And as we talk about this in this interview psychiatric diseases aren't all that different from body diseases if you want to call it, a lot of it has the same the same baseline the same cause of disorder and the same potential treatment much of which needs to focus on lifestyle. So I really enjoyed this perspective and I think you'll get that from his approach and also how we sort of leading the way in Argentina.
This movement isn't quite as big in Argentina as it is in the United States and in Europe. So he's sort of blazing the path there which I really appreciate. Also this sort of ties in a little bit with the how DietDoctor launched their Spanish website. I wish I could've done this interview in Spanish but my Spanish is not good enough at all. But it's reaching out to a whole new market, a whole different world, this is truly a global event.
So if you want to hear more about this and read the show notes go to DietDoctor.com. Otherwise I hope you enjoy this interview with Dr. Ignacio Cuaranta. Dr. Ignacio Cuaranta, thank you so much for joining me on the DietDoctor podcast.
So you are a psychiatrist based in Argentina and now you are part of the whole low-carb movement as treating your patients with nutrition for their psychiatric disorders. So let's rewind for a second, go back to your training as you were learning to become a psychiatrist. Was there any discussion about nutrition in any of that training?
And let's talk for instance SSRIs that are one of the most available drugs that are used in depression and anxiety, in obsessive-compulsive disorders, in psychotic disorders, for many, many functions, they have a plethora of side effects and adverse effects that are very hard to counteract, and those are drugs that are often very hard to take away from patients. And I think that these strategies that I'm using in my clinical practice can have a huge impact in reducing doses or even avoiding to prescribe a drug altogether.
I mean there are estimates that a third of all people will have some mental health condition during their lifetime. The Association of psychiatric diagnoses with reduced mortality and substance abuse problems and decreased quality of life. I mean it's rampant and I don't think it gets the same attention as you can say the other problems, the diabetes, the body problems rather than the brain problems. Do you think that that's an accurate statement? That it's sort of been not given the attention it deserves?
There is an average of between 2 kg and 17 kg of weight gain over the course of treatment and that's about I think between 4 and 30 pounds of weight gain on average and this severely increases mortality among psychiatric patients and psychiatric drugs are dose-dependent and so if you have a severe condition you will probably need higher doses thus increasing mortality and highly reducing the quality of life and expectation to get better, it really highly limits recovery expectations in this group of patients. And yeah, it is an accurate statement, of course.
So walk us through this - so you went through your training, you learned to become a psychiatrist, you started your practice... how did you take the path less traveled, how did you differ from everybody else and start to think, let's look at how nutrition actually affects the function of the brain and see if that's going to help people... How did you make that transition?
So, it is kind of like a 14 to 15-year route for me and when the time came to decide what specialty I'd like to go in, I was between psychiatry and endocrinology. Psychiatry kind of like suited me a lot more than endocrinology because there were other aspects that I didn't really care for and really, psychiatry, I have a passion for it, you know.
Really, when I study this type of topics, I get really invested in, and so I decided to go into psychiatry. But you know, inside of me, nutrition was always- and obesity was always a very important topic for me. So, I kept studying it. Even for myself, for my own health, you know, it's something that doctors sometimes... we will put aside and doctors ourselves are very unhealthy people and that's kind of like a pretty strong statement, you know. And so, I did my residency in psychiatry where I did, you know, I focused on all of the psychiatric large topics but nothing about nutrition.
And, so, after, it was about 2013, I came across the paleo diet, I started doing it myself. And then on year 2004, I travelled to France, I did a 3-month rotation at a psychiatric hospital there in Paris and I kept studying and studying. When I came back my girlfriend got pregnant and she was- my daughter was born in December 2015. So, I started studying ways to minimalize things in my house. It was pretty, you know, kind of like a, you know, a different path. But I came across the intermittent fasting through a minimalist site.
So I started seeing this very frequent pattern of metabolic disorders among patients. I started seeing all of these compulsivity trades, all of this deterioration in the quality of life and I started asking more about nutritional aspects. So, you know, as a surprise came that they were- most of them were following the standard diet, you know, with high carbohydrate ingestion without affecting their sleep patterns, you know, with sedentary lifestyles.
So, I started you know, with some patients that were suitable, and I have a very strong patient-to-doctor relationship that is a very important aspect of my practice. I started implementing intermittent fasting and they started getting a lot better but in a matter of days, in a matter of weeks, I was able to start getting people off medication or de-titrating medication, lowering doses, you know, they started getting more energy levels, start feeling better, start telling more people. So, this is how it started.
Because if you start eating a low carbohydrate diet, a secondary effect is that you starve, you know, reducing your appetite, reducing your carb cravings and reducing your high compulsivity. So, actually my first approach is about implementing intermittent fasting but right now I do it as a combination. I also talk with my patients to reduce, in the first place, sugar or highly limit sugar or try to tell them to avoid sugar altogether, but I am flexible in regards to health and goals, you know.
I try to be coherent with what the chief complaint of the patient is and their goals, and so I try to tell them, okay you're going to have and see a lot of better results if you do this synergistic strategy. Not one or the other, just to lose weight or be in good shape for the summer. My goal with my patients is quality of life, that's what I always talk with them.
So, I try not to be dogmatic or rigid in my interventions because, you know, when you are in the clinical practice, face-to-face with patients, you have to be more flexible, you have to be able to talk with different personality traits, different goals, different activity levels, different ages, genders and all of the different types of patients that we see.
And that's why it's also linked to type 3 diabetes or dementia. It is my hypothesis that it's not only affecting memory and concentration, but it's also affecting behavior, it's also affecting mood. I mean, how would you behave if your brain was not able to use the main fuel that your body is using? If you have already fixed your metabolism to use glucose as energy and your brain is not able to use it efficiently, how are you going to be?
Are you going to be tranquil? Easy? Are you going to be calm or are you going to be excited, desperate, irritable? I mean, it makes a lot of sense for me and this is what I am seeing in the practice, in my everyday practice. So it's not that you have to wait until someone is 60 or 70 to make an intervention, but my proposal is that we should be training metabolic flexibility at an early age, you know. Even though you're not perennially in ketosis but you can you know, be in the outskirts of ketosis daily, doing some types of fasting, training the fasting ability, and being able to use both types of fuel.
Some patients that's more in the psychotic side like schizophrenia, there's studies, very old studies linking gluten, you know, gluten sensitivity to schizophrenia. I recently had the opportunity to talk with a patient that was having hallucinations and really persecutory ideas since she was a child, since after some traumatic event at 5 or 6 years old and she was 34 with continuous hallucinations.
And after she read Dr. David Perlmutter's Grain Brain, she dropped gluten and started doing a ketogenic diet in January, and two or three weeks after that, all the hallucinations were gone. And those are pretty, you know, strong N=1s and experiences and observations, and this is one of the limitations because we try hard in psychiatry to get people to do these types of investigations.
So, what we are seeing at the office is very important because I don't think we should disregard the results that people are seeing, so that sometimes many people are starting to lose weight, but they see secondary effects, "secondary effects" on mood conditions, they start feeling better, they start seeing more mental clarity, thus, making better decisions if you are able to make. In fact, we are the results of the decisions we take moment to moment to moment. If you start taking better decisions for yourself, that's better outcomes to be expected.
And these dramatic case reports definitely have something behind them. But therein lies part of the problem because right now, we're in a world of anecdotal experience and case reports and not clinical trials and large bodies of clinical research, so it might be a little challenging to say, yes, this works, yes, this should be recommended, because what do we have to back it up? How would you respond when someone asks you that?
And I think we should not see ketosis or the ketogenic diets or ketogenic pathways as, you know, the panacea, as you know, the end of it all. And the solution for everything is not the panacea for psychiatric conditions and it's not the panacea for major depressive disorders, schizofrenia, bipolar disorders, severe anxiety disorders. But it is and it could be a great co-adjuvant tool to implement, for any psychiatrist or for any clinician or someone working at a primary care and being able to intervene and do prevention.
I mean, how unsafe could it be to prescribe to your patients that they eat real food, that they stop snacking all the time, that they start to talk with them about prioritizing sleep patterns, that they implement any type of stress management, you know, strategy. Those are very safe interventions, and we have a lot of evidence to say that those are safe interventions.
So, what I am proposing is not an excuse to irresponsively dropping medications if you are under treatment, but it is a proposal to widen our views about what we are doing with our patients. Because especially under severe conditions because of what I told before in regards to dependence, the dose dependence of the effects of psychiatric medications, we could really reduce and improve their metabolic profiles even if we are prescribing medications.
And there are also studies regarding the 16:8 protocol and joining, you know, giving the time of the medication at the time of the meal, of meals and, you know, that is a kind of intermittent fasting protocol. And it really reduces the metabolic derangement of the medications, especially of the anti-psychotic that are very, very tough on insulin levels.
And that's also what makes it difficult to study from a scientific standpoint because where do you draw the line? Because there are lots of these studies that show low-carb diets don't work and then they define low-carb diets at 45% carbohydrates. And so, it all depends on how you define it. So, I think that would make it challenging from a psychiatric perspective but what I'm hearing from you is you don't think it's necessarily ketosis.
So, we hear lots of things about how ketones are beneficial for the brain, whether it's in Alzheimer's disease or a traumatic brain injury and people talking about how to use exogenous ketones to boost the beta hydroxybutyrate level to get a bigger effect and bigger penetration into the neurons. And there's studies that ketones decrease oxidation of neurons, there's studies that it increases mitochondrial function in the brain.
So, from your perspective though, is there something beneficial about ketones and ketosis that you think would be helpful for psychiatric patients above and beyond just healthy lifestyle and low-carb?
So, I think it's a lot about the energy availability and the energy quality because ketones don't only provide for very large deposits of energy that are very reliable, predictable, thus providing for a brain state in which you have energy predictability, that's fundamental. And then you have neurotrophism that is linked to a higher production of BDNF - brain drive neurotrophic factor.
It strengthens synaptic signaling, helps provide a more physiological environment for the brain. I am a really big fan of Dr. Cunnane's work about brain evolution. He's working also, you know, he's doing a lot of work in relation to dementia. And really, this is not about surviving, this is about thriving.
And what I like to tell, you know, I am focused on prevention and I would like people to know about these types of strategies to start exploring themselves and don't wait until they start getting severe symptoms to start implementing, because it might be too late and it might not gain functions, lost functions back.
Because when we're talking about the brain, it's really an energy hawk and it needs a constant fuel flow, and ketones provide that. I mean, especially in patients where they are insulin resistant. I love Dr. Naiman's meme, it's the dam concept. I don't know if you are familiar with it.
And this is what I see in the clinical practice because in one week, two weeks, and three weeks after implementing, a well-formulated ketogenic diet and intermittent fasting protocols, patients do start to wake up, do start to feel a lot more focused, more stable, they really reduce cravings and they start feeling more energetic. One of the main chief complaints that the patients have at the office when they come is low energy levels, low initiative.
Seeing that they want to do something that highly differentiates from melancholic depression that they have no motivation to do anything, but they know they see their goal, what they want, they recognize they have everything that they want but they don't have... they just don't have the energy to go with what they want to do. I think if we can rule out all of those patients, we'll keep other conditions that probably don't respond as well to this type of strategies.
We also have typical depression, which is melancholic and more related to childhood trauma, it has a later onset, it has a different profile more linked to psychiatric conditions maybe to schizophrenia running in the family, very low appetite levels, with clinophilia, that is like wanting to be in bed all the time.
That could have some serious adverse consequences. They need to work closely with somebody. But the problem of course becomes finding the person to work with, finding a psychiatrist or even a primary care doctor who's willing to work with them on this. So, you're in Argentina. I don't know much about the medical culture there, but I'd imagine it's- you sort of stand out from the crowd as a rare breed. Is that the case? Tell me a little more about that.
But they might not, related to what I said before in relation to the under-report of psychiatric conditions, they might not do a consultation with a psychiatrist or a psychologist because the taboo, because of stigma, because they don't recognize or some of the symptoms are harder to recognize and they might not even know that they have depressive symptoms.
They kind of maybe feel that they have low energy, they are overweight, it's all related to that, and they have a reason to think that. But the problem is that they go to the wrong professional and there is a big "Why" because there's- not all of them, and I'm not saying that everyone that is not doing what I'm doing is wrong, I'm far from that, but I really get very mad when I hear stories from my patients, there is a high rate of verbal abuse about professional abuse with obese patients, and you can see it on live TV, you can see in the Biggest Loser.
We also have our version of the Biggest Loser. It gives me nausea to watch that program. Really, you see people suffering, you see people relapsing all the time, you see people with probably mental conditions or psychological traits. It's really, you know, we have a lot of work to do. And this is part of why I decided to, kind of like expose myself and expose what I'm doing in order to incentivize more psychiatrists to start prescribing or using or at least increasing awareness and observants about this metabolic profile.
Ignacio: If they are taking medications, I think we really need to-, it's more from our side what we need to do, we need to really-, I'm launching online consultation in order to be able to help patients so it's not only in Argentina. I can include people that probably want to know how to do it. But I have to work close with a local physician, because if you are taking medication like you said, you need to know personal history, you need to know- I mean, psychiatric relapse is not a joke and it's very important to be cautious about this.
But I - like I said before - a 16:8-hour protocol is a safe intervention, eating real food is a safe intervention. It's like, that's kind of like weird to say. But improving quality of sleep is a safe intervention. So, really, these are very- even though it may not sound like it- these are very conservative interventions. I mean, and I start from there. I always talk with my patients. 16-hour fast is like an anti-seismic structure, I do the same gesturing with my patients. This is a anti-seismic structure, this is where we start from, we are going to move from this.
But it is a structure that is going to give you an ability to better management and to better manage stress in your life, and it's very flexible. So if you wake up one day and you don't follow it, not a big problem, you'll get back on track the moment after you did something you weren't planning to do or to ate something you weren't planning to eat, you drank something you weren't planning to drink.
So, I'm also seeing when you're lowering your compulsivity, I'm also seeing an easier pathway into reducing addictive behaviors, being whatever, alcohol, tabacism, marijuana, cocaine, I'm seeing, you know if you reduce- and a stressed brain will look for a relief and this is where culture comes in, or your personal history.
Some people rely on food, some people rely on other types of substances or binge watching a TV show or Netflix... and it is one on one work. I'm hoping that more psychiatrists and psychologists jump into this, you know, into this wave and into this movement because it's bringing back the customs that we had 40 to 50 years ago. Really, and intermittent fasting is kind of like a cool name for something we shouldn't stopped doing ever.
And it's also fructose, so I'm a big follower of Dr. Robert Lustig's work. And really has helped me a lot, the approach that he proposes in The Hacking of the American Mind, his latest book, I really love that book. It really helped me into finding the way between stress, addiction and the ways to, you know, the ways you provide relief. And also, enhancing- this is very important- enhancing serotonin pathways. There are many, many natural ways, physiological ways, to enhance your feeling of tranquility.
And it's not just taking an antidepressant, and this brings me back to kind of like a joke that I'm going to tell. It's like most patients- well not most, but frequently I get at the office the consultations; "Doc, I have low serotonin, I need something to put it up." And this is kind of like you know, this clear example how this monoaminergic imbalance dogma has penetrated the population you know.
Someone is like, I know I have low serotonin, I have to put it back and everything will be normal again. Why don't we address what might have happened, why your serotonin is low in the first place?
And we have this accessible meat, especially the meats that I propose my patients to eat, that are not the lean cuts, that are probably more expensive, but are the cheaper cuts. That's what I eat personally myself. And this is kind of the diet that I follow. I don't only intervene with my patients, I have a lot of friends that I kind of like supervise their diets and they come to me and they say, "What can I do? I need to do something about my diet."
So, there I go, you know, straight to the source because first of all, cut this everything out and focus on meat, kind of like a carnivore transition diet but not dogmatic. Not like, I had the lettuce, no, you ruined your diet, no, it's not what I propose. But it is a great transition because, they get better, you know. They start feeling better and it's like I said before, they start asking, what else can I do, what else can I add to my life in order to improve it.
And it's very tasty to prepare too with butter, garlic, those are kind of like prohibited in the usual diets. And people- this is the sad part- people remove butter, remove organ meats, remove all the fatty cuts, remove olive oil, remove nuts. It's like they remove everything that is healthy because of this caloric-centric view, you know, it's like this eco strategy.
And that's, okay, you want to reduce your calories voluntarily, you will be able to do it maybe for two weeks, three weeks, but you will relapse. I mean, it's like because it's not what our bodies and brain expect from your diet. They start sensing that is, you know, a shortcut. So, most of the time, most often that elicits responses.
And this is important in my practice to address stress levels. Because I don't necessarily suggest a patient going under severe stress to do long fasts, but I go easier, easier with them. And try to of course reduce stress load, improve sleep patterns. I do a lot of emphasis on sleep, maybe you've noticed.
If you don't address the technology addiction that is the most prevalent... to our cell phones, and nobody forgets their phone when they go out their house. And it's the first thing we do in the morning, the last thing we do at night. And it causes most of chronic sleep deprivation and we all know that this increases insulin resistance you know, and a host of others.
So, picking up what I left before- this is a very important message that I like to tell in regards to being a psychiatrists and working with these conditions. Many patients come in and they say, I want to lose weight, and I try to talk to them about quality of life and being able to intervene in other aspects of their life and this is what I call really prevention and capitalize all the opportunities of the contact of a the patient with a health professional, you know.
Capitalizing each opportunity because you never know if it is going to be the last opportunity that the patient has or the last time he or she are going to try to get better. You never know that.
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