A new paper entitled, “Impaired Vagal Activity in Long-COVID-19 Patients” sheds light on the vagus nerve’s involvement in Long-COVID-19.

COVID-19 is divided into three phases of infection:

1. “Acute COVID-19” (signs and symptoms of COVID-19 infection up to 4 weeks).

2. “Ongoing symptomatic COVID-19” (from 4 weeks up to 12 weeks).

3. “Post-COVID-19 syndrome” (signs and symptoms persist beyond 12 weeks).

Click here to learn more about the Hedberg Institute Membership.

Study Methods

30 Long-COVID-19 patients were compared to 20 control subjects who never had COVID-19.

21 patients were classified based on their experience while having COVID-19 as mild/moderate and 9 as severe/critical.

7 patients had no/negligible functional limitations, 6 had slight functional limitations, and 17 had moderate/severe functional limitations.

No significant differences were found among study subjects and controls regarding gender, demographics, medical history, drug use, and vital signs. However, previous studies have shown that females are more affected by Long-COVID-19.

Heart rate variability was measured through ECG. Heart rate variability parameters are controlled by the parasympathetic nervous system.

The sympathetic nervous system promotes inflammation through catecholamines and beta-adrenergic stimulation in contrast to the parasympathetic nervous system which is anti-inflammatory. COVID-19 causes an imbalance between these two systems, thus driving inflammation and a procoagulative state.

Study Findings

Heart rate variability was found to be lower in the Long-COVID-19 patients.

Left ventricular ejection fraction was lower in Long-COVID-19 patients.

When SARS-CoV-2 comes into contact with the eye, it may reach the central nervous system via the trigeminal nerve. And when the virus contacts the nasal mucosa, it may reach the brain through the olfactory nerve. It may also travel to the central nervous system via the vagus nerve from the respiratory system, the heart, the digestive system, the kidneys, bladder, uterus, and testicles. This occurs through neuronal retrograde transport to the axonal terminal.

SARS-CoV-2 has been detected in the vagus nerve, thus persistent damage to this nerve could explain impairment of the parasympathetic nervous system in Long-COVID-19 patients.

SARS-CoV-2 can also invade the brain through a dysfunctional blood-brain barrier, which has been damaged by cytokine storm.

SARS-CoV-2 binds to the ACE2 receptor found in the respiratory airway, lung, vascular endothelia, kidney cells, and small intestine. ACE2 receptors are also found in neurons and glia in the brainstem regions responsible for cardiovascular function and regulation.

SARS-CoV-2 neuronal invasion drives epinephrine and norepinephrine from the adrenal gland known as the “catecholamine surge” which causes cardiovascular, lung, and brain injury.

NT-proBNP levels were found to be increased in Long-COVID-19 patients, which reflects myocardial strain due to increased vascular pressure. This persistent myocardial strain may drive the dysautonomia, or it could be due to increased ischemia and inflammation.

D-dimer can have prolonged elevation in Long-COVID-19 patients, which can lead to increased thromboembolic complications.

Dysautonomia, neurotropsim, inflammation, and the persistence of a procoagulative state with an elevated myocardial strain may explain vagus nerve impairment in these patients. However, the authors state, “...it remains unclear whether dysautonomia associated with Long COVID-19 directly results from post-infectious immune-mediated processes or from the autonomic-virus pathway.”

The authors call for research on evaluation of cholinergic nerve fiber damage in Long-COVID-19 patients to confirm impaired vagal activity.

How to improve vagus nerve function?

I have patients do a variety of exercises throughout the day such as singing, humming, gargling with water,

Histamine is often overlooked as a cause of chronic health problems yet the fix for this issue can be quite straightforward. In this article, I cover the details of histamine and how to follow a low histamine diet.

Histamine intolerance (HIT) affects approximately 1% of the population. Approximately 80% of those affected are middle-aged.1 Histamine intolerance occurs when an individual has more histamine in their system than they can breakdown. Excess systemic concentrations of histamine can result from overproduction, overconsumption, and/or having a reduced ability to clear out histamine from the body. For those with HIT, eating a diet that results in increased histamine can contribute to chronic inflammation due to the ongoing exposure to histamine. This excess histamine often accumulates as a result of decreased diamine oxidase (DAO) activity.2, 3 The resulting excess histamine contributes to the physical symptoms associated with HIT. Following a low-histamine diet along with supplemental DAO is often recommended to decrease the symptoms associated with HIT. Eating a low-histamine diet involves more than simply eliminating foods that are high in histamine. This article will help to explain the challenges with following a low histamine diet and will highlight the many ways excess histamine can occur in food and in the body.

Histamine Synthesis and Degradation

Excess histamine concentrations may be exogenously released from food or endogenously produced. Histamine is synthesized by a variety of cells in the body including mast cells, basophils, platelets, histaminergic neurons, and enterochromaffin cells. Endogenous histamine is released in response to a variety of immune and inflammatory related stimuli as well as certain foods, alcohol, or drugs which can activate release.1 Endogenous histamine supplies are also controlled by genes that code for the enzymes that synthesize and degrade histamine. Genetic polymorphisms in histamine receptors and DAO can decrease the rate of DAO activity, reducing the rate of clearance and increasing systemic histamine concentrations.3 Exogenous sources of histamine mainly comes from ingested foods. Several factors in food processing and storage can increase the histamine content of certain foods as well.

Histamine is normally metabolized by amine oxidases in healthy individuals. These amine oxidases include monoamine oxidase (MAO), DAO, and histamine N-methyltransferase (HNMT), with DAO being the primary enzymes for metabolism of histamine.5 It is thought that low gastrointestinal levels of DAO contributes to an individual being unable to break down histamine in the intestines, resulting in the increased sensitivity to histamine found in common foods. As excess levels accumulate, intolerance symptoms develop.1, 2, 6, 7

Symptoms Associated with Histamine Intolerance

There is great heterogeneity in the presentation of symptoms in those with HIT, making it difficult to define a clear clinical picture. Histamine intolerance is generally suspected when symptoms appear after the ingestion of histamine containing food.3 Symptoms may develop immediately or can be delayed as much as three hours following ingestion.5 Histamine receptors are found ubiquitously throughout the body, making different organ systems susceptible to adverse reactions due to excess histamine concentrations. This results in a wide variety of symptoms that may be exhibited by an individual, contributing to the difficulty in diagnosis.

These symptoms include gastrointestinal issues such as abdominal pain, bloating, diarrhea, and constipation. Extraintestinal complaints may affect neurological, respiratory, dermatological, and/or hemodynamic systems.2 Histamine has vasoactive properties that may result in flushing, headaches, and/or hypertension.5 Other common symptoms related to HIT include brain fog, fatigue, dizziness, itching, and difficulty swallowing, low blood pressure, nasal congestion, sneezing, and menstrual cramps.2, 3

Low-Histamine Diet and DAO Supplementation

Following a low-histamine diet along with DAO enzyme supplementation is currently the recommended strategy to prevent the symptoms associated with HIT. Sanchez-Perez et al. (2021) reported a >70% efficacy rate among the clinical studies examined in their review of low-histamine diets. They also found that only 32% of the excluded foods in a low histamine diet contained histamine.  Foods containing other biogenic amines (BAs), like putrescine, were thought to be responsible for the increased symptoms related to HIT. They state that it is possible that certain foods, while containing no or low levels of histamine, may act as histamine liberators resulting in excess accumulation of histamine.2 There is also great heterogeneity in the foods recommended for a low-histamine diet. Fermented food products and beverages were consistently recognized as a primary food group to be avoided.

Decreasing the amount of histamine in the diet has been shown to decrease symptoms related to HIT. Following a low histamine diet can be confusing as there is a lack of consensus as to which foods should be included versus excluded. It can also be difficult for individuals to monitor the intake of histamine from the diet as there are no labeling requirements on foods for histamine.2 The daily intake of histamine, on average, is 1000mg/kg. Healthy individuals should be able to metabolize this amount without any problems.5 The recommended range for those undertaking a low-histamine diet is between 5-50 mg/kg.  Some experts suggests that even lower levels are necessary and recommend an intake of foods with histamine levels below 1 mg/kg.2 Supplementation with DAO may also prove beneficial in reducing symptoms. Manzotti et al. (2016) demonstrated that individuals with DAO activity <3U/mL were highly likely to have HIT and those with DAO activity <10 U/mL were likely to be intolerant. Histamine intolerance was not expected in individuals with DAO activity >10U/mL.8

Biogenic Amines and a Low-Histamine Diet

Fermented foods (cured cheese, sausages, fish, fermented foods, certain vegetables) and fermented beverages (wine and beer) contain biogenic amines (BAs). These BAs are produced when amino acids undergo decarboxylation by substrate specific decarboxylase enzymes.5 The BA, histamine, is formed from the amino acid histidine. Other common BAs in foods include tyramine, putrescine, phenylethylamine, spermine, spermidine, cadaverine, and agmatine.5, 9  High amounts of histamine have been found in semi-cured and grated cheeses—particularly parmesan and bleu cheese, fermented foods such as fish paste and fish sauce, sauerkraut, fermented soy products, and cured sausages.2

The BA tyramine is found in some aged cheeses and can be related to increased symptoms such as increased blood pressure and migraines in HIT individuals.3 Other substances and foods may affect histamine levels. Foods high in putrescine (citrus fruits, bananas, and fermented foods—sausages, soy products, and cabbage) may interfere with DAO activity in the intestines.2 Food sources of putrescine may also enhance the toxic effects of histamine.5 Foods high in any of these BAs should be avoided on a low-histamine diet as they may affect the metabolism and degradation of histamine.3

Alcohol and Nutritional Deficiencies May Affect Histamine Levels

Alcohol and certain medications may elicit a release of histamine or inhibit MAO and DAO.5, 1 Consumption of alcohol can also increase the toxic effects of histamine. This results in competitive inhibition as the acetaldehyde produced in the breakdown of alcohol competes with histamine for the enzyme aldehyde dehydrogenase, resulting in increased histamine.2 It is worth noting that a deficiency in any of the cofactors needed by the enzymes used in the metabolism of histamine may impair its biotransformation and elimination, resulting in increased systemic levels of histamine as well. Therefore, nutrient deficiencies may need to be addressed for those that do not get sufficient relief solely from dietary avoidance of histamine-rich foods. For example, cofactors used by DAO include copper, vitamin C and Vitamin B6. A deficiency in any of these would affect DAO synthesis.3

Factors Affecting Histamine Levels in Foods—Length of Storage, Temperature, Vacuum Packing, and Additives

It is impossible to completely eliminate histamine from the diet. There are many factors that determine the content of BA and histamine including freshness, pH, food source, salt content, content of proteins, processing and storage. There are several factors involved during the manufacturing process that affect the BA concentration in foods. Increased storage times increases the amount of BAs formed by the microorganisms present in food during storage. For those with HIT it is important to choose fresh foods sourced with a minimal amount of contamination prior to and during processing. Choosing foods as fresh as possible helps decrease the histamine content, providing less time for the creation of histamine from the increased bacterial decarboxylase activity seen during storage.2 Foods with a shorter period of fermentation may also have lower BA levels. Several bacterial groups have been shown to have decarboxylase activity and can thereby increase BAs and histamine specifically. These include yeasts found in cheeses and some bacteria species found in seafood, wine, fermented soy products, and  yogurt.2, 5

An increase in BAs is also noted as storage temperatures increase. It is therefore a good idea to keep histamine-rich foods chilled during storage. Storing and processing fish at or below temperatures of 39.9 degrees Fahrenheit has been shown to decrease the amount of histamine that is formed.5

Choosing foods that have been vacuum packed may also decrease the amount of BAs that develop during storage, though some studies show no benefit to this type of storage.

The National Institutes of Health (NIH) states that five out of every 100 Americans over the age of 12 have hypothyroidism. The prevalence of this disease increases with age.(1) This makes hypothyroidism the most common disease arising from a hormonal insufficiency.(2) Gender is an influencing factor, as women are three to seven times more likely to develop hypothyroidism than men.(1) Known risk factors that increase the likelihood of developing this disease include having a family history of hypothyroidism and pregnancy.(1) Recent research by the British Medical Journal (2021) suggests that taking birth control pills, or oral contraceptives (OCs), may also increase the odds of developing hypothyroidism.(3)

Birth Control Pills Statistics

Oral contraceptives are a widely used form of birth control by women. Many individuals turn to these medications for reasons other than birth control such as relief from symptoms such as abnormal uterine bleeding, endometriosis, hormonal and menstrual irregularities, etc.(3)Approximately 6 million women in the US, aged 15-49, take oral contraceptives (OCs) each year.(4) The National Survey of Family Growth (2015-2017) reported that OCs are the second most common method of contraception used by women between the ages of 15-49.(4) The use of OCs is higher among younger populations and decreases with age. Approximately 90% of women taking birth control pills are < 40 years old and 54% are under the age of 20.(1)Therefore, an association between the use of OCs and the risk of hypothyroidism could potentially affect a significant number of individuals. These individuals, when presented with other options for contraception and/or better monitoring of thyroid function, may be able to avoid the increased risk of morbidity and mortality associated with hypothyroidism.

Birth Control Pills and Risk of Hypothyroidism

The British Medical Journey (2021) recently stated that women with a history of taking OCs for more than 10 years have greater odds of developing hypothyroidism (OR, 3.837; 95% CI 1.402-10.500; p=0.0090). Their finding was the result of a retrospective, cross-sectional study derived from information gathered in the National Health and Nutrition Examination Survey (NHANES) 2007-2012. This large epidemiological survey included a total of 30,442 participants. Of this number, 5116 females met the inclusion criteria for participation in the study. These individuals were divided into two groups: those with a history of OC usage (n=3034) and those that had never used OCs (n=2082).

Approximately 16% (830) of the combined individuals were identified as hypothyroid. Hypothyroidism was more frequently diagnosed in those with a history of taking OCs (17.7% vs 14.1%). The state of being hypothyroid was defined as either those taking levothyroxine, regardless of thyroid stimulating hormone (TSH) or those with a TSH >5.6 mIU/L.(3) Women should therefore consider the long-term health effects of OCs and the increased odds of developing hypothyroidism associated with their use.

This study had several strengths, including the large population surveyed, and the strict criteria used to control for confounders. Limitations were also inherent in this type of study. One of the main limitations is the lack of data to differentiate between the types of OCs used, including their chemical composition. Knowing the types of contraceptives used, i.e.: combined contraceptives containing estrogen and progestin versus progestin only contraceptives, may have provided different outcomes. Other limitations included possible recall bias due to the use of self-reported data from individuals, which can often be incorrect. These factors may have skewed the results obtained. It is also important to recognize a cross-sectional, retrospective analysis can only demonstrate an association between the OCs and hypothyroidism and cannot establish causation.(3)

According to the National Institute for Health (NIH), hypothyroidism can be mild and present with few symptoms.(1) Common hypothyroid symptoms include constipation, weight gain, fatigue, lethargy, cold intolerance, change in voice, and dry skin.(1),(2) Other symptoms may include depression, anterior neck pain, dizziness, wheezing, hair loss, difficulty swallowing, restlessness, palpitations, shortness of breath, and mood lability.(5)  The presentation of these symptoms decreases as an individual ages, making symptomatology an unreliable diagnostic tool for individuals over 60.(5) For this population, tiredness and respiratory issues are the prevalent symptoms that may signal the onset of hypothyroidism.(5) The non-specific nature of these symptoms contributes to the difficulty of reaching a definitive diagnosis. Including the prior use of OCs in a patients’ history may help identify those with increased odds of developing this disease.(3)

Oral Contraceptives Increase Thyroxine-binding Globulin

The estrogenic effect of OCs has been shown to increase various proteins synthesized by the liver involved in processes such as atherosclerosis, hypertension, and thrombosis. These proteins include thyroxine-binding globulin (TBG), sex hormone binding globulin (SHBG), and coagulation factors.(6) Torre et al. (2020) reviewed the effect of OCs on the hepatic production of TBG and the coinciding effect on serum levels of thyroxine (T4) and triiodothyronine (T3). They stated that increased estrogen resulted in decreased TBG renal clearance, which led to an increased amount of TBG available for binding to thyroid hormones. The increased TBG resulted in increased binding of T4 and T3 and therefore an increase in TSH and thyroid hormone synthesis.

Thyroid hormone synthesis is controlled by the hypothalamus and the anterior pituitary. The hypothalamus releases thyrotropin-releasing hormone (TRH) which stimulates the anterior pituitary to release thyroid stimulating hormone (TSH). An increase in the concentration of TSH triggers the thyroid into producing the iodine containing hormone thyroxine (T4). This T4 is converted to the biologically active form, triiodothyronine (T3), in peripheral tissues.(6)

The majority (99.8%) of circulating T4 and T3 are bound to serum proteins, with 70% binding to the high affinity, low concentration, protein—TBG. The remainder binds to the low affinity proteins—transthyretin (TTR) and albumin.(6) This binding is necessary for their transport in the blood stream as well as the extension of their half-life. These bound T4 and T3 hormones are unavailable to tissues, making them inactive.(7) An increase in the concentration of TBG, as has been noted with the use of OCs, can therefore impact the concentrations of total thyroid hormone available for use by binding up more T4 and T3. The body produces more TSH to try and make more hormone available. As this TSH level continues to rise, hypothyroidism develops.

A review conducted by Torre et al. (2020) concluded that an increase in estrogen production in the body, either through OCs or hormone replacement therapy (HRT) was shown to increase TBG and T4.  They stated that the serum concentrations of TBG increased due to an increase in salicylation stimulated by the natural estrogens. They observed a 30-50% increase in TBG concentrations and a 20-35% in T4 concentrations within two weeks of beginning standard dosages of OCs (ethinyl-estradiol—20-35 ug/d; conjugated estrogens—0.625 mg/d). Due to the increased binding of thyroid hormone to the increased TBG present, it was necessary to increase the dosage of Levothyroxine by ~45% to maintain normal TSH concentrations in those being treated for hypothyroidism and in pregnant women.(6)

It is important to note that this increase in TBG and T4 was only observed with oral administration of estrogen. Transdermal applications did not alter TBG or T4 levels. Adding progesterone to the OCs did not alter the change in TBG and T4 concentrations observed. Progesterone, when used alone, acted in an opposite fashion, and was shown to decrease TSH levels and increase FT4 levels. Progesterone based OCs, therefore, were found to be a safer choice for those with or at risk of developing hypothyroidism.(6)

Oral Contraceptives Increase the Risk Of Venous Thromboembolism

Torre et al. (2020) also reported a three to eight times higher risk of venous thromboembolism (VTE) in those that used combined OCs (estrogen and progesterone) compared to those that did not. They noted a positive correlation was found between increased levels of TBG and increased levels of activated protein C resistance (APCR), linking increases in both to an increased risk of venous thromboembolism (VTE). Using combined OCs (estrogen and progesterone) was associated with an even higher risk than estrogen alone. As previously noted with estrogen-based OCs, the transdermal application of estrogen and progesterone was not linked to an increased risk of VTE, making transdermal application a safer choice for those at risk.(6)

Subclinical hypothyroid (SCH), defined as normal FT4 and elevated TSH levels, has been associated with an increase in mean platelet volume (MPV) and an increase in pro-thrombotic events. Abnormal lipid profiles and hypertension have also been observed in SCH individuals. The larger platelets present with an increased MPV have increased metabolic activity and an increased potential for thrombotic events. An elevated MPV can therefore be used as a useful predictor of cardiovascular disease (CVD) and VTE. As TSH increases, so does the risk of abnormalities associated with CVD including dyslipidemia, hypertension, and increased markers of inflammation (C-reactive protein).(6)

This increased risk of CVD and VTE with hypothyroidism, whether clinical or subclinical, necessitates the monitoring of thyroid status for those on OCs.

In this episode of Functional Medicine Research, I interview Palmer Kippola on how to beat autoimmune disease and her new book "Beat Autoimmune: The 6 Keys to Reverse Your Condition and Reclaim Your Health". We had a great talk walking through her F.I.G.H.T.S. protocol which includes food, infections, gut health, hormones, toxins, and stress.

Our focus in this interview was on practical strategies for those with autoimmune disease to implement right away into their lives. Palmer has dealt with autoimmune disease herself, so she offers a unique perspective.

Full Transcript on How to Beat Autoimmune Disease with Palmer Kippola

Dr. Hedberg: Greetings everyone, and welcome to "Functional Medicine Research." I'm Dr. Hedberg, and I'm looking forward to my conversation today with Palmer Kippola. She's a best-selling author, speaker, and functional medicine certified health coach who specializes in helping people reverse and prevent autoimmune conditions. She developed a framework called F.I.G.H.T.S, which stands for food, infections, gut health, hormone balance, toxins, and stress to help others beat autoimmune conditions based on her two-decade battle to overcome multiple sclerosis. Her book is "Beat Autoimmune: The 6 Keys to Reverse Your Condition and Reclaim Your Health," with a foreword by Mark Hyman. And as she shares the science stories and strategies to help people heal and thrive, today she provides total health transformation programs for people who seek to heal from any autoimmune condition by addressing the root causes head-on with functional lab testing and comprehensive mind-body strategies. She also serves a growing community of people in a guided online membership program called Beat Autoimmune Academy. Palmer, welcome to the show.

Palmer: Thank you so much, Dr. Hedberg. It's such a pleasure to be here.

Dr. Hedberg: Right. So, as I mentioned in the bio, you dealt with multiple sclerosis. So, I'm sure there's a story there. So, why don't you walk us through your healing journey, what that was like, and that whole process?

Palmer: Sure, sure. I do need to take you back in time a little bit because I was diagnosed at 19. Let me tell you the story. I was a happy, healthy, well-adjusted 19-year-old, by all accounts. I was home for summer after my freshman year of college, and I was working as a hostess in a restaurant. And one day I woke up and the soles of my feet were tingling, like that feeling you have when you've slept on a limb too long, when the blood flows back, it gets all tingling. But this particular morning, the blood wasn't flowing back. But I thought it'll just go away, so I went off to work. And the tingling just continued to creep up my legs like a vine. It got to my knees and by that time, I knew something was really wrong. So, I called my parents who called the family doctor who said, "Get her over to the neurologist at UCLA today." And we did. That's where we were that afternoon. And this particular neurologist had me do really simple heel-toe walking across her floor and tapped my reflexes. And after about five or six minutes, pronounced that she was 99% certain that I had MS, multiple sclerosis. And if she was right, there was nothing I could do except take medication. And we were absolutely shocked. Remember, this was in the mid-80s, so there was no guidebook, there was nothing. We had never heard of MS.

And we just left that office completely confused, devastated, and with very little hope. But I was sent home and that night, my mom lay in bed with me and she was holding me and I was crying and she was crying and it turned out that all of the parts of my body that had been tingling, which by the time I got to the neurologist's office, it had reached right under my collarbone, so all the way up, full body. And then by the time we got into bed that night, all my body went completely numb from the neck down and I would stay numb for a full six weeks. So, an absolutely terrifying first experience, not having any information, not having any idea how this came on, or what my future was gonna look like. But that summer, the Olympics were on TV and I was really grateful because that's about all I could do is lie on the couch and watch the Olympics.

And I do have to say that I'm so grateful that my parents were so supportive and rocks and I had friends that came by and brought gifts, like, you know, 19-year-old friends do, books and watch movies with me. But this one family friend who was into things metaphysical came and asked me a question, which at the time I didn't think was a gift, but it turned out to be the guiding light for the rest of my life because she asked me the question, "Palmer, why do you think you've got the MS?" And I was incensed like, "How dare you? What do you mean why do I think I got this? Are you accusing me of doing something that brought this on?"

So, I lay there like a dog with a bone just chewing on that question. And it did come to me in a flash of insight as I lay on the couch. So, I'm 19, I'm on the couch, and I just need to take you a tiny bit farther back in time because I had been adopted at three days old by very loving parents. But my dad had been a fighter pilot and his way was proverbially the right way and so we butted heads quite a bit. He was verbally abusive, very judgmental. And the earliest memory that I had that came to me in that flash of insight lying on the couch was my dad is calling my mom names, she's locked herself in the bedroom, and I can't remember if I'm three or four, but whatever, I'm standing with my little dukes up with words to the effect of you call my mom names and I'll suck lights out. So, I had become this little child warrior. And that had meant that I wasn't sleeping through the night, I developed insomnia because I was always scanning the environment for safety. So, that initial hypothesis of why I got the MS of chronic stress still rings true for me today, even though I know there's much more to the story. So, I'll pause for a moment and see if you have any particular questions at this point.

Dr. Hedberg: Right. Well, we often see that strong adverse childhood experiences or some kind of ongoing stress or a stressful event as a major player in the triggering event and that could be a single event or like I said, something ongoing. And we're just so vulnerable as children as our immune systems and central nervous system is developing. And so, I'm sure you see it with the people you work with and we often see something like that that leads up to the development of an autoimmune condition. So, that must have been really scary, especially something like MS because I've seen MS patients in wheelchairs and there's some pretty devastating effects for some individuals who have MS as it progresses. So, did you do anything else other than focusing on nutrition and lifestyle to help you get through that?

Palmer: Sure. Well, I can address that. You're absolutely right. I do wanna add that after we left the neurologist's office, the neurologist held my parents back and said to them privately, "You better get ready for her life in a wheelchair because that's where she's heading," which just you know, makes me angry. But that's the best that some have to offer and that certainly at the time, the best that could be done. So, yeah, I did multiple experiments over the years. I was fortunate that the numbness faded enough for me to go back to my sophomore year of school. So, it didn't completely go away for a couple of years, but I was functional. I could walk and I had good cognition. So, off I went back to school and there was a period of denial, which is probably normal. But there was also no internet. I was really left to my own to figure out what to eat, you mentioned nutrition. And the only thing I had was the public library, and the only thing available on MS was the Swank diet, which purported that a low-fat vegetarian diet was the best for MS. So, I gave it a try. And that did not help me. In fact, it made my gut symptoms worse.

Now, for my entire life, I had symptoms of constipation. So, I kinda thought that was normal and I always felt a little tummy grumbling after eating, but I also chalked that up to being normal. I didn't think it was a problem. So, it would take more than two decades for me to address what was really going on. And I wanna really be clear to say this is something that now we have the science, we have the stories and the strategies, it doesn't need to take nearly the time that it took me because I was really going on my intuition that if stress was the big problem, I needed to figure out how to reduce the stress. So, that led me to meditation, that led me to yoga, started doing those in the late 80s, early 90s. And I did notice almost immediately that when I was able to bring the stress down, and as my yoga teacher would say let it go with this very long go, I would actually have a diminishment of symptoms.

It turned out that I had relapsing-remitting MS. So, that means it comes and goes, it's not necessarily progressively worsening. But it became really clear that the more stress I had in my life, whether that was conflict at home or exams at school, or whatever I perceived as being stressful, you could almost count on it that I would develop more MS symptoms, whether that was numbness and tingling or tightness or this symptom called Lhermitte's syndrome where you bend your head down and get this zapping energy down your back. All of these things got worse with stress and better with relaxation. So, that was a big win, but it wasn't complete.

Nutrition, as I said, I wouldn't learn for years what I was doing wrong. And finally in 2010, I decided to pay attention to what was going on with my gut after eating and that is when I went to a functional medicine nutritionist who did some tests and found out that I had non-celiac gluten sensitivity.

Functional medicine practitioners often take a “Foods First” approach, recommending dietary modifications to improve health. However, for those with low stomach acid, diet alone may not be enough to ensure adequate nutrition. Low stomach acid can impair digestive ability, causing nutritional deficiencies even in those individuals consuming an optimal diet.

This article will focus on the main digestive chemical associated with the stomach, hydrochloric acid. The causes of low stomach acid and the associated symptoms will be covered. In addition, natural treatment options for low stomach acid, such as betaine HCL and herbal bitters will be discussed.

What is Digestion?

Digestion is the process of breaking food down into particles small enough so that the nutrients in the food can be absorbed and then transported throughout the body. Digestion begins in the mouth with the mechanical process of chewing along with salivary enzymes that begin the digestive process. This process is continued as the food passes into the stomach, activating the release of hydrochloric acid. The bolus of food then passes to the small intestines where the majority of digestion takes place. The useful nutrients are digested and absorbed and the waste products are sent through the large intestines for evacuation as feces.

Why Does the Stomach Contain Hydrochloric Acid?

The stomach is a naturally acidic environment, especially following a meal, with a normal pH value of <3. Low stomach acid (hypochlorhydria) is observed with a rise in pH >3 and an absence of stomach acid (achlorhydria) is obtained with a pH > 7.1 This acidity comes from the hydrochloric acid that is secreted by the parietal cells in the lining of the stomach.

Healthy stomach acid levels serve as an immune system barrier, providing a first line of defense against unwanted bacterial or microbial invaders that enter the stomach. Hydrochloric acid is also necessary for the digestion of proteins. Proteins are a conglomeration of amino acids folded together into different shapes.

Stomach acid serves to denature (unfold) the proteins and expose the bonds that hold the amino acids together. These bonds can then be cleaved by pepsin, which breaks the protein down into smaller, easier to digest, amino acids. The formation of pepsin from pepsinogen is dependent on sufficient stomach acid levels as well.

Hydrochloric acid is also responsible for deactivating the enzymes of salivary amylase as it enters the stomach and for stimulating the release of cholecystokinin in the small intestines. Both processes are essential for healthy digestive function. Certain vitamins and minerals depend on hydrochloric acid to liberate them from their carriers, such as vitamin B12 and calcium. Having low stomach acid levels can impair all of these functions.

What causes low stomach acid levels?

Factors that contribute to low stomach acid include:

Chronic stress

Aging

Poor diet

Infections

Medication use

Stress—Stress impairs digestion. Chronic stress may decrease the production of hydrochloric acid in the stomach due to associated nutrient deficiencies.2 Stress also causes the vagus nerve to lose its proper tone. The vagus nerve is a major part of the parasympathetic nervous system, and it is deeply involved in stomach acid production. With chronic stress it loses its ability to fire properly which disrupts normal stomach acid production.

Aging—Low levels of stomach acid following a meal are more common with aging. Studies that compared stomach acid levels in young individuals (mean age 25) versus older individuals (mean age 75) found that older individuals experienced low levels of stomach acid following a meal for a greater length of time than their younger counterparts. It took 89 minutes for the elderly participants versus 42 minutes for the younger participants to regain normal stomach acid levels (pH 3.0) following a “standard meal”.1, 3, 4 These studies help support the existence of “functional low stomach acid levels” in the elderly following meals.

Poor Diet—Eating a diet comprised of highly refined sugars and carbohydrates, alcohol, and/or smoking may result in nutritional deficiencies of B vitamins or zinc, both necessary for the production of hydrochloric acid in the stomach.

Infections—Healthy stomach acidity provides a barrier for the immune system's first line of defense against invading substances. Low stomach acid results in an impaired immune response and an increased susceptibility to viral and/or bacterial infection and to bacterial/microbial overgrowth. Common conditions associated with low stomach acid include Helicobacter pylori, small intestinal bacterial overgrowth (SIBO), and Clostridium difficile.1

Medications—Medications, such as antacids, proton-pump inhibitors (PPIs), and H2-receptor antagonists (H2-RAs), are another widespread cause of low stomach acid. These medications are used to decrease the symptoms of gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD). Long-term use of these drugs has been associated with an increased risk of fracture due to nutrient deficiencies connected to low stomach acid. Approximately 25% of Americans may be using some form of acid reducing medication as the prevalence of GERD in North American has been estimated to be between 18.1% to 27.8%.5

Surgery—Gastric bypass surgery can reduce the production of stomach acid.

What are the symptoms of low stomach acid?

Burping, Bloating and Gas—An adequate level of stomach acid is necessary for the digestion of minerals and proteins into smaller amino acids that can be passed into the small intestines for further digestion and absorption. Low stomach acid can lead to undigested proteins being present in the stomach and being subsequently passed into the small intestines. These undigested particles are too large for absorption and create increased burping, bloating, and gas as they ferment. This increased gastrointestinal inflammation can set the stage for the development of intestinal permeability, commonly referred to as leaky gut.

Indigestion/Heartburn—Heartburn may occur when stomach acids leak up into the esophagus, causing burning. This displacement of stomach acid away from the stomach leaves low stomach acid levels in the stomach. If left untreated, this acid reflux can lead to conditions such as asthma and/or esophageal cancer.

Undigested food in stool—The undigested food particles may be passed through the digestive tract and expelled in feces. These can often be visible in the stool.

Food allergies and/or hypersensitivities—In the presence of intestinal permeability, the large, undigested protein particles can pass through the leaky intestinal membrane barrier. This activates the immune system into action as these large particles are targeted as invaders. The net result is the development of food allergies and/or hypersensitivities.

Stomach pain—Inflammation in the lining of the stomach (gastritis) can result in stomach pain. This is often due to a H. Pylori infection. Increased levels of gastrin are produced that destroy parietal and chief cells. This results in a decrease in stomach acid and can result in a loss of intrinsic factor, leading to a B12 anemia. There is an increased risk of gastric cancer if left untreated.

Avoidance of Meat—Many individuals will avoid eating meat due to their decreased ability to digest the proteins when stomach acid is low. They find they experience fewer digestive complaints when they do not eat meat.

Weak or Brittle Nails, Hair, Bones—The inability to digest proteins and certain minerals and vitamins, such as calcium, magnesium, iron, vitamins B6, B12, and folic acid, can be related to low stomach acid. These nutrients are necessary for the growth of healthy nails, hair, and bones. Common diseases that may develop include anemias, osteoporosis, and osteoarthritis.

Neurological issues—The nutritional deficiencies, particularly the B vitamin anemias and magnesium, can contribute to neurological issues such as numbness, tingling, and vision changes.

Diarrhea—Low levels of stomach acid increases the risk of gastroenteritis, diarrhea, and Clostridium difficile colitis.

Fatigue—Ongoing nutritional deficiencies, infections, and/or diarrhea can contribute to fatigue.

Betaine HCL and Herbal Bitters supplementation

Guilliams and Drake (2020) reviewed the practice of using Betaine HCL with meals as a treatment option for individuals with low stomach acid. In this review they discussed many of the issues that we have discussed associated with low stomach acid. They also reviewed research that supports methods to increase stomach acid easily. Two of the more practical methods included the use of plant extracts, commonly known as bitters, and the use of betaine HCL to temporarily increase acid levels with meals.1

Bitters promote digestion by stimulating the secretion of stomach acid, digestive enzymes, and bile. Original Bitters is a liquid herbal formula developed by David Winston that can be used for this purpose. It is recommended to take this mixture 10-15 minutes before meals to ensure adequate time for the digestive secretions to develop prior to food entering the system. They do suggest caution in those individuals with gastric ulcers, GERD, or gastritis. The use of bitters is not recommended in those with too much stomach acid.

Betaine HCL can replenish stomach acid levels, increase the body's ability to digest proteins and minerals, and help decrease the symptoms associated with a deficiency. Moss Nutrition makes a Betaine HCL that supplies 750 mg of pure anhydrous betaine hydrochloride in an easy-to-swallow, vegetarian capsule. Use of this product can help decrease digestive distress and improve digestive function.

Betaine HCL works by easily donating its H+ ions in an aqueous environment, creating an acidic solution. Because of this,

In this episode of Functional Medicine Research, I interview Sally Norton in a discussion about how oxalates affect your thyroid and your health. We covered what oxalates are and how they can damage the body. We also discussed how oxalates affect gut health, liver health, thyroid health as well as all the symptoms and associated conditions connected to oxalates.

If you're really struggling to get well, but your diet appears to be healthy, oxalates may be the missing link.

Full Transcript on Oxalates and Thyroid Health

Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research." I'm Dr. Hedberg, and I'm really looking forward to my conversation today with Sally Norton. Sally is a consultant writer, educator, and speaker with over 30 years in the health promotion and wellness field. Sally specializes in helping people improve their health with an oxalate-avoiding diet. Sally holds a nutrition degree from Cornell University and a Master's of Public Health degree from the University of North Carolina at Chapel Hill. She worked in the field of medical education at UNC Medical Schools Program on Integrative Medicine and as a research grant writer and research administrator at the Virginia Commonwealth University School of Medicine. Despite a healthy lifestyle, she struggled for over 30 years with seemingly unanswerable health challenges, including chronic pain and fatigue. When she finally discovered the cause and turned her health around, she committed to teaching and reaching out to others stuck in similar frustrating situations. Sally, welcome to the show.

Sally: Thank you. It's great to be here.

Dr. Hedberg: Yeah, I'm looking forward to this and we were kind of discussing this early on. Oxalates is something that I've always kept my eye on for the last 17 years and I was really looking forward to this conversation. So why don't we lay a little bit of bedrock for the listeners? And if you could just talk about what are oxalates, and do we know why plants actually have oxalates?

Sally: Yes. Plants are a major producer of oxalate and obviously, it's also ubiquitous in nature itself. Soil is loaded with it. Even apparently sea spray produces some oxalate and polluted air produces oxalates, so, in really heavily polluted cities, the air has got oxalate in it too. So oxalate is this really minuscule molecule that its parent compound is called oxalic acid. And acids ionize and become charged particles because they drop off the acidic protein and so they become these negatively charged ions that attract positively charged things and oxalates can have a one negative or two negative. It is a tiny, tiny little compound. It has four oxygens, which is a heavy load of oxygen on just two little carbon molecules. So it's very oxygen-heavy, which is probably partly why it's such a pro-oxidant molecule, you know. Oxidation is very bad for tissues, membranes, mitochondria, and it is a great mitochondrial poison, membrane destroyer, and troublemaker. And it's not just the oxygen, though. It's much more about this reactivity that the charge creates where it bonds with minerals and becomes salts. And so, salt is a chemical term for things that can dissolve, but when it...because it can have two negative charges, it will also hook up with minerals that won't dissolve well. So calcium, for example, is a two positive charge mineral. With that double-positive and double-negative marriage between the two, you create an insoluble oxalate, which is the backbone of oxalate you see in nature because calcium is everywhere in soils and in nature, and plants are having to manage their calcium. And one of the ways they do that...because too much calcium can be toxic to the plant. So one of the ways they do that is they make oxalic acid. Often they make vitamin C first, very similar compounds, and vitamin C naturally degrades just hanging around into oxalic acid and oxalates.

So plants will create vitamin C and they'll create oxalic acid so they can manage their calcium and store it away like a pantry. And in a siege, you need to store that calcium because calcium can be an enzyme co-factor and promote the germination process. So you store it, you deep-six it in these crystals in your seeds, and then when you germinate as a seed, you liberate off the oxalic acid in the calcium and you get your enzymes going. And in the meantime, those lovely crystals of calcium oxalate in the seed coat protects the seed from degeneration and from predators, and from deterioration, so it helps preserve the seed. But the oxalate has many other uses for plants, and plants deliberately construct special shapes of crystals.

They lay out this kind of protein matrix and then the crystals nucleate and create these crazy shapes, including a double-pointed toothpick, super fine invisible toothpicks made in bundles of like 200 or more. And the plants literally use them as poison arrows to disturb the mucous membranes of predators and so on and it can kill off caterpillars and bugs and can be damaging to be eating a lot of them in certain foods. Or they haven't actually studied, like, what shape crystals in food plants that much. So we know of a handful. The kiwi is notoriously full of these tooth-picky [inaudible 00:05:05] crystals, for example. So, they use them for self-defense in a direct kind of...I say that plants invented warfare because they have these poisoned arrows and they put on these arrows, proteases and soluble oxalate-related and things that are quite toxic to cells, and if you injure the mucous membrane, then you can enter the intercellular space and potentially enter the circulation and be quite dangerous and hazardous to the victim. But, like, trees will put out hundreds of pounds of oxalate crystals in these cube blocks in their bark, which helps make the bark inedible to the beetles.

And so, they figure maybe six or seven uses of oxalate, and in desert plants, plants make oxalate during the nighttime, create the calcium oxalate crystals, and then during the day in the desert, they have to close their breathing holes under the leaves in order to not dry out. But if you can't get CO2 through your breathing holes in your leaves, you can't produce energy as a plant. You need sunlight and you need air. So instead of using CO2 to do photosynthesis in the day, you use calcium oxalate. You break off that... Oxalate becomes a reservoir for carbon because there's so much oxygen, CO2, right? There's so much oxygen in that oxalate so perfect carbon-oxygen sync so you can make energy as a plant in the desert. So, like, there's this really cool stuff. The plants need it for their biology and they're using it against the predators, against them, and so in us, oxalate is quite toxic. In a plant, it's a clever strategy for survival.

Dr. Hedberg: Okay. So that was really interesting, and it's interesting that you bring up the structure of the oxalates because I do remember seeing some microscopic pictures of oxalates and I just thought, "Wow, that looks really deadly looking at them." The number of spikes, the size of the spikes, how sharp they look. And, you know, you've mentioned plants defending themselves and we see that not just with oxalates but also, you know, like, things like methylxanthines in coffee beans and cocoa beans are, you know, natural pesticides and a large human usually can detoxify those but sometimes small amounts or moderate amounts can also be damaging. So can you talk a little bit more about what foods contain oxalates and what foods people should look out for?

Sally: Yes, yes. So the animal kingdom does not have a lot of oxalates, although there's one rare exception of some giant snail in Asia that is not going to run across your menu anytime soon. It is the plant kingdom. It tends to be the seeds. There are four leafy greens that are particularly problematic and, unfortunately, a lot of people have flattened out the idea about where oxalates are to say all leafy greens are high in oxalate, and that's just not the case. There's spinach, which is the poster child of a high oxalate food. Beet greens and...Swiss chard is basically beet greens without the beet, is even worse than spinach. Swiss chard and beet greens are...Spinach is plenty bad enough, but that's even worse. And then there's sorrel, which is popular in other countries, not so much here unless you're going to upmarket restaurant. So those are leafy greens. Beans as a group are generally quite bad, the white beans, the black beans. The peas are not as bad, like a better choice would be black-eyed peas, green peas, and chickpeas would be much safer to use than black beans, for example.

Let's see. And the grains, it's almost all of them because the bran and the germ contains oxalate. So bran, whole wheat, bran-related things can really add up to a lot of oxalate. So the white flour stuff tends to be lower in oxalate but, of course, that's really devoid deficient food, and even that can add up. So even heavy bread users can get into a lot of oxalate, but I think the two most, or I would say the three most common foods that's universally interesting to modern people across the planet include potatoes and sweet potatoes. You know, the French fries, the tater tots, the potato chips, that is loaded because we eat it so much. Peanuts and peanut butter and anything made with peanuts, nuts in general, and then chocolate. So if you love your Reese's Peanut Butter Cups and your super dark chocolate and you like nuts, or if you're on a keto diet, you're probably super overloading your diet with oxalates.

Dr. Hedberg: Right. And one of the things that I've found is that the resources outline for oxalate content in foods tends to be highly variable. So on your website, I purchased the oxalate handout. And then if you compare that to, you know, some of the other handouts that are out there from certain universities and other...you know.

In this episode of Functional Medicine Research, I interview Dr. Theodore Belfor in a discussion on cranial facial development and airway resistance. If you have read James Nestor's new book "Breath" then you are aware of Dr. Belfor's work.

We talked about the causes of abnormal cranial development and how this causes airway resistance and a number of health problems including sleep apnea, insomnia, IBS, bruxism, and more.

Our cranial bones don't form properly when we aren't breastfed and eat a modern diet of processed foods. Dr. Belfor's oral appliances help to correct these abnormal developments to restore proper facial bone structure and improve the airway.

Full Transcript with Dr. Theodore Belfor

Dr. Hedberg: Well, welcome everyone to "Functional Medicine Research." I'm Dr. Hedberg, very, very excited today to have Dr. Theodore Belfor on the podcast. I first heard about Dr. Belfor in James Nestor's new book called "Breath." And we're gonna be talking about all of that today on the show.

And Dr. Belfor, he's a graduate of New York University College of Dentistry, and a senior certified instructor for the International Association for orthodontics. In the 1960s, Dr. Belfor was sent to Vietnam to work as the sole brigade dentist for 4000 soldiers of the 196 Light Infantry from the jungles of Vietnam to Park Avenue in Manhattan. Upon his return, he opened his own private dental office in New York City, and has been in private practice for more than 40 years. And Dr. Belfor specializes in the treatment of the cranial facial system, and that's what we're going to be diving into today. So, Dr. Belfor, welcome to the show.

Dr. Belfor: Well, thank you for having me. It's my pleasure.

Dr. Hedberg: Excellent. So, why don't we start by talking about how this all began, and go back to, you know, what happened that changed the cranial bones, the cranial structure, our skulls, that led to this epidemic of airway issues, breathing issues, and all of the health issues that come with that?

Dr. Belfor: Well, how we develop, how we grow and develop is based on how we breathe, how we swallow, and how we chew. So, just looking at how we chew, according to the U.S. Department of Agriculture today, in the U.S., 63% of our diet is processed and refined foods. So, without the proper stimulation to the body, we are not fully expressing our genes, we're not developing to our full potential. Because of that, particularly when our jaws do not grow forward enough, the retrusion of those jaws helps to push the tongue backwards into the airway and down the throat, so now we have compromised sleep and breathing.

Dr. Hedberg: So, it's a combination of things. I know Dr. Nestor talks about it in his...or James Nestor talks about in his book, the changes in diet, soft food, not enough hard foods, not breastfeeding. Can you talk a little bit more about these changes in our society and some of these predisposing factors that can cause an abnormal airway?

Dr. Belfor: Well, for me, the enlightenment came, when almost 20 years ago, I was treating performing artists who couldn't wear braces and they wanted straighter teeth, and I used an appliance and had a unilateral bite block, which basically, in essence replaces the missing hard food in our diet. And guess what? The actors, performers were coming in, and their makeup artist was telling them that their faces are changing, and the singers were coming in and saying they were reaching higher notes. So, that's what set me on the path.

You see, the concept in dentistry is to balance the bite all the time. And it's kind of an anathema to have, when you bite down, to hit on one side. However, if I give you a stick of gum to chew, nobody on the planet is going to chew on both sides at the same time. We chew on one side then we chew on the other. And apparently from the research, many articles that have been written, the latest one in August 2018, the Journal of Orthodontics and Dentofacial Orthopedics the concept, they used a mammal, a pig, and they sent cyclical signaling to just two cranial sutures.

And the result was that that changed...it reached all the cranial sutures, it created strain on the sutures, and that's the key word, because we chew on one side, we create strain at the suture level. And the result was a widening and mineralization of the sutures. So, in other words, there's your direct example of how we're chewing works. And, by the way, chewing is basically a communication that the body uses for development. The body works this way. There's only certain things the body understands. So, chewing is really a reciprocal pressure, alternating pressure. And that reciprocal, alternating pressure and strain is what helps to generate the growth.

So, our breathing is reciprocal, cyclical, alternating pressure. And from a lot of articles which are written, when we breathe correctly, as we're developing, that air goes into all of the spaces in our skull, and that helps to stimulate the growth. So, the body is responding to alternating pressure. And for swallowing, when we swallow, we create a volume pressure change. So, all of this is how we develop.

So, the concept is, let's take an oral appliance and let's duplicate what the body expects. And as a result of that, what we get, literally, is we get expression of genes that have not been expressed before. We get cranial facial growth and development. We get the upper jaw growing bigger. But the key element is the central bone of the skull where the jaw hangs off. That's known as the sphenoid. And what we want is balance in the neurocranium, which is the eight bones, including the sphenoid, which are central to the skull.

And I can go on and on about this, but we just had a conversation you and I, what I believe is, when this is an imbalance, your jaw is misaligned, for example, then your head is crooked, your neck, the shoulders, your back, everything is crooked, your body is in stress 24 hours a day. That's high allostatic load, according to the U.S. government. That basically reduces the body's resilience. Reduction in resilience can lead to all kinds of issues and problems.

So, I believe by aligning, by developing the cranial suture, by getting a jaw balance, by getting the jaw to grow bigger so you breathe better, for example, all of this is a key, central factor for improving your health.

Dr. Hedberg: So, we have a lack of breastfeeding and then we have increased consumption of processed foods that don't put enough strain on the chewing mechanism that would normally create healthy bones in the cranium. It sounds like that's one of the real main issues here and the drivers of this.

Dr. Belfor: [inaudible 00:07:26].

Dr. Hedberg: And so, I just think back when I was a kid, I mean, I was raised on breakfast cereal, and the rest of the day didn't really entail much consumption of foods that were difficult to chew. And what we're seeing now...and you have a list of conditions that you like to see and things that you can help. So, can you talk a little bit about some specific conditions that you see a lot of?

Dr. Belfor: Well, I start with an evaluation. I do a very, very comprehensive evaluation. What we do is we have the patient...We send them for a cone beam scan, or we take a cone beam scan, it's three-dimensional cranial scan and also a facial photo. Now understand this, even if you look in the mirror, you can tell whether you have a facial asymmetry. So, for example, one eye is lower, or you have a deeper depression on one side between your nose and the corner of your mouth. What's this all about?

Well, our midface, our midface, the way it grows, it's two separate bones. It's called one bone, it's called the maxilla, the upper jaw, but that is actually two bones. And it literally grows downward and forward as we grow. Now, if one of those two bones does not grow as downward and forward as much as the other, then that bone is set back, your face ages more rapidly on that side. And by the way, your jaw is up and back on that side, so your jaw is crooked. So, literally, my first evaluation I can help to diagnose a patient's problem by just looking at their face.

Then we also are interested in the head posture. Where we look at the cervical spine, the head posture, forward head posture. Let me explain forward head posture. Today, it's a disaster. Everybody's on their computer, their cell phone, their tablet, they have forward head posture. Dentists, for example, they're working all day long in a forward head posture. So, what's the story with the forward head posture? Well, if you have your head forward and then you lift your chin to look around, what happens is literally your...the back to your tongue drops down your airway.

So, you have either folks who start out using their computer too much, cell phones, etc., with forward head posture, and they end up with a tongue in the airway, or it is the reverse. That is the folks that don't develop their jaw forward, they have retruded mandible and the tongue is in the airway. And when the tongue is in the airway, since the air has to go through our nose and make a right turn to go down behind our tongue, because our tongue is in the airway, our head must come forward for us to breathe properly.

So, in the end, either way, we end up with forward head posture, and the forward head posture makes things worse when the back of the tongue drops down the throat. So, this is part of my diagnosis, first the face, then the posture.

Then, we actually look at your development. Now, the whole cranial system, the development of the face, for example, is based on, in our womb, in our womb, when we're growing, the first thing that grows is the brain, the cranium, and the basicranium, the base of the brain that supports the brain. That basicranium, those dimensions are what determine or should determine the dimensions of your face.

In this episode of Functional Medicine Research, I interview Dr. Ron Parks in a discussion about COVID-19 and the mental health crises. Dr. Parks has written a new book "COVID-19 and Mental Health Crises" which we discuss as well as a variety of other topics that can help those afflicted by this pandemic.

The mental health aspects of COVID-19 are often overlooked with more of a focus on the physical aspects of the illness, medications, vaccines etc. As usual in the United States, mental health is pushed to the back of the bus with little to no dialogue or support for those who need psychological support. Dr. Parks provides a voice for those in need with his excellent new book.

Full Transcript on COVID-19 Mental Health Crises

Dr. Hedberg: Well, welcome, everyone, to Functional Medicine Research. I'm Dr. Hedberg. Very excited today to have my good friend and colleague, Dr. Ron Parks, on the show. And we're gonna be talking about his new book. And Dr. Parks is a respected physician, teacher, book author, writer, and mentor, with an integrative and holistic perspective. He especially trained in internal medicine, nutrition, preventive medicine, and board-certified in psychiatry. Currently, Dr. Parks is the medical director and psychiatrist for The Center for Spiritual Emergence and Katharos Sanctuary in Asheville, North Carolina. He has an MD from the University of Maryland and a master's degree in public health and health service research from the University of California at Los Angeles. He has completed specialty training and internal medicine at George Washington University, preventive medicine at UCLA, and psychiatry at the University of Maryland. Dr. Parks is a former assistant professor at the Albany and University of Miami Medical School, chief of internal medicine at the Homestead Air Force Base Hospital in Florida, former director of the Center for Preventive and Nutritional Healthcare in Baltimore, Maryland, and founder of the MacroHealth Medicine, a comprehensive and holistic consultative and treatment service, formerly in Asheville, North Carolina. Dr. Parks, welcome to the show.

Dr. Parks: Well, thank you, Nik. Thank you for having me.

Dr. Hedberg: Yeah. I'm looking forward to this. So, you've written a new book, it's called "COVID-19 and Mental Health Crises." So, we're gonna dig into that. But before we do that, can you just talk a little bit about how you got into integrative functional medicine and psychiatry?

Dr. Parks: Well, that's a good question. Actually, it started when I was very young. I think I write a little bit about this in the book. I came down one summer as a kid with polio. And it was very upsetting, of course. And I compared it to the current COVID crisis. Back then there was no treatment and everybody had been waiting 10 years, 8 to 10 years for a vaccine. But here I was, a young, healthy, athletic kid that suddenly was running high fevers and a stiff neck. So, I ended up in the hospital at a children's ward. And back then the only treatment they had was more of a natural treatment called the Sister Kenny treatment. It was like a heat treatment. They wrap you in warm towels. And so that was my first exposure to, you know, what I would call functional medicine or holistic medicine. Though I had a sweat through it, but luckily, I didn't end up with the paralytic form of it, but sometimes I do think I have some of the long...they're talking about with a new virus, the long hauler syndrome. But with polio, there were some aftermaths there, and I think maybe some of the weakness I had some time in the legs and things like that might be from that.

But anyway, that got me started on the path of interest in broader treatment programs. But a lot of it came, though, from my being formally, formally trained in internal medicine, where everything was about labels and diagnosis. And I remember in training, I got yelled at by the pathology teacher because I looked at a slide and I said, "I know what this is. It's such and such." He said, "The secret and the art is you spend time looking at that, you get the full picture, you let it sink into you before you tell me what it is." So, maybe he was seeing, you know, or trying to lead me in the right direction. But after working in more traditional medicine and you've seen my credentials, I mean, I would see some of the most rigorous formal training. I just finally decided to get out of it.

And actually, you know what, Nik? This is very, very interesting. I always keep up to date, you know, and I start my morning with doing some review of some current stuff. And I came across an article about burnout syndrome they call with COVID-19, and how that's affected many academics and professional people because it's so changed their lives, that it's caused them to relook at themselves. And this article just snapped something in my head and I realized in writing this book and in telling some personal stories in there, I missed the most important one. And guess what that was. When I was an internist, you know, like that conventional internist-type person, one day I was seeing somebody in my office and suddenly, it was like somebody kicked me in the gut. I never felt anything like that. And it doubled me over the floor. And the patient was, you know, on the table and I said, you know, much of like...I said, "Well, you'll have to excuse me." And I literally crawled out of the room and I called my associate, he used cover for me. And he said, "Oh, that doesn't sound too good, Ron." I said, "Why don't you go home and I'll cover for you?" I said, "Go home. You kidding? I'm going to the emergency room." So, he said, "Okay."

So, long story short, it turned out I had pancreatitis. And I thought everybody was thinking it was for alcohol or something, but it was from small gallstones. But I was in crisis, you know, and I had to, you know, go into surgery and everything. And while I was in that stressful crisis situation, my life changed. I did a whole evaluation. And I said, "I don't wanna be a traditional internist anymore. I want to see all the depths and breadth of things." And so from there, I thought the solution, of course, was to go into psychiatry. So, I sorted in the residency with the right intentions and, eventually, I went from there into holistic integrative medicine where I really belonged. But that crisis situation is what changed my life. And in the book, I tried to bring that across, you know, that there's a little bit of a raised stretch and a silver lining and sort of a place where, you know, crisis and tragedy can bring opportunity. I think that comes from oriental medicine. And just to end this little thing, I realize that I missed in the book one of the most important chapters, but don't worry. I'll write that as a new sequel or a blog, I don't know. I forgot that most important experience. But anyway, so that's a little bit how I ended up in holistic integrative medicine.

Dr. Hedberg: So, this book, you know, "COVID-19 and Mental Health Crises," we're obviously just over a year now into the pandemic. And obviously, there's gonna be a lot of mental health issues as a result of this. We know that social isolation increases inflammation and can cause mood issues and affects the immune system, all kinds of things. And then you compound that with, you know, losing jobs. And I know that divorce rates are, you know, increasing. And there's all kinds of these stresses going on because of the pandemic. And as usual, mental health is kind of pushed to the back of the bus, so to speak, and not a lot of people are really talking about it. I mean, there's a little bit out there on mental health and COVID-19. But what is this... How would this book, you know, benefit someone who has been really traumatized by this pandemic or has...you know, family members who have been traumatized and people like that? So, who are you looking to target with this book?

Dr. Parks: Actually, that's a very good question. And that triggers a whole lot of things in my mind. Let me just take the first thing that came to mind, and that was this is typical of the whole dimension between conventional medicine and holistic integrative medicine because a lot of people now that are having, you know, significant problems, and they're getting deeper into it. And so they will reach out to help. And so where they end up and, you know, mostly what's available is very conventional-oriented thinking and treatments so on. They'll say, "Oh, this is COVID-related. This is related to isolation," as I think you were saying. "This is related to the lack of being able to socialize or to get outside or..." But, again, they're missing the broader perspective. This person or the people who are listening, I mean, they know darn well, there are other issues that need to be looked at. For instance, there could be a marital problem going on. And in the close contains of, you know, an apartment or house, it could bring this to the forefront, it could flare. And that needs addressing. I mean, it's not diminishing the impact of COVID, but they need to address that.

There could be other issues. These people could have had prior trauma in their lives or even to the extent to what we call post-traumatic stress disorder. And that needs to be addressed. I mean, because when you have a new trauma, it just plays back on the old one, you know, because most people never really worked out those things. So, they're more susceptible. So, anybody that's going through the COVID experience, it's gonna be a much broader picture. For instance, you know, we're all interested in broader things like nutrition and all that kind of thing. And you were talking about inflammation of the brain. I mean, all these things were at work, but it's not just because of COVID. It's because of all the underlying things that haven't been addressed in the past and they've just gotten compounded. So,

In this episode of Functional Medicine Research, I interview Tom Fabian, PhD in a detailed discussion about the GI-MAP stool test interpretation. We covered virtually every aspect of the GI-MAP stool test including what the test results mean and how to use them in clinical practice.

Dr. Fabian has tremendous knowledge of the gut microbiome and the intricacies of the GI-MAP stool test markers. This is a vital interivew to listen to if you're utilizing the GI-MAP stool test in your practice.

Full transcript of the GI-MAP Stool Test Interpretation interview with Dr. Tom Fabian:

Dr. Hedberg: Well, welcome, everyone to Functional Medicine Research. I'm Dr. Hedberg, and I'm looking forward today to my conversation with Dr. Thomas Fabian. He is a PhD., and he's a clinical laboratory consultant, translational science expert, functional nutrition practitioner, educator, and speaker. He is a former biomedical research scientist and deep expertise in the role of the human microbiome and health, chronic disease and aging. As a leading expert in translational applications of microbiome research and functional medicine and integrative health settings, Tom's primary focus is on providing educational resources and consulting services for practitioners and scientific advisory and consulting services for clinical testing laboratories. Dr. Fabian, welcome to the show.

Dr. Fabian: Thanks so much, Nik. It's great to be here today, and I'm looking forward to the conversation.

Dr. Hedberg: Excellent. So, we're gonna be talking about the diagnostic solutions, lab, GI-MAP test, and we're gonna cover interpretation, you know, what these markers mean. And so, for all the practitioners listening, they'll have a strong idea of how to approach this test and how to use these things clinically. So, why don't we start with...take it from the top in the pathogen section? And I wanted to ask you specifically about C-diff. There's toxin A and toxin B Clostridium difficile markers on this test. And what is your interpretation of this if it's positive and the patient is symptomatic, and then you treat them, and then they're no longer symptomatic, but the toxin still shows up on the stool test? Can you elaborate a little bit on that type of presentation?

Dr. Fabian: Sure. No, I haven't personally seen that particular scenario but, in general, it's important to keep in mind a lot of people can be carriers of C-diff. So, the majority of the time that we see it detected positive, whether it's low levels or high levels, typically, patients don't have the classic symptoms. So, that suggests that they're probably just a carrier. And there's, sort of, kind of, a gray area in between where there still may be some effects of C-diff. Of course, that's one of the purposes of looking at the markers on GI-MAP like calprotectin, zonulin, etc. to see if there seems to be any evidence that may be have an impact, even if there aren't symptoms. So, we're also learning a lot more from research about factors that can control or influence the ability of various pathogens to thrive and also whether or not they can cause infection or if they have their, you know, typical pathogenic effects. So, that's essentially factors that influence virulence.

So, one of the first things I want to mention is all the microbial markers on GI-MAP are assessed based on detection of DNA. So, when you're looking at DNA, you're looking at detection of the organisms or the genes but not necessarily whether the genes are being expressed. And that's definitely true for toxins. So, lots of research has been coming out in research years in terms of, again, as I mentioned, things that regulate toxins, and it's very specific. So, pathogens tend to only express those toxins under very specific conditions when conditions are favorable for them. So, for example, if you've detected C-diff and it really syncs up with what's going on with the patient, symptomatically, and you decide to treat, and then on a retest, symptoms are better, but the C-diff is still detected, that's telling you that it's still there. But you may have improved the gut environment to the point where they're not expressing their toxins at that point. So, they may just at that point become carriers.

Dr. Hedberg: Yeah, that just makes me think about, you know, some of these patients because we can't or I can't necessarily say that it's the C-diff, you know, that was causing the symptoms because then these other patients, they had other pathogens and dysbiosis and other issues. And so, that could have also been the reason why they were symptomatic.

Dr. Fabian: Absolutely.

Dr. Hedberg: Yeah. So, that can make it difficult to really get a clear picture of what exactly is causing the symptoms if there's multiple issues there. So, that makes sense. And, you know, for the practitioners listening, so when it says less than DL, that's less than the detectable limit. Correct?

Dr. Fabian: Correct. Yeah.

Dr. Hedberg: And then, if we see a number there but it's in the black, can we assume that it has been identified, it's just not at a high enough level to be flagged in the red?

Dr. Fabian: Correct. Yeah. We do see that pretty frequently. And, of course, through our extensive validation that's required as a CLIA-certified laboratory, those are, you know, definitely true positives. So, it is there when they're present at low levels. And the type of method that we use called quantitative PCR is highly sensitive and also highly accurate in terms of its quantitation. So, you can have a high level of confidence in those numbers when you see them at low levels. But there is a lot of confusion or misunderstanding, I should say, among clinicians about these low levels because that's, essentially, kind of, a new way of looking at pathogens. Because in the past, most of the methodology, whether it's culture or standard PCR, for example, those methods generally have higher cutoff levels, in many cases, due to lower sensitivity.

And so, essentially, what you're seeing in those tests is when it's positive, it's at a much higher level. So, clinicians, if they're coming from that sort of background and using those sorts of tests, they assume if it's "positive," then it's likely to be high and produce symptoms.

And so, this looking at pathogens at a low level is, kind of, a new scenario. And, of course, it's a gray area. In some cases, it does appear that they still can cause symptoms for some patients. For example, with H. pylori, we do often see that below that cutoff for being considered high. Clinicians have reported anecdotally that, in some cases, it fits with the symptoms. So, they've decided to go ahead and treat, even though it wasn't officially high. And in many cases, they reported that symptoms improved. So, that suggests, at least for some patients, that lower levels may still be relevant for that particular patient.

There are other things, though, that you can potentially get insights from just by the presence of pathogens, whether they're high or levels. And, again, this is all coming out from relatively recent research that indicates that the gut environment, as you can imagine but there's really a lot of research now supporting this, that the gut environment influences whether or not pathogens can basically thrive in the GI tract, you know, again, at low or high levels. Just to, kinda, cut to the chase, common ones that have emerged from research that we also see clinically would be low stomach acid. So, for example, it's commonly known that proton pump inhibitor use can lead to an increased risk for various infections, including C-diff. Also, poor digestion, potentially, can contribute, as well. So, there's a lot of growing research around the idea that, particularly for pathogens that are in the colon, that typically thrive in the colon, that they often depend heavily on the presence of amino acids, the availability of amino acids, which in a healthy colon are present at very low levels.

And that's due to, when digestion is working as it should, digestion absorption, very little protein gets into the colon. And then the protein that does get in the colon is broken down and then quickly used up by the normal, healthy bacteria to fuel their growth. So, when you have certain types of disruptions like antibiotics, etc., or even a really poor diet that lacks fiber, that potentially can increase the risk for pathogens because it leads to less competition for those amino acids. And then the pathogens can use those amino acids to fuel their growth. C-diff is a classic example. That one, actually, has been shown to thrive on a number of amino acids, in particular an amino acid called proline, which happens to be present, and ironically in high levels, in collagen and, of course, products that have collagen in them. Also, bone broth, for example, collagen supplements. And this is something that we actually do see occasionally clinically, that patients who have relatively high levels of C-diff may or may not be symptomatic. But when I asked a clinician, "Are these patients on any sort of collagen supplement?" oftentimes, the answer is, "Yes." And, again, that really fits with what we know from research.

Dr. Hedberg: Yeah, interesting. You brought up some really great points. And, I mean, that's one of the things I like about the GI-MAP. As you said, it allows for a gray area rather than just a binary, you know, positive or negative. And that leaves a lot of interpretation to the clinician, because if all you did was just report the so-called positive and then nothing else, then maybe, you know, they could have say 5, 6, 10 different pathogens but they're all just at a low level. But they're just not technically positive. And so, I like that. And that would allow me to do things like make some indirect interpretations. And you brought up a really great one, which is hypochlorhydria,

In this episode of Functional Medicine Research, I interview Robb Wolf about his new book and documentary Sacred Cow. We had a great conversation dispelling some of the myths about meat and saturated fat as well as climate change, plant-based diets, sustainable agriculture, veganism, cattle and methane, and the ethics of eating animals.

This was a well-rounded interview packed with information that should help people make better decisions about what they eat but also become educated about the facts around meat. I highly recommend watching the Sacred Cow documentary and reading the book which goes into tremendous detail on these issues.

Full Transcript of Sacred Cow with Robb Wolf Interview

Dr. Hedberg: Well, welcome, everyone, to "Functional Medicine Research." I'm Dr. Hedberg. And I'm really looking forward to my conversation today with Robb Wolf. And Robb is a former research biochemist, and he's a two-times "New York Times," "Wall Street Journal" bestselling author of two books, "The Paleo Solution" and "Wired to Eat." And he coauthored a book with Diana Rodgers, which we'll be talking about today, called "The Sacred Cow," and that explains why well raised meat is good for us and good for the planet. Robb has transformed the lives of hundreds of thousands of people around the world via his top ranked iTunes podcast, books and seminars. He's known for his direct approach and ability to distill and synthesize information to make the complicated stuff easier to understand. Robb, welcome to the show.

Robb: Doc, a huge honor to be here. Thank you.

Dr. Hedberg: Great. Yeah, I had Diana on last year. And we talked a little bit about plant-based diets and meat and things like that. And then since then, we've had the "New Sacred Cow" book that you co-authored, and the documentary, which is excellent. And so, why don't we begin by...I'd really like to focus on helping the listeners understand some of, you know, the misunderstandings and the truths and the myths about eating meat versus plants and things like that. And so why don't we start with a discussion about why meat has become a scapegoat. And I think, and you can expand on this, of course, but I think part of this probably goes to Ancel Keys' work in the 20th century, his promotion of misinformation on saturated fat. Can you take us from that point up to where we are now, and why you think meat has been getting such bad press?

Robb: Yeah, you know, it's interesting and worth noting the book covers the health, environmental, and ethical considerations of a meat or animal product-inclusive food system. You know, so the raising and the selling and the slaughter and the whole deal. And all of those points are important, and all of those points have some really interesting, historical antecedents, I guess, kind of describing why in different cultures meat would become vilified to varying degrees.

And like, food is an interesting cultural tool for defining self from non-self. Like, if we look within the Abrahamic religions, there are some very specific delineations of what is and is not allowed within, say, Judaism versus Christianity versus Islam. And we see similar things within different Buddhist traditions and whatnot, so I mean it...Or even just within Christianity itself, you have like the Seventh Day Adventists versus, you know, certain rules and followings within Catholicism, you know. And so, it's interesting that food is a powerful tool for defining self from non-self. And not infrequently it is the beginning point of creating out of accepted groups of people. Like, there's some pretty ugly historical examples of where the different food practices of one religion or one type of people start being used as a means of, kind of, ostracizing and, kind of, walling those folks off.

But we have these three different pieces that if we're really gonna do diligence on this topic that we have to address. And, you know, the Ancel Keys piece is interesting in that he was a very well-known biochemist, did some early research that suggested that fat intake, in general, and animal fat intake specifically was, kind of, a linear correlation with cardiovascular disease. And he did this around the 1950s and it was called the Seven Countries Study. One of the problems with this was that he omitted, either purposefully or unpurposely, a bunch of other data that didn't really fit this linear demarcation. Like, there were places where folks eat far less fat than, say, in westernized countries and have higher incidences of cardiovascular disease. And there are places that eat far more fat than, say, like Western Europe and the United States that have far less. And so there's really, kind of, a not great overlap there.

And it's worth noting that Keys spearheaded some really fascinating research. And one of these research projects is something that we could never ever do today, there's no IRB board that would sign off on this. And it involved a study with thousands of institutionalized mental patients who were fed, kind of, a standard diet and, you know, fairly rich and saturated fat, and then a modified diet that was enriched with, in theory, heart-healthy, polyunsaturated fats from like corn oil and safflower oil and what have you. And what's interesting is, this is as close to like a metabolic ward study as one is ever likely to have, and it had a lot of people in it. So, you know, the power there is fantastic from a statistical standpoint.

But what they found in this is that the folks that were eating the polyunsaturated fats, their cholesterol did in fact go down. But that actually correlated with increased rates of morbidity and mortality as it relates to cardiovascular disease, more stroke and heart attack. So it was completely counterintuitive to what, you know, kind of, the standard diet, heart hypothesis would put forward. And it's worth noting that this study was completed, wrapped up, and then never published, and ended up just, kind of, sitting in a basement for the better part of 40 years, until somebody found it. Not that long ago, maybe 2016, 2017, this thing was rediscovered and got a fair amount of airplay. Because it really calls into question all of the Ancel Keys' original, kind of, findings and suggestions. And it certainly flies in the face of what we're generally told to follow from the United States dietary guidelines.

So in the book, we kind of detail the work of Ancel Keys, kind of some interesting developments, kind of, socio-politically. Like, Richard Nixon was looking to get reelected and he wasn't doing so well. And he needed a loyal, conservative base that would support him. And farmers were a pretty good option in that regard. And part of his offerings for building loyalty was re-expanding the farm subsidies programs that had been largely wound down after World War Two. And with this, the subsidies program, these farmers were incentivized to just produce. It didn't really matter if we needed more corn or soybeans or wheat or what have you, we were just incentivizing that production. And so for several years, we had these huge gluts of food that we didn't know what to do with it.

And then right around this time, a process had been understood to convert corn syrups into high fructose corn syrup, and make it very, very sweet, very palatable. But it was a very expensive process. But it was right around this this early 1970s that an industrial scale, inexpensive process for converting corn into high fructose corn syrup was developed. And this was the beginning of the relationship also between what we would now, I think, call the junk food industry and the governmental food surplus, you know, kind of, scenarios. So we needed to do something with this food. This food needed a long shelf-life and, you know, these food manufacturers were all too happy to employ their food chemists in figuring out how to make this stuff both taste tasty and also kind of like a Twinkie, like have a nearly infinite shelf-life.

So, some folks present this as, kind of, like this evil cabal of people, you know, twisting moustaches to enslave the masses. And I don't buy into that stuff at all. But I do think that we are the recipients of a bunch of really dumb luck, that some decisions that were unconnected initially but became connected on the backend ended up leading us to what is our modern, industrial row crop food system, and the dietary guidelines that go along with it that support the perpetuation of basically what that row crop food system stands for.

And so, you know, it's been a 60-years-long process with that. And there's back and forth on the topic, you know, one week, high-carb diets are good for you, the next week, low-carb diets are good for you. I think the one commonality within this whole story is that highly processed foods are probably a big problem. And that also depending on the individual, higher or lower-carb diets may be more appropriate given an individual's circumstance. And you know, we are investigating topics like individualized or personalized medicine.

Like, they're finding that some people when they undergo chemotherapy, they do far, far better if the chemotherapy is administered in the morning versus the evening, and other people are the exact opposite. And so when we understand things like that, when we understand that, you know, within a population if you give, you know, a thousand people a blood pressure medication, some percentage of those people may see a 10-point reduction, and some people a 20-point reduction, and some people, you see no reduction.

We know that with pharmaceuticals, we know that with the dose response to exercise. But we still haven't applied that same latitude to dietary practices, that there may be different ways of eating that suit different people better. And that is a lot of what we attempt to unpack in the book,