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A | Welcome to the Huberman Lab podcast, where we discuss science and science based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today, my guest is doctor Chris Palmer. Doctor Chris Palmer is a medical doctor specializing in psychiatry at... |
B | Thank you Andrew, for having me. |
A | I have a lot of questions for you, and I'm really excited about this topic because I think most people know what mental illnesses, or they have some idea what that is. Most people have some idea what nutrition is. Fewer people certainly know how closely those things can interact. And I think everybody is familiar with ... |
B | Sure. You know, this story really starts with my own personal story, and I don't need to go into great detail, but to set the stage, when I was a kid, I definitely had mental illness. Started with OCD. A series of events happened in my family. My mother had a horrible kind of psychotic break and all sorts of adverse ch... |
A | Were you overweight? |
B | No. Technically, no. I had a gut, so that's a sign of insulin resistance. I know now, I didn't know it then, but. And he actually kind of leaned in at one point and said, you know, do your parents have diabetes? Yeah. Do your parents have high blood pressure? Yeah. Are your parents overweight? Yeah. Oh, I'm really sorr... |
A | So blood pressure normalized, lipids normalized. Did your weight change, or you mentioned that you were of healthy weight, but that you had a bit of abdominal fat. |
B | So I lost the abdominal fat. I probably lost about ten pounds through this process, but everything got normal. And when I went back to my doctor, he was shocked. He actually said, what the hell are you doing? |
A | During the time before you switched to this new diet, how was your mental health, if you don't mind me asking? Because it sounded like you're very clear that there was metabolic syndrome, or you were headed towards more severe metabolic syndrome. You mentioned OCD. I actually am familiar with this. As a kid, I had a lo... |
B | So before the nutritional switch, I was still struggling with low grade depression and OCD. Again, it wasn't necessarily interfering with my ability to function, because I was functioning at a high level. I mean, anybody looking from the outside, you're a top student. You just got into one of the most competitive. Actu... |
A | Psychoanalysis. |
B | Various psychotherapies, not psychoanalysis per se, but some of them were psychoanalytically oriented psychotherapies. I was actually hospitalized at one point, had been put on lithium and imipramine, which is a tricyclic antidepressant, and other things. And they were actually horrible. They were horrible. They did no... |
A | The kids with genuine smiles in the yearbooks. |
B | Yes, exactly. |
A | Whereas the rest. And by the way, I really appreciate you sharing some of your personal story, because I think it is very important for people to hear and understand that people like yourself, who are extremely high functioning and accomplished, that the road was, from everything I'm hearing and understanding, very cho... |
B | I was a resident at that point. |
A | Did you decide that you were going to explore this in a professional context? |
B | Not yet. |
A | Okay, so what was the journey forward into the work that you're doing now? |
B | So the next step was that I just had friends and family who saw me, saw that I had improved my health, saw that I lost some weight pretty easily. In particular, I remember, like, my sister and sister in law, they got really pissed at me one thanksgiving because I could resist all the pumpkin pie and apple pie and every... |
A | And may I just ask about the diet? When you say Atkins diet, so this is low to zero starch, so low carbohydrate diet, certainly low sugar. And was it traditional Atkins? Were you tailoring it to the individual patient, depending on their psychiatric symptoms, whether or not they were overweight or not overweight? I'm a... |
B | So early on, I was winging it and I was, you know, the first few patients, it was, try this AtkinS diet, I want to see ketosis. So I was going for ketones. |
A | So they were pricking their finger and they were doing a blood ketone test. |
B | I didn't know about blood ketone monitors, if they existed back then. So we were using urine strips, which. |
A | Are not quite as accurate, but still useful as a general guide, from what I understand. Is that right? |
B | Absolutely. And so I was strongly recommending that patients achieve urinary ketosis. And the interesting thing is, I noticed a pattern that when they were trying the diet and not getting ketones, they often did not get a clinical benefit. It was once they got into ketosis that I began to notice the clinical benefit an... |
A | So probably any nutrition plan, aka diet, that elevated ketones in the urine to the point where you would say, this person is in ketosis, or they would say, I'm in ketosis. That was a step in the right direction, independent of exactly what they were eating or not eating to get there, including fasting. At that time, p... |
B | It will. |
A | Did you have any patients fast or do intermittent fasting? |
B | I did. I had some patients who did what Atkins had called a fat fast, where they eat primarily fat. So they either fast and or they eat primarily fats to try to get into a state of ketosis. So for some patients, it was actually quite easy to get into ketosis, especially overweight and obese patients. They have a lot of... |
A | And they probably feel better too, I imagine, because when we limit our starch intake, we start to excrete a lot of water. People can get some pretty quick weight loss. That, even though it may not be fat loss, makes them feel literally a little lighter and maybe a little more energetic. Is that right? |
B | Absolutely. And as the years went on, the field was advancing. More research was coming out. People were getting a little more sophisticated with blood ketone monitoring, with different versions of ketogenic diets. And I was evolving my practice. The thing that completely upended everything that I knew as a psychiatris... |
A | Could you clarify for people what schizoaffective disorder is? I'm not a clinician, but as I recall, it's like a low level of schizophrenia. So there might be some auditory hallucinations. If I met this person, I might think they're kind of different, quote unquote weird. But they would not seem necessarily scary to me... |
B | So. No, actually. So schizoaffective is the same as schizophrenia. Essentially. The only difference is it's schizophrenia with superimposed mood episodes. |
A | Oh, so it's actually more severe than it can be. Okay, so I have it backwards. |
B | So schizoaffective disorder is essentially schizophrenia, and plus some mood episodes, maybe. |
A | I'm thinking of schizotypal. |
B | Schizotypal is the low grade kind of mild paranoia or kind of eccentric beliefs and other things. |
A | Okay, so folks out there, I have my nomenclature backwards. Schizotypal is the quote unquote low level schizophrenia or schizoid like schizoaffective is as. |
B | Or full blown schizophrenia plus full blown, usually bipolar symptoms. |
A | And now it's absolutely clear who the clinician in the room is. Thank you for that reminder. |
B | No worries. So this man had schizoaffective disorder. He had daily auditory hallucinations. He had paranoid delusions. He could not go out in public without being terrified. He was convinced that there were these powerful families, that they had technologies that could control his thoughts. They could broadcast his tho... |
A | These are the medications, as I recall, for schizophrenia. The classical ones are dopamine receptor blockers. Cause people to huge increases in prolactin. That's why sometimes men will get breast development and they'll put on a lot of weight and they'll be catatonic or movement disorders. They make you feel like, I ha... |
B | And it's a huge challenge in our field because a lot of patients don't want to take them. And then you get these rebound effects. If patients are on them for several months and then they stop them cold turkey, they can get wildly psychotic and ill end up aggressive or hospitalized or sometimes dead. So that's him. He w... |
A | Wow. |
B | He was able to do things he had not been able to do since the time of his diagnosis. He was able to complete a certificate program. He was able to go out in public and not be paranoid. He performed improv in front of a live audience. At one point, he was able to move out of his father's home and live independently. Tha... |
A | That is indeed mind blowing. I'd like to take a quick break and acknowledge one of our sponsors, athletic greens. Athletic greens, now called ag one, is a vitamin mineral probiotic drink that covers all of your foundational nutritional needs. I've been taking athletic greens since 2012, so I'm delighted that they're sp... |
B | So in terms of medications, he has remained on medication. So early on, I wasn't adjusting anything. I was just in disbelief and shocked that this was happening. I didn't know what was going on. Over the years, we have slowly but surely tried to taper him off his meds. He has been on meds for decades. He started medica... |
A | Is that true for depression as well? |
B | It's true for any psychiatric medication. The brain makes adaptations in response to psychiatric medications. And when you stop them cold turkey, some people are fine, but I wouldn't recommend finding out because I've seen patients when they stop antidepressants, I've seen patients get floridly depressed and suicidal w... |
A | Occasions, but that is, if I understand correctly, what perhaps not you, but many psychiatrists do with medication. It's. Here's your prescription. Let's talk in a month or three months. |
B | Yes. |
A | So that's a variable that it's probably worth us exploring a little bit here as the conversation continues. |
B | Absolutely. |
A | You know that frequent contact and making micro adjustments or macro adjustments to medication or nutrition could be meaningful. |
B | Absolutely. So with this particular patient early on, he was actually pretty adherent. I was seeing him once a week, and so I could do a lot of education. I was weighing him, I was checking his ketones, I was checking his glucose levels. At that point, I had a blood ketone monitor in my office, so I knew whether he was... |
A | Such a key point, and again, brings to mind for me the parallel with medication. I mean, a patient can say they're taking their medication, and unless they're in a hospital setting where somebody's checking under their tongue and all of this, they very well could not be taking it or taking more. And you and I both know... |
B | No, no. And when we looked at, on that front, when we've looked at studies of compliance, the majority of patients are at least somewhat non compliant with prescription medications. It's not on purpose. They forgot. They take it at night. They were out late, they were off their routine. They forgot to brush their teeth... |
A | When you say measuring ketones, I want to drill into this a little bit because it does seem that the presence of ketones and somebody being, quote unquote in ketosis turns out to be the key variable. Certainly in your book, that's one of the major takeaways, although there were many important takeaways that people get ... |
B | So, it really depends on the patient and what I'm treating, quite honestly, and I don't think every patient needs the ketogenic diet. For some patients, simply getting rid of junk food can make a huge difference in a mood disorder, for instance. |
A | So a junk food, meaning highly processed food, food that could last on the shelf a very long time, highly processed. |
B | Foods that are usually high in both sugar, carbohydrate, and carbs and fats, those seem to be the worst foods. That combination, high sugar, high fat, seems to be the worst combination for metabolic health. And lo and behold, we've got emerging data that suggests that strongly suggests it's also bad for mental health. ... |
A | Yeah. And sorry, I didn't mean to imply that people need to be in ketosis in order to see some mental health benefits from changing their diet. You make very clear in your book, and we'll go into this in more detail, that avoiding insulin resistance reversing insulin resistance and essentially trying to reverse what ea... |
B | You're the Harvard of the west. |
A | We're not going to talk. |
B | We're the Stanford of the east coast. |
A | That argument could go back and forth a number of times, but, you know, this is, you're a serious clinician and a serious scientist, and you're a serious thinker. But for a lot of people out there, the notion of using diet, they immediately think, ah, well, that makes perfect sense. Or I think there's a category of peo... |
B | No. |
A | And rather, you're saying, if I understand correctly that nutrition needs to be considered one of the major tools in the landscape of effective tools, and that it can be very effective, evidenced by the story that you shared, and there are many other stories in there as well, of truly miraculous transformations. So let... |
B | Yeah. And the reality is that this literature and this clinical history and all of the research we have was the godsend that I needed to do the work that I'm doing. Otherwise, I would have been discredited on day one. Chris Palmer's claiming that a dietary change can influence schizophrenia or schizoaffective disorder.... |
A | And this child was ingesting water? Correct. It was just food elimination. |
B | Fast food elimination. So no special diet. But the problem with fasting for epilepsy is that as soon as people start eating a normal diet again, their seizures usually come right back, oftentimes with a vengeance. And so it can be a good short term intervention. The fasting can take a few days, because it can take a fe... |
A | Sorry to interrupt. I didn't mean to do that there. Was it just for pediatric epilepsy or for adult epilepsy as well? |
B | So, back in the 1920s, we didn't have many anti epilepsy treatments, and a lot of adults were struggling as well, so they were using it on anybody who would do the diet. By the 1950s, pharmaceuticals were coming out, and we had many more anticonvulsant treatments. And there's no question they work for a lot of people. ... |
A | Would you mind listing off a few of the mental disorders? And I know this is not meant to be inside ball, but we should distinguish between psychiatric disorders and neurological symptoms and diseases. The fields of psychiatry and neurology hopefully someday will just emerge. But, for instance, typically, if somebody i... |
B | Yeah. So the field, in terms of nutritional psychiatry, it's a broad field, and it's in its infancy, is the real answer. If you're looking for randomized controlled trials documenting efficacy in large numbers of patients with these disorders. We don't have them. They're underway now, but we don't have them yet. What w... |
A | I love it. I love it. And I should say I love it, because we had a guest on here early days of the podcast. He's a colleague of mine at Stanford. He's a bioengineer and a psychiatrist, phenomenal scientist and psychiatrist Carl Diceroth, who won the Lasker prize and so on and so forth. And he made a really important po... |
B | Yeah, no. So I guess the first thing that I'll say is that this field is one of the most cutting edge fields in medicine right now. 20 years ago or so, I think the majority of research scientists thought of mitochondria as nothing more than little batteries. They take food and oxygen and turn it into ATP. And that's re... |
A | Yeah, I would call those. I would consider those. I know you listed more than three, but the primary colors of neurotransmission, any one of those in excess or deficiency is going to have profound negative effects on a nervous system, or it's going to alter the way that people and animals feel, think, move, remember, e... |
B | And so, as part. So mitochondria are providing both some of the building blocks, if you will, for some of those molecules, they're part of the Krebs citric acid cycle. Some of the intermediate products actually go into making those neurotransmitters. Much more importantly, mitochondria provide the energy for the produc... |
A | Super interesting little sub cellular goodies these mitochondria are. I come from a field where people are often divided into lumpers and splitters, and I'm somewhere in between. For those of you who don't know, lumpers are people that like to make things really simple. Lists of no more than three functions, or dividin... |
B | It is. So, in many ways, mitophagy is a subset of autophagy, but it's got its own name because it is specific to mitochondria. There do appear to be some unique regulators of mitophagy compared to autophagy. More broadly, mitochondria actually are playing a role in autophagy itself. And this makes sense because the glo... |
A | For you, comes from all the noise about antioxidants. Like in the nineties, I was like, it contains antioxidants. Not to say antioxidants are bad, but they are certainly not the be all, end all of health. |
B | They are not. But that's exactly where that research came from, is that researchers were narrowing in on these reactive oxygen species are highly, highly correlated with all of the diseases of aging and poor health outcomes. Turns out they're also highly, highly correlated with all chronic mental disorders. Interesting... |
A | Before we talk about mitochondrial biogenesis, and I certainly accept the idea that mitochondria are extremely important in physical health and mental health. That's, for me, is a straightforward conclusion at this point, based on what you've said, what I've read elsewhere, et cetera. And if various diets, including ke... |
B | I am not convinced that glucose is the real story. Glucose may, in fact, be a symptom. So we know that. We know that parts of the brain. There have been a couple of studies that just came out in the last couple of weeks, I think, documenting that, actually, astrocytes in the hypothalamus play a key role in glucose regu... |
A | And what about the typical person? Like, I've never really liked junk food that much. Maybe as a kid, I can recall liking candy, but I was a sandwich for lunch person for a long time. And as I've changed that out for salad and, uh, maybe a small piece of meat with my salad or something like that, I feel far better duri... |
B | Subclinical depression burnout is what I would call it. |
A | Yeah. And just feeling like some days are great, and then other days they feel lousy for reasons they don't understand, and those make for less dramatic case studies. And yet I have to assume that that description will net a large fraction of the general public. |
B | So the way that I kind of break this field, and I'm probably getting too nerdy right now, but I kind of break this field into cause. What's the actual root cause? What are effective treatments? And I really see them as two separate things. Just because the ketogenic diet is an effective treatment does not imply that th... |
A | They don't think excess caloric intake, beyond one's daily metabolic needs, is causing obesity. |
B | Some will argue that. And so some will say, yes, it's all energy balance, but why do we have an epidemic of obesity? |
A | Well, that's the gazillion dollar question. |
B | And some will say it's all the junk food. But we had junk food in the 1970s when I was growing up. I grew up on Kool Aid and Twinkies and King Dongs and ho Hoshe. |
A | I'm rewatching. I'm rewatching the Mad Men series now. I love that series, and I'm rewatching it, and I happen to know someone who worked on that series. They research everything for the props and the costumes, everything but right down to diet. And if you look at the diet, it was terrible. It was mostly, yes, there wa... |
B | And at the end of the day, I believe some will call this speculative, but I actually think we've got a tremendous amount of evidence that continues to point in this direction. I believe that mitochondria are the key to the obesity epidemic, that there is something in our environment. So that is either our food environm... |
A | Although I totally agree, although I would just like to say that it seems to me that compared to when I was growing up, and again, I haven't run the statistics, there are fewer and fewer of those individuals around now. Just as when I was growing up, it was one or two kids in class that were quite overweight. And then ... |
B | They're getting increasingly rare. And that leads me to think it may be epigenetic factors in the womb environment, so that kids are actually coming out predisposed to obesity. |
A | Well, let me ask you about that because I had a note here to ask this later, but I'm going to interrupt you now in order to capture this moment. My understanding is that, well, as everyone knows, we inherit DNA. We get genes from both of our parents and they mix. Although there are incredible data from Katherine Dulock... |
B | So it's a great question and I've been asked this before, and yeah, psychiatrists are known for blaming mothers. And some might say that I'm, like, trying to redo that whole thing and. |
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