Bipolar Disorder and Diet Part II: Low Carbohydrate Diets

Can food stabilize mood? Is there a diet out there that could prevent mania, mood swings, deep depressions, and uncomfortably anxious and agitated states? Sound far-fetched? Maybe not. Dietary changes can have very powerful effects on brain chemistry. Low carbohydrate diets, in particular, are fascinating.

Ketogenic diets and epilepsy

When most people think of low-carbohydrate diets, they think of weight loss. But did you know that neurologists have been successfully treating severe cases of epilepsy with low-carbohydrate (“ketogenic”) diets for nearly 100 years? Ketogenic diets are specially designed low-carbohydrate diets that typically contain between 60-80% fat, with the remainder consisting of roughly equal amounts of protein and carbohydrate. In most cases, patients in clinical studies were hospitalized children whose seizures could not be controlled with anticonvulsant medications. Yet, with diet alone:

• nearly all patients achieve more than a 50% reduction in seizures
• with 33% experiencing a 90% reduction in seizures
• and 10 to 15% achieving complete remission from seizures

What more powerful evidence could there be for the role of diet in brain chemistry? Not only is this phenomenon remarkable in its own right, but it also has potentially powerful implications for the treatment of a wide variety of neurological disorders.

Ketogenic diets have magical healing properties

All of the following conditions have been shown in animal models or in human studies to improve on a ketogenic diet:

• Autism
• Traumatic Brain Injury
• Alzheimer’s Disease
• Parkinson’s Disease
• Brain Cancer
• Diabetes
• Prostate Cancer
• Obesity
• Chronic Pain/Inflammation
• Multiple Sclerosis
• Insomnia/Circadian Rhythm disorders

How do ketogenic diets work?

Nobody knows. It is a subject of intense research, and there are many theories. Ketogenic diets restrict carbohydrate intake to 10-20 grams per day (the typical American diet contains at least 200 grams per day), and limit protein to just what’s needed. Therefore, the body has no choice but to burn fat for energy. Fat from the diet or from excess body fat gets broken down into three “ketone bodies” [“ketogenic” means that the diet generates ketones]: acetone, acetoacetate, and beta-hydroxybutyrate. Acetone leaves the body, but the other two compounds circulate in the blood and serve as fuel sources for our cells.

Ketogenic diets are very low in carbohydrate, therefore blood sugar and insulin levels are lower and much more stable than on standard “balanced” diets that are high in carbohydrate. We do not know whether it is the presence of ketone bodies in the blood, or the stabilization of blood sugar levels, or the reduction in blood sugar and insulin levels, or some combination of these changes that is responsible for the therapeutic effects of the ketogenic diet.

What we do know is that epilepsy and other neurodegenerative diseases are all associated with “mitochondrial dysfunction”. Mitochondria are the miniature generators inside of our cells, so when they are not working properly, energy production is disrupted, and all cell activities can be affected as a result. Studies consistently find that mitochondria produce more energy (ATP) more efficiently on ketogenic diets than on standard “balanced” diets which force cells to burn glucose (sugar) for energy. Put simply, most of our cells work best when they burn fat instead of carbohydrate.

We also know that epilepsy and other neurodegenerative diseases are universally associated with inflammation. Diets rich in sweets and refined starches that cause high, unstable blood sugar and insulin levels are well known for their ability to set the stage for inflammation throughout the body, therefore diets that are low in refined carbohydrates tend to quiet inflammation.

Bipolar disorder and diet

So, what does all of this have to do with bipolar disorder? It is well-established that epilepsy and bipolar disorder share many biological features, including:

• similar neurotransmitter imbalances (serotonin, norepinephrine, GABA, and glutamate)
• alterations in sodium and calcium distribution
• changes in chemical messenger activity

In fact, it just so happens that many of the mood stabilizing medications we psychiatrists prescribe for bipolar disorder are anticonvulsants that were originally designed to treat seizures—Depakote (Valproate), Lamictal (Lamotrigine) and Trileptal (Oxcarbazepine), to name a few. The fact that epilepsy and bipolar disorder have so much in common begs the question of whether perhaps a low-carb diet could be useful for mood stabilization, as well. Unfortunately, there has yet to be a single scientific study of ketogenic diets in bipolar disorder. I have not yet had a patient in my practice who has been willing to try a strict ketogenic diet, which not only limits carbohydrate, but also limits protein and requires blood monitoring of ketone levels.

However, I can tell you that my patients who have been willing to try low carbohydrate “modified Atkins” diets, low carbohydrate “Paleo” diets, or low glycemic index diets for mood problems—from depression to anxiety to eating disorders to bipolar disorders—report significant improvement in their symptoms. It stands to reason that these dietary changes, which have profound effects on other neurological disorders, would have the potential for profound effects on psychiatric disorders, as well.

Yet, even if a ketogenic diet worked beautifully for all cases of bipolar disorders of all types, I doubt that most people would choose to commit to a lifetime of eating a ketogenic diet. These diets are very restrictive and require major lifestyle changes. Most foods that people are accustomed to eating all day long are off-limits on this diet. For this reason, neurologists have recently begun to experiment with more relaxed versions of the diet to see how much carbohydrate patients can consume and still have good seizure control.

Studies of low glycemic index diets and modified Atkins diets (Atkins diets that allow unlimited protein and fat) look very promising but do not seem to work quite as well for seizures as ketogenic diets do. However, bipolar mood disorders and seizures are different in that seizures are black and white phenomena, whereas mood swings are a matter of degree. Perhaps people with bipolar mood disorders would be satisfied with less than perfect control over their mood swings in exchange for wider dietary variety?

If you have a bipolar mood disorder should you change your diet?

That’s up to you. While there are no scientific studies to support this idea yet, if you wait for the science to properly test the theory, you could be waiting for many years. You have nothing to lose by doing your own individual experiments, because it is well established that low glycemic index diets, Atkins diets, and ketogenic diets are safe. In fact, it is likely that they are far healthier than the low-fat, high-carb, low-meat diets recommended by public health officials, which are the very same diets that have worsened our collective health over the past four decades. If you do decide to try a dietary change, just keep in mind that it can take three to four weeks before potential benefits become noticeable.

A few words of caution

Dietary changes are difficult to make, and benefits can be slow to take effect, therefore nutritional approaches are not recommended in emergency situations.

If you are currently taking a mood stabilizing medication, please do not make any changes to your medications without discussing it with your clinician. Please see my article "Ketogenic Diets and Psychiatric Medications" for important information about drug interactions.

Very low-carbohydrate diets can alter the way medications are processed by the body, so if you are taking medications of any kind (including blood pressure and diabetes medications) and decide to try a low-carbohydrate diet, please do so with close medical supervision.

*If you are taking Depakote (Valproate), please be aware that there is a case report in the literature of a man who became manic and psychotic after starting a ketogenic diet, despite taking Depakote. The reason may have been that the diet reduced his Depakote levels (Depakote is a fatty acid, and the ketogenic diet is a fat-burning diet).

How about you?

Have you ever tried a low glycemic index diet or low carbohydrate diet? If so, did you notice any effects on your mood?

To learn more about about how diet can impact bipolar disorder, read my blog post “Bipolar Disorder and Diet Part I: Omega 3 Fatty Acids.”