Ketogenic Diets and Brain Health with Dr. Terry Wahls

- The incidence of Alzheimer's disease and other neurodegenerative disorders continues to increase in the US and around the world. Maintaining brain health and preventing neurodegeneration are important goals for many patients as they age. Research suggests that dietary interventions can help keep the brain functioning more optimally at any age and can prevent or even reverse some conditions. - There is more and more evidence that the physicians who take care of MS patients are being taught that yes, diet really matters. Yes, exercise matters. Yes, sleep matters. And you know, people are beginning to understand that it's not an either or. It's not either you take disease modifying treatments or you do diet and lifestyle, but you should offer patients both. - Today we welcome legendary IFM educator Dr. Terry Wahls, a well-known clinical researcher, functional medicine thought leader, and a patient with secondary progressive multiple sclerosis who restored her health using her own diet and lifestyle program. Today we'll discuss how low carbohydrate dietary plans like paleo or keto can provide the necessary nutrients to fuel the brain and help prevent cognitive decline and neurodegeneration. We've been really looking forward to this one. Welcome to the show, Dr. Wahls. - Hey, thanks for having me. - Well, we know that many of our functional medicine clinicians have a personal story about how they came to functional medicine, and yours is a story that's pretty well known. But for those who may not be familiar, will you give us a recap of how you first came to research the impact that diet can have on our neurological health? - So, quite a while ago, in 2000, my left leg grows weak, and I end up seeing my neurologist who ultimately diagnoses me with relapsing-remitting multiple sclerosis. I'm 45 years old. I find the best MS center in the country. I see their best physician take the newest drugs. And three years later, age 48, I'm in a tilt-recline wheelchair. I take mitoxantrone, a form of chemotherapy, then Tysabri, the new biologic, but I continue to decline. And that's when I start reading the basic science and I decide that mitochondrial dysfunction is what's driving disability. I create a supplement cocktail for my mitochondria. It helps my fatigue a little bit, and I'm super grateful. I'm still declining. Four years later, I can no longer sit up. I can take just a few steps using two walking sticks. I'm beginning to have brain fog. I've had trigeminal neuralgia already for 27 years, relentlessly worse. And it's very clear I'm destined to become bedridden by my illness, demented by my illness, and probably die with intractable pain. And that's when I discovered the Institute for Functional Medicine. I take your course on neuroprotection. I have a longer list of supplements, which I'm happy to add. Then I have this really big ah-ha, like what if I redesigned the paleo diet that I've been following already for five years based on this long list of supplements? And that's a bit more research. And with this very structured paleo diet, my fatigue is resolved, my brain fog is resolved, my physical therapist notes that I'm getting stronger, he's advancing my exercises and we have added electrical stimulation of muscles, so we're advancing that as well. And I began walking with walking sticks, you know, stunning my colleagues. And then a few months later, I ride my bike for the first time in six years around the block, which really changes how I think about disease and health. It will ultimately change the focus of the research that I do. And I since made it my mission to teach clinicians how to use my concepts to teach the public how to use my concepts. You know, and my TED Talk, has been viewed over 4 million times. So we're having a major impact. The research that, you know, in my message, which was so condemned back in 2009 is now celebrated in the MS community that I'm one of the leading innovators, leading MS dietary researchers. - Such a compelling story. And you mentioned you were doing all this research and you were implementing these interventions and seeing these massive improvements, but there was some skepticism and some-- - Deep skepticism. - Resistance. How did you overcome that? I mean, how did you stay the course? - Well, what is really helpful is that I'm sort of socially oblivious. So I just kept going where I was invited and, you know, giving my lectures, publishing our research, you know, in very low impact journals, progressively higher impact journals. And my research started getting cited and cited. We were presenting our research at scientific meetings. And now, you know, most recently it was at the consortium of MS Centers, which has the scientists and the clinicians together, people were citing my research. And furthermore, they were also citing my books. So super interesting. It takes about 30 years to change the standard of care. I'm only 15 years into this, so I'm halfway there. My ideas are not quite so crazy. But certainly in another 10 years, I predict that physicians in the autoimmune space, and in the neurodegeneration space will be taught that diet quality, stress management, sleep, exercise are just as vital as any FDA-approved drug treatments. - Umm hmm. In the early days you were doing much of this research on your own, it sounds like, and kind of implementing these things in a stepwise fashion. And I'm interested to hear about the evolution of nutrition interventions. And has your protocol changed based on what you've learned? - Yes. You know, at the very beginning I implemented a very low fat diet, very much like the Swank diet. I then I, you know, had the mitochondrial theory, it was relying on supplements, didn't really help. When I restructured my paleo diet in a very specific way, that's really when a dramatic change happened remarkably quickly. And that's when I leaned into, yeah, supplements can be important to adjunct, but the whole lifestyle program with stress management, sleep, exercise, and very specific nutrition is vital. And now that we understand, or at least I understand epigenetics more effectively and the microbiome more effectively, I realized that I was fixing my microbiome. I was also shifting my epigenetics in a very favorable way. It's the accumulation of all of those things that really led to this dramatic improvement. - Right. When we look at the nutrition piece specifically, much of your research uses kind of a modified paleo or a ketogenic diet, but the theme is that there's a low carbohydrate intake. And I'm wondering, is it the low-carb itself that is the most helpful or it's the addition of the other macronutrients, the higher fat, the moderate protein? - So I want to give your listeners the reference point. The standard American diet probably has about 300, 350 grams of carbohydrates. The Mediterranean diet cuts that down to about 125 grams of carbohydrate. The modified paleo diet that I teach consistently has about 80 grams of carbohydrate. The medium chain triglyceride ketogenic diet would have 50 grams of carbohydrate, a olive oil ketogenic diet will have 35 grams of carbohydrate. You know, and a modified Atkins diet, ketogenic style would have about 20 to 35 grams of carbohydrate. So the lower your carbohydrate, you're going to have more ketones in the bloodstream. It depends if you're using medium chain triglycerides coconut oil, MCTs, you could probably get by with 50 grams of carbs. And that's easier for people to comply with. I personally prefer the olive oil ketogenic diet because you get more olive oil. There's so many studies showing the benefits of olive oil for protecting the brain, protecting the heart. And even in a modified paleo with a bit more, 80 grams, you don't have that many ketones, but you still have a very favorable shift on your microbiome with any of those paleo to ketogenic diets. - I'm just wondering about the progression of, do you have patients who start out at a higher carbohydrate intake and then work to lower or the other way around? - Sure. So my first question when I'm dealing with my patients is, "Do you need a small next step that's everybody can do as a family, or are you ready for a really big change that encompasses all aspects of your lifestyle, because you have so much suffering, you're ready for a really big change?" And I have people come to me who have severe suffering and the whole family is ready for a great big change, and we will do that. I also have families who are like, no, no, we have to do things bit by bit. And so then I may do much smaller changes. And for that family, I may take them from the standard American diet to a Mediterranean diet to a paleo diet, and depending on their response, we may stop the paleo diet, we may continue to march them towards a ketogenic diet. I also will look at what are their metabolic health factors? If they have insulin resistance, metabolic syndrome, type 2 diabetes, severe obesity, I'll encourage them to go lower-carb sooner because by improving all of those metabolic factors, we're also going to address, really protect their brain as well. So you really have to, but people will do, will be vastly more successful if we do this as a family intervention. So a very critical part of the conversation is "What can you and your family do together?" And, "Is your family on board with this?" I want to have both adults that are in the household agree with what the plan is going to be and how they're going to approach their children. And then we can design the appropriate-level plan. Now, I may have an opinion and tell them that given your overall health issues, I think a ketogenic diet will be where you want to end up, but that may not be where we start depending on these other factors. - Does that approach change for someone who maybe they have a family history of neurodegeneration and they want to do preventive versus someone who has a diagnosis already? - Well, certainly if you already have issues with brain fog, cognitive decline, I really will be encouraging a ketogenic lower-carb diet. At the very least, I would like them to do the modified paleo diet, preferably a 50 grams of carbs or less. But for some, the modified paleo diet will be an easier starting point. If you go from the standard American diet straight to a 35 gram carb diet, we have to have some transition period to avoid that keto flu. Otherwise, that first couple weeks will be very, very difficult. And there are some things we can do to help reduce that with more salt, more light salt, more magnesium, taking supplemental ketone salts those first couple weeks. But going from the standard American 350 grams of carbs down to 35 is very hard, you know. And in our clinical trials, we put people through that. So we have to give them a lot of support as they transition from their standard American diet into a ketogenic diet. - I know when I'm doing dietary interventions with my patients, they always want to know, "Is this forever? Is this my new normal?" How do you frame that conversation with your patients? - So I remind them that they are always the one who is in charge, who's in charge of their life. And I invite them to think of this as an experiment and let's decide how long you want your experiment to be. Now, if you're in my trials, it's like, okay, this is a two-year experiment. And what has been super interesting, so people come in, they're like, oh my God, they're so pleased with how well they have done and they're finished. Now they, I'm going to sort of go back to my old diet and they increase their carbs, maybe not all the way up to 200, you know, 300. And they write us and say like, "Oh my God, I feel so terrible. I have so much more pain, I'm having more brain fog. I have to see my neurologist," and they realized, you know what? It is forever, because I felt so much better on that ketogenic diet, or it may have been the modified paleo diet that thought, okay, they were going to go back and have, you know, way more carbs in the modified paleo and they felt remarkably worse. What we've seen consistently in every one of my dietary intervention studies, whether I'm doing a modified paleo, a ketogenic or the low fat diet, is people, you know, do the intervention then decide, okay, it's done. I can go back to my previous diet. They go back and then they send us an email like, "Well, you know, my symptoms are really much worse when I leave the dietary plan, and so I've gone back to it." The modern westernized diet is very inflammatory, very destructive. It's bad for us on so many levels. And so there are many diets that are helpful. The, however, I think the research would suggest for cognitive decline and brain fog, a ketogenic diet because the ketone bodies are an alternative fuel to glucose for the brain. And there's evidence with severe mental health disorders and cognitive decline that those brains are not using glucose as well. And, but we can still use ketones really well, and the ketones wake up our brains, improve our moods, reduce anxiety and reduce brain fog. So for those people, I really want them to experience what a ketogenic diet can do for them. And then I tell them, "You know, we can decide how long you want to try this. I want you to at least six months and then to go off if you want and see how you feel." Nine times out of 10, they contact me back and say, "You know what? It is forever, because I feel much better doing that." - The results speak for themselves. - Yeah. Although I should make another observation that there are some individuals, and we see this in pediatrics seizure disorders, they put kids on a ketogenic diet and usually after a year, they can liberalize the carbs for those children and they can continue to not have seizures or they have seizures, they're much more mild. So I think it is possible that there, we may find in adults that some adults, after some time period of being a ketogenic eater, is it a year or two years, three years, that they could go back to a more paleo diet of perhaps 80 grams and still have good control of their symptoms. We don't really have the answer for that for adults yet, but for children six months to a year, some of those kids are, can maintain good control of their seizures on a more moderate, not a standard American diet, but probably a more moderate paleo level carbohydrate eating. - So really the only way we would know is to experiment, right? Is to liberalize our carbohydrate intake a little bit, see what happens. - And see what happens. You know, I want people to go preferably a year, ideally two. And so we tell our patients, yes, you can liberalize your carbs and see how you feel and if you feel worse, go back on your diet. And so, you know, people are finishing our study, they're two, you know, have done their two years, they're liberalizing their diets. What we hear back is, you know what? I felt much better on the study diet, so I'm going back to it. - Right. I think we have a good grasp on the macronutrients that we're looking for. Are there some micronutrients that we need to be aware of for neuro protection too? - Yeah, so Omega-3 fats, a vital nutrient. We know the, all the B vitamins are super important, and B vitamins are water-soluble. So keep in mind when you're cooking your vegetables, the greens, and if you discard the fluid, you are discarding the B vitamins. So be sure if you're cooking your vegetables, eat all the fluids. Meat is a good source of B vitamins. Liver, really terrific source of B vitamins and a great source of easily absorbed minerals. You need magnesium and zinc, manganese, selenium, iodine as well. And then I really like the vitamin K2 because in, at least in the animal models, vitamin K2 is a critical nutrient for myelin and it's a critical nutrient for calcium, managing calcium in your teeth and bones. So I really want people to have three cups of greens cooked, in raw fermented foods and that's whether you're a ketogenic eater or a modified paleo eater, or actually a Mediterranean eater. - Hmm. I know the Wahls Protocol has very intentional intake of certain foods. And when we look at micronutrients, is this something that we need to have patients tracking with an app or working with a dietician, or if they eat the foods, they're going to get the right things? - I think it's ideally, if you eat these radical things known as non-starchy vegetables and berries, if you are a vegetarian, you need to work with a nutrition professional. Be sure you know how to have balanced protein intake. That will go a long way. If you're interested, you want to track your micronutrients, I think that would be fine. Mostly I want to be sure that people have enough of their omega-3 fats. So wild fish, grass-finished meats. If you're a vegetarian, you have to lengthen the vegetarian sources of omega-3s. And so you need, you can only convert about 5% of the vegetarian omega-3s to the long form DHA, EPA omega-3s that we use in our brain. So that means you need 20 times as many omega, vegetarian omega-3s as animal-based omega-3s. So either DHA from algae or fish oil. It could be very, very, very helpful. - And as we're looking at all these specific nutrients, the conversation about anti-nutrients always in and lectins come into the conversation. - Oh, yeah, yeah. So let, let's talk about the anti-nutrients. Lectins and oxalates. People are like, oh my God, you get all those greens, they're filled with oxalates, they're terrible for you. You can have low oxalate greens, things like parsley, kale, collards, and there are high oxalate greens like spinach, Swiss chard, beet greens. Those will be higher in oxalates. For the vast majority of individuals, as long as you're having a rotated source of your greens, you'll be fine. Keep in mind, we evolved from primates. We separated from other primates 6 million years ago. For millions of years, we've been eating greens. We co-evolved with the enzymes to detoxify the toxic compounds in plants. And there are plenty, I will certainly agree. Those enzymes that detoxify them reduce our inflammation, improve our ability to detoxify and help us run the chemistry of life more efficiently. There are societies that are carnivore only, eat only animal products. And yes, and there is the carnivore movement. If you have a high fat diet with the carnivore movement, you'll be in a ketogenic diet. There are some risks with the carnivore diet, accelerated aging, higher risk of cancer because it, these are, it's a pro-growth state. So the carnivore diet is not without it's downside. - When we're kinda thinking about all of these nutrients that we're taking in very intentionally and specifically, let's bring inflammation, chronic inflammation into the picture. Is that, is chronic inflammation something that you're very aware of as kind of perpetuating neurodegeneration? - So I want your listeners to know that inflammation is a normal physiologic process that we need to maintain and repair our tissues, to destroy pathogens, destroy internal threats, to repair the wear and tear that occurs through everyday life. So inflammation is part of normal physiology. Excess and dysregulated inflammation becomes pathologic. Because of the toxicities in our environment, we can change the receptors on our cells so cells look foreign and damaged. That becomes a problem. We can have excessive inflammation because we have increased permeability in the gut lining, allowing food proteins to get into the bloodstream where our body, you know, sees that as foreign and begins creating antibodies, attacking those food proteins. And if those food proteins are similar to other structures in my body, then, you know, that's a problem. Milk proteins are similar to structures in my brain. And of course if I'm creating antibodies against those milk proteins, I'm also creating antibodies against structures in my cerebellum affecting my movements, my coordination. So dysregulated inflammation is a huge problem. This is tied deeply to toxic toxins in our environment, and to increase leakiness of the intestinal lining, allowing these food proteins to get into our bloodstream. - Well, now you've opened the gut health door, so I must walk through it. And I know you've looked at how these dietary interventions can impact the microbiome. Will you talk to us a little bit about that? - Well, we've presented some really interesting data from my waves trial comparing the low saturated fat Swank diet to the modified-paleo Wahls diet, and then the observation period when people were eating their usual diet. We collected poop at, during the observation period and poop during the intervention period. And then we asked the question, are there microbial communities that predict you're going to have a very nice response when you start on the Swank diet, or you start on the Wahls diet? And it's super interesting. We could see that yes, there are microbial communities that will tell us that you're going to respond really well to Swank. A different set of communities will respond really well to Wahls. And there are, again, different communities that tell us, you will not respond well to Swank, and you'll not respond well to Wahls. What this tells me is that the, you know, the food that we eat is going to be acted on by our microbes, and that will then create new metabolites that get into our bloodstream that will, again, talk to my brain and to my immune cells. If I have the right microbial community, then I'm going to have a great response to Swank or maybe a great response to Wahls. I predict that there will be a time when I can come in to my physician's office, I'll give them some saliva, they'll take some blood, I'll give them some urine, they'll give me a little wipe or go to the bathroom and I'll wipe my backside. So we'll have a little rectal swab as well, and they'll analyze that for the next four weeks, then we'll get a report that will say, okay, Dr. Wahls, given your microbiome and your genetics, what we know is that you could do really well on a ketogenic diet. You do fairly well on a paleo, you'll do terribly on a low fat diet, but Kalea, you on the other hand, would do great on a low-fat vegetarian diet and you would do terrible on a carnivore or ketogenic diet. So there'll be a time when we can give people that very specific information, here are the diets that you'll do really well with, here are the diets you'll do okay with, and here are things that you'll not do at all well. And then you and your family could say, well, we can't do that culturally, it's just not going to work for us, but we could do these diets that maybe while they aren't the the best, they still would be pretty good. And those are things that we actually could implement. Because this will be, I think, really a game changer for people. - That sounds like a dream come true in terms of precision medicine, but right now when we don't have access to those tools. How do we select the right diet for someone in terms of Mediterranean versus paleo versus ketogenic? - So in my approach, I look at their metabolic health. I look at their, so I look at insulin and insulin sensitivity. I look at their current lipids, I look at their family history, and ideally get an APOE4. That will be very helpful if they're open to doing that. And then I talk with their family, "You want a big intervention, do you need the easiest intervention for you to implement? Do you need a intervention that takes into account your spiritual beliefs?" You may have a deep commitment to being a vegetarian. You may have a strong cultural preference to a Mediterranean diet. You may have a strong preference for a carnivore diet. So I want to know both about the family and the family's cultural preferences, the risk factors, what are the health conditions that the person wants to address, wants to prevent? And then we will, I'll tell them what I think is the most therapeutic diet, and then we'll have a conversation. "Can you implement that? Is that too hard? Do we need something that is more realistic for you? And what are you most curious about?" - Something, a question that plagues me that I'm so excited I get to ask you is sometimes it seems like there are patients who are good candidates for a ketogenic diet, but they don't need to lose weight. Can we put them on a keto diet and maintain their body weight? - So we've been very successful at that. My clinical trials, we have to keep, you know, I have a plan. We won't put people on a ketogenic diet in our study. If their BMI is below 20, in my practice, I won't put in my ketogenic diet if their BMI is below 19. And then we increase... So I put them on a ketogenic diet. If they're losing weight, we re liberalize the carbs and then I may use ketone salts and supplement that way. - So it can be done. - But there are some absolute contraindications. I'm going to run that run that. - Please do. - For everyone. If you're pregnant, you cannot do a ketogenic diet. If you're breastfeeding, you cannot do a ketogenic diet. And by the way, you can't do a low carb paleo diet pregnant or breastfeeding. If you're pregnant, you gotta have the OB doc sign off on whatever diet plans they're going to do. And I caution people that even the lower-carb paleo diets breastfeeding, because that is a big demand on mom, can tip people into ketoacidosis. So if mom starts having nausea, vomiting, she needs carbs and has to go to the emergency room and get checked and taken care of. And usually a carbohydrate drink And some IV fluids will take care of all that. But if, you know, if she's developing a bladder infection, that can also accelerate that as well. And then, you know, severe weight loss. I've had people understand that ketogenic diets are really good for cognitive decline and they can develop ketogenic diet and then develop orthorexia and become more and more fixated on their food and get into a spiral of weight loss that's quite damaging. And people who are on a ketogenic diet for their autoimmune condition have often taken very potent disease-modifying treatments that do increase the risk of developing a lymphoma, leukemia and other cancers. And so anyone who's losing weight on any of our diet plans, I want them to also talk to their primary care doc and ask the question, do they need an evaluation for malabsorption, for occult parasites and for occult cancers. - I really appreciate how comprehensive, I mean, I'm visualizing the functional medicine matrix and you're talking cellular energy production and environmental toxicity and the gut health piece. I mean, there's really so many areas of the matrix that you're addressing with these dietary interventions. And I imagine that patients, when they start on your program, they're wondering how long until I see symptom improvement? How do you discuss timeline? - What I tell them that in my clinical trials, in my, and in my clinical practice at the VA, people would often begin noticing some improved energy, mental clarity that begins to be noticeable as sometimes as early as four weeks. Certainly within 12 weeks. Seventy to 80% will see it within 24 weeks. And when I can do a little more specific guidance, a little more comprehensive of a lifestyle intervention, we couldn't get that up to a 90%. People seeing reduction in fatigue, improvement in mental clarity, reduction in anxiety, reduction in depressive symptoms within three to six months. Motor changes, as measured by something called the functional, the MS functional composite, which combines the 25-foot walk test, nine hole PEG board, a measure of hand function, the simple digit modalities test measure of working function. That we can see improvement at 12 weeks, which further improves at 24 weeks just by changing the diet. Now if you did everything, diet, sleep, stress, exercise, I anticipate we'll see more. And the other thing that I want to comment on is that in the study that I'm doing now, efficacy of diet and quality of life, comparing the keto diet, paleo diet, usual diet with dietary guidelines info, we're following them as functional composite at month zero, month three and month 24. And that's going to be super interesting to see just how much improvement of reduction of disability that we'll see over a two-year period. - Wow! All the abundance of evidence that you've compiled over the last 15 years, do you see this becoming more mainstream? Are you observing that, that this is more acceptable? - Well, you know, I am observing that when, when I go to the scientific meetings, the MS consortium of MS centers, when I'm walking around, people are pulling out their phones saying, Hey, Dr. Wahls, can I get a picture with you? My research team would be thrilled, my patients would be thrilled. And I see in the lectures, people talking about diet as a way to influence the immune activity, the way to influence neurotransmitters. So there is more and more evidence that the physicians who take care of MS patients are being taught that, yes, diet really matters. Yes, exercise matters. Yes, sleep matters. And you know, people are are beginning to understand that it's not an either-or. It's not either you take disease modifying treatments or you do diet and lifestyle, but you should offer patients both. You can encourage them to take disease-modifying treatments. And people can be shocked to know that I encourage people to take disease-modifying treatments, particularly if your disease is still active, still having relapses, still having new enhancing lesions. Yes, I would take the DMTs, implement diet and lifestyle, and then we get to no relapses, no new enhancing lesions, which is a goal I endorse for everyone. Then is it after a year, two years, or three years, we don't really know how long that should be, somewhere between one and three years. Then you could transition to a DMT with fewer side effects and then potentially to no DMTs and maintaining diet and lifestyle. And even my neurology colleagues are agreeing that we don't know how long people should stay on these drugs because after age 45, the immune cells are not so active. There aren't so many relapses, there's progression. The risk of harm for the DMTs begins to be much greater than the benefit. And so we don't know, do you stop at 55, 60, 65 or maybe even 45 if there's no evidence of disease activity? We don't know. I keep writing grants to try and answer that question. So far I've not been able to have my grants funded. We'll see. We'll keep at it. - Well the way that you talk about these interventions just for supporting cognitive function, do you think people are becoming more aware, like, gosh, I do feel like I have some brain fog or some fatigue and they're being more proactive and they're catching neurodegeneration earlier? - Well, I think patients are more and more interested in diet and lifestyle. We know about half of patients with MS are making changes to their diet. You know, it's very exciting. It will make having a control a little more challenging for doing dietary intervention studies. And there is more recognition that the reason people have to stop working for MS is brain fog, anxiety, depression, and fatigue. And the good news, and DMTs do not help any of those four symptoms. Diet and lifestyle and the interventions that we use are very effective for all four of those symptoms. And patients are using that. And there are more neurologists that are now also saying, yes, I want to take these DMTs, but it's also really important that you improve your diet. And you know, I'm certainly hearing from my tribe that it was their neurologist who gave them my book. So we're making, we are making progress. - The landscape is shifting, which we appreciate. And you are constantly doing research. The curious part of my brain has to know, are you learning new things that you're then implementing into your own health strategy as you continue to research? - Well, as a matter of fact, yes, there are lots of new things that I'm influencing in terms of what are some of the new longevity strategies. An interesting... You know, some of the technologies that the billionaires are using for their longevity. I'm sure many of your audience have heard about that, banked stem cell infusions, therapeutic plasma exchange, H pad, pulsed electromagnetic fields, molecular hydrogen, ozone therapies. These are the interventions that the billionaire class are using for their longevity strategies. - So you're doing some experimenting and we'll stay tuned for your-- - You stay tuned for that, yes. - Report. - But I want to assure you the audience, I'm not in that billionaire class, so I can't do all that fancy stuff. - Well, we'll await your full report, but I know when we get back to the basics of the modifiable lifestyle factors, especially the nutrition piece, there may be patients who are listening and I'm just wondering if you have any advice about how patients can advocate for themselves in their neurologist's office. - So in the neurologist, you can talk with them. Yes, make your decision about the DMTs. You can ask for a referral to physical therapy to help you design an exercise program that will support you. You could look for people who are teaching the public such as myself in terms of how to approach a modified paleo diet or a ketogenic diet or a Mediterranean diet. We teach those things. You could look for other nutrition professionals. You could ask your neurologist for referral for a dietician. If you have, I believe there are some medical indications for, that are approved for a referral to dietician, including things like obesity, high blood pressure, heart disease, diabetes. So if you have any of those comorbid things, you could ask your primary care doctor, could you send me to a dietician so I could get some guidance on that? You can look for some online programs, you can look for some diet and wellness books. I have several that you could, that will get you started. Or you could do this radical thing, eat more non-starchy vegetables, get rid of the sugar-sweetened beverages, get rid of the white flour-based bread, cereal, pasta. In their place, eat non-starchy vegetables. Or you could even still eat the starchy vegetables, the yams, the potatoes, squashes. All of that would be vastly better than a flour-based bread, pasta, or cereal. - Okay, so if any-- - It doesn't have to be hard. - Yeah, step one, just start implementing some of these things that you've talked about. - Hang on. You know, step one, have more greens. You could take your favorite green, some green grapes, kale, lettuce, parsley, blend it with green grapes, ice and perhaps a little olive oil and make a green smoothie. Your kids will like that. You'll like that. And this makes it easier to get more greens in your diet. Start with that simple first step. - You mentioned a mix of raw and cooked greens. Is there a ratio we're going for in terms of cooked to raw? - So, if you are constipated, more raw. If you're having diarrhea, less raw, more cooked. So it depends, are you constipated or are you having diarrhea? And for people with MS and neurodegeneration, whether it's Parkinson's, Alzheimer's, cognitive decline, we're at risk for having fecal accidents. And we prefer to be a little constipated so we're not pooping our pants. So that's, I ask, are you constipated or are you having fecal accidents? And so I make some titrations based on that. - That's actually a nice pro tip because then you can modify based on what you need on any given day, right? You can shift it a little bit. - Correct. - Well, we need to know what's coming next for you in terms of research and the work that you're doing? - Well-- - What are you working on? - Yeah, the, we have a, we're evaluating a online course that we've created for the research, and we'll be adding the next disease cohorts for that. It'll be rheumatologic diseases like rheumatoid arthritis, lupus, psoriatic arthritis, Sjogren's. We're working on that. That will probably get started in the very near future. We will then, once that is up and going, we will, the next study after that, we'll take the online course and we will be comparing, well, taking this online course and learning how to improve your diet, your exercise, your self-care, lead to less dysbiosis in the mouth and in the gut. And so we have a household control in the person with MS. And then the study that we'll do after will be a progressive MS study. So I've got three studies that we are working on getting developed, and I want to put a thank you out to all of the wonderful philanthropists that have given us funding to allow us to do our clinical trials. Because I still have not been able to get funding from the NIH, but we have been able to secure funding from the thousands of people whose lives that my work has touched that have called the University to give very generously to my research program. - What a testament to all the people that your work has really served. And I always ask researchers, are you doing, are you doing your dream research already? I mean, is this what you love to learn about and to study or is there some other thing that you're hoping to research that just hasn't happened yet? - Well, I will want to keep expanding the disease states that we can investigate. And so I invite the listeners, if you have another disease state that you care about, you can reach out to my team and we can have that conversation. This is why we're adding the rheumatologic diagnoses because we've had some additional funding requests for that. So we'd like, okay, if you can help, help me fund that, we will get that to happen. - Well, Dr. Wells, will you give us what you think is the most important takeaway from today's episode for any of our functional medicine clinicians who are listening? What do you want them to walk away from? - Well, I want you to know that the ketogenic diet is really very helpful for people with a brain fog, cognitive issues, and people with psychiatric problems, anxiety, depression, psychoses, bipolar. And so work, you know, take them where they're at and help that patient. Yeah, I would take that person, put them on a paleo diet, see if they get results, and if they get great results, that might be enough. If they have not gotten enough results, then keep marching the grams of carbs down. Go from 80 to 50 to 35. You may even need to go all the way down to 20 and you may need to give them ketone salts. So if they're losing too much weight, you can liberalize the carbs and give them ketone salts. It can be really quite profound. And I invite my patients to decide how long their experiment needs to be. I want them to go at least six months, preferably a year, ideally two. And then, yes, they could liberalize their carbs gradually to figure out what is the amount of carbs that maintains control of their mental health issues or their brain fog. - Hmm. Well, I just wanted to thank you so much for all of these really practical, actionable insights that you've shared. I mean, they're really things that I feel like many of us can go out and help patients with immediately. So I wanted to thank you so much for your time today and for the years that you've served as a teacher to so many of us. It's just been a pleasure chatting with you today. - I thank you and much love to you and my IFM family as well. - See you next time, everyone. - To join the conversation on this topic, visit IFM's pages on Facebook and Instagram. For more information about functional medicine, visit ifm.org. The future is functional.