Taking Charge of Your Health

I’m Neha Shah. It’s a pleasure to
be here, and I’d like to thank Nora
for inviting me here today to speak with you. Our objectives are
plain and simple. I have 45 minutes to give
you a very brief and somewhat superficial introduction of
integrative rheumatology, because it really is
a very broad topic, and something I’m
very passionate about. So I will do my best
in the limited time that we have, and I have
no disclosures or conflicts of interest to disclose. So a little bit about myself. I grew up right up here,
up the road in Cupertino– Monta Vista Matador. And I grew up in a
traditional Indian household, and growing up, whenever I was
sick or my siblings were sick, my mother– the first thing
she would reach for was not the telephone to call
the pediatrician, it was the little stainless
steel spice container in the kitchen cabinet. And there was a lot of turmeric,
and ginger, and garlic oil, and all kinds of home remedies
that went around, particularly in the winter months. So then I went to medical
school at University of Florida, I did my residency
in internal medicine at University of Miami, and then
ended up back here at Stanford for my fellowship
in rheumatology and went on to practice
conventional rheumatology. And I always felt like
there was something missing. I had pills and things
to give to my patients, but I had this
secret in my closet. I had the secret that there’s
all kinds of other things out there that work,
and that can help, and that can be used
with the medications. So I just didn’t feel qualified
to share that with my patients. So I went on to do a fellowship
in integrative medicine at the University of
Arizona under Dr. Andrew Weil and Tieraona Low Dog and
several really amazing mentors, and it really
broadened my horizons and opened up a whole
new world to me. So my whole practice
of rheumatology transformed after that
two-year integrative medicine fellowship. So what exactly is
integrative medicine? It is combining the
best of all worlds, and really having this shared
relationship with my patients where we really work as a
team and look at all options to try to achieve their greatest
health, as best as we can. But we do this in a way using
evidence, and making use of all appropriate therapies. But for me, this fellowship
really opened my mind, and I hope it also helps me let
my patients open their minds, but not so open that
our brains fall out. So I’ll be the
first to say, I love a double blind, randomized,
placebo-controlled clinical trial to prove that
something works, but for me, 3,000 years of
experience and observation and tried and true
remedies is also a different kind of evidence,
and this stems from, I guess, the first precision medicine
that was out there before we had all kinds of
amazing DNA technology, namely Ayurvedic medicine,
traditional Chinese medicine, some of these ancient art forms
as [INAUDIBLE] that are very scientific in their own right. And they can really
provide patients with a whole system,
form of medicine, that that really approaches
all aspects of health. So integrative medicine. How does that tie
into rheumatology? Well, this is a
little bit outdated, this study’s from
2007, and it shows how complementary and
alternative medicine practices have been used amongst
adults in the United States. And if you can see here, back
pain, neck pain, joint pain, arthritis, other musculoskeletal
complaints, and I might argue that everything
else that’s listed there, in some form or
another, also falls into the realm of rheumatology. So it seems like I picked
a pretty good specialty for being able to integrate
these complementary and alternative– I don’t like to use the
word alternative– holistic practices. So really, in
integrative medicine, and what my approach
is towards patients, is this idea that we’re not
just treating one disease or one symptom, we’re really looking
at patients as a whole. And that includes
kind of three aspects of their care, their body,
their mind, and their spirit. I kind of think of it as
three legs on a stool. And if any one of those legs
is off-balance or shorter than the other or
whatever, that stool is just not going
to be very balanced. And so we really need to
look at the whole person. And starting with body, I
think one of the main areas to look for– there are so
many, and we’re only going to touch on a few of them. But I think a lot of our
health starts at the gut. And if you ask a
gastroenterologist, they’ll say this is the brain. It’s not up here, it’s here. And so 30, 40 plus
years ago, probably before I was even born,
naturopaths, chiropractors, the granola 1960s,
’70s, crunchy, earth-loving Americans,
they had this idea about leaky gut, this idea that
the intestinal barrier allowed in environmental
allergens and triggers that prompted
inflammation in the body. And conventional
wisdom at the time– and I use the word
wisdom lightly– was that that was
a bunch of hogwash. So they just said, OK, no, no,
that can’t be, the gut’s tight, this is ridiculous. Fast forward, and now
conventional medicine had this novel idea of
intestinal permeability– it’s the same
thing as leaky gut. We’ve come a long ways, and
now conventional medicine recognizes the fact that,
like the skin, like the lungs, the GI tract is a huge portal
through which the environment can affect our health. And so much of that is
through medications that travel through the GI tract. Stress and how that
affects nerves, how that affects the GI tract. Toxins, food particles,
food allergens. And when I use the
word allergens, I don’t necessarily
mean foods that cause hives and tongue swelling. They can be foods that trigger
other forms of inflammation, not just your allergic type,
anaphylactic type of reactions. And then a big part of that–
and this is now a huge, huge area of intense research– is the idea of bacteria. We have– and I might
get this number wrong– I want to say about 10 trillion
bacteria that live in our gut, and that is way more
than the number of cells that we actually have
in the human body– human cells. So our microbiome is
a huge part of us. We live symbiotically
with this microbiome– that’s the word
we use to describe this whole body of
bacteria that lives in our intestines and our skin,
and our respiratory tract. And in the ideal world, we
are living symbiotically with this microbiome, but
we live in unideal world, and that is that the
microbiome isn’t necessarily what it’s supposed to
be in a lot of patients. And so what happens is
all kinds of things. Lack of physical activity
or too much of it. Surgical interventions. We used to think an appendectomy
was a pretty benign thing. A lot of women undergoing
elective procedures like hysterectomies, years ago,
when the surgeons were there, they would just nip the
appendix out of there, too, because they figured,
we’re in there, we’ll just prevent
appendicitis in the future. So that’s now been linked to
an increased risk of dysbiosis, abnormal microbiome,
and increased risks of certain autoimmune diseases. Smoking, stress, vitamin–
lack of vitamin D, rather. How clean we are,
how much we wash our hands, how much time we
spend outside in the dirt, what we eat, how much we sleep. All of this has a huge impact
on this whole world of life that’s living inside
of our intestines. And really, we are
just now touching on the tip of the iceberg of
how that microbiome is affecting our health. So when I use the
word dysbiosis, I want to clarify that. Certain types of dysbiosis,
are very obvious. If somebody is walking around
with amoeba or parasites that are in their
gut that we know are not supposed to be there,
it’s kind of an easy thing. Tapeworms, we can
recognize that. But there’s also
this idea that there is an ideal wild type
of microbiome patterns, a high number of certain
types and certain families of bacteria, lower
numbers of other ones, that should be all
living in balance. And when that is off-balance,
it starts affecting our health. We have yet to, I
think, fully grasp exactly what is the
perfect balance, but we are starting to recognize
what patterns are maybe negative patterns that affect
health in a negative way. So when we feel that a patient
has dysbiosis going on– and some of you may
be familiar, there are many companies
out there that offer stool testing to see, what
does your microbiotic family look like. And there are– some companies
have put out patterns that they think are
associated with good health, and other patterns
that are associated with negative health. I’m not sure that a
lot of these tests have been completely
validated yet, but I think that science is
approaching a place where we’ll have a better understanding
of what’s a good microbiome and what isn’t necessarily
a good microbiome. But what I tend to
do with my patients is this weed,
seed, and feed type of approach to this dysbiosis. And I kind of go
with the presumption, or with the assumption,
when a patient comes to me with some kind
of autoimmune disease, that they likely have some
kind of dysbiosis going on, even if I haven’t done
a stool study to look at what’s growing in their gut. And like I said, so
many things affect that. The biggest things,
in this day and age– c-sections. Right? We saw this huge
rise in c-section. So from day one,
from birth, you had babies being born that
were not being exposed to the microbiome
of their mother because they didn’t pass
through the vaginal canal, you have antibiotics that are
being doled out like candy– little better
nowadays, but back 20, 30 years ago, and still
in a lot of countries, antibiotics, you don’t need
a prescription to get them. So there are a lot of
resistant bacteria. So the first part is
this weeding idea, is we should try to
get rid of things that really shouldn’t be there– or at least lower
populations of bacteria that shouldn’t be there. And then the second part
is the seeding part, probiotics, fermented foods. And the last part
is the feeding, is our bugs need to eat. Our little pet bugs that
are in us, our friends, they need to eat. So foods that support the
growth of friendly gut bacteria. So these are things that,
when I see a patient– maybe not on the first
visit, maybe the first visit we’re focused on trying to
figure out what they have, because a lot of
rheumatology can be a little bit of a puzzle. But as we get deeper
into our relationship, we start talking about diet
and lifestyle and other things. Have they had a lot of
antibiotics over the course of the last few years? What was their birth history? When they were growing up, did
they have a lot of infections? So we look into
all of these things to figure out, intuitively, what
does their gut flora probably look like right now? So I’m not going to go into
detail about a lot of these, I’m just kind of listing
them, but in general, we need to love our guts. We need to take
care of our guts. And that can be done
in a lot of ways, and the way I’m going
to focus on right now is through the diet. If any of you are more
interested in learning about the microbiome, we
have a husband-and-wife team of really brilliant
microbiologists here at Stanford, Justin
and Erica Sonnenberg, and they’ve written this great
book called The Good Gut, and it really is
an amazing insight into the research
they’ve done, as well as a lot of other
research that’s been done in the area of the microbiome. And this was actually a picture
of them that was taken– I think it might have
been the New York Times. New York Magazine. It was set up. They don’t usually have
dirt on their dinner table. So the next step forward
from this microbiome idea is our diet, because it
has such a huge impact on what’s growing in our gut. In addition to direct effects,
macro- and micronutrient effects, on our inflammation
in our immune systems in our body– that’s separate
from its effect on our gut microflora. And specifically for
rheumatoid arthritis, there’s actually a
somewhat limited, but impressive in terms of
results, a body of evidence for diet having an impact
on rheumatoid arthritis and inflammation. And going back hundreds of years
ago, food was medicine, right? There weren’t pharmaceutical
companies and pills, people used food as medicine. And then conventional
Western medicine sort of got away
from that, but kind of in the ’80s and
the ’90s, there was this resurging
interest in looking at diet and inflammation,
and diet specifically in rheumatoid arthritis. Most of the studies
in the ’80s and ’90s that came out that supported
a role of dietary change and its impact on
inflammation and RA came out of Scandinavia,
mostly Sweden. You know, they have a
socialized medicine. You can take a bunch of
patients and throw them into a health spa and force
them to eat a certain diet. A little harder to
do that in America. So most of those studies
come out of Sweden. And some of the studies
supported a gluten-free diet for improvement in inflammation,
many studies that were done out of Sweden supported vegan and/or
vegetarian diets/ So like I said, it’s limited data, but
it is very impressive what is there. Our Standard American Diet,
the SAD diet, and Western diets in general, do
confer a greater risk for developing
rheumatoid arthritis. And I’m saying
rheumatoid arthritis because that is where a lot
of the studies have been done, but I think just
in general, that can be somewhat extrapolated to
autoimmune diseases in general. There was another study that was
looking at fish consumption– oily, cold-water fish
that are high on omega 3– consumption and
the potential risk for developing
rheumatoid arthritis. And they found that
the patients who were in the highest quartile
develop of omega 3 fish consumption had the lowest
risk of developing RA, whereas those who were in
the lowest quartile of fish consumption had the highest
risk of developing RA. So in general, I
propose to my patients that they try to shift
their diets to more of a Mediterranean,
low-fat, plant-based diet with some addition of
omega 3 heavy fish. And I also do a lot
of elimination diets with my patients. There are many, many diets that
are out there that propose some sort of elimination,
gluten-free, dairy-free, soy-free, corn-free,
meat-free, sugar-free– sugar is a huge promoter
of inflammation. And I think, even though
from the standpoint of the kind of
research Stanford likes to see, that double-blind,
placebo-controlled, randomized clinical trial, there’s not a
lot out there for specific food antigens and
rheumatoid arthritis, or other types of
inflammation, I think this is a really
low-risk intervention that we can do with our patients. There’s not a lot of harm
in taking certain things out of the diet for
three to four weeks and then reintroducing
them to see, do patients have more pain? Do they get a flare
of any skin rash? Do they get headaches? Do they get sinus congestion? What happens when we
reintroduce certain things? And in my clinical
experience, I’ve had patients decide they
don’t want to go back. You know, they’ll do
their three to four weeks of an elimination, and
they feel so much better after they’ve cut
out certain things that they just don’t
want to go back. For other patients, they
really miss their bread, or they miss their
cheese, and so we try. We’ll try different
things and see what happens with reintroduction. And I don’t think there
is a hard-and-fast. In my clinical experience– and
these are anecdotal experiences with my patients as
opposed to a large trial– I can say that, in
general, many– not all, but many patients with
rheumatoid arthritis and lupus can be sensitive to gluten, can
be sensitive to cow’s dairy. Many can tolerate
sheep or goat’s milk. And my patients
who have psoriasis or psoriatic arthritis or
inflammatory bowel disease– unless they have
celiac, which is a whole different
autoimmune disease– many of them don’t
tolerate eggs and poultry, but they can eat all
the bread they want without any major problems. So going back to that idea
of precision medicine, things are very individualized
for any given patient, and we really need
to keep that in mind when developing a plan of care. So these are just a couple of
resources for a Mediterranean or anti-inflammatory diet. And I do see there are some
people in the audience who don’t come from a Western
background, and the ideas, or the basis for a Mediterranean
or anti-inflammatory diet can very easily be extrapolated into
other cuisines, Mexican food, Indian food, Thai food. So the idea is,
in general, if you look at the base of this
anti-inflammatory food pyramid, the base is green,
leafy vegetables. And next to that, other,
very colorful vegetables. Balanced proteins that are
mostly plant-based or fish, and really limiting,
limiting red meat. And fruits, of course, we
love all the different colors. Particularly in patients
who are diabetic or have cardiometabolic
syndrome, we want to watch the amount of
fruits they’re taking in and be a little
more veggie-heavy. And then there are what
we call functional foods, specific things,
spices, green tea, and other things
that have nutrients that help fight inflammation. So specifically,
omega 3 fatty acids. Everyone hears about
omega 3s and fish oil, and how exactly is
it– or are they– related to inflammation? So these fatty acids are
essential fatty acids. We absolutely need
them to survive. They make our cell membranes. And then when our body
needs to metabolize them into something else, we
snip a little bit out of the cell membrane. The standard American diet
has a ratio of omega and– let me just say,
omega 3, 6, and 9 are all considered
essential fatty acids. However, the standard American
diet has a ratio of 6 to 3, omega 6 to omega 3,
of about 20 to 1. That’s the standard
American diet. Hamburgers, French fries, not
a lot of color on the plate. Eskimos have an omega 3 to
omega 6 ratio of 4 to 1. Ideally, I think a good
anti-inflammatory Mediterranean diet aims for a ratio of
2 to 1 omega 6 to omega 3. And basically, the omega 6
fatty acids, some of them are essential. You don’t need to memorize
this, don’t worry. I’m not going to test you on
it at the end of our time here. But basically, the omega 3
fatty acids, some of them, like the ones that come
from evening primrose oil and borage oil, actually can
go down this metabolic pathway into an anti-inflammatory
chemical. But if you have an
overabundance of omega 6 in your diet, soybean oil,
corn oil, meat, lots of dairy, lots of eggs, it drives
the metabolism down to arachidonic acid, which is
a pro-inflammatory chemical. Arachidonic acid is what
aspirin and ibuprofen blocks the production of. Whereas your omega 3
fatty acids go down a different metabolic
pathway and get metabolized into
anti-inflammatory chemicals. So these diets that are
omega 6-heavy really make patients more
prone to developing chronic inflammation. So one of the other tips
that I tell my patients is just eating a rainbow
of fruits and veggies. And some people are
aren’t used to that, so you will start slow. But the different-colored
fruits and vegetables, they’re colorful for a reason. They have phytonutrients, and
I’ve listed a bunch of them here. I won’t go into too
many detail, but most of these phytonutrients in these
different fruits and vegetables have antioxidant,
anti-inflammatory action, anti-carcinogenic action. So it doesn’t
surprise me when you have a study in rheumatoid
arthritis showing that vegan and vegetarian
diets lower inflammation, and you have a study
that the cardiologist ran that show that vegan and
vegetarian diets decreased risk of heart disease and stroke. These are all different types of
inflammation, some autoimmune, some just chronic
inflammation, but diet plays a huge role in how much
inflammation we have going on. And then my favorite is spices. I love spices. I’m Indian. So one of the thing about spices
is that, it’s a great deal. It’s an upgrade on your meal. You get added flavor and you
get added health benefits with minimal calorie count. So spices are fantastic,
and you can throw things into smoothies, you can spice
your tofu or your salmon. They really add flavor,
they make food enjoyable. I’m a bit of a foodie,
as well, so when I have patients
come to me and we’re talking about cutting out
this and cutting out that, and I’m seeing their face just
dropping because their food is, too. We start talking recipes. And the internet now is
such a fabulous resource for patients who are
thinking about, if not doing, an elimination diet. Just overall improving
their dietary intake and their nutrition. And there’s fantastic recipes
that you can find online. So the gist regarding diet
and autoimmune inflammation. Overall I didn’t talk
much about sugar. I mentioned it once,
but it’s a big no-no. Sugar definitely stimulates
more inflammation in the body through various
different mechanisms. Refined flours and
meat, same thing. I suggest cooking
with more spices, eating a rainbow of fruits and
vegetables, really varying it. Kind of, that has to go
along with the season. Eating more fermented foods,
which, after we’re done today, I’ve brought a little
sample of this fun thing called a gut shot. Eating more prebiotic foods. So prebiotic foods, onion,
garlic, banana, chickaree, Jerusalem artichoke, prunes. These are all foods that
our gut flora just loves. Adding in– if you’re
not vegetarian or vegan, adding in some cold-water,
oily fish to your diet. And drinking more green tea. Justin Sonnenberg, in his
journey towards, I guess, a better microbiome– he was
testing his own stool to see what would happen
with certain changes– started growing a lot
of his own vegetables in his backyard with his
children and with his wife, and kind of followed. They got a dog. They did all kinds
of things to try to sort of improve their gut
flora, go to farmer’s market, join a CSA. So the purpose of
this is multiple-fold. One, gardening can
be very relaxing. Two, it’s probably better
for the environment not having to truck tomatoes
in from Mexico or wherever they come from. And thirdly, if
you’re joining a CSA or some local organic
farmers, you’re supporting the local economy. A note on organic foods. There is currently
not a ton of data specifically on pesticides
and autoimmune inflammation. However, I would probably say
that they’re not good for us. We have all these bacteria
that live in our gut, and many of these
pesticides are used to kill bacteria and fungus
and other things that grow on plants. So when we ingest
different pesticides- glyphosate which is Roundup,
and several other things– we’re doing something
to our microbiome. And we may also be doing other
things to our own bodies, to our hormonal systems
and other things with these ingested toxins. But organic can get pricey, and
so what I tell my patients is, not everything absolutely
has to be organic. And the Environmental
Working Group has this fantastic website,
you can put it on your phone, you can print up a
little card-sized thing to carry in your
wallet, and it has their– it might be
more than 15 and 12 now, but it’s their Clean Fifteen
and their Dirty Dozen of foods that really should be
bought organic and others that are fine if you go conventional,
just give them a good wash. So it’s a resource that I
frequently turn my patients to. And other ways to work around
the expensive little basket of organic strawberries is
frozen fruit and vegetables, that you can get organic
and they’re not as expensive as buying them fresh. And particularly when
they’re out of season, it’s an easy way to get them. And the last thing. Again, I talked about
elimination diets, and I encourage my patients
to keep food journals to see, are there specific
foods that we haven’t tried to eliminate that
might be triggering more inflammation for them? And then the last thing,
which I haven’t noted on yet, is these AGEs. AGEs. Advanced Glycocelation
Endproducts. They are chemicals that age us. They cause oxidative stress in
the body, they can damage DNA. s happen when we cook
food at high temperatures. So you’ve got that lovely
salmon with all that omega 3 and you throw it on
the grill, and it’s got nice little black marks on
it, perfectly lined up, and– we’re good. But you’re feeding yourself
Advanced Glycocelated Endproducts. So avoid cooking at
high temperatures and doing things like
boiling, steaming. It’s a better way
of cooking food that ends up keeping
it healthier. So as a note, one
size does not fit all. So these are sort of general
ideas that I’m giving to you, but really, every patient
has to kind of find what makes them tick
in terms of food. But in general. I love this quote
from Michael Pollan. And in case you haven’t
read any of his books, they’re really fantastic
books, but basically, eat food, not too much,
and mostly plants. And I think that rule kind
of goes for everybody. So in terms of dietary
supplements– and this is always a question I
get from patients is, if I’m eating a
fantastic diet and I’ve got every color of the rainbow,
do I need a supplement? And I often say, the
answer is no, you don’t. But I’ll be the
first to say that I don’t get as much turmeric in
my diet as my grandmother did– we eat Indian food maybe
three times a week– so I take a Curcumin supplement. In terms of omega 3 fatty
acids, I’m vegetarian, I don’t eat fish. I get a lovely algae oil
DHA supplement that I take. And a note about
omega 3s for anybody who is vegetarian or vegan
and who doesn’t eat fish. There are plant sources
of omega 3 fatty acids, but it’s not DHA and EPA. Those are only– those only
come from animal sources. The plant source
of omega 3 is ALA, it’s a shorter-chain fatty
acid, and our body really needs to utilize the DHA form. And as humans, there are other
animals and bacteria and other that convert ALA into DHA very
efficiently, but as humans, we only convert about 6%
to 8% of our ALA into DHA. So particularly in patients who
have autoimmune inflammation, and if they are
vegetarian or vegan, I certainly recommend that
they take on an algae-based DHA supplement. But there is a
lovely caveat, and I think the ancient
Ayurvedic doctors knew this, is that when
you take turmeric, it actually increases that
conversion rate of 6% to 8% of ALA to DHA up to, like, 20%. So there are ways to
improve our DHA intake even if we’re vegetarian or vegan. There are several
other herbs and spices that I mentioned on here. Some of them come from
our Ayurvedic medicine. Vitamin D. I can’t stress enough
how important vitamin D is. We tell patients not to
spend too much time outdoors because of skin cancer and so
forth, and if you are outdoors, cover up with tons
of sunscreen– but it should be a mineral-based
one, not a chemical one. And particularly for
some of our patients who have certain families
of autoimmune disease, lupus and dermatomyositis,
it is actually contraindicated for them to be
out sunbathing– or even not sunbathing, walking from their
car to the grocery store, even a little bit of
UV exposure can trigger flares of their disease. So vitamin D supplementation
for some patients is essential, but it should be done
in a monitored setting, so we’re checking. You can very easily
get toxic on vitamin D if you’re taking too much. I mentioned, on
a previous slide, some different things
that are used to support the intestinal flora. And again, I don’t
think everybody needs to be on supplements. I think, first and
foremost, food is medicine. But some people
might, particularly if they have an
underlying condition, need a little extra support. A little caveat
about supplements is that many supplements can
have a blood thinning effect, particularly fish
oil and curcumin, so if you are taking
those and you’re about to undergo some type
of surgery or intervention, they should be held the same way
you would hold an aspirin prior to the surgery. And there can also be a lot of
drug supplement interactions. So particularly in
patients who are on immunosuppressant
medications, there can be some
negative interactions between supplements. So certainly before
starting anything, I always recommend patients to
check with their practitioner or their health care provider. So we’ll just skip over that. So the next step– so that
was the main thing in body, is really this idea of
gut health and nutrition. And there are a lot
of other aspects to this idea of
body balance, and I think sleep is one of
those that bridges, or straddles, body and mind. Certainly our bodies
need rest, but it also is a rest time for our mind. And for patients who have
chronic pain, whether it’s from degenerative joint disease,
back pain from lumbar stenosis, or autoimmune inflammation,
it’s this vicious cycle of pain making it hard
to get comfortable and waking them up in
the middle of the night, and they’re having this
disturbed, interrupted sleep. And then during the
day, the lack of sleep increases their
sensitivity to pain. So their pain threshold drops. A lot of patients who have
autoimmune diseases can also have other co-morbid conditions
that can affect their sleep, depression, anxiety,
restless leg syndrome– which is often associated
with an iron deficiency. So there sometimes
can be medical causes for some of these sleep issues. And they can have daytime
fatigue and somnolence, they can have poor
work productivity, and besides this pain
issue and fatigue, there is clearly evidence
that shows that lack of sleep contributes to a lot of
other health problems. So it increases risk of
hypertension, diabetes, obesity, mental health
issues, heart disease, stroke, and overall shortens
our lifespans. We actually– I’m not going to
quote it, because I’ll tell you the wrong numbers,
but there was a study that had averaged a certain
number of years taken off your life if you didn’t average
a certain number of hours of sleep. So, show of hands, who
gets on average eight hours sleep every night? Pat yourself on the
back, that is awesome. OK. In this crazy world, most of
the people that I talked to do not get eight hours. Many of them barely get seven. Quite a few of them are
running on empty with five to six hours of
sleep every night, and some even less than that. And if you tag into that sleep
duration, their sleep quality, it’s not a good mix. So specifically sleep and
rheumatologic disorders, there has been research
done in this area. There is a researcher
down at UCLA who has a very special
interest in this. Particular study was done with
some of our own colleagues here at Stanford
through the sleep clinic and the
pulmonary care clinic, as well as some
collaborators at PAMF. And they found that patients
who had arthritis overall slept a shorter amount of time,
had more sleep co-morbidities like restless leg syndrome, and
that their inflammation itself was actually worse. Patients who had partial
sleep deprivation had higher levels of tumor
necrosis factor in aisle 6 the morning after their
partial sleep than a day that they were allowed
to sleep fully. So we know that even
at a cellular level, at the immune level, that
the sleep deprivation can have a very big effect on
the rheumatologist disorders. And my patients will
tell me all the time, I haven’t been sleeping
well, my joints hurt more. It’s a very obvious connection. So often in my clinic,
we talk about sleep, and we talk about
what the issue is. Is it trouble falling asleep,
is it trouble staying asleep? And I always love pulling
out the Ayurvedic clock to share with my patients. And this was something that I– I don’t have special
training in Ayurveda, it’s my next thing
I’m going to do. But even having grown up in a
household where all the home remedies were based in
Ayurveda, I actually had not been exposed
to this until recently, when I met with an
Ayurvedic practitioner. And the idea is that we
all have, in Ayurveda– similar to traditional
Chinese medicine– we have something called doshas. Those are our predispositions. And doshas not just describe
a person’s body type, but also their mental texture,
their emotional texture. And no one person
is all of one dosha. You can be a mix of all three,
or more predominantly one. My dad is almost all
Pitha, I’ll tell you that. Super type A, super thin. I might be a little bit Vata
and Pitha, not too much Kaffa. And so each of these doshas
have certain characteristics that go along with it. But even for any
individual person, certain doshas predominate
throughout the year at different seasons, and
throughout the 24-hour day, certain doshas predominate. So for those
patients who say, you know, I have trouble
falling asleep, many of them are going to bed
at 11:30, 12:00. Well, 10:00 PM, Where are we? This is a 24-hour
clock here, 10:00 PM is when the Kaffa, the
quiet, subdued self is out. And then all of a sudden,
around 10:00 PM, approximately, is when Pitha, the
high-metabolism self, evolves. And during the day
that’s great, that’s our most productive time. That’s when we should
have our biggest meal. But if you go past 10:00 and
you leave the Kaffa dosha and you enter the Pitha dosha
and you aren’t already asleep– and during that Pitha time at
night, your cells are working. They’re regenerating,
they’re doing all the work they need to do that they
can’t do during the day when your body’s moving
and your mind is working. But if you go past
that stage, well, all of a sudden, your
mind is back awake again. Your body’s back awake again. You get your second wind. Has anybody experienced
that second wind? But then your
cellular regeneration that’s supposed to happen during
that time is not happening. 3,000 years ago. This is amazing, and
makes so much sense. It’s one of those things. I love Google Images, so I
pulled up that Ayurvedic clock, and I would encourage you
to go home and read up a little bit more about it. So, tips for getting good sleep. Set a regular time for bedtime. You know, going
to bed at 9:30 one day and 11:30 the
next and 2 o’clock in the morning
the next day, it’s going to mess with your
pineal gland that’s supposed to be
secreting melatonin that tells your body
it’s time to go to bed. So set a regular bedtime hour. Have a bedtime routine. Whether it’s a warm
bath, journaling, reading a book, deep
breathing, guided imagery, essential oils– I love lavender. Avoid eating three
hours before bedtime. Again, our metabolism,
our gut working, is sort of counter to
sleeping and our body resting. Avoid screen time. We love our cell
phones and our laptops and our iPads and
everything else, but this lovely blue light
that comes off of these screens tells our brain
that it’s daytime, and our little pineal gland
doesn’t secrete melatonin. So turn it all off. I just saw a patient
yesterday who said, oh, but I love
my crossword puzzles. I said, they sell them for
$3 at the grocery store, get yourself a paper version. So the screen time
is a huge thing. People don’t realize that
that’s keeping you up. And then making sure
you’re comfortable. I love extra pillows. Having a good neck and spine
alignment when you’re sleeping, making sure the
clock’s not ticking. That’s one of those things
that drives my husband crazy. We’ll be at a hotel and
he’ll find the clock and take the battery
out so it doesn’t tick. And then, if a patient
needs to, then we will use supplements to help
them sleep better until they kind of get into a routine. So melatonin is one
of my favorites, particularly with seniors. Natural production of
melatonin goes down with age, and so many seniors have
difficulty falling asleep– except during the day
it will be 2 o’clock and you see them
there in their chair– but because that’s because
they didn’t get a good night’s sleep the night before. So a lot of seniors do need a
little bit of melatonin support to help keep their
sleep regulated. Valerian hops, lemon balm, 5HTP. A caveat to that is, if you’re
on any kind of anti-depressant, I do not recommend
patients take 5HTP. Passionflower, chamomile,
teas, tinctures, they come in all different forms. Most of them are safe to
use, but again, I always recommend to
patients, before you do anything, talk to
your practitioner to make sure there’s no interactions. So moving on to stress. So back in the day, there’s
that sabertooth tiger, and if you had a good,
strong stress response that told you to run or that told
you to brake really hard when a deer ran in front of
your car, that’s great. That’s survival of the fittest. So a good, strong stress
response through evolution has come down. And nowadays we don’t have the
sabertooth tiger chasing us. We sometimes have a deer
running in front of the car. But it’s this chronic stress
that is there all the time. So we have evolved to have a
very strong stress response, but it’s supposed to be
acute, short-term stress, and instead we have
this strong stress response to what has turned
into chronic, long-term stress. Stress on the body modulates
inflammation in a lot of ways. It has a lot of
other things too. So short-term, acute stress
can actually be beneficial. There were researchers
out of UC Berkeley that found that short-term,
acute stress actually improved certain types
of brain functions, specifically areas of
the hippocampus, which is responsible for our memories. It’d be good to remember which
cave had the angry lion in it so you don’t go back
there again, right? So we’ve evolved that way. So acute stress, good for the
hippocampus, good for memory. Chronic stress, not so much. We secrete more
corticosteroid, more cortisol. That actually causes
down-regulation of certain genes
in the hippocampus, makes our memories worse. And if any patients have
ever been on prednisone and they tell you,
you know, I just– I’m not thinking as clearly
anymore, I have brain fog. There is a reason for that. So chronic stress,
like many of us have been under for the
last 11 months or so, and we might still have
another three years and two months and 10-ish days
more of this chronic stress, I’m hoping that my hippocampus
is affected by that so I don’t remember these four years. But anyways, I digress. So anyways, several
pro-inflammatory cytokines can be up-regulated
in chronic stress. And so there is a lot
of different effects. You have, of course,
mental effects, depression, anxiety, and so forth. And this is modulated
through various different neurotransmitters. You have circadian
rhythm disruptions. So we talked about
sleep already, and stress has such a
huge impact on sleep. We talked about–
well, we haven’t talked about glycemic dysregulation. Diabetes and obesity. Two things that you would think
sleep had nothing to do with. Oh, I should stay
up that extra hour so I can work out and exercise. That’s not going to work. You need the extra
hour of sleep. So there are a lot
of different things that that stress modulates. And so going back to
stress, meditation is probably one
of the things that has been studied
most extensively when it comes to stress. And with meditation,
we’ve seen that people who are intense meditators,
like this lovely Buddhist monk here, that we see
changes in brain activity. We see changes in the frontal
lobe in the hypothalamus like I’d mentioned already, the
hippocampus, the memory areas. You see changes in
neurotransmitter levels, serotonin and
dopamine, in melatonin. So sleep improves
with meditation. And you actually see structural
changes in the brain. So these Buddhist monks
who are really deep meditators and do
it very frequently, they have thicker
volume of their cortex. And then moving on
to sympathetic and parasympathetic. So sympathetic is that
flight-or-fight response with the sabertooth tiger,
and it causes your heart rate to go up, your blood
pressure to go up. And the parasympathetic response
is a relaxation response. Heart rate down, breathing
down, we’re relaxed. And so meditation has
been found to increase our parasympathetic
activity, which has impacts on a lot of our organ systems. And in a lot of
these studies, there are various different
ways to measure parasympathetic activity. One of the ways is looking
at heart rate variability. And now there are a lot of
these fancy little gadgets that you can wear that will
tell you your heart rate variability, and if you’re
stressed out and you can check, oh, my sympathetic
system’s going strong here. Let me breathe. And then you can monitor
your heart rate variability. So for many years, doctors
and rheumatologists did recognize that,
yeah, stress was making their patients already worse. They were coming in
more inflamed after they lost a spouse, or they lost
a job, or the big mortgage issues, and the house
thing, they lost a house. Whatever the stress
was, they found that their disease was flaring. And it wasn’t
until more recently that we understood one of
them– and there are probably multiple mechanisms, but
one mechanism by which this is happening, and
that is a vagus nerve control of the immune system. So you’ve got your brain,
you’ve got the vagus nerve that’s coming down– it kind of follows this
track, cranial nerve 10– follows it down, goes
through the diaphragm, and it innervates the spleen. And at the level of the
spleen, the vagus nerve releases norepinephrine,
a neurotransmitter, and it activates these
suppressor T-cells, T-cells that tell the immune
system, calm down. So when the T-cell gets
turned on by this vagus nerve norepinephrine, it then
secretes acetylcholine, and that’s a turn off a
signal to these macrophages. And macrophages are required. They’re kind of at the top of
the chain for inflammation. They present antigens to
the rest of our lymphocytes, and so if you get your
macrophages to calm down, you can sort of
calm down the rest of the inflammatory cascade. So we now have a very clear
understanding, at least, of how the vagus nerve works. So how do we increase
our vagal tone? We know it’s good
for a lot of things. I’m just talking
about inflammation, but we know risk
of heart disease, and stroke, and diabetes,
and all kinds of other things go down when your
parasympathetic nervous system is more active and your
sympathetic is more calm. So, meditation we
mentioned already. Reflexology. Who loves a good foot massage? Yeah, I do. So, reflexology. We have different nerve endings
that go through our body, and certain pressure
points in the foot can trigger the vagus response. Singing and chanting. The voicebox is right
next to the vagus nerve. So– ohm. That reverberation in
the back of my throat is stimulating my vagus
nerve and calming me down. Singing in a choir in a group
setting, hymns at churches, there’s a reason why a
lot of these practices through different cultures
have come forward. Group singing and chanting
as a part of worship, there was a reason, and
people had better health, and felt better, and were
happier when they did that. Breathing techniques. So deep, diaphragmatic
breathing. I told you, this vagus
nerve, it passes down through the diaphragm. We normally, when we’re
just sitting here, we’re breathing in the
top half of our lungs, but if you take a
nice, deep, slow breath and you push your
diaphragm down, and then you let it all out
and it comes right back up, well, it’s stimulating
that vagus nerve. So again, up-regulating
parasympathetic activity. There are other
breathing techniques that are part of
ancient yoga practices, we call that pranayama. One of them is alternate
nostril breathing, and I’m going to
teach this to you all. It takes two seconds. So do like a hang loose
sign, like you’re in Hawaii, but you’re going to pop
up your ring finger. OK? You’re going to
close one nostril, and you’re going to
breathe in and breathe out. Close, breathe in, breathe out. Simple process. You don’t need
anything but your hand. And we have parasympathetic
nervous endings in the top of our
nasal bridge here that get stimulated when we do
that slow, alternate nostril breathing. Several thousand years
ago that was discovered. I love it. So, laughter. Who’s heard about
laughter clubs? Anyone? So this was a trend– I believe it started in India– and it’s a club. You show up at a park,
other people show up, you decide what time
you’re going to go. And there’s typically a
leader, and he’ll start out. Ha, ha, ha. And then everybody
laughs, ha, ha, ha. And then they try different
forms of laughter. And it’s first forced,
but eventually people are just cracking up,
they’re just laughing. It’s exhilarating, and it’s good
for vagus nerve stimulation. We talked about gut health. I’m not going to go into too
much more detail about that. Intermittent fasting. I can’t claim to understand the
whole physiology of this yet, but intermittent fasting
also stimulates vagal tone, increases vagal tone. So this idea of not eating
right before bedtime, trying to have
dinner around 6:00 PM and not having breakfast
until after 8:00, where you get a good 12 to 14
hours of full, complete fasting has a lot of positive
health effects. How much of that is
through vagal tone and how much is it
through other mechanisms, I couldn’t tell you. Yoga, tai chi, exercise. And then, of
course, my favorite, the implantable vagus
nerve stimulator. How much easier can
it get than that? So I do believe there is an
FDA implantable vagus nerve stimulator that has been
approved for depression. There are several companies
out there that are currently making these
implantable devices that are under testing
for, specifically, rheumatoid arthritis, and it
hasn’t gotten FDA approval yet, but it’s a really
interesting, drug-free, potential intervention
that can help inflammation. So this kind of takes
me onto this junction. So sleep was the junction
between body and mind, and this area of
this the science of psychoneuroimmunology
is this junction between mind and spirit. And this is sort of the
science that thoughts can change gene expression,
which can change structure, which can change
function, which can change phenotypic expression in a
particular patient, animal, whatever you’re looking at. So basically, thoughts are
driving physiologic change. Psychoneuroimmunology. And specifically, in this
case, physiologic changes in the immune system. So the science behind
placebo effect, which we know exists, falls under this idea
of psychoneuroimmunology, but I think there are a lot of
other things in this, prayer, guided imagery and hypnosis,
cognitive behavioral therapy. And for what I do
with my patients, I very often will
suggest guided imagery, whether it’s for
sleeping better, whether it’s for fibromyalgia,
whether it’s for osteoarthritis and pain control, rheumatoid
arthritis and lupus, whatever the case may be. The more organ senses that
you use in your imagery– so you not only
visualize a place, but you imagine
what it smells like and you engage your
sense of smell, and you bite into
that juicy strawberry, so you’re engaging
your sense of taste. As much as you’re imagining and
you’re using multiple senses, the more physiologic effect
that guided imagery will have. So this is the idea
of neuroplasticity. And there is some limited
research done specifically in the areas of pain
and inflammation for guided imagery. There is a website I
frequently send my patients to, it’s,
that has a huge array of guided imagery
that you can download or order a CD for various
different things. Smoking cessation. There is a great
one on there that can help people quit smoking. How are we on time? OK. Just a super quick anecdote,
and this is my n of 1 patient. So my brother had a
congenital kidney issue, and by time he was a
freshman in high school, he essentially had
kidney failure. But he was doing OK,
numbers were fine, so he didn’t get his first
kidney transplant until he was a senior in high school. It was my mom’s kidney. It was not good. He had tons of acute
rejection, had to get massive doses of steroids. This skinny, scrawny Indian
kid, who was probably less than 100 pounds
before the transplant, suddenly gained over 100 pounds. He lost his hips with avascular
necrosis due to the steroids. Eventually, things calmed down. His baseline kidney
function wasn’t fantastic, but it was decent. He didn’t need to
be on dialysis. That kidney lasted
around 12 years, which, for a kidney that started
out kind of with a rocky start, that was pretty good. Fast forward. He’s on dialysis, he’s been
waiting 4 and 1/2 years, he’s having anxiety, he’s
having panic attacks, he’s having a lot
of health issues. And finally he
starts eating better, he starts exercising, mentally,
he’s in a better place. He gets the call, he
gets a new kidney. And I was just
thinking, I’m like, we can’t have a repeat of
the first time around. So I found this woman online
who does custom guided imageries and had her
make one for my brother that was very specific
to his situation. She mentioned
places that he liked to go to relax, my uncle’s
condo in St. Augustine, the park around the corner
where he used to go for a walk. She mentioned his immune
system, loving and embracing this new kidney and
not rejecting it. She mentioned his
bladder getting bigger so he didn’t have to
pee every two seconds. And lo and behold, he
was on minimal steroids, completely off prednisone by
six weeks, and– knock on wood– it’s been smooth sailing. We’re four years out. So that’s my anecdotal
report of guided imagery. In my thought, I
think it likely helped him, and made that transition
with that transplant much better. So actually, it’s
my last two slides. So this is sort of a quick
introduction to how I practice rheumatology, which is how I
think everybody should practice rheumatology– and
not just rheumatology, any patient-doctor relationship. We really need to look
at all of our options, and when we need to really have
this goal of optimizing health, and not just treating
a specific symptom. So I’d like to open up
the floor for questions. [APPLAUSE] Yes? What is your opinion
of farm-raised fish? OK. The question was, what is my
opinion of farm-raised fish? I think, like anything,
we are what we eat, and it depends on
what environment this farm-raised
fish is growing in. In terms of the nutritional
aspect, what they’re feeding, what’s in the feed. If it’s corn- and
soy-based feed that they’re giving these farm-raised
salmon or other fish, they are not going to have
the same omega 3 content as the fresh, wild
salmon from Alaska. And the other caveat of this– and again, it’s this idea
of, you are what you eat. I think food also
embodies the spirit. This the idea of
energy medicine– which is a little bit more
of an esoteric science, but a science none the least. And kind of going back to
the example of my brother, it was another
family’s loss, but he was blessed with this kidney
that gave him a new life. And his personality changed
after he got this transplant, and what I knew of
the young girl who was who donated her kidney,
or who lost her life and then he got
her kidney, I feel like he embodied what people
said of her personality. So in terms of food, food
that has been raised lovingly and– you know, I love these
local farms and supporting CSAs and going to
the farmer’s market, because I think food also
embodies it’s environment. And it’s not just what went
into it, it’s how it was grown. So I don’t have a
black-and-white answer for you, like, absolutely don’t
ever eat farm-raised fish. It’s probably better
than eating a hamburger. And for some patients, a
lot of my patients come from backgrounds where they’re
lucky if there’s something on the table besides,
like, $1.20 hamburger from McDonald’s. So I’m never hard-and-fast
about recommendations. Yes? On your spice chart, I
didn’t see any saffron. Saffron. The question was, on my spice
chart I had excluded saffron. I think it was because
I had missed it. Saffron, actually, there
is some limited data on saffron’s ability to
somewhat suppress the appetite. It’s mixed data, I’ll
be honest with that. There are some positive studies
and some negative studies that noted that saffron
can help with weight loss. And there are also
studies of saffron in terms of mental
health and depression. So certainly I
recommend to patients to use it in their cooking. Laughing spice, it’s called. It’s called laughing spice. In which culture? I’m a cook. You’re a cook? OK. Out in [INAUDIBLE] in the
Middle Eastern countries. Middle Eastern countries. So that’s– [INAUDIBLE] OK. Also, you didn’t mention between
the hot black tea or white tea? So tea. The second question
was the different types of tea, white tea versus
green tea versus black tea. I do think all of
them have benefits. Green tea in
particular has ETCG– I think I got the letters
right, and I’m not going to try to say
the full compound. But it’s the main
compound in green tea that has a lot of
the anti-oxidant, anti-carcinogenic effects. But black tea certainly has– it’s basically a fermented
version of a green tea. It starts out as green tea,
and then it’s fermented and it becomes black tea. And there certainly is data
for black tea, as well. There is some newer
data supporting low doses of caffeine
for cognitive function. I tell patients, particularly
if they’re having sleep issues, to limit their caffeine
intake to the morning hours so that they’re not
affecting their sleep. And white tea? And white tea, I
can’t comment as much. I’m not sure, but I think– [INAUDIBLE] Yeah, I don’t know any of
the new data on white tea. So as a health care provider,
what initial evaluation– is it an hour appointment
with you, or– I mean, we went over
a lot of things, and I’m just trying to
think, in reality, how– So in reality, when patients
do the little survey– I get the lowest
points for wait times. Because I do tend to
run over in my clinic– usually not too, bad
and I try to– but I have an hour for new consults,
30 minutes for follow-ups. And a lot of times we can’t
do it all in one clinic. I think there are a lot
of integrative medicine practitioners that
have the ideal setup. They’ve got a nutritionist,
they’ve got a health coach, they’ve got a
psychologist, or they’ve got this whole team
of providers that are working with
them that can really address all aspects
of care with patients. And I’m sort of a– I mean, I’m in the
division of rheumatology, and I have fantastic colleagues,
but from the standpoint of patient care and
integrative rheumatology, I’m sort of a sole practitioner. So I rely a lot on handouts, and
we do what we can with the time we’re allotted,
and a lot of times it’s not squeezed
into the first visit. Yeah. Back there? Can autoimmune
disease and arthritis be reversed and put into
full remission following good food diet and supplements? OK. So the question was,
can autoimmune diseases be completely put into
remission and, essentially, cured with lifestyle changes? And I’m going to answer
that in a way that may not be satisfying, is yes and no. It depends on the disease. It depends on the severity. I do think, overall,
autoimmunity is– this is the analogy I give
to my patients all the time. Is, it’s the light in the room. So light in the room
is inflammation, and the light switch on
the wall has been turned in the on position, in the up. And with a lot of
our interventions, we currently have a means of
unscrewing the light bulb, whether it’s through
diet or medications or sleeping better
and quitting smoking, but we currently
do not have a means of hitting the wall switch
back in the down position. And that term that we use on
the medical side is tolerance. How is your immune system able
to know and recognize yourself as yourself and leave
you alone compared to recognizing bacteria and
virus and other things that are not supposed to be there? And what happens in autoimmune
disease is, we lose tolerance. Our immune system
starts recognizing parts her own body
as something foreign and causing inflammation
in those parts. So certainly,
patients’ symptoms can be put into remission
with either all lifestyle and dietary changes, depending
on the severity of the disease, or with a combination of
that along with medications, but that underlying
predisposition to autoimmunity may always be there. And genetic predisposition
for autoimmunity is only a small portion of what
occurs when a patient develops an autoimmune disease. I would say– not quoting
scientific numbers, but just throwing out
there, like 20% genetic, but 80% is some type
of environmental insult that triggers the
disease to go on. But really, I have had patients
with mild rheumatoid and mild lupus in whom we’ve
really strongly addressed their diet and their
lifestyle, and either with no or minimal medications,
they’re doing great. And then I have
other patients who have been so fantastic
about being true to a diet, and they’re sleeping better,
and they quit smoking, and whatever else, and they
just have a rip roaring autoimmune disease that requires
some heavy-duty medications. So we see both things. Yeah. What’s the applicability
to osteoarthritis? Good question. So, what’s the applicability
to osteoarthritis? If you look at cartilage
under a microscope, or you measure certain cytokine
levels within synovial fluid– that’s the joint fluid–
like for tumonecrosis factor, or some of the interleukins,
you’ll actually see elevated levels in an osteoarthritic
knee compared to– like, matrix
metalaproteinase There’s a lot of other
chemicals that we’ll see in an osteoarthritic joint
that is not in a normal joint. And so the difference
between rheumatoid and osteo often is that the inflammation
in an osteoarthritic joint, a lot of it is being
triggered locally. There is damage
to the tissue that stimulates an inflammatory
response there locally. Like, you know, if
you cut your arm, well, your immune
system cells are going to come in there to
try to repair the damage. Whereas in rheumatoid
arthritis, it’s kind of like a headquarters
that says, OK, sending the immune system cells
out to cause inflammation in specific parts of the body. But a lot of these
lifestyle changes are definitely applicable
to osteoarthritis. There is limited data,
but positive studies for turmeric– for
curcumin, which is the active
component of turmeric– there are studies looking at
boswellia and inflammation and osteoarthritis. I do feel, overall,
however, osteoarthritis is a chronic
degenerative condition that has not been
studied as extensively as rheumatoid arthritis,
and there’s not as many drug companies or
others interested in developing great cures and treatments. So whereas we have a whole
armamentarium of treatment choices and options for RA,
we don’t really have as much for osteoarthritis. But we have some
fantastic researchers. Bill Robinson, in our
division, has a huge interest in osteoarthritis,
and is looking more at the pathophysiology so
that, if you catch it early, can you arrest it and
keep it from progressing? He’s doing translational
work in that area. Any the other questions? Yes. Do you think that things
such as cat’s claw, is it psychosomatic or
can it have a real effect? So the question was,
supplements like cat’s claw, is it a psychosomatic
sort of effect in terms of improving pain,
or is it a real thing? So I would say, number
one, does it really matter so much if
you’re feeling better? Number two, specifically
for cat’s claw, it can have a little
bit of an effect, kind of like a non-steroidal
anti-inflammatory. So if used in high doses,
similar to Advil, Motrin, Aleve, it can cause GI
ulcerations in some patients. So cat’s claw needs to
be used judiciously. But I do think cat’s
claw specifically does have some anti-inflammatory
effect, however. So it likely is effective
apart from a placebo effect. But to give you an
example of placebo, I can’t remember if it
was Paxil or Zoloft, one of these anti-depressant
medications that was studied
20 some years ago, it got FDA approval for
treatment of depression, but it was pretty much as
effective as the placebo in the studies. So another placebo
is, back in the day, orthopedic surgeons used to
go and do these cleanouts. You had osteoarthritis,
well, they went in and did some nip and
tuck and clean things out. So I believe it was somewhere
in Texas, maybe about 10 years ago or ago, they did a
study of sham surgery. And the patients
went into this study, they had to sign
on the dotted line, they had to give their
consent, yes, I’ll sign up. So they knew they
had a 50/50 chance of getting the real surgical
cleanout versus getting a sham surgery. The patients go to the OR,
they get three little incisions on their knee. Some of the patients got the
full arthroscopic cleanout, the other ones only
got the three incisions and then they were sewn up. No difference in
pain and no mobility. Four weeks, three months,
and six months, I think, were the time periods, but
don’t quote me on that. [INAUDIBLE] study? I don’t recall, but
it was big enough where orthopedic
surgeons stopped doing arthroscopic cleanouts. Now, if you had a
meniscal tear, or you had synovitis that
needed to be cleaned out, that gets cleaned out. But just the– you’ve
got osteoarthritis, let’s get in there
and smooth things out, that is not being done anymore. So the power of
placebo is very– there is there’s a man who’s–
and I’m blanking on his name. He’s written an entire
book about the science behind placebo effect. Any other questions? Yes. The website for guided imagery? She’s a fantastic woman,
Belleruth Naparstek. She has a very soothing voice. There are also a lot of other
guided imageries on there. My kids sometimes used
to have trouble sleeping, so there’s one
called Sleep Fairy. It’s fantastic. The things that you talk about,
does that also apply to thyroid issues like Hashimoto’s? The question was, if
anti-inflammatory– these approaches
apply to Hashimoto’s. So autoimmune thyroid disease,
it still is autoimmune. There have been
some small studies– they’ve yet to be validated
and repeated, replicated– that showed that
a gluten-free diet lowered the antithyroperoxidase
levels in Hashimoto’s patients. I certainly think, regardless
of whether somebody has Hashimoto’s, following an
anti-inflammatory lifestyle has broad health benefits. Whether or not following these
anti-inflammatory practices and an anti-inflammatory
lifestyle reduces your risk of developing
hypothyroidism in years down the road if you
currently have Hashimoto’s, I don’t know the data for that. But I think these
basic lifestyle things apply to everybody. They really do. No matter what you
have, if you want to live healthy and
vital and strong, and sleep well, and be
energetic, and be productive, I think it applies to everybody. Anybody else have
any other questions? We’ve got your samples
over here [INAUDIBLE].. OK. Hashimoto’s [INAUDIBLE] I mean,
specifically, [INAUDIBLE].. That’s a huge diet change. Is that necessary? I don’t know the data for
Hashimoto’s specifically. And I’ll be honest, for a lot
of our autoimmune diseases, we just don’t have the data
to say, eliminate X, Y, and Z and disease Z or– what letter– A will get better. We have trial-and-error
with patients. Now, if you have
big joint swelling, or you’ve got skin rashes, or
you have specific numbers, CRP or sed rate that’s elevated,
it’s pretty easy to monitor. If you have Hashimoto’s,
it’s really hard to say– you could follow thyroproxidase
antibodies, certainly, and like I said, there
was that one study that showed that gluten-free
diet did lower the thyroproxidase
antibodies, but I don’t know if there’s
data for the other things. Yeah. So I brought a little treat. It’s a probiotic
and a prebiotic. So we’ve got prunes. If you’re prone to
healthy bowel movements, maybe you want to
avoid the prunes. And I would say stick with one
unless you really need more. And then the probiotic
is this lovely drink, it’s called a gut shot. They sell it at Costco. It’s a beat ginger,
so you’re getting all kinds of fun antioxidants
and trace minerals. Beets are super high in
manganese and magnesium, they’re high in an antioxidant– and I’m going to
blank on the name. It’s on my PowerPoint. That deep red color
is great for people. There’s ginger in this gut shot. It’s tart and it’s
a little bit salty, but one shot has about 10
billion CFU of life culture. So help yourselves. What’s the recommended
dosage of probiotic? There is no standard
recommended dose. It hasn’t been established. What do you usually
start people with. If I– and I’ll tell you, this
is not based on any studies. It’s kind of what I’ve
been doing anecdotally. If I’ve had patients who
have had a ton of antibiotics for whatever reason,
I’ll start them off on a pretty hefty dose, 35
to 50 billion CFUs, just to try to replenish
things– that seed part. Is there specific
data on how much? If there is, I’m
not aware of it. I haven’t dug through
the literature to know if there are
specific numbers. For patients just sort
of on maintenancing, I certainly recommend eating
a lot of fermented foods. I didn’t mention– I mean,
I mentioned this gut shot, but sauerkraut, yogurt, kefir. And if you’re
dairy-free, then you can make coconut milk yogurt. We do that at home all
the time, it’s delicious. And then beet kvass, miso. There are a lot of different
sources for fermented foods that provide
naturally-occurring probiotics, but if you want to take
an extra support pill, then I usually say, like,
5 to 10 billion CFU. A Again, not based on
any specific studies. Yeah. You mentioned stimulation
for vagus nerve. Is it something [INAUDIBLE]? Is it a device? The question was about the
vagus nerve stimulator. There is an FDA-approved
nerve implantable vagus– so it’s a surgery. It’s a surgery. It’s an implantable
device that’s been approved for depression. An implantable
device is currently under study for
rheumatoid arthritis. And I do know there’s
a study at Stanford looking at an
implanted vagus nerve stimulator for gastroparesis. So there could be a lot
of potential indications, or places where this might work. But there’s so many ways that
we can stimulate the vagus nerve without having surgery, so
singing, laughing, meditating, all of that. So anyways, the back table
there, help yourselves. And I think we’re going to
stick some of my business cards over there, as well. Thank you. You’re welcome. [APPLAUSE]

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