Podcast: Ask Me Anything About Keto & Healthy Eating for Mental Health

Jenn talks to Dr. Chris Palmer. He provides an overview of the ketogenic diet, explains its potential benefit in mental health treatments, and debunks myths and misunderstandings about keto and other healthy eating habits.

Christopher M. Palmer, MD, is the director of the Department of Postgraduate and Continuing Education at McLean Hospital and an assistant professor of psychiatry at Harvard Medical School. He has been pioneering the use of the ketogenic diet in psychiatry, especially treatment-resistant cases of mood and psychotic disorders.

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Episode Transcript

Jenn: Hey everyone, welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

So, hi folks, thanks so much for joining today and I hope wherever you are, you are doing well. I’m Jenn Kearney. I’m a digital communications manager for McLean Hospital and today’s session is all about the link between the brain and the body, more specifically, how what we consume can impact our physical and our mental health.

And while personally I’m really well versed in how productive I am after like four cups of coffee, I’m also totally aware that what it does to my energy level and my anxiety and my stress over an extended period of time, not the best thing in the world.

Turns out, it’s not just food and drink that contains stimulants like caffeine that can affect your mood, your sleep, your mental health conditions even more but I’m going to let Chris address all of that.

So, if you are unfamiliar with Chris, you are in for a real treat. Dr. Palmer is internationally known for pioneering the use of the ketogenic diet in psychiatry, especially treatment-resistant cases of mood and psychotic disorders. And he is currently serving as the director of the Department of Postgraduate and Continuing Education at McLean Hospital.

So, Chris, we are going to get started with a question of my own. Can you talk a little bit about the connection between our brain and our stomach and how that can impact our mental health?

Chris: Absolutely. So, it is a huge field, huge field, massive so I will, you know, I wrote an article for an academic journal and then I also published kind of a lay version for Psychology Today so if people are interested in it, if you go to my website, chrispalmermd.com, if people don’t know about it, there are tons of resources there.

So, if I mention something and you’re like, where do I get that paper or where do I, just go there. But in that paper, I broke down the mechanisms of action or the types of dietary interventions used in the mental health field. And so, the longest standing one that most people are aware of are vitamin and nutritional deficiency.

So we have known for decades that certain vitamins are necessary for the function of our brains and our bodies, and that when people have certain vitamin deficiencies, they can actually exhibit all sorts of symptoms of mental illness, all the way from depression, anxiety to psychosis to dementia.

And so, some key vitamins are vitamin B12, thiamine and folate, so those are routinely screened in psychiatric patients especially patients with new onset dementia. So, I could go on about vitamin and vitamin deficiencies.

The next bucket that I’m going to mention are allergens or toxins in our foods. So a lot of people think about gluten-free diet or do organic foods only don’t, you know, free range meats or eggs or whatever, let’s get rid of all the artificial dyes and all the chemicals that are toxic to the brain.

There are some evidence for that and certainly there are people who are gluten sensitive and have all sorts of symptoms including psychiatric symptoms when they consume gluten. So that second model I kind of represent as removing toxins or allergens from the diet.

The third model that I represent is just healthy diet. Mediterranean diet or a whole foods diet, or a vegan diet or vegetarian plant-based diet or you know, so different people’s definition of what healthy is widely variable. People get into heated debates and arguments about what the healthy diet is and there’s tremendous disagreement but that’s another model.

And we have some research, especially with the Mediterranean diet, showing that it can help some people with treatment-resistant depression. So healthy diet is kind of another model. The third bucket that I or the fourth bucket that I usually mention is the gut microbiome and the gut-brain connection.

So that is a complicated, complicated topic and it involves actually three different mechanisms of action, the gut and the brain communicate with each other in three very distinct ways and then under each one, there are tons of topics that we can talk about.

But the first way is that our gut actually has a nervous system, largely fueled by the vagus nerve that goes from the brain to the gut and there’s actually bi-directional communication between the vagus nerve and the brain. So, the gut is actually communicating with the brain and the brain is actually communicating with the gut through these direct nerves.

There’s recent research in the Parkinson’s disease literature showing that some toxins that we consume can actually be absorbed by the vagus nerve, travel all the way up to the brain and poison specific brain regions associated with Parkinson’s disease. And so, these nerves connecting the brain and the gut are critically important.

The second mechanism of the gut-brain connection is that the cells lining our gut produce all sorts of hormones and neuropeptides and other things so when we eat food and those gut cells sense this food, they send out signals to the rest of the body like get ready here, it’s comin’, we got some glucose comin’, we got some amino acids comin’, get ready to process them.

You know, yay, we got some food, figure out what you’re going to do with it, and it turns out that these hormones and neuropeptides and other things have dramatic effects on the brain.

So, an easy example just so people really understand this. When I say dramatic effects, I mean dramatic effects. You can have a screaming infant because this infant is hungry. The mother or father or caretaker feeds this infant. Infant now as a full belly and what happens, the infant actually falls asleep.

Food filling up this belly results in sleep, that’s a brain thing and then we can take it even further though because in adults, you know, everybody knows the phenomenon, at least in the United States, when you binge eat on Thanksgiving Day, you get drowsy and tired and lethargic and all you want to do is sit around, lay on the sofa, watch a football game or whatever, just take a nap or something even though you normally wouldn’t take a nap.

Even though maybe you’re not even interested in football, like you’re willing to just lay there like a log and do nothing because you’ve overeaten, well, that’s the same thing happening.

But if you imagine if somebody’s just slightly overeating on a regular basis, they might be affecting their energy level, their ability to concentrate, their motivation. Again, think of just wanting to sit on the sofa, lay on the sofa and do nothing because you’ve lost all your energy and motivation.

If that’s happening to you chronically, that could be a problem that could easily be construed as something like depression or lack of motivation or whatever. And then the third thing that’s part of the gut-brain connection are all of the microbes within our guts.

So, all of the bacteria in particular, our guts actually contained viruses and fungi and all sorts of things.

The bacteria in particular seem to be key and the bacteria end up getting first dibs at what we eat and they actually take what we eat and they eat it first, and then in response to that, they secrete all sorts of chemicals and neurotransmitters and hormones and all sorts of things that actually get absorbed into our bloodstream and then travel throughout our body and brain.

And so, the gut microbiome is a huge area of interest to a lot of researchers right now.

And then finally, the fifth mechanism of action that I talk about is so, you know, all of those are about eating food and what effects the food has like vitamins either they’re there or not, or toxins or healthy diet, or what is the food doing to the gut microbiome and all of the gut cells lining the gut and all those kinds of things.

But then the fifth one is actually about going without food and that’s a state that I’ll, you know, that starts with what we would call fasting.

If it goes on too long, it turns into what we call starvation which is obviously a life-threatening problem and people die of starvation all the time. People with severe eating disorders die of starvation. So, this is a serious matter and I don’t want to underestimate it, but the process of fasting seems, you know, we’ve known for thousands of years that it seems to have healing effects.

And for a long time in Western medicine, we just assumed that was just quackery, that was just religious folklore. Oh, Hippocrates and his fasting. Well, we’ve got modern science nowadays, we know what we’re talking about.

Well, guess what the modern science is showing, the modern science is actually proving that that phenomenon of fasting is actually quite beneficial to the human body and so there’s the process of fasting but there are also fasting mimicking diets.

And so you can’t fast for too long because then you go into starvation which is dangerous and life-threatening and so we have fasting mimicking diets, the most popular one is the ketogenic diet that is an area of research for me and an area that I’m quite excited about.

Because people can do a ketogenic diet for a long duration and get all of the benefits of fasting without actually starving, without actually becoming nutritionally deprived and for some people that can have tremendous benefits.

So I’m going to stop there, that’s my whirlwind tour through, but the reason I think it’s important to mention all of those is ‘cause when people talk about diet and brain health, they’re usually actually only thinking of one of those, oh yeah, vitamins and nutrients, yeah, they’re really important.

And I’m like, well, actually there are lots of other mechanisms of action that are potentially at play. And so, it’s important that we be clear about what are we talking about, what are those things doing and how might they play a role in brain health.

Jenn: That was basically like going through scientific Disney in one day, that was fantastic. You’ve teed me up right for my next question.

Can you dive a little bit deeper into what the keto diet is specifically, and does it differ from Atkins? Because I know that that was popular a little while ago but what’s the difference?

Chris: So, the ketogenic diet is now that we are in 2021, it is 100 years old this year. So the ketogenic diet was developed in 1921 by a physician and it was developed exclusively for one and only one purpose.

It was actually developed to stop seizures and this was based on this longstanding observation that, you know, dating all the way back to the time of Hippocrates that if somebody is having recurrent seizures, so the best proven way at the time before we had any medication, the best proven way to stop those seizures was to actually fast the person.

Again, that was largely thought to be religious folklore and quackery but in the early 1900s, Western physicians actually started studying and lo and behold actually found, oh my gosh, this really works, it like really stopped seizures, to fast people.

But again, they had this dilemma of if we fast them for too long, they’re going to starve to death and that’s not going to be good for their health. They might die seizure-free but they’re going to die of starvation.

And so a physician at the Mayo Clinic actually concocted the ketogenic diet to mimic the fasting state so that people with epilepsy could do this diet long-term and get the benefits of fasting which is the stopping or reducing seizures but they could maintain their health.

And so, what is the ketogenic diet? It’s a diet that’s very high in fat, it’s usually moderate in protein and it’s very low in carbohydrates. It is different than the classic low carbohydrate diet, so the classic low carbohydrate diet was actually described in the early 1800s as a weight loss intervention. So low carb diets have been around for a long time.

The Atkins diet is in some ways it is a ketogenic diet and in other ways it’s somewhat different than the medical version or the epilepsy version of the ketogenic diet.

And so Dr. Atkins’ “Diet Revolution” in that book, he was very clear that the goal of his diet was to achieve ketosis and that he encouraged everybody to test for ketones in their urine using ketone strips and that if they didn’t have ketones, they weren’t doing the diet right or they needed to modify the diet until they got ketones.

And so his goal was very specific to we want you to be in ketosis and his diet was different than that classic ketogenic diet in that he basically said, you don’t have to be as rigorous, so the classic ketogenic diet, you actually have to be meticulous. You have to weigh and measure everything.

You have to calculate how many grams of fat, how many grams of protein you’re getting each day, how many grams of carbohydrates.

It’s difficult and onerous to do and yet thousands and thousands of people are doing it every year throughout the world because their children or they themselves have treatment-resistant epilepsy and nothing else has helped and this diet can stop seizures in even those people so lots of people are doing it.

The Atkins diet was basically the rule of thumb was eat as much meat.. eat as much meat as you want and eggs. Meat and eggs are unlimited, sources of pure fat are unlimited, so that’s olive oil or butter, other types of oils, mayonnaise, you can basically eat as much of that stuff as you want.

He encouraged people to eat low carbohydrate vegetables, and his diet specifically, at least in the weight loss phase, he wanted people to limit nut consumption which can be part of the classic ketogenic diet.

So, nuts tend to cause weight gain or maintain weight. So, if you’re looking to lose weight, nuts are probably one culprit that I would look out for. And so, the Atkins diet, he had figured that out and was very clear in his recommendations that when you’re starting this diet, if you really want to lose weight, don’t eat any nuts.

And then he furthermore said, you need to limit dairy consumption to no more than four ounces per day and so that included hard cheese, heavy cream, and other types of dairy.

He did not include butter in that, butter was an unlimited kind of food but other types of dairy, the cheeses, cream and stuff, he said no more than four ounces because if you eat a lot more than that, you’re probably not going to lose weight.

So, the big distinction between those is that nuts and heavy cream can be staples of a classic ketogenic diet. And sometimes especially when these diets are used in children who are still growing, we actually want them to gain weight, we need them to gain weight.

They have to grow and thrive. They’re not done growing yet so we need them to be able to gain weight on a diet that a lot of people nowadays are using as a weight loss intervention.

So, we can’t have them losing weight. So actually, nuts, and heavy cream are a godsend for those people, and they taste really good too, heavy cream tastes really good, nuts tastes really good.

I personally like nuts and heavy cream but if I eat a lot of them, I’m going to gain a lot of weight so I try not to eat a lot of them because that’s not a desired effect in myself, but I’ll stop there and we’ll keep going.

Jenn: So, if someone is on the, if they’re doing the keto diet, do you have any advice about what level of ketones they would necessarily need to be at if they’re aiming for better mental health?

Chris: So, it’s a really great question and I will give you some guidelines that I use but I need to clarify it first, this is a wide-open question. We need more rigorous research and larger samples of people with other clinicians doing it, other sites doing this kind of research to really determine that effect and you’ll find lots of different answers from different experts.

So, some people even in the epilepsy world will say, it doesn’t really matter, just as long as you have ketones, you’re good. Some people describe ketosis as similar to pregnancy. It’s either a yes or no answer, like you’re either in ketosis or you’re not, you’re either pregnant or you’re not.

I actually disagree with that and I disagree with that in part based on my clinical experience. I have definitely seen some disorders respond to low levels of ketones pretty well.

The disorders that tend to respond to low levels of ketosis are more of the mood and anxiety disorders. Though people can sometimes get a powerful antidepressant effect with very low levels of ketones.

At least in my experience, for people who have a more serious mental disorder, we call them more serious, not that they necessarily are ‘cause some people with depression are incapacitated, disabled and eventually kill themselves because of their disorder so that’s serious too.

And I don’t mean to minimize that in any way, but a lot of times people refer to the serious mental disorders as bipolar disorder and schizophrenia because they almost across the board are disabling disorders for most people.

And for those disorders especially when, you know, with schizophrenia, psychotic symptoms are a given because that’s the definition, it’s part of the definition of it.

For bipolar disorder, if it’s somebody who has a lot of psychotic symptoms during their episodes and they have many episodes per year, I would put them more in the category of having a chronic psychotic disorder as opposed to just a mood disorder.

And those patients I’ve found need blood beta hydroxybutyrate levels usually greater than 2.0 in order to get a therapeutic effect and that’s pretty high. I’ve had some patients who need between three and five which is even higher.

There’s a lot of debate in the epilepsy world about should we be measuring ketones levels, and do they matter? And again, there are people on both sides of the fence on that debate.

There’s a camp and some research published that says you need levels greater than five or it’s not that you need levels greater than five but levels greater than five are more efficacious than lower levels.

And so a lot of times what we do clinically or at least what I do clinically is I start people on a diet that they are able to do and if I’m going for a ketogenic diet, I’m going to start them on some version of a ketogenic diet and we’re just going to see what level of ketones they get.

And if they have ketones kind of low-ish like 0.5 or 0.8, something like that, if they’re getting a therapeutic effect that’s significant for them, we might stop there. I’m going to say, hey, it’s working, like who cares?

It’s kind of like when we use a medication. If somebody asks me, well, what dose of this medicine do I need? Well, who knows, like some people need a low dose, some people need a high dose, some people need above the FDA limit dose and so we kind of go with whatever works and with the ketogenic diet, it’s really similar.

And ketogenic dieticians and neurologists and myself will often play with different doses of the diet to achieve different levels of ketones simply looking for a therapeutic effect and trying to figure out do we notice a pattern? Do people need higher levels of ketones or not?

So, it’s a work in progress especially for people treating a mental disorder with especially a mental disorder that potentially has serious ramifications like suicidality or psychosis or intense mood instability. I really, really cannot stress enough how important it is that you work with your mental health professional on that.

So, ketosis itself will not result in weight loss. Again, the two key factors that I’ve found for, so if you’re an adult who is currently overweight or obese and you would like to lose some weight and that’s the only thing you’re looking for is weight loss, you don’t have diabetes, you’re not on hypertensive medications, you’re not on psychiatric medications, your sole purpose is weight loss.

Then I would say the benefits of the ketogenic diet for that group of people are that we have a fair amount of evidence that they will lower levels of insulin resistance and more importantly, the thing that I’m really fascinated with and interested in is it restores the function of brain cells in an area of the brain called the hypothalamus which regulates appetite and feeding behavior.

And when those cells are not functioning properly, people can overeat, and they overeat because they’re hungry a lot and or they don’t get a full signal.

Like most people will feel hungry, they’ll eat something, an appropriate amount of food and then they’ll feel full and they’ll stop, and they’ll say, “No, I’m all set. I don’t want any more. If I eat more, I’m going to get that lethargic, tired feeling and I don’t want that, I’m stuffed, I’m done.”

And if they do overstuff themselves, like the next day when they wake up, they aren’t hungry. They’re not hungry at all. They’re like, “Oh my God, I’m still stuffed from last night. I can’t believe I ate all that and I’m skipping breakfast. I’ll have some coffee or something but I’m just skipping breakfast ‘cause I don’t.” And that’s our brain’s way of regulating our weight.

So, when people become obese, I actually think it’s this brain region problem, that the brain cells stop functioning properly and that’s actually what leads to people becoming overweight or obese because they’re not getting those signals anymore. They’re not getting the normal on/off for hunger and on/off for satiety or feeling full.

And what the ketogenic diet can do for some people and I actually think a lot of people, if not most, is that it can restore the function of those brain cells so that people start to get normal hunger signals and full signals. And then I tell them now you need to pay attention to your brain and if you’re not hungry, you don’t eat. And they’re like, “But I’ve been told to eat three meals a day.”

I’m like, no, if you’re not hungry, your body is trying to get you to a healthy weight now and your brain is actually functioning properly and it knows what a healthy weight is.

And by telling you you’re not hungry even though you haven’t eaten in a while, it recognizes you are stuffed and the brain is actually getting signals from fat cells all of the time and in people who are obese, their fat cells are actually sending out very high levels of hormones that are trying to tell the brain stop eating.

And in essence, the fat cells are screaming at the brain, stop eating, stop eating but the brain isn’t getting the signal, so the person is just sitting there still eating because they’re oblivious to that signal.

So for a lot of people, when they start the ketogenic diet for weight loss, they’ll actually, you know, the first week or two is very difficult and we can talk about that later if we need to but as those brain cells come back online, they’ll actually say, “Oh my God, I feel nauseous. I feel nauseous or I feel stuffed and I haven’t eaten anything.”

And I actually tell them, “Well, that’s because your fat cells are screaming at your brain to stop eating and your brain is now waking up and getting that signal.”

Jenn: So I know keto is something that if you search online, you’re going to get millions of page hits for it, same thing with Atkins, same thing with intermittent fasting, the carnivore diet, the caveman diet, the paleo diet.

There’s a lot of fun, sexy buzz words out there but how far do we go on these and how sustainable are these in the long-term? Do you have any information about how people fare on these types of diets when they try to make it a permanent lifestyle?

Chris: So, it’s a great question. It’s a really important question. So, a lot of people will kind of argue against diets like the ketogenic diet or low carb diet because they say it’s not sustainable so I’m just going to have to disclose my own personal bias.

So, I have pretty much been on a low carbohydrate diet that is sometimes ketogenic, not always ketogenic, for over 23 years now and I started the diet because in my 20s, I had metabolic syndrome which is really young. I have a strong family history of metabolic syndrome and diabetes and cardiovascular disease and all of that.

So, a lot of people look at me now and say, oh, he must come from a good family with good genes and he’s had a good life and that’s why he can maintain a normal weight and it’s like, actually, no.

Jenn: You’re like, oh contraire, I drink heavy cream but thank you.

Chris: Well, and yeah, more importantly, I’m like, oh, contraire, no, my family was loaded with metabolic problems and diabetes and all sorts of problems and I myself had metabolic syndrome in my 20s. And so, it worked for me and I will tell you that it has been easily sustainable.

There are lots of celebrities out there who will talk about it being sustainable for them as well. Rob Lowe is one, he’s been on the Atkins diet for about the same amount of time, 20, 25 years, something like that.

Halle Berry does a ketogenic diet for her type 1 diabetes and swears by it, feels it’s sustainable. Al Roker who lost a lot of weight with bariatric surgery but then gained a lot of it back is an advocate for low carb ketogenic diets. He’s been doing it less time but.

So in the epilepsy literature, there are patients who’ve been on the diet for over 40 years and so when you’re treating a serious health condition, sometimes if you have to choose between doing a diet and seizing every day, the choice isn’t that difficult actually, it’s really not. And so, for some people it’s easy.

We have evidence, I’ve published papers on a woman in North Carolina who had chronic lifelong schizophrenia. She has been on the diet for 13, 14 years now and is still going strong. Lost 150 pounds, has kept it off. And so again, is that sustainable?

Well, yeah, 14 years, 150-pound weight loss. She had full remission of her schizophrenia symptoms. She doesn’t take anti-psychotics anymore. She doesn’t see a mental health professional anymore.

She sees her primary care doc, but she is still on a ketogenic diet after 53 years of being diagnosed with schizophrenia and she was in and out of the hospital. She had a guardian; she no longer has a guardian.

So, is that sustainable? I would say yeah, 14 years, 150 pounds off, keeping it off still, is that sustainable? Sounds sustainable to me.

But of course I’ve dealt with people who can’t last more than four days on a diet and they’re like, “Oh my God, that diet is torture. I hated it, I felt awful. I don’t get it any of my treats or sweet. I don’t get, you know, I can’t do that diet.” Well, obviously it’s not sustainable for that person.

Now maybe it would be if that person got better coaching, better advice but it’s not sustainable for that person. I want to make the clear unequivocal point. This is not limited to low carb or ketogenic diets, this is across the board to every diet, even the Mediterranean diet, even other diets.

We have an obesity epidemic in the United States and throughout the world. We have an epidemic of prediabetes and diabetes.

That strongly suggests the majority of people can’t stick with a quote unquote healthy diet however you want to define it, whether you want to define it as vegan, vegetarian, Mediterranean, low fat, low carb, keto, the majority of these people are not able to stay on a diet that helps them maintain health and that’s a problem.

And so, I’ll stop there with my diatribe, but my quick answer is yes, it is sustainable at least for people for whom it works. And a lot of people feel better if they find a diet that really works for them.

And I’m going to go out, I’m going to say, I know people who swear by the vegan diet or who swear by a vegetarian or plant-based diet or swear by the low fat diet and my opinion to all of them is if your diet is working for you by all means, keep doing it.

Just because I’m advocating for a low carbohydrate or ketogenic diet in my patients doesn’t mean I’m anti-vegetarian or anti-vegan or anti-anything else and in fact, you can do a vegan ketogenic diet, you can do a vegetarian ketogenic diet.

So there are lots of ways to mix and match but if you find a diet that not only addresses health concerns, ‘cause addressing health concerns is never a long-term motivating thing for anybody, it just isn’t.

You have to find a diet that you feel like I can pretty much eat what I want to eat or need to eat and I’m not feeling hungry, I’m not feeling irritable, I’m not feeling deprived. If you’re feeling hungry, irritable, and deprived, often whatever diet you’re doing is probably not going to be sustainable.

So, I would say, you know, with most diets, I would say the first week or so you will feel deprived, hungry, irritable and that’s not the time for you to evaluate. I usually tell people evaluate a dietary intervention after three months.

Give whatever diet you want to do three whole months, white knuckle it, huff it out, try your best, if you fall off the wagon, get back on the wagon, just try your best, do it for three months and then really do an assessment of where am I at?

Is this really sustainable for me? Could I keep this up? ‘Cause at that point, your cravings have gone for most people, cravings have gone away, if you are getting mood or energy improvement, you’ve probably got it by then and then you can make a more informed decision about is this dietary intervention really sustainable for me?

Jenn: It’s also important to recognize that a lot of folks don’t know the value of having a food log, especially if you are trying a new diet because if you don’t think that something that is necessarily working for you, you can go back and look and see, did I eat enough? Did I eat too much? What do I need for my body? And remember that individualism too, right?

Chris: Yeah, I know, so food logs are a mixed bag. So, some people hate them, won’t do them, for them right out of the gate, that’s unsustainable. And so, some people aren’t interested, don’t have the time, don’t have the patience to do a food log and to them, I would say, okay, then don’t. Let’s come up with a dietary plan that you can do without doing a log, but I agree with you.

For people who have the motivation and the wherewithal to do a food log, whatever diet you’re doing, even if you’re just going to do a log for three to five days, it can be so invaluable because it really gives you a sense for how many calories am I actually eating? What are the macros that I’m eating?

And how am I doing? Is this dietary intervention working for me? So, after five days, have I lost any weight, have I gained weight, have I just maintained and how am I feeling? Do I feel like this is sustainable? Do I feel like this is horrible and depriving, and that information can really be helpful.

Jenn: Can you address how to deal with things like dietary modifications for example, adopting the keto diet for individuals who have eating disorders.

Chris: I can say a couple of things but for a person who has an eating disorder, I think I would be less inclined to talk about binge eating disorder which is now the most common eating disorder. I think people with binge eating disorder can easily do something like a low carbohydrate or ketogenic diet with the help of a dietician or with the help of a primary care doc.

I don’t think they need an eating disorder specialist necessarily, but for people who have bulimia nervosa and especially for people who have anorexia nervosa, those are really dangerous eating disorders and they kill people, they can kill people and they are also associated with a lot of very severe and intense mood symptoms.

People with bulimia and anorexia are much more likely to be severely clinically depressed. They’re also more likely to have suicidal thoughts. Sometimes they’re more likely to have self-injurious behaviors so those are all really dangerous.

And so, for that population I would say you need to be working with a mental health professional, number one, who knows something about your eating disorder and can help you manage it. That’s the first and foremost thing.

The second thing that I’d say for that population in particular is it probably would be really helpful to work with a dietician because the dietician will make sure that that person’s getting an adequate amount of calories.

Depending on where in the eating disorder the person is, that person may need to gain weight. If it’s somebody who’s very malnourished and severely underweight, that person might decide to try a ketogenic diet with a clinician or with a team, but they still need to gain weight.

It’s not okay to be 80 pounds if your normal body weight should be 120 pounds, it’s not okay to stay at 80 pounds, you’ve got to gain weight and so in order to do that, you really do need to be working with, you know, in that kind of a severe case, an eating disorder specialist and a dietician.

And if they agree that trying a ketogenetic diet is reasonable then it really needs to be customized at different phases of your illness. So you need one version to rapidly hopefully gain some weight and get some healthy tissue back to your body.

But then once you’ve done that, you don’t want to keep gaining weight, you want to plateau somewhere at a normal, healthy weight and the dietician can help you modify the diet to get to be there and then your eating disorder specialist can work with you on body image and everything else that goes along with that.

Jenn: Can you address dietary recommendations for patients that have bipolar disorder, and what about those who have both bipolar disorder and OCD?

Chris: So, yeah. We have some published case studies of the ketogenic diet being used in bipolar disorder in particular. I’m not aware of many other dietary interventions that have been published to actually show any kind of a significant effect on bipolar disorder or schizophrenia.

And for those who don’t know, one of, you know, we’ve done a lot of research over the last 10, 20 years trying to figure out what’s different about bipolar and schizophrenia and it turns out that there’s actually very little that’s different about them.

And most people now think that those are probably a disorder on the same spectrum and that they certainly represent different symptoms but that they seem to have the same biological hallmarks.

And so, I’m going to talk about this to include people with schizoaffective disorder and also with schizophrenia. And so, we do have case reports, we have one small study of the ketogenic diet being used in bipolar disorder and in schizophrenia, schizoaffective disorder.

And we have some cases, the woman that I mentioned, of complete remission off all meds long-term like, you know, 5 years, 14 years now and that doesn’t happen with Mediterranean diet, it doesn’t happen with the vegan or vegetarian diet, at least not that’s published in the literature.

And so, one of the reasons that I’m particularly interested in the ketogenic diet is because it is an evidence-based treatment for epilepsy. We have a very strong, solid clinical evidence base documenting that it really does stop seizures in a significant number of people who have treatment-resistant epilepsy.

We also have a lot of neuroscience data showing like, what is this doing to the brain? And it’s having powerful, dramatic effects on brain function, we know that with certainty.

Clinically, one of the reasons it’s so interesting and just intuitive and common sense is because we use epilepsy treatments all the time in psychiatry and we use them in particular for bipolar disorder.

So valproic acid, Tegretol, valproic acid is also called Depakote. Depakote, Tegretol and Lamictal are all FDA approved for the treatment of bipolar disorder and they all started as anticonvulsants.

And so, we routinely use anticonvulsant or anti-epilepsy medications in the treatment of psychiatric patients, especially for bipolar disorder and this diet is an evidence-based treatment that stops seizures.

So, if the diet works for seizures and we use all these other seizure treatments in bipolar, it really is just obvious and common sense that we should be thinking about it and considering it for bipolar disorder.

Jenn: “Are you aware of any foods that could help improve serotonin production,” and a follow-up question to that is, “how does an increase in serotonin production to help us physically and mentally?”

Chris: It’s a great question. So, the quick and easy answer is serotonin is derived from an amino acid called tryptophan, and tryptophan it’s in protein so you have to eat protein. If you’re not eating protein, you’re not going to create serotonin.

Serotonin actually gets converted into melatonin which is a sleep hormone that you can buy over the counter nowadays and use it for jet lag or use it if you have insomnia, whatever but our body actually normally has a pathway that goes from tryptophan, which is in protein, to serotonin to melatonin.

Part of that pathway also goes through this really complicated pathway called the kynurenine pathway which involves a lot of complicated molecules and ends up with a molecule called NAD.

Abnormalities in this pathway have actually been implicated in a lot of psychiatric disorders, not just depression, but also bipolar disorders, schizophrenia, Alzheimer’s disease, epilepsy, all sorts of things. And so, we know that abnormalities in that pathway have been highly associated with brain disorders and is the easiest way to say it.

And so, I wouldn’t say you have to be getting at least an adequate amount of protein in order to produce an adequate amount of serotonin.

Most of the serotonin in the human body is actually produced in our gut, not in our brain. 90% of the serotonin in the human body is produced in our gut lining and again, that then leads us down the rabbit hole of, so is it the gut, is it this gut-brain communication that’s actually the bigger role?

So, when we take an SSRI like Prozac or Zoloft or Paxil, those pills actually might be predominantly affecting the serotonin in our gut that is then affecting our brain function.

Researchers have been really highly focused on its effects in the brain but to this day, we still don’t have diagnostic scans that show it. We don’t have a diagnostic test to tell us that somebody has low levels of serotonin or high levels of serotonin, that story is not at all clear.

So a lot of people think of it as a simple story, low serotonin makes people depressed so if you take an SSRI like Prozac or Paxil, that boosts serotonin and that boosts your mood, that’s the way most people think about it. That’s like completely just way, way, way too simplified and almost a joke, honestly, I consider it a joke.

If you really understand human physiology, the way the brain functions, where serotonin is located and if you really look at all of the research that we actually have, it doesn’t at all suggest that that kind of a simplistic way of thinking about it is at all accurate.

Now that’s not to say that SSRIs don’t help people with depression, they do, but again, it might be because they’re affecting your gut, it might be turns out serotonin is not just a neurotransmitter but it also has profound effects on metabolism in the human body and that’s really a particular area of interest of mine.

And so as opposed to seeing it as a neurotransmitter that makes people happy, I see it as a neurotransmitter slash hormone that profoundly affects metabolism.

Jenn: So, do you know if there’s any specific foods, I know you’ve mentioned proteins for serotonin, but any specific foods that would help major depressive disorder?

Chris: No, and I’m really going to say it that way, no. People who are really looking for simple answers like that, I fully understand and appreciate a simple answer and if I had one, I would give it to you. I’m not trying to be mean; I’m not trying to be withholding.

I really wish I had a simple answer. I know that you can go out on the Internet and read all sorts of people with simple answers like that. Eat berries, berries will make you not depressed. Eat some fatty fish, they have omega-3s, that will make you not depressed.

Jenn: So, we all have to live like brown bears is kind of what you’re getting at?

Chris: Exactly, exactly. If only it was that simple, we would have solved our problem. Depression is now the leading cause of disability on the planet, and it’s not because those people aren’t getting treatment, most of the people are getting treatment and our current treatments aren’t working.

So for anyone to suggest that if people eat this one food that that’s going to somehow miraculously prevent them from getting depressed or help them remit from their depression, that is unfortunately really naive.

And I get kind of angry and passionate about it because there are these, I’ll call them charlatans, out there who will say that, eat berries, eat fatty fish and then you shouldn’t be depressed anymore and I’m mad about that because number one, it doesn’t work.

They have no evidence that it works. They don’t even have a case report in the literature to suggest that it works, let alone any more rigorous evidence.

And number two, it serves only to shame and frustrate people who are desperately trying to improve their depression and to tell people that there’s a simple answer like eat more fish and you won’t be depressed anymore is insulting and frustrating and shaming and so I don’t like that kind of simplistic stuff.

Jenn: And it also points blame at the person too, that if it turns out that like, oh, I ate a lot of salmon and I still feel terrible, must be my fault then.

Chris: Yeah or maybe you just want to be depressed, or maybe you’re not trying hard enough, or maybe you didn’t eat enough salmon, eat some more or, like again, the charlatans will just start spinning their wheels.

The charlatans, unfortunately, usually aren’t treating real patients, they’re not working with real human beings who are suffering because for those of us who are actually working with real human beings who are suffering, we are humble enough to acknowledge like here’s what we know, here are some really hopeful things and here’s what we don’t know and here’s the quackery and the crazy stuff.

Jenn: So, the next question I’m going to ask you is something that I think a lot of us can relate to considering there’s a phrase coined the quarantine 15.

“Since the pandemic and loss of so many social connections, I’ve gained over 10 pounds while working remotely and I find that food is the only comfort in my life now. How can I redirect my anxiousness away from food?”

Chris: So great question and I will, for anyone who’s also affected by it, I will expand beyond food because I think there are one or two other really unhelpful coping strategies right now, rates of alcohol use have skyrocketed since the pandemic began, rates of opioid use and opioid overdoses and deaths from opioids have increased significantly, rates of marijuana use are going through the roof.

So, people are using ‘cause it’s legal now and what’s not to love about it and so everybody’s kind of self-medicating and it’s a really... I just kind of railed on people who give simple answers and then kind of, so I want to be careful in the way that I answer this because there are answers, let me start with that.

There are solutions to learn how to cope with whatever you’re going through without resorting to overeating, without resorting to over-drinking or using more marijuana or using more drugs.

But clearly people who are doing those things don’t know what or how and they wouldn’t be doing them otherwise. And so, I think the first step really is the step that you’ve already taken which is recognition that maybe I have a problem, that this isn’t working for me and my health is deteriorating because of my coping strategy. So, I think that’s step number one.

Step number two is to try to find some help and support. So, you came to this webinar, that’s a great step, but you might need more support than what I’m going to be able to offer you in a minute or two in my answer.

So if you don’t currently have help or support and that, so it could be professional help but I don’t mean it has to be professional help, it could just be open up to your spouse, call a friend, call a family member, reach out to somebody and let them know like this pandemic is really getting to me, I can’t take it anymore. I’m so exhausted, I’m so fried, I’m just burned out.

All I do is overeat and I don’t know what to do and see if you can enlist some support from somebody who is having a better time with the pandemic.

Who’s, I don’t mean having a good time but just a little more resilient and has figured out some strategies. So strategies are all over the gamut and you may have tried some of these or all of these already so I don’t mean to imply that if you tried them and they didn’t work, that you need to try them again.

You’ve already tried them, and they don’t work, then you need to figure out, okay, what’s the next step or what’s the next thing to try. Just keep looking for coping strategies, but coping strategies, they run the whole gamut.

So, some of it’s about self-care and self-preservation. So if you’re working more because you’re working remotely and you’re working around the clock and you’re not taking breaks anymore, getting up, going, you know, self-preservation, self-care might be, I’m going to start setting some limits for myself.

I’m burning out. I can’t keep doing this the way I’m doing it. I need some me time, I need some just time to unwind. If you’re not currently walking or exercising or getting out of your house, apartment, whatever, get out, like get away from your dungeon, get away from your prison.

Just, you know, you don’t have to be around other people, necessarily being outside, even in the cold, it’ll wake you up if nothing, it’ll wake you up if nothing else. I’m here in Boston, you might be somewhere else that’s warm and sunny so, but try to get out of your prison. If it’s increasingly feeling like a prison, try to get out at least once a day.

Reach out to people like I said, even if you’re not going to open up about what you’re struggling with, just reach out and connect with other human beings. Watching television isn’t the same thing as engaging with another human being who understands that you are a person, can respond to you, you have to respond to them.

That reciprocal kind of communication with another human being is extraordinarily powerful. It’s built into our brains. We are hardwired to crave that and when we don’t get it, people get a stress response, they feel stressed and then when they feel stressed, they want to overeat or over-drink or overuse recreational drugs to numb that pain.

So, reach out to other human beings if you’re not connecting enough. I’m a huge fan of exercise, the more vigorous, the better but work your way up to whatever your current capacity is. Don’t hurt yourself, don’t injure yourself.

If you have a lot of health conditions, talk to your doctor first but do some kind of exercise. You can go on a screen and you get a class. You can do YouTube. A lot of people are doing Zoom exercise live so that you can have some live interaction as well and that can be anything.

It can be yoga, it can be stretching, it can be aerobics, it can be weightlifting, it can be pushups, calisthenics, like so many options for exercise. You can certainly try stress relaxation techniques, deep breathing, take a warm bath, treat yourself with just a non.

So one thing I’ll definitely say is it’s really critically important that you figure out what can I do to treat myself that isn’t food because a lot of people really see food as the ultimate treat and so when they’ve had a bad day, what do they deserve?

They deserve a treat, they deserve some food, they deserve to relax and unwind and it’s really important that you find some non-food ways to treat yourself but you do have to find something that you would actually enjoy, that will be soothing, that will be relaxing, something.

And if you happen to have a romantic partner, enlist your romantic partner in that, like we’ll give each other back massages when we’ve had a bad day, or we’ll do favors for each other or whatever. And if you support that partner and that partner supports you, that could be huge instead of both of you just feeling burned out. I’ll stop there ‘cause I can go on about that forever.

Jenn: So, we’ve actually received multiple questions about the benefits of vitamins and probiotics, which ones in particular especially vitamins are good for mental wellness.

Some folks want us to know about vitamin D impacting our mental health and at what point does our diet not suffice and when would we need a supplement for probiotics or vitamins? I know that was like half a dozen questions at once, so let me know if you need me to repeat ‘em.

Chris: No, so I’ll take the easiest one first. Probiotics, I personally do not recommend for mental health and the reason I say that is because we have very, very little data, it’s scant data.

There is one study that I’m aware of looking at a specific probiotic that was reported in a small study to help some patients with bipolar disorder but the challenge with probiotics is that the gut microbiome consists of trillions, literally like over a trillion microorganisms.

There are thousands and thousands of different species of bacteria and viruses and fungi and everything else and they all have a little community going and they interact with each other.

And so when you take a probiotic, it usually only has one or two strains of bacteria and again, it comes down to this kind of charlatan-esque simplistic thinking like one bacteria out of all of those trillions is going to be the magic bacteria for you, no.

And again, if there was really a powerful effect from it, we would already know that because millions of people are taking probiotics and we are not seeing dramatic cures across the board in people taking these probiotics.

So I’m particularly kind of anti-probiotic to be honest with you because I’ve had two patients who were actually doing really, really well on a ketogenic diet and both of them independently started a probiotic, it was a different one for each of them and within 24 hours, both of them were kicked out of ketosis and had dramatic worsening of their symptoms.

Both probiotics said they were very low on carbohydrate, so we don’t think that it was the carbohydrates but there’s reason to believe that the effect of the ketogenic diet may actually be its changes on the gut microbiome.

And so, we change the gut microbiome in a really beneficial way, and they were getting benefits from it, and then they went and took a probiotic and threw a wrench in the works. Like we were getting to where we needed to be, they throw a wrench in the works that clearly disrupted that little microbiome community and it had adverse effects for them.

I talked with a ketogenic dietician who saw the same thing in a child who was stable seizure-free for two years on a ketogenic diet. Mom started a probiotic just because she heard that was good for you and within 24 hours, this child had what’s called status epilepticus which is a very dangerous life-threatening prolonged seizure that won’t stop.

So, this kid seized for more than 24 hours in response to a probiotic. So again, at least when I think about ketogenic diet therapy, it is profoundly affecting the gut microbiome.

We don’t know exactly what it’s doing or how it’s doing it but it’s doing something to the gut microbiome that seems to be really beneficial so I usually tell people, please don’t muck with it, like don’t interfere with that process by taking a probiotic.

In terms of vitamins, as a rule of thumb, if people are eating a balanced diet with a lot of different vegetables in particular, they can be very low carb vegetables, but if they’re eating a lot of different vegetables, they’re eating some animal sourced foods, so eggs, meat, eggs and meat in particular, if they’re eating all of those things, as a rule of thumb, I don’t think they probably need a vitamin.

If they aren’t eating all of those things or if they’re just worried, I would say take a multivitamin. Do they need more than that? As far as we can tell, not necessarily. Omega-3 fatty acids have been found to be slightly beneficial for people with all sorts of disorders including mental disorders.

But I’ve talked with other clinicians and most of us have not seen robust miracle cures from omega-3 fatty acids so I would say as long as you’re eating like some kind of fatty fish like maybe once a week like salmon or something like that, you’re probably getting a decent amount of omega-3s.

If you really want to take an omega-3 supplement, I’m certainly not going to tell people not to so go for it. In terms of vitamin D, vitamin D is the new hot vitamin, everybody’s talking about it, it’s going to save us.

I am old enough that I have lived through other hot vitamins before so we had vitamin E for a while, we had vitamin C for a while, we had just antioxidants in general and I lived through periods of time where those hot vitamins were going to save the planet, they were saving the human race, they were going to wipe out all illness and disease.

If everybody just takes vitamin E, we will all be saved. We will be antioxidanted to the max. We won’t get Alzheimer’s disease, we won’t have heart attacks, we won’t be overweight, we won’t have mental illness, everything will be great and none of them panned out.

And in fact, some of them, actually the longer-term larger study showed that some of them were actually toxic to human health. Large doses of vitamin E actually increase mortality overall and so some vitamins in high doses are not good for you.

We do have some preliminary data with vitamin D that, so here’s the conundrum, ‘cause all of that research was based on this observation that people who have all these bad health conditions have low levels of these vitamins and that was the research, that’s what the research showed.

Well, guess what, that’s where we’re at with vitamin D. People have all sorts of bad health conditions or bad health outcomes with COVID for instance have low levels of vitamin D and so everybody assumes, well, let’s take vitamin D and that should solve the problem. Well, we don’t really have data to support that it will solve the problem.

It may very well be that the reason that the levels of vitamin D are low, just like the reason the levels of vitamin E are low in so many people is because the disease processes actually end up using up that vitamin at much higher frequency but taking more of the vitamin actually doesn’t stop the disease process at all.

And in some cases, just one caution that I have to share with people is that if the disease process is using vitamin D for instance, and that’s why people who have all sorts of bad health conditions have low levels of vitamin D, if the disease process needs vitamin D or thrives with vitamin D and it has become deficient, if you give your body more vitamin D, you may actually accelerate your disease process.

That disease process might be more unleashed with more vitamin D ‘cause now you’re not holding it back with low levels of vitamin D.

We don’t know for certain but again, the vitamin E story ends up turning out kind of that way, that’s probably why vitamin E is associated with increased mortality is because it is somehow fueling the disease process even though low levels of it have been associated with the disease process.

So, it’s a really complicated story. At this point, until we get more definitive data with vitamin D, I am not recommending that people take a vitamin D supplement. When it’s nice weather and sunny, I do recommend the people get natural sunlight on their skin.

Natural sunlight on your skin will help your skin naturally produce vitamin D so that’s number one. Natural sunlight on your skin also usually means you’re getting some sunlight in your eyes and that’s actually good for mental health, that’s why we have bright light therapy and other things.

That’s why a lot of people get depressed in the winter, but they’re not depressed in the summer. So being exposed to light is good. Now I know I’m not an advocate for laying out in the sun on the beach without any sunscreen for five hours a day because then you’re going to get skin cancer and you certainly don’t need that much sun exposure.

Jenn: “So if a diet specifically worked for me, how can we inspire our loved ones and friends to become committed to change and feeling the powerful effects of a better lifestyle?”

Chris: It seems like there should be a simple answer for that question, really does and I will be 100% honest with you, there’s not. So I’m going to assume the worst, I’m going to assume the reason that you’re asking that question is because you have a loved one who isn’t seeing the light, you have a loved one who doesn’t want to do the diet.

You have not sold them your Kool-Aid, whatever Kool-Aid you’re on whether it’s low carb, keto, vegan, vegetarian, like I don’t care what it is, whatever epiphany you’ve had for your own health, you now want to spread it around the world and I totally get it. I have a little bit of a case of that myself.

I had my own improvement with a low carb ketogenic diet and that absolutely played a huge role for me in wanting to help other people with this dietary intervention but the reality is that, we all see people in the world that we see struggling or suffering or making poor choices and we all usually have our opinions about what they need to do to fix that.

If that person’s not ready for a change, if that person’s not asking for help, if that person is actively refusing help or easily annoyed by the suggestions that they might need help, it’s going to be hard to help them and it just turns into a bitter argument and resentment and people feel shamed or judged.

So, I would say the first step is to motivate the person to change and that, you know, the quick answer is I’ll refer you to a concept called motivational interviewing if you’re not familiar with it.

There’s a whole body of literature on motivational interviewing and it really is about how do you motivate people to make changes in their lives and the first step is that they have to identify a problem that they want to fix and it has to be on them. You can’t shame them into it. If you try to shame them into it, it probably won’t work.

So if you look at somebody and say, “Oh my God, I used to be like you, I used to be really overweight and lethargic and depressed and I see your like that, you should do this diet because it really worked for me.”

They’re going to feel judged and angry at you for bringing all of that up. So instead I would just talk to them about how’s life? What do you think of this or what do you think of your weight? Or what do you make of your depression? Or what do you make of whatever?

Try to get them aligned, before you jump in with solutions, try to get them aligned with I am depressed and I would really like to do something about it and I would actually be willing to do quite a bit to make it better and that’s where you start.

You have to start there and then you can say, you know, the motivational interviewing philosophy is before you make any recommendation or give any advice, you have to first ask their permission.

Could I share something with you? Could I share a perspective on what you might try? You have to wait for them to say yes. If they look at you and say, “No, I really don’t want to hear it, they’re not ready to hear it.” You have to respect that. If they say yes, that means you’ve really done a good job so far and now they’re open to hearing your advice and then you can share your story.

You can say, “I feel like I used to feel exactly like you, and I couldn’t see any hope, I couldn’t see a way out and I did this diet and it helped. I thought I was just doing it to lose some weight and it ended up having profound effects on my depression and other things and I just can’t help but wonder maybe it could do something for you too and maybe you should give it a try.”

And then you have to work with them and give them hope and give them agency to be able to do the diet. You can’t own it; you can’t say I’m going to do it for you. Soon as you do that, it’s destined to fail, trust me, it’s destined to fail. You have to get them to say, no, my life is worth it. My problem is severe enough or bad enough that I’m willing to fight, I’m willing to do something.

I’m willing to experience some hardship and then you can help them, help them but you really want to empower them. You don’t want to do it for them, you don’t want to preach at them.

They have to be willing to fight for their own health and the sad reality as a psychiatrist is I can tell you that way beyond dietary interventions is I see a lot of people suffering and getting over that hopelessness is really difficult and at the end of the day, the sad conclusion that I came to a long time ago is that that’s their choice.

I’ll keep trying, I will keep trying to persuade them. I’ll keep trying to convince them to change their mind but for now, if they’re digging in their heels refusing the help, there’s probably not a lot I can do, and I think the same goes for family members and other people.

And I’m a big fan of sticking with people, I’m a big fan of staying with them and being a friend, a support, a therapist, whatever and then bringing it up every now and then to see if maybe they’re open to a change later.

So, don’t give up on them. Try not to get too frustrated with them but just understand that the plan’s not going to work if they’re not 100% aligned with it.

Jenn: A lot of times and you know, it’s something I’ve encountered because I work in mental health and a lot of people come to me even though I don’t have a PhD to say, “Hey, I’m having some trouble and I don’t think I can get out of this. I don’t think I can get out of this hole mentally, physically,” and a lot of it is just introducing that behavior of self-efficacy.

You can do it but whenever you’re ready to think that you can do it, that’s when you can get started and introducing that opportunity to people, hey, you’re not ready now, I’m here whenever you are and that’s enough to just leave the door open a crack and that might be enough to get them started too.

Chris: Yeah, no, exactly, exactly.

Jenn: I did want to say thank you so much for talking all things food, diet, mental health, you are just a treasure trove of knowledge and I can’t thank you enough and thanks to everybody who’s joining for watching or listening.

This actually concludes our session. Until next time, be nice to one another, be nice to yourself and eat well. Thank you again, have a great day.

Chris: Thank you all.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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