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Dr. Georgia Ede: What ketogenic eating does to the brain

Harvard-trained psychiatrist Ede explains the ketogenic brain: how bipolar, depression, and ADHD respond to insulin, inflammation, and metabolic repair.

Dr. Georgia EdeguestSteven Bartletthost
Jan 16, 20251h 47mWatch on YouTube ↗

EVERY SPOKEN WORD

  1. 0:00 – 2:02

    Intro

    1. GE

      Most people will experience tremendous reductions in anxiety within three days to three weeks of starting a ketogenic diet. In fact, we did a study where patients with bipolar disorder, major depression, or schizophrenia tried the ketogenic diet and 43% achieved clinical remission from their chronic mental illness, and 64% of them left on less psychiatric medication 'cause it improves the balance of chemicals in the brain. But the question is, what's causing those chemical imbalances in the first place? And so, let's start there.

    2. SB

      Dr. Georgia Ede is a Harvard-trained psychiatrist...

    3. NA

      ... who specializes in nutritional science and mental health. She was one of the first psychiatrists to offer nutrition-based approaches as an alternative to psychiatric medications to optimize brain function and enhance performance.

    4. GE

      People need to know how powerful nutrition strategies can be for the brain, because if you're feeding it the wrong way, things will go wrong, and that's exactly what happened to me. My health was declining in my early 40s in ways that was true for a lot of my patients, chronic fatigue and IBS, being really anxious and depressed. And so, I did all kinds of tests and they said, "There's nothing wrong." Of course there was something wrong. And so I instinctively started experimenting with my diet, and the diet that I ended up on was backwards from what we're told is healthy for us. It should theoretically kill me, but it resolved every single one of my symptoms. And so I studied for years learning things about food that most people don't know and which foods contain the nutrients the brain needs or the ingredients that damage the brain, and found three principles of nutrition. They can help you in ways no medicine can, as well as improved mood, memory, concentration, stamina, productivity. So, let's unpack that.

    5. SB

      This has always blown my mind a little bit. 53% of you that listen to this show regularly haven't yet subscribed to this show. So, could I ask you for a favor before we start? If you like this show and you like what we do here and you wanna support us, the free, simple way that you can do just that is by hitting the subscribe button. And my commitment to you is if you do that, then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen to your feedback, we'll find the guests that you want me to speak to, and we'll continue to do what we do. Thank you so much.

  2. 2:02 – 2:21

    What Do You Do?

    1. SB

      Dr. Georgia Ede, how would you define wha- what it is you do?

    2. GE

      I'm a psychiatrist specializing in nutritional and metabolic psychiatry, so how food affects the brain, and how food affects brain metabolism, and how brain metabolism affects our mental health.

  3. 2:21 – 3:38

    Is Metabolic Psychiatry a New Term?

    1. GE

    2. SB

      This is a fairly new phrase, metabolic psychiatry. Am I right in thinking that?

    3. GE

      Yes. It's a really, it's a very new field and really exciting field. Uh, the, the term itself was coined by Dr. Shebani Sethi, who's a metabolic psychiatrist at Stanford University, eh, maybe five years ago or so, maybe a little longer than that. So it's a very, very new field. It's even newer than the other exciting new field in psychiatry which is nutritional psychiatry.

    4. SB

      Mm.

    5. GE

      And so, eh, and th- this is a really exciting time to be a psychiatrist, uh, and it's also a really exciting time or a hopeful time, uh, an empowering time for people with mental health conditions because we're finally able to explore, um, root causes, the real root causes, the deeper root causes of mental health conditions that go beyond things like what we're told all the time which are these mysterious chemical imbalances, you know, that need to be addressed with medication. We now understand that the real drivers, the primary drivers of mental health conditions are inflammation of the brain, something called oxidative stress, which is why we're always told to eat more antioxidants, and insulin resistance or prediabetes, which is now a- affects more than 90% of Americans.

  4. 3:38 – 4:40

    Why Is the Ketogenic Diet at the Heart of Your Work?

    1. SB

      In your work, you talk a lot about the ketogenic diet. Why is that so r- prevalent in your work?

    2. GE

      'Cause the ketogenic diet energizes the brain differently, so it, it really fundamentally changes the brain's operating system. So, when you switch from a high carbohydrate, high insulin diet to a low insulin, which is usually a low carbohydrate diet, ketogenic diet, the way that cells, uh, receive energy, the, their mixture of fuels that they're using changes, and that has profound influences on just about every pathway, just about every chemical pathway inside of that cell. So it is as though you are fundamentally changing the brain's operating system, uh, in very healthy ways that allow not, brain cells not only to work better, but for, uh, but for brain cells to heal. So the longer you stay on a ketogenic diet, the more healing, the more brain healing can take place.

  5. 4:40 – 5:38

    What's Your Academic Experience?

    1. GE

    2. SB

      And what is your sort of academic and career experience? What's that? Can you run me through that sort of timeline?

    3. GE

      Yeah. So I, uh, got a degree, an undergraduate degree at Carleton College in Minnesota in biology.

    4. SB

      Mm-hmm.

    5. GE

      'Cause I always have loved science and biology, understanding how things work. And, uh, then for years I worked as a laboratory research assistant, different types of research labs around the world, Boston, Munich, e- including in diabetes research, until I could, figured out what I wanted to do and I decided that I wanted to go to medical school. So then, four years of medical school at the University of Vermont, in Burlington, Vermont, which is a great place to go to medical school, and then four years of psychiatry residency training, um, at a Harvard program called Cambridge Hospital in Cambridge, Massachusetts. And then, so it was 25 years ago that I finished my psychiatry residency training, and I've been practicing, uh, psychiatry ever since.

  6. 5:38 – 6:07

    What Does Practicing Psychiatry Involve?

    1. GE

    2. SB

      And what does practicing psychiatry involve?

    3. GE

      What it usually involves for most psychiatrists is psychotherapy and medications, and for some psychiatrists, only medications. Some psychiatrists prefer to focus exclusively on psychopharmacology or medication management. There are some psychiatrists who choose to focus only on psychotherapy, uh, and, and don't prescribe medications, but the vast majority of psychiatrists offer a combination of both medications and psychotherapy.

  7. 6:07 – 7:39

    When Did Nutrition Become Part of Your Career?

    1. SB

      When did nutrition become part of your career?

    2. GE

      Well, I, I never thought about the relationship between food and the brain once. Um, during medical school, we had maybe two or three hours worth of nutrition lectures in four years, and in four years of psychiatry residency, we didn't talk about food and the brain once. So, I honestly had no idea how important it was to, to brain health. Uh, so I practiced conventionally, as I was saying, you know, medications and psychotherapy for the first 10 years of my practice. And as much as I love my work, I, it was becoming painfully obvious that most people in my practice were just not getting that much better, like, no matter how hard I tried. Um, and, and it wasn't just true for me. You know, it wasn't as though I was thinking, "Well, you know, I don't have en- maybe I don't have enough experience, or maybe I am not reading enough, or maybe I need more supervision. Um, when am I going to be able to really be able to help people?" Because when I looked around, even very senior psychiatrists who had been in practice for decades, the same was true for them. I mean, we had, we had been taught to think of mental illnesses as chronic, mysterious, and incurable, and that the best way you can help people is to support them with medications and psychotherapy, and, uh, but, but that these are lifelong illnesses that we really don't understand very well and that we can do very little about.

  8. 7:39 – 9:46

    Social Component of Mental Illnesses

    1. GE

    2. SB

      Presumably, there's, like, a significant social component to mental illnesses as well, right?

    3. GE

      Absolutely. I mean, the brai- the brain is a very responsive organ, and it's listening to, uh, it- it's not just paying attention to the food you eat. It's paying attention to every aspect of your life, how much light the brain receives, how much love you have in your life, how, how much you love your work, what kinds of people are around you, um, how you use your body, exercise, stress, um, e- everything. Everything matters to the brain. But most people are led to believe that food doesn't matter that much to the brain, and that's partly because we've only recently started to think about it. But the other piece, um, is that the information that we're given about how to feed the brain and the body properly is incorrect. And so when people are trying their best to improve their mental health using nutritional strategies, those strategies fail most people because those strategies are grounded in the wrong information. And so a lot of people just think, "Oh, well, you know, I, I tried eating more whole foods," or, "I, I tried, uh, you know, I tried putting blueberries on my oatmeal or making my flax seed smoothie every morning or, uh, eating more plants than animals. I tried all of those things, and they just didn't help very much. So I'm just gonna go back to eating everything in moderation, um, because it doesn't seem to matter." But what's really great about you inviting me here to talk with you today is that people need to know how powerful an intervention, uh, these nutrition strategies can be. They can help you in ways no medicine can. In days to weeks, in many cases, people can experience meaningful improvement to their mood, their memory, their concentration, their stamina, their productivity, um, and, and th- their, their mental stability, their, their effectiveness in their lives if they have the right information about how to change their diet. So, you have to know which changes are the ones that are worth making, and they're not the ones we're used to hearing about.

  9. 9:46 – 16:50

    The Eureka Moment

    1. GE

    2. SB

      Is there a particular case study that comes to mind when you think about this? Is there a most prominent case study or a first case study that was a eureka moment for you?

    3. GE

      I wouldn't say there was a e- eureka moment case in my life because I came to it, uh, in a different way. Uh, the, my eureka moment really came through my own personal experience. I think a lot of physicians who, uh, practice nutritional and metabolic strategies, most of us stumble into this work accidentally because we're not taught it, and most of us stumble into it either because a patient comes to us and says, "Hey, you know, I've tried this new way of eating, and that's why I'm so much healthier than when you saw me a year ago," or the, the physician themselves encounters their own health challenges, you know, uses the conventional nutrition approaches, they don't help, and they find that they're n- kind of left to their own devices to solve their own health problems. And that's exactly what happened to me. So, when I was experiencing all kinds of, uh, health issues in my early 40s, despite doing everything correctly, you know, eating a low-fat, low-cholesterol, calorie-restricted diet, um, uh, that was high in fiber, uh, mostly whole foods, and exercising religiously, despite doing all of those things, my health was declining in my early 40s in ways that was true for a lot of my patients as well, and I had no idea how to help my patients with these issues. These, these were things like chronic fatigue and IBS and fibromyalgia and migraine headaches, very common in middle-aged people and older, and even younger people nowadays. So, when I encountered those issues, and I was working at Harvard at the time, I had access to all kinds of specialists, caring, intelligent, thorough. They did all kinds of tests, all kinds of tests, and they said, "Everything is normal. There's nothing wrong." Of course there was something wrong. But I, I... So I instinctively started experimenting with my diet. Uh, and long story short, six months later, trial-and-error changes, food and symptom journal, at the end of six months, and this was back in 2007, um, the diet that I ended up on-... purely by trial and error, was almost upside down and backwards from what we're told is healthy for us, and that was the diet that resolved every single one of my physical health symptoms. But as a psychiatrist, what really got my attention was that it improved my mental health significantly, and I wasn't even trying. I wasn't even aware that my mental health needed that much attention. I think like most people, I was walking around with suboptimal mental health, you know, more anxiety than was necessary, than was, uh, uh, you know- (sighs) ... slumping in the middle of the day, brain energy, you know, faltering a couple of hours after lunch, coming home at the end of the day and h- and being completely spent and not being able to get anything else done after 5:00, being really anxious on a Sunday night before Monday morning work, um, you know, being depressed in the wintertime. Uh, I mean, all of these things we think of as really normal. We've come to expect so little of our mental health. We've come to expect poor mental health as normal, and it isn't. (laughs) Uh, if you feed the brain properly, it works better and you can expect so much more of yourself. So when that happened to me, I thought, "Well, that's interesting. (laughs) This diet seems to be good for the brain."

    4. SB

      Which diet was that?

    5. GE

      This was a mostly meat, low carbohydrate, low fiber, low cholesterol, high fat diet. No whole grains, no legumes, very few plant foods. Mostly seafood, meat, poultry, non-starchy vegetables, and fats from whole foods. It really was as simple as that. And a diet similar to that is, um, uh, one of the starting places in the book, so I have a variety of different dietary strategies people can explore in the book, not just one. So there's different places for people to grab on, depending on what they feel comfortable doing. But that, but that way of eating resolved all of my physical issues and mental health issues I wasn't even aware needed attention, and that, that really s- was what inspired me to begin studying nutrition. I certainly did not go out and start recommending this dietary pattern to my patients. That would've been reckless. I didn't know the first thing about nutrition and based on the little that I did know, the diet that I had ended up on should theoretically kill me. So it could be dangerous for people. And so I studied for years independently, took a graduate course at the Harvard School of Public Health and studied independently, read everything I could get my hands on, studied the, the primary literature, the actual scientific studies to try to understand, okay, why? Why is red meat bad for us? What's the difference between red meat and white meat? Why are whole grains good for us? Why are whole grains good for us, but refined grains are bad for us? Why do we need a rainbow of fruits and vegetables? Uh, are some of them more important than others? Are they all equally beneficial? I mean, all- I just became so curious about food. I really wanted to get to the bottom of it. So for years, I studied nutrition and fell in love with nutrition science and, um, so a lot of what I share in the book is all these fascinating things about food that most people don't know, um, and that can really... It's not just that it's interesting, it's useful. It's empowering because if you understand which foods contain the nutrients the brain needs, which foods contain the ingredients that damage the brain, which foods are going to damage brain metabolism and cause inflammation and cause oxidative stress, cause all these things that we're told we need to fight with supplements and superfoods, um, that's real power. The real power in dietary change is not adding special things to the diet. It's actually subtracting the things that are harming the brain and working against your best efforts. It's- it's- it's just like anything, you know. You don't make money by spending money. You make money by s- by not spending money, right? So it, it's the power of subtraction. What are you not doing? Um, and that's really step one, is first do no harm. Understand where the harm is coming from in the diet because it's not where you think it's coming from. It's not coming from the red meat. It's not coming from the cholesterol. It's not coming from the saturated fat. So if you understand where the damage is coming from, then you can turn things around very quickly.

  10. 16:50 – 18:54

    Adapting Diet to Personal Needs

    1. GE

    2. SB

      You used a word there, you used the word explore, um, a- as it relates to different diets that you've written about in your book and that, you know, that are available online. Uh, I, from what I understood there, you're, you're not saying that one diet is the right diet for everybody. You're saying that it's as almost, the word explore suggests sort of experimentation, personal experimentation, and what worked for you in that case might not necessarily work for someone else in a different situation. Is that accurate?

    3. GE

      That's exactly right. And you're bringing up a really important point, Steven, which is that there are two levels of dietary knowledge. So one is that there are fundamental nutrition principles that apply to all human beings. These are the rules, the cells require these nutrients, um, and you must consume foods that provide those nutrients to those cells, and you must exclude these certain, uh, ingredients that can damage those cells, and you must keep your glucose and insulin levels in, in the right range for your personal metabolism. You have to, you have to nourish, protect, and energize yourselves. You must do that. But then beyond that... So, so those rules and- and the rules that you have to follow to, to get there are not, are- are not commonly known. But then beyond that, there's the personalization, right? Because we are all different. We're not different in what our cells need, but we're different in what we can tolerate, we're different in our metabolic health, we're- we're different in how old we are, how active we are, what, um, wha- what conditions we- we already have, what conditions we're most at risk for, what our goals are, what our preferences are.What, and, and whether we have food sensitivities, for example. Um, and so all of those pieces, you know, f- food intolerances and- and different- different goals and different aspects of our- of our lives, that's where the personalization comes in. And I teach people in the book how to take these fundamental principles, so I teach them what the fundamental principles are, which are very simple, nutrition is not rocket science, um, and- and then show them how to personalize it to their metabolism, to their preferences, to

  11. 18:54 – 21:45

    Fundamental Principles of a Healthy Diet: Nourish, Protect, Energize

    1. GE

      their goals.

    2. SB

      What are the fundamental principles? Let's start there.

    3. GE

      So the fundamental prin- principles are nourish, protect, energize. So nourish, what does a brain-healthy diet look like? And by brain healthy, uh, we are talking about what's healthy for all cells because it wouldn't make any sense to, uh, for the human body to require a different diet for every organ you possess.

    4. SB

      Mm-hmm.

    5. GE

      So a brain-healthy diet is a diet that's healthy for every organ in the body. So it's good for the brain, it's good for the heart, it's good for the liver, et cetera. So what is a brain-healthy diet? It needs to nourish, protect, and energize. Nourish, it must contain and be able to safely deliver all essential nutrients to your cells. So you have to know where those nutrients are. You cannot and i- using whole food principles and n- not including supplements or specially fortified processed foods, you cannot meet that goal without including some animal foods in your diet. That's just the truth of our biology. Protect, protect the brain from damaging ingredients. So what damages the brain? Inflammation, which you can't see or feel. It's not as though the brain is red or swollen or sore. You- we- the brain doesn't have nerve endings, but many, many people have brain inflammation without being aware of it. That's a main driver of depression and all kinds of other brain conditions, so you need to exclude... Protection is not about addition, it's about subtraction. You need to subtract the foods from your diet that cause inflammation, that cause something called oxidative stress, which is why we're always told to eat more antioxidants. What we really need to be told is what's causing all that oxidative stress in the first place and remove those things because the antioxidant strategy really doesn't work, and energize. Nourish, protect, energize. The third principle is energize, which means the brain, which is a very high energy electrical organ, it needs a constant supply of high-quality, clean-burning energy. And if you're eating the wrong way, your brain will not... will gradually lose its ability over time to generate energy. That's primarily about c- getting your glucose and insulin levels into a healthy range, not just your glucose, although getting your glucose levels in a healthy range is extremely important. You have to go one step further 'cause underneath that glucose, you need to know what's happening with insulin. And that's- that's a really empowering strategy. It's sort of next level, right?

    6. SB

      Mm-hmm.

    7. GE

      So getting your glucose and insulin levels down will allow your brain to, uh, um, to energize itself in the most clean, efficient, um, and reliable way

  12. 21:45 – 25:12

    Diet Personalization: Trial and Error

    1. GE

      possible.

    2. SB

      Nourish, protect, and energize. And then beyond there, you said there's a level above that, so that's the sort of fundamental level. Beyond there is you go into sort of personalization, what's best for you, and is that where the sort of trial and error comes into play?

    3. GE

      Exactly. So these principles nourish, protect, energize. The nourish you need to include some animal foods. The protect you need to exclude things like refined carbohydrates and vegetable oils, uh, which are the signature ingredients of the standard American diet or standard Western diet. Um, and the- the energize is- is the- the glucose and insulin levels, which for some people, this is some per- a level of personalization begins here at the energize piece because if you have excellent metabolic health, and we can talk about what that means, then you may not need to eat a ketogenic diet to- to properly nour- to- to really get those glucose and insulin levels under control and thoroughly energize your brain cells. But if you have significant metabolic damage, if you're sedentary, if you're older, if you have pre-diabetes or type two diabetes, um, then you may need to reduce the amount of carbohydrate in your diet, even from whole foods. You may even need to go to a ketogenic level, and- and that's where- that's where assessing your metabolic health, understanding where you stand on the insulin resistance spectrum, the spectrum of metabolic health, that's the empowering piece because if you know where you stand on the insulin resistance spectrum and you can get your glucose and insulin levels into a healthy range, you... then you have tremendous power over your emotional, intellectual, and your- and your physical health future. It's really the number one risk factor for almost all chronic diseases, mental and physical. So personalization starts with a metabolic personalization. So how much carbohydrate can you safely tolerate? That's one example. But then there's another level of personalization that has to do with how well does your immune system work? How- how good is your... how's- how robust is your gut function, your gut barrier? Many of us have lost our ability to safely and comfortably tolerate a wide variety of foods that we should be able to tolerate, and that's because our environment multiple... multiple toxins in the environment are- have broken down a lot of our defenses, our gut barrier, our blood-brain barrier, uh, and- and our immune system has become overwhelmed by trying to process lots of toxic ingredients in our environment. So these are things like plastics and pesticides and antibiotics and, um, and- and food additives.... and, and all kinds of, you know, ultra-processed foods that we were never designed to handle. These are really stressful on the human body and they do break down our defenses over time. So this level of personalization is very much about trial and error, but to save people some of that frustration of trial and error approaches, I, I give them very specific lists of foods, um, the, the, the, that are more likely to be culprits than others.

    4. SB

      Mm-hmm.

    5. GE

      And so that helps cut back on some of the trial and error elimination.

  13. 25:12 – 27:05

    What Is the Ketogenic Diet?

    1. SB

      This keto diet, you, um, you did a study on the ketogenic diet.

    2. GE

      Mm-hmm.

    3. SB

      Got the study here, "The Ketogenic Diet for Refractory Mental Illness: A respec- a Retrospective Analysis of 31 Inpatients." What is the ketogenic diet, for someone that might not know?

    4. GE

      So a lot of people think or they've heard about a ketogenic diet as a weight loss diet. Um, they think of it may- maybe it's a fad weight loss diet. Um, they think of it as a very, very low carbohydrate diet. They might think of it as a diet that's very high in meat and dairy products. Um, and but actually the ketogenic diet was originally created in 1921, more than 100 years ago, to stabilize brain chemistry in children with severe seizures. Um, and this was long before the availability of useful seizure medications. So these were children who, um, uh, were having multiple seizures per day in many cases, and so the ketogenic diet was designed back then, created back then, a very strict version of the ketogenic diet, um, to get as close as possible to f- to fasting without starving children to death. Because for millennia, people had noticed that those with epilepsy would often improve if they were fasting, but you can't fast forever. So how do you get close to fasting? This is the original fasting mimicking diet. How do you get as close to fasting as you can while still providing some nutrition? So that was the original goal of the ketogenic diet, and it was very successful for seizures. More than 50% of children had more than a 50%, and, and adults as well, it's since been shown, more than 50% response rate in children and adults and 10 to 20% completely, uh, uh, free of seizures following a ketogenic diet.

  14. 27:05 – 29:42

    What Does the Ketogenic Diet Do to the Brain?

    1. SB

      How is it acting on the brain? What's it doing to the brain?

    2. GE

      The ketogenic diet does many, many things. It's like a multipurpose tool for brain health. So one thing it does, 'cause we talked about how, uh, some of the root causes of mental illnesses, which are only relatively recently a focus of research, are inflammation and oxidative stress and insulin resistance. The ketogenic diet reduces inflammation, it reduces oxidative stress, and it reduces insulin resistance. Uh, it also improves the balance of chemicals in the brain. So a lot of people think of, um, uh, mental illnesses as problems with chemical imbalances in the brain, and these are the chemicals that they're talking about. You might have heard of serotonin or dopamine or norepinephrine. There are others, glutamate, GABA. Many different chemicals in the brain are, uh, associated with or in some cases even very much, uh, causing mental health symptoms. But the question is what's causing those chemical imbalances in the first place? And, uh, one of the things that's causing those chemical imbalances is that inflammation and oxidative stress. But another thing is that the brain i- is, uh, if you're feeding it the wrong way, it will not be able to, in many cases, produce energy reliably. And if it can't produce energy reliably, all kinds of things will go wrong and in quite spectacular fashion. What actually goes wrong is going to depend on who you are, and that's where our individual differences come in. So if I eat the wro- if you and I eat exactly the same bad diet, depending what runs in your family and how you've lived your life to this point, you might develop Alzheimer's disease, you might develop bipolar disorder, you might develop type 2 diabetes, you might develop fatty liver disease. Um, I might develop completely different conditions. I might, I might develop, um, cardiovascular disease. I might develop depression. Um, I might develop, um, ADHD. It- And that's where the individual differences are, but all of these conditions are just a metabolic malfunction really at, at the heart of it. That's what's going on. If cells aren't functioning properly, you will develop a disease, physical and mental diseases. And which ones you get, it's really kind of luck of the draw. Um, but you have tremendous control over what you are at risk for if you understand how to help your cells operate at their personal best.

  15. 29:42 – 34:07

    Impact of the Ketogenic Diet on Refractory Mental Illnesses

    1. SB

      Can you tell me about what you learned in this study and what this study concluded?

    2. GE

      Yes. So this was the work of my friend and colleague, Dr. Albert Danot. He's a psychiatrist who's been practicing in Toulouse, France for more than 35 years. So after witnessing a young family member, someone in his extended family, with autism and seizures improve within weeks of adopting a ketogenic diet, he thought, "Well, I wonder if this diet could help my patients, especially my patients who are not responding to anything else that I have tried to help them. Psychotherapy, medications, hospitalization." And so he invited 31 of his most treatment-resistant patients with bipolar disorder, major depression...... or schizophrenia to come into the hospital and voluntarily try a very mildly ketogenic, whole foods diet in the hospital under his supervision to see whether or not they would respond. And this was, these were folks who... These were all adults. These were people who had been ill for an average of 10 years, some for as long as 30 years. These were people who were taking, when they came into the hospital at the beginning of the study, an average of five psychiatric medications, not at all unusual for people with chronic mental illness, and all of them had one or more markers of poor metabolic health: obesity, high blood pressure, high blood sugar, things like that. So these were, uh, people with poor metabolic health and poor mental health, and they eagerly came into the hospital to try this intervention because nothing else had helped them. And what was remarkable about what he observed was that of the 31 people, 28 were able to stay on the ketogenic diet for more than two weeks, which is what you need to do to start to see benefit. Every single one of them improved to the point that 43% of them achieved clinical remission from their primary psychiatric treatment-resistant chronic mental illness, and 64% of them left the hospital on less psychiatric medication, and all of them improved metabolically as well. And th- you do not see results like this in conventional psychiatric care.

    3. SB

      So there's a few things that spring to mind when you talk about this study. The first is that they were inside a hospital.

    4. GE

      Yes.

    5. SB

      So I guess that's a confounding factor potentially.

    6. GE

      Oh, yeah. Well, uh, a blessing and a curse. (laughs)

    7. SB

      Yeah.

    8. GE

      So a blessing is that, um, the diet was ver- was, was very carefully supervised. Six days out of seven, they were allowed to go home on Sundays.

    9. SB

      Okay.

    10. GE

      And, uh, th- which still, I'm, I'm just mentioning about that, but they had tremendous amount of support and supervision.

    11. SB

      Mm-hmm.

    12. GE

      And, and that's, that's really, really helpful when you're switching from a standard high carbohydrate diet to a low carbohydrate diet. They also had very careful medical and psychiatric supervision, which is also really important, uh, because when you, when you change to a ketogenic diet, brain chemistry fundamentally changes-

    13. SB

      Mm-hmm.

    14. GE

      ... in ways that can, at first, uh, when you're transitioning from one operating mode to another operating mode, it's st- it's stressful, and sometimes you can feel worse before you feel better.

    15. SB

      Mm-hmm.

    16. GE

      And medications can be affected, so medications need to be monitored. And th- uh, everything, everything changes. These are all really healthy ch- Your blood sugar can drop. Your blood pressure can drop, especially if you're taking blood sugar lowering medications or blood pressure lowering medications. If you switch to a ketogenic diet, it's so effective at lowering blood sugar, many physicians who prescribe blood sugar lowering medications for diabetes need to cut the diabetes medication in half on day one in order to prevent dangerously low blood sugar because you've got a medication that's lowering blood sugar, now you've added a diet that lowers blood sugar-

    17. SB

      Mm-hmm.

    18. GE

      ... and this could be potentially dangerous. The diet on its own is not dangerous. It's the diet in combination with medications, so you need to know what you're doing. And so th-

  16. 34:07 – 35:21

    Calorie Restriction

    1. GE

      uh, yes?

    2. SB

      I- in the case of these, um, 31 adults, you... So a c- certain proportion of them... Was it 28 that managed to see it through?

    3. GE

      28 of 31. Mm-hmm.

    4. SB

      28 saw it through. Had I just restricted their calories, for example, but kept them on whatever diet they were on, would I have seen an improvement as well?

    5. GE

      That study has not been done, to the best of my knowledge. However, you're bringing up a really interesting point. So what a ketogenic diet is, it's really not about carbohydrate. The definition of a ketogenic diet is any diet that lowers insulin levels, uh, to the fat-burning point, so that if your insulin... You can't burn fat if your insulin levels are too high, and most people are walking around with insulin levels that are high 24 hours a day.

    6. SB

      Yeah.

    7. GE

      They don't even come down overnight 'cause people are just eating too much, too frequently, and the wrong foods. To get into ketosis or generate ketones, you need to lower your insulin levels to the fat-burning point, and when you, and, and if, and if you're burning fat vigorously, the liver will turn some of that fat, chop that fat into ketones, which are very small fragments of ready-to-burn fat, and these cross easily into the, into the brain and can be burned for energy, and they can bridge any energy gaps that may be there, which many of us have.

  17. 35:21 – 37:27

    Alternative Ways of Lowering Insulin Levels

    1. GE

    2. SB

      If these people had done the Mediterranean diet, would they have seen the same consequences?

    3. GE

      The Mediterr- oh, sorry. Please.

    4. SB

      'Cause, 'cause I imagine they were probably on the Western diet, like the American diet, which is ultra-processed, high sugar. So bringing them into a controlled environment and just depriving them of that would have surely caused... Just, uh, that on its own would have been beneficial.

    5. GE

      Yes. So I wrote in the paper, I, I, I, and I, I mention this. You're making a really excellent point, and I address this in the paper, is that because when you, when you change from a standard, junky, modern diet to a ketogenic diet that's whole foods, you're changing a lot of variables, right?

    6. SB

      Mm-hmm.

    7. GE

      So how do we know that it had anything to do with the ketones, right? And y- and this is a good question and a fair question, and we don't know the answer, but new studies are helping us to understand that. But before we get to that, I just wanted to say, the point you're making is so important because there are lots of ways to lower your insulin levels. So you can lower your insulin levels through fasting-

    8. SB

      Yeah.

    9. GE

      ... intermittent fasting. You can lower your insulin levels through exercise. You can lower your insulin levels through calorie restriction. If you restrict your calories below 750 grams per day, many people will go into ketosis. That's another version of a fasting-mimicking diet made popular by Dr. Valter Longo. So there are many ways to lower your insulin levels. Um, the ketogenic diet is just one way to do that.But the ketogenic diet is the only way to safely, sustainably maintain a state of ketosis long-term. So you can initiate, you can get into ketosis using these other strategies, but it's, it, it, you can't fast forever. You can't exercise all day long. You can't restrict calories below 750 for the rest of your life. But you can safely and comfortably eat a ke- a well-formulated ketogenic diet, which is very low in carbohydrate, moderate in protein, not excessive in protein, and relatively higher in fat, depending on your energy needs, indefinitely.

    10. SB

      Sustainably.

  18. 37:27 – 41:15

    Why Is the Ketogenic Diet Difficult to Sustain?

    1. SB

      You used the word sustainably there. That's kind of always been my challenge with a ke- keto diet, is being able to stay on it. I mean, you saw in this particular study that even trying to g- get people to do it for two weeks resulted in some portion of them dropping out.

    2. GE

      Yes.

    3. SB

      Um, why is it so hard to stay on the ketogenic diet? I've managed to do it for a s- I was saying to you before we started recording, once a year, around this time of year, I do it for about eight weeks, and it has a really profound impact on a lot of my life. It helps me feel more focused. Um, my body composition radically changes faster than any other diet or thing that I've ever tried, faster than just exercise alone. Um, I f- I sleep a little bit better as well, I noticed. But you've been doing it for a long time. You've been doing it for roughly, what, almost 10 years?

    4. GE

      For the better part of twel- I mean, f- more oft than not (laughs) , I'll say. I've been following a ketogenic diet for 12 years.

    5. SB

      Mm-hmm.

    6. GE

      And I agree with you, it's not always easy. I'm not perfect about it myself, but I have been on the ketogenic diet the lion's share of the last 12 years.

    7. SB

      It being hard is an important factor.

    8. GE

      Yes.

    9. SB

      Because when you're trying to prescribe it to somebody who has got, you know, treatment-resistant depression or is really suffering in some way, I, I imagine they'll find it even harder than I do.

    10. GE

      Yes and no.

    11. SB

      Okay.

    12. GE

      So, uh, it's har- well, it's definitely h- there's no question about it that it's hard to eat a low carbohydrate diet in a high carbohydrate world.

    13. SB

      Yeah.

    14. GE

      So there's that. There's th- the environmental temptations and the social temptations and the habits and the addiction. Sugar addiction is a very real biochemical phenomenon. So there's that. But, but w- it, it, I mean, I've been, I, I, I had a weight issue growing up. Everyone in my family did. Um, and I've been on lots of different diets (laughs) in my life. This is the easiest one to stay on. Uh, I, I can't say about any other diet that I followed (laughs) for 12 years. And the reason why is this diet really stabilizes appetite hormones, so your cells are getting energized in between meals. You're not getting those spikes and crashes in glucose which cause spikes and crashes in appetite hormones, satiety hormones, stress hormones, reproductive hormones, uh, brain chemistry. Um, you're not getting, you're not on that rollercoaster anymore. So your cells are, are, are being satisfied. They're getting their energy needs satisfied in between meals, and everything is quiet and calm on the inside. It doesn't mean you're 100% protected against temptation. Uh, so I describe it to my patients with food addiction, I describe being in ketosis as a suit of armor. You know, the sword can still get you, but you (laughs) , but you know, you're not, you're not 100% protected, but you've got a real fighting chance. And for, for anybody who's never tried a ketogenic diet and been on it for at least, I would say six to 12 weeks, it, most people have no idea how much easier it is, um, to follow, to follow a healthy eating plan when their appetite is in good control. A lot of people know they've shifted into ketosis without even checking their ketone meter because they can go for so long without eating or even thinking about food. They can work through lunch and not even realize that they've missed a meal. Most people, the way we eat most of us now, are thinking about food all the time. You haven't even finished breakfast and you're already thinking, "What, what can I have for lunch?" You, you're carrying food around with you everywhere you go. You're eating at least six times a day in many cases. This is not the, I mean, we would never have survived as a species if we needed to eat six times a day. So we're not eating in a way that is, that is nourishing us and s- and satisfying us. We're eating in a way that's making us

  19. 41:15 – 45:26

    Keto-Adaptation or Keto-Flu

    1. GE

      hungry.

    2. SB

      I find what you've said there to be sort of true in my experience, especially in the context of the rollercoaster analogy. So when I'm not on keys- ketosis, I do feel like sometimes I'm in a bit of a rollercoaster of, like, temptation, craving, et cetera. And then when I do k- ketosis and I s- get past the first week or two, the, the rollercoaster seems to stop.

    3. GE

      Right.

    4. SB

      I, I am, I'm, I'm off the rollercoaster. It's then maybe six, eight weeks later, you're busy. Life happens. You're traveling. You're tired. That temptation creeps in, and it just takes that one moment of weakness in my head to then fl- fling me off ketosis and all my effort is gone. And in my head, the way I've, I've always thought about it, and I'm sure this is wrong, but I've thought about it, like, it takes a couple a days to get into a state of ketosis, and then once you're in, and I usually get a headache-

    5. GE

      Yeah.

    6. SB

      ... on my way into ketosis. I feel a little, little bit bad on the way in.

    7. GE

      Mm-hmm.

    8. SB

      And then once I'm in there, it's fine. So when I have something that breaks my keto, this is what I refer to, me and my girlfriend talk about it, when, "Oh, I've broken my keto," whatever, I think, "Oh my God, I've gotta go through another headache and another five days of, you know, uh, getting back into it." What, uh, is that correct?

    9. GE

      It's a very common experience because there are these adjustments, uh, that happen inside, uh, with your physiology, uh, as you're shifting from one operating system to another. When you're shifting from a carbohydrate burning system to a more, uh, you're shifting your ratio of your fuels, so the body and the brain are a hybrid engine, so we're never burning 100% fat. Um, we're burning a mixture of, of fat and carbohydrate. When you're shifting from a-... from a system that's fueled almost entirely by carbohydrate almost all the time, to a system where you're burning more fat than carbohydrate, um, that's uncomfortable for some people, shifting back and forth, especially if what they have, if, if the reason why you've, quote, "broken your keto" is because you've had something, um, that has a lot of refined carbohydrate and a lot of sugar or flour in it, for example. Um, so it depends on what you've eaten and how much and for how long. Um, but, but many people do experience the so-called keto flu when they are shifting from a carbohydrate-based system to a fat-based metabolism. And some of this can be, uh, m- much of this can be prevented in a couple of different ways. One is with electrolyte supplementation, supplementing electrolytes to keep your, your salt balance even as you're transitioning, and another, uh, is by transitioning slowly onto the ketogenic diet rather than all at once. And so, and there are many, there are other tips in the book about how to do this more comfortably, but those are the two big ones, uh, and going slowly. So in the book, I don't recommend that people start, uh, on a ketogenic diet just straightaway, like learn about it on a Monday, start it on a Tuesday. But ease into ketosis over a week or two, and, uh, there's a, there's a, uh, kind of a moderate carbohydrate plan in the book that allows people to do this. So you, you follow that plan for a couple of weeks to gradually lower those glucose and insulin levels. It's gonna be a lot more comfortable. It's gonna be a lot less of a shock to the brain and body, um, and, a- and if you're supplementing electrolytes and going slowly, most of these, quote, "keto flu" symptoms will, uh, will not occur or they'll be very brief and mild. So, um, again, these are posi- it's, it's a positive change to have these electrolyte changes and, um, it's, it's po- e- all of these things are, are good, but there is this transition period which can sometimes be uncomfortable. And this is, um, not to say that it's dangerous. Again, it's a very s- we're designed, our biology is designed for us to be able to shift back and forth between fat and carbohydrate as fuel sources, but many of us have lost some of our metabolic flexibility because we've done some damage to our metabolic engines by eating the wrong way for too long, so we don't shift as comfortably back and forth as we used to be able to.

  20. 45:26 – 46:55

    Misconceptions About the Foods Included in the Ketogenic Diet

    1. GE

    2. SB

      I guess most people don't even know what foods are included in a keto diet because most diets are restrictive to the point that, you know, people think they just make your life miserable.

    3. GE

      (laughs)

    4. SB

      But what are the sort of big misconceptions you've seen with the foods you're able to eat on a ketogenic diet?

    5. GE

      Yeah, so because a ketogenic diet, uh, uh, it, it, because the definition of a ketogenic diet is any way of eating-

    6. SB

      Okay.

    7. GE

      ... that lowers insulin levels enough to turn on fat burning and generate ketones in the blood, because, because it's about insulin, it, i- the, it's really not a food list. So you can, i- you can, it's not about plants and animals. It's not even about fat or carbohydrate. It's about understanding how to lower your insulin levels, which you can do with a vegan dietary pattern, with a vegetarian dietary pattern, uh, with an omnivore dietary pattern, um, uh, with, or even with a carnivore dietary pattern. So whatever your dietary preferences are, you can get the benefits, the brain-healing benefits of, of ketosis. So it's not about the foods you're eating. Um, it's, it's more about understanding what raises and lowers insulin. The things that raise and lower insulin are refined carbohydrates, whole foods carbohydrates, refined proteins like protein powders, whole food sources of protein, and guess what barely touches insulin at all? Fat. Fat is metabolically the quietest and safest macronutrient you can eat because it barely stimulates insulin.

  21. 46:55 – 50:46

    Is Ketosis a State?

    1. SB

      Is ketosis a state? Like do I, is it like a binary state? Like now I'm in ketosis and now I'm not?

    2. GE

      So yes, but there's, there's, um, yes. Um, let me put it this way, that most experts will agree that, um, in order to be, quote, "in ketosis," um, your level of beta-hydroxybutyrate on a blood ketone meter, uh, a blood ketone meter, um, uh, um, is prick your finger and, and put a drop of blood on this little test strip, and it will read the amount of a particular ketone in the blood called beta-hydroxybutyrate, and it will give you a reading. If that reading is point- is 0.5 millimole or higher, you are in ketosis, in ketosis. So what does that mean? Why do, why is the cutoff 0.5? Because three things have to happen for you to get to at least 0.5. One is your glucose levels have to come down. The second thing is your insulin levels have to come down. The third thing is you have to burn off a certain amount of the stored starch in your liver. We have a, a storage tank for carbohydrate in our liver. It's not very big. It holds less than a day's worth of carbohydrate because really, as animals, we're designed to store energy as fat. Carbohydrate's there for quick energy, emergency, short term. Um, the fat, we, uh, for better or for worse, we have almost an unlimited capability to store fat. We can store months and months and months worth of fat. (laughs)

    3. SB

      Wow.

    4. GE

      And so, um, but we can only store a very small amount of carbohydrate. So if your storage tank in the liver is full, your body will not switch to fat burning because it says, "Oh, we've got plenty of starch to burn. Let's start there." Once it comes down to a certain point, the body goes, "Oh, we're running out of energy. Let's go to fat now." And that's when the, the liver will start breaking fat down, whether it's fat on your body or fat from your plate.... and start chopping it up into these ketones. And, uh, but, so those three things have to happen. And once that happens, th- you'll see the ketone levels rise on the meter. So most people who are not eating a ketogenic diet are walking around with ketone levels either undetectable or they're 0.2 or they're 0.3. They might, they might float up into, above 0.5 every once in a while if they're not eating for a long time or, um, uh, or if they've just exercised. But for the most part, most people, uh, eating a typical diet are not in ketosis. And when you get above 0.5, a lot of metabolic magic starts to happen, because there are lots of pathways in the body and brain that, uh, are not very active unless you're in ketosis, and those are the healing pathways, the recycling and maintenance and cleanup pathways, the recovery pathways. All of us, uh, this is something that I- I came to appreciate a number of years ago as I've been studying this, is that there are many people, unfortunately or fortunately (laughs) , there are many people who discover, with mental health issues, that they need to be in ketosis long term in order to be well. But I've become convinced by the science that all of us need to be in ketosis, um, at least intermittently. All of us need to spend some time in ketosis on a regular basis or else we can't heal. We'll only be... It- it's like a, it's like a manufacturing plant where the plant is just running 24/7, uh, 12 months a year, and- and they never take time to replace the parts or clean up the floor or, you know, th- they never do any maintenance work, uh, repair work, and so eventually everything breaks down.

  22. 50:46 – 53:34

    Getting Into Ketosis

    1. GE

    2. SB

      And when you say ketosis, again, you're not saying the, the keto diet. You're saying the low levels of glucose, um, and insulin-

    3. GE

      Exactly.

    4. SB

      ... in the blood. And that can be achieved by calorie restriction, potentially fasting I guess you could achieve it, and other diets like the Mediterranean diet if administered in the right sort of doses, right?

    5. GE

      Well, um, we c- we should come back to the Mediterranean diet in a minute, but first, the, the first part of your question is important because ketosis is, uh, you can, uh, as you said, you can get into ketosis a variety of different ways. If you're eating properly, and this would've been our evolutionary heritage, our ancestors, especially our prehistoric ancestors, um, th- they didn't have access to these, l- lots and lots of refined carbohydrates. Uh, a long time ago, um, they were eating carbohydrates from, uh, whole foods.

    6. SB

      Mm-hmm.

    7. GE

      Uh, fruits and starchy root vegetables, right? And, uh, and, uh, so even grains and beans are very, very relative, relatively much newer sources of carbohydrate. So let's think about fruits and vegetables. But, so they- they would've been, we can only guess ba- looki- uh, looking at their diets, we don't have proof of this, but think about it. If you're eating in a way where your insulin levels are allowed to come down overnight, if you're eating, if you're eating a, a balanced diet so to speak, but it's got everything it needs in it and it's not giving you exaggerated spikes in your glucose and exaggerated spikes in your insulin and you're not eating six times a day or all day long, your insulin levels will naturally come down overnight and that will, that will allow you to go into healing mode. So I believe that if people have the right information about what a healthy diet is supposed to look like, they may not even need to, in many cases, especially if you're younger or athletic or don't have a lot of metabolic damage already, um, you may not need to, you may not need to lower your carbohydrate intake during the day. You might just need to be careful about what kinds of carbohydrate you eat and how often. Um, so for example, it's known that in children, um, they're e- who are eating a regular diet, many of them wake up the next morning in ketosis. They're metabolically much healthier than, uh, we are as we get older. So they're much more metabolically flexible. Um, and, uh, so, uh, now they didn't go on a ketogenic diet. They were eating a regular diet, they slept overnight, didn't eat anything, the next morning they were in ketosis. That's not true for all children, but it's true for enough children that we know it's possible. Most adults, it takes them several days at least to get into ketosis even if they're not eating anything at all. So fasting can take two to three days at a minimum for most people to get into ketosis, but some people it can take a whole week.

  23. 53:34 – 55:56

    Connection Between Food and Neurodivergent Disorders

    1. GE

    2. SB

      And you talked about children, and one of the big conversations at the moment around children is the, the rise in ADHD diagnosis. And there's a lot of different sort of thoughts on the causal factors of this, and wha- what is it that's making children be diagnosed at higher and higher rates with these sort of neurodivergent disorders. I- is there any evidence to suggest that what we're eating is playing a role in these neurodivergent disorders?

    3. GE

      Yes. The first thing I would like to tell you about is that there were studies, uh, quite a few studies back in an- '80s, '90s, and early 2000s in Europe by variety of different research teams that explored exactly the question you're asking. And what they did, um, was they placed children with ADHD, some quite severe ADHD, even hospital-level ADHD, and put them on something called a few foods diet. This is, uh, uh, the scientists called it an oligoantigenic diet, which just means it's kind of a low allergen diet. So it, they removed all of the common culprits and they focused mostly on just a few whole foods, uh, and- and- and a few extras. So, uh, th- very specifically describing this diet, most of these diets were, um, chicken, lamb, fruits, vegetables, um, and sometimes they'd throw in some apple juice and margarine 'cause they couldn't use butter because dairy is a common allergen. So, but these were mostly whole foods diets.... you know, um, uh, poultry, red meat, fruits, vegetables, um, and there were 62 to 82% response rate to these diets, no matter which study you looked at. And in some of these studies, there was a 70% cure rate within weeks of changing the diet to a few-foods diet. So, what does this tell us? It doesn't tell us which foods were the problem. It tells us that food can be the problem, that if you make die- the right dietary changes, it's possible for children even with very severe ADHD to improve within weeks to the point that they no longer qualify for having ADHD anymore.

    4. SB

      Because there's a change in the symptoms?

    5. GE

      Oh, yes. Um, um, the children's, uh, behavior as rated by parents and teachers, um, and the researchers themselves.

  24. 55:56 – 57:46

    Why Are Dietary Modifications Not Commonly Prescribed to Alleviate Symptoms of ADHD?

    1. SB

      So I- I just, uh, did some research to find some stats on this.

    2. GE

      Sure.

    3. SB

      Diet modification isn't widely prescribed as a way to alleviate ADHD symptoms, is it? But it says, "As of 2019, major health organizations including the American, um, Academy of Pediatrics and the National Institute of Health and Care Excellence do not recommend dietary modifications as standard treatment for ADHD due to insufficient evidence. A 2014 review found elimination diets might offer minor benefits in subs- in a subset of children, particularly those with food sensitivities or allergies. However, these benefits are not substantial enough to advocate for widespread dietary changes in ADHD management."

    4. GE

      So, what I would say to that is, uh, uh, there are multiple studies all pointing in the same direction that I think give parents and families and children tremendous hope with really no risk.

    5. SB

      Mm-hmm.

    6. GE

      What are we doing instead? We're medicating children. We're giving children stimulants which can stunt their growth, make them anxious, um, and, and cost money.

    7. SB

      Mm-hmm.

    8. GE

      And is the- Um, I mean, I, I'm... One of the reasons I do this work is because I really don't think that for most people, the right thing to do is to medicate our way out of this situation. I mean, just about every mental and physical health issue we have i- we think about, we've just kind of been conditioned to think about medications as the solution. But medications don't solve problems. They cover them up, and what we really wanna do is we wanna get to the root of these problems and not just treat them, which nutrition interventions can do in many cases, but perhaps even prevent them from happening in the first place.

  25. 57:46 – 1:02:42

    Are ADHD Medications Helpful in Some Cases?

    1. SB

      Can they all be treated by... 'Cause, you know, I, I was, I guess, technically diagnosed with ADHD, but I don't take any medication for it. I'm... It's a personal choice. I personally just, um, don't think that the net impact it has on my life is worth taking any medication. I also have friends with ADHD who have significantly worse symptoms. When I say worse, I mean more pronounced symptoms than I do. So, my personal decision was just not to take the medication. However, I sat here with a guy called Dr. Amen who-

    2. GE

      Mm-hmm.

    3. SB

      ... has a daughter who had ADHD. She got the medication, and it turned her life around. Like, she went on to become super successful but was, like, struggling in school. So, it's really difficult, isn't it? 'Cause it's such a personalized, sort of personal decision, and some people have it more extreme and in a way that makes their life more dysfunctional than others. You know, and my fr- some of, some of my friends do really say, they say, "Oh, I took this medication for my ADHD or my, my attention issues, whatever, and it's been revolutionary for me." They just, like, they, they just offload on me how profound it's been for them. So, I guess it goes back to b- being a personal...

    4. GE

      It does, but you know... So, I have a lot of experience treating ADHD because I worked for two years at an ADHD specialty clinic called the Hallowell Center outside of Boston. I also worked for 13 years in college mental health at Harvard and at Smith College and saw lots and lots and lots of students with ADHD, most of who actually had it, some of who didn't. (laughs)

    5. SB

      Mm-hmm.

    6. GE

      Some of who were just looking for stimulants. But I, I can tell you as a psychiatrist who's prescribed medications for 25 years, the stimulants are some of the most effective medicines we have in our toolbox. For the people it works for, it works very, very well. So, and it can be life-changing. And a lot of people think of ADHD as, oh, a minor issue. Oh, you can't concentrate, or, or maybe you daydream, or maybe you're fidgety, or you know, maybe you, you get distracted. ADHD can be a really serious condition. Just like all mental health conditions, it exists on a spectrum of mild to very severe. And so, people with ADHD are at much higher risk for suicidal ideation. They're at much higher risk for substance abuse. They're at much higher risk for accidents. They're at much higher risk for depression, for anxiety. These a- a- and, and twice the, twice the rate of divorce in people with A- with adults with ADHD. These are serious, can be for some people, really disabling conditions. People cannot function in their lives. They can't function in their relationships. They can't hold a job. You know, they, they feel so frustrated and powerless. S- I mean, I was telling you that I worked with students in, in, in, uh, you know, these elite universities, right? These are very intelligent people who were struggling 10 times harder than their peers in, in classes. They had to work so much harder. They had to stay up four or five hours later than everybody else, and, and, and they did 'cause they were hardworking, but they're really suffering. And this discrepancy between...... how smart I am and how much I think I should be able to do and how much I'm actually able to do makes me feel bad about myself, right? They feel bad about themselves and because they know they're capable of more but they can't get there, and it's a real biological condition. Now, the great thing about... This is a perfect example. You could, we could have this conversation about any mental health condition, but ADHD is a great example because there's always a risk-benefit analysis when you're thinking about how we're going to treat this condition. Uh, so do you want to take medication? What are the pros and cons of that? Does the medication work for you? Does it give you side effects? Can you access the medication? (laughs) Uh, can you afford the medication? Um, how hard is, is lifestyle change for you? One of the most powerful interventions for ADHD, and I think you're probably the es- just maybe one of the most stellar examples I can think of is this: change your lifestyle to suit your strengths. Play to your strengths and don't try to swim upstream against your weaknesses. People with ADHD often have tremendous talents in certain areas and are tremendously gifted in certain ways because they can make connections, because they don't always think in a straight line, because there's, they often have very diverse interests and they can pull different kinds of information together and, you know, given the right path, they can be hugely successful, right? But that's not possible for everybody and for more severe cases of ADHD, it's not possible at all.

  26. 1:02:42 – 1:03:53

    Research on the Link Between Ketogenic Diet and ADHD

    1. GE

    2. SB

      Has there been any studies on the link between the ketogenic diet and ADHD?

    3. GE

      So not yet, but I'm, I'm very excited to, to, to be involved in two brand new studies of the ketogenic diet for ADHD. So one is a, a ketogenic diet for, uh, adults with ADHD and depression that's getting started at Oxford University in 2025, and the other is a study of, uh, ketogenic diets for ADHD in adults at the University of Michigan. It's also going to be starting in 2025. We have no data on ketogenic diets and ADHD, but we have good reason to believe... The reason we were able to get funding for these studies is because there's, there's reason to believe that it could be useful, uh, because when you look at ADHD, you see clues to poor metabolic health. So for example, children with obesity are twice as likely to have ADHD. Obesity is a marker for insulin resistance. Adults with type two diabetes are twice as likely to have ADHD. Type two diabetes is severe end-stage insulin resistance and the ketogenic diet is the most effective way to address insulin resistance that we have at our disposal.

  27. 1:03:53 – 1:09:23

    Could ADHD Lead to Diabetes?

    1. GE

    2. SB

      Is it hard to establish cause and effect there? I was thinking about the, the diabetes one where if you've had ADHD, maybe your life has been harder. Again, I don't know what I'm talking about here, but-

    3. GE

      (laughs)

    4. SB

      ...maybe your life has been harder, and if your life has been harder, you're more likely to be obese potentially if you've been- gone- had more stress and you've, you know, you've had a worse, a worse, more challenging job and... So is it, you know, s- a- a- and will, will a test be able to exclude these sort of confounding factors to the point that we'll know for sure?

    5. GE

      I think that would be a very difficult study to, to design, but I think what I can tell you from my clinical work 'cause I work- I'm a, a general psychiatrist so I see adults of all ages and with all psychiatric conditions from major to minor, and I've worked, as I said, with people with ADHD, uh, you know, hundreds and hundreds of patients with ADHD. What I can tell you is that it's the same with medication, um, if someone comes in and says to me, "Uh, I can't tell if this medication is working. Um, uh, so should I keep taking it?" And I'll say, "Well, you know," (laughs) "if you can't feel it working, then it's not working." Uh, so when the diet works, it works regardless of what's going on around the person. So, a- and this is true for all conditions that I've worked with. So people with bipolar disorder, people with depression, people with ADHD, people with PTSD, people with anxiety. As you have said, we talked about the ketogenic diet's not easy to stick to, right? People fall off the ketogenic diet all the time, uh, sometimes accidentally, sometimes intentionally, right? And you can see their symptoms come back within often 24 hours even though their external factors have not changed, so life hasn't changed. It's the diet. And when you follow the actual ketone levels daily, you can make that correlation. So what's really exciting about both of these studies is it's not just getting somebody into ketosis, it's, it's tracking, um, on a day-to-day basis their ketone level and their attention symptoms and seeing if we can see them go up and down together, and we've always got a little bit of data already from a pilot study at, uh, um, uh, um, by Ally Houston at, uh, at Oxford University. We're starting to see some signals there, but it's too early really. Uh, we need to, yeah, actually launch the official study. So in my patients, it's, it's a phenomenon I've seen over and over and over again. Um, a great example is I have a patient, um, that I worked with for a couple of years who had, uh, a condition called bipolar disorder type two. So it's a, it's a form of bipolar disorder. Uh, bipolar disorder people u- used to call manic depression. You've got periods of mania often, uh, followed by periods of deep depression. Bipolar type two is a milder form where you don't get quite as manic, um, and, uh, but you still can, can get very depressed. So he had bipolar two, um, and whenever... Uh, so, so, uh, he came to me because he wanted to try a ketogenic diet for bipolar disorder because, um, uh, uh, he had heard it might help.So, the other issue he was dealing with was that he, um, and his wife were having some difficulties, some difficulty in their relationship that had started up a few years before. And, you know, every time they got into an argument, he would want to die and he would start to think about ways of killing himself. Every single time he went on the ketogenic diet, the suicidal ideation went away, even though his wife had not. So, he used to associate the depression with the marriage, but he learned over time to associate it with his metabolic state, that when he was in ketosis, he could then imagine other ways of coping with the stress in his marriage other than just killing himself. So, he, it, a lot of people say to me that the ketogenic diet gives them this space. It allows them to pull back and see things from a different perspective. It buys them time, perspective. It's like a buffer so that people, people aren't reacting as reflexively to difficult situations. The situation hasn't changed, but people are able to deal with the situation in a more effective way. They feel they have more control, not just over their emotions, but also over their behaviors and how they react to situations.

    6. SB

      At my company, Flight Studio, which is part of my bigger company, Flight Group, we're constantly looking for ways to build deeper connections with our audiences, whether that's a new show, a product, or a project. It's why I launched the conversation cards. I've relied on Shopify before, who's a sponsor of today's podcast, and I'll be using them again for the next big launch, which we'll hear about soon. And I use them because of how easy it is to set up an online store that reaches all of you, no matter where you are in the world. With Shopify, the usual pain points of launching products online disappear completely. No matter the size of your business, Shopify has everything you need to make your business go to the next level and better connect with your customers all over the world. To say thank you to all of you for listening to my show, we're giving you a trial, which is just $1 a month. You can sign up by going to shopify.com/bartlett. That's shopify.com/bartlett or find the link in the description below. (paper rustles)

  28. 1:09:23 – 1:13:40

    Benefits of Ketogenic Diet for People With Food Addiction

    1. SB

      And for people that have f- food addictions and binge eating problems, w- the ketogenic diet, I guess it's knocking you off that roller coaster. Well, well, being i- in a state of ketosis is knocking you off that roller coaster of craving, eating, craving, eating, craving, eating. Is that accurate? Is that what it's doing?

    2. GE

      Yes. So, um, the ketogenic diet, by lowering and stabilizing glucose and insulin levels, the thing about insulin (laughs) is that a lot of people think about insulin as a blood sugar regulator. They think of it as, "Oh, you know, it, uh, when your glucose goes up, the insulin brings it down." And, and that's true, but that's, it's just one of many important roles that insulin has, it's the one it's most famous for. But the thing that, uh, i- what is not well known is that insulin is so much more than a blood sugar regulator. It's actually a master metabolic hormone, and it's regulating the activity of every cell in the body. Every cell has an insulin receptor on its surface, multiple insulin receptors, to pay attention to the insulin level in the blood. And so, uh, when you're on a glucose and insulin roller coaster, that's just where the trouble begins. Insulin is talking to and controlling the behavior and levels and activity of many other hormones in the blood, including stress hormones, like adrenaline and cortisol, um, reproductive hormones, like estrogen and testosterone, your blood pressure regulating hormones, your satiety hormones, the hormones that make you feel full after you eat, your hunger hormones. So many other hormones are on this roller coaster, uh, that you're unstable from within. And people often will think, "Well, I'm stressed and that's why I'm eating. I, I, I feel really anxious. Um, I get irritable, I get stressed, I'm hungry, I need to eat and then I feel better." And that's true, they will. They will feel better for a few hours. But what h- what happens four to five hours later, if they've eaten something that's spiked their glucose and insulin again, is they're gonna get... Th- there was this great study with, um, healthy teenage boys. They took healthy teenage boys and they gave them either a sugar-free cola, uh, caffeine free or a caffeine-free cola sweetened with sugar. And the boys who had the sugar-sweetened cola, their adrenaline levels, their stress hormones of adrenaline quadrupled four to five hours after drinking the soda. And the boys who drank the other soda stayed flat. It's the food that's causing the stress that's causing the food eating. So, there's this vicious cycle.

    3. SB

      Mm-hmm.

    4. GE

      If people understood that most of what's happening there, it's not your fault that you want to overeat those foods, they are designed to be overeaten by chemical engineers. These, this is very int- very intelligent, um, engineering that's going on. Very clever. And, uh, you will sell more of a product if you make it irresistible and if you make it unsatisfying. How many people feel that they can't control their consumption of certain foods? That's by design. If you, if you wanna keep eating it, you'll buy more of it. If you eat real food, you have to stop after a little while. They're so satisfying. Things like meat, seafood, poultry, eggs, fruit, vegetables, even fruits. Fruits, some people will overeat fruit, but, but fruit has fiber, it has water. It's really hard to eat, you know, ten pieces of fruit. (laughs)

    5. SB

      Mm-hmm.

    6. GE

      Very easy to drink, you know, a bottle of, y- several bottles of fruit juice. Very easy, um, to eat multiple packages of candy.... because those (sighs) - what happens with ultra-processed carbohydrates, these refined carbohydrates, they blow past your hormonal stop signs. I- and that's not your fault, but if you understand that that's what's happening, then you can ... Takes a few days. You've got to step away from them, but, but on the other side is tremendous freedom and control.

  29. 1:13:40 – 1:20:58

    Depression, Anxiety, and ADHD - Case Study

    1. GE

    2. SB

      The gentleman you mentioned in that case study a second ago you referred to as Carl, which I guess is a cloaked name, um, he's the one that had the bipolar disorder?

    3. GE

      Uh, no. Carl is a different case.

    4. SB

      Ah, okay. Tell me about Carl.

    5. GE

      Yeah, so I opened the book with the story of Carl, who has, you know, generously allowed me to share his story. Um, a gentleman, great guy in his mid-60s, who had had lifelong depression and anxiety, and, uh, for years, he, he didn't seek any treatment, and then maybe about 15 years or so before he consulted with me, he went to an- a psychia- a psychiatry specialty clinic for some specialized brain imaging and, uh, extensive evaluation and lots and lots of specialized tests, and he left the clinic with (laughs) a th- you know, thousands of dollars later, with three diagnoses, depression, anxiety, and ADHD, and three prescriptions, one for depression, one for anxiety, one for ADHD. So, he started those medications, and his depression got a lot better, but he then, uh, had a brand new problem on his hands, which was he was becoming manic, and he had never had mania before. So, he was being uncharacteristically, um, energetic and, uh, um, uh, irritable and unpleasant, and so it was changing, it was changing his character, his personality in a certain sp- behavior in a certain way that was becoming very unpleasant at work and at home. So, he then turned to marijuana to try to take the edge off. Developed a marijuana addiction. Now, he's got another problem. And so, he thought to himself, you know, "This isn't (sighs) , this isn't what I signed (laughs) up for. I was trying to solve a problem, and now I've got two new problems on my hands." So, he took himself off the medications and said, "You know, I, I, I can't use medication. Medication's not for me. I'm going to try to manage my mood issues, my depression, anxiety with rigorous exercise. I'm gonna let exercise be my medicine," and he started cycling, uh, bikes, uh, over 100 miles a week, and it actually helped a lot. It didn't completely resolve all of his symptoms, but it brought them down to a m- a very manageable level, um, for years. So, exercise was his medicine. Exercise improves metabolic health, and so he was still eating a standard American diet. He'd never tried any dietary changes before, and then, um, uh, what happened is as he entered his 60s, the depression and anxiety started to rise in the background. The exercise wasn't working quite as well as it had, and then, uh, just before he met with me, something stressful had happened at work, and it was essentially a, a shift in his job description which was making him anxious, and he started experiencing very suddenly these bouts of, um, agitation and anxiety and restlessness, and exercise being his medicine, he would, he would cycle, uh, on the weekends, and at night if it was a, if it w- if it was (gasps) , if it was happening on a week night, a work night, he would be walking 'cause he couldn't bike at night when it was dark, he would walk sometimes eight, even 25 (laughs) miles to try to get rid of this excess energy, and he said, "I don't have time for this. I can't exercise enough to keep my symptoms under control." He didn't know what else to do, starts searching online for solutions, came across information about carnivore diets and mental health, contacted me for a consult, and said, "I wanna try the carnivore diet for my, for my anxiety." And, I mean, there were lots of other things we could have done, uh, to improve the quality of his diet, but this is what he wanted to do because he was hoping that it would bring him the most, th- the fastest relief. So, switched to a carnivore diet, three to four pounds of fatty meat per day, mostly pork and beef. This was dairy free, no plants, and, uh, he checked his ketones u- using urine testing, which is less expensive than blood testing. Uh, he's in mild ketosis every day using urine strips, and, uh, he started to improve by week three. By week six, his score was zero on all depression and anxiety scales. He had no symptoms at all of, of depression and anxiety, not just of those recent extreme symptoms that he was experiencing, but the symptoms that went back his entire life that had never completely resolved before. So, he said, you know, "I've, I've, this is the ... I've never felt this well in my entire life." And so, this is the power of these strategies, is they don't just reduce symptoms a little bit. They actually have the power to heal the underlying problem in ways that ... I mean, this is a phrase I've heard so many times, "I feel better than I've ever felt in my entire life." You don't hear that when you prescribe (laughs) medications for people generally.

    6. SB

      That was in 2019, was it?

    7. GE

      Uh, I couldn't tell you what year, but that sounds right.

    8. SB

      How is he doing now?

    9. GE

      Yeah, I mean, we st- we are still, we- we still talk with each other, uh, several times a year. He's doing very well. In fact, so he's s- one of the interesting things about what happened with this diet is that during that long period of e- of intermittent agitation, uh, he, you know, he's a very physically fit guy because of all the exercise, and he, and he was lean-He lost 10 pounds during that period of agitation that he could not afford to lose. When he first started working with me, he was underweight and despite eating four pounds (laughs) of fatty meat per day, he couldn't regain that 10 pounds unless we added, uh, back some carbohydrate into the diet. This is really a, this is a subtle point, but for athletes, sometimes especially in the early f- phase of the transition, um, there needs to be a certain amount of carbohydrate in the diet, um, to support high performance.

    10. SB

      He didn't stay on the carnivore diet?

    11. GE

      No, he did not. So, he was on the carn- carnivore diet for many months and then bec- but because he couldn't regain that weight, I asked him, I said, "Well you know, I think we need to put some carbohydrate in to help you, uh, uh, regain this weight." And so, I asked him which foods he missed the most, gave him a list of whole foods to choose from, and the things he missed most were, uh, potatoes and yogurt. So, some starchy root vegetables, some plain unsweetened yogurt, um, up to about 100 grams of carbohydrate per day seemed to be about right for the days when he was e- excuse me, exercising. On the days when he wasn't exercising, he would cut it back. So, he was tailoring it to his personal energy needs. And so- so this is another, um, uh, interesting thing about wha- what happened for him, is that, um, I mean, his- his scales are still at zero, but he has been, uh, as we've talked to each other on and off over the years, he has been able to make adjustments to his diet, understanding the principles. If you understand the principles, then you know which changes you can get away with and which changes you can't, and he has stayed well.

  30. 1:20:58 – 1:22:09

    Carnivore Diet

    1. SB

      There's a couple of key things people always talk about when they hear the c- carnivore diet. The first is they say there's n- nutritional deficiencies to the diet that aren't s- like, sustainable. So, if you eliminate certain food groups like fibers, vitamin Cs, vitamin E, magnesiums, et cetera, then ... which are essential nutrients, then you're gonna have problems.

    2. GE

      So, a carnivore diet theoretically does provide all essential nutrients. So, if you look at what is inside animal foods, you will find all essential nutrients. You can't say that of any plant food. Eh, there's not a plant food on Earth that can, that provides all essential nutrients. Animal foods can. Uh, I would say meat, seafood, poultry. Eggs are missing a couple of nutrients and dairy is missing even more, um, but, uh, meat, seafood, and poultry contain every nutrient we need. The question is how much do you need?

    3. SB

      Like fiber.

    4. GE

      Oh, well fiber's not a nutrient.

    5. SB

      Oh, okay, but do you get fiber in a carnivore diet?

    6. GE

      There are different definitions of carnivore, but the strictest, sort of purest definition of carnivore is animal foods only and fiber comes from plants so it's fiber free. A true carnivore diet is fiber free.

  31. 1:22:09 – 1:25:40

    Do We Need Fiber?

    1. GE

    2. SB

      So y- could you last on a true carnivore diet without getting some kind of like gut microbiome issue or some kind of ... 'cause you need fiber, right?

    3. GE

      Why?

    4. SB

      I thought it was good for like digestion and your gut microbiome and stuff like that.

    5. GE

      What does it do?

    6. SB

      A lot of people tell me that it prevents glucose going into the blood or something?

    7. GE

      Where's the glucose coming from?

    8. SB

      So you don't need it?

    9. GE

      Fiber- fiber is very helpful, and I spell this out in the book. So, because there's th- we have a lot of half-truths in our minds about food. Um, even people who are paying really close attention to the- to nutrition science have a lot of half-truths in their minds about food. So yes, fiber for example, you're exactly right, lowers glucose spikes, but the glucose is coming from a diet that's too high in sugar, and so you won't get glucose spikes if you regulate your glucose levels. Um, so- so that's one, uh, interesting thing about fiber. So, if you're eating a high carbohydrate diet, fiber can soften your glucose spikes and that's a plus, but there's a more effective way to lower your glucose spikes is to not get a glucose spike in the first place. Um, and that may not require taking all the carbohydrate out of your diet. It might just mean lowering it to your personal tolerance. Um, another thing people often say about fiber is that it sweeps your colon clean of toxins and they're kind of, um, um, and, uh, that- that might otherwise build up and cause problems. But fiber, um, there's no evidence that fiber is sweeping anything clean or there's never been a study that demonstrates this. It's really just a belief about w- what we imagine fiber as being like the broom of the intestines, but there's no ... That- that's just a belief. There's no science behind that whatsoever. Um, the- the intestines clean themselves. The lining sheds regularly, actually very frequently, and has- and the border of the intestines, um, sweep themselves clean. So, they- the intestine knows how to take care of itself that way. But the biggest myth about fiber is that it's good for digestion because fiber by definition is indigestible by humans. So, there are two kinds of fiber. There's soluble and insoluble, and the soluble is, um, you know, the kind that holds water. It's like in an apple. And the insoluble is the kind of st- tough, stringy, woody stuff that you might find in, like, broccoli for example. So, the soluble fiber, the bacteria in the lower parts of our intestine can ferment that to a certain extent, um, but, uh, but then we, but then we can't make use of the sugars that it's releasing. Um-

    10. SB

      I read here, "Fiber is traditionally considered essential for feeding beneficial gut mi- bacteria and promoting regular bowel movements."

    11. GE

      Yes. Okay, so a couple of things to unpack there. So one is that the, uh, a lot of people, uh, th- there are quite a few papers on this, uh, claiming that we need fiber because, uh, we need to feed ourselves butyrate which is a breakdown product of fiber, but butyrate if you think about what a ketone is, it's beta-hydroxybutyrate.... feeds the intestinal cells just as well. So, you don't need to eat fiber to feed your cells butyrate. If you think that the cells need butyrate, then you can get it from a ketogenic diet. Um, so, uh, I, I explain that in the book too, is that there's more than one way to generate that molecule.

  32. 1:25:40 – 1:29:23

    Is the Carnivore Diet Sustainable Without Supplementation?

    1. SB

      Can someone exist on their carnivore diet, like the extreme version of the carnivore diet, for a long time without any supplementation?

    2. GE

      So, we really don't know, and we really don't have any long-term data on any dietary pattern. I think this is really important for people to understand, is this very common criticism of diets that we feel uncomfortable with or might be worried about, like ketogenic diets or carnivore diets. Because they're so different from what we're told we're supposed to eat, there's a lot of fear and worry, uh, about them, and so a lot of people think, "Well, okay, it's, it's, um, it's normalized my blood sugar level. I used to have type 2 diabetes." Um, you know, "I've lost 50 pounds." Um, "My depression went away." Um, "My, uh, I normalized my coronary artery calcium scores, I'm at lower risk for cardiovascular disease. My triglycerides came down." Um, you know, "I feel better, I'm, I, uh, eh, in every way, like, all of my health markers have improved." And so when you show people study after study after study of a ketogenic diet, um, improving multiple aspects of metabolic health and physical health and mental health, "It's cured my seizures," "It's cured my bipolar-" whatever it was, the only, the only last, the, sort of the last thing somebody could say is, "Well, well, yes, okay, it's made you extraordinarily healthy now, but I wonder what's gonna happen 20 years from now."

    3. SB

      Mm-hmm.

    4. GE

      Nobody can tell you that because there's no way you could design a 20-year-long study of any diet. So you could say this about the Mediterranean diet, you could say this about a carnivore diet, you could say this about a vegan diet. Well, vegan diet unsupplemented is, is fatal. Um, it's, it has dangerous nutritional hole- holes. So why aren't we saying this about vegan diets when we can look at a vegan diet and see that it, that, that it's incompatible with human life unless you eat fortified processed foods or supplement, which most people in the world cannot do? Um, we look at a carnivore diet, and you can actually find all of the nutrients in these animal foods, and that's the diet that you're more worried about because theoretically, long term, something bad might happen. Now, I am not at all saying that a carnivore diet is the right diet for everybody, um, or that it's even the right approach for everybody to consider, but I think we have to keep an open mind and stay curious and look at the biology of food and allow people to make their own... I, I, I'm nutritionally pro-choice, which means I would sup- uh, if you came to me with a mental health issue, um, I would support you in optimizing the diet of your choice and making it as brain-healthy as I possibly could because I, because, uh, it's very important that you feel comfortable with the diet that you're eating. And so there are lots of ways to do that. But I think it's really important, and one thing I encourage people to do in my work and in my book, is to open our minds and get curious about food, the biology of food, the biology of the brain. Because most of what we hear about nutrition doesn't come from biology, it doesn't come from clinical experiments or, uh, information about how cells work or about what's actually inside food. It comes from this type of study called a nutrition epidemiology study, which is just questionnaire-based guesswork, untested theories about what we should eat. Most of what we believe about nutrition is untested theories, wild guesses and wishful thinking.

Episode duration: 1:47:03

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