How Diet Improves Mental Health - Dr. Westman



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Mental Health

How Diet Improves Mental Health – Dr. Westman and Dr. Georgia Ede

Dr. Georgia Ede’s Background

Dr. Eric Westman: Why don’t we just start out with you introducing yourself and how you got into the keto world; it’s a fascinating story.

Dr. Georgia Ede: Sure. I’m a psychiatrist, and I’ve been a psychiatrist for about 25 years now. For the first 10 years of my career, I practiced the way most psychiatrists do. I was trained to think of mental health problems as having biological root causes that had to do with chemical imbalances in the brain. I was trained to treat those root causes with medications, and I was trained to treat the psychosocial root causes of mental health problems, things like stress, trauma, and family issues with psychotherapy. I still use both of those tools in my work even now every day. They’re both very valuable and have their place.

But about 10 years into my career, in order to try to solve some of my own health problems that started popping up in my early 40s, some of which a lot of my patients also had, things like fibromyalgia, chronic fatigue, IBS, and migraines, I just thought, “Well, I’m just getting older, and this is normal. You’re supposed to just fall apart when you turn 40.” But it’s really not supposed to happen. I was working at Harvard at the time, and I had access to lots of really smart and caring doctors and specialists, and I had every test in the world. They all told me nothing was wrong. But, of course, something was wrong. I really didn’t want to take medications because I’m very sensitive to medications. One of the issues I was having was related to stomach pain, and so I thought, “Well, maybe it’s something I’m eating that was causing the stomach pain.” So, I just started experimenting with my diet instinctively. Food and symptom journal – this was back in 2007, 2008, so a long time ago. I had never heard of keto or Paleo or anything. I just started experimenting with my diet to see if I could help my stomach feel better. I kept a food and symptom journal, and by the end of six months, by changing my diet in these various trial-and-error ways, everything improved. It went away, including the migraines, the chronic pain – everything. Not just the stomach pain.

The thing that was so fascinating to me as a psychiatrist was that my mental health improved too, and I wasn’t even trying to improve it. I didn’t think I had a lot of trouble with my mental health, although I was kind of depressed in the winter and I was kind of an anxious person prone to stress. But it was unbelievable – my concentration was razor-sharp, my energy stable, good work stamina, much more productive, and I slept better. My mood, my concentration – everything was better. And I thought, “Hmm, this diet seems to be good for the brain.” And wouldn’t that be something if something about this diet could be useful to all of my patients, most of whom weren’t getting better enough with the standard tools I had in my toolbox? But because the diet I’d switched to was pretty unorthodox and wasn’t recommended by nutrition authorities – it was really mostly based on animal foods, high fat, and high cholesterol – I thought, “This diet feels amazing, but I can’t recommend this to my patients because what if this diet’s going to kill me?” I mean, this is what I was taught. So what I decided to do was study nutrition and really educate myself, as doctors aren’t taught about nutrition. In four years of medical school, we took about three hours worth of nutrition education, and then in psychiatry residency, another four years of specialty training, we didn’t talk about food once. So, I had to really educate myself about the truth of how the body works, what kinds of foods the body needs, metabolism, and what the brain needs to thrive. I studied independently for several years.

Dr. Eric Westman: So, you didn’t really know that you were doing an Atkins diet?

Dr. Georgia Ede: Well, along the way, my mom had lost 90 pounds on the Atkins diet. So, I knew that was something one could do to lose weight, but I wasn’t at that point trying to lose weight.

Dr. Eric Westman: By process of elimination and with your own detective work, you ended up with something very similar? It reminds me of a story of a doctor who was diagnosed with diabetes, and he reasoned that he should just take the carbs out. His wife told him, “You dummy, you’re doing the Atkins diet.” We all have to come up with our own conclusion about it.

Dr. Georgia Ede: Exactly, yeah. That’s how I got into it.

Implementing Keto in Psychiatry

Dr. Eric Westman: That conundrum of “what do I do?”, “how do I deal with my patients?”, is again fascinating because there are a lot of doctors who are eating this way in the closet. I just say, “Well, say you’re doing the Mediterranean diet to other health professionals, and they’ll say it’s great. That’s so good for you.” Then, they don’t ask you anything else because they don’t really know what a Mediterranean diet is. Nobody really does. What was the process for being able to use it with your patients? Have you used it with patients?

Dr. Georgia Ede: Oh, yes. For sure. I was working at the Harvard University Health Service at the time, and the director there at the time was very supportive of the psychiatrists on staff. We were all hired, of course, primarily to prescribe medications, and therapists were prescribed to do the therapy piece of the work. We were primarily hired to prescribe. But the director at the time was very supportive of us also nurturing and offering other options. For example, there was somebody on the staff who was interested in acupuncture, and they were allowed to do a little acupuncture. I was allowed to do some nutrition consultations, which I really enjoyed so I started weaving in nutrition principles – really, just at that point, whole foods principles and lowering sugar and cleaning up the diet.

Gradually, the more I learned about nutrition and the brain, I stumbled upon a paper about a ketogenic diet for bipolar disorder. Suddenly, all these light bulbs went off in my head. This was a long time ago, probably in 2009. It was these similarities between bipolar disorder and epilepsy because we use the same medications to treat both. We use the same medications to treat mood swings as we do to treat epilepsy. The ketogenic diet has been used to treat epilepsy quite successfully for about a hundred years. I thought, “Well, if this diet works for epilepsy, I wonder if it could also work for bipolar disorder.” That just really got me interested in not just the nutritional parts of the diet that can help with brain function, but the metabolic piece. What happens when you go into ketosis? How does that change brain chemistry? That’s about 10 or 12 years ago now that I stumbled on that.

Success Stories

Dr. Eric Westman: What I often hear is that most doctors try it themselves first. But this then becomes a slow process, if every doctor has to try it themselves first. I try to leap ahead; it’s like an FDA-approved drug. You don’t have to go through it and try it. In fact, you don’t even have to do it as a doctor because everyone else has studied it. You can just prescribe it. But it’s common, I think, for those of us who will write about it and teach about it, to have had to try it ourselves, test it, kick the tires, so to speak.

Can you share some success stories? I remember at the Metabolic Health Summit, there were some people put on stage who had unbelievably hard lives with psychiatric problems, they’re homeless, and then afterward they’re holding jobs and look like they never had any problems. Have you had transformations like that in your practice?

Dr. Georgia Ede: Oh, lots of them. I put some specific patient stories in the book that I just finished writing, so people can hopefully be inspired by those. I’m a general psychiatrist, so I treat only adults. I see all kinds of different people – people with everything from ADHD and mild depression to severe mental illness and early Alzheimer’s. I’ve been using ketogenic diets and other types of nutritional strategies in my work for more than 10 years now. I’ve treated lots of people with different dietary approaches, but the cornerstone of my practice has been the ketogenic diet because that’s really the most powerful intervention we have to re-energize, heal, and protect the brain. And that’s exactly what you want to do if you have a mental health issue of any kind, really.

A woman with early Alzheimer’s had mild cognitive impairment for about 20 years due to a mild head injury. She was on medication to control seizures and had some trouble with her memory and finding her way around. She eventually had to give up her job because she couldn’t manage with cognitive impairment. The cognitive impairment was stable for a long time, nearly 20 years. But as she approached her 70s, there was a decline in her cognitive function. It was noticeable to her. She went to sit down at the sewing machine that her mother had given her and she had used it for decades and couldn’t remember how to thread the machine. She was terrified. She thought, “Okay, this is it. I knew this was coming.” She went to her doctor who tested her, saw the decline in testing, and said, “This is Alzheimer’s. There’s really nothing we can do about it. Just go and enjoy your life. I’m going to make an appointment for you with a neurologist to do some testing but this is what’s happening.” The neurology appointment was 10 weeks out and so while she was waiting for that appointment, her son, who was working with me on bipolar mood issues with a ketogenic diet, asked if I would see her. I met with her and she was very excited to try a ketogenic diet. It gave her hope when I explained how it could help re-energize her brain. I said I didn’t know whether it would help or not but it was worth a try. She was very excited to start. She has the support of her son who was doing well on a ketogenic diet.

Within two to three weeks, she markedly improved. She was able to remember directions to find her way in her car without even having to write them down. She, of course, could sew again. She wasn’t losing her train of thought in the middle of sentences anymore. She felt that she’d gotten her brain back. By the time she got to her neurology appointment, they said, “There’s no diagnosis here. Everything looks fine.” You can see really remarkable improvements. Not in all patients, of course. Not in all cases. But in my experience, I’ve worked with hundreds of patients, with different diagnoses, I almost always see a noticeable degree of improvement to some extent. Some people improve all the way. Some people improve partly. Some people are able to come completely off medication. Some people are able to reduce the number or type of medications that they’re taking. It’s, in my opinion, always worth trying. There are very few reasons not to try it but it’s a really useful intervention almost regardless of the diagnosis that you’re dealing with.

Keto is Worth Trying

Dr. Eric Westman: Not being a psychiatrist myself, I am struck by labeling things. In our first case that I recall in internal medicine, I was treating someone for obesity, for weight loss, and she came back saying her voices were gone after eight days. And I was struggling. I didn’t even know she had a long history of schizophrenia, although when we tried to publish the case study, and we did, they said, ‘Well, she didn’t really have schizophrenia. It was more complicated.” I don’t know that the labeling is all that perfect for psychiatry. People ask me, “Well, okay, it’s for schizophrenia, but what about this one?” Or, “I have this diagnosis, that diagnosis.” It seems to me that because of the imprecision of our ability to label mental health issues, it would be worth trying a keto diet regardless of what the diagnosis is. Is that your experience?

Dr. Georgia Ede: Yes, because exactly as you say, we don’t have diagnostic precision in psychiatry. There are lots of different types of brain health problems, and they can manifest in different ways. Most people with depression also have anxiety. Most people with anxiety have depression. There are different degrees of bipolar disorder, from mild mood swings to severe bipolar type one with true episodes of mania. There are different degrees of psychosis. Everything, just as in all of biology, exists on a spectrum and everything’s overlapping. It’s not like there’s one part of the brain that’s devoted to schizophrenia and one part of the brain that’s devoted to ADHD. Almost everyone with any psychiatric diagnosis has problems with concentration. Do they all have ADHD? No, they’ve got a disruption of their attention system, which is widespread throughout the brain. These are really just crude terms that we use to try to put people in boxes. Most people don’t fit neatly into any of these boxes.

An Inpatient Study

Dr. Eric Westman: I often think, “What a great opportunity.” There are so many people hospitalized with psychiatric illnesses in mental institutions, and to my knowledge, no formal state institution has ever tried putting a ward on a diet like this. How did you come across Dr. Albert Danan? Because he did have people in a ward. Tell us that story.

Dr. Georgia Ede: You and I worked very closely on this. My friend and colleague Dr. Albert Danan, a psychiatrist in Toulouse, France, has been a psychiatrist for 35 years. He has been working primarily with people with serious chronic mental illnesses of North African and French descent for a really long time. He’s very dedicated, using medications and psychotherapy, and really gets to know his patients and works closely with them over time. Some of these patients he’s known for 35 years. What happened was there was a family member of his who had autism and epilepsy. That family member started a ketogenic diet, and within a few weeks, the seizures disappeared, and even the autism improved to a significant extent. When he witnessed that, he thought, again, this diet seems to be good for the brain. He wondered if this diet might help so many of his patients who weren’t responding well to medications, who really hadn’t gotten much better despite all of the work he was doing to try to help them, all the medications and everything.

He invited 31 of his most treatment-resistant patients with bipolar disorder, major depressive disorder, and schizophrenia to see if they would be interested to try a ketogenic diet in the hospital under his close psychiatric and medical supervision. 31 of them agreed to do this. We published the paper together. We helped him publish his findings, which are really extraordinary. With the exception of the three people who were not able to follow the diet for longer than two weeks, all of the 28 patients who did follow the diet for longer than two weeks improved substantially. 43% of them reached clinical remission simply by following a whole-foods ketogenic diet that was based on the diet that you’ve been studying at Duke for so many years. This was really remarkable. About two-thirds of them left the hospital taking less psychiatric medication than when they went in. And, of course, their metabolic health improved as well. Triglycerides dropped like a stone, blood sugar came down, and blood pressure came down. People lost a significant amount of weight, even though almost all of them were taking antipsychotic medications that are notorious for causing stubborn weight gain. This was really remarkable and had never been experienced before. Nobody had ever put a group of people in the hospital and put them on a ketogenic diet. He had done this simply to help his patients, not to run a study, but when he called me and told me what he had done (he reached out to me because he knew that I was interested in this topic, we had never met each other) he just kind of mentioned it, casually. I said, “You did what? Do you realize that nobody’s ever done this before?” He said, “Really?” And I said, “No.” He said, “You haven’t done this?” I said, “I haven’t done this.” And he said, “Dr. Palmer hasn’t done this?” I said, “No, Dr. Palmer hasn’t done this.” He said, “Really?” And I said, “We need to find a way to publish this and share this with other clinicians so that they know that this is safe, feasible, and that the people got not just a little bit better, but seven to ten times better than they tend to do in medication studies for depression and psychosis.” The magnitude of the effect was really big. It was amazing. I really cannot thank you enough, Eric, for helping us publish that work. I hope that will be helpful to other clinicians.

Dr. Eric Westman: I’ve observed other cases and other doctors doing things but the remarkable thing that Albert did is that he used systematic questionnaires that were validated. There were multiple questionnaires that got at the same issue. It was really well documented. As a clinician doing that, I’ve thought that was just really outstanding, remarkable, and publishable. I wonder, has that paper gotten some traction? We haven’t really talked since the publication.

Dr. Georgia Ede: We were so heartened to see the response to this paper. There’s something called an altmetric score, which is a measure of how much attention people are paying to the paper. This is among the top 1% of papers that this journal and any division of this journal has ever published.

Dr. Eric Westman: I didn’t know that, congratulations!

Dr. Georgia Ede: The altmetric score is 1,750 or something like that. It’s really, really high. It’s been viewed almost 100,000 times now. I think the information is resonating. There’s now this field called metabolic psychiatry, and this paper helps to fuel new research and helps to convince funders and grant makers that this is a safe and really low-risk, high-potential benefit intervention that’s worth studying more rigorously.

The Baszucki Group

Dr. Eric Westman: There were a couple of conferences this year on metabolic psychiatry and integrative medicine. One of them is called Metabolic Mind by the Baszucki Family. Do you know much about that? I’ve just watched the video; it looks like their son has greatly improved and they have some wealth to be able to give to the field, is that right?

Dr. Georgia Ede: I cannot say enough good things about this family. Everything that they have given, not just financially, but in terms of what they’ve donated, in terms of their time and energy and personal resources and generosity of information. They’ve shared their family story, which is a very painful but also very inspiring story. I’m talking specifically about Jan Ellison Baszucki. She’s the president of the Baszucki group, which is a philanthropic organization that she and her husband, David Baszucki, founded to educate people and fund scientific research in metabolic psychiatry and new approaches to mental health conditions because their son, Matt Baszucki had his college career interrupted by severe psychotic illness and was for a time homeless. The family was distraught and traumatized by his experience.

Eventually, after many medications and many doctors, his mother, Jan Ellison Baszucki, heard about a ketogenic diet for mental health. She sought out the support of Dr. Chris Palmer who was a psychiatrist here in Massachusetts at Harvard. He and Denise Potter, who’s a very experienced keto dietician, put him on a ketogenic diet. Within about four months, his illness went into remission and has remained in remission for, I want to say, at least two years, maybe three years now. If people are interested, he and Dr. Ian Campbell, who’s now a prominent researcher in bipolar disorder, have a YouTube channel called “Bipolarcast,” where they interview people who have gotten better on a ketogenic diet. It’s a really great YouTube channel.

Resistance in Psychiatry

Dr. Eric Westman: I didn’t know that it took four months. One case that I had, the index case in my clinic, lasted eight days. It’s important to know that there’s some variability in how much time it might take. The unknown to be discovered is what percentage of people respond, kind of like in your practice where it’s not going to be the same for everybody. There may be responders and non-responders. why wouldn’t you try this? I want to shout out for everything that the Baszucki group has done. I saw Ian Campbell’s talk at the Integrative Medicine conference, Integrative Psychiatry, and he was measuring himself with ketone levels and symptoms. That was really the first time that I’ve seen the correlation between the higher the ketone level, the lower the symptoms. Now, of course, this is one individual, and you could even say it’s susceptible to the placebo effect, but again, the knowledge that can be gained by measurements of ketones, breath, blood, or urine, and then subjective scores, it’s really not difficult to do this intervention and to test this out. It’s just getting the engine of research and people who are in power – in control of research studies – to get them on board.

And like you said, to have Dr. Danan’s inpatient experience will open the door for other people to want to try it. Although, I fear the resistance, like in internal medicine, is that everyone looks to medications in internal medicine, and everyone looks to medications in psychiatry as well.

Dr. Georgia Ede: That’s true. But you know what occurred to me? I was giving a talk in Switzerland at a conference called “Food for Thought.” This year, they decided to include multiple talks about Metabolic Psychiatry because it’s such a new and exciting field. I was up there talking, and it occurred to me because there were several talks also about obesity and type two diabetes and how these new medications are coming along now that everyone is so excited about; they can actually help people lose weight and control blood sugars. For a long time, we’ve had medicines that can help control blood sugars. It occurred to me that there’s even a stronger argument for using the ketogenic diet in mental health disorders than there is for almost any other disorder because we don’t have great psychiatric medicines. The medicines we have are really limited, and at best, the most reliable psychiatric medications, which are the antipsychotics, only help about 25% of people.

Dr. Eric Westman: That’s an underappreciated reality. Even some of the medications, when you look at placebo-controlled trials, don’t work at all, and yet they’re being used. On the other hand, what a great time to be able to study it, use this clinically. The work with Dr. Albert Danan was a fantastic find, that you were approached by a doctor who had done this work. I think it’s really important for so many people to be around and be accessible. I could imagine that person would have called the professor in charge of the Psychiatry department chair at Harvard, and they wouldn’t have picked up the call.

Dr. Georgia Ede: I feel very fortunate to know him for many reasons. He’s just a wonderful psychiatrist, a wonderful human being, just a lovely, lovely guy. He’s nearing retirement now, so he’s really not particularly interested in going around the world and sharing this information. I’m more than happy to do that for him.

Dr. Georgia Ede’s Book: Change Your Diet, Change Your Mind

Dr. Eric Westman: Fantastic. Let’s switch now to your book. what possessed you to go through that pain and agony?

Dr. Georgia Ede: You know, as you’ve written many books, you know, it is painful. I was joking with my friends, saying this book is killing me and it’s probably going to need to be published posthumously. It was just a lot of work. I had no idea how much work, but it was joyous, the best of times and the worst of times.

What drove me to do it was I was just possessed by this desire. It’s frustrating to help one person at a time and teach one person at a time when there’s so much information that everybody needs. A lot of that information they can use right away without a lot of special help. There are some great basic changes that people can make even if they don’t use a ketogenic diet per se. There are so many myths about what a healthy diet looks like, what the brain needs, which foods are good for the brain, which foods are bad for the brain. It’s all upside down. What I was really driven to do in this book was to put all that information in the same place. Not just what should you eat for a healthy brain, but why? Why am I recommending these things that fly in the face of conventional wisdom? For the people who are picky about the science, there’s plenty of science in there to back up these arguments. Then there’s also a lot of practical advice as well. All the way down to recipes and meal plans, how to deal with insulin resistance and everything. It’s kind of half science, half practical.

Dr. Eric Westman: And the title is Change Your Diet, Change Your Mind?

Dr. Georgia Ede: Yes.

Dr. Eric Westman: We have a saying, “Change your food, change your life.” It’s similar. Of course, Adapt Your Life, meaning every organism that is able to survive has to learn to adapt to new situations. I like that similarity. Is the intended audience the general public?

Dr. Georgia Ede: It’s for the general public as well as nutrition professionals and clinicians. It speaks to both groups of people, and that’s on purpose. If we speak just to patients and don’t include enough of the deeper science, then the clinicians and nutrition professionals will poo-poo it. If we speak just to clinicians, then it doesn’t help everyday people who are looking for information about how to change and improve their mental health. It was really aimed at both groups.

Clinician Directory

Dr. Eric Westman: Recently, in the clinic, I was asked how someone can find a keto-friendly psychiatrist. Is there a resource for that now?

Dr. Georgia Ede: I’m glad you asked. In the past year, maybe eight or nine months ago, I started on my website a completely free public resource. It’s a clinician directory specifically listing about 150 clinicians so far. This is specifically for mental health only. We curate that; people will submit their listing, but we will only post them if they treat mental health conditions and have that expertise. It’s prescribers, but it’s also nutrition professionals, therapists, coaches, and different types of providers.

Dr. Eric Westman: You also have a training program for clinicians, is that right? Tell me about that, please.

Dr. Georgia Ede: About three years ago, I developed a clinician training program that’s continuing education certification. People need access to professionals who will support them in a safe and knowledgeable way to transition to a ketogenic diet. Especially if you’re on medications of any kind or have serious mental health symptoms, you really need to work with somebody as you transition to the diet. Not because the diet is dangerous, but because navigating the medications and existing health issues, especially when your body is shifting gears, takes a little special knowledge and skill.

There are very few of us who were doing this a few years ago. Just a few of us really in the world. People were emailing me every day saying, “Can I see you? Can I see you?” I can’t help everybody who writes to me. We need more people. I decided to train other people, and so we’ve trained hundreds of clinicians around the world. We continue our training every month. This is continuing education certified and for clinicians of any background. You don’t have to be a prescriber, though we love prescribers because they’re the ones who are most in need. We’re really trying to improve access to Metabolic Psychiatry services, and the Baszucki Group is trying to help us in that regard as well, trying to make the course more accessible.

Dr. Eric Westman: How do you do all this? Everyone asks me that, too.

Dr. Georgia Ede: It’s a lot of work, but it’s a passion project. It’s a calling, really. I can’t explain it otherwise because I’ve invested a lot of time and energy and my own resources into doing these. A lot of these projects are not profitable, but I really am doing it because I love it. I was trained conventionally, and the typical treatments just don’t help most people. We need a better way.

Dr. Eric Westman: I was reminded that we have had the chance to spend some time together, traveling, and I’m reassured because there are a few of us who still care about people getting better. It does become a calling. It’s almost like the clergy, the medical doctors. Not everyone, but I’m glad that you’re one of those.

Dr. Georgia Ede: I’m glad that you are too. You’ll see this when you get your galley copy of the book. But I did make a point to acknowledge you in my acknowledgments because your work has been such a foundation for my work. You’re one of the pioneers in the field, and we wouldn’t be here without you. I really appreciate everything you’ve done and continue to do for all of us.

Grassroots Efforts

Dr. Eric Westman: Thank you! All that we did here at Duke is to formalize with Dr. Atkins and Dr. Eades and Rosale and Bernstein. That was an important step to gain credibility, the ability to have a worldwide group of contributors in a really amazing text. It went from doctors writing books about it to now studies being done. There’s a classic book that Dr. Atkins wrote, Dr. Atkins’ Health Revolution, and that became my roadmap of what studies to do because he wrote about fixing GERD and heartburn but he didn’t write a whole lot about mental health, which is pretty interesting. He was a cardiologist internist at the time. I see this as a necessary transition for credibility. Now we need to get it to catch on. I think what I’m seeing in your approach is it’s grassroots as well, because you’re not targeting the NIH or the American Psychiatric Association. In my world, they’re so entrenched in either finding a mechanism or a new drug that we’ve had to just build up from the grassroots. It seems like that’s what you’re surmising in the mental health world too?

Dr. Georgia Ede: Yeah, I think we need a combination of grassroots and higher level changes. We’ve put in two submissions to the American Psychiatric Association meeting for this coming spring on metabolic psychiatry and so hopefully, at least one of those, the two that I’m involved in applying for, hopefully at least one of them will be accepted because that’s a huge meeting, as you know, thousands of psychiatrists around the world come to that meeting. We just need to get the word out because I actually think that most psychiatrists, when they hear about this intervention, get really excited because most psychiatrists are frustrated that they have nothing left to offer some of their patients. They love to have new tools, ao it’s a really exciting time to be a psychiatrist. Something new is happening.

Implementation Strategies

Dr. Eric Westman: Switching gears, I wanted to pick your brain a little bit about your experience in using keto diets. Is the implementation different for mental health conditions or for metabolic conditions like diabetes and obesity, or do you look at it differently or more similar than different?

Dr. Georgia Ede: It’s more similar than different. There are a few special challenges. This is one of the things I teach in my training program. Even clinicians are coming to the training program already knowing a lot about ketogenic diets for things like obesity and type 2 diabetes. There are some special things they need to learn to use those same skills to treat mental health conditions. One of them is that people with mental health conditions, whether it’s depression or difficulty concentrating or feeling disorganized, being impulsive, any of those things can interfere and make it harder to change your diet. So it’s just an extra obstacle. But then also, some of the psychiatric medications cause insulin resistance and make it harder to get into ketosis. And so you often need to be stricter with the diet in order to get people to transition.

There are some other challenges. For example, if people have cognitive impairment – like older people with cognitive impairment – it’s really hard for them to learn new diet rules. It takes some extra time and some extra patience and some extra visits to implement those changes. The other thing, and this is pretty important, is that when you’re transitioning to a ketogenic diet, unless you do it very slowly and carefully, you can cause somebody to feel worse before they feel better, psychiatrically. So they may feel more depressed, more anxious. They may even experience what’s called hypomania or mild manic symptoms, like an uncomfortable high-energy state as the brain is seeking its new equilibrium. When people do feel worse, it usually resolves by week three. But that’s why it’s so important, especially when medications are involved or when someone has a history of dangerous symptoms because if any of those get worse, that could be a real problem. The medication levels of certain psychiatric medications can change as the body chemistry changes. People can start to feel more sensitive to their psychiatric medications in the first few weeks. It’s really navigating those first few weeks, which is where a lot of the skill and knowledge comes to bear. Once you get to the other side, once your body has reached its new equilibrium – which can take anywhere from three days to three weeks to three months, depending on who you are, on average, three to six weeks – then what most people experience is a very different state of mind than they’re accustomed to. Most people will say, “I’ve never felt like this before. This is something completely new.”

Dr. Eric Westman: It cries out for inpatient use. Starting the diet on someone who’s severely ill. I thought that would be necessary for someone who’s on 10 different medications for diabetes and high blood pressure. I have to backpedal, get people off the medicines. It would be safer if they were in the hospital. I wonder if Dr. Danan’s model of hospitalizing people with psychiatric illness to start people out could be a way to get people through that hurdle?

Dr. Georgia Ede: I think in some cases that would be a good idea, depending on the particular circumstances. If someone is in fragile mental health, they’re already unstable. If they’re already dealing with, say, suicidal ideation or self-injury agitation, you certainly don’t want that to get worse. So in some cases, I think that would be a really good idea. Dr. Albert Danan is a very skilled psychiatrist. We could adjust psychiatric medications themselves, but he also was trained in psychosomatic medicine, so he has internal medicine skills. He was able to adjust the diabetes medications and the blood pressure medications himself. That’s just a special circumstance. He was in France where they let you stay in the hospital as long as you wanted. In the United States, we frown on that. But yes, I think in some cases, yes, but in most cases, no.

I’m an outpatient psychiatrist. I think that if you transition slowly, if you pay attention to the medications and you monitor things, and you work closely with the other clinicians, you can do it safely. But you do need to know what you’re doing.

The Psychology of Subtraction

Dr. Eric Westman: Along those lines of implementation, I’ll never forget a lecture you gave – thanks for all you’ve done and teaching at our meetings through the years – which I believe was titled “The Psychology of Subtraction.” What does that mean?

Dr. Georgia Ede: We’re always told, and there’s a lot of this in my book, that the way to protect our brains is to add more things to our diet. Add special superfoods like blueberries, dark chocolate, and red wine. Ridiculous. Red wine. That’s psychiatric malpractice to recommend wine to people who have depression and cognitive impairment. But in any case, we’re told that you should add superfoods and supplements and eat these special things. There’s absolutely no science behind any of those recommendations, which is one of the things I talk about in the book and explain why there’s no science behind these things. Everybody finds it easy to add things. It’s easy to add things. It feels empowering. It feels positive and it’s exciting and new. Nobody wants to subtract things from their diet. That’s where the power is because taking things out of the diet feels negative. It feels depriving. It’s harder. But some of the most powerful changes you can make have to do with subtraction. If you add things to your diet, you will see little to no improvement. You may even get worse, depending on which intervention you’re using. If you subtract the right things, you can see benefits within three days to three weeks. It’s very substantial. The psychology of that is challenging, though, because nobody makes money telling people what not to eat!

Dr. Eric Westman: I remember it was very influential for my teaching because I would not just say, “You can’t have this,” and get the “no-no list.” No, bread, no pasta, no rice, no fruit. I totally switched my discussion of the new program to you can have, yes, bacon and hamburgers, and look at all the things you can add in that you thought you could never have again. I think it made a difference. Right now, I have a list of the foods on the wall and a big poster. It’s very helpful to teach from it. Some people look up there and their eyes express, “Oh, my gosh. I could never do this.” Once I explain that after a day, your hunger’s gone, the cravings go away, you won’t believe it unless you try it, I can usually barter for a day of subtracting all of those junk foods.

My approach is all or nothing on one day of the mindset and like with taking a Band-Aid off, you want to do it quickly. There’s less pain. But I can see that in certain circumstances like severe mental illness, you’d want to do it more gradually. Again, as a just caution, to reiterate that if you don’t have stable mental health or if you’ve had difficulties, you want to do this with a doctor who understands how to monitor your mental health and then to get you off medicines safely if needed. Don’t just try this on your own without supervision. It’s my caution even with severe medical illness. You want to do this with someone who understands and is trained in it.

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