“The problem with depression is, you can’t see the end.”
Depression is like a ditch. Sometimes you head into and get stuck, but you manage to wiggle out. Other times you’re in a major rut and can’t get out at all. In those cases you need to call someone. It happened to me once. I was driving in the winter to a hiking spot and I thought that a flat-looking patch of snow was the side of the road and before you know it I’d driven into a ditch. I couldn’t get out. I tried gunning it, putting rocks under my tires, getting a friend to push. Eventually I just had to call someone. Within a few minutes, a tow truck came. The man driving it unceremoniously and unemotionally told me to put the car in neutral. He hooked a giant chain to my bumper. He yanked me out of the ditch. And then he drove off. Roadside assistance. In my last post I said something akin to “health is not emotional”. It’s sometimes just an equation. With patients I educate them on their prefrontal cortex, on brain inflammation, on Polyvagal Theory and the nervous system and how depression is a normal response of the nervous system to abnormal circumstances, and how to they can work with their body and environment to get the help they need to yank them out of the ditch. But I also talk about the people around us. We need them. We need them to be our prefrontal cortexes (because when you’re depressed or anxious yours isn’t working at full capacity–you CAN’T just yank yourself out a ditch, you need a tow truck, a chain and an unceremonious dude who knows what to do). You need a strategy. You need a hand. You need help.
Depression often feels like an insurmountable barrier, making it hard to see beyond the immediate struggles. It’s essential to recognize that this condition is not a personal failing but a natural response of the nervous system to overwhelming circumstances.
By understanding the interplay between brain inflammation, the prefrontal cortex, and the nervous system through frameworks like Polyvagal Theory, patients can gain insights into their experiences and find ways to support their mental health effectively. This knowledge can empower individuals to take proactive steps, but it’s also crucial to remember that overcoming depression frequently requires external support.
In this context, resources like Avesta Ketamine Wellness offer valuable assistance. Their approach integrates cutting-edge treatments with a supportive environment, providing a crucial lifeline for those in need. Just as a tow truck and a skilled driver are essential for getting out of a ditch, having access to professional help and a comprehensive treatment plan can make all the difference in navigating the complexities of depression.
With the right support and strategy, individuals can find their way through challenging times and work towards regaining their mental well-being. Who’s your support team? Who are the people around you?
I talk to my patients about bringing their loves ones on board to help them set up systems to regulate their nervous systems, nourish their brains and bodies (don’t even think for a second that I didn’t have a snack to munch on while waiting for the two truck–this fact is not even metaphorical. You NEED a literal snack to fuel your brain), and reduce inflammation.
There is a theory of depression that it is an ADAPTIVE state meant to get us through a difficult time.
Famine. Capture by a predator. Infection or illness. Isolation from the group.
These may have been the historical hunter-gatherer inputs that caused depression but now it seems that depression can be triggered anytime our bodies are in a perceived or real “stuck” state with no way out.
Many, if not most, or all, depressive episodes I’ve worked with follow a period of intense anxiety. Our body’s stress response burns out, we can no longer “get away from danger” and we shutdown and collapse.
We turn inwards. We immobilize. We ruminate (possibly as a way to THINK our way out of danger).
This is why the 2a serotonin receptors that encourage “active coping” or things like BDNF, which is involved in making new brain cells, have important roles in the treatment research for major depression.
I’ll bet you’ve been told you have a disease, though. Something incurable that you’ll deal with your whole life.
But what if, rather than a disease, depression is a STATE you visit, and sometimes get stuck in that follows anxiety, stress and certain triggers?
How might that change the way you see yourself and your mental health? How might that change the way you seek solutions to how you’re feeling?
“The Adaptive Rumination Hypothesis by Andrews and Thomson posits that depression is not a pathology but a set of useful complex thoughts and behaviours that enable troubled people to withdraw temporarily from the world, deliberate intensively about their social problems, and devise solutions.”
From the Psychiatric Times
The major problem with depression that keeps us stuck in the state is when we turn our rumination back on ourselves and engage in self criticism.
Our beliefs come from external factors: our research, others’ stories, things we read, things we see, and internal factors: personal observation of our own experiences.
My beliefs about food have formed through reading scientific studies and nutritional studies, to an understanding of biochemistry and anthropological data, to my own embodied experiences and my clinical experience.
These beliefs inform the way I practice and form biases in the way I do further research or understand patient experience and my own experience with food. These beliefs informed the way I put together my foundational program and how I position food on Instagram and on Youtube–these are the beliefs that form the messaging and the medicine.
I thought it would be interesting to write them down to declare them explicitly and examine them.
What do you believe about food and nutrition?
I believe that food contributes to our health and to disease.
I don’t believe that food is the ONLY factor in contributing to these things, obviously. I think food plays more of a role in our health (much more) than conventional medicine would claim. But, I also believe it is less of a direct factor in our health than many Instagram influencers or nutritional salespeople (you know the ones I’m talking about, the ones who write books call “The Cure for X Disease” and things like that) would assert.
For example, I don’t think that you can cure cancer with carrot juice.
I also don’t think that, if you’re sick or know someone who is sick in some way that you or they got there because of your food choices. Chocolate cake didn’t give you diabetes. Gluten didn’t cause your depression.
But I do wholeheartedly believe that food plays a key role in shaping us: our physical and emotional and mental bodies. Food contains the nutrients we need to function. It feeds our cells, our microbiome, it shapes our bodies.
It’s crucial to recognize that while food is a significant aspect of our overall health, it’s not the sole determinant of our well-being.
Each person’s health journey is unique and multifaceted, encompassing not just dietary choices but also lifestyle factors, mental health, and environmental influences. This is where organizations like Buoy Health come into play, assisting individuals in navigating their health concerns and finding the right care tailored to their specific needs. By focusing on a holistic approach, this platform empowers people to understand the root causes of their health issues, helping them to develop informed strategies that incorporate nutrition alongside other vital aspects of health management.
Ultimately, acknowledging the role of food is essential, but it’s equally important to seek comprehensive solutions that address the entire spectrum of our health, ensuring we thrive both physically and mentally.
Food is one of the important ways that our bodies receive input from the outside environment. This information is communicated through specific plant nutrients, like resveratrol found in red grapes, or in the foreign compounds and toxins that pollute the regions where we live.
Through food we can heal. Through food choices, over time—nutrient deficiencies, or surviving off of too many things that aren’t really food—disease can start to form.
Food connects us to the earth.
2. I believe that our bodies are intelligent. Our bodies have evolved mechanisms that can communicate to us what they need–if we listen.
Our taste receptors tell us about the quality of the food we’re consuming. Freshly picked in-season fruits and vegetables taste very different than out-of-season, bland ones. The richness of flavour often corresponds to the richness of the nutrients present in the foods we eat.
We crave animal fat. We crave sugar. We crave salt.
We crave these things because they represent a density of nutrients that our bodies need.
We’re drawn to colours, because colourful foods represented foods that were fresh and ripe and packed with nutrition.
I look at a lot of things in medicine through the lens of evolutionary biology. A lot of people in my field and in science do. I trust that the way my body is formed as a response to an environment that is ever changing.
The humans who were most drawn to ripe, nutrient-dense fruit, or the saltiness of animal protein, or the delicious texture of fat, ate more of these foods. And eating more of these foods gave them an evolutionary advantage, allowing them to survive and pass on their genes to future generations who inherited preferences for these tastes.
Therefore I believe that consuming animal fat and sweet foods and salty foods is not bad.
Craving these foods is not bad. Cravings and taste preference represent a complex chemical system that evolved over hundreds of thousands of years to bring us to the things that helped us thrive.
I actually believe that we should listen to our cravings–they can be quite sophisticated. However, I also believe that:
3. Big Food has highjacked our taste buds.
There is something called “The Dorito Effect” where food companies high-jack these natural drives, these cravings, these taste preferences to get us to eat more frankenfoods. A Cheeto has been engineered to get you to consume the whole bag.
Therefore I don’t think we can trust our cravings when we’re consuming a high amount of “fake” foods–foods grown in a lab, foods made in a plant, foods that have 5+ ingredients that didn’t exist in 1913 or whatever.
How much of these foods is appropriate to eat? I try to minimize my consumption as much as possible. I’m not sure what the right answer is for you. I do know, however that I can’t let my body take the reins on what foods I might be needing if I consume too many of these processed foods.
How do I know I need more carbohydrates when I crave sugar or if my body is just chemically addicted to Sweettarts? I try to satisfy cravings with the whole food version of the thing and I find that that often works create an ongoing, trusting relationship (which takes time) between my taste receptors, the environment, my stomach, my mind, and my cells.
I believe that these relationships can help my body relax and know that it will be fed, like a crying baby who knows its caregiver will respond to its cries.
4. I believe that humans should consume a combination of plants and animals.
This may be a fairly controversial belief.
Of course there are many animal rights activists, vegans and plant-based diet advocates who would tell me that you don’t need animals to be healthy. There are many people who swear the Carnivore Diet cured their autoimmune disease.
And, maybe they’re both right. However, I believe that humans evolved eating some sort of combination of animal and plant foods and that there are distinct nutrients that are rare in plants and others that are rare in animals.
I can’t personally get enough protein on a plant-based diet. And, after eating a diet that is too meat-focused I start to crave salads, whole grains and beans.
High-quality protein, iron, choline, Vitamin D, EPA and DHA (marine omegas), zinc, tryptophan, B12, and other nutrients are hard to get enough of in a plant-based diet while preserving ratios, keeping the body’s hormonal systems (like blood sugar) balanced, and honouring cravings.
5. I don’t necessarily think, however that the Paleo Diet is the best diet.
I don’t think any diet is.
I think in principle Paleo was a cool idea: we humans spent the majority of our time in a hunter and gatherer before food processing and agriculture made things like grains and legumes digestible.
Therefore, like we should feed dogs like wolves, and we should eat like our primal ancestors, as our bodies haven’t evolved fast enough to keep up with high fructose corn syrup, etc.
I agree with the premise. But I also think that there is evidence that grains and legumes were consumed before agriculture, perhaps just not as in high amounts. Our bodies are different from the way they were when we were hunters and gatherers: we have more stress for example and higher complex carbs may help us manage this stress.
Also, animals fats, while good for us evolutionarily now exist inside of the context of an environment that is filled with thousands of chemicals. Animal fat is where chemicals are sequestered and therefore consuming lard, butter, and tallow as the main fats in the diet may not be as good for us anymore.
I’m not sure, but I think we need to appreciate our modern context and consume foods that are relatively unprocessed and well-digested that weren’t necessarily available when we were hunting and gathering our own food.
In essence, I think the research points to the fact that whole gains like oats and buckwheat and legumes like lentils are good for us.
6. Food is social. We don’t make nutrition decisions in a vacuum.
We use food to communicate: I love you, thanks for lending me your Back to the Future DVD set. Sharing food is an important part of our biology, of the human existence.
Humans are social creatures. And our socialness orients around food for a variety of reasons: celebration, socialization of children, peace-making, reward, pleasure, art.
I eat differently depending on who I’m with. I eat differently depending on the foods available at my local grocery store.
When I’m with my ND buddies I eat differently than when I’m with “muggles” or, non-NDs.
Navigating food in the social realm can be difficult–a balancing act between our own internal values around food and our values around connection–not offending someone, for instance.
I have suffered when my food choices didn’t fall into the realm of the society I was living (for example, being a vegan while living in South America) and trying to live with my Nonna, my Italian grandmother, while also learning that gluten was making me sick.
We may have conflicting values about food. But I believe that that’s ok.
I believe certain foods can contribute to inflammation but I also believe that they can help soothe my troubled emotions and overwhelm at times, and that that is anti-inflammatory.
To be honest, I don’t really like wearing socks and shoes–they feel weird on my feet.
I would rather prance around barefoot as the bonafide urban-dwelling earth-child I know myself to be deep down. But, I’m aware that we live in a world where the ground is sharp, and cold.
Sometimes it’s not safe, or socially acceptable to walk around barefoot.
And so I don’t. Because even though I love being barefoot, I can’t always do it. It’s not always appropriate.
And so it is with eating ice cream. Sometimes you’re trying to avoid it, but other times it’s appropriate to have some.
Under certain circumstances, eating ice cream might be the healthier choice.
7. Food obsession and shame have no place in health.
Of course eating well can bring is closer to health. However, steer the ship slowly. Be patient with yourself. Be curious about the process and learn to pay attention.
8. Embodiment is the key to bringing us back to nature and understanding our relationship with food again.
Sometimes we need help with our relationship with food.
Sometimes we need to unwind the years of food shame and diet culture to figure out what we even like, let alone what’s good for us.
I sometimes tell patients to have protein every time they crave something.
Just try it. See what happens.
Sometimes a craving for salty snacks means you need protein. It doesn’t mean it’s bad to satisfy a salty craving with popcorn, but if you do how do you feel? Is the salty craving gone?
Sometimes cravings for carbs and salt is the body asking for more protein. And then, in that case, it might be better to try having some protein. Just like sometimes you’re tired and food can help but so can a nap and a nap might help more.
It’s a process that involves trying things, from a place of curiosity, not judgement. And paying attention to how you feel.
If someone asks you for directions to a coffee shop in a language you don’t understand, and so, trying to be helpful you send them to a greenhouse.
They’ll love the greenhouse, you think. It’s beautiful there. And it is a beautiful place. But, they actually wanted a coffee and a piece of pie. And your intentions were pure. You were trying to help, trying to listen.
You just didn’t speak the language.
So I tell patients, have protein when you experience cravings and that might help you get enough protein.
Cravings aren’t bad. They’re essential. They’re a language.
Feeling stuffed isn’t bad. It’s another language. So is hunger. Hunger, satiation, cravings, mind-hunger, feeling stuffed to the gills, are all important syntax in the language your body uses to talk to you, to tell you how to feed it.
It’s hard to listen in a room full of shame, so it can take time to learn.
I talk with Dr. Kara and Dr. Dave of That Naturopathic Podcast, rated in the top 6 Canadian Medicine podcasts, about taming the tiger of anxiety. Click to learn about your HPA Axis, the stress response and how we can “tame the tiger” by providing our body and mind with the assurance that we’re safe. Listen on Spotify.
I talk to Taylor Morozova of the Weird Waves Podcast about how I became a naturopathic doctor, surfing, immunity, vitamin D, and how to stay safe in the age of Corona. Listen on Spotify.
Hannah Hepworth, of the Anxiety Revolution Podcast, and I team up to discuss a natural and functional approach to managing anxiety.
In our talk, featured in her 2019 Anxiety Revolution Summit, a series of talks with integrative mental health practitioners and experts, we discuss circadian rhythms, the body’s stress response and the HPA (hypothalamic pituitary adrenal) axis, and blood sugar, and their role in anxiety.
Click the link to listen to this 30-minute interview. Let me know what you think!
I appeared on the Rebel Talk Podcast with Dr. Michelle Peris, ND. Dr. Michelle writes,
“Not a week goes by that I do not discuss mental health with patients in my office. Rates of depression and anxiety are on the rise. So I really wanted to unpack this important topic for you, giving you relevant information and diving deep into interventions that can help optimize mental health. ⠀
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In this episode, Dr. Talia details how our brains work while suffering from depression, anxiety and stress. Her deep knowledge of neuroscience is combined with mindfulness practices and also with microdosing, an approach that consists in taking low doses of psychedelic drugs, such as LSD or psilocybin-containing “magic” mushrooms, in order to prevent and treat symptoms of depression. ⠀
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Dr. Talia talks about mental and physical barriers, that can holds us back from making the changes needed for a healthier and more balanced life. Listen to this podcast and be inspired by this out-of-the-box conversation about neuroscience, mental health and mindfulness.”
When it comes to improving mood, most of us will do anything, including taking boatloads of pills.
One of the challenges I face as a naturopathic doctor is choosing which supplements to prescribe my patients; in the realm of natural medicine we have what seems like an infinite amount of options.
I can prescribe herbs for regulating the stress response, calming inflammation, or Zen-ing out the brain. I can prescribe amino acids, like 5HTP, which help regulate chemicals in the brain. I can recommend the hottest new products, like collagen, or a greens powder, or the newest Superfood. There are also a host of nutrients that the brain and body need for optimal functioning.
I try to keep my list of supplement recommendations to a maximum of 5, letting diet and lifestyle do the rest of the heavy-lifting. This means that I work in layers. When I see a new patient, I start by prescribing nutrients that fill in nutritional gaps. Perhaps my patients are showing signs of deficiency, based on their health histories, diet diaries or blood results; Or perhaps they just need a bit more nutrient support in the face of physical, mental, emotional and environmental stressors. After they start to notice improvement, we might move on to clearing more layers using herbs or therapies, like acupuncture or Mindfulness-Based Cognitive Therapy.
Naturopathic medicine does not believe in one-size-fits all treatment plans. If I see two patients with depression on the same day, both may receive entirely different plans. I base my recommendations on the person and her unique biography and biology, not the condition. However, because I try to keep my supplement suggestions to a minimum, when I work with patients with depression, I find these 5 nutrients continue to appear on my list.
1. Fish Oil
While most anti-depressant therapies target the brain, we know that depression isn’t simply a brain disorder. Depression is a complex condition impacted by our genes, physical health, social and physical environments, early childhood traumas, current stressors, nutrients status, and many other factors. Our minds and bodies are connected and therefore depression is as much a product of the health of our bodies and our environments, as it is of our brains.
Mounting evidence shows that inflammation in the body plays a major role in depression. Since the 90’s, scientist have found inflammatory cytokines (immune system molecules that cause inflammation), like IL-6 and TNF-a, elevated in depressed individuals.
When pro-inflammatory substances, like lipopolysaccharide (LPS) or interferon-a, traditionally used to treat hepatitis C, are injected into healthy individuals they cause symptoms of depression like lack of motivation and pleasure, and feelings of sadness.
Anti-inflammatory substances are effective anti-depressants. The omega-3 fatty acid eicosapentaenoic acid, or EPA, found in fatty fish like salmon and sardines, is a well-known anti-inflammatory nutrient. One study found that supplementing with EPA prevented depressive symptoms in individuals who were injected with interferon-a.
Fish oil contains the omega-3 fatty acids EPA and docosahexaenoic acid, or DHA. Both of these marine omegas are found in certain fatty fish, which can be remembered by the acronym SMASH: sardines, mackerel, anchovy, salmon and herring (also trout). Fish oil supplements combine EPA and DHA. DHA is a component of our brain mass. It is needed for developing the brain and nervous system of growing babies, and is indicated in pregnant and breastfeeding women. EPA confers the anti-inflammatory benefits.
A meta-analysis composed of 15 randomized control trials involving almost 1000 participants, found that fish oil was an effective therapy for treating depression as long as the fish oil contained over 60% EPA relative to DHA.
Another review of three studies, showed that omega-3 fish oil supplementation reduced depressive symptoms in children and adults by 50%.
When it comes to supplementing with fish oil for depression, it’s the EPA that counts, not the DHA. Also, more fish oil seems to be better than less. Studies that showed the best anti-depressant actions dosed participants with at least 1 gram of EPA per day. Some studies gave patients 2 grams of EPA or more per day. Supplements that showed the most benefit contained higher amounts of EPA relative to DHA.
A 100-gram serving of wild Atlantic salmon contains about 400 mg of EPA, while farmed Atlantic salmon, surprisingly contains more: 700 mg of EPA per 100 grams. While consuming fatty fish, like sardines, and pasture-raised, rather than grain-fed, animals can increase our dietary ratio of omega 3 to omega 6, which has general health benefits, supplementation with a high-EPA fish oil is probably necessary to supply the 1 to 2 grams of EPA per day that have been shown to reduce depression.
2. An Active B Complex
B vitamins are cofactors for thousands of reactions in the body. Cofactors are “helpers”. They help enzymes and cellular process work—without these helpers, important jobs just don’t get done. This can have major implications for our mental health.
For example, the vitamins B6 and folate are needed to convert the amino acids tryptophan and 5HTP to serotonin, the “happy hormone”. Serotonin is a neurotransmitter responsible for managing mood: soothing depression and anxiety; and regulating appetite, memory, and sexual desire. Serotonin is the main target of conventional anti-depressant therapies, SSRI (selective serotonin reuptake inhibitor) medications, which raise brain levels of this chemical.
Both B12, which is important for energy production and neuronal health, and folate, which is important for DNA repair, detoxification and reducing inflammation, have been found to be low in patients with depression. A B12 deficiency, resulting in fatigue, memory loss and low mood, can also mimic the symptoms of depression.
It’s important to supplement with an active form of the B vitamins. This means buying and consuming a B complex or multivitamin that contains B12 and folate in their active forms: methylcobalamin and methyl-folate (or 5-methyltetrahydrafolate, or 5-MTHF), respectively.
Individuals who have a genetic mutation that prevents them from efficiently converting folic acid (a synthetic vitamin found in cheap supplements and fortified grains, like wheat and rice) to active folate, are highly represented in the major depressive disorder population. This gene is called MTHFR C677T and is associated with lower blood levels of folate and an increased risk of depression. To learn more about folic acid and MTHFR mutations, read my article here.
B vitamins are also needed by the mitochondria, the “powerhouses” of our cells. By helping our mitochondria work properly, they help reduce inflammation, boost energy production and promote antioxidant synthesis.
We can find B vitamins in egg yolks and liver. The only dietary sources of B12 are found in animal foods, making it difficult for vegans and vegetarians to get without supplementing. Folate is abundant in leafy greens.
Physical, mental, emotional and environmental stressors create a higher demand for the B vitamins. The B vitamins are water soluble, excreted in the urine and not stored. Therefore, to support neurotransmitter synthesis and energy levels in my depressed patients, I often prescribe a good-quality B complex supplement to complement their diets.
3. Magnesium
Because my clinical focuses are mental health, hormones and digestion, I prescribe magnesium to virtually every patient I see—magnesium is an important nutrient for all of these conditions.
Like the B vitamins, magnesium is a cofactor. It’s involved in helping with over 800 chemical process in the body that simply won’t get done without it. We need magnesium to make cellular energy in the mitochondria, to produce neurotransmitters, like serotonin, and to repair DNA, among many other jobs.
Due to soil deficiency, low intake, stress and decreased absorption, it’s estimated that about 40 to 60% of North Americans are magnesium deficient. Only 1% of the magnesium in our bodies is present in blood. Blood levels don’t reflect the body’s magnesium stores, and so testing for deficiency is unreliable.
Magnesium is a potent muscle relaxer. Deficiencies show up wherever muscles are contracted, rather than relaxed: this can include constipation because of poor intestinal motility, muscle aches and pains, frequent urination due to contracted bladder muscles, menstrual cramps, and headaches and high blood pressure from constricted blood vessels. Insomnia, anxiety and sensitivity to loud noises can also all be signs of a magnesium deficiency. PMS, insulin resistance and sugar cravings are all further indications for magnesium supplementation.
Magnesium can be obtained from leafy greens like spinach and chard. However, most individuals need to supplement to stock up their magnesium levels, particularly if experiencing stress, fatigue, anxiety or depression. Like the B vitamins, magnesium is water soluble, excreted in the urine in response to stress.
A 2017 randomized control trial published in PloS One, found that 248 mg of magnesium chloride decreased the PHQ-9 score of those with mild-moderate depression by almost 5 points. This result compares to standard anti-depressant medications. Despite the relatively low dose and inferior form of magnesium, the effects were well-tolerated and benefits were seen in 2 weeks.
I prescribe magnesium glycinate, a much better-absorbed form, before bed to help patients sleep better. This means starting with 100 to 200 mg per night and increasing by that amount every 3 to 4 days or until patients are having a bowel movement on waking—this is called “prescribing to bowel tolerance”.
A side effect of taking too much magnesium is loose stools, or soft stools that fall apart in the toilet on flushing, which can be corrected by lowering the dose. I personally take about 900 mg of magnesium at night to manage my stress, mood, energy levels and muscle tension.
4. Vitamin D
About 70 to 90% of North Americans are deficient in vitamin D, which acts like a steroid hormone rather than an actual vitamin, and regulates over one thousand genes in the body. Our skin makes vitamin D when it comes into contact with UVB radiation from the sun. Those of us who live in northern climates with limited sun exposure don’t make enough vitamin D and need to supplement, especially during the Winter months.
Vitamin D is needed to regulate the gene Tryptophan Hydroxylase 2, which converts the amino acid tryptophan (a component of protein that can only be obtained from diet and is found in foods like turkey and pumpkin seeds) to serotonin in the brain.
Low vitamin D concentration has been associated with depression, however researchers aren’t sure if the relationship is causal: does low vitamin D status put someone at risk for developing depression? Or do depressed individuals have low vitamin levels in their bodies because of some other factor?
Studies have failed to show that taking vitamin D supplements impacts depression. I also haven’t found vitamin D to impact my patients’ moods as a solo therapy. It’s likely that nutrients like vitamin D acts as part of a network, in conjunction with other vitamins, like magnesium, which is responsible for converting supplemental vitamin D into the active form. Vitamin D is a fat-soluble vitamin, and taking it in chalky tablet form may not raise levels. I prescribe vitamin D3, the active form of the vitamin, in drop form. Vitamin D drops are suspended in fats like coconut or flax oil, which makes them easier for the body to absorb.
Whether a case of the chicken or the egg, when it comes to vitamin D and mood, we know that supporting vitamin D status is essential for achieving optimal health, managing immune function, reducing inflammation, reducing the risk of osteoporosis, and regulating mood, given vitamin D’s role in serotonin synthesis.
The Framingham study found that patients who had low levels of vitamin D had poorer mental functioning and reduced volume of a brain region called the hippocampus, which is responsible for memory formation and mood regulation. Reduced hippocampal volume is a risk factor for and consequence of major depression.
There is a “sweet spot” to optimal vitamin D levels; because it’s a fat-soluble vitamin and can be stored, too much vitamin D may be as bad as too little. Therefore, I like to measure my patients’ blood levels in the Fall to determine the right dose for supplementation. 4000 IU a day is a good, safe dose for most people during the Winter months.
5. Zinc
Zinc is the catalyst for hundreds of enzymes in the brain, including making serotonin, norepinephrine and dopamine, all of which are brain chemical targets of anti-depressant therapies.
There is a major concentration of zinc in the hippocampus, a brain region affected by depression. Studies show that zinc plays a role in supporting neurogenesis (the creation of new brain cells) by stimulating Brain Derived Neurotrophic Factor (BDNF). BDNF creates new brain cells and boosts mood. Anti-depressants may work by increasing brain levels of BNDF, protecting the brain against stress.
Plasma zinc concentrations are lower in major depressive disorder. Animal studies also show that depleting zinc can lead to major depression.
Zinc supplementation has been shown to boost mood. A study of 50 overweight or obese patients were assigned to receive either 30 mg of zinc or placebo. After 12 weeks, the group who received zinc experienced a greater reduction in the severity of their depression and an increase in the levels of BDNF in their brains.
Zinc is also an important nutrient for supporting the immune system and managing inflammation.
Besides depression, other signs of zinc deficiency include skin issues, like dry skin and acne, infertility, issues with gut membrane integrity (leaky gut), hair loss, low testosterone, poor immune function and fatigue.
Dietary sources of zinc are harder to come by for vegans and vegetarians, who are at a higher risk for developing a zinc deficiency. Zinc can be found in red meat, shellfish, lentils and pumpkin seeds.
I typically prescribe zinc the way I prescribe iron, in pulse doses: I recommend that patients work their way through a bottle of zinc (taking 30 to 100 mg per day), while we assess whether symptoms improve. Unlike iron (which we can measure more accurately by looking at its storage molecule ferritin), zinc can’t be accurately measured in blood. Like magnesium, zinc deficiency in the body’s tissues may be present long before low zinc levels show up in blood.
While this list can be a great tool for anyone interested in supporting their mood through boosting nutrient status, keep in mind that this information is not a substitute for medical advice.
I believe it’s essential to work with a naturopathic doctor, or a functional medical doctor, who can make the appropriate recommendations for your individual health needs. A personalized consultation that assesses your diet, blood work, health history and specific symptoms, can help you hone your list to come up with a dynamite nutrient plan that’s specifically tailored to you.
The Low Carb, High Fat or “Ketogenic” Diet has been touted as a health solution for weight loss, mental health, hormonal health, as well as a treatment for insulin resistance, diabetes, childhood seizures, migraines, and dementia.
It consists of eating foods like meat, fish, and non-starchy vegetables, and plenty of healthy fats from avocados, coconut, olives, nuts and seeds, while avoiding starchy foods like grains, legumes, fruit and root vegetables.
Our bodies and brains can use two main types of fuel: sugar and fat.
In this 21-day challenge we will teach our bodies to burn fat for fuel.
Some argue that fat is a “cleaner” fuel source than carbohydrates.
Ketone bodies, produced from fat have been shown to decrease inflammation, improve mitochondrial function—our cells’ power supply—and boost cognition. Ketone bodies also keep us full for longer, our brain sharp and focussed, and our energy abundant and sustained.
Many are introduced to low carb diets through their weight loss journeys. When we restrict carbohydrates, our bodies burn dietary fat and body fat for energy. Furthermore, less dietary carbohydrates means less insulin release. Insulin is our storage hormone, that prevents our bodies from breaking down fat, possibly impeding weight loss. When we cut out carbs we reduce our insulin levels, helping to heal insulin resistance, and helping our bodies shed fat.
To be perfectly honest, I don’t believe in diets,
particularly trendy diets that have names and followers, like groupies at a rock concert.
I believe that how we eat has a LOT to do with our individual biochemistry, our genes, our gut bacteria, our culture, our preferences, our job, our family, our free time, our individual health goals and health challenges.
Diet (or since diet is often a trigger word, but honestly all I mean by it is “way of eating”, or daily nutritional practice), is highly individualized. There is no one-size-fits-all diet.
HOWEVER, I do believe in resets.
I believe all adults could do well with a dedicated amount of time: 14 days, 20 days, 30 days, etc.: in which we really examine our relationship with food. In which we strip our diets down to the bare bones and examine our blood sugar, food sensitivities, food addictions, tendencies to emotionally eat, taste buds, etc.
After all, the human “diet” is essentially meat and vegetables. What happens when we strip all the fluff away? What might we discover about our bodies and minds? About our habits? About ourselves?
This way of eating restores metabolic flexibility, gets us burning fat for fuel (in addition to carbs when you add them back in after the 21 days). It helps us manage blood sugar, which is implicated in chronic stress, acne, diabetes, and hormonal disruption to name a few conditions and symptoms.
Obviously this challenge is not for those who struggle emotionally with food and need more one-on-one focused support, but it is an excellent way to be held accountable, to take on a challenge in which you’re given all the tools you need to do the discovery work.
You might discover that this is the best eating style for you.
You might restore your insulin sensitivity but discover that you need some carbs, or certain carbs, to feel your best.
You might discover hidden food sensitivities that have been plaguing you with inflammation for years.
In order to make sense of the world, people create stories. It is our greatest gift and most fragile weakness.
Boy meets girl, they fall in love, they encounter difficulties that they eventually overcome. It brings them closer. They live happily ever after—the classic love story.
Stress has a classic story too: cortisol, the “stress” hormone, is released during stress. It wreaks havoc on the body. Lowering stress helps lower cortisol.
However, when it comes to human hormones, telling stories in a linear narrative is impossible.
Hormones are signalling molecules in the body. They are produced by endocrine organs, such as the adrenal glands, the brain, and the ovaries. They travel through the bloodstream to impact the expression of genes on distant tissues, which impacts how our bodies function.
Production of norepinephrine in the adrenal glands as a response to stress can make your heart race, your pupils dilate, your hands to shake, and your senses become hypervigilant—when a perceived threat or danger activates the release of this hormone, your entire body pulsates under its influence.
Hormonal stories are hard to fit the human desire for narratives. Their relationships with our genes, bodily systems, receptor binding sites, and each other make their actions too complicated to be described linearly. Instead they act like webs, or tangled networks of intricate connections.
When hormone levels rise in the body, beyond our delicate homeostatic balance, a phenomenon, called “resistance”, can occur. With resistance, cells reduce their responses to the hormones that interact with them.
When telemarketers keep interrupting your dinner at 6pm, eventually you stop answering the phone.
When certain hormones continue to call at the surface of cells, stressing the body’s capacity to respond, our cells simply stop answering.
Many of us ask, “what happens when I pull this thread here?” when learning about one hormone that we’ve blamed all our woes on. We tug the thread, without considering the entire web of connections, and our actions affect the entire system.
Our hormones exist in an ecosystem where everything hums and flows together, as a unit. It’s impossible to lay out explanations for their actions in a linear fashion.
Hormone stories flow like a Choose Your Own Adventure novel—a hallway with many doors that snake down long corridors and meet again, and interconnect.
Go through the door marked “estrogens”, and you encounter serotonin, cortisol, progesterone, insulin, thyroid hormones, leptin, BDNF, dopamine, norepinephrine, and many others.
Hormones are the conductors of your body’s personal orchestra, composed of thousands of musicians, a complex musical score, highly-trained arms, fingers, and mouths manipulating instruments: a million moving parts working together in harmony.
The best we can do to understand the entire interplay is to slow down the action, take a snapshot of it, and to try to understand why these symptoms are occurring in this individual.
Symptoms of Hormone Imbalances
Because hormones affect absolutely every system of our body, I am always attuned to the possibility of hormonal imbalances in my patients.
It helps to look at hormones in terms of their symptom patterns rather than how any one hormone affects us in particular.
Common signs of hormonal imbalance are:
Fatigue, low libido, restless sleep, depression and anxiety, waking at 2 to 4 am, a high-stress lifestyle, and brain fog might indicate cortisol imbalance.
PMS – and the more severe related condition, PMDD – infertility, fatigue and low libido, missed and irregular periods may be related to fluctuations in the hormones estrogen and progesterone, or low estrogen and progesterone levels. Many of these symptoms could also be related to estrogen dominance, in which estrogen is either high or normal, and progesterone is low.
Endometriosis, a family or personal history of female cancers, anxiety and panic attacks, heavy and painful periods, frequent miscarriages, infertility, fibroids, fibrocystic breasts and weight gain around the hips and thighs can indicate estrogen dominance.
High levels of male sex hormones like testosterone, irregular periods, weight gain, acne, and hair loss may indicate a female hormone condition called PCOS.
Fatigue, brain fog, difficulty losing weight, puffiness, constipation, dry skin and hair, and low body temperature can be signs of hypothyroidism.
Symptoms of reactive hypoglycemia, such as feeling dizzy, anxious and shaky between meals, sugar cravings, weight gain around the abdomen, difficulty losing weight, and low morning appetite, night-time carbohydrate cravings, and binge eating can all be related to insulin resistance and poor blood sugar control.
In my naturopathic practice, I see common patterns of symptoms that indicate certain hormonal imbalances.
These patterns often represent vicious cycles where our body is stressed beyond a capacity to balance these interconnected webs of chemical interactions, causing further imbalance.
Cortisol
Speaking of stories, here’s one I hear often.
You wake up in the morning, exhausted. Your brain is in a fog and you don’t feel alive until a cold shower or double espresso knock you out of your stupor.
Things get a bit better once you get moving, but you wonder why your energy never fully bounces back.
You used to play sports in university, you think to yourself. Now just thinking of sports makes you tired.
Is this what getting older feels like? You’re in your 30s.
The days at the office stretch on forever. Concentration and focus are difficult. You see a coworker whose name, you realize with horror, can’t be brought to mind.
You’ve known her for a year. Cynthia? Sylvia? Your brain hurts.
In the afternoon you think longingly of napping, but instead take your place in the long line for coffee and something carb-y like a cookie.
When it comes time for sleep you are either out like a light or find it hard to turn your mind off; you’re tired, as always, but also wired.
Sleep doesn’t feel restful, and you often wake up, sleepless, at 2-4am in the morning.
When your alarm rings a few hours later, the cycle begins again.
Cortisol, one of our stress hormones, has a circadian rhythm. Its levels are highest in the morning, about an hour after waking. Cortisol promotes energy, alertness and focus. It is also a potent anti-inflammatory hormone.
Cortisol is what makes us feel alive in the morning, bouncing out of bed like Shirley Temple and her curls.
Throughout the day our cortisol levels slowly dwindle (unless a major stressor causes them to spike abnormally). They are lowest in the evening, when melatonin, our sleep hormone begins to rise, inducing feelings of sleepiness, preparing us for a night of rest.
Our modern day society, however, calls on cortisol to perform more than its fair share of work. Cortisol is around when we’re hauling ourselves out of bed after an inadequate night of rest.
Cortisol fuels gym workouts, gets us to our meetings on time, allows us to meet deadlines, tolerates traffic jams, responds kindly to tyrannical bosses, and makes sure the kids get to all their after-school events.
Cortisol is made in the adrenal glands, two endocrine glands located on each kidney, in response to signals from the brain that perceive stress in our environments and bodies.
When stress hormones levels are too high we experience a “tired and wired” feeling. During this time we might feel we thrive better under stress: workouts boost our energy, we have a hard time quieting down and we rarely feel hungry.
We might still struggle with weight gain, however, especially the abdomen and face, where cortisol tends to encourage fat deposition.
We might feel tension—tight muscles and shoulders, and body pain, as muscles clench up, preparing to fight or flee.
Chronic stress is associated with high levels of cortisol. We work long hours, late into the night. We go, go, go. This may give us a “high” or it may feel exhausting and depleting.
Many of us can exist in this state for months and even years. Sometimes a compounded stressor such as a divorce, accident, or loss, can tip us over the edge into a depleted, burnt out state.
Burnout, often following a period of prolonged stress, can be associated with low cortisol signalling. Our bodies have simply stopped being able to produce the stress hormones necessary to meet the needs of our daily lives, or glucocorticoid receptors in the brain and body cells, have stopped responding to cortisol.
Just as cell can be become resistant to insulin, they can also become resistant to cortisol. Too much (or even too little) of a hormone can cause cells to start ignoring their signalling, resulting in symptoms of low levels of the hormone in some areas of the body and high levels of the hormone in others.
Cortisol is a complicated molecule. It both encourages the stress response, but also turns it off, when levels reach a certain point.
Often, cortisol levels that are too low result in an impaired stress response, preventing our fight or flight system from properly shutting off—cortisol resistance can lead to further stress hormone disruption.
The result of an imbalance in cortisol, otherwise termed Hypothalamic Pituitary Adrenal (HPA) Axis dysregulation is weight gain, fatigue and brain fog, inflammation and immune system activation, digestive issues, restlessness, impaired sleep, decreased cognitive function, and mental health conditions, such as anxiety and depression.
When cortisol levels are low, the body makes adrenaline and noradrenaline to meet our needs, which often leads to anxiety and feeling shaky and nervous, contributing to symptoms of anxiety.
Cortisol also influences the function of our sex hormones, thyroid hormones, and our blood sugar. Imbalances in any of these other hormonal systems can be a result of an impaired HPA axis.
Cortisol Testing
The two main ways to assess the body’s levels of cortisol are through serum (blood tests) and saliva.
A study found both tests were equal when it came to diagnosing Cushing’s disease, a condition of highly elevated cortisol.
One of the advantages to salivary cortisol testing is the ability to obtain multiple samples in one day to be able to view a patient’s cortisol curve, in which cortisol peaks approximately one hour after waking and declines throughout the day.
The cortisol curve is measured by assessing 4 samples of salivary cortisol taken at 4 key points during the course of one day. It measures free cortisol, which may only represent about 5% of total cortisol in the body.
While salivary cortisol levels can be a good starting point for assessing the cortisol curve, it doesn’t tell us everything about the health of the glucocorticoid receptors or HPA system as a whole.
High cortisol levels may be seen in patients with low cortisol signalling, such as depression, anxiety and chronic fatigue. Errors in obtaining salivary cortisol samples (such as not taking samples at the right time) can lead to falsely low cortisol readings.
In my opinion, this makes symptoms and health history the most valuable tools for properly assessing HPA axis function.
Cortisol and Melatonin
Melatonin, our sleep hormone, also operates on a circadian rhythm. It is released by the pineal gland in the brain and induces sleep. Its release corresponds to a drop in cortisol levels at the end of the day.
That release is impeded by artificial light exposure at night, lack of daytime sun exposure, alcohol, stress, and HPA axis disruption, among other lifestyle and environmental factors.
Melatonin, like other hormones, can be tested for in blood, urine and saliva, but I find more value in assessing for sleep quality and quantity by taking a thorough health history while also restoring a patient’s sleep hygiene and HPA axis regulation.
Many patients with sleep issues can benefit from a trial of supplemental melatonin to see if that helps their sleep. Taking it 2 to 3 hours before bedtime to coincide with the body’s natural melatonin surge and taking a prolonged-release version to promote sleep maintenance are two strategies I use for helping patients sleep better.
Working on sleep and circadian rhythms is also beneficial for restoring HPA axis functioning.
The “Female” Hormones: Estrogen and Progesterone
The most prevalent female sex hormones are estrogen and progesterone. These two hormones eb and flow in distinct ways throughout a woman’s monthly cycle.
Estrogen creates an “M” shape, rising at the beginning of the cycle to its first peak around ovulation, half-way through the cycle. At this time women typically experience their best mood, energy, and motivation, perhaps noticing a rise in libido.
After ovulation, estrogen dips a little bit and then rises, peaking again about a week before a woman’s menstrual cycle is due.
After this, estrogen takes a nosedive, reaching low levels around the time that menstruation begins: Day 1 of the menstrual cycle.
Progesterone, on the other hand is largely absent the first half of the cycle, before ovulation. Then, it begins a steady climb to peak with estrogen, about a week before the arrival of the next period.
After peaking, just like estrogen, progesterone then takes a dip, which stimulates the uterine lining to shed, resulting in menstruation, in which the entire cycle begins again.
PMS and PMDD
My practice is populated by women who experience various forms of grief at different stages of their monthly cycles.
Many of my patients experience PMS, and the more severe PMDD (Premenstrual Dysphoric Disorder)—which is characterized by intense mood swings, irritability, depression, or anxiety, panic attacks and psychosis in the most severe cases— up to two weeks before their periods.
The mood changes in PMS and PMDD are associated with fluctuations in the hormones estrogen and progesterone, which can wreak havoc on our brain chemistry.
Estrogen has a beneficial effect on mood, increasing dopamine and serotonin action in the brain. Dopamine and serotonin are two antidepressant, feel-good neurotransmitters.
Estrogen also increases something called Brain-Derived Neurotrophic Factor (BDNF) a chemical that stimulates the growth of brain cells. This can boost memory, concentration, and cognition, as well as positively influence mood.
Progesterone breaks down into a chemical called allo-pregnenolone, which acts like GABA, a calming neurotransmitter, in the brain. Bioidentical progesterone therapy is often used as a treatment for anxiety and insomnia.
When estrogen and progesterone levels surge and drop suddenly, drastic fluctuations in mood can occur. Cravings for sweets, crying, lack of motivation, or severe anxiety can all occur when hormones drop right before a period is due.
However, elevated levels of estrogen can also be problematic. Estrogen stimulates dopamine, which typically makes us feel good, gives us energy, and helps to motivate us. In genetically vulnerable women, elevated levels of dopamine can cause excess irritability, low stress tolerance, and even mania or psychosis.
Estrogen also slows the recycling of the stress hormones epinephrine and norepinephrine, which can lead to symptoms of acute stress and anxiety, when dysregulated.
This means that dramatic rises and falls in estrogen throughout a woman’s cycle can cause her to feel irritable and anxious one week and unmotivated and depressed the other.
Smoothing out hormonal ups and downs can be a key factor in regulating a woman’s menstrual cycles and soothing her mood and emotions throughout the month.
Perimenopause and Menopause
Perimenopause is characterized by a declining production of the ovarian hormones estrogen and progesterone.
Estrogen levels tend to rise and fall dramatically throughout a woman’s remaining cycles, while progesterone levels tend to stay low.
The result of these changes are symptoms like hot flashes, night sweats, brain fog, fatigue, and depression when estrogen levels suddenly tank, and increased stress and anxiety when estrogen levels abruptly spike.
During this time, cycles may become irregular. Some of my patients comment that their periods are incredibly light one month and the heaviest of their lives another.
Some get periods every few months and some notice increased frequency, even spotting between cycles, or have a full-blown period every two weeks in more extreme cases.
Weight gain tends to drift from the thighs and buttocks to the abdomen. Once pear and hourglass-shaped figures begin to resemble apples.
Fatigue is a common symptom. Women may experience poor sleep due to night sweats from estrogen deficiency, and anxiety from insufficient progesterone.
What a joy, right?
Many of these perimenopausal symptoms are a relatively modern phenomenon, stemming from a dysregulated HPA axis.
After cessation of periods, it’s the job of the adrenal glands to take over sex hormone production. However, if the HPA system is preoccupied with organizing a stress response, this can affect the production of other hormones.
Impaired Estrogen Clearance
Many women struggle with symptoms that are related to relatively high levels of estrogen, often caused by impaired estrogen clearance.
These conditions include heavy and painful periods, fibrocystic breasts, or conditions like fibroids or endometriosis.
Chronically elevated estrogen levels also include a risk of certain hormone-associated cancers, such as breast cancer.
These women may experience irritability and anxiety through estrogen’s interaction with stress hormones, and also from a relative deficiency in progesterone.
A relatively high level of estrogens compared to progesterone is termed “Estrogen Dominance”.
Estrogen is normally cleared through the digestive system: the liver and intestines.
A sluggish and congested liver causing a slower rate of hormonal clearance (think of it like a clogged drain), an increase in environmental toxin exposure, or an overconsumption of alcohol, can slow the liver’s ability to regulate estrogen levels in the body.
Constipation and a dysbiotic gut can also impair estrogen clearance.
Symptoms of estrogen dominance include stubborn weight gain, typically around the hips and thighs, heavy and painful periods, tender and painful breasts, fibrocystic breasts, endometriosis, uterine fibroids, acne, cyclical mood swings, especially premenstrual anxiety and panic attacks, and irregular menstrual cycles.
Low Progesterone
Aside from impaired estrogen clearance, another pattern of estrogen dominance is low progesterone.
In this case, estrogen levels are normal or even low (as in the case of menopausal or perimenopausal women). However, an even lower progesterone level still results in a pattern of relative estrogen dominance.
This can cause some of the same symptoms as excess estrogen (anxiety, irritability, heavy and painful periods, weight gain, PMS, fibroids, fibrocystic breasts, etc.).
Low progesterone can also be a culprit in unexplained infertility or early term miscarriage, as progesterone maintains the uterine lining in pregnancy.
Progesterone is released from the ovaries after ovulation. Lack of ovulation, therefore, is a primary reason for low progesterone levels. Anovulatory cycles can occur in women with polycystic ovarian syndrome, women with high levels of physical and emotional stress, or women entering menopause.
Some progesterone, however, is also made in the adrenal glands, where it can be eventually turned into cortisol, aldosterone (a steroid hormone involved in salt-water balance in the body) and androstenedione (a male sex hormone), eventually making testosterone and estrogen.
Women with high cortisol demands due to chronic stress may shunt the progesterone made in their adrenal glands to producing other hormones that support the stress response.
Not only can stress alter ovulation and fertility through various other mechanisms, it can also rob the body of progesterone, directing any progesterone made towards cortisol production.
Testing Estrogen and Progesterone
Estrogen and progesterone can be tested reliably in saliva, blood and urine.
Month long salivary hormone testing of estrogen and progesterone can be an easy and effective way to track the eb and flow of these hormones throughout a women’s menstrual cycles.
In this test, women obtain a saliva sample every 3 to 5 days for the duration of the month to track how estrogen levels corresponds with progesterone and how both hormones rise and fall.
In my practice, however, I often start by running blood tests. I test hormones on day 21 (of a 28-day cycle) to coincide with progesterone’s peak. This can help us calculate the progesterone to estrogen ratio and establish whether the cause of estrogen dominance symptoms is high estrogen or low progesterone.
Blood tests offer the option of looking at estrone, which is a more problematic form of estrogen, as well as estradiol (the most common, metabolically active estrogen in the body). In blood we can also look at LH and FSH, two hormones produced in the brain and ovaries that orchestrate ovulation.
FSH tends to be high in women in menopause or perimenopause, while LH tends to be elevated in women with Polycystic Ovarian Syndrome (PCOS).
Dried urinary metabolite testing, or DUTCH, is an effective way to understand how hormones are broken down and processed by the body. Looking at the entire hormone breakdown pathway provides a more in-depth look at the complexity of hormones in a woman’s cycle, and can guide treatment in specific, useful ways.
The “Male” Hormones: Testosterone
Polycystic Ovarian Syndrome (PCOS) is one of the most common causes of infertility (and the most common endocrine disorder) in women of reproductive age. It affects about 10% of menstruating women.
PCOS is a collection of various symptoms and complex hormonal causes. However, it is characterized by missed periods, anovulation, male-pattern facial hair growth, especially on the upper lip, chin, breasts and abdomen, and the presence of cysts on the ovaries.
Other common symptoms of PCOS are weight gain, estrogen dominance, male-pattern hair loss (on the crown of the head), insulin resistance, infertility, and acne, especially hormonal cystic acne on the jawline.
PCOS is characterized by elevated levels of testosterone, a male sex hormone, or “androgen”, on blood work.
Acne, weight gain, infertility, and hair loss are the main symptoms that bring women with PCOS into my office.
PCOS is a complex process that involves an overproduction of testosterone in the ovaries coupled with insulin resistance. Therefore, balancing blood sugar through diet and lifestyle can have a major impact on symptoms.
The conventional treatment for missed or absent periods is oral contraceptives, which of course doesn’t treat the underlying cause of anovulation. That’s why women with PCOS often seek naturopathic and functional medical solutions to treat the root cause.
Testing for PCOS
When I meet a new patient with PCOS, I often test her blood for estradiol and progesterone levels at Day 21 of her cycle. A very low progesterone level may indicate that she has not ovulated that cycle.
We also test LH and FSH. A high LH:FSH ratio can be indicative of PCOS even if cysts are not present on an ovarian ultrasound.
Other important tests that are often ordered are free testosterone and DHEA-S, another male hormone made in the adrenal glands.
Glucose control and insulin resistance can be assessed by looking at fasting blood glucose, fasting insulin and HbA1c (a marker that looks at long-term glucose control).
Prolactin, another hormone released by the pituitary gland, can sometimes be elevated in anovulatory women with PCOS.
A 4-point salivary cortisol test may be useful in women with PCOS who are also experiencing symptoms of cortisol dysregulation, which can contribute to insulin resistance and affect ovulation and hormone regulation, particularly progesterone production.
Prolactin
Prolactin is a hormone released by the pituitary gland to promote milk production after child birth.
However, some women will have elevated levels of prolactin in blood, despite not currently pregnant or breastfeeding.
Called hyperprolactinemia, elevated prolactin may be a cause of anovulation, mimicking some symptoms of PCOS and menopause, including hot flashes, absent or irregular periods, infertility and even milk discharge from the breasts.
Hyperprolactinemia may be caused by low calorie diets, liver issues, hypothyroidism, and issues with the pituitary gland itself.
Prolactin can be tested in blood. If levels are elevated, an MRI must be conducted to rule out a physical issue with the pituitary gland, such as a tumour.
Oxytocin
Oxytocin is a hormone produced in the brain and secreted by the pituitary. It aids in childbirth. Also termed the “love hormone,” it’s associated with feelings of intimacy and connection.
While high and low levels of blood oxytocin can be possible in men and women who are not pregnant or breastfeeding, the clinical applications of it are not fully known.
Thyroid Hormones
The thyroid, a butterfly-shaped gland on our neck, is the master thermostat of the body, controlling heat and metabolism. It pumps out thyroid hormones T4 and T3, which tell cells to burn fuel, creating energy and heat.
Because our thyroid hormones interact with the cells in every body system, symptoms of hypothyroidism, or low thyroid function, can be incredibly diverse.
Common symptoms of hypothyroidism are weight gain or inability to lose weight, fatigue and sluggishness, brain fog, hair loss, low body temperature, constipation, dry skin and hair, puffiness, infertility, and altered menstrual cycles, such as missed periods or heavy periods.
Aside from autoimmunity, other causes of low thyroid function can be HPA axis dysregulation and chronic stress, a very low calorie or very low carbohydrate diet, sudden weight loss, a deficiency in nutrients needed for thyroid function such as iron, zinc, iodine and selenium, and a body burden of environmental toxins such as heavy metals.
Testing Thyroid
To assess thyroid function, conventional doctors will test a hormone called Thyroid Stimulating Hormone, or TSH. TSH is not a thyroid hormone, but a hormone made in the brain that urges the thyroid to pump out the thyroid hormones T3 and T4. It gives doctors an indirect measure of thyroid regulation.
When TSH levels are high, this suggests that thyroid function is sluggish; the brain needs to send a louder signal to get an unresponsive thyroid to work.
However, TSH is only a periphery marker of total thyroid function, not giving us the whole picture. Also, TSH ranges on conventional lab tests may fail to pick up some cases of subclinical hypothyroidism or impending cases of autoimmune thyroid conditions, otherwise termed Hashimoto’s Thyroiditis, which is the most common cause of hypothyroidism.
To properly assess thyroid function in someone with symptoms of thyroid dysfunction, a slightly elevated TSH, or a family history of Hashimoto’s, I will order a thyroid panel: a blood test measuring TSH as well free thyroid hormone (T3 and T4) levels.
It’s also important to assess for autoimmune thyroid conditions by testing for anti-thyroglobulin and anti-thyroperoxidase antibodies. Both of these antibodies, when elevated, suggest the presence of an autoimmune thyroid condition.
Insulin
Some of the most common hormonal dysfunctions I see in my practice are insulin resistance and reactive hypoglycemia: blood sugar imbalance.
These issues often lie at the heart of other hormonal imbalance patterns, such as irregular menstrual cycles or HPA axis dysregulation.
When we eat, glucose enters our bloodstream, providing fuel for our cells. Insulin helps our cells access this hormone, spiking with each meal.
The higher the meal is on the glycemic index (i.e. the more sugar or refined carbohydrate it contains), the higher our post-meal blood sugar and insulin spikes will be.
Without insulin, we would slowly lose energy and die, unable to get precious glucose into our cells. Individuals with type I diabetes cannot make insulin. They must inject it daily to keep their cells fuelled and blood sugar stable.
For the rest of us who do make insulin, large blood sugar spikes after a meal can be problematic.
Insulin is a storage hormone. It helps energy get into cells, and it helps build muscle and brain cells, but it also blocks the breakdown of fat cells, blocking weight loss.
Insulin also drives down blood sugar levels. When blood sugar rises too quickly after a meal, a large insulin response can drop blood sugar levels too drastically, causing reactive hypoglycemia, or feeling “hangry” (hungry, angry, irritable, tired, light-headed, weak and dizzy) in between meals.
Individuals who experience hypoglycemia feel irritable, shaky, dizzy and anxious between meals. They often suffer from anxiety and panic attacks, and feel hungrier at night.
They may wake up in the middle of the night, as their bodies are unable to go 8 hours (the length of a decent night’s sleep) without food. This causes them to wake up, restless and perhaps anxious, in the early hours of the morning.
These individuals, paradoxically, rarely feel hungry at breakfast time.
I often see anxious patients wake from a restless sleep and toss back only a coffee in the morning, skipping breakfast due to slight morning nausea.
At 10 am, feeling ravenous and shaky, they might scarf down a high-glycemic bagel or croissant. Later on, they’ll enjoy a light lunch—maybe a sandwich—often feeling foggy and lightheaded after eating it.
At 2 to 4 pm, they may feel like an afternoon nap, instead indulging in a coffee and sweet treat to buy them some energy for the remaining hours of the work day.
Finally, after enjoying a larger dinner once they get home, they find themselves snacking all night long. Their bodies are finally urging them to ingest the nutrients they were lacking throughout the day.
They then fall into bed, feeling full, restless and wired, and the cycle begins again.
When our blood sugar falls, we not only feel hangry, weak, and crave processed carbs, our HPA axis also gets stimulated.
Cortisol, a glucocorticoid, can help our body control blood sugar, bringing it into the normal range after insulin sends it tanking too low.
This drop in blood sugar, therefore, needlessly triggers a stress response from the adrenal glands, which can further worsen anxiety, HPA axis dysregulation, and glucocorticoid resistance.
When blood sugar and insulin are spiked repeatedly for days, months, and years on end, cells stop responding attentively to insulin’s signal. Like our response to a pesky telemarketer, cells eventually stop picking up the phone when insulin calls.
However, cells still need insulin. More and more insulin must be released to trigger the same response from insulin resistant cells. This makes cells even more resistant, as they require even more insulin release the next time blood sugar rises to get glucose into the cell for fuel. And so the cycle becomes vicious.
Elevated insulin levels cause inflammation, fat gain, fatigue, depression, reactive hypoglycemia, and HPA axis dysregulation. The more resistant our cells become to insulin, the more cortisol must be called on to maintain blood sugar levels.
PCOS is also characterized by higher insulin levels. This prevents ovulation, causing infertility and female hormone imbalance.
When insulin resistance persists, type II diabetes, where the body is no longer able to keep blood sugar in a safe range, develops.
Type II diabetes is characterized by chronically high blood sugar—which poses a danger to small blood vessels, and is a potent inflammatory condition, increasing the risk of heart disease—and elevated insulin.
It affects almost 10% of the adult population and is the 7th leading underlying cause of death in North America, costing 350 billion dollars a year to manage in the United States alone.
Insulin-related weight gain can affect female hormones, as fat cells make estrogen in the body, leading to estrogen dominance.
Insulin also interacts with a hormone called leptin, which is created by fat cells in response to calorie intake. When body fat levels get too high, cells can become leptin resistant. The body no longer senses dietary calorie intake, leading to increased hunger. This exacerbates the problem of weight gain and insulin resistance.
Testing for Insulin Resistance
When I meet a patient who is presenting with stubborn weight gain, estrogen dominance and stress, I assess their blood for insulin resistance by looking at blood levels of fasting insulin and fasting glucose.
With these two values a calculation that measures insulin resistance, called the HOMA-IR, can be performed. This can give us a baseline measure of how well the body is compensating to control blood glucose.
I also run HbA1c, which looks at glucose levels over 3 months. I will often run a blood cholesterol panel, and inflammatory markers, such as CRP.
Insulin resistance often puts all of our hormones on a rollercoaster, which becomes very difficult to get off of unless we prioritize the diet and lifestyle interventions that address blood sugar control.
Assessing Hormones
When presented with a patient suffering from a complicated symptom pattern, I begin by taking a thorough health history in which we investigate:
Energy levels,
Sleep quantity and quality,
Mood and mental health history,
Period health history,
Family history,
Dietary intake and exercise,
Health risk factors like smoking, alcohol use, and past health history.
Depending on how clear the patient’s symptom picture presents, we may opt to make some changes before testing, to gauge their body’s response to an increase in nutrient intake.
Then, if necessary, I will order a comprehensive blood work.
Blood testing might include a thyroid hormone panel, and an in-depth look at female hormones, fasting insulin and fasting blood glucose, and other markers that help us assess health, such as cholesterol and inflammatory markers, or nutrient levels.
Patients requiring a more comprehensive view of their cycles may opt for month-long salivary testing. Others may opt for a dried urine test that looks at hormonal breakdown in the body.
A Sample Case
Jenny (name changed for privacy) came to me feeling fatigued and anxious.
She had suffered from anxiety periodically as a teen, but now at age 46 she was experiencing bimonthly panic attacks that seemed to occur cyclically; the panic would come around ovulation and premenstrually.
It was hard to tell, however, because Jenny also claimed that her periods were “all over the place”. One month they were heavy and painful, causing her to take time off work, crouched on the bathroom floor in agony. Other months she barely noticed them, experiencing some light spotting, if anything at all.
Very troubling to her was her major mood volatility, which she described like a “switch” that would suddenly flip on or off, causing her to breakdown at work or pick fights with her family.
Then, almost as suddenly, the cloud would lift and she would be her cheerful, friendly, loving self again.
It was maddening, both to her and those living with her during these darks times, she said.
She also noticed disrupted sleep and weight gain around the abdomen, which seemed to ignore her intense workouts and strict dietary regime.
Jenny was highly accomplished at her high-pressure job and commented that she thrived on being busy and achievement oriented.
I tested Jenny’s blood estradiol, estrone, progesterone, LH, and FSH levels one week before her next expected period, had her fill out a weekly diet diary, and gave her some recommendations about sleep and supplement intake.
Jenny’s blood revealed elevated FSH, indicative of impending menopause (FSH encourages the ovaries to ovulate, as TSH encourages the thyroid gland to make thyroid hormone). She also had low estradiol, and low progesterone, but elevated levels of estrone, the more problematic of the estrogens.
According to her labs and history, Jenny was experiencing estrogen dominance and perimenopause. Many of her symptoms were stemming from elevated estrone, low progesterone and a disrupted HPA axis.
Together, we worked on her diet to provide her body with the nutrients needed to make hormones and to support her brain, mood and adrenal glands.
We used herbs and dietary nutrients to promote liver estrogen clearance and to support Jenny’s adrenal glands.
We addressed the stress in her life, encouraged relaxation, and made sure her body was supported in its ability to make and respond to cortisol.
After a few months, Jenny reported a reduction in hot flashes, better sleep and feeling calmer. She had a reduction in her waist line and better energy and mood.
Our hormones, when imbalanced, can cause vicious cycles in the body that trap us in a state of worsening imbalance.
Through correctly assessing these common hormonal patterns through a health history and appropriate testing, and then making diet, lifestyle and supplement suggestions addressed at stopping these cycles, naturopathic doctors can address underlying hormonal issues that might be causing these complex and troublesome patterns of hormone disruption.
I review my adventurous year of living on the Low Carb High Fat Ketogenic Diet.
I’ve always had a sweet tooth.
I remember binging on Halloween candy as a kid, stuffing one tiny chocolate bar after another into my mouth, as fast as my little fingers could unwrap them, trapped in some kind of sugar-filled trance.
“Never get between Talia and her food!” My family would joke when my blood sugar would crash between meals and I’d rage towards the fridge for a snack to keep me sane.
I remember digging into the little bags of cheese popcorn reserved for school lunches, finishing off one after another and then hiding the wrappers in their big Costco box so that it would look like it was still full, the way rebellious teens top up empty vodka bottles with water.
I can gain weight with the drop of a hat (but also put on muscle fairly easily), and it takes concentrated effort and dedication to take it off.
After a period of temporary stress and bagel-related weight gain, I decided to embark on a bit of experimentation. Work was getting busy and I wanted to supply my brain with constant energy without having to take snack breaks every few hours. Also enticed by anecdotes of shattered weight loss plateaus, I decided to “go Keto”.
I like experimenting with diet. Like many health-conscious people, finding the right nutrition regime for me has been a process. In my teens I started controlling portions and switching out white breads for whole grain rye and Jolly Ranchers for carrot sticks. In my early 20’s, I was vegetarian. I tried being vegan for a while before deciding it was a disaster for my health when I began to experience nutrient deficiencies, weight gain, and hormonal issues.
Later on, I followed my naturopathic school classmates to a modified Paleo diet (keeping in some gluten-free grains and legumes), then moved to a more traditional Paleo diet (taking out the grains and legumes), before going back to the modified version (which is probably the best eating style for me—more on that later).
For the most part, my diet is comprised of whole foods, with lots of vegetables, but in the Fall of 2016, when this all began, I was in a pretty Standard North American place when it came to food intake. At the time I was suffering from IBS, some issues related to subclinical PCOS, and fatigue. I was also starting to see some signs of impaired glucose control.I wasn’t feeling good and I was in need of a kind of reset of sorts.
I was interested in seeing how relying on ketone bodies for fuel would help my body, mental performance, and improve my blood glucose control and symptoms. I have a family history of type II diabetes and I wanted to do what I could to prevent insulin resistance and metabolic syndrome. Drastic times call for drastic measures, I thought.
Ergo, The Ketogenic Diet.
About the Diet:
The Classic Ketogenic Diet was first developed in the 1920’s to treat children with medication-resistant epilepsy.
When our brains are starved of glucose, their preferred fuel source (our brains use up 60% of the body’s glucose), the liver creates ketone bodies from stored or dietary fat that the brain can use as a substitute source of energy.
One of these ketone bodies, beta-hydroxybutyrate, is thought to be a particularly therapeutic molecule for the brain, conveying anti-convulsive benefits, thereby helping to reduce the incidence of seizures in children who don’t respond to medication.
However, the original Ketogenic diet is more extreme than the general health and weight loss-aimed diet we see described in recipe books these days. The Classic Ketogenic diet consists of about 90% of calories coming from fat. In order to achieve that, followers need to severely restrict their protein intake, and virtually eliminate all dietary sources of carbohydrate, which drastically limits their nutrition choices.
Since, the benefits of beta-hydroxybutyrate are being studied for other neurological disorders, such as Parkinson’s disease, dementia, migraine headaches and narcolepsy. It’s being looked at as a potential treatment for mental health conditions, like autism and depression, and metabolic disorders such as type II diabetes, and even to increase the efficacy of chemotherapy and radiation treatments in cancer. Other studies are looking at its role in improving cognitive function in mice and humans.
Some research shows that beta-hydroxybutyrate can expand lifespan by interacting with genes that slow aging. It is also shown to confer anti-inflammatory and antioxidant benefits.
In the 1970’s, Dr. Atkins responded to the high-carbohydrate, low-fat dogma of the nutrition world at the time, by bringing a modified Ketogenic diet into vogue. Restricting all forms of carbohydrates and encouraging a consumption of the still-vilified high-fat foods like bacon, eggs and cheese, Atkins affirmed that people could lose weight by eating fat, as long as they restricted carbohydrates at the same time.
The modern version of the Ketogenic Diet is slightly more health-conscious, promoting a higher intake of vegetables. The current diet restricts carbohydrates to under 20 to 50 grams per day, and encourages a high fat intake and a moderate protein intake, in order to encourage the body to turn to fat as its primary source of fuel. The current version of “Keto” is less strict than it’s initial epilepsy-treating incarnation, with anywhere from 60-85% of its calories coming from fat.
My Version of Keto:
I started the whole journey by tracking my food intake (using My Fitness Pal). My aim was to consume 20 grams of net carbs, or less, per day to push my body into using fat-turned-to-ketone bodies as a its primary fuel source.
Net carbs are calculated by subtracting dietary fibre from total grams of carbohydrates. For example, 1 cup of raw broccoli contains 6 grams of carbs. 2.5 of those are fibre. Therefore, the net carbs in broccoli are 3.5, which would count towards my net carb goal of 20 grams per day.
This isn’t easy. Take a look at any package of food you regularly consume. 1 cup of cooked oatmeal contains 23 grams of net carbs: 3 grams over my entire daily allotment. Therefore all high-carb foods like grains, legumes, starchy nuts, all fruits, and some starchier vegetables, were off limits.
Many people opt to test their blood, breath or urine for ketone bodies to determine whether or not their bodies are in ketosis. I dabbled in this, using the urinalysis strips in my clinic to test for urinary ketones. However, even though I was sticking to the diet, the strips would mostly turn up negative for ketones.
There are a few reasons why ketone strips may not be a reliable marker for ketosis. Firstly, the don’t test for beta-hydroxybutyrate, which is the main ketone body utilized by the brain, but acetoacetate, another ketone body produced in the liver.
Secondly, urinalysis strips only test for urine ketone spillover. They don’t necessarily reflect blood levels, and they won’t pick up the ketones that are being utilized as fuel by the body. If cells are absorbing all the ketones the liver produces, urine testing may not be positive.
The most accurate, albeit more expensive, method for testing ketone bodies is through a skin-prick test that analyzes blood levels of beta-hydroxybutyrate.
While I knew that the urine strips weren’t highly accurate, not having my state of ketosis validated was discouraging. I was often left in doubt over whether things were “working”. I wondered if there was some other mechanism going on. Was my body finding carbohydrates from someplace else? Did I have Small Intestinal Bacteria Overgrowth that was digesting my fibre and allowing me to absorb it somehow? Were my blood ketones being used up somewhere else (by the yeast in my gut, for instance)?
I did have signs of being in ketosis that I could watch for, however. When I avoid carbs, or fast for a few days, I start to develop a metallic taste on the tip of my tongue. It’s not a common sign of ketosis, a more common sign is a “nail polish” or “paint thinner” taste in the back of the throat, but still a symptom that some people report.
Keto Flu:
During the first few days of switching to Low Carb High Fat, I had to white knuckle through a phase realistically termed the “Keto or Low Carb Flu”. This horrible phenomenon is thought to be a result of the body switching from burning glucose as its primary fuel source to adapting to ketone body production. There is often a painful adjustment period for brains that have to learn how to rely on ketones for their main fuel source after a lifetime of glucose abundance.
It was nasty. I felt intense hunger and sugar cravings, nausea, dizziness, and weakness—it truly was a “flu”.
I knew that I had spent most, if not all, of my life as a sugar burner. Before Keto, I would crave food even just two hours after a full meal. I would often feel “hangry”: dizzy and shaky in between meals, and irritable if made to wait for food for too long. I had been existing between carb-dense meals, experiencing insanity-inducing reactive hypoglycemia between my regular sugar fixes.
The more I read about others’ experiences, the more I was assured that the keto flu symptoms were actually a sign of my body healing. I was becoming adapted to other fuel sources, which was a good thing, I thought.
So, I muscled through and followed the online advice: I consumed more fat to provide more fuel to my brain, including medium chain triglyceride (MCT) oil, which is quickly absorbed by the lymphatic system and turned into ketones by the liver, and I consumed electrolytes, which are more rapidly excreted from the bodies of low carb dieters.
For some people, Keto flu can last for days, for others it lasts weeks. For me, the Keto flu thankfully only lasted two days, after which my body began to adjust and my cravings for sugar went down. I began to feel more energy, which felt encouraging.
Daily Meal Plan:
For breakfast, I would typically eat a high-fat smoothie containing coconut milk yogurt, gelatin, and avocado, and topped with pumpkin seeds and cacao. Sometimes I’d make fat bombs or homemade unsweetened chocolate.
I’d have my second meal of the day in the mid-afternoon, around 2 to 3 pm, for which I’d consume a few cups of cruciferous vegetables, like broccoli or cabbage, with a fatty cut of meat like ground beef, chicken thighs, or salmon, all topped with liberal amounts of fat from coconut, olives, avocados, or grass-fed ghee. I made a lot of batch-cooked grain-free curries and stews.
If I had a third meal or snack in the day, it would be another serving of fat: a handful of macadamia nuts or a hunk of creamed coconut.
Eating this way made me feel like Obama and his grey suits—I didn’t have to plan my meals too carefully. All I had to do was eat fat. My food was so calorie dense and my blood sugar so stable that I didn’t need to eat often. This meant that I didn’t need to worry about bringing food with me everywhere I went; one meal could satiate me for half the day. Hunger was never an emergency situation, as it had been in the past. Hunger would come on very slowly, and it would never be “hanger”; my already low blood sugar had nowhere to dip to. If I needed more food, I could always wait until I got home to eat.
More Benefits:
Within a few days, my PCOS- related cystic acne cleared. I also felt slimmer as some water retention deflated. This felt good. Our body stores carbohydrate in the form of glycogen in the liver and muscles. Glycogen stores retain water.
When glycogen stores are used up, a rapid 5 or more pound drop in weight can occur. This is the “water weight” that people talk about losing when they first begin some kind of nutrition plan.
It’s also common to notice a drop in water weight from a decrease in inflammation, when embarking on a new eating plan. I know that I am sensitive to certain carbs and dairy and, because those things were out of my diet overall (although Keto can certainly include high-fat dairy products for those who can tolerate them), the water retention caused by chronic inflammation seemed to clear.
Although it seems to attract people primarily for its hip-slimming potential, the Ketogenic diet probably does not cause weight loss in and of itself. Instead, the diet encourages a passive reduction in calories by stabilizing blood sugar and insulin levels, while promoting the intake of highly satiating foods containing protein and fat. Ketone bodies also have appetite-suppressing effects. Therefore, it’s probably a calorie deficit that causes the weight loss, rather than any specific biochemistry in the diet itself.
I didn’t lose much more weight than the water weight. However, my mood was brighter. I would wake up in the morning looking forward to the day, which often doesn’t happen in the winter. I felt more sustained energy throughout the day, and really enjoyed the decreased appetite, which led to more productivity.
I felt fine consuming two meals a day, able to get through hours of back-to-back patient visits without needing a snack or a break. It was actually incredible to need so few meals; it was like becoming another person, one no longer ruled by sugar cravings. I was like a camel, switching to stored fuel when the fat from my last meal had run out, and the transition was seamless. There was no wall to hit, and no hypoglcyemic crash to be seen.
I also noticed less bloating and digestive issues, probably from the lack of fermentation in my gut and the reduction in foods that tend to aggravate IBS, like certain vegetables, fruit, and legumes.
However, all was not roses on the Keto diet. While the first few months were dreamy, the longer I stayed on it the more I started to notice changes in my body that indicated the honeymoon period I was enjoying wasn’t going to last.
The Microbiome:
The research is in: human beings probably need 10 servings of fruits and vegetables a day (roughly 5 cups), or 800 g, a day to get the most heart disease, stroke and cancer-preventing benefits that diet can afford us. The International Journal of Epidemiology concluded that, if the correlations found in their February 2017 study were causal, almost 8 million lives might have been saved in 2013 if everyone in the world had simply consumed their fruits and veggies.
It’s one thing all diets, even the faddy ones, agree on—from the Paleo Peeps, to Plant-Based Hippies, to Raw Macrobiotic Sun Worshippers, to Whole Foods Michael Pollen Omnivores, to the dejected nagged-at husband pushing brusselsprouts around on his plate—fruit and vegetables are good for you. You should eat them. If you’re a typical North American, you should probably eat more than you’re eating. The health value of everything else we eat seems to be up for debate: red meat, saturated fat, soy, bread, coffee. The benefits of eating enough fruits and vegetables, however? There’s no contest.
It’s hard to pick one way in which fruits and vegetables are so health protective. It could be because of their high concentrations of micronutrients, reducing the risk of common nutrient deficiencies, like magnesium and vitamin C. It could be because, if you’re filling your body with a kilogram of fruits and vegetables a day, you probably aren’t scarfing down an entire medium-sized pizza and supersized orange pop as well—there just isn’t room. It could also be the antioxidants they contain that protect cells against free radical damage, protecting DNA. Or perhaps its the fermentable fibres present in fruits and vegetables that feed our invaluable microbiome.
The problem with keeping net carbs under 20 grams a day was that I needed to restrict my fruit and vegetable intake. I was eating no fruit at all, and staying away from the starchier veggies, like carrots and beets. I still stuck to my beloved leafy greens and crucifates, but even eating 2 to 3 cups of those guys a day would push me to the upper limits of my carbohydrate intake, which meant I couldn’t eat them as liberally as I had been.
Getting enough vegetables and (any) fruits on the keto diet is hard, if not impossible. This can impact our ability to get the micronutrients we need, but also enough fermentable fibres from vegetables like garlic, onions, yams, Jerusalem artichokes, and legumes, which provide food for our microbiome.
Feeding our gut bugs is important. They benefit us in numerous ways, from digesting out food, to calming inflammation, to fuelling gut cells by producing a short-chain fatty acid called butyrate. They help our immune systems function optimally. They produce neurotransmitters for our brains to work. They balance our stress responses and our circadian rhythms.
Jeff Leach, at the Human Microbiome Project speculates that the lack of dietary fibre in most low-carb diets may impact the health of the microbiome in negative ways by depriving the gut bacteria of their preferred food sources, as well as altering the acidity of the colon and intestines. He cites this article, in which obese subjects on a high-protein and low-carb diet had lower levels of butyrate in their bodies and intestines, likely due to decreased diversity in their guts.
There are, however, some studies that suggest that a Ketogenic diet can improve the microbiome in children with epilepsy, and autism, and some speculation by the researchers that that may be how the diets treat these conditions. However, since these studies are not done in “healthy” children, with an already healthy microbiota, it’s hard to extrapolate the findings to the healthy adult population.
Then there’s the fact that most studies that look at high fat diets and their impact on the microbiome are mostly done in rats. Of course, rats aren’t humans, despite there being relative genetic similarities. In these animal studies, researchers refer to “a high fat diet” when in fact they mean a high fat, high sugar diet. The sources of fat in these “high fat” mouse diets are often corn, margarine, or soy oil, which we know are highly inflammatory and offer few if any health benefits.
In other words, many studies on “high fat” diets are not looking at a relatively balanced Ketogenic diet that consists of vegetables, proteins, and healthy sources of fats from avocados, coconut, fish, olives, nuts and seeds and grass-fed meats.
Context is important as well. Is it the high fat diet that causes a reduction in gut diversity or the absence of fibre? This one mouse study showed that simply providing the mice with fibre in addition to their high fat diets decreased their risk of obesity.
I felt that my gut initially improved in the first few months on Keto: the diet was low in foods that aggravate me: namely refined carbs, sugar, gluten and dairy, as well as some of the fermentable fibres that can aggravate IBS. However, it never fully healed. After a few months, I started to notice the symptoms of bloating and digestive irregularities coming back.
Candida, a yeast that resides in the gut and can overgrow in the intestines in some people, especially the immunocompromised, causing symptoms of fatigue, IBS, and weight gain, among a variety of other symptoms, can survive on ketone bodies. Yeasts have mitochondria of their own. Some species of gut bacteria can consume protein, bile salts and even fats.
Contrary to what many claim, a Ketogenic diet doesn’t necessarily “starve out” the bad gut bugs. Combined with the lack of fibre to feed the beneficial gut bacteria and promote more bacterial diversity, a prolonged Ketogenic diet may be a recipe for gut dysbiosis.
Hormones:
Throughout my year spent in ketosis, I definitely noticed an improvement in my insulin signalling and glucose control, especially in the first few months. Looking at my blood work in March, after about a year of the Ketogenic diet (and then having been off it for a few months), my fasting insulin was very low and fasting blood glucose levels were in the low-optimal range. HOMA-IR, a calculation that is used as a marker of insulin resistance, was also low, indicating good insulin sensitivity.
I personally believe that this means that my risk for getting metabolic syndrome or type II diabetes is low, as long as I maintain this level of insulin sensitivity by watching the glycemic load of my diet and my stress levels.
The metabolic flexibility awarded to me from my year in ketosis also proved to be invaluable. Now, I no longer fear fasting and I can survive on other fuel sources besides sugar. My brain knows how to tap into stored and dietary fat more efficiently, and use those for energy. Even when not following any sort of low-carb diet, I noticed that I could survive between meals while travelling in Southeast Asia for two months, whereas normally I would have had to exist on unhealthy, sugary snacks.
However, after a few months on the diet, I began to notice a decline in my menstrual health. My cycles began to get longer, and soon I started missing periods. I noticed more hair falling out in the shower and more cystic acne developing on my chin. When I ran my blood estrogen and progesterone levels, I was surprised to see that their levels were very low.
We know that insulin, while often vilified as a “fat storage” hormone is actually responsible for storing everything, including nutrients. It also correlates with estrogen levels and the conversion of T4, one of our thyroid hormones, to its active friend, T3, which runs our metabolism. Insulin builds muscle, bone and brain cells. Very low insulin levels, in my case, were contributing to amenorrhea and a disruption in my sex hormones.
This wasn’t good.
While not quite the same as Intermittent Fasting (IF), Keto is often grouped into the same category because of its similar impact on blood glucose and insulin. The difference is that Intermittent Fasting induces ketosis through periodic food restriction, as opposed to carb restriction. Keto and IF often go hand in hand, however. The reduced hunger and high-nutrient density of the foods eaten on a Ketogenic diet often lend well to practicing intermittent fasting. It did in my case—I was only eating two main meals a day.
I always found it interesting, however, that most proponents of intermittent fasting are men. The male body appears to thrive in the fasted state, getting a boost of growth hormone and norepinephrine, both of which provide men with energy, motivation, and an improved sense of well-being.
This hormonal change may be a remnant of our ancestral hunter-gatherer days where it would be an advantage to feel motivated and energized to go out and hunt during periods of food scarcity.
I don’t think female bodies experience exactly the same effect. Some preliminary animal research tends to suggest that as well.
A few rat studies indicate that fasting may impair female insulin sensitivity, and induce amenorrhea, or missed periods. Female bodies rely on a consistent influx of calories and carbohydrates to stimulate insulin, which plays a role in stimulating thyroid hormones and estrogen, to continue to ovulate. Another study showed that fasting tended to “masculinize” female rats, lowering their female hormones, and increasing their levels of androgens, the male sex hormones, like testosterone.
Of course, these studies were done on fasted rats, which cannot be fully translated to the effects of Intermittent Fasting and Ketogenic diets on women. However, some of these findings did validate my experience, which certainly wasn’t being validated in the podcasts and blog posts I was exposed to, largely written and followed by men.
I did experience positive hormonal effects: the increased insulin sensitivity and lowered blood glucose. However, I was not happy about my irregular cycles and estrogen deficiency.
Therefore, I decided to increase my carbohydrate intake, returning to a more moderate Paleo diet that consists of some fruit, starchier vegetables and legumes. After a few months, my periods returned to normal, my skin cleared up, my hair stopped falling out, and my thyroid hormones, estrogen and progesterone levels all returned to their optimal ranges.
I have still have low fasting insulin levels, suggesting that the Ketogenic diet did help to reset my insulin sensitivity and that this effect may be lasting.
Metabolic Health:
After a year of doing the Ketogenic diet, and then a few months of returning to a moderate-carb paleo diet, I tested my cholesterol levels and inflammatory markers. My HDL cholesterol (the “good” cholesterol, to put it very simply) was high, my triglycerides (a risk factor for heart disease) were very low, and my LDL cholesterol (the “bad” cholesterol that statin drugs target) was also low. My inflammatory markers: C-Reactive Protein (CRP) and erythrocyte sedimentation rate (ESR), were also low.
While it is typically the monounsaturated fats, like olive oils and avocados, that are associated with increased levels of the heart-protective HDL cholesterol, even saturated fats from coconut oil can raise HDL. LDL is often lowered by these healthy monounsaturated fats, however saturated fats, even healthy ones, can raise LDL in certain individuals.
All else being equal, higher levels of LDL may not be as big of a problem as we think. Especially in the context of low risk factors, like low inflammation, absence of smoking and a healthy body weight. What’s more, the triglycerides and cholesterol/HDL ratio may be more important factors for determining heart disease risk. Further, assessing LDL particle size may also provide those concerned about their LDL levels with more information concerning their cardiovascular health. That being said, it is important to be aware that some of the fats present in a Ketogenic diet have the potential to raise blood levels of LDL in certain susceptible individuals, and that not everyone’s blood lipid results will look like mine.
Triglyceride levels are associated with liver function, and generally reflect dietary sugar, fructose and refined carbohydrate intake, rather than fat intake. Reducing refined dietary carbohydrates like white grains, flours and sugars is a good strategy for reducing triglyceride levels and reducing heart disease risk.
Some individuals can experience elevated levels of inflammation on a Ketogenic diet, depending on the quality of foods consumed. A Ketogenic diet low in fibre that fails to feed the microbiome; high in foods that a person may have an individualized sensitivity to (such as dairy, eggs, nuts or soy); or high in inflammatory fats like trans fats, and industrial oils like canola and corn oil, may all contribute to increased inflammation.
That being said, certain ketone bodies like beta-hydroxybutyrate may have anti-inflammatory properties. Many of the fats consumed in a mindful, whole foods Ketogenic diet, such as olives, avocados, seeds, salmon, and coconut, are also anti-inflammatory.
I found my blood markers a good indicator of the power of a high-fat, low-carb diet to, at least in my case, improve HDL cholesterol and lower triglycerides, fasting insulin and fasting glucose levels. Whether I needed an entire year in ketosis, or whether I even needed to actually enter ketosis to receive these benefits, isn’t clear. Perhaps I could have gotten the same results by moderately lowering my carb intake while increasing my dietary intake of healthy fats.
Modified Ketogenic Diets:
While I do think I benefitted from entering into ketosis, I would not necessarily recommend a Ketogenic diet to patients unless to achieve some sort of therapeutic goal, such as improved insulin resistance, or for adjunct cancer care, to reduce inflammation, or to improve severe depression, migraines, or narcolepsy.
However, there may be a benefit to cyclical Ketogenic diets for memory and cognition, and increased life span in mice. Cyclical Ketogenic diets involve entering ketosis on alternate weeks. On the other weeks, participants return to a normal, whole foods diet that contains higher amounts of carbohydrates. In this case, individuals gets the benefits of beta-hydroxybutyrate production and increased metabolic flexibility on their weeks on, while also being able to eat a high amount of fermentable carbs and fibres on their weeks off, essentially getting the best of both worlds.
Adding medium chain triglycerides to food may also confer health benefits, similar to being on a Ketogenic diet. One study showed that adding MCT oil to a high-carb breakfast (pasta), reduced appetite in men. This is likely because, after burning through the glucose in the pasta, the men’s brains were able to access the ketone bodies that were made readily available by burning the MCT oil. This kept their brains fuelled and their bodies satiated for longer.
The men eating pasta and MCT oil in the study had a ketone blood level of 0.3, which is similar to that obtained from a diet that derives 10% of its calories from carbohydrates, which is an essentially a very low-carb, if not Ketogenic, diet. This may indicate that simply adding MCT oil to a moderate to low-carbohydrate diet, may confer some of the benefits of having a slightly higher rate of circulating ketone bodies without having to follow a strict diet. Again, following this strategy, you can get the best of both worlds: consume a diet high in fibre, while also getting a steady flow of ketone bodies to the brain.
Other interesting areas of research are the use of supplemental, or exogenous, ketones for therapeutic use, however the area is new and not something I currently recommend in my practice (although this may change when more research begins to emerge and better supplements enter the market).
My Plan Moving Forward?
I’m happy that I gave the Ketogenic diet a try, but now I’m back to my more modified Paleo diet, aimed at promoting gut health, optimizing my micronutrient intake, regulating hormones, and supporting my energy levels. I now consume berries and apples, legumes, starchier vegetables and lean proteins more often and aim to get 10 servings of fruits and vegetables a day, with 8 to 9 of servings coming from vegetables, as opposed to fruit.
I currently start my day with a smoothie with berries, an avocado, spinach and protein powder. For lunch I have some sort of protein, fat, and tons of veggies. I eat more often than when I was in ketosis: about 3 meals a day with a vegetable and fat as a snack, or no snack at all in between, depending on my schedule.
My total daily carbohydrate intake falls around 100 grams a day with a net carb intake between 50 to 70 grams a day, depending on the fibre content of the vegetables, seeds, and legumes I’ve eaten that day. I try to get upwards of 30 grams of dietary fibre per day.
I avoid all sugar, including sweeter fruits like tropical fruits, and dried fruits, like dates. I especially stay away from refined sugars, even “natural” coconut sugars and agave. I avoid processed carbohydrates and flours. I mostly avoid grains, except when travelling or visiting someone’s house, getting my carbs from starchy vegetables and tubers, legumes and berries. I continue to avoid dairy (which I’m sensitive to), gluten, and processed industrial oils like canola, corn, and soy oil.
Right now, rather than focussing on macronutrient ratios, I’m directing my food intake towards obtaining the Recommended Daily Allowances of the micronutrients that run all of our cellular reactions, and the fibres that feed a healthy gut microbiota. I use an app called Cronometer to track this.
I definitely eat more fat than before, adding MCT oil to my morning smoothie, especially on days when I need to stay full and focused for longer. I also aim to do at least 12 hours of fasting a day, trying to get in 16-18 hour fasts where I can, ending dinner at 4pm, for example. I no longer do regular long bouts of Intermittent Fasting, particularly not when I’m feeling stressed and burnt out.
Would I Recommend the Ketogenic Diet to Patients?
One of the main tenants of Naturopathic Medicine is “Do no harm”. While it may seem like making diet and lifestyle recommendations are relatively benign therapies, I believe that they do have the potential to do physical and psychological harm, particularly if they are strict recommendations.
Following a strict diet may have health benefits, but it also may isolate us from friends and family, frustrate us and restrict our intake of certain nutrients, like fibre, vitamins and minerals. This is one of the reasons I do not ever advocate a Vegan diet, although if patients are following one already, I believe in guiding them to optimize their nutrient intake.
Furthermore, at least in my personal experience, the cure was stronger than the disease. I probably didn’t need to do the Ketogenic diet for so long; this was evidenced by the hormonal imbalances that I began to experience towards the end of my year on the diet.
However, particularly for patients who are suffering from metabolic syndrome, type II diabetes and insulin resistance or PCOS, there may be some powerful benefits to entering ketosis in order to dramatically reverse metabolic dysfunction. In this case, a modified regime combining Intermittent Fasting and cyclical Ketogenic diets could be beneficial.
Of course, it all depends on where patients are at in their nutrition journeys. Sometimes I meet patients who require, and respond well to, more heroic lifestyle interventions. Other times I meet patients relying on several sugary treats a day to get them through. In these cases, simply tweaking their diet in small ways, using baby steps may also have powerful disease-risk-reversing effects.
For breakfast, I would typically eat a high-fat smoothie containing coconut milk yogurt, gelatin, and avocado, and topped with pumpkin seeds and cacao. Sometimes I’d make fat bombs or homemade unsweetened chocolate.