Dr. Barrett's Blog

Stress + Immunity

12/2/2020

Photo by Luis Villasmil on Unsplash

Is stress slowly killing you? It feels that way right now and surprisingly the answer might be yes! Lately I’ve been focusing my continuing education and reading on Psychoneuroimmunology defined by Merriam Webster as “a branch of medicine that deals with the influence of emotional states (such as stress) and nervous system activities on immune function especially in relation to the onset and progression of disease”. I had been noticing a significant relationship between mental/emotional stress and immune function since I started specializing in autoimmune disease but I had no idea there was an entire field of medicine devoted to this topic. I was reading an article and I noticed the author’s bio included psychoneuroimmunology and from then on I have been reading as much as I can about this fascinating topic.

Unfortunately the word ‘stress’ has become such a commonly used term and normalized in our society that when I try to broach this topic with patients I often hear, ‘I know stress is bad but let’s talk about XYZ diet and why I should follow it to fix my autoimmune disease’. Digging into the stress response is not a place many of us want to explore. I wonder if it’s because it feels too overwhelming and out of our control? Or maybe we just think that stress can’t possibly be the root cause of such significant illness? Why is it easier to blame food? Humans are poor reporters of their stress levels. It’s so indoctrinated in us that high levels of stress are normal that we no longer do a good job even recognizing that we are under high stress.

The work of Emily and Amelia Nagoski was helpful for me in breaking apart the stressors from the stress. Often we can’t control the stressors (work, kids, family) but we can control how we manage the stress in our body. Here are some clues that you might be struggling with stress (this is not a comprehensive list):

Depression/anxiety
Anger, irritability
Trouble sleeping or sleeping too much
Problems with memory/concentration
Feeling overwhelmed or unmotivated
Digestive distress (constipation, diarrhea, bloating)
Appetite changes
Pain/tension in your head, chest, abdomen or muscles
Lowered sex drive
Irregular or painful menses
Increase in blood pressure and/or heart rate

If you want to hear more about stressors vs stress and how to manage this check out the Nagoski sisters book- Burnout: The Secret to Unlocking the Stress Cycle. If you prefer to ‘cliff notes’ version check out this podcast episode interviewing the authors.

So how does this relate to our immune system? Well, our stress response system was designed to be activated in short bursts when we need to survive. Unfortunately, it’s activated much more often and we are feeling the consequences. When I talk to patients about stress many are familiar with the hormones adrenaline and cortisol. These two are our major players in the stress response but many other hormones are impacted when our stress response system is activated.

When we are under stress the following hormones are released:

Glucagon (increase blood sugar)
Prolactin (decrease reproduction)
Endorphins and enkephalins (decrease pain)
Cortisol (a major stress hormone)

When we are under stress the following hormones are suppressed:

Estrogen
Progesterone
Testosterone
Insulin
Growth hormone

We could deep dive into each of these hormones and how the changes impact you but this is a blog not a book. I will give you a few nuggets to get you thinking.

Cortisol suppresses our immune response, if you are under threat of bodily harm you don’t have time to waste resources fighting that pesky cold. The trouble is chronic infections are often lurking behind the scenes just waiting for your immune system to check out. EBV, varicella and herpes all contain stretches of DNA that sense glucocorticoid (cortisol) levels. When levels are higher these viruses reactivate. Isn’t that incredible (and also scary?)

Each of us process stress hormones differently for a variety of reasons. We are all biochemically unique and a great example of this is the COMT SNP. That’s quite the acronym huh? It stands for catechol-o-methyltransferase (COMT) single nucleotide polymorphism (SNP) and what it means is that there are some of us whose enzymes that process catechols a little differently. This can lead to higher levels of catechols such as adrenaline and noradrenaline staying in our system for longer. Folks with COMT mutations tend to have a bigger stress response to stressors than the average person.

Each of us processes stressors differently. As we grow up our brains learn how to appropriately respond to stress. When the young brain is constantly in a state of ‘fight or flight’ it causes lasting changes. The original research on how stressors in childhood impact long term health was called the ACE (Adverse Childhood Experiences) study. The results were profound. There is a direct association with the number of adverse events in childhood and risk of illnesses as an adult such as heart disease, IBS, diabetes, migraines, insomnia and more. This is after they controlled for diet, socioeconomic status, smoking, etc. Over 60% of us have experienced at least one significant adverse childhood experience.

In summary, chronic stressors lead to an overactive stress response that causes lasting damage. Each of us are unique in how we process these hormones and how easily we are triggered by stressful events. We are not great at recognizing and reporting how much stressors are causing an increase in the stress response. This is a really important piece in managing chronic illness.

Now that we understand how incredibly impactful our stress response is on our immune system what can we do about it?

Physical activity is probably one of the best tools that we have to combat the ever increasing levels of stress. Moving your body is a non-negotiable. We need 30 minutes of movement daily and this can be as simple as a walk outside.

Some other ideas for reducing the stress response include:

Singing
Dancing
Creative outlets
Nurturing healthy relationships
Breathwork
Formal exercise
Meditation/Mindfulness
Spending time in nature

In all honesty it doesn’t matter what tools you pick for stress management 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 stress resilience.

AUTOIMMUNITY SERIES EPISODE #3, PART 2: NUTRITION

11/16/2020

This part two of the nutrition article in a series covering autoimmune disease. Don’t miss upcoming articles covering chronic infections, hormones, environmental medicine and mind body medicine. If you missed the first articles covering GI health or loneliness check those out! I have so much to say about nutrition I had to break it into two articles! Check out the first article here.

Photo by Nadine Primeau on Unsplash

In part one of this article I reviewed several nutrients that benefit the immune system and the foods rich in those nutrients. In addition to looking at specific nutrients and how they impact our immune system we can also look at particular inflammatory mediators and discuss what foods or nutrients can be beneficial. One example is NF-κB, a well-known pro-inflammatory mediator. When NF-κB is deregulated, it’s associated with the chronic inflammation of autoimmune diseases. NF-κB has been implicated in a number of autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, type I diabetes, multiple sclerosis and inflammatory bowel disease (1). Certain foods and nutrients modulate NF-κB, these include:

Green tea
Curcumin
Rosemary
Grapeseed extract
Selenium (brazil nuts)
Indole-3-Carbinol (cruciferous veggies)
GLA (hemp and borage oil)
Zinc (pumpkin seeds, oysters, beef)

Foods that modulate NF-κB are just one example of how food can be our medicine. We could pick other important inflammatory mediators such as TNF-alpha or IL-6 and review which foods support a healthy response for these markers specifically. Instead of doing that I am hoping to convey that a whole foods diet rich in variety is supportive of a healthy immune system.

Let’s pivot to some components of our diet that can impair our immune system.

Moderation is important. But it’s also important to be realistic about what is truly food for humans and what is not. With the rise in packaged and convenience foods, we have been brainwashed to think that diet soda, boxed macaroni and cheese with a laundry list of unknown ingredients, and twinkies that never expire are food. Here's a baseline for determining food from not-food: if it wasn’t around for your great-grandmother to eat, it’s not food.

Food additives are particularly concerning and the amount of additives in our food has skyrocketed. A review article published in the journal Autoimmunity Reviews in 2015 found that changes in intestinal tight junction permeability (i.e. 'leaky gut') are associated with industrial food additives and may explain the rising incidence of autoimmune disease. (2) We must be vigilant in reading food labels and striving to minimize our consumption of processed foods.

There are two more things we must cover when discussing nutrition and autoimmune disease: sugar and alcohol. Both of these were around for your great-grandmother to consume, but we are indulging in much higher quantities and to our detriment. Sugar and alcohol are good examples of where we need more moderation. Many people end up eating much more sugar than they realize because it’s hidden in so many of our packaged foods and beverages. Start bringing more awareness to your sugar intake by reading ingredients and nutrition labels on packaged food that you purchase. Sugar is inflammatory, can contribute to ‘leaky gut,’ and is damaging to our immune system.

Note: When I use the word ‘sugar’ I am talking about refined products such as sugar cane, beet sugar, corn syrup, dextrose, maltodextrin, rice syrup etc. I am not talking about fruit. I see fruit lumped into the ‘sugar’ category and demonized right along with it so I want to be clear - fruit is an important part of a balanced diet.

Regular and excessive use of alcohol is normalized in our culture. Unfortunately, alcohol is very irritating to the GI lining, depletes the body of nutrients, and impairs our immune system. This is a link to a chapter in a medical text that walks through how alcohol impairs the immune system. Be forewarned, there are MANY complicated mechanisms. Safe alcohol consumption is no more than 1 drink per day for women and 2 drinks per day for men. A binge is drinking 4 or more beverages in 2 hours and 1 in 6 US adults binge drink 4 times or more per month (3). Excessive alcohol use is a problem in our country and, unfortunately, the stress of a pandemic is exacerbating this problem. If you find yourself drinking more than usual, consider other activities to help manage your stress such as an Epsom salt bath, exercise, time with friends, etc. If you need help to reduce your drinking, please consider talking to your doctor or mental health professional.

Many of the ‘diets’ found on the internet claiming to treat autoimmune disease focus heavily on what you should avoid. I hope this article has helped you see that instead of looking at tomatoes or other whole foods as a major culprit we should be looking to food additives, sugar and alcohol. There are so many critical nutrients for our immune health and eating a wide variety of foods is our best chance for adequate consumption.

In part one we reviewed critical nutrients to support the immune system and in part 2 we reviewed non-food compounds that can damage the immune system such as additives, sugar and alcohol. But we haven’t talked about the middle ground: foods that are inflammatory for some folks and not others. This is where individualized medicine comes in. Some people react poorly to dairy and it could be part of the problem. Other folks consume dairy without issue. I’ve even experienced a case where garlic was the migraine trigger. We are all unique and what foods nourish our bodies is different person to person. So before you jump on a ‘one size fits all’ diet plan for autoimmune disease, consider consulting with a professional who can help guide you.

Resources:

AUTOIMMUNITY SERIES EPISODE #3, PART 1: NUTRITION

10/14/2020

This is the third article in a series exploring autoimmune disease with a holistic lens. Don’t miss upcoming articles diving into chronic infections, gut health, nutrition part 2, hormones, environmental medicine and loneliness.

Photo by Karsten Winegeart on Unsplash

There are no shortage of ‘diets’ out there claiming to treat or improve autoimmune disease. You may have come across AIP (Autoimmune Paleo), low-nightshade, gluten-free, sugar-free, vegan, and the carnivore diet, just to name a few. In this two-part blog, I aim to provide research around nutrition and the immune system and put to rest the notion that you must follow a strict ‘diet’ if you have an autoimmune disease. Instead, we need to consume a variety of whole foods, especially plants, and limit non-food additives/preservatives that are commonly found in packaged foods.

I am going to start by highlighting the importance of a few key nutrients that you may be low in if you are currently eating the SAD, or Standard American Diet. According to the most recent US Dietary Guidelines, there are 7 nutrients that most American’s aren’t getting enough of: calcium, potassium, fiber, magnesium, vitamin A, vitamin C and Vitamin E.(1) Several of these are critical for our immune system. Below, I outline a few reasons why each is important for immune function and include some food options to get more of each.

Vitamin A: Vitamin A is critical for immune tolerance. Researchers from Emory University found that “Dendritic cells, the microbe-sensing alarms of the immune system, can send out a "red alert" to stimulate immunity, or a "calm down" message that tones down excessive immunity that might damage the host. The "calm down" message makes use of vitamin A, providing an explanation for the link between vitamin A deficiency and autoimmune diseases.” (2)
Food sources: (3) liver, meat, dairy and fish contain preformed vitamin A. Sweet potato, pumpkin, spinach, carrots, cantaloupe and sweet peppers contain a precursor to vitamin A

Vitamin C: This might be the most ‘famous’ immune supportive nutrient. Vitamin C is a potent antioxidant and required for many reactions in our body. Vitamin C supports both the innate and adaptive immune system (4). When we don’t have adequate vitamin C in our tissues we can develop impaired immunity and higher levels of inflammation.
Food sources: (5) raw sweet peppers, oranges, grapefruit, kiwi, broccoli, strawberries, and Brussels sprouts

Vitamin E: Vitamin E is well known for its antioxidant activity but lesser known for its role in the immune system. Vitamin E is highly concentrated inside of white blood cells and plays a role in stimulating our defense mechanisms. A literature review published in Reviews in Clinical Medicine found “A decrease in the serum levels of vitamin E in almost all autoimmune diseases. Furthermore, there is evidence regarding the possible therapeutic value of vitamin E in the management of autoimmune diseases.” (6) A clinical trial from 1978 found that providing vitamin E to patients with varying autoimmune skin conditions provided benefit.(7)
Food sources: (8) wheat germ, sunflower seeds, almonds, sunflower oil, safflower oil, hazelnuts, peanut butter

Fiber: I don’t have any interesting research studies to share on fiber and the immune system. I bring up this important nutrient because fiber is a major way that we feed our beneficial flora otherwise known as the microbiome. I explained the importance of our microbiome in my article Holistic Autoimmunity Series: Gut Health (link to GI and autoimmune article) so I will be brief. Our microbiome helps to train our immune system and likely play an integral role in autoimmune disease. So eat fiber to feed your microbiome friends!
Food sources: (9) beans, chia seeds, flaxseeds, barley, green peas, raspberries, pear

Omega-3’s: A nutrient that I believe is missing from this list is omega-3 fatty acids. The most important fatty acids for immune health are EPA and DHA which are found in certain fish. Omega-3’s reduces tumor necrosis factor-α and interleukin-6 production which are two inflammatory signals in the body (10). Omega-3’s are also important because autoimmune disease increases the risk of cardiovascular disease via increased inflammation and omega-3’s can help reduce that risk. “Many of the placebo-controlled trials of fish oil in chronic inflammatory diseases reveal significant benefit, including decreased disease activity and a lowered use of anti-inflammatory drugs.” (11).
Food sources: There is an acronym that helps me remember these fish; SMASH (Salmon, Mackerel, Anchovies, Sardines, and Herring). It’s ideal to consume a fish high in omega-3’s twice per week. Food is best, but if you can’t get these in twice per week I recommend using a fish oil supplement.

Vitamin D: I would be remiss if I didn’t at least touch on vitamin D. We don’t get much from food BUT it’s name is vitamin D so I will include a brief note about it here. Vitamin D truly acts as more of a hormone in the body. We make vitamin D from cholesterol when our skin is exposed to sunlight. It’s challenging to make enough in Minnesota since we are so far from the equator where the sun’s rays are the most direct. A literature review conducted in 2016 found “an inverse association between vitamin D and the development of several autoimmune diseases, such as SLE, thyrotoxicosis, type 1 DM, MS, iridocyclitis, Crohn's disease, ulcerative colitis, psoriasis vulgaris, seropositive RA, polymyalgia rheumatica.” (12). What this means is that when your vitamin D levels are in an optimal range you are less likely to develop an autoimmune disease. I advocate for testing vitamin D levels in patients and typically aiming for a blood level around 60 ng/mL.
Food sources: We can get some vitamin D from mushrooms, pasture-raised egg yolks and liver, but this is usually not enough to meet biological needs.

Resources:

Additional reference not specifically cited above: Diet, Gut Microbiota, and Vitamins D + A in Multiple Sclerosis

Digesting the Digestive System

9/8/2020

Photo by Joshua Coleman on Unsplash

I often hear patients express a desire to ‘health their gut’ as a means for achieving their health goals. In naturopathic medical school I often heard the phrase ‘health starts in the gut’ or ‘treat the gut first’. Treating gut health has become popular, but what does it really mean? According to online ‘experts’, it can mean many things ranging from drinking cups of bone broth daily to downing special ‘gut healing’ powders. Let’s break this down a little bit and start with why digestive health is so important.

The main function of our digestive system is the breakdown and assimilation of nutrients. We use these nutrients as the building blocks for our tissues, as cofactors for reactions, and as the fuel we run on. I am sure you have heard several tired analogies around nutrition and your health. But food really is the gas we put in our tank. If that gas is full of preservatives, sugar, highly refined carbohydrates, dyes, etc., it can seriously clog your engine (I couldn’t help myself!).

Another aspect of digestive health is that the majority of our immune system resides in our gut. This is a major training ground for our immune system. Our immune cells are learning how to fight and what to fight. If they are trained well by the beneficial flora (microbiome), they can better recognize self and non-self tissue. This is a big deal for folks predisposed to allergies and autoimmune disease.

Which leads me to another important aspect of your ‘gut’, the microbiome. I could spend an entire article singing the praises of a healthy microbiome. In short, these little guys make short chain fatty acids that keep your colon healthy, make vitamin K, likely ‘talk’ with your central nervous system, play a role in keeping pathogenic flora out of your gut, keep the lining of your gut intact, and the list goes on.

Once I ask a few more questions of the patients inquiring about ‘healing their gut’, they often follow it up with an explanation that they suspect ‘leaky gut’. The technical term for leaky gut is intestinal permeability and it’s still not recognized by most conventional gastroenterologists. The official test used in research is to drink a large sugar molecule, too large to be absorbed by your intestines, and then check the urine for presence of this sugar. The test isn’t very helpful in clinical practice because it just tells you that intestinal permeability is present and that’s it. The biggest misconception I hear is that it takes months to heal a leaky gut. The cells that make up our intestines turn over often, every three days in fact. My approach is to reduce or eliminate the culprits damaging the lining rather than flooding your GI with nutrients/supplements to ‘heal’ the gut. We’ve been a little brainwashed into thinking we need to take things to make use better.

When your intention is to work on your digestive health, you want to consider a few things before you jump on the supplement train:

What are you putting in your gut? This includes food, alcohol, NSAIDS, antibiotics…
Are you taking time to chew your food?
Are you consuming the right blend of fibers/prebiotics to support a healthy microbiome?
How is your current stress and past stress impacting your microbiome and digestive capability?
What is your breathing pattern and posture like? Are you using your diaphragm and giving your body the space it needs to do its job?
How often are you physically active? Fun fact: physical activity can beneficially alter your microbiome.

Most folks who make their way to my office have complex and complicated digestive concerns. That does not mean we skip the basics listed above. If you don’t have a strong foundation, it’s very challenging to heal. Often the root causes of even the most complicated conditions can be an issue with one of the basics. For example, a sluggish gallbladder can put you on the path to SIBO especially when combined with chronic stress. Don’t even get me started on how strong the connection is between chronic stress and IBD. Holistic medicine incorporates all of the lifestyle basics with the most current research on nutrients, botanicals, and functional testing to help guide a person back to wellness. For digestive health, this may include functional stool testing, prescribed diets, targeted probiotics, specific nutrients/herbs and more. With so much information at our fingertips, it’s tempting to try and tackle your health challenges alone, but I highly recommend working with an experienced provider. In addition to providing you guidance from education and experience, you gain a cheerleader in your corner.

AUTOIMMUNITY SERIES EPISODE #2: GUT HEALTH

9/2/2020

This is the second article in a series exploring autoimmune disease with a holistic lens. Don’t miss upcoming articles diving into chronic infections, nutrition, hormones, environmental medicine and mind body medicine.

The National Institutes of Health estimate that 5-8% of Americans have an autoimmune disorder. There are approximately 80 human diseases caused by an autoimmune response and that list keeps getting longer. Autoimmune disease occurs when our immune system attacks our own tissues by mistake. This attack can escalate and lead to tissue destruction such as the joint tissue destruction seen in Rheumatoid Arthritis (RA).

Naturopathic Medicine takes a holistic or whole-person approach to treating and managing autoimmune disease. An important part of the holistic approach is to explore root causes or triggers of disease. We go searching for areas where the body is out of balance. In a series of articles I will cover different aspects of this search for root causes for autoimmune disease including environmental exposures, hormones, mind/body medicine, nutrition, and chronic infections. We are starting with a major area - gastrointestinal health.

Gastrointestinal (GI) or ‘gut’ health is a foundation of Naturopathic treatments. You have probably heard the saying ‘health starts in the gut’. There is a lot of truth in that statement for several reasons; the GI tract is responsible for digestion and assimilation of nutrition, it’s where the majority of our immune system and microbiome reside, and it’s a major training ground for our immune system.

Microbiome: We have trillions of microorganisms (bacteria, viri, parasites) living in our GI tract. This is called the microbiome or gut microbiota. Your microbiome starts to develop the moment you are born and complete colonization occurs within the first three years of life. Starting at birth, our microbiome helps train the developing immune system. The commensal (good) microbes can directly attack the disease causing microbes signaling to the human immune system when to launch an attack. This training also includes teaching the immune system to ignore harmless stimuli (such as pollen or even self tissue). Without this critical training we are more at risk for conditions such as autoimmune disease and allergies.

When our microbiome is unstable or out of balance it is called ‘dysbiotic’. We are finding that a dysbiotic flora or dysbiosis is a factor in many conditions including autoimmune disease. Dysbiosis increases the production of inflammatory cytokines.

Molecular mimicry: This is a critical piece to autoimmune disease. The basic concept is that your body mounts an immune response to something (pollen, food, virus, bacteria, etc.) and then those immune cells become confused and start attacking your tissues. Klebsiella in the GI has been associated with ankylosing spondylitis and ulcerative colitis; Yersinia in the GI has been associated with autoimmune thyroid conditions; Citrobater in the GI has been associated with rheumatoid arthritis to name a few. Association isn’t causation but it warrants investigation especially into the microbiome of patients with autoimmune disease.

Intestinal permeability: Intestinal permeability is often called “leaky gut”. Our GI tract is technically outside of our body, you could eat a penny and it would pass right through your GI and out into the stool. Your body determines what is brought in through the GI tract into your bloodstream. When there is a breakdown in this process and larger particles are allowed into the blood we call that intestinal permeability. When larger strings of amino acids (pieces of food that aren’t entirely broken down) make it through, the body attacks these as foreign invaders (as it should!). This attack can go awry and lead to attack on your own bodily tissues. Intestinal permeability is caused by stress, poor diet, food additives, overuse of NSAIDS, alcohol and more.

Assessing digestive health is often a first step working with autoimmune patients. Each approach is tailored to the patient.

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.

Resources:

AUTOIMMUNITY SERIES EPISODE #1: LONELINESS

7/20/2020

This is the first article in a series exploring autoimmune disease with a holistic lens. Don’t miss upcoming articles diving into chronic infections, nutrition part 1 + part 2, hormones, environmental medicine and mind body medicine.

Photo by Keenan Constance on Unsplash

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. Most of us know that we should ‘eat right,’ sleep well and exercise. The jury is still out on how to eat right, how much to sleep and exactly what kind of exercise is best BUT we at least have awareness around how these areas impact our health. Unfortunately loneliness is on a dramatic rise and the effects on our health are pervasive.

You can feel terribly alone in a crowd and perfectly content being alone. Loneliness is a subjective emotional state; it is the perception of loneliness that matters. Humans have an instinctive need to belong, this need is as basic to human functioning and survival as the need to obtain food, water and shelter. When this need is not satisfied it impacts not just our psychological health but also our physical health.

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! If that isn’t startling enough, the World Health Organization predicts that loneliness will reach epidemic proportions by 2030.

In 2018, CIGNA surveyed 20,000 US adults using UCLA’s loneliness scale and here is what they found:

1 in 2 reported sometimes or always feeling alone
1 in 4 rarely or never feel as though there are people who really understand them
2 in 5 sometimes or always feel that their relationships are not meaningful
1 in 5 rarely or never feel close to people
Generation Z (18-22) is the loneliest generation

What does this have to do with autoimmune disease? Loneliness actually changes how our immune system is working. Our cellular immunity is impaired, natural killer cells decline, and antibody titers rise. Loneliness triggers our 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 our levels of inflammation and changes our immune response.

Inflammation impacts regions of the brain that process fear and anxiety, thereby changing people’s experience of the world. Loneliness may act as a regulatory loop. Lonely individuals have increased sensitivity and surveillance to social threats. They preferentially attend to negative social information while remembering more of the negative aspects of social events. This leads lonely individuals to behave in ways that confirm their negative expectations. These changes in behavior perpetuate loneliness.

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. Let’s attend to our social health.

No one has the answers to this problem but what is clear is that loneliness is skyrocketing in developed nations. Moving out and living on your own is a right of passage. We walk around with airpods in our ears and our faces in our phones. These days it is very easy to feel alone in a crowd.

I propose a simple shift in mindset. Instead of the mentality that meeting a friend for coffee is a ‘treat’ let’s put it on par with your morning exercise or your kale salad. I also just want to remind all of us (myself included) in this era of ‘instagram selves’ to not forget who we truly are, and show up with authenticity to our friendships. Nurture your relationships, spend time with the people you care about. Your health depends on it.

References:

Hashimoto's Research Update Summer 2020

7/1/2020

Photo by Karina Vorozheeva on Unsplash

I am starting up a new blog series to highlight research updates for Hashimoto’s Thyroiditis (HT). My intention is to review recent literature every 6 months. I am starting by pulling together a variety of research articles until I feel ‘caught up’ (will I ever feel caught up?!) and will then focus solely on new research. My plan is to publish an update every January and July.

For this first installment I have pulled together a variety of research articles.

Gluten and Hashimoto’s (2019)

Krysiak R, Szkróbka W, Okopień B. The Effect of Gluten-Free Diet on Thyroid Autoimmunity in Drug-Naïve Women with Hashimoto's Thyroiditis: A Pilot Study. Exp Clin Endocrinol Diabetes. 2019;127(7):417-422. doi:10.1055/a-0653-7108

I read this article in 2019 when it came out and was excited to see that research is starting to support what we have known clinically for years. Many patients with Hashimoto’s Thyroiditis (HT) benefit from a gluten free diet. The sample size was small and it wasn’t randomized, patients were allowed to choose the gluten free group or the control group. That said, even with the small sample size there was an improvement in both TPO and TG antibodies in the gluten free group as well as a slight increase in thyroid hormone output.

The authors hypothesize that the improvement in autoimmunity may be due in part to an increase in vitamin D that was seen in the gluten free group. The participants did not increase their vitamin D intake and it’s unknown why a gluten free diet would have improved their vitamin D status.

This study is very interesting and I hope it’s the first of many exploring the important connection between a gluten free diet and HT.

Vitamin D and Hashimoto’s (2016 + 2018)

Sahin, M., Corapcioglu, D. The effect of vitamin D on thyroid autoimmunity in non-lactating women with postpartum thyroiditis. Eur J Clin Nutr 70, 864 (2016). https://doi.org/10.1038/ejcn.2016.56

Xu J, Zhu XY, Sun H, et al. Low vitamin D levels are associated with cognitive impairment in patients with Hashimoto thyroiditis. BMC Endocr Disord. 2018;18(1):87. Published 2018 Nov 26. doi:10.1186/s12902-018-0314-7

We know from observational studies that low vitamin D status seems to contribute to thyroid autoimmunity. What sets this research apart is that they looked at women post partum to see what impact vitamin D supplementation has on antibodies. ⁠If you are familiar with Hashimoto's you probably know post partum is a common time for the condition to flare. ⁠
⁠
The investigators found that the women with post partum thyroiditis (PPT) had lower levels of vitamin D than post partum women without thyroiditis. Giving vitamin D (either 2,000IU or 4,000IU depending on the patient's vitamin D blood level) to the PPT women significantly lowered their antibodies without any side effects. Between 20-40% of women with PPT go on to develop permanent hypothyroidism and lowering antibodies is an important step to prevent that outcome.

The second study looks at the relationship between vitamin D, Hashimoto's Thyroiditis (HT), and cognitive impairment.
⁠
We already know that low vitamin D is correlated with cognitive impairment in the general population and that there is a high prevalence of low vitamin D in patients with HT. It wasn't surprising that they found low vitamin D is associated with cognitive impairment in patients with HT. ⁠

The authors also found that vitamin D levels were inversely related to TPO antibody levels.

Bottom line study #1 and #2: If you have Hashimoto's I highly recommend talking to your provider about your vitamin D level. ⁠
⁠
Depression and Hashimoto’s (2011 + 2014)

Giynas Ayhan M, Uguz F, Askin R, Gonen MS. The prevalence of depression and anxiety disorders in patients with euthyroid Hashimoto's thyroiditis: a comparative study. Gen Hosp Psychiatry. 2014;36(1):95-98. doi:10.1016/j.genhosppsych.2013.10.002

Hardoy MC, Cadeddu M, Serra A, et al. A pattern of cerebral perfusion anomalies between major depressive disorder and Hashimoto thyroiditis. BMC Psychiatry. 2011;11:148. Published 2011 Sep 13. doi:10.1186/1471-244X-11-148

The first study looked at the prevalence of depression and anxiety in euthyroid Hashimoto’s thyroiditis. Euthyroid Hashimotos’ is when a patient has Hashimoto’s but their thyroid hormones are not abnormal (yet!). They looked at patients who have a normal FT3, FT4 and TSH but also have thyroid antibodies and an abnormal thyroid ultrasound. There are already several studies that show a higher prevalence of psychiatric disorders in patients with Hashimoto’s but this study is unique in that they only included HT patients who had ‘normal’ thyroid function based on thyroid hormone testing. Surprise! They found there was a higher prevalence of anxiety and depression in these patients than in the general population or control. There are many theories as to why HT patients have a higher incidence of psychiatric disorders and many center around imbalanced levels of TSH, FT3 and FT4. There is likely more to the story. This study might be the first to find a relationship between OCD and HT. The prevalence of OCD in the HT group was 15.7% and the prevalence in the general population is around 0.8% to 3.2%.

Bottom line study #1 - If you have anxiety or depression and your thyroid has been screened with just a TSH make sure to talk to your provider about a comprehensive screen that includes antibody or ultrasound testing especially if you have a family history of thyroid disorders.

The authors summarized the second study very well so I am going to quote the authors directly “The debate on the pathogenesis of depression in thyroid autoimmunity involves two hypothesis, it is suggested that the neuronal tissue is hypersensitive to hormonal deficiencies and are more vulnerable to possible subclinical hormonal deficiencies not detectable with routine laboratory tests. In the second hypothesis, a possible pathogenic factor linked to inflammation is postulated, consequent to cytokine activation or extraglandular lesions similar to vasculitis induced effects.”
In other words it could be that our brains are hypersensitive to fluctuations in thyroid hormone so even when the levels are ‘normal’ our brains might suffer and/or there is likely a role of inflammation in altering blood flow.

Bottom line study #2: Depression and brain blood flow changes happen with HT (both euthyroid and hypothyroid) and patients with depression, especially atypical depression, need comprehensive thyroid screening.

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Self Compassion and Autoimmunity

6/24/2020

Photo by Giulia Bertelli on Unsplash

I have been writing about how self criticism and perfectionism have negative health consequences. If you missed those articles you can read them here (self criticism and autoimmunity; perfectionism and autoimmunity)

The antithesis to self criticism is self compassion. Self compassion is extending the same compassion to yourself that you would to a good friend. Kristin Neff, Ph.D, an associate professor in human development who studies self compassion, explains that self compassion is composed of three parts: mindfulness, common humanity and self kindness. Dr. Neff has created an online quiz to assess your level of self compassion.

It sounds like a nice notion, treating yourself with kindness, but it’s more than that. Practicing self compassion can actually improve your health. Positive emotions are the counterbalance to our threat activation system. If we are soothed, calm, or feel contentment, it stimulates our vagus nerve and our parasympathetic nervous system. Compassion meditations lower the stress hormone cortisol and inflammatory cytokine IL-6.

It can be challenging to accept kindness from strangers and even harder to accept it from ourselves. You know what I hear most often when I ask patients about accepting kindness or being kind to themselves? They think they don't deserve it. Take a minute to think back to the last time someone did something kind for you. Did you accept it with gratitude? Did you feel awkward? Maybe even a little guilty because you couldn’t or didn’t reciprocate? What about the last time you performed a random act of kindness? How did you feel? It feels really good to do something kind for someone else, but we struggle to extend that same kindness to ourselves and accept it from others.

I want to be clear that self compassion is not a cop-out. We all make mistakes. We all have biases, prejudices and learned behaviors to work on. Healthy self reflection and improvement can be done from a place of love and caring. Self compassion teaches you to approach yourself with kindness, even when you need to grow and learn. Let’s be clear, we are all constantly growing and evolving. We all make mistakes and have a lot to learn about being human. If your friend or a young child made a mistake, how would you speak to them about it? Self compassion is extending that same grace to yourself instead of harsh self reproach.

Healthy self-improvement may help boost your self-esteem. Instead of tearing yourself down, what if you built yourself up? Focus on your good qualities and recognize when you stop, reflect and grow. Self esteem may buffer against acute stressors and lead to more resiliency.

Dr. Neff’s website is full of tools you can use to improve your self compassion. One of my favorites I recommend to my autoimmune patients is loving kindness meditation. Compassion medication can reduce stress induced immune changes.

Working through your inner self critic and cultivating self compassion can be challenging. I recommend checking out Dr. Neff’s resources including her book Self Compassion: The Proven Power of Being Kind to Yourself and consider working with a mental health professional especially if you are working through shame and trauma.

I will leave you with a mantra from Dr. Neff’s book about building self compassion:

“This is a moment of suffering.
Suffering is part of life.
May I be kind to myself in this moment.
May I give myself the compassion I need.”

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311753/
Self compassion as a predictor of interleukin-6 response to psychosocial stress

www.ncbi.nlm.nih.gov/pubmed/18644432.
Higher self esteem reduced the inflammatory response to acute stressors.

www.ncbi.nlm.nih.gov/pmc/articles/PMC2695992/.
Compassion meditation reduced stress induced immune changes

Self Compassion: The Proven Power of Being Kind to Yourself by Dr. Kristin Neff

Perfectionism and Autoimmunity

6/10/2020

Photo by Jonathan Hoxmark on Unsplash

This is a follow up to Self Criticism and Autoimmunity.

Perfectionists are often the harshest self critics. Brene 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.

Why create a whole blog on perfectionism? 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 our sympathetic system. Our stress activation system is closely linked with our 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 ourselves and striving for perfection unfortunately do not produce the desired outcome and can harm our health.

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

Click to read Part 3 Self Compassion and Autoimmunity

References:

https://www.ncbi.nlm.nih.gov/pubmed/2148613
Women with autoimmune disease found to be more self deprecating than controls

The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are by Brene Brown, PhD.

Book Review: Self Compassion

6/1/2020

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 leading to brutal self criticism when we can’t meet those expectations.

Dr. Kristin Neff put together a beautiful book explaining why we are critical of ourselves and what we can do about it.

Self compassion is extending the same compassion to yourself that you would to a good friend. Dr. Neff explains that self compassion is composed of three parts: mindfulness, common humanity and self kindness.

While I completely agree with her work I was a little bothered by her tone in the book. It was a little too laid back for me. I also would have appreciated more concrete examples and details from her research. Dr. Neff used many anecdotes from her own life in the book to illustrate her points, which is ok but I think the combination of the tone with the anecdotes was a little off putting. These critiques are not enough of a reason to skip the book. It is still a worthwhile read. I believe it’s important to understand why we are self critical and learn to cultivate self compassion. The book provides examples and tools that you can use to cultivate self compassion.

I will leave you with a mantra from her book that I think is particularly helpful:

“This is a moment of suffering.
Suffering is part of life.
May I be kind to myself in this moment.
May I give myself the compassion I need.”

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