Introduction to Dr. Shebani Sethi
Dr. Eric Westman: It’s my pleasure to introduce Dr. Shabani Sethi, who is a psychiatrist. Normally, I talk about obesity and diabetes reversal – metabolic illness that occurs below the neck – but perhaps the same issues go on in the brain, which is a little internal medicine humor. That’s my background. The brain’s just another internal organ. We artificially have a separation between the body, which is totally connected.
Please tell a little about yourself, for someone who is brand new to who you are and the work that you do.
Background and work
Dr. Shebani Sethi: Thank you for having me here today. It’s a pleasure to be here. I am a psychiatrist, board-certified in Psychiatry as well as Obesity Medicine. That’s partly because of inspiration from you and the work that you’ve done over the years. I run a Metabolic Psychiatry program at Stanford. I am an associate professor, and I see patients, but I also run clinical trials.
Dr. Eric Westman: You spent some time at Duke, I recall, some pre-pandemic years ago, or even before that. How did you get involved in medicine and psychiatry, and then ultimately the work that you’re doing now? What was that pathway?
Dr. Shebani Sethi: You mentioned Duke. It brings back a lot of great memories. A lot of my early years in both medical school and training were while I had the pleasure of working with you. I saw a lot of obesity, which was an issue. Weight gain and mental health were also issues. I often saw that we silo ourselves a lot in different fields, with mental health, and with internal medicine.
It dawned on me when I was working with you and others, that there is this relationship, and we shouldn’t ignore it. One of the deans at the medical school at Stanford said to graduating medical students several years ago that “the greatest discoveries occur in the intersection between fields.” I completely agree with him because this is something that I think can often be overlooked. Especially, there’s a gap in care. Folks aren’t necessarily having their mental health addressed, or their weight or metabolic dysfunction addressed, while they’re seeing a psychiatrist, or vice versa. It ended up being something that was helpful to at least home in on during the early years. I think working with you was also very inspirational because I saw that you made strides to make efforts and to actually put those things together.
You had a patient who had schizophrenia – and treatment-resistant schizophrenia, if I remember. I saw improvements in that patient with the hallucinations. At first, I was very skeptical. Was this actually something that was helping the patient for psychiatric symptoms? I wasn’t skeptical about the weight loss or the insulin resistance. Interviewing the family or the caregivers of that particular patient, seeing all the medications that this patient was on over the years, and then seeing other patients that I have seen over the years as well, it’s very rewarding to see what an intervention can do. Like, a dietary intervention for improving mental health outcomes. That’s what got me very interested in understanding nutrition better and realizing that I needed extra training in the Obesity Medicine aspect in order to get deeper into how I can apply that to those with serious mental illness.
Going into Psychiatry
That’s really where it started for me. I went into a psychiatry residency training program knowing that I wanted to focus on metabolism and obesity, as well as eating disorders. I carved out this path in residency, created it in our program, and offered it to residents. Now, I get to train other residents, see patients, and integrate these two fields that I think should have been integrated a long time ago.
Dr. Eric Westman: To recap, you went to clinical trial training, or had it along the way, and started doing research studies. Which, in contrast to other psychiatrists who are in this area, they’re writing books and being very clinical. I am reminded of the work we did 20–25 years ago that was starting to assemble the metabolic changes for obesity and diabetes. It was different because I knew that people could lose weight on a low-carb diet. We just didn’t know it was safe.
Let me give you the baton to say, after 20 years, we know it’s safe. Now you’re exploring how it works for mental illness. How do you see what you’re doing and where you’re starting in this big field? Schizophrenia, I don’t know how many people like Doris (former patient) will be improved like that. Even if there’s a fraction of folks, it’s just a devastating disorder. Do medicines really help a lot of the mental illness that you deal with? Or is it like a Band-Aid? Like treating diabetes or managing it with medicine really doesn’t fix it.?
Trials
Dr. Shebani Sethi: These are great questions. So first, I just want to say, 20, 25 years ago, you’re right. So much time has flown by.
One of the things that struck me was when you saw your patients, you treated them like family. That’s very rare. And you had books, I think, that you took out and showed, and it is rare to see physicians like that in this day and age.
I know I’m going on a bit of a tangent here, but I do want to point this out because I think it’s very rare and special. I think that did inspire me to go into the clinical side in the way that I did. But at the same time, you were also doing research. So you had this program of a physician-scientist type.
I didn’t go into the Duke program thinking necessarily that I was going to be a physician-scientist. I didn’t necessarily have plans to go into research, but I did research. I started with HIV drug resistance research in medical school, which gave me good, robust training in clinical trials and research in general. In residency, I got into a drug trial where I was looking at an obesity drug, Qsymia, in binge eating disorder and bulimia. It was an eating disorder-focused RCT study. That, by itself, and metabolic psychiatry really came about as, is a metabolic intervention actually improving mental health conditions? Is it improving psychiatric outcomes?
In this trial itself, there’s an obesity drug, what we call “metabolic medication,” that is actually improving a psychiatric outcome by itself, like binge eating or purging. The weight, of course, is also improved. But at the same time, the eating disorders are improving as well – the symptoms. So that was also another kind of confirmation to me that we’re heading in the right direction. There are different factors, probably different tools, that can be used, and metabolic interventions that can be used to improve psychiatric outcomes. A lot has been studied on that, and more is being studied.
With the ketogenic diet specifically, I realized the more patients I was treating, I couldn’t be this one physician treating a patient and then have a clinic. That, to me, felt like I needed to make sure other people were aware of this. I need to make sure that it’s written in the literature. That’s why I went into the research piece more. I did this pilot trial with the ketogenic diet in schizophrenia and bipolar disorder as well and looked at the metabolic outcomes and psychiatric outcomes. I adapted a lot of your protocol with others and my experience with folks with SMI (serious mental illness).
That was what led me to do it, to answer your question regarding that. The other question you mentioned is about the drugs themselves and how effective they are in this population. The objective of this study was to do a proof-of-concept study. Look at are the metabolic outcomes improving. Because we know that a low-carbohydrate or ketogenic diet is helpful in obesity and helpful in insulin resistance. But is it helpful in those people who have serious mental illness, who also have medications on board that make it harder for them to lose weight? So that’s one question.
Dr. Eric Westman: Many of these psychiatric medicines cause weight gain. Take the history: “I was depressed, I was put on a medicine, I didn’t know what was going on.” And now they’re 100 pounds heavier. I often shake my fist at the psychiatrists who aren’t paying attention to the weight. But you’re saving the life of the depression, and you might not focus on that 100-pound weight gain. So treating a side effect and then seeing if the psychiatric disorder gets better. You’re not directly saying it’s going to fix the psychiatric problem, but at least it can mitigate the weight gain of the medications that are used. That’s a great place.
Weight gain a side effect of psychiatric drugs
Dr. Shebani Sethi: That was one of the questions: can this actually help with that side effect that is a problem? The side effect could be weight gain, like you mentioned, or it could be dyslipidemia, or it could be high blood sugar and insulin resistance that can come about. They can be normal weight and just have insulin resistance.
One, it was a question of is this intervention going to help these patients who are on these medications. Then two, does it help their psychiatric symptoms? What’s the signal that we’re getting?
It ended up being very encouraging. We can go into that later, but I think the idea behind the study was that. Sometimes I get the question of, why not just have everyone enrolled, and why not include someone without metabolic dysfunction? I did that on purpose because I wanted to ask that first question that we talked about, is this going to help people who maybe discontinue their medications because the side effects are not something they want? They’re monitored by psychiatrists, their A1c is monitored, and their weight is monitored, but it’s not treated. There’s this idea, I think, amongst my professional community, that they go to a specialist to get that addressed, or a PCP to get that addressed.
I think we need to take a little bit more, as a community, responsibility for those pieces. The effectiveness of the medications for serious mental illness is variable. They can be life-saving, but they’re variable based on the patient. Mental health conditions are not homogeneous; they’re very heterogeneous, and so it becomes quite difficult. It’s a difficult-to-treat condition.
Dr. Eric Westman: I would like to first start with what your latest thoughts are about binge eating disorder. I was trained as an internist and got very little nutrition training. When I finally got into the weight loss world and studied the Atkins diet, which was taboo, nobody really had studied it. Then I started learning that in the dietitian world and the psychiatric binge-eating world, limiting a food group, like cutting out carbs, was taboo. I was like, “You can’t do that; that goes against everything.”
I’d like to tell you just a brief story about someone who saw me. She was admitted to the psychiatric ward at a local prominent university hospital, and they wanted to put her on medicine. It was actually anorexia. She was down to about 88 pounds, and she should be 140.
When she was there, just to see the confusion here, in a book she wrote afterward, she said, “I tried to tell them that it was my stomach that was the problem, not my brain.” Yet, they wanted to give her medicine for her brain. And she said, “I’m not in the right place.” This really wasn’t a psychiatric issue primarily; it was from the gut.
It turns out that by cutting out the food she was intolerant to, she figured out that she had a problem. It included highly processed foods, but also just some vegetables that people normally can have. It was probably gluten involved and all this. She did a very strong elimination diet after I had met her and said, “I really don’t know what to do.” She fixed herself finally by figuring out what foods were causing the problem.
I have to say that the radical nature of cutting out junk foods as a treatment for binge eating is not radical to me anymore. When someone says, “You can’t cut out…” Well, it’s just a different paradigm. What we’re looking at is that these are foods that you can’t control, and of course, you’ll binge on them. So why don’t we stop eating those foods? But for years, that was thought to be, in fact, probably in your circle, in your sphere, you’re looked at as doing something bizarre because the tradition is that you want people with binge eating disorders to eat a wide array of food.
So, what do you know about it? You explain what binge eating disorder is and then what your research has shown.
Binge eating disorder and research
Dr. Shebani Sethi: The eating disorder world is a kind of area that I had a lot of interest in early on and worked in quite extensively. What I’d say is, with binge eating, it’s characterized as a disorder where you’re consuming a large quantity of food that’s associated with basically a loss of control. The patient endorses a loss of control.
Some folks can binge eat that don’t endorse loss of control that’s associated with binge eating. There’s a distinction between what the field calls binge eating disorder versus just binge eating, some subjective binging. You also have to have certain symptoms in addition to that, which match the criteria of eating alone or in shame, feeling guilty afterward, eating more than you intended, but also eating when you’re not hungry and still eating. It’s a maladaptive pattern of behavior that ends up happening.
That’s how it’s been characterized. With anorexia, we think of it as a neurocognitive condition as well. It’s interesting the story that you mentioned because oftentimes, with anorexia, they do endorse problems in the stomach.
It’s important to have a shift in the paradigm of looking at metabolic pieces in the evaluation of psychiatric care. The eating disorder world has been primarily psychology. Some psychiatry has been there.
I am probably a little bit outside of the box in this area because I do look at medications for eating disorders as obesity drugs. I do look at changing the diet as part of the eating disorder. I’ll tell you the reason why, there has been a lot of literature that there’s a dietary restraint hypothesis. That hypothesis says if you restrict yourself in some way in one area, then you’re exacerbating your eating disorder symptoms.
That’s primarily been based on research that is done with low-fat diets or, it’s not been in, say, a low-carbohydrate or less ultra-processed food environment. By not looking at the other side of the coin, by not looking at, this is not a normal diet, to begin with that we’re eating right as a standard American diet, and what is the standard American diet doing to our cognition? We know it affects the default mode network in our brains. We know it affects the reward pathway. We know it affects cognition.
If cognition is changing and the structure and function of the brain is changing with food, and if we’re not eating well, it leads to increased inflammation or more insulin resistance. Then we’re creating psychiatric symptoms. We don’t know exactly what the mechanisms are, but that’s my take on this. I think that we could get into the whole health-at-every-size movement, and we can get into that side of things. I think there are good intentions that, ultimately, the community has. However, I think what’s being ignored is the metabolic dysfunction that is in the brain, centrally and peripherally, in these conditions.
That’s where the field needs to be moving forward. That’s why, as part of the case series that we wrote, together in conjunction with other eating disorder experts, we agreed that this method, a low-carbohydrate, ketogenic approach, has actually been helpful for binge eating symptoms. We theorize that it’s dampening the reward pathway, the dopamine response. It’s decreasing hunger. So, there are a lot of those physiological changes. You’re also stabilizing glucose, you don’t have these peaks and troughs of glucose, where you’re affecting the insulin release as well. The idea is that, once you are stable, you don’t necessarily feel like you have those cravings. It’s physiological, but also, cognitively changing.
Dr. Eric Westman: I used to be in the nicotine world, the smoking cessation world. For about 10 years, I worked on clinical trials using medication, mainly nicotine replacement, the drugs that led toward Chantix and all these other ones.
I was primed to think of food as an addictive substance. Then the whistleblowers came out, saying the food industry is making food that you can’t stop eating. You don’t see “Lay’s potato chips, you can’t eat just one” anymore. I think they would get into trouble with that kind of advertising now.
The idea that food can be addictive and that with binge eating, abstinence might be a cure for it, to me, seems pretty natural. But to the world around us, the treatment world, it still seems kind of bizarre. Like, for dietary obesity or diabetes reversal, it’s so obvious to me that you would want to cut carbs because diabetes is a problem of too much sugar. We do buck these paradigms. I admire your approach, which is, let’s get some real science, let’s get some studies going. That’s what’s needed for replication and for persuading the medical community, which thinks it’s based on science (maybe not all the time).
Are you doing any work now with binge eating, or what are you doing?
Ultra-processed food
Dr. Shebani Sethi: I would add that the evidence for that hypothesis was not very robust with the dietary restraint hypothesis. It was very focused on one type of way of eating and looking at it, like low-calorie and low-fat. That’s not how everyone necessarily should be eating.
Regarding ultra-processed food, it’s really interesting that you mentioned nicotine. I remember that you had a background in that and you had worked quite extensively in that area. I recall that. I think the idea of abstinence is a great one. It works, and research shows that. Why we don’t think about ultra-processed foods that way is a question. At least harm reduction could be taken as an approach.
Hopefully, with Robert Kennedy’s opinion on ultra-processed food and wanting that away from schools, I think it will be a huge improvement for the food supply. Even if you think about big tobacco and big food, this is not that different. I have a 5-year-old son in kindergarten, and I don’t want him to come home with Pirate’s Booty every day. So, I agree.
Research with children in school
Dr. Eric Westman: Have you explored that area? You’re like me, you’re an adult practitioner. Can you do research with children in schools? Is that on your radar?
Dr. Shebani Sethi: Unfortunately, no. I’m not a child psychiatrist. I treat adults. I do treat eating disorders, and I will treat those that are in the teenage spectrum.
But regarding binge eating and the question you had about it, and how that might be related to the work I’m currently doing, we’ve designed a randomized control trial that we’re waiting for IRB approval on at this point at Stanford.
Ketogenic diet in schizophrenia, bipolar disorder and major depressive disorder
It’s looking at a ketogenic diet in schizophrenia, bipolar disorder, and major depressive disorder. So, it’s transdiagnostic. It’s the next step from the pilot study that we did. This would be an adequately powered trial. A lot of the secondary outcomes that we’re looking at, the primary outcome is quality of life, but a lot of the secondary outcomes will include binge eating, for example. I’m going to do a sub-analysis looking at that, but I’m not necessarily doing a trial specifically only in binge eating disorder.
I’m focusing on the main SMI population right now, just to get to the more prevalent conditions first, with the metabolic issues especially, where rates are so high.
Dr. Eric Westman: When you’re designing a study like this, you could take the worst of the worst who nobody else wants to treat. That’s kind of what my clinic has turned out to be, where other doctors don’t. They’re on 12 medicines, and they don’t care what I teach about because they’re overwhelmed. They really can’t handle it.
But then, that’s putting a strain on a diet. Now, thinking about mental illness, if it helps a percentage of folks, or let’s say it’s just a mild treatment, and you start with the sickest of the sick, while the IRB might say, “Okay, sure, no one else can help these people,” you might not give the diet a fair shake.
I’d be curious, are you targeting folks trying to get people who are not able to be managed on medicines? Or early on? Or it would be ideal if you took new diagnoses, incident mental illness, and then randomized folks to either diet or treatment. I don’t suppose an IRB is going to be ready for that yet.
Choosing folks for the study
Dr. Shebani Sethi: That’s a really interesting question. A lot of the folks that come to you, you’re the hopeful doctor.
I think with the IRB, I’m not sure if it would be an issue or not. It’s a good question because you then end up studying a different population, where it’s first diagnosis, first episode psychosis-type of diagnosis, versus someone treatment-resistant for 10-15 years. They are different populations.
I’m trying not to limit the population too much because we do need to recruit enough for an adequately powered study, at least 120 folks. They can have any of the three diagnoses. Even with treatment-resistant cases, I am hopeful about some improvements.
Recently, I saw a study that I’ve been involved in at UCSF, which is also an RCT for patients on a ketogenic diet in schizophrenia specifically. One of the most treatment-resistant cases I’ve seen so far entered that study, and I still saw some improvement.
Maybe not all these assessments can detect all of the improvements because they are designed the way they’re designed, and so we don’t detect all of them.
Dr. Eric Westman: Often I look at the drug company studies. I was reviewing a few today, and 5,000 people were recruited all over the world with dozens of centers. When you’re targeting, and starting with a small group, the other thing I was thinking about is the story of Matt Baszuski. Let’s say you have a super supportive family. I wonder, in your RCT, if you come in, whether someone can follow the diet is really a major factor in whether you’re going to see benefits from the diet.
If you give everyone a drug, but they all cheek the pill and spit it out, you really don’t assess the drug. It’s whether someone is going to follow and do it.
So, I wonder. It seems to me you want people with social support or at least the ability to have the assistance to follow a program. Ideally, it would be a feeding study, like Jeff Volek has done somehow at Ohio State and UConn. You would get the food, a lot of people now use these food-to-home types of programs and delivery services.
Support and food delivery during the study
Dr. Shebani Sethi: We have been doing that with the UCSF study, food delivery. Patients like the meals. They’re pretty happy overall. With the pilot study, we didn’t do that. We taught them, and we provided them with books, recipes, and health coaching. They received support, and surprisingly, the adherence was high, 90% or more. This wasn’t a mildly ill population at all. I think the average suicide attempt at baseline was about one or two for this population.
I would say that the way that it’s structured is really important, making sure they know that. We had weekly appointments with them, making sure their family was on board or a caregiver or their partner, coming to a support group, or making sure the family understood or knew what to do to help them.
We would measure their ketone levels, and we’re planning to do the same thing for the RCT to make sure that there’s support around. I think that matters a lot with this population in particular.
I think a feeding study would definitely, inpatient, be a lot. That’d be more expensive, and it would be more recruitment. But I’m hopeful that we’ll be able to do that on an inpatient basis.
Dr. Eric Westman: If there’s interest, it’s not all that expensive. We did a pilot study using the Duke student-run program that fed people once a week, and I got to change the food delivery for some people. We gave them meat and veg, not fruit, and when we just delivered it once a week, a patient reversed her diabetes and came off 600 units of insulin with just the weekly contact.
There are a lot of ways if you’re finding there’s trouble with adherence. It’s really important to say that that didn’t really test the ketosis part of it. I’m wondering, has there been any research on drinking ketones or the keto gummies, or those sorts of things with mental health? Have you seen anything in that regard?
Exogenous ketones in mental health
Dr. Shebani Sethi: It’s still new, looking at exogenous ketones in mental health specifically. I haven’t researched exogenous ketones myself. I have used it in clinical practice occasionally, especially in times when they know that they tend to have, let’s say, mania in the spring. In March, maybe in addition to their medication, we want to just kind of top off a little bit. It does help with some prodromal symptoms, I have found, and that’s been helpful for a lot of my patients. As far as the research, I’m not as familiar with that for mental health specifically.
I don’t think it’s going to be the solution. I think the kind of endogenous approach of doing a ketogenic diet is going to be so different.
Dr. Eric Westman: As you know, I relaxed my criticism in that, it’s not like the keto diet has penetrated pop culture to that extent, so these other things could be adjuncts, of course.
The interesting thing in the medical internal medicine world is there’s a drug that causes ketosis. It’s the SGLT2 inhibitor – it’s used for diabetes and heart failure. They figured out that the mechanism of heart failure reversal is probably the ketosis. Now studies are being done of exogenous ketones and even IV ketones to look at heart function in a very detailed way. And yet, the investigators don’t know anything about a keto diet. So, it’s coming around. They’re kind of learning that ketones are good for heart failure, but how do we get ketones?
We might be seeing the medication that’s being used, the GIP and GLP-1s, because they’re so strong. So many of the patients that I see other doctors using these medicines for, they must be in ketosis. The weight loss is just really dramatic.
I wonder if there will be any reports of mental health improvements with the second generation ones – that’s the Zepbound and Mounjaro. The appetite suppression is so strong. If you don’t have a GI side effect from it, I think it’s going to help a lot of people. They need to realize that it’s the diet when they’re done with the drug, or they’re just going to go back to where they were.
Dr. Shebani Sethi: That’s interesting. I know that some trials are looking at GLP-1s in alcohol use disorder. There was a study with binge eating disorder as well, and they have good outcomes. I believe there’s one that’s starting for OCD. As far as whether it’s semaglutide or whether it’s Mounjaro or tirzepatide, I don’t think it’s the newer one. It’s the sulfonylurea type most likely.
Dr. Eric Westman: So the first generation. Then there’s the second, and then there’s going to be the third. It’s fascinating to see that develop. I sat in a board meeting of the Obesity Medicine Association where the Novo Nordisk team came and said, “Here’s our plan for the next 10 years of developing these drugs.” And it happened. It was pretty amazing to see that progress. We have the internet, we have these stories of dramatic improvement. We had the Matt Baszucki case, reversing his disease. The parents now happen to be philanthropic and are funding a lot of research in mental health.
What’s your take on these individuals and cases? Is this going to be a big deal in terms of metabolic psychiatry? I try not to be too sensational about things. The movie, The Magic Pill, basically showed this unbelievable transformation of a child behaviorally where they just took the child off sugar and everything got better. Is this the tip of the iceberg, or is this not going to be a big deal? It’s hard for me to gauge using my internet sleuthing.
Using metabolic psychiatry
Dr. Shebani Sethi: I’m the same in the sense I don’t like to sensationalize things as well. The Baszucki family supported the pilot trial at Stanford, so I am very grateful to them for that. They’ve generously funded many other researchers now doing trials that are focused in this area as well, with different conditions and with ketogenic diets specifically. That’ll be exciting to see the results in the future for that.
They’re also digging into mechanistic aspects of the study, too, with endoscopy, as well as fMRI, and brain metabolism, looking at default mode networks and changes. I’m excited to see what the field will show. As far as the case reports that you’re hearing here and there, from our pilot, I’ll say that across the board, even if you look at the people who weren’t completely adherent, and they were semi-adherent, but they’re still 60–80% of the time in nutritional ketosis, they still had a benefit.
When you look at the overall CGI improvement, if it’s the Clinical Global Impression, our standard scale which we could use both in schizophrenia and bipolar, was 79%. Seventy-nine percent of them had at least a one-point change, and that is, in our world, clinically meaningful.
Dr. Eric Westman: What’s the range of the CGI? Is it a zero to 10?
Dr. Shebani Sethi: It’s like a one-to-six kind of range.
Dr. Eric Westman: One to six. So a one-point change is a big deal in that world.
A success story
Dr. Shebani Sethi: Yes, it is. What we did was, we made sure that it was two different physicians, and then we took the average scores to reduce bias as well.
I didn’t necessarily measure cognition with the kind of validated cognitive scales in the pilot. But in the RCT, I plan to do that. In other trials right now, we are seeing changes in the cognitive aspects of these individuals.
I saw a patient today who didn’t necessarily notice a change in himself but has been on a leave of absence from UC Berkeley for five years. He has a diagnosis of schizophrenia. His mother notices changes in conversation, speech, and a lot of different aspects. That is a very common thing I hear in a lot of patients. I am hopeful that this will help a significant portion of the population. We can’t say it helps everybody because that’s not true. But it is helping a lot of people, and I think it’s just one additional tool in the toolbox of a metabolic intervention that can be helpful. To give someone, especially with this, another tool in addition to the medications and therapy they may be having, feels empowering for them. They feel like they’re in control, that they can do something about their illness. You do see changes, and then it becomes rewarding and meaningful to see that.
Serious mental illnesses
Dr. Eric Westman: The acronym you used, SMI, is that serious mental illness?
Dr. Shebani Sethi: Yes, serious mental illness. Sorry, I get to use acronyms a lot.
Dr. Eric Westman: Schizophrenia, bipolar, people who can’t hold a job sometimes. So schizophrenia, bipolar, and major depressive disorder are considered serious mental illnesses?
Dr. Shebani Sethi: Yes, exactly. With schizophrenia, for example, 33% of them end up in remission. There’s a lot that’s not in remission and will end up going to the ER and getting hospitalized, it’s a cycle. The quality of life is challenging. They may not be able to hold a job, or they may have problems, or they may be on disability.
This patient in particular is actually going back to school. He’s going back to UC Berkeley this year. He started a ketogenic diet two months ago, but he’s not necessarily seeing an improvement yet. But it’s really interesting, after five years, he started a ketogenic diet and now wants to go back to school. The family is noticing cognitive improvements. This is just an example from today. I do have a lot of stories every week that I see, and it’s heading in a hopeful direction for me.
Dr. Eric Westman: I’m so happy that you’re doing the hard work of writing clinical trials, going through that. Most people don’t appreciate that.
In today’s world, there’s some influence there, and it is a lot of work, and yet really important to do for us to know what proportion of people will benefit. Maybe there are subgroups of folks who will be fixed. But that can’t be determined by just looking at internet stories.
Dr. Shebani Sethi: It won’t move the needle in our field at all with clinicians, and you know that. You need the science, you need the publications, you need the randomized control trials to actually convince us to even think of it as a treatment.
Dr. Eric Westman: After some time, I’m not so convinced I need to change the needle of the pharma world of internal medicine. I’ve kind of given up. If anyone gives you grief about it causing harm, you let me know.
Dr. Shebani Sethi: I’ll let you know.
Dr. Eric Westman: Send them Professor Noakes’ edited textbook that we all contributed chapters to. Especially when there’s a big or reasonable risk of benefit here, there’s really no harm.
Dr. Shebani Sethi: I think the problem sometimes is when people are not educated on the topic, they have fear around it. I think you might have taught me that. I think I saw yesterday on Epoch Times, “Dangers of the Ketogenic Diet.” I haven’t even read it yet, but it’s unfortunate.
Dr. Eric Westman: Yes. People read that, and many of them respond to that. So anyway, what a great chance. Thank you so much for letting me catch up with what you’re doing and sharing your work with the rest of the world. The world has changed.
I’m at a meeting with the SMHP (Society of Metabolic Health Practitioners). One of the fellows who’s in Dave Feldman’s lean mass hyper-responder coronary artery angiogram study is at the microphone, and he’s telling his result at a year. I’m like, you’re not supposed to tell us that! Yes, you’re studying, and you’re supposed to, and he says, “I don’t care,” But he said he did not have progression of any atherosclerosis over a year in that study, and yet we’re still waiting on a publication there.
It’s probably stalling to have people be able to respond, and so time has passed, and I hope you don’t have to experience any of that. I wonder, have you connected with the other Stanford nutrition group? I have kept up with Christopher Gardner and that group a little bit.
Pilot study – Stanford chose it as one of the top scientific advancements of the year
Dr. Shebani Sethi: Interestingly, you asked that because, after the pilot study was published this year, Stanford said it was the most-watched video of 2024. As we’re reflecting on the year, Stanford chose it as one of the top 10 scientific advancements of the year.
I was very humbled by that and excited because I did this pilot study, even though it was really meaningful for my patients, I didn’t think that it would end up in Stanford’s top 10.
Collaborating
Christopher Gardner messaged me after the pilot study was published and was like, “Wanted to know if you’d want to collaborate on a study?” Then he had some concerns about the ketogenic diet with heart disease, and so we chatted a little bit. We didn’t end up collaborating, but that was the last of the conversation.
I did speak with Mike Snyder, and we’re going to be working together on a deep omics profiling in this RCT itself, so looking at proteomic, metabolomic data, and epigenetic data in this study. So, maybe not Christopher Gardner’s group, but we’ll be collaborating with the genetics group and some other folks. There’s another researcher who does research in ketogenic diets at Stanford. It’s in animal models, and he’s looking at the precursor ketones and how that might be important.
I think there’s a lot of excitement, especially in the neurology world, the epilepsy world. There’s someone else who reached out to me from Stanford, so there’s definitely some community being built here, and I’m excited about that. We preprinted a definitional metabolic psychiatry paper just recently, and we’re hoping we’ll find a good journal for it soon. But that is more the umbrella of different metabolic interventions, including a ketogenic diet and how that would mechanistically be helpful for the brain. So yes, excited.
The ketogenic diet and childhood epilepsy
Dr. Eric Westman: If anyone asks or is skeptical about how food affects the brain, just teach them about the ketogenic diet for childhood epilepsy. It can take away seizures overnight. It’s like 15%, it certainly can affect the brain. Eric Kossoff, who still is in the field at Johns Hopkins, laments that most of the neurologists still use drugs for children with epilepsy.
While we have all of this, don’t get too hung up on having to fix and change the minds of the drug prescribers.
Dr. Shebani Sethi: The last thing I’ll say is that I have started an initiative because I really care about the evidence base. And then I care about access to care.
The two things for me that I feel are my purpose in my career, those are the two things. Access to care is something I’m trying to work on. So I’m building this virtual, remote monitoring solution for giving metabolic psychiatric care to other clinics, and other providers. They don’t necessarily have to adopt the protocol or train themselves or learn how to, but we support them and their patients. That’s kind of the way that I’m thinking about providing a solution.
Dr. Eric Westman: Excellent. The tool that I teach with food, you don’t need a doctor’s prescription. You don’t have to have it. Doing it through the grassroots, teaching people how to use food, and having that kind of monitoring and mentoring is a great way to go. Thank you. I’ll let you go. Thank you for chatting.
You can watch the full video here.
