Q&A: Harvard Trained Psychiatrist Answers Your Mental Health and Diet Questions. Ep. 1

Bret: 
What is the difference between a low carb diet and a ketogenic diet? How high do ketones need to be for mental health benefits? How much proteins did someone need on a ketogenic diet? How long do I have to stay on this ketogenic diet?

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, 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. With all the new evidence and new discussion about ketogenic diets for treating mental illness, they’re bound to be a number of questions that come up over and over again. welcome to our mailbag episode. In our mailbag episodes, Dr. Georgia Ede and I are going to address some of the most common questions that come up.

So by introduction, I’m Dr. Bret Scher. I’m a cardiologist with a focus on ketogenic diets as medical interventions. And I’m the medical director at Metabolic Mind and Dr. Georgia Ede is a board certified Harvard trained psychiatrist who for over a decade has been treating mental illness with ketogenic diets.

And we are going to start doing these mailbag episodes where we’re going to take your questions and answer them on air, on our videos, and on our podcast. So please send us your questions wherever you’re getting this. If it’s on YouTube, leave us a comment. If it’s on Instagram or X Twitter, dm us with your questions so that we can help address the most common concerns that come up so we can help people be better educated to either discuss with their clinician the best ways to potentially approach ketogenic therapy.

So once again, enjoy mailbag episode number one with myself and Dr. Georgia Ede. Many of the interventions we discussed can have potentially dangerous effects if done without proper supervision. Consult your healthcare provider before changing your lifestyle or medications. In addition, it’s important to note that people may respond differently to ketosis and there isn’t one recognized universal response.

Georgia, welcome to our first mailbag episode. How you doing today?

Georgia: 
Good. How are you doing, Bret?

Bret: 
I’m great. I’m excited to get into these questions. Because look, we get so many questions about ketogenic therapy for mental health and you’ve been doing this for over a decade. And, how do you see it?

A lot of these questions that we’re going to talk about today and, what you’ve experienced over the past decade or so, what stands out for you about the importance of these questions? 

Georgia: 
So ketogenic diets in general for weight loss or for type two diabetes, blood sugar control.

There are some basics that apply to everybody, but then ketogenic diets for mental health is a little bit different. There are some special things people need to know about ketogenic diets specifically for mental health. But the other reason I think it’s good to go over these questions is because even for people who have been doing ketogenic diets for a while or think they have been, there can be some

points of confusion, or sticking points, or places where people may not realize why they’re not getting the benefits that they were hoping for. And there are some really common questions that even veterans of ketogenic diets for mental health, may want help to get some clarity on those.

So these questions are not just for beginners; they’re for everybody. Who is interested in ketogenic diets for mental health? 

Bret: 
Yeah, I think that’s a great lead in, and the first question, a question that comes up all the time, is what is the difference between a low carb diet and a ketogenic diet?

Because often it seems like people can use the two terms interchangeably, but when it comes to mental health, they’re probably not the same. So give us some of your thoughts on that. 

Georgia: 
The difference between a low carb diet and a ketogenic diet, a low carbohydrate diet lowers glucose levels. A ketogenic diet lowers insulin levels, not just glucose levels.

So on a simple, low carbohydrate diet, all you’re doing is keeping your carbs very low. That won’t necessarily get you into ketosis. It depends on who you are. So how low is a low carb diet? Most people would say, it’s below 50 grams per day of carbohydrate. But some would even say that below a hundred grams per day counts as a low carb diet.

And there are even some people who would say that the cutoff should be below 130 grams per day. To be ketogenic, most people need to go below 50 grams and many people need to go down to 20 grams to have the chance of getting into ketosis or being in ketosis on a regular basis. So some people say that if you lower carbohydrate to 20 grams or less, then that is automatically ketogenic, but it’s only ketogenic

if you are producing ketones. Yeah. And there are plenty of people who limit their carbohydrate to 20 grams a day, and that’s all they’re doing. They’re not paying attention to anything else about their diet or lifestyle, and there are many people out there who are counting their carbs religiously getting down to 20 grams, and they are not ketosis most of the time.

Bret: 
That’s a great point though. That is a great point because two people can be eating the same foods and it’s, quote, a ketogenic diet, but if you’re not ketosis, it’s not a ketogenic diet for you. So it’s one of probably the only diet that you can really test compliance, or compliance is the wrong word,

you can test efficacy of the diet in getting the state that you want by testing your ketones. So I think that’s such an important point that you just brought up. Now, the other thing though that’s really interesting is a lot of people can go on a low carb diet. if you’re eating the standard American diet, 350 grams of carbohydrates per day with ultra processed food and refined carbs and sugars

and you go to a hundred gram per day low carb diet, chances are you’re going to lose weight. Chances are you’re going to improve your metabolic health somewhat. Chances are you’re going to feel better. But when it comes to mental health, do you think that’s really enough to treat bipolar depression, to treat schizophrenia, to put OCD into remission?

Not that we have randomized controlled trials showing all that, but we have lots of clinical experience with it. Is that where you see the difference between low carb and keto? 

Georgia: 
Yeah, so as we were saying before, low carb, lower risk glucose levels and ketogenic diets, lower insulin levels, and you can’t get into ketosis.

You can’t make ketones unless, there are three steps to getting into ketosis. And so the first is you have to lower your blood sugar levels, and a low carb diet will do that. The second step though is you have to lower your insulin levels to the fat burning point, and that we can talk about in a little while, may require doing more than just counting your carbohydrates.

And the third thing you have to do is you have to burn off a certain amount of stored starch in the liver called glycogen. You have to burn down enough of that so that the body gets the signal. We’re running out of carbohydrate energy. We better start burning fat. Yeah. And when you’re burning fat vigorously enough, the liver will turn some of that fat into ketones.

It’ll chop fat molecules. It’ll break them down into these small fragments, these ready to burn fragments called ketones that cross the blood brain barrier and can bridge any energy gaps that might be their supplement brain. Energy and if you have a mental health condition that is rooted in, brain energy production problems, then ketones are going to be essential for you to improve those symptoms of the mental health.

That’s very different than trying to get your blood sugar levels under control. If you have type two diabetes, if you have type two diabetes, and you want to get your blood sugar levels under control. You don’t need to get into ketosis, you just need to lower your glucose levels. 

Bret: 
Yeah. Such a critical point that it’s getting the ketones in your brain that can really, I dunno, you could say supercharge the effect of your diet is like a sort of simplistic way of saying it.

So yeah, I think that’s really important to note. 

Georgia: 
Yeah. Keto not just a low carbohydrate diet. It’s a low insulin diet, so it’s low enough that fat burning switches on and produces ketones. You don’t see ketones on your meter, 0.5 millimole or higher on your blood ketone meter, it’s not a ketogenic diet. It’s just a low carb diet.

Bret: 
And that leads us to our next question perfectly. This is a question we get often. How high do ketones need to be for mental health benefits? And, of course, we can’t give an individual recommendation to say, this is for you where your ketone level needs to be. But, in general, that question comes up a lot.

So how do you respond to that? 

Georgia: 
Yeah. So how high do your ketones need to be for mental health? That’s the most common question I get from clinicians in my training program, and the most common question I get from patients. And so the answer is we don’t know. And it probably depends on who you are, right?

Bret: which is an answer that nobody likes, right? Nobody likes that answer. 

Georgia: 
Nobody likes this answer. But it’s the truth, the truth shall set you free. Emerging data from, there are pilot clinical trials, in particular Dr. Iain Campbell’s, pilot trial for bipolar disorder suggest that ketone levels do matter for symptom management.

So at least in the early phase of treatment and in his study, for example, he found, and people were measuring their ketones every day in his study, that the higher the ketone levels were, the better people’s mood and anxiety and impulsivity symptoms were, for example. But this is very early days when it comes to the research.

The newer trials that are going to be coming out soon will have even more information about the relationship between depth of ketosis and degree of mental health improvement. That will be really interesting. But if I had to guess based on my clinical experience and that of my colleagues is, I think it’s going to vary quite a bit, depending on who you are, how metabolically healthy you are, what medications you’re taking, what kind of condition you’re up against.

And you know what’s really the root cause of your mental health problem? There are some mental health problems, which I think are going to need very high ketone levels, things like neurodegenerative diseases like Alzheimer’s disease, perhaps bipolar disorder, and other conditions where we may not need

deep ketosis at all. We may not even need to be in ketosis at all. I have got patients with anxiety disorders, for example, mild depression, certain types of ADHD, other types of milder conditions where they don’t even need to be in ketosis most, or even most of the time, or even at all. Some people just benefit from getting those glucose level and insulin levels down, but most people

this is clinical experience talking and, of myself and my colleagues, aiming for somewhere between 1.0 millimole and 3.0 millimole, is a great place to start. It doesn’t mean that everyone is going to benefit in that range. Some people need to go even higher, and it doesn’t mean that everybody needs to be in that range.

But that’s where most people are going to start to notice benefit is above 1.0 millimole. And really we’re talking about consistent ketosis being in ketosis as much of the time as you possibly can. 

Bret: 
Yeah. It’s such an important point that consistent ketosis. And that leads to another question.

When should somebody monitor their ketones? Now, we know ketone levels vary greatly during the day, and if you’re checking once per day, you’re getting a snapshot. We don’t yet have complete wide availability of the continuous ketone monitors, although that’s coming and they’re available in some places, which I think can really revolutionize our understanding of ketosis and ketone levels.

But when you’re talking about a goal ketone level between, one and three millimole for treating someone’s brain-based disorder, when should they measure it? To get that best understanding of where their ketones are. 

Georgia: 
Yeah, that’s a really important question, Bret, because, for example, if you’re using a blood ketone meter, you, of course, it’s uncomfortable.

The strips cost money. you don’t necessarily want to be testing many, times per day to see what’s going on with your ketone levels. So most people who are using a blood ketone meter as opposed to urine strips or a breath meter, which are far less accurate and reliable, Then many people may not be able to afford to or be able to measure more than once a day.

So if you’re measuring just once a day with a blood meter, there’s no consensus about the answer to this question. But my favorite time to recommend is first thing in the morning when you’re fasting, when you wake up. it gives you a really clean baseline so you can compare from day to day what that looks like before.

All kinds of variables start to interrupt your day, like exercise and stress and meal timing and food choices. So it gives you a clean baseline day to day. And the other thing, and I think this is another common misconception about ketogenic diets, I really find that my patients do best when they wake up in ketosis, not when they have to wait until later in the day to get there.

And if you’re testing later in the day, ketones have a rhythm and they do tend to rise in many people towards the later part of the day. A lot of people are not waking up in ketosis, and so they’re chasing ketones for the rest of the day, and they’re only in ketosis towards the end of the day, and that’s not going to give you,

in most cases, as good results as if you’re in ketosis from first thing in the morning. 

Bret: 
Yeah, and I think another helpful tip is maybe in the beginning when you’re first learning about ketosis is to test multiple times then and to learn how your ketones vary during the day, how your meals affect them, how your exercise affects them.

And then once you’re more in like a steady state and more of a routine, that’s when you can, because of the cost and the discomfort, go to once a day, although there’s some debates, you check when your ketones are highest, or do you check when your ketones are lowest? And if you’re going to check twice a day, you want to check when they’re the lowest and the highest possibly.

But if you’re only checking once a day and you see that’s your pattern, do you want to check when you’re the lowest or the highest? 

Georgia: 
I would like the lowest because I want that low to be higher. And so I really think it’s important for people to make sure that their lowest ketone levels are, I would definitely not want to go below 0.8.

but 1.0 is a nice floor, I think for a lot of people, and as I said, some people will need that bottom to be even higher, but if you’re testing at your lowest point, you’ll know if you’re actually falling out of ketosis, which it is one of the most common reasons for poor clinical results. So if you’re not getting the results you’re looking for,

it might be that your ketones are not high enough, consistently enough. 

Bret: 
So another very common question is I think I’m doing everything right and I’m trying to get my ketones in that one to three millimole range that I hear is most impactful for mental health, but I can’t get it above 0.5. I can’t get it above 0.8, and it’s just inconsistent.

What can I do to raise it now with the caveat that this could be an hour long discussion in itself, but what are some of the highlights of what you think people can do to help with their ketone levels? 

Georgia: 
Yeah, I’ve had so many people say my metabolism must be broken, or I’m just different.

Or, I’m too old, or whatever it is. I just, I probably just, this is the best that my metabolism will do, and that’s not true. So if your ketones are too low, your insulin is too high. It really is that simple. So to raise your ketones, you have to lower your insulin and to lower insulin, you have to know what raises insulin.

And everybody knows that carbohydrates raise insulin, and most people are doing a great job limiting their carbohydrate already. So carbohydrate raises insulin the most, especially processed carbs like sugar flour, cereal, fruit juices. But protein also raises insulin, especially processed proteins, like whey protein powder, raise insulin substantially.

Whereas pure fat has virtually no effect on insulin levels. So from a metabolic perspective, fat is the safest macronutrients you can eat. So carbs are the worst for insulin, followed by protein, and then fat really doesn’t touch insulin at all. So really step one is getting your macros right? So because

carbohydrates, followed by proteins are the macronutrients that raise insulin. You can think of carbohydrate plus protein, the way I describe it in the book, is that’s your ketone control knob because carbohydrate plus protein is your insulin control knob. The more carbohydrate protein you eat, the higher your insulin levels will be,

the lower your ketones will be. Ketones and insulin mirror each other like this. When ketones are high, insulin is low and vice versa. So you want to lower your carbohydrate as much as you can. And since we have no biological requirement for it, you really can’t go too low. And, a lot of people already know to do that, but it’s the overeating protein that is the most common problem that I see in clinical practice.

And so I think that this is a really important thing. But there are other simple things people can do too, like eating less frequently because everything we eat, except pure fat, raises insulin to some extent. So nothing is more effective at lowering insulin than not eating at all. It drops insulin like a stone, and that’s the power of intermittent fasting.

Bret: 
Those are some great food related and eating related answers, but there’s so much more that can still impact your ketones. Someone can say I’m following all the recommendations and my ketones still aren’t up. But, you ask how are you sleeping? How are you exercising?

What’s your stress level like? Where’s your cortisol levels at based on that stress, et cetera? So do you find in your practice that those impact the level of ketosis as well? 

Georgia: 
Yes. So, although those affect glucose levels, right? So, stress for example, affects glucose levels so there are two places that glucose can come from.

Everybody knows you can get it from food, but even if you’re not eating any carbohydrate at all, even if you’re eating no visible carbohydrate at all, let’s say you’re eating a carnivore diet that has no carbohydrate in it, no visible carbohydrate. That doesn’t mean that your blood sugar can’t go up.

Your blood sugar can go up because there’s another place that glucose can come from and that’s from your liver. So under stress, for example, if you’ve got stress hormones like adrenaline and cortisol surging through your bloodstream that sends signals to your liver to break down the starch that it’s stored away and break it down into glucose and release it into the bloodstream.

This is how medicines like Prednisone, steroid medications, can raise blood sugar really quite substantially is because they triggered that cortisol liver mechanism. So there are definitely other things that can cause problems with glucose levels that have nothing to do with food.

So yes, cortisol is a major player. 

Bret: 
Yeah. And so there’s also, if someone’s insulin levels are low, they’re doing everything quote unquote right, it does seem like some people just have trouble getting their ketone levels up. So at some point, do you recommend exogenous ketones or MCT oil, coconut oil, things like that to help boost ketones if they find they feel better from a mental health standpoint at those higher levels?

Georgia: 
So there’s something else I would recommend first before we go to adding supplements and things like that. And that is exercise because again, these three things have to happen before your body is going to fire up your fat burning machinery. So your blood sugar levels have to come down, your blood insulin levels have to come down and you have to burn off some of that stored star in the liver.

And working muscles will help you in this regard. So working muscles soak up glucose like a sponge. From your bloodstream, no insulin required so you can lower your glucose without an insulin spike and exercise triggers the liver to break down stored glycogen to make glucose for the muscles to use for energy.

So it starts burning down some of that stored starch in the liver. So that can help you get into ketosis faster and stay in ketosis more consistently. So really, the bottom line with getting into better ketosis before you start looking at supplements is, and this is going to sound, this is going to sound strange, but it really is eat less and exercise. 

Bret: 
The famous advice, within the context of a ketogenic diet, though.

That’s great. That’s great. All right. So, you’ve talked about protein raising insulin levels. So there’s always this question that comes up about how much protein should I eat on a ketogenic diet? And again, it’s going to vary from person to person, but first there’s an assumption that ketogenic diets are, by definition, high protein diets, which they are not.

And second, there’s a concept that the RDA for protein is 0.8 grams per kilo, which we know is maybe adequate for survival, but not optimal for metabolic health and lean mass development. So with all that as a long lead in, how much proteins did someone eat on a ketogenic diet if they’re using that ketogenic diet for a mental health benefit? 

Georgia: 
The same amount of protein that everybody needs, regardless of what diet you’re eating, everybody needs this

the protein rules are the same for all diets, and so the main message is that the amount of protein that you need. It depends. It varies, but it varies within a very widely agreed range. So like you said, there’s no, there’s controversy, there’s no consensus around how much protein do we all need.

Many of us would look at the standard recommendations and think that they’re too low, but there are also many of us who think that they should be much higher than others of us might. So there’s not a lot of agreement, but there are some things about, which I think we can all agree, is that protein requirements vary depending on how old you are, how tall you are, how active you are, and your health situation.

So for example, whether you are recovering from an injury or you’re pregnant or you’re breastfeeding, that will affect your protein requirements. And if you’re very physically active athletic, that may also affect your protein requirements to a small extent, but it’s a broad range depending on who you ask.

But it to keep it simple, especially for people who think in pounds as opposed to kilograms, which is just harder for a lot of us to think. And in the United States anyway, it’s somewhere between half a gram and a whole gram, 0.5 to 1 gram per pound of ideal body weight. I would say do not go below 0.5 grams per pound of ideal body weight and that nobody should need to go above one gram per pound of ideal body weight.

And so somewhere in the middle there is probably the sweet spot for a lot of us, but if you’re very physically active, metabolically healthy or growing, you might need to be on the higher end. If you’re sedentary, have a lot of weight to lose, you may or older, you might need to go a little bit lower to get into ketosis, right?

So that range and the math is easy because let’s say that your ideal body, weight is, say you’re a woman 120 pounds, you’re five four of your ideal weight’s 120 pounds. That’s easy to do the math. You don’t want to go below 60 grams per day and you don’t want to go above 120 grams per day.

And somewhere in the middle is probably going to be where most people are going to fall. 

Bret: 
Yeah, and the great part about ketogenic diets though, is you can measure its impact, right? You can measure your ketone level. So it really is possible for someone to titrate their protein level if they’re doing a controlled experiment.

That’s the only thing they’re changing. You could really titrate your protein and see how it changes your ketone levels. But, it’s funny, this discussion about pounds and kilos, if we talk pounds, we lose all the Europeans. If we talk kilos, we lose all the Americans. It’s like, why can’t we agree?

Why can’t we just pick one metric? Ugh, that’s awful. 

Georgia: 
So don’t go below one. So one gram per kilogram would be the absolute lowest, but more like 1.2 to 1.7 grams per kilo ideal body weight. For those of you who thinking kilograms. 

Bret: 
Right, and it’s also really important to define your goal. If your goal is a ketone level to treat a mental health condition, that’s very different than if your goal is building lean, mass and trying to build muscle.

And one might be on the lower side and one might be on the higher side. So you got to define your goal as well, which I think is so important. Yeah. 

Georgia: 
Exactly. Exactly. 

Bret: 
Yeah. Another very common question is, all right, I’m going to try ketogenic diet for my mental health condition because I’ve heard so much about how it can improve and seen the research, et cetera.

But how long do I have to stay on this ketogenic diet? Is it forever? Is it just a few months? What do you think? 

Georgia: 
Again, we really don’t know, we don’t have enough data to be sure about this, but we do have information from, for example, the field of epilepsy to tell us that there’s some intriguing information from the history of many decades of using ketogenic diets to treat epilepsy.

And that intriguing information is that some children, who were following ketogenic diets for seizure control were, after a few years able to stop the ketogenic diet, go back to eating normally, and their seizures never returned. So that suggests that at least in those cases, that some very deep and permanent healing had taken place.

And, so we don’t know if this is possible yet in the field of psychiatry or for adults. So for mental health conditions other than epilepsy, or for adults, I can tell you that from my clinical experience, some of my patients, a small number of my patients, have been able to after a while, loosen up their diet around the edges, not go back to the way they were eating before, clearly, but just loosen their diet up around the edges, not being deep ketosis all the time, or add a few foods back in that they enjoyed and they were able to maintain their mental health benefits.

Most of my patients, that has not been the case. So most of my patients have seen their symptoms return within 24 to 48 hours of falling out of ketosis, but that’s a really important learning opportunity. It’s a great. In a certain way, it’s a great experience to have because it tests, you’re testing the waters right to see, okay, where is the boundary for me and what is the safe outer limit for me?

And because we’re human beings, pretty much everybody does this, eventually they test the waters. That’s how I know because pretty much all of my patients try this and most of them do not get away with it. 

Bret: 
Yeah. it’s really amazing that we’ve heard ex people share their experience that, on the weekends they eat with their kids, they eat whatever they want, and then during the week they go back and into the ketosis and they don’t really notice a return of their symptoms.

But interestingly, one individual, he says, all right, if I do it on the weekend, I’m okay. But if I stretch that to Monday or Tuesday, now all of a sudden my symptoms come back. But yet, on the other hand, if someone drops below three millimoles per liter, that’s when they experience their symptoms come back.

So it really is interesting how much variability there is, and this is where. we all have to become our own scientists in a way, and, learn. But the safest thing, if you don’t want to experiment, if you don’t want to risk it, stay in ketosis. There’s, really no harm, other than, giving up the foods that you may be missing.

But, that seems like a fair trade off for preventing a relapse of a serious psychiatric condition. Would you agree with that? 

Georgia: 
Absolutely. Absolutely, and as you were saying, there’s no evidence to suggest that a well formulated ketogenic diet should be risky to any aspect of health long-term.

And so there’s no reason to believe that would be unsafe ,and this is one of the things that a lot of people worry about with the ketogenic diet. They think this is a diet just for extreme circumstances, dire circumstances, special situations, there’s some risk involved.

So I don’t want to stay on it too long. There’s no risk that I’m aware of that’s been shown in any, there’s no theoretical risk or, demonstrated risk, for a well formulated ketogenic diet that contains all the nutrients you need, enough protein, enough calories, nutritious foods for your needs.

There’s no reason to believe that being in ketosis for the rest of your life would be dangerous. 

Bret: 
Alright, Georgia, I think this has been a really good exploration of some of the common questions we get, but of course there are many more. So I want to thank you for joining me today, but also plant the teaser.

We’re going to do this again and we’re going to talk about what happens if keto doesn’t help your mental health? Or what if it makes it worse? Or, some of the more specific things about the ketogenic diet, like sweeteners and dairy and like the processed foods and baked goods and things like that.

And also this big comparison about vegetarian diets versus keto diets who lives longer. What do we know about that? Thank you for joining me for this and I look forward for episode two where we can get deeper into these other questions. 

Georgia: 
Me too. And I hope people will send in their questions because we really want to, we really want to hear from you about what you think is most important, what kinds of things you’re struggling with or what kinds of curiosity questions you have about ketogenic diets for mental health.

So I hope we hear from you. 

Bret: 
Yeah, and like I said in the intro, wherever you’re watching this, if it’s on YouTube, comment on YouTube. If it’s on Instagram or Twitter or X, send us a dm. So we want to hear from you. So great point. Thank you. Yep. Our favorite thing is questions, so bring them on. Fellow mental health clinicians and healthcare providers, you now have access to a suite of free CME lectures on metabolic psychiatry and metabolic health.

Each of these CME sessions provide insight on incorporating metabolic therapies for mental illnesses into your practice. These CME sessions are approved for a MA category one credits. CNE nursing credit hours and continuing education credit for psychologists, and they’re completely free of charge on my cme.com.

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