American’s are underslept. I knew this before I read Why We Sleep by Matthew Walker, Phd but I didn’t fully grasp the health implications. Dr. Walker opened my eyes to the staggering statistics regarding sleep in our country and how insufficient sleep increases our risk for a whole host of health concerns. 

An excerpt from Dr. Walker’s book reads “Scientists have discovered a revolutionary new treatment that makes you live longer. It enhances your memory and makes you more creative. It makes you look more attractive. It keeps you slim and lowers food cravings. It protects you from cancer and dementia. It wards off colds and the flu. It lowers your risk of heart attacks, stroke, not to mention diabetes. You’ll even feel happier, less depressed and less anxious. Are you interested?” The evidence to back up these claims has been well documented. You just need adequate sleep. 

Unfortunately, 1 in 3 US adults fail to achieve the absolute minimum of 7 hours of sleep per night. 

Insufficient sleep impacts all the major physiological systems of the body, this includes our cardiovascular, immune, reproductive, and metabolic systems. Lack of sleep increases our risk for cancer, cardiovascular disease, diabetes, and dementia. Insufficient sleep also shortens our lifespan.  

I screen every patient for sleep quality and length. In my experience, many patients dismiss lack of sleep as a possible root cause of disease, they want to talk about "more important" things such as changing their diet. I am here to tell you, sleep is just as important (likely more so!) than what you eat. I am often debunking common misconceptions about sleep. Some think they can just ‘make it up’ on the weekends (spoiler, you can’t!). Others feel they function "great" on less than 7 hours of sleep. We even have a new term ‘revenge bedtime procrastination' because so many of us are staying up late looking for a little downtime in our busy schedules and missing out on critical sleep time. 

Sleep is the fundamental need for our bodies that all other aspects of our health are built on. If you read this far and you still think that you can skimp on sleep and remain unscathed I urge you to read or listen to Dr. Walker’s book. It was eye opening. 

I think one reason patients can be convinced that their lack of sleep isn’t impacting them is that their baseline of health has shifted and they don’t realize it. Dr. Walker wrote “With chronic sleep restriction over months or years, an individual will actually acclimate to their impaired performance, lower alertness and reduced energy levels. That low-level exhaustion becomes their accepted norm, or baseline. Individuals fail to recognize how their perennial state of sleep deficiency has come to compromise their mental aptitude and physical vitality, including the slow accumulation of ill health.” In other words you don’t realize how good you could feel with adequate sleep. 

With the advent of wearable technology, we have a whole new way of gathering data about ourselves. It’s been interesting for me to look at my sleep data overlaid with my stress levels (I picked my tracker particularly for the HRV data). I can absolutely see a correlation with nights that I sleep poorly and elevated levels of stress. I am a sucker for data but you don’t need a sleep tracker to optimize your sleep. Dr. Stamer wrote a great article with some tips for getting a good nights sleep. You can read that article here. 


Having read a small summary about how sleep deprivation can be a root cause of your illness I hope it empowers you to take a closer look at your sleep and make sleep a priority. 





References:

1. Matthew Walker, PhD (2017) Why We Sleep Unlocking the Power of Sleep and Dreams
2. CDC article “1 in 3 adults don’t get enough sleep” Accessed 11/13/2021 https://www.cdc.gov/media/releases/2016/p0215-enough-sleep.html 

Warm baths are actually good for your health.

That’s right, a simple soak in warm to hot water actually has proven health benefits. These benefits include improving blood circulation, relaxing muscles, improving sleep quality, and reducing stress. 

When I prescribe baths for my patients I recommend adding 2 cups of Epsom salts to the tub.  Epsom salts are a particular type of salt mined from a spring in England. Epsom salt breaks down to magnesium and sulfate in water. Historically, epsom salts have been used for a laundry list of ailments from sore muscles to enhanced detoxification. Epsom salt baths are another traditional therapy that we don’t have the science to back up (yet!).

Anecdotally, adding Epsom salt to baths appears to increase the therapeutic benefit of a bath. I’ve heard all sorts of theories about how Epsom salt improves our health. There is one myth I want to dispel. Some folks are under the impression that the Epsom salt in a bath can somehow pull toxins from our tissues into the bath water. Not only is there no evidence to support this, it’s biologically improbable. What I suspect is happening is that we are absorbing some of the magnesium and sulfate in the water. This theory is also unproven but a small report in 2014 did show a modest increase in sulfate and magnesium in the blood after an Epsom salt bath. Magnesium is necessary for over 300 biochemical reactions in our body. We don’t know exactly how the magnesium moves from the water across our skin and into our tissues but that’s the main theory behind the additional benefit of adding Epsom salt to the bath water. 

When I recommend Epsom salt baths I instruct patients to add 2 cups of salt to the bathtub, allow the salt to dissolve (4 minutes or so) and then soak for 20-30 minutes. I encourage patients to take an Epsom salt bath 2-3x per week in the evening. 

I recommend Epsom salt baths to patients regularly for a variety of reasons:

• Forces folks to slow down and relax even if it’s just 20 minutes
• The warm bath will likely improve their sleep quality that night
• It may increase their tissue levels of magnesium
• Soothes sore muscles and joints
• Likely improves gentle detoxification via increased magnesium 

Some reasons to be cautious or skip Epsom salt baths:

• Low blood pressure, high blood pressure, POTS, or orthostatic hypotension: warm baths relax your blood vessels and increase your heart rate both of which can cause changes to your blood pressure. If you have any of these conditions be cautious getting out of the tub and make sure someone is nearby to help you in case you feel faint. I also recommend just a warm bath instead of a hot bath in these cases. 
• Sulfate allergy: the sulfate in the water could cause hives

In summary, Epsom salts are a low cost and safe addition to a therapeutic warm bath. 



References: 

1. Hoekstra, S. P., Bishop, N. C., Faulkner, S. H., Bailey, S. J., & Leicht, C. A. (2018). Acute and chronic effects of hot water immersion on inflammation and metabolism in sedentary, overweight adults. Journal of applied physiology (Bethesda, Md. : 1985), 125(6), 2008–2018
2. http://www.epsomsaltcouncil.org/wp-content/uploads/2015/10/report_on_absorption_of_magnesium_sulfate.pdf
3. https://www.epsomsaltcouncil.org/faq/
4. https://health.clevelandclinic.org/reasons-to-take-a-bath/​

This is a follow up to my recent blog post on alcohol titled, "Are You Drinking Too Much?" That article prompted some interesting conversations with patients. Many folks use alcohol in the evenings as a way to ‘unwind’ after a long day. With so many of us working from home, pouring an alcoholic beverage can be that ritual that signals the work day is over. Ritual is important and having a ritual of crafting a beverage for yourself at the end of the day is lovely. I found myself helping patients concoct an alcohol-free version of a drink that helps them relax without the negative impact of alcohol. I am going to share some ideas with you below - happy (alcohol-free) drinking!

My relaxing beverage changes with the seasons. Something warm is soothing in the colder winter months but I love a sparkling and refreshing mocktail in the summertime. 

My go-to in the winter time is warm tea. There are so many fantastic relaxing herbs to choose from. I will list a few of my favorites that I like to drink alone or blended together:

• Tulsi 
• Ashwagandha
• Chamomile
• Lemon balm
• Passionflower

Don’t forget you can mix tea bags together. I often add a bag of hibiscus tea to improve the flavor of whatever herbal tea I’m drinking. Also consider buying combination blends. 

If you want to increase the relaxation power of your tea consider adding some L-theanine powder and/or magnesium powder. 

L-theanine is an extract from green tea that increases alpha waves. This means that L-theanine helps you feel relaxed without causing drowsiness. You could try using a decaffeinated green tea or you can open a capsule of L-theanine and dump the powder into your beverage. I recommend using 100-200mg of L-theanine. 

Magnesium is a mineral that has a calming effect. I personally use ‘Natural Calm Powder’ aka magnesium citrate powder regularly in an evening beverage to help me relax after a long day. You can pick up an unflavored magnesium powder so it’s easy to add to a warm beverage or a ‘mocktail.’ Note: magnesium may cause loose stools in large quantities so be careful with your dosing and start with 100-300mg. 

If tea isn’t for you, try Golden Milk, a lovely blend of warm milk, honey and spices. 

Use relaxing herbs to boost your mocktail. In the warmer months I enjoy putting together a ‘mocktail.’ I keep tinctures of chamomile, lemon balm, passionflower, valerian, and kava kava* on hand. My favorite way to make a refreshing mocktail is to mix some sparkling water (flavored or unflavored) with some tart juice and add a few droppers of a tincture. A tincture is a concentrated herbal extract in alcohol. You will get about ½ tsp of alcohol using this recipe so please skip this if you struggle with alcohol addiction. I listed the tinctures above in order of ‘strength’ for their ability to help you relax. The tincture also adds a little bite and helps it taste like an actual cocktail. Consider using tart cherry juice in your mocktail. Tart cherry has been shown to boost melatonin levels.

Since we want to lean into the power of a ritual, use a fun glass! If there is something about holding a wine glass that really helps you shift into ‘home mode' then use a wine glass for your new beverage of choice. 

What helps you unwind at the end of the day?



*Caution with Kava kava root. Please do not combine with alcohol and don’t use this tincture daily. It can damage your liver (just like alcohol!) if you use it daily for longer than 3 months. 

We are heading into my favorite season, Fall! It’s the time of the year I like to spend hours at a time outdoors. Being in nature feels good for my body, mind and spirit and science backs up that feeling. I have heard nature referred to as ‘Vitamin N’ and I love it! A vitamin is defined as an organic substance that is essential to the nutrition of most animals. While time in nature isn’t really essential for nutrition, in my opinion it is essential for optimal human function. 

Spending time in nature has physical benefits including a reduced heart rate, muscle tension, and blood pressure as well as a reduction in stress hormones. That’s not all, researchers at Tokyo’s Nippon Medical School found an increase in the white blood cells that fight viruses and cancer in women who spent 6 hours in the woods over the course of a two-day period. The increase in white blood cells lasted at least 7 days after their nature exposure. 

Spending time in nature improves mood. We move from depressed, stressed and anxious to more calm and balanced. This is the main reason I turn to nature. In our overstimulating world nature offers a sense of calm that is incredibly grounding and so needed.  
 
‘Forest bathing’ or Shinrin-yoku was developed in Japan in the 1980’s and has become a cornerstone in Japanese medicine. The concept is simply to visit a natural area and walk in a relaxed way to enjoy health benefits. The proven benefits are long and include a bolstered immune system, improved recovery from surgery, improved sleep and reduced stress.

I am often prescribing vitamin N to my patients and it doesn’t have to be a large dose. The Shinrin-yoku research has found that the sweet spot is 2 hours per week which is roughly 20 minutes per day. 
 
A 2015 study published in the International Journal of Environmental Research and Public Health  found that even looking at pictures of green space for 5 minutes increased parasympathetic activity (calm) after a stressful event. It’s pretty incredible that even pictures of nature can reduce your stress. If you can’t get yourself outside more often, consider adding nature images to your home and workplace.

Ideas to increase your dose of vitamin nature:

• Take a less urban route when driving.
• Eat your lunch outside
• Go for a walk around the block
• Read in the grass
• Walk on a less urban street or make a point to walk near or in a park.
• Find windows in your home or office that overlook nature and make a point to look outside and appreciate what you see.
• In the wintertime if you are cold sensitive, spend time in a conservatory such as Como Park in St. Paul.
• Get physical outside, make a point to run outside vs on a treadmill
• Put a bird feeder outside a window that is easily visible and make a point to appreciate the animals that stop by.
• Add plants to your home and office.
• Garden! Consider a community garden if you don’t have a yard.
• Make sure you have natural light entering your home.

References

1. Li Q, Morimoto K, Kobayashi M, et al. A forest bathing trip increases human natural killer activity and expression of anti-cancer proteins in female subjects. J Biol Regul Homeost Agents. 2008;22(1):45-55
2.  Pearson DG, Craig T. The great outdoors? Exploring the mental health benefits of natural environments. Frontiers in Psychology. 2014;5:1178. doi:10.3389/fpsyg.2014.01178.
3. van den Berg MM, Maas J, Muller R, et al. Autonomic Nervous System Responses to Viewing Green and Built Settings: Differentiating Between Sympathetic and Parasympathetic Activity. Int J Environ Res Public Health. 2015;12(12):15860-15874. Published 2015 Dec 14. doi:10.3390/ijerph121215026

Are you drinking too much? I know I’ve asked myself this question more than once during the pandemic. Like most Americans, during the pandemic my drinking dramatically increased. It’s so easy to unwind at the end of a long day with a glass (or two!) of wine. Once you start this cycle it’s hard to break free. Before I jump into the data, I invite you to check in with yourself. Has your drinking increased during the pandemic? How does it feel in your body? How are you sleeping? Is your energy level where you want it to be? When you think about cutting back on your consumption do you feel resistance? If you are feeling resistance try to meet that with some compassionate curiosity and see what you find. 

If you want more on this topic and you don’t want to continue reading check out this link to watch a Curiosity Corner where Jesse Haas and I discussed the documentary, "The Truth About Alcohol."

Alcohol use is so pervasive in our culture that it’s considered normal and safe. Unfortunately, alcohol is not a benign substance. In fact, it’s a known carcinogen. The UK spent 3.5 years reviewing all of the literature on alcohol and health and in 2016 overhauled its alcohol guidelines. The new guidelines are 14 units per week. To put that into context; a glass of red wine can be between 2-3 units depending on the strength of the wine and the size of the glass. For beer, a pint is typically between 1.5-2 units. So if you are drinking one or more alcoholic beverages per day you may be exceeding these guidelines. The UK also recommends 14 units or less regardless of your gender.

The main reason the UK took such a hard stance on alcohol was the research proving that alcohol is a potent carcinogen. Folks that regularly consume alcohol increase their risk of developing a wide range of cancers. Cancer is concerning but honestly, the cancer risk isn’t what really convinced me to reduce my consumption. How damaging alcohol is on our sleep is what did it for me. I don’t know about you but I have been so tired throughout the pandemic. The increase in daily stress and workload is a lot for us to carry. So when I started listening to Dr. Matthew Walker’s book, Why We Sleep, and learned about the relationship between alcohol and poor sleep I took action. Even 1 alcoholic beverage consumed hours before bed inhibits your ability to achieve REM sleep. Walker jokes that if you want to consume alcohol and still sleep well you have to start drinking with your morning coffee (please don’t try that). He goes on to discuss the shocking impact alcohol has on memory. I have heard from so many patients about memory trouble in the past year. Of course, the stress we are under will negatively impact memory but I wonder if alcohol consumption is playing a part for some folks as well. 

You might be thinking, but a little red wine every day is good for me, right? Well, the only demographic that benefits from alcohol consumption are folks with ovaries who are 50+ years old and consume 2-3 glasses of wine per week. That’s it. So unless you fit in that demographic, the red wine you are drinking is likely not helping your heart. Alcohol contributes to leaky gut, depletes nutrients, and it weakens our immune system. 

I know, I know I really shouldn’t be coming for your alcohol. It’s been a hard year. You feel that you need that wine or beer at night. I hear you. It’s been a very hard year. Most of us are exhausted and completely drained. It’s time to be honest, the alcohol is not helping. 

What if you start with one day per week that you skip the alcohol and slowly increase to more days during the week? Can you find something truly nurturing to replace it with? An epsom salt bath? Hot tea? A stroll after dinner? A chat with a friend? Some people are better with abstention vs moderation. If that’s you then try a month without alcohol and see how your health changes. I know it's difficult but I think it's worth exploring the impact alcohol is having on your health and wellbeing. 

I regularly read through recent literature on autoimmune thyroid disease/Hashimoto's. I post about each of these studies on instagram as I review them and put it all together on this blog twice per year. 

You can use the categories located to the right of this post and click 'Hashimoto's Research Update' to see all of the updates. ​

Vitamin D Treatment in Patients with Hashimoto's Thyroiditis May Decrease the Development of Hypothyroidism (2016)

What if you have elevated thyroid antibodies but your TSH isn’t elevated yet, ie it’s Hashimoto’s Thyroiditis (HT) but not yet progressed to hypothyroidism? Conventionally patients are often told to just watch and wait. Wait until it turns into hypothyroidism, then you can take medication. 

This study published in 2016 demonstrated that supplementing with vitamin D actually reduced thyroid antibodies and prevented the progression of HT into hypothyroidism. So there is something you can do instead of just watch and wait. 


One limitation of this study is that it was performed in Turkey, a country with notoriously low vitamin D levels. The average vitamin D level in patients with HT entering the study was 9 and the control group average was 12! During the study all of the groups raised their vitamin D blood levels to around 50. So it’s important to test your vitamin D levels. If you are already around 50/60 you likely wouldn’t benefit from additional vitamin D supplementation. 


The Composition of Gut Microbiota in Patients Bearing Hashimoto's Thyroiditis with Euthyroidism and Hypothyroidism (2020) 

This study compared the gut microbiome between three groups; normal controls, people with Hashimoto’s but normal thyroid function (HT), and people with Hashimoto’s and hypothyroidism (HTH). This study consisted of 97 people all from a particular region in China. The researchers found that the richness of diversity in the gut microbiome was significantly lower in HT patients than in the control group. The patients with HTH had the least microbial abundance. Our gut microbiome plays a vital role in our immune system so it makes sense that shifts in the microbiome could be playing a role in autoimmune diseases. Something else to consider is that thyroid hormones also influence the function of our GI, especially motility. It’s possible the change in diversity from HT to HTH could be partly due to the influence of low thyroid hormone on GI function. 

This research further confirms why it’s so important to nurture a healthy gut microbiome. 


Psychological Wellbeing in Hashimoto’s (2017) 

The main finding of this study is that health related quality of life is impaired in euthyroid Hashimoto’s patients. Let’s break this down a bit. Euthyroid Hashimoto’s Thyroiditis (HT) is when a patient has thyroid antibodies and/or Hashimoto’s specific abnormalities on thyroid ultrasound but a normal TSH. This study evaluated the quality of life for HT’s patients and found that HT’s patients had lower quality of life regarding physical functioning, general health and mental health. Specifically this study found that patients with euthyroid HT had increased levels of both anxiety and depression. Interestingly, this study included a group of euthyroid HT patients that were taking levothyroxine and a group not taking any medication. There were no differences between these two groups in terms of depression, anxiety or quality of life scores. So medication did not improve these symptoms. 

My patients are consistently told by endocrinologists if they are on medication and their TSH is normal then their symptoms are not from Hashimoto’s. Not true. Evidence is mounting that there are deeper mechanisms here. 

Another nugget from this paper that I have to directly quote, it’s so good! “TSH levels were slightly higher in HT group than control group although all the participants were in euthyroid state in our study. Higher TSH levels were also found in previous studies comparing euthyroid HT and control subjects. These findings might suggest that slightly higher TSH even in the normal range might be related with impairment in psychological well-being in patients with euthyroid HT.” One more time for the folks in the back! HT patients have been fighting to be heard around this issue for such a long time. It’s time to reevaluate the ‘normal’ range for TSH especially in HT patients.  


Effect of Low Carbohydrate Diet in Autoimmune Thyroiditis (2016) 

The title is misleading because they changed a lot more about the diet than just carbohydrate content. The authors removed several common food intolerances (dairy, eggs and gluten) in addition to implementing a low carbohydrate diet. 

Here’s the breakdown: 180 total participants 84 males and 96 females aged 30-45 years. All subjects tested negative for celiac disease (in truth the specific language they use is “all subjects did not present celiac disease” so I am uncertain if they actually tested them or not).

The experimental diet was followed for 3 weeks and included aiming for macro’s of carbs 12-15%, proteins 50-60%, and lipids 25-30%. Foods excluded: goitrogenic foods (unlisted specifically what these were), eggs, legumes, dairy, bread, pasta, fruits and rice. Control group followed a low calorie diet without restrictions on types of food to consume. 

The author referenced goitrogenic foods repeatedly as part of the dietary exclusion but in the materials and methods section these foods were not specifically listed. In the introduction the author discusses goitrogenic foods and states “These substances (known as goitrogens) are found especially in products of the cruciferous (Brassicaceae) family (rape seed or canola, cabbage, turnip, watercress, arugula, radish, horseradish) and in milk produced by cattle nourished with these vegetables. Other goitrogens include soy, spinach, millet, tapioca, and lettuce. Even certain food additives, ie, nitrates used for fish and meat preservation, prevent iodine uptake by the thyroid gland.” So it’s unclear which foods were actually excluded in the experimental group. What is clear is this is not a simple low carb diet analysis. 

The author also put a heavy emphasis on goitrogens and Hashimoto’s. I haven’t seen goitrogen’s make much of a difference clinically with Hashimoto’s patients. Check out this article written by Dr. Alan Christianson for a much deeper dive into goitrogens and Hashimoto’s.  

Bottom line: don’t switch your diet just yet, we need more research on nutrition and Hashimoto’s. This study used too many dietary variables and was very short in duration. 

Oxidative Stress and Hashimoto’s (2014) 

This study is straightforward. The investigators compared biomarkers in people with euthyroid autoimmune thyroiditis (read: Hashimoto’s disease but normal levels of TSH, FT3, and FT4) and people without any thyroid disease. It was a small study with only 70 participants. I appreciate that they looked at a diverse set of biomarkers to assess oxidative stress including oxidized LDL. They controlled for variables that could impact oxidative status such as age, BMI, and fasting glucose. It is not surprising that folks with Hashimoto’s had a decrease in antioxidants and an increase in oxidants vs controls. We have a delicate balance of free radicals (oxidative stress) and antioxidants keeping our bodies healthy. If the scales tip and we are under higher levels of oxidative stress a whole host of disease can occur. Excessive levels of oxidative stress is considered one of the factors underlying the autoimmune response. 

Bottomline: Folks with Hashimoto’s have lower levels of antioxidants and higher oxidative stress. It’s important to consume a diet rich in antioxidants. 





​References: 

1. Ucan B, Sahin M, Sayki Arslan M, Colak Bozkurt N, Kizilgul M, Güngünes A, Cakal E, Ozbek M. Vitamin D Treatment in Patients with Hashimoto's Thyroiditis may Decrease the Development of Hypothyroidism. Int J Vitam Nutr Res. 2016 Feb;86(1-2):9-17. doi: 10.1024/0300-9831/a000269. Epub 2017 Jul 12. PMID: 28697689.
2. Liu S, An Y, Cao B, Sun R, Ke J, Zhao D. The Composition of Gut Microbiota in Patients Bearing Hashimoto's Thyroiditis with Euthyroidism and Hypothyroidism. Int J Endocrinol. 2020 Nov 10;2020:5036959. doi: 10.1155/2020/5036959. PMID: 33224194; PMCID: PMC7673947.
3. Muhittin Yalcin M, Eroglu Altoniova A, Cavnar B, Bolayir B, Akturk M, Arslan E, Ozkan C, Cakir N, Balos Toruner F. Is thyroid autoimmunity itself associated with psychological well-being in euthyroid Hashimoto’s thyroiditis? Endocrine Journal. 2017, 64(4), 425-429
4. Esposito T, Lobaccaro JM, Esposito MG, Monda V, Messina A, Paolisso G, Varriale B, Monda M, Messina G. Effects of low-carbohydrate diet therapy in overweight subjects with autoimmune thyroiditis: possible synergism with ChREBP. Drug Des Devel Ther. 2016 Sep 14;10:2939-2946. doi: 10.2147/DDDT.S106440. PMID: 27695291; PMCID: PMC5028075.
5. Baser, H., Can, U., Baser, S. et al. Assessment of oxidative status and its association with thyroid autoantibodies in patients with euthyroid autoimmune thyroiditis. Endocrine 48, 916–923 (2015). https://doi.org/10.1007/s12020-014-0399-3

The balance between our hypothalamus, pituitary and adrenals (HPA axis) is tightly linked to our health and well being. Many of us live in a hypervigilant state with a chronically activated sympathetic nervous system. An overactive stress response can lead to elevated cortisol, insulin, inflammation, and even autoimmune disease. It’s a complicated connection and it continues to show up in my clinical practice. Just talking about "stress" with patients isn’t enough and it’s not getting to the core issues that throw our body out of balance. In my never-ending desire to understand autoimmune disease I continue to read and learn more about psychoneuroimmunology, the relationship between immunity, the endocrine system, and the central and peripheral nervous systems. A few months ago I came across the concept of "overfunctioning" and it highlights a phenomena I recognize in patients (and myself!) but didn’t have language for. As I read more about overfunctioning I realized it’s a fast track to burnout. Overfunctioning is doing more than is necessary, appropriate and healthy in our lives and relationships. This article in Psychology Today provides a laundry list of behaviors that may indicate a pattern of overfunctioning. I picked a few to share with you: 

• Worrying about other people’s responsibilities.
• Taking over a group project that is coming together slowly.
• Trying to convince someone that your thinking is right.
• Furiously completing tasks for others when you feel bored, anxious, or distressed.
• Updating your friends and family about people they could contact themselves.
• Reminding your spouse or partner to call their family.
• Taking on a task at work because teaching another staff member will be frustrating.
• Doing something for your child that they can do, so it will create less of a mess.
• Giving advice to a distressed friend who hasn’t asked for any.

Dr. Sara Gotfried explains overfunctioning as:

• Doing things for others that they can do for themselves
• Absorbing other people’s feelings
• People-pleasing to avoid disappointing others
• Difficulty saying no and setting boundaries
• Assuming more responsibility than is your share
• Giving advice whether the person asks for it or not
• Fretting about others
• Feeling responsible for others, or knowing what is best for them
• Talking more than listening
• Having goals for others that they don’t have for themselves
• Codependence, or imbalanced relationships, whereby you enable someone else’s immaturity or irresponsibility through caretaking or fixing
• Behaving like a martyr, taking care of everyone else, giving without receiving, and then occasionally feeling like you were taken advantage of
• Overworking and over-scheduling yourself

There can be several core beliefs and coping mechanisms underlying overfunctioning. This article does a really excellent job of summarizing some of the roots of overfunctioning behavior. I also encourage you to work with a therapist if you resonate deeply with this information. This is challenging work. I am a recovering perfectionist and it’s easy for me to fall back into the false belief that if I want something done right, I need to do it myself. This leads me to constantly "do." I often remind myself that I am a human "being" and it’s ok to just "be" sometimes (thanks Tara Brach!)

The following are some ways you can support yourself:  

• Give yourself permission to rest
• Practice saying "no." If that’s a big step for you, consider starting with "let me think about it" and give yourself a few days to make a decision. 
• Creating unstructured time in your schedule
• When you feel the urge to "do" challenge yourself to get grounded first. Take a deep breath, maybe go outside and check in with yourself about your intentions and desired outcome.  
• Evaluate your definition of happiness and wellbeing. Check in with yourself and make sure this is your definition and not influenced by anyone else.

I saved this article as the last one in my autoimmune series because it’s arguably the most important. Autoimmune disease and mind-body medicine are tightly linked. 

Early on in my career I met a patient with mast cell activation disorder and chronic hives. She was so ill that she had been hospitalized a few times with her throat swelling shut. We worked on all sorts of things looking at environmental triggers, using supplements to reduce histamine, changed her diet - you know, the typical naturopathic treatments. She was a little better but nothing dramatic. I lost her to follow-up and out of the blue about 6 months later she sent me a message letting me know she had found a wonderful therapist who had changed her life. Her therapist recognized that my patient had an elevated ACE (Adverse Childhood Experience) score and they had worked extensively on her childhood trauma. Much to my patients' surprise, her very difficult-to-treat condition resolved. This was a turning point for me. I started researching psychoneuroimmunology and reading everything I could about the connection between our mind and our immune system. 

I am going to take a brief pause here to address what mind-body medicine IS NOT before I go on to explain all of the fascinating research. I want to be crystal clear that mind-body medicine is not about blaming the patient. I was surprised to receive an unpleasant message over social media after sharing some research on mindset and health about how unhelpful it is to point out this connection. I was surprised because I think it is incredibly empowering to know that we may be able to use our minds to heal our bodies. In my experience no one is free from the mind-body connection. We are all impacted by our minds. Once we are aware of just how powerful the connection is we are back in the driver's seat. So remember that as you continue reading. If your physical illness is manifesting in part due to emotional wounds, trauma, early childhood experiences, your mindset, etc. this does not mean that your illness is your fault AND there might even be some tools to help you. 

According to the Center for Mind-Body Medicine “Mind-body approaches use the conscious mind to directly affect the workings of the brain and the rest of the body. The techniques exert their effect on the hypothalamus, the switching station in the brain, which exercises control over the autonomic nervous system (which controls heart rate, blood pressure etc.), the endocrine (glandular) system and the immune system.”

The Autonomic Nervous System (ANS) is the part of the nervous system responsible for control of the bodily functions not consciously directed, such as breathing, the heartbeat, and digestive processes. It controls what is going on behind the scenes. You don’t have to think about digesting your food or sending out immune cells to fight off foreign invaders. The ANS has you covered. The ANS has two divisions, the parasympathetic and the sympathetic systems. These two systems oppose each other and ask for different responses from the organs and systems they control. For example the sympathetic nervous system will slow down digestive function while the parasympathetic system will increase digestive function. 

When the sympathetic (fight, flight, or freeze) is dominant we feel more tense and alert. Stress hormones such as cortisol and epinephrine surge through our bodies. Our heart rate and blood pressure increase. Our immune cells secrete inflammatory cytokines such as IL-6 and IL-2. In contrast, when the parasympathetic (rest and digest) system is dominant we feel a sense of relaxation, tranquility and contentment. This is the baseline of balance that our body desires. Our heart rate slows, blood pressure lowers, our muscles relax and we can digest food adequately. Unfortunately, many of us are sympathetic dominant in our daily lives.

There are so many mind-body medicine topics we could cover but I am only going to pick a few since this is a blog not a book. Let’s cover self-criticism, perfectionism and loneliness. While also incredibly important, I am going to leave ACE and trauma to the experts (see the bottom for some good books to read though). 

SELF-CRITICISM
When we are critical of ourselves, it has negative consequences for our health and even impacts our immune system. According to Merriam-Webster self-criticism is "the act of or capacity for criticizing one’s own faults or shortcomings." We have a complex system designed to monitor our environment for threats. When a threat is identified, we are flooded with stress hormones to help us survive. The trouble is, this system can’t differentiate between threats in our environment and threats inside our head. Criticizing ourselves activates our threat system in the same way anxiety does. Chronic stress happens when this system is constantly engaged. 

Chronic stress increases interleukin-6 (IL-6). IL-6 plays an important role in signaling during an active infection. IL-6 increases inflammation and antibody production. Elevated IL-6 actually increases anxiety, alters the immune system, and increases neuro-inflammation. 

We live in a culture that teaches us to be self-critical. We grow up internalizing the ideal that we must push ourselves to achieve greatness. It’s easy to put high expectations on ourselves, which leads to self-criticism when we can’t meet those expectations. Some use self-criticism as a tool to push themselves harder and harder and even fear that without the inner critic they might become "lazy."

A good rule of thumb is to stop and think about whether you would talk to someone you love the way you are talking to yourself. Most people would never speak to another person the way they speak to themselves.

PERFECTIONISM
Perfectionists are often the harshest self critics. Brené Brown, Ph.D defines perfectionism as “a self-destructive and addictive belief system that fuels this primary thought: If I look perfect and do everything perfectly, I can avoid or minimize the painful feelings of blame, judgement, and shame.” 

Self-criticism is used as a way to ensure you are "perfect." The lie perfectionists tell themselves is that constant second guessing means you will not make a mistake. The trouble is you spend so much of your life second-guessing yourself that you don’t get a chance to live in the moment. Instead, you are caught in a constant fight-flight-or-freeze sympathetic loop. 

I noticed a pattern in my practice that patients with autoimmune disease tend to be hard on themselves. I started looking into the research and I found this paper revealing that patients with autoimmune disease are more self-deprecating than controls, which confirmed my suspicions. Years of overwork and stress to prove your worthiness leads to chronic activation of your sympathetic system. Your stress activation system is closely linked with your immune system. The full mechanisms of action for self-criticism and immune activation are not fully worked out yet, but there is a connection. 

Just like Dr. Brown said, perfectionism is a misguided tool to reduce or minimize the painful feelings of blame, judgement and shame. Criticizing yourself and striving for perfection unfortunately do not produce the desired outcome and can harm your health. 

Instead, try holding a hand over your heart and saying to yourself: "I am enough."

LONELINESS
Another aspect to consider is loneliness. Loneliness actually changes how the immune system works. Cellular immunity is impaired, natural killer cells decline, and antibody titers rise. Loneliness triggers the fight/flight/freeze stress response. Humans have spent most of our existence as a species being supported and protected by each other. Loneliness signals to our body that we are in danger, which kicks up levels of inflammation and changes immune response. 

The real kicker for me is that folks who have or develop a chronic illness, such as an autoimmune disease, have a higher risk for becoming socially isolated. So not only does loneliness increase the risk of developing an autoimmune disease, having an autoimmune disease increases your risk of becoming lonely. 


We have so many mind-body medicine techniques at our disposal. Here are some resources I share with patients: 

• Tara Brach has free downloadable talks and meditations on her website and is also available on your podcast app.
• Sharon Salzberg offers meditations for download at no cost on her website. 
• John Makransky teaches a beautiful meditation style based on receiving love downloadable for free from his website.
• The Last Best Cure: My Quest to Awaken the Healing Parts of My Brain and Get Back My Body, My Joy, and My Life by Donna Jackson Nakazawa 
• The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk

In all honesty it doesn’t matter what tools you pick as long as you actually do it. Don’t wait until it’s convenient, you have to incorporate relaxing activities into your daily routine. I find myself falling into the same trap I hear from patients - I can manage the tools on days that aren’t too busy but sometimes (read most of the time) I am ‘too busy’ to get in that exercise/meditation/coloring, etc. These are the days that you need it most. Creating new habits takes time and I hope that learning just how important stress management is for your health will help inspire you to take the time to cultivate new habits to build resilience. 


If you are struggling with an autoimmune disease I recommend working with a naturopathic doctor to help identify the root cause and support your body. It is important to maintain all medications while working on your health from a holistic perspective. Autoimmune disease is serious and tissue destruction is permanent. Our goal with naturopathic treatment is to keep the medication dose stable and slow or stop the autoimmune destruction. I am often asked if patients can expect to stop their medication eventually and that depends on a variety of factors and is a decision made with the prescribing practitioner and patient. 
 

References:
Self compassion as a predictor of interleukin-6 response to psychosocial stress
Compassion meditation reduced stress induced immune changes
Neural concomitants of immunity--focus on the vagus nerve
Personality traits and the immune system
IL-6 Induced by Social Stress
What is Mind Body Medicine

Autoimmune disease occurs when our immune system starts attacking our own tissues. Autoimmune diseases are complex illnesses that develop when there is just the right combination of genetics, epigenetic factors, and environmental triggers (infections, chemicals, stressors, etc). In this article I will focus on a few chemical or xenobiotic exposures that are linked to the development of autoimmune disease.  I want to start by saying it’s very challenging to conduct research trying to link specific chemicals to any disease. Humans are exposed to a myriad of chemicals daily and there is likely a compounding effect happening. There can also be a long delay between exposure and the onset of disease. For example, someone could work in a hair salon touching and inhaling chemicals for 10 years before they finally develop an autoimmune disease. Drug (ie medication) induced autoimmunity is well known and most associated with SLE (lupus) like disease. I will skip that in this article. I want to focus on chemicals in our environment that we can control. 

Endocrine Disruptors
Arguably the most notorious endocrine disruptors we are exposed to are bisphenols with BPA being the most well known. Unfortunately, when the dangers of BPA were brought into public awareness we saw a boom in ‘BPA free’ products that are quite misleading. Many of these products just replaced BPA with it’s cousins BPF and BPS which are also estrogen like compounds. Bisphenols are used in the production of polycarbonate plastics and at this point are ubiquitous in our environment. Research from 2003 found that more than 90% of the US population has detectable levels of BPA in their urine and females BPA levels were at higher concentration than males. Growing concern about the impact on children from bisphenol exposure has caused BPA to be banned in baby products in Canada and the European Union. BPA is a known endocrine disruptor but it’s role in autoimmunity has not been elucidated yet. What happens to our bodies from BPA exposure is quite similar to the autoimmune process. More research is needed but I am concerned that this could be a potential trigger and the people who already have an autoimmune disease may see a worsening in their pathology with higher exposure to bisphenols. 
Some of the products where bisphenols are found include:

• Food packaged in cans or tetra packs
• Beverage cans
• Hard translucent plastic marked #3, 6 or #7
• Cash register receipts
• Plastic food wrap
• Frozen meals in plastic trays
• Heating or microwaving plastic
• Placing plastic in the dishwasher

One relatively easy change is to avoid plastic containers for food or water and opt instead for glass or stainless steel. 

Phthalates are another endocrine and immune disruptor that are ubiquitous in our environment. Phthalates help make plastic soft and to dissolve raw materials when making fragrances. In the US, chemicals such as phthalates are considered safe until they are proven dangerous. Unfortunately, most of the research on phthalates has been done on animals. A 2019 study in rats found that a particular phthalate exacerbates the most common autoimmune disease, an autoimmune thyroiditis called Hashimoto’s. 

Below is an example of products that may contain phthalates. 

• Plastics both PVC and #3
• Children’s toys
• Cosmetics
• Nail polish
• Perfumes
• Almost anything with fragrance
• Detergents
• Solvents
• IV tubing

There is no easy way to tell if a product has added phthalates. There are numerous compounds and are identified on labels often as acronyms (BBP, DBP, DEHP, DEP, etc). Dust may also contain phthalates so consider washing your hands before preparing food and eating, cleaning your floors regularly using a wet mop and using a vacuum with an HEPA filter. 


Solvents
A meta-analysis in 2012 reviewed research studies that explored the potential link between exposure to solvents and autoimmune disease. Common routes of exposure to organic solvents include:

• Nail polish
• Nail polish remover
• Perfumes
• Dry cleaning
• Paint thinners
• Spot removers. 

Many of the studies the authors reviewed look at occupations that have a higher exposure risk such as nurse anesthetists, painters, people who frequently use hair dye and nail polish, and textile workers. Their findings indicate that organic solvent exposure is a risk factor in developing autoimmune disease. The researchers recommended that people with genetic risk factors avoid organic solvents. I think it might be wise for all of us to avoid organic solvents as much as possible.

I find two free apps helpful when trying to avoid chemicals in the products that we use daily,  Think Dirty and ‘Healthy Living’ by The Environmental Working Group. Both apps contain a barcode scanner so you don’t have to memorize the thousands of chemicals that might be a concern for you- you can just scan the barcode and see the product's score. 

There are so many more chemicals we could talk about in relation to autoimmune disease but instead I want to finish this article with some ideas to support healthy detoxification.


Our detoxification system is quite complex and the major players are our liver, kidneys and GI tract. Our liver processes not just the chemicals we are exposed to daily but also things we produce naturally such as hormones and bilirubin. Some of what the liver processes goes back into our bloodstream to be filtered through our kidneys and excreted through our urine. Other substances are deposited into bile to be dumped into the intestines. Our liver produces roughly 3.5 cups of bile every day! Here is an important piece- when that bile binds to fiber it leaves our body through our stool. Regular bowel movements are a very important part of our detoxification system. Laxatives are not the answer, a healthy diet rich in fiber is!
 
Some practical ways to enhance your natural detoxification process include:

• Drink ½ body weight (lbs) in ounces of water daily
• Consume a diet rich in vegetables, especially vegetables in the brassica family such as broccoli, cauliflower, cabbage, and brussels sprouts.
• Get your body moving. Physical activity moves our lymphatic system which helps remove waste. Bonus if you work up a nice sweat!
• Eat 25+ grams of fiber daily. Excellent fiber sources include legumes, avocado, chia, flaxseed, artichoke hearts and oats.
• Have 1 bowel movement per day. If you struggle with constipation consuming adequate fiber and water is a good place to start.

We are all exposed to chemicals on a daily basis. So I recommend taking small steps to both reduce your exposure to chemicals and support your natural detoxification system. 



References:
Toxicology of Autoimmune Diseases
Organic solvents as risk factor for autoimmune diseases: a systematic review and meta-analysis
A Potential Link between Environmental Triggers and Autoimmunity 
Exposure of the U.S. Population to Bisphenol A and 4-tertiary-Octylphenol: 2003–2004
The Potential Roles of Bisphenol A (BPA) Pathogenesis in Autoimmunity
DINP aggravates autoimmune thyroid disease through activation of the Akt/mTOR pathway and suppression of autophagy in Wistar rats

​I am fascinated by the connection between loneliness, social isolation, community and our health. I am not alone, there is an entire field called sociogenomics that is dedicated to examining how social factors affect the activity of our genome. Prior to the pandemic we knew that loneliness was on the rise worldwide and it was projected by the World Health Organization that we would hit epidemic levels of loneliness by 2030. Looks like we got there 10 years early. 

The health risks associated with loneliness are comparable with well-established risk factors for disease such as physical inactivity and substance abuse. Loneliness increases mortality to the point that it is similar to smoking 15 cigarettes per day!  The impacts of social isolation on our physiology include a reduction in sleep quality, increased risk of depression, HPA axis dysregulation and adverse cardiovascular outcomes. 

Humans have spent most of our existence as a species being supported and protected by each other. Loneliness signals to our body that we are in danger, which kicks up our levels of inflammation and changes our immune response. Our cellular immunity is impaired, natural killer cells decline, and antibody titers rise. Loneliness also triggers our fight/flight/freeze stress response. 

Technically the term used in research is Perceived Social Isolation or PSI because loneliness is a subjective emotional state; it is the perception of loneliness that matters. You can feel terribly alone in a crowd and perfectly content being alone. As an introvert I am acutely aware of this distinction. I often feel content alone and lonely at a party with people I don’t know (you know back when we actually went to parties). How can we use this to our advantage? I found a research study published in February 2021 that reviewed existing literature about what actually works to combat loneliness during the pandemic. The most effective interventions included mindfulness-based techniques as well as Tai Chi Qigong meditations and laughter therapy. Interestingly there was research on robotic pets that was generally positive and I wonder if living pets would provide more emotional support? That could be why adoption rates from animal shelters skyrocketed in the Spring of 2020. The researchers also found that leaning into existing relationships had more positive outcomes than trying to create new friendships. 

The interventions studied around more screen time or making new friends wasn’t as positive for reducing PSI. I thought back to research I reviewed a few years ago from Oregon Health & Science University which reported having limited face-to-face social contact nearly doubles someone's risk of having depression. Interestingly, participants who made the effort to regularly connect with family and friends in person were much less likely to report symptoms of depression, when compared with participants who only texted, emailed, or spoke to friends and family on the telephone. I realize that it still isn’t quite safe yet to meet with people in close proximity but maybe the solution isn’t necessarily relying on technology as a sole means to bridge the gap. 

What can we take away from this information? If the perception of loneliness is what causes us to become ill how can we shift our mindset? It seems as though mindfulness might be the answer. Some of my favorite mindfulness resources include: 

• Tara Brach’s podcast 
  
• Mindful.org 
• UCLA free guided meditations 

What is helping you combat loneliness?




Resources: 
Mindfulness Can Reduce the Effect of Loneliness Among Youth
Interventions to reduce social isolation and loneliness during COVID-19 physical distancing measures: A rapid systematic review