People are often surprised to learn that I put bipolar 1 disorder into remission following a vegetarian keto diet. Many have the misconception that keto is a fad diet that consists mostly of meat and dairy. In fact, a therapeutic ketogenic diet is an evidence-based medical treatment for many illnesses. And though most people do incorporate animal-based nutrition into their keto diet, if you are a vegan or vegetarian, it may still be possible to follow a ketogenic diet to treat a mental illness or other health conditions. 

It is important for the metabolic health community to be inclusive and kind, recognizing that different nutritional strategies can help individuals on their unique healing journeys. In embracing the science behind ketosis and its mental health benefits, we move beyond dietary dogma and focus on the metabolic mechanisms at play. As research continues to uncover the intricacies of ketosis and its effects on the brain, and as individuals’ share their anecdotal evidence and experiences, we are gaining valuable insights into optimizing mental well-being.

I started vegetarian ketogenic therapy in the summer of 2021 after discovering the work of Harvard psychiatrist, Dr. Christopher Palmer, author of Brain Energy. I have since put my illness into complete remission. 

My decision to be a vegetarian is not health-based, nor is it related to the impact of animal husbandry on the environment. In fact, regenerative planned grazing can be an important part of the climate solution. 

Since early childhood, the idea of eating an animal has made me lose my appetite. I do not judge others for eating meat or consider it morally wrong. There are numerous reasons someone might choose a vegetarian or vegan lifestyle, and, in many cases, there may be no need to compromise personal diet preferences in order to implement ketogenic therapy successfully. At the same time, it is important to note that there are essential nutrients in animal foods that are absent or nearly absent in plant foods, or that may be less bioavailable in plant foods, so supplementation is often recommended. 

Research investigating the underlying mechanisms of ketogenic therapy is ongoing and there is still a lot to learn. There is no one-size-fits-all diet because we are all metabolically different, and we have our individual dietary preferences. I have had incredible success using a vegetarian ketogenic diet to treat mental illness and know others who also thrive using this dietary intervention. Dyane Harwood, co-host of the Our Healing Journey with Metabolic Psychiatry podcast, raises awareness of her vegan keto diet to treat bipolar disorder. Some, however, like metabolic health writer Jessica Apple, find meat beneficial or even instrumental to their healing journeys. Jessica spent a decade on a vegetarian keto diet to treat autoimmune diabetes, without experiencing mental health benefits. "Vegetarian keto worked great for blood glucose management,” she says. “But it was only when I finally started to incorporate beef fat into my diet, that I began to feel improvements in my mental health. My long-standing anxiety disorder dramatically improved when I began to eat meat. For me, it really felt like my anxiety was a symptom of my brain begging for animal fat."  

Keto is about carbohydrate reduction

The goal of a therapeutic ketogenic diet is to enter the physiological state of ketosis, which is achieved during carbohydrate reduction. In ketosis, the body switches from burning glucose (from carbs) to ketones (from fat) to fuel the body. Ketosis is not defined by consumption of specific foods but by the presence of ketones in the blood. Fasting can also induce ketosis, as can intense exercise. By providing the brain with ketones, a more efficient energy source than glucose, ketosis may alleviate symptoms of anxiety, depression, bipolar disorder, schizophrenia, and even cognitive decline. Furthermore, the anti-inflammatory and neuroprotective effects of ketones offer additional support for overall brain health. The state of ketosis is also associated with ongoing benefits to mitochondrial health that may improve the body's ability to transform and utilize energy.

The dietary choices of keto, outside of carbohydrate restriction, are flexible. It’s possible to be in ketosis and subscribe to a variety of other dietary patterns such as carnivore, omnivore, Mediterranean, paleo, vegetarian, or vegan. Those who fuel primarily with plants will need to take precaution and may need supplements to achieve optimal health. According to metabolic psychiatrist Dr. Georgia Ede, “For those who choose vegan diets, it is important to know that plant foods contain no DHA.” DHA (docosahexaenoic acid) is an omega-3 fatty acid that plays a central role in the human brain. In her book, Change Your Diet, Change Your Mind, Dr. Ede discusses common deficiencies for vegans that may need supplementation including: B12, D, zinc, EPA and iodine. 

Track Ketones 

I recognized early on in my ketogenic journey that meticulously tracking macros, measuring all my food and carefully calculating grams of carbs would not be a sustainable strategy for me. It seemed tedious and overly time-consuming for my lifestyle, and would have made adherence difficult. I have met others who love detailed tracking and recorded data as it gives them a sense of control over every element of their ketogenic diet. Individuals can reflect on their personal preferences to find an approach that works. 

In my case, to avoid needing to track every morsel that went in my mouth, I decided just to focus on the invaluable currency of this intervention: ketones. I wrote an article in the Brain Energy Magazine on why I recommend using a Keto Mojo meter, especially for vegetarians. My regime was pretty simple and I tried my best to just zero in on what really mattered: staying in ketosis. 

Using my Keto Mojo meter, I discovered that I could eat the delicious vegetables I love to satiety and maintain ketosis, as long as I steered clear of the obvious high carb culprits that everyone avoids on a keto diet: grains, most fruit, sugar, potatoes, beans, lentils, etc. Some great resources that explore the specific foods that can be eaten – and should be avoided – on a vegetarian and/or vegan ketogenic diet include:

• How to Follow a Healthy Vegetarian Keto Diet by registered dietician, Franziska Spritzler

•  A Comprehensive Guide to the Vegan Ketogenic Diet by Craig Clarke

• Ketotarian by Dr. Will Cole

• Vegan Keto by Liz MacDowell.

I also needed to be careful not to over-consume keto-friendly foods that can be enjoyed in moderation like berries and nuts. I learned early on to avoid packaged processed “keto” snacks and treats almost entirely, as they would often knock me out of ketosis. In general, I eat whole, “real” foods. To keep things simple and less time consuming, in the early stages of figuring out how various foods impacted my ketone level, I would snap photos of meals so that I had a record in case I needed to troubleshoot. This simple process of trial and error worked great for me. There are some free photo food diary apps that some might find helpful, such as Foodview. 

Back when I started, there were few resources available for someone wanting to try ketogenic therapy for a mental health condition. I couldn’t find a clinician to work with me. I was fortunate to be able to manage my condition well on my own. But even now with Metabolic Mind providing a plethora of helpful resources for individuals, many still have trouble finding support from a mental health clinician trained in metabolic therapies. Here are some resources to find trained clinicians who can help establish an appropriate, tailored ketone target level for the individual patient. The field of metabolic psychiatry is emerging, so it can be difficult to find trained clinicians. One option some patients find helpful is to work with a specialist, like a keto coach, counselor, or dietician, who can provide guidance and support and coordinate and communicate with their care team. 

I initially aimed to regularly hit higher “therapeutic levels” above 3 mmol/L. A combination of intermittent fasting and a vegetarian keto diet helped me reach this consistently. I found it fairly simple to maintain, primarily because I love the way I feel energized and sharp when in deep ketosis, which creates a positive feedback loop and is highly motivating. One of our collaborators, Lauren Kennedy, is doing a Keto and Metabolic Health Project  documenting her journey of implementing ketogenic and other metabolic therapies to treat schizoaffective disorder in real time on her prominent YouTube channel, Living Well with Schizophrenia. In the initial three months of her treatment, she has found that high ketone levels around 4 mmol/L are best to control her symptoms.

Once Dr. Palmer published Brain Energy near the end of 2022 and began his podcast tour, I heard him share that, in most cases, people treating bipolar and schizophrenia should aim for a ketone level around 1.5 mmol/L. (Again, ideally, this should be determined for each individual with the help of a clinician.) Based on that information, I loosened the reins a bit, but I still incorporate intermittent and extended fasting and get into higher therapeutic levels at least a few times a week, mainly because it enhances my mood and energy levels. 

Get labs done throughout ketogenic therapy

Though diet in and of itself is not the only factor that can cause mental disorders, many nutritional deficiencies can contribute to poor mental health. For example, according to this paper published in Nutrients, “Deficiencies in nutrients such as protein, B vitamins, vitamin D, magnesium, zinc, selenium, iron, calcium, and omega-3 fatty acids have a significant impact on brain and nervous system function, which can affect the appearance of depressive symptoms.”  

To find out which lab tests you may want to consider, I recommend this video from Metabolic Mind director, Dr. Bret Scher, and this printout, covering labs to get throughout ketogenic therapy. You can even order these yourself through Own Your Labs. Routine lab work can identify problems, and seeing improvements can be motivating and inspiring. I wish I had done labs at baseline, as it would have been fascinating to compare my metabolic health then and now. Additionally, when I did finally get lab work done, I found a few deficiencies including vitamins D,  B12, and carnitine. These deficiencies, as well as low iron levels, are fairly common for vegetarians. I now take supplements. For anyone with deficiencies, supplementing as needed may lead to optimal health and energy levels. 

Experiment with recipes and practice positive framing 

At the very beginning of following a vegan keto diet, it did feel restrictive. Once I saw the enormous benefits to my physical and mental health, however, it became incredibly easy to focus on all the delicious ingredients that I could eat and the limitless ways to prepare them. I am a foodie who loves cooking with spices and experimenting with a variety of ethnic foods and flavor profiles. I prepare many dishes that have complex flavors and are rich and creamy with fat–utterly delectable and satisfying. I love making Indian and Thai vegetable and coconut milk curries and salads galore with a variety of homemade creamy dressings. Zoodles, cauliflower rice and cabbage are staples for me. I incorporate a lot of fried tofu and tempeh for protein. While I initially started keto as a vegan, I later incorporated eggs from local family farms. They are a great source of protein and fat that I find satiating and delicious, and they provide a wealth of bioavailable nutrients. 

At this point in my journey, I do not feel even the tiniest bit deprived. One of the most surprising benefits of eating a ketogenic diet is that I feel more satiated all of the time, a phenomenon commonly reported on keto. This has helped me heal my relationship with food, which in the past was complicated by addiction and emotional eating. Using food to self-soothe while taking the antipsychotic Olanzapine, a drug known to cause metabolic harm and weight gain, was a recipe for disaster that led me to put on more than seventy pounds and become obese. Thanks to metabolic therapies, including my ketogenic diet, fasting and exercise, I am now back at a healthy weight. I can also be present while I am eating to truly enjoy my food in a mindful, healthy way. To me, like most things in life, the key is positive-framing. Focusing on all the incredible ingredients and the limitless ways to combine and prepare them, paired with how this dietary intervention has transformed my physical and mental health, keeps me very satisfied with this way of eating.