Q&A’s: Are Sweeteners Helpful or Harmful? Dairy? Ketone Levels, Longevity, and More

Bret: 
Should I include sweeteners in my keto diet or should I avoid them? What about the baked goods and the keto bars and the keto snacks? What role does dairy play in a 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 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.

Hey, Georgia welcome back to our second episode, our second mailbag episode. Good to see you again. 

Georgia: 
Nice to see you, Bret. 

Bret: 
So we already did a first episode where we went through a lot of the common questions people have about ketogenic diets, ketogenic therapy for mental health benefits but there are so many others.

We get so many questions from people, which we want more questions. So let’s get into some of the other common questions starting with what if I’m on a ketogenic diet and it doesn’t help my mental health, or if my mental health even gets worse on a ketogenic diet? What do I do then? 

Georgia: 
Yeah, so ketosis does help most people feel noticeably better, but it doesn’t work for everyone. However, make sure first that you really are in that small group of people where it’s not working. So when I consult with patients who tell me that a ketogenic diet didn’t work for the mental health problem. The first two questions I always ask are how long did you try it forand were you measuring your ketones? Because nine times outta 10, they either didn’t try it for long enough, they didn’t realize that it takes time, or that their ketones weren’t high enough because they weren’t measuring so were you in good consistent ketosis for at least 12 weeks?

Six and the minimum 12 is even better, and by good consistent ketosis, as we were talking about in the last episode, blood ketone levels one quwain or millimolar higher almost all the time, including when you first wake up in the morning. And if that’s the case, if you have been in really good ketosis, then you need to do some troubleshooting, right?

So if you’ve good, consistent ketosis for long enough, if that hasn’t helped, other things matter, too. So troubleshooting, you might troubleshoot your food choices, your meal frequency, your meal timing. You might wanna see a functional medicine practitioner for deeper testing to find out if there are some other issues that might be going on.

I don’t want you to give up on lifestyle strategies for mental health, but nine times out of 10, it’s either that the ketones weren’t high enough, or consistent enough for long enough, to allow the brain and body to shift gears and let that healing process start to take place. 

Bret: 
Yeah, and that’s why we have a number of videos that talk about the difference between ketogenic therapy and a ketogenic diet and they’re not one and the same. Someone can’t just think they’re gonna start eating lower carb and higher fat, and it’s going to be an adequate enough ketogenic intervention.

And what differentiates ketogenic therapy is how long are you doing it. Are you measuring your ketones and how high they are? What are your goals and what are you trying to achieve with your ketogenic therapy? What are you doing with your medications? What are you doing with the rest of your lifestyle?

What supplement, there’s this whole sort of, this whole sort of umbrella of ketogenic therapy that is far beyond just a ketogenic diet. So if you’re going to say the keto diet isn’t working, it’s so much more detailed than just that which, you went into. But, there is a subset of people who, when they start a ketogenic diet, they may feel their mental health actually gets worse.

So how do you address that? Because that seems counterintuitive to what we’re talking about. 

Georgia: 
Right? And so you do see this sometimes, but if this happens, first of all, you’ll usually feel better by week three, but even more important, there are things you can do to minimize the risk of this happening.

So usually when people feel worse on the ketogenic diet, if their mental health feels worse, they’re more depressed, they’re more anxious, if they have a tendency to have a history of manic or hypomanic episodes, they might slip back into the, those patterns. They might start to lose sleep, might have trouble concentrating. If your mental health gets worse on a ketogenic diet, it’s almost always related to the keto adaptation phase. There are a lot of changes, shifts that are happening, as the brain and body are seeking to find their new equilibrium, and this is a longer topic than we have time for, but just suffice it to say, the ketogenic, the keto adaptation phase can be, stressful on the brain and body, especially if you’re not managing that period of time properly. Working with somebody who understands ketogenic diets, keeping an eye on your medications, getting the right electrolyte supplementation, and I can’t stress this enough, switching over to a ketogenic diet gradually. So if you, because if you switch too quickly, cold turkey from hundreds of grams of carbohydrate per day, down to 20 grams of carbohydrate per day, it’s a huge shock to the brain and body and completely unnecessary. So if you transition gradually, get the right electrolyte support, get the right clinical support and plan ahead, it usually the symptoms that some people report getting, when they switch over, those are almost always, those are almost entirely preventable.

So I would say back up, start again with the right information and give it another try, but more slowly and with the right support. 

Bret: 
Yeah, I think that’s such, such a great perspective. And, I think a lot of people talk about it as if it’s a light switch one day you’re eating 300 grams of carbs, you flip the switch, and next you’re eating 20 grams of carbs.

But like you’re saying, there’s absolutely no reason that it has to be that way. And in fact, that can set you up for some complications and for feeling worse. So why would you do it that way? So yeah, such an important perspective there. 

Georgia: 
Yeah. So Beth Zupec-Kania who’s an expert dietician, registered dietician in ketogenic diets for all kinds of health conditions, more than 30 years of experience, I believe you’ve interviewed her on your channel before, she has this lovely way of transitioning people to ketogenic diets, which is just first you switch over your breakfast and you get used to that. Then you switch over your lunch and you get used to that, and then you switch over your dinner, and then you, then all now all three of your meals are ketogenic.

The way that I recommend in my book is just to do two weeks of, whole foods, kind of paleo style, 90 grams of carb per day, which is about two thirds less than most people eat, and that’s gonna lower your glucose and insulin levels and give your body some time to adjust before you drop down into the ketogenic range.

Bret: 
There are also lots of questions about the specifics of a ketogenic diet, right? There isn’t one ketogenic diet, and as we’ve talked about, you can do vegan, vegetarian, carnivore, omnivore, everything in between, but you can also do it with or without sweeteners, with or without dairy, with or without baked goods. So let’s take a lot of those individually. So when it comes to sweeteners, should I include sweeteners in my keto diet or should I avoid them? How do you respond? 

Georgia: 
Yeah, so it depends on who you are. And I know I keep saying this, but it really does depend on who you are.

So some people do fine with certain sweeteners in their ketogenic diet and others do not. And so if you’re having trouble with cravings, for sweets, if you’re having in particular, or if you’re glucose levels are running too high, or if you’re not getting into ketosis, you really wanna look at your sweeteners because.

There are some sweeteners that raise glucose and insulin levels and many sweeteners can keep those cravings for sweet taste alive and make it harder for you to you’re just gonna need an awful lot more willpower. And the beautiful thing about ketogenic diet is when it’s properly formulated for those cravings, you need so much less willpower on a ketogenic diet that’s well formulated for your needs. So sweeteners, the best choices of sweeteners for a ketogenic diet are allulose and monk fruit. And that’s because they’re both natural molecules that are extracted from plants.

And according to the best available study so far, they don’t seem to raise glucose or insulin levels, whereas the worst sweeteners are sugar alcohols. These sweeteners that end in “ol” especially malitol and xylitol, they can raise glucose and insulin levels quite substantially. So different sweeteners have different effects.

If you have a beverage that’s sweetened with your favorite sweetener and you see your ketones drop or your glucose goes up, that’s something that you wanna really be really careful with. 

Bret: 
Yeah. But I like how you answered that, it’s about the glucose and the insulin, but it’s also about the cravings.

because even if you’re eating a ketogenic diet, but you’re getting the sweet cravings, so you’re eating more and more of sweetened products, it can. sabotage your progress with ketosis and with, mental health benefits. So you really have to pay attention to both the glucose insulin response and the cravings response.

That leads to another part, what about the baked goods and the keto bars and the keto snacks versus this concept of, a whole foods Keto diet? How do you talk to your patients about that? 

Georgia: 
Whole Foods principles are important for all human beings, not just, and not just people on a ketogenic diet.

All of us are better off and healthier if we’re following whole foods principles and ketogenic diets are no exception. So all of these keto friendly, packaged and processed bars and cereals and shakes and cookies, and all of those treats. None of that is good for you. And most of those products are, first of all, they’re most of ’em are highly processed, and second of all, many of them are made with whey protein and dairy protein, which can spike insulin levels and work against your ability to get into ketosis.

So whey protein spikes insulin almost as much as pure glucose does. It doesn’t raise glucose, doesn’t raise blood sugar levels. It raises insulin levels substantially. So even though the bar may say, or the cereal may say, or the shake may say that, it’s very low in carbohydrate and that’s keto friendly.

It’s neither ketogenic nor friendly to your health or to your metabolic goals. I am not a fan of keto treats However, certain types of treats can be really important for helping people sustain the diet. So if you know which ones are safe for your glucose and insulin levels and aren’t gonna trigger you to overeat for days on end afterward, the judicious use of a particular type of treat can really help if you are feeling, if you’re feeling tempted.

Rather than going all the way to something, like ice cream or cake or cookies, before you go down that road, I think there is some, there is a place for harm reduction strategies in terms of certain keto treats. 

Bret: 
Yeah. I think there’s no question that for the majority of people, cravings for treats and sweets and things go down substantially on a ketogenic diet, but they don’t go away for everybody, and cravings can still exist, and so people still need to scratch that need sometimes. And we’re emotional creatures, right? We get emotional sometimes. We want to eat, emotionally. So if someone is sad or upset or something big happens, and they want to turn to these keto treats.

It can be helpful, but it can also be a double-edged sword. So how do you discuss with them about sort of their responses to those emotions? 

Georgia: 
Yeah, this emotional eating is a real thing. So as you were saying, cravings don’t just come from your metabolic inner workings. They can come from your environment, right?

So they can come from a stressful event, they can come, you see a commercial, you walk past a convenience store, they can be triggered from the outside. and as some you smell something sweet, you walk by a bakery. all of this is gonna waken the beast, right? So, that’s where, having a plan in advance is really helpful.

Like thinking it through, talking it through, and thinking, okay, what can I do instead? What can I do instead of reaching for those things when I’m under stress? And that’s where, understanding the kinds of things you really enjoy doing. You really wanna ask yourself is, there anything you enjoy doing more than eating that particular thing?

Is it playing music or being in nature, or, being with your friends, whatever it is, do more of that. But the other thing is we were talking about these kind of harm reduction strategies. If you can find a treat that doesn’t trigger you. Some people, for example, find the sweetener allulose to be relatively straightforward when it comes to.

They’re able to have a treat that has allulose in it without feeling triggered. But you have to really test this for yourself and have some of those available for the times when you’re worried that you’re gonna be vulnerable. 

Bret: 
And this is the little bit of a glib response. But, one of the good things about allulose is it is self-protective for overeating because if you have too much of it, your GI tracts gonna let you know. So you’re gonna it’s almost self-protective that you’re not gonna overeat allulose because you’ll pay the consequences. So I guess that’s a good thing. 

Georgia: 
That is true. And a lot of people do have that reaction to allulose, but not as much as they do to sugar alcohol.

Bret: 
Good point. Good point. Not unique to allulose. Okay, one very common question is, which can come from clinicians and dieticians and, if someone is on a ketogenic diet, they may get the advice. Look, there’s no studies or no evidence that, people are surviving to a hundred years old on a ketogenic diet and thriving.

But we have all this evidence on vegetarian diet. The ketogenic diet may help you a little bit, but in the beginning for a short time, but it’s not a long-term solution. How do you respond to that? This sort of just flat comparison that we have evidence of vegetarian diets, but not keto diets for long-lived populations.

Georgia:
We don’t have long-term data on any population for any diet full stop. So it may appear as though we have long-term data on diets like vegetarian diets and blue zones diets and Mediterranean diets, but we don’t. What we have are questionnaire based guesswork about how these diets are influencing our health.

And it’s, this could be an entire episode in itself, but the type of study that is used to generate those claims is not scientific. The methodology is not scientific. There is no data. There are just people reporting what they remember, eating and only reporting certain aspects of their diet from time to time. And then researchers jumping to conclusions about what those wild guesses about people’s diets actually means about their health.

And so there’s a whole chapter in my book about this, so I will not go into it unless you wanna do a whole episode on it. But suffice it to say, please, there is no long-term data on any dietary pattern of any kind. It would be impossible to conduct a study over many decades where you know exactly what everyone’s eating and you follow their health.

It would be exorbitantly expensive and it would be impossible to control. This is not something that we may never know the answer to this question. 

Bret: 
Yeah. But I, can see, unfortunately, I can see how clinicians, dietician, physicians, et cetera can react that way because we’ve been taught for so long that we know the one healthy way to eat.

And we’ve been taught for so long that this epidemiology data or guesswork as you put it, is like the standard of evidence in nutritional research. So I can see where they’re coming from, but it’s really that foundation that we have to get across or change that. We all have to realize exactly what you said, that data that we think exists really doesn’t exist and is not strong at all.

And instead, why can’t we just follow our response to a diet? If my metabolic health is improving, if my mental health is improving, if all my markers are improving, where’s the harm? Like I want someone to tell me where the harm would be, where the concern is if all those markers are improving? Do you, have you had discussions with other physicians or other clinicians about this type of way of seeing it?

Georgia: 
I think it would be good for us all, no matter what kind of diet we follow, to keep an open mind about what the ideal diet might be and that there we may not know the answer to that question and therefore it’s just good. As you were saying, use your own health markers as your guide rather than any kind of these untested theories or ideologies about what healthy diet is supposed to look like.

These really are untested theories by and large when it comes to. A lot of these dietary patterns follow not just the biology, but also your own response to the diet. So if you switch your diet and all of your health markers improve, that’s a pretty good piece of evidence right there, that you’re doing something right.

And, there are good things to be said about whole foods, plant-based diets. There are, some pluses to that pattern compared to the standard Western diet. and there are, so every diet. Compared to the standard Western diet. almost any change you make to the standard western diet is found to be an improvement Question is are you getting to where you’re trying to go or are you only getting part of the way there and do you need to make additional changes?

Bret: 
Yeah, and I mean for someone to put their bipolar disorder or their schizophrenia into remission with a keto diet, but then for their doctor to say, yeah, but this isn’t healthy for you long term. That’s just risk benefit analysis and not seeing the whole picture. And really, I think we need to reeducate from that standpoint.

But like you said, we could do like a whole episode on this one. But let’s get to our last question for this mailbag episode. Something that can seem very simple and yet very controversial at the same time. Dairy, what role does dairy play in a ketogenic diet? And some people do great with dairy, some people don’t do well with dairy, so how do you advise people?

Georgia: 
Yeah, so there’s a whole chapter in my book about this because it is really controversial and I think really fascinating topic. So dairy’s really popular ingredient in ketogenic diets because, especially the low carbohydrate high fat dairy products like butter and cream and aged cheeses. They’re delicious, they’re versatile, they’re convenient, they’re really popular to including ketogenic diet.

So many of them have this naturally high fat to protein ratio, which supports ketosis, but dairy is risky. It’s nutritious. It’s delicious, but it’s risky. And, dairy is different from other animal foods that we eat. It’s different from meat and seafood and poultry because milk. All dairy products come from milk, which is a species specific growth formula intended exclusively for very young mammals of a particular species.

We clearly weren’t designed or we didn’t evolve to require these foods. No mammal is really supposed to consume dairy beyond weaning age. We’re supposed to graduate to solid food at a certain point. So dairy for a lot of people, it’s a really common cause of inflammation.

And remember that inflammation is a root cause of mental health problems, not just high glucose insulin levels, but inflammation. And but your brain doesn’t have nerve endings, so you can’t really tell if it’s inflamed. You can’t feel if it’s inflamed. So how do you know if you have inflammation? Skin problems and pain problems are the easiest way to tell.

If you have acne or eczema or any kind of skin issue, that often is a sign that your system is inflamed. Or if you have pain, migraine headaches, back pain, muscle aches, any kind of chronic pain syndrome, it’s, that’s a sign that inflammation is occurring in your body but dairy can also cause digestive problems.

It can even cause metabolic problems, appetite control issues, weight plateaus, weight gain. I, like you said, some people do much better with dairy than others, but the bottom line is I recommend that everyone explore how dairy affects them personally by doing a month long dairy experiment, and then you can decide whether you put it back in and which types of products you put back in. 

Bret: 
Yeah. Some things just become so common, so commonplace and so universal that we don’t even think that it could be an issue, which you don’t know unless you try it. You can say the same thing for ketosis, right?

You don’t know how you’re gonna feel in ketosis unless you try it. You don’t know how you’re gonna feel by adding meat to your diet unless you try it. You don’t know how you’re gonna feel by adding or excluding dairy unless you try it. So just like anything, an end of one experiment, which people might become overwhelmed with if there are too many, but I think dairy is something that’s so ubiquitous, and for some people can be harmful. But gosh, cheese tastes so good, doesn’t it? It can make it hard. So does cake. Yeah. And, so there’s some evidence actually that dairy can trigger opioid receptors as well, maybe not as strongly as others, but that so some people who have that like addictive personality or the addictive trends can overeat dairy as well, right?

That’s something that can be a source of too many calories and too much overeating as well. 

Georgia: 
I have to tell you that it’s the most useful intervention that I have and my most useful troubleshooting one, just a few really useful troubleshooting steps that I take with my patients if they’re not getting good appetite control, if they’re not feeling well, if they’re not, if they’ve hit a weight plateau or if they’re even gaining weight on their ketogenic diet, or if their mental health still isn’t improving. This is a simple and brief thing that you can try to see whether or not this is an issue for you because I guess that’s the only way to really know. 

Bret: 
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.

Now, back to the video. All right, again, another wonderful episode of our mailbag episode. Mailbag episode number two in the bag. So thank you so much for joining me and thank you for taking the time to respond to everyone’s questions, which we just want more of, like you said, right? 

Georgia: 
Yes.

Please send in your questions. We love questions and we’d really love to help you. 

Bret: 
Great. Thank you, Georgia. 

Georgia: 
Thanks Bret. 

Bret: 
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