This week on the podcast, psychiatrist Dr Georgia Ede joins fx Medicine ambassador Dr Adrian Lopresti to explore the profound role that diet, blood glucose, and insulin resistance play in mental health management.
Together they explore the role of diet in complex mental health conditions, looking at the potential inflammatory role of the typical Western and the way it may contribute to symptom intensity for patients.
Dr Ede shares her clinical experience in adopting low carbohydrate diets in conjunction with medications, to safely and effectively mitigate symptoms, supporting patients with a holistic lens, and ultimately managing both mental and metabolic health, with long term effective outcomes.
Dr Ede stresses the importance of individualised care when it comes to effective dietary protocols, sharing how healthcare professionals may adopt these practices to support patients through dietary interventions for better mental and metabolic wellbeing.
COVERED IN THIS EPISODE
(00:25) Welcoming Dr Georgia Ede
(01:32) Nutrition as a first line treatment in mental illness
(09:30) The ketogenic diet
(11:18) Diets to support the brain
(17:08) Insulin and sugars role in brain health
(20:57) Insulin resistance, metabolic and brain health
(25:45) Risk factors for the development of insulin resistance
(28:45) The ketogenic diet as an adjunct treatment to medications
(33:46) Effectiveness and implementation of ketogenic diets in psychiatric disorders
(54:43) Resources available: Dr Ede’s book, testing, forms of the diet
(57:37) Thanking Dr Ede and final remarks
KEY TAKEAWAYS
- Brain function and blood glucose regulation are intricately connected: Glucose enters the brain via an insulin-independent transporters. The level of glucose is directly proportional to the level of glucose in the blood, working on a concentration gradient.
- Over time insulin receptors that carry insulin to the brain to balance brain glucose can become insulin resistant, contributing to cerebral glucose hypometabolism.
- Cerebral glucose hypometabolism: a sluggish brain glucose processing, is associated with neurodegenerative diseases such as Alzheimer’s disease, and psychiatric conditions including anxiety and mood disorders, PTSD, OCD, and depression.
- Insulin deprivation in the brain (cerebral glucose hypometabolism) has been shown to slow glucose processing by up to 25% and shrink the hippocampus by up to 10%.
- The typical Western diet is traditionally carbohydrate heavy, which may exacerbate blood glucose spikes, and in turn brain glucose spikes, leading to glycation processes.
- Advanced glycation end products (AGEs): are caused by excess glucose in the brain, that interfere with cell signaling and illicit a brain immune response. This chronic inflammation contributes to oxidative stress and the destabilisation of neurotransmitter systems, leading to glutamate excitotoxicity.
- Glutamate excitotoxicity: High levels of glutamate in the brain contributing to mental health conditions.
- Antipsychotic medications can contribute to metabolic conditions including insulin resistance. Therefore, low carbohydrate diets can be an effective adjunct to medication treatments.
Resources discussed and further reading
Dr Georgia Ede
| Georgia's Website |
| Dr Ede’s Book |
The Ketogenic Diet
Metabolic and Mental Health
| Research: Metabolic Dysfunction and Bipolar Disorder |
| Metabolicmind.org |
Transcript
Adrian: Hi, and welcome to fx Medicine where we bring you the latest in evidence-based, integrative, functional and complementary medicine. fx Medicine acknowledges the Traditional Custodians of country throughout Australia where we live and work and their connections to land, sea, and community. We pay our respects to the elders, past and present, and extend that respect to all aboriginal and Torres Strait Islander people today.
Dr Georgia Ede is an internationally recognised Harvard-trained psychiatrist specialising in nutrition science and brain metabolism. She has 25 years of clinical experience working with people experiencing a range of psychiatric conditions where she offers nutrition-based approaches as an alternative to psychiatric medications. She developed the first medically accredited course in ketogenic diets for mental health practitioners, co-authored the first in-patient study of the ketogenic diet for treatment-resistant mental illness, and has recently published the book Change Your Diet, Change Your Mind.
So, welcome to fx Medicine, Dr Ede. Thanks for being with us today.
Georgia: Thank you very much for having me.
Adrian: I'm really interested, I suppose. You're trained as a psychiatrist and now specialise in nutritional interventions for people experiencing a range of mental health conditions. Now, that's certainly not typical for a psychiatrist. So, can you tell me a bit about how you got into nutrition rather than, kind of, medication as a first-line treatment?
Georgia: Oh, yes. I practised conventionally for the first 10 years of my clinical years, medications and psychotherapy. And honestly, the relationship between nutrition and mental health didn't cross my mind once. I had absolutely no training in that. We didn't discuss food and the brain in four years of medical school and four years of residency. It just never came up. And so it wasn't until I was experiencing some of my own health issues that were cropping up in my early 40s and decided to try some changes to my own diet to see if I could help myself with some of those issues that were arising. Things like chronic fatigue and fibromyalgia and migraines and IBS, so things that a lot of my middle-aged patients were complaining to me about and I had no idea how to help them with.
And so, I was doing some trial and error changes to my own diet. And long story short, after about six months of these trial and error changes and keeping a food and symptom journal, I was able to reverse all of these issues that I was having, essentially turning my diet almost completely upside down from what we're told to eat. And that was one thing, because I was trying to address some physical issues. But what surprised me and got my attention as a psychiatrist was that these changes had a very noticeable effect on my own mental health, which I wasn't even trying to accomplish. I hadn't even been aware of any significant issues of my mental health at that point.
And so my mood was better, my mental stamina, my concentration, my sleep, my productivity was noticeably improved. And so I thought to myself that this unusual diet, this was back in 2008 or 2009, this unusual diet, which is low in fibre and high in animal foods, high in cholesterol, high in fat, low in plant foods, low in carbohydrates, this diet seems to be good for the brain, but I really knew nothing about nutrition at that point. And so I was genuinely concerned that the diet was going to be dangerous for me long-term and I didn't want to recommend it to my patients. So, I thought I need to study nutrition and understand more about this before I even think about introducing this into my clinical work. And so I started studying nutrition independently and did that really intensively for years before I fully began incorporating these principles into my practice.
Adrian: Wow. Wow. So, I suppose certainly you mentioned changing your diet and often the recommendations are your food pyramid, you eat more grains and plants and so forth. But your approach is different. It's not necessarily just about obviously plants. You've mentioned... Well, can you tell me a bit about the diet that you advocate with your clients?
Georgia: Sure. And I want to emphasise that the diet I recommend for my clients is not my own personal diet that I've tailored to my own personal needs. It's not what I recommend to everyone. The diet that I write about in the book that took me years to sort out, the plans that are in my book, there are several approaches, I'm not recommending that you eat exactly the way I do. But the principles in the book, I think, hold true for everyone, and that's from years of studying and clinical practice and so forth that have helped me sort that out.
So, as you say, it is very different from what we are recommended to eat. So, for example, there are three big-picture strategies in the book that people can use to begin troubleshooting their mental health and trying to understand whether or not the way they're eating might be partly or largely or even entirely responsible for their mental health condition. And so it's really a journey of discovery. It takes 6 to 12 weeks.
But the first step is really essentially a moderate carbohydrate paleo diet that's modified in a few unique ways to be gentler. I call them a quiet paleo diet. It's meant to be gentle and not only on glucose and insulin levels, contains about 90 grams of carbohydrate per day as opposed to at least 300 grams per day in the typical diet. But it's a paleo pattern. So, it removes grains, and legumes, and dairy products, and modern processed foods, and added sugars and alcohol, lots of common culprits that can cause inflammation and oxidative stress and reduce the efficiency by which nutrients are absorbed in the system. And it has a few other modifications as well to be gentler on the nervous system, to be gentler on the gut, to be gentler on the immune system.
And then the next level, if that's not useful enough, is a ketogenic version of that very same diet. And so that brings the carbohydrates down to closer to 20 grams, depending on who you are. That can be customised to your personal metabolic tolerances. And in a lot of cases, that will be down to 25, 20 grams per day, so ketogenic version of that same diet. And then there's a third level, too, of exploration if those other interventions haven't been helpful enough, which is actually a modified version of a carnivore diet, which is a very low-plant or plant-free. And in the case of the diet that I'm recommending in the book is a plant-free version of the carnivore diet and is also uniquely modified to be a little gentler on a variety of systems. So, these are meant to be short-term exploratory dietary patterns that then can be expanded as tolerated once you figure out whether or not they're helpful to you.
Adrian: So, do you start in a stepwise fashion? Do you start with the quiet paleo diet first and then go to the... If that's not sufficient enough to resolve your symptoms, then you go to the keto and then to the carnivore. Is that how it works?
Georgia: Yes. And the reason why I don't ask people to transition immediately from their current diet to a ketogenic diet is because when you do that, when you go immediately from say an average of 300 grams of carbohydrate per day, particularly if a lot of those carbohydrates are refined like sugars, and flours, and cereals and so forth, then if you plunge yourself immediately onto a ketogenic diet - squeaky clean, ketogenic diet, wholefoods, 20 grams of carbohydrates per day, what happens then is you have a really steep and abrupt drop in insulin levels, not just glucose levels but also insulin levels. And that can be a tremendous shock to the brain and the body that can be very uncomfortable. And for people who are taking certain medications or who have certain health conditions, it can actually be dangerous. And so this is why I recommend, sort of, in a stepwise fashion, easing your carbohydrate level down so that you gradually lower your insulin levels, much more comfortable and tolerable. And then you avoid a lot of unnecessary, what are called, keto flu symptoms. I mean, there are other recommendations in the book to minimise those so-called keto flu symptoms to make it more comfortable, that transition. But that's why I don't start immediately with the ketogenic diet for everybody.
Adrian: And is that what you mean by the uncomfortable symptoms? Is it flu-like symptoms that people would experience if they did it too abruptly?
Georgia: Yes. I mean, there's this term called keto flu, which at least people who are familiar with ketogenic diet or are in the ketogenic diet community are very... This is sort of a common term for these transitional, for these keto-adaptation symptoms. And really what they are, they can be a variety of things: headaches, dizziness, carbohydrate cravings, moodiness, even sleep disruption that can occur as the body and brain are seeking their new metabolic equilibrium. And this can take...depending on how healthy and flexible the person's metabolism is, it can take three days to three weeks or maybe even a little longer to get through that adaptation period.
And so now not everybody needs to progress to a ketogenic diet and certainly not everybody's going to want to, and that's another reason why I offer this Step 1 approach as well for people... There are quite a few people out there for whom keto is a non-starter, and I want all of those people to have... I want them to know that there are so many changes that they can make to their diet that could bring them much better mental health, perhaps even bring them complete relief from a mental health condition without even going to a ketogenic diet in some cases. So, I really wanted to make sure that everybody had an option where they could grab on where they felt comfortable and do more if they wanted to. But if it's a book just about ketogenic diets, I think that we've been missing a lot of people who could benefit from other healthy dietary changes.
Adrian: I mean, certainly the interest, I was similar to yourself. I mean, I started out as a traditional clinical psychologist and then branched out more into integrative and nutritional-based approaches, too, as part of my intervention. But typically and certainly nutritional psychiatry, I think people are becoming more aware of it, and the research is accumulating in the area. But typically the recommendations are around Mediterranean diets and lots of plant-based foods and colours and things like that. But you have reservations about that. Can you tell me a bit about that?
Georgia: Absolutely. So, one of the topics that I address, and actually I address both these topics at length in the book, but one of the points I make in the book about the Mediterranean diet is there's no question that the Mediterranean diet has been shown in study after study after study to be healthier for the brain and for the body than the so-called standard American or standard Western diet, which you can give me a new name for it because it's now a global diet. So, the modern ultra-processed diet that most of us are eating around the world. So, the Mediterranean diet is healthier than that diet, but, A, what diet isn't? And, B, could we do better? And when you actually look at the components of the Mediterranean diet, I think there are many reasons to believe that, although the Mediterranean diet is absolutely healthier than the sort of standard modern global diet, it doesn't necessarily mean it's the healthiest, but it's the best diet for the brain or for the body. And when you look at the components, you see lots of reasons to question its superiority to other plans.
For example, the Mediterranean diet, the foundation of the Mediterranean diet is starchy staples. And these are things like whole grains, legumes but also refined grains, breads, and pastas, and cereals are not excluded on the Mediterranean diet. Some of them are even explicitly encouraged. So, not only is that diet, which is 40% to 60% carbohydrate, not only is that diet too high in carbohydrates for the growing majority of us who now have insulin resistance and we can't safely process that amount of carbohydrates anymore, but it's also the food, the actual foods that form that foundation, they really don't deserve...they haven't earned that place in the human food pyramid because they're very, very low in nutrients unless we fortify them. And beyond that, they're even high in anti-nutrients. You have things that interfere with our ability to access the nutrients that they do contain.
And so it's a very strange choice to be the foundation of the human diet. They're primarily a source of starch, and starch is optional in the human diet. Human beings really don't...we don't require any dietary carbohydrate. We certainly can nourish ourselves with carbohydrate. We don't need to, because we can make all of our own glucose inside of our own bodies from protein and fat if we choose to do so. So, it's an optional macronutrient to begin with, and a dangerous one for a lot of us now who have a significant degree of insulin resistance, unfortunately. So, there's a number of problems there. And then of course there's the encouragement of red wine, which is certainly not a brain-healthy beverage.
And the other thing is that the Mediterranean diet, it's a very complicated diet. It's very hard for a lot of people to describe. It's, kind of, vaguely described and includes foods which may or may not be necessary for human health. And so I think that, yes, it is healthier because it includes some healthy animal foods, nutritious animal foods, and so it's not a vegan or even a vegetarian diet. But the diet is a very complicated pattern that's hard for a lot of people to describe. And so it's hard to know if people are even following it. When you're looking at studies, how do you know they're actually adhering to it? It's difficult, when people are studying Mediterranean diet, how's it defined. So, many reasons to question it.
And this is why... For example, when we look at ketogenic diet, there's lots of growing science about ketogenic diets over even the past hundred years or more about ketogenic diets having, kind of, unique brain stabilising properties, brain chemistry stabilising properties. And so one of the things that's a quandary for us to sort of wrestle with is, how could a ketogenic diet, which is so different from a Mediterranean diet in terms of its, for example, carbohydrate content, how could a Mediterranean diet and a ketogenic diet both be good for the brain? And I think the answer is they both are. They're both better than the standard American or standard global ultra-processed foods diet that most of us are eating. But if you're not getting enough benefit from a Mediterranean diet, a ketogenic diet, it makes sense as your next step, because it energises the brain in a completely different way, and it really has uniquely brain healing benefits. That's what we're discovering in the field of metabolic psychiatry.
Adrian: Okay, okay. So, certainly Mediterranean diet better than the standard American diet. Once you know what it is because certainly we're talking about the more traditional Mediterranean diet as opposed to the current Mediterranean diet, which is very different to the traditional one with pizzas and pastas and all that stuff. But then potentially that's not going to be enough, and then you could potentially move into the more ketogenic diet. Now, in your book, you talk a lot about insulin and blood sugars. I mean, how does that affect the brain? Because typically insulin and blood sugars is linked with diabetes rather than, kind of, brain health. So, how does insulin and sugars affect the brain?
Georgia: What I like to tell my patients is that, if they have pre-diabetes or diabetes, they don't just have a blood sugar problem. They also have a brain sugar problem. And the reason for that is the brain is attached to the rest of the body and it is influenced by our metabolic health, in fact, profoundly. And so what's interesting about the glucose-insulin in the brain is that glucose enters the brain quite easily using an insulin-independent transporter. So, glucose can cross easily into the brain. Essentially, no questions asked. And the level of glucose inside the brain is always directly proportional to the amount of glucose in the blood. So, it follows a concentration gradient. That's not so with insulin. So, insulin which also needs to cross into the brain, the insulin receptor that carries insulin into the brain, that transport mechanism can become insulin-resistant over time.
So, as insulin levels are climbing and climbing and people with worsening insulin resistance over the years, the more insulin resistant a person is in their periphery, the more difficult it is for insulin to cross into the brain. And this is a serious problem because the brain can't turn glucose into energy efficiently or to full capacity or use it for anything else without adequate insulin. So, you can have over time a brain that's swimming in glucose and still slowly starving to death. And this is called cerebral glucose hypometabolism, a sluggish brain glucose processing. And this is now very, very well-established over the 19 or 20 years now researchers have known that there's not just an association between insulin resistance and Alzheimer's disease but actually a direct causal relationship between insulin resistance, cerebral glucose hypometabolism, and the neurodegenerative process of Alzheimer's disease.
So, by the time patients notice any memory problems, their glucose processing can already have been slowed by 25%, and the hippocampus can already have shrunk by 10%. And so this same process of insulin deprivation and glucose hypometabolism is we're learning that this is not just a problem with Alzheimer's but that we're seeing this across a wide variety of common psychiatric conditions from anxiety disorders to mood disorders to attention disorders even PTSD, OCD, depression, anxiety. Most psychiatric disorders we now know are at least associated with insulin resistance. It's not directly influenced by insulin resistance in a way that influences the severity and/or course of the condition.
Adrian: So, does the insulin resistance... I know there's obviously accumulating research around the relationship between inflammation, and mental health, and cognitive health. Does insulin resistance also contribute to some of the inflammatory processes that are going on?
Georgia: Oh, that's an interesting question. So, there are many different things that can cause inflammation in the brain, but the relationship between glucose and insulin metabolism and metabolic health in that sense, the glucose and insulin system and inflammation is very well-established. And it has largely to do with glucose levels being too high in the brain. So, remember we were saying that there's a direct relationship between the level of glucose in the blood and the level of glucose inside the brain. And so it's always proportional to it.
So, every time a person with insulin resistance or... If you have insulin resistance and you eat too many healthy wholefood carbohydrates from starchy vegetables or if you don't have insulin resistance and you're eating too many of the wrong carbohydrates too often, refined carbohydrates, what you'll get is an exaggerated glucose spike in the bloodstream and you will then therefore also of course get an exaggerated glucose spike inside the brain. And the brain is exclusively sensitive to excess glucose. In fact, that gradient we're talking about before is very steep. It's always 80% lower. Brain glucose is always 80% lower than the blood glucose, and that's on purpose because the brain can't tolerate, doesn't need much, and cannot tolerate too much glucose.
And so if there's too much glucose inside your brain, every time you're eating the wrong way or getting the spike, you're getting a brain glucose spike as well. And that excess glucose literally sticks... Glycates. It sticks to proteins, and DNA, and lipids, and other kinds of other important cell components inside the brain and turns them into these advanced glycation end products or AGEs. And these elicit a brain immune response to... The brain deliberately mounts an inflammatory response to clear away these AGEs so that they won't interfere with cell signalling. So, what you get is an inflammatory response, which is quite healthy, first step of the immune response, and then you also get, along with that, a wave of oxidative stress, which is also part of that first phase of the immune response. So, you get lots of oxygen-free radicals being released and inflammatory cytokines being released on purpose to clear away those AGEs.
But then what's supposed to happen? And that's what would happen no matter what the insult was to the brain, whether it's injury, or infection, or a glucose spike. But then what's supposed to happen? That's supposed to be a temporary controlled reaction. But then instead of that, for most people around the world now who are eating too many of the wrong carbohydrates three, four, five, six times a day, refined carbohydrates with every meal and snack or people who have insulin resistance, which is now a growing majority of people in quite a few areas of the world, particularly the Pacific Islands actually and the United States, but growing percentages of Australia, and New Zealand, the UK, Europe.
What you see now is that, instead of that temporary, controlled, healthy, inflammatory and oxidative stress response, what you see instead is chronic uncontrolled inflammation and oxidative stress that never gets a chance to quiet down and allow healing to take place because there's a constant wave... These constant waves of glycation are occurring. So, this is very damaging to the brain and can ultimately destabilise neurotransmitter systems and lead to something called glutamate excitotoxicity, which is just extremely high levels up to 100 times the normal level of glutamate in the brain. Glutamate is the brain's primary excitatory neurotransmitter, the brain's gas pedal. And that's physically directly damaging to just about every molecule and surface of the brain's delicate architecture. So, it's one thing for this to be happening from time to time under emergency circumstances. It's another thing for it to be happening all day long and well into the night, the way we're eating now. So, it's really very, very concerning the relationship between our modern ultra-processed diet and brain health is very a profound and concerning connection.
Adrian: So, the insulin resistance, is it just a result of food or somebody is experiencing chronic stress or poor sleep or there's certain medications that can affect insulin resistance or is it just from food?
Georgia: What a fantastic question. So, yes, all of those things do contribute to insulin resistance. Absolutely. Poor sleep contributes to insulin resistance. Stress contributes to insulin resistance. Medications, and of course, unfortunately, many of the most effective and psychiatric medications directly contribute and cause insulin resistance, including the anti-psychotic medications, medicines like risperidone, and olanzapine, and quetiapine, clozapine but also some of the anticonvulsant mood stabilisers like valproate and mirtazapine, one of the antidepressants. And so there are lots of psychiatric medications that can cause this problem and exacerbate this problem. And this is of course a difficult conundrum for a lot of patients to find themselves in. Anybody out there who prescribes psychiatric medications, which is now most prescribing professionals and anybody in the mental health field... I'm sure you yourself have worked with many patients who are taking these medications. And what do we usually see? Just a tremendous increase in appetite, blood sugar levels, much higher rates of... up to triple the rate of type 2 diabetes in people who take antipsychotic medications, obesity, people can gain dozens of pounds that are almost impossible to shed, and a tremendous decrease in not just quality of life but also length of life through the cardiovascular disease and type 2 diabetes and all kinds of other health problems that come along with metabolic dysregulation. So, a lot of patients find themselves between a rock and a hard place. Do I want my mental health to improve or do I want my physical health or do I want my mental health?
Adrian: Yep.
Georgia: And so it's a really, really tough situation to be in. And this is one of those situations where a ketogenic diet is just a godsend, and we can talk about this more if you want, but in a study I helped publish in 2022, we showed this, that if you add the ketogenic diet to the psychiatric medications, metabolic health improves across the board despite the fact that they're still on these medications. And so it's a wonderful at least adjunctive treatment if not alternative treatment for those who are good candidates for this intervention. So, there's a lot of hope here in terms of turning things around. But when people start taking antipsychotic medication, their blood glucose and insulin levels can rise within minutes to hours of the very first dose.
Adrian: Wow. So, you've got then medications that potentially they're to treat the condition but then put potentially exacerbate the condition over time and then lead to not only medical conditions that are increased obesity, insulin resistance, diabetes but then can also affect the brain. So, this is where the ketogenic. So, the ketogenic, is it safe to go on a ketogenic diet on these medications?
Georgia: Absolutely. So, I teach a CME clinician training course in ketogenic diets for mental health. I've been teaching it for about four years. And one of the things I teach my clinicians is how to safely combine the ketogenic diet with psychiatric medications. And there are a few medications where you need to be very careful. You may need to adjust doses. You may need to check levels. You may need to monitor for certain types of special side effects and interactions between the ketogenic diet and certain psychiatric medications. There's a whole module in the course about that, but the short answer to your question is that the antipsychotics in particular, it is absolutely safe and I would venture to say may even be a good idea to add the ketogenic diet to those medications, if nothing else, to help counteract the serious metabolic side effects that those medications can cause. And it can be more difficult for people who are taking those medications to get into ketosis, but I've had lots and lots and lots of patients successful at doing that. And once they do do that, once they're able to cross that keto adaptation...you know, kind of, get through that initial keto adaptation phase for several weeks, there are usually tremendous metabolic benefits and also many cognitive benefits as well. People feel much better. And a lot of my patients don't come to me because they're trying to get off of all of their psychiatric medication. Quite a few of my patients come to me hoping to stay on their psychiatric medication but simply to feel better or lose some of the weight that they have gained on psychiatric medication. Some people are really quite loyal to certain medicines. They've been really, really helpful to them. They don't want to stop them. They just want to feel better on them, and it's a wonderful option to now have to offer all of those patients.
Adrian: Wow. So, what about then... Potentially if sugar's the problem and insulin's the problem and insulin resistance is a problem, why not just put everybody on anti-diabetes medication?
Georgia: Oh, well, diabetes medications are an option. So, I'm certainly not an across-the-board anti-medication person. I really, A, I think we need to offer patients a choice and let them decide what they feel is the path that they wish to go down. But also there are definitely some cases where people can't change their diets because they're in an institutional setting, for example. There's too much cognitive impairment at that point or whatever the situation may be or they also... There are some situations where a ketogenic diet is not going to help enough or in some cases that may not help at all.
And so we need choices, right? And so I will often use a combination. If someone comes to me who's already taking psychiatric medications, which is most of my patients come to me on at least one psychiatric medication, sometimes two or three or four or five, and it's not at all unusual, as you know. The first step is not to take them off their medications, not by any stretch, and obviously if there are any people listening who are taking a psychiatric medication, then it's definitely not Step 1. So, Step 1 is to work with somebody or learn more about this diet before you start the diet, because there are quite a few safety precautions that you need to be aware of before the diet started, especially when medications and health issues are concerned. But also the first step is not to change the medications. The first step, 9 times out of 10, is going to be to add the diet to the medications and then see how things go. And then gradually, let's hope that we've got a situation and it's a very common situation, that the patient improves on a ketogenic diet. And that does happen in a lot of cases. Then, after a sufficient period of adaptation and stability and, kind of, reaching a new equilibrium, then you can start beginning slowly and carefully to taper one medication at a time and see what's possible for that patient in terms of reducing or even eliminating medications that they've been finding helpful over time.
Adrian: Wow. So, how effective? I mean, when you're using ketogenic diets with your clients, are you noticing most people experience benefit from it? What's your experience and what's the research say around ketogenic diets and psychiatric disorders?
Georgia: Oh, my gosh, this is such an exciting time to be a psychiatrist. Very little has happened in psychiatry for far too long, and this is really a wonderful... I mean, I find it the most powerful and most effective tool I have for helping patients across a wide range of psychiatric conditions. So, in my clinical practice, and I've worked with hundreds of patients over the years using this and other special dietary interventions, that I did go into more detail in the book, in almost everyone. I mean, not everybody. I mean, I haven't counted, but I would say 90%... I mean, it's unusual for me to come across a person who experiences no benefit from improving the quality of their diet. And so most of us have been feeding our brain improperly our entire lives. So, when you feed the brain properly, whether you follow a ketogenic diet or not, if you're just eating properly, there are tremendous benefits possible there. And you're nourishing the brain completely, which standard diets do not do. Y
ou're energising the brain differently, and more efficiently, and more reliably, which modern diets do not do. And you're protecting the brain from all of the very damaging ingredients of the modern ultra-processed diet, particularly the refined carbohydrates and the vegetable oils. And so how could you not feel better? But most of my patients do experience a significant and meaningful degree of improvement. And quite a few of my patients are able to reduce either the dosage of the medications they're taking or the number of the medications they're taking and some are able to not need to...they're able to avoid starting medication in the first place, and some are able to come completely off all of their psychiatric medications.
And then the research... So, I helped to publish a study in 2022. The work of my friend and colleague, Dr Albert Danan in Toulouse, France, psychiatrist in practice for now more than 35 years. Wonderful guy. He invited 31 of his most treatment-resistant patients with serious chronic mental illnesses, treatment-resistant, depression, major depression, schizophrenia, and bipolar disorder. These folks were taking an average of five psychiatric medications at the time. These folks had all been hospitalised one or more times in the past, most of them under his supervision. These people had been in treatment for an average of 10 years, some for as long as 30 years, most of them under his care for all that time, and had never experienced a remission. And they came into the hospital voluntarily to try a simple, mildly ketogenic, wholefoods diet in the hospital under his supervision. And 28 of those 31 patients were able to stay on the diet for two weeks or longer, which is what you need to do to start to see benefits. And every single one of those patients improved both psychiatrically and metabolically. Forty-three percent of them achieved clinical remission from their primary psychiatric diagnosis and 64% left the hospital on less psychiatric medication. And so what that tells me... This is not a randomised control trial. I need to point that out, but this tells me that there's tremendous hope even for people who think they've tried everything, who haven't responded to anything, who've been ill for many years, even with very serious mental illnesses, no matter how many medicines they were taking, no matter what the diagnosis was, it didn't seem to matter. People responded and responded robustly at a level that was 6 to 10 times better in terms of what's called Cohen's d effect size, 6 to 10 times more robustly than we see in antidepressant and antipsychotic medication trials.
Adrian: Wow. And so was there particular conditions that it, kind of, works better for or faster for? When you're talking about remission, are you talking about remission in people with schizophrenia?
Georgia: Indeed, indeed. Absolutely. I know it sounds incredible, but this is what's happening. It's not just in this study. It's in my own patient population. It's in beautifully documented case reports in the scientific literature. It's in patient testimonials, which are now, of course, thanks to social media easy for people to access, listen to people's stories. And there's a wonderful website. I might recommend to folks if they're curious to learn more about the science and...much of the science but also the family and patient experiences and the research and the clinical work that lots of us are doing in this space. And that website is called metabolicmind.org. It's a lovely home for all of this information, and it's funded by...set up by a philanthropic organisation called the Baszucki Brain Research Fund. And that fund was started by Jan Ellison Baszucki and her husband David Baszucki after their son, Matt Baszucki put his very serious bipolar disorder with psychotic features, which had interrupted his college career and had him homeless for a time on the streets into complete sustained remission about three years ago, and he is completely well.
Adrian: Wow.
Georgia: And there are many, many stories like this.
Adrian: All right. We'll certainly put a link to that website in our show notes for sure. So, in terms of ketogenic diets, then basically depression, you've mentioned schizophrenia and bipolar disorder. What about PTSD, ADHD? Would it help people experiencing those conditions too?
Georgia: So, theoretically, yes. And in my clinical experience, yes. But we don't have any studies yet on PTSD or ADHD. Those studies are in the works. There are studies now being funded and being started up around the world at many prestigious institutions around the world. The research in this area is suddenly exploding, and with good reason. There's tremendous potential in this field. One of the most exciting types of research going on in this area is at the University of Edinburgh. Dr Ian Campbell, who put his own bipolar disorder into full sustained remission more than seven years ago using the ketogenic diet, is now one of the world's leading researchers in this area. And he's conducted some beautiful and published some beautiful pilot data on ketogenic diets in bipolar disorder and is on the brink of starting a randomised controlled trial in the field. And there's all kinds of research going on in this area now. So, I think because this diet is not...it's not really a diet. You had asked earlier about plant-based diets, and I hadn't gotten around to answering you about that. I want people to know, because a lot of people think of the ketogenic diet as a high meat diet and it doesn't need to be. The ketogenic diet is not a food list. It's not a dietary pattern. It's a metabolic state of mind. It's a metabolic intervention and a quite powerful one. And you can get into ketosis, whether you eat plants, animals, or both. It's not about plants and animals. It's about your macronutrient ratio. It's about switching the primary source of fuel in your brain from a carbohydrate to fat. And when you do that, the brain is energised in a much more stable, more reliable, more efficient way with much less inflammation, much less oxidative stress. And it's a uniquely healing metabolic state that anyone, regardless of your dietary preferences, can benefit from.
Adrian: Is it difficult to stick to? I suppose the issue for me is that working with many patients over the years that obviously there's numerous behavioural recommendations, lifestyle recommendations that we regularly make to our clients, and some of them, they implement and they're able to, kind of, continue with and others they struggle with. And diet is one of those that some people do really well with and other people really struggle with making those changes. So, particularly we've got somebody with schizophrenia or somebody with bipolar experiencing manic and your depressive episodes, Are they able to stick to the diet? Is it difficult? How do you work with such patients?
Georgia: Well, I can tell you I speak from experience because this is of course very, very challenging, right? And so a big part of my training courses, helping people with behaviour change, which it's obviously quite difficult for human beings to change behaviour, especially eating behaviour. So, there's a lot of motivational interviewing, and relapse prevention strategies, and those sorts of things. But I will also say... And so any diet is hard to stick to long-term, right? But I would also say that this diet strangely enough is easier to stick to for a lot of my patients than other diets they've tried in the past. And there are several reasons for that.
So, one is that, when you shift your metabolism in this way, you can go safely and comfortably for much longer periods of time between meals without getting hungry because your insulin levels are low enough, that fat burning turns on and you dip into your fat stores in between meals, and you're able to sustain yourself between meals for often quite long periods of time. So, people aren't as preoccupied with food. That's one thing.
Another thing is that people feel much better. Most people... And this is the beauty of working this way. Most people have never experienced this state of mind before because they've been relying on carbohydrates as their primary fuel source since they were young, and it's a completely different state of mind. And when you shift over, when your body and brain make that shift, which it can take a few days to a few weeks, depending on who you are. On the outside, three months, if you really get a tough case, then they feel so much better. A lot of times people don't want to stop the diet because they've never felt this well before. And in fact, in Dr Ian Campbell's pilot study of the ketogenic diet and bipolar disorder, one of the questions he was trying to answer was, could people with serious mental illnesses like bipolar disorder adhere to this diet? And could they deal with measuring their ketone levels every day and staying in ketosis? One of the wonderful things about this diet is that we have a biomarker for whether or not people are following it. If you're on a Mediterranean diet, we don't really know what you're eating. We're listening to what you report, and maybe you're eating those things and maybe you're not. There's no way for us to know unless we lock you up in a metabolic ward. But if you're on a ketogenic diet...if you're in a study on a ketogenic diet and you're not in ketosis, you're not on the diet. So, if you're following the diet, you'll be in ketosis. And we can follow these levels remotely using wearables.
And so in any case, in his study, one of the fascinating things that happened was that they were... I can't remember the percentage off the top of my head, but there was a certain period at a certain point in the study where, as part of the protocol, patients were supposed to stop the diet. And many of them refused to do so because they were feeling so well.
Adrian: Wow. So, they would monitor through, what, glucose monitoring and do they monitor ketone levels and things like that? Is that how they help people, kind of, stick to it too?
Georgia: Yes, exactly. So, glucose monitoring can serve a purpose, but even more important is ketone levels. And there's a lot more research that needs to happen before we can be clear about what the therapeutic range of ketosis that is most likely to benefit most people with a particular condition, if there even is such a thing, whether the depth of ketosis matters for every condition and for every person.
But in my clinical practice, I find that blood ketone levels, which is ketones meaning circulating beta-hydroxybutyrate, a particular type of ketone stable in the blood, the beta-hydroxybutyrate level, somewhere between 1 or 1.2, 1.5, and 3 millimole, some above 1.0 millimole seems to be when we start to see a lot of the benefits occur for a lot of patients, not everybody. Some people don't need that level. Some people need higher levels. But, yeah, so you can monitor blood ketone levels with a finger stick metre. And soon on the horizon will be continuous ketone monitors, which would be lovely. But right now, it's finger stick monitoring, and there are apps and platforms that allow researchers and clinicians to log on and see what their patient's ketone levels are. So, that's a lovely tool to be able to help us understand and help people troubleshoot. So, if I see one of my patients has fallen out of ketosis and they're not feeling well, then I can help them troubleshoot that with them.
It sort of, fosters a sense of curiosity about the root causes of their symptoms. And there's a lot of people for years have thought of their symptoms as, "This is all about my childhood, and there's nothing I can do about that," or, "Maybe I'll be in therapy for many years or maybe there's some permanent damage from a trauma, and maybe that's what's wrong. And maybe there's some mysterious chemical imbalance or genetic vulnerability that I can't do anything about that's going to require lifelong medication." And all those things may be factors, but for a lot of people, it's a brand new way to think about things to think about, well, maybe my symptoms have a potentially reversible metabolic explanation. And the paradigm shift is just wonderful.
Adrian: Yeah. I mean, I suppose that's where the education comes into play because all the things that you mentioned previously, trauma, and genetics, and neurotransmitter disturbances, and all those factors are believed to, kind of, be the drivers of mental health disturbances. And then you're talking about diet and you're talking about the foods we eat and that potentially being a major driver or contributor to the mental health disturbances people are experiencing. So, there needs to be a lot of education with the patients. And I suspect, do you work with the families too? Because they're also potentially ones that either can support or sabotage the client's efforts in making changes in their diet. So, do you work with families?
Georgia: Oh, all the time. I mean, it's difficult in a lot of these cases to work without the family.
And it makes the course much easier if instead of having an identified patient in the home who's changing their diet, for everyone in the family to make some healthy changes to their diets as well, because whether they actually follow a ketogenic diet or not, it of course may or may not be necessary, some families do. And some family members do adopt a ketogenic diet in solidarity with their loved ones, but not everybody will but I do encourage family members to at least keep the foods that are going to be most likely tempting to their family member out of sight or out of the home and to adopt some healthy changes themselves to be a role model and also for their own health. And even if it's not ketogenic, sort of, what I'm saying in the book, there's a level one that people can engage with to the degree they feel they can of just cleaning up, kind of, really fundamentally restructuring their diet from the ground up, even if they are eating lots of carbohydrates, but to eat the healthy carbohydrates and to make sure they're getting the right kinds of protein and avoiding the foods that are riskiest to the brain. And that would serve everybody well.
Adrian: I mean, as I'm listening to you, I'm thinking... I mean, obviously, for practitioners who are recommending dietary changes and whether that be ketogenic diets, which certainly we're talking about today, but it's not just about knowing the foods, and ketones, and all those things that are really important for practitioners to know about, but it's also really important to know about how you're going to support your clients in implementing the changes. And you mentioned motivational interviewing. There was working with families. There's doing some relapse prevention, problem-solving different scenarios, different situations, how are we going to manage dietary changes in different situations. I think they're all conversations that need to happen, I think, and they're the things that practitioners really need to spend time with their clients to discuss because ultimately it's not just the diet. It's about ensuring that the diet is implemented and... Because this is not something that you can just do for two or four weeks and then you can go back to a normal standard American diet. That's correct, right?
Georgia: Well, you could but you won't.
Adrian: Yeah, you'll relapse. Yeah, I have to clarify that. You could, yes, absolutely. I mean, and this is it. I mean, can the insulin resistance go? Can you just like, okay, you've been on it for six months, okay, so now you're now more insulin-sensitive, and you could relax and go back to your old ways and not relapse? Or, is this something that you just got to really continue to strictly stick to for the rest of your life?
Georgia: Oh, such a good question. So, there are two answers to that question. So, one is, can you put insulin resistance into remission and reverse it? You absolutely can. Can you go back to your old ways and remain healthy and metabolically healthy? No, but the other question that's wrapped up in your question is, can after you've been on a ketogenic diet for a certain length of time where enough healing has taken place in the brain, and body, and metabolism for you to be able to loosen things up and remain well? And we do see that happen. When I say we, I don't mean me. I mean, the field, especially the field of epilepsy. For over a hundred years now, ketogenic diets have been used quite successfully in children and even adults with a treatment refractory epilepsy. That's how the diet was originally designed to stabilise brain chemistry in children with paediatric epilepsy before the availability of useful antiseizure medications came along. And so in those cases, we often will see that children can come off the diet after a year or two and remain seizure-free.
Now in adults who are far less metabolically flexible, I don't see that very often in my patients. So, I've definitely had a few patients over the years who have been able to loosen up their diet around the edges and have more flexibility in their choices and remain well; my metabolically healthier patients, more physically fit patients, my patients who are just generally healthier. But most of my patients, unfortunately their symptoms come rolling back within 24, 48 hours of stopping the diet.
Adrian: Okay, okay. So, it's something really that, for adults, they certainly need to continue with. So, all right. Well, I mean, look, I've just finished reading your book and it's a great book. So, I really encourage people... I mean, there's lots of questions I would love to ask if we could continue to go forever, but a lot of it is covered in your book and obviously you talk about testing options too and different options we have available in terms of testing. And then you obviously talk about more information about the different forms of the diet, the paleo diet, and the keto diet, and so forth. So, I really encourage people to read the book. It's a brilliant read and I'm really excited. I think that it's something that we really need to do more research on to confirm its efficacy, its safety, and also I'm interested in how we can ensure that people do stick to it and is it something that's implementable with people who are experiencing severe depression or experiencing bipolar disorder or even children. Are they able to... So, I'd love to see that research accumulate and it certainly sounds like the interest is absolutely increasing.
Georgia: It really is. I mean, I think, both clinicians and researchers are excited about it as well as patients and families. And as you know, the treatments that we have to offer people up until this point have been, well, let's just say, disappointing And so we do need new strategies, new approaches for people. But at least the people could be introduced to it from the beginning as an option for people to learn about. The reason I wrote the book was for clinicians and families and individuals who are struggling with mental health issues, trying to reach all of those groups hopefully. What's happening is that patients are going to the clinicians and saying, "Will you help me get onto a ketogenic diet? I'd like to try to see if I can improve my symptoms." And a lot of clinicians don't have the tools or the confidence to be able to do this. And I think at the very least is to at least start with a very simple metabolic evaluation to be included in the initial evaluation just to look at the person's metabolic health, which can be done with, like you said, a very few simple tests that are listed in the book that are easy to obtain. And even if it's not a ketogenic diet but to include some nutrition counselling as part of the overall treatment plan for everyone to help them understand how important it is, how much the brain cares about what we eat.
Adrian: I mean, certainly thank you, Dr Ede, for the book and for some of the work that you're doing. I know that... As I said, I've just finished reading the book, and I got highlights throughout the whole thing. So, it's just... It originally started off with a white cover, now it's full of yellow highlighted marks all over it. So, I hope you don't mind me wrecking it like that, but certainly, there's lots of great information in there. There's chapters in there that are really useful. There are practical chapters there that people can read and refer back to in terms of being able to implement the diet. So, I thank you for that. And you've also got a website that people can refer to and learn more about some of your work.
Georgia: Yes. so the website is called diagnosisdiet.com. And so there's information about the book there, but there's also information about the training programme. And perhaps most important, there's a free clinician directory should you click on the Clinician Directory tab on the website. If you're a patient out there who's looking from a clinician, you can look there. It's free to search international and we're trying to grow it every day. And if you are a practitioner who already practices this one, it's free to list your practice there. We're trying to improve access to these kinds of services. And you have clinicians from all backgrounds there who are using ketogenic diet specifically to treat mental health conditions, which it's a very special directory in that way. So, I hope that's useful for people, and we really appreciate those fantastic, very thoughtful questions, and again the ability to connect with your practitioners. I hope it's useful.
Adrian: Yeah. No, definitely. I'm sure there's lots of people who are referring back to your website and to your books. So, thank you very much.
Georgia: Thank you. Bye-bye.
Adrian: So, thank you, everyone, for listening today. Don't forget that you can find all the show notes, the transcripts, and other resources from today's episode on the fx Medicine website. I'm Dr Adrian Lopresti, and thanks for joining us. We'll see you next time.
Emma: This podcast is intended as healthcare practitioner education only, and it is not a substitute for medical advice, diagnosis, or treatment.
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