For many, the ketogenic diet conjures up images of “keto bros” flexing their muscles and obsessively avoiding carbs. But keto is a serious therapeutic approach for brain disorders dating back more than a century. As we learn more about the connection between metabolic health and mental health, researchers are increasingly studying this nutritional approach as a treatment for severe mental illness.
What is keto, how might it help the brain and should ordinary people consider it? Few are better equipped to answer these questions than Dr. Bret Scher. A board-certified cardiologist and lipidologist, he hosts the Metabolic Mind podcast and is medical director of the Baszucki Group – a nonprofit whose mission is to “make metabolic health mainstream.”
The group was founded by Jan and David Baszucki, whose son Matt was diagnosed with bipolar disorder in college. Eight years, 29 medications and 40 doctors later, his illness was declared treatment-resistant. After just a few months of ketogenic therapy, his symptoms improved dramatically and over time he has been able to greatly reduce his medications.
Ketogenic therapy works by changing the brain’s fuel source, Scher explains. In modern society, our brains primarily burn glucose to generate energy, but in some brain disorders, cells may have trouble using glucose efficiently. The ketogenic diet provides ketones as an alternate fuel. The liver makes ketones when glucose availability is low, such as during fasting. “Ketones aren’t like a drug,” Scher points out. “They are natural to the body.”
Sustained nutritional ketosis is not merely eating low carb. It involves carbohydrate restriction and getting most of one’s calories from fat. Patients can enter ketosis within days of beginning the diet. For some, Scher says, “it’s like a lightbulb goes on right away.”
More commonly, when benefits occur, they may take months to emerge. Patients’ ketone levels are closely monitored with breath and blood tests, and their psychiatric medications are adjusted as needed. This is no ordinary diet and requires medical supervision. “The goal isn’t weight loss. It’s achieving ketosis and maintaining it.”
The metabolic approach to treating brain disorders traces back to the early 20th century treatment of childhood epilepsy. Doctors at the time observed that fasting reduced seizures.
“Obviously patients need to eat,” Scher says, “but a high-fat diet mimicked fasting conditions.” By the 1920s and ‘30s, the ketogenic diet was an established epilepsy treatment, but it fell out of mainstream use as new antiseizure medications appeared. The 1990s saw renewed attention after the much-publicized case of Charlie Abrahams, who became seizure-free after starting a ketogenic diet.
Today, evidence continues to accumulate for the potential benefits of ketogenic therapy, but despite growing interest, it remains outside mainstream psychiatry. Why? Scher attributes this to two factors. First, he says, the evidence is still limited.
“Mostly we are relying on observational studies, case studies and so forth. What we need are randomized controlled trials,” he says. RCTs are the gold standard for determining whether a treatment works. While a promising RCT of keto in patients with schizophrenia-spectrum and bipolar disorder was published this summer, research has been slow.
Part of the reason research is lagging is the second problem: a common misperception of what keto really is. When most people hear “keto,” they think of red meat and full-fat dairy.
“But you can have a vegan keto diet, a Mediterranean keto diet, or any other version so long as your fuel source is primarily fat,” Scher says.
Fat sources can include salmon and other fatty fish, olive oil, nuts, coconut, avocado – a wide range of foods. When asked how ketogenic therapy might someday enter mainstream psychiatric care, Scher envisioned multidisciplinary care teams.
Not every psychiatrist would need expert nutrition training, he says. They could manage clinical care and medications while collaborating with diet and behavior specialists helping patients implement and sustain the therapeutic diet. For laypeople wondering whether changing their diets could improve their metabolism and mental health, Scher had this advice. Absent a diagnosis of mental illness, “anyone’s metabolism and overall health will benefit from reducing sugar and starch.”
A good start is eating fewer highly-processed foods and more produce, protein and healthy fats. But ketogenic therapy shouldn’t be undertaken without medical supervision.
One in five Americans is now medicated for some form of mental illness, and suicide is the second-leading cause of death in people ages 10 to 24. The evidence isn’t sufficient yet to make ketogenic therapy mainstream – but it’s sufficient to justify doing the rigorous research needed to find out.
Kelly Rogers Victor, PhD, MPH, MPP is a writer and consultant on nutrition, health policy and public health. Her columns appear regularly in The Detroit News. Reach her at Kelly@upstreamhealthconsulting.com.