Metabolic Psychiatry: How Modifying Metabolism Can Create Mental Health, With Matthew Bernstein MD

The emerging field of metabolic psychiatry is revolutionizing mental health care by focusing on the connection between metabolism and mental health. Dr. Matthew Bernstein, a leading voice in this field, recently joined FMCA for an enlightening webinar. Drawing from over 20 years of experience in clinical psychiatry, Dr. Bernstein highlighted how addressing metabolic dysfunction through nutrition, exercise, and other lifestyle interventions can significantly improve mental health outcomes—even in treatment-resistant cases.

In this webinar, Dr. Bernstein discussed:

• The connection between metabolic dysfunction and mental health issues like depression, anxiety, and treatment-resistant conditions.

• How lifestyle interventions, including ketogenic diets, exercise, and circadian rhythm alignment, can reverse metabolic dysfunction and improve mental health.

• The critical role health coaches play in guiding clients toward sustainable lifestyle changes that support metabolic and mental health.

• Eye-opening data and case studies showcasing the potential of metabolic psychiatry to transform outcomes for individuals with mental illness.

This replay is a must-watch for health coaches eager to deepen their understanding of this cutting-edge field and enhance their impact on clients’ lives.

Watch the Replay

Metabolic Psychiatry: Understanding How Modifying Metabolism Can Create Mental Health, With Dr. Matthew Bernstein

Transcript

Patty: The field of metabolic psychiatry is developing thanks partly to our guest today, Dr. Matthew Bernstein. And in addition to being a respected clinical psychiatrist for more than 20 years, Dr. Bernstein is… Accord. You can look that program up. He’s chief executive officer and one of the leading voices in the emerging fields of metabolic psychiatry. Dr. Bernstein has developed his passion for community-based care as the chief medical officer of Ellenhorn, a sister program of Accord where he has pursued alternative ways. Now this is going to be interesting. Guess what these alternative ways are. Nutrition, circadian rhythm biology, mind-body approaches, exercise, and brain function. So, this is something that is at the core of health coaching, so not so alternative to this audience. And that’s really… He’s seen that this really helps individuals achieve their best levels of functioning without relying solely on traditional psychiatric approaches, which I’m assuming is medicine in that case. And then in addition to serving on the clinical advisory board at Metabolic Mind, Dr. Bernstein is also known for organizing the first-ever public conference on metabolic psychiatry in 2023. He’s doing amazing work. I learned about him from one of our graduates who’s working on an outpatient coaching program with him at Accord, and I’m just so honored to have you here today and passing on some of your wisdom in this area. So, welcome to the Functional Medicine Coaching Academy community, Dr. Bernstein.

Dr. Bernstein: Thanks for having me. I’m really happy to be speaking with all of you where the things I’m talking about are not alternative. That’s a great reminder. This is the core of what you guys do. And just to say that this is this field and the medical aspect thinking about metabolism to help mental health is pretty new. It’s been going on for maybe about a decade and really has been picking up steam in terms of interest and research money going into it. I really believe that, in the next few years, this is going to change how mental health care is delivered. And there are going to need to be an army of people who can coach individuals in how to do this. There’s no way that our current system of doctors, and therapists, and dietitians and the standard, sort of, medical team is going to be able to deliver all of this coaching. And so I’m really happy to be speaking with this group who is on the front lines of this.

So, first of all, we’re just going to talk a little bit about metabolism. This diagram is just to, sort of, show how complicated this is. We’re talking about literally thousands of biochemical reactions going on in cells. We’re not going to go into all the detail of that today. But this is essentially the process by which nutrients are converted to energy and also building blocks to maintain and grow cells. And it also includes the effective management of waste products from cells. And really this is fundamental to life essentially. You know, it’s at the foundation of living organisms.

So, why are we focusing on metabolism in the mental health arena? So, number one our population has had worsening metabolic health over recent decades following the USDA guidelines of eating three meals a day. The food pyramid, we’re going to take a look at that. Obesity rates have doubled in the past three decades, now over 40% in the U.S. The rate of diabetes in 2021 was 11.6%. Most of that, type 2 diabetes and it’s growing rapidly. There’s literally an epidemic of diabetes. In addition, 35% of people have pre-diabetes. Most of the people who have that are not even aware of it. And there was one study of young people, 18 to 44, where it showed that 40% of them already had insulin resistance and most of these people were non-obese. So, we’re not just talking about obesity here. We’re talking about metabolism. And there’s this new name for a diagnosis. It used to be called NAFLD or non-alcoholic fatty liver disease. It’s now called MAFLD, metabolic dysfunction associated fatty liver disease. There’s actually an epidemic of that going on as well. Now, 30% of the U.S. population has fatty liver. And almost all of that has to do with food, not alcohol. It used to be, back before 1980, almost everyone who had fatty liver disease had it due to alcohol and now it’s the opposite. It’s because of the way we’re eating and not moving. It’s now fatty liver disease due to nutrition and metabolic dysfunction.

But in addition, our mental health is worsening at the same time. So, the prevalence of depression in the U.S. went up from 7.3% to 9.2% in the 5 years between 2015 and 2020. It’s now significantly higher than that after the pandemic. People with severe mental illness also have significant excess mortality, meaning the lifespan is 15 to 20 years shorter in that population. So, that’s very important. Most of that is due to metabolic dysfunction. Some of that is due to medication-induced metabolic dysfunction, a good proportion of it. There’s also this bidirectional correlation between almost all the mental health disorders and metabolic disorders. So, if you have depression, you have a much higher risk of obesity, diabetes, cardiovascular disease, but it goes the other way as well. If you have obesity, diabetes, or cardiovascular disease, you also have a much higher risk of depression. And that’s true for pretty much all of the mental health diagnoses.

And not only that, metabolic disorders often precede the mental disorders. So, this one study that I’m citing here from JAMA Psychiatry in 2021 was really interesting. So, they looked at the kids with the highest level of insulin resistance by measuring their insulin levels at age 9 were three times more likely to develop a psychotic disorder by their early 20s. So, that’s really important and significant. In addition, the children who gained the most weight at puberty ended up being five times more likely to develop major depressive disorder. So, again, really interesting data showing that the metabolic dysfunction actually can precede the mental health disorder, and it’s highly correlated.

So, again, I just want to emphasize we’re not just talking about weight here. We’re talking about metabolism, and they’re not exactly the same thing. So, just to take a brief look at this slide. So, this is from 2021 study, 108 million people in America who were obese and then 150 million who were non-obese in this circle on the right. And then the dashed oval is the people with metabolic syndrome. Metabolic syndrome is defined as having at least three of these things over here on the right, things like elevated blood pressure, blood sugar, triglycerides, large waist circumference, and a low HDL, so all signs of metabolic dysfunction. If you have three of those, you have metabolic syndrome. That’s this oval here. So, you can see that it’s a higher proportion of the people who are obese who have metabolic syndrome, but there are plenty of people who are obese who did not have metabolic syndrome. And on the other side, there’s a larger proportion of these non-obese people who did not have this metabolic dysfunction but quite a few people were not obese and did have significant metabolic dysfunction. So they’re correlated to some extent, weight and metabolic dysfunction, but they’re not exactly the same thing.

Okay, I’m having trouble advancing my slide for some reason. Give me one sec.

Patty: Yeah, well, I wonder if this is a good… because I find that fascinating. Obviously, a lot of children… that best statistic about kids, they’re not really, unless they are overweight, are not being checked perhaps, or even if they are not being checked for metabolic dysfunction and that correlation between developing depression or some form of mental illness. And then also that so many people, because they don’t have weight gain or they’re not considered someone who fits maybe a physiological stereotype for that, that they can have metabolic dysfunction. And I’m wondering how health coaches can help in that way when working with clients and maybe what questions are they asking, so maybe that client goes on and investigates this area a little bit further.

Dr. Bernstein: Yeah, that’s a great question. I mean, I think just really being aware of that distinction between weight and metabolic dysfunction is very important because I think, in a lot of individuals’ minds, they say to themselves, well I’m not overweight. I’m fitting into my pants. I’m healthy. You know, I’m metabolically healthy. They just equate those two things in their mind. But meanwhile, that person might be eating a fairly unhealthy diet, not moving their body, and they’re really not metabolically healthy. And so I think encouraging people to get evaluated for some of these metabolic parameters, some of them are pretty easy to measure. Things like waist circumference and blood pressure are pretty easy to get done either at home or at the pharmacy. Some of these things are blood tests and would require… but they’re kind of things that are done routinely on an annual physical kind of blood test and certainly something that people can ask for their doctors to order or can get ordered pretty easily through an independent lab. So, I think the education piece is really key there.

Patty: Yeah, I agree. That’s great. Yeah, thank you. And encouragement and advocacy as always. Thank you.

Dr. Bernstein: Absolutely. Yeah. Okay. So, just a little bit about metabolism from an evolutionary perspective. So, we evolved… You know, before we were humans, we were proto-human hunter-gatherers, and then we were human hunter-gatherers. We had no capacity for food storage. We needed to hunt, and gather, and scavenge in very challenging environments. And there was always this cycle of feast and famine. That’s the milieu in which our brains evolved. Scarcity, which led to ketosis. We’re going to get into what ketosis is a little bit. And then there’s periods of abundance. And that was constantly going back and forth throughout our entire development. In many people’s view, that’s how our large brains developed is to solve the problem of finding food and with that metabolic milieu of switching back and forth in these different types of metabolism. So going back and forth essentially from a carbohydrate-based metabolism into a fat-based metabolism. And we’re designed to go back and forth in our evolutionary history.

It’s only in recent years since agriculture and especially in late agriculture through industrialization where we weren’t doing fat-based metabolism on a regular basis. And most people in our country are not metabolically flexible, meaning they can’t actually access fat for fuel, which is the way our bodies are designed. So the way we think about it is you got to keep eating, especially people in a carbohydrate-based metabolism in order to keep the fuel coming in to avoid being irritable, to avoid being low energy, etc. This is the state of insulin resistance or pre-diabetes or diabetes that most of us are in. But in our evolutionary past, that’s not what was going on. Our ancestors literally needed to, even if there was no food for a day or two days or three days, be able to be energetic, to be able to think clearly. And we’re all capable of that. We all have the genes to adapt to that way of living, but those genes have essentially been turned off through epigenetics.

So, not to get too deep into this, but essentially epigenetics is which genes are turned on and which are turned off, which ones are being expressed. So, if you’re eating carbohydrates all the time, all day long, you’re not expressing these genes that know how to metabolize fat, that know how to turn fat into ketones and turn fat into energy. So, we could talk about that one a lot, but I think I’m going to move on because that’s just, sort of, a sideline, I think, note of, sort of, the background of this.

Patty: Yeah. No, we’ll definitely follow up with some questions later about that. But, yeah, we’ll go ahead right now.

Dr. Bernstein: Okay. Yeah, I’ll just forge ahead a little bit. So, this is the way people are eating now. This is what we’re being told to eat. And generally, people do follow this. So, 50% to 60% of calories from carbohydrates. And of those, half are allowed to be simple carbohydrates, according to the USDA guidelines. And then going up to vegetables and fruits and then proteins and fats at the top. This is essentially what we’re being told. And we’re being told to do this three to six times per day. And essentially what I’m describing here is that’s what’s led us into the problem. And here we can see when these dietary guidelines were launched in about 1980, this is what happened to the percentage of people who are overweight and obese in the United States. So a significant increase in that percentage, starting with these guidelines.

And then in terms of what macronutrients people are eating, I mean, one complaint people say is, well, people aren’t following the guidelines. It’s not the guidelines that are a problem. It’s that people aren’t following them. But it turns out that there’s actually data showing that people do basically follow these guidelines. There’s an increase in the amount of carbohydrates people were eating since these guidelines came out. The amount of fat people were eating went down, and the amount of saturated fat people were eating went down. Basically, again, people are doing what they’re told. Here’s another slide showing the same thing. So, refined grains went down by 12% during that period of time. The total sugar actually went down between 1999 and 2011. During that time, the amount of added sugar went down and the amount of whole grains went up. So, it’s not that people are completely not following these guidelines. It’s just that the guidelines are actually leading us astray.

Carbohydrates consumption was up as people were being told to do. Their fat consumption went down. Saturated fat went down. So, people are really following these guidelines. This is just showing that refined grains went down. Total sugar content went down during this period of time. Added sugar went down. Whole grains went up. And then this is just one page from the USDA guideline website showing just one page of the strategic partners. There was something like 160 strategic partners that are all pretty much giant food companies that are helping influence these guidelines. There’s been exposés about the people on those committees and the conflicts of interest that they have. On average, the people on the USDA guideline committee that made that food pyramid or the most recent version had on average 30 conflicts of interest on average each person. And so there’s no wonder that we’re getting guidelines that are not necessarily in line with what we need for health and with science.

So, enter metabolic psychiatry to think about not only improving metabolism but improving the mental health of individuals. This is a study that was done… It’s really a retrospective review of cases that were in a hospital in France. There was this one psychiatrist who decided he was going to offer a whole foods ketogenic diet to inpatients in his hospital. These are people who he had treated in the past, most of them, with severe mental illness. So, people with bipolar disorder, major depression, and schizophrenia who needed inpatient hospitalization. And the intervention was this ketogenic diet, 75% to 80% fat, 15% to 20% calories from protein, and 5% from carbohydrates. And it was a pretty well-formulated version of the ketogenic diet with a lot of whole foods and fresh food. So, just the graphic, as it says, 100% of people had symptomatic improvement, 43% of these people had achieved what was considered clinical remission, which is unheard of in terms of what we see on inpatient units in the U.S. and with general care. Ninety-six percent of the people lost weight and 64% of the people were discharged on less medication than they came in, which again is also unheard of in psychiatric units in general. Some of the reductions, the HAM-D is a depression score. The average reduction was from 25.4 to 7.7, so huge reduction in depression score, huge reduction in this. This is PANSS as a scale for psychosis. It was literally cut in half on average. And then CGI is just a total global impression of how someone was doing. Two CGI points is also a huge reduction in symptoms and a huge improvement in functioning.

Patty: And can we just clarify the word refractory for the audience?

Dr. Bernstein: Oh, yes, for sure.

Patty: Refractory mental illness? Yeah, thanks.

Dr. Bernstein: Well, refractory means… And the other term people sometimes use is treatment-resistant, which is thrown around a lot.

Patty: Yes. Yeah, thank you. Mm-hmm.

Dr. Bernstein: So, it essentially just means people have been tried on multiple psychiatric medications and not had significant reductions in their symptoms and are still severely impaired from their symptoms essentially. So, yeah.

Patty: Thank you.

Dr. Bernstein: Yeah. So, these are people who had been hospitalized before. And this did not have a control group, this study, but they basically said that the people serve as their own controls because when they were hospitalized before, they did not have these kinds of positive outcomes from their standard treatment that they had in the past. And I just wanted to point out, so this is just a chart from the same study, looking at the overall amount of people, these are the rating scales, HAM-D and MADRS are both depression scales, the PANSS is the psychosis scale, and the CGI is a, sort of, global clinical scale. These P values are highly significant and these Cohen’s d sizes, it’s really a statistical measure of how big the effect is. And just to give you a sense of this, we call anything up to about a 0.5, a small effect, between 0.5 and 0.8 is a medium effect, and anything above 0.8 is a large effect. And the standard for antidepressants, SSRIs is about 0.32 on average. So, considered a small effect. We’re getting 10 times that effect from the ketogenic diet with a reduction of medications.

So, there’s definitely issues with this study being considered not fully scientific, it doesn’t have a control group, etc. It’s not prospective. But on the other hand, when we see these kinds of effect sizes with people with a severe treatment-resistant condition, this really gets people’s attention. So, how does the ketogenic diet improve brain health? So, there’s about seven mechanisms described. And the reason why we know about these mechanisms is not all research that’s been done in the last 5 or 10 years on people with psychiatric conditions. The reason we know all of this is that ketogenic diets have been used in epilepsy for over 100 years. So, the diet was invented in the Mayo Clinic in 1921 to treat kids with refractory epilepsy. And it’s been used in epilepsy and studied in epilepsy from then until now. And it’s known to be effective. It’s considered part of the standard of care in epilepsy. And yet, it doesn’t get used as much as it probably should. And the reason we know all this again is that they’ve been trying to figure out, “Why does this work in epilepsy?” And so neuroscientists have been studying this for a couple of decades, at least, maybe three decades.

So, these are all complicated terms. I’m not going to go into all the science here, but I can definitely take questions on any of these mechanisms if someone has questions. But the first is that ketones are an alternative source of fuel to bypass insulin resistance in the brain. Essentially, the brain can be bathed in glucose but still be starving for energy. And ketones are able to bypass that because ketones don’t need insulin to be taken into brain cells or neurons to be used for energy. And so that’s a really key mechanism here. The other key mechanism is the second one here, which is mitophagy, or the process of mitochondrial biogenesis and renewal, essentially recycling of old, non-functioning, or partially functioning mitochondria, breaking them into parts, and making new mitochondria that functioned better. And that is induced by ketones.

We also change these neurotransmitters, more GABA, less glutamate, and that’s very important for a lot of psychiatric and mental health conditions. Ketones are known to reduce oxidative stress in the brain. Ketones also reduce inflammation in the brain. They increase brain-derived neurotrophic factor, which essentially is a signal telling neurons to make more connections and connect to more neurons. And finally, we know there’s some mechanisms that involve the microbiome gut-brain access, that ketones significantly affect the microbiome. And we think that that’s one of the ways in which ketones improve brain health.

So, here’s another study. This was done at Stanford, this one. This was a pilot study in the metabolic psychiatry clinic at Stanford run by Shebani Sethi, who’s one of the leading researchers in this world. She took 21 people with bipolar or schizophrenia, and they also had metabolic dysfunction. And she started them on a ketogenic diet. And this was done in outpatients, so not on any inpatient, sort of, demonstrating that this is possible to be done on an outpatient basis with people with a severe mental illness. The average duration of illness was 16 years. Seventy-one percent of these people had been hospitalized, 38% had suicide attempts. So, these are people with a significant disorder. They had excellent metabolic outcomes. They had improvements in their visceral adipose tissue. And visceral fat is highly correlated with metabolic dysfunction. They had reductions in their weight. They had improvements in waist circumference and blood pressure. There were six people who started the study with full-blown metabolic syndrome. All of them had that reverse during the course of the study. And then there were also impressive improvements in their psychiatric rating scales as well. So, 79% of people had a marked improvement in their CGI, that, sort of, global scale. And then if you broke it up by who was more adherent to the diet, there was a dose effect essentially so that 92% of the people who are fully adherent to the diet. So, that level of of improvement and their CGI.

So, again, this one was also a small study. It wasn’t randomized. There was no control group, so it can be criticized from a scientific point of view. But, again, it just showed these really remarkable outcomes, and it’s just a graphic from that study essentially showing this improvement in their mood over here, adherent v. semi-adherent. Not only we get these improvements for anyone who did the diet, but anyone who adhered closer to the diet had even more of an improvement, suggesting that it really was the changing and eating. That was the important factor here. And I was referencing that this field is, sort of, exploding. This is just a slide showing where a bunch of studies are being done now. These first three are studies that already have completed enrollment. These last 10 or so are ones that are still enrolling. And you can see they’re going on throughout the country and around the world. The ones with the diamonds are randomized controlled trials. And in addition to that, a lot of these have not just a clinical component, where they’re a randomized clinical trial, but they also have a big basic science component. So, we’re really going to learn more about the mechanisms by which these metabolic changes are improving brain health and mental health in the next few years.

So, just going to talk a little bit about these different types of ketogenic diets. Maybe we’ll start with the classic ketogenic diet, which is the one that was invented in the 1920s at the Mayo Clinic. This is this very high ratio of calories from fat to calories from protein and carbohydrates, like a 3 to 1 ratio, or even they sometimes start kids on a 4 to 1 ratio. It turns out that that’s not necessary for most kids to get control of their epilepsy, and it’s certainly not necessary for most people in a mental health arena. Typically, we’re doing more like a 2 to 1 ratio, or even a 1.5 to 1 ratio, and getting really good results with that. We can sometimes combine those lower ratios with a little extra boost for ketones. There’s something called MCT oil, or medium-chain triglyceride oil, which is essentially refined coconut oil, which gets converted immediately to ketones, and that helps boost people’s ketones while they’re doing a lower ratio, or they could also practice a little bit of intermittent fasting while they’re doing this kind of ratio, and that would also boost the ketone levels.

Some people think about ketogenic diets as the sort of old Atkins diet from the 1970s. And that term now gets thrown around in lots of different ways, but what I’m talking about is the sort of popularized one that was done in the ’70s, where there was really just an emphasis on just getting the macronutrient ratios right but little regard to the nutritional content of the food. So, people ended up eating lots of fatty meats and a lot of keto snack foods and desserts that were, sort of, highly processed, contained a lot of sugar alcohols, and artificial sweeteners, and inflammatory oils. A lot of that stuff is still sold under the Atkins brand, and that’s really not the same thing as doing this version that I’m talking about, which is this, sort of, whole foods, well-formulated ketogenic diet, which is what we’re trying to emphasize now, which is really not using processed foods, really eating a variety of non-starchy vegetables for the phytonutrient content and the variety of fibers and polyphenols in there. Emphasizing the quality of the fat is very important, so really getting the highest quality fats we can get. There’s some controversy still about saturated fat, which we can get into if people have questions, but either way, if we’re getting our fat from healthy sources, extra virgin olive oil, avocados, nuts and seeds, we may veer into healthy versions of saturated fats like grass-fed butter or grass-fed dairy products and high-quality proteins as well.

We need to maintain adequate protein while doing this diet. I advocate people eating animal protein. I’ll get into that a little more later. It is possible to do this diet as a vegetarian. It’s even possible to do this diet as a vegan, but it’s very challenging to do so. Okay. Whoops, okay. This is just a slide just talking about the relationship between glucose, glucose crashes, and this idea that people have of intuitive eating. The real demonstration here is that if someone is in a purely carbohydrate-based metabolism and is not metabolically flexible, intuitive eating is really almost impossible to achieve. People do need ground rules to fix their metabolism. And then once someone’s metabolism is healthier and they have this idea of metabolic flexibility, sort of, demonstrated by this green curve here, blood sugar is not going up super high after meals, it’s not crashing super low a few hours later. There’s not this huge hormone response from a glucose crash, and there’s energy on demand from fat metabolism at all times, then it’s much more possible for people to eat in a healthy intuitive kind of way. But people need to get to this kind of curve and not be on this kind of roller coaster in order to achieve or even be able to practice with any degree of success the idea of intuitive eating.

So, when I start talking to someone about this, I’m really talking about a lot of different options that they can think about, and I think this is an area that we could talk more about. So, initially, you might only be talking to someone starting to lower their sugar intake, starting to increase healthy fresh food, vegetables, and fruit, decreasing their ultra-processed food. That might be a great place to start, and you can get really significant results with people going from an ultra-processed food diet just to a whole foods diet, and lowering sugar, just there you can see some huge benefits. If people, kind of, want to take it to the next level, we can think about doing a little bit of intermittent fasting, especially if someone is metabolically still unhealthy and still overnourished or overweight. Intermittent fasting can be a really useful tool, starting people off saying, “Look, let’s just start having a 12-hour window between when you stop eating at night and eating in the morning and seeing if they can do that,” because a lot of people are eating only fasting for about 8 hours at night. So, if they can get to 12 hours, that’s great. Then we may increase that number and maybe even get to something like a 16-hour fasting and 8-hour eating window. And for a lot of people, that can be a really effective strategy to help heal their metabolism.

We may add some MCT oil in there in the morning, because that really helps people not have the hunger and, sort of, brain fog they may have in the morning when they wake up if they’re not eating something and they’re used to a glucose-based metabolism. We may then add in a lower carbohydrate diet try to get rid of all simple carbohydrates at that point things like flours and refined grains. And then we may even try some longer fasts for some people, if that’s something that they like doing and it’s helping them, but I wouldn’t do that for extended periods of time. You know, fasting is a tool but, in my view, I don’t think it’s a healthy lifestyle ongoing for most people, and I can talk about why if people have questions. We may move on to, sort of, a more classic ketogenic diet. I like to emphasize exercise, especially when people are fasting, that will increase progress for their brain health, and then we want to add as many of these, sort of, well-formulated aspects as can be managed, so the high-quality fats I was talking about and the high-quality proteins that we were talking about.

You know, in my practice as a, sort of, psychiatrist, I’m really talking to people about brain health benefits and mental health benefits, and I see these, sort of, physical health benefits and weight loss as, sort of, beneficial side effects, although I know that a lot of the people I’m working with are more interested in those physical health benefits, and we, sort of, meet in the middle and, kind of, come up with a compromise, sort of, that works for both of us, of a language to use. I think the decision to offer this to people or how much to, sort of, push people really needs to be based on their motivation to make these kinds of changes. Motivation needs to be there. If someone’s doing it because you’re telling them or someone’s telling them, it’s not going to necessarily go as well as if they want to do it. This may allow people to do well on lower doses of medications or even get off of certain medications that I’m prescribing, which is a big incentive for a lot of people.

This could be an option to offer people who are refusing medication who otherwise would be thought to need it, but they simply don’t want it, and this could be another option for them. We have to have some caution for people who have restrictive eating disorders, although there is a successful case series using a ketogenic diet plus ketamine for people with anorexia, and it’s something that’s actually currently being studied in more detail right now. There’s some lab work to check and some other vital measurements to check while someone’s doing this kind of approach, and then I say optional monitoring of ketones. If someone’s really doing a full version of a ketogenic diet, I think it is really, really helpful to measure ketones. And for some people, measuring glucose on a continuous glucose monitor can be a really wonderful tool as well.

So I just wanted to add this little piece about protein, and then I’m just going to stop and take questions, but protein is really important. The USRDA for protein is 0.8 grams per kilogram of body weight, which is really the minimum needed for survival. It’s really too low for optimal health, most experts now think. We now think the target for optimal health should be something like 1.2 to 1.6 grams per kilogram of ideal body weight, and it needs to be higher in people who are aging and people who are trying to build some muscle, which in my view, everyone should be trying to build muscle.

And for adults, people above about age 35 or 40, you need 30 grams of protein at a time of high-quality amino acids to even turn on your protein synthesis machinery in your cells. So, ideally, you’re trying to get three to four protein doses per day, somewhere between 30 to 50 grams, depending on the size of the person. It could be two doses at 50 grams for certain people, but that’s the, sort of, rule of thumb that we’re looking at. It is important to think about amino acid profile, and this is where we, sort of, get in this difference between plant and animal protein. So these three amino acids are some of the essential amino acids, meaning we have to get them in our diet, we can’t make them, and these are some of the things that they do. These are not just building blocks, they’re really important signaling molecules in our cells. And plant proteins are much lower in those three essential amino acids.

In addition, plant protein amino acids are bound up with indigestible fiber, so only 60% to 70% of the amino acids in plant protein are actually absorbed. So, whereas it’s close to 100% in animal protein is absorbed and is bioavailable. So, if someone is a vegetarian or a vegan, in addition to some other micronutrients, they have to be concerned about… One of the things that they need to do is actually aim for a higher total intake of protein to make up for the lower concentration and lower bioavailability of those amino acids. So, that was a lot of information. I’m going to pause. I have a few more slides, but I think I’m going to skip those and move on to, I think, taking questions and having a discussion because I think that’ll make it a little more interactive and hopefully a better experience.

Patty: Yeah, well, certainly we could always talk about them if we have some time. We do have a lot of questions, but all of this information is really important. Thank you for showing the link between metabolic dysfunction and mental health and the story that how medication… that approach can have limited improvement, which makes sense if the underlying cause of mental health is metabolic dysfunction. And what lifestyle factors have been studied that actually show to have an impact in this area? I wonder if we can make a distinction, though. So, we talked about how people who are treatment resistant, the ketogenic diet is effective, but I’m wondering if others would be able to achieve those results on other diets, obviously healthier diets, but have you looked at any of that information?

Dr. Bernstein: So, just to clarify, you’re asking if someone didn’t have a treatment-resistant condition…

Patty: Correct.

Dr. Bernstein: …what sort of metabolic or dietary intervention might be indicated for that person? Yeah, that’s what I was talking about on that one slide about the different range of options to start with. So if someone’s coming in and saying, okay, I have a little bit of depression and anxiety, it’s not at the level where I feel like I want to take a medication. I don’t think I need one. I just want to try some lifestyle interventions that might really improve my mental health. That’s where we’re talking about even something like removing ultra-processed food as much as possible, removing sugar as much as possible adding in some exercise and seeing what kind of benefits might come from just those more elemental interventions more fundamental interventions. And for a lot of people, I think that that may be enough. You may get a real boost just from doing that. So, they may not need to go on to the next, sort of, level of things, but if people do want to move on to the next level, maybe reducing carbohydrates a little bit further, focusing on quality of fats and proteins and you can go into deeper levels as someone maybe is ready for more, I think.

Patty: That’s great. I just want to make that distinction. These health coaches are going to be meeting people where they’re at. And so they might need to start somewhere aside from the ketogenic diet, unless this is somebody, like you had said, who’s coming for the intervention because they are treatment-resistant. So, that’s wonderful. Thank you. And maybe we can talk a little bit too just about what other lifestyle factors is. This is where health coaches work in that are a have been shown to improve metabolic and mental health. So, I know you talked about circadian rhythm interventions, mind-body medicine. Do we have some nice data around that?

Dr. Bernstein: Yeah. I mean, we don’t have as much hard data on circadian rhythms from a clinical perspective, but we do have a lot of basic science data about circadian rhythms and how important they are. We know that circadian disruption in the form of, for example, shift work leads to a much higher rate of cancer, higher rate of heart disease, higher rates of death. And so, those are some pretty hard outcomes that you can point to. And we do know that circadian rhythms and metabolism are intricately connected through hormones. And so as part of the program that I run at Accord, we do have a big component about circadian rhythm alignment. And I think it’s a very helpful adjunct to dietary changes to try to get people up in the morning. I think the things that I talk about that I’m sure a lot of the people listening already know are getting up in the morning at the same time, getting up in the morning and seeing morning sunlight outside much more powerful than any lamp or even a special circadian rhythm lamps are nothing compared to natural sunlight in the morning. Timing is important. We want to get up out there as close to sunrise as possible. But even if someone can’t and they’re waking up a couple hours later, it’s still better than nothing. And then getting outside throughout the day and then minimizing blue light at night. Those are, sort of, the cardinal, sort of, features and really keeping the same schedule throughout the whole week, not changing one schedule on the weekends is also a big tool that I think that can be really powerful and helpful. And it’s not something that I think generally people know or are doing out there in the world.

And then the last part that we add besides… And then exercise is a big component. It really works hand in hand with all these metabolic interventions that I’m talking about with diet. And then the last piece is, sort of, mind-body practices which also have some really significant data on improving mental health. So, it’s good to have, I think, a range of options for people to try, whether it be meditation, breathing, yoga, Tai Chi. I mean, there’s a myriad of options out there. And I think offering people different choices and seeing what resonates with that person tends to work well, because some people just can’t get themselves around the idea of meditating but they’re really good at doing breathing exercises and it really works for them. So, I find that giving people lots of options and trying to get them into something and doing it regularly is really powerful.

Patty: Yeah, and that’s what our health coaches are really great at is really helping people find out what’s best for them, as long as they’re engaging in something of that form. Also, exercise, weightlifting, cardio, a combination. Do we know what works best in this area to either… We either want to talk about potentially metabolism, right? Because if that’s at the heart of what we’re seeing mental illness, or do we see something that benefits people with mental illness in terms of the form in data?

Dr. Bernstein: There is good data about that actually. Yeah, and it turns out that exercise is a really powerful intervention for mental health. There’s very high-quality evidence for that. And it’s on the order of magnitude similar to antidepressants. We do know that actually resistance training is really an important part of that. When they compare the two, resistance training versus cardio, resistance training actually wins in terms of brain health and mental health benefits. It’s not to say that cardio training is not important. It’s just that the resistance training needs to be part of it, or it is an important part of it from a metabolic and brain health point of view. And part of the reason for that, as I was referencing muscle before but muscle is one of the most important organs of longevity but it’s also the most important organ of metabolism. So, when we eat carbohydrates in any form, it gets converted to glucose. The biggest sink for that or the reservoir for that is our muscle. And the more muscle we have, the more we can handle without it causing elevated insulin levels and insulin resistance and that whole, you know, sort of, cascade of things. And so a big believer in resistance training, eating adequate protein for people of any age. And it’s highly correlated to mental health and brain health.

Patty: That’s great. And maybe if we could shift to, because that statistic about kids is interesting for sure. If we want to really think about prevention, we really need to focus on preventing insulin resistance in children. Do we measure insulin resistance the same way as adults? And would the interventions for resolving insulin resistance be the same for children?

Dr. Bernstein: Yeah, I mean, they are, except it’s probably a little easier to resolve insulin resistance in a kid than someone who’s been insulin resistant for 20 or 30 years already. But it’s really the same type of interventions. It’s really reducing simple sugars, reducing refined carbohydrates, getting someone exercising. Those are the tried and true interventions for reducing and even reversing insulin resistance. Insulin resistance, by the way, is completely reversible, as is the most extreme form of insulin resistance, type 2 diabetes, is 100% reversible by these types of interventions. And that’s been shown in pretty good randomized controlled trials that if someone has type 2 diabetes, that level of insulin resistance, the, sort of, end-stage, that is completely reversible by a ketogenic diet. And it may need a full version of the ketogenic diet to do so.

So, in terms of measuring insulin resistance, this is another, sort of, a place where our medical system really fails. We don’t routinely measure insulin resistance in kids or adults, unfortunately. So, the simple test is a blood test of measuring fasting insulin levels that is not part of standard annual physical blood work for anyone. And it should be. So, the only thing we’re measuring is fasting blood sugar and hemoglobin A1c. And those are only going to be out of line in the late stages of insulin resistance. They’re not very sensitive tests. So, we can pretty much assume, based on the data, that 75%, 80% of adults in America are insulin resistant, even if their blood work says, “Oh, my fasting blood sugar is fine. My hemoglobin A1c is fine.” They still probably have insulin resistance. And the way to really find out would be to do some of these other measurements like a fasting insulin level.

Patty: And you could also get an insulin resistance score too in terms of what that is. Can you talk to the audience a little bit about that? Because I think that’s something they could potentially do on their own with maybe some blood work results.

Dr. Bernstein: Yes. Yeah. So, the more expensive… So, I talk about fasting insulin levels. That’s the more inexpensive test. That’s just measuring fasting insulin. There’s another thing called a HOMA-IR, or that’s the insulin resistance score that you’re talking about. And most labs will do that. And it’s a calculation with the fasting insulin level, fasting glucose level. And there’s something called a C-peptide. And they do a calculation and give you a little bit of a more insightful insulin resistance. But the fasting insulin, the inexpensive test also is a very good measure of insulin resistance, too. Yeah.

Patty: Great. Yeah. Thank you. And certainly, there are other causes of mental illness aside from metabolic health. Would you just, kind of, quickly… I just want to frame this conversation so that we… Today we’re talking about the metabolic dysfunction and how that contributes to mental health. And of course, talking about how a lot of that is lifestyle factors in an area that those interested in being a health coach or a health coach can really make a huge impact for people. But the other causes, let’s kind of briefly talk about that just so we kind of have this… We know that maybe if everybody is doing the right thing metabolically, but there’s still mental health issues, so they can have these other areas to look at.

Dr. Bernstein: Absolutely. Yeah. Yeah. I’m not trying to say that 100% of mental health issues is due to a poorly functioning metabolism. So, I mean, obviously people have traumatic events. They have difficult relationships. People have stress in their workplace or in their other relationships. Those are of course highly contributing to someone’s mental health symptoms as well. However, the thing I will say is that a lot of those other things are now being shown to be mediated through metabolism. So, when someone’s under stress, their mitochondria doesn’t function the same as if they’re not under stress. Their hormone systems don’t function the same.

And so a lot of those other factors that are leading to mental health problems end up actually expressing themselves through metabolism as well as through these mental health symptoms at the same time. And so fixing someone’s metabolism seems to have these surprising results. I’ve seen it happen multiple times where metabolism gets better and people say all kinds of things are improving that they thought never had anything to do with their metabolism. So, at first, we say, “Oh, yeah, we’re going to see some improvements in energy, clearing up your brain fog,” very common things. But then all of a sudden people say, “Oh, well, my mood’s better. My relationships are better. The stress at work that was stressing me out isn’t stressing me out the same way.” And so we didn’t change anything else except their metabolism and they’re much more resilient to those stressors that were going on. It doesn’t mean that it will solve everything. There’s still, like I said, lots of other factors and there may be important to attack these things in different ways at the same time. But it’s surprising how much all of this is mediated through metabolism.

Patty: Yeah, or improved by making improvements in metabolism. So, things like schizophrenia have a genetic component that can be improved by some of these strategies that you were talking about today, right?

Dr. Bernstein: Not just improved. There are case reports of that being completely reversed. And so I think we oversubscribe to this idea that genetics is destiny. It turns out it looks like about 20% of medical issues are genetic at the most, 80% is epigenetic, meaning 80% is modifiable through lifestyle. And genes are not destiny. And so one of the case reports is that Chris Palmer, who’s one of the leaders in this field, always presents is this person who had 52 years of chronic schizophrenia, a woman in her 70s. She had been hospitalized over 100 times in her life, was on the most powerful antipsychotic medication for all intents and purposes lifelong condition, totally irreversible on the strongest medication. She went on a ketogenic diet for weight loss. And within three months, she had no more psychosis. By the end of the year, she was off of all of her psychiatric medications and lived another 10 years completely symptom-free, completely medication-free just by maintaining a ketogenic diet. And so we can’t promise those kinds of results, but what that does demonstrate is that we have to be careful to say that, “Oh, well, this is a permanent condition and you’re only going to get a little benefit from these lifestyle interventions.” It’s much more potentially powerful and bigger than that. And I think that’s, to me, a really empowering thing to think about that it’s not just the genes are destiny, that we can really control which genes get expressed and what ends up happening through these powerful lifestyle changes like nutrition and exercise, etc.

Patty: Yeah, well, there you have it. What a great example and testament to how much impact, even though they really haven’t been at the forefront of traditional medical care, but how much of an impact lifestyle modifications can have for people. Thank you so much for your work in this area and bringing all this to light. We were really just honored to have you here and to have this discussion with you. And I hope everybody feels empowered by this information and how they can help make an impact.