Most people have heard of the high-fat, low-carb “keto” diet for weight loss and blood sugar control, but a therapeutic ketogenic diet (TKD) is different (read more here). A therapeutic ketogenic diet is a type of medical nutrition therapy used as adjunct treatment for specific physical or mental health conditions that is either prescribed by a Physician (doctor) and implemented by a Dietitian, or implemented by a Dietitian under Physician oversight.
In a therapeutic ketogenic diet, the amount of protein, carbohydrates, and fat is carefully controlled to keep ketone levels steady throughout the day, and both glucose and ketone levels must be monitored so that a specific therapeutic level called the Glucose to Ketone Index (GKI) is achieved.
Therapeutic ketogenic diets have been used for over 100 years for epilepsy and diabetes, and more recently, in the treatment of various mental health disorders, including depression, bipolar disorder, and schizophrenia.
Therapeutic Ketogenic Diet for Mental Health
A 2022 study in Frontiers in Psychiatry included 31 adults with treatment-resistant depression, bipolar disorder, or schizoaffective disorder in a psychiatric hospital in Toulouse, France. They followed a therapeutic ketogenic diet that restricted carbohydrates to 20g per day. Of the 28 individuals who stayed on the diet for more than two weeks, all showed symptom improvements within three weeks. Forty-three percent achieved full remission, and 64% were discharged on less psychiatric medication [1].
Other pilot studies show similar results in bipolar disorder and schizophrenia [2][3].
“Brain Energy” Book – role of therapeutic ketogenic diets
The release of the book Brain Energy by Harvard Psychiatrist Dr. Chris Palmer in 2022 brought public attention to the role of therapeutic ketogenic diets in mental health [4], which has led to an increase in inquiries about using them.
But what is a therapeutic ketogenic diet?
Types of Therapeutic Ketogenic Diets
Therapeutic ketogenic diets are a form of medical nutrition therapy using a specific ratio of fat to protein plus carbohydrate.
Classic Ketogenic Diet (KD)
The Classic Ketogenic Diet has a 4:1 ratio, which means 4g of fat is provided for every 1g of protein plus carbohydrate. This diet is 80% fat and protein may be set at 15% of calories with a maximum of 5% of calories coming from carbohydrate, or protein may be set lower at 10%, and carbohydrate as high as 10%. This type of diet is used when the need to achieve and maintain high levels of ketones is necessary.
Modified Ketogenic Diet (MKD)
The Modified Ketogenic Diet (MKD) has a 3:1 ratio, which means 3 parts fat for every 1 part protein and carbohydrate. This diet is 75% of calories from fat, and 25% from a combination of protein and carbohydrate. Protein may be set at 15% of calories, with a maximum of 10% of calories coming from carbohydrate.
Some Psychiatrists will start their patients on a 3:1 therapeutic ketogenic diet. Once their patient is producing significant levels of ketones and is stable with respect to symptoms, they may gradually have them transition to a Modified Atkins Diet (2:1) while monitoring their symptoms, as this can be easier to maintain long-term and is more suitable for those who cannot tolerate very high-fat diets.
Modified Atkins Diet (MAD)
The Modified Atkins Diet has a 2:1 ratio, and is only 60-65% fat, and is used in specific mental health conditions that do not require the higher levels of ketones that can be produced using a Modified Ketogenic Diet (3:1).
As mentioned above, some Psychiatrists will start their patients on a 3:1 therapeutic ketogenic diet, and once the desired level of ketones has been achieved and the person is stable with respect to symptoms, they may gradually transition them to a Modified Atkins Diet (2:1).
Calculating Ratios Based on a Percentage of Calories
As a Dietitian who designs therapeutic ketogenic diets, the first step is to determine the amount of energy (calories, in kcal) the individual needs. Then, I calculate the percentage of calories that need to come from fat, protein, and carbohydrate based on the specific dietary prescription.
Meals of therapeutic ketogenic diets are much smaller than conventional meals because they are higher in fat. Fat provides the same number of calories for much less mass (weight, in grams), so to get 500 kcals as protein, one would need to eat 125g of protein, but to get the same amount of calories as fat, one would only need to eat 55.5 g of fat. Fat is much more calorically dense, providing 9 kcal/g, whereas protein and carbohydrate have only 4 kcal/g.
A Dietitian’s Role in Therapeutic Ketogenic Diets
In a recent Psychiatry and Psychotherapy podcast where Dr. Chris Palmer was interviewed, he talks about how Psychiatrists can incorporate the use of a therapeutic ketogenic diet in their practice [8]. The first thing he said was that there was a need for the physician to determine if this approach is appropriate for a specific patient.
As outlined in a 2018 article titled “Don’t Try This at Home – when medical supervision is needed“, following a ketogenic diet needs to be done with the knowledge and oversight of one’s doctor — especially when taking specific types of medication such as;
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- insulin (or insulin analogues)
- medication to lower blood glucose, such as sodium glucose co-transporter 2 (SGLT2) medication, including Invokana, Forxiga, Xigduo, Jardiance, etc..
- medication to control blood pressure, such as Ramipril, Lasix (furosemide), Lisinopril / ACE inhibitors, Atenolol / βeta receptor antagonists, etc..
- mental health medications such as antidepressants, medication for anxiety disorder, bipolar disorder (such as Lithium), and schizophrenia
Dr. Palmer recommends that doctors have their patients remain on their medication while starting a therapeutic ketogenic diet and be evaluated during the stages of ketosis to see if there has been any significant change in symptoms [6].
[People who follow a therapeutic ketogenic diet for medical reasons are often asked to track their Glucose-Ketone Index (GKI) so their doctors can monitor the benefit of the diet. I teach people how to do that.]
Dr. Palmer suggests that individuals should trial a therapeutic ketogenic diet for a period of three months [4], and if the doctor finds that the diet is helping, they may begin to gradually discontinue some medications. As mentioned in the “Don’t Try This at Home” article, changing dosages of medication is not something people should do on their own.
In the podcast, Dr. Palmer emphasizes that with the gradual decrease in medications, people are more reliant on the ketogenic diet to keep symptoms under control. The ketogenic diet is therapeutic; therefore, taking “cheat days” is not an option. Dr. Palmer notes that it takes several days to get back into ketosis after breaking the diet, and during this time, symptoms can dramatically reappear [8].
Dr. Palmer says that if a Psychiatrist is interested in beginning to use a therapeutic ketogenic diet in their clinical practice, they must be “well-informed on the science behind a therapeutic ketogenic diet, as well as metabolic functioning as a whole”.
Dr. Palmer recommends that doctors begin with the following first two steps [6]:
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Find a licensed Dietitian knowledgeable in therapeutic ketogenic diets and partner with them.
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Read the book “Ketogenic Therapies” by Dr. Eric Kossoff
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Dr. Eric Kossoff’s book, Ketogenic Diet Therapies for Epilepsy and Other Conditions, is one that I have referred to often in designing therapeutic ketogenic diets for different physical conditions.
Steps to Getting Started
If you are thinking of adopting a therapeutic ketogenic diet for improved mental health, then the first step is to reach out to your doctor and discuss it.
If your doctor is willing to oversee your health and medications while you adopt the diet, then the next step is to have them complete and return a Request for Medical Supervision Form by fax to our office.
More Info
Under the Services tab, you can learn about the 3:1 and 2:1 therapeutic ketogenic diets that I design, and where you will also find the corresponding Request for Medical Supervision Form.
To your good health!
Joy
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References
- Danan A, Westman EC, Saslow LR, Ede G. The Ketogenic Diet for Refractory Mental Illness: A Retrospective Analysis of 31 Inpatients. Frontiers in Psychiatry, 06 July 2022. https://doi.org/10.3389/fpsyt.2022.951376
- Sethi S, Wakeham D, Ketter T, Hooshmand F, Bjornstad J, Richards B, et al. Ketogenic Diet Intervention on Metabolic and Psychiatric Health in Bipolar and Schizophrenia: A Pilot Trial. Psychiatry Research, 2024 May 1,
https://www.sciencedirect.com/science/article/pii/S0165178124001513 - Campbell IH, Needham N, Grossi H, Kamenska I, Luz S, Sheehan S, et al. A Pilot Study of a Ketogenic Diet in Bipolar Disorder: Clinical, Metabolomic and Magnetic Resonance Spectroscopy Outcomes, Oct 2023,
https://www.medrxiv.org/content/10.1101/2023.10.23.23297391v1 - Palmer, C.M., J. Gilbert-Jaramillo, E.C. Westman. “The Ketogenic Diet and Remission of Psychotic Symptoms in Schizophrenia: Two Case Studies.” Schizophrenia Research. 2019 June; 208: 439-440, ISSN 0920-9964. https://doi.org/10.1016/j.schres.2019.03.019
- Sarnyai, Z, Palmer, C.M.,Ketogenic Therapy in Serious Mental Illness: Emerging Evidence, International Journal of Neuropsychopharmacology, Volume 23, Issue 7, July 2020, Pages 434–439, https://doi.org/10.1093/ijnp/pyaa036
- Norwitz, N., G.A. Dalai, S. Sethi; C. Palmer. “Ketogenic diet as a metabolic treatment for mental illness.” Current Opinion in Endocrinology & Diabetes and Obesity: 2020 Oct: 27(5): 269-274.
- Eastman, M., KetoConnect, The Ketogenic Ratio Explained, September 16, 2014, https://www.myketocal.com/blog/the-ketogenic-ratio-explained/
- Dr. David Puder, MD, Psychiatry Podcast, Episode 163, Dr. Chris Palmer: Ketogenic Diet for Mental Health, November 15, 2022, https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/163-treating-mental-health-disorders-with-a-ketogenic-diet
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