I am well aware that using the word “rules” is an unpopular stance. That some of you immediately have the urge to argue about what the rules are, should be, and whether the concept is even valid. Writing a post titled keto diet rules is just looking for trouble.
So let me begin by clarifying that by keto diet rules, I mean guidelines. By keto diet rules, I mean these are the considerations I have seen that need to be addressed and the best practices I have seen with clients attempting to use a keto diet to improve their mental health.
For many people, having keto diet rules really helps. And saves them from months and months of difficult adjustments, stops and starts, and general discouragement. Not things that people already struggling with mental illness have a lot of bandwidth for.
My first rule is if you are using the ketogenic diet for mental health, you must use a nutrient-dense and well-formulated ketogenic diet. Eat with the intention to heal your brain.
My second rule is that your carbohydrate restriction level must be low enough to consistently and generously produce ketones that your brain will use for fuel and healing.
My third rule is that you take the time to weigh the pros and cons of going down in your carbohydrates quickly or slowly. There may be some factors around this you have not yet thought about that are very individual to you but can make or break your initial attempts at success.
My fourth rule is that if you are on medications, you do not go into it without a prescriber ally. Someone who can help you modify your medications as needed. You deserve this very basic level of care.
Let’s talk about each of these rules in more depth.
What is a well-formulated ketogenic diet?
Before we talk about how fast or how slow you should go in adopting a ketogenic diet, it is essential that we define what a ketogenic diet to treat mental illness is and is not. When doing a ketogenic diet for mental health, doing the well-formulated version is crucial.
A well-formulated and nutrient-dense ketogenic diet by my definition that I use with my patients is as follows:
It includes plenty of animal foods with highly bioavailable nutrients, including fish, eggs, beef, lamb, chicken, turkey, or other meats.
It can, but does not have to, include ingestion of dairy. If it does include dairy, it will have cheese, butter, and sometimes heavy whipping cream (usually the liquid form, not the fluffy sugar bomb you used to put on pie)
It includes plenty of healthy fats that brains love and include tallow, lard, butter, ghee, coconut oil, avocado oil, and olive oil.
It includes low-carbohydrate nuts like pecans and almonds, in moderation.
It includes low-starch and low-carb vegetables such as cabbage, cauliflower, green beans, and a whole lot of other ones that are delicious.
It includes keto desserts using low-carb sweeteners that do not affect blood sugar levels. Sometimes not in the first few weeks, but eventually if that is something you want to enjoy.
It completely excludes industrialized seed oils like canola, vegetable, soybean, and sunflower oils.
It completely excludes grains such as wheat, barley, and corn. It excludes legumes such as lentils, split peas, and all beans (that are not green and actually a vegetable).
Doing a well-formulated ketogenic diet for mental health is not an “if it fits your macros” kind of situation. For those that do not know what that means, the “if it fits your macros” version includes inflammatory oils, grains, and forms of processed sugars as long as one is keeping their carbohydrate level within a specific range. As you can imagine, if you are trying to heal a mental illness and have read anything about neuroinflammation, you know that keeping those things out of your diet is going to be best for your healing.
If you are using a ketogenic diet to treat a mental illness, it is likely not simply a “low carb” diet that many people use primarily for weight loss, although you may find significant symptom relief from those versions alone. If you are doing a ketogenic diet specifically to treat a mental illness, you are doing so as though you are treating a neurological disorder.
How low in my carbs do I have to go?
Low-carbohydrate diets are well classified by dietdoctor.com in this post here. They discuss three ranges of carbohydrate consumption by measuring NET carbs. The lowest range they discuss is 20g net carbs a day.
Net carbs are the total amount of carbs minus the fiber. However, there are people who have gut microbiomes that are somehow able to use fiber to produce their favored fuel of carbohydrates. People with mental illness are often also trying to change their gut microbiome to a healthier mix of bacteria. And so for that reason, when I work with clients, we work with total carb measurements.
I keep my clients to 20-30 grams TOTAL carbs per day. This means about 10g of total carbs per meal. Or some clients will save up their carbs to have with their dinner. I do not generally support the use of NET carb counting but instead, suggest total carb counting. I want the carbs very, very low so that the patient can begin to make ketones and feel the effects as soon as possible, and there is no danger of an energy roller coaster for a vulnerable brain to experience.
So you will look for and evaluate foods and recipes from a ketogenic lens as opposed to a low-carb lens because sometimes the carbohydrate levels of “low-carb” are too high for many people to reliably and consistently produce ketones. This post is about how to do a ketogenic diet to have higher ketone levels to be used for brain fuel and body healing. It is about eliminating as many inflammatory influences as possible from the diet and providing nutrients and building blocks needed to improve your brain health.
This is why we use keto diet rules, especially if we are treating mental illness. It’s not because we enjoy being told what to do. It is about following some guidelines to make the outcome as positive as possible and to reduce the likelihood of problems along the way.
How fast or slow in my carbohydrate restriction should I go?
Knowing what a well-formulated ketogenic diet that is nutrient-dense entails may be part of what makes you decide how fast or how slow you want to adopt the diet.
For example, if you have budget concerns, you may want to begin stocking some of the staple items and foods over the course of a few weeks or months. You may want to start looking at recipes and meal plans or begin discussions with a spouse about how meals in the household will be changing to support your treatment.
If you are in no hurry for symptom relief, you can most certainly go slower in your transition and swap carbs out in your diet more slowly. The average daily carbohydrate intake from the standard American diet is a bit over 300 grams of total carbs (often much higher). So if you want to begin by learning how to count carbohydrates, and then start to lower them to 100 net total, then 40 to 60 net total, and finally down to 20 net total, that is a very valid option and a steady state of behavioral change and improvement.
I do have some clients that reduce their carbohydrate intake slowly. We make weekly net carb goals, and they strive to meet them. We work on behavior changes, problem-solving, and mental adjustments needed for a lifestyle change for their health.
There are many pros to doing it this way. You would learn to adjust your shopping, entertainment, and cooking habits and there is less possibility that there will be any noticeable electrolyte imbalances to deal with.
But a significant con is that it can take you several more weeks to get symptoms relief. And the several more weeks that one does not experience a substantial reduction in symptoms can cause motivation to stay with the dietary therapy to reduce.
Other clients want to jump in right away and feel better. You may not want to commit to going down in carbohydrates over many weeks to see if the therapy will work for you. You may not be functioning well enough for a bunch of meal planning or have the energy to do any kind of extensive meal prep. And that’s OK. You don’t have to. It can be kept amazingly simple for the first few weeks. If you are truly miserable and in great distress, you may want to want to get started with minimal preparation, get into a consistent level of ketosis, and see what is possible.
So this particular keto diet rule is not one that I make for you. It is one that you make for yourself and then you stick to the plan. You can come up with this rule based on what works best in your life, what you know about the level of difficulty you have in making behavior changes, and by evaluating your support system and what needs to be in place for success.
Are the very low carb rules forever?
The thing that always seems magical is that no matter how my clients decide to approach the adoption of the ketogenic diet, the benefits seem to continue and improve as time goes on.
This makes perfect sense. If they are staying relatively consistent on a ketogenic diet and are producing and using ketones as fuel, the brain continues to heal. The improved level of energy in the brain provided by ketones allows cell membranes to continue to repair, upregulate BDNF to facilitate connections and learning, and upregulate memory function in the hippocampus. Because ketones keep neuroinflammation down, the brain can catch up steadily on repairs. And because the client is using a well-formulated and nutrient-dense ketogenic diet, they have micronutrients to make these critical repairs. So it is no wonder that I have people continue to see improvements well past their first or second year of using a ketogenic diet.
As your brain and metabolism heal, it is possible that you will be able to move to 40 to 60 total grams of carbohydrates a day and still have plenty of ketones for a beautifully functioning brain.
You are used to a medical model that tells you that you will always have to take this or that medication, that you will not likely get better from a variety of conditions, and that has the word “chronic” is in almost all disease definitions.
And so when I first put my patients on 20 to 30 total grams of carbohydrates, they despair a little, thinking that they will have to eat that low of carbohydrates their entire life. And it is because they have been part of a medical model for so long that doesn’t show them healing. But I see people I have worked with be able to increase their carbohydrate intake after one or more years.
Never have I seen them go back to the huge amounts of carbohydrates that likely contributed to their original disorder. But with additional lifestyle changes that include sleep and exercise, many can go up to moderate or even sometimes liberal low-carb ranges using whole food that gives them more ideas for recipes and more access to a variety of food choices.
Medication rules of engagement
One of the most important keto diet rules for mental illness has to do with medication.
Regardless of your intention to follow the above rules, or whether you decide to restrict carbohydrates quickly or slowly, it is vital that if you are on any medications, you both research what types of medications you are on and talk to your doctor.
Dietary changes that are implemented quickly often need much quicker medication adjustment, and there is the danger of potentiation effects if you are already taking psychiatric medications.
What often happens is with a ketogenic diet, your brain begins working better. And because your brain is working better, your current dose of psychiatric medication may be too high for you, and you will start to get side effects at your current doses. You or your prescriber may believe that it is the ketogenic diet causing your symptoms when in actuality, it is much more likely a sign that your brain is healing.
Not all prescribers have experience working with people on ketogenic diets for mental illness. And so, it becomes important for you to learn what you can about your medications so you can have a collaborative relationship with your prescriber about the possible need of adjusting medications.
If you are taking any kind of diabetes medication that influences your blood sugars, drugs for heart disease that could affect your electrolytes or blood pressure medication, you need to have your prescriber available to make adjustments, sometimes quite quickly.
Because of these issues, this may also help you determine how fast or how slow you should begin to reduce your carbohydrates. It is part of the decision-making that will happen as you start to work towards symptom reduction, improved functioning, and better health.
You may find the following posts helpful in finding a prescriber to be your ally during your transition to the ketogenic diet for mental illness.
As always, this post is not medical advice. I am not your mental health professional, and I am not your doctor.
But if you want to learn more about me or contact me for a consultation I am happy to help you on your journey to know all the ways you can feel better. You may also want to sign up to receive announcements about webinars, workshops, and group wellness opportunities on these topics here.