Chris Palmer MD 

SUMMARY KEYWORDS 

diet, people, patients, brain, brain inflammation, mental disorders, depression, epilepsy, ketogenic diet, bipolar disorder, metabolic syndrome, diabetes, treatment, metabolic, genic diet, disorder, rania, harvard, insulin, happening 

SPEAKERS 

Jack Heald, Dr. Chris Palmer, Dr. Philip Ovadia 

Jack Heald  00:01 

Well, you're back with us at the Stay Off My Operating Table podcast. I’m Jack Heald. This is my illustrious founder of the of the show, Philip Ovadia. Phil, who’d we got with us today? 

Dr. Philip Ovadia  00:13 

Well, we got a real honor today, Jack, to have Christopher Palmer with us. Listeners who have been with us for a while know that many of our episodes turn into blowing Jack's mind. And I remember one of the earliest examples that I think way back in season one was when I mentioned that improving your metabolic health might improve your mental health. And Jack's mind was appropriately blown and said, I gotta learn more about that. So, keeping that in mind, I've gone out and found what I would consider the godfather of mental health and metabolic health, Chris Palmer, and I'm gonna let you introduce yourself a little more, Chris, and then get into the discussion. 

Dr. Chris Palmer  01:00 

Sir, it is an honor to be here. So, thank you. So, I am a psychiatrist at Harvard Medical School, been a psychiatrist for over 25 years. My day job is running an education department for McLean Hospital and Harvard Medical School. I also do neuroscience, psychiatric research, and have been doing that for over 20 years and I work with patients as well, usually patients with treatment-resistant mental disorders. Usually by the time people see me, they have seen numerous other mental health professionals, have usually been tried on dozens of medications, have been in and out of hospitals, often even tried ECT or other... Electroconvulsive therapy, shock therapy or other forms of aggressive psychiatric treatment. And when all of that fails, they end up at my doorstep. And I'm supposed to do something. So that's a little bit about me. And last, for about 20 years, I've been using low carbohydrate ketogenic diets and Clinical Practice with people with depression, anxiety disorders. And over the last 7 years, I've been using it in patients with treatment-resistant chronic-severe mental disorders, like schizophrenia and bipolar disorder. 
 

Dr. Philip Ovadia  02:39 

Amazing. Yeah, so, 20 years ago, you started using this and 20 years ago most people had never even heard of low carb, maybe outside of Dr. Atkins’ work, but how did you first start using that? Why did it occur to you that that might help in the treatment of others? 

Dr. Chris Palmer  03:03 

Good old, Dr. Atkins. It started with my own personal story, I was in my 20s, was finishing up residency, already diagnosed with metabolic syndrome. So, I had high blood pressure, pre-diabetes, bad lipid numbers, triglycerides, low HDL. And I had been pretty diligent about following at that time the highly recommended low-fat diet. And so, I was obsessively on a low-fat diet and exercising pretty regularly and my metabolic syndrome was only getting worse. And so, after several years of that, and it not getting better, my doctor started pushing more aggressively, various pills on me for blood pressure and cholesterol, and in a lot, I kept pushing him off saying I really don't want to go down that road, what the hell? I'm doing everything right, like I am doing the program, and it's not working. Why is it not working for me? And of course, I do have a strong family history of diabetes and cardiovascular disease and all of that. So, he's like, oh, must be genetic. Sucks to be you. There's nothing you can do. So, in the last-ditch effort, I tried the Atkins diet, which I had heard through the rumor mill might improve metabolic syndrome for some people, which I, at the time, was pretty skeptical of. I was pretty traditionally trained and bought everything I was being told hook, line, and sinker. So, I really did not think it would work. But it was my last...  It was the only thing I knew to try before just kind of going on medications and probably having my first heart attack when I was 50 and being on your operating table. So, I tried the Atkins diet, and lo and behold, within three months, everything improved. My metabolic syndrome was completely reversed, and eliminated. But interestingly, I noticed significant changes in my mental state. I was not clinically depressed at the time that I tried it. But I noticed significant improvement in my mood, my energy, my motivation, my sleep. I was more confident. I had just a lot more energy for life. And it was striking to me because I'd never been like that in my entire life. And so, I started to wonder like, gosh, if this is doing this for me, what about all these patients that I see who have treatment-resistant depression, and they've tried everything and nothing has worked for them? I wonder what this diet might do for them. Took me a couple of years... 
 

Jack Heald  06:12 

You didn't have a clinical diagnosis of any kind of emotional or mental health issue, right? You just noticed that you felt better. 

Dr. Chris Palmer  06:21 

At that point in time, I did not. Although I had had a history of depression. I have a long history of depression as a child and adolescent and young adult, so and that may be relevant for why I noticed such a profound improvement. I don't know. It's certainly probably relevant about why I had never felt that way before. I had never felt so good. But at the time that I was doing it, I wasn't clinically depressed. I'd gotten through medical school, I was doing residency, I was working 80 plus hour weeks, and I was fine. I was actually getting awards for achievement in medical school and residency. So, I was a high performer high achiever. So, I was a work-hard kind of person. But you know that saying work hard, play hard. I never could understand who the hell would want to play hard. I was always like, aren't you tired and exhausted from working hard? Like, why would you also want to play hard? Like, don't you just want to relax on the sofa and watch TV like me? But yeah. 
 

Jack Heald  07:33 

So, you notice your own changes? And you I guess, ask the question, any good scientist would ask, wonder if I would see a similar effect under different set of circumstances with these patients. Carry on with that story. 

Dr. Chris Palmer  07:52 

Yeah, so I started using it in several patients with treatment-resistant depression and related disorders. So, some of them also had been diagnosed with anxiety disorders, or personality disorders or other things along with their chronic depression. But not everybody was able to do the diet, I will fully disclose and, but of the people who were able to do the diet, almost all of them had significant improvement. One woman actually got hypomanic, and that was one of the first things that I noticed, within a month of her achieving ketosis, she was almost too happy. And it was profound and striking, because she had been depressed, severely crippled, crippling depression for over 10 years, was suicidal all the time. Just had no energy and became hypomanic for about three weeks. It didn't cause problems in her life, but it was striking that she was so ridiculously happy, that calmed down and she actually did quite well on the diet. And so, I continued to use it, especially in patients with diabetes, because I knew about its use as an anti-diabetes treatment, and had seen that work in my own parents. So, for patients who also had comorbid diabetes, I was absolutely using it because it just seemed like the right thing to do. Like even if it wasn't gonna help their mental health. It probably helped their physical health but sure enough, lo and behold, when I could get them in ketosis, lower their blood sugars, their mental health almost universally improved as well. So, their depression, anxiety and other symptoms across the board were improving. 

Dr. Chris Palmer  09:57 

But back then, the Atkins diet was extraordinarily controversial. Today, we have quite a few studies of low carbohydrate, ketogenic Atkins-like diet, interventions for both weight Loss and for diabetes. And so, I can today say that we have a rigorous evidence-based to support these interventions for weight loss and for diabetes. But at the time, we didn't have that rigorous database. Dr. Atkins was largely considered a quack in the medical community. And his diet was largely considered dangerous. And so, I kind of laid low, I was just trying to help the patients in front of me, and I'm using it, but I wasn't out there publishing anything, I wasn't out there speaking, I wasn't on the speaking circuit or anything. Because I certainly didn't want to get in trouble. But I didn't feel bad about what I was doing. Because these patients all had treatment-resistant mental disorders, there really wasn't a whole lot more to offer them. And it was working, and I was tracking their metabolic health at the same time. And it was improving. So, I was kind of like, well, I don't care what the rest of the medical community thinks, like I saw improve my metabolic syndrome, my blood pressure went down, everything got better. My LDL actually went down on the diet. And so, at literally, everything got better. And my primary care doctor said, whatever the hell you're doing, just keep doing it. Because this is phenomenal progress. So, I had no qualms about what I was doing. I wasn't worried I was ready to defend myself, but I wasn't ready to be so public about it. And then that all changed for me. It's about seven years ago now, when one of my patients was schizoaffective disorder, which is kind of a cross between schizophrenia and bipolar disorder. He asked for my help to lose weight. And he had already tried several other weight loss methods and could not lose weight using them. And so, I was familiar and comfortable, and a big fan of ketogenic diet. So, we decided to try the ketogenic diet. 
 

Dr. Chris Palmer  12:34 

And at the time, I tried it with him, I truly, honestly, was just trying to help them lose weight. Depression is not the same thing as schizophrenia. At least at that time, in my mind, they're completely different disorders. And that's evolved now. At that time, I thought of these as completely different disorders. And even though I had seen it work on depression, I really knew in my heart of hearts, I mean, I knew this was certainty. Chronic psychotic disorders are brain, they're serious brain disorders. They are lifelong disorders, they ruin people's lives, there's no escaping them, even with the best treatments. People don't get better. And that's just the way and they go to their deathbed, being schizophrenic and being disabled by their illness. And so, I had no conception that this was going to help his mental symptoms. Sure enough, within a couple of weeks, he was losing weight. And within about two weeks, I noticed this very strong antidepressant effect. And he was much less sedated, was making better eye contact, was making jokes, was talking a lot more. And I initially, I was kind of shocked at how much better he seemed. But I wrote it off to oh, here's that antidepressant effect that I see in these other people, it's happening for him, that's great. But he was still psychotic. He was still quote, unquote, crazy. He was hallucinating, having delusions, all of the same stuff that he always had. It took probably about six to eight weeks. So, it did not work overnight for psychotic symptoms, but within about six to eight weeks, he spontaneously reported that, to me, he's like, “You know those voices that I hear all the time?” I'm like, “yeah.” He's like, “they're going away.” They're getting quieter, and they're not really happening as much anymore. And when they do happen, I can kind of ignore them. I just I don't want them to bother me. And probably a couple weeks after he told me that, he said, “you know how I always talked about those families that owned all of this technology, they control the world. And they were targeting me and they can put thoughts in my head and, and they're tormenting me, and they're trying to... I don't know what I've done, but they, they have it out for me...” So, he had all of these elaborate conspiracy theories that have been going on for years, about 10 years at that point. And he was tormented by these conspiracy theory delusions. Couldn't go out in public, because he was convinced everybody out in public was part of the scheme, and they were all part of the plan to hurt him and torture him. I'm like, “oh, yeah, we get to talk about that again.” And he said, “I kind of don't think that's true anymore. And now that I say it, it sounds kind of crazy, right? Like maybe it never was true. Maybe I've had schizophrenia all along. And that those things were never really happening. But I don't think those families exist. And I don't think they're targeting me. I think if I did have schizophrenia, it's going away.” 
 

Jack Heald  16:26 

And what was your response here? 

Dr. Chris Palmer  16:30 

I was dumbfounded. I was truly dumbfounded. He was also working with a psychologist. And his father was very actively involved. And so, I had to ask both of them. Over time, like, are you guys seeing what I'm seeing? Because I'm kind of not believing what I'm seeing...This, this cannot, this can't be happening. I don't know how to understand this. 

Jack Heald  17:02 

Our model says this is impossible. 

Dr. Chris Palmer  17:05 

Yes, everything that I've learned as a psychiatrist says, this is impossible, this cannot be happening. His schizophrenia cannot be going away. Because I didn't change his meds. He didn't get ECT. He wasn't in the hospital. I just have him on a diet and he's just losing weight. That's all we're doing. I'm helping him lose weight. And, like the fact that that might help depression, never initially, it was shocking to me. But at that point, I'd been dealing with it for 15 plus years. So it wasn't that shocking to me that your mood might improve as you lose weight, or as you improve your metabolic syndrome, or I didn't really fully understand how to think about it. But the fact that his schizophrenia was going away was truly dumbfounding to me. And so, I quickly went on a search to try to understand how and why that might even be possible. And only then did I learn that the ketogenic diet has been used now for 100 years in the treatment of epilepsy. I didn't know that at the time. I knew about the ketogenic diet, Atkins or keto diet as a weight loss or diabetes intervention, but I'd never heard of it being used as an epilepsy treatment. And that, 

Jack Heald  18:28 

In your previous model of mental health, did epilepsy and things like schizophrenia and bipolar, all occupy the same general space? 

Dr. Chris Palmer  18:43 

Absolutely. So that that was the huge connection for me as soon as I found out this is an epilepsy treatment. And there's a robust evidence base to support its use in epilepsy. It became a no brainer. The connection was obvious and clear. We use epilepsy treatments every day on tens of millions of people with mental disorders. So, in fact, anticonvulsant medications are used probably tenfold or more in mental patients than they are in epilepsy patients. Medications like Depakote, Tegretol, Lamictal, Topamax, Neurontin or Gabapentin, all the benzodiazepines, Valium, Klonopin, Xanax, those are all anti-epileptic treatments, but the majority of your listeners are going to recognize those names because they know somebody who took them for a mental disorder for anxiety, depression, bipolar disorder, something else. Epilepsy is a relatively rare disorder. Mental disorders are extraordinarily common disorders and so it's not necessarily that they're more effective for mental disorders. It's just that there's so many more people with mental disorders that they get used all the time. And so, as soon as I recognize that connection, it was a no-brainer to me. It's like, well, whoa, if this is an actual evidence-based treatment for epilepsy, yeah, this really might be working for like, it's doing something to his brain. If this if his diet can stop seizures, it's doing something in his brain to maybe stop the schizophrenia. 

Jack Heald  20:25 

Oh okay, that’s what the connection was. All right. Yeah. Makes sense. Yeah. 

Dr. Chris Palmer  20:29 

So, the diet can stop seizures. And we actually have a robust evidence base on all of the mechanisms of action that might be contributing to that effect. But if anything, can stop seizures, it also has the high likelihood of possibly helping with mental symptoms. So, at that point... 

Jack Heald  20:52 

How did that shift your model of the type of medicine you were doing? 

Dr. Chris Palmer  21:09 

So, at that point, quite honestly, I felt like I had discovered something really important in terms of its effect on schizophrenia. And the reason I felt it was so important is because schizophrenia is such a hopeless diagnosis. Even with like, as I said before, even with the best treatment, people are tormented and disabled by their symptoms. And the treatments that we have make people fat, they make people gain weight, they make people diabetic, they give them premature cardiovascular disease. And on average, people with serious mental disorders die very early deaths. On average, they die. Depends on what study you look at. But on average, they probably die about 20 years, early deaths. So, they use lose 20 years of life. And so, anything, even if it's got toxic side effects, anything that improves the symptoms dramatically, and gives people their life back, let alone this, which oh, the side effect is weight loss and diabetes remission and all of that. Yeah, not getting hard. I mean, I'm like, wow, this is like really phenomenal. And so, lo and behold, I started searching the literature, I was using this with many more patients, I started collaborating with researchers all around the world. I learned that Eric Westman had had a similar case that he reported at first in 2009, but that nobody had really done anything with that since that case report. There was a small pilot trial way back in 1965, which for the most part, nobody knew about, nobody talked about, nobody even heard about, but I found it in my literature search. And there were just a tiny handful of other case reports using this treatment for bipolar disorder. And so, at that point, I started publishing, as I said, collaborating with a lot of people, publishing case series, small clinical pilot trials and others. And since then, there's really been an explosion of interest in the ketogenic diet for mental disorders. This has the attention of some of the leading psychiatrists and neuroscientists in the world, who are also publishing science reviews. So even though they themselves are not necessarily using the diet yet in patients, they are they are doing exhaustive reviews of the science of what do we know about this ketogenic diet in neurology, and how is it stopping seizures? And then how could those mechanisms pair up with what we know about brain abnormalities and people with mental disorders? And in fact, it's a match made in heaven in many ways. Numerous ways. So, this diet changes neurotransmitter systems. So, it's consistent with the chemical imbalance theory of mental illness. It's rebalancing chemical imbalances. It improves insulin signaling, and insulin... Most people know insulin as it relates to type 2 diabetes, even type 1 diabetes. But insulin actually has profound effects on brain function that are insulin receptors located throughout the brain and has profound effects on brain function. And we know that high levels of insulin resistance are associated with serious mental disorders, like bipolar disorder and schizophrenia and chronic depression. And so, this diet improves insulin resistance. And so that might be one of the mechanisms of action. The diet decreases brain inflammation. It changes the gut microbiome. And there are some scientists who believe that actually might be the primary mechanism of action for its brain effects. And its anticonvulsant effects. It’s the way that it changes the gut microbiome in beneficial ways. And I could go on and on it does many other things to metabolism and brain function. And so
 
Dr. Philip Ovadia  25:44
I was gonna jump in at this point, what is your perception of how many patients with mental health disorders have overt metabolic syndrome? And in patients who you deal with that don't have overt metabolic syndrome? Do you still see the same improvements with ketogenic diets?
 
Dr. Chris Palmer  26:12
It's a great question. So, I think the answer to your first question, it depends on the diagnosis, it depends on the patient and how long they've been in treatment, and what treatments are getting. So, one of the biggest challenges in our field is that the treatments that we give antipsychotic medications in particular, but also mood stabilizers, and some antidepressants, as I said, cause weight gain, they cause diabetes, they cause metabolic syndrome. And so, a lot of people in the field, there are a lot of just patients and family members think that that is the primary cause. It's the medications. So, if you're diagnosed with schizophrenia, the reason you have metabolic syndrome is because the pills that they're giving you. It turns out that there's no question. The pills that we are giving people are absolutely positively making the problem dramatically worse, there is zero doubt about that. However, that isn't the whole story. So, the connection between for instance, diabetes, and schizophrenia and bipolar disorder has been observed since the 1800s, even before we had antipsychotic, and mood stabilizing medications. And we have several studies. Recently, in the last five years, that I've looked at patients who come in with their first episode of bipolar disorder, or schizophrenia, and they already showed signs of glucose dysregulation or insulin resistance before we even give them one pill. And so, I would say in terms of the total number, probably a decent average for people with chronic serious mental disorders relatively recently diagnosed, at least probably 50%, especially if they're taking antipsychotic. I mean, it's as soon as you say they're taking antipsychotics and they've been on them for more than a year, that number is gonna go way up, because the rates of obesity and the chronically mentally ill are – it depends on what study you look at. One meta-analysis, of all of the studies done, suggests that patients with serious mental disorders are about three times more likely to have obesity than patients without mental illness. Three times and it's kind of like how do you even get to three times when the rates of obesity are so high?
 
Dr. Philip Ovadia  28:47
40% that baseline
 
Dr. Chris Palmer  28:49
You’re going above 100% now and like but so, but the rates are very high in the chronic mentally ill so. But the interesting news is some researchers at McLean Hospital, where I work, have done studies on this and they have actually found signs of brain glucose, glucose hypometabolism which may be suggestive of insulin resistance or a problem with insulin signaling. So, insulin and I'll just say to make it more complicated, insulin in the brain is different than insulin in the rest of your body. So, most people know insulin as like a lock and key thing. It lets glucose into the cell. In the brain, that's not necessarily always true. There are probably some cells in which insulin might play a role in glucose getting inside the cell but for the most part, glucose can get into brain cells and so insulin appears to be more like a hormone or neurotransmitter in the in the brain that regulates brain metabolism more broadly.
 
Jack Heald  30:13
So, insulin in the brain, it acts more as a neurotransmitter?
 
Dr. Chris Palmer  30:20
Almost. And so. But the researchers at McLean Hospital did some studies of people with schizophrenia, their siblings who did not have a mental illness, and then normal healthy controls. And what they found is that both the patients with schizophrenia and their siblings had high levels of insulin-resistance or insulin-signaling problems in the brains compared to the healthy controls. But that...
 
Jack Heald  30:56
Does that imply there's a genetic component to it?
 
Dr. Chris Palmer  31:01
Well, it implies that that might be a risk factor that runs in families. And most people would assume it is genetic, I actually don't think it's necessarily genetic, but it does run in families.
 
Dr. Philip Ovadia  31:16
And he just raised in a similar environment, eating similar foods, leading well anabolic changes.
 
Dr. Chris Palmer  31:22
It could be that or it could even be just the womb environment. So, the womb environment affects a lot of epigenetic signaling. And, and so if your mother, for instance, is insulin resistant, she can pass that on to you not through genetics, per se, but through epigenetics. So, the reason I make that clarification, and the reason I think it's really important clarification, is because when people say it's genetic, everybody assumes you're screwed. If it's written in your DNA, there's no way to change it, you are just screwed. And we actually have an abundance of evidence, because we've mapped the human genome, we have had the map for over 20 years, it is not in the genes. So more than likely, this is being transmitted epigenetically. And the reason that to me is such a hopeful message is because epigenetics can be changed. You can change your epigenetics; you can't change your genetics right now. But you can change your epigenetics. And so even if this is something that runs in your family, it doesn't mean that it's hopeless, you can do something about it. And there's something that you can do is lifestyle interventions, diet, exercise, and other things can change your epigenetic patterns and can actually reverse diabetes. And in my experience now, at least in some cases, reverse chronic severe mental illnesses.
 
Dr. Philip Ovadia  33:07
I think we really need to emphasize that part of it, that giving hope, to these patients who have told there is no hope and they're coming to you with these chronic severe mental conditions, they're coming to me with advanced heart disease, they're battling obesity their entire lives. And they've been told there's no hope, and the power of these interventions to give people hope, and they get these results. I will say being at the metabolic health summit a few weeks ago with you and the session that you did with your patient to just get their stories out there of how there is hope in what seems like a hopeless situation is just so important.
 
Dr. Chris Palmer  34:03
Yeah, I completely agree. And if, again, if you had asked me nine years ago, do I think there's a lot of hope for people with schizophrenia or bipolar disorder, I would have said the party line, I would have said, well, it's a chronic brain disorder, probably runs in family, we think it runs in families. So, it's probably genetic. And that means that it's written in your DNA, sorry, there's not a lot we can do. We're doing our best. The treatments suck. We're all waiting on a miracle or we're waiting on some genius to figure this all out. Then in the meantime, you just have to suffer and be disabled and I don't believe any of that anymore.
 
Jack Heald  34:47
So, talk about the environment in your specialty, and how this new way of thinking has been received in your field and are we seeing it propagate through the discipline of psychiatry.
 
Dr. Chris Palmer  35:09 
So, we are in the early stages right now. The really kind of almost dumbfounding to me, at least, kind of reality is that this has been extraordinarily well-received. I have been shocked at how easy it has been to persuade mainstream psychiatry to take this seriously. And so, getting mainstream psychiatry to take the ketogenic diet seriously was actually pretty easy. And it was pretty easy because again, it's an evidence-based treatment for epilepsy. So, I focus on the science and the brain science, and I don't really talk about this diet as a weight loss diet. I don't talk about it as a trendy diet, I don't talk about it as a diabetes treatment, I talk about it as an evidence-based epilepsy treatment. And we use evidence-based epilepsy treatments in psychiatry every day on millions of people. And as soon as I say that, and present the science and present the data, I have most psychiatrists and neuroscientists’ attention, they're like, either they knew it already. And they're like, okay, I'm listening, or they didn't know and they're like, tell me more like, I had no idea, that two Cochrane Reviews like that's a gold standard meta-analysis in the medical field. And we have two Cochrane Reviews that were positive for ketogenic diet for epilepsy. So that gets people's attention. And people are really interested and excited. My work, so, we actually have at least five clinical pilot trials getting underway of the ketogenic diet for bipolar disorder, and/or schizophrenia now. So those are the next steps in the medical field to really advance a treatment. There are trials getting underway for the treatment of major depression, for the treatment of PTSD, the National Institute of Alcohol Abuse and Alcoholism. Our federal government just did a study of the ketogenic diet for alcoholism, believe it or not, and it was a positive study, it worked.
 
Jack Heald  37:31
Expand on that, what does that mean that it was a positive study?
 
Dr. Chris Palmer  37:34
It was a pilot study, I think about 40 participants, and they admitted them for a detox at the national government building. And they assigned half of them to the standard American diet, and the other half got a ketogenic diet. They did brain scans, tons of blood tests, and a traditional detox. And what they found is that the patients who got the ketogenic diet required less detox medication. In spite of getting less medication, they had fewer withdrawal symptoms from alcohol. They reported fewer cravings for alcohol. And then they did brain scans on these people and the people who are getting the ketogenic diet had improved brain metabolism in areas that are known to be affected in alcoholism. And they also had reduced brain inflammation, which they also think might be playing a role in chronic alcoholism. 
 
Jack Heald  38:47
How's brain inflammation measured? What does that even mean?
 
Dr. Chris Palmer  38:51
Well, that's the thing. As soon as you get into details, there are lots there lots of ways to measure brain inflammation. So, off the top of my head, I cannot recall the specifics of what metric these researchers used. But this was coming from the federal government and Nora Volkow, and she's like a world premiere leader. And so, I'm gonna trust she said, decreased brain inflammation, I'm going to just decrease brain inflammation.
 
Jack Heald  39:20
Could this be the same mechanism that's involved when just your average overweight Joe reports that in addition to losing weight, when I went on this diet, my brain fog cleared up? Is that the same thing that's going on?
 
Dr. Chris Palmer  39:35
Yes, I think it is. And depending on who the person is, and how serious some of that inflammation is. We know that brain inflammation is related to obesity itself. And it's interesting, so in animal models, so mouse models primarily, we know that when they feed mice, obesity-inducing high-fat diet, so it's not just the fat, it's also sucrose and other crap that they put in those foods. But researchers have concocted a specific diet that almost universally makes mice fat. And when they feed mice this diet, their brain becomes inflamed first, that is the first thing that happens. They first get brain inflammation, that then affects the feeding behavior centers, and the reward centers in the brain which can then lead to overeating, which can then also affect whole body metabolism because your brain plays a role in your body's burning calories. And, and so this brain inflammation seems to be a key part of the pathway. I don't think it's fair to say it is the key pathway. Some people would say that I don't feel like we have the evidence to actually say that, but we know that it comes first. And then the mice get fat. When researchers tried to interfere and prevent the brain inflammation, oftentimes, it mitigates the damage of that high-fat diet. So, the mice can still be eating that same diet, and it can mitigate some of that damage.
 
Jack Heald  41:37
So, make it entirely a bit of leap. Eating crap affects your brain first.
 
Dr. Chris Palmer  41:48
Yes, it does. And that might be playing through the gut. Because we know the gut and the brain communicate with each other. And they're directly connected through nerves. But there are all sorts of hormones and neurotransmitters even being released from your gut that affect your brain function. So, one interesting little factoid, 90% of the body's serotonin is in your gut, it's not in your brain. So, everybody knows serotonin is a happy molecule, because that's supposed to cause depression. But the overwhelming majority of it is found in your gut, it's not found in your brain.
 
Jack Heald  42:30
When you say found in, that means when it's circulating in your system, it's primarily circulating in your gut?
 
Dr. Chris Palmer  42:35
Well, the gut has its own nervous system. And the cells of the gut also produce a variety of neurotransmitters and hormones that do get released into the bloodstream and then travel throughout the body, including to the brain and have effects. And so yeah, so the nervous system...
 
Jack Heald  42:58
We're going way down. Here, this is, this is...
 
Dr. Philip Ovadia  43:04
You're blowing Jack’s mind, again,
 
Dr. Chris Palmer  43:06
All of this is what I would call metabolism. Totally, this is all metabolism. This is what metabolism is, this is what metabolism, how it works. It is it's ridiculously complicated. And yet, it is all connected. What's happening in your gut is influencing the entire rest of your body. I'm a psychiatrist. So, I love the brain. And I think the brain is kind of the control center of the human body. Now, some cardiologists might disagree, feel pretty strongly. The heart actually uses the most energy per like square inch of any organ in the human body, even the brain. Even the brain does not beat the heart, the heart is the energy consuming organ of the human body. So, I will throw you that bone. But otherwise, I love the brain.
 
Dr. Philip Ovadia  44:09
Well, it's just and it's kind of amazing that we have gotten to this point in medicine where we don't think these things are all... We think that a diet that can improve gut health and improved brain health can be damaging the heart at the same time or vice versa. So, it really doesn't make any sense that we don't realize that this is all interconnected, and one thing is going to affect the other. I want to kind of follow up on some Jack was asking you about your psychiatric colleagues and how they received it. But I do want to bring up that you're at Harvard. And there's the nutrition school at Harvard, that is one of the most vocal opponents of ketogenic diets out there. What has your experience been around that talking to your colleagues at Harvard and in the Harvard system?
 
Dr. Chris Palmer  45:07
So, the real answer is Harvard is a huge, huge place. And it is. It encompasses numerous hospital entities and schools of health. And it's got the college and all of the graduate schools and everything else so I don't run in to Walter Willett on a daily basis. He doesn't accost me, or argue with me. Because Harvard is such a huge place, we have a lot of different opinions. And so, David Ludwig is at Harvard. We have a harvard medical student, Nick Norwitz, who is a vocal, ketogenic diet proponent because it improved his health dramatically. We have ketogenic epilepsy centers at Harvard hospitals. We have a lot of ketogenic diet researchers doing basic science research on the ketogenic diet, for cancer, for diabetes, for brain disorders, and for weight loss. David Ludwig is certainly doing a lot of weight loss stuff with low carb and keto diets. So, Harvard is a big place, there are lots of opinions there on all sides of the fence. So, Walter Willett does not speak universally for Harvard. Nor do I. I don't speak universally for Harvard either. The one thing that I will say is again, so I'm at McLean Hospital, which is a psychiatric hospital only. That's what we do is we specialize in psychiatry only. And the reception that I've gotten there has been phenomenal. Phenomenal. So, I have a book coming out on a much deeper dive of all of this, and the hospital is ridiculously supportive of everything I'm doing all the way to the chair, the chair of the board of trustees, the president of the hospital, all of them are aware of it. Some of that is because I'm getting donations from some wealthy philanthropists. And that gets the attention. That gets the attention of the leadership, and then the leadership loves what you're doing. So, that could be playing a little bit of a role. But there are researchers at McLean Hospital, where I've been for 25 years, there's a whole group of researchers who have been looking at the metabolic basis of have schizophrenia and bipolar disorder, and in particular, mitochondrial function and dysfunction as they relate to these disorders. They've been doing that work for over 20 years now. And they are actually some of the world's leading authorities in this work. So, when I first talked to them about using the ketogenic diet, one of them actually said, “we tried to do a study on the ketogenic diet like a couple of years ago, but we couldn't find a dietician or anybody to work with us. Like, there's no way you can get a schizophrenic patient to do this diet. Are you telling me you've gotten a schizophrenic patient to do this diet?” They were coming at it from the science angle, they had never done a keto diet. And this researcher actually said to me, “I wouldn't be able to do that diet. It sounds so restrictive and awful, like I wouldn't be... So how could I get a schizophrenic patient to do that?” And I'm like, “yeah, no, I am getting schizophrenic patients and patients with bipolar disorder and chronic depression. I'm getting them to do the diet.” And he's like, “what does it do? Does it actually work?” I'm like, “yes, it works. Like it's shocking how well it works.” So, he came at it from the science angle, based on all of the basic neuroscience that he's been doing for two decades. And knowing the neuroscience literature on the ketogenic diet, and thinking like, this is a match made in heaven, but you can't get anybody to do the diet. And then I come at it from a more pragmatic stance, because I've been doing the diet myself for 20 years, and I know how to do the diet. I know how to get people to do the diet. So, I can combine both the science but also just the pragmatic art of how do you get people to do this and so we're actually working together on putting together a study now. People are, yeah, the reception at Harvard in general has been extraordinarily positive for me. And I really have been blown away at how positive it's been.
 
Dr. Philip Ovadia  50:24 
Yeah, that's good to hear. The other thing that I think is maybe positive to bring out about your story is, as opposed to... We've had many physicians on here who have talked about the difficulties of sort of staying within the traditional system, and instituting metabolic therapies to help their patients. But you've been able to find a way to do that successfully. So, talk about what that's been like. And it might be the psychiatric practice is maybe a little different than the traditional family practice. You don't have the 15-minute visits forced upon you, like many of the family physicians do, but talk about the challenges of just instituting this in your practice on a daily basis. 

Dr. Chris Palmer  51:24 

So, I think you hit the nail on the head is the luxury that I have is that I can sometimes see patients for 50 minutes sessions once a week. And, and so normally those would be for quote unquote, psychotherapy, but I can use them for anything I want. If that's medically indicated, I'm not saying I'm just talking about nothing, but in this case, I'm implementing a treatment, patients need a lot of education, they need a lot of coaching, they need a lot of support. And so, I can do this treatment. So usually, when I start the treatment with patients, I give them reading material. I give them several websites to go to and just get information on it. I encourage them to do as much of that as possible. But I always have at least probably two or three sessions with them, where we are talking very pragmatically about what is this diet going to be like? I have found one of the keys to my success is that I tell people up front to expect a living hell for the first two weeks. And some people in the Keto community are like, why would you say... Don't diss our diet. And I'm like, no, you have to diss the diet, because if you don't diss it, people are going to be horrified or terrified when they feel bad. If they start experiencing keto flu, they are going to think something has gone terribly wrong, or that you don't know what you're talking about. And they're going to quit the diet because they're not feeling good. So instead, I go the other extreme, I say the first two weeks are going to be a living hell, you're gonna feel weak, dizzy, lightheaded, you're gonna feel hungry as hell, you're gonna have cravings so irresistible, it's gonna be awful. But I'm gonna get you through it. And we are going to do it together. And we're going to talk about that for two or three sessions. And we're going to talk about what you are going to do, you're going to eat and you're going to eat a lot, and I don't care about weight loss or anything else in the first week, what I care about as ketosis. I want to get you in ketosis. And once we get you there, things will start getting easier. And then we'll worry about the weight, if weight loss is one of the goals. It isn't always because sometimes I am treating thin patients who have a psychotic disorder. And so, I'm really targeting their brain physiology, not their weight or fat stores. 

Jack Heald  54:25 

That's fascinating to think about it that way, that you're using this particular way of that, everybody on this show, what, we're 50 episodes into it now talks about the body, but you're specifically targeting brain function using this particular way of eating or the effects of this particular way of eating. That's an interesting spin. 

Dr. Chris Palmer  54:46  
And it does in many ways set me apart from many people in the Keto community because a lot of people in the low carb and keto community will kind of say, well, this is the way everybody should eat, or will say this is proof that sugar causes whatever illness they're trying to target. And I don't. I think there is some truth to those statements. But I don't say those things. And I don't believe that's always true for people. So, an extreme example, you're gonna have a child, an infant who is breastfeeding to a metabolically healthy mother. And that child can have epilepsy. That child isn't eating a bad diet. That child has epilepsy for some other reason. But nonetheless, a ketogenic diet can stop the seizures in that child, often. And so, it's not that you're getting rid of a quote unquote, bad diet, it's that you're doing a metabolic intervention. And you're changing brain metabolism to restore normal brain function and promote healing in the brain. And that's the way I think about and use this intervention. Even though I, myself, have primarily been on a relatively low carbohydrate diet for over 20 years, and I am convinced that that works for me. And so, I'm very familiar. And I'm not anti, that other model of keto, or low carb diets can be good for general health and can be a lifestyle. I'm 100% agree with that. But when I'm using this in people with treatment in with serious mental disorders, I'm thinking about it is a very different intervention. And so back to the patients, so I do this education, warn them, and if they're coming in person to see me, I am monitoring their ketones and their glucose levels and their weight, which is invaluable, because if they don't have ketones, and we're having a conversation about what's going on, what are you eating? And they can be swearing up and down, that they're doing the diet and I can look them in the eye and say, no, you're not because you don't have ketones. And, and I'm not saying that you're lying to me, but clearly, whatever you think you're doing that's right isn't right. So, we need to do some detective work, like, and sometimes it's as simple as they're chewing gum, sugar gum. Sometimes it's as simple as they thought they... I've had one patient. Well, my other doctor told me I have to eat a banana every day. I have to because that's good for potassium. I'm like, well, the banana needs to go, that's not on the list of foods. You can't have a banana, I'm sorry. And so sometimes, a lot of the patients really are trying their best that they just need more education, they need more coaching, they need help to get through it. 

Jack Heald  58:09 

I'd like to try to untangle a knot that I realize is in my thinking that I think you're doing but I'm going to try to articulate this question. Being a layman... in brain science or psychology or any of that stuff. When I hear the term illness, I also think about all the words. Mental illness means in screwed up. Hearing you say is that... I think you use the phrase chronic mental illness, chronic brain disorder. What I'm hearing is that at least some of these aren't a thinking issue. They're an issue, the lump of gray matter in your skull. That's what the problem is. The electrochemistry, the hormones, that stuff. I realized that may sound like a silly question, but... 

Dr. Chris Palmer  59:21 

It is a brilliant question. And so, this is an issue that has plagued the mental health field ever since the mental health field existed millennia ago. And so right now, DSM doesn't separate, necessarily, what we might call normal depression that lasts for more than two weeks from pathological depression that's occurring for no reason. So, in other words, if you are happily married with two children, your wife and two kids get killed in a car accident, you become depressed. Most people would say that's normal. That's not a disorder. That's not a mental illness. That's not a mental illness, that's normal. That's called being a human being who loved his wife and two kids. If your depression lasts for 15 days, DSM - 5 says you now have a mental illness. So, it's a day 13, you didn't have a mental illness, at day 15 it switched over to a mental illness. And that alone just lacks common sense. That just completely lacks common sense. So prior versions of DSM, allowed for two months of grief, with some caveats. But it's one of the conundrums and kind of even defining, well, what is mental illness. And because everybody gets anxious at times. Everybody has been... most people have been depressed even for a few days if something bad happens to them. And I don't think of those as mental disorders, I think of those as normal human mental states. And for those, if you're having one of those things, then talking to somebody about it can be immensely helpful. And that may be all you need to do is talk to somebody about it, because you just need support, you need human compassion... 

Jack Heald  1:02:09 

You're going through a human issue that humans can help each other with, just by connecting emotionally... 

Dr. Chris Palmer  1:02:17  
By kindness and compassion, and then empathy and all of that. However, there are other people who can develop that exact same depression, for no reason whatsoever. No reason whatsoever, as far as we can tell. In other cases, people with pancreatic cancer, that this is a classic one in textbooks, at least, people with pancreatic cancer often develop clinical depression before they get diagnosed with pancreatic cancer. So that cancer itself seems to be causing depression. So, these people get depressed out of the blue for no good reason. And then a few months later, get diagnosed with their pancreatic cancer. And then we know, oh, the cancer must have been causing that depression that you're experiencing. Now, in those cases, it's not a normal reaction. So, I think of those as disorders of brain function, that something is happening in the body or the brain that is impacting the function of those same circuits, those same circuits that exist to make that man who loses his wife and two kids depress, those same circuits exist in all of us. But if those circuits get inappropriately activated, if they go off at the wrong time, then I would call that a mental disorder. If those same circuits failed to turn off, so if that man remained severely crippled depression for five years, five years later, he still can't get out of bed. He can't find a way to go on with his life. I would say that man probably has a mental disorder. At some point, people have to move on, no matter how tragic something is, at some point, people need to move on with life. It doesn't mean they need to forget about the person. It doesn't mean they need to be heartless. I'm not trying to say that they just should forget about the wife and kids, or even move on to another relationship, but they have to, they have to start moving on with life and re-engaging with society. And if they're not able to re-engage with society, then that might be a mental disorder, I would probably say it is. And then there are extreme examples, somebody's hallucinating, talking to themselves. They're delusional. They're paranoid all the time. They're convinced of so many things that aren't true. I think in everyone's mind, that is a mental illness. And those mental illnesses represent the brain malfunctioning. And talking to people about your brain malfunctioning usually doesn't help a whole lot. In some cases, it can that be helpful... 

Jack Heald  1:05:17 

What I'm hearing is that that we can have two different causes present with the same, apparently, same effect. Sometimes the cause is just a natural part of life. But sometimes the cause that looks exactly the same in terms of the symptom, sometimes the causes, you got a problem in your brain, you'd literally have a biological or chemical issue that that we're finding can be resolved by getting your body into a state of ketosis. And my guess, is also that normal depression is probably not as strongly affected by being in a state of ketosis. the guy who lost his wife, he's probably still gonna take a little time.  

Dr. Chris Palmer  1:06:15 

He could be on a ketogenic diet when the wife and kids got killed. And I don't know that I don't think that the ketogenic diet would protect him from having a depression reaction. And in many ways, I think all of us would probably be horrified if he didn't get depressed. Even if he was on a ketogenic diet, because that would mean he's not even human anymore. Like he's lost all of his compassion and love and attachment to other humans, like that would not be a good thing to be happening. So, yeah, so I think that there are normal mental states and mental disorders. And unfortunately, the mental health field right now does not do a good job of distinguishing those. 

Jack Heald  1:07:06 

Okay, but that did help me. That helped to clear up some of my thinking in that regard. I appreciate that. 

Dr. Philip Ovadia  1:07:13 

And this has been a great discussion, Chris. I think, Jack, season three is just going to be inviting all our season two guests back on for part two of the discussions. Or we need to get Joe Rogan style and have three-hour podcast soon. But before we go, I definitely want to hear about the book, Chris, I'm certainly excited for the book. Tell us a little bit about it, what it's called when it's coming out and where people can get it. 

Dr. Chris Palmer  1:07:42 

Thank you. So, the book is called Brain Energy. If you go to my website, you can search for it on Amazon, or any bookseller, it's available for pre-order already, but it doesn't release until November 15. And the book represents the work I've been doing for the last five, six years now. Trying to understand how in the hell does a ketogenic diet cure, for all intents and purposes, schizophrenia, because it was really mind blowing to me. And essentially, what I what I came up with is I came up with a, kind of this is gonna sound crazy, but I came up with a unifying theory for all mental illness 

Jack Heald  1:08:29 

Well, I gotta tell you, that was the first thing I thought when you started talking was, oh, my God, this sounds like they're made. Yeah, please go. 

Dr. Chris Palmer  1:08:38 

And so, the in a nutshell, the unifying theory is that mental disorders are metabolic disorders of the brain. And in my book, I do distinguish what we were just talking about. There's a difference between a mental disorder and a mental state, a normal human reaction. So, depression is not always a mental disorder. But when it is a mental disorder, it is a metabolic disorder of the brain. But this applies to all mental disorders, alcoholism, schizophrenia, eating disorders, all mental disorders, can be tied to metabolic abnormalities that essentially are causing the brain to malfunction. In essence, that's what it is. So, the different disorders have different symptoms, because different areas of the brain can be affected by metabolic problems. And so, if one area of your brain, it's like the depression pathways of your brain are metabolically compromised, you're gonna have depression symptoms. If the pathways of your brain that affects OCD symptoms are affected, you're going to have more OCD symptoms, and on and on. But the thing that I love about this theory is that although it may sound like it's new, and in some ways, it is like. Not many people are out there saying all metabolic disorders, or all mental disorders or metabolic disorders of the brain. I've never heard anybody say that myself. But basically, all I've done is I've taken all of the existing literature that we have accumulated over the last 100 years. So, all of it. All of the neuro imaging research, all of the biomarker research, the inflammation research, but also the psychological and social research, like why does, why does trauma lead to mental disorders in so many people? How does stress lead to a mental disorder? All of these things, how does it all fit together? The thing I love about this theory is that metabolism and more specifically, mitochondria, which are the regulators of metabolism, can connect the dots of the mental health field. And once the dots are connected, it presents new treatment pathways. And obviously, to you and this audience, the ketogenic diet is one of those treatments. But it's not the only one. There are many other treatment pathways that open up once you understand this paradigm. And, and so far, I'm actually getting really good reviews. The most exciting thing is just in the last two days, I got a very positive endorsement of the book, which will soon be a public endorsement from one of the leading psychiatry researchers in the world who thinks that this is maybe the first step toward finally, once and for all, disease-modifying treatments for people with mental illness. So instead of treating their symptoms, and letting them suffer for the rest of their lives with chronic debilitating disorders, maybe we can begin to reverse and effectively treat some of these disorders. 

Jack Heald  1:12:15 

That's a great place to start, but I hope we're not done. 

Dr. Philip Ovadia  1:12:22 

Now, we're certainly not done... 

Jack Heald  1:12:24 

There’s so many things I want to ask, but we're, we're here. So, all right. Yeah.  

Dr. Philip Ovadia  1:12:30 

Thank you. Well, thank you Chris. Before we go tell everyone where they can find you. The website or social media where they can connect with you.
 
Dr. Chris Palmer  1:12:42 
Best place to connect with me and the book if you're interested in the book is right on my website, ChrisPalmerMD.com So Chris Palmer, MD all one word, dot com and if you're interested on social media, I tend to be most active on Twitter. So, you could follow me on Twitter if you want. 

Jack Heald  1:13:05 

Excellent. In the show notes. Listeners, thanks for this one Chris. Here I am. I'm just speechless. This is amazing. I can't wait to read the book. I want to ask all the questions that I still have in the next time we talk to you which I hope will be here in the next six months or so. Do keep hitting it out. Really good fun. This is the Stay Off My Operating Table podcast. Our guest has been Chris Palmer, MD. If you'd like to  learn more about him… Doctor metabolic health quiz. You can take it ifixhearts.co and you can follow him on Twitter @ifixhearts. And I can't wait for the next one. I'm Jack Heald. We'll talk soon.