How To MASTER Hunger & Food Cravings TODAY! | Mark Hyman & Elizabeth Boham

People who consume artificial sweeteners actually feel more hungry. When we can help people get off of this vicious cycle of hunger and eating and hunger and eating and hunger and eating, they can be successful at getting to where they want to be.

So, you know, hunger is complicated because it's, you know, it's not, and we talked about a lot of the aspects.

That regulate hunger, right?

The protein you eat, the fat you eat, how much starch and sugar you eat, because those make it worse. artificial sweeteners, whether you use substances like cannabis, for example, sleep deprivation, stress, and so even hormones or, you know, levels of insulin, which goes along with carbohydrate intake, all drive our appetite. And so if we begin to understand how to regulate our appetite, we can really have a huge impact on our metabolism and health. Why do you think people's hunger is so dysregulated? And what are the other sort of strategies from a functional medicine perspective? that we can use to help people get into the place where they're feeling even and not swinging all over the place with hunger and cravings and sugar.

I think the biggest reason that people are so dysregulated is from our food supply. I think it's hijacked, as you always say, our taste buds and our drive for food and just helping people.

Get.

Off of processed foods and onto real whole foods, that that natural ability for us to regulate our hunger just happens. So one of the biggest things we can all do is just stop eating things with labels on them, right? And, you know, stop eating processed food because so many things, even if they're sort of marketed as being more healthy, have things in it that contribute to hunger and dysregulated hunger signals in our body. So I think that's probably the first thing we should be focused on with everybody.

So our diet and then sleep. Right?

Yeah, absolutely. Absolutely. Like we said, people are just sleep deprived in this country. We're living this lifestyle of sleep deprivation and chronic stress, and all of that is just driving our hunger. And we're not really able to listen to our body. If we're just going, going, going, looking at our phone, checking an email, rushing, eating quickly, not taking the time to let our food digest and signal that we're full. We're just rushing, rushing, rushing, and not sleeping and not managing stress. We're not paying attention to what our body naturally knows how to do.

And so what about sugar and carbs and stuff and artificial sweeteners? How does that affect ghrelin and how do we should be thinking about our diet in terms of regulating our appetite when we eat those things?

Yeah, you know, so it's interesting that foods, you know, foods will, when we're, when we're, our stomach is empty, we produce more ghrelin, and then when we eat, our ghrelin level decreases and we feel more full, right? So, or we're not as hungry. So we know that, that, that, that carbohydrates, as well as protein and fat can all result in a lower ghrelin release. And it's really important to have that meal that's balanced with good protein and fat and fiber to feel full and cause that suppression of ghrelin. But one study that was really interesting, or many studies that are interesting, they're looking at these non-caloric sweeteners and how they impact the ghrelin. And so they've been able to show that artificial sweeteners don't suppress ghrelin. in the body. So we think that when we are reaching for these low calorie sweeteners, these artificial sweeteners, that okay, we are not getting any calories, but we're getting this substance that is going to make us feel more satiated, but actually not at all. So artificial sweeteners don't suppress the ghrelin levels in the body like food does, whether it's carbohydrates or protein. And so, you know, people who consume artificial sweeteners actually feel more hungry a lot of the time. And that's a concern in terms of food regulation and what you were mentioning before about listening to our body's natural hormone levels and the natural things that drive us to eat or not eat. And I think that's really important when it comes to these artificial sweeteners. We think some people will come in and be like, okay, it's like a free food, but it's really not in terms of how it's impacting our hunger and satiety.

Yeah, it's true.

I think that if you're eating something that makes you mimic sweetness, like artificial sweetener would sort of suppress your appetite, but it doesn't. You drink artificial sweeteners and you want more and more and more food, which is really concerning.

And there are a bunch of other.

Things that affect you mentioned stress, sleep deprivation, lack of sleep in any way, but also stress plays a huge role in your grilling, right?

Stress has a huge impact. High levels of stress will cause us to have higher levels of ghrelin and eat more. And isn't that fascinating? It kind of probably makes sense from an evolutionary perspective that if we're going through a stressful time, we want something to be triggering us to make sure we're getting enough food so we are staying alive, right? So that probably makes sense evolutionarily, but it's important for us to pay attention to that when we're working with our patients and help them understand that this chronic stress that they're under can really be disrupting their hunger cues. And so, you know, we know that, as I mentioned, ghrelin can cause or stress can cause high levels of ghrelin, and for some people cause them to eat, we feel more and more hungry and want to eat all the time. And so in order to help them feel less hungry, one of the things we have to talk about is that chronic stress that they're under. And what can we do to help with managing that chronic stress? You know, whether it's getting outside and enjoying nature and doing regular exercise, getting on a good meditation program, doing your breath work every day, you know, journaling, gratitude, working with a therapist, doing some other types of treatment like EMDR or other ways to help release some of this chronic stress from the body is really important for many people.

That's huge. That's huge. So the other thing that people talk about with Grelin is other things that regulate so stress, we talked about. If you're overweight, it seems like this hunger is so dysregulated, so people are literally overeating and they're already so obese and it just seems to be counterintuitive. Why would people feel like they need energy if they're already so overweight and they have so much energy in their body? But it really is about this particular hormone rate that's being dysregulated.

I mean, one of the things we know with ghrelin is when people, when they do gastric bypass surgery on people, Their ghrelin levels do decrease. And one of the reasons why that surgery can be successful, I say that with some caution because it depends on how you define success and there's a lot of issues with the surgery that are important for us to talk about. But where they can be successful for some people is decreasing that ghrelin levels and helping their hunger. And not that I recommend the surgery necessarily for people, but that is one way that it works because it decreases your hunger.

Our hunger regulation is something that most of us don't think about. We think we're at the effect of our hunger and not at the cause of our hunger. That we can't really do anything about it. That if we have cravings and we want to eat bagels and muffins and donuts and we just have to have them, then there's just nothing we can do because willpower certainly can't fight those cravings and urges. And we think that's just how our bodies work. But I can tell you and you can tell me and we can tell each other after seeing so many thousands of patients that This just isn't true that we do understand the science of hunger. And we're going to talk about hunger today in a particular way because I think there's so much we can do to regulate our appetite so we're not starving and overeating. And I, you know, I found that for myself, I, you know, if you don't eat right, you definitely feel your blood sugar swing all over the place. You feel hungry and you feel out of sorts and you tend to overeat. So none of us want to do that. So how do we naturally regulate our appetite? And I think most people don't understand that if you have an inherent that you have an inherent wisdom in your body that knows how to regulate the hormones that control your weight, your metabolism and appetite. If you're off just by 100 calories a day and you're, and by the way, nobody can count calories because it's kind of a ridiculous effort in the sense that you can guesstimate, but if you're off 100 calories a day over the course of 20 or 30 years, that's 30 or 40 pounds of weight gain in terms of the cumulative effect of those 100 calories that you're off every day. So it's really about letting your body's own intelligence come back find out how to regulate these. So, Liz, tell us about the sort of biology of hunger and particularly about this particular hormone ghrelin, which is maybe people have heard about it, don't really know what it's about. It's really an important appetite regulator and the key to appetite regulation is regulating this particular compound, ghrelin, which is so prevalent and so dysregulated in our bodies.

I think it's such an important topic, like you said, because with When our hunger is out of control, it is very hard to control what we eat and why we eat. And so it's important to understand how all of these hormones work together. And like you mentioned, taking a step back and listening to the natural intelligence of our body is really important for maintaining a healthy weight and having great energy and vitality. And so ghrelin is really an interesting hormone and it is secreted from the stomach, mostly stomach and part of the small intestine, and it goes to the brain, and then it says to the brain, okay, you better eat, you're hungry. So it is that hormone that makes us feel hungry. And so when we eat, typically, our ghrelin levels go down. And we'll talk about this a little later, sometimes our food composition, what we eat in a typical meal, impacts our ghrelin levels differently. So when we eat, typically our ghrelin levels go down and it says, okay, now you're full and you can stop eating. And so one of the reasons people always say, don't eat too fast or if you're hungry, take a few minutes to make sure you still want to get seconds, is just to give the body time for that, for the hormones to shift and for that ghrelin level to go down. the other reason we know a lot about ghrelin is because when people lose weight, they often feel more hungry. And, and, and I always explain this to my patients. You know, I'm like, you know, they, they need to and want to lose weight. And, and when they do, sometimes they feel more hungry for a period of time. And I think that's a really natural, normal thing. And we sometimes have to work through that to continue to get to our goal if we're working to lose weight. So we've got a lot of hormones that that have an influence on what we choose to eat when we choose to eat.

Yeah, it's so critical because if we don't understand how those are regulated, it's really a big deal. I think when you're not eating and when you're losing weight and when you haven't eaten for a while, your body will naturally produce this hormone in your stomach that makes you hungry, which is a good thing.

So we don't starve to death, right?

Right, and so it goes down if you eat and so forth.

But.

If you have.

A diet that's causing dysregulation of that hormones, it can really create a problem. And I think we mentioned the microbiome, which also is key. So tell us about how from a lifestyle perspective we're affecting ghrelin, and what we can do with our diet, with our timing of eating, with sleep and other factors that are really driving a lot of issues.

Yeah. One of the things we know is when we have a meal that has sufficient amount of protein in it, that our ghrelin levels decrease and we feel less hungry with that type of a meal. So it's really important, you know, we've talked a lot about how insulin can trigger hunger too, right? But ghrelin also, so when we eat a meal that's that has sufficient protein and fat, along with all the good healthy carbohydrates, that helps with making us feel more full and not as hungry. So it's really important to think about each of your meals in your day and say, okay, did I have sufficient protein there? And remember, protein is like your eggs and fish and chicken and beef and beans and legumes and nuts and seeds, and that protein will help When you consume it, help that ghrelin go down and make you feel more satiated after a meal. And ghrelin is one of those reasons that that occurs. You mentioned also with lifestyle, sleep. Sleep is critical. When people are sleep deprived, ghrelin levels go up and they're more hungry. And so we're seeing an epidemic of sleep deprivation in this country and worldwide even, right? So we're seeing this epidemic of sleep deprivation, which is one thing that's driving higher levels of ghelin. And we want to make sure that we're getting adequate sleep. If somebody has this process called sleep apnea, if somebody has interrupted sleep where they are, they're having episodes where they're not getting oxygen into the body. That's what sleep apnea is. They're having episodes where either they're somewhere.

In.

Their nasal area, the back of their throat that's preventing oxygen from getting into the body. then the body has to wake itself up to take a deep breath. So people will often be snoring and then will stop breathing for a period of time and then take this really big deep breath. They might not even realize they're having these episodes of apnea or not getting oxygen into the body. But what we're learning is that when you have sleep apnea, ghrelin levels are higher. So people who have sleep apnea have higher levels of ghrelin, And again, one reason why that drives this vicious cycle of weight gain, obesity, weight gain, obesity, fatigue, hunger, hunger, hunger, right? So it drives this vicious cycle. They know that when people have sleep apnea, their levels of ghrelin are higher than the same group of people that even have the same body weight. So even if both groups are overweight or obese, if you have sleep apnea, your level of ghrelin will be higher. And so it's really important that we pay attention to the sleep, work with our patients and find out, you know, are they getting adequate sleep, first of all? And, you know, adequate hours of sleep, that is. And of the hours of sleep that they're getting, are they restful? Are they sufficient? Is there any concern about apnea or something that would be disrupting their sleep?

But, you know, Liz, it's really true that, you know, sleep apnea is a big factor. And I remember a patient I had who was a lawyer and telling me about his struggle to lose weight and he needed to lose about 50 pounds. He says, nothing you could do about it. I said, well, tell me about your life. What do you do? He said, well, I'm a lawyer. I'm like, what do you do? I'm gonna do this and that. But I have to stand up on my desk every day to work. Otherwise, I fall asleep at my desk. I'm like, oh, well, maybe you have sleep apnea. So we tested him. He had severe sleep apnea. We put him on a CPAP machine and he lost 50 pounds. like that. And I think, you know, most people don't understand the connection between sleep. But it's not just sleep apnea if you're not getting enough sleep. And you and I both, as doctors, know that when we were on call and we're working all night or we don't sleep, that we tend to crave more food. We crave carbs, we crave sugar, and our appetite's so screwed up. And I remember this one study, it was healthy young 20 year olds who weren't overweight, who were sleep deprived on purpose compared to a control group. And they found that the sleep deprived group we're much hungrier and they are craving more carbs and sugar. So that's an interesting phenomenon. That's why we see such an incredible consumption in this country of these products. We're sleep deprived as a nation and we have poor quality sleep and, you know, there's 70 million people that suffer from some type of sleep issue, which.

Is a lot of people.

I think maybe even more actually.

It's a lot of people.

And so it's not just sleep apnea, but it's all the sleep deprivation.

What about other foods like protein and fiber and fat? How do those affect grilling? Right, well they'll trigger ghrelin levels to go down after you consume them. So it's really important, you know, we work with all of our patients to say at every meal, each meal you have, make sure you've got a good source of protein, a good source of fiber, which is all your vegetables and beans, legumes, nuts and seeds, ground flaxseed, and healthy fat, and every meal, because that's going to help you feel more satiated, it's going to help those ghrelin levels go down. I mean, we also know things like cannabis, right, can cause ghrelin to increase. And that may be why people get the munchies, right? And so it's important to understand what things you're doing and how they're impacting your hunger in your body.

Yeah, I think that's right. And, you know, obviously people will small pot and they get the munchies for sure. And that drives appetite. So how do we work with people who have these problems? How do we sort of help?

And by the way, you know, one.

Of the things that I wanted to sort of mention was sort of the theory about gastric bypass. One of the theories about gastric bypass is that since ghrelin is produced in the stomach, that when you have a gastric bypass, it shuts down the ghrelin levels. But, I'm not sure if that's the.

Only thing that's going on.

And, I think the reason I say that is it was a recent randomized controlled trial comparing people who had gastric bypass with those who were matched to them but who didn't have a bypass but just went on the bypass diet. and they both lost the same amount of weight. Now, I don't know what their appetites were like or if there was a difference, but they basically went and lost the same amount of weight. So, I'm being very curious actually to look at the fine print of the study, see if the people who didn't have the bypass were hungrier, they just.

Starved them and lost weight, or if it was that they actually cut down their diet and they actually were able to accommodate to a lower caloric intake. Yeah, I think it's really important what you just said is that, and prior, actually prior to working with you at both Canyon Ranch and the Ultra Wellness Center. I worked in a practice where we worked with surgeons who were doing gastric bypass surgery. So I saw a lot of patients who were going through the surgery. And I saw a lot of the side effects and the negative side effects of the surgery as well. And what I think is what you mentioned is really so critical to understand is that when we can help people get off of this vicious cycle of hunger and eating and hunger and eating and hunger and eating. When we can help them break that cycle, they can be successful at getting to where they want to be in terms of their intake of food. So you're right, maybe at the beginning for that group of patients who didn't have the surgery, that first couple of weeks may have been really hard of saying, okay, I'm gonna really cut back on the amount of calories, the types of calories that I'm eating. the balance of my nutrients. And they might have felt really hungry for those first couple weeks, but we see this all the time. Once people get through that time, they start to feel better. They don't have that hunger anymore, that drive to constantly eat and snack and choose unhealthy foods. And then they can kind of start to be successful. The surgery prevents, makes it so you can't eat for those first few weeks, and then that just spiral into, yeah. But then of course you're dealing with all the side effects of the surgery, unfortunately. So, you know, that is an interesting thing that we see. You're right.

Fascinating. And, and the, you know, you've seen patients with this and you've had, you know, I remember many patients who've struggled with this and you get their numbers dialed in and you kind of sort through everything with them and they do so much better. So can you tell us about this patient as a 45 year old guy was like, hungry all the time, was overweight and struggling with his sort of appetite and hunger.

Yeah, you know, I mean, so he came to see me and he was really trying to be healthier. I mean, he was working hard to be healthier and really frustrated that he couldn't get his weight to where he wanted it to be. And he had gained 25 pounds over the last couple of years. He was feeling hungry all the time. He didn't have the same level of vibrancy anymore. He was just feeling kind of sluggish and low energy. We noted when we did his vitals and his physical exam that he had really gained a lot of weight around his abdomen and around his belly, that visceral adiposity, that belly fat that really causes a lot of inflammation in the body, causes high levels of insulin, and is associated with all of those negative things like heart disease and stroke and cancer. So, he had gained a lot of weight around his belly. His waist to hip ratio was one, which is higher than it should be. And, you know, when you look at his diet, he was trying to be healthier, but he was grabbing coffee, drink for breakfast. At lunch, he was having orange juice. He had switched that out instead of soda, sandwich and chips. He did have a few beers at dinner, you know, and then maybe snacked on crackers and popcorn after dinner. So, he felt like he was trying to make the healthier food choices, but we saw a lot of issues when we really delved deeper in terms of his diet where we needed to do some work. And we also, when we got his full history, realized that he was a snorer.

So.

He was snoring frequently. And we talked about how snoring can be a sign that you may have sleep apnea. I mean, there's lots of other signs too, high blood pressure, weight gain, fatigue, falling asleep during the day or when you don't want to fall asleep. But because of all this, I really encouraged him to get a sleep study. And we found out that he did end up having sleep apnea. But what we saw with his blood work, we saw high levels of fasting insulin. They were 10. We saw a C-reactive protein, that marker for inflammation, was really high. We saw that he had low levels of vitamin D, and we know vitamin D is critical for so many things in our health, including insulin sensitivity. We saw that his omega-3 fat levels, you can do something called an omega quant, which looks at the amount of omega-3s in the red blood cell membrane, and we saw that his Omega-3 levels were low. And we know that Omega-3s are really important for resulting in, you know, helping lower inflammation in the body. We can also do some special testing of something called an organic acid testing. And we did that for him. And we saw that his mitochondria, which were, which are the powerhouse of your cells, needed a lot more support. And one of the reasons that people develop problems with with hunger and weight gain and insulin resistance is when you with issues with their mitochondria. And we saw that we needed to really support that. He had high levels of free radicals or oxidative stress. And so there were a lot of things we needed to work on with him. One of the first things we did is we got him his sleep apnea treated, he got a CPAP machine, and he started to feel better right away. You know, patients resist this a lot, but we see that when they when they really do jump on board and start using that CPAP machine and it's fitted right, many times they just feel so much better, their energy is better. And one of the reasons, and their hunger decreases because that ghrelin decreases. Because remember we said that if you have sleep deprivation or sleep apnea, your ghrelin is going to be higher and you're just going to just be wanting to eat and eat and eat. So, that was one of the first things we really really helped him do. And it really was very helpful for that decreasing his hunger and that drive to just eat and eat. We also really supported him nutritionally with cutting way back on his carbohydrates, getting more vegetables in his diet, more nutrient dense foods. We gave him some supplements that supported his mitochondria like CoQ10 and B vitamins and alpha lipoic acid. And he did really well. With some of these simple shifts, he started to lose weight. After like six months, he got down to his ideal weight. After about four months, his waist-to-hip ratio got to 0.9, which is really where we wanted to see it. And he just started feeling better and he was having more energy and not hungry all the time. And he really understood what foods to choose. And then most importantly, from my perspective was that, you know, we just really decreased his risk of all sorts of diseases, right? Because we know that that insulin resistance pattern drives heart disease and stroke and cancer and dementia and diabetes. And, you know, so we really, you know, that was really great that we were able to intervene at this age and, I think, help prevent a lot of diseases for him in the future.

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Check it out and link below. With people who are struggling with hunger and cravings, I think one of the books that I really loved about this is called Always Hungry by David Ludwig, who's a friend of ours, brilliant book. He's a Harvard professor and he's really studied the biology of hunger. And he showed that you can literally retrain the the brain to not be hungry by regulating what you're eating, by increasing fat, protein, decrease starch, your sugar, timing eating when you're eating, you know, not eating late at night, making sure you have a little period of fast snacking is probably the worst thing in the world. When you go to the grocery store, I mean, most of the food is snack food, which is crazy, you know, and it's just like, I don't even go into those aisles, but it's mostly just snack food. And, it's just striking to me how we've kind of gotten this culture of eating all the time and snacking and hunger and ups and downs and something that we can really manage by addressing these underlying biological systems and paying attention to the simple daily rhythms that we need to follow in order to regulate our appetite. And then, you know, I just noticed in my own biology when I am dysregulated, I get hungry, I get cravings, I want this, I want that. When I'm eating well and I'm eating whole foods and I'm giving myself the nutrients I need, I don't feel hungry. I don't want I should have something before dinner, I'll get all hungry. That's fine. Or if I'm working out a lot, I'll get all hungry. But, it's not this crazy, oh, I want to eat a muffin or I have to have something bad. So, I think there's a real science of hunger and for people to be more on this topic, I'd encourage them to read his book called Always Hungry. He's got a great cookbook that goes along with it. But, this is something we see all the time, Liz. We see so many people struggling with weight and with metabolism and hunger and cravings and feel discouraged. But, I found people live within days. can change quickly their biology and get rid of the craving, get rid of the hunger. And, just remember this one woman who came to one of my workshops years ago on ultra metabolism, I think. And we basically put people on a, you know, really simple whole foods diet. We even broths and protein shakes and lots of vegetables and good quality protein, good fats. And she was like, look, I'm never gonna be able to do this. I've been craving sugar my whole life.

I have to eat it.

I don't know what to do. I'm really worried about it. I'm so stressed. I'm like, look, just try it for a couple of days, see what happens. And, and the design of the program was really to design to regulate these hormones, to regulate the ghrelin and to regulate the insulin and to regulate the blood sugar and the brain chemistry. And within two days, she's like, I can't believe it. I don't have any cravings anymore. I don't want this. I don't want that. So she's like so happy. And I, I think people don't realize.

Just how close they are to feeling good and getting rid of all those cravings that are really driving their behavior, and you can't do it really without.

Using the science of understanding all of this.

Absolutely, absolutely. It's so powerful and people's bodies change really quickly. I mean, and they can start to feel better really quickly with just some simple changes. I agree. I love that book, Always Hungry, question mark. I recommend it to so many of my patients.

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So the rates of obesity and binge eating and addictive like eating are rising. alongside the increasing dominance of ultra-processed foods in the modern food environment. And there are several mechanisms as to how this works.

Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman, and that's Pharmacy with an F, F-A-R-M-A-C-Y, a place for conversations that matter. And if you've struggled with mental illness and are looking for some new insights about why we struggle as a society and individuals with this overwhelming burden of depression, anxiety, and more, then this conversation is going to matter to you because it's with an extraordinary physician, Dr. Shervani Sethi-Dlamai, who's a Stanford and Duke-trained double board-certified physician in obesity medicine and psychiatry. So, just stop and think about that for a minute. Obesity medicine and psychiatry, they don't seem connected, but you're going to find out exactly how they are connected. the founding director of the Stanford University's Metabolic Psychiatry Program and the Silicon Valley Metabolic Psychiatry Program, a new center in San Francisco Bay Area focusing on optimizing brain health by integrating low-carb nutrition. And we're going to talk about that comprehensive psychiatric care and treatment of obesity associated with metabolic disease. She's just an extraordinary physician. She's been, I think, leading the way in redefining what psychiatry is because for so long we've created this stigma of mental illness as a problem that is an emotional problem, but it might be in many cases a biological problem and it might be related to what we're eating. So I really want to welcome you, Shamani, to the podcast and thank you so much for joining us today.

Thank you very much for having me, Dr. Hyman.

So you have kind of an interesting background. You have trained at the best institutions in the world and you have somehow come to the conclusion that our psychiatric problems may be related to metabolic issues. And you coined this term metabolic psychiatry, which really when I first saw that I was so excited because I wrote this book 12 years ago called the UltraMind Solution about how the body affects the mind. We know about the mind-body effect, but nobody really talks about the body-mind effect. And most psychiatrists think about the brain as sort of disconnected from the rest of the body and you treat the brain, but what about what's going on south of the neck? It doesn't get much attention. And you've really taken a very different approach. So why don't you tell us how did you come to this idea that we should be treating psychiatric issues with nutrition and through metabolic approaches?

Yeah, that's a great question. So early on, I went into, I knew I wanted to do medicine. And when I went into medicine, I saw that there were a lot of conditions that weren't necessarily addressed with nutrition. And there was a lack of training in the medical education system with obesity as well as nutrition. And with psychiatric conditions, I saw a lot of overlap with nutritional deficiencies and insulin resistance and even higher rates in that population versus the general population. And we know in the general population, it's even, it's pretty bad already in our country. So the relationship between mental health and metabolic disease is bidirectional, which means if you have a mental illness, you're more likely to have metabolic disease and vice versa. And if you have a metabolic disease, you're more likely to develop a mental illness. You're more likely to have a heart attack, for example, if you have depression. And you're more likely to develop depression after you have a heart attack. So these observations that I made really put questions in my mind as to there must be something more to what we're doing that needs further investigation. And I believe that there are metabolic issues that are not necessarily addressed within the field that I think needs to start occurring. I mean, we need to start including that in the way that we diagnose and treat and evaluate disease.

Yeah, you were talking earlier about this idea of comorbidities, which is a term we use in medicine to describe diseases that occur in the same patients. So if you have high blood pressure, diabetes, depression, reflux, we call these comorbidities. But we were talking earlier about how they may not really be unrelated, that in fact they may be very connected. And sounds like from your observations you made the conclusion that maybe it wasn't a coincidence that the fact that people who were overweight or unhealthy also had mental health issues. maybe there was a relationship, nutritional deficiencies, metabolic issues. You talk a lot about insulin resistance. So how did you come to sort of understand that that was really going on, that the biology of that was something that was real?

So I originally started off with an interest in learning about nutrition and metabolic issues. and obesity, and I wanted to treat obesity. And then I saw that in a lot of the patients, there were psychiatric conditions in those patients. So I started to Veer into the realm of psychiatry and got very interested in that. So what happened was that when I was treating metabolic dysfunction, not necessarily obesity, but metabolic dysfunction, which is problems with blood sugar or insulin resistance, or high blood cholesterol, I saw improvements in quality of life, in mood, in anxiety symptoms, in psychiatric symptoms essentially. And that really got me interested in what is this relationship? Why is this occurring? And it got me interested in treating these patients in a slightly different way than standard of care, really integrating the understanding of what metabolic dysfunction is. And I then started a clinic and I started to do research and that's how my path started. And I started early on developing this clinic in residency training.

Which is incredible because when you look at the the level of mental illness in society. It's one of the biggest causes of disability and one of the biggest costs is depression and anxiety. And I remember when I was seeing patients early on treating them for insulin resistance and pre-diabetes and other issues or gut issues or other factors that were going on related to autoimmune disease or inflammation and we would get them healthy, they would sort of say, wait, you know, my depression went away. my anxiety went away, my panic attacks are gone, my bipolar disease is better, my ADD is better. And I'm like, well, how did that happen? And then you begin to go down the rabbit hole and you begin to look at the biology of what's happening. And one of the, I think the greatest discoveries around mental health is that it's an inflammatory problem very often, that the brain is inflamed, but the brain can't say ouch, like you have a sore throat or, you know, a swollen ankle. it manifests as all these psychiatric symptoms. So I'd love it if you sort of take us down the road of how inflammation is connected to mental illness and what the approaches that you're using to help correct that.

Sure. So that's, you know, quite an important question. And, you know, when we talk about how nutrition affects the brain and specifically focusing on reducing that sugar and processed foods and refined carbohydrates to improve mental and physical health, we know that consuming excessive amounts of sugar, processed foods, and refined carbohydrates lead to obesity, metabolic problems, fatty liver, heart disease, even cancer. There is evidence for this, and the body is really one whole system. And what happens in the body also affects the the brain, the brain has a delicate balance of neurotransmitters or chemical messengers with more sugar and processed foods. These levels really become unbalanced and they're significantly off. So I'm talking about- Dr.

So wait, so your brain chemistry gets screwed up when you eat processed food and sugar, is what you're saying?

Yeah, yeah. And I'm talking about ultra processed food also in particular, because I do think that there's a difference between processed food and ultra processed food. Ultra processed food is like the real sugar, the cookies, the cakes, the chips, the potato chips, it's kind of highly processed things versus minimally processed foods, maybe some oils, vegetables that are frozen, that's a little bit different than ultra processed food. And so the research is showing differences between those things. in the brain.

Yeah.

And you need the right raw ingredients for chemical reactions to occur in the brain and elsewhere, like vitamins and minerals and nutrients. You need proper functioning, you know, of the brain. You need proper speed of transmitting signals. Your brain is composed of electrical cells, and it's a complicated web of signaling molecules. Those cells need fat to develop and to function properly. So you need those omega-3s in your diet. And if you eat sugar and ultra-processed foods, the chances are that you're likely not getting those important nutrients, those vitamins and minerals, for those important reactions that you need, nor are you absorbing them. The most people with metabolic dysfunction actually have nutritional deficiencies and are malnourished.

So, you're saying is people who are overweight and obese often are very malnourished and vitamin and nutrient deficient?

Yes, that's right. That's sort of a paradox, right? Right. They're eating all this food.

Why are they nutritionally deficient? But they're actually among the most malnourished.

They are.

They're looking in all the wrong places for the nutrients. They're eating more and more food. I think a study from Kevin Hall and others showed that if you let people eat as much as they want, and you give them ultra processed food versus whole foods, they'll eat about 500 calories more a day of ultra processed food because they'll keep eating and they're hungry and they keep driving. And you talk a lot about that in your work about the biology of what these do to your brain in terms of dopamine and the addiction reward pathways in the brain that make you literally become addicted to these compounds and how that affects you.

Right. So the rates of obesity and binge eating and addictive like eating, are rising alongside the increasing dominance of ultra-processed foods in the modern food environment. And there are several mechanisms as to how this works. Some which act directly on the brain and some that indirectly act through hormonal signaling. So our body is very complicated and the brain is connected to the body. And we used to learn in medical school that you have this blood-brain barrier that nothing can get across it. But that's not, it's like the Berlin Wall, but in reality, it does leak, right? And there are things that do cross.

It's more like a coffee filter, you know, it's a sip.

Right. Yeah, so ultra-processed food and sugar decrease our dopamine receptors and make us eat more compulsively, much like addictive drugs, the highly processed foods, they trigger dopamine reward pathways, and they invoke addictive-like behaviors, which have been well-documented and include intense cravings, includes feelings of withdrawal when cutting down on ultra-processed food, continuing to eat these things despite knowing the adverse consequences to it, and repeated attempts to try to quit. I'm describing addiction here, basically, and the consumption of larger quantities over time. than intended.

People go, oh, it's like emotional eating, it's not really biological true addiction, but what you're saying is this is really a true biological addiction, just like heroin or cocaine or alcohol that you get withdrawal, you get cravings, you get increased need for more and more of the substance to receive the same pleasure. You down regulate the receptors for pleasure, so you have to take more of the stuff to actually stimulate that reward pathway. And it's really this vicious cycle that people get into, and then they blame themselves and they feel guilty. you know, for doing it, and they think they just have no willpower. But you're saying it's much bigger than that.

Yeah, that's exactly right. It's so sugar is an addictive substance. It's not just something we say. It has a straightforward neurochemical basis in the brain, just like any other drug. And I think of sugar as a, it's a recreational food. It's not a, it's not a food that's essential for survival. We make sugar through the process of gluconeogenesis, through other foods that we consume. And so it's really about excess carbohydrates.

It's not- I call it sugar a recreational drug. I've never heard anybody say it, but I always write down in my book, sugar is a recreational drug. It's like if you like tequila, it's fine, but not breakfast, lunch, and dinner in the quantities we're having in America.

Exactly. Yeah, and we also, actually I would like to share a story about this just during the era of COVID since we're in it. Yeah. You know, just to give context as to why I wrote about this and why I'm working on this as well and continuing to feel motivated to continue to do my work is the shelter-in-place order had come you know, a couple months back for my county, and I'm in California. I live in Menlo Park. When it was announced, my husband, he's an infectious disease physician at Stanford, and I'm a psychiatrist and a UCSD medicine physician, as you mentioned. We both felt doubly invested in this pandemic. We went to our neighborhood Safeway grocery store, and we saw many people loading up their carts with Pop-Tarts, Hawaiian Punch, popcorn, anything ultra processed basically. And they weren't loading up their carts with fresh vegetables or, you know, they were out of cookies at the grocery store. Yeah.

Using toilet paper.

And toilet paper, exactly. And there were still, you know, produce left in the store. You know, it wasn't like they ran out of produce.

No.

So here I was.

I wasn't gonna run on broccoli.

No. Here I was at the checkout counter and I was thinking to myself, you know, staring at the person's car in front of me that is full of the recreational food, as I mentioned, the food that's not necessary for survival and detrimental to our health. I thought to myself, this is certainly not preparing them for the pandemic and or helping their immune system and if anything, weakening it. And this is our local Safeway. This is the heart of Silicon Valley. So in this context, it wasn't about affordability or access. That is what motivated me to kind of get that public message out on this topic.

Yeah, you did write a great article on the Hill and I read it. And you really talked about the way in which the pandemic we're facing is much more serious because of the underlying chronic disease pandemic we have in our society where it's driven by this ultra processed food that makes us overweight and sick and causes all these underlying chronic inflammatory issues like diabetes and heart disease high blood pressure, which are really the same mechanisms. If you look at the mechanisms of high blood pressure, heart disease, and diabetes, it's insulin resistance, it's oxidative stress, it's inflammation, and it's the same thing that's affecting our psychiatric illnesses, which is so fascinating. And most people don't think about using the doorway of food to help treat the brain. And you're doing that in your research and in your practice. So tell us some of the kinds of things you're seeing in your patients using this approach? Because it's pretty radical. You're going all the way sometimes to ketogenic diets with these patients with bipolar disease, schizophrenia, depression. It's fascinating.

Yes. What I have noticed is that a lot of my patients that come for psychiatric treatment and evaluation, a lot of them have pre-diabetes and diabetes. And when I look up the statistics on this in our country, 44% of adults today in our country are either pre-diabetic or they have diabetes. And I wonder to myself, what is that doing to our brain? We know that affects all these different organ systems, the liver, the pancreas, the heart, but what is that doing to the brain? Right? I'm happy to talk more about my research and patient care, but one thing that I felt I didn't completely answer before was how these hormones affect the brain with the addictive piece.

How does it drive inflammation and all of that?

Yeah. Yeah, so going back to that, You know, so I was talking about.

The.

Definition of addiction and we know that hormones like insulin and leptin, which is the hormone that tells us we're full, it sends a signal to our brain, and ghrelin that tells us that we're hungry. These hormones modify natural and drug reward pathways in the brain. I mean, they have so many effects on the brain. Our hunger hormones go awry and it can actually increase the reactivity itself of the dopamine system. And so this happens when we consume that excess sugar and the excess carbohydrates in our diet, and they cause these rapid shifts in blood glucose and insulin levels similar to other addictive substances. So, My approach in patient care has been to work on this system to decrease these shifts that occur in our blood sugar and our hormone levels to kind of go back to the homeostatic state that our body and our brains were meant to be in. And so I treat the metabolic dysfunction and I look at how that improves both metabolic issues as well as psychiatric outcomes. Yeah, so it's fascinating.

So basically you're treating the body to fix the brain, right? You're dealing with these physiologic changes that have to do with our diet and nutritional psychiatry that most psychiatrists aren't thinking about. I mean, most psychiatrists are thinking about, you know, psycho-emotional issues or thinking about medication and prescribing antidepressants, but they don't really work as well. And I, you know, I just found that the amount of benefit you get by addressing these underlying factors is so much greater than you get with medication, which are marginally effective for most people. I think, you know, unless you have really severe depression, but I think the data is just not that exciting about these drugs, right? I mean, they can be helpful for people and they can be life saving, but, but there are also other doorways that you're exploring, which are seeming to be way more fruitful. Is that your experience?

So, you know, the field has come, you know, a long way. They've, there's a lot of research that's been done on the biological piece and neuroscience and looking at, you know, obviously the serotonin hypothesis, but that's the hypothesis and an observation from like 30 years ago. And all of these research and money has been thrown on developing drugs, but we're not necessarily addressing some of the root causes of why are these chemicals imbalanced? And so that's an important question that I and others are trying to study through research studies and clinical trials. And like you said, we know that although our medications are necessary and life-saving for many, they have undesirable side effects that can worsen metabolic health. And while it's helping in one domain, it may in some people also be hindering improvement in psychiatric symptoms, especially if the metabolic health is poor. So psychiatric treatment is never going to be a one-size-fits-all approach. Mental health conditions are varied. They're heterogeneous and they have different phenotypes or presentations. We don't have a single mutation or a gene that we can point to or a lesion. There's no smoking gun. It's a complex relationship of multiple genes and environment. And unfortunately, a metabolic assessment is not part of that routine care. And stigma certainly plays a role in this. Obesity stigmatized and so is mental health. Education about nutrition and metabolism is lacking in medical education. Most psychiatrists recognize this relationship.

They do. They understand the connection between food and mood.

They're starting to. They understand that there are side effects with psychotropic medications. I think they don't necessarily have the expertise to treat it or address it. They don't know necessarily what to do about it. But most psychiatrists that I speak with, and my department certainly has been very supportive of this idea. And if someone has to do the research and someone has to do the work to kind of move the field forward. There's a growing body of other researchers working on this, and we hope that evidence-based research has to be done to kind of change the mainstream's generative care.

Yeah, I mean, you were talking about metabolic psychiatry. I was also noticing that Harvard had a whole department of nutritional psychiatry, which is, you know, seems like bookends on the country. I don't know the rest of the psychiatric world is thinking about this, but you mentioned earlier that you work with Bruce Ames, who's an incredible biochemist and nutritional scientist from California, one of the most published sort of scientists in the world. And, I spent a lot of time with him and he talks about this whole idea of a metabolic tune-up and that so many of our biochemical reactions are regulated by vitamins and minerals and that each of us have different needs for different components of those vitamins and minerals. I remember one guy, I was sitting in my office one day working on something. I was thinking I might have been working on that book and I was talking to somebody about folate and B12 and B6. He said, oh, yeah, I had really bad depression and I took some of these B vitamins and it just went away. And, I think there are some people who have a higher need for, for example, folate or B6 or B12 based on these genetic variations that Bruce Ames talks about that really are so prevalent. In fact, one-third of our entire genome codes for enzymes and those enzymes all need helpers, which are vitamins and minerals, and we don't really pay much attention to that. So when I look at depression or psychiatric illness, you know, I see so many different things that are going on there, whether it's insulin resistance and prediabetes or vitamin D deficiency or folate insufficiency or zinc or magnesium, all these various nutrients play a role in brain function. and they're not something we really learn about when we learn about psychiatry, right? Is that changing?

I think that is changing. There's a complex relationship between metabolic dysfunction and nutrition, food, mental health. And I want to start off by saying that the idea of food as medicine is not a new concept in the field of nutritional psychiatry. It's really grown over the past few decades by several prominent psychiatrists and researchers. However, the focus has largely been looking at specific foods or supplements, eliminating certain things from the diet, the microbiome. We're looking at the Mediterranean diet, for example, affecting depression symptoms. These are all very important questions, but what I thought was missing and why I named our clinic and our group, SWIRK Metabolic Psychiatry, is to distinguish that this is a study of how treatment of metabolic dysfunction can affect psychiatric symptoms.

Yeah.

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That'S GetPharmacy with an F, F-A-R-M-A-C-Y.com Now back to this week's episode. If a majority of us are suffering from obesity, type 2 diabetes, insulin resistance, metabolic syndrome, what is that doing to our brain? We know that these diseases affect multiple things, mental illness rates have increased over the past 20 years, in fact doubled. We know that mental illness like depression, bipolar disorder, psychosis, they're strongly associated with inflammation. That research is really indisputable. And research is also showing that there's an energy deficit in these brain illnesses, and the mitochondria, the energy powerhouses of our cells, are not functioning optimally, causing changes in brain signaling itself. And the thought is, if we can target inflammation, insulin resistance, the abnormal blood sugar, et cetera, as a method to improve mental health symptoms, then we can really improve our patients' lives further. And Again, mental illness has many different causes, but even if we, you know, can five to 10% of people have an improvement in these symptoms with this method, then I think that would be a pretty significant improvement of the overall mental and physical health of our country.

I think it's a lot more than five to 10%. I mean, when you think about the most amazing thing you just said to me is such a paradigm shift, which is that depression is inflammation in the brain. And that when you look at autopsy studies and when you look at the biology of this disease, the brain's on fire and it's also on fire in autism, in Alzheimer's, in schizophrenia. And a lot of these disorders that are, we think of as mental disorders, but are actually brain disorders that are manifestations of inflammation that show up differently in different people. And the question is, you know, what's driving that inflammation? and I think diet clearly is probably the biggest factor, which makes it an incredible thing to use to actually alter the course of these diseases because it's an easy tool to change and actually get a result. And that's what you're talking about, is your therapeutic use of metabolic medicine to actually fix psychiatric problems, which is pretty amazing.

Yeah, and I'm glad that you bring that up because I do want to clarify that with inflammation, It's not a complete clear picture. We know that there's inflammation, but there have been studies showing that treatment with anti-inflammatories, for example, in patients that have inflammation but not necessarily depression, can actually cause depression symptoms. So that's kind of a little bit of a paradox, right? So people- Do you mean like Advil.

Or do you mean like the interferon? the treatments for MS or?

Yeah, I think it was interferon. I'd have to look back at the studies, but there have been studies that have shown differences, you know, generally with some of the psychiatric symptoms when you're trying to combat inflammation or reduce it. But in people that have metabolic dysfunction, I think it's a different story. And that's, you know, what I'm trying to study further. So we have to be careful and cautious also because otherwise we do a little bit of guesswork if we're not.

Looking at it carefully.

Then you got the microbiome.

People are talking about antibiotics causing depression because it destroys the microbiome. The microbiome is another huge source of inflammation. You're talking about diet and you've got the gut microbiome and you've got environmental toxins and nutritional deficiencies. All these factors are affecting our brains in ways that we actually of a doorway to fix. And I'm so excited that at Stanford and places like Harvard, they're actually looking at these issues now because we do have a pandemic of mental illness. And it occurred to me when you're talking that as we've seen this rise in mental illness, it's the same curve as obesity and diabetes, right?

It's the same curve. Maybe they're related. Yeah. And I think that's what is interesting about that. And even with eating disorders, we were seeing more in that population too. And you mentioned something about, you mentioned about patients and how they've benefited. And what I'd like to share is that some of my patients with eating disorders, for example, which traditionally you don't want them to go on a diet, right? You want to prevent them from exacerbating their condition with binge eating, for example. But what I'm finding is that if you Tell them not to be afraid of a fat, for example, if they increase the fat in their diet. That's improving their binge eating. They're reducing their binge eating. And all the studies with diet in the past have been like low-calorie diets. It hasn't been looking at and low fat, right? And not the quality of the diet itself. So that's another interesting area of study, which I'd like to pursue. You know, I had a patient who couldn't get pregnant for years, had a history of bulimia, and I found that she was iron deficient and insulin resistant. And once we treated that, she was able to get pregnant and she cried in my office with a joyous outcome. Another patient who was an athlete suffered from anorexia nervosa and hadn't had a period in months, and I emphasized the fat and the brain needs the fat. when she increased her saturated fat intake, you know, I don't tell you to decrease saturated fat. So her symptoms significantly improved and her menstruation returned. And so there are a lot of things with diet that we can do to significantly improve patients outcomes. And two additional patients, I'll just briefly mentioned while I was in my training, they had schizoaffective disorder and they went completely off just ultra processed foods.

That's like schizophrenia, right? I mean, that's more like where they have psychotic behavior, which you think of as not really an emotional issue, but really a more structural brain problem. But you're seeing that changes with that.

Hallucinations, specifically these patients had auditory hallucinations and-- Hear voices. Yeah, and what gets so affected, they also had the mood component. with rage and that raging behavior, I guess it's known. So that would be something that's very interesting that requires further study too. And the quality of life significantly improved for these patients, which is really fascinating.

So yeah, I was digging into some of your research and you're looking at doing ketogenic diets for things like schizophrenia and bipolar disease, which to me is fascinating because we think of those conditions as less treatable than depression. You can do talk therapy for depression, but you can't really talk your way out of psychosis. So how does this approach work for those disorders? Because those seem a little bit more intractable, but you're seeing real changes.

Yeah, so a ketogenic diet is that higher fat, low carb, moderate protein diet, and it shifts the body metabolism to utilize fatty acids. So other words, you're burning fat and ketones as the primary source of energy rather than glucose or carbs. And they're well known for being powerful in epilepsy, in diabetes, in obesity and insulin resistance. And now newer research is showing some improvements in some of the neurodegenerative conditions, Alzheimer's disease, some autism, And so some of the possible mechanisms include energy metabolism and reducing inflammation, reducing that oxidative stress. And oxidative stress is, I like to think of it as the burden to the cell, the environmental burden to the cell. And so it's an intervention that's worth studying for other psychiatric illnesses. And we think the diet does similar things in the brain to what psychiatric medications do like mood stabilizers. So in these patients that I saw through my training, I saw improvements when they went on this particular diet. That's actually why I got really interested in...

So who was prescribing? Were they doing it on their own or was there a psychiatrist who said you should try a ketogenic diet?

So this was a clinic that they came to specifically for weight loss because they were on psychiatric medications. They had some side effects from that. They had weight gain. They wanted to improve. They already had a baseline poor metabolic state from, you know, before the diagnosis of schizophrenia. But they wanted to get improvement right with that. So they were placed on a ketogenic diet for treatment of insulin resistance. treatment of obesity, and these side effects from the medication. But what was interesting is that, you know, there have been some reports about even gluten sensitivity in schizophrenia. And so ketogenic diets are gluten-free diets.

Yes, they are.

Yeah, so this was, that's another, you know, added dimension of it. But I think there are a lot of possible mechanisms that, you know, I have mentioned. And so, what I am studying right now is I'm enrolling patients in a clinical trial looking at how this ketogenic diet intervention, which is really an anti-inflammatory metabolic intervention, how it affects individuals with bipolar disorder or schizophrenia, where we often prescribe these smooth stabilizers or neuroleptics for symptom control. And I'm also looking at obesity and metabolic dysfunction in these patients. And so while the trial is still ongoing, the early results are promising or encouraging and patients have been really thrilled with their results and there have been patients who've been able to reduce their medication dose and they've proved their health overall.

And so, it's really striking when you think about it because there has not been a lot of advances in schizophrenic care since I've been a doctor. I mean, there's better medications, but it's still the same old anti-psychotic medication, which will often have a lot of side effects. And, this is a radically different idea. I mean, I think I read once that about 17% of schizophrenics have elevated gluten antibodies and about 20% of autistic kids do. And, gluten is something that causes damage to the gut, it causes inflammation in the brain, and you know, I think that these are all patterns that connect, and you're connecting dots that haven't really been connected before in the field of Psychiatry. And it's, it's, it's really, it's pretty stunning because if what you're saying is true, and I believe it is, because I've seen this in my practice over the last 30 years, that the doorway to the brain is really through food and through your metabolic Pathways and optimizing those, it often, it often is more effective than medication and the side effects are all good ones, like weight loss and energy. So, it's pretty exciting. The other thing you sort of mentioned that I don't want to skip past is you talked about energy in the brain. So, we talked about inflammation and you talked about mitochondria and energy. These are little energy factories in the brain. And, it made me think of one of these researchers from Harvard. I think that was in San Diego, Suzanne Goh. I don't know if you've heard of her. She's a pediatric neurologist who studied autism, and she's done very sophisticated studies in the brain looking at the energy deficits in autistic kids' brains, which are, by the way, also inflamed. And if you have inflammation, it also causes damage to the mitochondria. So it's sort of a vicious cycle. And she found by giving these kids mitochondrial support nutrients like CoQ10 and carnitine and there's compounds that the mitochondria need to function, should be able to help these kids improve their autism. And I'm wondering, you know, in some of these metabolic disorders where there are energy deficits in the brain, in psychiatry, if that would be a fruitful area for research or if there's any research on that looking at using mitochondrial therapies to approach and treat psychiatric issues.

I think that's a really great question. and I don't know the research on that. I don't know whether there's a bit been a focus on that, but I think that's a really important question and something I would love to look into further. Well, you know, we know, we know that there's mitochondrial deficits in autism.

You know, there's mitochondrial deficits in Alzheimer's and Parkinson's. Parkinson's is a huge area where, you know, mitochondrial therapies have been used ALS. There's a lot mitochondrial issues and therapies that are used. So, you know, it's something we don't really learn about in medical school. We don't learn about mitochondria and sense of how to treat them. We don't learn about inflammation in the brain or how to really treat that. We don't learn about nutrition. All the things that seem to be the most relevant now as science advances are sort of gaps in our training. And, and now we're sort of have to put the pieces back together to try to sort through what to do. And, I mean, functional medicine is really a map. for helping us figure that out. And that's why I found it so effective. And like I jokingly said, you know, I called myself the accidental psychiatrist because I was treating people for all these physical issues and their mental problems get better, you know?

Yeah. Yeah. It's really interesting. It's fascinating. I. Yeah, I don't. I'm not an expert in, you know, kind of nutritional supplements and how that affects mitochondrial. function. And so, I really focus on the metabolic part of treating metabolic dysfunction and how that improves how your brain kind of self-corrects some of that mitochondrial dysfunction. Yeah.

We'll talk about the ketogenic diet in mitochondria because it's really one of the key ways that it works is by improving the function and health of the mitochondria in the brain and also reducing inflammation, which seems kind of paradoxical because you think, oh, I mean, a high fat diet. That seems like very inflammatory and bad, but it turns out it's the opposite. So, can you explain how that works in the biology of how the ketogenic.

Diet is affecting the brain?

Yeah.

So, with the mitochondria specifically, because there's.

A lot of other mechanisms. All of it. All of it.

Yeah.

Insulinistance in the brain, inflammation, oxidative stress, mitochondrial function, all those things that we know now are the underlying biology of brain disorders, how does a ketogenic diet influence those?

Yeah, so I will give an example of, in particular, the clinical condition, you know, food addiction or binge eating. Yeah. Right? So, the ketogenic diet.

By the way, how prevalent is that? I mean, how would you say food addiction? Is this like, 10% of the population, 30%, 2%.

So ultra-processed food addiction is about 40-50% in patients with obesity and about 40-50% similar to patients with binge eating disorder.

So if you're overweight, 40% of the people who are overweight or binge eating have this issue.

Right, right.

That's a lot. And considering 75% of us are overweight, this is probably the biggest addiction in America.

This is the big addiction in America, that's right. Wow. Yeah, the ketogenic diet, it stabilizes blood sugar, as I mentioned, but you avoid these hormonal shifts and that's really a big, we think that's a big reason because that affects the dopamine reward system in the brain. And what we also know about binge eating disorder in particular and ultra processed food addiction is that the functional connectivity, which is really the amount of connections between your nerve cells, networks in the frontal lobe, which is responsible for your planning and your executive functioning, and even within the reward pathway, reward processing, these networks are actually a lot less that functional connectivity and people's brains are less and we're less functioning.

So the adult in the room that is managing your impulses, your basic impulses, is not functioning because of the food you're eating. So you can't make good executive decisions based on the dysfunction in your brain, is what you're saying.

Well, what we do know is that imaging studies show that these folks have less connectivity I don't know that anyone's proved that it's related to what we're eating or metabolic functions per se, but that's something that we hope to learn more about.

But the grown-ups left the building, basically.

Yep. But what's really interesting is that the ketogenic diet increases expression of that miracle grow that you described in your book, that BDNF. Yeah. And that has been linked to decreased food intake. and these diets high in sugar and refined carbohydrates have been shown to decrease that BDNF expression and actually make you hungrier. So there's something about ketosis or the ketogenic diet that dampens down that reward signaling and the excitatory activity in the brain, which leads to a rise in the GABA inhibition. And interestingly, in addiction, we use medications that increase that GABA inhibition. And so indirectly, the ketogenic diet may be doing something similar to what medications are doing in playing a role in altering that neurotransmission.

Wait, so let me get this straight. So basically, when you eat a diet full of sugar and processed food, it turns off this miracle growing your brain called BDNF, a brain-derived neurotrophic factor that makes more connections in your brain and allows your brain to work better and make better decisions. And when you cut that out and you eat a ketogenic diet, you actually increase this miracle grow in your brain. You increase the connections and you get to make better decisions and choices about what you're eating in your life in general.

That's right.

That's pretty amazing.

Yeah, that's, you know, our, so Ashley Gearhart and I have been collaborating on this particular topic and she developed the Yale addiction scale. And so we try to use that in our studies because we're trying to look at how many of these people are actually identifying as having this ultra processed food addiction and suffering from the binge eating and the food addiction. So, you know, another thing that we know mechanistically with ketogenic diets are that it includes a moderate amount of protein and that protein has been shown to dampen reward response to processed foods and reduce ghrelin, which is our hunger hormone. So that might be another possible mechanism. And so there's exciting work being done in that area.

So I mean good quality protein, lots of fat and very, very little starch and sugar. You're talking about like 5% carbohydrates, right? This is very, very low carbohydrate diet.

Right. So for this, for a ketogenic diet that I'm talking about would be 5-10%. More like 10.

So have you seen people with schizophrenia, for example, stop their psychosis and auditory hallucinations by using a ketogenic diet?

I have seen two patients that that has occurred with, yes.

Yeah, this may be like Eureka, right? I mean, this is not, this is Nobel Prize kind of stuff, right? I mean, this is a big discovery.

It's really fascinating.

I mean, I could say I knew you when.

There are a lot of other researchers working on this and, you know, I'm really interested in helping these patients because, you know, I really just felt day after day just felt that there was something missing and we really needed to address this. I mean, just there's so much heterogeneity, you know, as I was mentioning in psychiatric conditions, but I do think that there's something more organic about some of the illnesses, and then I think there's different phenotypes, different presentations where we diagnose the same condition, but these strategies may help some people more than others. And many, many years ago, maybe thousands of years ago, we still had documentation of these illnesses, psychiatric illnesses.

Before McDonald's.

Yes, before McDonald's. So there's something happening. And also I'd like to point out that even psychological stress and major events in your life increase inflammation. So diet is very powerful, physical movement, lifestyle things are helpful, but I think diet is probably more powerful than some of the other things. And I do think that ultra-processed food and sugar is really, really messing up our health. And so I'm pretty worried about this country because I think that we're not recognizing it as a society. It's all around us and we think we're eating healthy food and it's marketed as healthy food, but not. I spend a lot of time re-educating my patients about what to eat.

It's true.

So it seems like our whole definition of mental illness is coming into question. I remember once having a conversation with Thomas Insel, who was the former director of the National Institutes of Mental Health. And I said, what do you think of the DSM-IV at the time was now it's DSM-5, which is the manual for categorizing psychiatric illnesses. It's based on grouping people together who share symptoms. You know, if you are sad and hopeless and helpless and you have no interest in life and sex and this and that, you have depression. And if you have this and that, you have schizophrenia. And he said, well, it's 100% accurate, but 0% valid, meaning that it was very good at grouping people into categories according to symptoms, but it didn't tell you anything about the cause or the mechanism. And what you're doing is you're saying, wait a minute, just because we say you have schizophrenia doesn't mean we know what's wrong with you. Just because we say you have depression doesn't mean we know what's wrong with you. It just means you have these symptoms. And it could be a lot of variables. It could be some psychological stress, but it could be also your diet or it could be a nutritional deficiency or it could be your microbiome or it could be a thyroid problem or it could be gluten or it could be whatever. And we don't learn how to think that way in medical school. And yet, this is really where medicine is moving at a pretty rapid pace. When you look at systems biology, when you look at the emerging concepts of network medicine, the body's a network, everything's connected by these biological mechanisms. And the things you talk about in the show today, in some resistance and inflammation and mitochondrial energy issues and oxidative stress, these are the fundamental things that tend to go wrong across almost all diseases that are chronic. And they show up differently in different people, but the doorways to fix them may be very similar, right? diet and using food as medicine. And, that's what you're doing really as a psychiatrist, you're using food as medicine in a pretty radical way, which is just so exciting. And, I think the fact that you're seeing people with schizophrenia stop hearing voices by giving them a different diet, whether it's the gluten or the sugar or the insulin resistance or the inflammation or the upregulation of their mitochondria through the ketogenic diet, all those pathways are active and you're actually activating the body's own healing systems rather than trying to interrupt some pathway or upregulate some pathway, which is what we typically do with drugs. They're much more, we call it pleomorphic in a sense. They have multiple effects when you look at the effects of lifestyle and diet that are so much more complicated than just a single drug pathway.

It is a lot more complicated than a single drug pathway. I agree with that. One thing is that The SSRIs are targeting serotonin. They target the serotonin and they increase it in the brain and it's supposed to rebalance your neurotransmitters and it's helpful for many people, but exercise also helps with depression symptoms. One of the ways that we think SSRIs may also be helping is through a different action. anti-inflammatory action. There is some anti-inflammatory component when they measured inflammatory markers with SSRIs and it decreased. So it's very interesting mechanistically to kind of understand what we are doing and what we're hitting.

That's true. Statins are the same way. It turned out that maybe the effect of statin drugs, the lower cholesterol aren't from lowering cholesterol, maybe because they're causing a lower level of inflammation. They have a side effect which lowers inflammation. And I remember one of the big studies called the Jupiter study, they found that if they lowered LDL but they didn't lower inflammation, there was no benefit. And if they lowered inflammation, and then there was benefit. So I think, you know, the inflammation story is really central to everything that's happening in chronic disease. That's, you know, and I think that's why with COVID-19 we're seeing such a problem in our society, particularly in America, because we are the among, you know, there's a few countries like Mexico, maybe worse, but we're among the worst in terms of our metabolic health. And you wrote about it in your article, like 12% of us down from 19% of us are metabolically healthy. That means 88% are not metabolically healthy and are experiencing some degree of this level of inflammation and even mood and cognitive issues. And so, you know, I think, yeah, what advice would you give people who are listening or at home? still struggling with the shelter at home, still struggling with trying to figure out how to get through this and feeling depressed and filling their shopping carts with Hawaiian Punch and Pop-Tarts. What should people be doing to protect themselves both physically and mentally?

So I would say to any American listening, whether they have a pre-existing chronic medical condition or not, the single most effective intervention that they can take today besides not smoking, obviously, especially now, is to not overload their body with that excess sugar and the highly refined carbohydrates. It causes a lot of damage to the body and we really should be encouraging improvements in health and immunity in every way possible. And we should look to other ways to increase our, you know, dopamine, for example, and improve our immunity and sleep is really important. Physical movement, you know, we may not necessarily have the same access to the gyms that we do before, but even if you can just move, that's going to be helpful. And getting connected to close friends or family and not feeling that loneliness or the isolation, it's physical distancing is different than social distancing.

Yeah, I know it's true. I mean, I think we are, I think, needing to think about different ways to raise our dopamine. I think that was a really brilliant thing you just said. And dopamine is the pleasure, you know, stimulating amino acid in the brain. It's a neurotransmitter. And, and we look to stimulate it a lot of different ways. And most of our society uses sugar and starch and processed food to stimulate it, but. things like love and connection and exercise and sleep, meditation, yoga, all those things. Food and the right kind of food, right? That also is so interesting to me when you look at the brain biology of what happens to the pleasure center in the brain. When you eat starch and sugar and processed foods, your ability to receive pleasure goes down the more you eat it. so you need more and more of it to get the pleasure, which is really the sort of definition of addiction, right?

Right.

Like, I drink a glass of wine, like, I can barely walk up to my room at night. And some people, you know, who are alcoholics can drink a bottle or two and they're fine. And I think that's what's really going.

On in our society.

Now, if I have a sugar load, I'm like, oh, you know, I feel pretty wired, but it really is a matter of redesigning your biology. And what do you see in your patients? How long does it take them to sort of break out of the sort of pattern that they're in and see the changes? Does it take months? Is it days, weeks?

Yeah, so it really depends on the individual and what they are coming to me with. There's a wide variety of different complications and symptoms. So usually within a couple weeks to a month, there's significant improvement. in their health. But there are patients that have a little bit more trouble because they've had past trauma or significant adverse childhood events still affecting them today. And I do think that that takes like talk therapy, as you said, psychotherapy to kind of even get them ready to make any changes in what they're eating, for example. And so for some people, weight can be protective. weight can be protective for them to feel more secure and because of past trauma.

That's real. I mean, those are issues that really have to get sorted through. But the food part is an interesting therapy that goes along with the talk therapy and other modalities to help people deal with these psychological issues. And it's often not used. And my experience, it just accelerates. people's progress. I always joke as if you're eating junk food or if you're thyroid not working or you're gluten sensitive and you're eating gluten, it's a lot harder to talk through your issues until you get your brain working properly.

Yeah, that's exactly right.

So, what do you think about things like ADD and nutrition? I think you have a number of papers on your on your site looking at, for example, artificial colors and additives and omega-3s and stuff. But just in terms of general nutritional quality in ADD, are you seeing this sort of epidemic of ADD and autism connected to our diet?

I do think it's connected to our diet. And, you know, like I mentioned before, that these conditions are heterogeneous. And I think that the number of cases of autism over the last 20 years has doubled, even maybe tripled. So both autism and ADHD is just rising and I don't think that we're giving our brain, we're not feeding our brains the right fuel. And that does affect attention, that does affect memory, that makes our brain cells more lazy or tired, not working properly. So those are conditions that require behavioral changes with autism and improvements in memory and concentration is really important. So I think what you're eating is so important for that. Yeah.

Now, I don't know if you said you mentioned you read my book, the UltraMind Solution. Now, if you saw the case of this little boy who had ADD and his handwriting before and after, he got treated.

Changed.

And, that was really what got me to write the book was when his mother brought in his handwriting before and after two months later after he started changing his diet and fixing his nutritional deficiencies. And, his handwriting went from completely illegible to really perfect penmanship. And, I thought, well, how did his brain go from being totally chaotic and asynchronous and uncoordinated to being coherent and functional. And I thought, wow, this is incredible. If that is really true, like, because, you know, you can, people can talk about their behavior and their mood. It's more subjective. But when you see, like, this objective reality of handwriting before and after, and it wasn't like he took penmanship lessons, what's actually happening in the brain? And when I went back to look at this kid's history, it was fascinating because he had a lot of inflammation, right? So if you look at all these comorbidities that he had, he had asthma and allergies and eczema and hives and plus he had irritable bowel and he had all these sort of physical issues that were inflammatory, but they were coming from his inflammatory diet. And the kid never had a real food in his life. He never even probably saw a vegetable in his life. And he had high levels of trans fats in his blood. He had no Omega-3s. He had very low levels of B6. He had low levels of zinc and magnesium and and, you know, it was really pretty striking when we just cleaned up his diet and we got him on some basic supplements, just a multi and fish oil and vitamin D. His, literally, his brain completely changed within just two months, and he became functional. And his ADD went away, and all his asthma went away, and his gut issues went away. And, you know, it's years later now, and he, you know, he graduated astrophysics from University of Colorado or something. you know, it's like, you go, you know, this kid got kicked out of kindergarten. He was on Ritalin for years. And yet this is not something that most psychiatrists even think about doing with their patients, which is, it's so frustrating to me because, you know, as a family doctor and someone who does functional medicine, like, this just seems so self-evident and your, your work is just such an example of how things are really changing. Do you find that your colleagues are like, what are you doing, Shivani? Or are they like, this is interesting or are they giving you a hard time?

I completely believe that story you told me. I can believe that a patient with ADHD has significant improvement after what you treated him with. And my colleagues have been pretty supportive actually and very interested to learn more and very open to making that change. In fact, even just last week, one of the We have different clinics based on subspecialties like neuropsychiatric clinic or mood disorder clinic or depression clinic. And the depression clinic and the bipolar clinic and this women's wellness clinics, they all reached out to me and want to collaborate. And I think one of the attendings told me last week that 40% of his patients have metabolic issues and talking about weight gain and Most likely, I think a lot of people have nutritional deficiencies. We already know the general population has a lot of nutritional deficiencies. So if we look at the population and mental health, we're going to see even more. So I do think that this is something that's going to change. I'm optimistic. I think you can tell.

Yeah, well, you're changing it. You're clearly at the forefront. Are you a lone wolf out there? are there other people out there in the psychiatric world who are on your same path?

I think there are other people out there on the same path. I think that metabolic dysfunction per se is not necessarily looked at as much compared to nutrient deficiencies or specific vitamins and supplements, for example. But I do think that, you know, the combination, these are all important all important topics and all important things to work on.

So let's last question. Looking forward five, ten years, how does it feel to psychiatry change? How would you like to see it change in how we treat mental illness based on what you're learning in your research?

So I would like to see the change actually across the board, and even in medicine, to focus on nutrition and metabolism and I think over time we need to really include that as part of the assessment in the initial history that we take and we have to have a careful intake history about nutrition and what people are eating for breakfast, lunch, dinner, snacks, their drinks, I mean how they're sleeping, you know, how they're looking at food. So I think that should change and I also think that the treatment of insulin resistance and detecting insulin resistance, because I often find that it's not being detected and I'm not necessarily the doctor that sees them as frequently. And so that's something that I feel needs to change within our whole system. We need to think about, aside from just looking at blood sugar every now and then and thyroid, we also need to look at Some, you know, like their fasting insulin level, you know, what is their consumption? What is that early process? The things that make us sick later start early.

Yeah.

And it's a gradual process towards decline. And what if we intervened earlier, detected things earlier, asked about things earlier, so that we can prevent what happens later. We know what happens later, right?

So this is just a radical idea, right? The doctor should ask their patients what they eat. That's the future of medicine. Actually, no one can come and see me in my practice unless they fill out a three-day diet record. And then on top of that, you can't get an appointment unless you agree also to see the nutritionist because if food is medicine, I can't practice without a nutritionist. And the other thing you said was really important is that the most common disease in America, insulin resistance, the most common problem that affects hundreds of millions of Americans is not diagnosed 90% of the time by the doctor. That's a shocking stat.

I think we're missing a lot of it, unfortunately. I think we're missing a lot of it. I think we don't necessarily know how prevalent it is as a medical society, perhaps as a whole. We don't necessarily know how common it is. And it's really common, and every time I mention that statistic, people are shocked. Yeah, and with kids now, too. So, I mean, it used to be that the majority of liver transplants in this country were done because of alcohol cirrhosis. And now the majority are being done because of fatty liver caused by fructose and high consumption of sugar, even in.

Young adults, which is terrifying. I mean, I was at an obesity conference, and there was this guy there who was a pediatric gastro neurologist. I'm like, what are you doing here? He says, well, you know, we see a lot of fatty liver in kids, five-year-olds I'm like, really? That's what we used to see in.

You know, old people with diabetes, right? Yeah, that's very sad.

So make sure you do your five, three-day diet record. And the other thing is ask your doctor for a fasting insulin. This is something I've been measuring for 30 years, and I almost never see it done by most physicians. And it's probably the most important test because your fasting insulin goes up way before your blood sugar. And that's something you can easily detect by checking your blood test. And it's an easy blood test. and if your insulin is over five, you're heading towards trouble. If it's over 10, it's not great. And if it's way more than 10, you're in trouble. So that's, that's an easy thing to measure, and it's something that'll tell you where you're going and it affects your mental health. So I would say to people who are listening, if you have mental health issues or you know someone with mental health issues, you should really think carefully about the role of food nutrition and how that plays a role in what's going on and experiment because there's really very little harm to cutting out processed food and sugar. In fact, there's only benefits. And there's a, even trying something more aggressive like a ketogenic diet, often with, you know, the help of a physician or someone who knows what they're doing can be helpful. But these are, these are simple things that have low risk, high benefit, and, and they're actually being validated in the research. And your work is just, it's just so exciting to me. Shavonni, I think, you know, this is really the future of Psychiatry and mental health in this country, and I hope that you can become a bigger voice than you already are because I think the world needs to hear this. I think our government needs to pay attention to this in terms of our policy of funding research in this area. So if I can help you get millions of dollars from the NIH, I'm going to do what I can.

That would help. I do need some research funding.

If anybody's listening, you can.

Find it.

I did want to just say, I had a comment to what you were saying is that Because people are listening, I want to make clear that it's not just people with obesity that have insulin resistance, but people who are even just normal weight can have this insulin resistance. And so it's really important to think about that as you decide whether you want that assessment. Because you may not even know that you may be insulin resistant and you may not know that you have a high blood sugar and you think you're eating healthy, but there are a lot of foods out there that you think are healthy that are not and have a lot of added sugar in these things. Well, that's a really important point because.

There'S a lot of people walking around saying, well, you know, I eat a lot of sugar, but I'm skinny, so it doesn't matter. It doesn't affect me. Well, it does. In fact, about 20 to 40% of skinny people are metabolically unhealthy, meaning they're what we call skinny fat or metabolically obese normal weight. So, you look thin on the outside, but you're fat on the inside. maybe not overweight, but you're over fat. And especially around your belly fat, which is what the danger fat is, it drives all the insulin resistance. So it's important to really have a real look at this for yourself. And I think I'm so encouraged by this conversation. I can't even tell you I've been waiting for you for 30 years to talk to you. And now you're doing this incredible work at Stanford. It makes me so happy.

That's very sweet. Another just comment is that with excess weight and that visceral fat that you were getting at leaks inflammatory molecules and causes damage in the body as well. And so how much of that is contributing towards mental health and mental health symptoms is also an important question. So I just wanted to mention that because sometimes that fat is not fat you can actually see. It's fat that's built, you know, around the organs and around the arteries and things like that.

Yeah.

Well, I just want to honor you for your work.

I want you to keep at it. I want you to convince all your colleagues and I want nutritional psychiatry and metabolic psychiatry to be actually the first thing that psychiatrists think of when they're treating patients. And then, you know, medications are useful, but it shouldn't be the first thing we think of, I think, in this situation because it's clear that this is such a powerful intervention when other things often and don't even work.

That's great. And Mark, you've had these ideas long, long before and you've been treating all these patients and it's so wonderful. It's really a fresh of breath air to meet someone who has these ideas and have them independently.

Yeah, well you should come learn about functional medicine. I think you would love it. It's exactly what you're doing and even though you don't know you're doing it.

Yeah, great, great.

Thank you so much for being on the Doctor's Pharmacy. I hope you love this conversation. If you're listening to it and you liked it, please share with your friends and family. Leave a comment. We'd love to hear from you. Subscribe wherever you get your podcasts and we'll see you next time on the Doctor's Pharmacy. And if you're interested in Dr. Shivani's work, check out her website, MetabolicPsychiatry.com, you can find her on the Stanford website as well.

There's a whole, just type in metabolic psychiatry.

Pop up all over the place on Google. So I'm excited to have had you on the podcast and thanks for joining us.

Thank you for a great conversation and for inviting me to your podcast.

If you love that last video, you should definitely check out the next one on food is medicine. Because you don't need a doctor's prescription for health. What you need to do is to make that part of your life in a natural way. Well, if we can get food reimbursed.

By health care, it's a game changer. I'm actually working on that at Cleveland Clinic with the food pharmacy, which is the idea of actually paying.