Can a Medical Keto Diet Treat Depression in College Students? – with Dr. Jeff Volek

Jeff: 
You know, what I’ve learned over nearly three decades of trying to rigorously study very low-carbohydrate ketogenic diets is that it’s a huge hammer. And you know when you learn to wield that hammer, and everything starts to look like a nail.

Bret: 
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a nonprofit initiative of Baszucki Group where we’re providing information about the intersection of metabolic health and mental health and metabolic therapies, such as nutritional ketosis as therapies for mental illness.

Thank you for joining us. Although our podcast is for informational purposes only and we aren’t giving medical advice, we hope you will learn from our content and it will help facilitate discussions with your healthcare providers to see if you could benefit from exploring the connection between metabolic and mental health.

Professor Jeff Volek, a professor of human sciences at the Ohio State University, has over 25 years of research experience with ketogenic interventions and ketogenic diets, ranging from type 2 diabetes and metabolic dysfunction to athletic performance, and now to college students at Ohio State with depression in this new study.

So, we’re going to hear from Jeff and his vast experience in this field and why he’s transitioned now to focusing on mental health. So, stay tuned for this interview with Professor Jeff Volek.

Jeff Volek, thank you so much for joining me today at Metabolic Mind. 

Jeff: 
Yeah, it’s great to be here, Bret. 

Bret: 
Yeah, anybody who is involved in metabolic health and ketosis, I’m sure knows your name because you’ve been involved in the field of research of ketosis for 25 plus years now. So, I want to rewind back to the beginning and hear from you.

What got you interested in studying and researching ketosis way before it was a popular thing, I guess you could say? 

Jeff: 
Yeah, thank you, Bret. That’s takes me back almost 30 years now, hard to believe. I studied dietetics, classically-trained. This is going back to the early nineties now.

And of course, what’s taught, that low-fat diets were the most healthy approach, and I believe that, and it was very low-fat. I followed a very low-fat diet myself. And then I think it was probably around 1992, I read Dr. Atkins book, whatever version that was at the time, and just decided that I should try this.

And not knowing really about the science or the rationale, but I was into self-experimentation at the time, and thought I would give it a shot, and I felt remarkably well on it. I wasn’t obese or metabolically-impaired at the time, but certainly didn’t impair my performance, cognitively or physically.

And so that really intrigued me. And, in particular, I was intrigued by how it might impact diabetes and obesity. And everything I’d been taught in class was that fat was harmful. And the more I got into the science, the more I started to realize that probably wasn’t true. It didn’t make a lot of sense.

I really started to challenge things. And I went on to grad graduate school and studied exercise physiology, but I was always interested in nutrition. And we were doing a lot of dietary supplement nutrition studies in the lab, and I was thinking about low-carb experiments throughout my entire grad work in the nineties.

And the more I learned, the more I realized that what I was taught, wasn’t the full story. And I really was on the right track here thinking that fat isn’t the demon and wasn’t justified to vilify fat the way we were. And this was very strong in the nineties, and we were really into the fat-free, low-fat products, were being sold everywhere.

The dogma had really solidified and hardened by that point, but this is not what I was being taught in classes. So, a lot of this was my own self-education and digging into literature and understanding, trying to understand the metabolism of carbs and fat. 

Bret: 
Yeah, and we, unfortunately, hear that a lot. That somebody only gets into this because of a sort of a personal experience, and then has to rethink and question kind of everything they’ve been taught to get further into it.

Now, you’ve done this more than anybody with now, like you said, almost 30 years of this, with extensive research. You’ve studied how it affects athletic performance. You’ve studied so much about insulin resistance, metabolic health, type 2 diabetes. And it would take probably two or three podcasts to go over all the work you’ve done.

But I’m curious, throughout that whole progression, now at Ohio State University, you’ve started a study, looking at ketogenic therapy for treating depression. So, I’m curious how that progressed, like how you got from athletes to type 2 diabetes and metabolic health and now to mental health and to depression?

Jeff: 
Yeah, I think the short answer is, what I’ve learned over nearly three decades of trying to rigorously study very low-carbohydrate ketogenic diets is that it’s a huge hammer. And when you learn to wield that hammer, and going back to my dietetic backgrounds, that’s really what I think my lab excels in formulation implementation of this ketogenic diet, everything starts to look like a nail.

And so there, the most obvious nail is obesity and type 2 diabetes, and that was an area I spent the majority of my career studying. There’s probably no better example of the power of ketogenic diets to reverse disease than in type 2 diabetes.

So, that’s been a major focus. But I’m very much now, that we’ve demonstrated that we can reverse diabetes, I’m more interested in the advocacy on that end. For example, giving some recognition of all the science in the dietary guidelines for Americans and so forth because we have the evidence. Not that there’s not more studies to do, but there’s sufficient evidence now that we should be embracing this in public policy and will not, and many people are suffering as a result.

But on the scientific end, there’s still a lot of other potential nails out there that would likely benefit from a ketogenic diet. And I think mental health, it’s just one of many areas where that could end up being also a very powerful condition or a condition, ketogenic diets show powerful therapeutic effects. And, no, I’m no expert in mental health. But fortunately, I have great colleagues here at Ohio State, and we’ve put teams together and are studying this now, and also very fortunate to be included in the rapidly expanding group that you’ve helped develop through Metabolic Mind and Baszucki Group. And I’m fortunate to rub shoulders with a lot of world experts in mental health.

This is probably the most rapidly progressing area in ketogenic diet research that I can recall in my 30 year career because a couple years ago, this wasn’t hardly on the radar. 

Bret: 
Yeah. And that’s a big part of, I think, our mission is getting people like you, the experts who’ve been doing ketogenic interventions for decades, combining it with the experts in mental health so everybody can learn from each other and grow along the way, which is exactly what’s been happening, which is really exciting.

But I want to go back to your analogy for a second of the hammer and the nail because there’s that old saying, right? If all you have is a hammer, everything looks like a nail. You could look at it both ways, I guess. So, the skeptic would say, there’s no way one intervention works for obesity, type 2 diabetes and depression and bipolar disorder and cancer and PCOS, right?

It’s like, it’s too much. So, how do you rectify that? How do you say, yeah, actually it does, and here’s why? How do you connect the dots? 

Jeff: 
Yeah, you’re right. You run the risk of sounding a little bit like a quack when you state that this intervention could have such broad spectrum therapeutic applications.

But the reality is, when you look at most chronic diseases, they have and underlying metabolic impairment as part of their pathophysiology or pathogenesis. So, in other words, whether you’re looking at cardiovascular disease or diabetes or cancer or neurological diseases, in all those cases, there’s underlying metabolic impairment and chronic inflammation.

And all of these relate back to nutrition. That they all share some common elements, in terms of what might be driving these disease processes. Now, they tend to manifest in different ways. So, people develop different symptoms and different disorders, but it’s quite striking how many of them relate back to problems managing carbohydrate.

And when you fix that, rather than just putting bandaids on things, which is what most drugs do, you’re actually getting at root causes. And therefore, you’re seeing really quite broad therapeutic effects across the spectrum of various metabolic diseases, including mental health.

Bret: 
Yeah, I think that makes a lot of sense. The way it comes back to the metabolic dysfunction at the root of the problem, and then also just being able to have your body run on a different fuel source and providing ketones. it really can affect so many different areas. But one hesitation or one concern that comes up with people who maybe aren’t as familiar with putting yourself into ketosis, ketogenic therapy, ketogenic diets, is that it’s so hard to do and people aren’t going to be able to do it and stick with it. And here you are doing it in your study in a college population, which is probably one of the more challenging populations, too, because there’s not maybe set schedules.

You can’t always have access to all the food you want. And the age group, and there are so many different things. So, I’m curious what you’ve found so far about just how well people can implement and stick to a ketogenic diet for that age group that you’re studying. 

Jeff: 
Yeah, the college-age population is challenging for a number of reasons, as you kind of laid out.

But the reinforcement from the positive effects, that does help a lot in terms of motivating them to want to stick with it. But the reality, Bret, is the ketogenic diet is a challenging diet for most people because we are so accustomed to having carbohydrates in our diet.

They’re everywhere. They’re ubiquitous. For many people, they can be addictive. So, you’re dealing with a lot of challenging, even cultural norms, around what constitutes a diet for a person. And asking them to switch their diet does take a lot of education upfront because there’s a lot of different components to a ketogenic diet that one needs to understand to implement appropriately.

But then even once you understand it, there are challenges just implementing it over time, for weeks and months and years, because there’s a lot of forces out there that want you to eat carbohydrate. Some of them might be your family or your friends or your healthcare team because they’re ignorant of the science.

They may think they’re helping you, but a lot of times you see people in your own network of supporters that might be sabotaging their efforts. So, the bottom line is, it is challenging. We have to recognize that all the challenges are solvable and the diet can be very sustainable for folks and pleasurable.

I would add food should be enjoyed. And there are a lot of meals that can be consumed and foods that can be consumed that facilitate pleasure and joy. And the fact that you’re improving your metabolic health exacerbates the pleasure you get from eating. We’ve certainly demonstrated that this can be a lifestyle. It can be sustained in folks, but we’ve also learned it requires ongoing support and education.

Yeah. And that’s the 

Bret: 
And I think that the more profound the benefits, the more likely someone is to stick with it. We’ve heard that time and time again, and that completely makes sense. And so, from a mental health arena, it seems like that is a big motivating factor. So, for someone without that experience to say, oh, it’s challenging, you’ll never stick with it, is really a misrepresentation of the reality, I think. But, so

Jeff: 
Every month, it’s pretty easier, too. The food manufacturers are increasingly producing ketogenic-appropriate foods and meal plans. So, compared to five years ago or even a few years ago, the accessibility to a lot of really good tasting formulated ketogenic foods has increased dramatically.

So that helps. 

Bret: 
Yeah, that makes a lot of sense. So, what can you tell us so far about your study on using ketogenic diet for treating depression in college-age students? 

Jeff: 
So, we’re focused on depression. So, these are students who are currently enrolled at Ohio State and are in a counseling program. And we’re working with the psychiatrist that oversee that program and psychologists as well at Ohio State.

It’s really a pilot study. So, our goal is to generate preliminary evidence supporting the ability of a ketogenic diet to improve symptoms of major depressive disorder. So. It’s a 12-week intervention and we are actively enrolling still. And I don’t want to get too much into the details in terms of what we’ve observed so far. 

But, I will say that we have been able to enroll students into the study. We have been able to maintain ketosis, which is one of the feasibility goals, is getting college-age students to be compliant with this diet and actually register ketones in the desirable range that we’re targeting.

And that our primary outcome, which is simply a PHQ-9 survey of the self-reported depressive symptoms, has improved dramatically in those participants who are able to achieve ketosis. And I’ll probably just leave it at that. We’re measuring a host of other metabolic physiological variables, including even doing MRI scans of the brain to look at structural and functional changes and a host of blood work and so forth, to correlate back. But I think it’s fair to say we’ve achieved our goal as far as a preliminary pilot study, seeing a pretty robust signal in terms of improving their depression.

Bret: 
Yeah, and I know it’s difficult to talk about the specifics of an ongoing study, but that’s just so encouraging what you’ve already said that it’s been, you’ve had great success in, having people start and maintain ketosis, and that so far, the results seem to be very encouraging. And obviously, we’ll learn a lot more when the study’s completed and, published, but it’s still so important to talk about it.

So people, whether it’s researchers, clinicians, or individuals, know what’s going on out there and can start to think more deeply about this. Is this right for me? Is this right for my patients? Is this right for me to look at the next research study that should be done? And that’s why it’s so important to talk about.

So, the other thing though I want to focus on is, you’ve mentioned the term well-formulated ketogenic diet, which is something we hear a lot, but I wanted to hear how you define that. If someone hadn’t heard that term before, or just thinks of a ketogenic diet as just all the bacon you can eat, how do you define well-formulated ketogenic diet?

Jeff: 
Yeah, there’s multiple sort of principles I like to call them that constitute a well-formulated ketogenic diet. First and foremost, because the name is ketogenic, the goal of the diet is to achieve a beneficial levels of ketones, and that requires primarily restricting carbohydrate but also modulating protein into the right range.

So, the combination of those two things, those are your two primary levers that control how much ketones are produced in the liver. We really focus on that to get people in the right range. Everybody’s different. That’s the other thing.

So, all this is done on a highly-individualized basis. And this is also requires that you have an ability to measure the ketones, which I think is a really critical component of this. So, by measuring ketones, you can provide feedback and dial in, so to speak, the exact right level of carbohydrate and protein a person can consume to achieve ketosis.

Now, for most people, that’s less than 50 grams of carbs per day. But for some, it might be less than 30. For some, it might be as much as 70 or 80, especially in some young, healthy, insulin-sensitive individuals. And then protein is not too low, not too high. It’s actually a very similar level of protein that most people consume.

It’s part of the traditional diet. But there is a tendency for some people to overeat protein because they might not be consuming enough fat or too many lean meats, and are just not satiated. You have to watch the protein as well. So, that’s a carb and protein, are two other components.

Now, the fact we don’t worry so much about in terms of quantity, we let people eat to satiety. We don’t count calories. We know that doesn’t work for weight loss and other things. So, we let people choose what level of caloric intake. So, fat is flexible and how hungry someone is. 

Bret: 
When it comes to fat, do you find that you have to overcome people’s pre-held beliefs that oh no, I can’t eat that much fat?

That’s bad for me, or I have to eat low-fat. 

Jeff: 
Yeah, certainly that fat phobia is, prevalent still. It’s less than it was 10 or 20 years ago, but certainly there and because if you don’t consider fat a friend, you’re going to struggle with a ketogenic diet. You can’t do low-carb, moderate protein, low-fat.

It’s not going to work long-term. So, you have to make peace with fat, and you have to make peace with saturated fat, too. Because what’s more important than quantity of fat is quality of fat. And because fat’s your primary macronutrient on a ketogenic diet, so if you express it as a percentage of your total energy expenditure, it’s usually around 70 to 80% of your calories coming through fat.

And you want the primary function of that fat in that context is fuel. And, of course, it’s also adding flavor and so forth to the diet. And so you want the fats there, the preferred fuels. And the preferred fuels are monounsaturated and saturated fats.

In other words, if you try to construct a ketogenic diet that’s very high in polyunsaturated fat, you are going to feel nauseous and not continue. We really coach people to avoid the vegetable oils, corn oil, soybean oil, anything high PUFA. But olive oil, canola oil, coconut oil, and almost all whole foods, animal-based whole foods are naturally low in PUFA.

So, those are encouraged. Butter, any type of meat, fat that’s accompanying meat is going to be primarily monounsaturated. So, those are fine. But yeah, so the quality of fat becomes important and try to encourage you a couple good doses of EPA and DHA if you could get salmon in a couple times a week and so forth.

So, those are the macros. And then you can get into the micronutrients, too. The only one I’ll just mention because it’s so critical, and there’s a lot of still misinformation, is around sodium. So, when you’re eating a high carb diet, the body keeps a lot of the salt. But when you switch to a ketogenic diet, the kidneys switch to excreting more sodium.

And that’s actually a good thing for a lot of people. A lot of people who are obese are also carrying some excess fluid. So, that’s what causes the rapid weight loss in a lot of people. They’re shedding a lot of fluid because where sodium goes, fluid follows. So, there is this, what’s called a natriuretic that simply means loss of sodium effect and diuretic effect of the diet, and that often accounts for the weight loss.

It also accounts for normalization of blood pressure. In a lot of people, they can reduce their blood pressure meds or even get off them. The problem is if you keep restricting, if you keep this effect going without replacing that sodium, you end up with what’s called the keto flu.

And I think most people kind of understand that. Now, it’s the dizziness, the fatigue, the lethargy that can manifest in headaches and various other symptoms. And the interesting thing is most people blame it on, oh, I’m not eating carbs, so that’s why I’m feeling lousy. And so they eat carbs.

And guess what? That makes them feel better because it’s their sodium problem. But it wasn’t a carb problem, it was a sodium problem. So, all they would’ve had to do is increase sodium intake by a gram or two. So, that’s really important, especially for the athletes, too, because the last thing you want is a reduced plasma volume when you go exercise.

So, being conscious of getting adequate sodium and potassium, too, because the problem is you don’t have a adequate sodium, it’s a stress response in the body, especially on the adrenal gland. Cortisol goes up, aldosterone goes up, all in an attempt to hang on to that sodium and fluid. Over time, that’s not a good scenario in terms of sustainability and just maintaining some efficacy of the diet.

So, you have to be comfortable with saturated fat. You have to be comfortable with sodium and just that in general. These are in direct contradiction to what we’ve been told for the last 40 plus years. 

Bret: 
Which gets us back to how we started with you saying you had to question everything you’ve been taught and and go against what the common knowledge has been, which has been so important. And we see it time and time again. But that has furthered research over the past 25 plus years. And like you said, now with this research for mental health, it’s been growing exponentially, but there’s still a big reluctance about this getting into, I guess you’d call it, mainstream medicine or first line therapy for various conditions.

And I know you’ve seen it progress, and it’s probably better now than it was 20 years ago, but there’s still a barrier. So, what do you think it’s going to take to get past that barrier to make it more acceptable as a medical intervention?

Jeff: 
Yeah, you know that’s a question that I’ve been struggling with for a long time, Bret. We’ve only made very small progress in that space. Actually, I’m not aware of any academic program in medicine or dietetics at any university that actually teaches ketogenic nutrition.

And so there’s still an abundance of ignorance when it comes to this. Now, there’s certainly a lot of information online on the internet, and you can self-teach yourself and whatnot. But it’s not formally taught to anyone, and that’s a problem because their just are not many healthcare professionals that are knowledgeable about all these nuances that we just talked about with the ketogenic diet or even aware of its therapeutic potential to offer it as a option.

But even if you do offer it as an option, then how do you execute on it? Because they don’t have dieticians or nurses or any healthcare professionals, really, that know how to implement this. So, it’s still a huge barrier that needs to be addressed, and I’m increasingly putting more attention on that.

I wish I knew the answer, but I think it’s more education. It’s putting on conferences. It’s putting out information that’s accessible, like you’ve done on the Metabolic Mind website, and people are seeing that, learning. But I think we need to actually get it into the medical curriculums and the curriculums at universities and make this mainstream in terms of what people are taught.

That was not the only approach, obviously, but it is a major arrow in the quiver that healthcare professionals need to be aware so that they can offer it to their patients. 

Bret: 
Yeah, that’s so well said. It’s not that everybody has to implement ketogenic diet in everyone, but they should at least be aware of it, and where it can be most beneficial, and one more tool to help people get healthy, which is what this is all about.

So, I appreciate that input. I thank you for your time. This has been really enjoyable conversation ,and I can’t wait to hear more about your study as the results come in. 

Jeff: 
We do have a tremendous amount of work underway, eventually, that’ll make its way into the peer-reviewed literature.

And I’ll be at meetings and trying to spread the word, but science moves slow, unfortunately, even when you have a high sense of urgency. But there’s a lot of great work underway, and I think a lot of important discoveries are going to be made over the next few years and beyond. 

Bret: 
Great, thank you for all your work.

Jeff: 
Thank you, Bret. 

Bret: 
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