Ketogenic diets and mental health with Dr. Chris Palmer — Diet Doctor Podcast

[Music] welcome back to the diet doctor podcast i'm your host dr brett sher today i'm joined by dr christopher palmer now dr palmer is a board-certified psychiatrist and he's an associate professor of psychiatry at harvard medical school and he's the director of the department of post graduate and continuing education at mclean hospital you can find him at chrispalmermd.com and on twitter at chris palmer md now what we're going to hear today is really a wonderful run through of mental health disorders and the role of nutrition and lifestyle in general but also ketogenic diets specifically for mental health disorders and dr palmer is really on the forefront of this field having practiced it for well over a decade and having contributed to the scientific literature by publishing reviews and publishing case uh reports and has some exciting things coming down the pike in the future as well on this so stay tuned for that he's going to give us a little teaser during this interview but we talk about mental health disorders sort of why nutrition would work specifically why ketogenic diets would work and what that means for the type of ketogenic diet or a low-carb diet that somebody might need to follow and also importantly where it fits into the treatment paradigm for evidence-based medicine for mild moderate or severe mental health disorders and he has some interesting takes on that which you know provides some caution but interestingly about using seizure literature so literature about ketogenic diets for epilepsy and how that can then apply to mental health disorders so an interesting sort of mechanistic combination and we go through so many other topics with some really good advice including eating disorders that we talk about at the very end which he has a really great way of explaining eating disorders and what a restrictive diet means for eating disorders but another part of this is you know as with any of our podcasts this is meant for general advice this is not meant to give medical advice so if you're thinking about starting a ketogenic diet or a low carb diet or changing your your medications or treating any kind of condition with nutrition please do it under the watchful eyes of an experienced clinician you can go to our find a doctor page at dietdoctor.com to find a clinician who's who's familiar with low carb diets and ketogenic diets who can help you or just follow up with your regular doctor because this is not meant to be medical advice for you to take into your own hands and treat your own mental health conditions right so please do it under the watchful eye of a trained clinician all right so with that out of the way let's get into this wonderful interview with dr chris palmer [Music] well dr chris palmer thanks so much for joining me today on the diet doctor podcast thank you brett thanks for having me yeah it's my pleasure it's great to talk to you i mean you've been so active lately with your publications with your speaking engagements about promoting low-carbon keto diets for the treatment of mental health disorders which is a fascinating field that's really growing both in terms of clinical experience and scientific knowledge but i'm curious i always like to get back to the beginning because you know i know from my standpoint i didn't receive hardly any nutritional or lifestyle training in medical school residency and i would assume it's the same for psychiatry but would like to hear from you how much of what your you've learned about nutrition did you gain after your training versus what you gained during your training uh so i'm exactly like you on uh for better or worse so mine you know the the training that i received in nutrition in medical school was a course that i think was one week long and uh it it went through basic you know at the time it was the low fat diet the lower the fat the better all fat was considered toxic that included things like peanut butter it included nuts it included olive oil um avocados every all fats were considered bad for human health uh and that was essentially the training that i got and you know we talked about rare nutritional deficiencies relatively rare ones we talked about things that you need to screen for when you're treating you know people with alcoholism for instance you know make sure you check for thiamin deficiency and other things um but uh we certainly didn't learn about using dietary interventions as treatments so even in your psychiatry fellowship was that the same because there is a little body of literature that is not all that recent that you know investigated some nutrition and exercise interventions for moderate depression which showed it was as good as or in some cases better than ssris was any of that taught or was it still basically focused on pharmacologic treatment of psychiatric disorders in your in your residency training so in my residency training i i trained um yeah i trained like 25 years ago so at that point we actually didn't have studies demonstrating that dietary interventions can be helpful as a primary treatment with one primary exception and that is with eating disorders um and so when people come in with anorexia nervosa or bulimia or other disorders and are severely underweight it has long been known that re-feeding those patients and essentially forcing them to gain weight has benefits because they are literally starving to death they often have life-threatening complications from a starvation syndrome and uh whether they like it or not uh and usually they don't like it uh we've the the field has essentially force fed them and uh tried tried to get them to gain weight that that was really the only dietary intervention uh that i i learned about yeah so so you're like a lot of us and you had to pick all this up after your training and probably had to do it on your own so give us a little summary of your journey and how you came to realize the benefits of nutritional and lifestyle therapies and start incorporating that in your practice and how you started to gear towards specific types of nutritional interventions like so many other people in this space that begins with my own personal story and i was pretty strong adherent to the low-fat diet when i was in medical school and residency and one of the primary reasons is you know i looked at all the patients that i was treating in the hospital heart attacks strokes cancer all sorts of other things and i was very determined to not be one of them i did not want to be one of them and so i followed the dietary guidelines to a tea and i was on an extremely low fat diet sometimes eating less than five or ten grams of fat per day because i was taught lower the fat the better um and you know for better or worse that did not work out well for me at all uh i um by the time i was in my late 20s i had metabolic syndrome uh despite strict adherence to this supposedly healthy diet i was exercising pretty regularly at least three times a week and doing everything else right i was not excessively drinking i wasn't using recreational drugs i wasn't doing anything else that i wasn't supposed to be doing and yet my blood pressure was high my ldl was high my hdl was very low my triglycerides were through the roof i had pre-diabetes and i was frustrated and pissed um because because i'm like i'm doing everything right and uh you know year after year the doctor kept telling me you got you gotta do diet in life you know i had and exercise diet and exercise to get these things under control i kept asking him exactly what diet exactly what exercise i was doing it all he finally decided he was going to push pills on me i said no you know what and we've been talking about it for a couple of years i said no uh i not yet uh give me six months i'm gonna try something else i didn't tell what i was gonna try but i've heard through the rumor mill that the atkins diet at the time uh was was somehow helping people improve their cholesterol even though you're eating eggs every morning um and i was in disbelief at that point i really was i i was a strong skeptic i i bought the medical dogma hook line and sinker um but uh given that i was following the medical dogma and it was failing me miserably um and i'd heard these kind of rumors that you know the atkins diet might be able to help i figured oh that'll be my hail mary pass i'm gonna i'm just gonna try i'm i am going to try this stupid atkins diet see what happens i was fully prepared for it to not work out i kind of expected that it probably wouldn't here's the interesting part so as this is a story that we hear time and again from clinicians which is such an important story here because the clinicians understand what it's like now to be the patient right to be the patient who lifestyle doesn't work for and just sort of gets written off for lifestyle but you had the personal experience and you improved your metabolic health as you're saying here but you are a little bit different because then you took the jump of improving your own metabolic health to then say as a practitioner for mental health disorders i can use the same dietary approach to help people with mental health disorders so it's different than just saying i can use this dietary approach to help people with metabolic health disorders because that's what worked for me that's what i see in the literature so how did you make that connection that jump to say well it's working for mental for metabolic health now i'm going to apply it for mental health disorders what did that look like so it's a great question so the um you know i personally i will share that i had um recurrent depression uh as a child and adolescent and but at the time that i was doing this um you know the atkins diet i did not have clinical depression i was working as a resident i was working ridiculously long hours every week i i could tolerate working 80 hours in a row um i wasn't having any serious problems um but when i made the dietary changes within you know within a few months i noticed dramatic changes in my mood my energy level my ability to concentrate my motivation just my outlook on life i uh the way i often put it to people is that i worked really hard to through medical school and through residency um and it often felt like a chore it really felt like i'm working hard this is a lot of information it's a lot of work i'm tired i'm i'm getting a little bit burned out and after i made this dietary change i was like one of these happy peppy people who just had this un this never-ending energy and i was no longer burned out quote-unquote i i just felt great and i had a lot of enthusiasm for life and i recognized that this was highly unusual i i had never been like that in my entire life and so i recognized wow this is this is really interesting i took a few years i mean at that point the atkins style was extraordinarily controversial in the medical field we did not have published studies in the literature yet um documenting that it was even safe as a weight loss intervention let alone any any other use and so uh it took me a few years before i started using it with patients but i i kept kind of thinking to myself if this is having such a profound effect on my mood energy sleep other things um i can't help but wonder what it might do for my patients with chronic treatment resistant depression who have tried you know tried dozens of medications who've been in psychotherapy for years or sometimes decades who've even tried shock therapy and nothing is working for them and so those were the first patients that i started with and that was probably 18 years ago well that's interesting because you really started with sort of the the you could say the sickest of the sickest or the worst of the worst because you weren't starting with a person who has mild depression and let's see if if lifestyle will work instead of medications you were trying the person who had sort of the most advanced case who who wasn't responding to anything so if anything you were it seems almost like a recipe to set yourself up for failure because if nothing's working good chance that nothing's going to work but my guess is you found something else right i i did um and uh so in in several of these patients uh in particular the ones who were able to do it not everybody was able to do the diet but in the ones that were able to do it and really stick with it um i noticed sometimes dramatic and remarkable improvement in symptoms patients recognized that family members recognized it i recognized it and it was unlike anything i'd seen with medications or psychotherapy or even ect in those particular patients because i have seen medications work i have seen psychotherapy work i've seen ect work but the reality is for far too many people they fail to work and uh and so with these patients in particular some of them had been my patients for years at that point and we had tried numerous medications and at best we might get improvement for a few weeks or a month or two and then the symptoms would be right back so that was kind of the start and uh and then things went on i you know i wasn't really willing to talk about that publicly because i i really was fearful of my license and what people would what people would think like i can't be prescribing the atkins diet to people in clinical practice and over the years we got you know an entire body of literature supporting the the effectiveness and the safety of the atkins diet and other low carb and ketogenic diets um for uh weight loss for diabetes control for other conditions and that started to empower me to to use this even more with patients and and then i think the you know the thing that really forced my hand to kind of make this a mission of my career was when i you know when i used this intervention with a patient probably about six years ago now and i it's a it was a patient that i'd had for a long time with schizoaffective disorder which is kind of a cross between schizophrenia and bipolar disorder and he had been my patient for about eight years at that point i had seen him on all sorts of medications in and out of hospitals nothing worked for him and that's actually not unusual for patients with that disorder it's a horrible kind of life sentence if you will and even with the best of treatments most patients with schizophrenia cannot work a lot of them can't live independently they continue to have horrible debilitating symptoms their lives are you know for all intents and purposes at least for some people their lives are ruined and uh and uh so one of these patients was obese and he asked for my help to lose weight and uh i really use this intervention with no expectation i'd seen this work for depression but depression and schizophrenia are totally different things so i'm now using this for essentially schizophrenia and um but uh again i just used it to help him lose weight i had no other expectations and uh sure enough he started losing weight um within about three two or three weeks i noticed profound antidepressant effects so he was kind of coming back to life he was making better eye contact he was more engaged he just seemed happier he was talking a lot more i was kind of like wow what's gotten into you like you're usually not this happy what's going on um and uh and then it was it took probably six to eight weeks but at about that mark um he started spontaneously reporting that his hallucinations were going away his long-standing paranoid delusions were going away everything was just melting away and he was dramatically improving um and quite honestly i was dumbfounded i was dumbfounded by that yeah i mean that sounds so dramatic so so fast forward to now and let's talk about sort of the state of the practice of ketogenic therapy for different mental health disorders and in a minute we'll break that down into specifics but just the general state of clinical practice um where the science is and how pervasive is it now because you know we've got you we've got dr georgia eid there there are a few people who are vocal about it but are you still like in the vast minority feeling like you're climbing up the hill trying to get people to uh realize this or do you think it's starting to to get accepted more now it's a really great question the um you know so in terms of where we're at in the state of the field so you know through the stories i just told you can hear that i kind of came upon some of this through serendipity i i had no expectation that i was going to discover these things but now when i talk with audiences i i can put everything together so the reality is that you know the ketogenic diet a specific form of the ketogenic diet has been used for 100 years in the treatment of epilepsy and uh you know the official ketogenic diet was actually developed specifically for the treatment of epilepsy and uh we have a tremendous amount of neuroscience literature on what this diet is doing to the human brain so we know that this diet is changing neurotransmitters it's decreasing brain inflammation it is changing ion channel regulation like calcium signaling it uh you know it provides an alternate source of fuel to you know instead of glucose it does all sorts of things um that we know about because of this neuroscience literature and lo and behold we in psychiatry use epilepsy treatments like candy really we we use them every single day in tens of millions of people so you know for those of you not familiar with this if you've heard names like depakote tegritol lamictyl topamax neurontin or gabapentin and all of the benzos that includes things like valium xanax clonopin ativan all of those meds that i just listed you probably know from the mental health field but in fact they're all epilepsy treatments um and uh that most of them were actually designed for the treatment of epilepsy and we quickly adopt them and use them in psychiatry the reality is we use them for for pretty much every mental condition we use them in psychosis we use them in bipolar disorder we use them in depression anxiety substance use eating disorders dementia we use them for a wide variety of disorders and at this point you know the ketogenic diet is an evidence-based treatment for epilepsy as i just mentioned we use epilepsy treatments all the time in psychiatry so it is not at all unreasonable to be thinking about using you know an evidence-based dietary intervention uh in people with mental disorders the um since i've been doing this work for the past six years or so it's really interesting because you know when i started there were very few people georgia eid myself maybe one or two other people who were even talking about this publicly um since that time um there's been an explosion relatively speaking of articles of articles on the ketogenic diet in mental health and the you know the the really good news is that um again this isn't relying on anecdotes this we have an entire body of literature 100 years worth to tap into that is directly relevant to mental disorders and so this is not at all a leap whatsoever um and and so the the way that i've been able to persuade a lot of leading neuroscientists and psychiatrists in this space is to just map out all of the lines of evidence the lines of evidence what do we know about schizophrenia what do we know about bipolar disorder what do we know about chronic depression what do we know is happening in their brains and then pair that with all of the science that we have on the effects of the ketogenic diet and it's a match made in heaven everybody that i talk to is like oh my god why isn't anybody doing like why isn't anybody using this in patients and i say well actually i am does it work i'm like yes it does read some of the case reports i've published and they're like they get all excited um yeah so the really good news is that we really do have we've had leading neuroscientists and psychiatrists publish their own articles um equally enthusiastic about hey this ketogenic diet deserves serious consideration like it really the science completely lines up we as a field need to really be thinking about using this as an intervention so what about the skeptic though who says well look these mechanistic theories kind of make sense but show me the randomized control trial that it works show me that it works better than cutting out sugar and ultra processed foods show me that it works better than a low-fat mediterranean diet what about the skeptic who says that lots of things to address in what you just said so i would say in terms of the randomized controlled trials of the ketogenic diet for specific mental health conditions we we don't have it depends on what you call a mental health condition so we just got a randomized controlled trial of the ketogenic diet for alcohol use disorder also known as alcoholism we've got a couple of randomized controlled trials of the ketogenic diet and alzheimer's disease and for those of you who think alzheimer's disease is only a neurological disorder and has nothing to do with mental disorders you are sorely mistaken every single patient pretty much with alzheimer's disease every single one just about 100 will have mental symptoms they will have depression anxiety insomnia agitation about 40 to 50 percent of people with alzheimer's disease have hallucinations and delusions those are the hallmark symptoms of schizophrenia um so uh you know alzheimer's disease is in fact listed in dsm-5 it it's on the border between what we call a neurological and a psychiatric disorder but um the reality is people with mental disorders are much more likely to develop that so we've got some randomized controlled trials there um we do have two randomized controlled trials of the mediterranean diet not ketogenic whatsoever the mediterranean diet for depression um one study was not that great because they relied on patient self-report of their depressive symptoms which is not a very rigorous study but the other study was actually in treatment resistant depression um and they randomized patients to the mediterranean diet versus a social support group and the people in the mediterranean diet had a 30 something percent complete remission rate and that compared to only eight percent in the other group so i think you know some people promoting that dietary intervention would say getting rid of the processed foods was probably one of the biggest ingredients in the success of that intervention the good news is that we now have randomized controlled trials getting underway in psychiatry with the ketogenic diet so i've been involved with three different research groups we we just got funding for three separate pilot studies of the ketogenic diet in serious mental illness which will include bipolar disorder primarily but also schizophrenia schizoaffective disorder in at least one or two of the studies well that's great news yeah so that that is definitely uh going to be a big contribution to the to the literature because that's i mean look everything you're saying to me makes sense right to people who believe in low-carb diets and ketogenic diets make sense but to the skeptic you know they're going to want to see more of this hard data so that's great that it's coming um but like you said for people who who've tried everything and have no other um really have no other option sort of like why not but what about that person who has sort of a more mild case you know a milder mild to moderate depression that you would usually just treat with an ssri or um or even bipolar disorder that you would treat with lithium like sort of the i don't know i want to call it the easy to treat conditions compared to the ones you just listed would you recommend ketogenic diets for those patients as well either as an adjunct to medical therapy or instead of medical therapy it's a really important question and i know people in the low-carb and keto community really want this to be a first-line treatment right now and for better or worse i do not recommend and cannot recommend it as a first-line treatment um and uh and the reason for that is that we don't have randomized controlled trials uh we don't have a good evidence base and so for licensed clinicians licensed clinicians really are held to specific standards and those are the standards within the medical community and there are evidence-based treatments for all of those disorders and those evidence-based treatments do work for some people they do and uh so i would say that people deserve a chance at at least two or three evidence-based treatments before you start using off-label treatments now i would apply this same logic to other types of treatments so i mentioned that we use off-label anti-convulsant medications commonly in psychiatry you shouldn't be using an off-label medication as your first-line treatment um so if somebody comes in with bread and butter depression you really need to use a first-line antidepressant treatment and or psychotherapy so people can do quite well with psychotherapy should a dietary intervention at some point become possibly a first-line treatment i'm hopeful and i have lots of reasons personally and professionally to believe that someday i think it in fact it might be the preferred first line treatment but for right now given where we're at as a field and given that i want to encourage clinicians to keep their licenses and stay out of malpractice cases and stay out of you know trouble it's important that we follow guidelines the good news i guess if you're a proponent of ketogenic diets the good news is there are tens of millions of people out there who've already tried all of these standard treatments and are desperately looking for a better answer so it's not like there's a shortage of patients to who could benefit from this treatment um there really isn't but uh but for now i don't think it's reasonable for me to suggest that we should use it as a first-line treatment yeah that's that's a really interesting answer now would you say the same thing about a mediterranean diet and you know 30 minutes of exercise per day do you think that is evidence-based as a first-line therapy and then if someone doesn't respond to that then maybe you escalate it to a more intense diet of carbohydrate reduction so if somebody's coming in with major depression uh to recommend the mediterranean diet and exercise as the only intervention that you're going to offer them no that's you would be in equal trouble uh if you do you need to offer a medication or psychotherapy now if the patient refuses both of those if the patient says no i don't want medication and i don't want psychotherapy i'm only interested in a dietary intervention then certainly the patient can choose that so patients have choice it's ultimately their decision but as clinicians we have to inform patients of the standard evidence-based treatments and right now the mediterranean diet is equally you know one decent trial does not make the guidelines so we need a lot we need many more trials uh we need more evidence um and even in that one trial of the mediterranean diet it only worked in 30 something percent that leaves a good 60 70 of the people for whom it did not work so uh um that you know it's not like this is a home run treatment for everybody with treatment resistant depression yeah that's a great point and then of course the whole definition of mediterranean diet what does that even mean it takes on so many different forms you'd have to go back to how they define it specifically in that study but even then only 30 so so that's a great point i think just well and just to clarify so i think that if if people want to lose weight um so if if if i have a patient who comes to me for treatment of depression and they wanna they they are primarily asking for help with their depression i'm gonna offer them at least the option of the standard evidence-based treatments if they at the same time say i'd also like to lose some weight we have no reason to believe that an antidepressant will help people lose weight there's we've actually had trials on that and they don't seem to help people lose weight so uh do the opposite many of them help people gain weight right they sure do so uh so if that person wanted help losing weight we have more than enough randomized controlled trials of low carb and ketogenic diets for weight loss more than enough that it is safe to say that you would clearly and easily withstand any kind of a lawsuit or any kind of you know accusations of quackery or anything else by recommending uh that for diabetes we're we're getting there um i'm hopeful we'll be there soon um you know some people would argue we're already there and that's great i would okay great awesome um and you know for the prevention of cardiovascular disease that really opens a hot potato as you know um uh or you know goes to so you know so i think different different conditions so if i've got somebody that's overweight and i really want them to be able to use a low carb keto diet i might talk to them about weight loss and then let's see if we can help you lose weight which in and of itself has been shown to have some antidepressant effects for people and we might use a low carb or keto diet even as a first-line agent but i would be clear in my reticle medical record documentation for better or worse i'd be clear we're using this for the weight loss we're using a standard treatment or patient is declining other treatment for their depression and we'll see how things go yeah i think you certainly present a very balanced approach and but an approach that someone who's a ketogenic diet enthusiast can take and someone who's a little bit skeptical can still take because you still fall back on the evidence-based therapy so i think that's a very balanced approach that that can appeal to a large swath of the medical population so i think that's great but one thing i want to unpack a little bit more with you is is we talk about low-carbon keto diets and you know when it comes to general health or general weight loss or even blood sugar management there is a spectrum there's you know strict low carb moderate low carb liberal low carb and you're likely to see a benefit at any point in that spectrum possibly with greater benefits with the more carbohydrate carbohydrate reduction but i'm curious if you think it's the same thing with mental health disorders because you know you don't need ketones for weight loss you don't need ketones for general health but is there something specific about not just reducing the carbohydrates but also having enough ketone production that you think that really plays into the mental health benefits because you talked about the keto diet for epilepsy which was this classic four to one you know uh the ratio of fat to protein plus carbs was four to one so it's a very high fat diet which is different than sort of the modified atkins diet or the what you could say the popular low carb or keto diet of today is so do you think it has to be a specific version of a low carb or ketogenic diet to see these impressive mental health benefits it's a really important question and one that you know that we do not have clear answers as a field i'll i'll give you my opinion but um i i just want to set the stage the real answer the trustworthy answer is nobody knows for sure right now because we don't have enough evidence in the mental field to be able to stay with certainty but i'll i'll call on some some other you know um research and and data to kind of inform the answer to that so you know in the epilepsy field the you know there's a cochrane review which in the medical field is kind of this gold standard meta-analysis of the research done so far and the cochrane review says that the ketogenic diet in fact is an evidence-based effective treatment for treatment-resistant epilepsy in children and adolescents only in children and adolescents why because adults have a hard time doing this diet especially like a three to one or four to one ratio diet and so at least in the epilepsy literature there are studies of it working for adults i'm not at all trying to say it doesn't work for adults but whether researchers can get adults to do the diet in research studies is another question so but that cochrane review also said that the modified atkins diet is not as effective as the four to one ratio diet um they they looked at all the studies that were done and there seemed to be a signal that the more intense the ketogenic diet the more effective it was however that's not to say that you know you as an individual just need to find the dose that works for you so if you are an individual trying to treat depression or bipolar or schizophrenia or whatever you just need to find what's going to work for you in reality in the in the epilepsy literature there is another dietary intervention called the low glycemic index diet that is also an evidence-based treatment for epilepsy now low glycemic index diets can sometimes be ketogenic but more often than not they are not ketogenic but essentially what a low glycemic index diet is doing is you're getting rid of a lot of the processed carbohydrates you're getting a rid of almost all sugar you're getting rid of a lot of flowers based kind of foods and you're eating whole foods it's not a low carb diet per se necessarily although it can be a low carb diet is certainly low in glycemic index as well but um but you can eat some foods like whole fruit whole vegetables that may have carbohydrates but because those carbohydrates are getting absorbed more slowly and with fiber included the glycemic index is lower and that that can be an effective treatment for seizures for some people so um so i think that you know the way that i think about this because some people get frustrated with this concept that may you know they're like which diet works dr palmer which one works like well you know if you give me a medication that we use in any medical field and say what dose works what dose works for everyone i would say you're being silly you clearly don't understand the medical field we we often will have a starting dose but sometimes that's too much for patients and we have to lower the dose sometimes it's not enough we have to raise the dose sometimes we have to add more medication so it we always are tweaking we start with one thing and then we tweak and increase decreased doses as needed or as the patient can tolerate and to think that we should do anything differently with dietary interventions is just silly you know my sense to get back to your original question is that i do think a dietary intervention that results in ketosis is a very powerful intervention for a lot of my patients and i have seen direct correlations between the level of ketones and symptom reduction and when patients and when patients still remain in ketosis but you know if their ketones drop from 3.0 their blood ketones drop from 3.0 down to 0.5 they can become flawedly psychotic they can become depressed or suicidal even though they still have ketones at 0.5 so um so for some patients in my experience the higher the ketones within reason you don't want them you don't want them too high there is like a a decent range that you want them in um but there there does seem to be a direct correlation between the level of ketones and the effect that's not to say that i think exogenous ketones are the answer because i'll jump to the chase i don't think exogenous ketones are the answer i think that the level of ketones in your bloodstream is a reflection of a vast array of complicated metabolic adaptations your body is making in response to the diet and uh and so it is a good biomarker for all of these things that are happening in your body and your brain but just increasing that biomarker with exogenous ketones likely is not going to be the magic bullet that everybody wishes it would be i wish it would be i really do because that would be so much easier than making people do a diet and trying to get their ketones you know greater than two or three but yeah well i sure hope we get some research about this i mean because like you said it'd be so much easier from a compliance standpoint to just drink your ketones or you could also see a hybrid you know a moderate low carb diet with exogenous ketones or you could also introduce intermittent fasting to raise your ketones i mean there are there are different um strategies you can imply to to raise your um ketones and it brings comes back to the question of compliance like like you said it'd be so much easier just to drink your ketones rather than to comply with the diet i mean we know for the general population to comply with any type of diet or lifestyle intervention it tends to have a poor long-term adherence and that could be in the best of circumstances so when someone suffers from chronic depression or from bipolar disorder i think we have to admit it's not sort of like a straight line of improvement but there are you know peaks and valleys and ups and downs as you go along your journey and when you have some of those those valleys and and some of those down moments i'd imagine complying with a diet would be very challenging much more challenging than the average person doing it so i'm curious what your clinical experience is there and what sort of advice you have for people to weather the ups and downs and to try and improve their their dietary compliance over the long run knowing is not a straight line yeah it's a really important question um so i have you know i have patients and i've written case reports about patients who've been doing this diet for their primary psychiatric condition for you know 13 14 years i have patients in my own practice six years now 150 pounds lost and kept it off um and that is the first patient that i described the one with schizoaffective disorder he basically lost 150 pounds is still in ketosis on the ketogenic diet six years in um it's actually the primary concern from psychiatrists and neuroscientists is you know we get the science chris you're you're you're selling us on the science but how the hell can you get anybody to do this diet and uh and what i tell them is guess what they're doing it i'm getting some people to do it am i getting every person to do it no i'll be the first to admit it so i have some patients that can't do the diet because they are impoverished and buying meat and a whole food type things buying mct oil is a lot more expensive than buying fruit loops and pop-tarts and uh and they just don't have money and we do not have systems in place to provide free food to them let alone free nutritional counseling or dietary support or anything else so you know insurance won't cover this right now i am hoping for the day when insurance will recognize that if this is in fact a powerful and effective intervention it's a lot cheaper than a medication it's a lot cheaper than 14 medications all at once so uh um i think insurance companies you know i'm i'm working for the day when we can persuade insurance companies to start getting more involved and maybe even pay for people's food for six months or a year just to get them going um so that uh so that they can stabilize and then start to become more independent you know at the end of the day the way that i get most of my patients to comply is i basically use a similar model that i use in trying to help an alcoholic stop drinking alcohol you know giving the advice is really easy stop drinking alcohol it's straightforward it's so easy it just makes so much sense and yet when you give that advice to the overwhelming majority of alcoholics they can't seem to do it not very easily um and that's kind of the definition of alcoholism if they could stop easily they wouldn't really be an alcoholic and but but we have treatment programs all over the world based on these models and and what do we do we we talk with them about practical interventions how are you going to manage your cravings what are you going to do when you have a stressful day what are you going to do when people are shoving a drink in your face and what are you gonna do during the holidays and family and friends are telling oh come on you can have just one really you can you've been so good all year you can have one you know we but you really have to support people in all of those ways because it's not intuitive so providing an opportunity for people to get support either from a clinician a you know dietitian practitioner whatever or or a support group where people are coming together to all talk about these types of issues and share insights how do you make the meals palatable what are foods that you can eat what are foods that you can pack with you when you're out and about and and you know that it's going to be hard to find appropriate foods in a restaurant um which restaurants can you go to and what can you order there like you can go to mcdonald's and burger king and get highly ketogenic meals and uh you really can it it's not rocket science but most people don't recognize that and or they don't know how to assert themselves with the wait stuff so you got to go in and say i don't want a bun i don't want ketchup i don't want this i don't want that um but you can that's a that's such a great answer about the need for support and i guess that's the problem because you don't need that same infrastructure to give a pill to give a prescription to take a pill you don't need all that counseling but you do for the lifestyle interventions and that's what makes it so frustrating that that's not part of the medical system right now so i mean i i'm sure we're we're on the same line there that we need to make that part of the medical system to have that baked into the therapy just like you're saying for the insurance coverage and uh hopefully that day will come i know you're a big advocate for that day coming and probably help further helping further the field so that we get to that point which leads me to how how else you are helping further the field not just by giving your talks not just by treating patients but also by contributing to the literature like you and nick norwich have written a wonderful review recently and you've written a number of papers um tell me about what else you're involved in right now from from uh an academic and literature standpoint to help further this field i think that you know i've i've published a fair amount in you know in ketogenic diet for mental disorders we've i've i've helped create a coalition of researchers and philanthropists and others to move this work forward um so as i said we've got clinical trials underway there are a lot of people who are really interested and passionate about this work you know i'll be honest with you the biggest thing that i'm focused on is you know as an academic psychiatrist i have been fascinated with this question of how the hell can a diet change a chronic brain disorder like schizophrenia that is dumbfound it has been dumbfounding to me and is still dumbfounding to most clinicians because it flies in the face of everything we've been taught about what schizophrenia is but also about what bipolar disorder is what chronic depression is what alcoholism is and you know most of us think of these as brain disorders that involve chemical imbalances those are the chem you know the neurotransmitters in your brain but we know that hormones play a role like cortisol we it's thyroid hormone we know that stress plays a role we know that all sorts of things play a role and i've been profoundly interested in this question of what exactly is happening in the body and the brain that's resulting in these sometimes miraculous treatment responses at least in some people and how and can we put that together with the existing literature and the existing theories and make sense of it and and the reality is that that has happened and so i'm not at liberty to share all of the secrets yet but um but that will be coming in about a year and i actually as crazy as this sounds um i actually think this could result in a paradigm shift for the mental health field um because it simply it simply integrates all of the existing theories for mental illness into one comprehensive theory that you know anybody who follows my work or has even listened to this conversation it's not a stretch for you to imagine i'm going to argue they relate to metabolism and but in order to really understand what that means you have to understand what metabolism is and the majority of people don't have any clue what metabolism is they think of metabolism as burning calories and fat and nothing more and in fact metabolism is so much more than that so in order to really understand how everything sits together you have to understand the complex world of metabolism and that means you have to understand the complex world of life living organisms and what keeps them living and how they use food and environment to stay alive um but when you put it all together it actually starts to fit and i think it offers some dramatically new models of how to understand and treat mental illness and if it's not a you know it's not a surprise to this audience to know that well one of the treatments is gosh dietary interventions like the ketogenic diet and uh they can have a profound role but um but i'm actually much more focused on the field of academic psychiatry and neuroscience right now and trying to trying to help the field understand why would a dietary intervention make such a difference so um so i'm working with a whole group of people neuroscientists clinicians um philanthropists and we are really hoping to uh to possibly make a big splash and a big change in the mental health field in about a year from now well that sounds amazing i'm very excited to see what comes from that and and good luck to you and congratulations on all the work you're already doing now that would be the perfect place to end this podcast on the high note to wrap it all up but i realized i forgot a question i wanted to ask i wanted to i wanted to ask you a little bit more about eating disorders and so it's going to be a little out of out of flow here but i think it's important that we touch on that so um just to recap i'm so excited for for what you're building for the future but now just to rewind and talk about eating disorders you know it's controversial especially with a ketogenic diet because a number of people have gone on record saying nobody with an eating disorder should do a ketogenic diet because it just brings out restrictive eating behaviors and can make make eating disorders worse but yet we have case reports and you have mentioned um that ketogenic diets can actually be used to benefit eating disorder so what kind of advice can you give to somebody with an eating disorder who's struggling in their own mind is this something i should or should not do because i've heard complete polar opposite things about whether a very low carb or ketogenic diet can help it or hurt an eating disorder it's a great question and the answer the real answer is a long and complicated one i i so i'm going to start with it depends on what eating disorder we're talking about so there are three you know they're different eating disorders i'm going to put them into three main buckets there's anorexia nervosa in which people are starving themselves and usually grossly very much underweight and you know anorexia nervosa is the single most deadly psychiatric illness just want to say that as a percentage more people die from anorexia or nervosa than any other mental disorder so um that needs to be taken very seriously then there's bulimia nervosa where people are binging and purging and there's a wide range of what their bodies might look like people can be obese and have bulimia people can be grossly underweight and have bulimia and then there's binge eating disorder and binge eating disorder is where people binge eat but they do not compensate for those binges and so as a rule of thumb the majority of people with binge eating disorder are overweight or obese um but not all of them are but most of them are and uh and so it those are different disorders and and the biggest difference that i'm i'm gonna just stress is this difference between whether you have fat stores on your body or not and that is critically important when your body is in starvation mode for a prolonged period of time it means that you are eating into your muscle and other organs for an energy source and people with anorexia nervosa have been eating into their heart muscle as well and as well as their you know liver and everything i mean they their organs are shrinking that is a profoundly different state than somebody who weighs 400 pounds and has a lot of excess energy stores on their body that they can tap into so that's probably the most critical distinction the the reality is that i have published some case reports and i've worked with some researchers there's a research study right now underway of the ketogenic diet for anorexia nervosa um but they are augmenting it with ketamine injections so it's it's um the ketogenic diet plus ketamine injections for anorexia nervosa there's one case um a woman that i've spoken with who has basically gotten her anorexia her long-standing anorexia into what appears to be remission it's going on a year uh now um and she is profoundly better um through this kind of dual intervention of the ketogenic diet plus a ketamine one round of ketamine injection um you know one of the case reports that i published of schizophrenia going into lasting remission that one particular woman also had a long-standing history of anorexia nervosa so as a rule of thumb i would say if you have a history of anorexia and certainly if you have current anorexia you must do this with a mental health clinician period hands down no no questions asked do not do this intervention on your own don't even try i would actually go so far as to say if you have bulimia you also need to do this hands down with a mental health clinician if you have binge eating disorder those are people who again tend to be overweight or obese and they can use this intervention in the same way that they would a weight loss diet and you know there are some published reports um more case series that when people do that they find that their urges to binge their quote-unquote addiction to junk food can seemingly evaporate or go away and you know if you are overweight or obese with binge eating disorder i feel less concerned about your immediate safety like you have to do this in a rigorous way with controlled supervision certainly if you can do this with controlled supervision with a medical professional i strongly encourage you to do so because people can get into trouble um with eating disorders and it's just important that you recognize what your eating disorder symptoms have been and that you are monitoring them and and really following them so for some people even with binge eating disorder you know i think part of the part of the recommendation against restrictive eating patterns for these people comes from a really long history of clinical observation and this long history is that you know people with binge eating disorder in particular they often want to lose weight and so they have they have tried innumerable diets it's not like they haven't tried a diet they've tried lots of diets and oftentimes those diets are restricting um they you know i'm not gonna eat as many calories but restricting for them can be eating in moderation so let's be clear about what restriction is it's if once you have to implement rules around how much and when you can eat that may feel restrictive to a lot of people and so if you're putting somebody on a 2000 calorie diet that's a restriction it just is and if you're telling them they can only eat three meals a day that's a restriction um and some of those people when they restrict themselves they end up becoming overwhelmed with hunger and they just get ravenous and famished and then they go on a binge and then they start binge eating and at the end of the day at best that ends up being a yo-yo diet at worst it ends up being like a plateau gain more weight plateau gain even more plateau gain even more and it's just this awful vicious cycle in which the problem's only getting worse the and and the the the attempts at restricting don't result in any meaningful health benefit but the consequence of that restriction results in even bigger binges and even more weight gain and even more health problems so i think that's where you know just to help at least people understand i think that's where some of the dietitians and mental health professionals are coming from is that they've seen that pattern time and again and so when they hear ketogenic diet they're like oh my gosh here we go again another restrictive diet and then people are going to be on this vicious yoyo cycle um as somebody who has you know professional experience with ketogenic diets i really do see a lot of potential and hope for this treatment i really do i think that it can be a very powerful intervention um and that if done correctly people should not have overwhelming hunger they shouldn't i i tell people eat as much as you need to eat but you've got to eat the foods that you're allowed to eat so in in the first week that might mean they're eating more calories than normal and that's okay with me when i'm when i'm in putting someone on a ketogenic diet i tell them look weight loss is not our primary goal right now even if i'm working with somebody whose goal is weight loss i tell them in the first week i'm not worried about losing weight i'm worried about controlling hunger and that means we need to get you off of the foods that you're used to eating we need to get your ketones up so that means that your body can use your fat stores as a fuel source and once we do that if we do that effectively your hunger signals are going to go down and then we can focus on you losing weight and because it will be so much easier and safer at that point yeah so such a great answer i mean and we use the term restrictive diet as if it means one thing but clearly as you just explained restriction that makes you count calories and drives your hunger is very different from restricting the foods you eat in a way that means you can eat whenever you want your hungers take care of itself and you don't have to count calories those are two completely different definitions of a restrictive diet i like how you sum that up and and talked about how it can have an impact there well once again uh thank you so much for joining us i mean i think this has been a wonderful uh discussion about mental health disorders about ketogenic diets and nutrition in general for mental health disorders and you teased us with what's coming over the next year and i i'm so excited for what you're working on and i can't wait to see the results of that so thank you thank you so much for joining us and we'll make sure that people know where to find you so they can hear more about what you're up to thank you brett thanks so much for having me [Music] you

Channel: Diet Doctor

Views: 76,714

Keywords: keto, low carb, diet doctor, mental health, mental illness, Chris Palmer, ketogenic, alzheimer, depression, schizophrenia, brain disorder, mental disorded, psychiatric, clinician, bipolar, mental, condition, over eating, eating disorder

Id: p_fj6L5tvvc

Length: 64min 18sec (3858 seconds)

Published: Wed Oct 20 2021