Mental Health Plartform.

Do I need help doing keto if I have a mental illness?

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Changes in diet can be hard and challenging even for people who do not identify as having a mental illness. There are a lot of reasons you may benefit from professional help transitioning to a ketogenic diet and many different kinds of professionals that can help you. Some of these include ketogenic nutritionists, ketogenic dieticians, ketogenic informed mental health counselors, nutritional psychiatrists, functional psychiatrists, or other low carb diet informed prescribers who work in the mental health space.

Introduction

In this blog post, we will discuss some of the factors you might want to consider if you have a mental illness, and how they inform your decision about whether or not to use a ketogenic diet specialist. And, if you decide that a professional would be helpful, you can read on and learn about the different types of professionals you could work with as you use a ketogenic diet as a treatment for your mental illness.

Reasons you may want a ketogenic diet professional

A lot of people do the ketogenic diet on their own, often to lose weight or to improve their diabetes. They do all kinds of variations on the ketogenic diet with carbohydrate intakes varying from 20g total to 100g total per day. And as long as they are producing at least a little bit of ketones throughout the majority of their day, we call it a ketogenic diet.

Psychiatric symptoms need the right macros

But people using the ketogenic diet for mental illness (or neurological disorders) often need a slightly stricter version, at least in the beginning. Sometimes if we are not careful with the carbohydrate consumption we recommend for someone with mental illness, they may not have levels of ketones at high enough or for a long enough period of time to truly test the diet out as a treatment for their symptoms. We are changing the primary fuel source for the brain. And so it becomes very important to produce enough ketones through dietary fat to keep the brain happy and not exacerbate symptoms because of an energy deficit in the brain.

So if someone goes to any of the many excellent diet coaches out there, they may be told that 50g of total carbs a day is “doing keto” because they are focusing on your weight loss, and perhaps not on the diet it must be used for the treatment of mental illness. They may even recommend you restrict your dietary fat intake prematurely because they are focusing on that weight loss and trying to help you lose weight.

I wouldn’t want you to think you had tried a ketogenic diet to treat your psychiatric symptoms and that it was unsuccessful when all you may have needed was some help to find the right type of ketogenic diet to find relief. The ketogenic diet may not work for you. But it would be a shame to walk away prematurely without the benefit of the customization and support you both need and deserve.

It takes a good three weeks of very consistent therapeutic carbohydrate restriction, in the form of 20g (maybe 30g max), for you to get some idea of whether a ketogenic diet might be helpful for your individual psychiatric symptoms.

Keto and medications are a big deal

Another reason you may want to work directly with a ketogenic diet professional is if you are on psychiatric medications. This is a very important factor in your decision-making and should weigh heavily in your decision about whether to attempt keto on your own or with professional help. Ketogenic diets are such powerful mental health interventions, that your medications may need to be adjusted during the first few days or weeks of the diet. Keto and antidepressants; or keto and other medications for diabetes, blood pressure, and a few others need to be monitored carefully.

Sometimes you need to go down on a few medications simultaneously, and that’s complicated. And sometimes, if you are not working with a professional and you have a worsening of symptoms, you will not have anyone helping you watch out for side effect potentiation and you will give up early, thinking the diet is making you worse. There are some instances when it is in fact your ketogenic dietary therapy creating symptoms and you need some additional supportive bridge medications or supplements to support your healing journey.

So you can see, if you are on psychiatric medications, it is particularly wise to work with a ketogenic professional who is able to modify your medications or work with a prescriber who will, and has experience with the ketogenic diet and psychiatric medications. And if you cannot find a prescriber, you can find a ketogenic mental health professional to coordinate and work with a prescriber with whom you already receive care. This could be a ketogenic dietician or even a ketogenic informed mental health counselor (like me).

Lifestyle change is hard

You may also really benefit from working with a ketogenic informed mental health professional to assist you. They will be able to help you work through any issues that come up while making a big lifestyle change like the ketogenic diet. Sometimes big lifestyle changes bring up feelings of resistance and it can be good psychological work to explore those with someone who knows how to move you through those potential obstacles.

I have written some blog posts about some of the psychological aspects of the lifestyle change involved in ketogenic dietary therapy, and how mental health counseling can help. You can find those here:

If you have decided that it would be helpful to find a ketogenic dietary professional, then read on. I will go through the different types of mental health professionals you may find trained in ketogenic dietary therapies that could help you on your journey to better mental health.

Ketogenic diet professionals

Luckily there are a lot of different types of mental health professionals trained in ketogenic diets that can help you. We will go through and describe each one, and provide resources below that could help you find one to help you on your mental health journey.

Ketogenic nutritionist or dietician

A ketogenic nutritionist is a nutritionist that has been trained to use the ketogenic diet to treat neurological disorders. As you may have read before, the ketogenic diet has been used for over a century to treat epilepsy, and it is now used for diseases like Alzheimer’s disease, Parkinson’s disease, and ALS.

A ketogenic nutritionist may also go by the term ketogenic dietician. Many work in hospital settings, but many provide services outside those institutions. A ketogenic nutritionist or dietician cannot help you adjust your medication, but they can work closely with your prescriber. And they are often very clever at addressing any issues you might have in implementing your new diet (e.g, shopping, meal prep, budgeting). These professionals will be able to give you the correct macros that will ensure you have plenty of brain energy and the nutrient support you need to feel better.

If you choose to work with a nutritionist or a dietician, be sure to clarify with them that you are looking for someone with experience providing help with ketogenic diets specifically. Not all nutritionists and dieticians understand that ketogenic dietary therapy is being used outside of epilepsy treatment for mental illness. Find one that is not going to discourage your use of it because they are not keeping up with the research literature on this topic.

Nutritional psychiatrist

A nutritional psychiatrist is an MD or Licensed Psychiatric Nurse Practitioner, who is able to monitor your medications and adjust them as needed. Some focus on dietary interventions and medication, and others include psychotherapy work with patients. One of my favorite nutritional psychiatrists, Georgia Ede, MD has a great quote:

The most powerful way to change your brain chemistry is through food, because that’s where brain chemicals come from in the first place.

Georgia Ede, MD – https://www.diagnosisdiet.com/blog-parent/category/mental-health

This is how a nutritional psychiatrist will approach your ketogenic dietary treatment for mental health. There will be some baseline tests run, and there may be supplements, but there will not be a focus on supplements as the mechanism by which you will change your brain chemistry and function.

Functional psychiatrist

A functional psychiatrist may or may not be well-trained in the use of ketogenic diets, but many of them are. They may have a focus on tests and supplementation over dietary therapies and you will have to ask them if they are comfortable helping you try one for your mental illness. They work to evaluate and correct what is causing your mental illness and they will likely have some advanced and well-thought-out recommendations for supplementation, both as a primary treatment and to support your ketogenic diet. They are good at ferreting out underlying causes of mental illness that traditional psychiatry does not. Functional tests and supplementation can become expensive, as they are not usually covered by insurance in the US. If you want to explore using a ketogenic diet or just explore options to traditional psychiatry on your mental health journey, a functional psychiatrist is a great potential resource.

Mental Health Counselor

A mental health counselor (or therapist, they are called different things in different places) can be an excellent choice. A keto counselor of sorts!

Full disclosure, this is the kind of ketogenic professional I am (About Me).

A mental health counselor can see you bi-weekly or weekly, which will help you monitor your symptoms and help you overcome any practical or even psychological obstacles you are facing as you attempt a ketogenic diet for your mental health. A mental health counselor can practice both nutritional psychiatry and functional psychiatry (without the medication component; I know, because that’s what I do). They can coordinate your care directly with your prescriber regarding possible needs for medication adjustments and even preliminary medical testing that might be helpful in tracking your progress.

Using a ketogenic informed mental health professional like a mental health counselor or therapist means that you can get evidence-based psychotherapy while you are using your ketogenic dietary therapy for your mental illness. The two are very complimentary. You can read more about how they can work together here. Be sure to find a mental health therapist that understands ketogenic diets. There can be problems finding one that is current in their understanding of the use of ketogenic diets for mental illness. You can read more about why that would be a problem here.

Finding a Ketogenic Professional

  • Chris Palmer, MD’s website has a directory of ketogenic dieticians here
  • The Charlie Foundation has a list of ketogenic dieticians here.
  • Society of Metabolic Health Practitioners Provider Directory is a directory of all kinds of ketogenic informed healthcare practioners. If you want someone who can help with medication adjustment be sure to find someone who is a prescriber, such as an MD, DO, Licensed Physcians Assistant, or Licensed Medical Nurse Practioner. Bonus if you can find one near you or via telehealth that specializes in psychiatric or neurological conditions.
  • Find a Low-Carb Doctor at DietDoctor.com also is a directory of ketogenic informed healthcare practitioners. Just like the directory above, you will want someone who can either adjust your medications, or help you knowledgably monitor your symptoms with you and help you advocate with your current prescriber as needed.
  • You can search for a functional psychiatrist in your area or via telehealth at a great organization called Psychiatry Redefined.
  • If you want to see someone in person, you can type in the search term for what you are looking for and add “near me” next to it into your favorite search engine.
  • Don’t beccome discouraged if you cannot find someone near you! Lots of independent ketogenic practioners us telehealth. Just type in the search term for the type of professional you are looking for. You will find a variety of great telehealth professionals able to help you meet your goals.

Conclusion

Finding a ketogenic health professional like a nutritional or functional psychiatrist, ketogenic dietician or nutritionist, licensed mental health counselor, or another ally with training in mental health can be really helpful.

I want you to know all the ways you can feel better.

But more importantly, I want you to know that you deserve a higher level of support and encouragement as you try to make big changes to help treat big issues.

If you are curious about how a ketogenic diet might help treat the underlying mechanisms of specific disorders, I have written carefully researched individual posts on Depression, Anxiety, ADHD, Alcoholism, PTSD, OCD, GAD, Panic Disorder, Social Anxiety Disorder, and many more. I add new ones all the time. So if you do not see the disorder you are interested in, please search the bottom of the main page.

Please feel free to reach out to me if you have any questions or I can help you on your wellness journey. You can contact me here.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

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Why are you irritable on keto

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Why does keto make me irritable?

It can take 3 to 6 weeks to adapt to a ketogenic diet. During that time irritability may occur from insufficient electrolyte supplementation (especially sodium), potentiation effects of existing medications causing side effects, or psychological factors related to making big lifestyle changes. You are not irritable because you are not eating carbohydrates. Your brain is supplied plenty of glucose endogenously through gluconeogenesis.

Introduction

Sometimes I do keyword searches to try to figure out what to blog about. And I came across a snippet that was so misinformed and downright misleading my stomach sank. That this snippet came from a revered institution made it all the more egregious. I was so upset by the damage such a snippet could do, that I actually reported it to Google as misinformation.

Misinformation Snippet provided by Harvard Health

I am not arguing with you that you feel irritable. It is quite possible you are feeling irritable while transitioning to the ketogenic diet. There are a lot of reasons this may be happening.

But it is NOT because your brain is not getting enough glucose. I promise you. Your liver makes all the glucose your noggin may want or ever need, right on-demand, from a process called gluconeogenesis. This process is not stressful for the body or damaging in any way. Your liver happily does it for you.

So why might you be irritable on the ketogenic diet? Let’s go through the many reasons you may feel irritable on keto.

You are irritable on keto because you are taking medications that need to be adjusted or discontinued

As always, this is with the help of your prescriber. But if you are doing keto and you are feeling irritable, this could be because you are still taking medications that are being affected by the diet. These can be psychiatric medications, medications designed to lower blood sugar, or even medications that are supposed to help other conditions but that raise your blood sugar as a side effect.

Medications that lower blood glucose

If you are on ANY kind of medication designed to lower your blood sugars, and using those in addition to a ketogenic diet, you are likely becoming hypoglycemic. And this could be making you quite irritable (hangry). Sometimes we need to adjust medications very quickly on a ketogenic diet.

Medications that raise blood glucose

Some medications actually RAISE your blood sugar, all by themselves. Actually, a lot of them do. And so it is possible that one of your other medications, not designed to lower blood sugar, is potentially getting in the way of your keto-adaptation or causing you to go in and out of a ketogenic state. Popping in and out of a ketogenic state early on, makes you feel awful and as your energy goes up and down unnecessarily it can make you feel irritable.

Here is a resource that will help you figure out which medication may be messing with your blood sugar and you can ask your prescriber about whether it is ok to lower it or even temporarily discontinue it as you work towards your keto-adaptation.

Drugs That Can Affect Blood Glucose Levels

So check with your prescriber and ask about reducing your medications.

Psychiatric medication side effects

As someone who helps people transition to a ketogenic diet to treat mental illness, this is an area I watch carefully with clients and their prescribers. A ketogenic diet is a powerful therapy and it changes how your brain works. Because it makes your brain work better, the medications you usually take for psychiatric issues (SSRIs, mood stabilizers, anti-psychotics, etc.) can begin to cause side effects.

This is called potentiation, and it basically means that because your brain is working better, your current dose of the medications use to help yourself feel better is now too high. The easiest way to be on the lookout for potentiation effects is to look up the side effects of the medications you currently take. One of those side effects may very well be irritability. If you see that you are having these side effects, it may be your current dose and not the keto.

You are irritable on keto because you are not being diligent about supplementing your electrolytes

The best way to do this is to get a good quality sea salt (I like Redmond) and measure out 5-7g in a small dish and make sure that you have salted your food or taken in that amount by the end of the day. If you are using pink salt, you must double this, because it only contains about 40mg of sodium as opposed to sea salt which contains 90mg.

I cannot stress this enough! Your brain cannot work well without enough sodium. You literally have sodium-potassium pumps that make your brain (and other cells) work. If you feel poopy or irritable or even just a little off while on the ketogenic diet, your first go-to is always electrolytes.

Some people need more than this 5-7g guideline. For people who get migraines for example you may need 13g. Keep salting until you feel better. I have clients take a 1/4 tsp of salt every few hours and chase it down with some water. Often they feel better in about 20 minutes. If you are someone who wants or needs to have a flavor to drink water you can use a lower carb electrolyte drink and add a good 1/4 to 1/2 tsp of salt to it, or you can purchase LMNT, which has a good amount of salt already in it, as any good electrolyte drink should.

You also may be needing a lot more magnesium than you think. This is an important mineral for EVERYONE and just about everyone walking the planet is insufficient in this nutrient. So please, get a good magnesium glycinate supplement, and don’t be afraid to take it generously. Some of my clients do really well with 600-800mg of elemental magnesium in glycinate form. You can even supplement with a small amount of potassium, but usually, this is not necessary because the sodium helps your body protect and manage your potassium levels. But if you are feeling irritable, possibly from low electrolytes, a tiny bit of potassium is not a bad thing.

You are irritable on keto because you need to eat more

A lot of people do keto to lose weight, which is great but they cannot get out of the calorie restriction mindset. During the first 3 to 6 weeks, their body is figuring out how to switch fuel sources. It is learning to adapt by turning genes on and off, upregulating certain enzymes, and doing a whole lot of other impressive things. The body needs adequate energy to do that, and if you are still manifesting a deep down phobia of eating fat you are going to struggle. You are going to be hungry and irritable.

If you restrict energy too much then your body releases stress hormones. This can make you irritable. Don’t calorie restrict for those first 6 weeks. Just enjoy your ketogenic foods. Sometimes it takes our body a little while to get good at learning to unlock our fat stores, particularly if we have insulin resistance. And so in the meantime, it is ok to use dietary fat to fuel your body. Don’t worry.

You are irritable on keto because you need additional supports for the brain

As someone who helps people use ketogenic diets for psychiatric and neurological conditions, I know that this can be a real thing. Sometimes we add supplementation with medium-chain triglycerides (MCTs) that the liver immediately makes into ketones. Sometimes we add ketone salts. Both of these provide an immediate increase in ketones, that the brain can then use for fuel. This can help a brain struggling with psychiatric and/or neurological issues. It allows them to maintain energy in areas of the brain that are no longer using glucose well (hypometabolism). Psychiatric issues are often brain metabolism issues, and sometimes getting ketone levels up with MCT oil or ketone salts can really help.

You are irritable on keto because you have not adjusted emotionally to the change

It is also quite possible that you are feeling irritable on the ketogenic diet because of how you are experiencing it and how your change in what you eat interacts with your environment. As a mental health therapist, I can tell you that our thoughts about things drive our emotions. Any of the following could create automatic thoughts that make you feel irritable while on the ketogenic diet. Remember, anger is often a defense against feeling sadness. And so your irritability may be coming from feeling a sense of loss or even fear about how the diet will or might change your life and relationships.

You are mad or sad to do this diet in the first place

Many people do the ketogenic diet to reverse chronic diseases such as psychiatric, neurological, or other metabolic disorders like diabetes, high blood pressure, or even chronic pain conditions. All those pills and medications did not work or had side effects that made you feel even worse. And so now, here you are, having to implement a particular dietary therapy in order to try to feel well, while other people seem to be fine just eating all the carbohydrates all the time. It feels really unfair. And perhaps you have not radically accepted that you were sick and/or miserable enough to have to do this in the first place.

You don’t feel supported by your family or environment

Your spouse keeps bringing Oreos into the house or your children demand highly processed packaged foods. They demand that you make two types of meals each night, one low carb and one reflecting the standard American diet, which you cannot have anymore. You are having a hard time finding keto-friendly foods at the grocery store, or the processed keto foods most like what you used to eat are expensive and not even very keto.

Someone keeps bringing donuts to the office or having Birthday cake, and you cannot figure out how to go out to eat or be social with friends. And even when you do go out to be social, your friends keep trying to tempt you with higher carbohydrate choices or get moody and offended when you won’t eat what they brought.

This may be why you are irritable on keto. These are all situations that require an adjustment and for which you deserve support and help problem-solving. Feelings of sadness and anger, dare I say irritability, are understandable and valid emotions while learning how to be on a ketogenic diet.

You miss the flavors of certain foods

There are a lot of well-loved foods that you need to restrict on a ketogenic diet. You may miss the taste of banana in your morning smoothie. Sometimes you really want the taste of salted caramel. And you don’t know how to taste those things again and you just really miss it. Again, this is an example of where anger (or irritability, a lesser intense form of anger) is masking sadness and loss.

There is a learning curve with keto. You probably didn’t know that you could get banana extract and add it to your morning smoothie. Or that you can find salted caramel bars with a ketogenic recipe (like the one here).

Conclusion

There could be a lot of reasons you are feeling irritable on keto. And those should all be addressed. I want you to feel amazing. You deserve to feel amazing.

It might be a good idea to work with a keto diet coach or find a low-carb informed physician (see the resources page) to help you with medication adjustments. You may benefit from seeing a mental health counselor (like me) help you make such a big lifestyle change. You may enjoy this post I wrote about how psychotherapy can help you stay on keto to improve your mental health.

Just make sure that the counselor is in some small way keto informed (see the blog post about that here).

Otherwise, they may tell you such a diet is dangerous without knowing better, or tell you that you suffer from an eating disorder, without a proper understanding that therapeutic carbohydrate restriction is a research-based medical and psychiatric intervention.


Below are links to some of the resources discussed in this blog post. A few are clearly labeled Amazon affiliate links. I use them to help pay for this blog. Please do not feel obligated to use them.

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Ketogenic Diet Treats Alcoholism

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Can the ketogenic diet be used as an effective treatment for alcoholism?

A 3-week RCT done by the National Institute of Alcohol Abuse and Alcoholism found that a ketogenic diet could reduce the need for detox medications, reduce alcohol withdrawal symptoms, and reduce alcohol cravings. The researchers also found that brain scans of participants using the ketogenic diet decreased inflammation and had positive changes in brain metabolism.

Introduction

In this blog post, I am not going to outline the symptoms or prevalence rates of chronic alcoholism. This post is not designed to be diagnostic or educational in that way. What I will do is tell you about a very well-done, high-level study using the ketogenic diet as a treatment for chronic alcoholism. And we will then discuss what the underlying mechanisms of treatment using a ketogenic diet could be based on what already exists in the research literature.

Ketogenic diet treats alcohol withdrawal symptoms in humans

The National Institute of Alcohol Abuse and Alcoholism did a 3-week inpatient study of chronic alcoholics. Participants were admitted to a hospital unit and detoxed. They were then randomly assigned to either a standard American diet or a ketogenic diet to see if it could make a difference.

They found that those who got the keto diet needed less detox medication (e.g., benzodiazepines), fewer alcohol withdrawal symptoms, fewer cravings for alcohol, and their brain scans showed decreased inflammation and changes in brain metabolism. (You can read the study here.)

As if those results were not stellar enough, there was an animal arm of the study that showed that rats given a ketogenic diet reduced alcohol consumption.

People are confused about how a ketogenic diet could help people who are chronic (hardcore) alcoholics, who cannot stop drinking, ruining their lives, relationships, and bodies. How could a dietary intervention like the ketogenic diet help to this degree?

What could some of the underlying mechanisms of treatment be?

Let’s apply some of what we already know about how the ketogenic diet can help treat mental illness from prior blog posts.

What are the neurobiological factors we see in chronic alcoholism?

In a previous post, we discussed the mechanisms by which a ketogenic diet could modify symptoms of anxiety. In another post, we discussed how it can treat depression. In this post we will see whether these same four areas of pathology are seen in alcoholism:

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Inflammation
  • Oxidative stress

Alcoholism and Glucose Hypometabolism

Glucose hypometabolism is well-established as a pathological mechanism in alcoholism. We see hypometabolism in the fronto-cerebellar circuit and Papez’s circuit and in the dorsolateral, premotor, and parietal cortices. When brains cannot use fuel properly we will often see shrinkages in brain structures. A shrinkage in brain structures is a consequence of long-term brain hypometabolism. In the alcoholic brain we see severe shrinkage in the following brain structures:

  • cerebellum (balance, posture, motor learning, movement fluidity)
  • cingulate cortex (executive control, working memory, and learning; a connecting hub of emotions, sensation, and action)
  • thalamus (several functions, including Circadian rhythms)
  • hippocampus (memory)

When someone is a chronic alcoholic, their brain’s fuel source switches from using primarily glucose as fuel to something called acetate.

It has been known that a major source of acetate in the body comes from the breakdown of alcohol in the liver, which leads to rapidly increased blood acetate.

https://www.news-medical.net/news/20191024/Acetate-derived-from-alcohol-metabolism-directly-influences-epigenetic-regulation-in-the-brain.aspx

How would a ketogenic diet treat glucose hypometabolism in chronic alcoholism?

Acetate does not have to be made just from alcohol being broken down in the liver. It is also one of three ketone bodies that are made in ketosis. And so for the alcoholic brain, which has serious glucose hypometabolism and that relies on acetate for fuel, it makes sense that a ketogenic diet may provide energy rescue for the hypometabolism we see in this population.

We reasoned that the abrupt transition form the brain’s consumption of ketone bodies, which occurs in Alcohol Use Disorder (AUD) as an adaptation to repeated alcohol intake, to the use of glucose as energy source, which reemerges with detoxification, may contribute to the alcohol withdrawal syndrome.

https://www.science.org/doi/abs/10.1126/sciadv.abf6780

In other words, if your brain is used to one fuel (acetate) and then you completely withdraw the source of its preferred fuel, it makes sense that your cravings for that fuel would increase. That an energy crisis would occur in the brain. But if you replace that fuel in another way, that doesn’t destroy your body and your brain, through a ketogenic diet, your brain gets to have fuel while your body and brain are doing the hard work of healing. And eventually, as the metabolic health of your brain and body improve, your brain may be able to use glucose better as a substrate. But until that happens, you need a rescue fuel that is similar. And the ketogenic diet provides that.

Alcoholism and Neurotransmitter Imbalances

Some of the neurotransmitter imbalances seen in alcoholism include dopamine, serotonin, glutamate, and GABA.

Dopamine fuels our motivation and has important functions in our reward centers. It is seen as having a role in both acute intoxication and increases simply at the anticipation of ingesting alcohol. When people go through alcohol withdrawal there is a decrease in dopamine functioning, which may contribute to withdrawal symptoms and alcohol relapse.

The brains of alcoholics are seen to be depleted in serotonin, and it is thought that this contributes to behaviors around impulsivity and drinking alcohol.

Alcohol consumption increases GABA activity. GABA is an inhibitory neurotransmitter that we usually want a little more of because it makes us feel relaxed. But in the alcoholic brain, as they go through withdrawal, GABA is downregulated, meaning you cannot make enough of it.

The GABA systems in the brain are altered in situations of chronic alcohol exposure. As an example, in some regions of the brain, the expression of genes that encode components of the GABAA receptor is affected due to alcohol.

Banerjee, N. (2014). Neurotransmitters in alcoholism: A review of neurobiological and genetic studies. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC4065474/

The receptors are dysfunctional from chronic alcohol consumption. This is why we so often give benzodiazepines to help with withdrawals in people attempting to abstain. It is an attempt to temporarily correct the neurotransmitter imbalance that comes from withdrawal.

On the other hand, glutamate is downregulated during alcohol consumption. In other posts on other disorders, particularly anxiety disorders, we see glutamate dominate neurotransmitter state. This could be why so many people self-medicate anxiety disorders using alcohol (e.g., social anxiety). In the alcoholic brain, glutamate is thought to contribute to the rewiring of the brain that creates hyperexcitability and craving during alcohol withdrawal.

How would a ketogenic diet help treat neurotransmitter imbalances seen in chronic alcoholism?

Ketogenic diets upregulate the production of several neurotransmitters for the alcoholic brain going through withdrawals. Ketogenic diets are shown to increase serotonin production, increase GABA, balance glutamate levels and dopamine levels.

One of the ways this is accomplished is through decreased inflammation, which we will discuss in the next section. When brains are suffering from neuroinflammation (spoiler: the alcoholic brain definitely has inflammation) it disrupts the balances and functions of neurotransmitters. Another way chronic alcoholism can disrupt neurotransmitter balance is through malnutrition. B vitamins, magnesium, and several other important micronutrient cofactors are depleted and not easily restored. Alcoholics may not prioritize a healthy diet, and even if they do there are changes that occur to the gut microbiome that can reduce the absorption of important vitamins and minerals. A lack of amino acid intake resulting from choosing alcohol over nutritious food can and will disrupt the brains’ ability to create neurotransmitters and produce enzymes that regulate neurotransmitter function.

Alcoholism and Neuroinflammation

Neuroinflammation occurs when there is some assault on the neurons. This can be from head trauma, substances getting through a leaky gut-brain barrier, or chronic alcohol use. This inflammation, when it gets out of hand, will cause the death of cells, usually next to one another. These cells swell up and their internal cell machinery breaks down. Eventually, these cells that are irreparably damaged from inflammation, will rupture and spill debris where they do not belong. This is not a normal or healthy cell death process. So the debris will then lead to a local inflammatory process as the body attempts to clean up the mess.

There are very specific effects that alcohol (aka ethanol) has in the brain that trigger neuroinflammation.

The neuroimmune system response to ethanol intake, in specific brain regions such as amygdala, hippocampus and frontal cortex [in mice], is involved in addiction and in behavioural deficits observed in alcoholism.

Haorah, J., Knipe, B., Leibhart, J., Ghorpade, A., & Persidsky, Y. (2005). Alcohol‐induced oxidative stress in brain endothelial cells causes blood‐brain barrier dysfunction. http://dx.doi.org/10.14748/bmr.v28.4451.

Neurodegeneration seen in chronic alcohol abuse comes from chronic neuroinflammation. This neuroinflammatory response is due to signaling by glial cells (TLR4) who initiate this form of cell death.

How does a ketogenic diet reduced neuroinflammation in those with chronic alcoholism?

A ketogenic diet has been shown to specifically decrease TLR4 cytokines, as well as regulate the inflammatory process. It does this by being a signaling molecule that is able to turn genes on and off to balance inflammation. This keeps inflammation down. And a brain that has been exposed to chronic alcoholism is one that is on fire.

Ketogenic diets can help quickly reduce this inflammation, improving the brains’ ability to repair, restore and heal. As we learned in the neurotransmitter balance section, inflammation must be down in order for neurotransmitters to be made in the right amount and balanced.

Neuronal membranes, which are an important part of brain cells, cannot function well if they are swollen and are dealing with impending cell death. Getting inflammation down with a powerful anti-inflammatory intervention, like the ketogenic diet, could only be beneficial. Study participants experienced much less inflammation than the control group and this reduction in inflammation may have been what helped these study participants to have such favorable results as they went through alcohol withdrawal.

Alcoholism and Oxidative Stress

Severe levels of oxidative stress occur in alcoholism. Oxidative stress refers to the burden that occurs when the body’s ability to deal with reactive oxygen species (ROS) is out of balance. People who do not consume alcohol create a certain amount of reactive oxygen species just breathing and creating energy and being alive. But in healthy individuals, this normal load of ROS is well-managed and does not seem to contribute to acute disease states (although we still age, unfortunately). As you can imagine, chronic alcoholism tips this balance in such a way that ROS is increased.

Less oxidative stress would be good for anybody, but it is particularly good for alcoholics. Why? Because alcohol is particularly good at damaging the blood-brain barrier.

Thus, oxidative stress resulting from alcohol metabolism in brain microvascular endothelial cells can lead to blood-brain barrier breakdown in alcohol abuse, serving as an aggravating factor in neuroinflammatory disorders.

Abbott, N. J., Patabendige, A. A., Dolman, D. E., Yusof, S. R., & Begley, D. J. (2010). Structure and function of the blood–brain barrier.  https://doi.org/10.1189/jlb.0605340

And that the blood-brain barrier is crucial to healthy brain functioning. It is the protection from assaults that the brain depends upon, and when those tight junctions get loose and let substances through that would not be, it causes a dangerous neuroinflammatory response. Chronic non-stop neuroinflammatory responses deplete nutrients trying to fight them, blow cells up, and cause inflammatory cytokines to increase inflammation. As reactive oxygen species goes up the body’s ability to handle it goes down, causing an increase in oxidative stress.

Alcoholics have a lot of oxidative stress going on in the brain, but they also have it in their bodies. Alcoholic fatty liver disease, a devastating disease process that happens in chronic alcoholism, is seen to create large amounts of oxidative stress.

Acute and chronic ethanol treatment increases the production of ROS, lowers cellular antioxidant levels, and enhances oxidative stress in many tissues, especially the liver.

Wu, D., & Cederbaum, A. I. (2009, May). Oxidative stress and alcoholic liver disease. https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0029-1214370

How could a ketogenic diet reduce oxidative stress in those with alcoholism?

Ketogenic diets reduce oxidative stress in several ways, some of which we already discussed in previous sections. Less inflammatory cytokines lead to reduced inflammation and create less reactive oxygen species to be neutralized. One of the ways it does so is to upregulate (make more of) an endogenous (made in our body) anti-oxidant called glutathione. This is a very powerful anti-oxidant that you get more of on a ketogenic diet.

Cerebral metabolism of ketones has been shown to improve cellular energetics, increase glutathione peroxidase activity, reduce cell death and possesses anti-inflammatory and antioxidant capabilities in both in vitro and in vivo models.

Greco, T., Glenn, T. C., Hovda, D. A., & Prins, M. L. (2016). Ketogenic diet decreases oxidative stress and improves mitochondrial respiratory complex activity. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5012517/

Ketones do this by increasing something that cells really need and that can be decreased in chronic disease states like alcoholism. This important something is called nicotinamide adenine dinucleotide phosphate hydrogen (NADPH) and you can think about it as a co-factor, meaning cells need it in order to do something. More of this co-factor helps your body to use enzymes to activate powerful antioxidants in your body, such as glutathione.

Other ways a ketogenic diet improves oxidative stress are the improved cell membrane function we already reviewed. This improved cell membrane function leads to better synaptic regulation, creating better neurotransmitter balancing. The increase in mitochondria, the powerhouses of neuronal cells, gives the cell more energy for improved cell signaling and enough energy to clean and maintain the cell and all its parts.

Conclusion

The ketogenic diet is not just a theoretical treatment for alcohol use disorder anymore. It is my hope that people will use this powerful dietary and nutritional intervention to help them in their recovery journey. Particularly in those who have struggled or failed in the past using the current standard of treatment.

With the help of a medically supervised detoxification, the ketogenic diet treats alcoholism and likely, according to the animal study arm of this research, helps improve the likelihood of relapse prevention.

I want to encourage you to learn more about your treatment options from any of the following blog posts. I write about different mechanisms in varying degrees of detail that you may find helpful to learn on your wellness journey. You may enjoy the Ketogenic Case Studies page to learn how others have used the ketogenic diet to treat mental illness in my practice. And you may benefit from understanding how working with a mental health counselor while transitioning to a ketogenic diet can be helpful here.

Share this blog post or others with friends and family suffering from mental illness. Let people know there is hope.

You can learn more about me here. If you would like to contact me you may do so here. It is my honor to tell you about all the different ways that you can feel better.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

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Can keto treat my depression without medication?

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How can a ketogenic diet help treat Depression?

Ketogenic diets modify at least four of the underlying pathologies seen in people with depression. These include glucose hypometabolism, neurotransmitter imbalances, inflammation, and oxidative stress. A ketogenic diet is a powerful dietary therapy shown to directly impact these four underlying mechanisms (and others) involved with depression symptoms.

Please note, there is an exponentially shorter version of this article with much less detailed information available here.

3 Reasons you are depressed and why keto can fix them

Introduction

In this blog post, I am not going to outline the symptoms or prevalence rates of depression and/or treatment-resistant depression. This post is not designed to be diagnostic or educational in that way. Other than to say that there are several levels of severity and chronicity when it comes to depression. This blog post is not going to discuss bipolar depression or mood disorders with psychotic features.

That is not to say that the ketogenic diet cannot be used for psychotic disorders. There are in fact, at the time of this blog post, published case studies in the peer-reviewed literature showing profound benefits and RCTs underway. I will very likely do a blog post on this topic in the future. In this post, we will discuss unipolar depression and how a ketogenic diet may be useful in treatment.

If you suffer from unipolar depression you may benefit from reading this blog post. Your depression may be chronic and severe enough to meet the criteria for major depressive disorder, and if so, you will also find this blog potentially helpful. If you have found this blog post, you know what depression is and likely you or someone you love may already be suffering from it.

If you have found this blog post, you are looking for treatment options. You are trying to find ways to feel better and heal. You are wondering if you can treat your depression with a diet.

By the end of this blog post, you will be able to understand some of the underlying mechanisms going wrong in the brains of people suffering from depression and how a ketogenic diet can therapeutically treat each of them.

You will come away seeing a ketogenic diet as a possible treatment for your depressive symptoms or as a complementary modality to use with psychotherapy and/or in place of medications.

What is the standard of care in treating depression?

Not surprisingly, the standard of care for depression is medication, therapy, or a combination of the two.

Medications most commonly used to treat depression include:

  • Tricyclic antidepressants (TCAs)
  • Selective serotonin re-uptake inhibitors (SSRIs)
  • Selective serotonin noradrenaline re-uptake inhibitors (SNRIs)

Less common ones include:

  • Adrenergic alpha-2 receptor antagonists
  • Monoamine oxidase (MAO) inhibitors
  • Selective noradrenaline re-uptake inhibitors
  • Selective noradrenaline/dopamine re-uptake inhibitors
  • Melatonin receptor agonists and serotonin 5-HT2C receptor antagonists

When one medication does not work, other medications from the same or different drug classes are added into combinations that the prescriber believes will reduce symptoms. We can look up any of these medications to learn their side effects, and imagine what side effects may look like for someone taking three or more of these medications. More prescriptions are then given to deal with the side effects of medications themselves.

However, a very large meta-analysis published in a peer-reviewed journal found that there is a lack of efficacy for SSRIs and that they significantly can increase the risk of serious side effects.

“SSRIs might have statistically significant effects on depressive symptoms, but all trials were at high risk of bias and the clinical significance seems questionable. SSRIs significantly increase the risk of both serious and non-serious adverse events. The potential small beneficial effects seem to be outweighed by harmful effects.”

Jakobsen, J. C., Katakam, K. K., Schou, A., Hellmuth, S. G., Stallknecht, S. E., Leth-Møller, K., … & Gluud, C. (2017). https://doi.org/10.1186/s12888-016-1173-2

This is consistent with my experience of medications as a practitioner treating clients. You or a loved one may have similar experiences. They may have worked great for you or a loved one. Your experience may be that they not only saved your life but that you will need to take them continuously throughout the rest of your life. And you may feel completely ok with that option.

The people who have had great success using antidepressants or other psychopharmacology to treat their depression are not the people reading this blog.

This blog is for those people who are looking for alternative treatments likely to help where other interventions have failed, or who want to work to fix the root causes of unipolar depression. They want to explore if a ketogenic diet may be able to treat their depression without medications or reduced medications.

Psychotherapy is a key component of treatment for depression, whether with or without medications. According to updated treatment guidelines provided by the American Psychological Association (APA), some psychotherapies identified as being helpful to treat depression include the following:

  • Behavioral therapy
  • Cognitive therapy
  • Cognitive-behavioral therapy (CBT)
  • Mindfulness-based (includes ACT)
  • Interpersonal psychotherapy
  • Psychodynamic therapies
  • Supportive therapy

As a mental health counselor, I am partial to therapy. I use a combination of those top 4 and sometimes if depression is mild or more situational I will rely even on supportive therapy. I see it work great in most instances. But sometimes I get clients who are having a hard time responding to the therapy I am providing.

In those cases, my job is to send that client out for medication, as the research literature has found that in cases of moderate to severe depression outcomes are better when medication and psychotherapy are provided simultaneously. And sometimes this works well. But the client is often afraid to titrate down from the medication. Even though psychotherapy can change your brain chemistry and literally rewire your brain in healthier ways, there is almost always this idea that the pill did the trick.

Some of my clients believe they need the medication, even if it has side effects or may be difficult to titrate off of later. Yes, many clients do not receive adequate informed consent that withdrawal symptoms can be a part of taking psychiatric medications. There is an excellent article about it here.

Sometimes my clients come into therapy feeling numbed and having side effects that they are finding not tolerable. There have been times a psychiatrist will put them on so much medication I cannot do effective therapy with them.

Medications used to treat depression are designed to reduce the symptoms of depression. Medications for depression are not designed to fix whatever underlying process was going on that caused your depression in the first place, whether physiological, social, cognitive or some combination of all three.

Most psychiatrists are not going after the root cause of what is causing depression. The prescribing of medications is designed to help you continue your life as it was. To help you get back to work. Parent the kids more. Stay in that marriage. Deal with that difficult family member. Continue at that job. They are modulators of symptoms (hopefully, at their very best) but do not address the underlying pathologies that occurred to create the depressed state in the first place.

But medication and psychotherapy together are not always sufficient to eliminate symptoms, reduce symptoms, or keep them from recurring. You may be asking yourself if a ketogenic diet is able to treat depression without medication. For people who have decided to not use medications or even those who have, and are still suffering from depression, this is a legitimate question. People who are suffering from treatment-resistant depression are valid in their want to explore alternative therapies. You have the option to attempt to treat your depression using the ketogenic diet without medication or as a complement to psychotherapy. But first, you should learn more about why this might be a valid option on your wellness journey.

What are the neurobiological factors we see in depression?

A previous post went into detail about how a ketogenic diet can modify symptoms of anxiety. In this post we will see whether these same four areas of pathology are seen in depression:

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Inflammation
  • Oxidative stress

In unipolar depression we see these same pathologies occurring. There are areas of the brain with hypometabolism (not using energy properly), distinct neurotransmitter imbalances affecting mood and cognition, and inflammation. The literature has identified oxidative stress as a component in exacerbating depression symptoms. Let’s review each of these. And consider how the ketogenic diet modulates all of these and may favorably improve symptoms.

In this blog post I will also discuss two other mechanisms by which a ketogenic diet may be helpful in the treatment of depression:

  • gut microbiome
  • brain-derived neurotrophic factor (BDNF)

Depression and Glucose Hypometabolism

Glucose hypometabolism is a prominent feature of depression. We see it in several areas of the brain. Hypometabolism means that for some reason, energy is not being used well. The term “metabolism” refers to how the cells are using, storing, or creating energy. This “hypo” (too low) metabolism in the brain can be caused by a variety of factors and are often the result of those factors causing inflammation and oxidative stress (which we will learn more about in this blog post).

Altered metabolism in insula, limbic system, basal ganglia, thalamus, and cerebellum and thus these regions are likely to play a key role in the pathophysiology of depression.

Su, L., Cai, Y., Xu, Y., Dutt, A., Shi, S., & Bramon, E. (2014). Cerebral metabolism in major depressive disorder: a voxel-based meta-analysis of positron emission tomography studies. https://doi.org/10.1186/s12888-014-0321-9

There are a lot of areas of hypometabolism involved in depression, and it is thought that these different areas of dysfunction reflect differences in subtypes of depression and different methods of study. For example, when we see decreased metabolism in the prefrontal cortex, particularly the dorsolateral prefrontal cortex, we see it associated with a reduction in problem-solving abilities and a higher likelihood for negative emotions to be acted upon.

Location of the dorsolateral prefrontal cortex

This tendency to be unable to solve problems and to react with negative emotions can put people with depression at risk for suicidality in those with Major Depressive Disorder (MDD).

Factors believed to contribute to the creation of hypometabolism in include the following:

  • aging
  • hypertension
  • diabetes
  • hypoxia/obstructive sleep apnea
  • obesity
  • vitamin B12/folate deficiency
  • depression
  • traumatic brain injury

Pay attention to that list. We will talk about it a bit more when we discuss ketogenic diets as a treatment for depression.

We are discussing brain hypometabolism as we focus in on brain dysfunction in depression. But me talking about hypometabolism must also be conceptualized as a metabolic disorder. Brain hypometabolism is a sign of metabolic dysregulation and disorder.

Three longitudinal studies among depressed patients found that a combination of multiple metabolic dysregulations contributes to the sustained chronicity of depression.

Penninx, B., & Lange, S. (2018). Metabolic syndrome in psychiatric patients: overview, mechanisms, and implications. . https://doi.org/10.31887/DCNS.2018.20.1/bpenninx

Remember this as we begin to discuss below how a ketogenic diet can treat this underlying pathological state in depressed brains.

How does a ketogenic diet treat hypometabolism in depression?

Now, let’s go back to the list we just reviewed showing the factors believed to contribute to the creation of hypometabolism in the brain. But this time, we will point out the conditions in which a ketogenic diet is used to treat and/or reverse those very factors.

  • aging
    • ketogenic diets are used to treat mild cognitive decline, Alzheimer’s disease, and other dementias (e.g., vascular)
  • hypertension
    • a ketogenic diet can get someone off hypertension medications in as little as 3 days
  • diabetes
    • ketogenic diets have been seen to reverse Type II Diabetes or put in remission to the point insulin is no longer needed
    • If you are surprised by this you may enjoy exploring Virta Health
  • hypoxia/obstructive sleep apnea
    • ketogenic diets help people lose weight, which can either reverse or reduce the severity of obstructive sleep apnea
  • obesity
    • there is a large research literature showing that the ketogenic diet can help reduce obesity and improve body composition
  • vitamin B12/folate deficiency
    • this can be due to genetic issues and may need special supplementation, however, a well-formulated ketogenic diet is high in these nutrients
  • depression
    • Why we are here reading about a ketogenic diet as a treatment for depression
  • traumatic brain injury
    • ketogenic diets are used as a therapy for traumatic brain injury

So before we even explore how a ketogenic diet helps reverse or improve brain hypometabolism, we can see that the ketogenic diet already has strong research and clinical base showing its use in conditions that are either associated with or create brain hypometabolism!

The ketogenic diet is, in fact, a treatment for metabolic disorders. Remember the quote from a few moments ago, from a research paper discussing how psychiatric illnesses are metabolic disorders? Ketogenic diets have the power to reverse metabolic disorders. Meaning they can reverse the mechanisms underlying metabolic disease. Even those that occur in the brain. We use ketogenic diets to improve the metabolic dysfunction in the brains of those suffering from Alzheimer’s Disease. Should we not be considering it to reverse the metabolic dysfunction we see in clinically depressed brains?

I would argue strongly that we in fact should.

But now we will talk about how a ketogenic diet can reverse or improve brain hypometabolism.

The most obvious way that a ketogenic diet improves hypometabolism is by providing an alternative fuel source for the brain. Sometimes, for a variety of reasons, the machinery used by brain cells to use glucose as fuel doesn’t work well anymore. Luckily, ketones, which are generated on a ketogenic diet, can bypass that faulty cell machinery and get right into those neurons to be burned as fuel. Ketogenic diets also upregulate the creation of something called mitochondria.

Mitochondria are the powerhouses of your neurons. They make energy. So your cells make more mitochondria and those mitochondria work really well when given ketones as fuel.

The other way that ketogenic diets help prevent and reverse hypometabolism is by helping cell membranes work better. Cell membranes working better mean healthy action potentials. Action potentials are what we call that moment when a cell fires. A firing cell, firing in a balanced way, without firing too much or too little, is an effect of ketogenic diets.

Ketogenic diets also upregulate (increase or make more of) important enzymatic activities (enzymes are essential in almost all things) needed to generate cellular energy.

The bottom line is that brains suffering from hypometabolism work better using a ketogenic diet. Got depression? You have hypometabolism. Need a treatment for that underlying pathology driving your depression? Ketones are a potential therapy.

Depression and Neurotransmitter Imbalances

It can be difficult to write about the effects of the ketogenic diet on mental illness, and on depression in particular, because each of the headings we will discuss influences the other. Here is a good example:

Thus, pro-inflammatory cytokines can interact virtually with all pathophysiological changes that characterise major depression and thereby influence neurotransmitter function, synaptic plasticity and ultimately neuronal structure.

Leonard, B. E., & Wegener, G. (2020). Inflammation, insulin resistance and neuroprogression in depression. https://pubmed.ncbi.nlm.nih.gov/31186075/

This section is not about inflammation. That comes later. But as you learn about how the ketogenic diet treats depression you will have to become a systems thinker. Keep in mind as we discuss neurotransmitter imbalances seen in depression, that the other categories of hypometabolism, inflammation, and oxidative stress influence the creation of those neurotransmitter imbalances. I will also do my best to wrap how these interact in the conclusion, but do your best to make these connections as you go.

The neurotransmitter imbalances we see in depression occur most likely because of neuroinflammation, often initiated by immune responses that create inflammatory cytokines. We will talk more about that later, but understand that when your brain is inflamed, it is an environment that is not in balance. And apparently, your brain needs to have a certain amount of stability in order to make neurotransmitters in the right amount and balance. To achieve neurotransmitter balance you need a brain that is not under a lot of excess stress, inflammation, or oxidative stress.

Neurotransmitters thought to be involved in major depressive disorder include serotonin, dopamine, norepinephrine, and GABA. Almost the entire psychiatric literature has been based on the idea that depression is a neurotransmitter imbalance, right? But let’s talk about how those neurotransmitters might be getting out of balance in the first place.

When your brain is suffering from inflammation (and yes, a high sugar diet can cause higher inflammation and immune system dysfunction that can lead to neuroinflammation), there is something called a tryptophan steal. This results in less serotonin, less melatonin, and less GABA being made. It also means more dopamine, which for some psychiatric disorders is not a good thing, as well as excitotoxic levels of glutamate. What does this mean to the depressed brain?

Tryptophan is an amino acid and gets made into neurotransmitters with a little help from cofactors such as important micronutrients. If your brain is inflamed at a time that neurotransmitters need to be made, this amino acid goes through a different pathway and makes more of an excitatory neurotransmitter called glutamate. Now, glutamate is not a bad neurotransmitter. you need glutamate. You just don’t need or want the 100x more glutamate that will be made when your brain is inflamed. That much extra glutamate is neurotoxic and ironically, creates even more inflammation through neurodegeneration.

Glutamate at these levels feels anxious. Or if inflammation levels get high enough probably feels depressed. Why? Because by going through the wrong pathway your brain has made much much less GABA than it was supposed to.

Was there some time in your life when you were feeling the opposite of overwhelmed? You felt chill and competent and exuded a sense of “I got this” as you thought about life and your future? That was your brain having the right amount of GABA. And that, my friend, is your natural state of being.

You are not your depression.

This tryptophan steal also reduces the amount of serotonin and melatonin you can make. So you get low, sad, depressed mood and terrible sleep. You start doing that thing where you don’t fall asleep at a reasonable time. And then you stay up late, possibly ruminating or feeling generally terrible, and then you have trouble getting up in the morning. So you call yourself a loser and reinforce the negative cognitive bias that develops and helps sustain depression. Which makes you sadder and worsens your symptoms causing more inflammation. Sound familiar?

You know what I am talking about. That is you living the consequences of an inflamed brain messing up your neurotransmitter balance. Depleting your micronutrients to upkeep your brain and make enzymes and neurotransmitters. And fixing this is actually more in your control than you would ever imagine.

Remember, medications do not help you make more serotonin. Only your brain can really do that. They just help what you can make hang out. And if you are not making enough because of this inflammatory neurotransmitter imbalance train-wreck and/or because of micronutrient deficiency (less likely on a well-formulated ketogenic diet), then those medications can only do so much.

How the ketogenic diet improves neurotransmitter imbalances seen in depression

Ketogenic diets significantly alter the neurotransmitters dopamine and serotonin but with a stable ratio, meaning it helps the brain make not too much and not too little. Something particularly useful in those with depression. Remember, you can be prescribed medication in the form of reuptake-inhibitors for both serotonin and dopamine. They will give you longer access to the neurotransmitters you have managed to produce and for a lot of people that will help to relieve symptoms.

What those medications will NOT do is ensure a balanced ratio, or be able to tell your complicated brain when it needs more or less. And that is why they often create side effects. Side effects can happen when a medication is trying to modulate something too far one way or the other, and it is affecting multiple systems. You do not get that with a ketogenic diet. There is just none of that nonsense going on.

And so a ketogenic diet, with its many pathways of intervention and its ability to regulate and balance neurotransmitter production and use, can make it an excellent treatment for depression. All by itself, or in addition to medications, under the care of your prescriber.

Depression and neuroinflammation

A lot of things can cause neuroinflammation. A high sugar or carbohydrate diet that your metabolism cannot deal with can cause inflammation. That high fructose drink you prefer? That can cause inflammation. No really, I am not making this up. Look here.

A leaky blood-brain barrier that lets toxins get up in the brain where they don’t belong can cause inflammation. A leaky gut that lets matter through for the immune system to freak out about can cause inflammation. An event that happens in your body, way far away from your brain, can trigger neuroinflammation, because the immune system in your body, talks to the one in your brain. A traumatic event can increase neuroinflammation, probably through mechanisms around cortisol. Having an immune response, whether viral or to injury, can cause neuroinflammation.

When we study depression and inflammation, we look for markers of inflammation. And the research literature is full of studies looking at these different types of markers for what are called cytokines. Cytokines are powerful and the way they play out in your brain is they control your behavior. Remember when you had a bad cold or flu, and you literally just laid down, and did not get up again for a very long time. You sat still. You had no motivation to go do anything or stimulate yourself overmuch with any sort of activity? That was your body’s immune system calling out to the separate immune system that is in your brain, to let it know to stay alert, that your body was under attack, and that you needed to rest. So that brain inflammation did just that, with inflammatory cytokines. So you rested.

How is this relevant to depression? Think about it like this. Are you motivated to get up and do things? Does being on the couch and not feeling motivated to move sound familiar? Your brain is inflamed. This inflammation is part of what creates your symptoms of depression. Signs of neuroinflammation include brain fog, anxiety, depression, headaches, and poor mental stamina. Do those sound like some of your symptoms?

Depression is not just neurotransmitter imbalances as you were led to believe, and told could be fixed with medication. It is also inflammation that is driving your symptoms. And inflammation needs its own special attention in the treatment of depression.

Chronic low-grade inflammation has been observed in major depression and other major psychiatric disorders and has been implicated in metabolic changes that are commonly associated with these disorders.

Leonard, B. E., & Wegener, G. (2020). Inflammation, insulin resistance and neuroprogression in depression. HTTPS://PUBMED.NCBI.NLM.NIH.GOV/31186075/

Let me use this as an opportunity to help you make connections. Remember when we discussed the need for the brain to not be inflamed in order to make the right combo of neurotransmitters? Remember our talk of the tryptophan steal? This is what the below quote from the research literature is talking about:

Thus, as a consequence of immune activation, the changes in the tryptophan-kynurenine pathway play a major role in the dysfunctional neurotransmitter systems in the brain and, in addition, contribute to the changes in the brain structure and function which characterise depression.

Leonard, B. E., & Wegener, G. (2020). Inflammation, insulin resistance and neuroprogression in depression. https://pubmed.ncbi.nlm.nih.gov/31186075/

Neuroinflammation sets the stage for your brain to not work well, which then creates the perfect conditions for that tryptophan steal to occur. And this consistent state of inflammation and imbalanced neurotransmitters starts to change your brain structures and the connectivity of those brain structures.

So as you can imagine, a powerful intervention to reduce inflammation is warranted if we want to treat depression. And I think you obviously know where I am going with this.

How ketogenic diets reduce neuroinflammation in those with depression

There is an excellent and well-written article on how ketones work here and one specifically about inflammation here. They are much more biochemically in-depth than the level discussed in this blog post. If you like the neurochemistry and biochemistry pieces you should definitely deep dive there for a more in-depth understanding.

But for the rest of us, it is just important to know that ketogenic diets are VERY powerful anti-inflammatory therapies.

First, the reduction in carbohydrates significantly reduces inflammation, because your body isn’t desperately trying to get your ideal blood sugar levels back down to about a tsp worth of glucose in your entire bloodstream. If you are insulin resistant (and you likely are because of how our diets are in modern times) then every second you are swimming in higher blood sugar levels for longer than they should be you are contributing to cell damage and inflammation. So ketogenic diets, with their restriction to low carbohydrates, really help that.

Second, ketones, which are produced on a ketogenic diet, are signaling molecules. This means they turn genes on and off. And some of the genes they turn on and off are those that manage inflammation in the body. And if that wouldn’t make them an effective treatment for the neuroinflammation that we see is rampant in depression, I do not know what would be. Perhaps someday gene therapies will occur for depression, that does the work of ketones. And you can wait for those, but I am not sure why you would want to when you have the ability to instigate your own gene therapy through a free, effective dietary therapy with no significant side effects.

Depression and Oxidative Stress

Oxidative stress, in general, works like this:

  • Cells make energy using ATP
  • ATP goes through a process called oxidative phosphorylation
  • This causes reactive oxygen species (ROS); which are destructive by-products of this very normal process
  • ROS damages DNA, and this damage can be cumulative
  • Oxidative Stress is what we call the burden on our system to repair this damage

It is not about whether you have oxidative stress, it is about what your levels of oxidative stress are and the burden and damage that occurs in your body as a result.

The brains of people suffering from depression have higher levels of oxidative stress. The higher your oxidative stress, the poorer your outcomes when using anti-depressants. Why would that be? Well, anti-depressant medications do not address this problem. As we discussed, medications for depression are about alleviating symptoms. Not causes.

If your inflammation is too high, you create more ROS. And too much ROS depletes the systems designed to reduce inflammation. This increases your level of oxidative stress. Oxidative stress is higher in those with depression. So we need an intervention that can address both inflammation and oxidative stress.

How ketones treat Oxidative Stress in those with Depression

B-Hydroxybutyrate, one of 3 types of ketones made in the body reduces the production of reactive oxygen species (ROS) and thereby improves mitochondrial function, which you experience as energy and better working everything. It also stimulates your own antioxidant system that uses endogenous glutathione production. I promise you, there is no antioxidant therapy you can take that will be as powerful as your own endogenous glutathione system that is upregulated with ketone action and plenty of glutathione precursors coming from a well-formulated ketogenic diet. I don’t care how much Vitamin C you are downing, you are not going to get the same level of anti-oxidant support you would get from your own well-working endogenous (made in your body) anti-oxidant system.

You were, after all, made to deal with reactive oxygen species. Seriously, you get them just by breathing. Do you think evolution didn’t think about that?

I am not saying our modern world with its pollutants, chemicals, current ways of eating, and the resulting chronic diseases, do not warrant some extra anti-oxidants or detoxification strategies. But I am saying that if you use ketogenic dietary therapy and upregulate your ketones you are going to treat the neuroinflammation in your brain that is contributing to, or more likely causing, your depressive symptoms. And it’s going to do it at a level you are just not going to get eating as you have and popping a lot of vitamin C and turmeric.

Glutathione aside, reducing your carbohydrate intake helps (immensely) to not deplete the glutathione you already make. Oxidative stress is a result of creating more reactive oxygen species than your current antioxidant systems (whether those you make or those you eat) can handle. And then we get cell damage, inflammatory cytokines, and quite frankly, serious DNA damage. And that DNA damage can never be fixed if you are constantly slamming your defenses with a diet (or environment) that creates a constant source of inflammation.

Usually, I stop with the above four mechanisms of action. But in depression, I thought it would be helpful to discuss two other ways that a ketogenic diet may be helpful in treating depression without medication (or with meds if you find a knowledgeable prescriber or mental health counselor).

Effects of ketogenic diets on gut microbiome and depression

There is a lot of research that I will not go into here about the gut microbiome and depression. There are some important nutrients involved in this (e.g., Vitamin D is HUGE) and it really warrants its own blog post. Also, what we know about the microbiome is very much in its infancy. There are a lot of educated assumptions going on as researchers are trying to figure things out.

But what I can tell you is that a well-formulated ketogenic diet makes for a happy and healthy microbiome. Beta-hydroxybutyrate is one of three types of ketones. The “butyrate” portion of this type of ketone is immensely helpful for gut healing and health.

Butyrate along with other fermentation-derived SCFAs (e.g. acetate, propionate) and the structurally related ketone bodies (e.g. acetoacetate and d-β-hydroxybutyrate) show promising effects in various diseases including obesity, diabetes, inflammatory (bowel) diseases, and colorectal cancer as well as neurological disorders. Indeed, it is clear that host energy metabolism and immune functions critically depend on butyrate as a potent regulator, highlighting butyrate as a key mediator of host-microbe crosstalk. 

Stilling, R. M., van de Wouw, M., Clarke, G., Stanton, C., Dinan, T. G., & Cryan, J. F. (2016). https://doi.org/10.1016/j.neuint.2016.06.011

I know what you are thinking. The benefits of the ketogenic diet just go on and on and on. It sounds like a scam. Like a too-good-to-be-true sort of thing. And I would understand if you were skeptical. But I promise I am not making this stuff up.

Do you know what food has the highest butyrate levels? Butter. That’s right. Your gut loves butter. Possibly more than it loves all the prebiotic fiber you are worried about getting. But don’t be concerned. A well-formulated ketogenic diet is full of that also in all those low-carb veggies you would be enjoying.

So don’t let people tell you the ketogenic diet is bad for your gut microbiome or it is going to “mess it up” or something like that. That is just not the case. If anything it can improve your gut health, help repair leaky gut, and as a result calm down that immune system activity that is contributing to inflammation, which then can cause neuroinflammation, and directly contribute to the imbalances in your neurotransmitters.

The gut microbiome is not my area of expertise at all. I am not up on my understanding of all those little bacteria and the effects they have on the body, or the metabolic pathways they may influence. But if you are way into that stuff and want to learn more about what kind of specific changes in the gut microbiome we see with ketogenic diets you can find a great blog post here.

Brain-Derived Neurotrophic Factor (BDNF)

Brain-derived neurotrophic factor (BDNF) is a protein encoded by a specific gene. It’s that important. It does some really important things:

  • enhance neurogenesis (new brain cells and parts)
  • brain cell proliferation and survival
  • an important role in learning and memory

It is required for a healthy brain. It is needed to grow, to heal, to make new connections, and to learn. Why does this matter if you have depression?

When you have a depressed brain the damage is progressive in nature and includes changes in brain structure and function. You are going to need nice high levels of BDNF to help restructure those pathways and to get the most out of any psychotherapy you use as an adjunctive treatment. When I sit down with a client using cognitive-behavioral therapy, I am there to help them restructure thought patterns. That is going to mean they need to make new connections of thought and memory.

Problems with BDNF have been identified as a factor in depression.

The maladaptive neuroplastic in depression may be related to alterations in the levels of neurotrophic factors, which play a central role in plasticity. Enhancement of neurotrophic factors signaling has great potential in therapy for depression.

Yang, T., et al. (2020). The role of BDNF on neural plasticity in depression. https://doi.org/10.3389/fncel.2020.00082

BDNF is this mysterious factor that is absolutely crucial for brain health and fixing broken connections, and it just happens to be upregulated quite nicely on a ketogenic diet. Seen, by the way, in both animal and human studies. The science on this is legit. Anyone saying the ketogenic diet as a treatment for depression is fringe just doesn’t know the research literature on its benefits. Because if they did, they would nod their head and say “yeah, I can totally see how that would work.”

Conclusion

So the reduction in carbohydrates that happens with a ketogenic diet is helpful because it reduces inflammation and it allows our bodies to make ketones. And as we have learned, ketones are a direct and powerful intervention for inflammation. Ketones, which are generated by employing a ketogenic diet, help you make more of your own anti-oxidants (glutathione). Ketones can help repair leaky brain and gut membranes to keep inflammation down from immune system over-activation.

There is even important research about how ketogenic diets improve immune function, but I had to have some limits on this post or it would go on forever.

Less inflammation helps your body hold on to more of its important micronutrients. These micronutrient levels could be boosted further in the choice to eat a well-formulated, whole foods ketogenic diet. These micronutrients would be used to repair damaged DNA, help cell membranes work better, and make neurotransmitters in sufficient and balanced quantities. The boost in cellular energy and power that you get with ketones helps your neurons repair themselves from the damage that has happened. That fuel helps them to do basic housekeeping and upkeep those cells and cell membranes.

I don’t know of a single medication that can do all of these things. And I do not believe a cocktail of medications could achieve these things without an awful lot of side effects. And it is for this reason that I really wanted you to know that a ketogenic diet might be used instead of medications for depression. I want you to know that many of the mechanisms by which ketogenic diets work are well-documented in research. As are their stellar effects. And I believe you need this information in order to make good treatment decisions, so you can live your very best life.

I want to encourage you to learn more about your treatment options from any of the following blog posts. I write about different mechanisms in varying degrees of detail that you may find helpful to learn on your wellness journey. You may enjoy the Ketogenic Case Studies page to learn how others have used the ketogenic diet to treat mental illness in my practice. And you may benefit from understanding how working with a mental health counselor while transitioning to a ketogenic diet can be helpful here.

Share this or other blog posts I have written with friends and family suffering from mental illness. Let people know there is hope!

You can learn more about me here. If you would like to contact me you may do so here. If you just have a simple question please do not hesitate to reach out. Or let me know in a comment if you have found this blog post to be helpful on your wellness journey.

I truly believe you have the right to know all of the ways you can feel better.

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Obsessive-Compulsive Disorder (OCD)

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How can a ketogenic diet help treat the symptoms of Obsessive-Compulsive Disorder (OCD)?

Ketogenic diets are able to modify at least four of the pathologies we see in people with obsessive-compulsive disorder (OCD). These pathologies include glucose hypometabolism, neurotransmitter imbalances, inflammation, and oxidative stress. A ketogenic diet is a powerful dietary therapy that has been shown to directly impact these four underlying mechanisms that have been identified to be involved with obsessive-compulsive disorder (OCD) symptoms.

Introduction

In this blog post, I am not going to outline the symptoms or prevalence rates of OCD. This post is not designed to be diagnostic or educational in that way. Other than to say that OCD is highly related to other disorders such as Body Dysmorphic Disorder, Trichotillomania, Hoarding, and Excoriation Disorder (aka skin picking). If you suffer from any of those with or without a formal OCD diagnosis, you may also benefit from reading this blog post. If you have found this blog post, you know what OCD is and likely you or someone you love may already be suffering from it.

If you have found this blog post, you are looking for treatment options. You are trying to find ways to feel better and heal.

By the end of this blog post, you will be able to understand some of the underlying mechanisms going wrong in the brains of people suffering from OCD and how a ketogenic diet can therapeutically treat each of them.

You will come away seeing a ketogenic diet as a possible treatment for your OCD symptoms or as a complementary modality to use with psychotherapy and/or in place of medications.

Current psychopharmacology uses selective reuptake serotonin inhibitors (SSRIs), often (and hopefully) with cognitive-behavioral therapy (CBT) to treat OCD.

Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC4120194/

We can easily look up the side effects of any of these medications. The symptoms of OCD with and without psychotherapy can be so debilitating and chronic for some people, that enduring side-effects may seem a small price to pay for improved functioning. As a mental health counselor, I am quite biased toward the use of cognitive-behavioral therapy (CBT) and mindfulness skills as a treatment for OCD, seeing improvements in patients who do protocols with or without medication. But for some patients, medication and psychotherapy are not sufficient to improve symptoms. And some of my patients simply do not improve on current medications or do not tolerate the side effects of medications. And they are not alone.

Nonetheless, as many as half of all patients with OCD do not attain remission with current treatments, suggesting the considerable potential for further innovations in psychopharmacology for the disorder. 

Szechtman, H., Harvey, B. H., Woody, E. Z., & Hoffman, K. L. (2020).  https://doi.org/10.1124/pr.119.017772

Because over half of the people we attempt to treat with medication do not improve, it is our right and our responsibility to look outside of the standard of care for those suffering from OCD. To ask people suffering to wait until psychopharmacology catches up and provides effective treatment is inhumane. Especially when there are other interventions that could prove beneficial for this mental disorder.

So we are going to look at the literature to learn of some of the mechanisms of pathology we have seen in people who suffer from obsessive-compulsive disorder (OCD). We will discuss how the ketogenic diet can be a treatment for the underlying mechanisms found in symptom presentation with OCD.

What are the neurobiological changes seen in people suffering from OCD?

A previous post went into detail about how a ketogenic diet can modify symptoms of anxiety by affecting four areas of pathology seen in these disorders.

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Inflammation
  • Oxidative stress.

In OCD we see these same pathologies occurring. There are areas of the brain with hypometabolism (not using energy properly), distinct neurotransmitter imbalances affecting mood and cognition, and inflammation. There is even a component of oxidative stress present in the obsessive-compulsive disorder (OCD) brain, exacerbating symptoms. Let’s review each of these. And consider how the ketogenic diet modulates all of these and may favorably improve symptoms.

OCD and Brain Hypometabolism

Changes in glucose activity have been documented in the orbitofrontal cortex (OFC) and the caudate nucleus and could correlate the presence and lack of obsessive-compulsive disorder (OCD) symptoms based on these findings. Neuroimaging studies using PET, SPECT, and fMRI have found that abnormally high activity occurs throughout the frontal cortex and connected subcortical structures. But that with successful treatment using SSRIs or behavior therapy this high activity returns to normal levels.  

Generally, we see hypermetabolism in obsessive-compulsive disorder (OCD). An increased metabolic rate in the left orbital gyrus and bilaterally in the caudate nuclei. But that is not to say that there is no hypometabolism component in OCD. It just may be more dependent on the course of illness and the activity being attempted.

Glucose hypermetabolism is later replaced by hypometabolism in the anterior cingulate cortex (ACC). This is thought to occur because the ACC eventually stops performing normal functions in this part of the brain. Why would the ACC do this? Because it redistributes functions to other brain structures because of abnormal circuitry that develops over the course of the illness. Brain structures will wire harder and stronger where there is increased activity. Brains are quite plastic, meaning if there is an area of overexcitability it will modify what brain structures are connected and to what degree.

Evidence from neuroimaging studies indicates that while there is one loop of hyperactivity, there is a second loop of hypoactivity between the dorsolateral prefrontal cortex (dlPFC) and dorsolateral caudate in patients with OCD. This hypoactivity is thought to underlie the cognitive inflexibility and deficits in executive function seen on neuropsychological assessments in OCD patients.

Thus, the prevailing hypothesis asserts that an imbalance between these 2 circuits is the underlying basis for OCD, as a hyperactive OFC generates obsessions and their associated ritualistic compulsions, while a hypoactive executive network prevents the individual from being able to switch to a new behavior.

McGovern, R. A., & Sheth, S. A. (2017). https://doi.org/10.3171/2016.1.JNS15601

We also see that OCD patients demonstrate working memory impairments that may be associated with glucose hypometabolism in the prefrontal cortex. These working memory impairments include not only simply trying to remember things for short periods, but also include problems with visual-spatial and executive functioning. These deficits in executive functioning, which are associated with brain hypometabolism, are part of symptom presentation. In order to have some control of our thoughts, or to move our thoughts away from more base thoughts devoted to fear and safety, we must have good executive functioning in the brain. For this reason, I would argue that hypometabolism is a relevant target of neurobiological intervention in those with OCD.

Also, I do not see many patients who do not have comorbidity with other disorders. Meaning, many of my patients have what is called dual diagnoses. Meaning they don’t just have OCD, but they have over mental illnesses that go along with it. And one comorbidity that I see quite often with OCD is depression. Depression is consistently seen to show a great deal of dysfunctional brain hypometabolism. This prominent hypometabolism component is correlated strongly and possibly causative of symptom presentation in depression in general, and is found present in those with comorbid OCD.

How a ketogenic diet treats hypometabolism in the OCD brain

Ketogenic diets are metabolic therapy for the brain. Ketogenic diets produce ketones. And ketones are used as an alternative fuel for the brain. Ketones can bypass broken metabolic machinery normally used to utilize glucose for fuel. Not only do brains love ketones, but a ketogenic diet helps neurons make more powerhouses for cells (mitochondria), increasing metabolism (energy expenditure) in important brain structures and connections seen in obsessive-compulsive disorder (OCD).

But wait, you may say. What about those other areas of hyperexcitability? Won’t a ketogenic diet rev all those up and make that loop (circuit) of the brain worse?

Absolutely not. Why?

our results suggest that brain network destabilization may reflect early signs of hypometabolism

Mujica-Parodi, L. R., et al., (2020). Diet modulates brain network stability, a biomarker for brain aging, in young adults. https://pubmed.ncbi.nlm.nih.gov/32127481/

Because the pathology of brain hypometabolism does not mean that the excitability is necessarily happening for the same reason. Ketogenic diets help to actually stabilize brain function by bypassing broken cell machinery that has resulted in the cell developing glucose hypometabolism. Also, supportive neuronal structures like astrocytes can upregulate their own ketone production, creating more energy overall in the brain. We will learn more about astrocytes later.

Hyperexcitability in some structures of the brain is much more likely due to neurotransmitter imbalance than glucose hypometabolism. Was I able to figure out exactly what causes the hyperexcitability? I don’t think the literature knows for sure. But we do see neurotransmitter imbalances that cause hyperexcitability and we know that unchecked inflammation can damage cell energy and cause areas of hypometabolism.

But because the ketogenic diet is not an intervention on a single component of mental illness, the way so many psychopharmacology treatments are, improving energy consumption in one hypometabolic structure is not going to cause another to rev up in a scary way.

recent evidence suggests that altering metabolism with a ketogenic diet enables a homeostatic state in the brain that is less excitable

Masino, S. A., & Rho, J. M. (2019). https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6281876/

Remember? This intervention works on at least four factors going wrong (with a few more thrown in we may discuss at the end), and the improvements on one system do not seem to imbalance or cause side effects with the others. The ketogenic diet appears to work holistically with all involved mechanisms of intervention.

OCD and Neurotransmitter Imbalances

Neurotransmitter imbalances we see in OCD include neurotransmitters, including serotonin, dopamine, glutamate, and GABA.

Serotonin imbalance plays an active role in OCD. So much so that at least half with OCD improve on medications that leave more serotonin available in the synapses (SSRIs) to be used by neurons. There are a lot of reasons why a brain may not be making enough serotonin. Some could be not enough cofactors like iron, vitamin D, or B6, and possibly not enough amino acid precursors (Vegans and those eating too many highly processed foods, I am talking to you). But in OCD the lack of serotonin is thought to create problems with obsessions. And when we treat some people with SSRIs their obsessions decrease in intensity and frequency. But it doesn’t work for everybody.

The clinical benefits of selective serotonin-reuptake inhibitors (SSRIs) have implicated serotonin, but a clear understanding of its role in symptom onset, aggravation, and resolution remains elusive.

Lissemore, J. I., et al. (2021). https://doi.org/10.1007/978-3-030-57231-0_13

While we don’t understand why this occurs in OCD, the consensus seems to be that low serotonergic activity alters the orbitofrontal cortex response and that people with OCD must be treated with a serotonin agonist. What if there was a way to produce a physiological reaction in favor of serotonin balance that was not a serotonin agonist in the form of medication?

When we evaluate neurotransmitter systems of dopamine in patients with OCD we tend to see problems with dopamine receptors (D2). But we do not see a significant correlation between the faulty D2 receptor function and disease severity. At least not consistently in the literature. But we do know dopamine is involved because, in a pharmacological fMRI study of reinforcement learning, the use of dopamine receptor antagonists with obsessive-compulsive disorder (OCD) saw an unexpected therapeutic benefit.

One neurotransmitter system that appears to be important for OCD is that between glutamate and GABA. Glutamate is an excitatory neurotransmitter that is important to normal brain function, but when out of balance can be neurotoxic. It is best described as a gas pedal. GABA is an inhibitory neurotransmitter and we generally think of GABA as a chill, feel-good, not overwhelmed sort of neurotransmitter when it is in balance. GABA can be thought of like the brakes. The two need to be in balance in a well-functioning brain. But we do not see these two balanced in OCD.

Imbalances between the glutamate and GABA neurotransmitter systems in certain structures of the brain are thought to create the repetitive behavioral nature of some obsessive-compulsive disorder (OCD) symptoms. Some researchers posit that glutamatergic hyperactivity (making too much glutamate) associated with over-activity of certain pathways may underlie the development of OCD. We have a ton of animal studies with mice showing this and even two human studies. Elevated levels of glutamate were found in both studies of those who were unmedicated suffering from obsessive-compulsive disorder (OCD).

There is a growing body of evidence from neuroimaging studies, which implicate glutamatergic dysfunction in OCD. However, the evidence is divided regarding the exact nature of dysfunction.

Karthik, S., Sharma, L. P., & Narayanaswamy, J. C. (2020). Investigating the role of glutamate in obsessive-compulsive disorder: current perspectives. 
https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC7173854/

It is not as simple that there is just simply “too much glutamate” although that could be the case in some brain structures. It is an issue of imbalance of glutamate. Because we have also seen evidence of too little glutamate in the thalamus in those with OCD. Again, the brain is a complicated system. That we are attempting to treat with single mechanisms interventions in order to attain that balance. And for a lot of people with OCD, this is not working.

Lower levels of the neurotransmitter GABA are seen to correlate with high symptom severity in those with obsessive-compulsive disorder (OCD). Lower GABA appears to exist in the rostral anterior cingulate cortex, which is thought to have a role in deficits in cognitive control we see with OCD (e.g., ruminating thoughts).

In a meta-analysis of neuroimaging studies conducted in 2021, it was found that there were reductions in D2 receptors (dopamine), GABA receptors, and cingulate 5-HT receptors (serotonin). These types of findings regarding neurotransmitter systems in OCD provide ample evidence there is dysfunction in neurotransmitter balancing. Would not an intervention that has been shown to improve neurotransmitter balancing, of several neurotransmitter systems, as opposed to just one or two, not be worthy of discussion in the treatment of obsessive-compulsive disorder (OCD)?

I would say yes. The discussion of the ketogenic diet as a way to balance neurotransmitters (and not just one of them willy nilly) is most definitely warranted.

How a ketogenic diet treats neurotranmitter imbalances in the OCD brain

Ketone bodies are signaling bodies. Meaning they turn genes on and off and help determine a lot of processes. One of those is neurotransmitter balance. For example, acetoacetate, one type of ketone body is able to inhibit glutamate release from neurons in some parts of the brain but will enhance its transmission in other parts that need and want it. Can you imagine a psychopharmacological treatment doing that? Being able to help your brain use it exactly when and where it is needed? Without somehow messing up all the ratios by trying to control how much is made, or how often it hangs out in synapses? I think not. But ketones can do that.

Ketones also exert influences that are considered indirect. As ketones break down, their byproducts are used in systems that regulate neurotransmitter synthesis. These downstream effects influence and regulate the neurotransmitters glutamate and GABA. There is less production overall of glutamate in those on a ketogenic diet, and we see more GABA. For example, children on a ketogenic diet for epilepsy have higher cerebrospinal fluid GABA levels than control groups. We also see this favorable increase in GABA when using magnetic resonance spectroscopy in human studies.

But what about glutamate? Well, we know that the decreases in neuroinflammation that happen with a ketogenic diet improve the environment in which the brain makes neurotransmitters. While we will learn more about inflammation later in this blog post, it is relevant here to note that when a brain is inflamed it can disrupt normal neurotransmitter production. And this has been seen in the production of glutamate, reaching up to 100x more production of glutamate than normal in the brain. Obviously, this has neurotoxic effects. So wouldn’t it be great if there were a way to balance this neurotransmitter system?

Ketones just happen to enhance the conversion of glutamate to GABA, which likely is a significant part of the balancing effects we see when people adopt a ketogenic diet. As for serotonin and dopamine, we see balancing effects of those neurotransmitters also with the ketogenic diet. We see an upregulation of serotonin and balancing of dopamine. We also see much-improved cell membrane function, which is going to improve how well those neurons communicate and use the neurotransmitters made. You can learn a little more about this here.

Ketogenic diets supply neuronal membrane stabilization. Ketogenic diets increase the amounts and actions of ATP and adenosine. ATP (needed for energy) and adenosine are critical for metabolic stability. Adenosine, in particular, is well known to be neuroprotective and promote homeostasis (balance), stabilizing cellular membrane potential, which you need in order to make the right amount of neurotransmitters, allow them to stay the right amount of time, and allow them to be broken down when they are supposed to. There is no successful balancing of neurotransmitters without healthy cell membrane function.

I could go on about how we do not have psychotropic medications for OCD, or other disorders, that provide this for people in a balanced way. But I won’t because that would be slightly off-topic and is better for a future blog post.

My very important point that is relevant to the reader of this blog, is that a ketogenic diet improves neuronal membrane function and allows your receptors to work better. It also helps you store cofactors, improves membrane potential, and a host of other positive brain benefits that I just have not seen advertised as being possible with psychopharmacology.

OCD and neuroinflammation

Inflammation is a process in which you are hurt or under attack in some way, and your body tries to make it right. It also does this in the brain. In the brain, neuroinflammation can occur because of things crossing a leaky blood-brain barrier, neuronal bodies not having adequate energy dynamics to maintain themselves, or microglial attempting to come to your rescue as a form of immune system activation. Chronic inflammation and neuroinflammation, in particular, are seen in psychiatric diagnoses including depression and anxiety, and neurological issues as in dementia. So it should be no surprise for us to learn that OCD has a significant inflammatory component.

OCD is associated with low-grade inflammation, neural antibodies, and neuro-inflammatory and auto-immune disorders

Gerentes, M., Pelissolo, A., Rajagopal, K., Tamouza, R., & Hamdani, N. (2019). Obsessive-compulsive disorder: autoimmunity and neuroinflammation. https://doi.org/10.1007/s11920-019-1062-8

Although many of the studies finding higher inflammation in those with obsessive-compulsive disorder (OCD) are considered associational (there is a relationship with one being with the other more often), there is enough evidence to suggest that there is a role in the pathogenesis (how the disease begins) of OCD. There is enough evidence of inflammation having a causative role that there is discussion in the literature suggesting anti-inflammatory drugs be developed and repurposing of immunomodulatory therapies to treat OCD.

And that is good enough for me. If inflammation is a component of OCD then we need to treat it. So let me tell you about the highly anti-inflammatory effects of the ketogenic diet.

How a ketogenic diet treats inflammation in people with OCD

Ketogenic diets reduce neuroinflammation in a variety of ways

  • reduces oxidative damage (we will learn more about this soon)
  • improved neural energy metabolism (remember hypometabolism above?)
  • epigenetic effects as signaling bodies that modulate or turn off inflammatory pathways (turn genes on and off!)
  • positive effects on gut microbiome that reduces inflammation

Ketogenic diets reduce inflammation in all of those ways. Ketones, which are produced in the body during a ketogenic diet, are what we call signaling molecules. And a signaling molecule can turn some genes off and some genes on, and in the case of inflammation, this action is quite favorable towards LESS inflammation. A ketogenic diet provides the conditions in which this favorable signaling can occur. But it is also a dietary strategy that reduces or eliminates problems with hyperglycemia.

You can have episodes of hyperglycemia even if you are not diabetic. And when you have hyperglycemia it affects immune cells in a way that causes more inflammation. You do not make ketones if you are eating a lot of carbohydrates that are causing hyperglycemia, because hyperglycemia means you have spiked insulin quite high, and ketones are not made in those conditions.

So eating a ketogenic diet in order to treat your OCD will take away the inflammation that would occur when eating a standard American diet higher in carbohydrates and processed foods. It would also reduce inflammation using the ketones you generate and the improved micronutrient availability in your food choices by eating a well-formulated ketogenic diet.

Because we are discussing how one thing influences the other, it is a good time to include the below quote. It does such a good job illustrating how a single approach to mental health that is not systemic in nature is just never going to be sufficient for wellness.

Recent studies display that inflammation processes and the dysfunction of the immune system are likely to play a role in the pathophysiology of OCD, indicating that the disturbances in neurotransmitters such as serotonin and dopamine cannot be alone involved in the development of OCD.

Ghasemi, H., Nomani, H., Sahebkar, A., & Mohammadpour, A. H. (2020). https://doi.org/10.2174/1570180817999200520122910

Obsessive-compulsive disorder (OCD) treatment using a ketogenic diet also improves the functioning of the immune system. As we see in the above quote, the inflammatory process is driven in part by immune system dysfunction. Research has suggested quite strongly that immune system function improves significantly on a ketogenic diet. The effects of the ketogenic diet on immune function are so positive that in a recent article it was proposed for use in COVID-19 as a preventative treatment. It is quite likely that improvements in immune system functioning could be instrumental in reducing the inflammation that exists in the brains of those who suffer from obsessive-compulsive disorder (OCD). Someone with OCD may wish to use the ketogenic diet for this purpose in place of medication.

OCD and Oxidative Stress

Oxidative stress occurs when the brain’s ability to upkeep itself or fend off assaults is no longer sufficient. This can happen from inadequate micronutrient stores, immune system responses, or toxins that make it through a leaky blood-brain barrier. Countless reasons really. Just being alive creates oxidative stress. There is an excellent diagram showing different factors related to oxidative stress here (seriously it is really good, check it out).

But a healthy brain and body are able to fight off these assaults using our own antioxidant production. But in people with obsessive-compulsive disorder, this is clearly not happening to a sufficient degree.

Recent studies have shown more activity of free radical metabolism and the weakness of antioxidant defense system in OCD.

Baratzadeh, F., Elyasi, S., Mohammadpour, A. H., Salari, S., & Sahebkar, A. (2021). The Role of Antioxidants in the Management of Obsessive-Compulsive Disorder. https://doi.org/10.1155/2021/6661514

Oxidative stress has such a strong role in OCD, that discussion is made of the use of antioxidant therapies in its treatment. But what a lot of people do not consider is the role of ketones in helping people be able to use their own antioxidant systems in the body. So let’s discuss that next.

How does a ketogenic diet treat oxidative stress in those with OCD?

Ok, let’s take a look at the figure I recommended you look at prior. It is just too good to not use in our explanation.

Baratzadeh, F., Elyasi, S., Mohammadpour, A. H., Salari, S., & Sahebkar, A. (2021). https://www.hindawi.com/journals/omcl/2021/6661514/

We already know from our studies that ketogenic diets upregulate mitochondria and mitochondrial function. So we know a ketogenic diet would inhibit the mitochondrial dysfunction we see in this figure that is a factor in causing oxidative stress.

We have also learned how a ketogenic diet improves neuronal membrane function. We see in this figure how impaired neuronal membrane functioning contributes to oxidative stress. So a ketogenic diet could very much keep this factor contributing to oxidative stress from happening in the first place.

We have discussed how ketones are signaling bodies, that are able to turn down inflammation by having a highly beneficial effect on inflammation pathways. This is not an assumption on my part. It is in the literature and provided to some degree in the reference list below. Ketogenic diets are powerful interventions for inflammation. And if we can keep inflammation down, we keep the oxidative stress down we see in OCD brains.

These are all very exciting aspects and show that ketogenic diets are a very powerful, multi-functioning holistic intervention. But the part of the figure that I like to focus on when teaching people about oxidative stress and its influence on psychiatric disorders pertains to this box here:

https://www.hindawi.com/journals/omcl/2021/6661514/fig2/ (I modified this figure with red circle)

I am a firm believer in the power of endogenous (your body makes it, you don’t eat it or swallow it as a supplement) antioxidants. And the most powerful one you make, under the right conditions, is glutathione. Glutathione is a very powerful antioxidant and ketones play a role in your body’s ability to make it and use it well.

Ketones have neuroprotective qualities that interfere with the formation of reactive oxidant species that create oxidative stress and they are also instrumental in tipping the balance of energy metabolism in such a way that it favors the destruction of oxidative products through the use of glutathione.

A well-formulated ketogenic diet also is nutrient-dense and will allow you to both increase and store (due to improved membrane function) those micronutrients that are needed to make glutathione in the first place.

Do you get it?

You don’t have to eat rainbow-colored vegetables and fruits or take a lot of vitamin C or E. You can have a nutrient-rich diet that provides the building blocks to create the most powerful antioxidant we know of, in your own body, and then use ketones to unlock their power.

And this can help you combat and/or completely eliminate the oxidative stress that is currently exacerbating your symptoms of obsessive-compulsive disorder.

What other ways do ketogenic diets help OCD?

Ketogenic diets do so many great things to a brain in distress, and to the OCD brain in particular. But there is another factor that really deserves mention.

Ketones upregulate brain-derived neurotrophic factor (BDNF). Why would this be important to a person suffering from OCD? Well, there are a lot of reasons. But first, let’s start by saying that part of the therapeutic effect that some people see from using SSRIs for OCD is that these drugs somewhat increase BDNF. We use them for traumatic brain injuries for this reason. Will they upregulate it as much as a ketogenic diet? I don’t think so but I have no data to support or refute that assumption. I mention it here because I want you to understand that BDNF is instrumental in your recovery from obsessive-compulsive disorder (OCD).

BDNF is what will help you rewire those brain structures together in new and healthy ways. BDNF is what is going to help you get the most out of that exposure-response prevention (ERP) work you are doing with your therapist. Need to learn new ways of thinking and being while doing cognitive-behavior therapy for your OCD? BDNF is needed. And ketones are excellent at increasing the amount of BDNF in your brain, which can only help and is yet another way that ketogenic diets can be a complement to psychotherapy work. So while BDNF is not one of the four factors I normally write about when discussing ketogenic diets as a treatment for mental illness, it deserves a strong and honorable mention.

Conclusion

It is my sincere hope that you are beginning to see how all the components of action in a ketogenic diet work together. That you have acquired an understanding that improved neuroinflammation reduces oxidative stress. That less oxidative stress improves the environment in which the brain is making and balancing transmitters and improves important membrane functions. That you now understand that reduced neuroinflammation and oxidative stress mean there are fewer nutrients being depleted, and more available precursors available to do important things, like making enzymes and neurotransmitters. I hope it is clear that the improved energy neurons get on a ketogenic diet allows them to function better overall. And that the improved energy of these cells along with an upregulation of BDNF allows those same neurons to do the basic housekeeping they need to stay in good repair and make new learning connections.

Again, there are no randomized clinical trials yet using a ketogenic diet specifically to treat obsessive-compulsive disorder (OCD). We can only extrapolate possible benefits to this population, based upon the results seen in other neuropsychiatric and neurological disorders. We can be open to the idea that an intervention seen to reduce oxidative stress in one or many different populations, both in animal models and with humans, may very well successfully do so in OCD. We should at least discuss the possibility, and more importantly, inform you of that possibility. So you can make the very best treatment decisions that make sense for you!

I want to encourage you to learn more about your treatment options from any of the following blog posts. I write about different mechanisms in varying degrees of detail that you may find helpful to learn on your wellness journey. You may enjoy the Ketogenic Case Studies page to learn how others have used the ketogenic diet to treat mental illness in my practice. And you may benefit from understanding how working with a mental health counselor while transitioning to a ketogenic diet can be helpful here.

Share this blog post or others with friends and family suffering from mental illness. Let people know there is hope.

You can learn more about me here. If you would like to contact me you may do so here. If you just have a simple question please do not hesitate to reach out. Or let me know in a comment if you have found this blog post to be helpful on your wellness journey.

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References

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Asl, M. A., Asgari, P., & Bakhti, Z. (2021). Treatment Approaches Based on Neuroscientific Data in Patients With Obsessive-Compulsive Disorder. International Clinical Neuroscience Journal, 8(3), 107–117.

Attwells, S., Setiawan, E., Wilson, A. A., Rusjan, P. M., Mizrahi, R., Miler, L., Xu, C., Richter, M. A., Kahn, A., Kish, S. J., Houle, S., Ravindran, L., & Meyer, J. H. (2017). Inflammation in the Neurocircuitry of Obsessive-Compulsive Disorder. JAMA Psychiatry, 74(8), 833. https://doi.org/10.1001/jamapsychiatry.2017.1567

Bannon, S., Gonsalvez, C. J., Croft, R. J., & Boyce, P. M. (2006). Executive functions in obsessive-compulsive disorder: State or trait deficits? The Australian and New Zealand Journal of Psychiatry, 40(11–12), 1031–1038. https://doi.org/10.1080/j.1440-1614.2006.01928.x

Batistuzzo, M. C., Sottili, B. A., Shavitt, R. G., Lopes, A. C., Cappi, C., Mathis, M. A. de, Pastorello, B., Diniz, J. B., Silva, R. M. F., Miguel, E. C., Hoexter, M. Q., & Otaduy, M. C. (2021). Lower Ventromedial Prefrontal Cortex Glutamate Levels in Patients With Obsessive–Compulsive Disorder. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.668304

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Baxter, L. R., Phelps, M. E., Mazziotta, J. C., Guze, B. H., Schwartz, J. M., & Selin, C. E. (1987). Local cerebral glucose metabolic rates in obsessive-compulsive disorder. A comparison with rates in unipolar depression and in normal controls. Archives of General Psychiatry, 44(3), 211–218. https://doi.org/10.1001/archpsyc.1987.01800150017003

Baxter, L. R., Schwartz, J. M., Phelps, M. E., Mazziotta, J. C., Guze, B. H., Selin, C. E., Gerner, R. H., & Sumida, R. M. (1989). Reduction of prefrontal cortex glucose metabolism common to three types of depression. Archives of General Psychiatry, 46(3), 243–250. https://doi.org/10.1001/archpsyc.1989.01810030049007

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Figure 2 | The Role of Antioxidants in the Management of Obsessive-Compulsive Disorder. (n.d.). Retrieved December 18, 2021, from https://www.hindawi.com/journals/omcl/2021/6661514/fig2/

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Social Anxiety Disorder (SAD)

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How could a ketogenic diet help treat the symptoms of Social Anxiety Disorder (SAD)?

Ketogenic diets are able to modify at least four of the pathologies we see in people suffering from Social Anxiety Disorder. These include glucose hypometabolism, neurotransmitter imbalances, inflammation, and oxidative stress. A ketogenic diet is a powerful dietary therapy that has been shown to directly impact these four underlying mechanisms that have been identified to be involved with the symptomatology of Social Anxiety Disorder.

Introduction

In this blog post, I will not be listing the symptoms or prevalence rates of Social Anxiety Disorder (SAD). This post is not designed to be diagnostic or educational in that way. If you have found this blog post, you probably know what Social Anxiety Disorder is and it is possible or likely that you or someone you love may already be suffering from it.

If you have found this blog post, you are looking for treatment options. You are trying to find ways to reduce symptoms and increase your functioning in social situations.

By the end of this blog post, you will be able to understand some of the underlying mechanisms going wrong in the brains of people suffering from social anxiety and how a ketogenic diet can therapeutically treat each of them.

You will come away seeing a ketogenic diet as a possible treatment for your social anxiety or as a complementary modality to use with psychotherapy and/or in place of medications.

Clinical experience and limited systematic data suggest that augmentation with benzodiazepines or gabapentin, or switching to monoamine oxidase inhibitors, benzodiazepines or gabapentin can be useful in treatment-resistant cases. Cognitive-behavioral treatment can also be a helpful adjunct or alternative in non-responders to pharmacological treatment of SAD.

https://doi.org/10.1016/B978-0-12-394427-6.00022-4

The current standard of treatment for Social Anxiety Disorder is the use of pharmacology and/or psychotherapy in the form of Cognitive-Behavioral Therapy (CBT). CBT helps clients look at their thoughts and beliefs around social situations which can be quite helpful There is also a significant behavioral component of exposure therapy, in which clients would create a list of social anxiety-provoking situations and rate the subjective level of anxiety they felt at the idea of doing those activities. They would then actually do the things on the list, exposing themselves to the behaviors until they felt zero anxiety doing so.

But when you look at the list of medication types above, that are considered standard of care psychopharmacology, you have some real potential problems.

  1. These medications often have side-effects that are really unpleasant. Some can even create physical dependance.
  2. Use of fast acting medications can create a psychological dependance on their use in stressful situations.
  3. Access to faster acting anxiety medications can become a barrier for people to learn to reach for other tools of coping (e.g., mindfulness or CBT techniques).
  4. These medications all potentially get in the way of effective behavioral therapy for social anxiety. If you are medicated while doing behavior therapy you cannot habituate and expose effectively. The anxiety will come back when you stop your medication.

What are the neurobiological changes seen in Social Anxiety Disorder? Where are possible pathways of intervention?

A previous post went into detail about how a ketogenic diet can modify symptoms of anxiety by affecting four areas of pathology seen in these types of disorders.

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Inflammation
  • Oxidative stress

In Social Anxiety Disorder (SAD) we see these same underlying mechanisms. There are areas of the brain with hypometabolism (not using energy properly) and we see overexcitability in others. Also seen in Social Anxiety Disorder (SAD) are neurotransmitter imbalances, neuroinflammation, and oxidative stress as part of the underlying disease process. Let’s review each of these as they are seen in the development and/or perpetuation of Social Anxiety Disorder (SAD).

Social Anxiety and Hypometabolism

“hypometabolism”

noun

  1. The physiological state of having an decreased rate of metabolic activity

When we compare whole-brain analysis using functional MRI (fMRI) of people with Social Anxiety Disorder there is significantly lower activation (hypometabolism) in the left anterior cingulate gyrus. This part of the brain is responsible for attention control.

Hypometabolism of the cingulate gyrus has a strong role in the creation of anxiety in social situations. Those with Social Anxiety Disorder show lower activation in the cingulate gyrus, which is responsible for the process of attention control.

What does this mean for those experiencing symptoms?

Anyone who has ever experienced social anxiety knows what this feels like. When you are socially anxious, you cannot be fully present with whomever you are talking to or even enjoy the environment you are in. Why? You cannot focus your attention exclusively on the interaction. And as a result, a huge part of your attention is being used to fuel your anxiety.

Instead of being able to have a simple conversation, your attention is focused on what to say next so you don’t feel stupid, evaluating what you think the other person thinks of you and possibly imagining worst-case social scenarios that are not even happening.

Successful treatment of Social Anxiety Disorder using behavioral exposure therapy will show positive changes in activation of the cingulate gyrus. Reflecting the person’s improving ability to utilize this part of the brain better and thereby holding attention on primarily the conversation they are having. This better brain activation results in more positive thoughts regarding the self in social situations and less tendency to ruminate on actual or perceived negative social moments.

How does a ketogenic diet treat hypometabolism in Social Anxiety Disorder (SAD)?

We know from past posts discussing ketogenic diets for mental illness (here, here, and here) that it is a powerful metabolic therapy for the brain. Sometimes brains stop using glucose effectively as a form of fuel in many structures. There are many theories about why this happens. It can develop in response to high carbohydrate diets. We can begin to to see impaired utilization of glucose as fuel in our 30s, and possibly sooner. The brain’s ability to take in and use glucose depends on insulin sensitivity. The higher carbohydrate laden our diets, the more insulin our body must produce. And over time that increase in insulin actually reduces the ability of our cells use glucose as fuel. While I could not find any specific studies suggesting insulin resistance was directly responsible for areas of brain hypometabolism seen in those with Social Anxiety Disorder, it does not seem an unlikely culpruit. Regardless of the causation, if a brain cannot utilize glucose as well, it needs an alternate fuel. Implementing a low carbohydrate dietary therapy can reduce levels of insulin and allow ketones to be generated by the body and used in the brain for energy.

Ketones themselves are an energy source for the brain that have powerful effects as signaling molecules. These signaling molecules help increase the number and health of important cellular energy structures known as mitochondria. These mitochondria are the power plants of your cells. Brains need and want a lot of them and they need and want them in good repair! Ketones provide this for the impaired brain. And they can most certainly theoretically provide it for the struggling cingulate gyrus we see prominent in Social Anxiety Disorder.

Social Anxiety and Neurotransmitter Imbalances

Treating Social Anxiety Disorder with psychopharmacology includes medications that act on GABA, glutamate, and other neurotransmitter systems.

We know from a past blog post (here) that a ketogenic diet improves the environment in which your brain makes neurotransmitters and it creates an environment in which they function better. Ketogenic diets increase the neurotransmitter GABA which has a natural soothing of anxiety. It is the neurotransmitter that makes you feel like you can handle life and that there is no reason to be overwhelmed. It is the neurotransmitter that psychopharmacology attempts to alter with benzodiazepines and gabapentin. Except when they do, it usually comes with side effects like being sleepy or feeling out of it. How nice would it be to increase your GABA without having to check out for the night? Ketogenic diets do that. They naturally increase your GABA in a balanced way that doesn’t cause these types of issues. You are just more chill. Not sleepy.

Brains that have stressful internal environments like inflammation and oxidative stress (spoiler alert: the Social Anxiety Disorder brain has this happening) influence the creation of different neurotransmitter ratios being made. A brain under the duress of trying to perform in a constantly hostile internal biological environment is not going to make more GABA. It is going to make the excitatory neurotransmitter Glutamate, and possibly 100x more than it would normally. The pathway in which this happens also depletes important resources needed to ensure balanced levels of other important neurotransmitters.

The neurotransmitter glutamate in too high of levels is neurotoxic and does a lot of damage. It also makes you feel terribly anxious and overwhelmed. Ketogenic diets keep the excitatory neurotransmitter Glutamate in check by improving the biological environment in which your brain is trying to function.

Additionally, recent research has shown that the interaction between dopamine and serotonin transport is a distinct type of neurotransmitter imbalance seen in Social Anxiety Disorder.

“We see that there is a different balance between serotonin and dopamine transport in people with social anxiety disorder compared with control subjects. The interaction between serotonin and dopamine transport explained more of the difference between the groups than each carrier individually. This suggests one should not focus exclusively on one signal substance at a time, the balance between different systems may be more important”

Olof Hjorth, Ph.D. student at the Department of Psychology at Uppsala University, Sweden. (https://neurosciencenews.com/serotonin-dopamine-anxiety-15558/)

You just might not need a medication like an MAOI if your cell membranes were working in top form. Ketogenic diets greatly improve cell membrane function through any number of mechanisms, including reduced inflammation and oxidative stress (I promise we will get there), the signaling powers of the ketones themselves, or their use as an efficient and preferred fuel source. And because a well-functioning cell membrane directly enhances your brains’ ability to balance neurotransmitters, I include it here for your consideration.

How does the ketogenic diet help treat neurotransmitter imbalances seen in Social Anxiety Dsiorder?

SAD is associated with mainly increased expression in the transporters for serotonin and dopamine seen in fear and reward-related brain regions. It just so happens that ketogenic diets have been seen to increase serotonin and decrease excessive levels of dopamine.  It was already known that there are differences in serotonin reuptake (how long the neurotransmitter hangs out to be used) in those with Social Anxiety, but this understanding of dopamine’s role is new and exciting.

The rationale for the use of the ketogenic diet is based on the potential mood stabilizing effects through level modifications of metabolites such as dopamine and serotonin and the regulation of GABA/glutamatergic neurotransmission, mitochondrial function and oxidative stress.

https://www.frontiersin.org/articles/10.3389/fphar.2020.578396/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_1498129_62_Pharma_20201203_arts_A

It would not be thorough to leave this section just at neurotransmitter function. When they discuss psychopharmacology for Social Anxiety Disorder, and they discuss the role of monoamine oxidase inhibitors (MAOI), they are attempting to control an enzymatic reaction to modify levels of the neurotransmitters norepinephrine, serotonin, and dopamine in the brain. They block the removal of these neurotransmitters. They do not balance these neurotransmitters. They do not make these neurotransmitters work together in a beautifully balanced symphony in any way. Also, these drugs have side effects which I will not go into here, but you can easily Google.

So, we have to talk about how ketogenic diets improve cell membrane function. I wrote briefly about it here but let me get you up to speed. Ketogenic diets optimize your neuronal functioning. So this means that these neuronal membranes can better accomplish all of these VERY important tasks:

  • accumulate nutrients
  • reject harmful substances
  • catalyze enzymatic reactions
  • create electrical potential
  • conduct nerve impulses
  • remain sensitive to neurotransmitters and modulators
  • decreased hyperexcitability

The well-documented neurotransmitter balancing effects of ketogenic diets, in particular, seen with GABA, glutamate, serotonin, dopamine, and norepinephrine, clearly provide support as a potential treatment modality for those suffering from Social Anxiety Disorder.

Social Anxiety and Inflammation/Oxidative Stress

I have included oxidative stress and inflammation together under the same heading because one condition perpetuates the other and vice versa. One marker of inflammation that is often studied is an immune-mediated response known as inflammatory cytokines.

Studies conducted over the past few years suggest that anxiety disorders may be characterised by lowered antioxidant defences

HTTPS://PUBMED.NCBI.NLM.NIH.GOV/29742940/

The easiest way to talk about it these two mechanisms is to think that our environment and experiences increase inflammation, and when inflammation can no longer be controlled, it results in oxidative stress.

Inflammation can come from many things. Pollution, substances, diets higher in carbohydrates than our body can currently metabolize, traumatic events, terrible relationships, being sick with a virus, or other lifestyle factors like not getting enough movement.

Oxidative stress is well-established as having a role in anxiety disorders. When it comes to fear and anxiety, there is some debate going on around whether having fearful experiences increases inflammation and thereby oxidative stress, or whether unchecked inflammation increases oxidative stress and then creates symptoms of fear and anxiety. I believe the etiology (how it starts) could be either. Regardless of what comes first, we want to reduce inflammation and oxidative stress as much as possible, by whatever means we can.

Perhaps unsurprisingly, we see a reduction in oxidative stress when we use Cognitive-Behavioral Therapy for Social Anxiety Disorder (SAD). This makes sense because we have reduced the level of stress involved in social situations by changing how we think about them or habituating our nervous system to them. This reduction in both perceived and actual stress would of course reduce inflammation and the body’s response to what was once determined to be scary or dangerous.

Your brain is going to have some level of oxidative stress that naturally occurs. We already have a great antioxidant system in the body and brain, using the most powerful antioxidant there is called glutathione. But when we are exposed to particularly stressful situations (i.e., experiencing trauma, unhealthy relationships, etc) or doing things that add more stress (i.e., inflammatory diets with sugar and highly processed foods, insufficient physical activity, smoking, etc.) then our body cannot make enough glutathione. Your body becomes depleted of micronutrients dealing with those stressors and it needs them to make enough antioxidants to reduce inflammation and combat oxidative stress.

And it’s great if you take antioxidants. In fact, taking antioxidants can help modulate symptoms of anxiety and other psychiatric issues. But you cannot outrun poor lifestyle and behavioral choices or events by ingesting a lot of antioxidants. There are plenty of people trying this with a lot of expensive supplements and it is my understanding the results are equivocal.

Also, this ignores the fact that we are behaving in a way that causes damage to our body. It would be like putting a hole in your wall every day and just making sure that you have enough spackle, sand paper, paint and dry time before the next hole happens. How long do you think it will be before your house is in very bad shape? With some holes only partially repaired and some not at all. At what point or how long will it take for the structural integrity of the walls to really not work well anymore? Probably sooner than you imagine. This would be a silly way to handle damage. But this is what we do when we try to outrun inflammation, whether through diet or lifestyle, by only increasing our antioxidants and/or popping a multivitamin. Much better to stop the behavior that puts holes in the walls. Much better to stop the conditions that cause excess inflammation and metabolic stress.

But I digress.

Oxidative stress depletes your micronutrient stores and glutathione. It puts cells in a constant state of stress and inhibits the number and functioning of important cell structures, like mitochondria. Eat all the food you want, but if your mitochondria are impaired your energy is going to be low, both to enjoy life and to repair your body. Insufficient and poorly functioning cell mitochondria mean that there is less energy to maintain cell functioning and do all the things that need to happen to combat inflammation.

Oxidative stress also decreases Brain-Derived Neurotrophic Factor (BDNF), which you need to help heal your brain after the damage is done, or even just to learn new things. Is it any surprise that we cannot learn easily when we are stressed?

Depletion of the brains most important antioxidants, like glutathione, allow significant damage to occur in the form of neuroinflammation and a faster aging brain. Oxidative stress, which is basically the brain’s inability to deal with the level of neuroinflammation going on, will create an environment that will influence your neurotransmitter balance. A high-stress environment in the brain essentially leads to uncomfortable and unfavorable neurotransmitter imbalances. We just learned about this above when we mentioned glutamate in the neurotransmitter imbalance section. But because inflammation and the subsequent oxidative stress have direct effects on neurotransmitters let’s revisit by naming a pathway involved.

When your brain tries to make neurotransmitters in an environment of oxidative stress, the kynurenine pathway will sneak tryptophan away from the making of other neurotransmitters. It then takes that precious tryptophan and makes more glutamate, increasing your anxiety.

Tryptophan is a building block (precursor) for serotonin, and when there is less available this means you get to experience less serotonin, and all the anxiety-producing and behavioral effects involved in that.

Oxidative stress also gets in the way of you making and effectively using these and other neurotransmitters in the balanced and magical ratios you need to live your life with less social anxiety.

For all these reasons we need to find an effective way to reduce oxidative stress when we think about treating social anxiety.

You just might not need a medication like an MAOI if your cell membranes were working in top form. Ketogenic diets greatly improve cell membrane function through any number of mechanisms, including reduced inflammation and oxidative stress (I promise we will get there), the signaling powers of the ketones themselves, or their use as an efficient and preferred fuel source. And because a well-functioning cell membrane directly enhances your brains’ ability to balance neurotransmitters, I include it here for your consideration.

How does the ketogenic diet help treat inflammation and oxidative stress in those with Social Anxiety Dsiorder?

An inflamed brain is not one that can function properly. For example, inflammatory cytokines trigger the activation of an enzyme that degrades serotonin and the amino acid precursor tryptophan. It is believed this is one of the many mechanisms involved between inflammation and the neurotransmitter imbalances seen in anxiety disorders. Ketogenic diets are very effective at reducing inflammation.

Ketones, which are what we produce on a ketogenic diet, happen to influence all of these relevant mechanisms and pathways needed to reduce oxidative stress.

Conclusion

Ketogenic diets are metabolic therapies, that improve metabolism in the brain. Metabolism is just a word referring to how well your cells make and burn energy. This has the potential to directly treat areas of hypometabolism (hypo=low, metabolism=energy use) seen in the neuronal structures of people experiencing social anxiety.

A reduction in the excitatory neurotransmitter glutamate and an increase in GABA and serotonin can only help social anxiety. And it will do it in a way that does not cause problematic side-effects. Ketones also increase the number and health of mitochondria in cells while improving cellular functioning at the level of the cell membrane. They reduce inflammation as signaling molecules that are able to turn down the expression of inflammatory pathways and turn up other important antioxidant functions, like glutathione production.

Improved cell membrane function helps increase micronutrient stores, cell communication, and allows those neurotransmitters to hang out for just the right amount of time before your body makes more in just the right amounts. Thereby, potentially alleviating your anxiety symptoms in a multifunctional way I am not sure any developed current psychopharmacology can duplicate with the same absence of side-effects.

It is my hope that after reading this post you will have a better understanding of not only the biological mechanisms involved in the pathology and symptoms experienced by those suffering from Social Anxiety Disorder (SAD), but also the understanding of how the ketogenic diet has direct influences on the multiple factors associated with healing and symptom reduction.

So ask yourself why would you NOT consider a ketogenic diet for the treatment of Social Anxiety Disorder (SAD)?

It’s OK if you don’t want to use a ketogenic diet, or other nutritional therapies to treat Social Anxiety Disorder (SAD). Convincing you to use the ketogenic diet to treat mental illness is not the purpose of my blog. The purpose of this post, and all the others, is to communicate that it is a viable option.

Because you have the right to know all of the ways that you can feel better.

You can learn more about me here. And if I can be of help on your wellness journey, please do not hesitate to contact me.

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References

Fedoce, A., Ferreira, F., Bota, R. G., Bonet-Costa, V., Sun, P. Y., & Davies, K. (2018). The role of oxidative stress in anxiety disorder: cause or consequence?. Free radical research52(7), 737–750. https://doi.org/10.1080/10715762.2018.1475733

Bandelow B. (2020) Current and Novel Psychopharmacological Drugs for Anxiety Disorders. In: Kim YK. (eds) Anxiety Disorders. Advances in Experimental Medicine and Biology, vol 1191. Springer, Singapore. https://doi.org/10.1007/978-981-32-9705-0_19

Blanco, C., Bragdon, L., Schneier, F. R., & Liebowitz, M. R. (2014). Psychopharmacology for social anxiety disorder. In Social Anxiety (pp. 625-659). Academic Press. https://doi.org/10.1016/B978-0-12-394427-6.00022-4.

Dąbek, A., Wojtala, M., Pirola, L., & Balcerczyk, A. (2020). Modulation of cellular biochemistry, epigenetics and metabolomics by ketone bodies. Implications of the ketogenic diet in the physiology of the organism and pathological states. Nutrients12(3), 788.

Gzieło, K., Janeczko, K., Węglarz, W. et al. MRI spectroscopic and tractography studies indicate consequences of long-term ketogenic diet. Brain Struct Funct 225, 2077–2089 (2020). https://doi.org/10.1007/s00429-020-02111-9

Hjorth, O.R., Frick, A., Gingnell, M. et al. Expression and co-expression of serotonin and dopamine transporters in social anxiety disorder: a multitracer positron emission tomography study. Mol Psychiatry 26, 3970–3979 (2021). https://doi.org/10.1038/s41380-019-0618-7

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Post-Traumatic Stress Disorder(PTSD)

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How could a ketogenic diet help treat the symptoms of Post-Traumatic Stress Disorder (PTSD)?

Ketogenic diets are able to modify at least four of the pathologies we see in PTSD brains. These pathologies include glucose hypometabolism, neurotransmitter imbalances, inflammation, and oxidative stress. A ketogenic diet is a powerful dietary therapy that has been shown to directly impact these four underlying mechanisms that have been identified to be involved with PTSD symptoms.

Introduction

In this blog post, I am not going to outline the symptoms or prevalence rates of PTSD. This post is not designed to be diagnostic or educational in that way. If you have found this blog post, you know what PTSD is and likely you or someone you love may already be suffering from it.

If you have found this blog post, you are looking for treatment options. You are trying to find ways to feel better and heal.

By the end of this blog post, you will be able to understand some of the underlying mechanisms going wrong in the brains of people suffering from PTSD and how a ketogenic diet can therapeutically treat each of them.

You will come away seeing a ketogenic diet as a possible treatment for your PTSD symptoms or as a complementary modality to use with psychotherapy and/or in place of medications.

It is not medical heresy to write the above statement. Why would we not consider using a ketogenic diet in place of psychopharmacology for PTSD? Psychopharmacology treatment for PTSD has been acknowledged as ineffective and sorely lacking since 2017, by a well-known Consensus Statement of the PTSD Psychopharmacology Working Group. Psychopharmacology as a treatment for PTSD has essentially been a failure.

Despite this high prevalence and costly impact, there seems to be no visible horizon for advancements in medications that treat symptoms or enhance outcomes in persons with a diagnosis of PTSD.

What are the neurobiological changes seen in PTSD? Where are possible pathways of intervention?

A previous post went into detail about how a ketogenic diet can modify symptoms of anxiety by affecting four areas of pathology seen in these disorders.

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Inflammation
  • Oxidative stress.

In PTSD we see these very same pathologies occurring. There are areas of the brain with hypometabolism (not using energy properly) and we see overexcitability in others. There are distinct neurotransmitter imbalances affecting mood and cognition and extreme oxidative stress and inflammation documented as occurring in the PTSD brain. Let’s review each of these.

PTSD and Hypometabolism

Brain hypometabolism means that the brain is not using energy correctly. Areas of the brain that should be active and using energy are not. Brain hypometabolism is indicative of a metabolic disorder in the brain.

Brain imaging studies consistently find areas of reduced energy consumption in the brains of people suffering from PTSD. These areas can include the occipital, temporal, caudate nucleus, posterior cingulate cortex, parietal and frontal lobes. It is theorized that hypometabolism contributes to the dissociative states reported in PTSD symptomology.

“…only patients with PTSD showed hypoactivation in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex—structures linked to the experience and regulation of emotion.”

Etkin, A., & Wager, T. D. (2007). https://doi.org/10.1176/appi.ajp.2007.07030504

How does a ketogenic diet treat hypometabolism in the PTSD brain?

Ketogenic diets are specifically a therapy for brain hypometabolism. So much so that it is used for other neurological disorders such as Alzheimer’s Disease and Traumatic Brain Injury (TBI) for just this exact purpose. Ketogenic diets produce ketones which can be used as an alternative fuel for the brain. Ketones can bypass broken metabolic machinery normally used to utilize glucose for fuel. Brains love ketones. And a ketogenic diet may improve energy expenditure in these important brain structures being affected by PTSD pathology. A brain with fuel will always have improved functioning than one without. And that is why a ketogenic diet may be an excellent therapy for this mechanism of pathology present in the PTSD brain.

PTSD and Neurotransmitter Imbalances

While hypometabolism occurs in some parts of the brain with PTSD, we also see some areas of hyperarousal and excitability. This hyperarousal and excitability are likely occurring due to the types of neurotransmitter imbalances we see in people suffering from PTSD.

PTSD patients have been found to have increased levels of dopamine and norepinephrine which are thought to be responsible for symptoms seen such as higher resting pulse rates, blood pressure readings, and startle response. Decreased levels of serotonin affect communication pathways between the amygdala and hippocampus, reducing the ability of the PTSD brain to modulate anxiety. These decreased levels of serotonin are thought to contribute to the increased hypervigilance, impulsivity, and intrusive memories experienced as symptoms.

Additionally, several studies have found decreased levels of the neurotransmitter GABA. GABA is a neurotransmitter that is crucial in helping a person deal with stress and anxiety. But not only is there a decrease in GABA but there is a large increase in the excitatory neurotransmitter glutamate and norepinephrine. These neurotransmitter imbalances are thought to help explain symptoms of increased startle responses and even disassociation.

How does a ketogenic diet treat neurotransmitter imbalances in the PTSD brain?

Ketogenic diets improve neurotransmitter imbalances by improving the metabolic environment of the brain as it is making neurotransmitters. The neurotransmitter balancing effects of a ketogenic diet are well known. Perhaps the best example of this is its assistance in the making of more GABA and its ability to reduce neurotoxic levels of glutamate. This same pathway that is beneficially influenced by the ketogenic diet can increase levels of serotonin and reduce an overabundance of dopamine. Each of these changes is relevant to the treatment of PTSD symptomatology. A well-formulated ketogenic diet is also nutrient-dense, providing multiple important cofactors to not just produce neurotransmitters but improve their ability to function in the brain. Ketones do this with improved cell membrane function, which improves communication between neurons. So not only do you get balanced levels of neurotransmitters, you get better functioning neurons ready to use them well.

PTSD and Oxidative Stress

Oxidative stress is a significant area of pathophysiology in the PTSD brain. There are decreased levels of important enzymes that help internal antioxidants, like glutathione, do the job of reducing oxidative stress. Oxidative stress that is chronic in nature, as we see with PTSD, has real neurobiological consequences that include accelerated cellular aging and the progression of neurological illnesses seen in aging brains. The powerhouses of our cells, known as mitochondria, cannot function in a brain that cannot manage its level of oxidative stress. The very machinery and function of the cells are impaired and under great duress.

Currently, the role of oxidative stress and associated neuroinflammation in … PTSD is well established. Increased production of free radicals and/or reduced antioxidant defenses under challenged conditions result in excessive levels of free radicals in the brain, leading to mitochondrial dysregulation, microglia activation, and neuronal death. These mechanisms are suggested to play a key role in helplessness, anxiety, and inappropriate retention of aversive memories.

https://doi.org/10.3389/fnut.2021.661455

How does a ketogenic diet treat oxidative stress in the PTSD brain?

The ketogenic diet treats oxidative stress in at least three ways.

The first is by reducing inflammation in the brain by interfering with pathways that produce a lot of inflammation (see the section on inflammation in this blog post below).

Ketogenic diets improve brain energy by providing an alternative fuel for brain cells that improves mitochondrial functioning (how much energy your brain has to burn) and this improved functioning allows the neurons to do a better job of fighting inflammation and maintaining neuronal health.

And finally, ketogenic diets upregulate (helps your body make more of) the most powerful antioxidant known as glutathione. You can take glutathione and precursors to glutathione as supplements, but you will never absorb and utilize the levels that your internal machinery can provide with the right dietary and nutritional environment. Which is what a well formulated ketogenic diet is and provides.

PTSD and Inflammation

In a recent (2020) meta-analysis, they reviewed 50 original articles examining inflammation in the PTSD brain. They found elevated levels of serum proinflammatory cytokines (inflammation) in individuals suffering from PTSD. Type of trauma did not matter. All had this pathological level of inflammation occurring and the level was much higher than those not suffering from PTSD. They also found through neuroimaging that this increased inflammation was associated with changes in brain structures and how those structures functioned. These changes were in brain regions responsible for our ability to regulate stress and emotion.

Inflammatory cytokines disrupt brain function in all kinds of ways, but one of those ways is our neurotransmitter balance. They trigger the activation of an enzyme that degrades serotonin and the amino acid precursor tryptophan. These types of complicated mechanisms are involved between inflammation and the neurotransmitter imbalances seen in depression/anxiety disorders.

Finding ways to reduce this level of inflammation in the brain is already being conceptualized as a target of intervention, through the use of antioxidants and psychopharmacology. Albeit unsuccessfully.

How does a ketogenic diet treat inflammation in the brain?

The ketogenic diet is amazing at reducing inflammation. While the exact mechanisms are not yet known, the data coming in consistently show that for a variety of populations the ketogenic diet significantly and dramatically reduces inflammation. We do know that ketones act as signaling bodies that inhibit the expression of inflammatory gene expression. Ketogenic diets are so anti-inflammatory that they are often used for chronic pain syndromes. One mechanism in which ketogenic dietary therapy provides symptoms relief is thought to be ketones’ ability to block the activation of inflammatory pathways as a signaling molecule, turning some genes on and other genes off.

Ketones also help us make more of a very powerful internal antioxidant. That’s right. You don’t ingest this antioxidant. You make it on your own, under the right conditions, in your own amazing body. It is called glutathione. This increase in glutathione provided by ketones may be a very important modulator of inflammation in the PTSD brain, improving the other pathological factors involved such as hypometabolism, oxidative stress, and neurotransmitter imbalances.

Conclusion

Ketogenic diets are shown to modulate disease at least four of the pathological mechanisms observed in Post Traumatic Stress Disorder (PTSD) symptomatology. Using the ketogenic diet as a primary or complementary treatment with psychotherapy is one based on the mechanisms seen in the scientific literature regarding this disease. The use of this dietary therapy is one based on the science of neurobiology and pathophysiology.

RCTs using the ketogenic diet for PTSD would be nice, and I really hope we get them. I think we eventually will. But I see no reason to deprive you of this knowledge in the meantime. I see no reason to allow unnecessary suffering when such a treatment might do wonders for your symptoms. The ketogenic diet for mental illness, and PTSD specifically, is not a fad, quackery, or mumbo-jumbo. It is based on an understanding of real biological mechanisms in mental illness and the conditions required in order to heal.

The real question is why wouldn’t you consider a ketogenic diet as a treatment for PTSD in you or someone you loved?


I am a mental health counselor that works with dietary and nutritional therapies to treat mental illness and neurological issues. You can learn more about me here. Feel free to contact me on your journey to mental health.

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References

Bhatt, S., Hillmer, A.T., Girgenti, M.J. et al. PTSD is associated with neuroimmune suppression: evidence from PET imaging and postmortem transcriptomic studies. Nat Commun 11, 2360 (2020). https://doi.org/10.1038/s41467-020-15930-5

de Munter, J., Pavlov, D., Gorlova, A., Nedorubov, A., Morozov, S., Umriukhin, A., Lesch, K. P., Strekalova, T., & Schroeter, C. A. (2021). Increased Oxidative Stress in the Prefrontal Cortex as a Shared Feature of Depressive- and PTSD-Like Syndromes: Effects of a Standardized Herbal Antioxidant. Frontiers in nutrition8, 661455. https://doi.org/10.3389/fnut.2021.661455

Elias, A., et al. (2020) ‘Amyloid-β, Tau, and 18F-Fluorodeoxyglucose Positron Emission Tomography in Posttraumatic Stress Disorder. Journal of Alzheimer’s Disease. https://doi.org/10.3233/JAD-190913

Etkin, A., & Wager, T. D. (2007). Functional neuroimaging of anxiety: a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. American journal of Psychiatry164(10), 1476-1488. https://doi.org/10.1176/appi.ajp.2007.07030504

Grigolon. R. B., Fernando, G., Alice C. Schöffel, A. C., Hawken, E. R., Gill, H., Vazquez, G. H., Mansur, R. B., McIntyre, R. S., and Brietzke, E. (2020)
Mental, emotional, and behavioral effects of ketogenic diet for non-epileptic neuropsychiatric conditions. Progress in Neuro-Psychopharmacology and Biological Psychiatry. https://doi.org/10.1016/j.pnpbp.2020.109947.
(https://www.sciencedirect.com/science/article/pii/S0278584620302633)

Kim TD, Lee S, Yoon S. (2020). Inflammation in Post-Traumatic Stress Disorder (PTSD): A Review of Potential Correlates of PTSD with a Neurological Perspective. Antioxidants. 9(2):107. https://doi.org/10.3390/antiox9020107

Krystal, J. H., Davis, L. L., Neylan, T. C., A Raskind, M., Schnurr, P. P., Stein, M. B., Vessicchio, J., Shiner, B., Gleason, T. C., & Huang, G. D. (2017). It Is Time to Address the Crisis in the Pharmacotherapy of Posttraumatic Stress Disorder: A Consensus Statement of the PTSD Psychopharmacology Working Group. Biological psychiatry82(7), e51–e59. https://doi.org/10.1016/j.biopsych.2017.03.007

Malikowska-Racia, N., and Salat, K., (2019) Recent advances in the neurobiology of posttraumatic stress disorder: A review of possible mechanisms underlying an effective pharmacotherapy. Pharmacological Research, v.142, p.30-49. https://doi.org/10.1016/j.phrs.2019.02.001.
(https://www.sciencedirect.com/science/article/pii/S1043661818311721)

Miller, M. W., Lin, A. P., Wolf, E. J., & Miller, D. R. (2018). Oxidative Stress, Inflammation, and Neuroprogression in Chronic PTSD. Harvard review of psychiatry26(2), 57–69. https://doi.org/10.1097/HRP.0000000000000167

Sartory G, Cwik J, Knuppertz H, Schürholt B, Lebens M, Seitz RJ, et al. (2013) In Search of the Trauma Memory: A Meta-Analysis of Functional Neuroimaging Studies of Symptom Provocation in Posttraumatic Stress Disorder (PTSD). PLoS ONE 8(3): e58150. https://doi.org/10.1371/journal.pone.0058150

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neurotoxicity. J. Mol. Neurosci. 2010, 42, 145–153.

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How do ketogenic diets help anxiety disorders?

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How could a ketogenic diet help my anxiety? Or improve my symptoms of Generalized Anxiety Disorder (GAD), Panic Disorder (PD), Social Anxiety Disorder (SAD), Obsessive-Compulsive Disorder (OCD), and or Post-Traumatic Stress Disorder (PTSD)?

Ketogenic diets help anxiety disorders by mediating the underlying pathologies of mental illness that are primarily metabolic in nature. These include glucose hypometabolism, neurotransmitter imbalances, oxidative stress, and inflammation.

Introduction

In this post, I will go into what the biological mechanisms of symptom reduction are when using a ketogenic diet for mental illness. My goal is to do so in a way that is easy to understand. Few people benefit from overcomplicated biochemistry explanations using words and processes they do not understand. My goal is for you to be able to read this blog post and then be able to explain how a ketogenic diet helps treat mental illness, and anxiety disorders in particular, to friends and family.

This blog post is an introduction to ketogenic diets for anxiety disorders in general. In this post, we describe the mechanisms involved in mental illness in general, in which anxiety is obviously a category, and discuss the therapeutic effects of the ketogenic diet on those mechanisms.

You may also want to read the posts I have written applying the ketogenic diet to the underlying pathologies seen in specific populations. There are more in-depth blog posts about using the ketogenic diet as a treatment for anxiety disorders.

This is a different way to evaluate the literature about whether or not a particular therapy can be helpful for a particular diagnosis. Usually, we wait (sometimes for decades or longer) for randomized-controlled trials looking at a very specific therapy paired with a very specific diagnosis and/or population. But that is not the only way to evaluate whether or not therapy might be useful.

It can make perfect sense to explore whether we can modify those mechanisms with substances or interventions that have an effect on those same pathways. And while I am always excited about RCTs, there are plenty of people suffering from anxiety disorders right now at this moment. Today. They may not be getting adequate symptom control from the standard of care or be looking for an actual cure as opposed to symptom reduction models. These individuals may want to better understand the ketogenic diet as a treatment for anxiety disorders.

It is my hope that by the end of this post you will have a better understanding of the current evidence base for its use in anxiety disorders and why it can have benefits beyond what is offered by current psychopharmacological treatments.

What is happening in my brain that is causing my mental illness?

In a review of biological mechanisms, this current (2020) review discussed the four key underlying pathologies that are seen in mental illnesses and discusses how a ketogenic diet can influence mental health symptoms.

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Oxidative Stress
  • Inflammation

Let’s go over each of these in a little more detail.

Glucose Hypometabolism

Glucose Hypometabolism is a metabolic disorder in the brain. It basically means that your neurons are not using glucose well as fuel in certain parts of your brain. A brain that does not have adequate fuel, even if you are eating plenty of food, is a starving brain. A starving brain is stressed and it calls the alarm in many different ways. These ways can include the other factors of inflammation, neurotransmitter imbalance, and oxidative stress that we will be discussing. When brain cells do not get adequate fuel they die. If enough brain cells in a particular area die we see brain structures shrink. Memory and cognition begin to become impaired.

A ketogenic diet, by definition, generates an alternative brain fuel known as ketones. Ketones can get into neuronal cells in the brain easily and bypass the broken cell machinery not allowing other fuels like glucose to enter. The brain shifts from attempting to use a primarily glucose-based metabolism to a fat and ketone-based metabolism. As you can imagine, a brain that can access fuel is a better working brain.

But the role of ketones as a fuel source is just the beginning of what they can do for an ailing or distressed brain. The ketones themselves have some of their own very positive effects. It is not just that the brain is being fed energy. The ketones themselves do not just maintain metabolic functioning, but they act as something called a signaling molecule. And a signaling molecule is basically like a little messenger running around, giving your cells updates about what is happening in the body, so that your cell can then manage its machinery to do the best thing at that moment. The information that these signaling molecules give is powerful enough to turn your genes on and off even! Ketones as signaling molecules have the power to help your cells do things to help you burn more fat for fuel or other purposes, reduce oxidative stress and increase the protection of your brain.

β-HB (a kind of ketone) is currently considered not solely an energy substrate for maintaining metabolic homeostasis but also acts as a signaling molecule of modulating lipolysis, oxidative stress, and neuroprotection.

Wang, L., Chen, P., & Xiao, W. (2021)

It is easy to see that a ketogenic diet, which acts as a signaling molecule that tends to make more of those important things happen, could be very beneficial in treating those underlying pathological mechanisms of mental illness (which includes anxiety disorders) that were introduced at the beginning of this post.

Neurotransmitter Imbalances

Hyperglycemia is a term used to describe blood sugar levels getting too high for the body to manage. If your body cannot manage glucose levels it cannot stop it from causing damage to tissues. Even people without a diagnosis of diabetes struggle with hyperglycemia. Many without even knowing it. It has been long established in the literature that hyperglycemia or the body’s inability to handle the amount of glucose (sugar) in the blood, creates inflammation. Oxidative stress is what happens when you don’t have enough antioxidants to offset the damage trying to occur from all the inflammation happening.

But wait a minute you say, this section is about neurotransmitter imbalances. Inflammation and oxidative stress are supposed to come later. And I would agree with you. Except for inflammation and the resulting oxidative stress that occurs because of inflammation sets the stage for severe neurotransmitter imbalances.

There are many different pathways that affect neurotransmitter creation, balance, how long they hang around in the synapses to be enjoyed and used, and how they get broken down. But the best example for neurotransmitter imbalance when inflammation is high has to do with something we call the tryptophan steal. Tryptophan is an amino acid that comes from the protein you eat. That part isn’t the important part of our example. What is important is for us to illustrate what happens to tryptophan when it is in an inflammatory environment. An inflammatory environment is often, and I would argue most commonly caused, by eating more dietary carbohydrates than your particular body can handle.

And what do we restrict in a ketogenic diet? Carbohydrates. And what does that do? Reduce inflammation. And what magical signaling properties do some ketones have? Reduction of inflammation. And a well-formulated ketogenic diet increases the pool of nutrients available to make the most powerful antioxidant ever, that your own body can make with the right metabolic environment and that will deal will oxidative stress? Ok, sorry. Now I am jumping ahead too far. I got a little excited.

But I know you are getting the idea!

So let’s say your brain is wanting to make neurotransmitters out of the tryptophan you ate. If your inflammation is high, your body will take that tryptophan and make MORE of a neurotransmitter called Glutamate. Up to 100x more than it normally would if that tryptophan had encountered a less inflamed and stressed internal environment. Glutamate is an excitatory neurotransmitter. And you obviously need some because it is part of a well-balanced brain. But the amount made while the body is inflamed or under oxidative stress creates a lot more than is needed. Glutamate at too high of levels CREATES ANXIETY.

In excess, glutamate is the neurotransmitter of being overwhelmed and freaked out. It is a particularly unpleasant neurotransmitter imbalance that too many people live with and think is just a part of their daily lives every single day. And it may just very likely be that their carbohydrate dominant diet is perpetuating this unpleasant neurotransmitter imbalance. This same pathway that makes too much glutamate in a high inflammation and oxidative stress environment negatively affects the balance in other neurotransmitters like dopamine, serotonin, and GABA. It reduces the creation of something called Brain-Derived Neurotrophic Factor (BDNF) which is what your brain needs (and plenty of it!) to help you learn, remember, and heal the effects of all that inflammation and oxidative stress that is happening (for whatever reason).

This next piece is just my opinion and even possibly a hypothesis I picked up from people I have followed and learned from along the way. But if so, I agree with them. It seems to me that it is almost as if because your brain knows it is being “attacked” or is in “danger” with all that high inflammation. It is trying to tell you it cannot handle what you are doing. It wants to tell you to be on alert! Anxious. It needs to sound the alarm that it is not ok! And it has no other way to tell you. But it is not a very efficient way, is it? Because you don’t make the connection. You think you are anxious because of traffic, or your kids, or your job, or that making dinner is just too overwhelming. We are human beings constantly trying to make sense of our experiences so we make connections between things that seem the most obvious. We start to avoid anything that we think stresses us out. Never knowing that a possible source of the stress we feel is happening internally as a direct result of our lifestyle choices.

But what happens to tryptophan if you do not have excessive amounts of inflammation or are suffering from oxidative stress? Tryptophan can then be used to “upregulate” or make more of the neurotransmitter GABA. GABA also needs to be balanced in the brain, but a little too much of it does not create an environment of excitability. In fact, many people would like more GABA.

Ever heard of Gabapentin? Often used as a mood stabilizer in psychiatric disorders? You guessed it. It works to increase GABA. Except in its attempts to increase GABA, it often causes side effects for people. Like sleepiness and brain fog. Increasing GABA with a ketogenic diet does not produce the same side effects of medications trying to accomplish the same thing.

GABA is the neurotransmitter of feeling “chill” and “I got this” and of not feeling overwhelmed with the ups and downs of life or the idea of new challenges. Who couldn’t use more GABA? Particularly those suffering from Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD), Panic Disorder, and Obsessive-Compulsive Disorder (OCD)?

Are there other neurotransmitter imbalances involved in anxiety disorders? Of course, there is! That was just one very important and easily illustrated example. Some happen just from nutrient imbalances alone, which can cause inflammation and oxidative stress in their own right. As I have said in other blog posts. You may not need a full ketogenic diet to improve symptoms of anxiety. But it is important to note that the majority of Americans are not metabolically healthy and are very likely eating a much larger amount of dietary carbohydrates than their body (and brain) can handle. And that this alone can cause and contribute to the development of anxiety symptoms. So in that respect, it is an important and relevant example for the majority of individuals reading this blog today, trying to discover how the ketogenic diet could work for them or those they love.

Doesn’t it make sense to treat a fundamentally metabolic set of pathologies, which mental illnesses are, with a complimentary metabolic approach?

Nicholas G. Norowitz, Department of Physiology, Anatomy and Genetics, Oxford University (link)

Oxidative Stress

As I explained above, oxidative stress is what happens when you do not have enough anti-oxidants to protect you from all the biological fallout of just being alive. The job of antioxidants is big and important. Most people believe that this means they need to consume foods that have been identified as antioxidant-rich and take supplements like Vitamin E and C in order to protect themselves from this particular type of biological damage. But the reality is that you could not take enough supplementation or eat enough antioxidant-rich food to match the power of an antioxidant you could be making yourself, from inside your body, known as glutathione. And your internal production of glutathione skyrockets on a ketogenic diet. Remember how ketones act as signaling molecules? They tell your body to make more glutathione. And as long as you are eating a well-formulated ketogenic diet that has an abundance of what you need to make more glutathione, your body will do just that!

You came equipped with your own antioxidant system. I am sure the supplement industry does not want you to know that but it’s true.

If you think about it, this makes sense. We did not have grocery stores or year-long access to a variety of fruits and vegetables full of antioxidants throughout our history. Were there some? Well yes of course! Regionally there were likely many different dietary sources of increased antioxidants. But also, you came with your own machinery and that machinery makes an antioxidant more powerful than anything else you can put in your mouth for that purpose. So what is happening that our own endogenous antioxidant power-house known as glutathione is not able to keep all that oxidative stress in check?

You guessed it. Diets that contain levels of carbohydrates our bodies cannot manage increase inflammation. To deal with that inflammation we have to use a LOT of nutrients as cofactors to try to keep the damage in check. And those cofactors are also needed to make our glutathione. And if we are using them up with a highly processed carbohydrate diet full of things industrial oils (that will likely be another blog post) we become depleted, and we are not available to make the glutathione levels we need. Also, if we don’t make sufficient amounts of ketones because our diets are too high in carbohydrates for us, how can those ketones signal to our cells to make some extra to help us out?

So what does Oxidative Stress mean in mental illness and in anxiety in particular? There is a very strong association between levels of oxidative stress and anxiety disorders, although the direct causal factors are still being teased out. It is a strong enough association that the use of antioxidants is discussed in the research literature as a treatment for anxiety disorders.

Well there you go, you may say to yourself. I don’t need a ketogenic diet. I can just take more antioxidants. And I suppose that is an option. But do tell me when you have determined just the right dose of antioxidants, in the perfect form and combination, that reduces the damage that comes from oxidative stress in the brain to such a degree that you can eat all the sugar, processed carbohydrates, and inflammatory seed oils you want and not suffer from anxiety symptoms. As you can see, theoretically, using antioxidants you eat or take as supplements as a way to reduce anxiety sounds like a great treatment option. And it may certainly help your symptoms, especially if you stop some of the other major metabolic stressors of sugar, refined carbohydrates, and other highly inflammatory industrial food products.

As I said, we do not always have to attempt a ketogenic diet to treat anxiety disorders. But eliminating unnecessary metabolic stressors AND rocketing your internal glutathione levels up using a ketogenic diet sounds like a level of intervention that you not only should know about but deserve to know is an option. Anxiety symptoms are awful. And you deserve to feel well and be without those symptoms as soon as possible. I don’t want to see you experimenting constantly with vitamin C dosages, taking a bunch of expensive anti-oxidant supplements, and continuing to suffer over years when you could feel the benefits of reduced oxidative stress with the ketogenic diet in as little as a few weeks or months.

In mental illness, and specifically in anxiety, there is increased oxidative stress. Ketogenic diets reduce that pathology by allowing the body to make more of the powerful antioxidant known as glutathione. The level of glutathione your body makes seems to be well equipped to deal with much of the oxidative stress that comes with being alive. When you remove unnecessary internal metabolic stressors and improve the nutrition availability in your diet, this directly improves your internal antioxidant mechanisms and reduces oxidative stress in your brain, quite possibly leading to a reduction in anxiety symptoms.

Inflammation

Inflammatory cytokines are a cause of neuronal inflammation. These inflammatory cytokines are actually a part of the brain’s own immune system. The immune system in the body and the one in the brain stay physically separate but they are able to talk to one another. For example, when you are acutely ill your body’s immune system will communicate with your brain’s immune system. The inflammatory cytokines then make you want to lie down, stay still, and rest. I give this example because I need you to understand that these inflammatory substances in the brain are powerful. And can literally control your behavior.

Anxious and overwhelmed and can’t get off the couch? It could be that unloading the dishwasher is just too much. It could also be that neuronal inflammation is telling you to stay still and not move. Do you have high neuronal inflammation because you are stressed about the dishwasher? Likely not. It likely is due to something else. It could be coming from a huge variety of things. But one of the causes could be your diet.

But wait a minute, you say! How can my food choices influence my immune system? That makes no sense!

Remember the term hyperglycemia? Meaning too much blood sugar or a level of blood sugar that is higher than your body can handle is occurring? This state influences your immune system in a negative way. It has been shown that hyperglycemia promotes the creation of proinflammatory cytokines (aka inflammation) and it makes it harder for your immune system to deal with threats. An immune system that is impaired by high blood sugars cannot knock out a threat in a quick and decisive manner. And the entire time that your immune system is fighting off some low-grade infection or virus, those inflammatory cytokines are hanging out in your brain just that much longer. And we know from what we have learned before how brain inflammation will then affect our neurotransmitter balance and our levels of oxidative stress. For example, inflammatory cytokines trigger the activation of an enzyme that degrades serotonin and the amino acid precursor tryptophan. It is believed this is one of the many mechanisms involved between inflammation and the neurotransmitter imbalances seen in anxiety disorders.

Because you have made it this far into this blog post, you know what that means for your anxiety! And if we have cerebral hypo-metabolism as well, we know how that lack of fuel stresses the brain and perpetuates your symptom cycle. You have learned that it is all connected.

So fine you say, I will reduce my sugar and my refined carbohydrates and that should do the trick! I will have a better immune system. And you absolutely would! That may be all you need to do and if that is the case I am super happy for you! A whole foods diet is a powerful intervention for many people. So why would you still maybe want to try a ketogenic diet for your anxiety disorder?

Because ketones have special properties. Not only are they important signaling molecules as described above, they are also powerful in reducing inflammation. We think that they reduce inflammation by blocking some of the inflammatory pathways. And while we have mostly been discussing metabolic stressors that increase inflammation, dietary influences are not the only source.

We are bombarded with chemicals. We have leaky guts causing autoimmune reactions (which also are mirrored in the brain). We have gut microbiomes that are not ideal and could be causing inflammation in our brain. We don’t prioritize sleep which can increase inflammation. We encounter normal and not so normal psychological stressors that induce inflammation. Heck, even just being under fluorescent lights has been shown to increase inflammation.

You can change your diet, which I absolutely think you should! That will definitely help. But there are so many places you will be potentially getting brain inflammation from that it makes sense to increase the production of ketones. Ketones can help you fight the neuronal inflammation that is just going to be a part of our modern environment.

And the less inflammation you have as a result of employing ketones to work for you, the fewer micronutrients you are going to use up fighting inflammation.

And the more micronutrients you have available, the more glutathione you can produce to help with oxidative stress.

And the lower your oxidative stress and neuronal inflammation, the better you will be able to balance your neurotransmitters.

And are you loving as much as I am how this is all connected?!! And how your knowledge of the underlying mechanisms involved in your anxiety symptoms are coming together?!

Sharing this with you in a way you can understand is an absolute joy for me!

Conclusion

The ketogenic diet is a powerful intervention that has benefits and may correct one or more of the four pathological underlying mechanisms underlying mental illness and your anxiety disorder.

You can choose to use it as first-line therapy for your anxiety disorder.

You can attempt to use it in place of medications.

You can use it as a powerful complementary therapy with mental health counseling (my personal favorite).

And if you decide to use it in conjunction with your medications that you are already on, do let your prescriber know. As the ketogenic diet modulates all of those pathways that have been influencing your anxiety disorder, it will change how you respond to your medications, both in what symptoms you might get, and their effectiveness. If you are on medications please work with a qualified mental health professional and prescriber that is knowledgeable regarding ketogenic and medication adjustment.

You may have anxiety and depression, and some other co-occurring disorders such as ADHD, Alcoholism or PTSD and may find those posts helpful in making your decision about whether a ketogenic diet is something you want to try for symptom relief.

As always, please feel free to contact me if you have any questions or if i can help you on your mental health journey.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!


References

Alessandra das Graças Fedoce, Frederico Ferreira, Robert G. Bota, Vicent Bonet-Costa, Patrick Y. Sun & Kelvin J. A. Davies (2018) The role of oxidative stress in anxiety disorder: cause or consequence?, Free Radical Research, 52:7, 737-750, DOI: 10.1080/10715762.2018.1475733

Ask the Scientists: What is Cell Signalling. https://askthescientists.com/qa/what-is-cell-signaling/

Betteridge D. J. (2000). What is oxidative stress?. Metabolism: clinical and experimental49(2 Suppl 1), 3–8. https://doi.org/10.1016/s0026-0495(00)80077-3

Bouayed, J., Rammal, H., & Soulimani, R. (2009). Oxidative stress and anxiety: relationship and cellular pathways. Oxidative medicine and cellular longevity2(2), 63–67. https://doi.org/10.4161/oxim.2.2.7944

Hu, R., Xia, C. Q., Butfiloski, E., & Clare-Salzler, M. (2018). Effect of high glucose on cytokine production by human peripheral blood immune cells and type I interferon signaling in monocytes: Implications for the role of hyperglycemia in the diabetes inflammatory process and host defense against infection. Clinical immunology (Orlando, Fla.)195, 139–148. https://doi.org/10.1016/j.clim.2018.06.003

Jeong EA, Jeon BT, Shin HJ, Kim N, Lee DH, Kim HJ, et al. Ketogenic diet-induced peroxisome proliferator-activated receptor-gamma activation decreases neuroinflammation in the mouse hippocampus after kainic acid-induced seizures. Exp Neurol. 2011;232(2):195–202.

Maalouf, M., Sullivan, P.G., David, L., Kim D.Y. & Rho, J.M. (2007). Ketones inhibit mitochondrial production of reactive oxygen species production following glutamate excitotoxicity by increasing NADH oxidation. Neuroscience, 145(1), 256-264. https://doi.org/10.1016/j.neuroscience.2006.11.065.

Inflammation. National Institute of Environmental and Health Sciences. https://www.niehs.nih.gov/health/topics/conditions/inflammation/index.cfm

Paige Niepoetter and Chaya Gopalan. (2019). The Effects of Ketogenic Diets on Psychiatric Disorders Involving Mitochondrial Dysfunction: A Literature Review of the Influence of Dieting on Autism, Depression, Anxiety, and Schizophrenia. HAPS Educator, v23 n2 p426-431. https://files.eric.ed.gov/fulltext/EJ1233662.pdf

Paoli, A., Gorini, S. & Caprio, M. The dark side of the spoon – glucose, ketones and COVID-19: a possible role for ketogenic diet?. J Transl Med 18, 441 (2020). https://doi.org/10.1186/s12967-020-02600-9

Norwitz, N. G., Dalai, Sethi, & Palmer, C. M. (2020). Ketogenic diet as a metabolic treatment for mental illness. Current opinion in endocrinology, diabetes, and obesity27(5), 269–274. https://doi.org/10.1097/MED.0000000000000564

Samina, S., Gaurav, C., and Asghar, M. (2012). Advances in Protein Chemistry and Structural Biology – Chapter One – Inflammation in Anxiety.
https://doi.org/10.1016/B978-0-12-398314-5.00001-5.
(https://www.sciencedirect.com/science/article/pii/B9780123983145000015)

Vincent, A. M., McLean, L. L., Backus, C., & Feldman, E. L. (2005). Short-term hyperglycemia produces oxidative damage and apoptosis in neurons. FASEB journal : official publication of the Federation of American Societies for Experimental Biology19(6), 638–640. https://doi.org/10.1096/fj.04-2513fje

Volpe, C.M.O., Villar-Delfino, P.H., dos Anjos, P.M.F. et al. Cellular death, reactive oxygen species (ROS) and diabetic complications. Cell Death Dis 9, 119 (2018). https://doi.org/10.1038/s41419-017-0135-z

Wang, L., Chen, P., & Xiao, W. (2021). β-hydroxybutyrate as an Anti-Aging Metabolite. Nutrients13(10), 3420. https://doi.org/10.3390/nu13103420

White, H., Venkatesh, B. Clinical review: Ketones and brain injury. Crit Care 15, 219 (2011). https://doi.org/10.1186/cc10020

Ketogenic diets treat mental illness – Part 2

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Ketones heal the brain.

BHB (a ketone type) modulates neurotransmitter balance. This is just one of many mechanisms that reduce symptoms of anxiety and depression. Ketogenic diets are amazing for mental health.

Modulation of neurotransmitters (NT) allow your brain cells to:

  • Produce more GABA
    • upregulation of the calming “I got this” NT
  • Reduce Glutamate
    • downregulation of the excitatory “I’m freaking out!” NT
  • Improved production of serotonin
    • upregulation of this NT improves mood, cognition and nervous system functioning

You have to give your brain what it needs to work better if you want to treat mental illness and neurological disorders. Ketogenic diets are powerful mental health interventions.

Imagine what a better working brain would mean for you.


Check out Part One and Part Three or the at the Mental Health Keto Blog to learn of more keto mental health benefits.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

References

https://aepi.biomedcentral.com/articles/10.1186/s42494-021-00053-1

https://www.mdpi.com/2072-6643/12/12/3822/htm

https://www.psycom.net/serotonin

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