Dr. Chris Palmer: Diet For Mental Health and Brain Energy

Chris Palmer, M.D., a board-certified psychiatrist and assistant professor of psychiatry at Harvard Medical School. We discuss the important connection between nutrition, metabolism and mental health and his pioneering work using the ketogenic diet to successfully treat patients with various mental illnesses, including depression and schizophrenia.

Dr. Chris Palmer Dr. Palmer’s website: https://www.chrispalmermd.com 

Brain Energy: A Revolutionary Breakthrough in Understanding Mental Health--and Improving Treatment for Anxiety, Depression, OCD, PTSD, and More: https://amzn.to/3XheFIV

Medical profile: https://www.mcleanhospital.org/profil...

Academic profile & publications: https://connects.catalyst.harvard.edu...

Twitter: https://twitter.com/ChrisPalmerMD

Instagram: https://www.instagram.com/chrispalmermd

TRANSCRIPT

[00:00:00.330] - Kayla Barnes

Dr. Palmer, it's such a pleasure to have you here with me today.

[00:00:03.510] - Dr. Chris Palmer

Thank you for inviting me.

[00:00:06.080] - Kayla Barnes

Absolutely. So today we're going to be discussing an incredibly important topic because, as you and I both know, mental health and depression is, I believe, the number one cause of disability worldwide. Right. Yes. It's something that, obviously, I think as a country and in the world in general, we've been struggling with for a really long time, but it seemed to have upticked during the most recent years, for obvious reasons. So I'm so excited to discuss your new book and kind of the paradigm or the new way of thought around mental health and nutrition and brain energy.

[00:00:45.630] - Dr. Chris Palmer

Awesome. Thank you. I'm excited to talk about it with you.

[00:00:48.960] - Kayla Barnes

Absolutely. So, first of all, tell us how you got why did you become interested in this? Tell us a little bit about your story.

[00:00:57.330] - Dr. Chris Palmer

So I became interested in the role of diet and kind of mood and mental illness. It really started with my own personal experience 20 years ago. I will share that I struggled with mental illness when I was younger and still had mild form of it when I was in my residency. So I'm in my 20s doing my psychiatry residency, and I'm diagnosed with metabolic syndrome. And for a variety of reasons, I decided to try the Atkins diet at that time, because what I was doing wasn't working. I was doing everything I was told to do. I was following a ridiculously low fat diet. I was exercising pretty regularly, I was not overweight, and yet I had metabolic syndrome, and my position was going to put me on meds. So as a Hail Mary path, I decided I'm going to go against all conventional medical advice and try the stupid Atkins diet. It probably won't work. And then I'll go on meds. And lo and behold, within three months, my metabolic syndrome was completely reversed. It was all gone. But the shocking thing was that I noticed significant changes in my mood, energy, concentration and sleep just because the diet was so highly effective.

[00:02:39.970] - Dr. Chris Palmer

And I definitely felt better on it, I am recommending it to family and friends. And lo and behold, I'm noticing some of them getting these mood benefits as well. And so it took me a couple of years before I got the courage to start using it in clinic. But I have patients with treatment resistant mental illness that is kind of the patient that defines my practice. I don't get people straight off the street who've never tried anything. I get people who've already tried dozens of medications, years of psychotherapy, sometimes electro convulsive therapy and other treatments, and then they come to me, having failed all of that, saying, what are you going to do? So with some of my patients, I start using the Atkins diet with them shooting for ketosis. So it is a ketogenic diet? Definitely. And lo and behold, it was working, at least for some of them. Some of them were getting very powerful antidepressant effects. But I kind of laid low with all of that because the Atkins diet was highly controversial, still kind of is. Ketogenic diet is highly controversial. Mainstream medical establishment doesn't really like it. They claim that it's very dangerous.

[00:04:04.920] - Dr. Chris Palmer

So I just laid low, used it with patients who were interested in trying something different. They've exhausted all sorts of other options. What do we have to lose? Try it for a few months, see if it works. And then everything kind of changed for me when I helped one of my patients with schizoaffective disorder do a ketogenic diet, and I really was just trying to help him lose weight, and he did. But the dumbfounding thing to me was that not only did he get this antidepressant effect, but his hallucinations started going away, his delusions were going away. He was able to function in ways that he had not been able to function since the time of his diagnosis. And that upended everything that I knew as a psychiatrist, because schizophrenia is not supposed to be treatable with diet. Certainly not. And as a result of my work with him, it's not just one anecdote. I've now treated dozens and dozens of patients, collaborated with researchers and clinicians from around the world. And so I am now aware of hundreds of patients who have put their chronic mental disorders, chronic depression, bipolar disorder, and schizophrenia into full in lasting remission using something like the ketogenic diet.

[00:05:42.190] - Dr. Chris Palmer

Many of the patients not all, but many of the patients were able to get off all their meds, stay off all their meds, and continue to do well. And that sent me on a journey to understand what the hell just happened. How is this happening? What can we learn from this?

[00:06:05.090] - Kayla Barnes

Well, I mean, you said so many incredible things, but I want to break down a few, I guess, definition. So when you said that you had metabolic syndrome, what does that mean, and how might someone define that?

[00:06:19.130] - Dr. Chris Palmer

So, metabolic syndrome officially is defined as three or more of five biomarkers, and the biomarkers are high blood pressure, signs of insulin resistance or high blood glucose, abdominal obesity, low levels of HDL cholesterol, which is otherwise known as the good cholesterol, and high levels of triglycerides, which are very bad. So if you have three or more of those, you get diagnosed with metabolic syndrome. And what that means is that you are at increased risk for going on to develop type two diabetes or having a heart attack or a stroke.

[00:07:06.810] - Kayla Barnes

Thank you for that. What are the stats these days of how many people in the US. Or worldwide have metabolic syndrome? I know they're very high.

[00:07:16.170] - Dr. Chris Palmer

Yeah. Up until this past year, the statistic that got floated a lot was 88% had at least one. They don't they don't necessarily have all. They don't necessarily meet full criteria for metabolic syndrome, meaning all three or more of those biomarkers, they had at least one or more of those biomarkers indicating somewhat poor metabolic health. So it was 88%. And now the latest statistic I saw was like it went up to 93%. So it's kind of like seven to 12% of the US. Population does not have any of the metabolic syndrome biomarkers.

[00:08:05.770] - Kayla Barnes

Wow. Yeah, that's the statistic I was thinking around 12%. And what's amazing is at one point you said that it is looked upon. The Ketogenic diet or the Atkins version that you're talking about, is looked upon as being almost dangerous. But I would say that if we have the results that we have now based on the diet recommendations, I would say that's kind of dangerous.

[00:08:32.630] - Dr. Chris Palmer

Oh, there's no question there is something that Americans are doing that is really, really bad for our health. There is no question about that. There's either something that Americans are doing or something that Americans are being exposed to. I can say that with 100% certainty, because obesity, diabetes, metabolic disorders are environmental disorders. That means they are being exposed to something in the environment. Now, the overwhelming majority of people believe that it is diet. Diet is the number one environmental exposure because we are putting stuff into our mouths and it is being absorbed into our bloodstream and fueling our bodies and cells and actually creating building blocks for those bodies and cells. So it's kind of a no brainer that diet is a powerful, powerful environmental influence. And we have a lot of substances in our modern day food supply that are not natural substances or chemicals or other things. But I will say for the record, there are other types of environmental exposures. Micro, plastics in the water supply, all sorts of chemicals that we use on our lawns and in laundry detergent and on cookware to make it non stick. And all of that stuff is also ending up in our bodies and brains.

[00:10:22.110] - Dr. Chris Palmer

Some of them are called forever chemicals because they stay in the human body forever. The human body does not appear to have mechanisms to get rid of these chemicals. So they just deposit themselves somewhere, fat cells, brain cells, somewhere in the human body, and they never go away. And those probably aren't helpful either.

[00:10:46.110] - Kayla Barnes

Yes, I absolutely agree with that. Actually, just before we hopped on I was going over there's tests, like total tox burden tests, and it can break down what's going on in the body and exposures. And it's just amazing. There's so many things that we don't even realize, like personal care products and shampoo and lotions and all of these different things that we're putting on our body, in our bodies that we don't even notice. So of course, being aware of that, I think, is so important. And did you make any changes, other lifestyle changes outside of the diet? Or was it primarily just diet when you went on your own journey through this.

[00:11:24.490] - Dr. Chris Palmer

It was diet. The one thing that I will say, because I was already exercising pretty regularly, the only slight change is that maybe within a few months, I began to notice that my sleep patterns were changing as a result, the change in the diet. So I wasn't intentionally changing my sleep patterns, but my sleep was actually getting more restful and I was able to get by on just a little bit less sleep than I normally felt like I needed. And I felt well rested. And then I think in terms of exercise, I don't remember exactly when, because this is 20 years ago at some point or another, I think I probably did start exercising even harder because I had the energy to like I felt good, I felt motivated. I felt like I wanted to push myself a little more. But there is zero doubt in my mind that was a result, the change in diet. So the change in diet resulted in my feeling better, having more energy, having more motivation, and then I probably exercised even a little harder, which we all know has benefits in and of itself. And that is called like a positive feedback cycle instead of a downward spiral, it's an upward spiral.

[00:12:56.910] - Dr. Chris Palmer

It's like, oh, I changed my diet. I do one thing to improve my health, and now I'm doing more things to improve my health. And then they build on themselves, and then it's all good stuff.

[00:13:09.210] - Kayla Barnes

I love that. I always say one win leads to many wins. So you just got to kind of get the ball rolling in one area. Maybe that's improving your sleep, maybe it's exercise, maybe it's diet. But that will usually propel you into multiple other healthy habits. So let's dive into kind of the protocol here. So I've never done the Atkins diet, but I definitely have done the keto diet. I felt amazing on it. So how do we start? Is it for everyone? Because for a long time too, when it comes to the brain, we've been told that the brain runs off glucose. So I would love to dive into that as well. But let's start with the protocol. So what does that look like?

[00:13:49.370] - Dr. Chris Palmer

Highly variable. And so, number one, I will say the keto diet is not a panacea. It's not a cure all for all mental disorders. And the keto diet is not necessarily for everyone. There are some people who are severely underweight, say with eating disorders, severely underweight, they need to gain weight. There are a couple of small pilot research studies using ketogenic diet for anorexia nervosa. So I can talk about that. So it's not that I'm saying I would never use a ketogenic diet with somebody with anorexia. But the primary treatment for someone with anorexia is gain weight. That is the intervention. They are starving to death, literally, and we have to get them to gain weight. So switching to a traditional ketogenic diet can actually have the effect of suppressing appetite. More often than not, it results in weight loss. So if I did this in somebody who's severely underweight, I'm going to want to do it in a very controlled, careful way. I'm going to really be focused on this person needs to gain weight. But when I make the decision, okay, this is one of the interventions that I want to use in someone.

[00:15:17.670] - Dr. Chris Palmer

I usually go all the way. We do a couple of sessions of education. I'll send them home with reading materials, send them websites, even a book they can read if they've got the bandwidth and motivation to do all of that. So I start with a lot of education. I let them know, this is a big deal. This is part of your treatment, and your mental illness is a really big deal. We're taking this seriously. This is not something I'm just going to say, oh, you know, keto diet, go home and try it and let me know how it goes. I wouldn't do that with any other treatment for something like schizophrenia or even chronic debilitating depression. I wouldn't say, oh, go wing some psychotherapy. Just figure it out. You can go do some psychotherapy on your own or go try some pills on your own. I don't care what you do. Just do whatever you think is right and read on the Internet and you'll figure it out. Let me know how it goes. I say this facetiously, but unfortunately, that's the way people treat the ketogenic diet. Far too often, it's just a crapshoot.

[00:16:31.620] - Dr. Chris Palmer

There's no science to it. Just wing it. It doesn't matter. Just do whatever you want, and then it's not going to work out. More often than not, guess what, folks? It's not going to work out. And then the clinician is going to say, oh, see, it didn't work. And I'm like, no, see, you didn't do it right. You didn't give them proper instructions. You didn't give them proper education and support and encouragement and monitoring and everything else that you should be doing as a healthcare clinician. So you can tell I'm a little bit on a bandwagon.

[00:17:07.370] - Kayla Barnes

I love the passion.

[00:17:10.330] - Dr. Chris Palmer

So I'm going to do a lot of education. We're going to create a start date. We're going to make sure that start. I usually let people know the first week is going to suck. You're going to feel like shit. You're going to be so hangry, and you're going to feel weak and dizzy and light headed and all this stuff. Go ahead and say all of that. And I really go overboard. It's going to suck. Almost every time they come back to me and say, it wasn't nearly as bad as you made it out to be done, I'm like, well, isn't that good? The reason I do that is because if you tell people you're going to feel so great, it is the best diet ever. Oh, my God, I'm doing, and I love it. I just feel great. If you don't warn them about keto adaptation or keto flu or carbohydrate cravings or carbohydrate withdrawal or the electrolyte disturbances that can happen or whatever we want to call it, however we want to think about it, if you don't warn people about that and seriously warn them. Then they go home, they try the diet, they feel like shit.

[00:18:22.510] - Dr. Chris Palmer

And they get terrified that something is seriously wrong. And now you've lost credibility as an advice giver because you didn't warn them and you should have known better. Or it's just well, even if that diet worked for Chris Palmer, it certainly isn't working for me and is clearly dangerous for me. And, oh, I heard all those doctors saying this is a dangerous diet, and now I have proof it is a dangerous diet. It made me feel like shit. Chris Palmer is a quack, and these other doctors who were saying it's a dangerous diet are all right. So I get ahead of all that. Make sure let's conversation. Let's talk about how there's going to be pain before pleasure, and that's going to be okay. And I'm not going to freak out, and I don't want you to freak out, but I do want you to tell me. I want you to communicate with me. I want to support you because maybe we are going to need to look at electrolyte levels, or maybe you need to be eating more than you're eating. Maybe you're not eating enough. That's a common problem, because when people switch over to hamburgers without a bun and they're not eating the French fries or the bun or the ketchup or anything else, they still think they're only allowed one hamburger patty, and that's their meal.

[00:19:50.810] - Dr. Chris Palmer

And I'm like, well, no, that's not your meal. That's not enough food. You're not eating enough. Of course you're going to get dizzy and light headed because you're not having French fries and buns and everything else that you would normally have. So you've got to eat more hamburger patties, maybe even four of them. And then they're like, oh, my God, four hamburger patties all at once. Oh, my God, I can't do that. I'm like, well, this is part of the education and encouragement.

[00:20:22.150] - Kayla Barnes

I love that. And, yeah, super important, I think. Yeah. The warning is everything. Okay, so once we know that it's not for everyone, but let's say you're going to proceed with this, what are your goals in terms of are they measuring their ketones at home? How do you like to measure them? What do you like to look for? What are they aiming for? What level of ketosis?

[00:20:45.150] - Dr. Chris Palmer

So I work with a wide range of patients, some who are just, quite frankly, poor. They're on disability. They do not have money for a blood ketone meter and blood ketone strips. So those patients I am going to get them to get urine ketone strips. I'm not going to settle. I'm not going to wing it. I'm going to be like, okay, you've got to Splurge, go on Amazon or go to Walgreens or whatever and get some blood ketone strips. We have to have some biomarker of what's going on. When I'm seeing patients in person, I have my own glucose meter and ketone meter and everything in my office, and I'm measuring when they come in. I'm weighing them and everything else. If it's patient who does have resources and who can figure out how to do this stuff, I'm going to strongly encourage a blood ketone meter. So it really depends on the diagnosis, though. And this is something that I've been using this for years now, but we don't have rigorous studies documenting what level of ketosis do we need to alleviate depression versus bipolar disorder versus schizophrenia. Do the ketone levels matter? Do they not matter?

[00:22:10.760] - Dr. Chris Palmer

There's a lot of debate in the field. A lot of people using the ketogenic diet for weight loss say it doesn't matter. Any level of ketosis is ketosis. And some of them will say it's like pregnancy. You're either pregnant or you're not. You're either in ketosis or you're not. Level of ketones doesn't matter. I firmly disagree with that. When I use this treatment for brain disorders, I think the level of ketosis does matter. Maybe I'll be proven wrong someday, but so far, my clinical experience in the real world tells me level of ketosis very much matters for brain function and mental symptoms. So if it's somebody with depression, I'm going to shoot for blood ketones greater than 0.8. If it's somebody with bipolar disorder or schizophrenia or the combination of the two schizophrenia effective disorder, I am usually shooting for blood ketones greater than 1.5, somewhere between 1.5 and three, or 3.5 if the person is capable of getting there. To be honest with you, one of the challenges is that a lot of psychiatric medications interfere with ketosis. A lot of antipsychotics in particular will cause the pancreas to secrete insulin. And when the pancreas decrease insulin, the blood will respond by producing more glucose.

[00:24:03.390] - Dr. Chris Palmer

So usually the pancreas secretes insulin. It prompts you to eat. It stimulates cravings, especially for sugar or carbohydrates. And people will eat. When I start them on a ketogenic diet, I'm telling them, do not eat carbohydrates. So instead, their body will engage in gluconeogenesis to meet that insulin demand. The diet alone will not prevent that effect from antipsychotic. Medications and some mood stabilizers do that. Some antidepressants may. Some antidepressants definitely cause weight gain. So any medication that causes weight gain causes diabetes, is kind of at odds with what we're trying to accomplish with the ketogenic diet. And so it's important that the clinician who's working with this patient understands that. It's important that the patient and family members understand that, because otherwise it ends up being a lot of blame and shame it's like you're not doing the diet. You should have higher ketones. And I've been there, done that. That's not true. Always, folks. It's not always true. The medications can screw people and make it really difficult, and it's not fair to the patient to blame them or whatever. So you got to work with them, and you got to figure out strategies.

[00:25:48.830] - Dr. Chris Palmer

So in some of those cases, if we've been trying for two months or longer and we're still not able to get ketosis, and I have every reason to believe that they are adhering to the diet, then I may actually even need to adjust meds in a safe way to try to enhance the effects of the diet. But I usually tell people, as a general rule of thumb, I usually tell people, we're going to give this three months, and I need a three month commitment from you. If you're not willing to do this for three months, let's not even bother. I don't want to waste your time or my time, so I let people know, three month commitment. And that's part of the planning and education, too, especially like this time of year. We're at least recording this right before Christmas, so people care about Christmas. And I usually don't start the diet right before Christmas or Thanksgiving because it's just too hard for people to stay on the diet, especially if they're in the keto adaptation phase. And then they go to a Christmas party and they see all these delicious foods. That's when their willpower is at the lowest keto adaptation at a Christmas party with delicious food, with all sorts of friends and family shoving that food in your face.

[00:27:21.950] - Dr. Chris Palmer

So I let people know, three month trial. And then at the end of three months, we assess. We assess two or three things. We assess, is this working, yes or no? We can try to kind of quantify how much is it working, but is it working, yes or no? And then probably the more important assessment is, can you keep this up? And that assessment only happens at three months. I don't want to hear it at week one or two or four, because what I hear at week one, two, and four are the cravings and the hangry, and I can't give up bread for the rest of my life. What kind of a life will this be without bread? Oh, my God. Dr. Palmer the meds were bad enough, but you are really kind of inflicting cruel and unusual punishment on me taking away bread. That's what they will say at two weeks and four weeks if I can get them to the three month mark. And their symptoms are dramatically better. Their cravings are usually dramatically better as well. And that's when they say, I think I can do this. It's not that bad. And I'm shocked because two months ago, I would have said, I quit.

[00:28:51.260] - Dr. Chris Palmer

Like, there's no way I can keep this up, but you made me promise three months, so I went ahead and did three months. But now that I've done three months, I could keep going. Yeah, why not? It's not that bad. I've got the foods that I like, and the diet is not nearly as bad as I thought it was. And if we get those two things, it's working, it's doable. Then we're going to keep on our way. And then I'm doing other treatments. I might adjust medication. I'm often trying to get people off medications, but we might be doing other things. We might be adding exercise. We might be doing rehabilitation. If it's a patient who's been disabled for years, they probably don't have a lot going on in their life. Probably not a lot in terms of relationships, certainly not in terms of work. They often feel useless. They feel worthless. And so if their symptoms are dramatically improved as soon as that happens, now I'm starting to talk to them about, okay, now we need to talk about how are you going to have a life? What is that life going to look like?

[00:30:06.190] - Dr. Chris Palmer

Do you want to try to get a volunteer job? Do you want to try to get a real job? Do you want to go back to school? Do you want to take a class? Could you help out your family a little more? Take on more household chores, take on more responsibilities, volunteer in a nursing home? Something like something to make them useful, to get them on a regimen, a cycle of responsibility. And that's part of the recovery as well. It's not just keto diet. They're magically cured and everything's fine, unfortunately. I wish it was.

[00:30:45.310] - Kayla Barnes

Yeah, of course. But that's so important and incredible work that you're doing. But let's go back to so they often call it the Keto flu, right? That period that you're talking about, when you're becoming Keto adapted or fat adapted, obviously that will change based on a lot of different markers. Right. I would assume someone's initial weight going in their stores, things of that nature. So what is, I guess, the quickest that they could get Keto adapted and what might be the longest? I know that you mentioned if they're on certain medications, it can definitely prolong how long it takes to get in Ketosis. But what could people expect if they were trying this at home?

[00:31:30.170] - Dr. Chris Palmer

They're trying it at home. They're not on prescription meds. Usually Keto adaptation, the hardest part is usually done within seven to ten days. For a lot of people, it's actually done even sooner than that. I usually tell people two and three are going to be the hardest. Lot of people can get through the first day fine. It's the second day that their cravings go through the roof, and it just and their hunger, it feels like a bottomless pit. That usually happens on day two or three. And no matter how much Keto safe food they're eating. So they can eat all the steak in the world, but they just feel ravenous. It's like they cannot get full primarily because their ketones aren't up yet. So their body is depleting. The last bits of glycogen, it is still running primarily on glucose. Those glucose stores are plummeting. Glucose levels are plummeting. If they normally had a baseline glucose of 100, now it's 70 or 60. And their body is going through major adaptations. As a result, their insulin levels are lower. But when people are insulin resistant, lower insulin levels initially are painful. Painful because it means your cells aren't getting enough fuel.

[00:33:11.130] - Dr. Chris Palmer

That's what it literally means. And your cells have not adapted yet. And I'll even share that science with most people. But to answer your question, usually seven to ten days, seven to ten days, keto adaptation is done. I usually tell people 30 to 60 days for the major cravings to go away. I usually tell them you're still going to crave bread or whatever your favorite foods are at two weeks. Even though you're kind of through the initial adaptation, if you go out to dinner with friends, you'll still look at the bread basket and be salivating over it. That takes 30 to 60 days for that to go away. But I let people know this trajectory that you're still going to be salivating at two weeks over bread, don't freak out. Don't give up. Don't think I can't live my life without bread. And I tell them that preemptively. And that is everything in terms of compliance. If you warn people about the challenges that you already know they are going to face I know it. I've been there. I've done it. I've seen lots of other people go there. So if you warn people, here's the journey, here are the risks, here are the challenges, and here's how you're going to get through them.

[00:34:46.010] - Dr. Chris Palmer

Number one, you just build so much credibility, because when it happens to them, they're like, oh, my God, he told how did he know that? Shit, he must really know what he's talking about. That is so wow. But I still don't like it. But wow. How did he know? Wow. Gee, that's great. And then you've given them strategies. And then if they do fall off the wagon, you're not going to be judgmental, you're not going to be impatient. You say, yeah, no, I told you it's going to suck. I told you it sucked. Did that? Yeah, it did. Okay. How are we going to get back on the wagon next time? What are we going to do different? How are you going to manage it differently next time? Maybe let's not eat out with friends for two months. No going out to restaurants for two months. Let's just keep temptation away and invite your friends over. Or eat your ketogenic meal before you go out to eat. Really fill yourself up. Eat more than normal. Like, stuff yourself. With ketogenic foods and then go and have a glass of water or have a little side of something ketogenic or whatever, because you won't be tempted.

[00:36:08.850] - Kayla Barnes

Yeah, that's amazing advice. And everyone listening to this podcast. If you go down this road, I think we have definitely laid out the warning. So it's going to be difficult. It might suck for a while, but odds are it will be worth it in the end. So that's great. So when it comes to ketone levels, now we understand how long it might take to get there are more ketones better. Should you be striving for a higher ketone level or is there like a law of diminishing returns here?

[00:36:39.970] - Dr. Chris Palmer

There's definitely a law of diminishing returns, and people can definitely have ketones that are too high. It's theoretically, it's definitely possible. So, again, if I'm treating depression, anxiety, I'm shooting for ketones greater than 0.8, probably in the 0.8 to two range, if they can get up to two. The ironic, tragic, sick, twisted part is that the patients with bipolar disorder and schizophrenia who have much more severe symptoms, on average, they're more disabled by their symptoms, and they're being screwed because they're on medications that are making it harder for them. I'm asking for higher ketones, which is so unfair. I know. Chris Palmer. You sucked. What a hypocrite. How dare you? That's asking the impossible of these already impaired, down and out people. That's what I do, and I'm able to get them to do it. And the reason I'm able to get them to do it is because their lives are usually decimated, and they're like, I will do anything. Just please tell me what to do. I will do it. I can't go on living this way. My entire life is on the line. My entire life is riding on this stupid diet experiment.

[00:38:12.760] - Dr. Chris Palmer

So tell me what to do and I'll do it. People with mild depression, the stakes aren't that high. They're just not people who want to lose weight. The steaks definitely aren't that high. Oh, I could always go off the diet when I go out to dinner with my friends. I'll just get back on it next week, and then they never do. But for them, it's not disabling to be overweight. It's not tormenting them every hour of every day. A lot of the patients I work with, they are tormented. For them, I'm going for let's see if at all possible, if we can get your ketones above 1.5 and maybe up to three or three and a half, they start going beyond three and a half. That's when I start to see problems, actually. Some people get super nauseous. They lose all appetite. They're really going into what might be similar to ketoacidosis. I've worked with some dietitians on cases like that where on a few occasions, we've actually had them pouring apple juice in a little teaspoon, and literally it's just teaspoon of apple juice to try to bring their blood sugar back up and bring their ketones down just a little bit because their ketones were too high.

[00:39:40.250] - Dr. Chris Palmer

It's very rare that that happens because, again, much more commonly, 95% of the time, that is not the problem. The problem is they can't get their ketones high enough to get the therapeutic brain effect that we're looking for.

[00:39:57.630] - Kayla Barnes

Got it. Yeah. That's important to know. So what is the mechanism here? What's going on? So how are these ketones of the ketogenic diet helping? Or how do you believe that they're helping?

[00:40:11.330] - Dr. Chris Palmer

So that is the great news and the godsend to me as a psychiatrist, a lot of people know keto as weight loss diet, or maybe they know it for type two diabetes. And yes, it is absolutely used for both of those. But it is a 100 year old evidencebased treatment for epilepsy, and it can stop seizures even when medications and surgery fail to stop seizures. And the reason that's so important to me as a psychiatrist is because we use epilepsy treatments all the time, tens of millions of people. And so we actually have decades of research, understanding, trying to figure out how the hell does this diet stop seizures? Like, what is going on? Like, diet is not supposed to stop seizures, even especially when our wonderful medications didn't stop them. Like, what the hell's happening here? So researchers have been studying mice and rats and humans doing ketogenic diets, looking at brains, brain scans, brain inflammation, other biomarkers. And so we actually know a tremendous amount about the ketogenic diet. Ketogenic diet is changing neurotransmitter systems. It's changing hormone systems, including insulin and insulin resistance and insulin signaling in the brain. It is changing calcium channel regulation or calcium levels, which is really important for brain function.

[00:41:45.250] - Dr. Chris Palmer

It is decreasing inflammation across the throughout the body, but also in the brain. It changes the gut microbiome in beneficial ways. Some researchers are actually arguing that that may be the primary mechanism of action, is its changes in the gut microbiome. It changes gene expression. It changes the expression of genes in your cells. And so ketogenic diet is doing all sorts of things for my research and the brain energy theory, the key thing that the ketogenic diet is doing is it is having a profound impact on these tiny things in our cells called mitochondria. And it does two things for mitochondria. It stimulates a process called mitophagy, which is getting rid of old and defective mitochondria and replacing them with new ones. And it also stimulates a process called mitochondrial biogenesis, basically mean that your cells are producing more mitochondria. So after people have been on the ketogenic diet for a while, their cells will often have more healthy functioning mitochondria, and that has extraordinarily powerful health benefits.

[00:43:14.110] - Kayla Barnes

Well, that's incredibly profound, to be honest. I love to hear all the reasoning behind this, because it's amazing that food can be used as medicine, as fuel as a treatment in this way. I think it's absolutely amazing. So what about ketones? Like ketone esters? Can those expedite the process? Can they be used in any way? Or is there really no help from ketones or exogenous ketones.

[00:43:46.250] - Dr. Chris Palmer

At this point? Lots of people are studying exogenous ketones at this point. I have not seen convincing evidence in animal models or human trials demonstrating a clear and unequivocal benefit of exogenous ketones in people who are eating a normal standard American diet. And I know that there are some researchers who disagree and who are passionate about exogenous ketones, and there are companies set up selling exogenous ketones. So obviously they have a difference of opinion, and that's fine. And maybe I'm wrong, so I'm open to being wrong on that. But at this point, I've tried exogenous ketones with lots of patients who, again, are just on regular diets. And I've seen some effects and benefits. Ketones can be stimulating. It's almost like a stimulant, like caffeine, but it's different than caffeine. So I know lots of biohackers who are not on a ketogenic diet but take exogenous ketones, and there's reason to believe that they may produce some. I mean, they're certainly producing some physiological facts. I tend to be working with patients with severe brain disorders, patients who are seizing, patients who are psychotic, hallucinating, delusional, patients who are plagued with unrelenting depression or anxiety.

[00:45:44.110] - Dr. Chris Palmer

Exogenous ketones do not seem to be the answer for them. And the reason I can competently state that is that to date, I am not aware of even one case report published in the medical literature of exogenous ketones being used to treat any of those medical conditions. Yet there are lots of case reports, clinical trials, even randomized controlled trials. The ketogenic diet for seizures, bipolar disorder, depression, schizrenia. And so there are thousands and thousands of people who probably feel somewhat trapped on a ketogenic diet because it is their treatment. And I can't imagine at least some of them haven't tried exogenous ketones and gone off the diet. And I know many people who have and have told me my symptoms came right back. I went off my ketogenic diet, I tried exogenous ketones, thinking that I could have my eat my cake and my ketones and everything would work out fine. And it did not work out fine. My mood symptoms or my psychotic symptoms came back with a vengeance. So we know that the ketogenic diet, in a nutshell, the ketogenic diet is doing so much more than just providing ketones. It is a major shift in metabolism throughout the human body when people are on a ketogenic diet.

[00:47:27.160] - Dr. Chris Palmer

And all of those benefits are not being realized when people just drink a bottle of ketones.

[00:47:37.170] - Kayla Barnes

Yeah, that makes a lot of sense to me because it's kind of just like adding something in temporarily. Of course, you're not going to be drinking ketones while you're sleeping, so you're not getting those benefits. Even if you were to consume, let's just say most people wouldn't do this, but if you were to consume ketones all day long, you would not be doing that while you're sleeping. So, yeah, I can see that makes a lot of sense to me, especially with the patients that you're dealing with and people that are really struggling, I think maybe for performance enhancement or something like that, people can find benefit. But definitely, I completely see where you're coming from with this. So what about duration? So can you be on the ketogenic diet for very long periods of time, maybe forever? Does that become difficult on the body because it has to go through its own glucose creation?

[00:48:29.010] - Dr. Chris Palmer

The glucose creation thing is not a big deal at all. So glucose creation, whatever our bodies can do, gluconeogenesis, they do it probably on a regular basis. They're certainly doing it in type two diabetics, because type two diabetics, for example, have their highest glucose readings first thing in the morning in the fasting state. Let me just say that again, fasting state. They have the highest glucose rating readings, that is from gluco, neogenesis. They haven't eaten in eight plus hours, and yet their glucose readings are the highest. And that relates to cortisol and other factors, stress hormones and other things that are happening related to waking up. But that glucose is not coming from nowhere. It's coming from Glucone. Again, the bigger picture question should people be on a ketogenic diet forever and ever? As a rule of thumb, I'm going to say no, they should not. However, there are exceptions to that rule of thumb. I'll give you a clear, unequivocal and this is actually standard, actually, medical recommendation. It is the number one treatment recommendation for people who have a Glucose Transporter Deficiency Syndrome. Glucose one transporter deficiency syndrome that is a genetic disorder.

[00:50:15.760] - Dr. Chris Palmer

Nobody ate a bad diet, nobody did anything wrong. They have a bad gene that causes a problem with their brain getting enough glucose. And as a result of that, people with this disorder who aren't on a ketogenic diet usually have seizures, all sorts of mental symptoms, cognitive impairment. They die early death. It is not pretty. Ketogenic diet is the number one treatment recommendation, first line treatment recommendation for these people, because glucose is having trouble getting into the brain, let's give them ketones and ketones. The ketogenic diet for most of these people works fine, and for them, it is a lifelong diet. There's no going back until we get a gene therapy that can somehow replace that gene or let's get more glucose on transporters in the right place, in the right way. And we're many years, decades, maybe even centuries away from doing that. So we're a long way away from pairing these people's genetics. And therefore the ketogenic diet, whether somebody says it has risks or not, if somebody says, oh, but it's bad for the stress hormones and the female hormones. We can get into all that if you want. So I already know what they're getting.

[00:52:03.500] - Dr. Chris Palmer

But that's bad. Well, now that you've got this genetic defect, it's not like what the option is to just eat carbohydrates and seize and have cognitive impairment and die. That's a pretty dumb thing to do. No, there are clear cases like that. Most of the people with epilepsy, usually when they use ketogenic diets to treat their epilepsy, they usually do the diet for two to five years and then do a trial off the diet. The majority of those people, more than 50%, can stop the diet and maintain whatever benefits they got from the ketogenic diet. And again, that seems to be probably related to this mitochondrial repair process, that the diet is actually healing their brain and they don't need it long term. It's not a lifelong intervention. It is a two to five year intervention. Heal the brain enough so that they can stop the diet and go on their merry way. A lot of people can do that, but not all. There are epilepsy patients who have been on the ketogenic diet for 40 plus years because when they stop the diet, their seizures come back. So what medical advice am I going to give to that person?

[00:53:23.870] - Dr. Chris Palmer

Say, well, do you want to spend your life seizing every day or do you want to keep eating a ketogenic diet? I don't know. It seems pretty clear cut to me. But do you really need to eat bread so that you can seize multiple times a day? That sounds like a really stupid decision. So for those patients, it's a lifelong treatment. Sorry. And if people are like, oh, but it's not good to be in ketosis all the time. So I guess my point is, I hate it when people try to make these simplistic. Ketogenic is bad for everybody, or ketogenic diets should only be done intermittently and everybody needs carbohydrates at some point. Well, let's not say everybody. See, most people or a lot of people or some people. Or let's at least leave room for these clear exceptions to the rule in terms of my work. Patients with schizophrenia, patients with chronic bipolar. Unfortunately, we don't have the answers right now. I am hoping that they are going to be more like the epilepsy patients and that we will be able to use the diet in a strategic way, hopefully do a multifaceted treatment.

[00:54:43.250] - Dr. Chris Palmer

So it's not just the diet. I'm going to get them off of drugs and alcohol. I'm going to start an exercise program. I'm going to make sure they're getting really good sleep, because that's important for brain healing, too. And so I'm going to do all of these things to help them heal. And my hope is that we will be able to stop the diet and they will be able to live happily ever after. We don't have enough cases right now to be able to say for sure. And if one or more of my patients with schizophrenia ends up stuck on the ketogenic diet for life, I'm going to have no qualms about that. Just like I have no qualms about an epilepsy patient making the decision to be on the ketogenic diet for life if it means the difference between seizing and being disabled or eating a ketogenic diet.

[00:55:41.610] - Kayla Barnes

Sure, yeah. Well, that's a great response, and every situation is different. And I think for overall, someone just generally experimenting with the diet versus actually needing the diet and using it in a therapeutic way, these are two very different situations, and there's just really no comparison to be made there. What about fasting? Does fasting play a role in this diet? Sometimes or always?

[00:56:05.670] - Dr. Chris Palmer

It doesn't have to always, but it is an extraordinarily powerful tool. So if patients are really struggling, I often use it most commonly when patients have cheated on the diet and get into trouble. So I'm not doing it as a punishment.

[00:56:28.350] - Kayla Barnes

I was going to say, what a direct and swift punishment there?

[00:56:32.610] - Dr. Chris Palmer

It's not a punishment. It is a rescue option. So this is when patients cheat on the diet, because they've been on the diet for six months, and their symptoms have been gone for like, three months, and they understandably, think they're cured. And their friends are going out for pizza, and they're like, I'm going to go out for pizza with my friends because I'm normal now and I don't have any brain symptoms, and I have schizophrenia anymore. I don't have bipolar anymore or depression. I'm going out for pizza. They go out for pizza within 24 to 48 hours. They're hallucinating, delusional, manic, psychotic, something. It's a mess. It's like a shit show mess. They're calling me. What do I do? Oops, you are right. I guess I need to diet a little longer. What do I do in those situations? The fastest way to get their ketones up again, and usually at this point now, they are highly motivated because they are being tormented. They just had no symptoms, recovery, and now they're flooded with all of these brain symptoms again and being tormented. And they're like, tell me the fastest way to get back to relief.

[00:57:58.710] - Dr. Chris Palmer

I say, do not eat anything, drink water. Let's get some electrolytes in, but that's it, nothing. Or let's do it for even one day, two days, three days, and we'll gauge it. For some people, it can be 24 hours fast and their symptoms are gone. And then it's like, okay, let's reintroduce the ketogenic diet that you had been doing that was really working so well that you thought you were cured. Let's reintroduce that and stay on the merry way. Other patients need to fast. Maybe a little longer. Certainly I use intermittent fasting patients who also want to lose a lot of weight if their appetite is being suppressed. I'll tell them, do not force yourself to eat like, I don't want you eating three meals a day if you're not hungry for three meals a day. So especially in patients who are obese, once they get high levels of Ketones, usually they experience extreme appetite suppression and they're highly interested and motivated to lose a lot of that body fat. So if I'm working with a patient like that, then I'll say, okay, I do not want you forcing yourself to eat breakfast or lunch or dinner if you're not hungry.

[00:59:25.100] - Dr. Chris Palmer

So let's see if we can get you on two meals a day or one meal a day or whatever, or just add lib, pay attention to your body. When you're hungry, eat. If you're not hungry, don't eat. So we'll use intermittent fasting, and then the third time that I'll use fasting or intermittent fasting, if I'm trying to start the diet with someone, they are really struggling to get their Ketones high. They're not getting the benefits that we want from the diet. So let's say it's somebody with bipolar disorder. We're trying to stabilize mood, maybe some possibly some mild psychotic symptoms or something. And their Ketones are only 0.8. They've been there for two months, they're still not feeling any better. I'm worried that this is kind of a sub therapeutic intervention because their Ketones aren't high enough. With those patients, I might purposefully ask them to do a 24 hours or even 48, 72 hours fast to see if we can get their Ketones higher. And then pretty quickly, within a day or two, we usually get an answer. Because the shocking thing, if they've already been out for two months and they had at least low levels of Ketones for two months, a lot of times at that two or three month mark, if I ask them to fast and get their Ketones higher, within days, their symptoms can go away.

[01:01:07.750] - Dr. Chris Palmer

And then it's just so clear to everyone, like, oh, once your Ketones went above 1.2, your symptoms vanished, and when your Ketones come down to 0.6, your symptoms come back. So now we're getting really great biomarker information. This is really powerful information, because now we know how to intervene. If you're having symptoms, we know what to do.

[01:01:38.610] - Kayla Barnes

Well, Doctor, thank you so much for this conversation. Your book, I definitely highly recommend. I mean, I really hope that this is going to change the world. I understand that it can be difficult to make a commitment like this, and the way that you set people up for success by telling them what to expect is so important. But we need this now more than ever. And I really appreciate your time, and I will definitely include a link to your book and all the shutters notes, but thank you so much.

[01:02:09.130] - Dr. Chris Palmer

Thank you, Kayla, for having me on. Absolutely.