#228 – Why nutrition matters for brain health and how to modify your diet | Dr. Georgia Ede & Dr. Dominic D’Agostino

The ketogenic diet is a low-carbohydrate, high-fat diet that has proven benefits for brain health. Research shows that the keto diet helps ease symptoms of some mental health conditions, including depression and bipolar disorder. But no diet, even keto, is one-size-fits all. Dr. Georgia Ede and Dr. Dominic D’Agostino discuss how diet and brain health are connected, how diet and gut health affect brain health, and how a ketogenic or other low-carbohydrate diets can be tailored to people’s specific needs.

Helpful links

Diagnosis: Diet: https://www.diagnosisdiet.com/

Change Your Diet, Change Your Mind: https://www.amazon.com/Change-Your-Diet-Mind-Powerful/dp/1538739070

Georgia Ede, MD, on Twitter: https://twitter.com/GeorgiaEdeMD

Dominic D’Agostino, PhD: https://www.dominicdagostino.org

Dominic D’Agostino, PhD, on Twitter: https://twitter.com/DominicDAgosti2

Dominic D’Agostino, PhD on Instagram: https://www.instagram.com/dominic.dagostino.kt/

6:51 — Dr. Georgia Ede describes her interest in nutritional science for mental health

Psychiatrist Georgia Ede, MD, works with patients experiencing mental health issues to change their diet to help the brain.

My interests broadened to not just food science, nutrition science, but also to brain metabolism and how we can use the science of brain food to feed the brain better. And as a psychiatrist, I became really interested in how I could use not just nutritional strategies but metabolic strategies to improve the mental health, metabolic health, and overall health of my patients. My work has evolved over time to include not just nutritional principles but also metabolic principles. Now the cornerstone of my work has become—in the past 5 to 10 years—the ketogenic diet, which as you know very well, is a really powerful metabolic intervention that I wish more people knew about, which is one of the reasons why I wrote the book.

16:45 — Metabolic health is tied to brain health

The brain needs to be able to use glucose effectively. However, most people in the United States aren’t metabolically healthy.

If you’ve been eating the wrong way for a long time and your metabolism is damaged, which is the case for most of us, the brain will not be able to use glucose. You won’t be able to metabolize carbohydrates properly, and you and your brain won’t be able to utilize glucose efficiently or effectively the way that it should.

23:16 — A ketogenic diet vs medications for mental health

According to Dr. Ede, a ketogenic diet has fewer side effects than medications used to treat mental health conditions or nervous system disorders.

It turns out that there are actually many, many similarities between bipolar disorder and epilepsy. And I thought, “Well, we’ve known for well over a hundred years now that ketogenic diets have the ability to essentially stop seizures in their tracks for many, many people. And that’s powerful evidence that this is a brain-stabilizing diet. This diet stabilizes brain chemistry… So it could potentially also be the case that it would stabilize brain chemistry for people with mood swings.” And that just made intuitive sense to me. And there had already been some papers written about that sort of hypothesizing. And that’s when I became interested. And that was maybe 10 years ago or so. That’s when I became interested in the potential of the ketogenic diet to improve the brain health and the mood and so forth of my patients. And the more experience you get, the more you see the power of these diets. I mean, when you use these in clinical practice, there’s nothing else that works as well as the ketogenic diet and not just better in most cases than medications alone—or even in medications at all—but with many, many fewer side effects.

27:19 — A ketogenic diet can be tailored to prevent side effects

The ketogenic diet is often used for weight loss. However, such a diet can be customized to prevent weight loss in people who need to ether maintain their weight or even gain weight.

You can formulate the diet to be weight neutral by constructing the diet so that the majority of the ketones being produced inside your body are coming from food as opposed to from your body fat. So you can do that. And I have had some normal weight patients and even some slightly underweight patients and some very physically fit patients, very athletic patients who did not need to lose any weight, adopt this diet and experience remarkable improvements in their mental health. And that had nothing to do with weight loss. So, at least in my experience, I see the weight loss as a side benefit but not necessarily the goal. And some of my patients do not need to lose weight. Some of my patients don’t want to lose weight. And some of my patients actually need to even gain weight.

32: 51 — Gut health and mental health are connected

Three major factors that are driving forces of psychiatric illness include inflammation, oxidative stress, and insulin resistance. And diet and gut health inform these factors.

The gut is the first line of defense. If you’re eating the wrong way, the gut is going to be the first to experience the impact of that. And that can be anything from foods that are physically irritating, mechanically irritating, to the gut that were never really meant for human consumption. Things like grains and legumes and certain types of seeds and all the way to foods that are very difficult to digest and foods that cause inflammation and that even contains certain toxins. So there are some plant foods that naturally contain toxins, which are damaging to ourselves. And so the gut will be your first line of defense. Your gut will be the first to experience the effects of an unhealthy diet in these = different types of ways, whether it’s mechanical damage or whether it’s biochemical damage. so a lot of my patients who have mental health symptoms, many of them will also have poor gut health as well.

39:00 — Diet is highly individual

The ketogenic diet, along with similar diets, exist on a spectrum. You can tailor such diets to fit your unique needs.

That’s exactly what I recommend in the book that I’ve written: to start with a Paleo diet and then gradually transition to a ketogenic diet if necessary. And then even experiment with a carnivore diet if necessary. So sort of different levels of intervention, depending on your goals and on your personal metabolism and your personal food sensitivities. So it just gives people different choices and it allows people to kind of personalize their diet to their own needs. And I think there really isn’t a one-size -fits-all diet. And this coming back to your CGM point. One of the ways that I like to use CGMs is to again sort of foster curiosity about metabolism. People love to know what’s going on inside of themselves. It gives you a real window into how your body’s working. And you can see, for example, what that bowl of oatmeal is going to do to your blood sugar in the morning. And I’ve seen this too many times to count. Oatmeal, in particular, can have a really profound impact on blood sugar, even if it’s steel-cut oats.

42:02 —CGM can teach people how foods and diet strategies affect their health

Dominic D’Agostino, PhD, explains the unique insights and food nuances you can glean from continuous glucose monitoring (CGM).

We have these massive mangoes, and I cut it and I ate it almost like a crunchy apple. And I looked at the Levels app, and my CGM was like nearly flat, but the night before, I had one that had fallen on the ground. It was kind of like a dessert really. But the sugar spike was—It looked like two different kinds of foods. I actually enjoyed the crunchiness of the semi-ripe mango. So yeah, there are insights like this that you would never, ever understand or acknowledge. The oatmeal thing too is something that you mentioned that I also observed. Probably one of my biggest spikes ever came from a bowl of Quaker Oats. Just a sprinkle of cinnamon on top too. And it spiked me really high. So it was almost like drinking Coke. It was really eye-opening.

44:57 — Following a low-carbohydrate diet will generally reduce insulin levels and triglycerides

Even in just a short time (a few weeks), a low-carb diet can help improve metabolic health parameters, which in turn, could help ease symptoms of mental health issues.

Carbohydrate is the macronutrient that spikes insulin the most—has the biggest effect on insulin. (It’s not that it’s the only thing that affects insulin, but it affects insulin the most.) if you lower your carbohydrate intake, that will drop your insulin. And that’s a really effective and really predictable response. And you can change it in just a matter of weeks. And the same with triglycerides. So triglycerides—which are part of the standard cholesterol panel—they almost always drop like a stone on a low-carbohydrate diet. You can see people’s triglycerides drop by hundreds of points in just a few weeks by getting their carbohydrate intake under control and following a ketogenic diet very, very reliably. Not in every single case, but in nearly every single case, we’ll drop those triglycerides. And that’s really, really good news for your cardiovascular health.

47:40 — Some psychiatric symptoms have links to higher C-reactive protein levels

A C-reactive protein (CRP) test can help gauge levels of inflammation in the body, and it could be a marker related to mental health.

CRP will give you one window into your inflammatory status. So I always measure that. And there’s some literature also to suggest that people with depression, particularly with depression with psychotic features, they are more likely to have an elevated CRP. And this makes sense when you think about it. And they’re also. less likely to respond to antidepressants. And this makes sense too when you think about it, because if their depression’s being driven by inflammation as opposed to being driven by a neurotransmitter imbalance, then a medication that is targeting neurotransmitters—it’s not going to be particularly helpful.

48:42 — Dr. D’Agostino summarizes one of Dr. Ede’s studies on the ketogenic diet and mental health

The small study yielded good outcomes with patients on the ketogenic diet.

Findings that the ketogenic diet is safe, feasible, and associated with unprecedented psychiatric and metabolic benefits have just been published in Open Access Frontier Psychiatry. So the question you pose: Can eating a ketogenic diet improve symptoms of serious mental illness? This included 31 patients. Bipolar, there were 12 of them. Major depression, schizophrenia… You describe a ketogenic diet, 75% to 80% fat, 15% to 20% protein, 5% carbohydrates. Symptoms improved in 100% of patients. And 43% achieved clinical remission. And 96% of patients lost weight, and 64% of patients were discharged on less medication. So that’s just a summary.

56:59 — A ketogenic diet may also help ease some menopause symptoms

Dr. Ede explains how aspects of menopause and perimenopause are connected to metabolic health.

Your metabolism changes when you go through menopause—in some ways in which we understand and in some ways which are very poorly studied. So lots we could talk about there. But I just want to say to women who are out there, who are in your forties and fifties: do not shy away from a ketogenic diet. In fact, it will be your best friend if you’re going through menopause and having some of the physical, emotional, and other types of changes that you’re experiencing that are making you unhappy with your body and with your emotional and cognitive health.

Georgia Ede (00:00:06):

The gut is the first line of defense. If you’re eating the wrong way, the gut is going to be the first to experience the impact of that. And that can be anything from foods that are physically irritating, mechanically irritating to the gut, things like grains and legumes and certain types of seeds, and all the way to foods that are very difficult to digest. And so a lot of my patients, who have mental health symptoms, many of them will also have poor gut health.

Ben Grynol (00:00:33):

I am Ben Grynol, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health. And along the way we have conversations with thought leaders about research backed information so you can take your health into your own hands. This is A Whole New Level, Ketogenic diets for mental health. Change your diet, change your mind. We’ve talked on the podcast before about the cross section of metabolic health and mental health, specifically with Dr. Chris Palmer, who is a Harvard professor and an author of the recent book, Brain Health. This episode is part of a three-part series where we talk about the cross section between mental health and metabolic health, and we’re doing it in association with the Baszucki Group and Metabolic Mind. Our great friend, advisor and mentor, Dr. D’Agostino, is hosting the series. So in this episode, Dom and Dr. Georgia Ede talk about this idea, the practice of metabolic psychiatry. How can you use ketogenic diets to improve mental health? Metabolic psychiatry, what exactly is it? Well, it’s the idea of taking these dietary interventions to improve metabolic health.

(00:02:01):

How do you mitigate insulin resistance over time? And how does poor metabolic health and insulin resistance lead, over time, to poor mental health? What we know is there are many similarities between the interventions taken from a metabolic standpoint to improve certain mental health conditions, specifically things like bipolar disorder and epilepsy. Many people who live with the conditions have seen improvements by focusing on improving their diet, specifically through the ketogenic diet. Eating things like whole foods, removing processed foods, seed oils, and focusing on overall metabolic health. How do you improve your diet and physical activity to improve sleep, energy, wellbeing, overall brain health and metabolic health? One thing they talk about is the idea of how we’re all individual, and how certain things in our diets work for some of us and not others. Even as we eat whole foods and limit processed foods, we have to make sure that we are eating the foods that we metabolize well so that we can improve our overall metabolic health. Dr. Georgia Ede is a Harvard trained psychiatrist specializing in nutritional and metabolic psychiatry.

(00:03:09):

She’s focused on empowering people with psychiatric conditions to reduce or eliminate the need for medications by changing how they eat. She’s got a book coming out in January of 2024, Change Your Diet, Change Your Mind, and Dom. Well, by now, many of us know Dr. Dom D’Agostino. He’s a friend, advisor and mentor to many of us at Levels. And Dom is an associate professor in the Department of Molecular Pharmacology and Physiology at the University of South Florida. Dom’s lab develops and tests metabolic based strategies for targeting CNS oxygen toxicity, epilepsy, and neurodegenerative diseases. The main focus of his lab, over the last 12 years, has been investigating the neuroprotective mechanism of ketogenic diet and metabolic health. Anyway, it was a great conversation between Dom and Georgia. No need to wait. Here is where they kick things off.

Dom D’Agostino (00:04:11):

Well, good morning, Dr. Georgia Ede. Thank you so much for being here. Welcome everybody to A Whole New Level podcast. Dr. Ede is a Harvard trained, board certified psychiatrist specializing in nutritional and metabolic psychiatry. Her passion is really empowering people with psychiatric conditions to reduce, or in some cases in the transition, to transition them off psychiatric medication, to de-prescribe them. And she’s a bit controversial on different topics, but the information that she’s putting out is very well-supported on views like fiber, animal-based diets, data that’s recently emerging. And we’re going to cover some of that. And actually, this topic is covered very nicely in her new book that’s coming out, Change Your Diet, Change Your Mind, A Food First Plan to Optimize Your Mental Health. Welcome, Dr. Georgia Ede. Thank you for being here today.

Georgia Ede (00:05:09):

Thank you very much. It’s a pleasure to be here.

Dom D’Agostino (00:05:11):

So before we begin, I think it’s really important for our listeners to… Many of them may not understand or know your background. And I was familiar with your website… I think I came across your website maybe 2013. I don’t remember exactly when you started, but it must have been 2013 because I saw you… The first time I saw you speak in public, I was really captivated by what you were saying because it was unlike anything anybody was talking about, especially a Harvard trained psychiatrist. And I think that was at the Ancestral Health Symposium, I believe. It was a while back. It was at least 10 years ago. But you were on this topic, it seems like, you were on the topic of metabolic psychiatry maybe almost before anyone else. You were put on my radar at least before anyone else, and you were out there, you took the initiative to get out there and speak about it. So maybe give our listeners a little background about what you do, and also metabolic psychiatry is pretty new topic, and maybe describe a little bit about what that is.

Georgia Ede (00:06:17):

Absolutely. I remember meeting you at the Ancestral Health Symposium. It was 2012. It was the first time I’d really spoken about, as you said, these topics in public in any kind of a professional form. At that time, I was practicing psychiatry at the Harvard University Health Service and was already beginning to incorporate some nutrition principles into my work there. I, of course, had been hired as most psychiatrists are hired, in clinic and institutional settings. I’d been hired to prescribe medication, primarily, but I was also incorporating some nutrition principles into my work. And at that time, I was very interested in food. So the nutritional differences between plant animal foods, some of the natural chemicals that exist in foods that I found surprising and fascinating. I was really diving into nutrition science. I know you have a background in nutrition science as well, Dom. And so that was my focus at the time, and it was really that presentation, which was called Little Shop of Horrors, the risks and benefits of eating vegetables.

(00:07:29):

And that was really a topic that I was really interested in and found just so surprising, so interesting. But then over time, my interest broadened to, not just food science, nutrition science, but also to brain metabolism, and how we can use the science of brain food to feed the brain better. And so as a psychiatrist, I became really interested in how I could use, not just nutritional strategies, but metabolic strategies to improve the mental health, metabolic health and overall health of my patients. And so my work has evolved over time to include not just nutritional principles, but also metabolic principles. Now, the cornerstone of my work really has become, in the past five to 10 years, the ketogenic diet, which, as you know very well, is really powerful metabolic intervention that I wish more people knew about, which is one of the reasons why I wrote the book. Yeah, and I do remember meeting there, and I’ve been speaking about a lot of different topics since then. That conference gave me the first audience to air these ideas, these controversial ideas.

Dom D’Agostino (00:08:45):

Well, fast forwarding more than a decade later, after you’ve put out so much information, you’ve helped so many people, you’ve really been a gift, I think, to this whole movement of metabolic psychiatry, as someone who’s credentialed, someone who’s knowledgeable, someone who has a personal story to add to it, much like Dr. Ian Campbell too. So you spoke recently and you were in Switzerland recently at the Keto Live Conference, which we attended too, and you talked about your upcoming book. And in addition to that, I think you’ve been traveling nonstop it seems, but you were also at the International Society for Bipolar Disorder. I believe that was in Chicago. I didn’t have the opportunity to go there.

(00:09:30):

But maybe share with our listeners here a summary of those stories. We’ll get into the research projects that you’re doing, but how many events have evolved, and upper level conferences have evolved, that actually become a platform to talk about metabolic psychiatry. That was unprecedented at a conventional… I present sometimes at American Epilepsy Society, and the ketogenic diet is largely marginalized. And so I’m wondering what feedback you got from Keto Live, which is a little bit of a different attendance there to the International Society for Bipolar Disorder and maybe your experiences there.

Georgia Ede (00:10:16):

Yeah. So it does seem that we run into each other at various places around the world. It’s such an honor and a privilege to be invited to speak in these places. I did just come back from a very series of conferences, two in the United Kingdom, one in the Netherlands, and then Keto Live in Switzerland, and then ISBD in Chicago, and then a conference here in western Massachusetts. Some of these conferences are really focused on ketogenic diets such as Keto Live. And so they’re, in a certain way, I’m speaking to people who already understand and believe in the power of the ketogenic diet for mental health and for other conditions. But some of these conferences, this is what’s new, is that some of these conferences are general nutrition conferences or general health conferences, where this has become a topic of interest. This is not something that I’d experienced before.

(00:11:06):

And so in some of these cases, I had the opportunity to speak to audiences who knew very little, if anything, about ketogenic diets. And that’s really exciting because this is information that’s new to them, and that gives people hope. There’s a lot of people who are listening, clinicians and general public alike feel as though they’ve already tried everything, they’ve tried the conventional wisdom about nutrition, they’ve tried medications, they’ve tried therapy, and nothing else has really been working in a lot of cases. And so this really does give people something new, new strategies to consider, new strategies to implement that, at least in my experience and experience of my handful of colleagues who do this for a living, it’s really exciting and really effective in most cases.

Dom D’Agostino (00:11:53):

It must be. I know it’s exciting, especially when you’re showcasing new data that you have on disorders that are otherwise intractable or resistant to pharmacotherapy. I know as I speak when I lecture to the medical students in our nutrition concentration program, which is now going to be a required course for our medical college, taking a while to do that, but it’ll be a required course that students will have to take. But when I lecture about ketogenic diets, the students are like a deer in headlight, but they’re captivated because they’ve never heard this information before. And we’ll get to the research that you showcased and talked about at the conference. But yeah, it’s so exciting to present a new idea, what is a fresh idea, to people at a new event.

(00:12:48):

And so before we get into the research that you’re doing, which I’m super excited to talk about, and also working with the Baszucki Foundation, for Brain Health too, we’ll get into more about that, but let’s dive into your work personally and how you personally integrate metabolic psychiatry or ketogenic diets into your practice. And for example, what’s your ratio of males to females, and do you treat everyone the same way? I can imagine there’s quite a bit of art and science and nuance associated with working with the patients. And how do you go about, and this is a question my sister had too, because she’s a psychiatrist who’s trained at Hopkins, and she treats people. And she’s warming up to the idea of using nutritional therapy. She has patients who definitely will respond, but her whole thing is, how do you transition them from a drug-based therapy to a diet therapy and adjust? So I know a lot of questions there, males versus females, and how do you personalize this approach in your practice?

Georgia Ede (00:13:57):

Sure. So yeah, lots of good questions there. So I’ve never counted males versus females, but I think they’re probably fairly well-balanced. I’m a general adult psychiatrist. I don’t see children or young teens, but I see adults of all ages and I treat all psychiatric conditions. And so everything from relatively straightforward cases of ADHD, and minor depression, and anxiety, panic attacks, to more complicated conditions, things like PTSD, bipolar disorder, schizophrenia, and even early dementia. And so really anything that people come in with, I will work with them to use nutrition strategies to try to improve how they feel. And so I’m really excited to hear that your sister’s a psychiatrist, and I’m happy to talk with her anytime.

(00:14:53):

Really what my goal is with people is to optimize their brain health using nutritional strategies, whichever strategies they are willing and able to try. And these can include very simple strategies. Most people who are coming to me are coming to me taking at least one psychiatric medication, often more than one psychiatric medication. This is often the case in psychiatry, unfortunately. Most people are taking multiple medications. So most people are taking medication, but there are also some people who come because they don’t want to start medication. They’re trying to avoid even starting a psychiatric medication. And that’s a really ideal situation because once the medications are there, it does become a little bit more complicated sometimes to adopt the diet, transition to the diet. And then, of course, it can be a rather long process to carefully reduce the psychiatric medications after the person has adjusted the diet.

(00:15:51):

So in any case, I use a lot of different… As you said, it’s more of an art than a science, a lot of personalized strategies. So everything from simply cleaning up the diet by removing as much of the ultra processed foods and modern industrialized foods as we possibly can, the sugars, the flour, the vegetable oils, and all of the snack foods. And then trying to clean the… I really love starting with a foundational diet, I think for human health is sort of a paleo style diet, which means removing the grains and the legumes and the flowers and the sugars and the modern processed foods, and even if people are willing, the dairy products, which we don’t have to talk about today. That’s a more complicated topic. But really just to go back to a Whole foods principles, a whole plant and animal foods, pre agricultural, whole plant and animal foods before the advent of agriculture.

(00:16:50):

So that alone can often bring people tremendous benefit because it’s so much healthier than what most people are eating. But then in many, many cases, because so many of us, depending on which study you read, it could be 52% or as high as 88% of us have poor metabolic health. Usually that, unfortunately, no longer will be enough to really get people feeling their best. And in those cases, which is many, many cases, we often need to address carbohydrate intake, and in many cases, transition to a ketogenic diet. Because if you’ve been eating the wrong way for a long time and your metabolism is damaged, which is the case for most of us, the brain will not be able to use glucose. You won’t be able to metabolize carbohydrate properly, and your brain won’t be able to utilize glucose efficiently or effectively the way that it should. And in those cases, a ketogenic diet will really be the strategy that you need to go to in order to re-energize your brain.

Dr. Casey Means (00:18:04):

This is Dr. Casey Means, co-founder and chief medical officer of Levels. If you’ve heard me talk on other podcasts before, you know that I believe that tracking your glucose and optimizing your metabolic health is really the ultimate life hack. We know that cravings, mood instability, and energy levels and weight are all tied to our blood sugar levels. And of course, all the downstream chronic diseases that are related to blood sugar are things that we can really greatly improve our chances of avoiding if we keep our blood sugar in a healthy and stable level throughout our lifetime. So I’ve been using CGM now on and off for the past four years since we started Levels, and I have learned so much about my diet and my health. I’ve learned the simple swaps that keep my blood sugar stable like flax crackers instead of wheat-based crackers.

(00:18:56):

I’ve learned which fruits work best for my blood sugar. I do really well with pears and apples and oranges and berries, but grapes seem to spike my blood sugar off the chart. I’m also a notorious night owl, and I’ve really learned with using Levels, if I get to bed at a reasonable hour and get good quality sleep, my blood sugar levels are so much better. And that has been so motivating for me on my health journey. It’s also been helpful for me in terms of keeping my weight at a stable level much more effortlessly than it has been in the past. So you can sign up for Levels at levels.link/podcast. Now, let’s get back to this episode.

Dom D’Agostino (00:19:40):

How has the field of metabolic psychiatry evolved and what are the principles behind it? I’m often interested in… Also, maybe we’ll get to a little bit later, but I’m very interested in amazing people and who their mentors were. In addition to who your mentors were, but what directed you down this path? And you’ve carved out a niche for yourself and created your own path, really, and probably took a lot of information from different types of people and integrated it into your practice. And I think it goes into the next question I want to ask is, how has the field of metabolic psychiatry evolved? And you did answer this in some… What are the key concepts involved? And it sounds like you’re really dialed in on insulin resistance and also glycemic control. And we know… I know personally I’m wearing a CGM device using the Levels Health app, and I know I could almost predict how I feel, not actually looking at my CGM trace, but how I feel.

(00:20:51):

I can look at my CGM trace and tell you what it’s saying if I’m low or high or variability. So there’s emerging technology and the hardware is very interesting, and that’s emerging too. But the apps integrate the information and can give actionable information. So that’s from the glucose management side, but also the insulin resistance side, which is the underlying problem. In our nutrition class, we talk a lot about what is insulin resistance? What leads to type two diabetes? Dr. Barbara Hanssen, she’s worked with Gerald Schulman and all the top people, and wrote a book, really, on metabolic health and insulin resistance. So we really go down the insulin path, although we don’t really approach the metabolic psychiatry and how it’s integrated into that. So maybe you could talk to our listeners here about the evolution of metabolic psychiatry and how that is integrating measuring insulin. What biomarkers do you look at and glycemic variability in glycemic control? How important is that?

Georgia Ede (00:21:54):

Yes. So another dozen questions to address. And so that’s okay. I am a morning person, so I’ll begin. So I think the evolution of metabolic psychiatry and how I became interested in it was really about my own personal story of improving my own physical health through dietary experimentation, which is something I really encourage my patients to adopt, a mindset of curiosity and experimentation and discovery, rather than saying, telling everybody, “This is what I think you need to do.” I say, well, “Let’s find out what you need to do and let’s find out what diet’s going to work best for you.” That is really where CGMs come in, but I’ll come back to that. But the evolution of metabolic psychiatry, and the reason I became interested is because I was trying to understand why this unorthodox diet that I had stumbled into experimentally, which was a higher fat, lower fiber, relatively low plant, a high cholesterol, high animal food diet.

(00:22:58):

Why was that diet, the diet that reversed all of the health problems that I’d encountered in my early forties and that so many of my patients had been struggling with, and I had no idea how to help them with those issues. So I thought, “Well, this diet must be good for the brain.” But that was surprising to me. I didn’t adopt this diet. I didn’t go down the dietary path to try to improve my brain health. I was trying to improve my physical health. But I noticed that my mood was better, my energy was better, my concentration was better, my stamina, my mental stamina was better, my sleep was better. I was much less easily ruffled by the stresses of daily living. And that was a really profound experience for me as a psychiatrist. And I thought, “Well, what is going on here?” And so I studied nutrition for the very first time.

(00:23:49):

I’d never studied nutrition before. Psychiatrists are not taught about nutrition. Thank you. Thank you for getting a class required for students. This is key. We need to teach the future clinicians about the science of nutrition. It’s very, very important. In any case, like most women, I thought of food as simply a way to control my weight. I never thought about how it might affect brain health. We didn’t talk about nutrition in four years of psychiatry, residency training, we didn’t talk about food once, not even when we were talking about eating disorders. And so it was really remarkable, that blind spot. So what I did was I just dove into the science, all the primary literature, the scientific articles, and started reading widely across a variety of disciplines, botany, anthropology, psychiatry, toxicology, animal husbandry, everything I could get in my hands or try to put together this information that I wanted to really get to the bottom of it.

(00:24:56):

And psychiatrists love getting to the bottom of things. So I wanted to get to the bottom of this. And so what that led me to was some… I came across, for example, a paper in 1965 that had been published, about 10 women with schizophrenia, who had been in the hospital setting, placed on a ketogenic diet for a brief period of time. And while the report is, it’s not very detailed, the clinicians there did notice that their schizophrenia symptoms improved. And I came across information in the literature about how bipolar and epilepsy, bipolar disorder and epilepsy are so similar. We use the same… Many of the same medications are used to stabilize seizure activity. Those very same medicines are, in many cases, used to stabilize mood in people with bipolar disorder. And so it turns out that there are actually many, many similarities between bipolar disorder and epilepsy.

(00:25:53):

And I thought, well, we’ve known for, well now over a hundred years now that ketogenic diets have the ability to essentially stop seizures in their tracks for many, many people. And that’s powerful evidence that this is a brain stabilizing diet, this diet, that stabilizes brain chemistry. And if that’s the case, shouldn’t it also be the case, so could it potentially also be the case, that it would stabilize brain chemistry for people with mood swings? And this just made intuitive sense to me. And there had already been some papers written about that sort of postulating of the hypothesizing about that. And that’s when I became interested. And that was maybe 10 years ago or so. That’s when I became interested in the potential of the ketogenic diet to improve the brain health and the mood and so forth of my patients. And the more experience you get, the more you see the power of these diets.

(00:26:52):

When you use these in clinical practice, there’s nothing else that works as well as the ketogenic diet. And not just better in most cases than medications alone or even in medications at all, but with many, many fewer side effects. Whatever side effects you’re going to see are usually very temporary, short-lived, just a few weeks often, and tremendous number of, what I like to call, side benefits. So you’re not… Instead of the psychiatric medications, which often really damage metabolic health, particularly the antipsychotic medications, you’re seeing the opposite. You’re seeing metabolic health and overall physical health improve. So it’s a pretty compelling weight practice.

Dom D’Agostino (00:27:39):

I have a question about… Oh, I have so many questions now. So the first question is a side effect of the ketogenic diet for epilepsy in kids is in adults is weight loss. So they actually view that as a side effect in kids if they’re not gaining enough weight, in this case, reducing BMI, reducing body fat mass and having favorable body composition alterations is typically associated with improved markers of cardio metabolic health, including inflammatory cytokines and things like that. So do you think that… And this gets talked about a lot when it comes to diet debates, high carb versus low-carb, when you lose weight and create a caloric restriction, then all the benefits, many benefits come with it. So in the context of metabolic psychiatry, when it comes to designing a clinical trial and actually disentangling the benefits of nutritional ketosis versus being in a state of ketosis versus weight loss, in your patients, do you see benefits, psychiatric benefits, improvements independent of weight loss, or do they parallel the changes in weight loss?

(00:28:54):

I guess you probably have patients that are under, maybe not necessarily they have to lose weight too. So what are your thoughts there? And yeah, I teach neuropharmacology and I teach psychiatric… I teach the schizophrenia and all the psychiatric drugs to typicals and the atypicals, and the atypicals in particular, anti-psychotics cause metabolic dysregulation that is highly disadvantageous I guess you could say. So you touched on that a little bit. So yeah, getting people off those drugs is a big thing. But when it comes to weight loss, do you think this diet is working? There’s many ways that it’s working, but do you think that’s a major factor?

Georgia Ede (00:29:38):

I think this is a fantastic question, and I think it will be difficult to tease this apart in studies, but the ketogenic diet is not necessarily a weight loss diet. You can formulate the diet, especially dieticians are very good at this. You can formulate the diet to be weight neutral, and simply by, not simply by, but constructing the diet so that the majority of the ketones that are being produced inside your body are coming from food as opposed to from your body fat. So you can do that. And I have had some normal weight patients and even some slightly underweight patients and some very physically sort of, what’s the right word? Very physically fit patients, very athletic patients, who did not need to lose any weight, adopt this diet and experience remarkable improvements in their mental health. And that had nothing to do with weight loss, obviously.

(00:30:30):

So at least in my experience, I see the weight loss as a side benefit, but not necessarily the goal. Some of my patients do not need to lose weight, some of my patients don’t want to lose weight, and some of my patients actually need to even gain weight. In those cases, it’s really helpful to work with a dietician to get the macros, to get the carbohydrate and protein and fat ratios in the right range so that people will not lose weight. A lot of the weight loss side effects that we’re seeing in children, again, I’m not a child psychiatrist, but I’ve studied the epilepsy literature, and as you know, the diets that had historically been used to treat a pediatric epilepsy, especially early on, were very restrictive with respect to protein. There were extremely high fat diets, about 90% fat, in many cases about 6% protein, far too little protein. Yeah, just too little protein to be healthy, especially for growth.

(00:31:35):

And so I think some of the side effects that we’re seeing in children may be explained by that particular relatively extreme version of a ketogenic diet. And that’s certainly not the type of diet that I use in my practice. And I think there is some confusion in the general public sometimes when people express fears about the ketogenic diet and what some of the issues can come up with it, sometimes they’re looking at that information, which is fair. It’s fair to look at that. But I think we should point out to people that ketogenic diets exist on a spectrum. So there are ketogenic diets that produce very high ketones, and, in some cases, are calorically restricted or restricted in protein.

(00:32:21):

And there are then ketogenic diets that are more balanced, so to speak, with respect to protein and fat, and are designed to meet your calorie needs so that you’re not losing weight. So these are kind of maybe in the weeds a little nuances, but I just want people out there who are listening who might not know a lot about ketogenic diets to know that there are different versions of a ketogenic diet, and that getting the macros right for your personal goals is really a big part of what will help you avoid some of those negative effects.

Dom D’Agostino (00:32:53):

I teach in medical physiology, the GI section, and there’s quite a few people who have ulcerative colitis, Crohn’s disease, IBS. Two people came up to me after… It’s 200 plus students or whatever. And I think they actually came across your work because it must’ve been your work, because they said someone from Harvard who was studying this you or Chris, but really delving into dietary interventions, and they looked to be underweight. But it led me… Even before I got interested in metabolic psychiatry, I would teach that there’s a bidirectional comorbidity associated if you have IBS with psychiatric disorders. And psychiatric disorders can contribute to irritable bowels… And I think you had some issues probably driven by the plant-based diet or maybe fiber. I don’t do well with fiber, especially in the morning and things, so I push it towards the end of the day just a little bit more like a garnish now than what I did in the past.

(00:33:57):

But maybe just because… The listeners probably are not familiar with the potential problems that high fiber diets. Like low fat high fiber diets can do. So maybe touch on that a little bit, and even from the context of, what I think is an important topic here, ulcerative colitis, and that’s multifactorial. The reason for these are multi… And that’s important to understand. There’s an immune based component like that too, but maybe discuss a little bit about that. And that bidirectional comorbidity, which is something that I teach about and it just popped into my mind that something I wanted to ask you about.

Georgia Ede (00:34:36):

Yeah, so that bidirectional comorbidity is really just, it’s a vicious cycle. So if your metabolic health, if your metabolic health, your immune health, If you’ve got a lot of inflammation, if you’ve got a lot of, what’s called, oxidative stress, which means too many free radicals being produced by your immune system, your immune system is in overdrive, too much inflammation, too much oxidative stress and insulin resistance, which means that your metabolism isn’t going to be… Your body’s not going to be responding to insulin the way it should, if you’ve got all three of those things going on, which many of us do, and these are the three of the major driving forces underlying neuropsychiatric illnesses are inflammation, oxidative stress, and insulin resistance. You’re going to see problems throughout the body, the brain and the rest of the body, including in… The gut is the first line of defense.

(00:35:24):

If you’re eating the wrong way, the gut is going to be the first to experience the impact of that. And that can be anything from foods that are physically irritating, mechanically irritating to the gut, that were never really meant for human consumption. Things like grains and legumes and certain types of seeds, and all the way to foods that are very difficult to digest and foods that cause inflammation and even contains certain toxins. So there are some plant foods that can naturally contain toxins which are damaging to ourselves. And so the gut will be the first… That’s your first line of defense. Your gut will be the first to experience the effects of an unhealthy diet in these various different types of ways, whether it’s mechanical, whether it’s mechanical damage, or whether it’s biochemical damage. And so a lot of my patients who have mental health symptoms, many of them will also have poor gut health as well, not all of them, but many of them.

(00:36:33):

And this is really what led me to experiment with my diet in the first place, was gut health issues. And I thought, well, of all the things that are going on for me, maybe food has something to do with it because sometimes my digestion isn’t what it should be, or I have uncomfortable… I have stomach pain or what have you. But we don’t typically think about the relationship between food and the brain, but we often think about food in the gut. So it was a natural progression from there. But I think in terms of fiber, it gets a little complicated because, and try to keep it as simple as possible because I don’t want to confuse everybody out there who’s listening.

(00:37:14):

I would say that my view is not that fiber is bad for people. I wouldn’t say that fiber is bad and that nobody should eat it. What I should say is that if you have gut health problems, one of the places to look for problems is the amount and type of fiber in your diet. And often the recommendation is to increase the amount and type of fiber in your diet, and there’s actually no science to support that whatsoever. There is some… This isn’t studied very well, unfortunately. There are a few studies that show us that actually if you do the opposite, if you reduce the amount of fiber in your diet and you ate a diet that is easier to digest because fiber is, by definition, indigestible, so it makes sense then, stands to reason that if you eat too much fiber, you might actually suffer from indigestion and other sorts of gut health problems.

(00:38:16):

So it’s very logical when you stand back and look objectively about what certain foods contain and how our bodies process that food. It all makes perfect sense. But if you go to the standard literature, the standard headlines and the standard guidelines about nutrition, which are not based on science, science, they’re based essentially on guesswork and wishful thinking and ideology about what we should eat, then you become really confused about what you’re supposed to do. And what we’re usually told is more fiber, not less. And actually what can be much more helpful is less fiber, not more. And again, some people do very well with fiber. So I’m not saying everybody should stop eating it, but keep it in mind as a potential culprit because it’s a very common culprit, especially foods that are hard to digest, like nuts and grains and legumes, and cruciferous vegetables, and even certain dairy products. So lots of things we’re told are really healthy for us, which can backfire for some of us.

Dom D’Agostino (00:39:21):

Yeah, thank you for sharing that. I think it’s an important thing is it’s highly individualistic too. I grew up eating, when I got into fitness and stuff when in high school, a big bowl of oatmeal, and then every day in… I always called it a nervous stomach. I was like, in the morning in high school, I always had a nervous stomach and maybe because I was just a nervous kid or whatever with school and everything. And I always had an unsettled stomach in the morning, always. Looking back, it really was the fiber, eating a big bowl of oatmeal or shredded wheat or whatever, thinking I was eating clean. And even today we live on a farm. We have avocado trees, lots of them. If I eat even a whole avocado in the morning, that fiber catches up with me midday and my stomach…

(00:40:09):

I think it just moved through my system fast in the morning, maybe it’s a coffee or whatever, but if I get… I do really well with cruciferous vegetables, at least broccoli, so I can have a bowl of broccoli even, but I won’t have that much, just more of a small amount or maybe a small salad, some arugula or something or asparagus or something at the end of the day, or I put my fiber in at the end of the day, then I’m fine. I feel like my gastric transit time has slowed down and I digest it better over at night. And it does have more of a satiating… So when in our nutrition course, we’re very big about fiber. So still, because the guidelines and the epidemiological data is so heavily skewed to fiber, you just got to get as much fiber as possible.

(00:40:54):

But I feel the dose makes the poison, and calling fiber a poison here, it’s maybe a little bit hyperbolic or whatever, and from a nutritional science conventional standpoint. But I really share your opinion that things like nuts and too much fiber is the culprit for so many people. And if they dial that back, it’s counterintuitive, but I think they’re going to feel so much better. So maybe starting with something like a paleo diet, if you have problems, and then as the barrier to entry, it may be hard with a ketogenic diet, but starting with a paleo and then transitioning to more of a ketogenic, more of an elimination diet, could be the way to go.

Georgia Ede (00:41:31):

That’s exactly what I recommend in the book that I’ve written, is to start with a paleo diet and then gradually transition to a ketogenic diet, if necessary, and then even experiment with even a carnivore diet, if necessary. So different levels of intervention depending on your goals and on your personal metabolism and your personal food sensitivities. So it just gives people different choices, and it allows people to personalize their diet to their own needs. And I think there really isn’t a one size fits all diet. And this is coming back to your CGM point, one of the ways that I like to use CGMs is to help, again, foster curiosity about metabolism. People love to know what’s going on inside of themselves. It gives you a real window into how your body’s working. And you can see, for example, what that bowl of milk is going to do to your blood sugar in the morning.

(00:42:30):

And oatmeal is one of the most, I’ve seen this too many times to count. That oatmeal in particular can have a really profound impact on blood sugar, even if it’s steel cut oats, which is supposed to be so good for us. And we are taught, we hear all the time that oatmeal is a brain healthy super food. Have your bowl of oatmeal, your steel cut oats with the blueberries on top, and that’s going to really set you up for good brain health. And nothing could be further from the truth. And I include in the book actually CGM tracing of someone who’s kind enough to share their data publicly of what the C M looks like with different types of oatmeal, and how she actually needed to remove all oatmeal from her diet in order to stabilize her mood.

(00:43:24):

It’s these types of curiosity experiments that I think really empower people to take control over their own brain health instead of thinking, ‘Well, I’m having panic attacks or hypoglycemic episodes, or I’m just feeling unstable out of the blue.” rather than thinking that they need medication, they could first, at least, unless they’re in a crisis situation, medications can be very useful, why not start with food first? Why not look there first? Because nine times out of 10 you’ll be able to help yourself feel so much better. And the CGMs are really game changers when it comes to people really being able to see that connection between what they’re eating and how they’re feeling.

Dom D’Agostino (00:44:08):

Yeah. Absolutely. And even the same types of foods using a CGM, I find… We have avocados, and I’ve learned to eat them when they’re a bit crunchy. So I will pick them from the tree when they’re still slightly green or whatever. Not avocados, mangoes, in this case, mangoes, yeah. So with the mango, my wife likes them almost mushy, like you could eat them with a spoon kind of thing. But last night I had a huge… We have these massive mangoes and I cut it and I almost ate it like a crunchy apple. And my CGM, I looked at the Levels app and my CG was nearly flat, but the night before I had one that had fallen on the ground. It was like a dessert really.

(00:44:49):

But the sugar spike was completely, totally, it looked like two different kinds of foods, and I actually enjoyed the crunchiness of the semi ripe mango over. So yeah, there’s insights like this that you would never ever understand or acknowledge. The oatmeal thing too is something that you mentioned that I also observed. Probably one of my biggest spikes ever came from a bowl of Quaker oats snow, just a sprinkle of cinnamon on top too. And it spiked me really high. So it was almost like drinking coke. Yeah, it was really eyeopening.

Georgia Ede (00:45:22):

Isn’t that something? The things you can discover, I find it endlessly fascinating. And like you said, the same food can cause different types of reactions depending on its state. So whether it’s unripe or ripe, whether it’s cooked or raw. That’s another big difference. And of course when it comes to grains, particle size, whether it’s highly refined or whether it’s just chopped into pieces, the degree of refinement can make a big difference too. So yeah, I think that’s fascinating what you discovered.

Dom D’Agostino (00:45:53):

In addition to the CGM and looking at glycemic variability, are there other… I know your outcome measures are how people feel, right? Are you feeling better? That’s the important outcome measure, but do you have people do blood work where you’re looking at insulin? And have you seen a correlation of improvement, not only in glycemic variability, but also reducing insulin resistance, by definition, lowered fasting insulin?

Georgia Ede (00:46:20):

Oh, of course. Fasting insulin is one of the most helpful laboratory tests a person can order, a psychiatrist or any other type of medical professional can order, that really gives… Along with the lipid profile. I think that’s another very, very useful one. The triglycerides HDL, with paying a lot less attention to LDL, of course. So getting a fasting insulin, that’s something I’ve been doing for years. And I used to do it even with my college students at Smith College where I worked for five years after I left Harvard. I would routinely see, for people out there who might not be familiar with standard insulin measurements, at least in the US, what you really want to see ideally is you want to see a fasting insulin of say, six or below. I always say to people, at least make… We’d like to see your fasting insulin in single digits, and six or below is really ideal.

(00:47:16):

But I would routinely see in young women, these are 18, 19, 20 year old people, insulin’s in the twenties and thirties, fasting insulin, routinely. And of course, if you lower your carbohydrate intake, because carbohydrate is the macronutrient that spikes insulin the most, has the biggest effect on insulin. It’s not that it’s the only thing that affects insulin, but it affects insulin the most. If you lower your carbohydrate intake, that will drop your insulin, and it’s really effective in really predictable response, and you can change it in just a matter of weeks. And the same with triglycerides. So triglycerides, which are part of the standard cholesterol panel, they almost always drop like a stone on a low carbohydrate diet. You can see people’s triglycerides drop by hundreds of points in just a few weeks by getting their carbohydrate intake under control and [inaudible 00:48:14] a ketogenic diet very, very reliably. Not in every single case, but in nearly every single case, will drop those triglycerides. And that’s a really healthy… That’s really, really good news for your cardiovascular health.

Dom D’Agostino (00:48:26):

Yeah, there are super important biomarkers. And another one that we measure in our research, and I’ve been measuring for quite some time with a home kit, actually, a cardio metabolic home kit is, a high sensitivity C-reactive protein. We know that systemic inflammation can contribute to neuro inflammation. So if you have inflammation systemically, that is undoubtedly affecting the blood-brain barrier and in ways… And your gut permeability too, those same tight junctions are in your gut or in your blood-brain barrier. And that’s highly impacted by your inflammation status. I remember getting a little gut bug when I was traveling and then doing a cardio metabolic kit. My HSCRP was off the charts, where it’s usually 0.1 or non-detectable. So gut health is so important for your immune function and inflammatory state, and if that CRP is popping up, that’s undoubtedly affecting your brain. So I was wondering, is that something that you’re measuring inflammatory markers too? Because We just think it’s so important.

Georgia Ede (00:49:33):

Yes. I always measure an HSCRP or a CRP, depending on what we can get. And at least, according to the literature, when I last reviewed it for the training program, it seemed that you could also use a CRP if you needed to, and it would be almost as good, because this gives you… Inflammation is one of, as we were talking about before, it’s one of the key driving forces behind neuropsychiatric illness, and just illness in general. You don’t want too much inflammation in the body. You do need inflammation. Inflammation is good and healthy part of the immune system. You need inflammation, but you don’t want too much of it, don’t want too much of a good thing.

(00:50:10):

And so that CRP will give you one window into your inflammatory status. And so I always measure that. And there’s some literature also to suggest that people with depression, particularly depression with psychotic features, they are more likely to have an elevated CRP. And this makes sense when you think about it. They’re also less likely to respond to antidepressants. And this makes sense too when you think about it, because if their depression’s being driven by inflammation, as opposed to being driven by a neurotransmitter imbalance, then a medication that is targeting neurotransmitters is not going to be particularly helpful.

Dom D’Agostino (00:50:54):

Yeah, super helpful. Well, I know we’re moving quickly, and I want to make sure that we cover the research that you did and publish. So I’m jumping now to your Twitter feed where you have a post that’s pinned there and it has almost 1000 retweets. Wow, I didn’t notice that before. And your post is, “Our new study finding that the ketogenic diet is safe, feasible, and associated with unprecedented psychiatric and metabolic benefits has just been published and Open Access Frontier Psychiatry.” So the question you poses, “Can eating a ketogenic diet improve symptoms of serious mental illness?”

(00:51:30):

And this included 31 patients, bipolar, there was 12 of them, major depression, schizophrenia, you describe a ketogenic diet, 75 to 80% fat, 15 to 20% protein, 5% carbohydrates. Symptoms improved in 100% of patients. 43% achieved clinical remission. 96% of patients lost weight and 64% of patients were discharged on less medication. So that’s just a summary. Not to scoop your discussion of that, but can you give a little bit of insight into those findings and these profound findings, which the world of psychiatry should really be taking notice of these results. And just a first step, obviously, an observational study with no control group, and they were kind of… But maybe describe some of the nuances with this study.

Georgia Ede (00:52:29):

Well actually appreciate you summarizing it. That takes a lot… Makes it easier for me. Yeah. This was the work of my colleague and friend, Dr. Albert Dena. He’s a psychiatrist practicing in Toulouse, France. He’s been practicing psychiatry there for more than 35 years. And the patients that he works with are primarily of North African and French descent, with serious chronic mental illnesses. And he’s been working with some of these patients for decades. And what I found… So many remarkable things I find about his work. The reason why he decided to ask 31 of his patients who had, what’s called, treatment resistant mental illness, the reason why he asked them to come into the hospital and try a ketogenic diet is because they were not responding to all of the different types of ways that he had tried to help them with medications and psychotherapy and support, and even repeated hospitalizations, and in some cases, even electroconvulsive therapy or ECT in the past.

(00:53:40):

So he had witnessed a young family member of his, in his extended family, with epilepsy and autism respond beautifully to a ketogenic diet within just a few weeks of having started it. And when he saw that, this was a number of years ago, he thought to himself, “This diet seems to be good for the brain, I wonder if this diet could help my patients. I have nothing left to offer them except my ongoing support.” And so these folks who trusted him, they came into the hospital and they stayed, in some cases, for very long periods of time. In any case, he put them on a ketogenic diet in the hospital setting. This has never been done before in any organized or systematic way.

(00:54:27):

And all of them improved. There were three people who weren’t able to stick with the diet for more than a couple of weeks, and so we didn’t analyze that information, because they didn’t stay on it long enough. But 28 out of 31 did stay on the diet and everyone improved. And I want to just reiterate what you said, 43% of these patients achieved clinical remission that you do not see that with conventional psychiatric care, especially without increasing medications. And the other thing that I want to say about this is that these were patients, we didn’t have a control group. And it’s really, really important to point that out, he didn’t take half of the patients and give them a different diet. He didn’t take half of the patients and tell them not to change their diet. He put all of the patients on the same diet.

(00:55:23):

And the reason he did that was because he’s not a researcher, he’s a clinician. He was simply trying to help his patients and seeing what would happen. And we published, it’s called a retrospective study. We published the outcomes after the fact because they were so noteworthy. And we just thought they deserved to be shared. And so hopefully it will help people, inspire people to do more rigorous research, which I think it has done. And so the other piece, even though we didn’t have a control group, what’s really interesting about this particular group of people, because he’s been working with them for so long, all of these patients had been hospitalized one or even multiple times, either at this same hospital where the study was conducted or at a similar sister facility, which is in the same county or equivalent in France, without this kind of response.

(00:56:17):

So really the only difference between this hospitalization and their previous hospitalizations, was the ketogenic diet. So we can’t, of course, say with any certainty, that the ketogenic diet was responsible for these really remarkable outcomes, but it would be hard to explain it otherwise. So we really do think it had a lot to do with it, but of course, we need to be careful in interpreting these results. And there are wonderful scientists like Dr. Ian Campbell and Dr. [inaudible 00:56:48] and other scientists around the world who are now testing these theories more rigorously. So I think it’s really a huge victory for ketogenic diets for mental health that Dr. [inaudible 00:57:00] did this work with his patients to show the rest of the world what might be possible if you try something different. And it’s really simple dietary intervention that he used.

Dom D’Agostino (00:57:13):

Yeah. Well, in the figure here, was there an equal amount of males and females in that? A follow-up question is that, have you had any problems with women that are, and someone asked me to ask you this, someone I talked to yesterday, with perimenopause or menopause? Is the transition into a ketogenic diet different? Because in that subset of females, some of them have more psychiatric conditions or the onset of that. So just wondered a little bit of insight into that. So again, two questions. Sorry for multiple questions, but yeah, males versus females in this trial, and then any experience with women post menopause or perimenopause?

Georgia Ede (00:57:57):

Okay, 71% female. So the mean age was 50 years old. The range was 27 to 73 years old, and 71% were female. And so I can answer your question about perimenopause and menopause from two perspective… Well, three perspectives. One perspective is, in this particular study, we had lots of middle-aged and older women, and they transitioned to the diet just as easily as everybody else did. The second is from a clinician perspective, I have many middle-aged and older women, perimenopausal and postmenopausal women, that I’ve worked with. And I’d be happy to talk with you about some of the challenges there with ketogenic diets and that particular stage of life. And I think it’s just as easy to adopt a ketogenic diet, and it’s just as easy to transition to the diet. It’s less easy to benefit as much from a ketogenic diet. You have to be stricter, you have to do certain other things to improve your metabolic health.

(00:58:59):

And simply just dropping your carbohydrate intake, if you are perimenopausal or postmenopausal, you’ll face additional metabolic and hormonal challenges. Happy to go into that. And then my personal perspective, as a woman who is about to turn 59 years old, I went through my perimenopausal years on a ketogenic diet, needed to make a number of changes to it in order to continue to get the same benefits. I had to make some adjustments to it, because your metabolism changes, your metabolism changes when you go through menopause in some ways in which we understand and in some ways, which are very poorly studied, and so lots we could talk about there.

(00:59:41):

But I just want to say to women who are out there who are in your forties and fifties, do not shy away from a ketogenic diet. In fact, it will be your best friend if you’re going through menopause and having some of the physical, emotional and other types of changes that you’re experiencing that are making you unhappy with your body and your emotional and cognitive health. A ketogenic diet’s really well worth considering. You just may need to work a little harder at it than younger people do.

Dom D’Agostino (01:00:15):

Yeah. Great advice. Yeah, I had several women send me blood work, and their T3 levels were lower, but they felt great. They were getting great metabolic benefits and things like that, and maybe the T3 was lower just because they might be exercising more or they’re in a caloric deficit. But I’ve seen that as a feature in females just from the volume of emails that I’ve gotten over the last decade. And it’s not like… In some cases it’s below normal, but it’s just there’s a reduction in T3 and sometimes within the normal range, sometimes below normal. But in the below normal cases, they’re usually caloric restricted or they’re usually over exercising, in my opinion. So just an observation here.

Georgia Ede (01:00:58):

And T3 is complicated. It’s very interesting what you’re pointing out, but T3 is also a little bit complicated because we can’t measure receptor activity and we can’t measure… So it’s a little bit of a black box. And so I usually… A lot of my patients who consult with me nowadays, because now I have a specialty practice where it’s all nutrition based, and a lot of the people who come to me are already quite savvy about nutrition, and they’ve already had lots and lots of tests, sometimes pages and pages of tests. And they’re really sometimes very focused on lots of these different numbers, and they’re worried about their MTHFR and they’re worried about their T3, and they’re worried about every number that they can get their hands on, genetics and microbiome testing, all kinds of other things. When I’m first working with somebody, I really try to help simplify all of that by saying, “Let’s focus on the basics first.

(01:01:52):

Let’s get the diet where it needs to be, the fundamentals first, and then we can look into the more complicated labs if you are not feeling better.” Because if your T3 is low, but you’re feeling well, I’m not sure if I care about that. If your T3 is low and you’re not feeling well, your energy is low, you’re depressed, et cetera, then we need to take that more seriously. But I really try very hard, despite my own interest in getting into the weeds and getting to the bottom of things, I really try very hard to treat the patient, not the levels, whenever possible.

(01:02:26):

And this is true even in terms of ketone levels. So not all of my patients need high ketone levels, not all of my patients even need ketone levels above one or 1.5, although many do, some don’t. And if their ketones are 0.7 and they’re feeling great, I think that’s great. It’s really about how they’re doing at the end of the day. But I will confess that I don’t fully understand everything about what you’re noticing, observing with T3 levels. I find it interesting, and I wish I could explain it more, but there’s so much more we can learn.

Dom D’Agostino (01:03:05):

Yeah. It’s more sensitive to energy balance too. If you’re in a caloric death and you’re losing weight and other things are improving. And then I think this is true with males too, with hormone levels. If testosterone’s low, some guys are like, “I feel great.” I think their androgen receptor density on the membranes might be higher, right? Training, lifestyle, these things can improve receptor function and things like that.

Georgia Ede (01:03:30):

Yeah, maybe their hormones are working better, they’re becoming more efficient, and so you need less of them. And that could be part of it too. So I agree with you. I think that’s really wise to think of it that way.

Dom D’Agostino (01:03:42):

Can you share, Georgia, and elaborate on your ketogenic diet clinical training program? Because what you’re talking about here, getting this information out and training practitioners is probably the most important thing. The benefits of the clinical training program, the continuing educational credits that people can get from it. Can you describe the framework for that and how you’re working on the education front?

Georgia Ede (01:04:12):

Yeah. So a number of years ago, when I was first speaking publicly about this and people were… And when I shifted from my college mental health, I was specialized in college mental health for many years at Harvard and then Smith. When I decided to leave Smith and focus exclusively on nutritional and metabolic psychiatry, a lot of people were interested in coming for help. Far more people, of course, than I could see myself. And this was true for my colleagues as well, the handful of us who were doing this at the time. Our practices filled up very quickly, and we had long wait lists, and I thought, “Well, there’s a huge demand for these services and all these people really want to do this, and I want to help them all, but I can’t, and I can’t refer them to anybody else.” So that was why I decided to create this training program, was because I thought, “Well, we need more people who know how to do this. And so we need better access to metabolic care for psychiatric conditions.”

(01:05:13):

And so in 2020, I developed this program, and it’s approved for CMEs as well, for lots of different types of medical professionals, including nurses, nurse practitioners, PAs, MDs, and it’s also approved for nutrition professionals through the ANA. So there are, I can’t remember exactly, I think it’s seven credits for MDs, and it might be a little bit more for nutrition professionals. But in any case, I now run it two different ways. It had previously been exclusively live in small groups at virtual, six clinicians per training, 90 minutes every week for five weeks. And includes lots and lots of supplemental materials to support people in their practice, and lots of scientific references and all kinds of resources. But in any case, it was previously just live, and I’m running four live classes in August. I think there are two or three spots left in those classes.

(01:06:08):

And then I’m running more classes in September. I usually run, almost every month, three or four groups. But also because so many people weren’t able to work out the scheduling, or because of the time zone differences, or they just prefer to learn on their own, there is now a way to take the course offline, so to speak, at a reduced cost where I can just send you the video recordings and the supplemental materials, and you can work on the program yourself. That’s not approved for education credits, but it is less expensive and it’s more convenient for some people. So two different ways to do it now.

Dom D’Agostino (01:06:48):

Hey, Georgia, maybe you can explain to our listeners three things that they could do in regard to implementing the ketogenic diet. So three first steps they would do in transitioning to basically the therapy that you’re talking about, which is nutritional ketosis.

Georgia Ede (01:07:07):

Sure. So that’s a great question. So the first thing everyone can do, and you don’t need any professional support to do this, is take as much as possible the ultra processed foods, junk foods and non-foods, out of your diet starting right now. Eliminate them to the extent that you can, meaning all of the snack foods and packaged foods and prepared foods, anything that isn’t a whole plant or animal food. If you transition to a paleo diet first, that is safe for everyone, for women, for pregnant women, for children, for elderly, whether you’re taking medications or whether you have any health issues, doesn’t matter. The paleo diet is safe and easy to do. And I will always recommend that as your first step, even if you are ultimately going to eventually transition to a ketogenic diet. If you start with paleo first, it will make the ketogenic diet transition period later smooth and more comfortable and less of a shock to your system, because it’s already taking out a lot of the refined carbohydrate and lowering your blood sugar and insulin levels to a certain extent.

(01:08:16):

So that’s step one. Step two is to get some very simple blood tests and other measures, evaluate yourself for insulin resistance. And there’s a few really simple ones you can do. Some of these you probably have already had done, or you can do simply for yourself at home. So one is you can measure your waist circumference and compare it to your height. And if your waist circumference is more than twice your height, then that’s a clue that you probably have insulin resistance. But also, you have probably already had a fasting, what’s called a fasting lipid panel or cholesterol panel test. And if you look at that test, and you look at your triglycerides, and you take your triglycerides and you divide it by your HDL, that number should be less than two. So if your triglycerides are more than twice your HDL, that’s another sign that you probably have insulin resistance.

(01:09:15):

And then the other thing is ask your doctor or order it for yourself online. It’s not expensive. It’s 15, 20 dollars. Get a fasting insulin level. That’s another really excellent test for insulin resistance. If you’re fasting insulin level is in the double digits, then that’s not a good sign. You really want to lower that by reducing the amount of carbohydrate in your diet. Even if you don’t want to eat a ketogenic diet, lowering your overall carbohydrate intake to say 90 grams a day, say 30 grams per meal, is perfectly safe for most people. Again, wouldn’t require a lot of professional assistance unless you have serious medical conditions.

(01:09:56):

And so I would say that the first thing is cleaning up your diet, transitioning to a paleo diet, I would recommend, getting some blood tests and doing some measurements at home. And the third thing is then to make an appointment with your healthcare practitioner to discuss whether or not a ketogenic diet… Say that you’re interested in a ketogenic diet, and have that discussion with your psychiatrist, your psychologist, your primary care doctor, your nurse practitioner, to start to get the wheels rolling in terms of what would it take for you to transition to this diet safely.

(01:10:31):

And if you can’t find somebody, if the practitioners you’re working with don’t know a lot about ketogenic diets, or they don’t feel comfortable learning about them, or don’t want to help you with it because they don’t have the time or the interest or the knowledge, on my website there is, if you click on the website’s diagnosis diet, there’s a tab called Directory, and there’s a free searchable database, a clinician directory, specifically to help you find practitioners of various kinds who use ketogenic diets in their clinical work to help people specifically with mental health conditions. And so this is an international searchable database. It’s free to search. And you can look for somebody who might be able to partner with your local clinicians or perhaps even somebody in your area that you might be able to work with directly, if you don’t already have somebody to work with. So those would be my three recommended steps.

Dom D’Agostino (01:11:29):

That is great advice. I’ve been to the directory too, and that’s an amazing resource. Thank you for compiling that and sharing that.

Georgia Ede (01:11:35):

Sure. Sure.

Dom D’Agostino (01:11:36):

Thank you so much for putting that information out there. I’ve shared it to quite a few people already. In addition, you have a forthcoming… You have a book coming out, and maybe describe what went into that book and if that will be a framework. Many things that you’re talking about today go into very high detail within the book, the rationale for it, the science behind it, and also, most importantly, the art and the nuances of implementing this, right? These approaches is going to be in your book. So people listening, really, pre-order the book. I forget when it’s coming out, but maybe share with our listeners what’s the essence of it and when it’s coming out.

Georgia Ede (01:12:17):

Yeah. No, thanks for giving the opportunity to talk about it because it’s not out yet. You can pre-order it now. It’s called Change Your Diet, Change Your Mind, and it will be coming out on January 23rd, but you can pre-order it now if that makes you happy. But really the goal of this book is to show people, not just the science, but also the science behind these nutritional strategies, which are paleo diets, ketogenic diets, carnivore diets and elimination diets. But not just the science behind it, but also how to. And so it’s really to show people how much more control they have over their mood, their energy, their concentration, their productivity than they realize. Because most of us have been feeding our brain improperly for our entire lives. And so you really have no idea how much better you can feel and function if you eat properly, no matter how old you are.

(01:13:16):

I was just sharing before we started rolling the cameras or whatever you want to call it, that my mom, who’s 89, just readopted a ketogenic diet after years of being off of it in January, and her health has improved remarkably. She’s 89 years old, and she’s still able to reap multiple physical and mental health benefits from this diet. So it’s never too late. And really what I designed this diet to do was to really redefine or maybe define for the first time, what a brain healthy diet is. We talk all the time, what’s a heart healthy diet? What’s a healthy diet for weight loss? But really what is a brain healthy diet? And so I think it’s quite simple. I think it needs to nourish the brain by providing all essential nutrients. It needs to protect the brain from damage, from excessive oxidative stress, excessive inflammation and insulin resistance.

(01:14:12):

And it needs to energize the brain in ways that safely promote healthy brain metabolism over the lifespan, which means protecting your brain’s ability to produce energy for your entire life. And that just means keeping blood sugar and insulin levels in good control. And I show people exactly how to do this, why to do this. And there’s lots of information in the book about why the nutrition science that we’re told about is wrong. And then there’s lots of information in the book about everybody’s favorite foods and food groups and the pluses and minuses of eating certain types of foods, and debunk some of the myths behind certain brain super foods like red wine and dark chocolate and flax seeds, and all of those things which are really just not going to be helpful to you at all, and in some cases quite the opposite.

(01:15:03):

And so just lots of information about food, information about how the brain metabolism works, and then how to put that information to use for yourself. There’s the whole fourth part of the book, the final section, is diets and meal plans and recipes put together by Patricia Daley. She’s a nutrition therapist based in Ireland, who has used ketogenic diets for years to put her own cancer in remission and help other people with cancer and other metabolic conditions improve their health. So I hope what people will find in this book is that really what I’m trying to do is, in the same way as the training program, really just educate and empower people to take their mental health into their own hands. And because right now we’ve got a lot of really exciting information, but not enough actionable information, and especially if you’re taking psychiatric medications or if you’re taking any medication at all, prescription medication at all, or if you have any kind of a significant health issue, heart disease, diabetes, high blood pressure, you have to be very careful.

(01:16:16):

You have to really know what you’re doing when you start a ketogenic diet, which was one of the reasons why I created the training program in the first place, is you really do need to understand that this is a powerful metabolic intervention that is going to change your blood sugar levels, change your insulin levels, change your medication levels in some cases, and change your fluid and electrolyte balance very quickly, often within 24 hours. So if you do not know how to navigate that transitional period safely, you could really be in trouble. And so it’s not that the diet is dangerous, it’s that the combination of this diet with certain medications or certain health conditions, especially if you adopt it too quickly and without proper preparation, can be dangerous.

(01:17:03):

The changes that are coming from this diet are very healthy. You want lower insulin levels, you want lower blood sugar levels, you want lower blood pressure levels, but you need to just navigate that safely. And so, one of the reasons I wrote the book was to help explain why it is that some people look at this diet as dangerous and why some people look at this diet as life changing and positive and amazing. The devil is really in the details. And so putting that information in the book so that people understand why you hear these two very different things about this really important dietary intervention.

Dom D’Agostino (01:17:40):

Those details are so important. And I thank you so much. This information is gold, and you are really, Georgia, you are a gift to the metabolic psychiatry community. Thank you for the work that you’re doing and for sharing this information on A Whole New Level podcast. It’s like the abstract version information. It’s like the cliff notes of what you’ll find in… Well on your educational training course and in your book, which really gets into the details and all the nuances on implementing this, which is really important for people, not to just jump into this, but to educate themselves on the details that you put in the book and in the training program. So thank you so much Georgia, for sharing this information. How can people connect with you? How can they… I know you have an active Twitter account and things, but maybe share with people before we go, the best way to connect with you.

Georgia Ede (01:18:33):

Yeah. So first, thanks for those really nice words. It means a lot to me. I really hope that this information helps people. That’s what it’s all about. And I apologize that I have been virtually silent on Twitter for the past couple of months because I’ve been traveling so much and writing so much and getting the book done. But I will be back on Twitter within the next week, I believe. But Twitter is where I spend most of my social media energy. But I’m also on Facebook, and I’m on LinkedIn as well, but Twitter is @georgiaedemd. My last name is spelled E-D-E. Also, my website, which is diagnosisdiet.com. Lots of free information and resources there as well. There’ll be a conference coming up in November in Boston, if people are into, Metabolic Psychiatry conference in Boston the first weekend in November. I hope that if you’re in the Northeast, you’ll come and join us there. That will be a great event. So I really want to thank you, Dom, for inviting me to speak with your listeners and hope that this information helps people.