#230 – How the ketogenic diet may work as a medical therapy for various conditions, such as migraine, epilepsy, mental health issues, and more | Beth Zupec-Kania, Denise Potter & Dr. Dominic D’Agostino

The ketogenic diet is often used as a tool for weight loss and to improve metabolic health. However, it is increasingly being considered, studied, and used as a medical therapy for chronic physical and mental health conditions, and it can be tailored to patients’ specific needs. Beth Zupec-Kania, Denise Potter, and Dr. Dominic D’Agostino discuss the benefits of the ketogenic diet, how they customize keto for patients with dietary preferences like veganism, how to ease into the change with a pre-keto diet, and how the keto diet may be able to help people reduce or eliminate medications under the supervision of medical professionals.

Helpful links

Advanced Ketogenic Therapies: https://www.advancedketogenictherapies.com

Charlie Foundation: https://charliefoundation.org

Beth Zupec-Kania, RDN, CD: https://www.bethzupeckania.com

Beth Zupec-Kania, RDN, CD on Twitter: https://twitter.com/KaniaZupec

Beth Zupec-Kania, RDN, CD on Instagram: https://www.instagram.com/zupiekania/

Denise Potter, RDN, CDCES: https://advancedketogenictherapies.com/team

Denise Potter, RDN, CDCES on Twitter: https://twitter.com/KetoPotterRDN

Denise Potter, RDN, CDCES on Instagram: https://www.instagram.com/ketopotterrdn/

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/

14:50 — Using the ketogenic diet as therapy for various conditions

Two dietitians, Beth Zupec-Kania and Denise Potter, are using the ketogenic diet to help people with mental health conditions, migraine, epilepsy, and more.

Zupec-Kania: People with epilepsy also have migraines. That was getting better. People with epilepsy also have depression. I saw that getting better, so I just knew this was something really unique and special that I wanted to commit the rest of my career to… Potter: They stick around because, as a dietitian, there’s nothing we’ve ever done that’s comparable to having the medical benefits of ketogenic therapies.

27:49 — Eating a ketogenic diet often helps people improve their nutrient intake

At first when starting a keto diet, Beth and Denise argue that it’s important to get the understanding of macros down rather than focusing on micronutrients. However, often the keto diet actually increases one’s micronutrient intake by focusing on whole foods.

But those are things that often come into the diet once people get off processed foods and start eating real foods. They tend to be getting more eggs, high in B12. We encourage them to get out and get vitamin D, sunshine. But they can get vitamin D from foods as well. Mushrooms, for example, is one vegetable that’s high in vitamin D . . . Some fortified foods as well. But I personally—and I know Denise does this too—we start people on a high-quality supplement with keto just in case. And in the beginning, they may not be getting a great variety of foods . . . when they’re learning keto. It’s more important that they understand the macronutrients and what carbs are. Oftentimes people don’t realize there are carbohydrates hidden in foods that are processed. So that education kind of precedes the quality of the diet, which we work on later—once they kind of get comfortable and get into a space where their brain is functioning a little bit better.

29:39 — The ketogenic diet can be customized to fit a person’s needs

From vegan to more meat-based diets, keto plans can work for a person’s specific eating styles.

So we’re recognizing that there are different ways to get into ketosis. And one of the things that we are experts in is really working with individuals to figure out what works best for them. Because, in the end, people will follow a diet longer when it’s personalized, right? When it works for their culture, their home situation, their support system. And I have people on all kinds of variations of keto. I’ve done keto for vegetarians. I’ve done keto for carnitarians. And Paleo. And they work. But they each have little nuances that make them work, such as supplementation or following certain labs. So there are lots of these variations . . .

33:42 — Medium-chain triglycerides can help increase fat intake

Vegan diets, by their nature, tend to be higher in carbohydrates. However, MCT oil can help tailor a vegan diet to be ketogenic.

On a vegan diet, we have to get plant-based proteins in. And that’s going to come along with carbs. So we just supplement that, usually using a lot of MCT oil. We have it. I haven’t tried to do that without MCT. I think it would be very difficult, but yeah, perhaps it could be done. I just haven’t tried it. It’s a tool we have, so we use it.

35:32 — Gluten is inflammatory

Gluten can drive inflammation. One theory about this is that gluten, at least in the United States, often has glyphosate in it. An elimination diet may help people who don’t have celiac disease determine if they have a sensitivity.

I wonder if eliminating gluten is also eliminating a lot of glyphosate, which is the weed killer, the chemical in the weed killer commonly used in the U. S. here. And just as an aside, a lot of friends and family who travel to Europe who have identified that they’re sensitive to gluten but don’t have celiac disease then go to Europe and have a croissant or something and say, “It didn’t bother me.” So you wonder also about the hybrid version that we have in our country. Going back to eliminating it, you really don’t know if you’re sensitive to it unless you do a trial of eliminating it. You really have to do at least two weeks.

38:18 — Beth encourages patients to do a pre-keto program

Her Pre Keto course helps people ease into keto be upping intake of certain foods while eliminating others.

I do suggest an elimination diet: first gluten-free, and then possibly casein-free. And Denise alluded to an education piece that I wrote called Pre Keto. It’s gluten-free whole foods, healthy fat, low-carb, of course—not intended to do induce ketosis. It’s basically like a low-glycemic index treatment, but there’s some more guidance as to what types of foods you should include or could include and what you should eliminate. And I want people to try that first before they go to keto, because it is easier. It’s much easier to be out and about and select things from restaurants, for example, than going keto, which is much more of an elimination diet as you said. You’re really limiting yourself to a smaller class of foods and limiting portion sizes . . .

46:12 — Looking at macros on keto

Some people on keto focus on macros totals for the day, but Beth and Denise like to take a per-meal approach.

We always try to get people to balance macros on a per-meal basis as much as possible. Not only thinking of per day . . . It depends why you’re doing it as to how strict or how high we might be trying to get ketones for somebody. So for some people, that’s fine to go with your totals. But then for when we’re really trying to induce medical benefit and hopefully reducing medications, we’re really pushing for that macro on a per-meal basis.

48:24 — A ketogenic diet can drive metabolic health changes

By encouraging metabolic flexibility, a ketogenic diet may help people fine tune the “when” and “what” of their nutritional needs.

People are really pretty good at listening to their bodies once they get into a state of ketosis, I think, and get rid of the junk. That’s one of the benefits. I tell them, “You’re going to be amazed at how differently you feel physically and mentally. It’s taking you to this different level of humanity where you’re really going to be more in tune to your body.” And people kind of look at me like, “What? What are you talking about?” And then when they get there, they’re like, “Yeah, I get it. I really feel like I can’t eat three hours before I go to bed. It messes up my whole next day, or I don’t need to eat until one o’clock in the afternoon. I’m fine.” So they kind of figure those things out with a little bit of my prodding . . . People lose that carb craving on keto and even low carb. They just stop having this, “I’ve got to eat. I’ve got to eat. I’m not really hungry, but I’ve got to eat.” That’s that carb craving, and I try to identify that with people initially so that they recognize that. Are they really hungry? Are you just looking for some carbs . . . ? And so I think once they’re in ketosis, they realize like, “I feel like I could go hours.”

57:49 — The benefits of the ketogenic diet that go beyond weight loss

A ketogenic diet doesn’t have to be a weight-loss diet. In many cases, people with underlying conditions may even need to gain weight or keep their weight stable. However, the ketogenic diet has other benefits, including providing more energy.

You were asking about other benefits aside from the weight loss, aside from the epilepsy [control]. The number one report I get about people going into ketosis is “I have more energy.” And often it’s “I wake up in the morning ready to get up, not sluggish and I feel like I can fall back to sleep, but I’m like, ‘I’m ready to get up.’” And that’s really something that keeps them going. Like this is a huge metabolic shift. And it makes them excited and engaged with the diet. So I love when that happens because that’s my like, “Ah, I got this one. This one’s going to make it. I’m going to see this one through.” It’s really hard to predict when I start working with people who’s going to be able to really do this and who’s not.

1:22:00 — Can keto help people reduce their medications?

In some cases, people with underlying conditions who try keto may be able to reduce or eliminate medications. However, that should be done under a physician’s supervision.

We also try to explain to the patient or the physician that when you add on ketogenic therapy, you’re adding on a medication. It is a treatment. It’s a therapy. It’s metabolically impacting them. And so it would be, I think, perfectly logical to titrate down, you know, one thing, if especially there’s a problematic medication. Early on, if they were on several things, it would be reasonable to look at doing that because you’re adding a med. If you were going to add on a different seizure med or psychiatric med, very often they would taper one while they’re increasing the next one.

Beth (00:00:06):

Pretty much what we’re seeing with a lot of these really successful cases with mental health is that there’s nothing that has worked so far and people are desperate and they are willing to try a restrictive diet. No one likes to restrict their diet. Everyone wants to eat whatever they like and just go out and about and be amongst friends and eat and drink. But when you have a serious medical condition that is metabolically based and a diet changes your metabolism and you’re willing to try that, I mean you’re going to do it because you’re desperate and other medications and other treatments just won’t be as effective.

Ben Grynol (00:00:45):

I’m 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.

(00:01:14):

Time and time again, we talk about the importance of individualized diets. How do we create optimal health and wellness for each of us on an individual basis? This is something that’s very much woven into the social fabric of health and wellness. When we start to think about mental health and neurodivergent conditions, well, this is becoming more deeply researched in academia. How can we intervene with diet, sleep, and exercise to improve upon some of these conditions? So in this episode, in conjunction with Metabolic Mind, Dr. Dom D’Agostino has been hosting and exploring these topics with different thought leaders in the space to explore this cross-section of mental health and metabolic health. So he sat down with the Beth Zupec-Kania and Denise Potter and discussed how things like ketogenic interventions can be used to treat conditions like epilepsy and other mental health conditions.

(00:02:04):

They also discussed things like gluten, dairy and other food sensitivities as they relate to some of these interventions for treating different conditions. For more than 30 years, Beth Zupec-Kania has been working with different medical professionals, patients and families to educate them about the safe and effective use of ketogenic interventions to treat neurological disorders. And for more than 31 years, Denise Potter has been a registered dietician nutritionist where she’s also focused on ketogenic medical nutrition therapy. And lastly, Dr. Dom D’Agostino, a friend, an advisor, and very much a mentor at Levels. Dom, as many of you know him by now, is an associate professor in the Department of Molecular Pharmacology and Physiology at the University of South Florida Morsani College of Medicine. Anyway, no need to wait. Here’s Dom.

Dom (00:02:58):

Thank you so much for being here today for sharing your expertise, which is really an expansive expertise over a decade. I connected with both of you probably about a decade ago, and I consider both of you early adopters to the use of the ketogenic diet for expanding applications. But you have an early history in using the ketogenic diet as an evidence-based clinical metabolic therapy with randomized controlled trials behind it, five or six probably. So maybe you could tell our listeners a little bit about what you do, your background in dietary therapies and how you got onto this track.

Beth (00:03:42):

I’ll go first because I’m older. Denise lets me go first, but we actually have somewhat similar backgrounds and we’re both Midwesterners and we’re also good friends. But I started working with ketogenic diet therapies over 30 years ago in a pediatric hospital here in Wisconsin. And it only took me one patient to get hooked on it because I saw an immediate change in that patient’s cognitive abilities and seizure control within 24 hours of being in a state of ketosis. It was absolutely stunning to me, and I decided the day I saw that this was it, I’m going to do this because I had been a jack of all trades nutritionist filling in for people and trying to work part-time raising a family, and I thought, nope, this is it. I am going to stick with this.

(00:04:41):

And I did, and I’m really glad I did because not only had I worked now 20 years with epilepsy, I eventually left the hospital and went out on my own because I just felt I needed to support other applications of it that I saw coming down the pipeline. People with epilepsy also have migraines, that was getting better. People with epilepsy also have depression. I saw that getting better. And so I just knew this was something really unique and special that I wanted to commit the rest of my career to. So Denise, I’ll let you take on.

Denise (00:05:23):

Yeah, and it’s funny you say that that your first patient convinced you because the first few patients just scared me because I didn’t know enough and I was trying to figure this out. And so I’ll make a long story short, but I was first trying to get out of doing ketogenic therapies because I wasn’t comfortable, didn’t really have a lot of training, hadn’t met you yet and done any training. And so we created a physician at the hospital to have it be an only ketogenic physician, but that took about a year. And so by the time we got that done, I realized, oh my gosh, then I was seeing what you were seeing Beth, and then I was seeing these kids getting better and better. And you see this with a lot of keto dieticians where they’re either all in or all out because it’s very demanding.

(00:06:11):

There’s a lot of work, usually a lot of extra time that people put in. And once they’re sold, they’re sold. So a lot of these mostly ladies, some gentlemen that have been in working with keto, we’ve been doing it a long time, they’ve been doing a long time. They stick around because as a dietician, there’s nothing we’ve ever done that’s comparable to having the medical benefits of ketogenic therapies. So yeah, I did the same thing. I was at the hospital at University of Michigan. It was great, great program, great growth and helping a lot of people. But then Beth was over here saying, hey, there are people with other conditions, there are people with cancer.

(00:06:51):

There are people with migraines, different conditions that need help. And the Charlie Foundation was supporting that. And so people started calling my office and I literally just hung a shingle out and started just because of need, just because people were asking for it. And it came to a point of saying, I either have to do one or the other. I really don’t want two full-time jobs. And I ended up choosing to go the path where it was a little more unknown and a little more interesting because I knew that they would find someone else to take care of these kids with epilepsy, but what about these other conditions? And so it’s been fun to do that.

Dom (00:07:30):

Yeah, Denise, I think it was around 2013, maybe about 10 years ago that you had reached out and you said you were working independently too, but I think you were still at Michigan at the time. And yeah, so I mean your background is using the ketogenic diet for its clinically evidence-based approved applications. But you were inspired because you knew from your experience that this had broader applications through helping individuals. And then Beth, I know you were working with the Global Symposium. I think you actually responded back. We connected, you probably don’t know it, but we connected in 2010. I think you approved my abstract for Scotland’s, the Global Symposium, and then 2012 too. And also when I had a TEDx talk, you were my contact for the Charlie Foundation because I was seeking pictures of Jim and Charlie for my TEDx talk on the ketogenic diet.

(00:08:30):

So you guys have been doing in addition to being in the trenches, a lot of advocacy for the ketogenic diet outside of that, and that’s an important theme and where I want to go is that specifically you have experience with this diet and neurological disorders, neurometabolic disorders like glucose transporter type one deficiency, and also an emerging application is neuropsychiatric disorders or psychiatric disorders. And I would love to hear sort of your experience with using the ketogenic diet outside of, at this time, its clinically accepted or approved applications beyond the standard of care and what your experience is with that.

Beth (00:09:18):

So it’s very similar to the days when we were working with pediatric epilepsy before the randomized controlled trials. I see so many similarities. Everyone’s questioning the therapy, is it going to give them heart disease? Where’s the research? But what we’re really hanging onto are case reports in early research, Iain Campbell’s early research specifically for bipolar disorders and schizophrenia. There’s people that can’t wait for the randomized controlled trials. And this is what Jim Abrahams used to say about keto for epilepsy. The doctors were telling him, “We don’t have the science. We don’t know the mechanism. We need to wait till we have the science.” And Jim said, Jim Abrahams of the Charlie Foundation, I should say he’s the executive director, “I had waited to start keto on Charlie when the science was available. It would be another 10 years and he would be much sicker than he already was.”

(00:10:27):

Charlie was diagnosed with the worst kind of epilepsy. It was called Lennox-Gastaut Syndrome, and it’s simply a diagnosis of last resort. Like this kid has terrible seizures, multiple different types. We don’t know the cause. He’s got Lennox-Gastaut. Most of the kids end up in wheelchairs and with feeding tubes. And he was diagnosed by three specialists, by three epilepsy specialists. And so it wasn’t a misdiagnosis, but keto saved him. And he was started on keto within a year of his diagnosis and had immediate response. And he was on the diet nearly five years and now he’s in his 30s, he’s been off for 24 years and doesn’t remember being on the diet because he was a little kid then, has never had another seizure, has never taken a seizure medication. He was weaned off of his medications actually because he was seizure-free.

(00:11:28):

So I mean, that’s a home run and there’s no way that he could have waited. He had a really catastrophic type epilepsy. And that’s pretty much what we’re seeing with a lot of these really successful cases with mental health is that there’s nothing that has worked so far and people are desperate and they are willing to try a restrictive diet. No one likes to restrict their diet. Everyone wants to eat whatever they like and just go out and about, be amongst friends and eat and drink. But when you have a serious medical condition that is metabolically based and a diet changes your metabolism and you’re willing to try that, I mean you’re going to do it because you’re desperate and other medications and other treatments just won’t be as effective.

Casey Means (00:12:26):

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.

(00:13:18):

I’ve learned which fruits work best for my blood sugar, like 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 (00:14:03):

The question for both of you, is the ketogenic diet unique as a dietary therapy in that… I guess the question is, is there any other diet that one could implement that would produce these kinds of results? And that is a question I get a lot from medical students, does it have to be this restrictive? Can we do a variation of different types of diets? A low-carb diet with a vegan diet could simply eliminating some of the potential triggers of a standard diet causing some of the pathology and just the nature of the diet is that it’s elimination diet. So could it be just restricting something or do you believe? In the community generally, the consensus is that by changing your metabolic physiology, that’s changing the neuropharmacology of your brain and other energy dependent mechanisms systemically throughout the body. So what’s your opinion and what’s your experience? Because I don’t necessarily want this to be completely about a ketogenic diet discussion because there’s the low glycemic index diet and other variations that are not necessarily ketogenic and would like to hear your experience, if at all with those diets.

Denise (00:15:23):

Well, I think Beth can piggyback on this, even with epilepsy, there’s some proof that some people can just go off gluten even and they may have gluten induced seizures. And so a lot of these cases and then there’s proof with ultra processed foods that were causing probably more depression and things. So I think absolutely there are a certain number of people that probably, maybe they don’t need to be on a full out ketogenic diet. Maybe they could first try going off gluten and try cutting out processed foods and eating just a whole food diet. Beth has a handout at the Charlie Foundation for that, a Whole Foods Diet. It’s a precursor to ketogenic therapy to say, you know what? Start here. So one, and then I also tell people, if you can’t do this, then you don’t want to work with me anyway.

(00:16:12):

If you can’t start here and start cutting those things out, then maybe you’re not a good candidate just because it’s too difficult. And two, maybe that’s enough. That’s how Hopkins came out with a modified Atkins diet because they sent someone home and said, “Hey, come back on carbs and we’ll bring you in to start keto in a month or two.” I don’t know the exact timeframe. And by the time this child came in to start ketogenic therapy, they were already seizure-free or almost seizure-free. They had such a dramatic difference. And so do we need full out keto for everybody? Maybe not. But also, we tend what the people I run into, and I think probably similar with Beth, are people that have been working on trying to do keto. And by time, this is different. 10 years ago, the people that came said, “I don’t know anything about ketogenic diet, please help me.”

(00:17:00):

And we would start them at square one with the whole food diet and work them onto keto. Now, they come in, they say, “Well, I’ve been doing keto for three or four months and I’m not getting anywhere, and my ketones are only 0.5 and my A1C is…” I mean, people come in so much more educated and just the past few years probably because of what you’ve done and the different educators and people have done and putting out content, and so they’re coming in at a different level for us. And Beth can piggyback on this, but to answer your question now, does everybody need full out keto? And what also makes me hopeful is can we put some of these people on keto for six months a year, maybe longer, two years, and get them in just the best state they can be?

(00:17:43):

And then can they live on a low glycemic index diet maybe and not have to be in full ketosis, but just eat a really healthy whole food diet. Maybe we can go there and not have to go so deep. And that’s what I really hope, because if you tell someone you have to do this the rest of your life, that’s tough. That’s discouraging. But if we can say, wow, maybe we can treat you for a period of time, and we don’t have proof of this yet, we just hope. But go ahead, Beth, I want to hear.

Beth (00:18:15):

Yeah, definitely. Gluten I think is a big one. And there are some case studies out of the UK showing people before a gluten-free diet and then after looking at their EEGs and seizures, and there’s some reports for epilepsy and there’s some for migraine. And we know that gluten can be inflammatory, so that’s one to cut out before going ketogenic. But also we know B12 deficiency could be a causal for depression, vitamin D deficiency. So there’s key nutrients that could be looked at first, but those are things that often come into the diet. Once people get off of processed foods and start eating real foods, they tend to be getting more eggs, high in B12, we encourage them to get out and get vitamin D sunshine, but they can get vitamin D from foods as well. Mushrooms for example is one vegetable that’s high in vitamin D and some fortified foods.

(00:19:26):

But I personally, and I know Denise does this too, we start people on a high quality supplement with keto just in case. And in the beginning, they may not be getting a great variety of foods and we don’t want to hound them about getting all of their green vegetables in when they’re just learning keto. It’s more important that they understand the macronutrients and what carbs are. Oftentimes people don’t realize there’s carbohydrates hidden in foods that are processed. So that kind of education precedes the quality of the diet, which we work on later once they get comfortable and get into a space where their brain is functioning a little bit better. So yes, there’s different variations of the diet and as Denise said, the new hybrid diets were discovered based on the fact that people were observing their patients getting better in low ketosis.

(00:20:26):

And we don’t have to do this classic three to one or four to one diet that’s 90% fat, and it’s quite constipating. We can get away with something quite a bit lower in fat, still high fat, still fat as a main source of calories or introduce intermittent fasting or ketone supplements, or if you’ve got some extra fat in your body, that counts as ketones too. So we’re recognizing that there’s different ways to get into ketosis. And one of the things that we are experts in is really working with individuals to figure out what works best for them. Because in the end, people will follow a diet longer when it’s personalized, right? When it works for their culture, their home situation, their support system. And I have people on all kinds of variations of keto. I’ve done keto for vegetarians, I’ve done keto for carnetarians and paleo, and they work, but they each have little nuances that make them work such as supplementation or following certain labs.

(00:21:34):

And if they are a void of red meats, for example, and were maybe worried about iron, if it’s a woman whose menstruating. So there’s lots of these variations and nutrients to be possibly concerned about. And follow-up is really important to make sure those are all working because for most people, a strict keto diet is temporary and no research has yet to prove this. It seems to be if we can get people in a good state of ketosis where their symptoms are mitigated, then they can relax later on. And that certainly is true for epilepsy. In fact, children with epilepsy actually completely off the diet and maintain their seizure control forever. Same I’ve seen that with migraines. Now, with mental health I believe, and I have seen that they have to maintain some type of lower carb, maybe really low degree of ketosis, but certainly it seems like they don’t have to maintain high ketosis. We like them to get in the initial months of, I call it the healing phase.

Dom (00:22:53):

I’d like to come back to the gluten issue again maybe, but before I do that, because we’re on this theme of variations of the ketogenic diet, it may come to surprise our listeners that a ketogenic diet can be implemented with a carnivore approach and also a vegan approach. I know recently Dyane Harwood emailed me about that she follows a vegan ketogenic diet and wrote a book about Birth of a New Brain healing from, I think, postpartum bipolar disorder she had, and I’m just getting into that book now and trying to understand the vegan approach, but the use of a plant-based vegan ketogenic diet and all being inundated with so many questions about that inspired me to write the first blog of KetoNutrition actually, which is a plant-based ketogenic diet approach and if it’s even feasible.

(00:23:50):

You had mentioned a vegetarian ketogenic diet approach in some of your patients. Have you had any patients have success with a vegan ketogenic diet? Because I get quite a few cancer patients that think a plant-based approach would be good, and if that could be done in a ketogenic way. So I know I get so many questions about this, so I’d love to hear your input and feedback on that.

Denise (00:24:18):

Yeah, I mean we do that pretty regularly and not so often, but often enough. And from the beginning, I remember the first time I had a vegan patient come up, I probably called Beth and Beth said, “Hey, you need to use a lot more MCT oil so we can allow more carbohydrates because a typical MCT diet would have 50, 60% MCT oil and you could allow the ratio or the macronutrient content of that diet to have a much higher carbohydrate content.” So on a vegan diet, we have to get plant-based proteins in and that’s going to come along with carbs. So we just supplement that usually using a lot of MCT oil. I haven’t tried to do that without MCT. I think it would be very difficult, but yeah, I mean, perhaps it could be done. I just haven’t tried it. It’s a tool we have, so we use it.

Dom (00:25:12):

So the plant protein would then be, there’s commercially available like pea protein powder and other things. And I know some advocates of carnivore diets would say that these can be problematic and eliminating them in some patients can be very helpful and beneficial. And maybe I do well off plants and nuts and nuts in moderation, I guess. But there’s two things that I want to circle back on is gluten. It sounds to me, Beth, that you were saying that patients do much better eliminating gluten, and these are not necessarily patients that have been diagnosed with celiac disease. So they are maybe, as I suspected, there’s probably a spectrum of sensitivity to gluten and you may not be necessarily, or other things that are in wheat like gliadin and maybe some other things that could impact intestinal permeability and cause an inflammatory response, but your experience with two things, eliminating gluten and also another question I get quite frequently is casein or milk protein, and if that becomes beneficial because the early ketogenic diets were based on dairy fat and dairy protein. So would like to get your feedback on those two.

Beth (00:26:36):

Yeah. So first, let’s start with gluten. I wonder if eliminating gluten is also eliminating a lot of glyphosate, which is the weed killer, the chemical and the weeded killer that is commonly used in the US here. And just as an aside, a lot of friends and family who travel to Europe who have identified that they’re sensitive to gluten but don’t have celiac disease, but then go to Europe and have a croissant or something and say it’s buttery. So you wonder also about the hybrid version that we have in our country. But yes, going back to eliminating it, you really don’t know if you’re sensitive to it unless you do a trial of eliminating it. You really have to do at least two weeks. And wheat gluten is in many foods, not only wheat, but maltodextrin, which might be an ingredient in even soy sauce and lots of flavorings and processed foods.

(00:27:45):

So if you want to do a true elimination, you want to get a good list of gluten. And there’s quite a few on the internet because it’s pretty common that people will eliminate this just as a trial if they have GI distress and they’re looking for ways to eliminate that. Casein is another one that people can be really sensitive to. And so I do a trial of gluten-free first and then gluten-free casein free. So the whey protein is okay, but we can eliminate the casein by eliminate dairy products pretty much using a whey protein powder if you sow desire to use a protein powder. And there’s other protein powders that could be used as well. But these are two that I say listen, especially if you have gut issues. And nearly every adult I work with comes to me with gut issues, which tends to be our first topic is let’s work on your microbiome first before we do this introduction to keto because it’ll help you adjust for one thing.

(00:28:57):

But we know so much about the microbiome now, not as much as we need to, but we know that what we feed into our guts definitely affects the microbiome. And the microbiome is where most of our neurotransmitters are produced and is our immune system. And you want to really treat your gut well so that your brain functions and the rest of your body functions too. So I’m getting off on a tangent here, but I do suggest an elimination diet of first gluten-free and then possibly casein-free. And Denise alluded to an education piece that I wrote called Pre Keto. It’s gluten-free, whole foods, healthy fats, low-carb, of course, not intended to do induce ketosis. It’s basically like a low glycemic index treatment, but there’s some more guidance as to what types of foods you should include or could include and what you should eliminate.

(00:30:00):

And I want people to try that first before they go to keto because it is easier. It’s much easier to be out and about and select things from restaurants, for example, than going keto, which is much more of an elimination diet. As you said, you’re really limiting yourself to a smaller class of foods. And limiting portion sizes is the main thing that people have to understand. Your portion sizes of not only carb, but even protein and the portion sizes of fat. People aren’t used to putting oil, olive oil, I should say it’s the virgin olive oil on their food. And that’s something you have to do if you’re going to be keto. You literally have to put oil on your food to get to the high fat content.

(00:30:54):

And your comment about the classic ketogenic diet, a 100 years ago, heavy cream was part of the classic ketogenic diet. And so heavy cream is very rich in fat, low in carbohydrate, low in protein. I have worked with kids who had lactose intolerance who could tolerate heavy cream just fine. There’s very little lactose in it, but I never gave it to a kid that had a dairy allergy because there is some dairy protein in it. Yeah. And I want to say the heavy cream a 100 years ago was probably quite a bit healthier than the cream that we’re getting these days. So those things probably came into play too is that people didn’t have a degree of food allergies and food sensitivities that we see now.

Dom (00:31:43):

Do you see that? And both of you treat some patients with autism, and with the casein, I think there’s a case report too, isn’t there a casein-free and dairy-free response? And I remember, I think that was presented in Scotland in 2012. And Beth, weren’t you part of that?

Beth (00:32:03):

Yeah, that was a doctor from Florida who’s a pediatrician, and her daughter was the case and she had her on a casein-free, gluten-free diet. And then I worked with her and made that into a keto diet and that child became completely seizure-free and she came off the autism spectrum, yet I am in touch with her once in a while. That doctor has written a book on autism and diet, and she doesn’t exclusively use keto for her patients, but she’s been more supportive of keto after her daughter had such a great response. But you know what, when we use classic keto with gluten-free, just by the nature of anything with gluten’s going to have carbs. So we never said gluten-free keto, we just said classic keto, and it was gluten-free, but it certainly wasn’t dairy-free. But we often made the dairy elimination for kids with dairy protein allergies, which is not that uncommon.

Denise (00:33:18):

I think too, just to add to that though, is because people sometimes wonder, do I have to do that? And I don’t do it as a rule, and I don’t know exactly what you do, Beth, but I don’t do it as a rule with those restrictions. But I just was speaking to someone today and she’s using some of the zero carb tortillas, allegedly, let’s put in quote zero carb tortillas. And she loves it, they taste great, but the concern is one, you’re probably getting even more gluten in those is my thought because of the content. And do they cause any issues and are they lowering your ketones? So now, with a lot of these low-carb products, sometimes keto can become very high gluten or much higher gluten than we would ever expect 10 years ago. So really the processed foods are always something we’re trying to say, man, either don’t or limit them, limit them, watch your ketones, et cetera.

(00:34:16):

And then firstly, with dairy, I really let people, unless there’s an issue, I let them make their own decision on dairy because it can be very difficult to take once you’ve taken some things away, then you take now their dairy away. So it’s not something I tend to do at the start unless we feel like there’s just some reason for it because it can be really difficult. But again, it just depends. But if they had autism, that would be a reason why I would say, oh yeah. And then a lot of times the parents, they come in with that. They’ve already been doing that. They’ve already been cutting out the dairy and the gluten. So yeah, it’s pretty common.

Dom (00:34:55):

What about fermented dairy? Not necessarily yogurt, but I have a cup of sour cream just to get… I’m usually calorie deficient by the end of the day and I fat load at night with a keto mousse thing. And I’m mildly dairy… If I drink, if I have cottage cheese or yogurt, I get very stuffy. But if I have a quality fermented dairy sour cream, I don’t have that dairy response. And I know sour cream’s mostly fat, I think. I don’t know if because it’s fermented or just because of the nature of it just being very low in dairy protein if that’s the case. But when we talk about dairy free, I feel like I’m doing a dairy free, but I have sour… Like dairy protein free. So have you had an experience with that, perhaps titrating in something like sour cream? But if I have whole cream, then I tend to get a little bit of a dairy response, but not so much with the sour cream for me.

Beth (00:35:57):

The fermentation probably is key there, and the proteins are also more broken down and it’s different animal. It’s a totally different animal. And you’re Italian, so you’re probably lactose intolerant as well, right?

Dom (00:36:17):

Yeah, and I can tolerate that, but if I have Greek yogurt or something like that, but I mean sour cream basically makes ketogenic diets possible for me because that’s how I meet my fat macros.

Beth (00:36:29):

Yeah, and for me, I love whipped cream. I love to have a bowl of organic heavy whipped cream at the end of the day, just by itself, I don’t put anything in it. I just love the whipped cream.

Denise (00:36:41):

I have to say something though because, and Beth, I’m sure you’ve had patients like this because sometimes Dom, and we all have our layers of how people can get away with keto, and it doesn’t always have to be the same for sure, but sometimes people will have, they’ll do that, they’ll get to the end of the day and you’re more saying, oh, it’s calories, not necessarily ketones. And they’ll get to the end of the day and they’re like, oh no, I need 40 more grams of fat. And then they’ll fat load, which is going to bring their ketones up at that time. But the whole rest of the day when they had their protein and carbs, not with enough fat, their ketones probably went down, down, down because they didn’t have the macros. We always try to get people to balance macros on a per meal basis as much as possible, not only thinking of per day.

(00:37:26):

So just not to pick on what you’re doing, but just sometimes that’s a problem for people they aren’t getting. And especially too when you’re like if you have bipolar versus you have, hey, I’m eating keto because of… It depends why you’re doing it as to how strict or how high we might be trying to get ketones for somebody. So for some people is like, that’s fine, go with your totals. But then for when we’re really trying to induce medical benefit and reduce, hopefully get some to the point of reducing medications, we’re really pushing for that macro on a per meal basis.

Dom (00:38:00):

So I mean, my next meal will be these Wild Planet sardines and they have extra virgin olive oil, and then I’ll do my other half dose of a ketone supplement. So the macros may be one-to-one keto, but then I supplement maybe some MCT or ketone supplement. And my diet’s protein heavy throughout the morning and afternoon, just maybe one or two meals. And then I realized that I’m not… So I’m only got a 1,000 calories by dinnertime, so I have to make up my calories just to maintain my weight really. So that’s how it works for me, and I just tend naturally not to be too hungry in the morning. So it does bring up another question in regards to intermittent fasting.

(00:38:46):

And for some patients, do you find that… Or let’s use the term, because just interviewed Dr. Satchin Panda, time-restricted feeding. Is that a lever that you will pull with your patients and does it work? I’ve communicated quite a lot with Mike Dancer and he is adult patient that has been quite successful in using this for 15 years, and he’s down to just doing one meal a day, and for seizure control, he finds that’s superior than spreading out his calories over several meals. And I wonder if what your experience with that is or if it’s too restrictive for your patients?

Beth (00:39:27):

Yeah, I’m all about whatever works and people are really pretty good at listening to their bodies once they get into a state of ketosis, I think, and get rid of the junk. That’s one of the benefits I tell them is like you’re going to be amazed at how differently you feel physically and mentally. It’s taken you to this different level of humanity where you’re really going to be more in tune to your body. And people look at me like, what? What are you talking about? And then when they get there’re like, yeah, I get it. I really feel like I can’t eat three hours before I go to bed. It messes up my whole next day or I don’t need to eat until one o’clock in the afternoon. I’m fine. So they figure those things out with a little bit of my prodding. And I just like to support that because if that works for you and you’ve been a good scientist and you’ve experimented a little bit, we can encourage them to be scientists and try things out.

(00:40:30):

Because we know what works for one person doesn’t work for the next, but as long as they’re doing things safely. I will say I don’t always encourage people just to eat one meal because I have had some patients who have gotten into trouble metabolically with that, that it’s just too much, I think, for their digestive tract, maybe their liver and they’re having problems digesting fat, I’m specifically talking about people being keto and it’s just a big fat load for them to process within a short period of time. And so for that reason, I have people with any kind of gallbladder issue, digestion issue, actually eat smaller meals, maybe three meals seems or two meals is pretty common, two meals with one little snack in between. And then it’s seasonal too. That might be their winter diet. In the summer, they’re back to just two meals or maybe four meals because they’re really active. So it’s got a shift with the seasons as well as the individual’s needs.

Denise (00:41:39):

Yeah, and I tend to shy people away from one meal, same thing. One, I worry that it’s just the same thing, can you get enough in? And if you really eat, say you need 2,000 calories, your body’s not going to process and turn out all the ketones. A lot of that I think is going to go and I have to research it more, but I feel like a lot of that’s going to go down to glucose and then maybe lower your ketones for a period of time and then bring them back. They’ll come back up. So I mean, I haven’t done research on it obviously, but I just think, and then I worry metabolically, you’re going to slow down your metabolism and you’re doing this, and then three years later, you try to eat, maybe you’re eating a 1,000 calories and now you try to eat 1,500 and you start gaining weight.

(00:42:23):

I worry that some of those things might happen with people. But again, if someone comes in, and I have a friend of mine that’s been doing this for years, and I said, “What? You only eat one meal a day, really?” And she’s great. It works for her. It’s not a therapeutic diet that she’s doing. But I just was surprised, it was one of the first years ago that I heard someone doing that and I thought, how can you just eat once a day? But again, she feels well on it. So yeah, I just would rather see a little bit. Oh, I know. I had another thought. And here it is, that with ketosis, I mean, we can get you into ketosis whether you eat three meals a day, three meals and a snack, two meals and a snack, we can help manage it with the ratios and with the fat percentages to get people into ketotic state using the tools and tricks we have, whatever food plan you want.

(00:43:17):

And again, intermittent fasting is great, but then I have some people, if they intermittent fast, they get to the end of the day, then they eat too much because, oh, I was going to fast. Well, I’m going to say, yeah, confession here, me too. And I’ll think, oh, I’m going to fast and I’ll think, well, I’ll just eat dinner. And then I just keep eating because I’m just so hungry. I think, oh, I should have just waited till morning and then I wouldn’t have eaten if I just wait till morning and that’d be fine. So I think it’s a real sensitivity. And we’re working with people with eating disorders too, and so that we don’t want to tell them to do intermittent fasting. And again, there’s just so many reasons. So I have it in my educational materials, definitely say, hey, here’s something to talk about. But I don’t personally use it as a standard like, okay, you’re working with Denise, you’re going to do a 16/8. No, I don’t do that personally.

Dom (00:44:06):

The general consensus and a little bit switching gears, but it ties into this from the nutrition science perspective, and now we have a nutrition course that’s a requirement for our medical students, and I’m part of faculty leader in that making it mandatory. So from a very general perspective, nutritional interventions produce positive outcomes because it’s improving overall metabolic health. Insulin goes down, glycemic control is better. And I want to ask you about continuous glucose monitoring, if that’s something you want to use. But the overarching idea behind the use of nutrition and medicine from the conventional point of view is that while all these benefits are coming about because you’re losing weight, that improves metabolic health and then insulin control and glycemic variability.

(00:45:01):

And it leads me to the question in patients that you’re managing, do you see changes that are independent of weight loss, I guess? Or stated another way, are the outcomes that you’re seeing correlated with or dependent upon that patient having improved metabolic health but also maybe improved like a decrease in weight or fat mass or favorable body composition alterations from a scientific perspective? But I know in the epilepsy world, weight cannot be… Generally, you don’t want children to lose weight, so they will have seizure control independent of losing weight obviously. But outside of the world of epilepsy, because this is an ongoing question I think that is important to address when it comes to managing, is it weight loss or what’s your experience?

Denise (00:45:58):

I’m excited. You just made me think of something I need to add to my poster. So I have a poster I’m taking to the conference that’s coming up next week, and it’s two patients with bipolar one who have done fabulous with keto, basically almost one of them symptom free entirely. And one of them, let’s say 90 to 95% symptom free. And this is going down to psychosis, hallucinations, depression, to the point of suicidal attempts, focus, anxiety, all the gamut of a bipolar one diagnosis. And neither of them had weight loss. Matter of fact, one of them, she was eating so much MCT oil that I said, “Whoa, you’re gaining weight. You need to pull that back a little bit, I think you’re overdoing the MCT oil.” And so yeah, neither of them had any weight loss. So that’s one case. And then lots of other cases where there’s no relationship because the people came in.

(00:46:59):

People always, this is a super common question. I’m sure Beths had it a million times, people come in and say, I had someone just email the other day, “Can you work with skinny people? I don’t want to lose weight.” Like, oh, we’ve got you covered. And I tell them, this isn’t necessarily a weight loss diet, this is a metabolic state. And we go right back to what you said about children. These children, almost all of them have to gain weight. We keep them on their girls’ curve. If you feed enough calories on a ketogenic therapy, it’s not a weight loss diet. So absolutely. But of course, we see all these benefits when people do lose weight. So yes, of course, and yes, we don’t need, or no, we don’t need weight loss just to do it.

Beth (00:47:38):

Yeah. I mean, if they need to lose weight, it is a state that it’s easier to lose weight because of the appetite control, particularly, people lose that carb craving on keto and even low-carb, they just stop having this, I’ve got to eat, I’ve got to eat. I’m not really hungry, but I got to eat. That’s carb craving. And I try to identify that with people initially so that they recognize, are they really hungry? Or are you just looking for some carb to stuff in there and chew on? So I think once they’re in ketosis, they realize, I feel like I could go hours. And this is part of why people don’t eat all day is they don’t feel hungry. And as soon as they eat, then they get hungry.

(00:48:31):

But if they eat a high-fat meal, they don’t get as hungry because they get their ketones up. And that’s something that we work on with people because people are still a little bit reticent about putting fat on their food just because it’s been ingrained in our culture not to do that. So yeah, that’s an excellent benefit. You were asking about other benefits aside from the weight loss, aside from the epilepsy, the number one report I get about people going into ketosis is I have more energy. And often I wake up in the morning ready to get up, not sluggish, and I feel like I can fall back to sleep, but I’m like, I’m ready to get up. And that’s really something that keeps them going. This is a huge metabolic shift, and it makes them excited and engaged with the diet. So I love when that happens.

(00:49:38):

Because that’s my ah, I got this one, this one’s going to make it, I’m going to see this one through because it’s really hard to project when I start working with people who’s going to be able to really do this and who’s not. And it’s not about how much money you have because I had somebody who was very wealthy recently who couldn’t do it even he had the money to hire a chef, have all the best foods in the world. He just couldn’t do it. And I’ve had people with very little education and not much money who are able to do it with tuna fish and hot dogs and eggs, which are the cheapest protein food. So it’s amazing to see the spectrum of motivation and willingness and all that come together once people get into ketosis and get going on this and just they get empowered by positive change in their brain function that keeps them going.

Dom (00:50:39):

Yeah, I’m really interested in to hear both of your opinions in the barrier to entry, for example, like that patient who had a chef make his meals and everything. Was it the carbohydrate restriction? Did they not give it enough time to get the adaptations to feel better? And I think as a community and as we push this into platforms where you get CME credits and it’s teaching how to do this, this barrier to entry seems like the big pushback. My sister’s at the Psych Congress, I guess right now in Tennessee, it’s like the biggest, it’s like the AES, it’s like the American Epilepsy Society, [inaudible 00:51:20], and there’s someone speaking there on ketogenic diets, actually.

(00:51:26):

But I think the pushback is that the barrier to entry is just so high and how do we address that? And in epilepsy, you guys were talking about a transition from just well, eliminating the foods and then transitioning, but that’s not really the conventional approach, but should it be? I mean, because you guys are specializing, there’s a science and the art, and you guys are really kind of artists in what you do and personalizing it to the patient. And I guess what we need to know is what are the major, the three big barriers to entry that we need to address for practitioners?

Beth (00:52:04):

Yes. So I would say one of the three big barriers to entry is access to the food portion of the diet. The diet is 90% food. We could say the rest is supplements and fluids, but 90% of the ability to do the diet is access to ketogenic meals. And what are our options? We make it ourself. We buy them pre-made. We have somebody make it for us, right?

Dom (00:52:39):

I mean, yeah, it is. And eating ketogenic can be more expensive, I guess.

Beth (00:52:44):

I guess I would argue that, it’s all relative to what you were paying before. Processed foods are more expensive than whole foods, and so there’s a little bit of know-how. If you buy frozen foods and not pre-packaged foods or buying quantity and freeze things, there’s ways to bring costs down, but by and large, processed foods are more expensive than eating whole foods and fats. Dominic, I remember a conversation with you years and years ago about fats being the cheapest food of all the macronutrients, right? [inaudible 00:53:23], yeah, but calories. So we’re talking about a high fat diet. Now, I would argue, okay, I want quality fat. I want extra virgin olive oil, not just olive oil. There’s a huge difference in polyphenol content. There’s actually a study coming out from Spain where they put a group of people on extra virgin olive oil and they just gave them extra virgin olive oil, said, use as much as you want.

(00:53:50):

And the other group got just the refined olive oil, like the third filing of it, which doesn’t have much polyphenol content, and they didn’t know which was which. They just used it. And then they did blood work. And as one would expect, the extra virgin olive oil had the major benefits, but they were significant benefits, even lower glucose levels. So this is coming out soon. They had a pre-print article out recently, and I can’t wait to get my hands on the real one because I’m a big believer in extra virgin olive oil in ketogenic diets for those polyphenols, which are antioxidants, and they support the gut microbiome. And we should be encouraging healthy fats on keto, not sunflower oil, not canola oil, which unfortunately a lot of the keto food companies are putting in as cheap fats, right?

Denise (00:54:49):

Yeah. Yeah. And then so to piggyback or just say, the second barrier I think is that people think they have to go full in keto to start. And I think as we start training or continue training with people is just helping them see that we’re okay if you start with gluten-free and you start taking out processed foods and you start slowly, we’re okay with that. It takes longer. A lot of times people do want to just jump in with both feet because they just want to do it and they don’t want to take the extra time. Because they could say, well, I’ve do two, three months of this and then I’ve got to do three more months of keto. So there’s that, but that’s a personality issue or not issue, but what you’re used to, what might work for you, whether you’re a slow mover or a fast mover.

(00:55:39):

And that takes me to, I think, the third person or third thing would be access to trained clinicians, which that’s something you guys are working on with training curriculum, we’re working on with training curriculum and trying to continue to just get good quality education out. So more and more people can have a good feel of what it’s like to work with people. And partly you train yourself and you start and you start and just continue to grow and learn because we all had a first day.

Dom (00:56:13):

That’s a really good perspective on this. I think we need to start with education, education first, and that’s why I advocate and all of my students that work under me and Angela Poff is spearheading metabolic health initiative, the Metabolic Health Summit, and then there’s INKS and Global Symposiums and Keto Live. I mean, it’s amazing to see what has happened since we connected over a decade ago. All these things have been growing. Another thing that has been growing significantly is monitoring technologies, wearables, like continuous glucose monitor, which I’m wearing now, and continuous maybe ketone monitoring is on the horizon.

(00:56:55):

I still have not been able to test that yet, but wanted to get your feedback on a CGM device just as I think it’s an amazing device that if a patient was wearing it and the data went to the clinician, that they could basically monitor adherence to the ketogenic diet. Because if you’re eating ketogenic, you’re not going to see any significant postprandial excursions in glucose at all. You shouldn’t. So there’s that there. And I’m wondering if this is something that you use, if it becomes affordable, should all practitioners be using this in their patients?

Beth (00:57:34):

Yeah, I would start with let the practitioner try it first, because then they’ll understand what their patients are going through, right? It’s an excellent way for anybody who is using keto to really understand what goes in their mouth and how it affects their blood, whether it’s carb, not enough fat, too much protein. I know you have been impressed with using it. I haven’t used a CGM. I’ve tested my glucose frequently enough where I practically use a CGM just to see impacts of different ketogenic ratios. But I think it’s an excellent tool. I wish all my patients could start out with one. I don’t think people need them forever, but I think because this is what happens is they get so… If they’re compliant and if they’re getting results, they usually are pretty compliant. But once they get going on this, after about six weeks, they feel like my glucose is always the same every time.

(00:58:38):

I don’t even look anymore. It’s always between 70 and yeah. Yeah. So you don’t need it very long, but using it in the beginning is really helpful to get you through keto flu, which some people suffer from more severely than others, and it could be helpful for that. But I think it is sort of putting a mirror up in front of you in terms of helping you with your diet too. You’re not going to cheat if you know your glucose is over a 100 and you’ve got a reading coming up in 20 minutes. It just is like your best friend until you get going. So I strongly recommend them. Continuous ketone monitoring, I just learned from Mr. Mojo that the current one that is being made in China is actually not super reliable. So I think that’s off in the distance a little bit, but I’m more comfortable, and I find the glucose actually sometimes more helpful than ketones because if someone’s running really low on glucose, they just aren’t getting enough calories.

(00:59:44):

And so if I hear I was feeling really great, now I don’t have any energy. What are your glucose is running? Oh, they’re great. They’re in the 60s and 70s, but my ketones are low. Ah, this is a situation where somebody needs more energy, they’re just not getting enough calories, and they may be having had lost some weight or maybe stagnated in their weight because now their body is preserving calories, thinking it’s starving. So I find that glucose monitoring is more helpful sometimes. And then ketones along because it tells me about those situations. And working now with eating disorders, I see I’m a little more worried about people with their weight. Other conditions not so much, but if I had to choose between continuous glucose monitoring or continuous ketone monitoring, I’d go for the glucose because you know when glucose is within a range that they’re going to have good ketones, generally.

Dom (01:00:44):

Yeah, it’s the single most important metabolic biomarker. And if you can measure it in real time with a closed loop system that giving you feedback. And there’s things outside of food too, that could exercise and stress and things like that. And I think it would be very insightful from the perspective of managing psychiatric conditions too, to see correlations in glucose levels and the onset of symptoms and the management of symptoms. And I think that’s important, could be a very… I see it in myself that my mood is generally stable. We had a hurricane come through last week. We had intruders enter the house, and at the same day, I dislocated my shoulder and had to get every… It all happened in a very compressed timeframe. And then I went back and looked at my glucose levels during that, and it was very interesting to see levels that I had otherwise not seen before, so like stress levels.

Beth (01:01:43):

So yeah, cortisol, your cortisol goes up, your glucose goes up. We see that when people go into the hospital for surgery, we always had to have an order in for keto patients when they come into the hospital for a procedure or a surgery that if their glucose falls below 50, there’s this order that pops into the order set system that they get a certain amount of dextrose to keep it up. Well, no one ever uses that order because their glucose always goes up because they’re stressed, their body is stressed. So it’s usually on the high end. So yeah, you experience the same thing. It was just a different type of stress.

Denise (01:02:20):

People need to understand though too, with glucose monitoring and always trying to help them understand that just saying that there are so many other things that can impact your glucose that are not food and that can be really discouraging for them. It just, yeah, you had a bad day, you had a bad night’s sleep, you got in a fight with somebody, an argument, you have an intruder, a broken shoulder, you name it. So all these things can influence. So I think that’s just part of the education so people know. But I think the access to the monitors is always frustrating unless there’s something I don’t know, it requires a doctor’s prescription to get a continuous glucose monitor.

(01:02:56):

And so unless there’s a brand or there’s a way to get them that I don’t know about, and so you have doctors saying, “Well, oh, well, you don’t have diabetes, you don’t need a glucose monitor.” And obviously, people are getting them, and I’ve written letters for patients to get them said, “Hey, they’re on keto and dah, dah, dah. We monitor glucose. Please give this monitor.” And so there are ways to get them, it’s just it would be nice, you can just go buy a glucose meter to poke your finger off the shelf. And so I’m a little confused as to why we can’t just purchase those off the shelf.

Dom (01:03:28):

Yeah, there’s a bit of regulatory just in the US and Canada, you can buy them off the shelf, but there’s third party like Levels Health for example, there’s a third party telemedicine that can handle it pretty quickly with just filling out a form. But I think once the economy of scale and the price point comes down, these are going to be cheaper than the point of care finger prick devices just because you’ll get two weeks of data, continuous data, and it’ll probably be 25 to 40 bucks or something like that for two weeks of continuous monitoring. And I think just wearing it for two to four weeks is so incredibly insightful and it helps you tweak your diet. And then once you tweak your diet over two to four weeks with a ketogenic periodically, I test so many different things. So it becomes very insightful to test different variations of the diet or ketone supplements or other things that would lower glucose. So it’s very helpful in that way.

Denise (01:04:27):

No, I think that’s great. Well, I’m disappointed if it’s going to take how much longer for the continuous ketone monitoring, but that’s going to be great because also, we sometimes have, and Beth’s had these parents too, and these parents that will test ketones and glucose five, six times a day on their child because they’re trying to keep them in a good range and they don’t want them to have seizures and their seizures may be life-threatening. So there’s absolutely good reason to do it.

(01:04:55):

And you do it in diabetes, so it’s not as if it’s harmful or that hurtful or anything, but wow, to have that option so they don’t have to dilute the day with all these finger pokes and they can get the data. But then some people, I worry that so much data also can take them just like woo over the top and that’s just some people are so much data nerds or it can cause more stress for them. I think that’s everybody knowing their boundaries. So maybe it’s TMI and they need to pull back, but you’re going to have that with no matter what.

Dom (01:05:29):

Yeah, that’s a possibility. Yeah, my colleague, and I’m on her, she’s studying eating disorders and basically using CGMs to see if you can predict eating behavior or disordered eating behavior in college students. So that study’s ongoing now. Yeah, Dr. Diana Rancourt. So another thing, a conversation that needs to happen is just because I get it from other doctors who are probably listening is, how do we integrate these nutritional therapies with the standard of care? So if you have patients coming in who are on atypical antidepressant or psychotics for example, and that cause weight gain or anti-epileptic drugs. So how do you begin to titrate and adjust the medication with the understanding that for bipolar and depression, other things that the diet should be, and people listening to this as an adjuvant maybe at first and then you can titrate the medication as you go. And how do you approach that transition?

(01:06:37):

Do you have to work with the neurologists, with the psychiatrist to wean them off the drugs or to use them? Is there synergy with the drugs? We went to a conference I think in Belgium, UCB pharmaceuticals, Dr. Jong Rho was there, a lot of the clinician and Keppra and I think there was some discussion about Keppras synergizing with a ketogenic diet in a way that you could use a much smaller dose and get better results with either one alone if they’re combined. So does that happen? In your eyes, do you see this synergy or contraindications?

Denise (01:07:17):

So what we always have to fall back on, hey, we’re dieticians, we cannot make medication recommendations. And so we always will say that, but I’ll say, I might recommend that it’s time to go talk to your doctor. So we always have to couch it with that because anything that I say, it’s not a professional allowance that we have. But what we tend to see, and Beth can agree or disagree, but is as someone goes into ketosis, very often they might see more medication side effects because now you’ve changed your metabolism. Like you said, you may not need both or all of the above. And it would be great if we ever got to a point of saying, wow, to start keto, if you’re on four medications, maybe you should get down to three first, or maybe if you’re on three, you should get down to two or maybe within four weeks of starting, we need to wait.

(01:08:07):

There are just different things. The sooner someone has benefit, the sooner I think that they should talk to their doctor about decreasing a medication. And I’ll tell people, if your child had epilepsy and you went to Hopkins and you saw Eric, Dr. Kossoff, and they were doing better, and I don’t put words in his mouth, but I’ve heard him speak about it. If they’re doing better in six weeks at a visit, he might start tapering one of their medications. He might look at that and I hope I’m correct on the timing, but within a relatively short period of time, if you’re at different places, different neurologists, they will say you have to be seizure free before we taper your medicine. And what I’ve learned from Beth over the years is less is more, less is more.

(01:08:49):

So we’re consistently seeing people seem to do better off this. And these are our experiences, our case reports, our anecdotal reports, not so much studies, but there is at least one really good study. I think it’s on Doose syndrome, Beth, where they look and they say, oh, five medications, you have this benefit. This isn’t epilepsy. Five medications, you have this benefit, you have more benefit with four, you have more benefit with three of the diet, you have more benefit… So as the medications go down, the diet benefit improves.

Dom (01:09:20):

Relieving the side effects too. I mean, you got to take into consideration all these drugs that’s polypharmacy is producing side effects. They get sleepy. Kids want to take naps during the day. And I know Mike Dancer is just basically walking around like a zombie, he was telling me. So he’s very adamantly opposed to using anti-epileptic drugs. And I think the less medication you could use, I think we can all agree the less medication that we need to manage a disorder. The same thing with diabetes, right? The less insulin we can use to manage type two diabetes, if we could do it with diet.

Beth (01:09:56):

It is, and I want to add a caveat. There are some medications that need to be used with caution with keto. And I’m the one that’s been the whistleblower in so many cases because I have to think about how often people see their specialist, for a neurologist, it’s like once every six months if you have epilepsy or migraine headache, the rest is phone calls. Whereas I’m on the phone with them once a week and I’m hearing about their progress. And so I’ve really honed in on the problematic medications and there’s a class of anti-seizure drugs that’s also used for migraine headaches. I’ve seen this in a lot of adults with migraines and they’re called carbonic anhydrase inhibitors and they can cause acidosis. And when you combine that with a ketogenic diet, especially at the start where you can be in a state of ketosis just by going into ketosis and usually the body compensates very nicely for that and that’s very transient.

(01:10:58):

But that in combination with one of these drugs can make somebody pretty lethargic. And so much so that there’s a doctor in Chicago who suggested to his colleagues, you got to cut down by at least 25% on a carbonic anhydrase inhibitor when you’re putting patients on keto because if you don’t, you’re going to have problems right away. And I would even maintain that on their carbonic anhydrase inhibitors, seizures get better when they’re completely off. So I’ve worked with a lot of people going to the neurologist saying, all right, this patient’s migraines are much less frequent, but they’re still suffering from the cognitive side effects of Topamax, for example, which can dull your senses and ketos making them brighter.

(01:11:57):

But can we please start reducing this? And they’ll ask, what’s the proof that this can help? And I’ll just say, “I have lots of anecdotal proof. Do you want me to tell you about each patient? I can do that over a phone call. It’s going to take about an hour.” And no, they don’t want to hear all that. They’ll just try it because they want me off their backs. Topamax and zonisamide are two drugs that I have run into many times with epilepsy and migraine headache and even other neurological disorders that just need to be cautiously watched. Valproic acid is another one. Valproic acid uses carnitine to get into the mitochondria, so does fatty acids on keto. So we see there’s competition. So this drug also has to be followed.

(01:12:46):

So this is probably the most commonly used anti-seizure medication out there that’s being prescribed. And we have lots of patients who are on valproic acid when they start keto and they get very sleepy about a week in and people want to stop keto. And now, I know enough to say no, let’s not stop keto. Let’s reduce the medication. And by the way, we got to get carnitine on board supplementally to help them process both the diet and the medication. So that’s a stick that I just won’t put down because I’ve just seen so many people suffer through that before I really figured out what the situation was.

Dom (01:13:28):

And any feedback for psychiatric disorders? I mean, you have just a huge amount of experience with epilepsy and for carbonic anhydrase inhibitors, I think acetazolamide diamox.

Denise (01:13:42):

As far as with psychiatric though, we feel like it’s the same thing. I’ve had a couple of people fail on the diet and I’ve said, “You’re on four medications and I don’t think the diet can get through. I just don’t think we’re getting there. And that’s probably a problem and you’d need to talk to your doctor.” It’s a very scary situation for them to be willing to do that. But we also try to explain to the patient or the physician that when you add on ketogenic therapy, you’re adding on a medication. It is a treatment. It’s a therapy, it’s metabolically impacting them. And so it would be, I think, perfectly logical to titrate down one thing, especially if there’s a problematic medication early on, if they were on several things, it would be reasonable to look at doing that because you’re adding a med. Because if you were going to add on a different seizure med or psychiatric med, very often they would taper one while they’re increasing the next one.

(01:14:39):

So it wouldn’t be out of line to do that. And I’ve heard Chris Palmer suggest that over three seizure meds, he doesn’t think the diet is going to be effective. So I’m holding onto that. And I’ve seen some inexperience. And so the one of the two that I mentioned and the poster that I’m doing, she’s still on several seizure medications, but at the start of her diet or doctor actually took her off four medications, different things right when she started within the first couple of weeks. And I was terrified. I thought, oh my goodness, that’s a lot of change going on metabolically. She did fine. She did fine, but also she was closely managed by her psychiatrist.

Dom (01:15:24):

Like four medications, if you don’t mind mentioning what they are, what is the advantage to stacking them? I could see an atypical and maybe a small dose of a typical antipsychotic and maybe an antidepressant or something. Are you talking about different drug classes when you remove four medications?

Denise (01:15:44):

This person, it was several different drug classes. It wasn’t for antipsychotics. I mean, they actually removed metformin, which I wouldn’t have done. I would’ve left metformin. And again, I’d have to look at that specifically, but it was not all for antipsychotics. She was just severely over medicated. I believe she was on probably eight or nine medications at the start. And thankfully he looked at this and said, “This is…” And I think she’d been recently hospitalized and probably sometimes things get added on, added on in a crisis situation and so that was… Yeah, and this is just a fun fact about that particular person, if I can tell an interesting story about her. So after about three months on the diet and we were doing a very specific diet, she wanted that. And after about three months, “I’ve had enough of this, this is great, I can’t do this anymore.”

(01:16:40):

And I said, “Ah, stop measuring your food. Send me pictures.” So we just totally did a pivot. She stopped being so precise and we just talked about what her food looked like. She sent me beautiful pictures of her meals. And so that was great. But then she traveled all over the world, literally went all over the world, did great. And then she went to New York and I don’t know what happened, but she went off keto and she was doing fabulous. Went off keto for a whole long weekend. And even then when she got home, she was still off keto, so off I believe a total of eight or nine days. And she said every symptom came back. Everything came back and she almost got hospitalized. Her family was able to get her back on the diet. After about five days, she started feeling better. So they were able to manage this.

(01:17:25):

And then after two weeks, she was 80% better. After four weeks, she was at 90%. Now, she’s really good. And what she told… Oh, I lost my thought for a moment. Oh, what she told me was that she said this would’ve taken three to six months if I had been hospitalized and been put on all the medications to get from where I was to where I am today, months and months. And then just fun fact, I spoke to her last week and I saw where she was at. It wasn’t her house. And she said, “Oh, I’m in the hospital.” And I thought, “Oh no, you’re in the hospital.” And she said her family member was in the hospital and she was visiting and she said, “I’m being the adult here in this situation. I’ve never done that before. It’s always me on the other side. It’s always me in the bed.” And here she got to be there and be the helper for her family member. So it was very cool.

Dom (01:18:20):

The recovery that you mentioned reminds me of the postictal phase when a patient epilepsy would have a seizure and they snap out of it pretty quickly if they’re on a ketogenic diet, if they have a breakthrough seizure. So it reminded me of that. So I’ve talked to a number of different friends and colleagues in psychiatry, and maybe this is what they say, “This approach looks highly relevant and I think there’s a lot of good science behind it. The theory makes a lot of sense, but my patients wouldn’t do this. And I have them managed fairly well on drug therapies.” So that’s almost like the ubiquitous feedback that I get when I reach out. And I don’t try to proselytize or try to really push it in a way. It’s like, have you considered this with your patients? And it’s like, thanks, but no thanks, but it makes a lot of sense. But no, you don’t understand psychiatric patients, bipolar depression. They’re not going to follow this kind of therapy.

(01:19:22):

And from their perspective, maybe not the patient perspective, it’s like we got things under control with drug therapy. And I know it’s not for everybody, but what would you say to doc… Because I do think that’s a bit of a barrier to breaking in and for example, presenting at Psych Congress, which is going on now in Tennessee, like a massive, huge convention where all the psych… It’s mostly drug sponsored, but what would you say to doctors that would say that? Or just ignore it altogether, I don’t think we should ignore it, but I think there needs to be a conversation here.

Beth (01:20:01):

Yes. So what it comes down to is choice and educated choice that adults make, but they have to be offered the options, right? In healthcare, there is a big push, at least in my state, where whether you believe in it or not, you give the patients the options and they determine the choice based on their abilities. So I’ve always said that with keto, it’s like, doctor, it’s not your choice. You have to tell them, this is an option. You can pick this, or we can do drugs, or maybe we can do surgery. Surgery’s going to take three months to get a workup, yada, yada. Drugs, we can start right now. Keto, you got to go see the dietician. And then the dietician will probably be the main person that you’re going to be connected with.

(01:21:04):

Those are choices, but let’s not shroud that with your opinion of what’s going to be best for them. Because let me tell you, and Denise has heard this too, I don’t know how many doctors have told patients of mine, whether they’re pediatric or adult, you can do keto, but it might kill you. You might get heart disease. That’s the kind of option they give them. Well, who’s going to further look into it? And I’ve had people that tell me, we would’ve tried these years ago, but this is what the doctor said and we were scared. So don’t scare them off. Give them the option, let them do some homework. And you give them some resources too. Resources can be the Charlie Foundation, Matthew’s Friends, there’s lots of organizations now that are putting information out.

(01:21:53):

I think Charlie Foundation might be the oldest, and I’m connected to them. So that’s the one I know the best. Denise and I do training for nutritionists primarily, but we have other health providers that take our keto mastery courses. Georgia Ede does training for psychiatrists and other health professionals. So those are somewhat name-dropping now. And Dom, I know you’ve got some of these in your blogs to mention, but there are resources, and the best doctors are those that have tried it themselves. And God bless them. There’ve been so many that have been non-believers. And then they get hit with a medical crisis, whether they’ve develop insulin resistance is usually what happens. They’re overweight, they’ve got insulin resistance, high blood pressure comes and they try first low-carb, and they may go keto and they’re like, “Oh my God, this is amazing.” And then they want to do it for their patients. So those are what I think are the best practitioners, those that find it themselves and then become believers.

Denise (01:22:59):

Yeah. One thing, and here’s some of my commentary on this is with the physicians and we’re trying to convince them, and like Beth said, please leave your opinions at the door. And also sometimes people will look at someone and they’ll say, well, they can’t do it. Or yes, they have bipolar, they have this, or they’re in psychosis, they can’t do it. Well, it depends on their support system. It depends on their determination. It depends on so many things. So it’s really unfair, as a clinician, you don’t walk in their shoes, you don’t know their life, you don’t know. And so to make that determination for them is really inappropriate and unfair. And the other thing is, as I was researching for something, a talk, I realized and looked up and it said 10 to 20% of all medications prescribed are prescribed off-label. And I’m like, oh, wait a minute.

(01:23:52):

People are always like, well, keto is not proven. There’s no evidence. There’s no evidence or not enough evidence. Wait a minute. We’re prescribing. The doctors are prescribing off-label medications consistently. And for schizophrenia and bipolar, there are very few on-label medications. These are all medications that are used off-label or many of them for these conditions. So already we’re treating them with something that wasn’t prescribed or proven and through randomized controlled trials to treat these conditions. And I don’t know the numbers on all those, but I know that there’re a lot.

(01:24:29):

And anyway, so when we look at that and they try to say, you’re off label with keto, well, you’re off label with half the meds the patients are on. And there’s, again, the evidence is growing. And yes, a lot it’s anecdotal and we’re working on case studies and we’re working on research, but it’s compelling enough. And I tell people, I say ethically as a human and ethically as a dietician, I’m seeing too many results almost to not do this. I would almost feel wrong to not be trying to help people, to know, to have something and to put your light under a bushel, so to speak, like the Bible says to not give this information, I would feel guilty, I would feel wrong.

Dom (01:25:13):

And those off-label medications have serious side effects. Ketogenic diets have manageable side effects and could be serious, but very minimal. Maybe you can share with our listeners here the resources that you have and the platforms and educational platforms. And we’re developing the Metabolic Health Initiative and the Metabolic Health Summit and creating with ACCME certification. So you can get medical education credits with that accreditation. But I think it’s super important. I mean, what you guys are doing, obviously, I mean, you’re in the trenches helping patients, but you’re also massive advocates of this and hopefully steering more general practitioners or just practitioners that are using conventional approaches to consider this as an option. And I think that conversation needs to happen, and it’s an ongoing conversation. It’s not going to happen overnight, as you both know. But what can we do? What are the platforms that you could advocate for and recommend for our listeners out there?

Denise (01:26:18):

Well, so our Keto Mastery courses, which is async we do, we present live and also it’s asynchronous. And so there are two levels of that. There’s a foundational course, and that’s what, 20 hours and there is a 20 education hours, and there’s an advanced course that goes over keto. The foundational includes epilepsy, and then the advanced course goes into migraines and pregnancy and psychiatric and all those conditions. And then starting November 1st, funny you ask, we are presenting a modified course, more condensed course for psychiatric only, which will present that in November. So that’ll be coming out. And then if you want to add to that, Beth.

Beth (01:27:03):

So ketomastery.pro, charliefoundation.org, this is the little commercial here, Metabolic Health Summit. Dom, your website has a vast volume of helpful blogs and information. That’s a great place for people to get going too. So these are great quality education resources that we can get started on, and we’d love to see you at a conference and help you get going.

Dom (01:27:38):

Yeah, and also the INKS society too, the Global Symposium and the INKS, and that’s coming up. But I actually have a study section and I can’t attend that. I know Angela and Victoria will be there, but that has been a growing society. And then Keto Live too, which was an amazing event in Switzerland. Josephine is doing a great job with that. And then of course, yeah, got to plug MHS, which will be in January 2024. These didn’t really exist. Global Symposium did. It was under a different name 10 years ago. But it’s been amazing to see all these different conferences come up and the different practitioners. And from a scientific perspective, the sheer number of PubMed publications, peer reviewed publications, and if you go on clinicaltrials.gov too, over the years, seeing that, the number of clinical trials, and I think that’s going to be super important to validate this for the expanding applications as was done with epilepsy.

Beth (01:28:34):

It’s exciting. It’s definitely grassroots but growing, because it continues to be effective. And keto has been around for over a 100 years now. No one can deny that it’s not safe when well formulated and managed medically. So I have to add those caveats to it. We really don’t want people doing this on their own because they can get into trouble.