N.B.: The following is not intended as medical advice but as food for thought. Consult an understanding physician before embarking on a major diet overhaul.

My past few posts (Friday, Monday, Tuesday) have covered a possible link between our current Western low-fat, high-carb diet with depression, obesity and cancer — all of which are at the top of national health agendas.

There are various diets on the market which promote higher protein, increased fat and reduced (or more efficient) carbohydrate intake: Hays, Atkins, Dukan, Paleo, the GI diet and so on.

One site which I have been reading over the past few days, Rocco Stanzione’s Low Carb for Health, documents the benefits of a high-protein, high-fat and low-carb diet. He has tried them along with his family. His site provides a year’s worth of findings.

Stanzione writes brilliantly. It is a pity he did not continue posting. However, his readers must be grateful that he shared so much information. His site brings back memories of my high school and university biology courses from the 1970s. I wonder if any of this knowledge is still taught. If not, it should be.

Stanzione recommends a very low-carbohydrate diet. In fact, he recommends a period of ketosis, which relies on burning the available calories we have unaided by the intake of additional carbohydrates. I am no expert, so shall not delve into ketosis, which he explains ably on his site. In short, one redresses any insulin imbalances by going through ketosis, which must be managed carefully by substituting fat for the missing carbohydrates. Not doing so can cause heart arrythmia and dizziness. Some people end up in the emergency ward because they do not have the balance right. This is why fat needs to be added to the diet. A minor side-effect is that as the body burns up fat stores, ketosis is evidenced by breath that smells like pear drops — not unpleasant, just strange. One’s urine also needs to become and remain acid; this requires monitoring twice a day via a home test such as Ketostix.

That said, if ketosis does linger for a few weeks, first with a few days with no carbohydrates whatsoever then a small addition of them back to the diet, Stanzione says that excess weight will melt off. More importantly, he says, one’s mental and physical health will quickly improve. Energy levels will also increase.

Stanzione found two clinical studies which have found that a ketogenic diet improves mental health. This diet was developed at the Mayo Clinic in the 1920s to help epileptics who found anti-seizure drugs useless. The ketogenic diet didn’t always help alleviate seizures, however, it did improve the epileptics’ general mood and feelings of well being.

Before I go into Stanzione’s post, ‘Carbohydrate Intake and Depression’, I’d like to explore the two studies he cited.

The first — ‘Ketosis and the Optimal Carbohydrate Diet: A Basic Factor in Orthomolecular Psychiatry’ by Dr Richard A Kunin — actually describes the ketogenic diet in detail (see p. 4 of the PDF).

I was intrigued to read Kunin’s citing of the New Testament, specifically Mark 9:14-29. Jesus’s disciples were unable to cast out a demon from a boy who had seizures and was also a mute. The boy’s father was the man who said, by way of appeal to Jesus, ‘I believe; help my unbelief!’ Jesus drove the demon out of the boy. Later, when the disciples asked him why they were unable to effect the healing, He explained (verse 29):

29“This kind cannot be driven out by anything but prayer and fasting.”[b]

So, ketosis, in changing the body’s chemistry via food restrictions, started to be experimented with in the 19th century, first as a weight-loss programme by the famous English surgeon William Harvey (ah, biology class!). It was later used in treating urinary tract infections and epilepsy.

Kunin concludes (emphases mine):

It is surprising, after so much clinical experience spanning a period of two thousand years, that this paper is the first [and last] by a psychiatrist describing the applications of the ketogenic diet in the treatment of anxiety, depression, and dysperception. Meanwhile, throughout this most advanced society of ours, in every modern psychiatric facility patients are exposed to an overdose of carbohydrates… It is time that the application of available knowledge in this field should be the rule rather than the exception. Ignorance and fear of controversy are no longer an excuse to withhold this basic and physiologically-oriented treatment from our patients.

Kunin’s results with the ketogenic diet were mostly successful, with some exceptions, as one would expect. He found the obese patients were able to handle ketosis better than leaner ones. Another patient deprived herself totally of carbohydrates for a few days longer than she should have, having disregarded Kunin’s instructions at the outset.

That said, in all cases, triglycerides were reduced (p. 9). As for depression, he noted:

The improvement in well-being and mood more than outweighed the short-term inconvenience, for eight out of 10 patients gained a significant degree of mastery over their symptoms of anxiety, depression, neurasthenia, and dysperception.

Furthermore, the diet can also benefit hyperactive children:

In conclusion, let me call attention to the clinical observation of Dr. Samuel Livingston (p.402, 1972), who reviewed the ketogenic diet in his book on epilepsy: “In addition to its excellent anticonvulsant value, the ketogenic diet also favorably affects the hyperactivity, increased restlessness and irritability which one encounters so often in young children with epilepsy. It does not dull mental functioning, as anticonvulsant drugs so frequently do. Many of our patients were described by their parents before the institution of the ketogenic diet, as: ‘wild as a little Indian’; and after the diet was started, as: ‘calm as a lamb.’ It is of interest to note that several of the parents were reluctant to discontinue the diet, in spite of a poor control of seizures, because their children’s behavior and disposition were so much better while on the ketogenic regimen than when they were being treated with antiepileptic drugs.”

For anyone wondering whether undergoing full ketosis is a good idea, the second study Stanzione cites, one performed on rats, concluded, as did Kunin’s that, even if seizures continued, a ketogenic diet could help alleviate mental health disorders. ‘The Antidepressant Properties of the Ketogenic Diet’ states (p. 2 of the PDF):

The present experiment did not demonstrate whether or not ketosis is necessary to effect a behavioral change. As ketosis was not manipulated, this variable cannot be used to explain a difference in behavior. Although the ketogenic diet group achieved a higher level of ketosis than the control group, this level was quite low. A low level of ketosis was also found in the control group.

There is no evidence to suggest that ketosis is necessary to achieve behavioral change. In addition, human studies investigating the behavioral effects of the ketogenic diet have shown that seizure control and behavioral change are separable. Improved behavior and improved mental alertness have been noted, even though seizure control has not been attained (MacCracken and Scalisi 1999; Pulsifer 2001). The present research suggests that the ketogenic diet deserves further study as a possible treatment for depression.

Stanzione’s conclusion is that:

The near-absence in medical literature of what looks like a pretty obvious conclusion, given the evidence, is disappointing and almost surprising.  There’s no shortage of informal discussion in online forums, blogs and so forth about this phenomenon, but serious treatment is conspicuously scarce in peer-reviewed medical journals.

All the available evidence seems to point to dietary carbohydrates as the major causal factor in endogenous depression [treated with antidepressants] but the specific reasons are elusive.  As you might expect, all this is really complicated.  For example, reducing dietary carbohydrates almost necessarily means increasing intake of something else, usually fat.  It also means reducing serum insulin levels, losing weight, and a pile of other things, any or all of which might be relevant to depression.  So do carbohydrates directly cause depression?  Is it the insulin secreted in response to elevated blood sugar from carby meals?  Is it the lack of dietary fat in high-carbohydrate diets, as suggested here?  The lack of vitamin D?  Is it caused by insulin resistance, diabetes, obesity? 

Some of these ideas can apparently be ruled out in at least some cases, but the entire body of available evidence speaks with a single voice: either directly or indirectly, increases in carbohydrate intake increase both the risk and severity of depression with remarkable consistency.  Given that, we would expect – and we do find – that reducing carbohydrate intake has the opposite effect.  Taken to its logical conclusion, these facts suggest that a ketogenic diet would be a fantastically effective treatment for depression.  Very little research has been done to confirm this, but what is available appears to be a strong confirmation of everything else we know.

Conclusion: dietary carbohydrates are the major cause of clinical depression, and a ketogenic diet presents itself as an ideal treatment.

Stanzione, incidentally, is an admirer of Gary Taubes’s Good Calories, Bad Calories: Fats, Carbs and the Controversial Science of Diet.

We might agree or disagree, however, when one watches documentaries about or goes to visit countries in the developing world, strangely, the populations unaffected by famine or natural disaster are remarkably healthy and happy people.

We think it is because ‘they have learned to live without money’ (an ex-colleague of mine actually said that). In reality, perhaps they have been eating properly for millennia.

More on the high-fat, low-carb diet tomorrow.