Is a Ketogenic Diet Effective For Adolescent Mental Health?

Lori: 
This is a very worthwhile, it’s a very worthwhile area of research and clinical work because if you can change an adolescent for the better, you change them like for the rest of their life.

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.

Dr. Lori Calabrese, a psychiatrist at Innovative Psychiatry, has tremendous experience using metabolic interventions to treat mental illness. But a lot of what we know comes from research and clinical experience in adults, but what about adolescents and teenagers? It turns out Dr. Calabrese has some experience there as well.

So, let’s hear about the unique challenges and opportunities of dealing with this population and how it compares to her experience with adults. Here’s the interview with Dr. Lori Calabrese.

All right, Dr. Laurie Calabrese, thank you for joining me once again at Metabolic Mind. 

Lori: 
Thank you. Thank you for having me, bret. 

Bret: 
We’ve talked a number of times, and there’s a lot of research going on in clinical experience of using ketogenic therapies to treat serious mental illness. And the majority of it is in adults, both the research and the clinical experience.

But you’ve talked about and even written about treating adolescents and not just adults. And I’m curious about your experience with that because adolescents aren’t just little adults, right? They’re completely different hormones, different life structures, so many different things.

So, what is your high level, just take home of treating adolescents versus treating adults with ketogenic therapy for mental illness? 

Lori: 
High level? 

Bret: 
Yeah. 

Lori: 
It’s actually about getting the whole family on board with both parents. Or if it’s a split parent household, at least both parents aware of and able to consent to helping the adolescent, that’s the first thing. The second is engaging the adolescent. 

Bret: 
Yeah. 

Lori: 
So, it’s critical more so than with medicine and more so than I think even with other treatments in psychiatry. Getting an adolescent to get excited about this kind of treatment is really key to getting the treatment to work.

Third high level thing, understanding the adolescent’s learning style. That’s something we don’t talk about in psychiatry, but teachers know this very well. There’s differentiated learning and differentiated teaching. Some kids respond better to visuals, info communication, written instructions.

And so figuring out how does this kid learn is going to be really important because we’re going to want to teach that patient all about this so that they can be really successful. And I think probably the last thing is having a really good dietician to work with adolescents, more so than any other patient group that I see.

They’re growing, they have sports in different seasons, there are hormonal changes that we have to take into account, and there’s all kinds of social things that we can really help them with when we help them ketofy what they want to do with their friends and what they want to eat with their friends when they’re on this kind of treatment.

Bret: 
Yeah, I think that’s a great overview. And you talked about having them buy in, really getting them to be excited about it. I imagine that can be a challenge for a lot of adolescents. And so what are, what do you do to do that? Like how do you really get in to reach them? 

Lori: 
I think it starts with the first visit because it’s usually the parent that’s calling. And so if I’m meeting with an adolescent and one or two parents, or were on Zoom with an adolescent, one or two parents very often, the most troublesome thing for an adolescent is to, I think so, is to hear their parents talk about them. 

Bret: 
Yeah. 

Lori: 
So often what I’ll say is, I’m going to ask your mom and dad actually to tell me about what you used to be like.

Last time you were in a really good place and what they saw change. And then we’re going to throw them out of the room, and I want to ask you the same thing. So, to have someone, even if they’re very fragile, listen to themselves being described, sometimes it’s the first time they’ve ever heard their parents say what they used to be like and then say what changed.

The buy-in happens when the parents leave the room. And then I say, you’ve heard this. Tell me a little bit about that. What if we could give you a way back? Very often adolescents coming to me aren’t coming to me. This is not their first rodeo. They’ve been in treatment. They’ve seen people. It hasn’t worked, or they haven’t wanted meds or they’ve been hospitalized.

And so coming to this kind of treatment is something that they do when they’re tired or they’re sick and tired and they’re still young. They’re 15. They’re 16. They’re 17. 

Bret: 
Yeah, and I probably should have started with this question, but even though we’re outside of the realm of research really, do you think ketogenic therapy is as effective in adolescents as it is in adults for treating psychiatric conditions?

Lori: 
So, this is based on my own, on my own experience, I think it’s actually more effective. 

Bret: 
Wow. 

Lori: 
Because there is all of this opportunity, young to model something and to actually get someone feeling very good very quickly. Ketogenic therapies are really easy for adolescents to adopt because they’re often not fighting metabolic disorders or weight that would maybe have an adult go into ketosis a little bit more slowly.

So when they’re in, it’s easy. They adopt, they adapt it and adopt it and adapt to it, I should say, in a way that doesn’t create an eating disorder because the family is eating the mom’s cooking. They’re like, the family ends up really doing it, not making a specific meal for their teenager.

They’re so invested in wanting to try this, that it works for the family. It works for the teen. 

Bret: 
Yeah. And like you led with, so important to get the family on board to really see success. And does the diagnosis matter? We talk a lot about bipolar disorder and major depressions, schizophrenia, and imagine the teenage population also has ADHD and OCD and anxiety. Do you think the diagnosis matters or do they all fall under conditions that will respond to ketogenic therapy? 

Lori: 
It’s a loaded question. 

Bret: 
Yeah. 

Lori: 
It’s a question that we don’t have answers for. 

Bret: 
I’m not an easy question. Come on. 

Lori: 
You’re only going to give me the hard ones. So, what I can tell you that we’ve treated in our practice is first episode psychosis, major depression, bipolar disorder with both episodes of mania and depression.

Patients who’ve had autism, OCD, anxiety, there’s been a cluster and ADHD is in there because most of the patients that I see don’t have one thing. What distinguishes ketogenic metabolic therapy is that it’s a treatment that, I think, biologically is so powerful that it gets at underlying mechanisms in all of these conditions.

So, the question is, how do you flex it then? What do you do with it in an adolescent who has a first episode of psychosis who hates their medicine? Whose parents say, can we get her off medicine or taper her medicine or do something? And is that different from what you would do with someone who has such severe OCD that she can’t go to school or he can’t go to school?

So, we’re working out what the ketones need to be, what the ratios need to be, what the measures need to be, and following that over time. But I think this is a very worthwhile, it’s a very worthwhile area of research and clinical work because if you can change an adolescent for the better, you change them like for the rest of their life.

Bret: 
Yeah. 

Lori: 
And then maybe the medicine that they thought they were going to need to be on for their whole life, they all of a sudden aren’t down anymore. It changes everything. 

Bret: 
You can change their education, their first job, their whole, their relationships, their entire, the entire rest of their 

Lori: 
They can have a girlfriend.

Bret: 
Yeah. 

Lori: 
Or get a boyfriend. It’s the yeah, it’s all of that. 

Bret: 
Yeah, which speaks a lot to that, the social structure, and you talked about the need for support and a good dietician. When your friends go out for pizza and beer, if you’re in college or if you’re in high school and your friends go out for pizza and milkshakes or whatever, what do you do? And you need to have the knowledge and the structure ahead of time to know what to do.

So, is that where working with your dietician is so crucial? Or how do you help them navigate that? 

Lori: 
I think we start with a dietician upfront. 

Bret: 
Yeah. 

Lori: 
And most of the meals start at home. They, it’s easier to control that if mom and dad and the adolescent or the kids in the family know what the meal structure’s going to be.

But an important part of that is that so many people who have heard about keto on YouTube or in other places, buy keto foods. 

Bret: 
Yeah. 

Lori: 
And so they don’t even know. They come to us saying, can you help us? Because we’re doing a ketogenic diet, but it doesn’t work. And so sometimes my dietician and I will look at each other and say, I don’t think that’s keto.

No. we have to find a nice way to say, let’s make sure that a ketogenic diet is actually going to produce ketones. As they learn what they can have, then we start to show them how they can flex out. We look at menus with them. My dietician is really wonderful at coming up with creative recipes for somebody who says, I need to have Alfredo sauce.

I want Alfredo. We are looking and creating and modifying things and often we’re modifying their family’s favorite foods. So, if they’ve got some favorite foods and we just need to make them keto and get something out of the menu that would otherwise be there, we find a way to do it.

Bret: 
Yeah. It feels like there are a lot of clinicians who dismiss ketogenic therapy, just dismiss it out of hand, that no one’s going to stick to it, so why try it? And that they would say that about adults and they would just say that even more emphatically with adolescents and teenagers. In your experience, have you seen that they will stick with it if they see benefits? That they’re sticking with it or is it still a challenge in terms of compliance and adherence?

Lori: 
No, I’ve seen them stick with it. Yeah, I’ve seen them stick with it. To a young person with the first episode of psychosis who’s totally off of his, totally off of his anti-psychotic and buff. So, his friends all want to know, what’d you do? And as they stick with it, they find once they are well or well enough that they say they’re well, they’re happy.

Then they want to know like, how far can I go? What can I do? How far can I flex? And really, the key to that is figuring out, gee, do your symptoms come back? Let’s check your ketones. Or if you want to go out, how can you correct and get back into ketosis a little bit more quickly? If you’re out with your friends, and it’s pizza night, then we can just kinda like quickly get you back.

But that depends on first getting into ketosis and then getting metabolically flexible. So, what we do is try to teach teens, like we would teach adults. You’ve got to get to the point where your body can switch on a dime. That’s going to take four months, like four months.

Can you give it four months? 

Bret: 
Yeah. 

Lori: 
And and then when they see it, then their friends want to know what they’re doing. 

Bret: 
So, yeah, it’s so interesting. We’ve, we definitely have heard examples of people are in ketosis Monday through Friday and then come out Saturday and Sunday and do whatever they want and then come right back.

On Monday and they do that just fine. But if they extend maybe for a long weekend, they start to see symptoms start to come back. So they learn where their threshold is and others, if their ketones fall below 2, they get symptoms. 

Lori: 
That’s right. 

Bret: 
So everybody’s a little bit different in that area. So, I’d imagine that takes a lot of, sort of handholding and education to really make sure someone’s safe when they do that. 

Lori: 
And willing to look. So you, if you have somebody who’s willing to say, let me see. And then we’ve got the data that, and the graphs that show, oh, wow. You look at how good you look and your ketones have been like in a good place and oh, like what was, like, what happened there?

Sometimes it’s not so clear. If someone’s a little out of ketosis or ketones fall for a day or two, they might not really know for another day. Yeah, that, oh, it’s going to catch up with them. So everybody learns their own little pattern and then very often they think it’s not worth it to me.

Yeah. Like I know what I was like, I know where I used to be. 

Bret: 
Yeah, and we talk a lot about the barriers of someone starting therapy or the hesitancy of a clinician even recommending it. Do you think those are stronger with a clinician sitting in front of an adolescent patient versus an adult patient?

And what would it take to break those barriers down? 

Lori: 
Oh, I think they’re a lot stronger. 

Bret: 
Yeah. 

Lori: 
The biggest barrier is that this is an off-label trial or an off-label treatment on a kid. Yeah. So all of the warning signs go up, both for the parent, sometimes for the adolescent and certainly for the doctor and the clinician.

So what is very different about this kind of treatment in adolescents is at this point, parents are calling us. Parents are calling clinicians saying, please, can you try this, please? This is an option. I don’t want medicines. I don’t want my, I don’t want my daughter to become like me. I’m on three different things.

I don’t want my son to become like his uncle. His uncle’s never gotten out of the hospital. He’s so, there is an automatic hope on the part of parents coming in, and I think that it makes the conversation about this is off-label. This is really the recommended treatment. I know you’ve tried it.

I know you, your child might be on it or maybe on it, but is unwilling to take it. So lots of, just lots of opportunity to discuss what does that mean? And unlike with medicines, with a ketogenic diet, there is no PRN. You don’t just take a swig of olive oil.

Bret: 
Meaning as needed, take it as needed. Take it as needed.

Lori: 
You don’t say oh, I’m having a panic attack. What can I, where’s my panic attack medicine for that? Or I’m having psychosis, where’s my psychosis medicine? So you have to be willing to work both with medicines, if patients are on them, and tapering and as needed medicines. Or with patients who say, I don’t want anything. You’ve got to come up with, then what?

Then what if you don’t feel well, then what are you going to do? What am I going to do? How are we going to talk about it? How are we going to get you feeling better? 

Bret: 
Yeah, yeah. I think that’s , good tour of ketosis for adolescents. The challenges, but also the opportunities. I think it really is a whole population that could benefit dramatically and I’m glad you’re out there doing the work and you really are trailblazing for this.

And then hopefully others will follow suit and the research will follow as well. 

Lori: 
And the research will be right there. Yeah. 

Bret: 
Yeah. Great. Thank you so much. 

Lori: 
Thank you. Thanks. Thank you. 

Bret: 
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