate Restriction Figure Into Dr. O’Neill’s Patient Care?

Question 3: Dana Carpender: Your practice is not focused on diabetes or weight loss; how does carbohydrate restriction figure into your patient care?

Answer: Dr. O’Neill: As a general internist, weight loss and diabetes management are my “bread and butter” areas of focus, so to speak. In fact, next to mood and anxiety disorders, obesity and diabetes are the most common problems I encounter in the outpatient setting, depending on the population I am working with.

These issues have come to intersect even more with the recent advent of newer diabetes medications, such as GLP-1 agonists (e.g. semaglutide and liraglutide), showing very exciting results for both improving glycemic control and – when used for patient struggling with obesity – demonstrating far more dramatic weight loss than seen with previous agents.

Although exercise is an essential part of promoting cardiovascular health, I counsel patients that caloric restriction is the main driver of weight loss. Because fat has more than twice the calories per unit as carbohydrate, historically dietary recommendations have aimed more at fat than carbohydrate restriction. However, the advantages afforded by carbohydrate restriction through shifting the body into ketosis while also improving cholesterol, finally have robust evidence to support this approach.

The main confusion patients seem to have when it comes to lower carbohydrate diets is that they approach them in the same way as other diets: generally restricting carbohydrates but still treating themselves to a little refined carbohydrate daily – a cookie here, and a slice of bread there – enough to repeatedly knock them out of ketosis. Often this happens by accident if the patient does not have the benefit of simultaneously monitoring their blood glucose to help identify carbohydrate-laden foods. As a general rule, the body will preferentially use carbohydrates as an energy source first, if one makes them available. Otherwise, with a little time, it will shift gears into “fat-burning” ketosis, a far more efficient way to lose weight and maintain good glycemic control for diabetics.

I advise patients that carbohydrates, especially refined ones, are not essential for our survival, as our bodies are well equipped to use other caloric sources for energy.

The ubiquitous Food Pyramid, pervasive in American schools’ health textbooks and on the backs of cereal boxes from the 1990s through the early 2000s, was not based on sound science. It stressed that 6-11 servings of carbohydrates (e.g. “bread, cereal, rice and pasta”) should be the largest food group consumed daily, with all fats and oils at the top of the Food Pyramid, to minimize whenever possible. The growing body of evidence suggests the Food Pyramid should have been inverted, though still reserving refined sweets for the top.

Refined carbohydrates – namely foods containing white flour, high-fructose corn syrup, and added sugar – spike our blood glucose to a degree that our bodies are not evolutionarily adept at handling. As a result, that morning doughnut, cereal, toast, and orange juice from concentrate starts us on a wild roller coaster of dramatic blood sugar swings throughout the day. And when we come crashing back down, we feel hypoglycemic – craving more refined sugar – starting the cycle all over again. Low glycemic and lower carbohydrate diets remove these wild swings in blood glucose and increase satiety – the feeling of fullness – thus reducing hunger and cravings that continually feed our carbohydrate addiction.

Importantly, I also talk with patients about the many fake products out there – as “Keto” and “Low-Carb” have unfortunately become meaningless marketing ploys slapped on many snack foods in an effort to sell products that certainly raise blood sugar. I know from personal experience. Many of these products are also calorically dense and not well-regulated with respect to their nutrition label claims.

Finally, I convey that neither all fats nor all carbohydrates are created equal. The carbohydrates that I do eat from time to time, especially when more active, are high in fiber, with a low glycemic index. Used sparingly, I am still able to hover in ketosis and provide added energy for increased exercise. As for fats, I target unsaturated ones that are liquid at room temperature or found in foods like olive oil, fatty fish, nuts, and avocados.

In the end, the debate over the best diet for patients has eclipsed the central importance of finding a sustainable approach to eating that is consistent with the patient’s health goals and values. So I support finding a strategy through shared decision-making with one’s primary care provider. But hopefully, some of these recommendations may help spark discussion to arrive at an approach that is not just effective, but also both feasible and sustainable.

Daniel F. O’Neill, MD, MBA, AAHIVS
Physician, General Internal Medicine
One Medical, Portland, OR

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