Changes in diet can be hard and challenging even for people who do not identify as having a mental illness. There are a lot of reasons you may benefit from professional help transitioning to a ketogenic diet and many different kinds of professionals that can help you. Some of these include ketogenic nutritionists, ketogenic dieticians, ketogenic informed mental health counselors, nutritional psychiatrists, functional psychiatrists, or other low carb diet informed prescribers who work in the mental health space.
In this blog post, we will discuss some of the factors you might want to consider if you have a mental illness, and how they inform your decision about whether or not to use a ketogenic diet specialist. And, if you decide that a professional would be helpful, you can read on and learn about the different types of professionals you could work with as you use a ketogenic diet as a treatment for your mental illness.
Reasons you may want a ketogenic diet professional
A lot of people do the ketogenic diet on their own, often to lose weight or to improve their diabetes. They do all kinds of variations on the ketogenic diet with carbohydrate intakes varying from 20g total to 100g total per day. And as long as they are producing at least a little bit of ketones throughout the majority of their day, we call it a ketogenic diet.
Psychiatric symptoms need the right macros
But people using the ketogenic diet for mental illness (or neurological disorders) often need a slightly stricter version, at least in the beginning. Sometimes if we are not careful with the carbohydrate consumption we recommend for someone with mental illness, they may not have levels of ketones at high enough or for a long enough period of time to truly test the diet out as a treatment for their symptoms. We are changing the primary fuel source for the brain. And so it becomes very important to produce enough ketones through dietary fat to keep the brain happy and not exacerbate symptoms because of an energy deficit in the brain.
So if someone goes to any of the many excellent diet coaches out there, they may be told that 50g of total carbs a day is “doing keto” because they are focusing on your weight loss, and perhaps not on the diet it must be used for the treatment of mental illness. They may even recommend you restrict your dietary fat intake prematurely because they are focusing on that weight loss and trying to help you lose weight.
I wouldn’t want you to think you had tried a ketogenic diet to treat your psychiatric symptoms and that it was unsuccessful when all you may have needed was some help to find the right type of ketogenic diet to find relief. The ketogenic diet may not work for you. But it would be a shame to walk away prematurely without the benefit of the customization and support you both need and deserve.
It takes a good three weeks of very consistent therapeutic carbohydrate restriction, in the form of 20g (maybe 30g max), for you to get some idea of whether a ketogenic diet might be helpful for your individual psychiatric symptoms.
Keto and medications are a big deal
Another reason you may want to work directly with a ketogenic diet professional is if you are on psychiatric medications. This is a very important factor in your decision-making and should weigh heavily in your decision about whether to attempt keto on your own or with professional help. Ketogenic diets are such powerful mental health interventions, that your medications may need to be adjusted during the first few days or weeks of the diet. Keto and antidepressants; or keto and other medications for diabetes, blood pressure, and a few others need to be monitored carefully.
Sometimes you need to go down on a few medications simultaneously, and that’s complicated. And sometimes, if you are not working with a professional and you have a worsening of symptoms, you will not have anyone helping you watch out for side effect potentiation and you will give up early, thinking the diet is making you worse. There are some instances when it is in fact your ketogenic dietary therapy creating symptoms and you need some additional supportive bridge medications or supplements to support your healing journey.
So you can see, if you are on psychiatric medications, it is particularly wise to work with a ketogenic professional who is able to modify your medications or work with a prescriber who will, and has experience with the ketogenic diet and psychiatric medications. And if you cannot find a prescriber, you can find a ketogenic mental health professional to coordinate and work with a prescriber with whom you already receive care. This could be a ketogenic dietician or even a ketogenic informed mental health counselor (like me).
Lifestyle change is hard
You may also really benefit from working with a ketogenic informed mental health professional to assist you. They will be able to help you work through any issues that come up while making a big lifestyle change like the ketogenic diet. Sometimes big lifestyle changes bring up feelings of resistance and it can be good psychological work to explore those with someone who knows how to move you through those potential obstacles.
I have written some blog posts about some of the psychological aspects of the lifestyle change involved in ketogenic dietary therapy, and how mental health counseling can help. You can find those here:
If you have decided that it would be helpful to find a ketogenic dietary professional, then read on. I will go through the different types of mental health professionals you may find trained in ketogenic dietary therapies that could help you on your journey to better mental health.
Ketogenic diet professionals
Luckily there are a lot of different types of mental health professionals trained in ketogenic diets that can help you. We will go through and describe each one, and provide resources below that could help you find one to help you on your mental health journey.
Ketogenic nutritionist or dietician
A ketogenic nutritionist is a nutritionist that has been trained to use the ketogenic diet to treat neurological disorders. As you may have read before, the ketogenic diet has been used for over a century to treat epilepsy, and it is now used for diseases like Alzheimer’s disease, Parkinson’s disease, and ALS.
A ketogenic nutritionist may also go by the term ketogenic dietician. Many work in hospital settings, but many provide services outside those institutions. A ketogenic nutritionist or dietician cannot help you adjust your medication, but they can work closely with your prescriber. And they are often very clever at addressing any issues you might have in implementing your new diet (e.g, shopping, meal prep, budgeting). These professionals will be able to give you the correct macros that will ensure you have plenty of brain energy and the nutrient support you need to feel better.
If you choose to work with a nutritionist or a dietician, be sure to clarify with them that you are looking for someone with experience providing help with ketogenic diets specifically. Not all nutritionists and dieticians understand that ketogenic dietary therapy is being used outside of epilepsy treatment for mental illness. Find one that is not going to discourage your use of it because they are not keeping up with the research literature on this topic.
A nutritional psychiatrist is an MD or Licensed Psychiatric Nurse Practitioner, who is able to monitor your medications and adjust them as needed. Some focus on dietary interventions and medication, and others include psychotherapy work with patients. One of my favorite nutritional psychiatrists, Georgia Ede, MD has a great quote:
This is how a nutritional psychiatrist will approach your ketogenic dietary treatment for mental health. There will be some baseline tests run, and there may be supplements, but there will not be a focus on supplements as the mechanism by which you will change your brain chemistry and function.
A functional psychiatrist may or may not be well-trained in the use of ketogenic diets, but many of them are. They may have a focus on tests and supplementation over dietary therapies and you will have to ask them if they are comfortable helping you try one for your mental illness. They work to evaluate and correct what is causing your mental illness and they will likely have some advanced and well-thought-out recommendations for supplementation, both as a primary treatment and to support your ketogenic diet. They are good at ferreting out underlying causes of mental illness that traditional psychiatry does not. Functional tests and supplementation can become expensive, as they are not usually covered by insurance in the US. If you want to explore using a ketogenic diet or just explore options to traditional psychiatry on your mental health journey, a functional psychiatrist is a great potential resource.
Mental Health Counselor
A mental health counselor (or therapist, they are called different things in different places) can be an excellent choice. A keto counselor of sorts!
Full disclosure, this is the kind of ketogenic professional I am (About Me).
A mental health counselor can see you bi-weekly or weekly, which will help you monitor your symptoms and help you overcome any practical or even psychological obstacles you are facing as you attempt a ketogenic diet for your mental health. A mental health counselor can practice both nutritional psychiatry and functional psychiatry (without the medication component; I know, because that’s what I do). They can coordinate your care directly with your prescriber regarding possible needs for medication adjustments and even preliminary medical testing that might be helpful in tracking your progress.
Using a ketogenic informed mental health professional like a mental health counselor or therapist means that you can get evidence-based psychotherapy while you are using your ketogenic dietary therapy for your mental illness. The two are very complimentary. You can read more about how they can work together here. Be sure to find a mental health therapist that understands ketogenic diets. There can be problems finding one that is current in their understanding of the use of ketogenic diets for mental illness. You can read more about why that would be a problem here.
Finding a Ketogenic Professional
Chris Palmer, MD’s website has a directory of ketogenic dieticians here
The Charlie Foundation has a list of ketogenic dieticians here.
Society of Metabolic Health Practitioners Provider Directory is a directory of all kinds of ketogenic informed healthcare practioners. If you want someone who can help with medication adjustment be sure to find someone who is a prescriber, such as an MD, DO, Licensed Physcians Assistant, or Licensed Medical Nurse Practioner. Bonus if you can find one near you or via telehealth that specializes in psychiatric or neurological conditions.
Find a Low-Carb Doctor at DietDoctor.com also is a directory of ketogenic informed healthcare practitioners. Just like the directory above, you will want someone who can either adjust your medications, or help you knowledgably monitor your symptoms with you and help you advocate with your current prescriber as needed.
You can search for a functional psychiatrist in your area or via telehealth at a great organization called Psychiatry Redefined.
If you want to see someone in person, you can type in the search term for what you are looking for and add “near me” next to it into your favorite search engine.
Don’t beccome discouraged if you cannot find someone near you! Lots of independent ketogenic practioners us telehealth. Just type in the search term for the type of professional you are looking for. You will find a variety of great telehealth professionals able to help you meet your goals.
Finding a ketogenic health professional like a nutritional or functional psychiatrist, ketogenic dietician or nutritionist, licensed mental health counselor, or another ally with training in mental health can be really helpful.
I want you to know all the ways you can feel better.
But more importantly, I want you to know that you deserve a higher level of support and encouragement as you try to make big changes to help treat big issues.
How could a ketogenic diet help treat the symptoms of Panic Disorder (PD)?
Ketogenic diets modify at least four of the pathologies we see in panic disorder (PD) and panic attacks. These pathologies include glucose hypometabolism, neurotransmitter imbalances, inflammation, and oxidative stress. A ketogenic diet is a powerful dietary therapy that will directly impact these four underlying mechanisms seen in panic disorder (PD) symptomatology.
In this blog post, I am not going to outline the symptoms or prevalence rates of panic disorder. This post is not designed to be diagnostic or educational in that way. If you have found this blog post, you know what panic disorder is, and likely you or someone you love may already be suffering from it.
If you have found this blog post, you are looking for panic disorder treatment options. You are trying to find ways to feel better and heal.
By the end of this blog post, you will be able to understand some of the underlying mechanisms going wrong in the brains of people suffering from panic disorder and how a ketogenic diet can therapeutically treat each of them.
You will come away seeing a ketogenic diet as a possible panic disorder treatment for your symptoms or as a complementary modality to use with psychotherapy and/or medication.
It is not medical heresy to write the above statement. Why would we not consider using a ketogenic diet in place of psychopharmacology for panic disorder? Medications used for panic disorder include selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Early panic disorder treatment may include benzodiazapenes. After 4 to 6 weeks you could be put on any combination of medications with a stunning array of potential side effects.
In many cases, a significant proportion of those suffering from PD shows little or no response to standard pharmacotherapies, CBT and/or their combination. Many people continue to suffer from residual symptoms that significantly impair functioning.
So why would we not consider alternative ways to treat panic disorder? When the rates of panic disorder treatment success using psychotropic medications with or without Cognitive-Behavioral Therapy (CBT) are so poor? CBT works to also change brain chemistry, all by itself. CBT is definitely an evidence-based treatment for panic disorder (PD). But why would we not consider alternative ways to change our brain chemistry and fix underlying pathological factors, with or without the benefit of psychotherapy?
We are told the only viable, science-based options are the standard of care. If there are no specific Randomized Controlled Trials (RCTs) yet looking at ketogenic diets and panic disorder (PD) in this specific combination, we are told it is not really a treatment option. That somehow, everything we know about how ketogenic diets work, the underlying mechanisms already identified, and the symptom profiles we have identified in panic disorder are completely unrelated logically in the absence of an RCT. And we are to wait for funding of such RCTs to occur in an environment that primarily funds research when there is psychopharm profit to be made.
What if there are people whose panic disorder symptoms are better on medication, but the medication side effects have their own significant burdens? Must they stay with the standard of care? What about those 20% of people who suffer from the terrible symptoms of panic disorder and have not been helped with medications and/or psychotherapy combinations. Shall we tell them they should just “hang in there” until Big Pharma catches up with an RCT they will not be financially motivated to make happen?
I think not.
What are the neurobiological changes seen in Panic Disorder (PD)? Where are possible pathways of intervention?
A previous post went into detail about how a ketogenic diet can modify symptoms of anxiety by affecting four areas of pathology seen in these disorders.
In panic disorder (PD) we see not only some hypometabolism between brain hemispheres but also hyperexcitability suggestive of significant neurotransmitter imbalances. The research also informs us that the panic disordered brain suffers from inflammation and oxidative stress. Let’s review each of these.
Hypometabolism in Panic Disorder (PD)
Actually, yes. We do see hypometabolism occurring in certain brain structures in people with panic disorder (PD).
Abnormal left/right (L/R) hemispheric ratios of regional cerebral glucose metabolic rates (rCMRglc) (hippocampus and inferior prefrontal cortex) have been noted in unmedicated panic disorder patients.
Pay attention to that part about WHERE we see the hypometabolism in panic disordered brains. The hippocampus and the prefrontal cortex.
How does a ketogenic diet treat hypometabolism in panic disorder?
Neurons, oligodendrocytes, and even astrocytes have the ability to take in ketones as a fuel source. This is very important for brains that for whatever reason, are not using glucose well as fuel anymore or are just not able to meet energy demands. When a brain is using ketones as a primary fuel (and yes, there are some parts of the brain that need glucose provided by the liver, but not dietary glucose) it makes that brain more energy efficient. There are fewer steps and less energy needed to utilize ketones for energy than glucose. This helps a hypometabolic brain, one that is not using fuel well, be able to upregulate brain energy.
In humans, both acute and chronic increases in ketone body availability to the central nervous system cause massive changes in cerebral fuel metabolism.
It is interesting to note, and now fairly well-known, that seizure disorders have been treated using the ketogenic diet for decades. The symptoms of panic disorder are so similar to those seen in some seizure disorders that differentiating between the two is of diagnostic importance in the field of neurology. For example, both temporal lobe seizures and panic disorder share the following symptoms:
If a ketogenic diet can be used to treat the symptoms of seizure disorders, why would it not be beneficial in panic disorder, which shares many of the same symptoms? Why wouldn’t we consider it?
Remember the parts of the brain found to have hypometabolism in panic disorder? The hippocampus and the prefrontal cortex.
Ketogenic diets enhance something called mitochondrial biogenesis. Mitochondrial biogenesis means that cells make more of their own batteries and create more energy. Ketones also elevate ratios of substances (phosphocreatine/creatine) that improve hippocampal metabolism.
Ketogenic diets improve symptoms of Alzheimer’s and other neurodegenerative diseases. Neurodegenerative diseases have many areas of the brain that suffer from hypometabolism. One of those very important areas is the prefrontal cortex. If ketogenic diets are used to improve hypometabolism in brain structures such as the prefrontal cortex in neurodegenerative diseases, why are we not using it for panic disorder, which also shows hypometabolism in the prefrontal cortex?
I would argue we absolutely can. And I have seen clients in my practice who have improved significantly using the ketogenic diet for panic disorder treatment, and even more so with the addition of Cognitive-Behavioral Therapy (CBT) in conjunction with ketogenic dietary therapy.
Panic Disorder and Neurotransmitter Imbalances
We actually see over-activation in the right amygdala, left and right insula left inferior frontal operculum, and left inferior frontal gyrus when we attempt to use behavioral extinction (the B in CBT stands for Behavioral) on various anxiety-provoking stimuli compared to healthy controls.
There is strong evidence for the importance of serotonin in the neurobiology of panic disorder (PD). In panic disorder, we see issues with serotonin binding to receptors and studies generally confirm that serotonin is inhibitory of symptoms in panic disorder. There are “functional and clinically relevant alterations in various elements” of the serotonin system that affects the neurocircuitry of panic (Maron, E., Shlik, J., 2006). There are also theories that the functioning of norepinephrine, dopamine and gamma-aminobutyric acid (GABA) neurotransmitter systems play a role in panic disorder symptoms.
In addition to serotonin imbalances, we also see problems in the use of norepinephrine in panic disorder (PD). There is a hypersensitivity in the presynaptic activity of norepinephrine in those with panic disorder (PD) and this is that is believed to be a factor in the expression of PD symptoms. Dopamine plays a role our experience of unconditioned fear responses. While there is not a large literature specific to panic disorder and dopamine neurotransmitter imbalances, we definitely see them in the expression of other anxiety disorders. Both dopamine D1 and D2 receptor mechanisms are important in mediating anxiety and we see a wide distribution of dopaminergic innervation over structures responsible for fear-related circuitry in the brain. Dopamine balance has an important role to play in panic disorder treatment.
How does the ketogenic diet help treat neurotransmitter imbalances in panic disorder (PD)?
We see hyper-excitability! The neurotransmitter balancing effects of a ketogenic diet are all the more important for the panic disordered brain. Reviews of the literature looking at neurotransmitter balancing in animal studies have shown improvements between glutamate (excitatory) and GABA (inhibitory) balances.
Neurotransmitter function was frequently reported in the included studies as a change within the nervous system favouring a reduction or restoration of normal levels of neuronal excitability.
Field, R., Field, T., Pourkazemi, F., & Rooney, K. (2021). doi:10.1017/S0954422421000214
Glutamate has been shown to play a fundamental role in the onset of anxiety-related disorders. While increases in the availability and function of GABA have been shown to decrease panic. For example, your psychiatrist may prescribe you a GABA reuptake inhibitor, hoping to allow the GABA you are making to hang out longer between cells. This increased availability of GABA for longer will be used to hopefully keep your brain from reaching a state of panic (panic attack).
This is well-intentioned but short-sighted. A GABA reuptake inhibitor will not help fix the other ways your brain is not functioning the way a ketogenic diet can. A GABA reuptake inhibitor will not influence brain structure hypometabolism, overall neurotransmitter balance, oxidative stress, and neuronal inflammation. But a ketogenic diet does.
When we look at the effects of the ketogenic diet on dopamine balance and function we see beneficial effects. We know that dopamine plays a role in learned and unlearned fear responses, which are relevant to the symptoms that people with panic disorder endure. A ketogenic diet is shown to influence dopamine receptor activity through its ability to influence the expression of an inhibitory neurotransmitter called adenosine. Issues with dopamine receptors (D1 and D2) are seen in panic disorder (PD) specifically. But luckily, the ketogenic diet exerts what appears to be a beneficial influence on the dopaminergic systems involved in anxiety.
How does improved cell membrane function contribute to improved neurotransmitter balance with the ketogenic diet?
Ketogenic diets improve cell membrane function. As we learned here in a previous post, improved cell membrane function leads to improved sensitivity to neurotransmitters.
It leads to decreased hyperexcitability and improved enzyme reactions. Enzymatic reactions are needed to make neurotransmitters, keep neurotransmitters around the right amount of time, and degrade them appropriately.
Improvements in neuronal cell membranes mean improved neurotransmitter binding to receptors. This matters to people with panic disorder because people with panic disorder (PD) show poor binding of serotonin to receptors. This means their brain cannot use serotonin as effectively as they would if their neuronal membrane health was working properly.
But wait, you say. When I look at the literature you pulled in your reference list, I see that there are genetic predispositions to panic disorder. That some of these issues with serotonin binding are because of my genes!
I need you to understand that ketone bodies turn genes on and off.
Ketones are known signaling bodies able to turn genes on and off, influencing the expression of genes all up and down their pathways of expression. . That’s right. I am not exaggerating in the least. Your genes are not your wellness destiny. There is something called epigenetics, meaning internal and external factors can turn genes on and off. Ketogenic diets have been shown to modulate genes for neurotransmitter production and function and synaptic transmission in a very beneficial way.
Ketogenic diets are also seen to upregulate serotonin and balance levels of other neurotransmitters like GABA, glutamate, norepinephrine, and dopamine. And not in a way that can make too much of any given one of these, and then give you weird side effects. Ketogenic diets help your brain make just the right amount of neurotransmitters and allow your brain to use them well.
There are no side effects when a ketogenic diet balances your neurotransmitters and improves your neuronal functioning. Medications often come with side effects that are bothersome or challenge long-term health and then lose efficacy over time. For this reason alone, ketogenic diets should be considered a favored or even preferred treatment for panic disorder and other psychiatric and neurological conditions.
Panic Disorder and Oxidative Stress
Oxidative stress is the impairment of cell membrane functions due to insufficient antioxidant capabilities to deal with free radical damage. Those with panic disorder have been found to have higher oxidative stress levels than normal controls, with the highest levels of oxidative stress seen in those who have panic disorder with agoraphobia. Disease severity in panic disorder is positively correlated with serum levels of markers showing higher oxidative stress.
We do not know the extent to which oxidative stress contributes to specific clinical symptomatology of psychiatric disorders, let alone specifically panic disorder. The causal role of oxidative stress in anxiety disorders is still being figured out. Finding out the causal role will be important for early treatment and target for preventative intervention.
But if you have panic disorder we know you have higher markers of oxidative stress. And even higher markers of oxidative stress if you suffer from panic disorder with agoraphobia. Is it too late to target oxidative stress for intervention? Absolutely not.
Ketogenic diets and oxidative stress
Remember how in prior sections of this blog we discussed how ketone bodies were signaling molecules? That ketones are able to turn some genes off and some genes off in a variety of cellular functions? Well, that is a big part of how ketogenic diets help reduce oxidative stress. One ketone body, in particular, β-hydroxybutyrate (BHB) upregulates antioxidant defenses to combat inflammation and free radicals.
β-hydroxybutyrate functions as a stress response molecule and orchestrates an antioxidant defense program to maintain redox homeostasis in response to environmental and metabolic challenges
So what can the ketone body BHB do for the oxidative stress of panic disorder? Perhaps a better question is what can’t these little ketone bodies do when it comes to upregulating our antioxidant capabilities.
BHB works to protect your brain against oxidative stress through direct and indirect mechanisms such as:
being an antioxidant for hydroxyl radicals
suppresses mitochondrial reactive oxygen species (ROS)
activates SEVERAL antioxidant programs through different gene expressions
For those that want to nerd out on these direct and indirect mechanisms, there is a great article here.
Inflammation and Panic Disorder
Chronic inflammatory markers are seen in those with panic disorder. Chronic inflammation is like a slow burning fire, pumping out various inflammatory substances that do cellular damage and affect cell function. These substances are often referred to as inflammatory cytokines. Inflammatory cytokines are found to be so consistent in those with panic disorder, that there are suggestion that they be investigated as a potential causal factor.
Systemic inflammation can access the brain, and enhance pro-inflammatory cytokine levels that have been shown to precipitate direct and indirect neurotoxic effects.
Untreated chronic inflammation ages the brain and causes negative changes in brain structure, function, and connectivity of prefrontal and limbic structures. Prescriptions of SSRI’s have some mild anti-inflammatory properties, but in severe panic disorder where we see higher levels of inflammation, a case could be made that the effects are insufficient.
Ketogenic diets for Inflammation
Ketogenic diets as a treatment for panic disorder could be beneficial because ketones offer anti-inflammatory and neuroprotective properties. It is almost as if our bodies planned for ketones to come to the rescue. Our neuroinflammatory cells already come with receptors (HCA2) to take in the completely endogenous (your body makes it) neuroprotective ketone body β-hydroxybutyrate (BHB)!
Ketone bodies act as signaling molecules that inhibit inflammation pathways, turning genes on and off along the way to accomplish this aim.
Ketogenic diets also help treat inflammation by improving metabolic health. The elimination of refined carbohydrates and reduction in carbohydrate intake overall leads to less metabolic stress on the body by treating hyperglycemia (high blood sugar) and hyperinsulinemia (insulin chronically high and causing cells to not burn glucose properly). Metabolic disorders can occur in people who do not yet have a Type II Diabetes diagnosis from their doctor. You can be thin and have a metabolic disorder. Ketogenic diets keep you metabolically healthy, which reduces your risk of increased oxidative stress.
The ketogenic diet is an effective intervention to treat glucose hypometabolism, neurotransmitter imbalances, oxidative stress, and neuroinflammation. These are all pathological states we see present in panic disorder (PD). People suffering from panic disorder should be given the option of a ketogenic diet as a primary or complementary treatment protocol that can include medication and/or psychotherapy as the client so chooses.
While the standard of care should always be offered to you, as someone who suffers from panic disorder, it is important for you to know other options that are also evidence-based. So you can make informed decisions regarding their care.
You have a right to know all the different ways you can feel better.
The ketogenic diet is one of them. And it is important to me that someone communicates that to you so you can make informed decisions about your treatment.
I want to encourage you to learn more about your treatment options from any of the following blog posts. I write about different mechanisms in varying degrees of detail that you may find helpful to learn on your wellness journey. You may enjoy the Ketogenic Case Studies page to learn how others have used the ketogenic diet to treat mental illness in my practice. And you may benefit from understanding how working with a mental health counselor while transitioning to a ketogenic diet can be helpful here.
Share this blog post or others with friends and family suffering from mental illness. Let people know there is hope.
You can learn more about me here. If you would like to contact me you may do so here. If you just have a simple question please do not hesitate to reach out. I am excited at the potential of you feeling well!
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