optimal health: functional medicine and nutritional genomics

2012 

AAPI’S NUTRITION GUIDE TO 

OPTIMAL HEALTH: 

USING PRINCIPLES OF 

FUNCTIONAL MEDICINE 

AND 

NUTRITIONAL GENOMICS 

PART 2 

www.aapiusa.org

AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS PART 2 

2012 

ISBN: 978-0-615-63857-7 

Copyright © April 2012 by The Association of Physicians of Indian Origin (AAPI) 

All rights reserved. 

No part of this E book may be reproduced or transmitted in any form or by any means, electronic or 

mechanical, including photocopying, recording, or any other information storage and retrieval system, without the 

written permission. Please do not participate in or encourage piracy of copyrighted materials in violation of the 

authors’ rights. 

This E book is intended as a reference volume only, not as a medical manual. The information given here is 

designed to help you make informed decisions about your health. It is not intended as a substitute for any 

treatment that may have been prescribed by your doctor. If you suspect that you have a medical problem, we 

urge you to seek competent medical help. Although every effort has been made to provide accurate and up-todate 

information, this E book cannot guarantee to be free of factual error. The authors shall have no liability of 

any kind for damages of any nature howsoever caused and will not accept any responsibility for any errors, 

omissions or misstatements that may exist within this publication. 

Internet addresses and telephone numbers given in this E book were accurate at the time of publication. 

Formatted by Ashley Dunham, MS 

Dietetic Intern, Tufts Medical Center 

viii


2012 

AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: 

USING PRINCIPLES OF 

FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS 

PART 2 

CONTRIBUTING AUTHORS 

Susan Allen, RD, CCN 

Vernon C. Barksdale, MD 

Keith Berndtson, MD 

Hal S. Blatman, MD 

Stephen S. Cowan, MD 

Marilyn Freedman, PT, DPT 

Alan R. Gaby, MD 

Leo Galland, MD 

Jeannette Graf, MD 

Erminia “Mimi” Guarneri, MD 

Massimo Guerrieri, MS 

Richard I. Horowitz, MD 

George Keanna, DDS 

David Perlmutter, MD 

Simcha Pollack, PhD 

Riva Preil, PT, DPT 

Robert Rountree, MD 

Poulina Q. Uddin, MD 

Micheline Vargas, DrPH, CNS, RCEP, CSCS 

Alberto Villoldo, PhD 

American Association of Physicians of Indian Origin 

600 Enterprise Drive, Suite 108 

Oakbrook, Illinois, 60523 USA 

630-990-2277 info@aapiusa.org 

www.aapiusa.org 

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2012 

Contents 

Acknowledgments........................................................................................................................................................xii 

Introduction………………………………………………..............................................................................................................169 

Rita Kashi Batheja, MS, RD, CDN 

Foreword…………………………………………………..............................................................................................................173 

Sunita Kanumury, MD 

Chapter 19….........................................................................................................................................................175 

Person-Centered Diagnosis: Principles and Practice 

Leo Galland, MD, FACP, FACN 

Chapter 20…..........................................................................................................................................................195 

Reducing Under-Evaluation and Over-Treatment: An Opportunity for Functional Medicine 


Chapter 21…..........................................................................................................................................................209 

Nutritional Treatment of Fatigue (Excluding Chronic Fatigue Syndrome) 


Chapter 22…..........................................................................................................................................................220 

Roundoc Rx The Human Microbiome – Humans as Super-Organisms 

Robert Rountree, MD 

Chapter 23…..........................................................................................................................................................231 

Neurogenesis: Growing New Brain Cells 

David Perlmutter, MD, FACN, ABIHM 


Chapter 24…..........................................................................................................................................................241 

Functional Medicine and the Patient-Physician Relationship 


Chapter 25…..........................................................................................................................................................252 

Mending the Mind-Body Connection for Better Health 

Susan Allen, RD, CCN 

Chapter 26…..........................................................................................................................................................269 

Healing Emotions in Children 

Stephen Scott Cowan, MD, FAAP 

Chapter 27…..........................................................................................................................................................277 

Atherosclerosis, Functional Foods, and Nutritional Genomics 

Micheline Vargas, DrPH, CNS, RCEP, CSCS 

Chapter 28…..........................................................................................................................................................296 

Integrative Cardiology: Nutrition, Nutraceuticals and Enhancing Resiliency in Cardiovascular Disease 

Erminia “Mimi” Guarneri, MD, FACC 

Poulina Q. Uddin, MD 

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2012 

Chapter 29…..........................................................................................................................................................313 

A Non-invasive Thermal-wrap Technique for Inducing Calorie Burning and Weight Loss 




Chapter 30…..........................................................................................................................................................324 

New Ideas for the Treatment of Pain 

Hal S. Blatman, MD 

Chapter 31…..........................................................................................................................................................332 

Multi-systemic Infectious Disease Syndrome: Understanding Chronic Lyme Disease and Persistent Illness 

Richard I. Horowitz, MD 

Chapter 32…..........................................................................................................................................................347 

What is Biological Dentistry? Dentists as Physicians of the Mouth 

George Keanna, DDS 

Chapter 33…..........................................................................................................................................................352 

Pelvicology: A Neuro Muscular Skeletal Approach to the Treatment of Pelvic Conditions 

Marilyn Freedman, PT, DPT, CAPP, BCB-PMB TM 

Chapter 34…..........................................................................................................................................................358 

Activating Our Healing Potential by Using Our Innate Faith 

Vernon C. Barksdale, MD, MPH, CPI 

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ACKNOWLEDGEMENTS 

Sunita Kanumury, MD and Rita Batheja, RD wish to thank everyone who has contributed to AAPI’s 

Nutrition Guide to Optimal Health: Using Principles of Functional Medicine and Nutritional Genomics 

Part 2. 

Susan Allen 

Louise Taber Barksdale 

Vernon C. Barksdale 

Kashi P. Batheja 

Keith Berndtson 

Hal S. Blatman 

Stephen Scott Cowan 

Yolanda Davis - American Medical Association 

Dietitians in Integrative & Functional Medicine Practice Group, Academy of Nutrition and Dietetics 

Colleen Fogarty Draper 

Ashley Dunham (Thanks for helping with AAPI eBook Part 1 & 2) 

Marilyn Freedman 

Phyllis R. Freeman 

Alan R. Gaby 

Jonathan Galland 

Leo Galland 

Jeannette Graf 

Elizabeth Graham 

Erminia “Mimi” Guarneri 

Massimo Guerrieri 

Richard I. Horowitz 

Institute of Functional Medicine (IFM) 

Erica Graham Keanna 

George Keanna 

Laura Koch - Hay House Publishing 

Sarah Harding Laidlaw 

Erica Lennon 

Mary Ann Liebert, Inc 

Alex Lubarsky 

Ricardo March 

Kathy Moore 

David Perlmutter 

Riva Preil 

Simcha Pollack 

Robert Rountree 

Jyoti Robin Shah 

Kathie Madonna Swift 

Poulina Q. Uddin 

Micheline Vargas 

Alberto Villoldo 

xii


Introduction 

2012 

Rita Kashi Batheja, 

MS, RD, CDN 

“Best way to lose weight is eat foods you absolutely adore” 

– Mehmet C. Oz, MD 

AAPI's eBook, Optimal Health using Principles of Functional Medicine and Nutritional Genomics Part 2, came 

into the picture immediately after the first eBook was posted on AAPI’s website. Some of the esteemed 

authors approached me and wanted to contribute valuable information for the global community's benefit. 

Linus Pauling award winner, legendary Leo Galland, MD, covers Person-centered Diagnosis: Principles and 

Practice. He assesses patients as unique individuals with practitioners recognizing and acknowledging the 

patient’s experience of their illness. Leo is consistently selected as America’s Top Doctors. He notes that 

diet, nutrition and exposure to environmental toxins play central roles in Functional Medicine because they 

may predispose an individual to illness and provoke symptoms. Visit the foundation of Integrative Medicine 

www.mdheal.org and www.pilladvised.com to learn more Dr. Galland’s work including interactions between 

drugs and dietary supplements. 

Young and talented MD, Keith Berndtson, functional medicine physician, authored 2 chapters: Reducing 

Under-Evaluation and Over-Treatment: An Opportunity for Functional Medicine and Functional Medicine and 

the Patient-Physician Relationship. Keith discusses three patients with chronic illness. He points out that 

delayed adverse reactions to staple foods resolve when the person stops eating them. Keith talks about how 

money is saved with Medicare and Medicaid. Keith explains the health care system’s clue to solving most 

clinical puzzles are in the patients’ history. Growing public interest in gluten free diets is not a fad but a 

serious matter of life and health. Visit www.onebodymind.com and kindly check out innovative online tools for 

the most effective approach to health education. 

Internationally recognized as an expert in nutritional medicine and past president of the American Holistic 

Medical Association, Dr. Alan R. Gaby, covers “Nutritional Treatment of Fatigue Excluding Chronic Fatigue 

Syndrome.” This chapter includes numerous studies referred in his textbook which may be of interest to 

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practitioners. Visit www.doctorgaby.com. Dr. Gaby was inducted into the Orthomolecular Medicine Hall of 

Fame in 2012 by the International Society for Orthomolecular Medicine. 

Doctor Robert Rountree has opened up an evolving area by increasing awareness of the role of gut flora in 

health and disease. Disruption of gut bacteria has been associated with inflammatory bowel disease (IBD), 

obesity, autoimmune disease, asthma, allergies, cardiovascular disease and other health problems. The 

causes of obesity are complex and a simple theory is that a person becomes obese due to overeating. Why 

does a person overeat? Perhaps the person’s intestinal micro-ecology has developed a microbial imbalance 

that disrupts the normal neurochemical feedback loops that control satiety. This individual often is not eating 

that much more food than a lean person, but their intestinal bacteria are metabolizing the food in a different 

way, leading to energy imbalances. 

Recipient of the Linus Pauling award and internationally recognized Neurologist Dr. David Perlmutter and 

world renowned Shaman Alberto Villoldo’s chapter on Neurogenesis: Growing New Brain Cells is brilliantly 

written. They also explore its association with other neurological conditions, including epilepsy, anorexia 

nervosa, depression, schizophrenia and obsessive-compulsive disorder. They believe that physical exercise, 

even to a relatively moderate degree, can actively take control of one’s mental destiny. Nigerian elderly with 

approximately 30% calorie reduction had the lowest risk of Alzheimer’s and Parkinson’s disease. Abundant 

use of turmeric in curried recipes in villages in India were associated with 25% less of Alzheimer’s disease. 

They also mention the value of DHA, a dietary omega-3 fatty acid. 

“When was the last time you felt perfectly well?” is the first hallmark question asked by your healthcare 

practitioner, states Susan Allen, a nationally recognized Registered Dietitian and functional medicine 

practitioner. This chapter is written for broad minded practitioners who care enough to go against the 

insurance mandated medical model and mend the mind-body connection for better health. 

“Nothing is more important in life than the Welfare of our own children” – Harry Truman – US President 

1945-1953 

Holistic pediatrician from upstate New York, Dr. Stephen Scott Cowan works with developmentally challenged 

children. He beautifully covers the chapter on healing emotions in children with positive reinforcement. 

Dr. Cowan states there is more to living a healthy emotional life than not having symptoms or labels. “Our 

gut is a brain that regulates our mood.” The quality of food our children eat certainly affects their emotional 

stability. Our children are “Digital Natives” and we adults are “Digital Immigrants”. 

Micheline Vargas, Preventive Health Specialist and instructor at UCLA Extensions teaches courses in food, 

mood and eating behaviors, along with exercise and sports nutrition. She shares her expertise with a chapter 

on atherosclerosis, functional foods and nutritional genomics. Prevention and treatment of atherosclerosis is 

accompanied by interventions that attempt to reduce LDL-C, oxidation of LDL-C, inflammation, and 

thrombogenesis. Functional foods appear to provide protection in each of these areas and can be useful in 

tailoring a diet to address the special needs of an individual. The emerging field of nutritional genomics can 

further help a dietitian determine a patient’s individual needs based on his or her unique genetic makeup. 

This knowledge will allow for a more personalized and effective nutrition care plan. 

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Founder and Medical Director of Scripps Center for Integrative Medicine, cardiologist Erminia Guarneri known 

as “Mimi” and Poulina Uddin, MD, have done a fabulous job with “Integrative Cardiology: Nutrition, 

Nutraceuticals and Enhancing in Cardiovascular Disease.” Dr. Guarneri uses state of the art cardiac imaging 

technology and lifestyle change programs to prevent, diagnose, and treat cardiovascular disease. She has 

made significant contributions to the transformation of the United States healthcare system. Dr. Guarneri was 

honored by Project Concern International for her work in Southern India. 

“A Non-invasive Thermal Wrap Technique for Inducing Calorie Burning and Weight Loss”, a first of its kind, 

is a study presented by the assistant clinical professor of Dermatology at the Mount Sinai School of 

Medicine in New York City, Jeannette Graf, MD and Vivinlinea’s cofounder Massimo Guerrieri. They show 

that by combining Thermal-Wrap5000 twice per week with a healthy diet over a period of 8 weeks, 

significant weight loss and body fat reduction may occur. 

According to Mahatma Gandhi, our hero says, “Be the change you want to see in the world” – A chapter 

on the novel ideas for the treatment of pain by the past President of the American Holistic Medical 

Association, Orthopedic Surgeon and Pain Management specialist, Dr. Hal Blatman. He writes about pain 

with insights as to why many common treatments do not work as well as we would like. He mentions that 

the way pain medicine is practiced needs change. Dr. Blatman notes that too many expensive procedures 

are performed that do not work as well, as they were really treating the actual injury or cause of pain and 

inflammation for arthritis, tendinitis, and bursitis. Learning more about physical examination and treatment of 

muscle and fascia where most pain is generated should be part of the medical curriculum, as well as the 

effects of nutrition on both causation and healing from pain. He also discusses how food choices contribute 

to causing chronic pain and outlines the future of pain and rehabilitative medicine. 

Another chapter, “Multi-systemic Infectious Disease Syndrome: Understanding Chronic Lyme Disease and 

Persistent Illness”, is written by Humanitarian Award winner Richard Horowitz, MD. As president of the 

International Lyme and Associated Diseases Education Foundation, whose mission is to educate health 

professionals in the diagnosis and treatment of Lyme disease and tick borne co-infections, Dr. Horowitz 

helps patients coming from all over the United States, Canada and Europe. His exceptionally well-written 

article is an eye opener. I encourage everybody to pay special attention to this highly ignored condition. He 

talks about a 15-point differential diagnostic category for Multi-Systemic Infectious Disease Syndrome 

(MSIDS) which is key to solving the underlying mysteries of a patient’s chronic conditions. It is no longer 

acceptable to just label an illness and then give a drug to treat the symptoms. We can do better. You will 

not be disappointed. 

As emphasized by former Surgeon General C. Everett Koop, a person is not truly healthy unless he also 

has oral health. A healthy mouth is essential for healthy living emphasizes Dr. Lamster, Dean of Columbia 

University College of Dental medicine in New York. Can you imagine dentists as physicians of the mouth? 

“What is Biological Dentistry” by George Keanna, a biological dentist from the Rocky Mountains called 

Sandia Mountains in Albuquerque, New Mexico. Mercury amalgam fillings opened his mind. Associate 

Professor of Dentistry, Evanthia Lalla of Columbia University, School of Dental and Oral Surgery says, 

“Dental clinicians can play a significant part in promoting the general health of their patients.” Better 

management of his or her diabetes lends to a partnership between dentists and registered dietitians to serve 

as a team. 

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2012 

Physical therapists are neuromuscular skeletal specialists and the role this system plays in creating a healing 

environment for pelvic system health is well documented. “Pelvicology: A Neuro Muscular Skeletal Approach 

to the Treatment of Pelvic Conditions”, by Marilyn Freedman and Riva Preil, has helped men, women and 

children with pelvic pain, urological, obstetrical, gynecological and colorectal conditions. Both authors state 

that there is a strong correlation between pelvic floor related and respiratory conditions and back pain. The 

authors have divided conditions into two main types of pelvic floor dysfunction and they are classified as 

pelvic floor hypotonicity and hypertonicity. There is hope for both women and men with chronic pelvic pain, 

incontinence and constipation. 

“We have travelled far in the science of medicine, but have yet to come full circle in acknowledging the 

power of the healing process each of us carries” says Psychiatrist Vernon Barksdale, MD. Dr. Barksdale has 

earned two degrees from John Hopkins University School of Medicine in Baltimore, Maryland in the USA. 

Vernon’s chapter encompasses “Activating Our Healing Potential by Using Our Innate Faith”. He mentions 

there are numerous examples in the medical and research literature on positive thinking, prayer and placebo 

effect to help patients overcome numerous health challenges. As clinicians we face challenges as we strive 

to promote health as a part of overall well-being. In his presentation on Spirituality and Healing, Herbert 

Benson, MD of Harvard Medical School and Director of Hypertension, Beth Israel Hospital reports that many 

patients believe the God of their faith plays a role in their treatment response. In his experiments with the 

relaxation response / meditation training revealed patients describing it as a “Spirituality Experience” 

regardless of religious beliefs. Dr. Barksdale relates that patients rarely ask about your faith, but often 

benefit from feeling that their health provider supports the use of their beliefs. If patients ask for a strategy 

to help them manage their illness, stress reduction is always a safe practice that can also contribute to 

overall health. Dr. Barksdale encourages practitioners to proceed with a nonjudgmental approach respectfully 

honoring the patient’s belief system. 

These are some of the most common conditions people are facing worldwide. I want to thank all the 

esteemed authors who, in spite of their extremely busy schedules, graciously accepted the invitation to share 

their expertise for AAPI’s global project. 

I could not have done this without the help of Dietetic Intern, Ashley Dunham, for being ready to help 

during her intense internship year at Tufts University. Obviously AAPI's eBook Part 2 would not have been 

possible if it was not for AAPI President Sunita Kanumury, MD. Thank you, Sunita for reaching out to the 

world through this global project and making this invaluable free resource available to the community 

worldwide through AAPI’s website. 

Health Media CEO, Alex Lubarsky, emphasizes on “My Health, My Life, My Terms… may you have optimal 

well-being and may joy follow you always” 

Om Shanti! 

Rita (Shah) Batheja, MS, RD, CDN 

Founder, Indian American Dietetic Association 

New York, USA 

Krbat1@juno.com 

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Foreword 

2012 


“The doctor of the future will give no medicine, but will interest her or his patients in the care of the 

human frame in a proper diet and in the cause and prevention of disease.” – Thomas Edison 

It is just beyond my imagination that in such a short period of time AAPI’s Nutrition Guide to Optimal 

Health: Using Principles of Functional Medicine and Nutritional Genomics Part 2 is complete. This is AAPI’s 

hidden treasure for all of you to benefit from! We are getting rave reviews throughout the World about 

AAPI’s eBook on Optimal Health. People are very happy globally for such a fine eBook. 

I am grateful to nationally and internationally recognized authors for their contribution. All of these chapters 

are brilliantly written utilizing evidence based, research based information by conventional physicians who are 

trained in functional medicine and other healthcare providers, like Registered Dietitians and Certified 

Nutritionists, Research Scientists, Biological Dentists and Physical therapists. 

I hope AAPI’s eBook on nutrition will be useful to you as it has inspired me. I would love to receive your 

feedback. This will help us meet your future needs. 

Ashley Dunham extended herself in editing and formatting the eBook in spite of her busy dietetic internship 

year at Tufts University. I do not know what to say about Rita Batheja, MS, RD, CDN, founder of the 

Indian American Dietetic Association. Rita diligently worked to meet the challenge and made sure to make 

AAPI’s fantastic free resource available to you. This is the first time in the 30 year history that healthy 

eating and lifestyle were given a priority. 

Once again, my heartfelt thanks to esteemed authors. This resource would not have been possible without 

them. 

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All of us together as physicians will strive for Prevention rather than managing Symptoms. “Eat food, not 

too much, plant based” says Michael Pollan, author of “In defense of food”. “Today’s doctor will be 

tomorrow’s nutritionist.” 

Warmest Regards, 


American Association of Physicians of Indian Origin, 

New Jersey, USA 

sunitakanumury@yahoo.com 

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19 

Person-Centered 

Diagnosis: 

Principles and 

Practice 

Leo Galland, MD, 

FACP, FACN 

2012 

The purpose of this chapter is to present an 

organizational structure for assessment of patients 

as unique individuals, an approach I have called 

Person-Centered Diagnosis 1 . The goal of Person- 

Centered Diagnosis is to enable healers to 

develop individualized treatment plans that are 

based upon an understanding of the physiological, 

environmental and psychosocial contexts within 

which each person's illnesses or dysfunctions 

occur. The information you need to effectively 

apply this organizational structure fills the 

remainder of this textbook. My goal here is to 

describe and illustrate the structure. To create it, 

you must start by eliciting all of the patient's 

concerns. In actively listening to the patient's 

story, you attempt to discover the Antecedents, 

Triggers and Mediators that underlie symptoms, 

signs, illness behaviors and demonstrable 

pathology. Functional Medicine is based upon 

treatment that is collaborative, flexible and focused 

on the control or reversal of each person's 

individual Antecedents, Triggers and Mediators, 

rather than the treatment of disease entities. 

ELICITING THE PATIENT'S STORY 

The first step in patient-centered care is eliciting 

the patient's story in a comprehensive manner. It 

is the Functional Medicine practitioner's job to 

know not just the ailments or their diagnoses, but 

the physical and social environment in which 

sickness occurs, the dietary habits of the person 

who is sick (present diet and pre-illness diet), 

his beliefs about the illness, the impact of illness 

on social and psychological function, factors that 

aggravate or ameliorate symptoms and factors that 

predispose to illness or facilitate recovery. This 

information is necessary for establishing a 

functional treatment plan. 

The importance of understanding the patient's 

experience of her illness cannot be 

overemphasized. Extensive research on doctorpatient 

interactions indicates that doctors who fail 

to pay attention to the patient's concerns miss 

important clinical information. The conventional 

diagnostic paradigm, Differential Diagnosis, leads 

doctors to ignore or denigrate information that 

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patients consider important, or that influences 

individual prognosis 2 3 4 . Not only does this 

ignorance impair the effectiveness of treatment 5 , it 

generates considerable dissatisfaction among 

patients. 6 7 8 

Extensive research done within the context of 

conventional medical care reveals what most 

patients know: doctors do not pay enough 

attention to what their patients have to say. A 

study done at the University of Rochester found 

that most patients have three reasons for visiting 

a physician, are interrupted within eighteen 

seconds of starting to tell their stories and never 

get the chance to finish. 9 

Although doctors excuse 

this behavior by citing lack of time, it would have 

taken an average of one minute and rarely more 

than three minutes for a complete list of problems 

to be elicited. 

Even when doctors know what their patients' 

concerns are, they typically ignore them 10 . Most 

patients have different ideas about their illnesses 

than their doctors and some form of clarification 

or negotiation is needed for an effective 

therapeutic alliance to be established 11 . A study 

that carefully analyzed taped transcripts of visits to 

a medical clinic found that patients attempted to 

clarify or challenge what their doctor had said in 

85% of the visits. Their requests were usually 

ignored or interrupted 12 . Understanding the patient's 

perspective allows the doctor to work in a 

collaborative way with patients, giving information 

that helps the patient make healthful choices 13 . 

The more information that the patient receives 

from the doctor and the more actively the patient 

is involved in making decisions about treatment, 

the higher the level of mutual satisfaction and the 

better the clinical outcome 14 15 16 17 18 . A 

systematic review of randomized clinical trials and 

analytic studies of physician-patient communication 

confirmed a positive influence of quality 

communication on health outcomes. 19 

Such a 

collaborative relationship depends upon the 

practitioner recognizing and acknowledging the 

patient's experience of the illness. Useful questions 

to ask include: 

How are you hoping that I can help you 

today? What do you believe is the source of 

your problems? What kind of treatment are 

you looking for? What do you most fear 

about your illness? What impact have your 

symptoms had on your life? 

ORGANIZING AND ANALYZING THE PATIENT'S 

STORY 

What modern science has taught us about the 

genesis of disease can be represented by three 

words: Triggers, Mediators and Antecedents. 

Triggers are discrete entities or events that 

provoke disease or its symptoms. Microbes are an 

example. The greatest scientific discovery of the 

Nineteenth Century was the microbial etiology of 

the major epidemic diseases. Triggers are usually 

insufficient in and of themselves for disease 

formation, however. Host response is an essential 

component. Identifying the biochemical mediators 

that underlie host responses was the most 

productive field of biomedical research during the 

second half of the Twentieth Century. Mediators, 

as their name implies, do not "cause" disease. 

They are intermediaries that contribute to the 

manifestations of disease. Antecedents are factors 

that predispose to acute or chronic illness. For a 

person who is ill, they form the illness diathesis. 

From the perspective of prevention, they are risk 

factors. Knowledge of antecedents has provided a 

rational structure for the organization of preventive 

medicine and public health. Medical genomics 

seeks to better understand disease by identifying 

the phenotypic expression of disease-related genes 

and their products. The application of genomic 

science to clinical medicine requires the integration 

of Antecedents (genes and the factors controlling 

their expression) with Mediators (the downstream 

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2012 

products of gene activation). Mediators, Triggers 

and Antecedents are not only key biomedical 

concepts, they are also important psychosocial 

concepts. In Person-Centered Diagnosis, the 

Mediators, Triggers and Antecedents for each 

person's illness form the focus of clinical 

investigation. 

ANTECEDENTS AND THE ORIGINS OF ILLNESS 

Understanding the antecedents of illness helps the 

physician understand the unique characteristics of 

each patient as they relate to his current health 

status. Antecedents may be thought of as 

congenital or developmental. The most important 

congenital factor is sex: women and men differ 

markedly in susceptibility to many disorders. The 

most important developmental factor is age: what 

ails children is rarely the same as what ails the 

elderly. Beyond these obvious factors lies a 

diversity as complex as the genetic differences 

and separate life experiences that distinguish one 

person from another. 

Congenital factors may be inherited or acquired in 

utero. They can most readily be evaluated from a 

comprehensive family history, including mother's 

health before and during pregnancy. Genomic 

analysis, which is now commercially available, can 

supplement the family health history as a tool for 

investigating unique nutritional needs or individual 

variability in sensitivity to environmental toxins 20 21 . 

The commonest single gene disorders in North 

America, celiac disease and hemochromatosis, 

may be confirmed by the presence of genetic 

markers, but should first be suspected from 

abnormalities in routine lab tests. Elevated serum 

ferritin concentration or transferrin saturation should 

prompt genetic testing for the alleles associated 

with hereditary hemochromatosis. 22 

Increased 

small intestinal permeability, as measured by the 

inexpensive, non-invasive and under-utilized 

lactulose/mannitol challenge test, has a sensitivity 

approaching 100% for untreated celiac disease 23 . 

Abnormal intestinal permeability should prompt the 

measurement of celiac-specific immune markers in 

patients with chronic fatigue, autoimmune disorders 

or chronic gastrointestinal complaints of any type; 

normal intestinal permeability in patients consuming 

gluten virtually excludes gluten-sensitive 

enteropathy as a consideration, whatever the 

serological markers reveal. Because 

hemochromatosis and celiac disease are common, 

have protean manifestations and can be well 

controlled by nutritional interventions, ferritin and 

intestinal permeability should be routine 

components of the laboratory testing for 

antecedents of illness. 

Some familial disorders may reflect intra-uterine 

rather than genetic influences. Twin studies of 

hypertension, for example, indicate a higher 

concordance for blood pressure between identical 

twins with a common placenta than identical twins 

with separate placentas. 24 

Presumably, the shared 

placenta mediates subtle nutritional influences that 

affect a tendency toward chronic illness in 

adulthood. 

Post-natal developmental factors that govern the 

predisposition to illness include nutrition, exposure 

to toxins, trauma, learned patterns of behavior and 

the microbial ecology of the body. Sexual abuse 

in childhood, for example, is associated with an 

increased risk of abdominal and pelvic pain 

syndromes among women 25 26 . Recurrent otitis 

media increases the risk of a child developing 

Attention Deficit Disorder 27 28 , an effect that is not 

associated with hearing loss but may result from 

the effects of antibiotics on the microbial ecology 

of the gut. 

Precipitating events are critical antecedents that 

closely precede the development of chronic illness. 

They represent a boundary in time: before this 

event the person was considered healthy; since 

the event, the person has become a patient. 

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2012 

Understanding the nature of the precipitating event 

may aid in unraveling the triggers and mediators 

that maintain the state of illness. The commonest 

precipitating events among my patients are a 

period of severe psychosocial distress, an acute 

infection (sometimes treated with antibiotics), 

exposure to environmental toxins at work or home 

or severe nutrient depletion related to illness or 

crash dieting. Useful questions for uncovering 

precipitating events include: When is the last time 

you felt really well for more than a few days at a 

time? During the six months preceding that date, 

did you experience any illness or major stress, 

change your use of medication or dietary 

supplements, or make any significant life 

changes? Cases in which cryptogenic illness was 

found to be precipitated by foreign travel, antibiotic 

use, dietary changes 29 , smoldering infection or the 

illness of a spouse 30 

have been presented 

elsewhere. 

TRIGGERS AND THE PROVOCATION OF 

ILLNESS 

A trigger is anything that initiates an acute 

illness or the emergence of symptoms. The 

distinction between a trigger and a precipitating 

event is relative, not absolute; the distinction helps 

organize the patient's story. As a general rule, 

triggers only provoke illness as long as the 

person is exposed to them (or for a short while 

afterward), whereas a precipitating event initiates 

a change in health status that persists long after 

the exposure ends. Common triggers include 

physical or psychic trauma, microbes, drugs, 

allergens, foods (or even the act of eating or 

drinking), environmental toxins, temperature 

change, stressful life events, adverse social 

interactions, and powerful memories. For some 

conditions, the trigger is such an essential part of 

our concept of the disease that the two cannot be 

separated; the disease is either named after the 

trigger (e.g., "Strep throat") or the absence of 

the trigger negates the diagnosis (e.g., 

concussion cannot occur without head trauma). 

For chronic ailments like asthma, arthritis or 

migraine headaches multiple interacting triggers 

may be present. All triggers, however, exert their 

effects through the activation of host-derived 

mediators. In closed head trauma, for example, 

activation of NMDA receptors, induction of nitric 

oxide synthase (iNOS) and liberation of free 

intra-neuronal calcium determine the late effects. 

Intravenous magnesium at the time of trauma 

attenuates severity by altering the mediator 

response 31 . Sensitivity to different triggers often 

varies among persons with similar ailments. A 

prime task of the functional practitioner is to help 

patients identify important triggers for their ailments 

and develop strategies for eliminating them or 

diminishing their virulence. 

Although the identification and elimination of 

triggers is not a foreign concept in conventional 

medicine, many physicians neglect the search. A 

study was conducted by telephone in which 

practicing physicians were asked how they would 

treat a new patient with abdominal pain, who had 

a recent diagnosis of gastritis made by a 

specialist in another town. Almost half were ready 

to put the patient on acid-lowering therapy without 

asking about the patient's use of aspirin, alcohol 

or tobacco, all of which are potential triggers for 

gastritis. The authors of the study concluded, "In 

actual practice, ignoring these aspects of the 

patient may well have reduced or even negated 

the efficacy of other therapeutic plans 

implemented." 32 

MEDIATORS AND THE FORMATION OF 

ILLNESS 

A mediator is anything that produces symptoms, 

damage to tissues of the body, or the types of 

behaviors associated with being sick. Mediators 

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vary in form and substance. They may be 

biochemical (like prostanoids and cytokines), ionic 

(like hydrogen ions), social (like reinforcement 

for staying ill), psychological (like fear) or 

cultural (like beliefs about the nature of illness). 

A list of common mediators is presented in Table 

I. Illness in any single person usually involves 

multiple interacting mediators. Biochemical, 

psychosocial and cultural mediators interact 

continuously in the formation of illness. 

Cognitive/emotional mediators determine how 

patients appraise symptoms and what actions they 

take in response to that appraisal. 33 . They may 

even modulate the symptoms themselves. People 

in pain, for example, experience more pain when 

they fear that pain control will be inadequate than 

when they believe that ample pain management is 

available. 34 

Perceived self-efficacy (the belief in one's ability 

to cope successfully with specific problems) is a 

cognitive mediator that determines coping with 

illness. People with a high degree of health selfefficacy 

usually adapt better to chronic disease, 

maintaining higher levels of activity, requiring lower 

doses of pain medication, adopting healthier 

lifestyles, and cooperating with prescribed 

therapies, compared to people with low selfefficacy. 

35 

Self-management education is designed 

to enhance self-efficacy 36 , and has been shown to 

improve the clinical outcome for patients with 

several types of chronic disease, including 

asthma 37 , arthritis 38 and diabetes 39 . 

The biochemical mediators of disease (listed in 

Table 1) are best known for their ability to 

promote cellular damage. Most are organized into 

circuits and cascades that sub-serve homeostasis 

and allostasis. In these networks, each mediator is 

multi-functional and most functions involve multiple 

mediators, so that redundancy is the rule, not the 

exception. The most striking characteristic of 

biochemical mediators is their lack of disease 

specificity. Each mediator can be implicated in 

many different, apparently unrelated diseases, and 

every disease involves multiple chemical mediators 

in its formation. 

Mediator networks that regulate inflammatory and 

neuroendocrine stress responses have been the 

subject of intensive research with important clinical 

implications. A detailed discussion of these 

networks is outside the scope of this chapter, but 

they are described in detail in Chapters....... 

Comprehensive reviews have appeared elsewhere 40 

41 42 43 

. Within the framework of Functional 

Medicine, a key feature of biochemical mediators 

is the natural rhythm of mediator activity, which is 

strongly influenced by the common components of 

life: diet, sleep, exercise, hygiene, social 

interactions, solar and lunar cycles, age and sex. 

Aging, illness and chronic psychological distress 

up-regulate activity of the inflammatory and 

neuroendocrine-stress response networks. Regular 

physical activity down-regulates both. 

INTEGRATING THE PATIENT'S STORY 

After listening to the concerns that led each 

patient to seek a consultation in Functional 

Medicine, make a series of distinctions: 

(1) For patients whose main concern is 

optimal health and prevention, ask about present 

and past health problems and the family health 

history. If these supply no indication of illness 

susceptibility, then turn your attention to risk 

factors for future illness: weight, fitness, type and 

level of physical activity, dietary pattern, sleep 

habits, use of alcohol, drugs, tobacco, firearms, 

environmental exposures at home and work, travel, 

sources of stress and pleasure, degree of 

involvement with others, spiritual beliefs and 

practices, sexual relationships, hopes and fears for 

the future. 

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(2) For patients with an active health 

problem, always ask, "What was your health like 

before this problem began?" An intake 

questionnaire that asks about previous health 

problems is also helpful, because it gathers 

information about what the patient was like prior 

to the present illness in a different fashion, one 

that is condition-specific, not open-ended. The 

two approaches complement one another. 

(a) Some patients will say that they were 

really healthy prior to their present illness. In that 

case, look for a precipitating event. If you or the 

patient can identify one, then ask about ongoing 

triggers that bear some relationship to the 

precipitating event. For example: if the precipitating 

event was marital or job stress, focus on stressrelated 

psychological triggers. If the precipitating 

event was an environmental exposure, focus on 

on-going exposures to volatile chemicals or mold. 

(b) The most challenging patients will 

usually indicate that their health was poor even 

before their present illness. In that case, take a 

detailed, chronological history from birth to the 

present that includes information about early life 

experience (including illness, injury and abuse), 

school and work performance, diet, drug and 

medication use, leisure activities, travel, family life, 

sexual experiences, habits, life stressors and 

places of residence. Because gathering this data 

can be very time-consuming, a self-administered 

questionnaire completed by the patient before the 

interview may help to prompt responses and 

improve memory of remote events. For many 

patients with complex, chronic health problems, it 

may be useful to take a detailed life history 

before seeking detailed information about present 

symptoms. Problems that emerge from such a 

review will have to be addressed for a successful 

outcome of treatment. Dealing with the present 

concerns by themselves will almost never succeed 

for patients in this group. 

Whatever rapport you establish with patients 

initially, maintaining the therapeutic relationship 

usually depends upon significant improvement in 

symptoms or in a sense of well-being within a 

few days to a few weeks of the initial evaluation. 

This is most efficiently achieved by addressing the 

triggers that provoke symptoms and helping the 

patient decrease exposure to them. When triggers 

cannot be identified or avoided, then symptomatic 

improvement must rest on control of mediator 

activation. A combination of the two will usually 

produce the most satisfactory long-term benefits. 

ASSESSMENT OF TRIGGERS 

A comprehensive search for triggers requires that 

you know the following about your patient: each 

drug--prescription, over-the-counter or 

recreational--that the patient has used and when; 

nutritional habits and each dietary supplement 

used and when; what effects the patient noted 

from the use of each substance; sources of 

stress--life events, environmental exposures, 

thoughts or memories, and social interactions--and 

when they occurred in relation to symptoms. Elicit 

the patient's own ideas about possible triggers by 

asking, "What do you think causes or aggravates 

your symptoms." The patient's observations may 

be insightful and accurate in ascribing causality. 

Of course the patient’s---and the clinician’s— 

observations can also mislead, or focus on nonessential 

factors. Teach patients to challenge 

their own observations by looking for consistency 

and replicability, wherever possible. Suggest 

alternative theories for the patient to consider and 

explain that the search for triggers works best as 

a collaborative effort between patient and doctor. 

The patient's ability to recognize triggers is an 

important step in self-care. 

Food and environment supply important triggers for 

the practice of Functional Medicine. Food 

intolerance is a very common phenomenon, 

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reported by thirty-three per cent of the population 

in one large study 44 . A minority of these reactions 

(4-14%) are due to true food allergies. Most 

food intolerance has no clear immunologic basis. 

Mechanisms include sensitivity to the 

pharmacological effect of alkaloids, amines or 

salicylates in food. 45 46 47 48 Histamine poisoning 

from scromboid fish and tyramine-induced 

headache are dramatic examples. 49 

Although 

most food intolerance is short-lived, severe 

chronic illness can occur, and the food trigger 

may elude identification unless the physician starts 

the investigation with a high index of suspicion. 

Gluten intolerance, with its protean manifestations, 

is probably the best example. Affecting about two 

per cent of people of European ancestry 50 , gluten 

intolerance is common and often unrecognized. In 

addition to being the essential trigger for celiac 

disease, gluten sensitivity may be manifest in 

patients with neurological disorders of unknown 

cause 51 , cerebellar degeneration 52 , dermatitis 

herpetiformis 53 , failure to thrive 54 , pervasive 

developmental delay 55 56 57 58 

, inflammatory arthritis 

59 60 

, psoriasis 61 62 Sjogren's syndrome 63 64 , and 

schizophrenia 65 66 . The different presentations of 

gluten sensitivity may derive from genetic 

differences among affected patients. 67 

Published studies on food intolerance and your 

patients' symptoms may be found through the 

National Library of Medicine. If the patient has a 

disease diagnosis, a Medline search may reveal 

previously observed associations between specific 

foods and the patient's condition. Access PubMed 

over the Internet (www.pubmed.gov) and run a 

search that cross-references the name of the 

patient's condition with "Hypersensitivity, Food" 

and also with "Food, adverse reactions". Both of 

these are Medline Subject Headings (MESH). 

There is no MESH listing for "Food Allergy" or 

"Food Intolerance". Your search will be more 

efficient if you list the patient's condition as it 

appears in MESH. A negative search does not 

eliminate food intolerance as a trigger for the 

condition being searched, but the number of 

positive findings may surprise you. 

Health effects of ambient air quality are as 

important as those of foods. Numerous studies 

conducted in U.S. cities, demonstrate a close 

correlation between fine particle air pollution and 

daily mortality rates, even at levels of pollution 

considered safe by the World Health 

Organization 68 

In the industrialized world, most 

people spend most of their time indoors, and 

indoor air pollution has become a serious cause 

of morbidity. Studies using experimental chambers 

have shown that volatile organic compounds 

(VOCs) released from building materials, 

furnishings, office machines and cleaning products, 

can cause irritation of the respiratory system in 

humans and animals at levels which are one 

hundred times weaker than permissible exposure 

levels or the World Health Organization Indoor Air 

Guidelines 69 . Controlled experiments with people 

who describe themselves as sensitive to VOCs 

confirm that VOC exposure causes headache, 

fatigue and difficulty concentrating. People who 

deny such sensitivity also experience symptoms 

but do not experience mental impairment when 

exposed. Air samples of buildings with and without 

Sick Building complaints have established an 

association between VOC exposure and human 

sickness. 70 

A questionnaire can elicit important information 

about environmental exposures at home and at 

work. The open-ended question, "Has your work 

or home environment been a concern to you?" 

should be accompanied by a checklist of potential 

exposures. 

Microbial triggers for chronic illness present a 

particular challenge, as exemplified by the many 

facets of Helicobacter pylori infection. Originally 

isolated from the gastric mucosa of patients with 

gastritis and peptic ulcer disease, H. pylori has 

been implicated in the pathogenesis of NSAID 

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gastropathy 71 , gastric carcinoma 72 and lymphoma 73 

and a variety of extradigestive disorders, including 

ischemic heart disease 74 , ischemic cerebrovascular 

disorders 75 , rosacea 76 , Sjogren's syndrome 77 , 

Raynaud's syndrome 78 , food allergy 79 , vitamin B12 

deficiency 80 

and open angle glaucoma 81 . For 

elderly patients with open angle glaucoma and 

incidental H. pylori infection of the stomach, 

eradication of H. pylori by antibiotics was 

associated with improved control of glaucoma 

parameters at 2 years. 82 

The mechanism by which 

H. pylori aggravates open-angle glaucoma is 

unknown, but may result from the ability of H. 

pylori colonization of the gastric tract to trigger the 

local and systemic release of Platelet Activating 

Factor, inflammatory cytokines, and vasoactive 

substances. 

In the case of untreated H. pylori infection, noninvasive 

screening tests, including serum 

antibodies, stool antigens and C-14 breath 

testing, are available. For other types of infection, 

inquiring about the previous response of a given 

symptom or symptom complex to antibiotics may 

be useful. In 1988, physicians at the University 

of Minnesota conducted a study in which they 

administered intravenous cephalosoprins to patients 

with various types of arthritis who also manifested 

antibodies to Borrelia burgdorferi. Most of these 

patients were not thought to have Lyme disease. 

Some met diagnostic criteria for rheumatoid 

arthritis, some for osteoarthritis, some for 

spondyloarthropathies. The response to antibiotics 

was quite variable and ranged from no response 

to dramatic and sustained improvement. The 

authors noted that improvement in arthritis 

following antibiotics was not related to the patient's 

clinical diagnosis or the level of anti-Borrelia 

antibody. The best predictor of a positive response 

to the experimental treatment was a previous 

history of improvement of arthritis associated with 

the use of antibiotics 83 . 

The most comprehensive way to ask the antibiotic 

question is: "During the time you have had 

symptom X, have you taken antibiotics for any 

reason? Which antibiotic? Did symptom X change 

while you were taking the drug?" Among patients 

with chronic diarrhea of unknown cause, for 

example, some will report that their gastrointestinal 

symptoms improved when taking a specific 

antibiotic, others will report that they worsened. 

The first case suggests that bacteria or protozoa 

sensitive to the antibiotic may be causally related 

to the patient's gastrointestinal problems. Repeating 

the antibiotic prescription can establish if this 

response is replicable. If so, therapy can focus on 

treating the microbe and understanding why a 

single course of antibiotics was ineffective. The 

second case suggests that depletion of bacteria by 

antibiotics and concomitant increase in antibioticresistant 

organisms, including yeasts, may be 

contributing to diarrhea and treatment can focus 

on restoration of a normal intestinal flora. 

ASSESSMENT OF PSYCHOSOCIAL MEDIATORS: 

Useful questions for eliciting a person's beliefs 

about her illness are: 

"What do you think has caused your problem?" 

"What do you most fear about your problem?" 

"How much control do you think you have over 

your symptoms?" 

Useful questions for eliciting information about the 

nature and sources of social support include: 

"Are there people in whom you can confide?" 

"How satisfied are you with your 

marriage/family/friends/social life?" 

"How much support do you receive in dealing 

with your health problems?" 

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"How often do you feel loved or cared for?" 

ASSESSMENT OF BIOCHEMICAL MEDIATORS 

Understanding the biochemical alterations 

associated with a conventional disease diagnosis 

can be helpful in understanding the biochemical 

mediators of each person's illness. Inflammation is 

believed to play a critical role not only in 

response to infection and in the classic 

inflammatory diseases, but also in the 

pathogenesis of coronary artery disease, diabetes, 

cancer and depression and the negative health 

84 85 

effects associated with obesity and with aging. 

86 87 88 89 90 

The orchestration of mediator 

signals in the inflammation and neuroendocrinestress 

networks, as they interact with one another, 

is critical for normal physiological functions, like 

the architecture of sleep, the repair of injury and 

the response to infection, and for the dysfunctional 

physiology central to the pathogenesis of most of 

91 92 

the major chronic diseases. 

Most chronic diseases is associated with chronic 

inflammation, but the patterns of immune response 

that underlie inflammation are not always the 

same. Patients with Type 1 diabetes mellitus, 

Crohn's disease or any other disorder categorized 

by granuloma formation or excessive cell mediated 

immune responses are likely to have an immune 

response to common triggers in which the TH1 

component is upregulated and not subject to the 

normal downregulation provided by TH2 activity. 

Their mediator response to inflammatory stimulation 

produces excessive levels of gamma-interferon 

(g-IFN) and interleukin-12 (IL-12), key TH1- 

related cytokines. 93 

Patients with severe depression 

often show a loss of negative feedback in the 

HPA axis. Urine free cortisol is elevated; the 

diurnal pattern may be disrupted, with increased 

P.M. cortisol secretion and blunting of 

dexamethasone suppression. This phenomenon 

appears to be driven at the level of the 

hypothalamus, not the adrenals, because spinal 

fluid Corticotrophin Releasing Hormone (CRH) is 

elevated. 94 

Several groups of researchers have 

speculated that impaired synaptic function due to 

a deficit of omega-3 fatty acids may contribute to 

the CNS dysfunction of patients with depressive 

illness. Their Omega-3 fatty acid levels tend to 

be lower in blood samples than in control 

populations; administration of omega-3 

supplements derived from fish oil has been shown 

beneficial in placebo-controlled studies of patients 

with depression, schizophrenia and attention deficit 

disorder. The key component appears to be 

eicosapentaenoic acid (EPA). 95 

To utilize the vast database of available 

information about biochemical disease mediators, 

integrative clinicians should consider three 

strategies. First, maintain up-to-date knowledge of 

disease pathophysiology by reading reviews in 

mainstream journals on mechanisms of disease or 

on specific mediators. In reading these, pay 

special attention to the types of mediators 

mentioned and their functions within the networks 

that subserve inflammation, oxidative stress, and 

neuroendocrine balance. 

Second, attend workshops and courses that 

emphasize integrative physiology, sponsored by 

institutions like IFM, the New York Academy of 

Sciences, the Center for Mind-Body Medicine, and 

the American College for Advancement in Medicine 

96 

Third, employ knowledge of the commonest 

biochemical imbalances in chronically ill North 

Americans and the influence of diet, nutrition and 

dietary supplements on these imbalances. 

TREATMENT PLANNING 

A Functional Medicine treatment plan should be 

collaborative and dynamic. Collaborative means 

that patient and practitioner work together to set 

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goals and priorities. Dynamic means that the 

treatment plan is adjusted as needed in response 

to feedback. Your knowledge of the patient's 

beliefs about her illness and perceived selfefficacy 

are essential for collaborative treatment. 

An appropriate therapeutic intervention for 

dysfunctional beliefs is the giving of information. 

Patients have an intense need for explanations 

about the causes of their diseases. 97 

They want 

to know how they came to be sick, so that they 

can attach some meaning to the illness, 98 

what to 

expect from the illness and what they can do to 

relieve symptoms or speed recovery. Information of 

this type can reduce anxiety, even when the 

diagnosis itself is frightening, may increase feelings 

of personal control, and improve the ability to 

cope with pain. People change their behaviors 

more readily when they receive information about 

the importance and the nature of the changes 

they need to make, help with setting goals and 

measuring progress. The kind of information 

needed is personal, not statistical. It must answer 

the question, "What can I do?" 

The physician can help patients who are suffering 

from isolation by calling this isolation to the 

attention of family members or friends or by 

attempting to connect the patient with a support 

group or community agency. Possibly, there is 

nothing that can be done to relieve the patient's 

isolation, but the doctor's awareness and 

acknowledgment of it can be important to the 

patient and serve to enhance the therapeutic 

relationship 99 . 

If potential triggers have been identified, an 

assessment of the patient's ability to control 

exposure to them is important. For patients who 

are reluctant to make major dietary or 

environmental changes, explain that each 

avoidance is an experiment that the patient can 

direct with your guidance. If eliminating foods 

(and reintroducing those foods as a challenge) 

has no effect on symptoms or measurable 

physiologic parameters, do not encourage the 

patient to persist in the avoidance of those foods, 

whatever the results of in vitro allergy tests may 

be. The patient will have enough work to do 

following a healthy diet. Food intolerance is only 

meaningful if its effects can be demonstrated in 

real life. 

For microbial triggers, the decision to use 

prescription antimicrobial drugs or natural products 

with antimicrobial activity may require negotiation. 

If the situation is not critical, it is usually 

worthwhile honoring the patient's preferences and 

intuition. 

Understanding the ways in which mediators are 

modulated by diet enables creative nutritional 

therapies to be applied. Salicylic acid, the major 

metabolite of aspirin, suppresses activation of the 

nuclear transcription factor NF-kB, an antiinflammatory 

effect that is independent of 

cyclooxygenase inhibition 100 

and may be 

responsible for some effects of low-dose aspirin 

therapy. 101 

Vegetables are rich sources of natural 

salicylates and vegetarians may have serum 

concentrations of salicylic acid as high as those of 

people ingesting 75 mg of aspirin a day. 102 

Dietary fatty acids may have profound effects on 

the network of inflammatory mediators, altering 

prostanoid synthesis, PPAR activity and the 

response to cytokines like IL-1 103 . They have 

subtler effects on the neuroendocrine-stress 

response network, modulating neuronal responses 

to serotonergic and adrenergic transmission. 104 

Therapy with omega-3 fatty acids provides an 

excellent example of nutritional modulation of 

disease activity though alteration of biochemical 

mediators. Three principles can guide this type of 

therapy. The first utilizes knowledge of the 

pathophysiology of specific inflammatory and CNS 

disorders. Using this model, omega-3 therapy has 

been successfully applied to the treatment of 

patients with rheumatoid arthritis, inflammatory 

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bowel disease, coronary artery disease, peripheral 

vascular disease, dysmenorrhea, cyclic mastalgia, 

cystic fibrosis, migraine headaches, bipolar 

disorder, schizophrenia, attention deficit disorder, 

atopic eczema and multiple sclerosis 105 . Because 

the fatty acid composition of the contemporary 

Western diet differs significantly from paleolithic 

and ancestral diets, reflecting a marked decrease 

in omega-3 consumption relative to total fat, the 

response of so many unrelated disorders to EFA 

supplementation may indicate that EFA's are not 

merely working as nutriceutical agents, but that 

EFA dietary status is important for disease 

pathogenesis. 

The second method rests upon the clinical 

evaluation of an individual's fatty acid status 

using clinical parameters that are independent of 

disease activity. Prasad has stated that the best 

test for nutritional adequacy is a functional test. 

Determine a parameter to follow and measure how 

administration of the nutrient(s) in question 

affects that parameter. 106 

This method can be 

applied to the use of EFA therapy in clinical 

practice. Stevens et. al., studying boys with ADHD 

and a randomly selected population of 

schoolchildren, found a correlation between low 

concentrations of omega-3 EFAs, learning and 

behavior problems, and symptoms associated with 

EFA deficiency (thirst, dry skin and dry hair). 107 

Evaluating the presence of these symptoms in 

patients and observing how they change with EFA 

supplementation is a quick guide to EFA status 

that may be used clinically to evaluate the EFA 

contribution to mediator imbalance. The author's 

method for doing this has been described 

elsewhere 108 . Finally, it is possible to measure the 

levels of fatty acids in plasma and erythrocyte 

phospholipids, although guidelines for level of 

change in fatty acid profiles needed to produce a 

known physiologic effect have not yet been 

developed. 

The successful application of nutritional therapies, 

especially dietary interventions, and other self-care 

practices, as part of a therapeutic plan is very 

helpful in enhancing self-efficacy among patients. 

Enhancement of self-efficacy should always be a 

cardinal goal of treatment in Functional Medicine. 

SUMMARY 

Functional Medicine is essentially patient-centered, 

rather than disease-centered. A structure is 

presented for uniting a patient-centered approach 

to diagnosis and treatment with the fruits of 

modern clinical science, which has evolved to 

serve the prevailing model of disease-centered 

care. The core scientific concepts of disease 

pathogenesis are Antecedents, Triggers and 

Mediators. Antecedents are factors, genetic or 

acquired, that predispose to illness, Triggers are 

factors that provoke the symptoms and signs of 

illness, and Mediators are factors, biochemical or 

psychosocial, that contribute to pathological 

changes and dysfunctional responses. 

Understanding the Antecedents, Triggers and 

Mediators that underlie illness or dysfunction in 

each patient permits therapy to be targeted to the 

needs of the individual. The conventional diagnosis 

assigned to the patient may be of value in 

identifying plausible Antecedents, Triggers or 

Mediators for each patient, but is never adequate 

by itself for the designing patient-centered care. 

Applying the model of Person-Centered Diagnosis 

to patients facilitates the recognition of 

disturbances that are common in people with 

chronic illness. Diet, nutrition and exposure to 

environmental toxins play central roles in 

Functional Medicine because they may predispose 

to illness, provoke symptoms and modulate the 

activity of biochemical mediators through a 

complex and diverse set of mechanisms. 

Explaining those mechanisms is a key objective of 

this textbook. A patient's beliefs about health and 

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illness are critically important for self-care and 

may influence both behavioral and physiological 

responses to illness. Perceived self-efficacy is an 

important mediator of health and healing. 

Enhancement of patients' self-efficacy through 

information, education and the development of a 

collaborative relationship between patient and 

healer is a cardinal goal in all clinical encounters. 

Table 1. Common Illness mediators 

Social/cultural 

Reinforcement for staying 

sick 

Behavioral conditioning 

Lack of resources due to 

social isolation or poverty 

The nature of the sick role 

and the doctor/patient 

relationship 

Biochemical 

Subatomic 

Cognitive/emotional 

Hormones 

Neurotransmitters 

Neuropeptides 

Cytokines 

Free radicals 

Transcription factors 

Ions 

Electrons 

Electrical and magnetic 

fields 

Fear of pain or loss 

Feelings or personal beliefs 

about illness 

Poor self-esteem, low 

perceived self-efficacy 

Learned helplessness 

Lack of relevant health 

information 

Courtesy to reprint this article from Institute of 

Functional Medicine Text Book. 

This chapter provides a key foundation for the 

practice of functional and integrated medicine. 

For extensive information on integrated medicine, 

including Dr. Galland’s articles on Leaky Gut 

Syndrome, Parasites, Detoxification and 

Magnesium, visit the Foundation for Integrated 

Medicine (http://www.mdheal.org/). In addition, 

Dr. Galland has created an extensive online 

resource featuring the wisdom of leading integrated 

physicians at Pill Advised (http://pilladvised.com), 

where you can also learn more about interactions 

between drugs and supplements, and between 

supplements, featuring highlights of published 

reports from research centers. 

Leo Galland is internationally recognized as a 

leader in Integrative Medicine and Functional 

Medicine. An experienced and dynamic speaker, 

he has lectured extensively to business and 

professional groups throughout the United States 

and the British Commonwealth, and in Europe. He 

is the author of three popular books, The Fat 

Resistance Diet, Power Healing, and 

Superimmunity for Kids. Dr. Galland is celebrated 

as a master clinician who has popularized 

innovative nutritional therapies for prevention and 

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2012 

treatment of chronic conditions, including obesity, 

metabolic dysfunction, allergies, immune system 

disorders, gastrointestinal problems and 

neurological diseases. He maintains a private 

consulting practice in New York City, where he 

treats patients from all over the world. Dr. Galland 

is the author of more than 40 scientific articles 

and has contributed chapters and material to 

numerous textbooks including Integrative 

Gastroenterology (2011), Textbook of Functional 

Medicine (2010), ACP Evidence-Based Guide 

to Complementary and Alternative Medicine 

(2009), Complementary Medicine in Clinical 

Practice (2006), Encyclopedia of Human 

Nutrition (2005), the Textbook of Natural 

Medicine, (2005) Integrative Medicine, 

Principles for Practice, (2004), Inside the 

Minds: The Art & Science of Being a Doctor 

(2002), Post-Viral Fatigue Syndrome (1991), 

Workers with Multiple Chemical Sensitivities 

(1987), He is the coauthor of Gastrointestinal 

Dysregulation: Connections to Chronic Disease 

(2008). Dr. Galland has been honored with the 

Linus Pauling Award from the Institute of 

Functional Medicine for developing key concepts of 

Functional Medicine. He received the Seelig 

Magnesium Award from the American College of 

Nutrition, the Clinician of the Year Award from the 

National Nutritional Foods Association, and the 

Harold W. Harper Award in Preventive Medicine 

from the American College for Advancement in 

Medicine. He has been consistently selected for 

America’s Top Doctors. Interviews with Dr. Galland 

or articles about his work have been featured in 

The New York Times, The Washington Post, 

Newsweek, Reader's Digest, Redbook, Self, 

Bazaar, Men's Fitness, Allure, Bottom Line, The 

New York Daily News and many other 

publications. He has appeared as a medical 

expert on The Today Show, Good Morning 

America, PBS, Fox News, CNN, MSNBC and 

dozens of local affiliates of the major broadcast 

networks. Dr. Galland graduated from Harvard 

University and completed his medical education 

and training at New York University Medical 

Center. Board certified in Internal Medicine, he 

has held faculty appointments at the Rockefeller 

University, the Albert Einstein College of Medicine, 

the State University of New York at Stony Brook 

and the University of Connecticut, and served as 

Director of Medical Research at the renowned 

Gesell Institute of Human Development in New 

Haven. Based on his extensive research of how 

supplements and medications interact, Dr. Galland 

developed Pilladvised.com, a web application 

where users can learn about interactions. In 

addition, he is the Director of the Foundation for 

Integrated Medicine (mdheal.org), a non-profit 

educational organization committed to integrating 

nutritional therapies into clinical practice. 

Contact Leo Galland at http://pilladvised.com 

References: 

1 

Galland L, "Person-Centered Diagnosis", in Power 

Healing, New York, Random House, 1998, pp 52-97. 

2 Reiser SJ. The era of the patient. Using the experience 

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3 Beckman HB, Frankel RM. The effect of physician 

behavior on the collection of data. Ann Int Med. 1984; 

101: 692-696. 

4 Frankel R. Talking in interviews: a dispreference for 

patient-initiated questions in physician-patient 

encounters. In Studies in Ethnomethodology and 

Conversation Analysis. No. 1. G Psathas, ed. The 

International Institute for Ethnomethodology and 

Conversation Analysis and University Press of America. 

Washington D.C. 1990: 231-262. 

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5 Roter DL, Hall JA. Physician interviewing styles and 

medical information obtained from patients. Journal of 

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Reducing Under- 

Evaluation and 

Over-Treatment: 

An Opportunity for 

Functional 

Medicine 

Keith Berndtson, 

MD 

An office clerk suffers a bowel obstruction and 

a stroke, and survives only because of highly 

skilled emergency and intensive care. Her bill is 

over $50,000 but her insurance covers only 

$4,000. She works out an agreement with the 

hospital to pay $200 a month for the rest, but 

after a while the hospital says that isn’t enough 

and raises it to $500 a month, forcing her into 

personal bankruptcy. She loses her house of 18 

years to other creditors. The hospital gets nothing. 

A woman with diabetes arrives in an 

emergency room with no pulse in her foot. She 

needs to have two stents placed into an artery to 

keep blood flowing through her leg. The procedure 

goes well and she stays overnight for observation. 

A month later she learns that the hospital 

billed her insurance for $50,000. Insurance paid 

about $20,000. Her family is responsible for the 

remainder. She showed the bill to the doctor who 

placed her stents. He sees that each stent was 

billed out at $14,000. Wholesale, they run about 

$900. Thinking it was a mistake the doctor takes 

the bill to the hospital’s chief billing officer for 

review, who verifies that the hospital charges are 

correct. 

A young mother obtains an integrative 

medicine consultation for help treating frequent and 

severe migraine headaches. She has tried various 

conventional and alternative medical treatments 

over six years without relief. She spent over one 

week as an inpatient in a headache unit. Her 

insurance and out-of-pocket payments during this 

time totaled over $60,000. Blood testing ordered 

by the integrative doctor reveals evidence of 

delayed reactions to dairy, wheat, and kidney 

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beans – staples in her diet. She stops eating 

them. Her headaches go away. 

These cases illustrate three key reasons why 

health care costs us more than it should in 

America: underinsurance, overpricing, and what I 

call the over-under dynamic in our health care 

system – the over-treatment of under-evaluated 

problems. 

All three of these patients had a chronic 

illness. The first two suffered acute health crises 

stemming from poor arterial circulation. The costs 

for treating these crises would have been lowered 

or avoided altogether in a system focused on 

wellness support and effective preventive medicine. 

The cause of the third patient’s migraines was 

invisible to various specialists who, before her 

food triggers were found, had prescribed 17 drugs 

over 6 years. 

In Overtreated: Why Too Much Medicine is 

Making Us Sicker and Poorer, journalist Shannon 

Brownlee sifts through the reasons why our health 

system costs more than it should, noting: 

We spend between one fifth and one third of 

our health care dollars, between five hundred 

and seven hundred billion dollars, on care 

that does nothing to improve health. Why do 

doctors and hospitals deliver so much 

unnecessary care? There are many reasons, 

but the most powerful reason doctors and 

hospitals overtreat is that most of them are 

paid for how much care they deliver, not 

how well they care for their patients. 

The common view is that the main cause of 

the over-treatment problem is our willingness to 

pay physicians for whatever they do, not how well 

they do it. I contend that the main cause of the 

over-treatment problem is our unwillingness to 

grant physicians the time they need to fully 

evaluate the root causes of chronic illness. Three 

out of four health care dollars are spent pruning 

away the symptoms of chronic illness—a superficial 

approach that takes the habitual form of drugs 

and procedures. Prescriptions and referrals are the 

quickest and easiest options for busy doctors 

looking for reasons to draw a visit to a close to 

avoid falling farther behind. These “hurry up” 

prescriptions and referrals account for much overtreatment 

that Brownlee describes. 

To address the over-treatment problem, 

Brownlee asks what kind of system would 

minimize it. She argues that such a health system 

would look something like our current Veteran’s 

Health Administration (VHA) which, while no one 

was looking, has developed into an advanced, 

fully wired health system subculture. The VHA: 

1. Rewards doctors who best interpret the 

evidence and translate it into good 

results. 

2. Does a better job of coordinating care 

among the providers involved. 

3. Uses electronic medical records. 

4. Reduces excess capacity of hospital beds 

and medical specialists. 

5. Makes sure every patient has access to 

a primary care physician and sees to it 

that these doctors are not overwhelmed 

with patients. 

6. Delivers the best care it can for the 

lowest cost, measuring efficiency in terms 

of results achieved per dollar spent over 

the entire course of an illness. 

7. Incorporates performance measures that 

assess which care processes reliably 

produce the best clinical outcomes for 

the least amount of money. 

Based on the VHA higher quality-lower cost 

model, it appears that less disciplined practice 

dynamics account for most of the over-treatment 

problem. From an integrative standpoint, the key 

aspect of a clinically effective, cost-efficient 

approach to chronic illness care is a subculture 

that sees to it that doctors are not overwhelmed 

with patients. A practice system could meet every 

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other milestone met by the VHA and still generate 

wasteful spending and poor clinical outcomes if its 

doctors are routinely overwhelmed and forced into 

hurried decisions about prescriptions and referrals. 

But even if all medical and hospital operations 

in the country were to similarly attack their overtreatment 

problems tomorrow, it would still take 

10 years or more to see the hoped-for results. 

Why? Brownlee explains: 

Hospitals, nurses, specialists, and all the 

industries that produce medical goods have a 

vested interest in maintaining the status quo; 

they don’t want to see health care shrink. 

Drug companies don’t want doctors to write 

fewer prescriptions, and latex glove 

manufacturers don’t want cardiologists to 

perform fewer angioplasties… Nobody would 

want to put thousands of people who are 

currently employed by the health care 

industry out of a job, unless it was 

absolutely necessary. But it is necessary, 

because the alternative to rightsizing health 

care is worse. 

Brownlee wrote that last sentence before the 

Great Recession, when unemployment rates were 

lower than they are now. But her point still 

stands. Wasted health care spending drags our 

economy into a quicksand that stalls hiring. 

Consider the business dynamics of medical 

imaging. In 2005, Ohio had more magnetic 

resonance imaging (MRI) scanners than all of 

Canada. So did many other states. Hospitals 

order new scanners because one of the levels on 

which they compete involves having the latest, 

greatest technologies. But as any hospital 

executive knows, the faster a profitable scanner 

runs, the more money it will make. Scanners are 

more often upgraded or multiplied for speed than 

for clinical reasons. 

There are also political reasons for keeping 

the hospital stocked with the latest imaging 

technologies. Radiology departments drive profits 

(“surpluses” in not-for-profit institutions). If a 

radiology group wants a new toy, the 

administration will find a way to make it happen. 

No business wants its rainmakers feeling 

disgruntled. 

In the 1990s managed care pressures bore 

down on medical practices. Medical technology 

companies sensed an opportunity. They developed 

office-based diagnostic and treatment systems and 

marketed them through mailings, journal ads, and 

conference exhibits. The best way to hook the 

attention of a doctor facing bottom line struggles 

is to offer a deal on a piece of equipment that 

will “make your practice more profitable and up to 

date.” 

Many doctors bought or leased hand x-ray 

units to measure bone density, semi-automated 

systems for measuring nerve conduction velocity, 

hand-held ultrasound units that can image blood 

flow to rheumatic joints, lower back traction units, 

infrared stimulation units for treating neuropathy, 

and so on. 

Once a physician has leased a piece of 

equipment, its effect on the bottom line starts 

figuring into any clinical calculation where the 

equipment has a conceivable rationale in diagnosis 

or treatment. Procedures that, prior to the lease, 

had never been considered or were rarely 

recommended by the doctor now become part of 

the standard workflow for as many patients as 

possible. 

Many of these machines generate information 

that falls into the category known as “TBU” – 

true but useless. Bottom lines do a little better 

early on, but enthusiasm often wears off and 

there sits a piece of stuff that collects more dust 

than money while generating a monthly lease 

payment. 

Some doctors looking for ways to boost their 

bottom lines entered into contracts with 

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freestanding MRI clinics that would route a portion 

of any insurance reimbursement for a scan 

procedure back to the referring physician. Under 

these arrangements, if your handshake was weak, 

you needed an MRI. These deals were found to 

violate federal anti-kickback laws and Stark laws 

applicable to Medicare and Medicaid patients. 

Brownlee’s review of data from several 

sources indicates that if you include imaging tests 

billed to Medicare by radiologists and nonradiologists, 

the average Medicare patient 

undergoes 3 imaging tests per year. Let’s say the 

cost of these studies (MRI scans, CT scans, 

PET scans, ultrasounds, x-rays, and so on) 

averages $200. There are some 50 million 

covered Medicare patients, so that’s roughly $10 

billion in imaging costs for Medicare annually. 

The question then becomes, what percentage 

of these imaging tests were medically necessary? 

For purposes of addressing this question, let’s 

define an imaging test as medically necessary if 

something significant and actionable was learned 

from the test. 

For example, when a doctor has historical and 

physical evidence to cause legitimate concern 

about the possibility of multiple sclerosis (MS), 

whatever the scan shows will be useful. It may 

detect brain plaque consistent with MS, which 

would prompt the creation of a disease 

management care plan. It might also disprove MS 

for now, removing it as a cause for concern but 

prompting a search for ways to better explain the 

patient’s clinical situation. 

Yet many tests are ordered to rule a medical 

condition in or out and the results accomplish 

neither task. The results fall into the category of 

true but useless information that is of no medical 

value. 

Based on several estimates, roughly one-third 

of medical procedures can be considered medically 

unnecessary or useless. Eliminating medically 

unnecessary imaging studies alone for Medicare 

patients would save Medicare roughly $30 billion 

dollars. 

The Henry J. Kaiser Family Foundation reports 

that Medicare benefit payments for 2010 totaled 

$509 billion. By these calculations, Medicare 

could reduce its total annual payout by six percent 

just by denying payment for medically unnecessary 

imaging tests. 

Yet it’s not easy to simply issue a policy and 

collect the savings. Medical necessity is 

notoriously tricky to pin down ahead of the clinical 

decision. It’s most often in retrospect that doctors 

realize that a test result didn’t seem to matter 

one way or the other. 

From a clinical standpoint, it is almost 

impossible to devise a rules-based algorithm for 

medical necessity when the task at hand involves 

setting up diagnosis and treatment plans for 

unique individuals whose chronic illnesses 

represent complex systems biology interactions. If 

clinicians are not allowed some flexibility to follow 

their hunches here and there, then it will feel to 

physicians that medical resources are being 

rationed by cost-reduction rules and that invisible 

third parties control clinical judgment. We need to 

clarify in advance the difference between a good 

clinical hunch and a profit-play. We’re not there 

yet—but we have reached the point where 

affordability must take precedence by necessity. 

We need wiser ways to go about reallocating 

health care resources. 

Health insurance companies, on the other 

hand, want more flexibility when it comes to 

defining the concept of medical necessity. 

Otherwise, they argue, doctors and hospitals are 

free to pee on their legs and call it medically 

necessary. 

Doctors who use a clinical systems biology 

approach to chronic illness lick their chops at the 

thought of competing on an ability to turn 

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evidence into better clinical outcomes at less cost. 

Nowhere is our health care system more 

dysfunctional than in how it approaches the care 

and prevention of chronic illness. These 

dysfunctions trace to an overly costly routine for 

assessing the patient that, despite many tests and 

visits to multiple doctors, fails to produce a 

coherent systems biology-based way of explaining 

the patient’s condition. The result is not an 

integrative care plan, but a conventional rubberstamped 

care plan for a diagnosis rather than a 

unique person. 

Chronic illness is a self-perpetuating loss of 

functional integrity. The reasons for lost health beg 

to be explained, not just diagnosed. Most 

diagnoses are illness labels, not explanations. 

Preventing or treating chronic illness poses a 

problem that differs for each patient in question. 

In the long run, the most cost-effective way solve 

problems is to understand their causes as fully as 

possible before moving ahead with a onedimensional 

care plan. 

Over 125 million Americans have one or 

more chronic illnesses. For many of them, overtreatment 

is a problem, but the deeper problem is 

under-evaluation—or too little evaluation based on 

a clinical systems biology approach to chronic 

illness. 

In this context, under-evaluation does not 

mean that conventional doctors are doing too little 

testing to properly manage or prevent chronic 

illness. We just covered that. The problem is an 

over-reliance on diagnostic testing that does too 

little to help explain the root causes of chronic 

health decline, and the failure to deeply explore 

the patient’s illness narrative. Doctors are not 

doing enough listening and history probing prior to 

making their diagnostic testing recommendations. 

A systems biology perspective will help make 

doctors more effective in their work with 

chronically ill patients. Insurers don’t’ get this fact 

because it is in their interests not to get it. They 

already have doctors over a barrel with their 

policies, their way of defining medical necessity, 

and the way they enforce an outmoded process 

for the coding and documentation of procedures, 

known as the Current Procedural Terminology, or 

CPT system. 

The American Medical Association (AMA) 

handed the CPT system to the insurance industry 

in 1966. Ever since, insurers have been 

exploiting the AMA’s rules for how doctors must 

allocate the time they spend with patients if they 

want to get reimbursed. These rules have not 

kept up with the growing complexity of the 

physician’s cognitive task. 

When using a clinical systems biology 

approach to the chronically ill, meeting standard 

coding and documentation requirements steals 

precious narrative construction and problem solving 

time from both the patient and the doctor. 

Insurers benefit by making doctors to jump 

through irrelevant documentation hoops in order to 

justify their time, whereas the systems biology 

perspective allocates every necessary minute to 

explaining the problem before jumping to its 

solution. 

Then there are the vague diagnoses that turn 

patients into medicine’s second-class citizens, like 

chronic fatigue syndrome, fibromyalgia, and irritable 

bowel syndrome. These nametags create a false 

sense of precision when all they really do is 

confirm that your pattern of signs and symptoms 

meet experts’ simplified criteria for a diagnosis. If 

you’re chronically ill, a diagnosis is a place to 

start, but you’ll want help solving the underlying 

systems biology puzzle using best working 

explanations for your particular illness experience. 

Anyone who runs a solution shop of any kind, 

be it medicine or motorcycle repair, will tell you 

that the path toward a workable solution relies on 

a solid understanding of the problem. Underevaluation 

is harder to grasp than over-treatment, 

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but it, too, is a serious cause of wasted money 

and bad clinical outcomes. 

The mainstream approach to chronic illness 

races to a diagnosis that, once made, trips a 

cookbook-style disease management protocol. Use 

the cookbook recipe and disease markers may 

start floating in the right direction, giving the 

clinician a sense of accomplishment even though 

the patient may have made little or no progress 

toward her goal of normal function. 

Say you visit your doctor because you’re tired 

of being a fat, lazy, couch potato. Looking at 

your blood test results, the doctor diagnoses you 

with hypercholesterolemia, prescribes a statin drug, 

and puts you on a low-calorie diet. It made 

perfect sense. You’d been on the same statin 

before without any problems, but stopped refilling 

it because you lost your health insurance. 

Two months later your doctor is all smiles. 

Your weight is down 9 pounds and your bad 

cholesterol (LDL) level is down 25 points. 

You ask the doctor, “Then why am I feeling 

so bad?” You report muscle aches, difficulty 

sleeping, increased anxiety, and a new type of 

killer headache. 

“Try this for the headaches, this for sleep, 

and this for anxiety. Let’s see if your muscle 

aches improve. See me in 3 weeks.” 

In three weeks you report that you are 

sleeping through the night and that you feel less 

anxious, but you also feel too tired to exercise 

and the muscle aches and headaches are a little 

worse. 

The doctor is thinking that the statin is not to 

blame since you’ve tolerated it before. You report 

that nothing about your life really changed since 

you started to lose weight. You and your doctor 

are stymied. 

From a clinical systems biology standpoint, 

feeling worse while losing weight can mean that 

the patient is mobilizing stored fat-soluble toxins— 

also known as persistent organic pollutants 

(POPs)—at a rate that exceeds the capacity of 

the body’s detoxification systems. The ability to 

tolerate mobilized POPs depends in part on 

lipoproteins like LDL and HDL and their ability to 

bind circulating molecules that are toxic and fatsoluble. 

Supporting a weight loss and exercise routine 

with dietary supplements that support detoxification 

systems can reduce the toxicity symptoms that 

can accompany weight loss in people who are 

storing POPs in their fat cells. Another option is 

to pause statin, not because we think it is 

causing the muscle aches, but because the body 

relies on its lipoproteins to bind free-floating, fatsoluble 

toxins and escort them safely to the liver 

for processing and deportation. In this case, an 

option to help the patient feel better while losing 

weight is to let the LDL run where the body 

wants it to run for purposes of effective 

detoxification. When you reach your target weight 

and you’re feeling more fit, we’ll recheck the LDL 

and see if you still need support from a statin. 

I know about this because it is part of my 

clinical experience as a functional medicine 

physician, not because a randomized, controlled 

clinical trial (RCT) proved it. Even if this issue 

were investigated using an RCT design, it could 

easily generate findings that are true but useless 

as far as patient care is concerned. The rap on 

RCTs is that their findings are often nearly 

impossible to translate into the medical care of 

uniquely individual patients. 

To better accommodate a systems biology 

framework, our chronic illness model would have 

to transition from being doctor-and-diseasecentered 

to being patient-and-wellness-centered. 

For a wealth of reasons this transition is overdue, 

but instead of a truly patient-centered, 

personalized approach to chronic illness, American 

health care is moving in the direction of selecting 

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for each patient more specific diagnoses from a 

list of codes that seem to lend precision, and 

selecting more overly simple treatments from a list 

of pre-packaged guidelines derived from studies 

that don’t translate well to individual patients 

anyway. 

To insurers, it’s the coding and documentation 

methods that matter. To patients, it’s the process 

and results of care that matter. Doctors are 

caught in the middle, unable to make their 

patients or third party payers happy at the same 

time. If the patient is paying, the doctor will try to 

make the patient happy. If the insurer is paying, 

the doctor will try to make the insurer happy. This 

may work fine assuming the insurer even remotely 

cares about whether the patient is happy. It is 

time for America’s health care system to care 

more about what patients think. 

ICD-9 codes are more accurate when they’re 

describing acute conditions such as pneumonia or 

fractures, but they do a miserable job of capturing 

the systems biology dimensions of chronic illness. 

In fact, not one of the 14,000-plus codes in the 

ICD-9 collection comes close to a clinical 

systems biology description of what’s going on in 

a given patient with chronic illness. 

The net result: programmatic oversimplification 

of chronic illness and fragmentation of patient care 

into specialty silos where the only doctors in 

charge of evaluating the patient as a whole feel 

so rushed by the clock that they can’t even afford 

to ask their patients open-ended questions 

anymore, let alone assemble a coherent view of 

the patient from a systems biology perspective. 

A description of a clinical evaluation based on 

systems biology thinking would read more like a 

working explanation than a list of codes. The 

working explanation would reference the 

hypothesized root cause (or causes) of a 

person’s chronic illness. 

Consider the case of Emma, a young 

mother of two little boys who presented with a 

history of intermittent intestinal bloating fatigue, 

non-restorative sleep, weight gain, anxiety, and 

difficulty concentrating. Blood work showed a mild 

elevation of anti-thyroid antibodies though the 

thyroid hormone levels were fine. Her fasting 

blood sugar was 143 mg/dL, high enough to 

qualify her for a preliminary diagnosis of diabetes. 

Her primary care doctor referred her to 

endocrinology, psychiatry, and gastroenterology, 

with instructions to arrange for help around the 

house, see what these doctors thought, and to 

follow up and see her again in 3 months. 

The endocrinologist agreed that the thyroid 

findings could not account for her fatigue. He 

suggested annual follow-up for a thyroid physical 

exam and lab tests. He ran more blood tests and 

found that she did have mild diabetes that should 

be able to correct itself without medication if she 

would change her diet and get regular exercise. 

Otherwise, medication would be needed to control 

her blood sugar. Not wanting to take medication, 

she agreed to the lifestyle changes knowing she 

was too tired to exercise. 

The psychiatrist prescribed a drug to enhance 

the action of serotonin in her brain. Within three 

days she felt worse from nausea, headache, and 

increased nervousness. At that point, he offered a 

drug to dampen anxiety, explaining it was for 

short-term use only due to tolerance and 

dependence issues that develops with long-term 

use. She declined the offer. 

The gastroenterologist did endoscopies of her 

stomach and colon, which were normal. A blood 

test for celiac disease wasn’t abnormal enough to 

make that diagnosis. She was told not to worry 

about gluten. 

When she followed up with her primary care 

doctor to see what should happen next, the 

doctor suggested psychotherapy. 

The ICD-9 record of this conventional primary 

care visit is summarized below: 

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CONVENTIONAL MEDICINE EVALUATION 

Diagnostic Codes: 

245.2 Autoimmune thyroiditis 

250.0 Diabetes without mention of 

complication 

300.02 Other anxiety disorder 

780.52 Insomnia, unspecified 

A friend of hers recommended that she see 

me. After our first visit, she commented that no 

other doctor had taken the time to hear the full 

story of what was happening in her life and show 

interest in what might explain why her symptoms 

unfolded the way they did. You’d never know 

from looking at her assigned ICD-9 codes that 

these four conditions were related to a cause that 

hadn’t yet been detected or described. 

I learned that her intestinal bloating began 

while on a 6-week course of antibiotic and oral 

steroid to get over a bout of severe sinusitis a 

year ago. She reported the bloating problem and 

the doctor advised that this was probably a 

complication of treatment and should resolve on 

its own afterward. 

It didn’t resolve. Within three months of the 

sinus treatment, fatigue became the next 

worrisome issue for her. Six months after that, 

she noticed that she’d wake up easily at night 

and have difficulty falling back asleep. She’d wake 

up tired and impatient. She developed intense 

sugar cravings and needed more caffeine to 

function. That’s when her anxiety level seemed to 

skyrocket. 

I ordered a celiac genotype test and it came 

back positive for the DQ2 marker – the most 

risky of the genes known to invite gluten 

intolerance and permit it to progress to its end 

stage—celiac disease. While she didn’t have celiac 

disease, she could well be gluten sensitive, and 

the immune system reactions triggered in her gut 

could be affecting her thyroid, and possibly her 

pancreas and brain. Here’s how I summarized her 

condition from a systems biology point of view: 

SYSTEMS BIOLOGY EVALUATION 

Narrative Summary 1: 

Bloating, fatigue, anxiety, insomnia, difficulty 

concentrating, and high blood sugar levels. 

Possible intestinal hyperpermeability triggered 

by prolonged antibiotic exposure, producing 

gluten sensitivity resulting in nutritional 

depletion and gastrointestinal, endocrine, 

psychiatric, and possibly neuroimmune 

complications. 

Narratives have more explanatory power than a 

list of codes. Any health professional can make 

sense of it. The layperson’s translation is easy 

too: the antibiotic-steroid use caused intestinal 

hyperpermeability, commonly called leaky gut. If 

your genes program your immune system to 

unleash a ferocious response to gluten fragments 

in your gut wall, and a leaky gut permits these 

fragments to enter your gut wall, then your 

system could well be headed for chronic health 

trouble at a rhythm and tempo that varies in ways 

explained by detailed narrative of your illness 

experience. 

The overreaction to gluten in your gut wall can 

flip a switch from “gluten tolerant” to “gluten 

intolerant.” You may or may not develop gut 

symptoms as a result, but the medical research 

literature shows how gut-based immune reactions 

can cascade to involve other parts of your 

system. In Emma’s case, the best working 

explanation for her symptoms was that a fastpaced, 

gluten-mediated autoimmune cascade had 

come to involve not just her gut, but also her 

thyroid, and perhaps her brain and the insulin 

producing cells in her pancreas. 

I checked for signs of autoimmune pancreatic 

disease, and these were negative, but her fasting 

insulin was slightly high, suggesting that she was 

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developing something called metabolic syndrome. 

Low-grade inflammation in her gut wall could 

produce enough of a systemic reaction to produce 

insulin resistance and explain her rising blood 

sugar level. Low-grade inflammation could put the 

system on yellow alert, including the brain, 

resulting in anxiety and disrupted sleep. 

The treating endocrinologist, psychiatrist, and 

gastroenterologist might cry foul because nowhere 

did I established a chain of causal explanations 

for how antibiotics led to gluten intolerance, let 

alone how gluten intolerance led to anti-thyroid 

antibodies or possible immune-driven brain excitotoxicty. 

This is the way it is between the 

conventional standard of care and the clinical 

systems biology approach: what appears to be a 

series of groundless assumptions to one side, 

looks to the other side, like an explanation of 

best fit despite a number of blanks unfilled. 

I had made assumptions, but they were made 

on grounds that meet a reasonable person 

standard. If gluten sensitivity had activated an 

inflammatory cascade that could explain her 

autoimmune thyroiditis, rising blood sugar, fatigue, 

anxiety, and disrupted sleep, then an integrative 

care plan comes into view. The care plan is not 

based on RCTs or expert guidelines. It is based 

on experience using a clinical systems biology 

approach to symptoms that elude explanation 

when left to usual and customary care. Emma 

says that in her little battle between conventional 

and integrative medicine, I won, at about onequarter 

the price of the previously unhelpful care 

she’d received for the same set of problems. 

I reassured her that a micronutrient-rich, 

gluten-free, low sugar diet would be of great 

help, and that she’d feel better, and that our 

nutritionist would help her make these changes. 

With our help, Emma eliminated gluten and sugar 

from her diet, ate more vegetables, and used 

supplements to boost her serotonin level and 

replete her stores of vitamin B12, magnesium, 

and vitamin D. 

Within three months, she felt like her former, 

healthy self. Her energy was up, bloating and 

anxiety were way down, and she was sleeping 

well. Though her anti-thyroid antibodies were 

about the same, this was not unexpected. She 

was doing much better. Was this a case where 

the patient coincidentally got better on the lucky 

integrative doctor’s watch? Or was it a case 

where clinical systems biology succeeded where 

usual and customary care had failed? 

Emma is happy to be well again, but also a 

bit miffed about why her health insurance 

company refused to cover services that a Medical 

Director found to be medically unnecessary. That 

insurer had no problem covering thousands of 

dollars in procedures and specialty consultations 

that had failed to help her system restore full 

functional integrity. 

The clues to solving most clinical puzzles are 

in the patient’s history. The presence of a celiac 

permissive genotype supported the possibility of 

gluten intolerance with potential to progress toward 

celiac disease at an indeterminate rhythm and 

tempo, or the possibility of non-celiac gluten 

sensitivity, a condition that responds to a glutenfree 

diet but which has little potential to evolve 

toward celiac disease. Alessio Fasano, MD, and 

his colleagues at the University of Maryland’s 

Mucosal Biology Research Center and elsewhere 

around the world established the distinction 

between these two types of gluten sensitivity. In 

March 2011, BMC Central published the paper 

by Sapone, et al proving that growing public 

interest in gluten-free diets is not a fad, but a 

serious matter of life and health. 

A clinical systems biology approach worked. It 

blended knowledge of the latest medical literature 

demonstrating the causes of leaky gut and how a 

leaky gut can trigger for gluten sensitivity, with a 

narrative-building history and a care plan based 

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on experience and inductive logic. For want of a 

clinical systems biologist, how many times would 

Emma play ‘around the horn’ with specialists and 

primary care? 

Gluten sensitivity is the poster disease for 

clinical systems biology. It demonstrates better 

than any other condition why incorporation of a 

clinical systems biology approach to chronic illness 

is justified. It also has the glam-factor of being 

reversible and being the illness that made it safe 

for physicians to use the long-derided term “leaky 

gut” in public. 

A celiac disease panel typically looks for two 

specific antibodies in the blood. One antibody is 

formed against an enzyme in the gut wall called 

tissue transglutaminase (tTG). The other antibody 

is formed against gliadin, the indigestible portion 

of gluten protein that appears to be the main 

troublemaker. 

The test ordered by Emma’s gastroenterologist 

showed no antibody against tTG. Anti-gliadin 

antibodies were detected, but not at high enough 

levels to suggest celiac disease. In the context of 

Emma’s illness experience it was a mistake to 

advise her not to worry about gluten. The most 

we could tell her about her test results was that 

if she was gluten sensitive, it looked like it hasn’t 

progressed to a point anywhere near celiac 

disease yet. That’s a clear difference of opinion 

that really mattered to Emma. 

The endocrinologist missed his opportunity to 

draw a connection between her early stage 

autoimmune thyroiditis and her high blood sugar to 

the possibility of gluten sensitivity. 

The psychiatrist was playing reasonable odds 

on going for serotonin enhancement using 

medication. She did not consider that Emma’s 

serotonin levels could have dropped too low in 

response to constant use as a buffer against the 

toxic effects of low-grade inflammation on the 

brain. 

Serotonin reuptake inhibitors help you squeeze 

more of a “don’t worry, be happy” message out 

of whatever serotonin you’re already making, but 

they do nothing to help you make more serotonin. 

When we checked Emma’s urinary serotonin level, 

it was very low. 

Emma’s anxiety and insomnia were almost 

certainly caused in part by her low serotonin level. 

Serotonin acts like a brake on brain pathways 

whose neurotransmitters act like accelerators on 

the brain. These transmitters include 

norepinephrine, glutamate, and histamine, all of 

which were running high in Emma. 

A leading explanation for why these transmitters 

run high in a case like Emma’s is that immune 

system messenger molecules, known as cytokines, 

rain a constant pitter-pat of “yellow alert” 

messages onto the blood-brain barrier. Some of 

these messengers may leak through stressed 

points in the barrier, gaining access to the brain 

itself. A brain that would otherwise be 

orchestrating several cycles of deep sleep each 

night is instead kept on edge, resulting in daytime 

fatigue. 

Her magnesium, vitamin B12, and vitamin D 

reserves were low. This is not unusual in 

someone whose gut absorbs things less efficiently. 

But each of these substances is neuro-protective 

in its own way, which means they help the 

nervous system less excitable and able to cope 

better with whatever stresses it happens to be 

under. 

We repleted her stores of these nutrients, used 

5-HTP to raise her serotonin level, and curcumin 

to suppress pro-inflammatory cytokine output. 

Along with her dietary and nutritional repletion 

changes, her energy improved to the point where 

she could exercise again. She felt like herself 

again with about three months—roughly sixteen 

months after the treatment for sinusitis that 

triggered her chronic health decline. 

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Her next systems biology summary looked like 

this: 

SYSTEMS BIOLOGY EVALUATION: 

Narrative Summary 2: 

Apparent resolution of patient’s glutenmediated 

intestinal, neuroimmune, endocrine, 

and psychiatric complications, by virtue of a 

micronutrient-rich, gluten-free, low sugar 

diet, 5-HTP-based serotonin enhancement, 

anti-inflammatory extract of curcumin, 

nutritional repletion using magnesium, vitamin 

B12 and vitamin D, and exercise. Patient 

advised to use self-monitoring tools as part 

of a general self-care program based on 

diet, exercise, stress reduction, and learning 

the art of happiness. She will follow-up with 

me in 3 months or as needed. 

Notice the emphasis on lifestyle medicine, 

natural therapies, self-care support, and the 

emphasis on the connection between happiness 

and wellness. It is probably harder to be happy 

when cytokine signals are annoying your brain. 

While it is the healer’s job to engineer hope that 

voluntary self- regulation methods will prove 

helpful in almost any illness circumstance, it may 

be asking too much of self-regulation methods 

alone if underlying imbalances are driving 

inflammation, nutritional depletion, and 

neurotransmitter imbalance. 

As you can see by this contrast between 

usual care and clinical systems biology, customary 

care is making the practice of medicine serve 

database format needs instead of the patient’s 

need for in-depth evaluation and the doctors’ 

needs for straightforward communication about 

patient care. All of the doctors involved in 

Emma’s care are intelligent, compassionate, hardworking 

professionals. They happen to use a 

mind-set for clinical problem solving that follows 

conventional standards for medical care—standards 

primarily set by health insurers and their 

consulting medical experts. 

The conventional standard of care commonly 

brushes aside the possibility of gluten intolerance 

as a factor in symptoms that are otherwise hard 

to explain, and it misses opportunities to help 

thousands of gluten intolerant patients every day. 

I was a proud factory-issue family doctor for 

10 years. My colleagues in family medicine were 

some of the smartest and hardest-working people 

I knew. Like me, most were a bit skeptical about 

alternative medical therapies, though I felt twinges 

of guilt for holding under suspicion something that 

I didn’t really know much about. 

When I joined an integrative medicine practice, 

it was to close my knowledge gaps about what 

tools the other side used to help patients. I did 

so with a chip on my shoulder because I didn’t 

think the “other side” new science from a hole in 

the ground. The other side eventually became 

“this side.” The main reason for this, in 

retrospect, was the emphasis on detailed narrative 

histories and respect for the deeply human nature 

of encounters whose task is supposed to be 

about healing. 

You may have noticed that Emma’s primary 

care doctor made no mention of intestinal 

hyperpermeability. This is unfortunate because 

leaky guts are linked to over a dozen autoimmune 

diseases and are suspected as root causes or 

complicating factors in a growing number of 

medically unexplained chronic illnesses. 

But there’s another reason why you don’t see 

intestinal hyperpermeability listed as diagnosis in 

the records of patients like Emma: there isn’t an 

ICD-9 code for it. 

We can send people to the moon, but we 

can’t enter a clinical diagnosis of leaky gut into 

the health record of the patient who has it 

because there is no ICD-9 code for it, even 

though it plays a major role in millions of cases 

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2012 

of chronic illness. Are we to discount narrative 

medicine and systems biology summaries because 

the higher priority is to fragment the story, as if it 

has no beginning, middle, or end, so we can 

shoehorn it into structured database? We are 

doing this because we think it will lead us to a 

more cost-effective approach to patient care? Are 

we spending hundreds of billions of dollars to 

digitize a flawed system for assessing, describing, 

and treating chronic illness? What was it that 

Linus Pauling said about doctors? 

Enter ICD-10 – a monstrous set of codes 

that physicians, hospitals, and healthcare 

organizations around the country are scrambling to 

implement by October 1 st of 2013. The ICD-10 

codes won’t improve on the ICD-9 system when 

it comes to describing chronic illness in narrative 

form using a systems biology point of view. Yet 

the lion’s share of chronic illness may involve a 

few patterns of overlapping losses of functional 

integrity that are best described by a mix of 

narrative, genetics, lifestyle, environmental 

exposures, and metabolic pathway disruptions. 

Figuring out how to pick from a list of 

hundreds rather than dozens of codes relevant to 

one’s medical practice is going to eat into clinical 

problem solving time during encounters between 

patients and their doctors. This is especially true 

for already pressed primary care doctors because 

they deal with the widest range of diagnostic code 

sets compared to other forms of medical practice, 

and they have the least time to spare. 

More importantly, to physicians anyway, is the 

real possibility that ICD-10 will create rampant 

new opportunities for claims processing delays and 

denials. What’s needed to get more cost-effective 

results out of primary care is less, not more 

fragmentation of the physician’s cognitive task; 

less, not more intrusion by third parties; less, not 

more of physicians having to second guess how 

they are being paid. 

If you carry the logic of “the more detail, the 

better” to its conclusion, we’d need a million 

codes to reflect the complexity of chronic illness 

and what makes it different for each individual 

compared to another. Better to settle for simple 

narratives whose words reflect medical evidence, 

analysis, experience, and inductive logic in pursuit 

of explanatory power. Pay doctors for their time 

and factor in an adjustment based on the costeffectiveness 

of their results and the clarity of 

their documentation. Don’t hold them to CPT rules 

that are from the pre-systems biology age of 

medicine. 

Let the competition in the health care sector 

unfold on a level playing field. Don’t use 

customary care definitions of medical necessity to 

deny claims that reflect a functional medicine 

approach when customary care has already failed. 

Don’t throw the good medical practice variations 

out with the bad. It’ll make it look like health 

care reform is just another chapter in a book 

about how to kill disruptive innovations before they 

eat into the margins or market shares created by 

business as usual. Citizen-consumers are getting 

wise to that move. They’re getting mad as hell 

and won’t take it anymore. 

Leaders will discover that hospital-run medical 

groups, independent multi-specialty medical 

groups, and the newer forms of collaboration 

we’re seeing in the health sector—patient centered 

medical homes and accountable care organizations 

—will better compete if, somewhere within their 

conclaves, they’ve made room for a clinical 

systems biology-driven solution shop. 

Doctors would have more time and freedom to 

probe the patient’s narrative for clues as to which 

pattern of antecedents, triggers, mediators, and 

perpetuating factors applies to this person’s 

chronic illness as opposed to that person’s. There 

would be less time wasted dressing patients with 

codes that explain little and more time devoted to 

finding the words and concepts to communicate 

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2012 

why someone fell chronically ill. Working 

explanations, not mere diagnoses, should precede 

the creation of care plans whose goal is to 

restore functional integrity to a given patient’s 

bodymind. 

Modern medicine seems too content with the 

idea that millions of people can qualify for the 

exact same ICD code when each of these 

persons owns a unique illness narrative. So 

physicians are doing back flips to document their 

care using codes in a manner dictated by third 

parties – codes that don’t begin to describe the 

systems biology of chronic illness, but codes that 

nonetheless must be used if the doctor wants to 

get paid. 

With the right training programs, most doctors 

interested in practicing functional medicine could 

gain their credentials by attending trainings three 

or four times a year over two years. The Institute 

for Functional Medicine offers an excellent series 

of advanced practice modules and other support 

for physicians who’d like to incorporate a clinical 

systems biology approach into their practice model. 

The most productive proving ground for the 

cost-effective care of chronic illness lays in the 

realm of a personalized approach to clinical 

systems biology, not in the realm of an assembly 

line, one-size-fits-all approach that jumps to a 

cookie cutter evidence-based practice protocol 

based on an ICD code. Resistance to change 

within our health sector may persist until 

consumers in the market for chronic illness care 

and prevention tell their health plans, “Hey! We 

found an innovative source of health value! It’s 

not where you’ve been looking!” 

Where you find teams skilled in applying the 

principles and methods of functional medicine, you 

will find many patients who are happy with the 

care process and its results, and many payers 

who are happy with cost-savings and customer 

satisfaction produced by the process. 

Functional medicine physicians have the skills 

needed to reduce both over-treatment and underevaluation 

of chronic health problems. Primary 

care and specialist physicians with an interest in 

functional medicine should take a look at the high 

quality training sources that are now available. But 

to advance the reach of a clinical systems biology 

approach to the care and prevention of chronic 

illness, interested doctors may have to change the 

way they think. 

Keith Berndtson practices integrative medicine in 

Park Ridge, Illinois. In 1996, after ten years in 

family medicine and corporate health, he chose a 

road less traveled. On this road he came to 

realize the wisdom and value of the integrative 

and functional medicine traditions. He uses this 

experience to explore the wider implications of a 

clinical systems biology approach to wellness. 

His medical practice, Park Ridge MultiMed, uses 

functional medicine principles to evaluate and treat 

patients with medically unexplained and nonresponsive 

forms of chronic illness. 

Berndtson founded onebodymind.com to supply 

innovative online tools for people interested in a 

deeper, more effective approach to health 

education, self-care support, and the stewardship 

of living systems. The website is also ground zero 

for a social network that will help prepare the way 

for the modern quest for health and sustainability. 

References: 

Brownlee, Shannon. (2007) Overtreated: Why 

Too Much Medicine is Making Us Sicker and 

Poorer. Bloomsbury USA: New York. 

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2012 

Sapone, Anna, Lammers, Karen M., Casolaro, 

Vincenzo, et al. (2011) Divergence of gut 

permeability and mucosal immune gene 

expression in two gluten-associated 

conditions: celiac disease and gluten 

sensitivity. BMC Central. March 2011;9:23. 

Institute for Functional Medicine. (2006) 

Textbook of Functional Medicine. Institute 

for Functional Medicine: Gig Harbor, WA. 

This previous essay appears in the upcoming 

book, Value Health: The Modern Quest for Health 

and Sustainability, by Keith Berndtson, MD. 

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21 

Nutritional 

Treatment of 

Fatigue (Excluding 

Chronic Fatigue 

Syndrome) 


2012 

Fatigue is one of the most common health 

complaints. It can be caused by a wide range of 

medical conditions and by various medications. In 

many cases, treatment of the underlying disorder 

results in an improvement in fatigue. However, in 

a large proportion of patients evaluated for fatigue, 

no underlying cause is identified. Conventional 

medicine has little to offer patients with 

unexplained fatigue, other than "reassurance" that 

their symptoms are not being caused by a serious 

illness. 

Nutritional medicine, on the other hand, is 

frequently beneficial for patients with chronic, 

unexplained fatigue. In my experience, 

approximately 70-80% of these patients 

experience substantial improvement with nutritional 

therapy. Most of the common nutritional/metabolic 

disorders that are discussed repeatedly in this 

book (e.g., reactive hypoglycemia, food allergy, 

micronutrient deficiencies, hypothyroidism, and 

candidiasis) can cause fatigue. The astute 

practitioner, relying on a combination of clinical 

history, physical examination, and appropriate 

laboratory tests, can usually develop a nutritional 

program for chronic fatigue that has a high 

probability of success. Determining which 

interventions are most appropriate for any 

particular patient requires a fundamental 

understanding of the art and science of nutritional 

medicine. To paraphrase Sir William Osler, who 

made a similar comment regarding syphilis in 

1897, to know chronic fatigue is to know 

nutritional medicine. 

Dietary factors 

Reactive hypoglycemia 

Reactive hypoglycemia appears to be a common 

cause of fatigue. 1 2 Patients with fatigue caused 

by reactive hypoglycemia may experience a 

worsening of symptoms in the late morning or late 

afternoon (before mealtime) and an improvement 

after eating. They tend to crave sweets and may 

note that consumption of refined sugar relieves 

their symptoms transiently, only to be followed by 

an exacerbation. In my experience, a program that 

includes avoidance of refined sugar and other 

refined carbohydrates; consumption of small, 

frequent meals; and supplementation with nutrients 

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that help stabilize blood glucose levels often 

relieves fatigue in patients whose clinical picture is 

suggestive of reactive hypoglycemia. The 

evaluation and treatment of reactive hypoglycemia 

is discussed in chapter 6. 

Food allergy 

Numerous investigators have reported that hidden 

food allergy is a common cause of fatigue, both 

in children and adults. 3 4 5 6 7 8 9 10 Allergic 

fatigue may be associated with other symptoms of 

allergy, such as nasal congestion, abdominal pain, 

headache, body aches, hyperactivity, hyperirritability, 

and edema. Some patients with allergic 

fatigue note that they feel better while fasting and 

worse after eating a meal. However, in other 

cases, fatigue improves after a meal containing a 

regularly ingested hidden food allergen, presumably 

because the patient is addicted to that food. 

Patients with allergic fatigue are frequently 

unaware that dietary factors are contributing to 

their symptoms. The evaluation and treatment of 

food allergy is discussed in chapter 7. 

Caffeine 

In case reports, 6 patients with severe sleepiness 

experienced an improvement or resolution of that 

symptom after they stopped consuming caffeine. 11 

Mechanisms by which caffeine may cause 

sleepiness or fatigue include interfering with 

nocturnal sleep and triggering reactive 

hypoglycemia. 

Nutritional supplements 

Potassium magnesium aspartate 

In 1959, a French scientist, Laborit, hypothesized 

that fatigue is caused by inefficient energy 

metabolism at the cellular level. 12 

He suggested 

that enriching the cellular environment with 

appropriate substrates and cofactors could promote 

greater metabolic efficiency and thereby reduce the 

subjective symptom of fatigue. 

Among the physiological compounds that were 

available at the time, the potassium and 

magnesium salts of aspartic acid (potassium 

magnesium aspartate) were considered likely 

candidates to enhance metabolic efficiency. 

Potassium regulates basic aspects of cellular 

functioning (i.e., transmembrane electrical potential 

and intracellular ionic strength) and is also 

involved in muscle contraction. Magnesium is 

required for the synthesis of the energy-yielding 

compound, adenosine triphosphate (ATP), and 

also enhances potassium transport into cells. 

Aspartic acid is converted in vivo to oxaloacetate, 

which is a substrate for the Krebs cycle. 

After a study in rats supported Laborit's hypothesis 

by demonstrating that administration of potassium 

magnesium aspartate delayed the onset of 

exhaustion during a forced swimming test, 13 

several uncontrolled and double-blind trials were 

undertaken in humans. 14 15 16 17 18 19 20 21 In 

these trials, 75-94% of patients experienced an 

improvement in fatigue after treatment with 

potassium magnesium aspartate. In contrast, only 

5-27% of patients given placebo improved. In 

most studies, 2 g/day of potassium magnesium 

aspartate was administered, although one study 

used 4 g/day. These dosages refer to total 

weight: 2 g of potassium magnesium aspartate 

provides about 240 mg of potassium, 170 mg of 

magnesium, and 1.6 g of aspartate. Symptom 

relief was usually seen after 3-14 days. Fatigue 

of diverse etiologies (i.e., postoperative, post-viral, 

postpartum, menopausal, and nonspecific) 

responded to potassium magnesium aspartate. 

Adverse effects were uncommon and consisted 

mainly of mild gastrointestinal symptoms. 

One hundred patients with chronic fatigue received 

potassium magnesium aspartate (1 g twice a 

day) for 2-18 weeks. Ninety-one percent of the 

patients improved within 5-14 days. 14 

One hundred forty-five patients complaining of 

fatigue received, in double-blind fashion 

(randomization not specified), potassium 

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magnesium aspartate (1 g 4 times per day) or 

placebo for 2 weeks. The proportion of patients in 

whom energy levels improved was 85% in the 

active-treatment group and 9% in the placebo 

group. 15 

Two hundred sixty-three patients with fatigue as 

their sole complaint were randomly assigned to 

receive, in double-blind fashion, potassium 

magnesium aspartate (1 g twice a day) or 

placebo for 2-4 weeks and then the alternate 

treatment for an additional 2-4 weeks. Seventynine 

percent of the patients improved while 

receiving active treatment, while only 27% 

improved while receiving placebo. 16 

The results of these studies are consistent with a 

more recent study in which 47% of 93 patients 

(median age, 38 years) with unexplained chronic 

fatigue had laboratory evidence of magnesium 

deficiency (i.e., they retained 20% or more of an 

intravenous magnesium load). 22 

In my experience, 2.0-3.35 g/day of potassium 

magnesium aspartate (i.e., 4 capsules per day of 

commonly available preparations) is one of the 

most frequently effective treatments for fatigue. 

Because of its high degree of efficacy and 

tolerability, it is often one of my first-line 

therapies for patients with unexplained fatigue who 

have no associated neuropsychiatric symptoms (if 

they do have such symptoms, then vitamin B 12 

may be tried first [see below]). Some patients 

who respond to potassium magnesium aspartate 

are able to discontinue treatment after about 6 

weeks without experiencing a recurrence of 

symptoms, but they may need to resume 

supplementation during periods of increased activity 

or stress. Other patients require continuous 

treatment (with 50-100% of the initial dose) to 

maintain their improvement. 

Vitamin B 12 

Since shortly after its discovery in 1948, vitamin 

B 12 given by intramuscular injection has had a 

reputation of being a "tonic," capable of improving 

fatigue, mood, and overall well-being in certain 

23 24 

people who are not deficient in the vitamin. 

The popularity of this treatment is evidenced by 

the results of a survey conducted in the 1970s 

in which vitamin B 12 accounted for 6% of all 

office injections, including allergy-desensitization 

treatments. 25 

Despite many impressive testimonials, the 

conventional medical community maintains that 

vitamin B 12 injections are useless for patients who 

are not deficient in the vitamin; 25 26 27 that any 

improvement in symptoms is merely a placebo 

effect. To be sure, "getting a shot from the 

doctor" could produce a significant placebo 

response. However, the glowing reports from some 

patients strongly suggest that something more than 

a placebo effect is involved. I have heard 

comments such as, "I cleaned the house for the 

first time in 10 years;" or, "you gave me all this 

energy, now find something for me to do with it;" 

or, "this is the best I have felt in my entire life." 

Some patients who responded dramatically to 

vitamin B 12 had previously noticed little or no 

improvement from injections of testosterone or 

other substances, indicating that receiving an 

injection per se did not evoke a placebo response 

in these patients. A double-blind trial provided 

some support for the empirical use of vitamin B 12 

injections. 

Forty-eight subjects with fatigue, all of whom had 

normal hemoglobin concentrations and serum 

vitamin B 12 levels, were randomly assigned to 

receive, in double-blind fashion, vitamin B 12 

(hydroxocobalamin, 5 mg intramuscularly twice a 

week for 2 weeks) or placebo. After a 2-week 

washout period, each person received the alternate 

treatment for an additional 2 weeks. Twenty-eight 

subjects completed the trial. The outcome measure 

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was the proportion of participants who preferred 

one treatment over the other for various subjective 

symptoms. Among subjects who received placebo 

before vitamin B 12, 12 preferred vitamin B 12 and 

2 preferred placebo with respect to "general wellbeing" 

(p = 0.006). For "happiness," 9 

preferred vitamin B 12 and 2 preferred placebo (p 

= 0.03). For "fatigue," 10 preferred vitamin B 12 

and 4 preferred placebo (p = 0.09). Among 

subjects who received vitamin B 12 before placebo, 

there was no difference in response to the two 

treatments, apparently because the effect of 

vitamin B 12 carried over to the second treatment 

period (serum vitamin B 12 levels were still well 

above normal in 10 of 13 subjects 4 weeks after 

the last vitamin B 12 injection). 28 

This study, while demonstrating that vitamin B 12 

has some degree of efficacy in non-deficient 

individuals, was not designed to be able to detect 

the dramatic improvement that occurs in a minority 

(perhaps 10-15%) of patients with unexplained 

fatigue. 

In some patients, a positive response to vitamin 

B 12 injections appears to be due to the correction 

of mild vitamin B 12 deficiency (which can be 

demonstrated by a borderline-low serum vitamin 

B 12 level and/or an elevated serum methylmalonic 

acid level). 29 30 In those patients, the benefit may 

be relatively modest and the duration of the effect 

may be relatively long (reflecting the time it takes 

for vitamin B 12 deficiency to recur). Effective 

vitamin B 12 therapy for these patients may consist 

of 1,000 µg intramuscularly once a week for 4 

weeks, then once every 3 months. In many of 

these patients, supplementation with vitamin B 12 

orally in doses of 500-1,000 µg/day may control 

symptoms and obviate the need for injections. 

In another subgroup of vitamin B 12 responders, 

there is no evidence of vitamin B 12 deficiency. In 

this subgroup, the benefit from treatment is often 

substantial and the duration of the effect is 

relatively short (typically about 4-9 days, 

sometimes up to 2 weeks). These patients 

probably have some type of vitamin B 12 

dependency, in that they feel well only as long as 

their serum vitamin B 12 level is well above the 

normal range. One possible explanation for the 

need to maintain an unusually high serum vitamin 

B 12 concentration is a defect in the transport of 

vitamin B 12 across the blood-brain barrier. 

Consistent with that explanation, some patients 

with neurasthenia have been shown to have 

subnormal vitamin B 12 levels in cerebrospinal fluid 

in association with normal levels in serum. 31 

Effective therapy for patients with presumed 

vitamin B 12 dependency usually consists of 1,000 

µg intramuscularly every 4 days to 2 weeks, 

depending on how long the treatment lasts. While 

the interval between injections varies from one 

patient to another, it is usually fairly consistent for 

any particular patient. To maintain the beneficial 

effect of vitamin B 12, injections may have to be 

continued indefinitely, unless another method of 

relieving the fatigue can be identified. 

Hydroxocobalamin is preferable to cyanocobalamin 

for intramuscular administration, because it 

produces higher serum vitamin B 12 concentrations 

and more prolonged elevations of these levels. 32 

Methylcobalamin is also commercially available, but 

it is not known how its efficacy compares with 

that of other forms of vitamin B 12. For patients 

with presumed vitamin B 12 dependency, oral, 

sublingual, or intranasal administration of the 

vitamin rarely improves fatigue, because these 

routes of administration cannot achieve the high 

serum concentrations that are attainable with 

intramuscular administration. When considering 

long-term use of vitamin B 12, the risks associated 

with repeated injections (e.g., tissue trauma or 

sterile abscess) should be weighed against the 

benefits. Many patients can be successfully taught 

self-injection, which saves them a considerable 

amount of time and money compared with 

injections at the doctor's office. Patients 

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administering injections frequently should be 

advised to rotate injection sites. 

Because of its potential to produce substantial 

clinical improvement, intramuscular vitamin B 12 is 

one of my first-line therapies for patients with 

unexplained fatigue. It is often tried first in 

patients who have associated neuropsychiatric 

symptoms such as anxiety, depression, insomnia, 

or decreased memory. In patients who do not 

have neuropsychiatric symptoms, potassium 

magnesium aspartate is often tried first (see 

above). 

Iron 

Anemia due to iron deficiency can cause fatigue, 

which is reversible with iron therapy. In addition to 

being a component of hemoglobin, iron is a 

cofactor for enzymes involved the electrontransport 

chain 33 

(which plays a role in energy 

production) and in the synthesis of dopamine 

(which appears to modulate fatigue). In cases of 

mild iron deficiency, the activity of iron-dependent 

enzymes may be decreased before a reduction in 

hemoglobin levels occurs. Consequently, iron 

deficiency could contribute to fatigue even in 

patients who are not anemic. 

Clinical trials have demonstrated that iron 

supplementation can improve fatigue in nonanemic 

iron-deficient patients. 34 35 36 Most of the 

improvement is probably due to an increase in the 

activity of iron-dependent enzymes, although some 

of the benefit might be due to an increase in 

hemoglobin levels within the normal range. 34 

One hundred forty-four non-anemic women (aged 

18-55 years) with unexplained fatigue were 

randomly assigned to receive, in double-blind 

fashion, 80 mg/day of iron (as ferrous sulfate) 

or placebo for 4 weeks. Prior to treatment, 51% 

of the women had a low serum ferritin 

concentration (20 µg/L or lower). Mean severity 

of fatigue decreased by 29% in the group 

receiving iron and by 13% in the placebo group 

(p = 0.004 for difference in the change between 

groups). Subgroup analysis showed that only 

women with ferritin concentrations ≤ 50 µg/L 

improved with iron supplementation. 35 

Administration of iron to patients who are not 

iron-deficient may increase the risk of developing 

certain chronic illnesses, and it can harm people 

who carry an iron-overload gene. Therefore, iron 

supplementation should be reserved for patients 

with documented iron deficiency or borderline-low 

iron status. 

Multivitamin-multimineral 

Fatigue is one of the early manifestations of many 

different individual micronutrient deficiencies. The 

typical Western diet provides only marginal 

amounts of a wide range of vitamins and 

minerals. In some patients, fatigue could be 

caused either by a relatively poor diet or by an 

average diet in conjunction with a higher-thannormal 

requirement for one or more nutrients. In 

clinical practice, patients frequently remark that 

they have more energy when they take a 

multivitamin or multivitamin-multimineral preparation. 

The beneficial effect of a specific product was 

demonstrated with marginal statistical significance 

in a double-blind study of healthy volunteers. 

Eighty healthy male volunteers (aged 18-42 

years) were randomly assigned to receive, in 

double-blind fashion, 1 tablet per day of a 

multivitamin-multimineral formula (Berocca) or 

placebo for 28 days. One tablet of Berocca 

contains thiamine (15 mg), riboflavin (15 mg), 

niacin (50 mg), pantothenic acid (23 mg), 

vitamin B 6 (10 mg), biotin (150 µg), folic acid 

(400 µg), vitamin B 12 (10 µg), vitamin C 

(500 mg), calcium (100 mg), magnesium 

(100 mg), and zinc (10 mg). Compared with 

placebo, active treatment was associated with a 

marginally significant decrease in tiredness (p = 

0.06). 37 

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As noted below, certain individual nutrients that 

are present in most multivitamin-multimineral 

products may be beneficial by themselves for 

some patients with fatigue. Other components of a 

broad-spectrum supplement might also be helpful, 

even though they have not been studied 

specifically as a treatment for fatigue. 

Thiamine, vitamin B 3, and vitamin B 6 

Several B vitamins play a role in energy 

production, and fatigue can result from a 

deficiency of various individual B vitamins. Studies 

on the treatment of fatigue with thiamine, vitamin 

B 3, and vitamin B 6 are described below. 

Of 222 people aged 65 years or older from an 

urban general practice, 16% were found to have 

laboratory evidence of thiamine deficiency. 38 In 2 

double-blind trials, supplementation of individuals 

aged 65 years or older with 10 mg/day of 

thiamine for 6 weeks and 3 months, respectively, 

improved fatigue when compared with placebo (p 

< 0.05 in one study, p = 0.07 in the other 

38 39 

study). 

In an uncontrolled trial, 18 of 19 patients with 

chronic exhaustion and asthenia improved after 

receiving 40 mg/day of pyridoxine for 1 week. 40 

In a study conducted in 1940, prior to the 

enrichment of grains with B vitamins, 

supplementation with 100-200 mg/day of niacin 

decreased fatigue in some patients. 41 

While some apparently well-nourished patients 

have commented that taking B vitamins gives 

them more energy, those observations have not 

been confirmed by controlled trials. Nevertheless, 

moderate doses of B vitamins are safe and 

relatively inexpensive, so a trial of B-vitamin 

supplementation (as a component of, or in 

addition to, a multivitamin-multimineral preparation) 

should be considered for patients with fatigue. 

Vitamin C 

Fatigue is one of the symptoms of vitamin C 

deficiency. In a study of miners, supplementation 

with 150 mg/day of vitamin C resulted in a 

decrease in fatigue. 42 

Although no controlled trials 

have been done, supplementation with vitamin C 

might improve fatigue in patients with suboptimal 

dietary vitamin C intake and in those subjected to 

stress. 

L-Carnitine 

Carnitine facilitates the transport of fatty acids into 

mitochondria, where they are metabolized to 

produce energy. Carnitine deficiency or suboptimal 

carnitine status would presumably lead to 

decreased energy production, potentially resulting 

in fatigue. Relative carnitine deficiency, resulting 

from decreased carnitine absorption, decreased 

endogenous carnitine synthesis, increased urinary 

carnitine loss, or an increased carnitine 

requirement could occur in various disease states, 

with the use of certain medications, or with 

advancing age. In double-blind trials, 

administration of 2 g/day of L-carnitine for 6 

months decreased fatigue in patients with celiac 

disease who were on a gluten-free diet, and also 

improved fatigue in a group of centenarians 

(≥ 100 years old). 

Thirty patients with recently diagnosed celiac 

disease who had been on a gluten-free diet for 

30 days were randomly assigned to receive, in 

double-blind fashion, 1 g of L-carnitine twice a 

day or placebo for 6 months. The mean severity 

of fatigue, as determined by a visual analog 

scale, decreased to a significantly greater extent 

in the L-carnitine group than in the placebo group 

(p = 0.002). At the end of the trial (7 months 

after commencement of the gluten-free diet), the 

mean serum carnitine concentration in the placebo 

group was 29% lower than in healthy controls, 

although the level was higher than before the start 

of the diet. 43 

The results of this study indicate 

that patients with celiac disease have serum low 

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carnitine levels, even while consuming a glutenfree 

diet, and that carnitine deficiency is a cause 

of fatigue in these patients. 

Seventy centenarians (aged 100-106 years) 

were randomly assigned to receive, in doubleblind 

fashion, 2 g/day of L-carnitine or placebo 

for 6 months. Compared with placebo, L-carnitine 

significantly improved both physical and mental 

fatigue. 44 

In uncontrolled trials, L-carnitine supplementation 

(250-6,000 mg/day for 1-4 weeks) appeared 

to decrease fatigue in cancer patients, including 

45 46 47 

patients with chemotherapy-related fatigue. 

While a double-blind trial produced equivocal 

results in patients with cancer-related fatigue, the 

results were consistent with the possibility that L- 

carnitine produces a progressive reduction in 

fatigue over a period of 4-5 weeks. 48 

Vitamin D 

According to one group of practitioners, vitamin D 

deficiency can cause fatigue, which is associated 

in some cases with aches and pains, especially in 

the shins and ribs. 49 

Vitamin D deficiency should 

be suspected in individuals who have inadequate 

sun exposure (particularly if they are overweight 

or elderly or have dark skin) and do not 

consume significant amounts of vitamin D-fortified 

foods such as dairy products. 

Intravenous nutrient therapy 

In my experience, intravenous administration of a 

combination of magnesium, calcium, B vitamins, 

and vitamin C is effective for some patients with 

fatigue in whom other treatments (including 

intramuscular vitamin B 12) have failed. The usual 

treatment consists of 4 ml of 20% of magnesium 

chloride hexahydrate, 2 ml of 10% calcium 

gluconate, 1.3 g of vitamin C, 100 mg of 

pyridoxine, 1,000 µg of vitamin B 12, 250 mg of 

dexpanthenol, and 1 ml of B complex 100. This 

treatment, commonly referred to as the Myers 

cocktail, is described in chapter 340. 

Other treatments 

Thyroid hormone 

Fatigue, often most pronounced in the morning, is 

a common manifestation of hypothyroidism. In 

hypothyroid patients, administration of thyroid 

hormone frequently improves fatigue. One group of 

investigators reported that 40% of 219 patients 

with chronic fatigue who underwent fine-needle 

aspiration of the thyroid gland had histologic 

evidence of lymphocytic (autoimmune) thyroiditis. 

In patients with lymphocytic thyroiditis, treatment 

with levothyroxine relieved the fatigue, even among 

the one-third of cases with TSH levels < 3.0 

mU/L. Of note, only half of the patients with 

histologic evidence of lymphocytic thyroiditis had 

elevated blood levels of thyroid peroxidase 

antibodies. 

Of 219 patients with fatigue for more than one 

year, 40% had histologic evidence of lymphocytic 

thyroiditis. TSH levels in patients with thyroiditis 

were widely scattered, with a median value of 3.8 

mU/L and a range of < 0.9 mU/L to > 15 

mU/L (normal range, 0.1-5.0 mU/L). In onethird 

of the patients with lymphocytic thyroiditis, 

the TSH level was < 3.0 mU/L, and in 59% of 

the patients the level was < 5.0 mU/L. The 

clinical response to levothyroxine therapy was 

"equally favorable" (details not presented) among 

patients with lymphocytic thyroiditis, irrespective of 

their initial TSH level. 50 

Of the patients with 

definite histologic evidence of lymphocytic 

thyroiditis, only half had elevated circulating levels 

of thyroid peroxidase antibodies, thyroglobulin 

antibodies, or both. 51 

These findings are consistent with my observation 

that laboratory tests for thyroid function are 

frequently normal in patients who are clinically 

hypothyroid (chapter 8). In my experience, many 

patients with chronic fatigue who have clinical 

evidence of hypothyroidism but normal laboratory 

tests experience an improvement in fatigue after 

receiving an empirical trial of thyroid hormone. 

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Some of these patients may have had 

autoimmune thyroiditis, as noted in the above 

study (thyroid antibodies were only occasionally 

measured in my patients). However, others may 

have had tissue resistance to thyroid hormone, 

impaired conversion of thyroxine to triiodothyronine, 

or some other abnormality that increased their 

need for thyroid hormone. Consequently, the 

presence of lymphocytic thyroiditis may not be the 

only predictor of a positive response to thyroid 

hormone. Moreover, notwithstanding the study cited 

above, it is unclear whether the presence of 

autoimmune thyroiditis per se is an indication for 

treatment with thyroid hormone. For these reasons, 

clinical evaluation may often be the most reliable 

method of identifying those patients with chronic 

fatigue for whom a trial of thyroid hormone is 

appropriate. 

Practitioners who are opposed to using thyroid 

hormone empirically have argued that tired patients 

may feel better when their metabolism is cranked 

up with thyroid hormone, but that does not mean 

they are hypothyroid or that the treatment is safe. 

However, that argument overlooks two points. 

First, people who are fatigued but not clinically 

hypothyroid often feel worse, not better, when they 

take thyroid hormone. Second, a specific set of 

symptoms, not just fatigue, usually improves when 

clinical hypothyroidism is treated. The evaluation 

and treatment of "sub-laboratory" hypothyroidism 

is discussed in chapter 8. 

Dehydroepiandrosterone (DHEA) 

In my experience, administration of 

dehydroepiandrosterone (DHEA) relieves fatigue in 

some patients whose serum DHEA-sulfate 

concentration is below or in the bottom 10-20% 

of the normal range for young adults of the same 

gender. Most of the patients who benefited from 

DHEA supplementation were elderly, but a few 

were middle-aged. The usual dosage is 5-15 

mg/day for women and 10-20 mg/day for men. 

Further information and precautions regarding the 

use of DHEA are presented in chapter 56. 

Candidiasis 

According to clinical observations, fatigue is one of 

the symptoms caused by chronic candidiasis (also 

called Candida-related complex). 52 53 Candidiasis 

should be suspected in patients with a history of 

recurrent Candida vaginitis, oral thrush, diabetes, 

or immunodeficiency. It should also be suspected 

in patients who have taken antibiotics (particularly 

if symptoms began after a course of antibiotics), 

oral contraceptives, or glucocorticoids. The 

evaluation and treatment of candidiasis is 

discussed in chapter 9. 

Recommendations for chronic fatigue 

1. Diet: Identify and treat reactive hypoglycemia 

and food allergies. 

2. Potassium magnesium aspartate: 2.0-3.35 

g/day. 

3. Vitamin B 12: 1,000 µg intramuscularly once a 

week for several weeks in selected cases, then 

as needed if effective. 

4. Iron: Identify and treat iron deficiency. 

5. Other nutrients: Other nutrients that may be 

beneficial include B vitamins, vitamin C, L- 

carnitine, and vitamin D. 

6. Intravenous nutrient therapy (Myers cocktail) in 

selected cases. 

7. Thyroid hormone in selected cases. 

8. DHEA in selected cases. 

Reprinted with permission from Nutritional 

Medicine, by Alan R. Gaby, M.D. 

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Alan R. Gaby is internationally recognized as an 

expert in nutritional therapies. He has recently 

completed a comprehensive textbook, Nutritional 

Medicine (http://www.doctorgaby.com/). He is 

past-president of the American Holistic Medical 

Association and was inducted in 2012 into the 

Orthomolecular Medicine Hall of Fame by the 

International Society for Orthomolecular Medicine. 

Contact Alan Gaby at www.doctorgaby.com 

9 Rapp DJ. Double-blind confirmation and 

treatment of milk sensitivity. Med J Aust 

1978;1:571-572. 

10 Crook WG, Harrison WW, Crawford SE, Emerson 

BS. Systemic manifestations due to allergy. Report 

of fifty patients and a review of the literature on 

the subject (sometimes referred to as allergic 

toxemia and the allergic tension-fatigue 

syndrome). Pediatrics 1961;27:790-799. 

11 Regestein QR. Pathologic sleepiness induced by 

caffeine. Am J Med 1989;87:586-588. 

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1 Karlan SC, Cohn C. Hypoglycemic fatigue. JAMA 

1946;130:553-555. 

2 Portis SA. Life situations, emotions and 

hyperinsulinism. JAMA 1950;142:1281-1286. 

3 Rowe AH. Allergic fatigue and toxemia. Ann 

Allergy 1959;17:9-18. 

4 Rowe AH. Allergic toxemia and fatigue. Ann 

Allergy 1950;8:72-79, 84. 

5 Speer F. The allergic tension-fatigue syndrome in 

children. Int Arch Allergy 1958;12:207-214. 

6 Randolph T. Fatigue and weakness of allergic 

origin (allergic toxemia) to be differentiated from 

"nervous fatigue" or neurasthenia. Ann Allergy 

1945;3:418-430. 

7 Randolph TG. Allergy as a causative factor of 

fatigue, irritability, and behavior problems of 

children. J Pediatr 1947;31:560-572. 

8 Speer F. Allergic tension-fatigue in children. Ann 

Allergy 1954;12:168-171. 

12 Anonymous. Chronic fatigue. Lancet 1963;1:872- 

873. 

13 Rosen H, Blumenthal A, Agersborg HPK. Effects 

of the potassium and magnesium salts of aspartic 

acid on metabolic exhaustion. J Pharm Sci 

1962;51:592-593. 

14 Oliver S. Relationship of fatigue to 

gastrointestinal inadequacy. Curr Ther Res 

1963;5:620-625. 

15 Hicks JT. Treatment of fatigue in general practice: 

a double-blind study. Clin Med 1964;71:85-90. 

16 Agersborg HPK Jr, Shaw DL Jr. Physiologic 

approach to the problem of fatigue. J Sports Med 

Phys Fitness 1962;2:217. 

17 Formica PE. The housewife syndrome: treatment 

with the potassium and magnesium salts of 

aspartic acid. Curr Ther Res 1962;4:98-106. 

18 Shaw DL Jr, Chesney MA, Tullis IF, Agersborg 

HPK. Management of fatigue: a physiologic 

approach. Am J Med Sci 1962;243:758-769. 

19 Crescente FJ. Treatment of fatigue in a surgical 

practice. J Abdom Surg 1962;4:73-76. 

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20 Friedlander HS. Fatigue as a presenting 

symptom. Curr Ther Res 1962;4:441-449. 

21 Kruse CA. Treatment of fatigue with aspartic acid 

salts. Northwest Med 1961;60:597-603. 

22 Manuel y Keenoy B, Moorkens G, Vertommen J, 

et al. Magnesium status and parameters of the 

oxidant-antioxidant balance in patients with 

chronic fatigue: effects of supplementation with 

magnesium. J Am Coll Nutr 2000;19:374-382. 

23 Woodrow M. The use of long-acting vitamin B12 

(Ducobee Depot) in 420 patients in a general 

medical practice. Curr Ther Res 1960;2:305-309. 

24 Kaufman W. The use of vitamin therapy to 

reverse certain concomitants of aging. J Am Geriatr 

Soc 1955;3:927-936. 

25 Alper PR. Legitimate indications for 

intramuscular injections. Arch Intern Med 

1978;138:1705-1710. 

26 Friend DG. Cyanocobalamin (vitamin B12) 

injections for nonspecific debilitation: no value. 

JAMA 1970;214:604. 

27 Lawhorne L, Ringdahl D. Cyanocobalamin 

injections for patients without documented 

deficiency. Reasons for administration and patient 

responses to proposed discontinuation. JAMA 

1989;261:1920-1923. 

28 Ellis FR, Nasser S. A pilot study of vitamin B12 in 

the treatment of tiredness. Br J Nutr 1973;30:277- 

283. 

29 Williams JA, Baume PE, Meynell MJ. Partial 

gastrectomy: the value of permanent vitamin B12 

therapy. Lancet 1966;1:342-344. 

30 Hvas AM, Juul S, Nexo E, Ellegaard J. Vitamin B- 

12 treatment has limited effect on health-related 

quality of life among individuals with elevated 

plasma methylmalonic acid: a randomized placebocontrolled 

study. J Intern Med 2003;253:146-152. 

31 van Tiggelen CJM, Peperkamp JPC, Tertoolen 

HJFW. Assessment of vitamin B12 status in CSF. Am 

J Psychiatry 1984;141:136-137. 

32 Glass GBJ, Skeggs HR, Lee DH, et al. 

Hydroxocobalamin. I. Blood levels and urinary 

excretion of vitamin B12 in man after a single 

parenteral dose of aqueous hydroxocobalamin, 

aqueous cyanocobalamin and cyanocobalamin 

zinc-tannate complex. Blood 1961;18:511-521. 

33 Jacobs A. The non-haematological effects of iron 

deficiency. Clin Sci 1977;53:105-109. 

34 Beutler E, Larsh SE, Gurney CW. Iron therapy in 

chronically fatigued, nonanemic women: a doubleblind 

study. Ann Intern Med 1960;52:378-394. 

35 Verdon F, Burnand B, Stubi CLF, et al. Iron 

supplementation for unexplained fatigue in nonanaemic 

women: double blind randomised placebo 

controlled trial. BMJ 2003;326:1124. 

36 Ballin A, Berar M, Rubinstein U, et al. Iron state 

in female adolescents. Am J Dis Child 

1992;146:803-805. 

37 Carroll D, Ring C, Suter M, Willemsen G. The 

effects of an oral multivitamin combination with 

calcium, magnesium, and zinc on psychological 

well-being in healthy young male volunteers: a 

double-blind placebo-controlled trial. 

Psychopharmacology 2000;150:220-225. 

38 Wilkinson TJ, Hanger HC, Elmslie J, et al. The 

response to treatment of subclinical thiamine 

deficiency in the elderly. Am J Clin Nutr 

1997;66:925-928. 

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39 Smidt LJ, Cremin FM, Grivetti LE, Clifford AJ. 

Influence of thiamin supplementation on the 

health and general well-being of an elderly Irish 

population with marginal thiamin deficiency. J 

Gerontol 1991;46:M16-M22. 

40 Annand JC. Pyridoxine and magnesium in the 

treatment of shock. Lancet 1957;2:340-341. 

41 Chesley FF, Dunbar J, Crandal LA Jr. The vitamin 

B-complex and its constituents in functional 

digestive disturbances. Am J Dig Dis 1940;7:24-27. 

42 Masek J, Hruba F, Novakova V, et al. Vitamin C 

and vigilance. Rev Czech Med 1976;22:209-215. 

43 Ciacci C, Peluso G, Iannoni E, et al. L-Carnitine in 

the treatment of fatigue in adult celiac disease 

patients A pilot study. Dig Liver Dis 2007;39:922- 

928. 

44 Malaguarnera M, Cammalleri L, Gargante MP, et 

al. L-Carnitine treatment reduces severity of 

physical and mental fatigue and increases cognitive 

functions in centenarians: a randomized and 

controlled clinical trial. Am J Clin Nutr 

2007;86:1738-1744. 

45 Gramignano G, Lusso MR, Madeddu C, et al. 

Efficacy of L-carnitine administration on fatigue, 

nutritional status, oxidative stress, and related 

quality of life in 12 advanced cancer patients 

undergoing anticancer therapy. Nutrition 

2006;22:136-145. 

47 Graziano F, Bisonni R, Catalano V, et al. Potential 

role of levocarnitine supplementation for the 

treatment of chemotherapy-induced fatigue in 

non-anaemic cancer patients. Br J Cancer 

2002;86:1854-1857. 

48 Cruciani RA, Dvorkin E, Homel P, et al. L-Carnitine 

supplementation in patients with advanced cancer 

and carnitine deficiency: a double-blind, placebocontrolled 

study. J Pain Symptom Manage 

2009;37:622-631. 

49 Prabhala A, Garg R, Dandona P. Severe myopathy 

associated with vitamin D deficiency in western 

New York. Arch Intern Med 2000;160:1199-1203. 

50 Wikland B, Lowhagen T, Sandberg PO. Fineneedle 

aspiration cytology of the thyroid in chronic 

fatigue. Lancet 2001;357:956-957. 

51 Wikland B, Sandberg PO, Wallinder H. 

Subchemical hypothyroidism. Lancet 

2003;361:1305. 

52 Galland L. Normocalcemic tetany and 

candidiasis. Magnesium 1985;4:339-344. 

53 Cater RE II. Chronic intestinal candidiasis as a 

possible etiological factor in the chronic fatigue 

syndrome. Med Hypotheses 1995;44:507-515. 

46 Cruciani RA, Dvorkin E, Homel P, et al. Safety, 

tolerability and symptom outcomes associated 

with L-carnitine supplementation in patients with 

cancer, fatigue, and carnitine deficiency: a phase 

I/II study. J Pain Symptom Manage 2006;32:551- 

559. 

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22 

Roundoc Rx 

The Human 

Microbiome – 

Humans as Super- 

Organisms 

Robert Rountree, 

MD 

2012 

New discoveries in the human microbiome have 

led to the realization that humans are not the 

“simple” multicellular organisms that we thought 

they were—in fact, humans are super-symbionts 

who are completely dependent on a lifelong, 

mutually beneficial relationship with our microbial 

selves. Through new polymerase chain reaction 

(PCR) techniques, researchers have discovered 

that there are more bacteria cells on our bodily 

surfaces—collectively amounting to 100 trillion cells 

—than there are human cells in the entire body 

by a factor of 10:1. This means that humans are 

90% bacteria! Furthermore, there are as many as 

two million distinct genes present on all the 

external and internal surfaces of our body. We 

have yet to identify all the different 

microorganisms that carry these genes, but there 

is no doubt that they are there. The implications 

of this finding are mind-boggling. 

As a direct result of our ability to map these 

genomes we have come to the profound 

realization that here are all of these 

microorganisms living on us and, only a few years 

ago, we did not even know they existed. This 

begs the question: “What do all of these 

organisms do and how do they interact with our 

physiology?” For starters, they are absolutely 

essential for our health and well-being. Human 

beings cannot live without these organisms. They 

direct our immune and neurologic function, and 

profoundly affect digestion and metabolism. Now 

let’s take a closer look at the human microbiome 

and the role these microorganisms play in our 

overall health. 

The Human Microbiome Unraveled 

The Nobel laureate Joshua Lederberg has 

suggested using the term “microbiome” to describe 

the collective genome of our indigenous microbes 

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(microflora), the idea being that a comprehensive 

genetic view of Homo sapiens as a life-form 

should include the genes in our microbiome. 1 

As 

a result of new genomic sequencing techniques, 

which have allowed us to quantify, categorize, and 

otherwise determine what is actually growing on 

our bodily surfaces, we realize that the size and 

extent of this human microbiome is much more 

profound than anyone would have imagined. 

Twenty years ago, if you wanted to know what 

microbes were growing in the crook of someone’s 

elbow, you would swab the skin in that area, then 

transfer the sample to a Petri dish that contained 

a mixture of agar along with nutrients designed to 

make bacteria grow. This is a classic experiment 

that is still performed in biology classes across 

the country. After a few days of incubating the 

Petri dish, various species of Staphylococcus, 

gram-positive bacteria, would form colonies on the 

surface of the culture medium. The conclusion of 

the experiment based on this prima facie evidence 

is that the Staph species growing on the plate 

are the predominant bacteria growing on the skin. 

What we have come to understand in recent 

years is that most of the species of bacteria that 

grow on the skin do not lend themselves very 

readily to this older culture technique, so we were 

actually missing most of what was there. An 

especially fascinating finding is that every region 

of the body has its own unique ecosystem of 

bacteria that is specific to that area. In other 

words, the types of bacteria found on the palm of 

the hand are distinctly different from those found 

in the axilla. 

The same concept is true for a stool analysis. If 

someone with acute infectious diarrhea comes to 

see a doctor, the doctor might order microscopy 

to look for certain protozoan parasites such as 

Giardia lamblia or Entamoeba histolytica, or a 

stool culture for specific pathogenic bacteria such 

as Salmonella, Shigella, Campylobacter, and 

certain strains of Escherichia coli. We look for 

these organisms because that is what we have 

known how to look for, but the new reality is 

that, in fact, there are many other organisms not 

revealed through standard culture and microscopy 

techniques, and that DNA sequencing by PCR is 

going to replace the old way of doing things. 

It is very similar to the old story of people 

looking for their lost keys under the light, and 

somebody asks: “Where did you lose the keys?” 

“Well, I lost them over there in the darkness.” 

“Well, why are you under the street lamp?” 

“Because this is where the light is.” That story 

very much applies to the evolution in microbiology. 

In the past, we have looked for organisms that 

we knew we could isolate, but, today, PCR 

techniques have become automated to the point 

where we can do a comprehensive analysis of the 

microbiota in the human body in a relatively short 

period of time, thus giving us a much more 

accurate picture of the composition of an 

individual’s conglomerate microbial genome. 

The five classes of microorganisms that have 

been found in the human microbiome include 

viruses, archaea, bacteria, microfungi, and 

protozoa. While the composition of normal 

microbiota varies from person to person, the 

majority of microorganisms found in and on the 

body are bacteria. These microbes exist on most 

bodily surfaces and wherever our body is 

interacting with “portals” to the outside world such 

as the respiratory, gastrointestinal (GI), and 

urogenital tracts. 

For example, we used to think that the urogenital 

tract was mostly sterile, but now we know that is 

not the case. Interestingly, babies start out in the 

sterile environment of the womb, and then as 

soon as they are born they become colonized 

with microbes that are primarily derived from the 

mother’s birth canal. In contrast, babies born by 

cesarean section are colonized with bacteria 

typically found on the mother’s skin, as well as 

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2012 

the bacteria found on the skins of other infants, 

nursing staff, and even in the air in the hospital. 

This can have a lasting impact on the gut flora of 

these babies. The difference in initial colonization 

may explain why some studies have suggested 

that cesarean-section babies are more prone to 

developing food allergies and asthma in 

childhood, 2 

although this association has admittedly 

not been a consistent finding. 

Most of these organisms reside in the GI tract, 

which is, by far, the largest source of 

microorganisms in the human body. The next 

largest source is the surface of our skin. Current 

research suggests that there are between 500 

and 1000 different species of oral and intestinaltract 

bacteria. Gill and colleagues estimate that 

“the human intestinal microbiota is composed of 

1013 to 1014 microorganisms, whose collective 

genome (“microbiome”) contains at least 100 

times as many genes as our own genome.” 3 

Humans, therefore, can really be viewed as 

“super-organisms” as our metabolism represents a 

mix of human and microbial attributes. 

What Controls Microorganism Populations? 

It is interesting to think about what keeps these 

microorganisms in balance. For instance, we wash 

our hands all the time and are naturally sloughing 

skin and mucosal cells, including cells that line 

our noses and mouths. When those cells slough 

off, they take with them any bacteria that might 

be attached. What is remarkable is that, if you 

temporarily sterilize the antecubital fossa by 

swabbing it with rubbing alcohol, within days—or 

even hours—it will be recolonized with a 

community of bacteria that is very similar to what 

was there before you sterilized the area. This tells 

us that there is something about every 

environment or “habitat” in the body that is set 

up to host a unique population of bacteria. The 

armpit is like a rainforest—damp and wet—so 

certain bacteria prefer that kind of environment 

and will grow there. Yet, the forearm, or the back 

of the hand, is much drier, so a different 

population will colonize there. 

It is important to understand that, after a baby is 

born, the first group of bacteria that colonizes the 

skin or mucosal surfaces of the baby interacts 

with the DNA of the cells on those surfaces, and 

the bacteria send chemical messages back and 

forth. Based on those messages, the cells are 

signaled to make adherence factors, which make it 

easier for the bacteria to stick to the epithelium. 

For example, Bifidobacterium—one of the first 

bacteria on the scene—begin to colonize the 

baby’s intestines and send messages to the DNA 

of the cells lining the gut that say: “Make this 

environment more hospitable for me.” 

This molecular dialogue takes place all over the 

body and continues throughout our lives. If 

something physically or biochemically disrupts that 

microecology, the result can lead to inflammation. 

Eczema is a good example of this phenomenon. 

Cold temperatures, insufficient moisture, or 

nutritional deficiencies can result in a breakdown 

of the normal skin barrier. That disrupts the 

microecology of bacteria that cover the skin so 

that pathogenic “bad guys,” such as 

Staphylococcus aureus, can start to move in and 

wreak havoc. 

In other words, chronic eczema results from a 

combination of an excessively permeable skin 

barrier along with an excessive immune response 

to the bacteria on or just underneath the skin’s 

surface. This is very similar to what happens with 

ulcerative colitis, in which a deficiency of 

protective mucin allows certain bacterial populations 

to have access to immune cells that reside just 

underneath the surface of the gut mucosa. This 

increased exposure to “conditionally pathogenic” 

microorganisms activates those immune cells to 

generate an inflammatory response. 

The bottom line is that disruption of the 

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microecology of the microbiota in the human body 

can lead to inflammation and chronic disease. Our 

microbiota may “Defend and Define Us” as one 

headline put it, 4 

but, in the right conditions, they 

can also stir up a lot of trouble. 

Microbiota Essential for Human Health 

Healthy microbes in the human body are 

associated with significant health benefits including 

proper immune and neurologic functioning as well 

as optimal metabolism and digestion. The 

strongest line of evidence we have about the 

value of the microbiota and our health has been 

inspired by what is referred to as the “hygiene 

hypothesis.” 

The hygiene hypothesis began with the observation 

in 1989 by David Peter Strachan, MD, a British 

epidemiologist, that people in industrialized 

societies experienced higher incidences of asthma, 

allergy, and perhaps autoimmune disease. 5 

An 

extensive body of research suggests that this 

increased incidence occurs as a result of 

excessive hygiene, vaccinations, and antibiotics, 

which make our internal and external environments 

“too clean.” What the hygiene hypothesis basically 

tells us is that excessively clean or sterile 

environments may deprive the body of important 

information that it needs to function properly and 

remain in balance. 

It wasn’t that many years ago that the numberone 

cause of morbidity and mortality was 

pathogenic infections. This dropped significantly 

with the advent of synthetic antibiotic “wonder 

drugs.” Yet, as a society, we have not been 

satisfied with our ability to simply control 

pathogens. We want to completely eradicate them 

—ALL of them—by doing everything possible to 

avoid exposure to infection or to stamp out 

infection in its earliest stages. We put antimicrobial 

compounds in soap, plastics, and toys. We treat 

babies aggressively with antibiotics for upper 

respiratory infections even though most of these 

infections are caused by viruses. 

According to the Centers for Disease Control and 

Prevention, 30% of the 150 million antibiotic 

prescriptions in the United States are 

unnecessary. 6 

Furthermore, at least 60% of 

manufactured antibiotics are used in animal feed 

as growth promoters. 6 

The hygiene hypothesis 

says the net effect of all this is that the human 

immune system does not get adequate education, 

and the consequence of underexposure to 

infections is a rise in allergy, asthma, and 

perhaps autoimmune disease. 

Let’s take a little closer look at how this 

immunologic education works on a cellular level. 

Perhaps the single biggest influence on overall 

immune regulation has to do with a type of 

immune cell called the dendritic cell (DC). DCs 

are roving sentinels, whose specific task is to 

monitor the surfaces of the body for potential 

microbial threats. These sentinels do this by 

continuously sampling fragments of the microbes 

(and/or foods) that traverse the gut lining, 

respiratory tract, and skin. 

DCs are found on every mucous membrane or 

epithelial surface on the human body—every place 

that human bodies come in contact with the 

outside world. 

DCs start out in a naïve and relatively 

undifferentiated state. After exposure to certain 

antigenic structures (e.g., microbes, foods, 

pollens), they become activated to mature down a 

specific pathway of cellular differentiation. The 

resulting mature DCs can be proinflammatory, 

anti-inflammatory, or actively tolerant (anergic). 

Each type of mature dendritic cell then acts in 

turn to program naïve T-lymphocytes to follow its 

lead and become proinflammatory, antiinflammatory, 

or tolerant. Given the huge number 

of foreign antigens present in the human 

microbiome, it is clear that tolerance of these 

antigens by immune cells is the norm rather than 

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the exception. The primary cells responsible for 

maintaining this tolerance are T-regulatory 

lymphocytes, often referred to as T-reg cells. T- 

reg cells develop from naïve T-cells that are 

programmed by DCs. 

In order to mature down the tolerance pathway, 

DCs require continuous low-level exposure to 

“innocuous” bacteria known as commensals. If 

DCs do not get that exposure then they behave 

erratically. It is essential to have a two-way 

communication between the DCs and the 

microbiota. If an imbalance develops in the 

microbiota because of overgrowth of pathogenic 

bacteria or microfungi, this disruption activates 

DCs to mature down an inflammatory pathway 

instead of a tolerant pathway. The downstream 

consequence is that, instead of naïve T-cells 

becoming T-reg cells, these T-cells become 

activated into becoming Th1, Th2 or Th17 cells, 

all of which are highly inflammatory. 

If the initial disruption leads to activation of Th-2 

cells, then humoral (antibody-mediated) immunity 

is upregulated and allergic reactions can result. If 

the disruption leads to activation of Th1 cells 

involved in cell-mediated immunity then the result 

can be excessive inflammation. T-reg cells that 

are activated via the tolerance pathway tend to 

suppress overactivation of both Th1 and Th2 

lymphocytes. 

DNA mapping of the human microbiome has given 

us a much greater appreciation of the implications 

of the hygiene hypothesis. We are just beginning 

to realize to what extent the microbiome is 

influencing us in very powerful ways that we 

never expected. 

Potential Effects of Disruption of Microbiota 

If the human microbiome is essential for health, 

then disruption of the body’s microbiota can lead 

to inflammation and disease. Numerous published 

studies show that disruption of gut microbiota has 

been associated with inflammatory bowel disease 

(IBD), obesity, autoimmune disease, asthma, 

allergies, cardiovascular disease, and other health 

problems. 

Disruption of the body’s 

microbiota can lead 

to inflammation and disease. 

Inflammatory Bowel Disease 

Let’s look for example at IBD, a situation in 

which the immune system becomes overactivated 

and attacks the gut lining. There are two major 

types of IBD—Crohn’s disease and ulcerative 

colitis. The current leading theory regarding the 

cause of Crohn’s disease is that it is actually a 

type of immune deficiency. An immune defect in 

specific cells that normally keep bad bacteria in 

check allows these bacteria to overgrow. This 

leads to localized inflammation in the gut wall, 

microabscesses, and fistulas. In other words, 

Crohn’s disease is not a disease of immunesystem 

overreactivity, but rather a disease in 

which the normal balance of the microbiota in the 

GI tract is disrupted. 

In contrast, ulcerative colitis is a condition in 

which the immune system overreacts to normal 

flora. The resulting inflammatory response 

damages the lining of the colon, causing ulcers 

and bleeding. In some ways, this is similar to 

what happens with periodontal disease. Periodontal 

disease is a chronic inflammatory condition in the 

tissue around the teeth that ultimately leads to 

bone loss. It turns out that it is not so much the 

specific bacteria that cause the problem, but 

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rather how the immune system overreacts to those 

bacteria. 

Researchers have mapped the gut microbiomes of 

people with Crohn’s disease and ulcerative colitis 

and compared them to the gut microbiomes of 

healthy individuals. The assumptions were that 

there would be overgrowth of one or two specific 

pathogens for each type of IBD and that these 

pathogens would not be found in healthy people. 

In other words, one organism would theoretically 

be responsible for each disease. Instead, the 

researchers found a distinctive overall pattern for 

each condition in which certain combinations of 

bacteria would predominate. 7 

There appears to be 

a nonspecific disruption of the microbiome 

occurring that is saying something about the 

pathophysiology of the disease. Cracking the code 

that explains the pattern of the disruption may 

well lead to a cure for both forms of IBD. 

As a consequence of these findings, researchers 

are looking at the cause of many chronic diseases 

differently now, especially chronic inflammatory 

diseases. Perhaps we should always be thinking 

of IBD, autoimmune disease, cardiovascular 

disease, asthma, and allergies as the 

consequence of an imbalanced microbiome that, in 

one way or another, has led to a loss of immune 

tolerance. That is what systems biology is all 

about—instead of looking for one cause, systems 

biology recognizes that the imbalances that lead to 

disease are caused by the interaction of many 

factors—both endogenous and environmental. 

Obesity 

An interesting new discovery is that there is a 

relationship between the GI microflora and body 

weight, and that the balance of microbiota in the 

gut may be an important predictor of obesity. 8–11 

There are three major phyla of microbes that 

populate the gut (making up ~ 80% of total 

bacteria), which are Bacteroidetes, Firmicutes, and 

Actinobacteria. Jeffrey Gordon, MD, a molecular 

biologist at Washington University, initially 

determined that the gut flora of obese humans 

and obese mice have a lower percentage of 

Bacteroidetes (~ 5%) and relatively more 

Firmicutes, in contrast to lean individuals who had 

relatively more Bacteroidetes (~ 20%–30%) and 

fewer Firmicutes. In animal studies, Gordon and 

his colleagues (see Reference 8 for a study led 

by Ley) discovered that, if bacteria were taken 

from obese mice and put it into the intestinal tract 

of thin mice, the thin mice would become obese 

even though they continued to eat a regular diet. 

This is a very profound finding because in the 

past there has been a tendency to assume that a 

person becomes obese simply because of 

overeating. However, the real question is why 

does a person overeat? Perhaps the patient’s 

intestinal microecology has developed a microbial 

imbalance that disrupts the normal neurochemical 

feedback loops that control satiety. Or maybe he 

or she isn’t really eating that much more food 

than a lean person, but intestinal bacteria are 

metabolizing that food in a different way. 

Much of the research that followed the mice 

studies has been an attempt to figure out to what 

extent this difference in gut flora is a cause of 

obesity or a consequence of it. Gordon (in the 

study led by Ley) and others have postulated 

that Firmicutes bacteria possess a wider array of 

digestive enzymes that make them more efficient 

at extracting energy from food than Bacteroidetes, 

implying that higher concentrations of the former 

could lead to obesity even without increasing 

caloric intake. 10 

It does appear to be true that 

certain bacteria are better at metabolizing food 

than other types. Bacteria also have a direct 

influence on satiety with certain bacteria increasing 

the appetite and others decreasing it. 

When we say that obesity is “multigenerational” 

this may refer to the microbiome as much as it 

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refers to a lifestyle issue—if a mother is obese 

her child has more of a risk of being obese, 

because of inheriting her bacteria. This is an 

incredible realization. Of course, the major goal is 

to figure out whether there is a way to manipulate 

the gut flora (with probiotics or antibiotics or 

both) to alter a person’s energy metabolism. 

Although the answer is still up in the air, the 

possibility that we could “treat” obesity with 

bacteria is astounding! 

If a mother is obese, her child 

has more of a risk of being obese 

because of inheriting her bacteria. 

The Role of Probiotics in Disease 

If we can figure out how to manipulate these 

populations of microorganisms that take up 

residence in the human body, then we should 

theoretically be able to make a significant impact 

on the course of a disease. There are two ways 

we might achieve this: (1) alter the body’s 

response and (2) actually change a person’s 

microbiome, particularly in the GI tract. 

An example of the first strategy comes from a 

published study, in which researchers found a 

lower prevalence of periodontal disease in people 

who had a higher dietary intake of omega-3 fatty 

acids (docosahexaenoic acid [DHA] and 

eicosapentaenoic acid [EPA]). 12 

One proposed 

mechanism is that the omega-3 fats have a mild 

immunosuppressive or anti-inflammatory effect. 

This is an example of how dietary changes can 

modify the immune response to the microbiome 

(by improving tolerance) and thereby alter the 

course of a chronic disease. 

The second strategy represents the hope of 

probiotics as a therapeutic intervention. Research 

suggests that certain probiotics may induce DCs 

to mature down the tolerance pathway, with a 

resulting increased activity of toleragenic T-reg 

cells. Unfortunately, some of the new microbiome 

studies have actually pointed out the potential 

limitation of probiotic therapies. For instance, if a 

person with Crohn’s disease has a major 

imbalance in the trillions of bacteria that make up 

the microbiome, it is unlikely that simply throwing 

a few billion CFUs [colony-forming units] of a 

couple of strains of Lactobacilli or Bifidobacteria in 

the GI tract for a few months is going to correct 

the underlying problem. This may explain why 

many of the clinical studies using probiotics for 

Crohn’s disease have not shown much of an 

effect. In addition, these particular bacteria may 

not be as powerful for inducing tolerance as 

more-abundant commensal bacteria such as 

Bacteroides fragilis. 13 

This may help explain the 

high degree of variability and inconsistent 

effectiveness found in clinical studies of probiotic 

formulas. 

Interestingly, some of the best clinical results have 

not been obtained with more popular probiotics 

such as Bifidobacteria or Lactobacillus species, but 

rather with Saccharomyces boulardii, a type of 

nonpathogenic yeast that is not a normal denizen 

of the gut microbiome. 14 

Similarly, a nonpathogenic 

strain of E. coli (E. coli Nissle 1917) shows 

significant promise for treating ulcerative colitis. 15 

The good news about clinical studies of 

therapeutic probiotics for IBD is that they have an 

excellent safety record even if they don’t always 

work that well. 

Expecting probiotics to be an easy cure for 

chronic GI disorders (or other chronic diseases) 

is somewhat naïve. However, the concept 

continues to have merit. After all, the potential of 

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using therapeutic probiotics was based on decades 

of observation that people who eat yogurt, kefir, 

or other fermented foods tend to have healthier 

guts—and to be healthier in general. Instead of 

trying to “seed the clouds” by implanting the 

intestines with new strains of bacteria, a moreeffective 

strategy might be to cultivate the growth 

of bacteria that are already there. A considerable 

body of research suggests that prebiotics—shortchain 

fatty acids such as inulin and fructooligosaccharides 

(FOS)—can act like fertilizer to 

enhance the growth selectively of certain beneficial 

strains of bacteria. 

In contrast to the sometimes-mixed results seen 

with commercial probiotic products, fecal 

transplants (fecal bacteriotherapy) have been 

shown to have a very profound and lasting effect 

on gut flora. First pioneered by Thomas Borody, 16 

a gastroenterologist in Sydney, Australia, a number 

of centers around the world are now doing this to 

treat people with severe imbalances of flora. Most 

of the transplants have focused on people with 

refractory Clostridium difficile colitis. 

When C. difficile recurs (up to one third of 

cases) in patients or becomes resistant to 

vancomycin or metronidazole, there aren’t a lot of 

other treatment options. Some of these people are 

in dire straits, because they have become 

cachectic and debilitated from persistent chronic 

diarrhea. 

A number of published studies have reported 

profound recoveries from people who have had 

fecal transplants. 17,18 

These studies show that it is 

possible to take an extract of fecal material from 

a healthy person, process it minimally, and then 

put the organisms into the GI tract of another 

person (by nasogastric tube, colonoscopy, or 

enema) and produce a significant and long-lasting 

alteration of new host’s gut flora. Fecal transplants 

in these cases are being called, “human probiotic 

infusions.” Most of the transplants have been in 

people with clostridia, but this is also being done 

increasingly for people with IBD. In fact, Dr. 

Borody has published case studies of people with 

ulcerative colitis who have gone into permanent 

remission after getting fecal transplants. 16 

This evidence from fecal transplants validates the 

concept that we can introduce healthy bacteria in 

a diseased gut and manipulate that person’s 

microbiome for better health. It may be the mode 

of delivery that is important or the amount of 

probiotics or a particular strain that is important. 

Conclusion 

What we have learned about the human 

microbiome can be summarized in three main 

points: (1) the hygiene hypothesis provides a 

plausible theory as to why we are seeing an 

increase in allergies, asthma and certain 

autoimmune diseases in modern society: it is a 

result of “under-education” of our immune 

systems early in life; (2) a persistent disruption 

in the microbiome can lead to chronic 

inflammatory disease; and (3) we can alter the 

course of certain diseases by changing the 

composition of the microbiome or by altering our 

immunologic reaction to the microbiome 

(increasing or decreasing tolerance). 

One of the major implications of our new 

understanding of the relationship between humans 

and microbes is that the consequences of 

overprescribing antibiotics are turning out to be 

much worse than we realized. We really need to 

get serious about stopping the inappropriate 

overuse of antibiotics. 

Instead of chasing down every single outbreak of 

foodborne pathogenic E. coli or MRSA 

[methicillin-resistant Staphylococcus aureus] as if 

they were isolated events, we need to get to the 

real source of the problem, which is the routine 

addition of antibiotics to grain feed as a growth 

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stimulant. We need to follow Europe’s lead and 

stop this practice completely. 

The consequences of 

overprescribing antibiotics are 

turning out to be much worse than 

we realized. 

Prescribing antibiotics like candy is disrupting our 

patients’ microbiomes in ways that we never 

imagined, and makes a negative impact on human 

health. Even a recent review on the effects of 

helminths on the immune system and human 

microflora published in The New England Journal 

of Medicine, concludes with this statement: “We 

should therefore continue to advocate for a 

restrictive use of NSAIDs [nonsteroidal antiinflammatory 

drugs], antibiotics, and food additives 

that will disturb microflora.” 19 

Yes, indeed, all of 

these things may profoundly disrupt the microflora. 

We also need to improve our research protocols 

for studying the therapeutic effects of probiotics. 

We need further information about the effects of 

specific strains on specific diseases, and about 

optimal modes of delivery and dosages. We still 

don’t know the answer to the perennial question 

of how many CFUs of a particular probiotic 

formula a person needs to take to have a 

significant long-term impact on the gut microflora. 

Is it a million CFUs? Ten billion? One hundred 

trillion? To get the best results, does the person 

need to take the formula for a month? Six 

months? A year? 

I strongly believe that the general trend toward 

using probiotics in everyday life to maintain 

general gut health is a good thing; however, we 

need to get a lot better at determining how to 

appropriately prescribe probiotics for people who 

are ill. We have discovered a powerful principle, 

which is that the health of the body’s microflora 

is essential to life, and, when the microecology is 

disrupted or when a loss of tolerance occurs, we 

have to restore the body’s microfloral balance to 

prevent the development of chronic disease. 

Reprinted with permission from Rountree R. 

Roundoc Rx: The human microbiome—humans as 

super-organisms. Alternative and Complementary 

Therapies 2011;17(2):70–75. © Mary Ann 

Liebert, Inc., New Rochelle, NY 

(www.liebertpub.com) 

Robert Rountree received his medical degree from 

the University of North Carolina School of 

Medicine at Chapel Hill in 1980 after graduating 

Magna Cum Laude from the University of North 

Carolina at Greensboro in 1976. He 

subsequently completed a three-year residency in 

family and community medicine at the Milton S. 

Hershey Medical Center in Hershey, Pennsylvania, 

after which he was certified by the American 

Board of Family Practice. He is currently boardcertified 

by the American Board of Holistic 

Medicine. 

Early on in his studies, he became deeply 

interested in a “patient-centered” approach to 

health and healing. Instead of following rigid 

protocols prescribed for specific diseases, he 

focused on the unique biochemical and emotional 

needs of individuals. To that end, he has 

augmented his training with extensive postgraduate 

studies in nutritional and herbal 

pharmacology along with certification as a master 

practitioner of Neuro-Linguistic Programming. 

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Dr. Rountree has been providing his unique 

combination of traditional family medicine, nutrition, 

medical herbology, and mind-body therapy in 

Boulder, Colorado, since 1983. In January, 

2002, he opened Boulder Wellcare, a private 

practice specializing in individual healthcare 

consulting. He is the medical editor for Delicious! 

Living (Penton Publishing) and Clinical Editor as 

well as a regular columnist for Alternative and 

Complementary Therapies (Liebert Publishing). 

He is coauthor of seven books on Integrative and 

Nutritional Medicine: Clinical Botanical Medicine, 

2 nd Edition (Mary Ann Liebert, 2009), Clinical 

Natural Medicine Handbook (Mary Ann Liebert, 

2008), The New Breastfeeding Diet Plan 

(McGraw-Hill, 2006), Smart Medicine for a 

Healthier Child, 2 nd 

Edition (Avery Publishing, 

2003), A Natural Guide to Pregnancy and 

Postpartum Health (Avery, 2002), Immunotics: A 

Revolutionary Way to Fight Infection, Beat Chronic 

Illness and Stay Well (Putnam, 2000), and A 

Parent’s Guide to Medical Emergencies (Avery, 

1997). In addition, he wrote chapter 23, 

“Immune Imbalances and Inflammation,” in the 

Textbook of Functional Medicine (Institute for 

Functional Medicine, 2005), authored numerous 

chapters in The Herbal Drugstore (Rodale, 

2000) and is the featured subject of chapter 16 

in the book, An Alternative Medicine Definitive 

Guide to Cancer (Future Medicine, 1997). His 

articles have appeared regularly in Let’s Live and 

numerous other popular health magazines. 

Dr. Rountree is the Chief Medical Officer for 

Thorne Research, a nutraceutical company based 

in Dover, Idaho. He is a long-standing member of 

the core faculty and regular lecturer for the 

Applied Functional Medicine in Clinical Practice 

training and Advanced Practice Modules of the 

Institute for Functional Medicine in Gig Harbor, 

WA. In addition, he is a faculty member for the 

Fellowship in Anti-aging and Regenerative 

Medicine sponsored by the American Academy of 

Anti-Aging Medicine. He has lectured widely to 

professional audiences as well as the general 

public, and frequently appears on radio shows 

throughout the United States and Canada. In 

November, 2005, he was given the Healthcare 

Heroes Distinguished Service Award by the 

Boulder County Business Report, for his 

“dedicated, holistic, personal approach” to 

medicine. A Professional Member of the American 

Herbalists Guild, he is passionate about the 

outdoors and enjoys hiking, backpacking, mountain 

biking, sea kayaking, scuba diving, and world 

travel. 

References: 

1. Hooper LV, Gordon JI. Commensal host– 

bacterial relationships in the gut. Science 

2001;292:1115–1118. 

2. Koplin J, Allen K, Gurrin L, et al. Is 

caesarean delivery associated with sensitization to 

food allergens and IgE-mediated food allergy: A 

systematic review. Pediatr Allergy Immunol 

2008;19:682–687. 

3. Gill SR, Pop M, DeBoy RT, et al. 

Metagenomic analysis of the human distal gut 

microbiome. Science 2006;312:1355–1359. 

4. Zimmer C. How Microbes Defend and Define 

Us. New York Times, July 12, 2010. Online 

document at: 

www.nytimes.com/2010/07/13/science/13micro.h 

tml Accessed March 30, 2011. 

5. Rook GA, Stanford JL. Give us this day our 

daily germs. Immunol Today 1998;19:114–116. 

6. Harrison PF, Lederberg J, eds. Antimicrobial 

Resistance: Issues and Options. Workshop Report. 

Washington, DC: The National Academies Press, 

1998. 

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7. Swidsinski A, Loening-Baucke V, Vaneechoutte 

M, Doerffel Y. Active Crohn’s disease and 

ulcerative colitis can be specifically diagnosed and 

monitored based on the biostructure of the fecal 

flora. Inflamm Bowel Dis 2008;14:147–161. 

8. Ley R, Bäckhed F, Turnbaugh P, et al. 

Obesity alters gut microbial ecology. Proc Natl 

Acad Sci U S A 2005;102:11070–11075. 

9. Ley R, Turnbaugh P, Klein S, Gordon J. 

Microbial ecology: Human gut microbes associated 

with obesity. Nature 2006;444:1022–1023. 

17. Khoruts A, Dicksved J, Jansson JK, 

Sadowsky MJ. Changes in the composition of the 

human fecal microbiome after bacteriotherapy for 

recurrent Clostridium difficile—associated diarrhea. J 

Clin Gastroenterol 2010;44:354–360. 

18. Bakken JS. Fecal bacteriotherapy for recurrent 

Clostridium difficile infection. Anaerobe 

2009;15:285–289. 

19. Hoerauf A. Microflora, helminths, and the 

immune system—who controls whom? N Engl J 

Med 2010;363:1476–1478. 

10. McAllister EJ, Dhurandhar NV, Keith SW, et 

al. Ten putative contributors to the obesity 

epidemic. Crit Rev Food Sci Nutr 2009;49:868– 

913. 

11. Turnbaugh P, Ley R, Mahowald M, et al. An 

obesity-associated gut microbiome with increased 

capacity for energy harvest. Nature 

2006;444:1027–1031. 

12. Naqvi AZ, Buettner C, Phillips RS, et al. n- 

3 Fatty acids and periodontitis in US Adults. J 

Am Dietetic Assoc 2010;110;1669–1675. 

13. Fiocchi C. One commensal bacterial molecule 

—all we need for health? N Engl J Med 

2005;353:2078–2080. 

14. Guslandi M, Mezzi G, Sorghi M, Testoni PA. 

Saccharomyces boulardii in maintenance treatment 

of Crohn’s disease. Dig Dis Sci 2000;45:1462– 

1464. 

15. Schultz M. Clinical use of E. coli Nissle 

1917 in inflammatory bowel disease. Inflamm 

Bowel Dis 2008;14:1012–1018. 

16. Borody TJ, Warren EF, Leis S, et al. 

Treatment of ulcerative colitis using fecal 

bacteriotherapy. J Clin Gastroenterol 2003;37:42– 

47. 

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23 

Neurogenesis: 

Growing New Brain 

Cells 

David Perlmutter, MD, 

FACN, ABIHM 


2012 

On top of the finding that we can create new 

neural pathways into adulthood, a virtual revolution 

in neuroscience has been launched by the recent 

discovery of the process of neurogenesis, the 

ability of the brain to actually grow new neurons. 

Stem cell therapy, a hot button of political debate 

and the focus of leading-edge research, holds the 

promise of offering a powerful tool in 

neurodegenerative conditions. We now understand 

that the human brain is constantly undergoing its 

own “stem cell therapy” through the process of 

neurogenesis. Every moment of our lives, several 

critically important areas of our brains are being 

replenished with stem cells that are destined to 

become fully functional brain cells, and there’s a 

lot we can do to enhance this process. 

NEUROGENESIS IN ANIMALS AND HUMANS 

Because neurogenesis had been noted in various 

other animals, scientists in the 1990s were hard 

at it, trying to demonstrate that humans indeed 

retained the ability to grow new brain neurons. In 

1998, the journal Nature Medicine published a 

report by Swedish neurologist Peter Eriksson titled 

“Neurogenesis in the Adult Human Hippocampus.” 

Dr. Eriksson had finally succeeded in launching 

what was to become a revolutionary paradigm 

shift. 

As Sharon Begley remarked in Train Your Mind, 

Change Your Brain, “The discovery [of 

neurogenesis in the adult human brain] overturned 

generations of conventional wisdom in 

neuroscience. The human brain is not limited to 

the neurons it is born with, or even the neurons 

that fill it after the explosion of brain development 

in early childhood. New neurons are born well 

into the eighth decade of life. They migrate to 

structures where they weave themselves into 

existing brain circuitry and perhaps form the basis 

of new circuitry.” 1 

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Dr. Eriksson discovered that within each of our 

brains there exists a population of neural stem 

cells that are continually replenished and can 

differentiate into brain neurons. Simply stated, we 

are all experiencing brain stem cell therapy every 

moment of our lives, a concept that remains 

iconoclastic in a number of scientific circles. His 

Holiness the Dalai Lama has stated, “It is a 

fundamental Buddhist principle that the human 

mind has tremendous potential for transformation. 

Science, on the other hand, has, until recently, 

held to the convention not only that the brain is 

the seat and source of the mind but also that the 

brain and its structures are formed during infancy 

and change little thereafter.” 2 

The revelation that neurogenesis was occurring in 

humans and that we retain this ability throughout 

our lifetimes provided neuroscientists around the 

world with a fresh and exciting new reference 

point with implications spanning virtually the entire 

array of brain disorders. Alzheimer’s disease, 

characterized by a progressive loss of brain 

neurons, had long eluded researchers seeking to 

develop ways to slow the inexorable decline in 

cognitive function that so devastates patients and 

families. But with the idea of actually regenerating 

brain neurons, a new level of excitement and 

hope was raised in scientists who were dedicated 

to studying this and other neurodegenerative 

disorders. 

So, now that neurogenesis was proven to be 

ongoing in humans throughout our lifetimes, the 

question became clear: What influenced this 

activity? Moreover, what could be done to actually 

enhance this process? And the fundamentally 

important question: What can we do to grow new 

brain neurons? 

■ ■ ■ 

David: Journey into Neurogenesis 

During my college years, I had the opportunity to 

explore the brain using technology that was just in 

its infancy. It was in the early 1970s when the 

Swiss began to develop microscopes that could be 

used by neurosurgeons to perform delicate brain 

procedures. While this technology was evolving 

and eager surgeons in the United States were 

anxious to adopt this new approach to brain 

surgery, a problem soon became evident. Although 

learning to actually use the operating microscope 

was relatively easy, the neurosurgeons soon found 

they were becoming somewhat lost when it came 

to understanding the anatomy of the brain from 

this new microscopic perspective. 

I was 19 and just starting my junior year in 

college when I received a phone call from Albert 

Rhoton, chairman of the Department of 

Neurological Surgery at Shands Teaching Hospital 

in Gainesville, Florida. Dr. Rhoton was leading the 

way for the expansion of the use of the operating 

microscope in the United States and wanted to 

create the first anatomy text of the brain, as seen 

through the microscope, to better aid surgeons as 

they began to embrace this new technology. I had 

applied for the position of student researcher and 

was surprised and gratified when he invited me to 

spend the following summer studying and mapping 

the brain. It was from this research that we 

eventually published a series of research papers 

and book chapters that gave neurosurgeons the 

needed roadmap to more carefully operate on the 

brain. In addition to anatomy, we also had the 

opportunity to explore and develop other aspects 

of microneurosurgery, including developing 

innovative instruments and procedures. Spending 

so much time behind the microscope, I had 

become quite adept at manipulating and repairing 

extremely small blood vessels that, prior to the 

use of the microscope, would have been 

destroyed during brain operations, often with dire 

consequences. 

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Our lab had gained international recognition for its 

achievements in this new and exciting field and 

often attracted visiting professors from around the 

world. It was soon after a delegation of Spanish 

neurosurgeons had visited that I found myself 

accepting an invitation to continue my research at 

a prestigious hospital in Madrid, the Ramón y 

Cajal Center. Their microneurosurgery program 

was in its infancy, but their team was dedicated, 

and I felt honored to be assisting them in their 

groundwork efforts, especially in the work dealing 

with understanding the brain’s blood supply. 

The Spanish hospital was named to honor Nobel 

Laureate Santiago Ramón y Cajal (1852–1934), 

a great pioneer of neuroscience. Images of Dr. 

Ramón y Cajal were numerous in the hospital, 

and there was clearly a deep sense of pride 

among my Spanish colleagues that they could 

claim such an influential scientist as one of their 

own. 

During my visit to Madrid, I felt compelled to 

learn more about Dr. Ramón y Cajal and came to 

deeply respect his explorations of human brain 

anatomy and function. One of his major tenets 

held that brain neurons were unique compared to 

other cells of the body, not only because of their 

function but also because they lacked the ability 

to regenerate. Thus, the liver, for example, 

perpetually regenerates itself by growing new liver 

cells, and there is similar regeneration of cells in 

virtually all other tissues including skin, blood, 

bone, intestines, and so on. But not so with 

neurons in the brain—or so stated Dr. Ramón y 

Cajal. 

I admit that I was pretty well sold on his theory 

at the time, but I did wonder why it wouldn’t 

make sense for the brain to retain the ability to 

regenerate itself, to have the ability grow new 

brain neurons. After all, researchers at the 

Massachusetts Institute of Technology had shown 

a decade before that neurogenesis, the growth of 

new brain neurons, occurred throughout the entire 

lifetime in rats. 

Soon after I concluded my research in Spain, I 

was off to medical school at the University of 

Miami. And it was while learning histology, the 

microscopic study of tissues, that I realized how 

deeply entrenched in science was this notion that 

neurogenesis, while clearly defined in some 

animals, was not something that occurred in 

humans. 

This teaching never sat well with me, especially 

when I thought back to my college years when 

the idea that “every beer you drink destroys 

20,000 brain cells” was often kicked around late 

on a Friday night when surely more than that 

number had met their demise. 

■ ■ ■ 

BRAIN-DERIVED NEUROTROPHIC FACTOR 

(BDNF) 

A major component in this gift of neurogenesis— 

and it is a gift to be revered—is a protein called 

brain-derived neurotrophic factor (BDNF), which, 

as we read in previous chapters, plays a key role 

in creating new neurons. And it also protects 

existing neurons, helping to ensure their 

survivability while encouraging synapse formation— 

that is, the connection of one neuron to another— 

which is vital for thinking, learning, and higher 

levels of brain function. Studies have in fact 

demonstrated that BDNF levels are lower in 

Alzheimer’s patients, which is no surprise, given 

our current understanding of how BDNF works. 

But we gain an even greater appreciation for 

the health benefits of BDNF when we consider its 

association with other neurological conditions, 

including epilepsy, anorexia nervosa, depression, 

schizophrenia, and obsessive-compulsive disorder. 

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BDNF Activation 

We now have a very firm understanding of the 

factors that influence our DNA to produce BDNF. 

Fortunately, these factors are by and large under 

our direct control. Increasing your production of 

BDNF and thus increasing neurogenesis while 

adding protection to your existing brain neurons 

doesn’t require that you enroll in a research study 

to determine if some new laboratory-created 

compound will enhance BDNF production. The 

gene that turns on BDNF is activated by a variety 

of factors, including voluntary physical exercise— 

animals forced to exercise do not demonstrate this 

change—calorie reduction, intellectual stimulation, 

curcumin, and the omega-3 fat known as 

docosahexaenoic acid. 

This is a powerful message because all of these 

factors are within our grasp; they represent 

choices we can make to turn on the gene for 

neurogenesis. So let’s explore them individually. 

Physical Exercise: Laboratory rats that exercise 

have been shown to produce far more BDNF than 

sedentary animals. But, interestingly, animals 

forced to exercise produce considerably less BDNF 

than those who voluntarily choose to spend time 

on the running wheel. Researchers have shown 

that there is a direct relationship between 

elevation of BDNF levels in the voluntarily 

exercising animals and their ability to learn. 

With the understanding of the relationship of 

BDNF to exercise, researchers have examined the 

effect of physical exercise in humans, both 

apparently healthy individuals as well as persons 

at risk or already diagnosed with Alzheimer’s. The 

findings have been fairly remarkable. In a recent 

paper, Nicola Lautenschlager of the University of 

Western Australia found that elderly individuals 

who engaged in regular physical exercise for a 

24-week period demonstrated an astounding 

improvement of 1,800 percent in memory, 

language ability, attention, and other important 

cognitive functions, compared with an age-matched 

group not involved in the exercise program. The 

exercise group spent about 142 minutes 

exercising each week—about 20 minutes a day. 3 

In a similar study, Harvard researchers found a 

strong association between exercise and cognitive 

function in elderly women and concluded, “In this 

large, prospective study of older women, higher 

levels of long-term regular physical activity were 

strongly associated with higher levels of cognitive 

function and less cognitive decline. Specifically, the 

apparent cognitive benefits of greater physical 

activity were similar in extent to being about three 

years younger in age and were associated with a 

20% lower risk of cognitive impairment.” 4 

These and other studies clearly indicate that 

exercise enhances brain performance and is 

directly associated with increased production of 

BDNF. Simply by voluntarily engaging in regular 

physical exercise, even to a relatively moderate 

degree, you can actively take control of your 

mental destiny. 

Calorie Reduction: Another factor that turns on the 

gene for BDNF production is calorie reduction. 

Extensive studies have clearly demonstrated that 

when animals are fed a diet with reduced 

calories, typically by around 30 percent, their 

brain production of BDNF soars, along with a 

dramatic enhancement in memory and other 

cognitive functions. 

But it’s one thing to read research studies 

involving rats in an experimental laboratory and 

quite another to make recommendations to human 

patients based on animal research. Fortunately, 

studies that show the powerful effect of reducing 

caloric intake on brain function in humans are 

now appearing in some of the most well- 

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respected medical journals. 

In a 2009 study, German researchers imposed a 

30 percent calorie reduction on the diets of 

elderly individuals and compared their memory 

function with a group of a similar age who ate 

whatever they wanted. At the conclusion of the 

three-month study, those who ate without 

restriction experienced a small but clearly defined 

decline in memory function, while memory function 

in the group who consumed the calorie-reduced 

diet actually increased profoundly. In recognition of 

the obvious limitations of current pharmaceutical 

approaches to brain health, the authors concluded, 

“The present findings may help to develop new 

prevention and treatment strategies for maintaining 

cognitive health into old age.” 5 

What a concept. Preventive medicine for the 

brain. While the tenets of preventive medicine 

have seemingly taken hold in so many other 

areas of health care, from heart disease to breast 

cancer, for some reason the brain has always 

been left out. Gratefully, with these new research 

findings, that is changing. 

Further evidence supporting the role of calorie 

reduction to strengthen the brain and provide more 

resistance to degenerative disease comes from 

Mark P. Mattson at the National Institute on Aging 

Gerontology Research Center, who reports, 

“Epidemiological data suggest that individuals with 

a low calorie intake may have a reduced risk of 

stroke and neurodegenerative disorders. There is a 

strong correlation between per capita food 

consumption and risk for Alzheimer’s disease and 

stroke. Data from population-based case control 

studies showed that individuals with the lowest 

daily calorie intakes had the lowest risk of 

Alzheimer’s disease and Parkinson’s disease. In a 

population-based longitudinal prospective study of 

Nigerian families in which some members moved 

to the United States, it was shown that the 

incidence of Alzheimer’s disease among individuals 

living in the United States was increased 

compared to their relatives who remained in 

Nigeria.” 6 

The Nigerians who moved to the United States 

were obviously genetically the same as their 

relatives who remained in Nigeria. Only their 

environment changed. And this research clearly 

focused on the detrimental effects on brain health 

as a consequence of the increase in calorie 

consumption. 

While the prospect of reducing calorie intake by 

30 percent may seem daunting, consider that 

Americans now consume an average of 523 more 

calories daily than in 1970. Current United 

Nations estimates show that the average American 

adult consumes 3,770 calories each day. In 

contrast, most health-care professionals consider 

normal calorie consumption (i.e., the amount of 

calories needed to maintain body weight) to be 

around 2,000 calories daily for women and 

2,550 for men, obviously with higher or lower 

requirements depending on level of exercise. A 

30 percent reduction of calories from an average 

of 3,770 per day provides 2,640 calories, still 

more than a normal minimum requirement. 

Much of the calorie increase in Americans comes 

from our overwhelming increase in sugar 

consumption. The average American now eats and 

drinks an incredible 160 pounds of refined sugar 

each year, which represents a 25 percent 

increase in just the last three decades. This 

becomes particularly troubling in light of animal 

research done at UCLA showing a strong link 

between “the typical diet of most industrialized 

Western societies rich in saturated fat and refined 

sugar” and reduced BDNF levels and, as 

expected, correspondingly reduced memory 

function. 

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Lowering sugar intake alone might go a long way 

toward achieving a meaningful reduction in calorie 

consumption; weight loss would likely be a side 

benefit. Indeed, obesity, in and of itself, is 

associated with reduced levels of BDNF, as is 

elevated blood sugar, a common consequence of 

obesity. Furthermore, increasing BDNF provides 

the added benefit of actually reducing the appetite. 

We hope that this data and the desire to help 

your brain turn on BDNF production will motivate 

you to follow a reduced-calorie diet. But, if you 

want to do more, you can implement a program 

of intermittent fasting, which we will describe in 

Chapter 14. 

Intellectual Stimulation: BDNF is described as a 

neuronal trophic factor, which means that it is a 

chemical that induces positive growth, health, and 

functionality in the target tissue—in this case, brain 

neurons. So it would only make sense to expect 

BDNF to increase when the brain is challenged. 

Just as muscles will gain strength and thus 

functionality when exercised, the brain also rises 

to the challenges of intellectually stimulating 

circumstances by becoming faster and more 

efficient as well as having a greater capacity for 

information storage. 

These positive features are all facilitated by the 

increase in BDNF caused by stimulating activities. 

Inversely, it is likely that BDNF levels are low in 

individuals who spend several hours each day 

watching television, playing rote computer games, 

or otherwise engaged in mindless and passive 

activities. 

An agile mind is also a good deterrent to help us 

avoid debilitating diseases associated with old age. 

Mark Mattson suggests that agility education and 

linguistics are two ways to keep an active, 

functional mind. He states, “In regards to aging 

and age-related neurodegenerative disorders, the 

available data suggest that those behaviors that 

enhance dendritic complexity and synaptic plasticity 

also promote successful aging and decrease risk 

of neurodegenerative disorders. For example, there 

is an inverse relationship between educational 

level and risk for Alzheimer’s disease; people with 

more education have a lower risk. Protection 

against Alzheimer’s disease, and perhaps other 

age-related neurodegenerative disorders, likely 

begins during the first several decades of life, as 

is suggested by studies showing that individuals 

with the best linguistic abilities as young adults 

have a reduced risk for Alzheimer’s disease. Data 

from animal studies suggest that increased activity 

in neural circuits that results from intellectual 

activity stimulates the expression of genes that 

play a role in its neuroprotective effects. Levels of 

several different neurotrophic factors, including 

BDNF, are increased in the brains of animals 

maintained in complex environments, compared to 

animals maintained under usual housing 

conditions.” 7 

Being involved in stimulating mental activities—such 

as problem solving, exploring novel environments, 

and, perhaps most important, meditating regularly— 

enhances BDNF production and creates a brain 

that is not only more resistant to deterioration but 

one that enables you to push the limits of dayto-day 

functionality. In this context, it is important 

to view meditation not as a passive activity but as 

an active, brain-stimulating exercise. Even among 

Alzheimer’s patients, the rate of disease 

progression is dramatically slowed in those who 

engage in spiritual practices, which, again, is likely 

a consequence of increased BDNF. 8 

Meditation helps us visit the complex environment 

of the inner mind as well as the universal energy 

field. And, not surprisingly, this might well be the 

most powerful stimulant for BDNF production. 

Meditation-induced production of BDNF should be 

looked upon as the fertile ground into which 

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seeds of spirituality-induced enlightenment are 

planted and flourish. 

Curcumin: Curcumin, the main active ingredient in 

the spice turmeric, is currently the subject of 

intense scientific inquiry, especially as it relates to 

the brain. But curcumin isn’t new to the medical 

research. In fact, practitioners of traditional 

Chinese and Indian (Ayurvedic) medicine have 

used it for thousands of years. Curcumin is known 

to possess a variety of biochemical properties that 

include antioxidant, anti-inflammatory, antifungal, 

and antibacterial activities. 

But it is curcumin’s ability to increase BDNF that 

has attracted the interest of neuroscientists around 

the world. Interestingly, in evaluating villages in 

India, where turmeric is used in abundance in 

curried recipes, epidemiological studies have found 

that Alzheimer’s disease is only about 25 percent 

as common as in the United States. There is little 

doubt that the positive effects of enhanced BDNF 

production on brain neurons is at least part of the 

reason why those consuming curcumin are so 

resistant to this brain disorder. 

Curcumin activates the Nrf2 pathway, a recently 

discovered “genetic switch” that works by turning 

on the genes to produce a vast array of 

antioxidants that protect mitochondria. We will 

discuss this more in depth in the next chapter. 

This ultimately protects the source of divine 

feminine energy that permeates our physiology and 

fosters well-being. But credit for this knowledge is 

best given to the ancients who describe in the 

Vedic texts turmeric’s key role in cultivating 

relationships with the feminine form of divinity. 

In contrast, Western civilization is only now 

recognizing that the feminine life force, in the form 

of life-sustaining mitochondria, are the conduits 

through which the healing, nurturing, loving 

energies of the biosphere flow. Interestingly, only 

recently have we begun to suspect that these 

seemingly simple intracellular particles may actually 

be thought of as cellular manifestations of qualities 

that were once ascribed to the Greek goddess 

Aphrodite, the Hindu goddess Shakti, the Buddhist 

goddess Kuan Yin, and Christianity’s Mother Mary. 

With this knowledge, we become intimately 

connected with our history and rekindle our 

respect for the gift of feminine energy. 

Docosahexaenoic Acid (DHA): Perhaps no other 

brain nutrient is receiving as much attention lately 

as DHA. Scientists have been aggressively 

studying this critical brain fat for the past several 

decades for at least three reasons.   

First, more than two-thirds of the dry weight of 

the human brain is fat, and one quarter of that 

fat is DHA. From a structural point of view, DHA 

is an important building block for the membranes 

that surround brain cells. These membranes 

include the areas where one brain cell connects 

to another, the synapses. This means that DHA is 

involved in the transmission of information from 

one neuron to the next and thus is fundamental 

for efficient brain function. 

Second, DHA is one of nature’s important 

regulators of inflammation. Inflammation is 

responsible for a large number of brain maladies, 

including Alzheimer’s, Parkinson’s, attention deficit 

hyperactivity disorder (ADHD), and multiple 

sclerosis. DHA naturally reduces the activity of the 

COX-2 enzyme, which turns on the production of 

damaging chemical mediators of inflammation. This 

inhibits the enzyme and helps put out the fire in 

our brains. 

The third and perhaps most compelling reason for 

studying DHA is its role in modulating gene 

expression for the production of BDNF. Thus DHA 

helps orchestrate the production, synaptic 

connection, and viability of brain cells while 

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enhancing functionality. 

In a recently completed double-blind interventional 

trial called the Memory Improvement with DHA 

Study (MIDAS), some members of a group of 

485 healthy individuals with an average age 70 

and mild memory problems were given a 

supplement that contained DHA made from marine 

algae and some were given a placebo. After six 

months, not only did blood DHA levels double in 

the group who received the DHA but the effects 

on brain function, compared with those who 

received the placebo, were outstanding. The lead 

project researcher, Karin Yurko-Mauro, 

commented, “In our study, healthy people with 

memory complaints who took algal DHA capsules 

for six months had almost double the reduction in 

errors on a test that measures learning and 

memory performance versus those who took a 

placebo. . . . The benefit is roughly equivalent to 

having the learning and memory skills of someone 

three years younger.” 9 

Humans are able to synthesize DHA from a 

common dietary omega-3 fat, alpha-linolenic acid. 

But so little DHA is produced by this chemical 

pathway that many researchers in human nutrition 

now consider DHA to be an essential fatty acid, 

meaning that health maintenance requires a dietary 

source of this key nutrient. Data also show that 

most Americans typically consume an average of 

only 60 to 80 milligrams of DHA daily, less than 

25 percent of what researchers consider to be an 

adequate intake of 200 to 300 milligrams each 

day. 

BDNF and Brain Protection 

BDNF is important not only in neurogenesis and 

neuroplasticity but also in protecting delicate 

neurons from being damaged by a variety of 

insults, including trauma, transient reduction in 

blood supply, and, perhaps most important, 

environmental toxins. Indeed, in laboratory studies, 

rats and even primates with higher levels of 

BDNF are far more resistant to brain-damaging 

toxins than animals with low or normal levels. 

One important neurotoxin often used in laboratory 

animal experiments, especially those designed to 

evaluate the protective effectiveness of BDNF, 

goes by the abbreviation MPTP (which stands for 

its chemical designation). This neurotoxin has the 

relatively unique ability to specifically damage a 

part of the brain in humans, as well as in several 

animals, that is associated with Parkinson’s 

disease. Therefore, MPTP is often used to 

measure the possible benefits of pharmaceutical 

preparations to defend the brain against 

neurotoxins. But, unlike many other investigations 

that are developed in laboratories, the MPTP 

street story is far more intriguing. 

In the early 1980s, seven individuals ingested a 

street drug they thought was similar to heroin. 

Instead, due to an error in the illicit production of 

the heroin-like drug, the substance they took was 

contaminated with MPTP. Shortly thereafter, they 

were diagnosed with Parkinson’s. 

While this was devastating to these people, it 

opened the door for researchers to develop a 

powerful experimental model for the disease as 

described by neurologist J. William Langston in 

his book, The Case of the Frozen Addicts: 

Working at the Edge of the Mysteries of the 

Human Brain (1997), which later became the 

subject of two NOVA productions by the Public 

Broadcasting Service (PBS). 

Langston found that treating squirrel monkeys with 

MPTP caused almost immediate development of 

Parkinson’s, with damage to the animals’ brains 

occurring exactly in the same area as in humans 

with the disease. Subsequent experiments with 

other animals generated the same results. 

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Langston and others ultimately concluded that 

MPTP destroyed neurons by destroying their 

specific source of energy production, the 

mitochondria. Thus, MPTP proved to be a 

mitochondrial toxin specific for the area of the 

brain associated with Parkinson’s. 

Once it was discovered that MPTP selectively 

damaged mitochondrial function and produced 

Parkinson’s, researchers focused their efforts to 

learn how they could block the damaging effects 

of this neurotoxin and, presumably, by extension, 

reduce the damaging effects of pesticides in 

general. Various drugs were developed, including 

Deprenyl, that, at least in animals, held promise 

of providing some protection for mitochondrial 

function against toxins like MPTP. 

While human trials showed only modest benefit, 

the most dramatic neuronal protection against 

MPTP was not found in some extrinsic laboratoryproduced, 

patentable drug, but with BDNF, a 

substance already within our physiology, encoded 

in our own DNA, a gift not purveyed on a 

prescription pad but from nature. 

Study after study has since confirmed that BDNF 

provides almost complete protection of brain cells 

not only from MPTP but from a variety of other 

mitochondrial neurotoxins. And in many of the 

reports, the methods by which BDNF is increased 

also come naturally: increased physical exercise 

and calorie reduction. 

Thus, turning on BDNF production, through natural 

means and lifestyle decisions, provides our brains 

with powerful protection against the ubiquitous 

onslaught of mitochondrial toxins, such as 

commonly used pesticides, to which we are 

exposed on a daily basis. Obviously, choosing to 

eat organic foods is helpful, but we cannot totally 

eliminate our exposure to these dangerous and, 

yes, brain-damaging chemicals. 

Excerpt from Power Up Your Brain: The 

Neuroscience of Enlightenment © 2011 by David 

Perlmutter and Alberto Villoldo. Published by Hay 

House; available at www.hayhouse.com. Printed 

with permission. 

David Perlmutter is a Board-Certified Neurologist 

and Fellow of the American College of Nutrition 

who received his M.D. degree from the University 

of Miami School of Medicine where he was 

awarded the Leonard G. Rowntree Research 

Award. After completing residency training in 

Neurology, also at the University of Miami, Dr. 

Perlmutter entered private practice in Naples, 

Florida. Dr. Perlmutter is a frequent lecturer at 

symposia sponsored by such medical institutions 

as Columbia University, the University of Arizona, 

Scripps Institute, New York University, and 

Harvard University. He has contributed extensively 

to the world medical literature with publications 

appearing in The Journal of Neurosurgery, The 

Southern Medical Journal, Journal of Applied 

Nutrition, and Archives of Neurology. He is the 

author of: The Better Brain Book and Raise a 

Smarter Child By Kindergarten, and is recognized 

internationally as a leader in the field of nutritional 

influences in neurological disorders. Dr. Perlmutter 

has been interviewed on many nationally 

syndicated radio and television programs including 

20/20, Larry King Live, CNN, Fox News, Fox 

and Friends, The Today Show, Oprah, Dr. Oz, 

Montel Across America and The CBS Early Show. 

In 2002 Dr. Perlmutter was the recipient of the 

Linus Pauling Award for his innovative approaches 

to neurological disorders and in addition was 

awarded the Denham Harmon Award for his 

pioneering work in the application of free radical 

science to clinical medicine. He is the recipient of 

the 2006 National Nutritional Foods Association 

Clinician of the Year Award and was awarded the 

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2012 

2010 Humanitarian of the Year award from the 

American College of Nutrition on October, 2010. 

Contact David Perlmutter at 239-649-7400. 

Website: www.DrPerlmutter.com 

Alberto Villoldo has trained as a psychologist and 

medical anthropologist, and has studied the 

healing practices of the Amazon and the Andean 

shamans for more than 25 years. While an 

adjunct professor San Francisco State University, 

he founded the Biological Self-Regulation 

Laboratory to study how the mind creates 

psychosomatic health and disease. Convinced that 

the mind could create health, he left his laboratory 

and traveled to the Amazon to work with the 

medicine men and women of the rainforest and 

learn their healing methods and mythology. 

Dr. Villoldo directs The Four Winds Society, where 

he trains individuals in the U.S. and Europe in 

the practice of shamanic energy medicine. He is 

the founder of the Healing the Light Body School, 

which has campuses in New York, California, Park 

City, Australia, the UK, Sweden, Holland, and 

Germany. He currently directs the Four Winds 

Society in the USA and the Center for Energy 

Medicine in Chile, where he investigates and 

practices the neuroscience of enlightenment. 

Journal of the American Medical Association 

300, no. 9 (September 3, 2008):1027–37. 

4. Jennifer Weuve et al., “Physical Activity, 

Including Walking, and Cognitive Function in 

Older Women,” Journal of the American 

Medical Association 292, no. 12 (September 

22, 2004):1454–61. 

5. V. Witte et al., “Caloric Restriction Improves 

Memory in Elderly Humans,” Proceedings of 

the National Academy of Science 106, no. 

4 (January 27, 2009): 1255–60. 

6. Mark P. Mattson et al., “Prophylactic 

Activation of Neuroprotective Stress Response 

Pathways by Dietary and Behavioral 

Manipulations,” NeuroRx 1, no. 1 (January 

2004): 112. 

7. Ibid., 113. 

8. Yakir Kaufman et al., “Cognitive Decline in 

Alzheimer Disease: Impact of Spirituality, 

Religiosity, and QOL,” Neurology 68 (May 

2007): 1509–14. 

9. Karin Yurko-Mauro et al., “Results of the 

MIDAS Trial: Effects of Docosahexaenoic 

Acid on Physiological and Safety Parameters 

in Age-Related Cognitive Decline,” Alzheimer’s 

& Dementia 5, issue 4 (July 2009): 84. 

References: 

1. Begley, Train Your Mind, Change Your Brain, 

65. 

2. His Holiness the Dalai Lama, “Foreword,” 

ibid., vii–viii. 

3. Nicola Lautenschlager et al., “Effect of 

Physical Activity on Cognitive Function in 

Older Adults at Risk for Alzheimer’s Disease,” 

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24 

Functional 

Medicine and the 

Patient-Physician 

Relationship 

Keith Berndtson, 

MD 

2012 

“I remember lying there and watching an anthill 

for hours. I would watch them scurrying back and 

forth, carrying things, digging new tunnels, and 

finally it hit me: they are the things that are biting 

me.” 

- Jack Handey (from What I’d Say to the 

Martians) 

“The idea of autonomy denies that we are born 

into a world that existed prior to us… We are 

basically dependent beings: one upon another, 

and each on a world that is not of our making.” 

- Matthew B. Crawford (from Shop Class as 

Soulcraft) 

What is it about ants? We’re the geniuses, but 

you don’t see them flailing to contain their health 

care costs. If America’s health system were an 

anthill, and we laid around for decades watching 

how work got done, it would finally hit us: ants 

are better organized, and their bites don’t come 

out of our wallets. 

Societies succeed when their members can 

depend on each other. Businesses succeed when 

they make money by hook or by crook. Our 

health care system is increasingly dominated by 

corporate entities bent on maximizing their 

revenues. The system as a whole is torn between 

using best clinical practices to serve the health 

interests of people, and using best management 

practices to make hay while the sun shines. 

In his book on the relationship between education, 

work, and the virtuous life, political philosopher 

and motorcycle mechanic Matthew Crawford makes 

clear that along any path to human flourishing, 

our best thinking will fail us unless we turn it into 

ethically disciplined action. Of the classes of 

wisdom gathered by humankind, we should expect 

our best medical traditions to uphold an ethic that 

recognizes our dependence on the world and each 

other. 

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If we shine the philosopher-mechanic’s flashlight 

of truth over to our health system, we can see its 

deepest flaw: a physician workforce increasingly 

divorced from the mechanics of healing. 

In this essay, I contrast the modern doctor-patient 

relationship with the age-old ideal of a tradesman 

whose primary aim is to develop effective 

solutions at a fair and reasonable price. 

The covenant between physician and patient is 

more than a business relationship – it is a deeply 

personal and moral relationship whose success 

requires expertise, virtue, and, in many cases, 

protection from corporate models whose policies 

impede the mechanics of the healing process. 

The Mechanics of Healing 

Health is a state to be achieved. Wellness is a 

way of being and coping with life. In living 

systems, health and wellness are built on 

mechanisms that: 

1. Minimize the loss of functional integrity in 

the presence of disruptive forces. 

2. Avoid or escape disruptive tensions so 

healing systems can focus on repairing 

what’s been damaged, allowing function 

and balance can be restored. 

Wellness depends on coordinated fluctuations 

between phases of damage control and 

restoration. Balance within the system as a whole 

is served when the damage control and restoration 

teams have adequate resources and time to fully 

perform their roles. This is true whether the 

system as a whole is you, your family, your 

community, your society, or your planet. 

Medical students are good at doing what they’re 

trained to do. Because most are not trained to 

develop wellness promotion skills, most are not 

good at promoting wellness. They enter the 

profession with little exposure to the ways of wise 

self-care, which is unfortunate because wise selfcare 

is emerging as a biological and ethical 

imperative for all of humanity. 

Crawford concludes that an important part of living 

a dignified life of excellence in action is learning 

how to fix and maintain our stuff. This builds 

self-reliance in the art of maintenance and repair, 

and it builds expertise and skills that can be 

taught or shared – a capacity that is essential in 

a world whose interdependent systems and 

relationships define our wellness potential as a 

species. 

As health care costs continue to inflate beyond 

what social systems are able to withstand, and 

with health care results awash in mediocrity, it 

becomes especially important to learn how to fix 

and maintain the stuff you’re made of – the 

biophysical wetware, loaned to you by nature, that 

is your bodymind. 

Perhaps the creative force that brought nature into 

being acted so in order to evolve interdependent 

living systems, from which an intelligent race of 

creatures might achieve a position of dominance, 

rise to the occasion, and become faithful stewards 

of health and wellness within their sphere of 

influence. Should such a species emerge wise 

enough to organize its members around principles 

of health and wellness, its functional role in the 

cosmic order, and its noble destiny within the 

earthly scheme of living systems, would be 

fulfilled. 

If health and wellness are core issues for which 

humanity must seek wisdom in this turning point 

of a century, who are the experts to whom we 

should turn? For ages men and women have 

depended on physicians for advice on getting and 

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staying well. Now, when we need it most, our 

physicians are increasingly too busy fighting 

disease and insurance companies to give the 

subjects of health and wellness their due. 

Medical specialists focus on specific parts of the 

system rather than the system as whole. Their 

expertise is deep, but too narrow to serve as a 

foundation for wellness. It is the medical 

generalists – internists, pediatricians, and family 

physicians – who are trained to assess each 

person as whole. They are taught to view each 

patient as a unique being whose roles in life are 

linked to a family, a community, and a job (paid 

or unpaid), as someone whose health depends 

on interactions happening at biological, 

psychological, and social levels. 

In truth and practice, our primary care workhorses 

are allotted too little time to hone their integrative 

problem-solving skills. They’re caught up in 

business models that won’t grant them the space 

needed to fully engage the mechanics of healing. 

If healing requires restoring metabolic balance 

that’s been lost, the healer-mechanic’s first task 

is to construct your health narrative – the arc of 

episodes that describe how wellness was lost, 

starting from the time you last felt perfectly well. 

Rendered in this way, the healer-mechanic can 

scrub your health narrative for the clues behind 

the details, looking for patterns that point to when, 

how, and why given metabolic systems began 

losing functional integrity. The long arc of your 

history, along with a focused physical exam, will 

prompt recommendations for laboratory tests or 

diagnostic procedures whose purpose is to better 

clarify your health situation. 

The mechanics of healing often go awry at this 

step in the process. The healer-mechanic limits 

himself to testing and procedures whose results 

have reasonable potential to guide the care 

process. The professional churner, on the other 

hand, places the interest of his franchise ahead of 

your health needs. Your procedural workup is 

ethically compromised and economically skewed 

toward the overuse of diagnostic testing and of 

treatments that serve little purpose beyond 

boosting the churner’s bottom line. 

The goal of the healer-mechanic is to achieve a 

sufficiently rich understanding of what’s wrong in 

your individual case, and to accomplish this before 

jumping to a solution. Snap medical judgments 

contribute to the rising costs of managing chronic 

health problems. Under-evaluation is as expensive 

as over-treatment. 

Another cause for healing to go awry at this step 

the doctor who feels pressured to minimize 

malpractice risks no matter the cost. This results 

in a defensive style of medicine where decisions 

are made after a fast-forward imagining of how a 

plaintiff’s attorney will play your case to a jury. 

Ironically, the best way to lower the risk of 

malpractice is to practice like a healer-mechanic 

whose expertise and virtues aim for service 

excellence. 

The healer-mechanic’s assessment is integrative 

by nature, and it leads to an integrative care plan 

that addresses therapeutic lifestyle change, 

nutrition counseling, manual therapies, physical 

activity, stress management, the use of natural 

therapies and, when clinically warranted, 

medication or consultation with a specialist. 

As your integrative care plan unfolds, you and 

your physician monitor what progress you’re 

making toward your wellness goals. Using a 

systematic wellness support program to stay on 

track, you follow up with your physician or allied 

team members at scheduled intervals. Members 

of the team communicate and help analyze your 

observations about how you’re responding to your 

care plan, looking for dials to adjust in ways that 

will keep you moving ever closer to your wellness 

goals. 

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Most primary care physicians have no trouble 

endorsing this way of conceptualizing the 

mechanics of healing. The difficulty arises when 

they try to implement a method of practice 

focused on wellness when they’re already caught 

up in the chop shop pace of disease management 

interspersed with urgent health problems. 

Squeezed by the overhead it takes to offer their 

full basket of services, they are hard-pressed to 

offer a pace of service that does justice to the 

noble traditions of the healing trade. 

This is not what the medical student who chose 

primary care bargained for. As residents, they are 

quick to grasp that the whole person rhetoric of 

primary care is highly inconsistent with facts and 

reality on the ground. An assembly line mindset 

fouls the habitats within which primary care 

doctors are expected to advance the ecology of 

health and wellness. 

Within our primary care settings, from the smallest 

community storefronts to the most prestigious 

medical center office suites, you will find patients 

moving from place to place in search of wise 

clinical guidance. In these habitats you’ll also 

find families, communities, and businesses small 

and large wading through a swamp of rising 

health costs where, if the crocodiles don’t get 

them, the mosquitoes will. 

Exploring Our Wellness Habitats 

To survive, a species must either adapt to 

changing conditions within its habitat, or find a 

friendlier habitat. The species of medical 

professional known as the primary care physician 

is endangered because their habitats are under 

siege. These environments can defile the 

meaning of wellness. Too many patients, too 

much overhead, and working conditions that at 

times defile the meaning of wellness. 

Primary care refers to a health care source that 

serves as someone’s first point of contact with the 

health care system. In theory, primary care 

physicians evaluate and manage a wide scope of 

acute and chronic health problems; they offer 

periodic health evaluations and perform some early 

detection procedures; they provide some preventive 

counseling in bits and fragments, and they 

coordinate care in ways that address the health 

needs of the person as a whole, in the context of 

his or her family and community. 

This makes them too busy to deeply engage the 

art and science of healing. Time pressures limit 

primary care doctors to a checklist style of 

revolving door care. As a result, patients turn to 

other species of health care practitioner, in search 

of habitats more conducive to an in-depth, 

personalized approach to wellness. This is a boon 

to practitioners of complementary and alternative 

medicine, yet demand for primary care services 

will balloon as millions without health insurance 

gain access to health care as a result of health 

care reform. 

This creates demand for nurse practitioners and 

physician’s assistants, but it’s unclear how fast we 

can pump them into place when most states 

license these practitioners to provide billable 

medical services only under a physician’s 

supervision, and the primary care physician base, 

which has been shrinking for more than a decade, 

will take years to recover. 

Primary care doctors are outnumbered several 

thousand to one by patients needing primary care. 

With over thirty million new patients gaining 

access to care, overworked general internists, 

family physicians, and pediatricians will have to 

bar the doors or be swept away. Universal 

coverage does not equal universal access. 

Coverage does not equal cost-effective results. 

By necessity we’ll need to involve other species 

of community-based health practitioner in the 

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delivery of primary care. Nutritionists and dietitians, 

physical therapists, chiropractic physicians, 

naturopathic physicians, acupuncturists, and other 

health practitioners have for some decades now 

been delivering health services that overlap with 

primary care. 

What good alternative health practitioners generally 

lack is credibility within the wider medical 

community. The reasons are mainly political, and 

this is unfortunate because there are thousands of 

highly capable and professional alternative health 

practitioners standing ready to complement primary 

care and help accomplish a shift to a wellness 

paradigm. 

The people who become patients of alternative 

health practitioners are generally well satisfied with 

the process of care. In alternative health 

habitats, the pace of care is typically less hurried 

and it involves more active listening and closer 

follow-up than the primary care model. 

Whether alternative health outcomes are the same, 

better, or worse is not clear, but studies of 

several common chronic medical conditions indicate 

that less invasive, natural approaches are capable 

of producing as good or better results at a 

significantly lower cost compared to conventional 

care. 

Insurance coverage for alternative medicine 

services is spotty, but that hasn’t stopped 

American health care consumers from spending 

upwards of fifty billion on alternative health 

products and services each year. With proper 

coordination and legislative support, alternative 

health and primary care professionals could 

become key allies in an effort to create wellness 

habitats that work for the American people. 

So what are medical schools, residency programs, 

Congress, and health lobbies doing to shore up 

primary care and move the system toward 

wellness promotion? 

Not much. 

The Patient’s Dilemma 

Seen from one lens, the American health care 

system is an engine that runs one of American 

society’s most productive economic sectors. Seen 

from another, it is a system run amok, an 

operation where cost-shifting and organizational 

inefficiencies daily trump the interests of patients 

and their need for wise health counsel, while 

neglecting the interests of primary care doctors 

and their need for adequate time to assemble 

deep and clinically meaningful narrative 

understandings of what’s going on with each 

patient. 

And so a divide is forming between primary care 

doctors and their patients, formed by third-party 

pressures on the doctor-patient relationship. High 

intensity third party pressures on doctors are less 

than a generation old. They persist because they 

enhance profit margins for the third parties. 

The doctor-patient relationship is the core process 

by which humanity discovers paths to wellness. 

How can wellness operate as an organizing 

principle for our business and social institutions if 

we can’t make it an organizing principle for 

decisions made in the very rooms patients enter 

in search of health wisdom from their primary care 

doctors? Most primary care physicians are forced 

to scribble or tap and make judgments in a hurry 

in order to meet third party demands. This is the 

root of the patient’s dilemma. 

Health care now accounts for one of every six 

dollars Americans spend in a year and it’s 

projected to reach two bucks of every five within 

a few years. We’ throw more than $2.5 trillion a 

year at a “name the disease, name the drug for 

the disease” approach to chronic illness. If we 

want better clinical results at a lower cost, we 

have to get primary care teams and their patients 

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together on the side of developing wellness 

habitats that support the mechanics of healing. 

We’re spending too much money on unnecessary 

drugs and procedures and too little time attending 

to our personal health and wellness 

responsibilities, wondering when somebody is going 

to fix our health system. Meanwhile our food 

chain, our waters, our soils, and our air are filling 

up with hazardous molecules that have no 

business in our bodies, courtesy of an 

industrialized, materialistic way of life that is 

progressively toxic to the living systems upon 

which we depend. 

Our children are acquiring belly fat, allergies, 

asthma, attention deficits, and other health 

problems at record rates. Could their junk 

nutrition and toxic exposures be harming their 

metabolic integrity earlier in life than we’ve 

witnessed before? If so, our child health 

problems are early detection markers indicating 

that our technologies and consumer appetites are 

promoting biological dysfunction on an epic scale. 

The public has too few places to turn for wise 

medical guidance on what to do about these 

spreading environmental toxicities. 

Our bodies, our families, our workplaces, and our 

communities are being physically, chemically, and 

emotionally stressed out of metabolic balance. 

What force of inertia allows our overfed health 

sector to keep greasing its chin at the expense of 

the American people? 

The answer is the same force that would send 

our economy off a cliff by repackaging mortgage 

debt and selling it for ten times what it was 

worth; the same force that would split the 

relationship between doctor and patient into 

opposing sides because it helps a third party’s 

bottom line; the same force that would have us 

pretend that in our search for solutions to complex 

health problems, we have no obligation to engage 

in wise self-care or responsible stewardship of the 

Earth. 

There are no simple solutions for complex health 

problems. If metabolic systems are losing 

functional integrity, your health problems are 

complex, and they’re headed toward becoming 

chronic. When metabolic systems lose enough 

degrees of freedom for solving problems on their 

own, the system as a whole becomes chronically 

ill. Only in a tortured corporate logic is turn-style 

medicine a match our nation’s chronic illness 

burden. 

When you present to a new doctor with a 

multidimensional illness, you are typically met with 

the question, “What brings you in today?” 

Medical students are trained to open visits this 

way, as doing so is a polite way to invite the 

patient to describe what’s wrong. 

For the hurried doctor it’s a polite way to trap the 

patient into identifying the single issue that will be 

the topic of another rushed encounter – the doctor 

enters the room in hurry-up offense mode with a 

checklist of things to do that competes with your 

list of questions and your defensive abilities to get 

them answered. Third parties profit nicely on 

corrupted mechanics of healing. 

Chronically ill patients don’t have single issues. 

Navigating through the health care system to a 

wellness destination poses a major dilemma for 

those burdened with chronic illness. Though 

surrounded by doctors, they struggle to find a 

single one who possesses integrative expertise 

and whose practice design makes that expertise 

accessible. 

People with a chronic illness want a clinical 

problem solver who can resist jumping to solutions 

before fully understanding the problem. To fully 

understand the problems of chronic illness, a 

physician must get the patient’s whole story. 

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Getting stamped with a diagnosis is something far 

short of a deeply nuanced explanation for what 

went wrong and why. To move beyond diagnosis 

toward a working explanation of your chronic 

illness, wise health consumers settle for nothing 

less than a clinical problem solver who wants to 

hear your story from the beginning. 

Your health narrative contains essential clues that 

help integrative problem solvers better understand 

what might be done to restore and maintain the 

functional integrity of your system as a whole. 

Proper treatment and monitoring of chronic health 

problems cannot be shoehorned into bite-sized, 

widely spaced visits. With each trip to the office, 

your goal, as the owner of a chronic health 

problem, is to help your doctor or health 

practitioner extract a clinical impression that has 

some power to explain the root dynamics of your 

illness. A healer-mechanic will settle for nothing 

less than the best possible working explanation for 

why you became ill. 

Where chronic illness is concerned, you and your 

doctor or health practitioner should come to 

reasonable agreement about your wellness goals, 

and about being accountable to each other in 

your efforts to reach them. Expect a few ups 

and downs as the care process unfolds. Lost 

prescriptions, phone delays, missed appointments, 

lab errors – a myriad of frustrations can stress 

the relationship. 

Remember that you may not be the only one who 

gets worn down by your complex health problems 

– especially when you are unwilling to hold up 

your end of the bargain by changing the way you 

live, and perhaps the way you interact with your 

doctor. Since therapeutic lifestyle change is the 

foundation of nearly every integrative care plan, 

your job is to engage the task of making healthy 

lifestyle changes. 

Natural therapies, including the targeted use of 

dietary supplements, often play a role in 

systematic efforts to achieve wellness goals. There 

are times when prescription drugs are warranted. 

When that’s the case, you should feel confident 

that the prescription was needed because it fit an 

explanation of what’s going on and what ought to 

be done about it, not because the doctor made a 

default judgment to avoid running behind. 

It takes a doctor roughly thirty seconds to write or 

transmit a prescription, where it might take thirty 

minutes to explore the nuances of your illness 

and discuss what lifestyle changes and natural 

therapies might do to help your metabolic systems 

perform better as a team. For doctors in a hurry, 

prescription drugs have a way of winning by 

default. The cost curve bends ever upward. 

Accepting responsibility for the lifestyle changes 

that wellness requires means changing certain 

behaviors. Wise health consumers must not only 

understand the pressures facing primary care 

doctors – they must develop the skills needed to 

obtain quality clinical assessments and care plans. 

Since medical professionals are often too busy or 

too strapped to provide systematic wellness 

support, health consumers are often left to their 

own devices. Options here include finding the 

right online or community-based wellness support 

system. 

The truth is, most doctors have plenty of wisdom 

to share – accessing this wisdom is the problem. 

The Doctor's Dilemma 

Surveys in the United States and elsewhere 

indicate that three out of four doctors now 

discourage their children from entering a career in 

medicine. In 2008, only two percent of internal 

medicine residents chose to practice general 

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internal medicine. The other ninety-eight chose 

to become medical specialists. 

The reason for this plummeting interest in primary 

care medicine as a career path is clear. Medical 

students and residents see many primary care 

doctors scrambling to survive their decisions to 

attempt satisfying careers in the primary care 

trenches. The primary care doctor’s dilemma is 

figuring out how to acquire the mindset and 

secure the practice systems needed to thoroughly 

assess which of your metabolic systems are losing 

functional integrity and why. 

In the medical professional food chain, generalists 

are bottom feeders. The pay is low and the 

prestige is lower. Primary care doctors work as 

hard as most specialists but for considerably less 

reward. For many patients, the primary care 

experience is like being rushed through your 

dinner so more patrons can be seated. 

The operational complexity of a typical primary 

care business far exceeds that of most specialty 

or hospital-based practices. Primary care 

practices generate more un-reimbursed work 

requests than any medical business known to 

man. 

A typical day may entail a dozen or two phone 

calls and emails (a few marked urgent), requests 

for a letter of medical necessity or referral, 

responses to faxed prescription refills and calls 

from pharmacists about prescription denials, a trail 

of voice and emails, and a stack of preauthorization 

forms for pills or procedures – 

poured on top of a brimming schedule in which 

each patient expects 100 percent of the doctor’s 

attention, an extra few minutes for questions, and 

no errors. 

Problems directly related to a specialist’s care 

often fall into the lap of a primary care doctor 

when, despite bad outcomes, the specialist 

concludes that his work is done. To prevent their 

primary care operations from falling apart, practice 

managers hire support staff to keep up with the 

un-reimbursed workload, subtracting the cost of 

added help from the doctors’ pay. 

There are also billing and collection costs to 

absorb. Insurance company denials and 

underpayments create a drag on the month-tomonth 

viability of many medical practices – and 

not just primary care. The documentation, coding, 

and billing requirements of each payer differ and 

their rules can change at any time. 

Consumer-driven high deductible health plans and 

health reimbursement accounts force primary care 

doctors to become collections specialists; their staff 

make calls and pull teeth to sort out how much a 

patient owes when, with the practice absorbing the 

costs of delay. Practices slow to adapt to this 

change alone have gone belly up. 

These pressures give many primary care doctors 

little choice but to adopt an assembly line style of 

care. A group may decide to pick up an already 

frenetic pace and become like a restaurant whose 

goal is to turn as many tables as possible. If 

the practice continues to operate in the red, it 

may consult a practice management expert. A 

few weeks and a few grand later, a report 

appears exhorting the doctors to “see more 

patients.” 

Another dilemma for the primary care doctor is 

figuring out how to get rewarded for delivering a 

personalized, in-depth approach to the evaluation 

and management of chronic health problems. 

Changing insurance reimbursement rules so 

primary care doctors get paid not by the duration 

of the visit, but by the medical conditions 

addressed during the visit, would be a more 

rational and socially cost-effective way to reward 

them for their expertise and service. 

Let’s say you have hypertension, joint pains, 

insomnia, and an irritable bowel. If your primary 

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care doctor tries to manage them all in a fifteenminute 

visit, each problem is likely to get 

shortchanged. 

If she takes the time needed to do a thorough 

job, she’ll risk running behind, adding to her 

stress. If she schedules patients like you for 

forty-five minutes, she’ll make less money 

because two forty-five minute visits don’t yield as 

much insurance payment as six fifteen-minute 

visits – even though the total time spent on care 

is 90 minutes. From a medical practice 

management perspective, volume trumps value. 

In many cases the busy primary care doctor will 

opt to refer to specialists for no other reason than 

she doesn’t have time to manage your multiple 

problems and she doesn’t want you to feel 

shortchanged. She’d take the time needed to 

address your concerns one by one if insurance 

companies paid her a separate fee for addressing 

each of your four problems. 

The insurance company would save big money by 

preventing unnecessary referrals. Your doctor 

would see fewer patients in a day. Medical 

students might even become more interested in 

the field of primary care. Even with such healthy 

logic behind policy proposals like these, as our 

health care reform slugfest demonstrates, once 

cash flow channels are cut into the health system 

terrain, they’re very hard to change. 

A little empathy for the exasperation that primary 

care generalists are feeling can help the wise 

health consumer get more than an extra minute or 

two – it’ll reinforce for your doctor why you 

deserve intense focus even on a bad day. 

The sad truth is that most primary care doctors 

are wise generalists whose wisdom is inaudible in 

the breathless hamster wheel settings that primary 

care habitats have become. Empathy is an 

important form of reward for the harried but caring 

doctor. 

Like all doctors, primary care doctors have to 

meet continuing education requirements to remain 

credentialed with their hospitals and health plans. 

Yet much of this education reinforces a “name 

the disease, name the drug for the disease” 

practice routine. Though integrative medicine 

education is making some headway, primary care 

physicians typically must go out of their way to 

find it. 

Perhaps the biggest challenge faced by today’s 

primary care doctors is figuring out how to avoid 

burnout. Imagine what will happen as the wise 

old generalists retire just as the twenty-year long, 

75 million strong Boomer contingent hits the 

system demanding nuanced medical opinions for 

everything from heart disease to hangnail. 

If Americans who’ve been neglecting their chronic 

health problems are able to get health insurance 

coverage, it will release a torrent of pent-up 

demand for primary care – a surefire recipe for 

burnout. 

To shore up the primary care fleet’s ability to 

handle this pent-up demand in a cost-effective 

way, primary care practice models should be 

exploring ways to incorporate an integrative 

medicine approach that uses allied health 

practitioners to support a wellness model for the 

prevention and care of chronic illness. 

In February 2009, a group of integrative and 

functional medicine dignitaries including Mehmet 

Oz, MD, Dean Ornish, MD, Andrew Weil, MD, 

Mark Hyman, MD, and Jeffrey Bland, PhD, met 

with members of the Institute of Medicine, 

Congress, and the White House, where they 

made a compelling case for promoting a more 

personalized, integrative, science-based, wellnessoriented, 

results-driven approach to health care. 

They made a compelling case for an integrative, 

functional approach to health and wellness 

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If the health care sector resists, we’ll have to 

wonder what forces are preventing integrative 

medicine from helping primary care groups 

compete for patients in mainstream medical 

habitats. Pity the front line generalists for the 

pounding they will take if health care reform 

unfolds without sending them integrative medical 

reinforcements. 

Whatever desire they’ll have to deliver integrative 

care to whole persons is going to be swept aside 

by the public’s need for at least a few minutes of 

access to an overworked primary care provider 

every few months. Perhaps access to a harried, 

impersonal, checklist style of gatekeeper medicine 

is better than no access at all, but we can do 

better. 

Finding a Path to Wellness 

That we depend on a world that is not of our 

own making is no small point. Any discussion of 

health and wellness, or of expertise and virtue, 

must begin with the plain fact that some creative 

force acted first upon us, and that no matter how 

self-reliant we become, we remain dependent on 

each other and the living systems of the Earth. 

The entirety of our non-fictional experience of the 

world exists in a fairly specific physical and 

historical context: 

Some ten billion years after the universe 

began under mysterious circumstances, selfreproducing 

living systems began jockeying for 

habitat on this planet. These habitats are now 

being fouled or destroyed in businesslike 

fashion by humanity. As the Earth’s living 

systems tangle with our toxic industrial 

presence, humanity is bulldozing its way into 

the future with no apparent aim and with no 

effective means by which to discern and fulfill 

a unified sense of its functional purpose in 

the cosmic order. 

Natural history is a tale about species and their 

various quests to find wellness and generational 

longevity within some kind of habitat. Most of the 

Earth is now our habitat. Though we dominate 

the world of living systems, we have yet to fully 

grasp the meaning of wellness as a healthy 

interdependence of widely connected systems. 

When the implications of what wellness requires of 

us are finally understood, we will begin to discern 

humanity’s functional purpose in the unfolding 

history of life on Earth. Only when we decide to 

make health, wellness, and ethics matter will we 

possess the wherewithal to fulfill our higher 

purpose – at home, at work, at leisure, and within 

the emerging cosmic order. 

To find its path to wellness, humanity needs to 

close a few divides. The divide between doctors 

and patients is emblematic of the divide between 

humanity’s industrialized, materialistically skewed 

relationship to the world, and the wellness we 

seek. But it is not the only divide in need of 

repair. 

Congress cannot legislate root cause solutions to 

the root level problems in our health care sector. 

What’s needed is an alliance of wise health 

consumers able to use their collective economic 

leverage to make health, wellness, and ethics 

matter in our national life, and in our globalizing 

world. The days where entrenched special 

interests and cost-shifters have the field to 

themselves must come to an end. Only by 

rewarding health value creators based on their 

results will wisdom and wellness prevail. 

Our society needs a new health care game plan 

– one that nourishes, cultivates, and grows more 

sources of bodymind wisdom – more communitybased 

medical homes where an integrative clinical 

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mindset can flourish in a habitat fenced off from 

the business and bureaucratic mentalities that 

corrupt the mechanics of healing. Only then can 

we create a health system that delivers more 

wellness at less cost. 

We can start by supporting new forms of strategic 

partnership between primary care, integrative 

medicine, and the best talent in the alternative 

health community. This will help create new 

community-based networks where primary care 

and wellness support systems are fully aligned. 

The fight for health and wellness is not just about 

the doctor-patient relationship – it’s about the 

health of living systems and fate of future 

generations. If the principles of metabolic balance 

that balance damage control and restoration in 

biological systems don’t begin to operate in the 

cultural, political, economic, and environmental 

dimensions of our lives, our legacy for future 

generations will be that we sat and watched as 

our presence became the driving source of 

inflammation and decay in the world. 

As you learn more about how your metabolic 

systems work together to make health possible, a 

bigger picture begins to emerge. In this picture 

you’ll see how the principles of metabolic balance 

that operate within you are the same principles 

that can underwrite global health, security, and 

prosperity. 

and functional medicine traditions. He uses this 

experience to explore the wider implications of a 

clinical systems biology approach to wellness. 

His medical practice, Park Ridge MultiMed, uses 

functional medicine principles to evaluate and treat 

patients with medically unexplained and nonresponsive 

forms of chronic illness. 

Berndtson founded onebodymind.com to supply 

innovative online tools for people interested in a 

deeper, more effective approach to health 

education, self-care support, and the stewardship 

of living systems. The website is also ground zero 

for a social network that will help prepare the way 

for the modern quest for health and sustainability. 

References: 

Handey, Jack. (2008) What I’d Say to the 

Martians, and Other Veiled Threats. Hyperion: 

New York. 

Crawford, Matthew. (2010). Shop Class as 

Soulcraft. Penguin: New York. 

Never has it been so necessary, or so possible, 

for people to pool their efforts to seek wisdom, 

value health, integrate, and aim higher. 

Keith Berndtson practices integrative medicine in 

Park Ridge, Illinois. In 1996, after ten years in 

family medicine and corporate health, he chose a 

road less traveled. On this road he came to 

realize the wisdom and value of the integrative 

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Mending the Mind- 

Body Connection 

for Better Health 

Susan Allen, RD, 

CCN 

The integrative or functional medical professional 

appreciates the value of a dive-deep and go-broad 

approach to patient care. Unlike their traditional 

medicine counterparts, who rush their patients into 

sticking only to the ‘problem of the day’, these 

doctors actually encourage their patients to tell the 

whole story. This paradigm shift towards more 

comprehensive, patient-centered care is a breath of 

fresh air. 

This section is written for these dive-deep and gobroad 

practitioners. The ones with fierce integrity; 

the ones who recognize the tremendous worth 

brought to their patients when they care enough to 

go against the insurance-mandated medical model. 

These practitioners are known by their first hallmark 

question, “When was the last time you felt perfectly 

well?” 

Indeed, these are the healers who utilize a broader 

assessment process and sometimes unconventional 

means to treat the chronically ill. In many cases, 

they are more successful than their traditional 

medicine counterparts and often with less chemical 

and radiographic assault, resulting in fewer side 

effects. These doctors accept that nutritional status 

and toxic burden have a much stronger role in 

health and chronic disease and make this a large 

part of what is addressed in their patient care 

model. 

We all know stress is connected to health. 

However, this may be the one area not addressed 

deeply or fully enough by practitioners. The missing 

piece, or at least underutilized in many settings, is 

the ability of the practitioner to tap into the power 

of the mind-body connection where stress hits 

hardest; to identify, and when necessary, mend the 

broken bond that many individuals have in this area. 

The purpose of this article is to focus on this 

missing piece and to better position practitioners to 

help overturn patient roadblocks in the healing 

process. It will examine a different approach than 

just looking at the physical manifestations of 

symptoms. Instead, this article will discuss the 

often underestimated, under-addressed, ever 

intertwining, and seemingly infinite emotional and 

spiritual roadblocks to better health. 

The mind-body-spirit connection is probably the 

most misunderstood and undervalued piece of the 

patient care model that can have the most profound 

effect when fully explored. Unfortunately, for many, 

this connection is addressed simply by a possible 

2012 

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referral to the psychotherapist and probably a 

prescription. Yes, of course, therapy and 

psychotherapeutic medications certainly have their 

role. It just seems that there is hardly any 

meaningful attention paid to the connection between 

emotional and physical health by health practitioners. 

Mind you, I do not profess to have a specialty in 

psychology. However, I am pretty intuitive and 

have many personal and professional experiences 

that have shaped my thoughts and recommendations 

you will read here. I consider it a responsibility of 

the integrative or functional medicine professional to 

shine this light of awareness into their patient care 

model. It is a necessary part of a patient’s “whole 

story” encouraged with a deep-drive approach. I 

also think nutritionists are well placed to explore this 

category as we typically have more time with 

patients — and just one reason (of many) why I 

believe all MDs should work in tandem with a 

nutritionist. 

Of course, as a professional, you must stay within 

your comfort level and give out referrals as needed. 

However, if you at least take the time to have a 

better understanding of the mind-body-spirit 

connection, you will have a greater awareness of 

possible disconnects that have led to roadblocks that 

you may be able to help overturn. 

The assessment process is your tool to discover 

more information for this task. Questions you might 

ask, either orally or on a written questionnaire, 

should cover subjects like happiness/satisfaction 

levels of work and relationships (love, social and 

family). Ask about stress levels, now and in the 

past, such as moving or a divorce. Ask about 

previous or current emotional traumas or losses, like 

the death of a loved one or a business failure. 

These are all areas where you may find potential 

connections and better understand how and why 

roadblocks are created. 

Sometimes, your role will only be to introduce the 

concept of the possible connection. Remember to 

only operate at your comfort level. If you sense 

deep or more comprehensive work needs to be 

done, you certainly must refer out. 

For the remainder of this read, I will detail 

connections for your awareness and discuss those 

places where you may be able to help overturn the 

roadblocks. These are basics that almost anyone 

can try. You may recommend your patient read a 

particular book. You may refer out for 

psychotherapy, and, if you think it may be related 

to an energy block, enlist someone who does 

clearing or other spiritual or energy practices to 

assist in the case. Bear in mind though, your work 

has only just begun. There is much you can do as 

a practitioner throughout the process. It is key to 

understand how roadblocks are created and how to 

break them down. 

Roadblocks to Better Health 

While roadblocks created by patients can make our 

job a little harder, it is almost never impossible to 

help our patients break through to relief and 

ultimately better health. People are often quite 

unconscious about their responsibility for these 

roadblocks, at least at first. It is important to 

understand that roadblocks are often created out of 

fear. (1) 

As these roadblocks are influenced by outside and 

by deep inner stresses, this article addresses what I 

consider to be the top seven roadblocks: 

1. Addiction and self-defeating behavior 

2. Negative thinking 

3. Judgment of others 

4. Self-judgment, low self-esteem, blocking 

happiness and joy 

5. Inability to forgive, guilt, and shame 

6. Stuck in the past, worry of the future, 

unable to be “in the now” 

7. Isolation, lack of faith, or spiritual 

disconnection 

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When referring to the roadblocks, there is some 

overlap. Nevertheless, they are all significant. 

Along the way you’ll see interjected various 

suggestions on “what can you do to help your 

patient,” while the last section of this chapter will 

detail more of “what your patients can do to help 

themselves.” 

Roadblock 1: Addiction and Self-defeating Behavior 

One of the most complex roadblocks, because it 

involves so many other roadblocks, is addiction. 

This can include addiction to alcohol, drugs, food, 

shopping, gambling, etc. Why is it so easy for 

some to succumb to an addiction while others are 

resistant? Is it a lack of coping skills, a nutritional 

deficiency, a chakra energy block, a neurochemical 

imbalance, or all of the above? 

Many health care professionals and much of the 

general population have a poor understanding of 

addiction. There tends to be a stigma associated 

with it. Whether it be destitute, rock-bottom, 

weak, illegal, or demoralizing, this stigma seems to 

further perpetuate an addict’s behavior through their 

own self-loathing. Unfortunately, these days the 

sole solution lies too often in an abstinence 

program or a prescription rather than our having to 

cope or find solutions to our problems. In essence, 

it’s really not even the addiction that is the core of 

the problem; the addiction is only the manifestation 

of something else going on. 

Addictive behaviors relieve the pain of suffering. 

Yes, it can be as straight-forward as an addiction 

to pain killers to block agonizing physical pain, 

however for others the high they experience is a 

momentary relief for the healing of separation, 

either from someone or something physical but 

often from their very source or higher power. For 

some, the momentary experience of not being 

afraid, euphoria, or a sense of well-being is a 

glimpse of what is actually their true being and 

they keep going back to addictions to try to 

recreate that connection that they can’t seem to 

get on their own. 

For others, it is their way of escaping worry and 

anxiety — often because they don't know how to 

be in the now. In the now moment, there is 

nothing wrong. All is well. But this is unfathomable 

for many people. We can do our patients a big 

favor by helping them try not to feel guilty about 

leaving their worry behind. Still for others, addictive 

behaviors are a way of having control when they 

otherwise feel a lack thereof. We see this often 

with eating disorders and hoarders. (2) 

Whatever the case, if the core of the addiction is 

not addressed, we are doing the patient a 

disservice. Time and time again, one additive 

behavior is simply replaced with another. Alcoholics 

turn to caffeine and sugar; as do smokers. The 

point is the answer does not lie merely in 

abstinence. The sooner we realize it, the quicker 

our patients can experience real freedom! (3) 

True recovery from an addictive behavior or 

unhealthy coping behaviors requires work on many 

levels including changing how one thinks. This is 

why psychotherapy can play a crucial role. Yes, 

abstinence is necessary until a cycle is broken. My 

dietitian colleagues often say, ‘Everything in 

moderation,’ and while I agree with this in the long 

run, it rarely works when an addictive habit needs 

to be changed. For example, we don’t always think 

of sugar as a true addiction but sugar can elicit 

the same dopamine response as cocaine. We know 

you can’t just have a little bit of cocaine and still 

break an addiction! 

Indeed, the addictive substance or habit needs to 

be blocked or abstained from as much as possible. 

We can aid the patient through withdrawal in any 

way we can but the real work begins from there. 

Addressing psychological factors and other 

roadblocks such as self-esteem issues and spiritual 

disconnectedness are key. Chakra clearing, 

acupuncture and other energy work may be quite 

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helpful. Likewise, assessing neurotransmitter 

imbalances and the physical stress response can 

also add a powerful component to success. Without 

this behind-the-scenes work, the root of addiction 

is not fully addressed and relapse rates skyrocket. 

Teri’s story 

Teri was tired, not sleeping well, overweight, 

anxious, depressed, unmotivated to change, yet at 

the same time desperate for relief. She was caught 

in a vicious cycle of over-eating, with a definite 

sugar addiction, and bouts of over-drinking. She 

was easily intimidated and seemed to lack 

confidence or sense of self. She also had many 

digestive issues although nothing remarkable or 

specific came from GI and gluten testing. She did 

have a few food sensitivities. However, avoidance 

only made a small dent in her symptoms. I’ve 

seen this before. No amount of my nutritional 

counseling would be effective if she was 

unmotivated to actually implement the behavior and 

diet changes I’d recommend. She would try but 

her attempts would ultimately fail. This just served 

to put her in a deeper hole of despair. 

Keep in mind, Teri had plenty of psychological 

counseling and medications prescribed. In fact, she 

came to us with a list that had built up over time, 

which included Welbutrin, Zoloft, Lamictal, 

Gabapentin, and Klonipin. In the end, this 

treatment plan bought her almost nothing as it had 

her numb to some degree. Interestingly, these 

drugs made her quite anxious at the same time. 

She was most certainly frustrated by her lack of 

progress and stuck in the same symptom set year 

after year. Furthermore, she felt shame for not 

being able to take care of herself and for being on 

all the medications. This only deepened her lack 

of self-esteem. There was clearly still a hidden, 

missing piece that kept her stuck. 

It was time to call awareness to a possible 

disconnect, or block, that may have explained 

some of Teri’s symptoms. When exploring her 

history, she told us the last time she felt like 

herself — pre-medication — was about age 10 or 

11. However, this was also a difficult time in her 

life. She remembered wanting strongly to dance 

ballet but she started late in the game. Therefore, 

her desire was squashed by her teacher who told 

her that she would never really excel considering 

her late start. Even her friends, already in dance 

for years, mostly agreed with the teacher. Her 

parents had their own agenda for her as well. In 

fact, she remembered her father being very 

unyielding in his opinion that his daughter should 

participate in sports instead. 

She recalled this time with sadness and frustration. 

All she wanted to do was express herself in a 

way she most desired. She felt intimidated, and in 

the name of making her dad proud, agreed to try 

sports instead. Not surprisingly, every sport she 

tried did not fit well. It was around that time 

she also remembers always having stomach aches. 

Her doctor never found anything wrong. It was 

diagnosed as stress and resulted in a prescription 

for her first medication. This quickly affected her 

self-esteem which led her to escape into food and 

alcohol. From there, it was a downward spiral into 

a deeper depression and a lack of self-care. 

Together, her history, emotional issues, stresses 

and physical symptoms presented a strong picture. 

With Teri, we chose to use the Chakra system, 

where seven major chakras (often called energy 

centers) are associated with different parts of the 

body. Oftentimes blocks in a chakra are related to 

stressful events during a certain age period of 

one’s life. In Teri’s case, we saw a strong picture 

of a third Chakra issue. The third chakra allows us 

to form opinions to express ourselves in the world, 

which Teri had not been able to do. Using the 

Chakra system is only one method, but in some 

cases, like Teri, it can help explain a connection 

from the emotional to physical. (4,5) 

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Some patients will be resistant at first to 

acknowledging an emotional cause of illness, as 

this can be quite a foreign concept. They want the 

cause of their physical issue to be something 

separate, from the outside. That said, when 

awareness is accepted, even as a possibility, this 

piece alone can produce such an “aha” moment 

that healing can already begin. 

Together with Teri’s counselor, we worked with her 

on this block to healing. She did not even realize 

the connection at first. Soon she knew that she 

needed to process forgiveness for those who held 

her back from expressing herself. She even 

realized she needed to forgive herself for not doing 

more to push what she really wanted at the time. 

She also had to reconnect to her self-worth again. 

We helped her with many exercises in this respect, 

like visioning and affirmations. We also encouraged 

her to consider taking a dance class to see if she 

could reconnect with her once-lost desire. 

Alongside this work, my MD colleague and I were 

able to identify and address adrenal stress markers 

and neurotransmitter imbalances through urine and 

saliva testing. (6) 

With this help, her continued 

counseling, and all the self-work she contributed, 

she was able to successfully abstain from sugar 

and alcohol. Over a year’s time, we were able to 

get her off one medication at a time while bringing 

in more natural amino acid, nutrient, and herbal 

support when necessary to bridge any gaps until 

all medications were discontinued. On a side 

note, it may not always be possible to discontinue 

medications, but often it is possible to decrease 

the dosage. This can also contribute to the 

success of the cases we see. (7) 

As Teri’s head cleared from the decrease in 

medications and neurotransmitter-balancing work, 

she was able to get back in touch with her 

feelings and she found motivation. She was able to 

learn how not to use food and alcohol for love or 

escape. She had no trouble including a little 

sugar without letting it get out of control and 

although she chose not to drink alcohol for the 

most part, she did imbibe on holidays and special 

occasions with perfect control even to this day 

many years later. 

Teri needed to learn how to set the example of 

how the world should love her by showing how 

she loved herself first. It was an uphill climb, but 

for every step forward her faith grew and she 

became more determined to reach her goals. She 

continued to work with her team of caregivers, and 

over time she even started dance classes again. 

She also meditated regularly, went back to school, 

and had the motivation to stay on track with the 

healthy diet I recommended. For the first time 

since she was a child, she felt free, empowered, 

motivated, focused, and healthy. But more 

importantly, she felt a joy and self-love she 

couldn’t ever remember feeling before. She could 

hardly believe it herself. 

This is the kind of success you want in your 

practice and for your patients! Not just Band-Aids 

but real healing. Not just top-layer treatment but 

deep-to-the-core-of-the-issues treatment. Whether 

or not specialty testing is needed and whether or 

not patients are on medications, I have many 

cases of success. They are often through 

collaboration. If you are a nutritionist, find an 

ordering physician you can team up with to order 

testing. I’m convinced the team approach is the 

most effective way to get the job done. There are 

many integrative medicine professional organizations 

with member databases to search for a local likeminded 

physician. One in particular is the Institute 

for Functional Medicine. Visit 

www.functionalmedicine.org. 

Roadblock 2: Negative Thinking 

By helping patients understand how fear and 

negativity affect their health, barriers can be 

overcome and successes can be achieved on a 

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larger scale. For most practitioners, there is a 

type of patient that is a mystery for many of us, 

the patient that seems to enjoy having an illness. 

We all have them from time to time. Instinctively, 

you can usually spot them quickly. They are the 

ones who have been to many practitioners and 

they have a long story for all that is wrong with 

them and the rest of the world, why nothing has 

worked, and why they have lost hope that anything 

will ever make them better. 

Many of us get drawn into these cases. After all, 

who doesn’t like a good challenge? And some 

really do have a valid plea. The root of their 

malady simply has not been identified because it is 

so obscure. We have had a few of these in our 

clinic recently as we embark on the mysterious 

realm of biotoxin-related illness. However, it does 

not take long to identify the “energy vampires” — 

the clients who may talk desperation but they do 

not always make the life changes needed to make 

themselves feel better. They are often the ones 

least likely to follow recommendations. I refer to 

this group as the “make-me-well, but-do-not-askme-to-do-anything-for-it” 

group. It is so counterintuitive! 

Why on earth, you ask, would someone 

want to stay ill? 

Healing from an illness often requires great change. 

Change is a very scary thing for people. 

Sometimes, the fear of change is harder to deal 

with than the illness itself and so one stays in the 

“safety net” of the illness. Your greatest gift to 

anyone who resists healing is to allow them time, 

at least until they are more secure and ready. 

To be fair, this type of patient, or negative emoter, 

does not desire illness and there is technically no 

enjoyment of the process of being ill. By the way, 

illness can also be used interchangeably with 

eating disorders, addictions and any self-defeating 

behaviors. It is important to note that negative 

emoters can benefit from their actions. For 

example, if negative emoters are looking for 

attention, having an illness garners the attention 

they may be wanting from others. We must be 

very gentle with these folks. We need to help 

them learn self-love and gather the courage to be 

reborn into an unknown and often brand new 

identity. 

No matter what your professional practice, you can 

have a role in helping your patients ready 

themselves for change. I can think of quite a few 

cases where the first several visits, sometimes 

lasting months, were all about preparation. In the 

beginning, with these kinds of cases, I felt very 

ineffective and it appeared nothing much got 

accomplished. As a nutritionist, I would repeatedly 

give the recommendations: eat more or less of 

this, exercise more, drink more water, etc. There 

would be some attempt to take one step forward 

that would result in taking two steps back. It is 

easy to blame the patient in these cases and to 

think they might not really care. 

Over the years, I have learned that the patient 

needs this time to explore and to gain confidence. 

If it is attention they need, I give them attention 

and take every opportunity to explore their fears 

and their potential roadblocks. Many times, it also 

requires a referral to a therapist of some kind. 

With each visit, there is an increased trust to go 

to those vulnerable places and gradually the patient 

sees success. None of this is wasted time. No 

real progress may have been made if the case 

had not been approached in this manner. 

One of the most important considerations when 

helping someone in a negative state is that you 

must avoid falling into negativity yourself. Empathize 

for a moment and move as quickly as you can 

into the better feeling place. You know how you 

feel after spending time with very positive people; 

you’ll tend to feel energized, uplifted, and 

inspired. You can be this person for your patient. 

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Remember, no matter how unconscious a person is 

when making the decision to sink into negativity, in 

this moment they still have the power to choose 

otherwise. In deciding to help such a person, your 

primary role is to help guide him or her to make 

a more conscious choice, one that will likely be 

much more empowering. So, how can we help 

negative people? 

An effective tool is to help patients define the 

gentler form of two feelings still closely related. 

Ask, “Do you feel more angry or fearful?” 

Followed by, “Do you feel despair or 

hopelessness?” Find the less-charged emotion 

going up the ladder as far as possible in that 

moment — always at least to the next better 

feeling place. Ask, “Can you see what to do about 

it?” “Can you change your view of it?” “What will 

it mean to you tomorrow, next week, or next 

year?” Help them put it into perspective. Often, 

we can find a way to move from hopeless to 

hopeful as we help them change their thought 

process and work toward potential solutions. Kind 

words, positivity, and attention can turn things 

around. (8) 

Give your patients suggestions for “time-outs” such 

as taking five or 10 minutes to take space from a 

stressful work situation to close their eyes and to 

listen to their favorite music. There are so many 

time-out exercises to draw from if one has their 

awareness called to the exercises and can then 

utilize them in times of need. 

Perhaps there is a friend or family member that 

will help intervene. Ask your patients to identify 

and enlist their supporters. You should give them 

fair warning, oftentimes it is not who they initially 

think. If appropriate, write or call to remind the 

patient that you care. Remind your patients they 

can do the same with others to help facilitate 

solutions to problems. It is true that helping others 

can go a long way to helping yourself. 

As a last resort with those more vulnerable or 

fragile, you can consider working one-on-one 

with the person yourself to help lift them out of 

their negativity. This requires a delicate combination 

of genuine caring and detached awareness. 

Because we all have free will, it is not always 

possible to help someone who refuses to accept 

your assistance. It is important to release your 

attachment to any particular outcome and remain 

open to all possibilities. If you become too 

attached to specific outcomes, you’ll drag your own 

awareness down, drain your energy, and ultimately 

diminish your capacity to help even others as well. 

Sometimes, the best thing you can do is to let go 

with love and have faith that everything will turn 

out for the best. Turn your attention to helping 

those you are able to help. 

Roadblock 3: Judgment of Others 

Debbie Ford in her book, “Dark Side of the Light 

Chasers,” describes a level of judgment as the 

concept that what we most dislike in others is 

often unconsciously what we dislike about 

ourselves. (9) 

What about traits we don’t care for 

in others, like insecurity, disorganization, overly 

critical, frugal, selfish, or weak? Could these just 

be parts of ourselves we’re not proud of either? 

According to this author, it is a good bet. Although 

not openly admitted, this lack of self-esteem 

comes to us very covertly. 

Judging can be a tool of awareness if we look 

inside and use it to self-assess. This will help us 

to grow and garner better self-perception. After all, 

we cannot change others only ourselves. Here is 

a novel thought. Instead of saying something 

judging, we should use a compliment instead. 

Hate is probably the most toxic and strong of all 

judgments. Yet much of our society underestimates 

this fact, and we allow the word to be used far 

too flippantly. For example, we hate to go to work, 

hate to drive in traffic, hate to exercise, hate 

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following rules, and even hate the color red. It 

starts at an early age when we might hate to eat 

our vegetables, hate to go to school, or hate our 

little brother for breaking our toy. Oh, sure, you 

might counter with, “Hate is a strong word. Don’t 

you mean dislike?” But in reality, how many 

parents and teachers actually counter any more? 

Because many times the conditioning while we’re 

young goes unchecked and many people head into 

adulthood with a blind eye. 

Though the lack of gratitude in people has been 

touted repeatedly by Oprah Winfrey and countless 

others, it is still a trend that needs much coaxing. 

Why is gratitude so hard to realize? Why is it so 

easy for people to get stuck far in the opposite 

direction? Is it because we stopped trying long 

ago? Here are two ideas. 1) For every time you 

heard someone say, “I hate…” you can ask back: 

“Tell me what you like,” “What are you grateful 

for,” or “What do you love?” 2) Writing thoughts 

down helps to embed them more solidly in a 

reality consisting of positive thoughts. Have your 

patients start by using journaling as an outlet for 

negative thoughts. Thinking positive thoughts is 

great but it is easy to get sidetracked. Have you 

ever tried to meditate when so many thoughts keep 

popping into your mind? It is hard to stay focused. 

The exercise of journaling brings a strong intention 

to your thoughts. It also brings the element of 

routine, which is the key for successful change. 

(10,11) 

Roadblock 4: Self-Judgment, Lack of Self-Esteem, 

Blocking Happiness and Joy 

Self-judgment is useful up to a point. However, 

once it becomes draining to self-esteem, it is 

destructive. Consider the fact that we are 

conditioned from an early age to compare 

ourselves to others. It is not socially acceptable to 

be fabulous all on our own. Instead, we know 

this as being self-centered, narcissistic, conceited, 

and selfish. 

Jealousy is an emotion that we all experience, and 

it’s a good barometer if we use it wisely. We can 

stop ourselves short and turn it around. By seeing 

what others have, it may help you see what you 

want to aspire toward becoming as a person. 

This self-judgment should never result in seeing 

yourself as not good enough! 

It does not help that many of us were not brought 

up in the most perfect way. In fact, many have 

experienced an upbringing where love had to be 

earned as though it were conditional. It is easy to 

grow up feeling like there is always a price to pay 

for love. With conditional love comes the pressure 

of having to measure up. Because many of us 

were not raised without condition, we have to learn 

anew. We need to release the belief that there are 

consequences when we come up short. We need 

to let go of the belief that it is not enough even 

when we are perfectly good at what we do. Our 

mantra for our patients should be, “Do not simply 

conclude you are wrong if something is not going 

right!” 

Another exemplification of low self-esteem is 

perfectionism. In our stress to hide our perceived 

inadequacies, it is easy to adapt the 

“Superman/Wonder Woman” smoke screen 

persona. Know anyone like this? They do not 

know how to say “No.” They take care of 

everyone else but themselves. It is easier to feel 

good about yourself and certainly others must 

admire you if you are selfless. In the end, this is 

what separates you from yourself. For some, this 

is a better fate than looking in the mirror and 

dealing with what they see. Many do not know the 

feeling of constant joy. First, the “do-it-all” 

syndrome must be escaped and the perfection 

must be overcome. Learning how to say, “No,” will 

lead to learning how to delegate. 

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By taking one gentle, healing step at a time, it is 

like learning how to walk all over again. You have 

to remind your patients that they’ll fall a lot in the 

beginning. It will feel uncomfortable, but eventually 

they’ll get better. They’ll have more confidence. It 

will even get to be fun when that walk turns into 

a skip, a jump, and eventually, an all-out sprint. 

As an exercise, I ask my patients to surrender the 

energy that holds them back and to just let it go. 

I ask, “Who are you now that you’re free?” so 

they can start to envision what they can become. 

Natural inspiration will come once the space has 

been cleared. We create our experience in this 

world much the same way a child creates on an 

etch-a-sketch. We should hold no more stock in it 

than this child does when they shake it, and make 

it disappear, and start over. In other words, do not 

take your form too seriously. 

I’ll say things like, “Recognize and welcome your 

spirit, strive for balance, share your gifts, remember 

what you love, and know that you deserve love. 

Accept life’s lessons with grace, and always 

choose to treat yourself and others with kindness.” 

I give the exercise of policing self-talk. Having the 

awareness first is the only way to change. How 

many times have you heard someone say, “I’m so 

stupid,” “I’m so slow,” or “I look ugly or fat in 

that.” We might think we’re exaggerating when we 

say stuff like this, but our soul believes it to the 

very core. For every time my patients catch 

themselves in negative self-talk, I ask them to stop 

themselves and immediately counter with a positive 

statement instead, such as the following statements: 

“I am good at my job,” “I have beautiful eyes,” or 

“People admire me for having courage.” 

They can also make a declaration: “By the power 

of my word, I declare that I am worthy of love 

and forgiveness. The thought that I was not is 

done. It is finished. There is no more room here 

for that thought anymore. Through the power of my 

connection to my source, I let go. I receive love. I 

am forgiven for judging myself. I love myself.” 

Feels good just saying the words, doesn’t it? 

Lastly, I remind patients to experience laughter 

every day. Choose where they want to be when it 

comes to being fun, alive, in love, and in joy. 

Take time to go dancing, to explore the world, and 

to empower others with the knowledge of 

connectedness of spirit and health. I ask, “What 

is the color of this freedom?” so they can better 

own the concept. I ask them if there’s anything 

that needs to move out of the way for their vision 

to have more room, to get unstuck, clear their 

energy, or de-clutter. I remind them a new life is 

being birthed, and it’s now alive to express! 

Roadblock 5: Inability to Forgive, Guilt, and Shame 

Many times our patients are stuck in a space of 

hurt. If you think about it, we have all been a 

victim at one time or another. For some, it is just 

a matter of time for healing to occur. For others, 

the time does not come and their inability to 

forgive manifests in a chronic emotional or physical 

response. I’ve noticed this especially with those 

who are repressed or avoid processing. For 

example, these individuals might have chronic 

depression, chronic pain conditions, digestive 

troubles, sleep, or fatigue issues. 

Forgiveness issues are tricky. Often, patients need 

the aid of psychotherapy while others will benefit 

from energy-clearing work. What about those who 

have experienced a traumatic event where it seems 

forgiveness is seemingly unfathomable? These are 

some of the hardest cases as most can easily 

justify the lack of forgiveness. (12) 

What is also challenging is when we have a 

patient who is still very connected to their event 

but refuses to acknowledge this fact. A natural 

tendency is to want to “be well.” In doing so, it is 

tempting for patients to talk themselves into 

believing that they have fully moved past that 

which needs forgiving or resolving. Sometimes, the 

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breakthrough moment occurs just with the 

realization and acceptance that more healing or full 

resolution has yet to happen. 

The flip side of this is the patient who repeatedly 

lives the story. You will hear it over and over. 

Living in the victim role has its benefits. For some, 

it affords them attention. For others, it is a 

convenient excuse to justify an action or lack 

thereof. An example of this might be the person 

who cannot practice positive self-care (exercise, 

take vitamins, eat right, etc.). Staying in the 

victim role is also a convenient excuse to stay 

stuck. Some would also say the negative energy of 

a victim is what prevents the very opportunities 

that can help them move forward. (13) 

As a practitioner, you can help people see past 

their stories. Hear the story. Use it to your 

advantage and then move past it. You can’t 

change form or condition but you can lift them up 

and allow healing. 

Lack of self-esteem often comes with, or from, 

shame. “Taking the blame” is often associated with 

feelings of guilt. These are probably the two most 

self-destructive emotions one can have. The toxicity 

of guilt and shame comes from our false beliefs 

that have kept us separated from our good. Guilt 

re-triggers the belief system that holds us back. 

Shame or guilt only serve one purpose and that is 

to block our full attainment of joy, happiness, and 

unconditional love. Guilt and shame are some 

heavy emotions. As an aside, it’s funny how many 

cases of back pain manifest in those who feel like 

the weight of the world is on their shoulders. 

Eventually, you feel the physical pain. In order to 

release shame and guilt, we often need to forgive 

ourselves. 

Here is an example of a homework assignment I 

might give a patient experiencing guilt and shame: 

Assignment: Have a week of grief and really feel 

the loss of that piece of you that you are letting 

go. Allow the grieving process to move though 

you and feel sad if you want. Nurture yourself as 

you would a little child. Give yourself a little gift in 

the same way you would to help a child feel 

special. You are loosening a perceived loss. Be 

angry if needed. Take a bubble bath to feel better. 

Hug yourself like you are hugging that child. Really 

feel it. Play both roles. Feel the child’s feelings 

and then be the parent who nurtures and forgives, 

exhibiting unconditional love. 

Many fail to realize that forgiveness is freedom. It 

is a release from the pain of victimhood. We do 

ourselves no good by continuing to manifest the 

pain. Our pain certainly does nothing to “punish” 

our abusers. It does not make them change, and 

it will never erase the event. Punishing ourselves 

has no purpose if we ever expect to move forward 

and realize our potential for love and happiness. 

There is a fine line that exists between forgiving 

and excusing. Forgiving is NOT forgetting. 

Forgiving is freedom! (12) 

Even if a patient is getting outside help, you can 

also have a role in helping to clear the playing 

field of resentments and finding what has not been 

forgiven. Here is another idea: 

Set an intention. Intend to forgive. Release the 

need to know how, just know you want to. 

Practice or try it on for size until you get it right. 

Another effective form of intention is through 

affirmation or a positive statement. You can affirm 

something more powerfully by saying or writing 

your statement of knowing. Affirmations must be 

stated in the place where you expect to be. That’s 

the beauty: you don’t have to know but you do 

want to be in the energy of knowing. An example 

of an affirmation of forgiveness is: “I allow the 

power of forgiveness to move through me and set 

me free from any belief I have about myself that 

says _________.” As a bonus, this example may 

tie into self-esteem as well. Affirmations are good 

for those who need to break free from their rut 

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beliefs that things always happen to them or this is 

the way it always is for them. (14,15) 

Roadblock 6: Stuck in the Past, Worry of the 

Future, Unable to be “in the Now” 

This roadblock is big and universal. It is 

practically impossible to stay in the present. Our 

egos are much too strong. Only the very few, fully 

spiritually evolved like the Dalai Lama, are capable 

of living in the present continually. For the rest of 

us, it is a worthy goal to at least try for living in 

the present — to not be stuck in the past or to 

continue to wait for the future to happen. 

As Eck hart Tolle would tell us, “Operate in the 

now.” (16) Take the good from your past and carry 

it into the now. The past is over, the future does 

not exist yet, and therefore the good is in the 

now. Your filter is your beliefs and perceptions. 

How do the past and the future steal our ability to 

transform? Free yourself of worry to propel 

yourself into action. Otherwise, you are crippled. 

The past is our gift and our teacher. When things 

don't work out, why do we look at it like failure 

rather than a learning experience? 

Put yourself in the company of people vibrating the 

energy you would like to project. Practice walking 

in the “let go.” Let go of the past. Let go of 

what you think life is supposed to look like in the 

future. Ask for help if you need it. 

Recognize the past is where shame is and the 

future is fear. The present is where your 

imagination is — don't let the ego get in the way. 

When you have an idea or desire, the ego comes 

in and asks, “How will you get it?” If you say 

you want something the following way: “I am going 

to get…” Then, you’re in an energy position of not 

having, or just short of having, because you’re still 

getting. Put yourself where you want to be. Don't 

worry about the how. Just know you’ll be there 

and the universe will align. Be open to all 

possibilities. The universe may have a way that 

you aren’t aware of right now. Do not block. Just 

be open to whatever comes your way. 

For patients with this roadblock, I encourage them 

to the following affirmation daily: “Today I release 

the past. It is over and it has no power. Today, I 

release the future. It is only a dream. Today, I 

live in the now moment where my source is and 

where I am free to choose, free to love and be 

loved, free to express and free to be me.” Then, 

I have them list all the things they release from 

their past and likewise their future. Indeed, living in 

the now moment take a lot of practice, but the 

rewards are infinite. I also recommend my patients 

practice visioning, as it has a purpose to bring the 

energy of what you want into the now. Planning is 

a now event. It is okay to plan for the future. 

Catastrophizing is getting lost in the future. It is 

dangerous territory. Enjoy what you have now and 

celebrate it. Do not let your happiness be 

conditional on your future. 

Roadblock 7: Isolation, Lack of Faith, or Spiritual 

Disconnection 

We are not our body; we are so much more. 

Some accept this concept freely, while others think 

this statement is very controversial. For example, 

we either believe when we die that it is all over 

or we believe we move on to reconnect with a 

higher source, who or whatever that is for each 

individual does not matter. Many believe that 

spiritual disconnection is a roadblock. If you cannot 

connect with your higher source, you cannot heal. 

This same group finds relief in knowing they are 

not alone or isolated in this vast universe. Many 

feel that faith is their freedom from the burden of 

the responsibility of being in total control. We learn 

from an early age, most of us, that there is much 

we have no control over at all. Some call it God’s 

will. Some call it the higher order. It doesn’t 

always make sense. We cannot see it or touch it, 

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we just trust. It is fearful not knowing, this is true. 

But, somehow, they feel it is okay to be afraid 

and still find a place inside that says, “I will do it 

or get through it. All is fine.” (17) 

The rest stay stuck in the bond of control. They 

believe they control life and others exclusively. 

They see the world through their five senses. If 

they can’t see it, smell it, touch it, taste it, or 

hear it, it therefore doesn’t exist. They rely less on 

intuition and more on facts as they can be proven. 

Some would call these young souls, if you even 

believe in a soul. 

The problem is, without faith, it is hard to believe 

you have any help in healing. It is a heavy burden 

to believe you have to do the job all on your own. 

At the base level, it is about having faith in others 

to help you. At the highest level, it is having faith 

that what is meant to be, will be, no matter what 

you say — as though there was a grand order in 

things. 

Indeed, there is something to be said about giving 

up the driver’s seat and taking your hands off the 

wheel. It is a trust, a knowing that you don’t 

control, and an understanding that outcomes are 

not always what we wish for or plan. It is knowing 

that good will come from any outcome even if it 

first appears not to be good at all. Yes, it is 

scary. You must trust that you really do not lose 

your uniqueness in the process. You only lose 

your ego, the master controller. 

I ask my patients to find their passion, 

commitment, and also to think about a global 

commitment. When you give yourself up or engage 

in service to others, you feel so much fuller. The 

ego lives in fear. If we hold on to our faith, I 

believe we can overcome the ego. In the oneness 

consciousness all problems dissolve, they may not 

go away, but they can transform. 

The exercise here is to pray, to whatever or 

whomever you choose, it doesn’t matter. Yes, 

there is research that shows it has effectiveness 

but it seems almost ironic that we even need 

research to tell us this at all. Prayer has the same 

frequency as play. When you play dress up as a 

kid, you become that person, if only for a short 

time. Prayer is like that; become who you want to 

be. Wish that for others. Have faith in what you 

don’t know, yet at the same time trust in your 

knowing. Find harmony. Find peace. It’s the 

ultimate intention. 

A Practitioner’s Role 

So now that we’ve gone through what I consider 

to be the seven most powerful roadblocks that get 

in the way of our patients’ better health, let’s 

summarize the general points of what you can do 

as a practitioner to help those you work with. 

Look for the underestimated disconnects in the 

mind-body-spirit triad that might delay or represent 

a full barrier to healing. When necessary, work as 

a team in concert with other healers to help your 

patient address all connections more fully and 

come to their fullest potential for success. 

Hold someone in their greatness, don't judge them 

if they slide back. Just know they will do what 

they do and they are great anyway, no matter 

what. Oh, and be sure to tell them so! Help them 

erase their checklist of lack and believe instead in 

their ability for abundance. Remind them to laugh, 

find joy and have gratitude for what they have 

every day. Cheer them on as they take small 

steps in their new beliefs. 

Promote freedom from dependence. Anyone 

dependent on help from others is not free. This 

doesn't mean we can’t ever accept the 

graciousness or guidance from others; we just 

shouldn’t be dependent on it to the point of giving 

up our own identity or our power to help 

ourselves. 

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On that same line of thinking, encourage your 

patients to stop identifying with their sick self, but 

instead to act as if they are well. Bruce Lipton, in 

his book, Biology of Belief, describes how 

neurochemistry is influenced by genetics, 

inflammation, toxic burden, etc., but points out it is 

also influenced by belief.” (18) This explains 

spontaneous healing. If you can make it disappear, 

therefore you can make it appear. I often say, 

“Lose the need to name your illness, instead claim 

your wellness.” A hard concept, some say. I say 

further, “Fake it until you make it. You just might 

surprise yourself!” 

Just as you can’t help your patients move forward 

without knowing where they’re moving from, equally 

important in knowing where they can go from here. 

Many practitioners will approach things from this 

point in a very different way — and that’s okay as 

long as the patient gets where they need to be in 

the end. There’s certainly no one-size-fits-all 

approach! 

Throughout the article, I have offered many 

practices your patients may enlist to help them 

move forward on their healing journey. If you 

haven’t experienced most of these yourself, you 

owe it to yourself and your patients to try them on 

for size. How better to speak to their virtues 

anyway? Oh, and if you’re feeling the need to find 

scientific research for the validity of these practices, 

release the need please. Yes, some are wellresearched 

but others may not be. Remember 

when we all thought the world was flat? The lack 

of research does not automatically bring discredit. 

As long as no harm is done, even a placebo has 

benefit if it gets a patient up the ladder one step 

further. I don’t know why this is such a hard 

concept in medicine, but it is. It’s time we opened 

our hearts and our minds. I know you have if 

you’ve read this far. 

All I can say is keep learning and growing and 

spreading the good word! 

Resources: What patients can do further 

Acupuncture 

Acupuncture is a method of encouraging the body 

to promote natural healing. It is done inserting 

needles and applying heat or electrical stimulation 

at very precise acupuncture points does it. The 

classical Chinese explanation is that channels of 

energy, called meridians, run in regular patterns 

through the body and over its surface. An 

obstruction in the movement of these energy 

streams is like a dam that backs up in others. 

The acupuncture needles unblock the obstructions 

by stimulates the nervous system to release 

chemicals in the muscles, spinal cord, and brain. 

This reestablishes the regular flow and therefore 

helps the body to correct imbalances in many area 

including digestion, energy production, pain 

conditions and more. The end result is a 

stimulation of the body's natural healing abilities, 

and promotion of physical and emotional wellbeing. 

(http://www.medicalacupuncture.org) 

Aromatherapy 

Aromatherapy is the art of utilizing naturally 

extracted aromatic essences from plants to balance, 

harmonize and promote the health of body, mind 

and spirit. It works through the physiological, 

psychological and spiritual realm of the individual's 

response to aromatic extracts to enhance the 

individual's innate healing process. As a holistic 

practice, Aromatherapy is both a preventative 

approach as well as an active method to employ 

during acute and chronic stages of illness. It is a 

non-invasive modality designed to affect the whole 

person not just the symptom or disease and to 

assist the body's natural ability to balance, 

regulate, heal and maintain itself. 

(http://www.naha.org) 

Biofeedback 

Biofeedback is a technique that trains people to 

improve their health by controlling certain bodily 

processes that normally happen involuntarily, such 

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as heart rate, blood pressure, muscle tension, and 

skin temperature. Electrodes attached to your skin 

measure these processes and display them on a 

monitor. With help from a biofeedback therapist, 

you can learn to change your heart rate or blood 

pressure, for example. At first you use the monitor 

to see your progress, but eventually you will be 

able to achieve success without the monitor or 

electrodes. Biofeedback is an effective therapy for 

many conditions, but it is primarily used to treat 

high blood pressure, tension headache, migraine 

headache, chronic pain, and urinary incontinence. 

(http://www.aapb.org) 

Dance/Movement Therapy 

Similar to music therapy and of course, often 

combined, dance/movement therapy is the 

psychotherapeutic use of movement to further the 

emotional, cognitive, physical and social integration 

of the individual. It is focused on movement 

behavior as it emerges in the therapeutic 

relationship. Expressive, communicative, and 

adaptive behaviors are all considered for group and 

individual treatment. Body movement, as the core 

component of dance, simultaneously provides the 

means of assessment and the mode of intervention 

for dance/movement therapy. 

(http://www.adta.org) 

Emotional Freedom Technique (EFT) 

EFT is a form of psychological acupressure, based 

on the same energy meridians used in traditional 

acupuncture to treat physical and emotional 

ailments but without the invasiveness of needles. 

Instead, simple tapping with the fingertips is used 

to input kinetic energy onto specific meridians on 

the head and chest while you think about your 

specific problem - whether it is a traumatic event, 

an addiction, pain, etc. -- and voice positive 

affirmations. The combination of tapping and voicing 

affirmation works to clear the "short-circuit" - the 

emotional block -- from your body's bioenergy 

system, thus restoring the mind-body balance, 

which is essential for optimal health and the 

healing of physical disease. 

Massage Therapies 

Massage therapy often referred to as bodywork or 

somatic therapy, refers to the application of various 

techniques to the muscular structure and soft 

tissues of the body that include applying fixed or 

movable pressure, holding, vibration, rocking, 

friction, kneading and compression using primarily 

the hands, although massage therapists do use 

other areas of the body, such as the forearms, 

elbows or feet. Massage positively influences the 

overall health and well-being of the client. Far 

reaching benefits affect the musculoskeletal, 

circulatory-lymphatic, nervous, and other systems of 

the body. (http://www.amtamassage.org) 

Meditation 

Practiced in a variety of ways, mediation allows 

contemplation and reflection through freeing or 

quieting of the mind. It can be an exercise in 

releasing troubling thoughts to just be in the 

moment. Regular meditation can provide many 

benefits such as lowing blood pressure and heart 

rate, improved breathing, relaxation and over all 

stress reduction thereby improving mood and 

decreasing depression. No one form of meditation 

is right or wrong; none is better or worse. There 

are many sources of guided meditation that are 

often good for beginners. 

(http://www.meditationsociety.com) 

Mentor/role model 

Look for a mentor or role model who has already 

walked the walk. Maybe this is a religious or 

spiritual guide, a healer, or a best friend. The 

premise in general is to surround one’s self with 

as many positive, successful people they can. 

Likewise, to release the negative people that 

influences their life as much as reality will allow. 

Role models will be found in personal relationships 

but also indirectly as authors of motivating books 

and as uplifting speech-givers. 

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Music Therapy 

Music Therapy is an established health profession 

in which music is used within a therapeutic 

relationship to address physical, emotional, 

cognitive, and social needs of individuals. After 

assessing the strengths and needs of each client, 

the qualified music therapist provides the indicated 

treatment including creating, singing, moving to, 

and/or listening to music. Through musical 

involvement in the therapeutic context, clients' 

abilities are strengthened and transferred to other 

areas of their lives. Music therapy also provides 

avenues for communication that can be helpful to 

those who find it difficult to express themselves in 

words. (http://www.musictherapy.org) 

Qigong 

Qigong (pronounced "chee-gung") is an ancient 

Chinese exercise that integrates physical postures, 

breathing techniques and focused intention. Qi is 

translated to mean the life force energy that flows 

through all things in the universe. Gong, means 

accomplishment, or skill that is cultivated through 

steady practice. Together, Qigong means cultivating 

energy, it is a system practiced for health 

maintenance, healing and increasing vitality. Qigong 

can be classified as martial, medical, or spiritual. 

Practices vary from the soft internal styles such as 

Tai Chi; to the external, vigorous styles such as 

Kung Fu. However, the slow gentle movements of 

most Qigong forms can be easily adapted, even 

for the physically challenged and can be practiced 

by all age groups. (http://nqa.org) 

Reiki 

Reiki is a Japanese technique for stress reduction 

and relaxation that also promotes healing, It is 

administered by "laying on hands" and is based on 

the idea that an unseen "life force energy" flows 

through us and is what causes us to be alive. If 

one's "life force energy" is low, then we are more 

likely to get sick or feel stress, and if it is high, 

we are more capable of being happy and healthy. 

(http://www.reiki.org) 

Visioning: 

Helps develop a clear sense of purpose and goals 

to focus and drive creative energy. Visioning can 

be done like brainstorming, in meditation or via a 

vision board that one creates using drawings 

and/or pictures. 

Yoga 

The classical techniques of Yoga date back more 

than 5,000 years. The word Yoga means “to join 

or yoke together,” and it brings the body and mind 

together into one harmonious experience. The 

whole system of Yoga is built on three main 

structures: exercise, breathing, and meditation. The 

exercises of Yoga are designed to put pressure on 

the glandular systems of the body, thereby 

increasing its efficiency and total health. Regular 

daily practice of all three parts of this structure of 

Yoga produces a clear, bright mind and a strong, 

capable body. 

(http://www.americanyogaassociation.org) 

Susan Allen has been evolving her nutrition career 

for over two decades. Now, nationally recognized 

as a functional nutrition expert, she provides a 

unique and very successful approach to 

personalized health and wellness as she 

incorporates an overall focus on the mind-bodyspirit 

connection in her work as a speaker, mentor, 

author and nutrition consultant. Susan earned her 

nutrition degree in Medical Dietetics from the 

University of Illinois, became a Registered Dietitian 

(RD), and completed post-graduate level training 

to become a Certified Clinical Nutritionist (CCN), 

which designates her specialty in the nutritional 

aspects of functional medicine, which is 

personalized medicine that deals with primary 

prevention and underlying causes instead of 

symptoms for chronic health conditions. 

Ms. Allen has worked in many settings in addition 

to her own private practice. She was involved in 

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2012 

one of the first free standing nationally based 

Integrative Medicine Clinics, then called American 

Whole Health where she worked with well know 

physician and author, David Edelberg, MD and 

many other doctors pioneering the Integrative 

Medicine path. She also consulted for the start up 

of The Center for Integrative Medicine affiliated with 

prestigious Northwestern Memorial Hospital in 

Chicago. 

Ms. Allen has held board appointments with The 

International and American Association of Clinical 

Nutritionists, the American Dietetic Association’s 

sub-specialty group: Nutrition in Complementary 

Care (NCC), now known as Dietitian’s in 

Integrative and Functional Medicine (DIFM), on 

the Nutrition Board of the Institute for Functional 

Medicine (IFM) and on the Scientific Advisory 

Board of Integrative Therapeutics, Inc., one of the 

largest natural medicine manufactures in the United 

States. 

Susan lectures nation-wide, has been a consultant 

to the natural vitamin industry and is a respected 

mentor/trainer to registered dietitians and other 

healthcare professionals. Considered an authority, 

she has appeared on numerous radio and 

television programs, has been quoted extensively in 

the press, and is also a published author. 

While she currently speaks, trains and consults 

coast-to-coast, Susan’s home is in the Chicago 

area where she enjoys a thriving practice as 

Director of Nutrition and Wellness at Park Ridge 

MultiMed (www.parkridgemultimed.com) with noted 

Integrative Medicine Physician and author, Keith 

Berndtson, MD. She also serves as Director of 

Nutrition for OneBodyMind.com. Founded by Dr. 

Berndtson, this website supplies innovative online 

tools for people interested in a deeper, more 

effective approach to health education, self-care 

support, and the stewardship of living systems. It is 

also ground zero for a social network that will help 

prepare the way for the modern quest for health 

and sustainability. 

Contact Susan Allen at nutriwellness@gmail.com or 

847-232-9800. 

References: 

1. Myss, Caroline M. Why People Don't Heal 

and How They Can. New York: Three 

Rivers, 1997. Print. 

2. Roth, Geneen. Why Weight? A Guide to 

Ending Compulsive Eating. New York: 

Penguin Group, 1989. Print. 

3. Petralli, Genita, and Abram Hoffer. 

Alcoholism: The Cause The Cure. Genita 

Petralli and Alternative Approaches to End 

Alcohol Abuse, 1999-2007. Print. 

4. Davies, Brenda. The 7 Healing Chakras: 

Unlocking Your Body's Energy Centers. 

Berkeley, CA: Ulysses, 2000. Print. 

5. Myss, Caroline M. Anatomy of the Spirit: 

The Seven Stages of Power and Healing. 

New York: Three Rivers, 1996. Print. 

6. https://www.neurorelief.com/index.php?p=h 

ome 

7. Ross, Julia. The Diet Cure: The 8 Step 

Program to Rebalance Your Body 

Chemistry and End Food Cravings, Weight 

Problems, and Mood Swings - Now. New 

York: Penguin, 1999. Print. 

8. Hicks, Esther, and Jerry Hicks. Getting 

into the Vortex. Carlsbad, CA: Hay 

House, 2010. Print. 

9. Ford, Debbie. The Dark Side of the Light 

Chasers: Reclaiming Your Power, 

Creativity, Brilliance, and Dreams. New 

York: Riverhead, 1999. Print. 

10. Beckwith, Michael. 

http://www.enlightennext.org/magazine/bios 

/michael-beckwith.asp 

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11. Dyer, Wayne. 

http://www.drwaynedyer.com/products 

12. Ferrini, Paul. The 12 Steps of 

Forgiveness: A Practical Manual for 

Moving from Fear to Love. Greenfield, 

MA: Heartways, 1991. Print. 

13. Myss, Caroline M. Defy Gravity: Healing 

beyond the Bounds of Reason. Carlsbad, 

CA: Hay House, 2009. Print. 

14. Evers, Anne M. Affirmations Your Passport 

to Happiness and Much More... 

Vancouver, BC: 5. Affirmations 

International, 1989. Print. 

15. Lord, Mark Anthony, and Michael Bernard 

Beckwith. Seven Living Words: Transform 

Your Life with This Illuminating Perspective 

on the Seven Last Words of Jesus. 

Princeton, NJ: Accelerator, 2008. Print. 

16. Tolle, Eckhart. The Power of Now A 

Guide to Spiritual Enlightenment. Novato, 

CA: Namaste, 1999. Print. 

17. Schucman, H. and William Thetford. A 

Course in Miracles. Mill Valley, CA: 

Foundation for Inner Peace. 1992. Print. 

18. Lipton, Bruce. The Biology of Belief: 

Unleashing the Power of Consciousness, 

Matter and Miracles. Carlsbad, CA: Hay 

House: 2005 

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26 

Healing Emotions 

in Children 

Stephen Scott 

Cowan, MD, FAAP 

2012 

The Diagnostic Statistical Manual (DSM), the 

bible of conventional Western psychiatry, has been 

relatively effective in providing detailed 

categorization of what’s wrong with us, but it 

doesn’t really tell us what is right with us. This 

presents a significant problem when it comes to 

growing a healthy child in your house or your 

practice. 

The explosive rise in the diagnosis of children 

with mental disorders over the past 20 years has 

led to significant overuse of strong psychopharmaceutical 

medications originally intended for 

adults and not FDA approved for pediatric use. i 

This has several untoward effects. It puts 

clinicians in the difficult position of having to treat 

a child once a diagnosis has been given or run 

the risk of malpractice. A recent report in the 

Harvard Medical Letter has gone so far as to 

suggest that the availability of psychopharmaceuticals 

may actually be influencing the 

clinician’s process of diagnosis. ii 

But DSM 

diagnoses are based on the collection of 

symptoms not pathophysiology, and treatment 

options give the impression that a symptom has a 

distinct neurochemical association. Contrary to 

what pharmaceutical companies would like you to 

believe, the promise of “better living through 

chemistry” can leave us crippled by a life-long 

dependency on pills without ever probing the 

deeper roots of our emotional problems. 

Another complication of the rise in clinical labeling 

of emotional disorders in children has led to an 

over-identification with their diagnosis. It is not 

uncommon these days to hear kids say “I’m ADD 

” or “I’m bipolar.” Identifying ourselves with a 

disease is a serious problem that actually prohibits 

full recovery. The use of “adult” psychiatric 

diagnoses in labeling children gives the impression 

that children are simply “little adults.” This 

negates the unique quality that defines children, 

namely their intense process of growth and 

development. A child is constantly adapting to 

his environment in an ongoing process of shaping 

his internal structures known as neural plasticity. 

The vibrancy of these changes is what makes 

children so much fun to be around. Their 

wondrous sense of exploration and creativity 

makes a child much less predictable particularly 

when it comes to labeling emotional states. 

There is a subtler problem in labeling children. 

The DSM gives labels to clusters of symptoms 

but these are often taken to mean that they are 

somehow permanent disease conditions. Treating 

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symptoms as if they are diseases can lead to 

quick fix interventions that ignore the causes 

underlying those symptoms. But perhaps the 

most problematic issue presented in the DSM is 

the complete absence of any definition of 

“emotional health,” giving the impression that 

health is simply the absence of a diagnosis. But 

there is more to living a healthy emotional life 

than not having symptoms or labels. 

Resilience 

The plasticity of our nervous system highlights the 

epigenetic phenomena that have revolutionized our 

understanding of the interrelationship between our 

hereditary influences and environmental factors. 

Rather than seeing ourselves from the perspective 

of hardwired genetic determinism, we now have a 

broader ecological view of what it means to be 

healthy. This is particularly important in defining 

emotional health. 

Mark Greenberg, the noted psychologist at the 

Penn State University has done groundbreaking 

work in searching for the factors that determine 

how we cope with what Hans Selye calls “the 

stress of life.” iii 

Stress is a necessary stimulus 

for growth, and adaptation and resilience can be 

defined as how well we bend and recover from 

the winds of change. Our coping mechanisms 

are influenced by the epigenetics of our 

circumstances. The more labels there are for 

emotional illnesses in children, the less tolerance 

there is for children who don't “fit in” neatly to 

rigid expectations of how a child should behave. 

The smaller the box, the more kids fall out of it. 

The epidemic use of psychiatric medications in 

children has its roots in such narrow perspectives. 

The first step in understanding how to improve a 

child’s emotional health is to look beyond 

chemistry at all the factors that either support or 

interfere with resilience. 

The Mandala of Epigenetic Fitness 

We are walking communities. 99% of the 

proteins made in the human body derive from 

non-human microbial cells. The food we eat 

contains micro-RNA that dictate how our genes 

are read. The health of our gut flora has a 

direct effect on the balance of our neurochemistry. 

Over 80% of the serotonin produced in the body 

comes from the gastrointestinal system. Thus our 

gut is a brain that regulates our mood. 

But a holistic perspective goes far beyond simply 

giving supplements instead of pharmaceuticals. 

That is still buying into the quick-fix mentality of 

drug companies. To truly appreciate the big 

picture, we must expand our perspective and take 

into account everything that influences our 

genome. The new field of behavioral epigenetics 

championed by Moshe Szyf at Mcgill University is 

just beginning to scratch that surface. iv 

In exploring 

factors that contribute to what I call “epigenetic 

fitness” we need to look at the mandala of 

influences in our life (see diagram). Mandala is 

an ancient Sanskrit word that means relationship. 

How we are related determines our epigenetic 

fitness. This is the key to promoting emotional 

wellbeing. 

Food: The quality of the food our children 

eat certainly affects their emotional 

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stability. The current obesity epidemic is 

directly related to the rise in high-energy, 

nutrient-poor foods that alter blood sugar 

balances, shorten frustration thresholds and 

drive compulsive behaviors. But it’s not 

just what we eat but where we eat, how 

much we eat, when we eat and why we 

eat that determine our emotional wellbeing. 

Hunger can be a positive motivator or a 

distraction depending on the degree of 

intensity. Many children today have 

become over-indulged with fast food and 

have lost the deeper meanings in eating 

linked to social relations and stressreduction. 

Toxins: We are exposed to toxic 

environmental factors every day. Our 

physical and emotional health is directly 

affected by the levels of toxic burden that 

come from living in a modern 

industrialized world. The air we breathe, 

the food we eat, the noise we are 

exposed to, the extended exposure to 

artificial light, heat and cooling all disrupt 

our connections to the natural rhythms of 

life. Lack of sleep, exercise, and proper 

digestion can all lead to excess stress 

hormone production that can overload the 

biomedical detoxification system causing 

chronic physical and mental suffering. 

Supporting detoxification is a fundamental 

aspect of emotional health maintenance. 

But toxic exposures extend beyond 

chemicals to the emotional stressors of 

our daily life. 

Family: Our family serves as our first 

support system. Family dynamics can 

also certainly become as toxic as chemical 

exposures. Indeed, our family 

relationships trigger neurochemical effects 

that can be contagious. How well we 

resonate within our family will contribute to 

our state of wellbeing or discomfort. 

Friends: How often does a clinician 

consider asking friends to participate in 

the treatment of a child with emotional 

disorders? There are many times in my 

career when a patient’s friends have come 

forth with valuable information that helps 

illuminate what is actually going on in my 

patient’s life. This is particularly true with 

teenagers who have evolved their own 

supportive social network. The recent 

rise in online bullying has highlighted the 

dark side of such exposures and need to 

be investigated carefully. 

Home: The structure and setting of the 

house where a child lives can have 

powerful effects on a child’s moods and 

emotions. Which side of the bed she 

sleeps on, the color of the walls, where 

she eats, where she watches TV all 

contribute to the level of stress or 

resilience in any child. The ancient 

Chinese study of Fengshui looks at the 

ways we can make subtle shifts in the 

energy and mood of one’s home to 

promote greater harmony and positive 

emotional states. 

Technology: Perhaps the most 

underappreciated influence on our 

childrens’ emotional resilience lies in their 

exposure to modern digital technology. 

Our children are considered “digital 

natives,” having grown up fluently 

speaking the language of the internet, cell 

phones and videogames. We adults are 

“digital immigrants.” We may be able to 

speak the language but it is not 

necessarily natural to us. Adapting to the 

highly visual, over-stimulating world of 

technology can leave children feeling bored 

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and apathetic in environments like school 

where they do not have access to the 

same kind of feedback. 

School: We must not forget the effect 

our schools have on our children’s 

emotional wellbeing. As our schools 

become more rigid in their standardized 

institutionalization of learning, there is less 

and less tolerance for the diverse ways 

children adapt, grow and express 

themselves. This is one of the most 

prominent causes of over-labeling in 

children. 

Each of these factors is critically important in 

considering a holistic approach to improving a 

child’s emotional fitness. One is not more 

important than the others and each can be used 

therapeutically to enhance a child’s ability to 

recover from emotional stress effectively without 

medication. 

Tong: the meaning of health 

one ever gets upset, but rather is defined by the 

free-flowing flexibility that gives the power to 

bounce back. 

In speaking about emotional immunity, there are 

important parallels with our physical immune 

system. As a holistic pediatrician, it is not 

uncommon to encounter parents seeking ways to 

“boost their child’s immunity” because their child 

is always getting sick. But all too often, when 

we examine the situation more closely, I find that 

the child is getting sick, recovering and then 

getting sick again. When looked at another way, 

parents begin to realize that their child is actually 

always “getting better.” Immunity does not mean 

one never gets sick. That would actually be 

abnormal. A healthy immune system is constantly 

exercising as it resonates with the world. Just as 

physical health does not mean the absence of 

sickness, a healthy emotional immune system 

does not mean never feeling upset. It simply 

means you are able to recover quickly. 

The Cycle of Emotional Recovery 

Emotional recovery is directly linked to our 

flexibility in responding to the circumstances we 

find ourselves in. Let us take a look at the 

powerful relationships between feelings, emotions 

and behaviors. (see diagram) 

The classical Chinese symbol Tong shows the 

image of a bell ringing. It means to connect, to 

communicate, or free-flowing communication. In 

Chinese medicine it is one of the defining words 

for health. How we resonate in the world gives 

a deeper sense of what emotional health means. 

This gives a sense of the constant dialogue that 

is taking place with our environment. In ecological 

terms, emotional health therefore means that we 

exist as unfinished business. Our “emotional 

immunity” does not rest on building a shell so 

In the developing child, feelings, emotions and 

behaviors happen so quickly they often seem to 

be the same thing. This can lead to considerable 

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confusion when a child is told to stop behaving in 

a particular way, and she takes it to mean “stop 

feeling.” This is the path to suppression that will 

manifest in deep-seated psychological pathologies 

later in life. One of the important first steps in 

enhancing emotional recovery in children comes 

with being able to separate these aspects of our 

emotional life. 

Neuroscience has shown that there is a gap of 

about 200 milliseconds between our sensory 

feelings and the moment when we begin to 

categorize these feelings. Resonating with the 

world involves that act of listening, looking and 

feeling, which very quickly become hearing, seeing 

and touching something. That something is a 

conceptual idea based on language, memory and 

beliefs that make up our reference system. Once 

labeled (recognized), we are motivated towards 

or away from the stimulus, or to simply disregard 

it. Such movements of attraction, aversion and 

ignoring are expressed as a kind of ringing or 

reverberation in an attempt to communicate 

(tong) with the world. The motion of our facial 

expressions and body language is what Antonia 

Dimassio calls our emotion v . We emote not just 

in response but in order to evoke something from 

the world, to stake our claim, whether it is 

passion for what we are attracted to, aggression 

for what we are averse to or by simply ignoring 

what seems neutral to us. 

There is another brief gap between the rising 

emotion and the ways these expressions are 

enacted as behaviors. For instance, we may 

form an angry face to evoke our aversion to a 

situation but this may not always propagate into 

behavioral actions. For the immature child, the 

lightning speed with which these impulses arise 

and become behaviors can be frightening. It 

takes time and experience to begin to modulate 

the speed of emotion-to-behavior. This is one of 

the great problems with current conventional 

diagnosis and treatment. By suppressing the 

symptom-behavior, there is little opportunity for a 

child to distinguish feelings from behaviors in order 

to develop mature emotional regulation. It is of 

paramount importance for children to realize that 

there are good and bad behaviors but no such 

thing as a bad feeling. 

During the heat of an emotion, however, there is 

a refractory period that makes intervention 

extremely difficult. But once the peak of the 

emotion passes, there is a recovery period that 

allows a child to return to simply listening, looking 

and feeling clearly again. The power of emotional 

recovery is directly influenced by the setting, 

feedback and personal practices that promote our 

habits. Much of my work with parents and 

children is developing strategies that shorten 

recovery time and return to feeling in order to 

enhance emotional immunity. 

Often when the setting does not provide 

opportunity for a child to “let go” of an emotion, 

we will see lingering moods that can distort 

sensory perceptions. This can set up a vicious 

cycle that fuels chronic pathological behaviors and 

interferes with the natural exchanges necessary for 

learning, memory and a sense of wellbeing. 

Our job as health practitioners is, in its truest 

sense, to prepare our patients for getting sick and 

to shorten their recovery time, rather than to 

simply stop illness from ever arising. This is a 

revolutionary concept in health care. Shortening 

recovery time puts a different spin on how you 

live your life and interact with others. Preparing 

to be emotionally upset and then practicing 

recovering is an active engagement with the 

natural processes of the heart. This changes the 

mood of medicine and clarifying goals of therapy. 

There are critical points along the cycle of 

feeling-labeling-emoting-recovering that represent 

opportunities to empower the patient to recover 

and return to clarity of perception. This begins 

with the power of attention that creates the space 

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and time to develop flexible communication with 

the world (tong). 

Xin: The Triune Heart 

We are wired to pay attention. As the eminent 

father of psychology, William James said, “That 

which I choose to pay attention to, shapes my 

brain.” This lies at the heart of emotional 

epigenetics. But we do not pay attention with 

one brain, we use three brains to do it. In the 

early 1970’s, Paul MacClean, working at the 

National Institute of Health, first described the 

structure of the brain as a reflection of our 

evolutionary progression. He called it “the Triune 

Brain.” vi 

At that time, emotions were thought to 

originate in the structures situated between the 

brain stem and neocortex known as the “limbic 

system.” As a long-time student of classical 

Chinese medicine, I have adapted this view of the 

brain to help parents and clinicians understand the 

emotional states of a child in ways that are less 

focused on pathologizing symptoms and more 

geared to helping each child maximize his 

strengths and virtues. 

In Chinese medicine, the idea of mind and heart 

are held within one term: xin. This ancient 

character shows what some believe to be a lotus 

blossom opening with a stem and three leaves. 

Others say it represents the major chambers of 

the heart. There is deep meaning in this imagery. 

As a pediatric neurodevelopmental specialist, I find 

that something marvelous happens when we 

replace the word “mind” with “heart.” Suddenly 

paying attention with all our heart begins to reflect 

our emotional state of mind. What I call the 

Triune Heart is made up of “the frog heart, the 

puppy heart and the big heart.” 

The frog heart pays attention to the basic 

connections to our world, the cycles and rhythms 

that maintain our basic life support: circulation, 

breathing, eating, sleeping, and eliminating. The 

heart connection in charge of circulation is one of 

the prime representations of tong 

(communication). Indeed studies have shown 

that when heart rate is synchronized with 

respiration, it can enhance emotional wellbeing and 

improve the flexibility of attention. Like the little 

frog that waits and then simply snaps the fly 

reflexively, we pay particular attention with our 

frog heart in order to develop a synchronized 

resonance with the world. 

Sitting on top of the frog heart is what MacClean 

described as the limbic system and what I call 

the puppy heart. We all have a puppy living 

inside us that drives our immediate urges to find 

security in the moment. The intensity of these 

urges fall into five expressions: excitement, 

hostility, fear-withdrawal, routine-compulsion and 

separation-anxiety. When we are in a threatened 

state, we each have a particular style of barking 

that lets the world know we are insecure. When 

the puppy heart is charged up, it has a downward 

influence on the frog heart: we overeat or don't 

eat at all, we hyperventilate or hold our breath, 

we can’t sleep or we sleep too much and we are 

unable to let go, getting constipated or developing 

loose stools. These are the physical 

manifestations of the over-stressed state; the 

puppy heart bears down on the frog heart causing 

loss of synchrony. 

Above this we have evolved the neocortex, what I 

call the big heart. Big heartedness allows us to 

see ourselves within our context. This drives the 

character that Martin Seligman describes as our 

character strengths and virtues. It is here that 

through our power of imagination, we can regulate 

our puppy heart impulses and shorten recovery 

time. 

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One of the most profound developments in 

neocortical imagination is symbolic language. When 

we can name our feelings, we are able to 

increase the time between feelings and emotional 

expressions. I teach parents to practice simple 

exercises with their children in order enhance 

attention to a wider range of shifting feelings. 

This provides children with more effective tools 

that they can use to communicate their feelings 

with greater security and less need for wild puppy 

barking. 

Creative play is an important way child can 

practice using their big-hearted imagination to 

effectively communicate with the world. Being 

able to imagine what others are feeling is the root 

of empathy. Imagining the effect one is having 

on others is the root of deep self-reflection. 

Imagining the consequences of ones actions is the 

root of heroic perseverance. Imagining one’s own 

death is the root of ethical judgment and moral 

behavior. Each of these big-hearted emotions 

enables a child to be master of her puppy heart. 

A recent study that followed children for 30 years 

clearly demonstrated the importance of developing 

emotional regulation in ultimate outcomes of 

economic success, social success and physical 

health. vii 

I teach children to use the power of 

their imagination in visualization-meditation 

exercises to help them return to a state of clarity 

in feelings. This is the key to mindfulness 

practices that can shorten recovery time from 

strong emotional states. 

In my book, Fire Child Water Child, I describe 

my holistic approach to helping children develop 

their virtues and become masters of attention. viii 

To 

be truly effective, I have found it essential that 

we embrace each child’s unique nature. Nature 

favors diversity. It is the key factor in our 

survival as a species. When we deny our 

diversity, we are forced to constrain our 

expressions and suppress our emotions. This 

leads to deeper distortions in emotional 

expressions. Using the naturalistic language of 

classical Chinese medicine, I describe the five 

adaptive styles: wood, fire, earth, metal and water 

that offer parents an ecological approach to 

enhancing each child’s attention and self-esteem. 

By seeing a child’s urgent emotional expressions 

as a barking cry for help rather than something 

broken, we open our own big hearts to 

compassion which is contagious to everyone 

around us. This is the therapeutic power of 

healing emotions. By empowering our children to 

resonate with the world, we empower the world in 

healthy and enduring ways. 

Stephen Scott Cowan completed his pediatric 

training at St. Luke's-Roosevelt Hospital Center in 

NY in 1987 and went on to complete a 2 year 

fellowship in Child Development at the 

Developmental Disabilities Center at Roosevelt 

Hospital. He is long-standing member of the 

American Board of Pediatrics, a fellow in the 

American Academy of Pediatrics and serves on 

the AAP committee of Developmental Disabilities. 

He is a clinical instructor at NY Medical College 

and has lectured internationally on the holistic 

management of chronic problems in children. He 

is certified in Medical Acupuncture and is a 

member of the American Academy of Medical 

Acupuncture. He is a long time student of 

Chinese medicine, studying with Efrem Korngold 

OMD and Stephen Aung MD. He is a member of 

the Autism Research Institute's Defeat Autism Now 

practitioners. Dr. Cowan is a co-founder and 

advisory board member of the Holistic Pediatric 

Association and serves on the advisory boards of 

the Integrative Health Symposium and the TCM 

World Foundation Building Bridges Conference. In 

1991 Dr. Cowan founded Riverside Pediatrics, in 

Croton, NY with Larry Baskind MD where he 

incorporates alternative therapies in the treatment 

of common childhood disorders. He is also the 

founder of The Westchester Center for Holistic 

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2012 

Families in Mt. Kisco, NY, where he offers holistic 

developmental consultations and treatments that 

include nutritional and biomedical interventions, 

acupuncture, biofeedback, and meditation. He 

specializes in the diagnosis and treatment of 

chronic pediatric problems such as Attention Deficit 

Disorder, Autistic Spectrum Disorders, Tourette's 

syndrome, Asthma and Allergies and Digestive 

disorders. 

Contact Stephen Scott Cowan at 

drstephencowan@gmail.com or 914-864-1976. 

Website: www.stephencowanmd.com 

References: 

i 

Hinshaw S. 2005 The stigmatization of mental 

illness in children and parents: developmental 

issues, family concerns and research needs. 

Journal of child psychol. 46:7 pp 714-734 

ii 

The Harvard Medical Letter 2007 May Bipolar 

disorder in children 

iii 

Greenberg, M. Promoting resilience in Children 

and youth: preventive interventions and their 

interface with neuroscience 2006 

iv 

Szyf, M. The epigenetic impact of early life 

adversity 2009 

v 

Dimassio, A. 1999 The feeling of what 

happens: body, emotion and the making of 

consciousness. 

vi 

MacClean, PD. 1973. A triune concept of the 

brain and behavior. The Hincks Memorial Lectures 

vii 

Moffitt, TE et al. 2011 A gradient of childhood 

self-control predicts health, ealth and public 

safety. PNAS 108 (7): 2693-2698 

viii 

Cowan, S. 2012, Fire Child Water Child, how 

understanding the five types of ADHD can help 

you improve your child’s self-esteem and 

attention. 

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27 

Atherosclerosis, 

Functional Foods, 

and Nutritional 

Genomics 

Micheline Vargas, 

DrPH, CNS, RCEP, 

CSCS 

2012 

INTRODUCTION 

The leading cause of mortality in both men and 

women in the United States is cardiovascular 

disease (CVD) due to atherosclerosis. 

Atherosclerosis involves chronic inflammation and a 

progressive buildup of lipids and fibrous elements 

in the arterial walls. It begins with the formation 

of “fatty streaks”. Fatty streaks can be found in 

the aorta by 10 years of age, in the coronary 

arteries by age 20, and in the cerebral 

vasculature by the age of 40. 1 

Early intervention 

is imperative. Preventive interventions focused on 

managing cholesterol, blood pressure, and weight, 

have been found to favorably alter atherosclerotic 

progression. Unfortunately, less that 50% of the 

cardiovascular events are prevented in the 

treatment groups of the most successful clinical 

trials. 1,2 

In fact, most myocardial infarctions (MI) 

occur in individuals with normal cholesterol levels. 3 

Greater focus on contributing factors (i.e., 

inflammation) involved in the atherosclerotic 

disease process may be helpful in preventing 

cardiovascular events. 

Biological data now demonstrate that most MIs 

occur after atherosclerotic plaque rupture and 

thrombosis (clot) formation. Inflammation can 

threaten plaque stability and increase its propensity 

to rupture and in turn cause thromboses that 

trigger a cardiovascular event. Approximately twothirds 

to three quarters of all fatal coronary 

thromboses are due to rupture of the fibrous cap. 4 

Autopsies show that rupture is more likely to 

occur in plaques with a soft lipid core and a thin 

inflamed fibrous cap. 5 Therefore, the contributing 

factors that lead to the lipid core and inflamed 

cap need to be addressed in an intervention. 

Nutrition therapy can play an integral role in the 

prevention of atherosclerosis and should aim to 

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reduce contributing factors such as low density 

lipoprotein cholesterol (LDL-C) deposition, LDL-C 

oxidation, and chronic inflammation. 

Nutrition plays a key role in reducing risk of CVD 

in populations. Individuals, however, differ 

significantly in the degree to which beneficial 

changes occur. 6 This individual response is likely 

due to differences in genetic makeup, known also 

as genotype. Only recently have medical 

researchers begun to understand how variations in 

genes affect an individual’s health. Personalized 

nutrition, or “nutritional genomics”, uses an 

individual’s unique genetic makeup to make 

recommendations that will potentially reduce risk 

for diseases and/or more effectively manage 

diseases such as atherosclerosis. 

This article will review the importance of nutrition 

in reducing risk for atherosclerosis. Specifically it 

will: 1) review the atherosclerotic process, 2) 

review heart healthy guidelines, 3) discuss how 

functional foods may modulate atherosclerosis and 

CVD risk, and 4) briefly touch on the role of 

nutritional genomics, as it relates to the 

atherosclerotic disease process and CVD. 

REVIEW OF THE ATHEROSCLEROTIC DISEASE PROCESS 

Chronic inflammation of the arterial wall is a wellestablished 

theory in the atherosclerotic disease 

process. 7,8 

Advances in basic and experimental 

science have established that inflammation is 

involved in mediating all stages of this disease 

from initiation through progression and, ultimately, 

to atherosclerotic plaque rupture. 9,10 

These findings 

not only enhance one’s understanding of 

atherosclerosis, but also aid in more appropriate 

targeting of therapy. 8 

Preventive therapies (i.e., 

dietary) that reduce chronic inflammation also 

appear to reduce the risk of CVD. 

The atherosclerotic disease process will be 

described in the steps and figures below as it is 

the basis for dietary treatment approaches. 5,9 

1. Injury to the arterial wall, which may be due 

to one or more risk factor(s) (i.e., 

hypertension, smoking, etc.), triggers an 

inflammatory cascade. Once injured, the 

endothelium (layer of cells that line the inside 

of the artery) will express adhesion molecules 

such as: selectins (E, P, L); vascular cellular 

adhesion molecule -1 (VCAM-1), intracellular 

adhesion molecule-1 (ICAM-1), and 

integrins. Adhesion molecules facilitate 

monocyte (white blood cells that are part of 

the immune system) attachment to the 

endothelium. Their function is just as their 

name implies. They act like an adhesive and 

hold the monocyte down to the endothelium. 

2. The injured endothelial cells will begin 

producing chemoattractants, such as 

monocyte-chemoattractant protein-1 (MCP- 

1), interleukin-8 (IL-8), platelet-activating 

factor (PAF), and leukotriene B 4 (LTB 4). 

Chemoattractants “attract” the monocyte to 

migrate through the endothelium into the 

subendothelial space of the artery wall. Here 

is where much of the action will take place. 

Figure 1: Recruitment of Blood Monocytes 

3. The monocyte, now in the subendothelial 

space, can directly influence the endothelium 

by secreting growth factors, chemotactic 

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substances, and cytokines (signaling molecules 

involved in cellular communication). 

4. Once in the subendothelial space, monocytes 

differentiate into macrophages. Activated 

macrophages express cytokines such as tumor 

necrosis factor alpha (TNF-α) and 

interleukin-1 Beta (IL-1β). These 

inflammatory cytokines further stimulate 

endothelial cells to express adhesion molecules 

(i.e. VCAM-1, ICAM-1) as well as 

additional proinflammatory cytokines. An 

inflammatory cycle is created. 

5. LDL-C infiltrates the extracellular matrix of the 

subendothelial space via passive diffusion and 

the action of specific receptors. Elevated 

serum concentrations of LDL-C, along with 

proinflammatory cytokines, enhance this 

process. The trapped LDL-C become exposed 

to reactive oxygen species (ROS) and 

undergoes oxidation. 

monocytes to the arterial wall which will be 

bound to the artery wall by adhesion 

molecules. The ox-LDL-C will stimulate the 

differentiation of monocytes into macrophages 

by inducing macrophage colony-stimulating 

factor (M-CSF). 

Figure 3: Monocytes Differentiate into 

Macrophages 

Figure 2: Modified LDL-C Stimulates 

Chemoattractants from Endothelial Cells 

7. Macrophages express scavenger receptors, 

which gives them the ability to “scavenge” or 

ingest the ox-LDL-C. The scavenger receptors 

are up-regulated by proinflammatory cytokines. 

The uptake of ox-LDL-C by the macrophages 

results in “foam cells”, a hallmark of 

atherosclerosis. The foam cells die and form 

the soft lipid core of the atherogenic plaque. 

Figure 4: Foam Cell Formation 

6. Oxidation of LDL-C is a major physiological 

mechanism behind the pathophysiology of 

atherosclerosis. The oxidized LDL-C (ox- 

LDL-C) is a powerful inducer of inflammatory 

molecules. It can initiate and promote 

proinflammatory responses within the artery 

wall. The ox-LDL-C can induce 

chemoattractants such as IL-8 and TNF-α. 

These chemoattractants will recruit more 

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8. Cytokines released from foam cells and 

macrophages stimulate smooth muscle cells to 

migrate to the intima. The intima is the 

innermost layer the artery wall. The fibrous 

cap that covers the soft lipid core is created 

by the smooth muscle cells and extracellular 

matrix secretion. Cell proliferation is directly 

stimulated by cytokines and growth factors 

from macrophages, interferon-gamma (IFN-γ) 

from T-cells, elevated homocysteine, and 

increased angiotensin II (a vasoconstrictor). 

9. The vessel is further compromised by 

alterations in vasoactive substances. An 

imbalance between endothelial-derived 

vasodilating (i.e., nitric oxide) and 

vasoconstricting substances (i.e., endothelin-1, 

angiotensin) impairs regulation of vascular 

tone. Normally nitric oxide (NO) inhibits 

leukocyte adhesion, helps maintain nonproliferative 

vascular smooth muscle, and limits 

platelet aggregation. 11 

As production or 

availability of NO is diminished, its ability to 

protect against vascular injury, inflammation, 

and thrombosis is diminished. 

10. As the process continues, macrophages and 

foam cells release fibrogenic mediators (i.e. 

peptide growth factors). These mediators can 

promote smooth muscle cell (SMC) replication 

and contribute to proliferation and production 

of dense extracellular matrix, creating a fibrous 

cap. 5,8,12 

IL-8, which is present in macrophage 

dense areas of the atheroma, can also induce 

proliferation and migration of SMC. 13 

11. The vascular smooth muscle cells (VSMC) 

that accumulate in the intima play a key role 

in the development of the arterial lesion. 

These cells synthesize collagen that stabilizes 

the fibrous cap. However, as the lesion 

progresses VSMC apoptosis occurs, 

contributing to plaque vulnerability. 5 

12. As the atherosclerotic disease process 

continues, the plaque becomes more unstable. 

Foam cells and macrophages produce 

metalloproteinases that contribute to matrix 

degradation. 11 

As the proteolytic enzymes 

degrade the collagen in the fibrous cap, it 

becomes thin, weak, and susceptible to 

rupture. 5,8 

T-lymphocytes are also involved in 

the degradation of the fibrous cap. They 

produce IFN- γ, which can halt the synthesis 

of collagen by the SMC, thereby limiting the 

renewal of collagen and increasing 

susceptibility of the fibrous cap to rupture. 5,12 

13. Once the plaque has been disrupted excessive 

apoptosis of the VSMCs can increase 

thrombogenicity. 5,10 

The VSMCs produce active 

thrombin, which activates platelet adherence. 12 

Macrophages produce tissue factor, which is a 

major procoagulant and can trigger thrombosis. 

Thrombus formation can lead to vessel 

occlusion and trigger a cardiovascular event 

(i.e. MI). 5 

Figure 5: Release of Fibrogenic Mediators and 

Plaque Rupture with Thrombosis 

Inflammation and Adipose Tissue 

Adipose tissue plays an important role in the 

atherosclerotic disease process. Although it will not 

be discussed in detail, it has been briefly 

addressed because of its contributing role in the 

inflammatory and atherosclerotic disease processes. 

Maintaining a healthy body weight, specifically 

maintaining a healthy body composition, is 

important in the prevention and treatment of 

atherosclerosis. Obesity has long been considered 

a risk factor for CVD, due in part, to adipocyte 

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secretion of cytokines that induce a 

proinflammatory state. 

It is now recognized that adipose tissue functions 

in part as an endocrine organ. 14 

It secretes many 

immunomodulatory factors and sends inflammatory 

signals. 15 

Elevated concentrations of TNF-α and 

IL-6 have been found in obese subjects. 16 

This 

proinflammatory state may contribute to the 

atherosclerotic disease process. Dietary 

interventions that aid in body fat reduction may 

reduce proinflammatory cytokines and the 

inflammatory response. This may in turn reduce 

atherosclerotic disease risk. 

GENERAL NUTRITION RECOMMENDATIONS 

Basic heart healthy dietary practices should be 

encouraged. The National Cholesterol Education 

Program (NCEP) has developed dietary 

guidelines (Table 1) for individuals with elevated 

cholesterol, those at risk for cardiovascular 

disease, or those with known cardiovascular 

disease. It should be noted that these guidelines 

are undergoing a revision and should be available 

in 2010. The goal of the current guidelines is to 

decrease total cholesterol (TC) and LDL-C 

levels, while maintaining or increasing high density 

lipoprotein cholesterol (HDL-C) level. 

Desirable/optimal levels of TC, LDL-C, and HDL- 

C can be found in Table 2. The following basic 

principles should be adhered to: 1 

o Eat a variety of fruits, vegetables, and whole 

grain or high fiber foods. 

o Minimize the intake of salt and sugary foods 

and beverages. 

o Dairy products should be fat-free or low-fat. 

o Legumes, lean meats, and poultry without the 

skin are good protein choices. Soy protein 

may be used to replace some animal protein. 

o Fatty fish (i.e., salmon, tuna, mackerel, 

sardines) should be consumed at least twice 

per week. 

o Saturated fat found in butter, cheese, and 

animal fat should be limited. 

o Trans fat, in processed snacks and sweets 

should make up less than 1% of total 

calories. 

o The majority of dietary fat should come from 

monounsaturated and polyunsaturated fats such 

as nuts, seeds, fish and vegetable oils. 

o Most people should limit cholesterol intake to 

less than 300 mg per day. 

o If the LDL-C level is over 100 mg/dL or the 

individual has heart disease, cholesterol intake 

should be less than 200 milligrams a day 

and the individual should follow the “ 

Therapeutic Lifestyle Changes (TLC)” diet 

created by the NCEP (Table 1). 

o Maintain a healthy body weight and body 

composition. 

o The use of functional foods and the support 

of nutritional genomics can further strengthen 

the basic dietary intervention. 

Table 1: TLC Diet 

Nutrient 

Saturated Fat* 

Polyunsaturated 

Fat 

Monounsaturated 

Fat 

Total Fat 

Carbohydrate 

Fiber 

Protein 

Cholesterol* 

Plant 

Stanols/Sterols** 

Increased viscous 

(soluble) fiber** 

Total calories 

(energy) 

Recommendation 

Less than 7% total 

calories 

Up to 10% of total 

calories 

Up to 20% of total 

calories 

25-35% of total calories 

50-60% of total calories 

20-30 grams per day 

Approximately 15% of 

total calories 

Less than 200 mg per 

day 

2 grams per day 

10–25 grams per day 

Prevent weight gain - 

balance energy intake and 

expenditure 

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*LDL-raising nutrients 

**Therapeutic options for LDL-lowering 

Source: American Heart Association 17 

Table 2: Cholesterol Classification (mg/dL) 

Total 

Cholesterol 

Desirable 

< 200 

Borderline high 

200-239 

High 

≥ 240 

LDL 

Cholesterol 

Optimal 


2012 

esters 

Soy 

o Soy protein 

Phytoestrogens 

o Lignans 

Sulfides/Thiols 

o Allyl methyl 

trisulfide, 

diallyl sulfide 

Flavonoids 

o Anthocyanins 

o Flavanols 

(i.e., catechins, 

epigallocatechin) 

o Flavanones 

(i.e., naringenin, 

hesperetin) 

o Flavonols 

(i.e., kaempferol, 

quercetin) 

Isothiocyanates 

o Sulforaphane 

Minerals 

o Potassium 

o Selenium 

Phenolic Acids 

o Caffeic acid, 

ferulic acid 

Vitamins 

o Vitamin C 

dietary supplements 

Soy beans, soy foods, soy 

protein isolate 

Flaxseed, some vegetables, 

rye 

Garlic, leeks, onions, 

scallions 

Berries, cherries, red grapes 

Apples, chocolate, grapes, 

black tea, green tea 

Citrus foods 

Apples, broccoli, onions, tea 

Broccoli, cauliflower, 

cabbage, kale, horseradish 

Bananas, beans, citrus 

juices, cereals, low-fat dairy, 

nuts, potatoes, tomatoes, 

whole grain breads 

Brazil nuts, garlic, grains, 

eggs, fish 

Apples, citrus fruits, coffee, 

pears, some vegetables 

Acerola cherry, citrus fruit, 

kiwi, strawberries, sweet 

o Vitamin E 

red/green pepper 

Almonds, hazelnuts, 

sunflower seeds, turnip 

greens 

ALA - a-linolenic acid; DHA - docosahexaenoic 

acid; EPA - eicosapentaenoic acid; MUFA - 

monounsaturated fatty acids; PUFA - 

polyunsaturated fatty acids 

*Adapted from International Food Information 

Council Foundation Functional Foods Component 

Chart. 21 

Table 4. Functional Foods Involved in Reducing 

LDL-C Deposition, LDL-C Oxidation, Inflammation, 

and Thrombosis 

Benefit 

Improve 

Cholesterol 

Concentration 

Reduce LDL 

Oxidation 

Improve 

Antioxidant 

Defense/Neutralize 

Free Radicals 

Reduce 

Inflammation 

Reduce 

Thrombosis 

Food or Food Components 

Oats, soy, psyllium, flaxseed 

Garlic, CoQ10, antioxidants 

(i.e. vitamin C, E), 

rosehips, green tea 

CoQ10, vitamin C, vitamin 

E, Beta-carotene, selenium, 

grapes, rosehips, 

blueberries, blackberries 

Omega-3 fatty acids, 

grapes, blackberry, blueberry 

Garlic, onion, flaxseed 

Beyond the TLC: Functional Foods with 

Cardiovascular Benefits 

Oats. Oatmeal and oat bran have been widely 

studied for their cholesterol lowering capabilities. 

Statistically significant reductions in TC and LDL-C 

have been seen in hypercholesterolemic patients. 

Based upon a meta-analysis of 20 trials, the 

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intake of 3 grams of soluble fiber (from oats) 

per day resulted in a 5-6 mg/dL reduction of 

plasma cholesterol in hypercholesterolemic 

subjects. 22 

This small reduction in plasma total 

cholesterol has been suggested to be clinically 

significant and likely to reduce risk for coronary 

heart disease by 27%. 23 

A health claim has been 

approved by the U.S. Food and Drug 

Administration (FDA) stating that soluble fiber 

from oat bran may reduce the risk of heart 

disease when added to a diet that is low in 

saturatedfat and cholesterol. Beta glucan, a 

soluble fiber found in oat and barley products, is 

credited for the lipid lowering effects. 

Soy Protein. Hypercholesterolemic patients that 

fortify their diets with soy protein are able to 

significantly lower TC and LDL-C. 1 

Evidence 

exists for the role of soy protein in reducing blood 

cholesterol. 24 

In fact, the FDA has approved a 

health claim based on scientific evidence for soy 

protein and reduced risk of cardiovascular disease. 

The claims reads, “25 grams of soy protein a 

day, as part of a diet low in saturated fat and 

cholesterol, may reduce the risk of heart disease.” 

It should be noted that the FDA is re-evaluating 

this claim due to recent mixed evidence. 

Stanols and Sterols. In 2001 the American Heart 

Association (AHA) released a science advisory 

for healthcare professionals. This advisory 

discussed the possible health benefits of plant 

stanols and sterols in conjunction with a low fat 

diet. The FDA has approved a health claim 

stating that diets low in saturated fat and 

cholesterol that include plant sterol and stanol 

esters may decrease the risk of heart disease 

through the direct link of blood TC and LDL-C. 

Plant sterols and stanols reduce LDL-C by 

interfering with cholesterol absorption. 25 

Consumption of plant stanols and sterols has been 

reported to reduce LDL-C concentrations by 5– 

20%. 24,26 A recent meta-analysis showed an 

association between plant stanol and sterol intake 

and a significant reduction in LDL-C (-12 

mg/dL). This study found a positive dose 

response relationship between LDL-C reduction 

and plant sterols and stanols intake up to 2.5 

gram per day. Doses higher than 2.5 grams per 

day showed little additional benefit. 25 

This dose is 

similar to 2 gram per day dose recommended by 

the AHA. 13 

Psyllium. Psyllium is an excellent source of 

soluble, viscous fiber. Psyllium has been found to 

decrease serum TC and LDL-C. It has 

consistently been shown to normalize or decrease 

blood lipid concentrations in patients with 

hypercholesterolemia and/or type 2 diabetes. The 

FDA has approved a health claim that consuming 

soluble fiber from foods such as psyllium seed 

husk (PSH) in conjunction with a diet low in 

saturated fat and cholesterol may decrease the 

risk of heart disease. To carry this claim a food 

must provide at least 1.7 grams of soluble fiber 

from PSH per serving. 27 

Garlic. Over the last several decades, scientific 

research has been examining the health benefits 

of garlic. Early clinical trials demonstrated very 

promising results. Recently, several of the early 

trials have been criticized for poor design, and 

lack of adequate controls. More rigorous clinical 

trials examining garlic's efficacy have failed to 

reproduce the same magnitude of effects reported 

in some of the early studies. However, when the 

entire body of research is considered, the benefits 

of supplemental garlic powder are apparent, albeit 

of less impact than previously thought. Garlic does 

appear to exert beneficial effects on cardiovascular 

health. 28 

Many clinical trials and several meta-analyses 

have reported significant reductions (2%-25%) in 

TC levels with garlic use. 29-36 

Garlic, however, has 

a number of protective effects independent of 

cholesterol related concentration changes, such as 

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reduced triglycerides, blood pressure, decreased 

platelet aggregation, improved blood flow, 

decreased fibrinogen, and reduced atherosclerotic 

plaque volume. 31,37 

Animal studies have 

demonstrated that purified allicin, an important 

bioactive compound in garlic, can reduce 

atherosclerotic plaque without lowering LDL-C 

concentration. 38 

Other bioactive compounds, such 

as ajoene, allixin, erubosides, S-allyl cysteine, and 

N-acetyl S-allyl cysteine, exist in garlic. Many of 

these compounds have antiplatelet effects, 

antithrombotic effects, and affect the expression of 

endothelial adhesion molecules elevated during 

endothelial injury. In vitro studies have 

demonstrated that several isolated garlic 

compounds reduce the oxidation of LDL-C. 39 

A dose ranging from 600 mg to 1,200 mg per 

day is often seen in clinical trials. This amount 

corresponds to approximately one to two cloves of 

garlic per day. Garlic powder is, however, typically 

used in clinical trials and the dosage is based 

upon the biomarker, alliin. It is recommended that 

the garlic powder be standardized to 1.3% alliin 

for observable health benefits. 40 

In most studies 

garlic powder was taken in multiple doses 

throughout the day rather than as a single dose. 

This may enhance absorption. 

Coenzyme Q 10. Coenzyme Q 10 (CoQ 10), 

commonly known as ubiquinone, is a vital cofactor 

in the electron-transport chain. Therefore, CoQ 10 

plays an important role in the energy metabolism 

of food as well as cellular energy production. 41,42 

Tissues with high energy needs or high metabolic 

activity, such as the heart, contain high levels of 

CoQ10. 43 

It is therefore not surprising that the 

therapeutic effects of CoQ 10 have been studied in 

patient with cardiovascular disease. It has been 

reported that individuals with cardiovascular 

disease have abnormal concentrations of CoQ 10. 44 

Preliminary research demonstrated an association 

between tissue levels of CoQ 10 and congestive 

heart failure (CHF). Some studies found 

improvements in ejection fraction, stroke volume, 

cardiac index, and exercise tolerance. 

Unfortunately, not all studies have shown 

improvements. This may be attributed to poor 

study design in early research. Additional evidence 

from in-vitro, animal, and human studies, 

however, does suggest CoQ 10 supplementation 

improves cardiovascular health. 45-49 

Benefits of CoQ 10 may be attributed, at least in 

part, to its antioxidant capabilities. In its reduced 

form, CoQ 10 (ubiquinol), acts as an antioxidant 

protecting biological membranes from free 

radicals. 50,51 

It effectively scavenges superoxide 

radicals. 52 

CoQ 10 is effective in protecting against 

oxygen-generated damage to cellular membranes 

and lipid transport molecules (lipoproteins). 53-55 

Preliminary evidence suggests that supplemental 

CoQ 10 may also mitigate statin (HMG-CoA 

reductase inhibitors) induced myotoxicity. Blood 

CoQ 10 concentrations are reduced by statin 

therapy. Statins inhibit cholesterol synthesis by 

inhibiting HMG-CoA reductase and the mevalonate 

pathway. 53 

CoQ 10 is synthesized from mevalonate 

and tyrosine. It is one of several end products of 

the mevalonate pathway. Hence, the inhibition of 

the mevalonate pathway by statins will reduce 

CoQ 10 synthesis. This reduction in CoQ 10 may 

contribute to myotoxicity via reduced mitochondrial 

metabolism. CoQ 10 supplementation has been 

found to increase CoQ 10 concentrations and may 

lessen the muscle damaging effects of statins. 

Routine use in all patients taking statins is, 

however, not recommended due to a lack of 

clinical documentation. 53 

Normal plasma levels typically fall between 0.7- 

1.0 µg/mL. 56 A 30-60 mg per day dose 

appears to maintain this level. 57 

Plasma levels 

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typically need to reach a level between 2-3 

µg/mL to stimulate a clinical effect. 56,58 A 100- 

200 mg per day dose appears to be required to 

reach a clinically effective plasma level. 58 

It may 

take several weeks to reach a value greater than 

2.5 µg/mL. 56 

Omega 3 Fatty Acids. Unsaturated fatty acids are 

receiving increasing attention as potential antiinflammatory 

and anti-atherogenic agents. 60 

Omega-3 polyunsaturated fatty acids (PUFA) in 

particular appear to possess the most potent 

immunomodulatory activities. Among the omega-3 

PUFA, the long-chain PUFA from fish oil, 

eicosapentaenoic acid (EPA) and 

docosahexaenoic acid (DHA) appear to be more 

biologically potent that a-linolenic acid (ALA). 

Effects brought about by omega-3 PUFA may be 

due to their ability to modulate the amount and 

types of eicosanoids made, but they also elicit 

eicosanoid-independent mechanisms. 61 

Omega-3 

PUFA appear to reduce endothelial expression of 

inflammatory markers such as, VCAM-1, ICAM-1, 

E-selectin, IL-1β, IL-6, IL-8, and TNF-α. 62-66 

Based on these anti-inflammatory effects, 

supplementation with omega-3 fatty acids 

theoretically has an antiatherogenic and plaque 

stabilizing effect. 

Numerous studies have found supplementation to 

reduce cardiovascular disease risk. Population 

studies globally have shown protective relationships 

between omega-3 fatty acids and CVD. Results 

from large-scale epidemiological studies and 

clinical trials suggest fish consumption or fish oil 

supplementation lead to reduced incidence of 

coronary heart disease, 67 

reduced risk of sudden 

cardiac death, 63,68,69 

and reduced all-cause 

mortality and coronary mortality. 70 

Based on 

existing evidence the FDA permitted a qualified 

health claim for foods and dietary supplements 

containing EPA and DHA and the reduced risk of 

coronary heart disease. 71,72 

The amount of omega-3 fatty acids that should 

be consumed depends on an individual’s health 

status. The American Heart Association makes fish 

and omega-3 fatty acid recommendations based 

on the population. These recommendations can be 

found in the following Table 5. 17 

Table 5. Recommendations for fish and omega-3 

fatty acid intake 

Population 

Patients without 

documented CVD 

Patients with 

documented CVD 

Patients who need to 

lower triglycerides 

AHA Recommendation 

Eat a variety of fatty fish 

at least 2 days per week. 

Consume approximately 1 

g of EPA + DHA per day † 

Consume approximately 2- 

4 g of EPA + DHA per 

day ‡ 

† 

Consult physician prior to supplementing 

‡ 

Provided in capsules under a physician’s care 

Antioxidants. Antioxidants are thought to inhibit 

atherogenesis and improve vascular function. They 

improve biologic activity of endothelial derived NO 

and help to dispose of reactive oxygen species 

(ROS). 1 In-vitro studies have found α - 

tocopherol to directly inhibit atherogenic 

mechanisms including monocyte release of ROS, 

monocyte-endothelial cell adhesion, IL-1 and 

TNF-α cytokine release, LDL oxidation, , platelet 

adhesion, and smooth muscle cell proliferation. 1 

Consumption of both vitamin E and vitamin C 

appears to provide greater antioxidant benefit than 

ingestion of either vitamin alone. 1,73,74 

The 

antioxidant selenium has an inverse relationship 

with both atherosclerosis 75 

and cardiovascular 

mortality. 76 

Selenium is a cofactor for glutathione 

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peroxidase, a critical enzyme involved in catalyzing 

the reduction of endothelial cell membrane 

oxidants (i.e., lipid hydroperoxides) to less 

reactive alcohols. 1 

Grapes (wine, juice, skins, 

seeds, resveratrol). Red grape skins and red wine 

contain many polyphenolic compounds, including 

pro-anthocyanidins, trans-resveratrol, and 

flavonoids such as kaempferol, catechins, and 

quercetin. 77 

These act as antioxidants. Resveratrol, 

in addition to its antioxidant effects, has antiinflammatory 

properties, can cause blood vessel 

dilation, and can inhibit platelet aggregation. 

Resveratrol has been shown to reduce 

inflammation in animal studies, in part, by 

reducing IL-1, TNF-, and PGE2. 77 

Grapeseed extract has been found useful in ways 

similar to other grape products. Grape seeds have 

a high content of catechins and proanthocyanidins; 

both are members of the flavonoid 

family and function as powerful antioxidants. 78-80 

The ability of grape seed extract to scavenge free 

radicals is reportedly better than that observed 

with vitamins C, E, and beta-carotene. 81 

Grape 

seed extract has also been shown to relax the 

endothelium via release of nitric oxide. 82-84 

Pro-anthocyanidins, found in grape seed extract, 

scavenge free radicals and prevent peroxidation of 

lipid membranes. 85,86 

Pro-anthocyanidins may help 

protect the integrity of vascular structures and they 

may reduce atherogenic factors such as blood 

pressure, cholesterol levels and the aggregation of 

clotting factors (platelets) in the blood. 87,88 

Rosehips, Blueberries, and Blackberries. Rosehips, 

blueberries, and blackberries have a number of 

heart healthy benefits. 89,90 

Rose hips are high in 

vitamin C, have high phenolic content, and 

scavenge free radicals (i.e. superoxide). 91 

Rose 

hips extract may also support cardiovascular health 

by limiting lipid oxidation and reducing the 

chemotaxis of leukocytes. 92,93 

In an animal model, 

blackberry extract reduced ICAM-1 expression. 

This may be one mechanism by which blackberry 

extract reduces the inflammatory process. 94 

In vitro 

studies further show that blackberry extract 

scavenges peroxynitrite free radicals to protect 

against endothelial dysfunction and reduces C- 

reactive protein (CRP). 91,95,96 Blueberry extract 

contains anthocyanins and hydroxycinnamic acid, 

which impact the inflammatory response in vitro. 97 

Anthocyanins appear to inhibit the expression of 

IL-8, MCP-1, and ICAM-1, while 

hydroxycinnamic acids inhibit the expression of IL- 

8 and ICAM-1. 98 

One botanical formulation discussed in the 

nutritional genomics section of this article found a 

botanical formulation containing rosehips extract 

(1200 mg/d), grape extract (40 mg/d), 

blackberry powder(165 mg/d), and blueberry 

powder (330 mg/d) effectively targeted mediators 

involved in the atherosclerotic disease process. 94 

NUTRITIONAL GENOMICS 

What is Nutritional Genomics? 

The wealth of information generated by the 

Human Genome Project combined with recent 

advances in molecular biology have fostered the 

emergence of nutritional genomics. Nutritional 

genomics is a new discipline in the field of 

nutrition science. This new discipline is paving the 

way for personalized nutrition as more associations 

between dietary components and gene variants are 

identified. 99 

It is anticipated that nutritional 

genomics will play a major role in disease 

prevention. Research in this area will lead to 

greater use of existing foods, food components, 

and novel foods in the prevention and treatment 

of atherosclerosis and other chronic disorders. 

There is a two-way interaction between genes 

and components in food. A person’s genetic 

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makeup determines how well they can use various 

food components to support health. The study of 

how individual genotypes determine a person’s 

response to food components is called 

nutrigenetics. Conversely, nutrients and other food 

components influence gene expression and the 

production of the proteins encoded in the genes. 

Essential nutrients (i.e. macronutrients, 

micronutrients), other bioactive substances (i.e. 

phytochemicals), and metabolites from food 

components (i.e. eicosanoids), and xenobiotics 

are all dietary components that can influence gene 

expression. 100 

Genes are exposed to nutrients in 

foods throughout life. Hence, diet is a critical 

environmental factor that influences gene 

expression. Bottom line, gene expression plays a 

major role in our very existence. Nutrients affect 

gene expression and formation of proteins that 

serve as hormones, enzymes, oxygen transporters, 

and building blocks for cells. Hence, the amount 

and the form of nutrients present during gene 

expression can alter protein synthesis and thereby 

affect health. The study of how food components 

influence gene expression is called nutrigenomics. 

Nutritional Genomics, Inflammation, and CVD 

Dietary recommendations, such as those set forth 

by the NCEP, have been found effective in 

populations. Individuals, however, respond 

differently to the treatment. This may be due to 

genetic variations within the population. Recent 

scientific evidence indicates that some CVD, 

including MI, is due to inherited gene variations. 

Genetic susceptibility may lead to more severe or 

earlier CVD. Some of these variants are 

susceptible to dietary intervention. 93,101 Nutritional 

genomics, sometimes called “personalized nutrition” 

, uses an individual’s unique genetic makeup to 

make recommendations. 

Some individuals have a genetic predisposition for 

over-expression of inflammation. Genetic 

susceptibility to overexpression of the IL1 genes, 

for example, may lead to more severe or earlier 

CVD. 7 

IL1 plays a key role in regulating and 

coordinating inflammation. 102 

In an inflammatory 

response the IL1 gene is one of the first to be 

activated. It activates other proinflammatory cells, 

proteins and other molecules. It is responsible for 

activating other cytokines and chemical 

messengers that will maintain the inflammatory 

response. 93 

Small differences in the activation of 

the IL1 gene can have a significant effect on how 

powerfully the inflammatory system responds. 93,103 

Evidence now shows that people that test positive 

for the IL1 risk pattern also have elevated CRP 

levels and individuals with elevated CRP levels 

are at increased risk for CVD. 104,105 

This 

knowledge can help the nutrition or healthcare 

provider develop a personalized nutrition plan. 

What’s Out There Now? 

Scientists are discovering new ways to uncover 

diet-gene interactions at the molecular level. One 

company, for example, has created a genetic test 

that analyzes two IL1 genes that lead to overexpression 

of inflammation and risk for CVD. 

Testing positive for these genes does not mean 

that the individual will develop cardiovascular 

disease, but it does let them know they are at 

greater risk. Nutritional interventions, including 

nutritional genomics supplements, designed to 

target these genes and reduce inflammation may 

improve cardiovascular health. 

Scientists are discovering gene-disease 

associations at a steady pace, investigating the 

molecular mechanisms, and identifying the 

influence of gene variants on disease susceptibility. 

The goal here is to identify gene variants that are 

strongly associated with risk for particular diseases 

so that disease susceptibility can be detected 

early in life and appropriate action taken to 

minimize risk. Additionally, gene-diet associations 

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2012 

are being detected that link gene variants and diet 

and lifestyle approaches that provide guidance for 

decreasing disease susceptibility. 

Numerous genes, gene variants, disease, and 

diet/lifestyle approach associations have been 

detected to date. Since inflammation is a major 

predisposing factor in the development of 

cardiovascular disease, the IL1 gene family is 

being studied in an attempt to identify gene 

variants that increase the risk of developing 

cardiovascular disease and diet and lifestyle 

approaches that target these gene variants, 

thereby decreasing this risk. 

Nutritional genomics is also facilitating research 

and development of novel nutraceuticals and 

functional foods that target mediators involved in 

the atherosclerotic disease process. One study 

demonstrated that a botanical formulation 

containing rosehips extract (1200 mg/d), grape 

extract (40 mg/d), blackberry powder (165 

mg/d), and blueberry powder (330 mg/d) could 

influence expression of the IL1B gene. 93 The 

mixture significantly decreased IL1B gene 

expression and CRP levels in healthy individuals 

with gene variants associated with over expression 

of the IL1 cytokine. These results suggest that 

dietary approaches can influence gene expression 

and thereby, decrease the magnitude of 

inflammation and risk of developing CVD. 93 

Evolving and powerful genomic technologies are 

shaping the field of nutritional genomics. As this 

research advances and the mystery behind genediet 

interactions unfolds, strategies for more 

personalized and more effective nutrition therapies 

will be developed. A few novel products have 

already hit the market place. As the science 

behind nutritional genomics evolves, we can 

expect new strategies for preventing and treating 

atherosclerosis. 

TAKE HOME MESSAGE 

Prevention and treatment of atherosclerosis is 

accomplished by interventions that attempt to 

reduce LDL-C, oxidation of LDL-C, inflammation, 

and thrombogenesis. Functional foods appear to 

provide protection in each of these areas and can 

help tailor a diet to address the special needs of 

an individual. The emerging field of nutritional 

genomics can further help a dietitian determine a 

patient’s individual needs based on his or her 

unique genetic makeup. This knowledge will allow 

for a more personalized and effective nutrition 

plan. 

Thanks to Sarah Harding Laidlaw, MS, RD, CDE, 

Newsletter Editor of the Dietitians in Integrative 

and Functional Medicine Practice Group of the 

Academy of Nutrition and Dietetics. 

Reprinted with permission: Vargas, M. 

Atherosclerosis, Functional Foods, and Nutritional 

Genomics. Dietitians in Integrative and Functional 

Medicine. 2009;13:22-30. 

Micheline Vargas is owner and CEO of Lifestyle 

Therapy Resource Inc., a health and wellness 

consulting company. She specializes in the 

prevention and treatment of chronic diseases 

including obesity. She is an advisor to the Center 

of Optimal Health in Buena Park California, a 

speaker, and an author. Dr. Vargas is an 

Instructor for UCLA Extensions where she will be 

teaching courses in Food, Mood, and Eating 

Behaviors and Exercise and Sports Nutrition. She 

is also a sports nutritionist. She has provided 

nutritional counseling to collegiate sports teams 

and professional athletes. She is currently 

working with two professional sports teams – 

Detroit Red Wings Hockey Team and AC Milan 

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2012 

Soccer Team in Italy. 

Dr. Vargas was a Research Scientist in the 

Supplement Product Development Department at 

the Nutrilite Health Institute. Her research 

emphasized the development of botanical products 

with functional properties designed to maintain 

health and well-being. She supported many 

product lines including, sports supplements, weight 

management, heart health, women's health, and 

men's health. 

Prior to joining Nutrilite, Dr. Vargas was a 

professor at California State University, 

Fullerton. She taught courses in nutrition, clinical 

exercise physiology, and health. She was also an 

adjunct faculty member at Loma Linda University 

where she taught a course in electrocardiography 

(ECG). Dr. Vargas worked as a Clinical 

Exercise Physiologist in Cardiac 

Rehabilitation. She also worked as a Preventive 

Care Specialist, where she provided lifestyle 

therapy to weight management patients. Dr. 

Vargas has authored manuscripts on weight 

management; atherosclerosis, functional foods, and 

nutritional genomics; and the relationship between 

CRP, metabolic syndrome, and exercise. 

Dr. Vargas is a Certified Nutrition Specialist 

(CNS), Registered Clinical Exercise Physiologist 

(RCEP), Certified Strength and Conditioning 

Specialist (CSCS), and an Emotional Brain 

Training (EBT) provider. She held a certification 

as a Group Exercise Instructor from the American 

Council on Exercise for 14 years. She holds 

professional memberships with the American 

College of Sports Medicine, the American College 

of Lifestyle Medicine, the Obesity Society, and the 

American Society for Nutrition. Aside from her 

scientific interests she is an avid runner, has 

participated in triathlon, and loves Pilates and 

yoga. 

Contact Micheline Vargas at 

micheline.vargas@yahoo.com or 818-383-4664. 

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Integrative 

Cardiology: 

Nutrition, 

Nutraceuticals and 

Enhancing 

Resiliency in 

Cardiovascular 

Disease 

Erminia “Mimi” 

Guarneri, MD, FACC 

Poulina Q. Uddin, 

MD 

Introduction: 

Cardiovascular disease is one of the most 

prevalent lifelong diseases, affecting over 50% of 

the population, and increasing in incidence every 

year. Despite major medical advances such as 

coronary stenting and statin therapy, cardiovascular 

disease still accounts for one out of every six 

deaths in Americans. The risk factors for having 

an acute myocardial infarction were clearly 

summarized in the Interheart Study (Ogden et al. 

2006). These factors (smoking, elevated 

ApoB/ApoA1 ratio, hypertension, diabetes, 

abdominal obesity, psychosocial factors, 

consumption of fruits and vegetables, regular 

alcohol consumption, lack of regular physical 

activity) were found to account for over 90% of 

cardiovascular risk. If you review Interheart, you 

will note that the identified risk factors extend 

beyond what is currently assessed by the 

Framingham score. Psychosocial risk in Interheart 

was as powerful a predictor of a cardiac event as 

mid-line obesity and hypertension. 

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At the Scripps Center for Integrative Medicine we 

have used Interheart as a road map to design 

programs that address all risk factors for 

cardiovascular disease from nutrition and physical 

activity to depression, anxiety and maladaptive 

responses to stress and tension. We take a 

holistic approach which addresses the entire 

person; body, mind, emotions and spirit. When 

considering an integrative holistic approach, one 

takes into account not only genetic and social 

predispositions, but emotional, environmental, and 

spiritual contributions as well. We now know that 

epigenetics plays a crucial role in manifesting and 

preventing disease and that seventy to ninety 

percent of chronic disease is related to lifestyle. 

Only when the entire spectrum of disease causing 

factors is addressed can we achieve a true and 

effective strategy for the care of patients with 

cardiovascular disease, and effect a true 

improvement in their quality of life. 

Nutrition: 

There is no question that diet and nutrition are 

the essential building blocks of good health. 

Hippocrates the father of medicine taught “food is 

medicine” and an ancient Ayurvedic proverb states 

“with proper food, medicine is of no need”. With 

regard to cardiovascular health the effects are 

tangible and apparent, with hard clinical endpoints 

such as myocardial infarction, heart failure, 

hypertension, obesity and cardiovascular mortality. 

There have been numerous epidemiologic studies 

highlighting the effect of diet on individuals even 

after accounting for genetic predisposition and 

variations among ethnic groups. 

One of the largest early epidemiological studies 

was conducted by Chen et al. in 1990, which 

followed over 10,000 individuals in China and the 

United States. The U.S. diet was found to be 

twice as high in fat, three times lower in fiber in 

and significantly higher in animal protein. This 

study also demonstrated that there was a 16.7 

fold increase in deaths from heart disease in men, 

and a 5.6 fold increase for women with notably 

higher rates of cancer, diabetes and hypertension 

in the U.S. population. More importantly, Asian 

immigrants adapting a standard American diet 

matched the American levels of heart disease 

within just two generations (Chen et al. 1990). 

The impact of diet was also highlighted by the 

pivotal Lyon Diet Heart Study, a randomized 

control trial which assessed the benefits of a 

Mediterranean diet for secondary prevention in 

cardiovascular disease. Individuals with a prior 

myocardial infarction (MI) were placed on a 

Mediterranean diet rich in fruits, vegetables, fish, 

oils high in -linolenic acid, and less red meat 

(n=302) compared to a standard diet (n=303). 

The benefits of the Mediterranean diet were 

profound, with a 50-70% reduction in recurrent 

cardiac events at as early as 46 months. The 

results were so compelling that the study was 

actually terminated early (Kris –Etherton et al. 

2001). These findings were reproduced in 

subsequent studies such as the HALE project, 

which concluded “Among individuals aged 70 to 

90 years, adherence to a Mediterranean diet and 

healthful lifestyle is associated with a more than 

50% lower rate of all-causes and cause-specific 

mortality” (Knoops et al. 2004). 

Earlier trials, simply evaluating the benefits of 

increasing dietary fruits and vegetables 

demonstrated similar positive health impacts in 

several risk factors for cardiovascular disease. In 

one study of 459 adults, the investigators found 

that “A diet rich in fruits, vegetables and low fat 

dairy foods and with reduced saturated and total 

fat can substantially lower blood pressure 

(p < 0.001) (Appel et al. 1997.) Similarly, 

the Nurse’s Health Study and Health 

Professional’s Follow up study conducted in over 

84,000 women for 14 years and over 42,000 

men for 8 years demonstrated, observationally, 

that “Consumption of fruits and vegetables, 

particularly green leafy vegetables and Vitamin C 

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rich fruits appears to have a protective effect 

against coronary heart disease” (Joshipura et al. 

2001). Other studies have shown similar benefits 

in the reduction of stroke. 

The similarity among all these nutritional 

approaches is the emphasis on incorporating high 

amounts of whole foods that are low on the 

glycemic index, low in saturated fat and antiinflammatory. 

Inflammation is a risk factor for 

cardiovascular disease and is clearly linked to 

nutrition. Foods such as cured red meats, sugar, 

simple carbohydrates and food sensitivity can lead 

to inflammation. The Mediterranean diet which is 

high in fruits, vegetables, beans and olive oil has 

been shown to decrease markers for inflammation 

such as IL6, IL 18, hsCRP and improve insulin 

resistance. The Mediterranean diet has also been 

shown to slow progression of Alzheimer’s disease 

which has also been linked with inflammation 

(Scarmeas et al 2006). The inclusion of whole 

foods and beneficial bioactive or medicinal foods 

(almonds, fiber, green tea, soy, oats, berries, 

dark chocolate) can help decrease cholesterol, 

blood pressure and blood sugar. 

Natural Supplements: 

Unfortunately, the industrialization of food has left 

the Standard American Diet void of micronutrients 

and high in sodium and omega 6. The omega 

6/omega 3 ratio is as high as 50:1 largely due 

to the high utilization of high fructose corn syrup 

as a food additive. Furthermore, the industrialized 

food system and current agricultural practices have 

significantly depleted the soil of essential vitamins 

and minerals. Refined foods have lost their 

medical quality and are high on the glycemic 

index leading to inflammation. Over 68% of the 

population is deficient in minerals such as 

magnesium and an equal percentage is deficient 

in vitamin D. 

Certain supplements are fundamental to our 

cardiovascular practice. The approach we take in 

lipid management is: disorders determine 

treatment. All patients are treated with an antiinflammatory, 

low glycemic index diet. Protein 

sources are preferably plant based. Physical 

activity is essential to maintaining ideal body 

weight and to decrease blood pressure, blood 

sugar and triglycerides. Supplements and 

pharmaceuticals are used to further achieve lipid 

goals. For example, an isolated LDL elevation 

may be managed with statin therapy, Zetia, red 

yeast rice, artichoke extract, citrus bergamot, plant 

sterols and fiber. A low HDL and high 

triglycerides would be managed with omega three 

fatty acids, niacin and on occasion fenofibrates. 

Combination therapy is frequently used. The 

following vitamins, minerals and supplements are 

commonly used in our cardiology practice but 

represent only a small sample of what is currently 

available to achieve our goals. 

Omega Three Fatty Acids 

One of the most commonly used supplements for 

cardiovascular health is omega three fatty acids. 

Observational and epidemiological studies in the 

past have demonstrated the association of fish 

consumption with reduced cardiovascular events. 

A review by Stone el al indicated that men who 

consume fish at least three times weekly had 

lower rates of coronary heart disease and mortality 

then men who did not (Stone 1996). Further 

observational studies have also shown a positive 

dose response with fish consumption and 

cardiovascular disease risk factors such as obesity, 

hypertension, and diabetes. More recently, the 

Nurses’ Health study demonstrated a dose 

responsiveness as well, comparing coronary heart 

disease death rates in women who consumed fish 

or omega3 less than one time per month, to 

those women who consumed fish or omega3 one 

to three times per month, once per week, 2-4 

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times per week, and greater than five times per 

week. The reduction in CHD related death for 

those who consumed the omega3 was found to 

be 21%, 29%, 31%, and 34% respectively as 

the fish consumption was increased (Kris-Etherton 

et al 2002). 

The positive associations and potential health 

benefits of omega 3, are also apparent when 

reviewing the randomized controlled trials. The 

strongest evidence in the form of randomized 

controlled trial is gleaned from the DART, GISSI, 

and JELIS trials. The DART trial demonstrated a 

29% reduction in all-cause mortality with 200- 

400g of fish per week, estimated to provide 

500-800mg per day of omega3. A post hocanalysis 

of those who received fish oil 

supplements (900mg per day of EPA+DHA) 

suggested a cardioprotective effect (Burr et al. 

1989). These findings were supported by the 

GISSI- Prevention Study wherein 11,324 patients 

were treated with Vitamin E 300mg versus 

Omega3 850mg. At 3.5 years, there was a 

15% reduction in the primary endpoint of death, 

nonfatal myocardial infarction, stroke, a 20% 

reduction in all-cause mortality, and 45% 

reduction in sudden cardiac death in the Omega3 

group (Hooper et al. 1999). Similarly, the Japan 

Eicosapentaenoic acid (EPA) Lipid Intervention 

Study (JELIS) was conducted in 18,645 patients 

in Japan with hyperlipidemia who consumed large 

amounts of fish at baseline. Individuals were 

treated with a statin plus 1800mg EPA versus 

statin alone for 5 years. Those on combination 

statin and EPA therapy had a 19% relative 

reduction in major adverse cardiovascular events 

(Yokoyama et al. 2007). 

These generally widely accepted benefits were 

recently called into question with the publication of 

the recent New England Journal of Medicine trial 

in 2010 (n-3 Fatty Acids and Cardiovascular 

Events after Myocardial Infarction). In this 

randomized controlled trial of 4,837 post MI 

patients age 60-80, subjects were randomized to 

receive omega3 in the form of margarine - 

EPA/DHA 400mg, -linolenic acid 2g (plant 

based), EPA/DHA & -linolenic acid, and 

placebo margarine. As expected, at such small 

doses, no benefit was apparent in the primary 

endpoint of fatal and nonfatal cardiac events or 

need for cardiac interventions (Kromhout et al. 

2010). 

What these important trials high light, is that there 

is not only a benefit, but perhaps there is a true 

dose threshold of the ideal amount of EPA/DHA. 

Unfortunately, these studies did not measure 

omega6/omega3 ratios which can vary 

significantly from person to person. Currently, the 

recommended dose of EPA and DHA is 900 mg 

per day for primary or secondary prevention, but 

for treatment of hypertriglyceridemia 1000- 

4000mg per day is recommended. Lovaza is 

FDA approved for the treatment of 

hypertriglyceridemia. A 4 gram dose of Lovaza 

per day is associated with a 45% reduction in 

triglycerides. Of course, one of the greatest 

challenges we face in the use of fish oil is the 

exploitation of our ocean resources. More 

sustainable omega 3 sources will have to be 

obtained in addition to limiting the amount of 

omega 6 in the diet. The later seems more 

reasonable. 

Niacin(Vitamin B3) 

Niacin has recently received some unfavorable 

press with the publication of the recent AIM-High 

data in the NEJM, in 2011. This trial, set out 

to assess the rate of coronary heart disease, 

non-fatal myocardial infarction, ischemic stroke, 

hospitalization > 23hr for ACS and symptom 

driven coronary or cerebral revascularization over a 

36 month period in 3,414 patients randomized to 

niacin 1500-1800 mg per day in addition to 

simvastatin 40-80 as compared to statin alone. 

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The trial was terminated early due to a lack of 

clear benefit in the niacin group. However, when 

examined more closely, it appears that the event 

rate overall was much lower than anticipated, and 

the population chosen was relatively low risk 

overall (average LDL=60) when compared to 

prior studies and compared to the general 

population. There was in fact a favorable benefit 

in the lipid profile with an increase in HDL from 

35-42 at 2 years, a reduction in triglycerides 

from 164 to 122, and reduced LDL from 74 to 

62, with the bulk of benefit occurring within the 

first year. Many questions have been raised 

regarding this research because of the low LDL at 

baseline from statin therapy and the small 

increase in HDL. Prior well established studies, 

such as Framingham, the Coronary Drug Project, 

the HATS trial, and ARBITER 2 have all pointed 

toward increased cardiovascular events in people 

with low HDL. The Coronary Drug Project, an 

early randomized controlled trial with long term 

follow up compared 5 drug regimens in males 

with prior MI, one of which was niacin. With 3 

grams of Niacin per day (n=1119) versus 

placebo (n=2787) there was a notable reduction 

in total cholesterol by 10%, triglycerides by 27% 

and a reduction of MI at 5 years. Over 15 years 

there was a 4% absolute reduction in mortality 

(Canner et al. 1986). 

Previously, Niacin has been shown to have a 

broad range of beneficial effects on the lipid 

panel, lowering LDL and Lp(a), shifting to more 

favorable particle size, and raising HDL. These 

benefits appear to be dose-dependent, and the 

current recommendation is 1000-2000 mg per 

day. 

Red Yeast Rice 

Red Yeast Rice (RYR) is a useful alternative for 

LDL lowering, particularly for those patients who 

are reluctant to take statin medication. RYR is an 

end product of the yeast (Monascus purpureus) 

which grows on certain grains of rice. Red yeast 

rice acts as an HMG-CoA reductase inhibitor, and 

is in fact chemically identical to lovastatin in some 

purifications. Numerous studies have validated its 

use, demonstrating reductions in LDL of 20-30%. 

RYR is well tolerated. Halbert compared RYR 

2400mg daily to pravastatin 20 mg daily in 43 

patients with a history of statin induced myalgia. 

At 12 weeks, the rate of discontinuation due to 

myopathy was 5% in the RYR group versus 9% 

in the pravastatin group, both demonstrating a 

27-30% reduction in LDL (Halbert et al. 2010) 

RYR has the same side effect profile as statin 

therapy. Patients should be monitored for 

myopathy and liver enzyme abnormalities. In 

patients with a history of statin induced myopathy 

red yeast rice should be used with caution and at 

lower doses. 

Garlic 

Garlic’s greatest role is in hypertension, with 

research demonstrating a reduction in systolic 

blood pressure by ~8%, and diastolic blood 

pressure by ~7%. The current recommendation for 

garlic is 600-900mg/day powder, or 2400mg 

daily of aged garlic extract. For those who prefer 

garlic as a food this is equivalent to four cloves 

of raw whole garlic per day. 

Vitamin D 

Although the mechanism is not fully understood, a 

number of previous epidemiological studies have 

associated low vitamin D levels with increased 

adverse cardiac events and increased mortality. 

Proposed mechanisms range from impaired cardiac 

contractility to effects on the renin-angiotensinaldosterone 

system, and even in glycemic control. 

The NHANES study 1998-1994 surveys found 

that Vitamin D < 20 was associated with a 

higher level of self-reported angina, myocardial 

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2012 

infarction or congestive heart failure. A more 

recent follow up NHANES survey from 2000- 

2004, corroborated this, in addition to adding 

peripheral vascular disease. Cohort studies support 

this data; in the Health Professionals Follow up 

study, a 10 year follow up of men with Vitamin 

D < 15 were found to have a 2 fold increase in 

myocardial infarction (Giovannuci et al 2008). 

Similarly, in the Framingham offspring study, 

individuals with severe Vitamin D deficiency 15. Additional studies have demonstrated that 

low Vitamin D levels are associated with 

hypertension, as in the Nurses’ Health Study 

(Forman et al. 2007). 

With regard to randomized control trials, the data 

is still inconclusive regarding the benefit of 

supplementation. Not only is the dose unclear, but 

the target serum levels are not agreed upon. 

There have, however been studies demonstrating 

a reduction in systolic blood pressure with 800IU 

of Vitamin D supplementation (Pfeifer et al. 

2001). The most recent RECORD trial (Avenell 

et al. 2012) which randomized over 5000 

individuals to either 800 IU of Vitamin D, 

1000mg of calcium, both, or placebo did not 

show a statistically significant benefit in the 

reduction of all-cause mortality, vascular mortality, 

or cancer incidence. Again, however the target 

dose and ideal serum level is still not well 

established. 

At the current time, there are no clear guidelines 

regarding the use or proper dose of Vitamin D for 

primary or secondary prevention of cardiovascular 

disease, despite the numerous observational 

studies linking vitamin D deficiency to increased 

adverse cardiovascular events. In our practice, we 

recommend a goal of at least 55ng/mL for serum 

levels, particularly for those at an increased risk 

for osteoporosis and breast cancer. Low vitamin D 

levels have been linked to depression, an 

independent risk factor for cardiovascular disease 

making treatment even more compelling. 

Magnesium 

Magnesium is one of the most important 

cardiovascular minerals. In the acute care setting, 

magnesium is used to treat malignant arrhythmias, 

preeclampsia, and constipation. Magnesium has a 

critical role in nearly all cellular functions, and oral 

magnesium has been shown to act as a calcium 

channel blocker, increase nitric oxide, and 

improves endothelial function. Magnesium has a 

role in the reduction of arrhythmia, sudden death, 

ventricular ectopy (DelGobbo et al, 2012 PVCs), 

palpitations, hypertension, hs-CRP, and metabolic 

syndrome. As with vitamin D, there is no 

consensus on the ideal amount or levels to attain 

with routine supplementation. This is complicated 

by the fact that serum magnesium levels do not 

reflect intracellular magnesium concentration. For 

an accurate assessment of bioavailable magnesium 

we measure intracellular RBC magnesium levels. 

In observational studies, a dietary intake of 500- 

1000mg per day appeared to be associated with 

reduced blood pressure (Houston 2011). 

Micronutrients in CHF 

In addition to the nutrients achieved through a 

diet rich in fiber and whole foods many individuals 

still have nutritional deficiencies. Our approach is 

to measure an individual’s antioxidant and 

micronutrient levels and to supplement accordingly. 

This is of particular importance when addressing 

patients with congestive heart failure or 

cardiomyopathy. The heart is a highly metabolic 

organ, reliant upon many macro and micronutrients 

to effectively maintain its activity and function. 

While healthy fats and dietary carbohydrates 

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provide the main substrate and sources of ATP, 

several micronutrients such as Coenzyme Q10, L- 

Carnitine, Thiamine, and Taurine are essential 

cofactors in the process of energy conversion into 

efficient continuous cardiac function (Soukoulis et 

al. 2009) 

CoEnzyme Q10, an essential component in 

cellular respiration in the mitochondria, has been 

shown to have significant benefit in individuals 

with congestive heart failure with regard to left 

ventricular (LV) function, cardiac output, exercise 

capacity and functional class. Early studies 

demonstrated decreased serum and tissue levels 

of CoQ10 in individuals with heart failure, with 

the degree of deficiency correlating to the level of 

LV dysfunction. In one of the largest studies 

2,664 patients with NYHA class I and II CHF 

were treated with 50-150mg of oral CoQ10 with 

clinical assessments at three months. This 

observational study demonstrated that 54% of 

individuals had demonstrated improvement in at 

least 3 of the 9 symptoms assessed, including 

cyanosis, edema, pulmonary rales, hepatomegaly, 

hepatojugular reflux, dyspnea, sweating, arrhythmia, 

and vertigo. Additional smaller studies have been 

conducted, which imply modest benefit, although 

the results are variable due to variations in study 

population, and in barriers to determining actual 

myocardial CoQ10 levels. CoQ10 has been 

advocated as an adjunct to statin therapy for 

prevention or reduction of statin-induced myopathy. 

The data are conflicting with regard to benefit, 

however one study (Caso et al. 2007) did show 

a 40% reduction in statin related muscle pain 

after 30 days of treatment with 100mg per day 

of CoQ10 (p


2012 

individual’s unique spectrum of illnesses, nutritional 

deficiencies, epigenetics and environmental risk. 

Exercise & Cardiac Rehabilitation: 

Exercise is one of the most powerful and effective 

methods for reducing cardiovascular morbidity and 

mortality, and for improving general health overall. 

Patients avoid exercise for a multitude of reasons. 

This is particularly true with regard to secondary 

prevention, as cardiac patients are often 

deconditioned, sedentary, or simply too frightened 

to begin exercising after a cardiac event. Well 

documented studies show up to a six fold 

decrease in cardiac death in post PCI and CABG 

patients who participate in a comprehensive 

cardiac rehabilitation program. (Taylor et al 

2004). Earlier studies demonstrated that even 

modest exercise, such a daily walking, decreases 

death in both men and women by 50%. Exercise 

not only decreases weight, lowers blood sugar and 

triglycerides but improves general well-being and 

is a cure for stress and insomnia. 

It should be emphasized that, alternatives and 

adjuncts to traditional exercise should be presented 

to patients. Ancient modalities, which have made 

a recent resurgence, may often better suit the 

needs and preferences of the individual. There 

have been a multitude of studies highlighting the 

health benefits of yoga, on a wide range of 

physical parameters, including cardiovascular 

disease. Benefits of yoga include enhancing 

resiliency in post myocardial infarction patients and 

improvement in heart failure, metabolic syndrome, 

blood pressure and overall quality of life 

(Jayasinghe 2004). Similarly, Qigong and Tai 

Chi, components of traditional Chinese medicine, 

have been shown to improve flexibility, strength, 

symptoms of congestive heart failure, hypertension, 

stress and anxiety. 

In addition to these modalities, meditation, (in 

particular Transcendental Meditation) has shown 

significant health benefits with improvements in 

blood pressure, anxiety, and insulin resistance. 

Transcendental Meditation and Mindfulness 

Meditation are powerful medicine in helping 

patients find inner peace. These forms of 

meditation not only reduce anxiety, stress and 

worry but have been shown to decrease alcohol 

use and cigarette consumption. It is no surprise 

that finding inner peace leads to less addictive 

behaviors (Rainfort et al. 2007). 

Social Support, Emotional & Spiritual Health 

Connections with parents 

Research confirms that our social connections are 

a key component to health. How we live our 

lives, our coping skills, habits and perception of 

the world all have a profound impact on health 

outcomes. Our first relationship is in utero with 

our mother and from there we begin to have 

relationships throughout our life. These 

relationships have been extensively studied and 

offer insight into health and illness. 

In the context of studying the personality traits 

and relationships that contribute to a physician’s 

health and well-being, 126 male Harvard students 

were asked questions regarding anxiety and 

related mental health issues. Included were 

questions about their relationships with their 

mother and father. They were then followed for 

35 years regarding their own development of 

health risks and illness. One of the key predictive 

questions was the following: Would you describe 

your relationship with your mother and with your 

father as very close, warm and friendly, tolerant, 

or strained and cold? On follow-up, 35 years 

later, the outcomes were: 

If relationship with Mother was: 

Tolerant or strained - 91% had significant 

health issue 

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Warm and close - 45% had significant 


If relationship with Father was: 

Tolerant or strained - 82% had significant 


Warm and close - 50% had significant 


If relationship with both parents was: 

Strained - 100% incidence of significant 


Warm and close - 47% had a significant 


scale.” Follow-up occurred 50 years later. The 

degree of closeness to parents strongly correlated 

with cancer rates, suicide rates, coronary artery 

disease rates, hospitalization for mental illness, 

and interpersonal difficulties. These findings were 

independent of smoking, alcohol use, or radiation 

exposures. The correlation was strongest for the 

development of cancer. (Thomas et al. 1974) 

These two studies strongly suggest a relationship 

between the connection of parent to child and the 

subsequent health of that child as an adult. It is 

also important to note that these studies 

accounted for other disease risk factors, and the 

results were independent of these risk factors. 

These findings indicate a correlation between the 

subjects’ parental relationships and their 

subsequent adult health. The authors offered the 

following explanations for the above outcomes, and 

why they are so striking: 

1. Nutrition, stress, loving energy, both before 

and after birth, will contribute to the health 

of the individual. 

2. Healthy and unhealthy lifestyle behaviors 

develop in childhood. 

3. Coping styles develop in childhood: 

anxiety, anger, optimism, self-esteem. 

4. Choices of stable relationships in 

adulthood are often mirrors of parental 

relationships. 

5. Healthy relationship with a parent in 

childhood usually means the presence of 

a supportive parent in adulthood. 

6. Spiritual values and practices are 

developed in childhood. 

(Russek et al. 1990) 

In a similar study, 1,100 male medical students 

were surveyed using a “Closeness to parents 

Connection in Marriage 

Ten thousand men were surveyed and followed for 

5 years. The key outcome was the development 

of angina. Men with substantial risk factors for 

CAD (elevated cholesterol, age > 45, HTN, 

diabetes, EKG abnormalities) were 20 times more 

likely to develop angina than men without those 

risks. When asked, "Does your wife show you her 

love?" men within the high-risk group who said 

"Yes" had half the rate of angina as those who 

answered “No.” This study indicates that men 

who perceive themselves to be loved gain comfort 

in that fact. It is postulated that these men have 

less elevations in their stress hormones such as 

adrenaline, noradrenaline and cortisol (Medalie et 

al. 1976). 

Nearly 1,400 men and women who underwent 

cardiac catheterization and were found to have 

coronary artery disease were followed for 5 years. 

Social issues were monitored. Two key questions 

were (1) “Are you married?” and (2) “Do you 

have someone in whom you can confide?” After 

5 years, roughly 15% of those who were married 

or had a confidant had died, while the mortality 

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rate was 50% for those who were unmarried or 

had no confidant (Williams et al, 1974). 

These two studies are good examples of the 

power of marital relationships. 

Other studies have shown the following: 

 

 

 

 

 

Men who are shown love by their wives have 

fewer gastric ulcers. 

Married men and women live longer. 

People who are in happy marriages live 

longer than people who are not. 

Couples who argue more have lower immune 

function and more frequent respiratory 

infections. 

People with CAD who live alone have twice 

the rate of MI as people who live with 

someone else. 

All of these studies point to one fact: that happy 

marriage and companionship are good for your 

health, independent of other risk factors. 

Contrast this to the effects of poor relationships, 

and similar correlations are noted. One study 

evaluated the effect of a relationships reported as 

“bad” on the individuals’ health. It involved 6,114 

male and 2,897 female British civil servants, with 

a 12-year follow-up. Adjustments were made for 

covariates, including age, sex, marital status, 

employment grade, obesity, hypertension, diabetes 

mellitus, and cholesterol level, as well as 

psychosocial factors (negative affectivity, 

depression, and work stress) and health behaviors 

(smoking, alcohol intake, exercise, and fruit and 

vegetable consumption). Unhappy marriages led to 

34% more coronary events regardless of gender 

and social status (De Vogli et al. 2007). 

The qualification of a relationship as “good” or 

“bad” however, is also reliant on the individuals’ 

perceptions of their situation. The degree of 

optimism with which a situation is approached has 

a significant impact on outcomes as well. In a 

longitudinal study of dating couples, the authors 

tested whether optimists (who have a cognitive 

disposition to expect positive outcomes) and their 

romantic partners are more satisfied in their 

relationships, and if so, whether this is due to 

optimists’ perceiving greater support from their 

partners. In cross-sectional analyses, both 

optimists and their partners indicated greater 

relationship satisfaction, an effect that was 

mediated by optimists' greater perceived support. 

When the couples engaged in a conflict, optimists 

and their partners saw each other as engaging 

more constructively during the conflict, which in 

turn led both partners to feel that the conflict was 

better resolved. In a one year follow-up, men's 

optimism predicted relationship status. Effects of 

optimism were mediated by the optimists' 

perceived support, which appears to promote a 

variety of beneficial processes in romantic 

relationships (Srivastava et al. 2006). 

Another study set out to examine whether 

optimistic individuals live longer than patients who 

are pessimistic. Participants were aged 65 to 85 

years (999 men and women) and completed a 

30-item questionnaire on health, self-respect, 

morale, optimism, and relationships. Of the 

participants, 941 (466 men, 475 women) had 

complete information on questions regarding 

optimism. These patients were divided into four 

groups based on their level of optimism. Over 

the follow-up period of 9.1 years (1991 to 

2001), there were 397 deaths. Compared to 

participants who reported a high level of 

pessimism, participants reporting high levels of 

optimism had a 55% lower risk of death from all 

causes, and a 23% lower risk of cardiovascular 

death. The researchers also found an inverse 

relationship between level of optimism and risk of 

death, with a stronger protective effect of optimism 

in men than women for all-cause mortality 

(Giltay, 2004). 

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Optimism reduces the risk of cardiovascular death 

through mechanisms largely unaffected by baseline 

values of physical activity, obesity, smoking, 

hypertension, and lipid profile. Pessimistic subjects 

may be more prone to changes across time in 

risk factors that affect the progression of 

cardiovascular disease (e.g., the development of 

smoking habits, obesity, or hypertension) than 

optimistic subjects. In addition: 

 

 

 

Optimism is associated with more physical 

activity, moderate alcohol use in women, and 

less smoking. 

Optimism is associated with better health in 

general. People in poor health tend to report 

more pessimism. 

Optimists may cope with stress differently and 

more effectively than pessimists do. 

Social Isolation and Lack of Connection 

Social isolation seems to contribute significantly to 

adverse health outcomes in many disease states. 

Several studies in the literature have documented 

this phenomenon. Depression, for example, is 

linked with multiple diseases, such as cancer, 

sudden death and coronary artery disease. Nancy 

Frasure-Smith, in multiple studies, demonstrated 

that social support ameliorates the effect of 

depression on patients with cardiovascular disease. 

Social support does not necessarily eliminate the 

depression, but it does eliminate the adverse 

health outcomes of the depression (Frasure-Smith 

et al. 2000). 

With regard specifically to coronary disease, 149 

men and women undergoing cardiac catheterization 

were questioned about the extent they felt loved 

and supported. The number of blockages found on 

subsequent angiography correlated positively with 

the degree of love and support (Seeman et al. 

1987). 

A separate, much larger study of sixty-nine 

hundred individuals were surveyed and followed for 

17 years. Key issues were contact with friends 

and relatives, church membership, membership in 

clubs or groups, and marriage. Those without 

close ties or frequent social contact had an 

overall death rate 3.1 times higher than those 

who did have these contacts. Both men and 

women in the low-connection category had higher 

cancer death rates. An analysis was done in 

breast cancer patients and it was found that those 

with low connection had twice the death rate, 

regardless of race (Kaplan et al. 1987). 

These studies, and others, indicate that social 

isolation and a perceived lack of connection, is a 

significant risk factor for coronary artery disease, 

cancer, and all-cause mortality. Nobel Prize 

winner Elizabeth Blackburn evaluated perceived 

stress in women. She concluded that those 

women with the highest perceived stress had cells 

that were on average 10 years older than their 

biological age when compared to women with low 

perceived stress. Her research is one of the 

greatest contributors to understanding the link 

between stress and aging. Furthermore, these 

women were more prone to major risk factors for 

chronic disease (Epel et al. 2010) It is 

important to note that social isolation and stress 

in these studies is self-reported, and this risk is 

therefore related to the individual's perception. 

Connection in the community 

The need for connection and support extends 

beyond the simple unit of family and friends. The 

collective support of one’s community plays a 

surprisingly significant role the prevention of 

disease. A remarkable 50-year observational study 

of the towns of Roseto, Bangor, and Nazareth, 

Pennsylvania (PA) demonstrate this concept. In 

the 1930s and 1940s, it was noted that the 

town of Roseto, PA had a significantly lower rate 

of acute MI than its neighboring communities, 

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2012 

despite equal prevalence of diabetes, obesity, and 

high-fat diet in the three towns. During the 

follow-up in the 1970s, the rate of MI and 

overall mortality substantially increased in Roseto, 

but not the other towns. When health behaviors 

were analyzed, there were still no significant 

differences in the three communities as to 

smoking, weight, diet, diabetes, or other risk 

factors. What had changed, however, was the 

social structure of the town. Roseto had been 

populated by descendants from southern Italy in 

the late 1800s. In the 1930s and 1940s, it still 

retained a much greater number of threegeneration 

households, close family ties and 

traditional religious values. As these ties began to 

disintegrate in the late 1960s, the rates of MI 

and mortality began to rise. This is the longest of 

the multiple studies of communities showing a 

clear relationship between community activity, 

social structure, and the rates of disease. It also 

points toward the role of religious practice and its 

effect on disease prevalence (Kaplan et al. 

1987). 

Lifestyle Change 

The Ornish lifestyle change program was one of 

the earliest instances in which this entire spectrum 

of potential health risk was studied and addressed 

in large scale observations and trials. This series 

of studies has included up to 477 patients. The 

Ornish intervention includes a low-fat vegetarian 

diet, exercise, yoga, and group support. Although 

these trials have had remarkable success in 

reversing coronary artery disease and diminishing 

adverse events, procedures, and cost of care, 

they do not specifically address the effect of 

group support. However, an interesting observation 

(yet unpublished) is that patients in the program 

improve (or do not improve) by group. This is 

referred to as the “cohort effect.” Individuals in 

groups that bond well and interact well in their 

group sessions tend to have greater improvements 

on subsequent angiograms and fewer adverse 

outcomes than those in groups that become 

dysfunctional. This is only an observation at this 

time, but will be tested for significance in the 

future. 

The group model (intentional connectedness) is 

clearly one of the most powerful tools we have to 

combat illness-related depression and anxiety. It is 

also one of the most potent effectors of behavioral 

change, as documented in chemical dependency 

programs. The above observations clearly suggest 

that group support significantly affects the clinical 

course of disease. 

The Healing Physiology of Connection 

To further explore the possible mechanisms for 

the health benefits of connection studies regarding 

the role of social connection have been 

undertaken. Intentional connection (group 

support), interpersonal connection (marriage, 

friendship, pets), and community connection 

(participation in church groups and social groups) 

have all been shown to decrease life stress. Life 

stress is internally mediated through the release of 

catecholamines, cortisol (if chronic) and other 

neuro-hormonal mechanisms. Social isolation is 

associated with elevated catecholamines and 

cortisol (Cacioppo JT, 1994). Catecholamines 

and cortisol contribute directly to cardiac risk 

through the following mechanisms: 

 

 

 

 

 

 

 

Increased blood pressure 

Increased blood viscosity 

Increased platelet adhesion 

Decreased heart rate variability 

Increased endo-vascular reactivity and 

endothelial inflammation 

Increased production and release of VLDL 

(triglycerides) from the liver 

Increased conversion of VLDL to small dense 

LDL (highly atherogenic) 

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2012 

The stress hormones (adrenaline, nor adrenaline, 

cortisol and aldosterone) that ultimately increase 

cardiac risk can arise from a multitude of sources, 

highlighting the importance of teaching people how 

to transform stress and anger. The devastating 

Northridge, California earthquakes in 1996 were 

followed by a 5- fold increase in cardiovascular 

death during the acute period. Fear, anger, 

anxiety were clearly risk factors for these 

cardiovascular events. Consider Takatsubo 

cardiomyopathy, a well-known cardiac disease 

entity that by definition is precipitated by severe 

emotional stress, resulting in significant and often 

severe cardiac dysfunction. One study of 1,623 

cardiac patients asked the question, “What 

happened during the 26 hours preceding your 

heart attack?” Particular attention was focused on 

arguments and anger, both of which were shown 

to trigger myocardial infarctions in both men and 

women (Mittleman et al. 1995). The authors 

concluded that an anger outburst increased the 

risk of a myocardial infarction 230%. 

Regardless of the source, stress leads to a clear 

negative cardiovascular outcome, which can at 

times have catastrophic consequences if not 

recognized and treated appropriately. 

Conclusions: 

While western medicine excels in acute care, it 

falls short in cardiovascular disease prevention and 

chronic disease treatment. Getting to the 

underlying cause of disease is the essence of 

Integrative Medicine which utilizes approaches from 

all global healing traditions. Treating the whole 

person, body, mind, emotions and spirit is 

essential to achieving optimal health. Interheart 

has provided us a roadmap to frame the direction 

we need to take. This direction is not onedimensional 

relating only to the physical body. 

Rather, it is multidimensional requiring multidisciplinary 

teams of practitioners dedicated to 

coaching, guiding and inspiring individuals to 

transform their lives. We recognize that information 

leads to knowledge but practice leads to 

transformation. Providing the tools and guidance 

for transformation is our goal in Holistic Integrative 

Medicine. 

Erminia “Mimi” Guarneri is board-certified in 

cardiology, internal medicine, nuclear medicine and 

holistic medicine. Dr. Guarneri is the founder and 

medical director of the Scripps Center for 

Integrative Medicine. Dr. Guarneri was an English 

Literature major as an undergraduate at New York 

University. Her medical degree is from SUNY 

Medical Center in New York, where she graduated 

number one in her class. Dr. Guarneri served her 

internship and residency at Cornell Medical Center, 

where she later became chief medical resident. 

She served cardiology fellowships at both New 

York University Medical Center and Scripps Clinic. 

Dr. Guarneri served as an attending in 

interventional cardiology at Scripps Clinic, where 

she placed thousands of coronary stents. 

Recognizing the need for a more comprehensive 

and more holistic approach to cardiovascular 

disease, she pioneered the Scripps Center for 

Integrative Medicine where she uses state-of-theart 

cardiac imaging technology and lifestyle change 

programs to aggressively diagnose, prevent and 

treat cardiovascular disease. She is a fellow 

member of the American College of Cardiology, 

Alpha Omega Alpha, the American Medical 

Women’s Association, and a diplomat of the 

American Board of Holistic Medicine. In 2009, 

Dr. Guarneri was honored as the ARCS scientist 

of the year. She is now president-elect of the 

American Board of Integrative and Holistic 

Medicine. 

Dr. Guarneri has authored several articles that 

have appeared in professional journals such as 

the Journal of Echocardiography and the Annals of 

308


2012 

Internal Medicine. Dr. Guarneri participated as a 

member of the writing committee for the American 

College of Cardiology Foundation Complementary 

Medicine Expert Consensus Document. This expert 

consensus statement on integrating complementary 

medicine into cardiovascular medicine was 

published in 2005. 

She is the author of The Heart Speaks, a 

poignant collection of stories from heart patients 

who have benefited from integrative medicine 

approaches. The Heart Speaks and her clinical 

work have been featured on NBC Today and PBS 

’s To the Contrary and Full Focus. In her book 

Dr. Guarneri takes the reader on a journey of the 

heart – exploring the emotional heart, able to be 

crushed by loss; the intelligent heart, with a 

nervous system all its own; and the spiritual 

heart, which yearns for a higher purpose. With 

groundbreaking new research and unparalleled 

experience, Dr. Guarneri skillfully weaves the 

science and drama of the heart’s unfolding. Her 

work was also featured in a two-part PBS 

documentary, The New Medicine. Dr. Guarneri is 

regularly quoted in national publications such as 

the Yoga Journal, Body+Soul, Trustee magazine 

and WebMD. 

She has been recognized for her national 

leadership in integrative medicine by the Bravewell 

Collaborative and now serves as chair of the 

Bravewell Clinical Network for integrative medicine. 

In 2008 Dr. Guarneri was honored by Project 

Concern International for her work in Southern 

India. She currently serves on the International 

sub-committee for Direct-Relief International. Dr. 

Guarneri served on an advisory panel for the 

Institute of Medicine to explore the science and 

practice of integrative medicine for promoting the 

nation’s health. The summit’s findings were 

released Feb. 25-27, 2009 in Washington, D.C. 

In 2011, Dr. Guarneri was the winner of the 

Bravewell Leadership Award which honors a 

physician leader who has made significant 

contributions to the transformation of the U.S. 

health care system. 

Contact Erminia Guarneri at 

Guarneri.Mimi@scippshealth.org or 858-554- 

3330. 

Websites: www.mimiguarnerimd.com 

Poulina Q. Uddin is an Integrative Cardiology 

Fellow at Scripps Center for Integrative Medicine. 

She is board certified in Internal Medicine and 

Chief Cardiology Fellow Elect at Scripps Clinic in 

La Jolla, California. 

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with coronary heart disease: Systematic 

review and meta-analysis of randomized 

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Medicine 116(10): 682-92. 

30. Jayasinghe, AR. Yoga in Cardiac Health: 

A Review. 2004. Eur J Cardiovasc Prev 

Rehabil.11(5):369-75. 

31. Rainforth, M.V., R.H.Schneider, S.I. 

Nidich, et al. Stress reduction programs 

in patients with elevated blood pressure: A 

systematic review and meta-analysis. 

2007. Curr Hyperten Reports 9: 520-8. 

32. Russek L.G., S.H. King, S.J. Russek, H.I. 

Russek. The Harvard Mastery of Stress 

Study 35-year follow-up: prognostic 

significance of patterns of 

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134:251. 

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Psychosocial and other risk factors as 

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36. De Vogli R, Tarani Chandola T, Marmot 

MD. Negative aspects of close 

relationships and heart disease. Arch 

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JM, Butler EA, Gross JJ. Optimism in 

close relationships: How seeing things in a 

positive light makes them so. J Pers Soc 

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38. Giltay, EJ. Dispositional optimism and allcause 

and cardiovascular mortality in a 

prospective cohort of elderly Dutch men 

and women. Arch Gen Psychiatry. 2004; 

61:1126-1135. 

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depression, and mortality during the first 

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and CAD: A comparison of the structure 

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Knudsen LP, Guralnik J. Mortality among 

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29 

A Non-invasive 

Thermal-wrap 

Technique for 

Inducing Calorie 

Burning and 

Weight Loss 

2012 




Abstract 

Context: With excessive weight being the secondmost-important, 

preventable cause of premature 

disease and death in America, a new way to 

reduce weight could provide important benefits to 

overweight or obese individuals who find 

exercising or dieting difficult. 

Objective: To determine if thermoregulation, in 

conjunction with the consumption of a wellbalanced 

Mediterranean diet, can increase calorie 

burning and weight loss. 

Design: This 8-week pilot study examined the 

effects of thermal-wrap technique on weight, 

percentage of fat composition, body mass index 

(BMI), basal metabolic rate (BMR), 

circumference of waist and hip, and water loss. 

Setting: The study took place between November 

2004 and January 2005 at the Vivinlinea Clinic 

in Great Neck, New York. 

Patients or Other Participants: The study included 

70 subjects who were either overweight or obese 

as determined by BMI. The study was 

nonrandomized, with the researchers assigning 

subjects to one of two groups based on the 

services the participants selected while attending 

the clinic—50 to the Thermal Group (TG) and 

20 to the Control Group (CG). The distribution 

of subjects was self-selected in that those who 

requested the thermal-wrap technique received it 

plus nutritional planning and those who did not 

received only the nutritional planning. 

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2012 

The researchers recorded baseline morphologic 

measurements and personal data, including height, 

weight, age, and menstrual status. The groups 

were not matched but did not differ on baseline 

measures. Researchers also calculated the 

baseline BMI and BMR (using the Sterling- 

Passmore equation 14 ). In the TG, 4 participants 

stopped the program due to claustrophobia and 3 

stopped due to lack of compliance with the 

nutritional plan. In the CG there were no dropouts 

All participants who remained active through the 

4-week point completed the study. 

Intervention: Intervention consisted of two, 50- 

minute sessions each week for eight weeks, 

consisting of thermal-wrap technique. The thermal 

wrap uses electromagnetic energy to create heat, 

directing it to specific tissue areas. A trained 

professional applied the thermal wrap. Intervention 

for the TG and mock intervention for the CG both 

employed a thermal wrap; the wrap for the TG 

group was heated to a temperature of 44°C, 

while the wrap for the CG was not. The study 

used the thermal wrap in 2 configurations, 

depending on the participant’s BMI. Members of 

both groups also received a series of dietary 

counseling sessions providing guidance on 

individualized eating programs based on a wellbalanced 

Mediterranean diet of between 1600 

and 2000 Kcal. 

Outcome Measures: The researchers examined 

cumulative weight loss over eight weeks as the 

primary outcome. Secondary outcomes included 

changes in percentage of fat composition, BMI, 

basal metabolic rate (BMR), circumference of 

waist and hip, and water loss. 

Results: At the end of the 8-week study, the CG 

had lost an average of 1.0 (0.7) kg while the 

TG had lost an average of 5.2 (1.3) kg (95% 

CI (Δ): 3.7-4.7, P


2012 

(25≤BMI


2012 

Guida B, Trio R, Pecoraro P, et al; and Sartorio 

A, Malavolti M, Agosti F, et al have shown this 

approach to be accurate in assessing body fat, 

lean body weight, and body water content. 11,15,16 

One kg of fat tissue burned is equivalent to 

9000 kcal, and one kg of lean tissue is 

equivalent to 4000 kcal. After weight loss was 

measured, the BCA allocated a loss of fat and 

lean tissue. Calorie expenditure was calculated by 

multiplying the number of fat kg lost by 9000 

and the number of lean kg lost by 4000 and 

summing the two products. 

Initially, each participant received a 30-minute 

assessment with a nutritional counselor during 

which they received guidance on an individualized 

eating program based on a well-balanced 

Mediterranean diet. The nutritional counselor was 

available throughout the 8-week study. This 

program emphasized fresh, fiber-rich fruits, 

vegetables, and whole-grain products but did not 

exclude nutrient-rich choices from the dairy and 

protein food groups. 17 The program included 3 

well-balanced meals per day with 1 or 2 snacks. 

Subjects were also urged to consume at least 1 

L of fresh water daily. The diet also permitted 

participants to drink 4 ounces of wine up to 

3x/week and a cup of coffee or tea once per 

day. 

The nutritional counselor personalized each 

participant’s eating program based on her BCAdetermined 

BMR, with a 15% increase in kcal. 

For instance, if a subject’s BMR was 1600 kcal 

at rest, her total daily intake was set at 1840 

kcal. Overall daily calorie intake was from 1600 

to 2000 kcal with 25 to 30 g fiber, an 

adequate intake for sedentary females. 18 

The 

counselor also encouraged all participants to 

participate in light exercise, such as walking 20 

minutes at a time, 2x/week. 

Materials 

Intervention for the TG and mock intervention for 

the CG both employed a thermal wrap with that 

of the TG using electromagnetism to create heat 

directed to specific tissue areas. The researchers 

used the wrap in 2 configurations, the use of 

which depended on the participant’s BMI. For 

those with a BMI


2012 

thermal wraps, that induce modulated and gentle 

heat in cutaneous and subcutaneous areas. 

Maximum extremely low-frequency electric field 

(ELF) was 11 µT. 

Each thermal wrap contains a series of insulated 

electrical resistances that the transformer controls 

to provide a 50 to 60Hz current at 24V and a 

power of 600W at maximum. 

All participants received 2 weekly, 50-minute 

thermal-wrap sessions for 8 weeks, with at least 

48 hours between each session. In the TG, the 

researchers heated the wraps to a mean 

temperature of 44°C; in the CG group, they did 

not heat them. They weighed all participants prior 

to and after each session. 

The TG and CG could drink up to 100 ml of 

water during each session. At the conclusion of 

each session, participants remained supine for at 

least 5 minutes after the removal of the wrap to 

allow vital-sign equilibration. They then showered 

and were weighed after urination. After eight 

weeks and 16 thermal-wrap sessions, the 

researchers completed another total set of 

measurements. 

Statistical Methods 

Research using this modality is quite novel, and 

little data is available to help plan scientifically 

meaningful studies. A major goal of this study 

was gathering data to help the field to design 

future studies that are properly powered. Despite 

this problem, the effect of treatment was large, 

and the researchers were able to detect significant 

differences in weight loss and other measures 

between the two groups. The study was powered 

to detect at least 0.5 BMI units of differential 

change between the groups (assuming a standard 

deviation of the difference of the change scores of 

0.6, power exceeded 85%). 

Statistical analyses: The researchers analyzed 

each dependent (outcome) variable using a 2x2, 

repeated-measures analysis of variance. They fit 

a model to estimate the interaction effect between 

the groups (TG vs. CG) and the repeatedmeasures 

effect for time (before treatment vs. 

after treatment). The study tested appropriate 

model assumptions, and no transformations or 

nonparametric analyses were necessary. The study 

analysis was on an intent-to-treat basis. The 

study reported a 2-tailed P-value of .05 as 

statistically significant for all statistical tests. It 

made no adjustment for multiple comparisons or 

multiple tests and presented confidence intervals 

(95%) for all parameters of interest. The study 

used the SAS System 9.2 (SAS Institute, Inc., 

Cary, NC) for all statistical analyses. 

Results 

Table 1 shows all baseline characteristics of 

the study’s participants, including 

postmenopausal status and ethnic heritage. 

Subjects’ ages ranged from 20 to 70 

years. The initial mean weight and BMI 

were similar in the 2 groups. In the CG, 7 

(35%) participants were obese and 13 

(65%) were overweight, while in the TG, 

19 (38%) were obese and 31 (62%) 

were overweight. The researchers observed 

no significant differences in demographic 

characteristics. (See Table 1 on next page) 

317


2012 

Table 1 - Mean (Standard Deviation) Baseline Measurements 

Parameter a 

Control Group (CG) 

(n=20) 

Treatment Group (TG) 

(n=50) 

Age, y (SD) 45.4 (12.6) 47.3 (13.0) 

Weight, kg (SD) 75.0 (7.7) 74.4 (11.3) 

Postmenopausal Status 

11 (54) 30 (60) 

No. (% Postmenopausal) 

Ethnicity, No. (%) 

Caucasian (non- 

Iranian) 

Iranian 

East Indian 

African-American 

17 (85) 

2 (10) 

1 (5) 

0 (0) 

39 (78) 

8 (16) 

2 (4) 

1 (2) 

Body Mass Index, kg/m 2 

(SD) 

Basal Metabolic Rate kcal/day 

(SD) 

29.1 (2.4) 28.9 (4.0) 

1503.5 (129.0) 1457.8 (177.3) 

Body Fat, % (SD) 35.2 (3.3) 35.6 (4.5) 

Waist, cm (SD) 93.5 (7.0) 89.8 (10.9) 

Hips, cm (SD) 104.8 (7.9) 107.8 (10.1) 

Right Thigh + Knee, cm (SD) 107.8 (7.5) 110.5 (9.4) 

Body Composition Analysis: 

Lean mass + Water % (SD) 

48.9 (4.3) 48.9 (9.1) 

a 

No significant or clinical differences between groups. 

318


2012 

Table 2 shows all changes in body composition 

and weight; i.e., the effects of treatment. During 

the 8-week treatment, the CG lost a mean (SD) 

of 758.6 (558) kcal/week while the TG lost 

5105.2 (1191) kcal/week (95% CI for 

difference (Δ): 3928 to 4765, P


2012 

No difference exists in weight loss between 

premenopausal or postmenopausal subjects, nor 

was any relationship with the menstrual cycle 

evident. 

Safety: No adverse events were observed or 

reported. 

Compliance: Perhaps due to the motivations of 

the 70 subjects in choosing the services they 

received and due to the comfort of the procedure, 

only 7 participants dropped out of the study (an 

attrition rate of 10%). 

Discussion 

To the researchers’ knowledge, the study is the 

first to demonstrate that thermoregulation 

technique, in conjunction with consumption of a 

well-balanced Mediterranean diet, can result in a 

significant amount of weight loss and a reduced 

percentage of overall body fat, without strenuous 

physical activity for overweight and obese female 

subjects. The women in the TG lost an average 

of 5.2 kg and 3.7% of body fat during the 8- 

week intervention. 

The researchers did not design the study to 

elucidate the mechanism by which the thermal 

wrap leads to weight loss; however, that 

mechanism is likely related to the increased blood 

flow, vasodilatation, and capillary recruitment that 

occurs during application—a series of events that 

improves lymphatic and blood circulation in the 

area of application. 20,21 

It has been shown that 

blood flow in the human skin can increase more 

than 15-fold when the skin is heated to 43°C. 

Such heating induces arteriole dilation and recruits 

capillaries, activating lipolytic enzymes in 

adipocytes. 22 

These changes greatly stimulate the 

thermoregulatory system of the body, which is 

under hypothalamic control, leading to heat 

dissipation to avoid systemic hyperthermia, and in 

the process, consuming energy. 23 

The mechanism 

also may involve mechanically and thermally 

enhanced blood flow, generally improved 

vascularization, lymphatic drainage, and an 

increase in interstitial metabolic oxygenation to the 

fat tissue with a resultant decompression in the 

lipolymphedema and decreased connective 

sclerosis and fibrosis. 24 

The reduction in body fat likely occurred not just 

through lipolysis but also through fatty-acid 

oxidation and thermogenic elimination of the 

reducing energy generated in brown adipocytes or 

through similar processes in other cells. 25 

Limitations to this study include the fact that it 

was not randomized or blinded. In addition, the 

actual caloric intake and daily physical activity of 

the subjects were not independently verified; thus, 

it is possible that the differences between the 

groups were due to differences in compliance 

rather than to the treatment per se. The 

researchers conducted no laboratory studies to 

indicate the effect of the intervention on lipids, 

blood glucose, and other risk factors for 

cardiovascular disease. Finally, long-term followup 

beyond 8 weeks is of interest. The field 

needs future studies that use a randomized, 

controlled design with measures of dietary 

compliance to confirm the hypothesis that the 

thermal wrap significantly impacts body weight. 

Conclusion 

This article reports on a study that used 

thermoregulation, to achieve a non-invasive 

approach to weight loss. As this pilot study 

shows, combining this technique with a healthy 

diet (Vivinlinea Methodology) over 8 weeks can 

lead to significant weight loss and body-fat 

reduction. Further controlled trials will be 

320


2012 

necessary to further assess the efficacy of the 

methodology. 

Acknowledgements 

Many thanks to Yolanda Davis, assistant 

librarian at the James S. Todd Memorial Library 

American Medical Association–JAMA for her 

assistance with references and Ing. Riccardo 

March, Rome, Italy, for his support and critical 

reading of the manuscript. 

Jeannette Graf, a leading skin science expert, is 

a board certified, clinical and research 

Dermatologist and an Assistant Clinical Professor 

of Dermatology at the Mount Sinai School of 

Medicine. 

Prior to completing her Residency in Dermatology 

at the New York University Medical Center, Dr. 

Graf earned her medical degree from the State 

University of New York - School of Medicine at 

Buffalo. While at NIH, she received an award for 

Outstanding Achievement from the National 

Institutes of Health, in addition to obtaining a NIH 

patent for her research on peptides in 1987. 

Dr. Graf has been published in prestigious 

journals such as Cell, Science, the Journal of Cell 

Biology and the Proceedings of the National 

Academy of Sciences, and also wrote the chapter 

on "Anti-aging Skin Care Ingredient Technologies" 

for the dermatology textbook Cosmetic 

Dermatology. Dr. Graf is the author of "Stop 

Aging, Start Living" (Crown, Fall 2007) and she 

is highly regarded as an expert resource and has 

been quoted in many national beauty, health and 

fitness magazines. 

She has been a guest on television shows such 

as "The CBS Early Show", "Fox and Friends" 

and "The View" and appears regularly on the 

Home Shopping Network with her successful line 

of dermatology-strength skin care. She serves as 

a consultant and advisory board member for a 

number of cosmetic and pharmaceutical companies 

including Johnson&Johnson, RoC, Neutrogena, 

Medicis, Allergan and Aveeno. 

For the past twenty years, Dr. Graf has been in 

private practice in Great Neck, New York. 

Contact Jeannette Graf at info@vivinlinea.com 

Simcha Pollack is an internationally recognized 

scholar in the field of applied statistics. He is a 

professor of Computer Information Systems and 

Decision Sciences at St. John's University in New 

York. He has a consulting practice. 

Massimo Guerrieri is a Co-Founder and Chief 

Executive Officer of the Vivinlinea Corporation, 

Great Neck, New York. 

Contact Masimmo Guerrieri at info@vivinlinea.com 

or 1-877-546-3201. 

Website: www.vivinlinea.com 

References: 

1. No authors listed. U.S. Obesity Trends 

1985–2006. 2007. Centers for Disease 

Control and Prevention. 

http://www.cdc.gov/nccdphp/dnpa/obesity/ 

trend/maps/. Accessed October 12, 

2011. 

2. Ogden CL, Carroll MD, Curtin LR, 

McDowell MA, Tabak CJ, Flegal KM. 

Prevalence of Overweight and Obesity in 

the United States, 1999-2004. JAMA. 

2006;295(13):1549-1555. 

3. Mokdad AH, Marks JS, Stroup DF, 

Gerberding JL. Actual causes of death in 

the United States, 2000. JAMA. 

2004;291(10):1238-1245. 

4. No authors listed. Overweight, obesity, and 

health risk. National Task Force on the 

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Prevention and Treatment of Obesity. Arch 

Intern Med. 2000;160(7):898-904. 

5. Peeters A, Barendregt JJ, Willekens F, et 

al. Obesity in adulthood and its 

consequences for life expectancy: a lifetable 

analysis. Ann Intern Med. 

2003;138(1):24-32. 

6. Phelan S, Wing RR. Prevalence of 

successful weight loss. Arch Intern Med. 

2005;165(20):2430. 

7. Romijn JA, Coyle EF, Sidossis LS, et al. 

Regulation of endogenous fat and 

carbohydrate metabolism in relation to 

exercise intensity and duration. Am J 

Physiol. 1993;265(3 Pt 1):E380- 

E391. 

8. Achten J, Jeukendrup AE. Maximal fat 

oxidation during exercise in trained men. 

Int J Sports Med. 2003;24(8):603- 

608. 

9. Vaupel P, Kallinowski F. Physiological 

Effects of Hyperthermia. In: Streffer C, ed. 

Recent Results in Cancer Research. 

Heidelberg, Berlin: Springer-Verlag; 1987: 

71-109. 

10. Patterson J, Strang R. The role of blood 

flow in hyperthermia. Int J Radiat Oncol 

Biol Phys. 1979;5(2):235-241. 

11. Fauci AS, Braunwald E, Isselbacher K, 

et al. Harrison’s Principles of Internal 

Medicine. 14th ed. New York, NY: 

McGraw-Hill; 1998. 

12. Guyton A, Hall J, eds. Textbook of 

Medical Physiology. 11th ed. Philadelphia, 

PA: Elsevier; 2005. 

13. Dean W. Effect of sweating. JAMA. 

1981;246(6):623. 

14. Passmore R. Reflexions on energy 

balance. Proc Nutr Soc. 1982; 

41(2):161-165. 

15. Guida B, Trio R, Pecoraro P, et al. 

Impedance vector distribution by body 

mass index and conventional bioelectrical 

impedance analysis in obese women. Nutr 

Metab Cardiovasc Dis. 2003;13(2):72- 

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16. Sartorio A, Malavolti M, Agosti F, et al. 

Body water distribution in severe obesity 

and its assessment from eight-polar 

bioelectrical impedance analysis. Eur J 

Clin Nutr. 2005;59(2):155-160. 

17. Denis Lairon. Intervention studies on 

Mediterranean diet and cardiovascular risk. 

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2007;51(10):1209-1214. 

18. US Department of Health and Human 

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30 

New Ideas for the 

Treatment of Pain 

2012 

Hal S. Blatman, 

MD, ABIHM, 

DAAPM 

Introduction 

Pain is something we all have experienced. Most 

people are fortunate to experience pain as a 

warning of bodily injury that stops as we recover. 

Others are not so lucky and continue to suffer 

from chronic pain despite the best of medical 

care. 

This chapter first reviews what we are taught 

about pain with insights toward why many 

common treatments do not work as well as we 

would like. New information follows that elaborates 

how muscle and fascia generate most of the pain 

in our bodies. The next section discusses how 

food choices contribute to chronic pain, and the 

last section discusses the future of pain and 

rehabilitative medicine and what can be done now 

to stop pain and help the body heal like never 

before. 

Medical students are taught several theories about 

what is thought to cause pain. One of these 

theories is inflammation. Doctors use words like 

arthritis, tendinitis, and bursitis to describe pain 

from such inflammation. 

Let’s consider George, an imaginary patient with 

shoulder pain. George has had shoulder pain for 

10 years and all of his friends have turned into 

doctors. He has been advised about food, 

vitamins, magnets, and other things that have 

helped his friends when they have had similar 

ailments. 

Finally, George hurts bad enough to go and see 

Dr. Jones. Dr. Jones was taught to do an x-ray 

and an MRI scan of the shoulder, and on the 

next visit points out to George how there are 

bones too close together and that spurs have 

formed in his joint. By the evidence of the 

studies, George is advised that he has arthritis. 

He gets a prescription for arthritis medicine, and 

he is a content patient--not because he gets any 

better, but because he knows what he’s got. 

Dr. Jones on the other hand, took a leap of faith. 

He was taught when he went to school that if he 

could demonstrate an abnormality on an x-ray or 

MRI scan that was close to where the patient 

complained of pain and symptoms, that he could 

attribute the pain and symptoms to the abnormality 

on the study. Unfortunately, this requires a leap of 

faith doctors have no right to make. Some people 

with bone-on-bone x-rays have no pain in their 

324


2012 

bad joint. Indeed, x-ray findings correlate with 

range of motion; they do not correlate with pain. 

Another theory students are taught in school is 

that radiating pain comes from a pinched nerve. 

For example, if a patient has pain that radiates 

from their neck down to their hand, doctors are 

taught to look for a pinched nerve in the neck. 

Similarly, if a patient has pain that radiates from 

their low back down to their foot, doctors are 

taught to look for a pinched nerve in the lower 

back. While there are many people who have had 

successful surgeries for such disc injuries, there 

are many more people who fail surgical treatment 

and continue to experience severe radiating pain. 

In addition, medical studies show that 30% of 

normal 40 year old men have at least one 

herniated disc in their lower back. These facts 

make us question what else might be causing the 

pain that mimics a herniated disc. 

Medical students are also taught that depression 

causes pain. Indeed, they are taught that if a 

woman is 40 years old and has had pain for a 

couple of years, she has pain because she is 

depressed and she should be prescribed 

antidepressant medication. Contrary to this thinking, 

more recent information teaches that pain causes 

depression. Pain signals from muscle and fascia 

go through the mood and depression centers in 

the brain on their way to the cortex where we 

become aware of the location of the pain. 

Bombarding these brain centers with pain darts is 

enough to cause depression--even in otherwise 

normal people who do not have a history of 

depression. 

One of the most arrogant theories young doctors 

are taught is the “supratentorial” theory of pain 

management. This refers to the idea that if all the 

medical tests are negative and the patient still 

complains of pain, he or she must be making it 

up. 

More modern theories in pain medicine include 

neuroplasticity, wind-up, the role of 

neurotransmitters, and the science of how nerves 

transmit and modify pain information signals. The 

science and current thinking on these issues are 

not the topic of this chapter. Even with these 

newer theories, there is so much more that can 

be done to decrease pain and heal from injury 

when muscle and fascia are taken into account. 

Myofascial Pain 

In the 1930’s and 1940’s, Janet Travell, MD 

was introduced to the idea that pain comes from 

muscle and fascia. Fascia is the tissue that holds 

muscles together, connects muscles to muscles, 

muscles to bone, and bone to bone. It also holds 

organs like the heart, lungs, liver, and intestines 

in place. When steak fibers are separated, fascia 

is the thin film between the fibers. Fascia is also 

the thick tissue called gristle that holds muscles to 

bone. Doctor Travell learned that all qualities of 

pain could come from muscle and fascia-- 

numbness, burning, tingling, aching, stabbing, and 

cramping. She also learned that the pain was 

actually generated by small knots that formed in 

the injured muscle and fascia tissue as a 

physiologic reaction to injury. As she developed 

the physical examination skills to be able to feel 

these knots, she learned that they were capable 

of referring pain to distant sites in the body i . 

Knots in the buttocks muscles would refer pain 

down the leg to the foot, and knots in the upper 

shoulders and neck would refer pain to the head 

and down the arm. Dr. Travell called these knots 

"trigger points," and the pain generated by these 

trigger points is called "myofascial" pain. 

As Dr. Travell discovered, each trigger point in 

the body generates both localized and referred 

pain patterns (see diagram). Humans and also 

animals have trigger points in most, if not all of 

their muscles. 

Diagram X’s 

represent the trigger 

points, and the red 

shadowing 

represents location 

of the referred pain 

pattern. 

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Awareness of the pain patterns from these trigger 

points depends on how "active" they are. The 

more active the trigger point, the more pain 

signals it transmits. Trigger points that generate 

pain outside of the mind's awareness are termed 

"latent." Even latent trigger points restrict motion, 

cause muscle weakness without atrophy, and 

predispose the body to acute attacks of pain. 

Common examples of re-activating latent trigger 

points include: 

• Throwing one's back out by doing too 

much yard work 

• Waking up in the morning with a stiff 

neck 

These examples of sudden onset pain are often 

attributed to a pinched nerve or inflammation. 

Indeed the pain is neither...it is usually myofascial 

pain from activated latent trigger points. 

Pain patterns are usually generated by groups of 

trigger points in several injured muscle and fascia 

areas. Pain levels vary with how loudly the 

ensemble or orchestra of trigger points plays and 

which solo artist stands up to sing. This typically 

varies with the following: 

• What the person has physically done in 

the past 3 days that has aggravated 

his/her muscles 

• How well the person slept last night 

• What the weather is going to do tomorrow 

• How much stress the person is under 

• What the person has eaten in the past 

1-4 months 

These things are more important in healing from 

pain than most anything else, including discs, 

nerves, depression, and inflammation. At least 

70% of most pain patterns are caused by muscle 

and fascia. And what is most important is Doctor 

Travell's discovery that making the trigger points 

less active will also make the pain they generate 

go away. 

What was more important was her discovery that 

making the knots go away would also make the 

pain go away. 

Indeed, most of the pain in our bodies comes 

from groups of these knots or “Trigger Points” 

that “sing” together to create a pain pattern. 

Some common examples of trigger point pain 

patterns include: 

• Migraine is generated by knots in the muscles 

of the jaw, neck, shoulder, and upper back. 

• Shoulder pain and upper back pain are 

generated by knots in the muscles and fascia of 

the neck, shoulder, upper back, and upper arm. 

• Lower back pain is generated by knots in the 

muscles and fascia of the abdomen, lower back, 

buttocks, pelvis, and thighs. 

• Pelvic pain and prostate pain are generated by 

knots in the muscles and fascial of the thighs, 

pelvis, buttocks, and abdomen. 

• Lower back pain is generated by knots in the 

muscles and fascia of the lower back, abdomen, 

pelvis, and thighs. 

• Plantar fascitis pain is generated by knots in the 

muscles and fascial of the calves and feet. 

This list is not complete, but it makes the point. 

Trigger points in muscle and fascia can also refer 

pain to joints. Thigh muscles can cause such 

intense and sharp pain in the knee joint that it is 

not possible to distinguish between joint and 

muscle pain. What confuses practitioners even 

more is that there is no pain sensation 

describable that cannot come from muscle and 

fascia. Doctors and nurses are taught that the 

patient's description of pain symptoms provides a 

solid clue as to the cause of the pain. This is 

unfortunately not true. All the sensations of 

burning, radiating, knife-like stabbing, numbness, 

and tingling can come from muscle and fascia. 

They do not have to come from pinched nerves. 

All of these pain patterns have much in common. 

The differences are the different muscles and the 

different areas of the body. The pain patterns all 

share the same origin for pain. In fact, pelvic 

pain has been called a “migraine” in the pelvis, 

and lower back pain has been called a "migraine" 

in the lower back. Is it any wonder that diagnostic 

testing is not more helpful? Trigger points do not 

show up on EMG, MRI scan, or CAT scan 

testing. They are most detectable by physical 

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examination, and most health care education 

programs do not teach examination or treatment 

techniques for this ubiquitous myofascial pain. 

Fascia 

The knowledge base and understanding of fascia 

has rapidly grown during the last several years. 

In 2009, Thomas Myers published the second 

edition of his book titled "Anatomy Trains." The 

book teaches about the anatomy of fascia and 

how it is contiguous throughout the body ii . He has 

been able to demonstrate the dissection of a 

single string of fascia tissue that goes from the 

bottom of the toes, up the back of the legs, up 

the back of the torso, continuing up the back of 

the neck, and then over the top of the head to 

stop at the eyebrow. 

Indeed, there are such strings all over the body. 

And the fascia planes exist in the form of sheets 

more than strings. These sheets of fascia tissue 

are all over the body. There are shallow and 

deeper sheets up the sides, front, and back of 

the body, as well as sheets spiraling around the 

trunk of the body. 

The knots in the muscles and fascia draw and 

tighten these strings and sheets of fascia. They 

tighten the strings that go lengthwise through the 

body, and also the 360 degrees of other sheets 

that intersect within the muscle fibers. Consistent 

with this concept, when the knots are released, all 

relevant strings and sheets also immediately 

loosen. Loosening the knots in the upper 

shoulders will reduce neck stiffness and headache 

pain. In a similar fashion, loosening the knots in 

the lower back and buttocks will decrease lower 

back and radiating sciatic pain. 

Understanding this anatomy of fascia, it is straight 

forward to understand the etiology of scoliosis. 

Scoliosis develops when there is an injury to 

fascia that makes some of the spiral sheets of 

fascia in the trunk of the body tighten and not 

lengthen as the spinal column grows longitudinally. 

The spine then grows along the path of least 

resistance--which happens to be a spiral. 

Releasing the tight fascia strings and sheets can 

slow or stop the progression of a scoliosis 

deformity (unpublished work from Blatman Pain 

Clinic). 

Another more recent discovery is that fascia has 

contractile properties that are independent of 

muscle. Where muscle contracts voluntarily and 

immediately, fascia contracts slowly and over 1.5 

hours. Similarly, where muscle can release 

immediately and voluntarily, fascia releases slowly 

and over 1.5 hours. Moreover it has been 

discovered that the triggers for fascial contraction 

are not voluntary. Research has yet to elucidate 

the triggers for fascia contraction. 

The part of the nervous system that transmits 

pain signals from myofascial trigger points is the 

sympathetic component of the autonomic nervous 

system. The sympathetic nervous system also 

controls temperature, sweating, heart rate, 

respiratory rate, and other automatic functions in 

the body. Biological response to stress is also 

mediated by this part of the nervous system. In 

the 1990's, Hubbard and Gevirtz demonstrated 

that trigger points have spontaneous electrical 

activity iii . They further demonstrated that stress 

dramatically increases the activity of trigger points iv . 

Their work shows how stress increases pain 

throughout the body by increasing the activity of 

trigger points, tightening muscle and fascia. 

Similarly, they showed that relaxation reduces the 

electrical activity of trigger points v . There is other 

research that demonstrates effective relaxation and 

pain relief with meditation, yoga breathing, and 

heart rate variability biofeedback training (HRV). 

Another mechanism of pain causation from fascia 

is also related to the level of tension and 

pressure in the area of injury. There are 10 

times as many sensory nerve receptors in fascia 

as in muscle. These sensors include: 

• Golgi tendon organs-measure stretch 

• Paciniform endings-measure pressure 

• Ruffini ending-inform CNS about shear 

forces 

Pressure (from tight fascia) and inflammation 

(largely from food) between the sheets of fascia 

stimulates these receptors and results in 

transmission of pain signals and referred pain 

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2012 

along the lines of fascia in the body. This 

produces pain and radiating pain that cannot be 

measured by diagnostic testing, and the pain 

symptoms cannot be distinguished from those that 

are taught to doctors and nurses to come from 

pinched nerves and herniated discs. 

Another common misconception is that muscles 

have memory. In actuality, muscles do not 

remember anything. If they did, people would not 

have so much difficulty relearning how to walk 

after a stroke. Fascia, on the other hand, 

remembers everything. It remembers every twist 

and trauma through life, as well as pain and 

sense of motion. What is called muscle memory 

of a golf swing is instead about fascia. The 

repetitive motion of a golf swing will cause a 

tightening of the fascia lines that support the 

swing motion so the muscles do not have to work 

so hard to reproduce it, and the brain can 

determine proprioception to reproduce it. If a 

person wants to change their swing, the previous 

fascia sheets and lines must relax and others 

need to tighten to support the new pattern of 

motion. 

Proprioception of motion and knowing where the 

body is in space is also due to fascia and the 

nervous system sensors within the layers of 

fascia. These sensors in the fascia are more 

active in detecting and regulating body movement 

than the joint ligament receptors. Joints do not 

feed back information about position as much as 

the fascia in the tissue around and distant from 

the joint. 

Treatment of pain from fascia is the common 

denominator for several types of therapy that 

include: 

• Trigger point work 

• Acupuncture 

• Osteopathic manipulation 

• Craniosacral therapy 

• Rolfing 

• Myofascial release 

Degenerative joint disease also contributes to 

decreased joint motion and pain. In addition to 

healing ligaments and tendons, there are now very 

effective therapies to regrow cartilage in damaged 

joints. Joints wear out because the immune 

system attacks the cartilage or because the joint 

performs at a higher level than its physical 

capacity. This gradually causes the cartilage of the 

joint to wear out because it does not have the 

ability to repair itself from this higher level of 

wear and tear. 

Glucosamine can change this equation and 

improve the body’s ability to handle repair of joint 

cartilage. Glucosamine orally works well for knee 

joints. Success is often brand specific; MSM and 

chondroitin are not needed in the formulation. It 

also does not seem to matter whether the 

formulation contains glucosamine sulfate or 

glucosamine hydrochloride. Any studies that 

reportedly demonstrate glucosamine to be 

ineffective, used a brand of glucosamine that did 

not work. Success seems to be brand specific, 

and it is most interesting that all brands listing the 

same ingredients do not work equally. For 

glucosamine to work for other joints, it must be 

injected or applied transdermaly. In these cases, 

glucosamine cream and injections will work to 

restore jaw, neck, shoulder, elbow, wrist, finger, 

lower back, hip, knee, ankle, foot, and other 

joints. 

While the glucosamine is often strong enough to 

change the equation of wear and tear so that the 

joint stops deteriorating, it may not be enough to 

regenerate the joint and dramatically improve 

function. The most effective protocol is to inject 

stem cells from bone marrow, platelet rich plasma, 

a fat cell graft, and other growth factors into the 

injured joint. This treatment restores cartilage to 

improve knee, hip, ankle, wrist, finger, toe, jaw, 

and other joints. 

Nutrition and Pain 

Food and nutrition are also major determinants of 

pain and healing. There are three rules that help 

with understanding the relationship of nutrition and 

pain. 

• Do not eat or put poison into the body 

• The body does not run well on low octane 

fuel 

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2012 

• The gut has to heal, and healthy flora are 

essential 

The most important poisons that affect pain are 

artificial sweeteners and hydrogenated fats. 

Aspartame processes in the body to methanol and 

formaldehyde vivii . Sucralose is chlorinated sugar and 

ingestion leads to a change in intestinal flora viii . 

Ingested oils and fats are important because they 

are used by the body to synthesize cell 

membranes. Indeed, the ingested oils and fats are 

used to make or repair all cell types in the body- 

-including the brain, muscles, and red blood cells. 

Cell membranes are much healthier if they are 

made of healthy omega-3 and omega-6 fats. 

Those that are made of hydrogenated fats do not 

function as well. Red blood cells, for example, do 

not deliver oxygen and nutrients to injured and 

tired muscles as well if they are made of 

hydrogenated fats. Since red blood cells live for 

120 days, deep fried food and many prepared 

foods will increase pain and slow healing for 4 

months. In addition, hydrogenated fats in cell 

membranes increase inflammation and pain 

signaling chemicals in the body. 

With regard to octane, the lowest energy and 

most dangerous foods are wheat and sugar. Many 

pain patients are so sensitive to these foods that 

eating a small amount can increase pain for 3-4 

weeks. 

The DO NOT EAT list for pain patients includes 

• Wheat 

• Sugar 

• Potato (not sweet potato) 

• Juice 

• Hydrogenated fat 

• Artificial sweeteners 

The third rule of nutrition is that food has to heal 

the gut and grow healthy flora. Foods on the "do 

not eat" list also encourage the growth of yeast 

and flora that cause harm to the body(dysbiosis). 

It is important to instead eat the vegetables that 

encourage the growth of healthy flora. 

Healing 

When the body is injured, a healing program is 

run to repair the injured tissues. In the case of 

an ankle sprain, the torn ligaments cause a 

release of inflammatory mediators that make the 

nearby blood vessels leak fluid and white blood 

cells. The fluid makes the ankle swell, and the 

white blood cells release enzymes that clean up 

and debride the injured ligament. Three days later, 

as a result of this process, fibroblast cells migrate 

to the ankle to repair and rebuild the injured 

ligament. 

If anti-inflammatory medications are taken in the 

first few days after injury, this process is stopped 

and the area does not swell, hurt, or heal. 

Indeed, anti-inflammatory medications should not 

be taken after injury. Moreover, these medicines 

also stop glycosaminoglycan synthesis in the 

body ix . This action stops the body from rebuilding 

cartilage in joints. NSAIDs should also not be 

taken for arthritis. While they may decrease joint 

pain, they accelerate joint degeneration. Herbal 

anti-inflammatory medicines may be helpful for 

decreasing pain and inflammation, and these 

agents do not have the unfortunate side effects of 

decreasing cartilage growth x . 

There are three trigger point zones in any muscle 

(see diagram 1). These are the origin, muscle 

belly, and insertion. A weakness in the fascia or 

tendon at the origin or insertion of a muscle 

perpetuates the trigger point in the muscle belly, 

perhaps as a protective mechanism to discourage 

further stress on the tendon and additional 

damage. If the tendon is tender to palpation, it is 

damaged and the trigger points within it will 

continue to generate and radiate pain. 

Figure 1 Three trigger point zones in a muscle. 1 

and 3 are origin and insertion, 2 is muscle belly. 

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2012 

The best way to get the body to heal and 

strengthen an injured tendon is to trigger the body 

to rerun the healing program. Triggering the 

healing program requires reinjuring the tendon. 

The most efficient way to do this is to poke the 

tendon or ligament with a needle. An acupuncture 

needle can do this. The actual process of 

stimulating the healing is called “Prolotherapy” or 

“Regenerative Injection” therapy. To augment the 

healing response, prolotherapists will inject a 

mixture of dextrose and local anesthetic, and 

possibly add an additional irritating or inflammatory 

substance. 

greatly reduce or stop the unwanted slipping and 

reduce neck and head pain. 

More recently, platelet rich plasma and stem cell 

injections have become available to inject as a 

procedure in the doctor’s office. If either of these 

substances is injected into injured or degenerated 

tissue when the healing program is triggered by a 

needle, the healing reaction is greatly augmented 

and proceeds strongly for 4-6 weeks. 

With the augmented nature of the healing 

response, significant improvement can be noted in 

just a few weeks. By this method of treatment, it 

has become evident that a weakness in the 

tendon causes referred pain along the fascia 

lines--and that pain goes away with tendon and 

fascia repair. Strengthening gluteal tendons at the 

upper part of the femur’s greater trochanter will 

decrease and stop SI joint, lower back, and hip 

pain. In a similar fashion, strengthening 

quadriceps, tensor fascia lata and hamstring 

tendons at the proximal femur will stop radiating 

pain that goes down the leg. In addition, 

weakness associated with the injury can improve 

so much so that the injured extremity stops giving 

out and the patient stops falling. 

Cervical trauma from a rear end motor vehicle 

accident can lead to chronic neck pain. One of 

the less known causes of this persistent pain is 

related to ligament damage in the neck. If the 

ligaments are injured so that neck flexion and 

extension results in anterior/posterior slipping of 

the vertebrae (see diagram 2), neck muscles will 

remain in spasm and spurs will grow on the joints 

as efforts by the body to minimize this slipping. 

This author has demonstrated in unpublished work 

that PRP injections into these ligaments can 

Diagram 2. Notice the anterior slip in flexion of 

C4 on C5. 

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Summary 

Pain is associated with tissue damage. 

Unfortunately our high technology testing and 

currently taught physical examination techniques 

miss detecting the damage that causes most of 

the pain in most people. The undetectable by 

testing and previously untreatable pain comes from 

fascia, muscle, and ligament damage and 

weakness. Doctors call these body parts "soft" 

tissues and think they cannot be a persistent 

problem and cause of pain. Juries tend to award 

victims who can demonstrate something wrong in 

a bone or joint, and not a "soft" tissue problem. 

The way pain medicine is practiced needs change. 

Too many expensive procedures are performed 

that do not work as well as they would if they 

were really treating the actual injury or cause of 

pain. This dramatically increases healthcare cost, 

both by being suboptimally effective in reducing 

pain and by causing bodily harm from irreversible 

procedures. Learning more about physical 

examination and treatment of muscle and fascia 

should be part of medical curriculum, as well as 

the effects of nutrition on both causation and 

healing from pain. 

Hal S. Blatman is the founder and medical 

director of the Blatman Pain Clinic in Cincinnati, 

Ohio, a nationally recognized specialist in 

myofascial pain, and co-author of The Art of 

Body Maintenance: Winners' Guide to Pain Relief, 

a reference for treating myofascial pain, from 

migraine headaches to plantar fascitis. He is 

credentialed in Pain Management, Occupational 

and Environmental Medicine, and Integrative 

Holistic Medicine. After receiving his medical 

degree from the Medical College of Pennsylvania 

in 1980, Dr. Blatman completed two years of 

training in orthopedic surgery. He later studied 

ergonomics and toxicology during his residency in 

Occupational and Environmental Medicine at the 

University of Cincinnati Hospital. In the early 

1990’s, he studied with the late Dr. Janet 

Travell, pain physician to President Kennedy. 

Dr. Blatman currently leads a team that 

specializes in the holistic and comprehensive 

rehabilitation and treatment of pain, ligament and 

tendon injury, fibromyalgia, and chronic fatigue 

syndrome. He is a past president of the American 

Holistic Medical Association. 

Contact Hal Blatman at 513-956-3200. 

Website: www.blatmanpainclinic.com 

References: 

i 

Travell, J., Simons, D., Myofascial Pain and 

Dysfunction: The Trigger Point Manual, vol I and II, 

Williams and Wilkins 1999. 

ii 

Thomas Meyers, Anatomy Trains 2 nd ed., 2008. 

iii 

Hubbard & Berkoff, Myofascial Trigger Points Show 

Spontaneous Needle EMG Activity 1993. 

iv 

McNulty,W., Gevirtz,R.N., Hubbard, D., and 

Berkoff,G., Trigger Point vs. Adjacent nEMGs across 

Conditions, Needle electromyographic evaluation of 

trigger point response to a psychological stressor. 

Psychophysiology ,31, (3), 313-316, (1994). 

v 

Jacobs, D., Gevirtz, R. & Hubbard, D., Autogenic 

Relaxation Reduces Trigger Point Activity Banks, S., 

Effects of autogenic relaxation training on EMG activity 

in myofascial trigger points. Journal of Musculoskeletal 

Pain , 6, #4, (1998). 

vi 

Stegink et al, Aspartame causes increase in serum 

methanol in rats and humans, J Nutr. 

1983:113:1600-1606. 

vii 

Trocho et al., Dietary labeled aspartame results in 

labeled formaldehyde bound to tissue in rats, 

Departament de Bioquimica, Universitat de Barcelona, 

Spain. 

viii 

Mohamed B, et al, Spenda Alters Gut Microflora 

and Increases Intestinal P-Glycoprotein and 

Cytochrome P-450 I Male Rats, Journal of Toxicology 

and Environmental Health. Part A. Vol 71, Issue 21, 

Jan 2008. Pg 1415-1429. 

ix 

Dekel S, Falconer J, Francis MJO. The effect of 

anti-inflammatory drugs on glycosaminoglycan 

sulphation 

in pig cartilage. Prostaglandins Med 1980;4:133- 

140. 

Brandt KD, Palmoski MJ. Effect of salicylates and 

other non-steroidal anti-inflammatory drugs on articular 

cartilage. Am J Med 1984;77:65-69. 

x 

Reddy GK, Chandraksan G, Dhar SC, Studies on 

the metabolism of glycosaminoglycans under the 

influence of new herbal anti-inflammatory agents. 

Biochem Pharm 1989; 38: 3527-3534. 

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31 

Multi-systemic 

Infectious Disease 

Syndrome: 

Understanding 

Chronic Lyme 

Disease and 

Persistent Illness 

Richard I. Horowitz, 

MD 

We are presently experiencing a rise in chronic 

illness worldwide. Increasing numbers of individuals 

are now suffering the medical consequences of 

unchecked obesity, hypertension, diabetes, and 

cardiovascular disease. Significant numbers of 

individuals are being diagnosed with cancer, with 

rates approaching one out of every two men, and 

one of out of every three women in the United 

States. Medical journals report that the rates of 

Alzheimer's disease continue to climb, presenting a 

significant emotional and financial burden to 

families and the health care system. In March 

2012, The New York Times 1 reported an 

alarming rate of autism where 1 in 88 children 

born in the US are now affected by this 

syndrome. Every day we are made aware of the 

burden of chronic diseases, either by reading 

about them or experiencing the consequences first 

hand as patients, caregivers, or healthcare 

providers. 

Physicians often treat patients complaining of 

chronic fatigue, joint and muscle pains, 

headaches, with associated depression, anxiety, 

and memory and concentration problems. These 

patients usually seek answers from their primary 

care physician, who usually refers them for blood 

tests and for appointments with specialists to try 

and determine the etiology of their illnesses. They 

may go to 10-20 doctors, and are often told 

that nothing can be found despite the best 

laboratory testing and imaging techniques that 

modern medicine has to offer. The end result is 

that they are frequently diagnosed with Chronic 

Fatigue Syndrome or Fibromyalgia. If they have 

evidence of inflammation and elevated levels of 

autoimmune markers, they may be told that they 

have rheumatoid arthritis, lupus, a nonspecific 

collagen vascular disease, or they are diagnosed 

with multiple sclerosis if there is associated 

2012 

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2012 

demyelination. These patients are often placed on 

antidepressants, anti-anxiety medications, antiinflammatory 

drugs, and immune modulators to 

deal with the clinical manifestations of their 

illnesses. We treat their symptoms, but fail to be 

able to find an underlying cause for their problem. 

Is this really the best that we can do? Are there 

no answers or common denominators that help to 

explain these patients’ chronic illnesses? 

I am a board certified internist who has been in 

practice for close to 30 years. I moved to the 

Hudson Valley of New York State in 1987 to 

open a medical practice after finishing my 

residency in internal medicine. I soon began 

seeing patients with a range of common ailments 

with uncommon regularity. In addition, my patients 

were exposed to a new problem in Dutchess 

County, N.Y. that I had only briefly heard about 

in medical school, which complicated their health 

issues even further. That problem was Lyme 

disease. Lyme disease is transmitted by the bite 

of the female deer tick, Ixodes scapularis. It 

sometimes produces a typical “bulls eye” rash, 

body aches and pains and flu- like symptoms. 

When I learned about Lyme disease in medical 

school, we were told that it is a relatively rare 

disease which was easy to diagnose and easy to 

treat. Nothing could be further from the truth. 

Infectious diseases, like other medical illnesses, 

are spreading rapidly. Apart from newer threats 

like SARS and bird flu, we often hear about 

rising rates of TB, HIV/AIDS, malaria, HPV, and 

hepatitis that are affecting millions of people 

across the globe. Most people don’t realize, 

however that Lyme disease is the number one 

vector- borne disease spreading worldwide 2 . I 

certainly didn’t realize that the Hudson Valley was 

the number one hotspot for Lyme disease in the 

northeastern United States. 3 

So I not only was 

seeing the usual high numbers of patients with 

cardiovascular diseases, cancer, and other chronic 

medical illnesses that are common in an internal 

medicine office. I was also seeing large numbers 

of patients with tick bites and an array of unusual 

symptoms. These patients would often complain of 

fevers, sweats, chills, severe fatigue, muscle and 

joint pain that would often come and go and 

migrate around the body, tingling and numbness, 

chest pain, shortness of breath, a stiff neck and 

headaches, light and sound sensitivity, dizziness, 

often with associated severe memory and 

concentration problems, as well as depression, 

anxiety and an inability to sleep. If they saw and 

removed the tick and then got the telltale rash, 

early treatment with doxycycline could eliminate 

their symptoms in 80 to 90% of the cases. The 

remainder of the patients however was not as 

fortunate. They would fail the antibiotic and go on 

to develop chronic symptoms that would severely 

impact their lives. Unfortunately the standard 

medical literature had no answers for me. I would 

retry antibiotics, and occasionally they were 

effective in relieving patient symptoms, but often 

once the antibiotics were stopped, the patients’ 

symptoms would relapse. What was causing these 

patients to remain chronically ill? 

I needed to better understand this disease, since 

so many of my patients were becoming disabled 

and were looking to me for answers. I therefore 

started out on a journey as a medical detective to 

understand an illness that was causing tremendous 

suffering. After several years in practice, I closed 

my office to new internal medicine patients and 

only accepted new patients with Chronic Lyme 

disease. I started scouring the medical literature 

for answers. I attended medical conferences on 

Lyme disease and tick-borne illnesses to better 

understand my patients’ symptoms. I started 

conducting research in my medical office, and now 

after treating over 12,000 chronically ill individuals 

with tick-borne diseases over the past 28 years, 

I have found many of the answers that I had 

been searching for to help my patients. There are 

often not one, but many factors responsible for 

these patients’ chronic symptoms. 

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2012 

Much of what we read in medical school 

textbooks is based on a paradigm established by 

Pasteur’s postulate and the germ theory which 

was elaborated in the 1800’s: if you can find 

the one cause and correctly name the one 

disease that causes it, you can then understand 

the underlying pathology and prescribe the right 

medications for the patient. However patients with 

chronic tick borne illnesses do not read those 

textbooks. Patients’ illnesses can be much more 

complex than “one cause, one illness.” The 

deeper that I searched for answers year after 

year, the more I discovered multifactorial causes 

for my patients’ illnesses. From my research and 

clinical experience trying to uncover why Lyme 

disease patients remain chronically ill, I postulated 

that Lyme is better situated as being part of what 

I am calling Multi-systemic Infectious Disease 

Syndrome (MSIDS) 4 

and I believe that 

understanding this syndrome is the key to 

understanding most chronic illnesses. 

Multi-systemic Infectious Disease Syndrome 

(MSIDS) is a symptom complex of Lyme disease 

and multiple associated tick-borne co-infections 

which encompasses not only infections with 

Borrelia burgdorferi, the etiologic agent of Lyme 

disease, but also encompasses other bacterial 

infections, viral infections, parasitic infections and 

fungal infections. It also includes issues with 

immune dysfunction, inflammation, environmental 

toxicity, allergies, nutritional and enzyme 

deficiencies with functional medicine abnormalities 

in biochemical pathways, mitochondrial dysfunction, 

neuropsychological issues, autonomic nervous 

system dysfunction, endocrine abnormalities, sleep 

disorders, gastrointestinal abnormalities with 

abnormalities of liver function, and issues with 

pain, drug use, and physical deconditioning. The 

15- point differential diagnostic map for chronic 

illness that I will elaborate in this chapter is the 

result of my work and research over the last 28 

years of medical practice. Although this work 

started out as a way to understand chronic Lyme 

disease, it has now evolved into a map for all 

chronic illness. I believe this model has important 

implications for all patients suffering with both 

“explained” and unexplained chronic 

symptomatology. 

Years ago many of the patients who initially saw 

me had been diagnosed with chronic fatigue 

syndrome, fibromyalgia, autoimmune diseases, or 

psychiatric abnormalities to explain their chronic 

symptoms. The problem that I discovered early on 

with Lyme disease is that like its cousin syphilis, 

it is a great imitator 5 . It can imitate many 

illnesses commonly seen in a modern day medical 

practice. The medical literature provides abundant 

evidence on this subject. For example, although 

patients were diagnosed with a primary psychiatric 

disorder when they first came to see me, Lyme 

disease has been known to cause a host of 

neuropsychiatric abnormalities. This is welldocumented 

in the medical literature 6 . In fact, 

virtually every DSM psychiatric diagnosis can be 

caused by Lyme disease and associated coinfections! 

Similarly, Lyme disease can mimic a 

whole host of neurological syndromes. For 

example, Lyme disease can cause neurocognitive 

deficits in both children and adults 7 

and has even 

been associated with Tourette’s syndrome 8 . It also 

has been associated with neurological syndromes 

such as Alzheimer's disease. 9 

Borrelia burgdorferi 

persists in the brain in chronic lyme 

neuroborreliosis and may be associated with 

Alzheimer’s disease, and has been linked to 

ongoing inflammation in the brain affecting amyloid 

metabolism. 10 

All health care providers need to be 

aware that any patient presenting with 

neurocognitive and psychiatric symptoms in fact 

might have Lyme disease. 

The same problem exists with Chronic Fatigue 

Syndrome (CFS) and fibromyalgia (FM). These 

are common diagnoses given to patients who 

complain of chronic fatigue, muscle pains and joint 

pains, with associated depression and a sleep 

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disorder. These are the same symptoms that we 

see in chronic Lyme disease and MSIDS, and 

Lyme disease has been shown in the medical 

literature to imitate CFS and FM. 11 

Lyme disease 

can mimic rheumatoid arthritis, lupus, and multiple 

sclerosis. Most medical providers are unaware that 

Borrelia burgdorferi can mimic rheumatoid arthritis 

(RA) and cause false positive rheumatoid factors 

with swelling and joint pain. Rheumatoid factor 

correlates with antibody titer against Borrelia 

garinii, a genospecies of Borrelia burgdorferi 12 

and 57% of patients with RA showed reactivity to 

multiple borrelial antigens 13 

Borrelia burgdorferi also 

has a similar pathology and immunology to Lupus 

14 

can lead to C3 deficiency like that found in 

lupus 15 

and similarly can cause the production of 

anti-phospholipid and anticardiolipin antibodies. 16 

It is not always easy to differentiate between true 

lupus and auto-immune diseases since Lyme 

disease can also cause an over stimulated 

immune system. 

Lyme disease and tick-borne co-infections are 

now spreading rapidly worldwide, and are capable 

of mimicking many common symptoms and 

diseases seen in a physician’s office. Why aren’t 

more patients therefore being diagnosed with Lyme 

disease? Unfortunately the blood tests for Lyme 

disease are extremely unreliable. Doctors are 

taught that they should order an ELISA test to 

look for the presence of the spirochetes, as the 

first step in a twotiered protocol to test for 

Lyme disease. If the ELISA is negative, they are 

instructed not to do a follow-up Western Blot. But 

the ELISA is a very insensitive test. An extensive 

review of the medical literature on the sensitivity 

and specificity of commercially available twotiered 

testing for Lyme disease has shown that 

the sensitivity of the ELISA in numerous scientific 

peer review journals is only 56%. 17 

This means 

on the average we will miss at least 44% of the 

patients who suffer from Chronic Lyme Disease. 

A 2005 study at John’s Hopkins University 

confirmed the poor sensitivity of the ELISA, and 

their estimates of the sensitivity of testing were 

even worse. They found that the CDC twotiered 

testing missed 75% of positive Lyme cases 18 

This 

mirrors what I have found in my own practice. 

Many of my patients have seen 10-20 medical 

providers looking for answers before consulting 

with me. They do have Lyme disease but the 

testing protocols that were used were not sensitive 

enough to pick it up. This is understandable once 

you realize that many laboratories testing for Lyme 

disease have had difficulty reproducing their own 

results, and that the sensitivity of the ELISA test 

can vary widely, ranging from sensitivities of 37% 

to 70%. 19 

Apart from the problem of the poor sensitivity of 

the ELISA test, the other problem testing for 

Lyme disease is that there are over 100 strains 

of Borrelia burgdorferi (Bb) in the US, and most 

commercial Western Blots only test for the 

presence of one strain (B31). Laboratories like 

IgeneX laboratory in California have a much better 

chance of finding the spirochetal infection on the 

Western Blot because they test using the 297 

and B31 strain, making it easier to see borrelialspecific 

bands on a Western Blot. IgeneX has 

passed all laboratory quality assurance standards 

in NY, California and in many other states, and I 

have reliably used their laboratory for over 20 

years. If a patient has evidence of even one of 5 

borelial-specific bands on a Western Blot (23, 

Osp C; 31, Osp A; 34, OspB; 39, and 83-93) 

this indicates that the patient has been exposed 

to Lyme disease. Why? These five bands are 

borrelial -specific bands, and should not otherwise 

be found in blood test results. The reason so 

many doctors miss the diagnosis is because they 

have adopted the CDC criteria for the diagnosis 

of Lyme disease: trying to find 5/10 positive 

bands on an IgG Western Blot, or two out of 

three specific bands on an IgM Western Blot 

(23, 39, 41). The CDC criteria however were 

only meant for health departments to screen large 

populations for epidemiological purposes and not 

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2012 

for other purposes. The CDC has clearly stated 

this on their web site: “This surveillance case 

definition was developed for national reporting of 

Lyme disease; it is not intended to be used in 

clinical diagnosis.” 20 

The problem we therefore face is that even if a 

healthcare provider suspects the presence of 

tick-borne diseases, and follow the twotiered 

protocol recommended by certain infectious disease 

specialists and by insurance companies, they will 

find that the testing is often negative. This false 

seronegativity has been extensively documented in 

the medical literature. 21 

Apart from the poor 

sensitivity of the ELISA, borrelial antibodies can 

also be sequestered in immune complexes, 

explaining the false negative test, and they have 

the ability to enter the intracellular compartments, 

where they can hide from the immune system. 22 

Borrelia spirochetes have also learned to adapt to 

their hosts, and can survive for long periods of 

time in the body despite seemingly adequate 

antibiotic therapy. This is due to their ability to 

transform into cystic forms 23 

Multiple peer 

reviewed scientific studies have shown the ability 

of borrelia to persist. If a patient continues to 

have symptoms despite months of antibiotic 

regimens, there are at least three reasons for the 

persistence of that patient’s poor health. It may 

be that not all of the different forms of the 

organisms have been properly treated 24 , or that 

tick-born co-infections that are present were not 

sensitive to the antibiotics used, or because the 

organisms were also protected by biofilms in the 

body and sequestered deep in the tissues of the 

body where antibiotics do not penetrate well. 25 

However in addition to these issues, the primary 

reason that many patients with Chronic Lyme 

disease remain ill is because of Multi-systemic 

Infectious Disease Syndrome (MSIDS). This 

syndrome encompasses a wide range of 

differential diagnoses, and the majority of my 

patients with chronic illness have multiple 

overlapping factors responsible for their ongoing 

symptoms. For example, patients that complain of 

fatigue with MSIDS usually have hormonal 

dysfunction with a combination of low adrenal 

function, low thyroid function and abnormal levels 

of sex hormones. They also usually have food 

allergies with overlapping reactive hypoglycemia, as 

well as environmental toxicities such as mercury 

and lead toxicity, detoxification problems, severe 

sleep disorders, and mitochondrial dysfunction. All 

of these can cause fatigue, and when they are 

combined with the multiple infectious agents they 

have been exposed to, such as Lyme disease, 

Ehrlichiosis/Anaplasmosis, Babesiosis, Bartonellosis, 

Mycoplasma infections, viral infections, other 

parasites, and Candida, the result is a patient 

with chronic resistant fatigue. It is as if they had 

15 nails in their foot, and they went to the 

doctor complaining of foot pain. The physician 

might identify several of the nails, but if they are 

not all removed, the patient will still complain of 

ongoing foot pain. The patient’s resistant 

symptoms are therefore not necessarily the result 

of failing to diagnose and treat the infections 

correctly, but rather from not having addressed 

enough of the abnormalities present in the MSIDS 

model. These abnormalities are summarized in the 

table below, with a brief explanation of some of 

the testing and treatment methods used to help 

patients with chronic persistent illness. More 

detailed information can be found in my 

forthcoming book (see reference #4). 

Chronic Lyme Disease/MSIDS: Differential 

Diagnoses 

1) Infections: 

a) Bacterial: includes, but is not limited to 

infections with Lyme disease, 

Ehrlichiosis/Anaplasmosis, Bartonella, Mycoplasma, 

Chlamydia, RMSF, Typhus, Q-Fever, Brucella, 

Tularemia, Tick paralysis... 

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2012 

1) Borrelia burgdorferi: Combine drugs to 

address all three forms of Bb simultaneously due 

to the ability of the organism to shift between 

different forms, go dormant, and evade immune 

surveillance. Continue treatment until the patient is 

symptom- free for two months. 

Treat the cell wall forms with drugs such as 

Amoxicillin, Augmentin, Ceftin ,Cedax, Omnicef, IM 

Bicillin, IV Rocephin, IV Claforan, IV Vancomycin, 

IV Primaxin… 

Treat the cystic forms, L-forms, spheroplasts, 

CWD forms) with drugs such as Plaquenil 

(hydroxychloroquine), Flagyl (metronidazole), 

Tindamax (tinidazole) or nutritional supplements 

such as grape seed extract, which has been also 

shown to have some activity against cell wall 

deficient forms. 26 

Treat the intracellular forms with drugs such 

as tetracyclines (doxycycline, minocycline, 

tetracycline HCL), macrolides (azithromycin, 

clarithromycin), quinolones (Cipro, Levaquin, 

Avelox, Factive), and rifampin. 

2) Ehrlichiosis/Anaplasmosis: Use 

tetracyclines (doxycycline, minocycline) or rifampin 

for allergic/intolerant patients 

3) Bartonella, Mycoplasma, Chlamydia, 

RMSF, Typhus, Tularemia, Brucella, Q-fever 

These are all intracellular co-infections, and are 

difficult to completely eradicate from the 

intracellular compartment. Consider two intracellular 

drugs simultaneously to improve clinical outcomes 

(doxycyline with a macrolide, a macrolide plus 

rifampin, a tetracycline plus a quinolone, a 

tetracycline with rifampin) and use Plaquenil to 

alkalize the intracellular compartment to achieve 

better intracellular killing. 27 

If one regimen of an 

intracellular combo fails, one should rotate the 

regimen to another double intracellular regimen, 

and consider treating other co-infections not 

addressed (such as Babesiosis, and other 

parasites, viruses). 

b) Parasites: Babesiosis and other piroplasms, 

filiariasis, amebiasis, giardiasis, strongyloides, 

pinworm, etc. Testing is unreliable, as with Lyme 

disease. Do not rely on Giemsa stains, but 

consider a Babesia panel through IgeneX 

laboratories with a Babesia IFA, Babesia WA-1 

(duncani), Babesia FISH test and or PCR to 

properly test for the presence of this piroplasm. 

Babesiosis is treated with antiparasitic regimens 

such as Mepron (atovaquone) plus a macrolide, 

or Clindamycin plus a macrolide or quinine. Due 

to evidence of Mepron resistance in the medical 

literature 28 , also consider treating with medications 

such as malarone (atovaquone/proguanil), 

mefloquine (Lariam), and Coartem, or herbs such 

as artemesinin or cryptolepis depending on the 

clinical response. 

c) Viruses: EBV, HHV-6, HHV-8, CMV, St 

Louis Encephalitis, W Nile, Powassan encephalitis 

and other viral encephalopathies,?XMRV 

d) Candida and other fungi: Use of Nystatin, 

Diflucan (fluconazole) and other antifungal drugs 

may be useful with high dose probiotics for the 

bowel, with a strict sugar-free, yeast- free diet. 

2) Immune dysfunction: Patients with MSIDS 

often present with a history of a positive ANA’s 

(Antinuclear antibody), RF (rheumatoid factor) 

and other autoimmune markers. Increased severity 

of symptoms is often seen if the patient has 

certain genetic HLA markers such as HLA DR2, 

or DR 4. A positive ANA or Rheumatoid factor 

does not necessarily imply that the patient has 

Lupus or Rheumatoid Arthritis. Patients with Lyme 

disease and MSIDS have overstimulated immune 

systems, due in part to the production of blebs 

from the organism’s surface. These autoimmune 

markers often return to normal once the underlying 

infections are properly treated. It is therefore 

important to differentiate between a true 

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2012 

autoimmune disorder, and a patient with MSIDS 

who has infections and environmental toxins such 

as mercury driving the production of inflammatory 

cytokines. 

3) Inflammation: Patients with MSIDS have 

increased production of inflammatory cytokines, 

such as TNF-α, IL-1 and IL-6. These are, in 

part, responsible for the “sickness syndrome” of 

fatigue, nausea, muscle and joint pains, 

headaches, memory and concentration problems, 

and mood swings present in these chronically ill 

patients. 29 

Classical therapy involves the use of 

immune modulators (Plaquenil, DMARD’s), drugs 

with anti-inflammatory effects (macrolides, 

tetracyclines), and occasionally require the use of 

IVIG, especially in patients with small fiber 

neuropathy and decreased levels of 

immunoglobulins. Integrative therapies can help 

with the down-regulation of the nitric oxide 

(NO/ONOO) cycle biochemistry with subsequent 

decreased production of inflammatory markers. This 

involves the use of antioxidants, CoQ10, B 

vitamins, α-lipoic acid, Mag++, Zn++, omega- 3 

fatty acids, glutathione precursors, as well as PO, 

and IV glutathione. Once the production of 

inflammatory cytokines is decreased and the 

detoxification pathways are opened to help remove 

the cytokines and neurotoxins, patients often will 

clinically improve. 

4) Toxicity: Multiple Chemical Sensitivity, 

Environmental Illness, Heavy Metals, Mold and 

Neurotoxins (external and internal biotoxins). 

Minimal testing for MSIDS patients includes doing 

a six- hour urine DMSA challenge to test for 

heavy metal toxins. This is routinely sent to 

Doctors Data, in Chicago, Illinois. Use 30 mg/kg 

of DMSA 1x as a loading dose, and collect urine 

for six hours to test for mercury, lead, and other 

heavy metals. Other commonly used tests include 

an Organix test/Ion test through Metametrix 

laboratory to look for blockages in functional 

biochemical pathways used for detoxification, and 

testing for mold such as stachybotris, as it is an 

often overlooked factor in biotoxin -related illness. 

Treatment for heavy metals involves different 

chelation protocols, using medications such as 

DMSA, (Dimercaptosuccinic acid), DMPS, or 

EDTA. DMSA may be given in low doses to the 

MSIDS patient if they have overlapping 

detoxification problems, since they may not tolerate 

standard doses of DMSA (5-10 mg/kg TID, 

three days on, 11 days off). The low dose 

DMSA protocol would involve administering 100- 

200 mg every 3rd night with Chlorella (split cell, 

seven tablets) with 600 mg of NAC (N acetyl 

cysteine), and 600 mg of α-lipoic acid (ALA). 

Other nutritional supplements such as Med Caps 

DPO (Xymogen, with B vitamins, NAC, α-lipoic 

acid) may also be useful to support and 

modulate the phase I and phase II liver 

detoxification pathways. For patients who do not 

tolerate oral DMSA, IV DMPS, +/-EDTA 

suppositories (Detoxamine) may be useful, 

especially if high levels of lead are also present. 

It is important to replace trace minerals the next 

day after chelation, since chelation will also pull 

out beneficial minerals along with the heavy 

metals. Use of a good multivitamin and mineral 

supplement which contains a minimum of 800- 

1000 mg of calcium, 400-600 mg of 

magnesium, and 30 mg of zinc with trace 

minerals (iodine, chromium, vanadium) are also 

important. Alternatively, DMSA 5-10 mg/kg TID, 

1 hour before meals, three days on, 11 days off, 

or two days on, five days off may be used 

effectively in the MSIDS patient with overlapping 

heavy metal toxicity. 

Glutathione (GSH), either oral (liposomal) or IV, 

has also been shown to be effective in a subset 

of resistant Lyme patients with symptoms of 

toxicity. Up to 70% of patients with some level of 

resistant fatigue, muscle and joint pains, mood 

disorders, and neurocognitive deficits improve with 

glutathione, implying a need to include a 

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2012 

detoxification regime in the treatment plan for the 

majority of these patients. Other detoxification 

protocols that can be added for patients with 

significant toxicity would include the use of oral or 

IV phosphatidylcholine exchanges to help remove 

toxins from the lipid layers of the body (the oral 

use of phosphatidylcholine is much easier, and 

can still be effective), with use of nutritional 

supplements such as magnesium, NAC, glycine, 

α- lipoic acid, DIM (Diindomethane), 

sulforaphane glucosinalate, combined with a diet 

high in protein and cruciferous vegetables. 

5) Allergies: Foods, drugs, environmental, etc. 

Testing involves doing both IgE and IgG panels 

for food allergies (Bioreference laboratories, 

Metametrix 90 food allergy panel, ALCAT among 

others).Treatment involves avoidance of the 

allergic foods, rotation diets, and occasionally 

immunizations. Some integrative practitioners have 

found that treating an underlying Candida problem 

with leaky gut can be helpful, plus using 

desensitization techniques such as NAET, NMT 

and others. 

6) Nutritional and Enzyme Deficiencies/Functional 

medicine abnormalities in biochemical pathways: 

Testing involves checking serum mineral levels, 

such as magnesium, zinc, and iodine, as well as 

checking red blood cell (RBC) minerals, 

especially the RBC magnesium level. This is 

important since magnesium is involved in over 

300 detoxification enzymes in the body, and 99% 

of the magnesium is intracellular. In difficult 

patients, checking amino acid (AA) and fatty acid 

(FA) levels, as well as doing an ION test/ 

Organix test (from Metametrix labs) may help to 

discover abnormalities in functional biochemical 

pathways. Some of the most useful parameters to 

monitor are the lipid peroxides, (from Metametrix) 

to check for increased free radical exposure 

(important in CNS disease, ALS…), as well as 

checking sulfate levels to evaluate the phase II 

detoxification pathways, and nitrates to measure 

the NO pathway (indirect/inaccurate with urinary 

tract infections).Treatment involves replacing 

deficiencies in vitamins, minerals, amino acids 

(AA’s), essential fatty acids (EFA’s), and/or 

enzymes (plant or pancreatic w/amylase, lipase, 

proteases). 

7) Mitochondrial dysfunction: Mitochondria are 

the energy powerhouses of the cell. They are 

vulnerable to free radical exposure. Mitochondrial 

disease can manifest as chronic fatigue, but can 

also be responsible for a wide range of 

neurological manifestations (neuropathy, myopathy, 

encephalopathy..). Testing: lipid peroxides, and 

the Organix test (Metametrix) may provide 

indirect evidence of mitochondrial dysfunction 

secondary to nutritional deficiencies, and increased 

free radical exposure. Treatment: NT factors 

(gycosylated phospholipids), CoQ10, NADH, L- 

carnitine, D-ribose. 

8)Psychological: Stress, PTSD, abuse, depression, 

anxiety, OCD and other psychological 

manifestations 

Many patients with MSIDS have been sick for a 

long time, and experience significant depression 

and anxiety. The most severely ill patients may 

have suffered some form of abuse and can often 

demonstrate overlapping PTSD. Health care 

providers should ask about the patient’s previous 

psychiatric history, and refer for 

counseling/psychiatric help when necessary. 

Treatment: Medications (SSRI’s, buproprion, 

Remeron, anxiolytics,), Stress reduction (yoga, 

meditation, TaiChi). Integrative: Herbs (Saint 

John’s Wort (SJW), Valerian, Kava Kava, L- 

theanine). Apart from psychotherapy and cognitive 

behavioral therapy (CBT), Cognitive processing 

therapy may also be useful (PTSD), as well as 

techniques such as the Journey work (developed 

by Brandon Bays), or the Emotional Freedom 

Technique (EFT). Once patients have worked 

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2012 

through the emotional issues surrounding their 

illness, greater levels of healing can take place. 

9) Endocrine abnormalities: This often involves 

the thyroid and adrenal glands, and can also 

affect the sex hormones and other pituitary 

hormones. In MSIDS and Chronic Lyme disease, 

the hypothalamic-pituitary axis (HPA) may be 

affected. Check FSH, LH, IGF1 levels, TSH, T3 

& T4, Free T3/4, as well as DHEA/Cortisol 

levels for adrenal function, and check sex 

hormone levels (testosterone, free testosterone, 

SHBG, estradiol, progesterone, DHT, and DHEA- 

S). It is also important to check Vitamin D 

levels, with 1:25 and 25 OH levels. Balancing, 

supporting, and replacing deficient hormones are 

important factors in recovering health. 

10) Sleep disorders: Acute and Chronic 

The chronically ill Lyme patient with MSIDS often 

suffers from severe insomnia. Apart from the effect 

of Bb and co-infections on sleep, other etiologies 

include, but are not limited to: Obstructive Sleep 

apnea (OSA), Medications, Caffeine, Nocturia, 

Pain, Depression/Anxiety, and Restless Leg 

Syndrome (RLS). Evaluations include doing a 

sleep study if the patient is unresponsive to 

standard treatment regimens. Treatment may 

include activating agents in the a.m. (such as 

Provigil, Nuvigil..), and sleep promoting agents in 

the p.m., especially those that encourage stage 

3/stage 4 non-REM sleep (Lyrica, Trazadone, 

Gabitril, Seroquel, Xyrem…). Integrative protocols 

include checking neurotransmitter levels. Balancing 

neurotransmitters with 5-HTP to increase serotonin 

and other brain chemicals such as melatonin, 

increasing GABA, and the use of 

phosphatidylserine at bedtime if the patient has 

elevated cortisol levels can also help with sleep. 

Herbs such as Valerian root, extracts of green tea 

such as L-theanine, and supplements such as 

melatonin may similarly be useful. Getting the 

patient back to sleep is essential in having them 

recover from MSIDS. Sleep deprivation increases 

levels of inflammatory cytokines such as IL-6 and 

interferes with production of growth hormones, 30 

which furthers the underlying inflammation and 

delays healing. 

11) Autonomic Nervous System (ANS) 

Dysfunction/POTS (Postural Orthostatic 

Tachycardia Syndrome) 

Many Chronic Lyme disease/MSIDS patients will 

complain of fatigue, dizziness, and concentration 

problems despite classical therapies. The blood 

pressure (BP) will be low on exam, usually 

equal to, or less than 90/60, with associated 

tachycardia, greater than 100 BPM at rest. 

Standing the patient up and testing serial blood 

pressure and pulse readings in both positions may 

help to determine the likelihood of POTS. 

Definitive testing involves doing a Tilt table test. 

The patient should keep a blood pressure log with 

home readings to determine the severity of the 

autonomic nervous system dysfunction, and to 

evaluate the efficacy of therapy. Treatment 

involves the use of salt (minimum 3-4 

grams/day), drinking increased fluids (3 liters 

+), and considering medications such as Florinef, 

Midodrine, Cortef, and/or B blockers. Occasionally 

clonidine and SSRI’s like sertraline (Zoloft) can 

be helpful if there is an inadequate response. 

12) Gastrointestinal: Leaky Gut, Candida, 

Dysbiosis, Celiac Disease, Colitis, Cancer… 

MSIDS patients may have varying levels of gluten 

intolerance or true Celiac disease, along with 

overlapping food allergies. Celiac disease is one 

of several malabsorption syndromes due to gluten 

sensitivity. Look for laboratory evidence of 

malabsorption such as decreased levels of 

albumin, low levels of cholesterol, calcium, 

magnesium, and B12 deficiency with a macrocytic 

anemia. The patient may also have low levels of 

iron and potassium. Testing involves checking 

Antigliadin antibodies, and a TTG (tissue 

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2012 

transglutaminase) level. Patients should avoid 

gluten as a therapeutic trial. Other overlapping GI 

problems may include undiagnosed Crohn’s 

disease, Ulcerative Colitis (UC), parasites, 

Candida/Leaky gut/dysbiosis, or other 

malabsorption syndromes. 

13) Elevated Liver functions (LFT’s): These 

may be due to tick-borne diseases, antibiotic use, 

ETOH, Hepatitis, Hemochromatosis, and Wilson’s 

disease, as well as α-1AT deficiency, chemicals 

(carbon tetrachloride, drugs) and many systemic 

and endocrine diseases. Testing: ANA, AMA, 

Hepatitis B and C screen, Fe-TIBC/Ferritin levels, 

Ceruloplasmin levels, α-antitrypsin levels, tickborne 

panel, lipid levels..Treatment: Treat 

symptomatically if the above etiologies have been 

ruled out. Integrative: Use milk thistle (silymarin), 

Hepa #2 (TCM), NAC, and α-lipoic acid. 

14) Drug use/Addiction. This may interfere with 

endocrine function, interfere with sleep, and cause 

a rebound phenomenon. Use of narcotics also 

interferes with the use of LDN (low dose 

naltrexone), an effective medication for pain and 

overlapping fibromyalgia symptoms. Referral to a 

pain/addiction specialist may be necessary. 

15) Deconditioning: Many patients with an 

extended illness are deconditioned, and may need 

to participate in a physical therapy and medically 

supervised exercise program to regain previous 

levels of functioning. 

This 15- point differential diagnostic category for 

Multi-systemic Infectious Disease Syndrome 

(MSIDS) is applicable to most chronic disease 

states. It serves as a map for the clinician when 

they are evaluating not just a patient with Lyme 

disease and co-infections, but for assessing any 

patient with a chronic unexplained illness. The 

majority of the chronically ill patients I have seen 

over the last 28 years with symptoms of 

unexplained fatigue, muscle and joint pains, 

neuropathy, memory and concentration problems 

with an associated sleep and mood disorders had 

usually received a diagnosis of chronic fatigue 

syndrome, fibromyalgia, rheumatoid arthritis or a 

non-specific autoimmune disorder, multiple 

sclerosis from other physicians, or were told that 

their complaints were from a primary psychiatric 

disorder such as depression or anxiety. Yet the 

majority of these patients in fact suffered with 

MSIDS. Their symptoms were due to not one 

problem, but to a host of overlapping factors on 

the MSIDS map. These factors included Lyme 

disease and associated tick-borne infections, viral, 

fungal and parasitic infections, autoimmune 

phenomenon, increased levels of cytokines 

secondary to inflammation in the body, heavy 

metal toxicity with other environmental toxins with 

associated detoxification problems, mineral and 

vitamin deficiencies, hormonal imbalances, 

autonomic nervous system dysfunction, 

mitochondrial dysfunction, sleep disorders, and 

psychiatric symptoms such as depression and 

anxiety. All of these factors simultaneously 

interfered with the patient getting well and 

regaining their previous state of health. Moreover 

patients with disseminated, multi-system infections 

face a host of potential stressors: one or more 

infections, reduced psychosocial functioning, severe 

pain, sleep disorders, cognitive and neurological 

impairment, and difficulty in finding appropriate 

care from an often skeptical medical and 

insurance community. What can health providers 

do? We can institute the regular use of a 39- 

item screening questionnaire for Lyme and other 

tick-borne diseases (www.ilads.org), combined 

with a detailed history and physical and 

appropriate testing along with this15- point 

MSIDS map for chronic diseases. These are the 

keys to solving the underlying mysteries of 

patients’ chronic symptoms. 

I hope that that in the years to come the 

concepts behind MSIDS will bring about a 

paradigm shift in how we think about chronic 

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2012 

diseases. I have been able to help the majority of 

the 12,000 ill patients who have come to see 

me after they have failed previous traditional 

medical evaluations and treatments. It is no longer 

acceptable to just label an illness, and then to 

give a drug to treat the symptoms. We can do 

better. Lyme disease and associated co-infections 

are occurring in epidemic numbers in the world, 

as are exposures to environmental toxins. We 

should suspect that the chronically ill patient may 

have an undiscovered tick-borne illness and be 

suffering from environmental toxicity with 

detoxification problems. The 39- item 

questionnaire and the 15- point differential of 

MSIDS give healthcare providers a framework with 

which to unravel the etiologies of a patient’s 

complex illness. The strength of using this system 

is that healthcare providers can be overwhelmed 

by an endless list of what seem to be unrelated 

symptoms that a chronically ill patient will report 

during their office visits. 

It is an enormously gratifying experience to help 

suffering, chronically ill patients regain their health. 

Look to MSIDS for diagnostic answers in your 

patients with chronic diseases. 

You will not be disappointed. 

treatment of Chronic Lyme Disease and other 

tick-borne disorders. He has treated over 12,000 

Chronic Lyme Disease patients in the last 25 

years, with patients coming from all over the US, 

Canada, and Europe to his clinic. He is former 

Assistant Director of Medicine of Vassar Brothers 

Hospital in Poughkeepsie, N.Y., and is one of the 

founding members and past president-elect of 

ILADS, the International Lyme and Associated 

Diseases Society. He now serves as president of 

the International Lyme and Associated Diseases 

Educational Foundation (ILADEF), a non-profit 

educational foundation whose mission is to 

educate health professionals in the diagnosis and 

treatment of tick-borne disorders. 

Dr. Horowitz has presented at numerous local, 

national, and international scientific conferences on 

Lyme Disease, and has published on the role of 

co-infections and toxins in Chronic Lyme 

Borreliosis. He was recently awarded Humanitarian 

of the Year award by the Turn the Corner 

Foundation for his treatment of Lyme Disease, 

and has dedicated his life to helping those 

stricken with this devastating illness. 

Contact Richard Horowitz at medical@HVHAC.com 

or 845-229-8977. 

Acknowledgments: 

I would like to acknowledge the assistance of Dr. 

Phyllis R. Freeman, Department of Psychology, 

State University of New York at New Paltz, and 

Research Associate at the HVHAC, who was 

instrumental in the research and editing of this 

chapter. 

Richard Horowitz is a board certified internist in 

private practice in Hyde Park, N.Y. He is medical 

director of the Hudson Valley Healing Arts Center, 

an integrative medical center which combines both 

classical and complementary approaches in the 

References: 

1 

Diagnoses of Autism on the Rise, Report Says 

The New York Times 20 March 2012, A20. 

http://www.nytimes.com/2012/03/30/health/rate 

-of-autism-diagnoses-has-climbed-study-finds.html 

2 

U S. Centers for Disease Control 

http://www.cdc.gov/ncezid/dvbd 

3 

http://newyork.cbslocal.com/2011/04/15/tickborne-disease-babesiosis-spreads-in-hudson-valley 

4 

Horowitz, R.I. Unraveling the mystery of Lyme 

disease and chronic illness. (forthcoming) NY: St 

Martin’s Press. 

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5 

Pachner, A.R. Neurological manifestations of 

Lyme disease, The new "great imitator” Infectious 

Disease; 11 Suppl 6:S1482-1486;1989; Fallon, 

B. Neuropsychiatric Lyme disease: The new 'great 

imitator'. Psychiatric Times. June 2004. 

6 

Fallon, B.A, Kochevar, J.M., Gaito, A., and 

Nields, J.A. The underdiagnosis of neuropsychiatric 

Lyme disease in children and adults. Psychiatric 

Clinics of North America. 1998; 21: 693-703.; 

Fallon, B.A. and Nields, J.A. Lyme Disease: A 

neuropsychiatric illness Am J Psychiatry. 

1994Nov;151(11):1571-83; Hajek, T., 

Paskova, B., Janovska, D., et al. Higher 

prevalence of antibodies to Borrelia Burgdorferi in 

psychiatric patients than in healthy subjects. Am J 

Psychiatry 159:297-301, February 2002; Hess, 

A., Buchmann J., Zettl, U.K., Henschel, S., 

Schlaefke, D., Grau, G., and Benecke, R. Borrelia 

burgdorferi central nervous system infection 

presenting as an organic schizophrenia-like 

disorder. Biol Psychiatry. 1999 Mar 

15;45(6):795; Brown, J.S., Jr. Geographic 

correlation of schizophrenia to ticks and tick-borne 

encephalitis. Schizophr Bull. 1994;20(4):755- 

75; Kaplan, A. Neuropsychiatric masquerades. 

Psychiatric Times. 2009 Feb 26(2)1-8; 

Barnett, W., Sigmund, D., Roelcke, U, and 

Mundt, C. Endogenous paranoid-hallucinatory 

syndrome caused by Borrelia encephalitis. 

Nervenarzt. 1991 Jul;62(7):445-7 [German];. 

Pfister, H.W., Preac-Mursic, V., Wilske, B., 

Rieder, G., Forderreuther, S., and Schmidt, S. 

and Kapfhammer, H.P. Catatonic syndrome in 

acute severe encephalitis due to Borrelia 

burgdorferi infection. Neurology.1993 

Feb;43(2):433-5; Sherr, V.T. Panic attacks may 

reveal previously unsuspected chronic disseminated 

Lyme disease. Journal of Psychiatric Practice, 

6:352-356, November 2000. 

7 

Benke, T., Gasse, T., Hittmair-Delazer, M., and 

Schmutzhard, E. Lyme encephalopathy: Long-term 

neuropsychological deficits years after acute 

neuroborreliosis. Acta Neurol Scand. 1995 May; 

91(5):353-7; Bloom, B.J., Wyckoff, P.M., 

Meissner, H.C., and Steere, A.C. Neurocognitive 

abnormalities in children after classic manifestations 

of Lyme disease. S: Pediatr Infect Dis J. 1998 

Mar;17(3):189-96. 

8 

Riedel M, Straube A, Schwarz MJ, Wilske B, 

and Muller N. Lyme disease presenting as 

Tourette's syndrome. Lancet. 1998 Feb 7; 

351(9100):418-9. 

9 

Miklossy, J., Khalili, K., Gern, L., Ericson, R.L., 

Darekar, P., Bolle, L., Hurlimann, J., and Paster, 

B.J. J Alzheimers Dis. 2004 Dec;6(6):639-49; 

discussion 673-81; Miklossy, J. Chronic 

inflammation and amyloidogenesis in Alzheimer's 

disease -- role of spirochetes. J Alzheimers Dis. 

2008 May;13(4):381-91. MacDonald, A.B. 

Review; Concurrent neocortical borreliosis and 

Alzheimer's disease: Demonstration of a spirochetal 

cyst form. Ann N Y Acad Sci. 1988; 539:468- 

470 

10 

Mattsson, N., Bremell, D., Anckarsater, R., 

Blennow, K., Anckarsater, H., 

Zetterberg, H., and Hagberg, L. Neuroinflammation 

in Lyme neuroborreliosis affects amyloid 

metabolism. BMC Neurol. 2010 Jun 

22;10(1):51; Pachner, A.R., and Steiner, I. 

Lyme neuroborreliosis: infection, immunity and 

inflammation. Lancet. Neurology, 2007 6:544-52. 

11 

Berman, D.S. and Wenglin, B.D. Complaints 

attributed to chronic Lyme disease: depression or 

fibromyalgia? Am J Med. 1995 Oct; 

99(4):440; Woessner, R. A. and Trieb, J. 

Pain, fatigue, depression after borreliosis. 

Antibiotics used up--what next? MMW Fortschr 

Med. 2003 Sep 18;145(38):45-8; Gaudino 

E.A., Coyle P.K. and Krupp, L.B. Post-Lyme 

syndrome and chronic fatigue syndrome. 

Neuropsychiatric similarities and differences.: Arch 

Neurol. 1997 Nov;54(11):1372-6. 

12 

Kologrivova E.N. et al. Intensity of the 

production of rheumatoid factor in patients with 

different degrees of sensitization to B. garinii 

antigens. Zh Mikrobiol Epidemiol Immunobiol. 

2005 Mar-Apr;(2):80-3. 

13 

Weiss N.L., Sigal L, et al. False positive 

seroreactivity to Bb in SLE: The value of 

immunoblot analysis. Lupus 1995 Apr;4(2):131- 

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7; Wilder, R.L. and Crofford L.J. Do infectious 

agents cause rheumatoid arthritis? Clin Orthop 

1991 Apr(265):36-41; Goebel K.M., et al. 

Acquired transient autoimmune reactions in Lyme 

arthritis: Correlation between rheumatoid factor and 

disease activity. Scand J Rheumatol Supp. 

1998;75:314-7. 

14 

Duray, P.H. and Steere, A.C. Clinical 

pathologic correlations of Lyme disease by stage. 

Ann N.Y. Acad Sci. 1988;539;65-79. 

15 

Pausa, M, et al. Serum resistant strains of Bb 

evade complement mediated killing by expressing 

a CD 59-like complement inhibitory molecule. J 

Immunol. 2003 Mar 15;170(6):3214-22. 

16 

Garcia Monco J.C. et al. Reactivity of 

neuroborreliosis patients to cardiolipin and 

gangliosides. J Neurol Sci. 1993 Jul;117(1- 

2):206-14. 

17 

Stricker, R. B. and Johnson, L. Lyme wars: 

Let's tackle the testing. BMJ. 2007 Nov 17; 

335(7628):1008. 

18 

Coulter, P., Lema, C. et al. Two-year 

evaluation of Borrelia burgdorferi culture and 

supplemental tests for definitive diagnosis of Lyme 

disease. J. Clin. Microbiol. 43:5080-5084. 

[PMC free article] [PubMed 

19 

Bakken, L.L., Case, K.L., Callister, S.M., 

Bourdeau, N.J. and Schell, R. F. Performance of 

45 laboratories participating in a proficiency testing 

program for Lyme disease serology. JAMA 1992; 

268:891-895; Marangoni, A., Sparacino, M. et 

al. Comparative evaluation of three different ELISA 

methods for the diagnosis of early cultureconfirmed 

Lyme disease in Italy. J. Med Microbiol 

2005, 54: 4, 361-367; De Marteno, S.J. 

Role of biological assays in the diagnosis of Lyme 

borreliosis presentations. Med Mal Infect 2007, 

July-Aug; 37 (7-8): 496-506 (French). 

20 

Centers for Disease Control Prevention 

http://www.cdc.gov/osels/ph_surveillance/nndss/ca 

sedef/lyme_disease_current.htm 

21 

Kaiser R. False-negative serology in patients 

with neuroborreliosis and the value of employing 

of different borrelial strains in serological assays. J 

Med Microbiol. 2000; Pikelj, F., Strle, F., and 

Mozina, M.; Seronegative Lyme disease and 

transitory atrioventricular block. Ann Intern Med 

1989 Jul 1;111(1):90. Oct; 49(10):911-5.; 

Dejmkova, H., Hulinska, D., Tegzova, D., Pavelka, 

K., Gatterova, J., and Vavrik, P. Seronegative 

Lyme arthritis caused by Borrelia garinii. Clin 

Rheumatol. 2002 Aug;21(4):330-4.; Brunner, 

M. New method for detection of Borrelia 

burgdorferi antigen complexed to antibody in 

seronegative Lyme disease. J Immunol Methods. 

2001 Mar 1;249(1-2):185-90.; Breier, F., 

Khanakah, G., Stanek, G., Kunz, G., Aberer, E., 

Schmidt, B., and Tappeiner, G. Isolation and 

polymerase chain reaction typing of Borrelia afzelii 

from a skin lesion in a seronegative patient with 

generalized ulcerating bullous lichen sclerosus et 

atrophicus. Br J Dermatol. 2001 

Feb;144(2):387-92.; Schutzer, S.E., Coyle, 

P.K., Belman, A.L., Golightly, M.G., and Drulle, J. 

Sequestration of antibody to Borrelia burgdorferi in 

immune complexes in seronegative Lyme disease. 

Lancet. 1990 Feb 10;335(8685):312-5.; 

Steere, A.C. Seronegative Lyme disease. JAMA. 

1993 Sep 15;270(11):1369.; Dattwyler, R.J., 

Volkman, D.J., Luft, B.J., Halperin, J.J., Thomas, 

J., and Golightly, M.G. Seronegative Lyme 

disease. Dissociation of specific T- and B- 

lymphocyte responses to Borrelia burgdorferi. N 

Engl J Med. 1988 Dec 1;319(22):1441-6.; 

Coyle, P.K., Schutzer, S.E., Deng, Z., Krupp, 

L.B., Belman, A.L., Benach, J.L., and Luft, B.J. 

Detection of Borrelia burgdorferi-specific antigen in 

antibody-negative cerebrospinal fluid in neurologic 

Lyme disease. Neurology. 1995 Nov; 

45(11):2010-5. 

22 

Ma, Y., Sturrock, A., Weis J.J. Intracellular 

localization of Borrelia burgdorferi within human 

endothelial cells. Infect Immun.1991 

Feb;59(2):671-8.; Dorward, D.W., Fischer E.R., 

and Brooks, D.M. Invasion and cytopathic killing 

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of human lymphocytes by spirochetes causing 

Lyme disease. Clin Infect Dis.1997 Jul;25 Suppl 

1:S2-8.; Montgomery RR, Nathanson, M.H., and 

Malawista, S.E.. The fate of Borrelia burgdorferi, 

the agent for Lyme disease, in mouse 

macrophages. Destruction, survival, recovery. J 

Immunol. 1993 Feb 1;150(3):909-15.; Aberer 

E; Kersten A; Klade H; Poitschek C; Jurecka W. 

Heterogeneity of Borrelia burgdorferi in the skin. 

American Journal of Dermatopathology, 

1996;18(6):571-9; Girschick, H.J., Huppertz, 

H.I., Russmann, H., Krenn, V., Karch, H. 

Intracellular persistence of Borrelia burgdorferi in 

human synovial cells. Rheumatol Int 

1996;16(3):125-32. 

23 

Preac-Mursic, V. et al, Formation and 

cultivation of Borrelia burgdorferi spheroplast-Lform 

variants, Infection,24 (1996);No 3:218- 

26; Brorson,O et al, Transformation of cystic 

forms of Borrelia burgdorferi to normal, mobile 

spirochetes, Infection 25 (1997); No 4:240- 

45.;Alban PS et al, Serum-starvation induced 

changes in protein synthesis and morphology of 

Borrelia burgdorferi, Microbiology (2000), 

146:119-27; Brorson, O et al, A rapid method 

for generating cystic forms of Borrelia burgdorferi, 

and their reversal to mobile spirochetes, APMIS, 

106 (1998):1131-41; MacDonald, A. 

Concurrent neocortical borreliosis and Alzheimer’s 

Disease: Demonstration of a spirochetal cyst form. 

NY Acad Sci. 1988. 468-470; MacDonald, A. 

Spirochetal cyst forms in neurodegenerative 

disorders,…hiding in plain sight. Med Hypotheses 

2006, 67(4):819-32. 

24 

Borrelia burgdorferi, the etiologic agent of Lyme 

disease, can persist in the body in cell wall 

forms, cystic forms, and intracellular forms. Ceftin 

or amoxicillin only treat the cell wall forms. 

Doxycycline will primarily treat the intracellular 

forms (and is also useful for multiple intracellular 

co-infections). Neither of these two drugs treats 

the cystic forms (sometimes also known as S 

forms, L forms, or cell wall deficient forms) which 

is one of the primary ways that the organism 

persists in the body. Work done in the laboratory 

of Dr. Eva Sapi at the University of New Haven 

showed that giving doxycycline alone with or 

without Plaquenil can cause the organism to 

transform further into cystic forms. This would 

explain why some patients treated with doxycycline 

alone go on to develop chronic symptomatology. 

In our medical practice we treat the cell wall, 

cystic, and intracellular forms simultaneously or at 

least rotate among the different drugs to treat all 

3 forms. 

25 

Bradley J.F.,et al, The persistence of 

spirochetal nucleic acids in active Lyme arthritis. 

Ann Int Med 1994;487-9; Bayer, M.E., Zhang, 

L, and Bayer, M.H. Borrelia burgdorferi DNA in 

the urine of treated patients with chronic Lyme 

disease symptoms. A PCR study of 97 cases. 

Infection 1996. Sept-Oct;24(5):347-53; 

Diringer, M.N., et al, Lyme meningoencephalitisreport 

of a severe, penicillin resistant case. 

Arthritis & Rheum, 1987;30:705-708; Donta, 

S.T., Tetracycline therapy in chronic Lyme 

disease. Chronic Infect Dis, 1997; 25 (Suppl 

1): 552-56; Fitzpatrick, J.E., et al. Chronic 

septic arthritis caused by Borrelia burgdorferi. Clin 

Ortho 1993 Dec;(297):238-41; Georgilis, K, 

Peacocke, M., and Klempner, M.S. Fibroblasts 

protect the Lyme disease spirochete, Borrelia 

burgdorferi, from ceftriaxone in vitro. J Infect Dis 

1992;166: 440-444; Horowitz R.I. Chronic 

persistent Lyme borreliosis: PCR evidence of 

chronic infection despite extended antibiotic 

therapy: A retrospective review. Abstract XIII Intl 

Sci Conf on Lyme Disease. Mar 24-26, 2000; 

Haupl, T., et al. Persistence of Borrelia burgdorferi 

in ligamentous tissue from a patient with chronic 

Lyme borreliosis. Arthritis Rheum 1993;36:1621- 

1626; Karma, A., et al. Long term follow-up of 

chronic Lyme neuroretinitis. Retina 1996;16:505- 

509; Keszler, K., and Tilton, R.C. Persistent PCR 

positivity in a patient being treated for Lyme 

disease. J of Spirochetal and Tick-Borne 

Diseases. 1995;2(3):57-58; Lawrence, C., 

Lipton, R.B., Lowy, R.D., and Coyle, P.K. 

Seronegative Chronic relapsing neuroborreliosis. 

Eur Neurol. 1995;35:113-117; Liegner, K.B., et 

al. Recurrent erythema migrans despite extended 

antibiotic treatment with minocycline in a patient 

with persisting Borrelia borgdorferi infection. J Am 

Acad Dermatol 1993; 2:312-314; Preac-Mursic, 

V., et al. Survival of Borrelia burgdorferi in 

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antibiotically treated patients with Lyme borreliosis. 

Infection. 1989;17:355-359.; Straubinger, R.K., 

et al. Persistence of Bb in experimentally infected 

dogs after antibiotic treatment. J Clin Microbiol 

1997; 35(1):111-116). 

26 

Brorson, O., and Brorson, S.H. Grapefruit 

seed extract is a powerful agent in vitro against 

motile and cystic forms of Borrelia burgdorferi 

sensu lato. Infection. 2007; 35 (3): 206-208. 

27 

Maurin, et al. Phagolyosomal alkalinization and 

the bactericidal effect of antibiotics. J. Infect 

Dis.1992; 166:1097-1102. 

28 

Wormser GP, Prasad A, Neuhaus E, Joshi S, 

Nowakowski J, Nelson J, Mittleman A, Aguero- 

Rosenfeld M, Topal J, Krause PJ. Emergence of 

resistance to azithromycin-atovaquone in 

immunocompromised patients with babesia microti 

Infection. Clin Inf Dis. 2010; 50:381-386. 

29 

Dantzer R. Cytokine-induced sickness behavior: 

a neural immune response to activation of innate 

immunity. Eur J Pharmacol. 2004 Oct 1; 500 

(1-3): 399-411; Dantzer R. Innate immunity at 

the forefront of psychoneuroimmunology. Brain 

Behav Immun. 2004 Jan; 18 (1): 1-6); 

Myers, J.S. Proinflammatory cytokines and 

sickness behavior. Oncology Nursing Forum 2008. 

(Continuing Nusing Education Forum). 

http://www.highbeam.com/doc/1G1- 

192317823.html 

30 

Redwine, L., Hauger, R.L., Christian Gillin, J., 

and Irwin, M. Effects of sleep and sleep 

deprivation on interleukin-6, growth hormone, 

cortisol, and melatonin levels in humans J. Clin 

Endocrin & Metabol 2000; 85 (10:) 3597- 

3603. 

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32 

What is Biological 

Dentistry? Dentists 

as Physicians of the 

Mouth 

George Keanna, 

DDS 

2012 

“ …Dental and oral conditions can be understood 

only in relation to the whole body. Just as your 

foot bone’s connected to your anklebone, your 

oral tissues are physically and energetically 

connected to every other part of your body. 

Biological practitioners know that the body reflects 

what goes on in the mouth—and that the mouth 

reflects what goes on in the body. Dysfunction 

or disturbance in one area will invariably show up 

as illness in related areas of the body. 

A biological approach is holistic. It is a blend of 

clinical practice, sound scientific knowledge, and 

the traditions of natural healing. It does not 

automatically equate symptoms with illness. What 

we call “symptoms” often indicate important signs 

of healing. To suppress these symptoms and 

then call this suppression a “cure” would be 

superficial and shortsighted. By ignoring the 

actual causes of illness, this allopathic practice 

leaves the patient vulnerable to even more 

dysfunction and future disease. 

In contrast, biological practitioners try to find the 

systemic causes of illness. To remove the root 

cause is to take a major step towards healing. 

As a rule, they opt for the least invasive, least 

traumatic, and least toxic means of diagnosis and 

treatment. True biological care supports the 

body’s natural abilities of self-healing and 

regeneration. 

Biological practice is socially, spiritually, 

ecologically, and environmentally aware. Its 

practitioners honor the right to informed consent. 

They know that the human body is more than a 

collection of parts that can be mechanically 

worked on in isolation. Seeing us as whole, 

unified beings, biological practitioners respect each 

person’s individual uniqueness and dignity. They 

are committed to providing the patient with the 

knowledge, tools, and power to take charge of his 

or her health….” (1) 

“Discovery consists in seeing what everyone else 

has seen and thinking what no one has thought.” 

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2012 

—Albert Szent-Gyorgyi MD, PhD; Awarded 

the 1937 Nobel Prize in Medicine for the 

discovery of vitamin C, in connection with 

biological combustion. 

Perhaps the greatest driving forces in creating the 

changes that are taking place in dentistry are 

today’s more highly inquisitive and educated 

patients. Gone forever are the days when the 

dentist was the lone source of information for a 

patient trying to learn about these issues. 

Dentists, when confronted on a regular basis by 

these highly informed patients, may initially feel 

threatened, but dentists are eventually forced to 

take notice and address these issues. 

Dentists as Physicians of the Mouth 

The evolution of dentistry in this country changed 

abruptly in 1833. Until then, there were two 

types of practicing dentists. The first was a 

physician-dentist. Dentistry was viewed as a 

subspecialty of medicine. Upon graduating from an 

accredited medical university, a physician would 

do an apprenticeship under a practicing physiciandentist 

and learn the craft of dentistry. This was 

truly comprehensive health care. The second type 

of dentist was the barber-dentist. The barberdentist 

came from the nonmedical trades, such as 

barbering, blacksmithing, and carpentering. Indeed, 

anyone who thought that working on teeth might 

be profitable could become a barber-dentist. 

These barber-dentists had no formal training or 

education in dentistry or its relationship to 

medicinal health care. These barber-dentists would 

fill teeth with whatever was at hand: with molten 

lead, pine resin, stone, woodchips, corks, tin foil, 

gold foil, etc. or just pull the troubled teeth for 

their clients. There were no dental schools, no 

licenses, no drills, no anesthesia, and no checks 

or balance in the profession of dentistry. The 

dental field therefore was wide open to swindlers, 

con artists, and snake-oil peddlers. 

The practice of dentistry in this country was 

forever changed by the introduction of mercuryamalgam 

filling materials or “Royal Mineral 

Succedum” in 1833 by the Crawcours brothers. 

This started the Amalgam Wars between the 

craftsmen-dentists’ ideal of ease of manipulating 

amalgam and the medical-dentists’ ideal of 

avoiding the dangers of systemic mercurial 

poisoning. 

Chaplin Harris, MD, the cofounder of the first 

dental school, said in 1833: 

“…Some have endeavored to [overcome] the 

objection to this amalgam by using silver 

perfectly purified, but it matters not how pure 

the silver may be; the material will be equally 

deleterious in it effects. . . . It is the mercury 

that does the injury, and it matters not, 

therefore, how pure or what the other metal 

may be that is employed with it for the 

formation of the amalgam….” (2) 

The first dental society was formed in New York 

in 1834. The first dental school was charted in 

1840 in Baltimore to educate craftsmen and 

future dentists. Months later, the world’s first 

national dental organization was formed in 1840: 

the American Society of Dental Surgeons 

(ASDS). (3) 

In 1843, the ASDS declared the use of mercury 

amalgams by any of its members to be 

malpractice and grounds for expulsion. All 

members were required to sign a declaration that 

they would not use the poisonous mercury filling 

material. This declaration against mercury amalgam 

led to the ultimate disbandment of the ASDA in 

1856. (4) The financial gain was too great for 

the barber-dentists, and they left the ASDA and 

ultimately formed the American Dental Association 

(ADA) in 1859. This was the beginning of the 

first of three Amalgam Wars in this country. 

Ironically, while it was the medical dentists who 

recognized mercury as a health hazard, and it 

was the medical profession [who] declared it 

unethical to use mercury fillings, it was the 

nonmedical barber-dentists who held the winning 

hand. This was the issue upon which the practice 

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2012 

of dentistry and the practice of medicine parted 

ways. In essence, the fracturing of dentistry from 

medicine occurred over a medical health issue, 

not a dental one; tragically, the fundamental 

reason for the split was not to improve the 

practice of dentistry or to provide better treatment 

to the patient, but for the pursuit of profit. (5) 

At this same time, the medical establishment 

turned its back on dentistry. Then dental schools 

dropped courses in physiology, pathology, medical 

matters, and ceased teaching anything about 

anatomy except for the head and neck. 

“…The atmosphere at most private dental 

colleges was more like the one prevailing in trade 

schools, and this attitude naturally permeated to 

the student body. Dental students gave scant 

attention to any subjects excepting those 

pertaining to the technical side of dentistry. 

Knowledge of anatomy, chemistry, or histology 

was considered useless and a sheer waste of 

time….” (6) 

The use of mercury-amalgam fillings caused the 

divorce of dentistry from the medical profession. 

All parties involved suffered, especially the 

patients. Now it is over 175 years later, and the 

medical profession is poised to give dentistry 

another chance to be part of it again. This has 

been necessitated by the continued growth of 

chronic and degenerative diseases in the U.S. No 

competent doctor or health-care provider can 

overlook the oral-systemic correlation of the 

disease processes any longer. The days of the 

tooth-mechanic dentist who blindly fills holes in 

teeth without any understanding of what caused 

the problem in the first place or what systemic 

problems could arise from their treatment are 

over. (7) 

As a result of research-based proof that an 

association exists between oral infection and 

systemic diseases (8,9,10), dentists have the 

opportunity—and some say obligation—to elevate 

their roles in their patients’ care from that of “ 

tooth technician” to “oral health physician.” 

What was previously an intuitive hypothesis has 

now been substantiated with research-based proof. 

An association was found to exist between oral 

infection and systemic diseases, particularly heart 

disease (11, 12, 13, 14, 15) and stroke 

(16), diabetes (11,17), and preterm low birthweight 

babies (18,19,20), among others. High 

correlations have also been made to pneumonia 

(21), respiratory diseases (22), and 

osteoporosis. (8,9,10) 

According to Associate Professor of Dentistry, 

Evanthia Lalla, DDS, MS, of Columbia University 

School of Dental and Oral Surgery: 

“…In light of the oral-systemic association, 

. . . dental clinicians can play a significant part 

in promoting the general health of their patients. 

. . . We—as dentists—are sometimes so focused 

on individual teeth and the mouth that we forget 

that they are part of a person who needs to be 

systemically managed. We can do our part in that 

. . . making dentists aware that they truly are 

health-care providers; that by improving clinical 

outcomes—by helping a patient . . . better 

managing his or her diabetes—they are promoting 

the general health of their patients. We have to 

forget about being isolated to the mouth because 

we now know that the mouth mirrors the body….” 

(23) 

“Half of what we have taught you is wrong. 

Unfortunately, we do not know which half.” 

—Dean Burnell, MD, addressing medical 

students at Harvard University 

While biological dentists are made out to be 

quacks, it is interesting to note that the German 

term for mercury is “quecksilber,” and the 

German pronunciation for queck is “quack.” For 

this reason, dentists who placed mercury 

amalgams, at that time, came to be known as 

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2012 

“quacks.” The term has now come to mean 

anyone who is an “ignorant pretender of medical 

skill”. (24) It is in fact the biological dentists 

who are attempting to initiate a scientific debate 

on this subject of the medical, social, and 

economical ramifications of using mercury in 

amalgam fillings for over 175 years. 

George Keanna was born in 1961 when Queens, 

New York was a brighter place. After completing 

high school, George attended Trinity College in 

Hartford, Connecticut where he earned a Bachelor 

of Science Degree in Psychology. The awareness 

that he enjoyed working with his hands, combined 

with his love of science, healthcare and 

psychology motivated George to seek a career in 

dentistry instead of psychology. Thus, he 

attended Georgetown University School of Dentistry 

from 1984 to 1988 and was awarded his 

degree in dentistry. 

Even though his dental training was 

comprehensive and encompassed every facet of 

the practice of dentistry, George felt the need for 

further training. He applied and was accepted 

into a residency program at Castle Point Veteran’s 

Hospital in upstate New York. This experience 

was the turning point in his perception and 

understanding of health care in this country. This 

veterans’ hospital was a spinal cord injury facility. 

The horrors that George saw at that veterans’ 

hospital have stayed with him for twenty years 

and have served to motivate him to seek “a 

better approach” to health care. 

In his quest to provide improved health care to 

his patients, George began researching the issue 

of mercury amalgam fillings. After ten years of 

conducting research and reading volumes of peer 

reviewed articles and books from all over the 

world, George was lead to the realization that he 

had closed his mind to the issue of mercury 

based fillings, and he could no longer practice 

dentistry as he had been taught. He decided he 

needed to become a biological dentist. His quest 

led him to Albuquerque, New Mexico where he 

purchased an existing Biological Dental practice. 

After a quick review of the needs of his new 

environment, it was immediately evident to him 

that his dental education was woefully lacking in 

the ability to allow him to service his new 

patients. 

Thus, the next steps of his journey began. 

During the next nine years, George traveled all 

over the country taking innumerable hours of 

continuing education in nutrition, physiology, and 

alternative medicine to mention a few. His 

greatest pleasure and accomplishment was that of 

graduating as the valedictorian of his class from 

Capital University of Integrative Medicine in 

Washington, D.C. His title of Doctor of 

Integrative Medicine is just as cherished as his 

degree from Georgetown University. 

George and his wonderful wife, Erica, currently 

reside at the base of the majestic Rocky 

Mountains called the Sandia Mountains in 

Albuquerque, New Mexico. George and Erica 

stand shoulder to shoulder and support each other 

to practice and live the philosophy of Biological 

Dentistry. 

Contact George Keanna at 

georgekeannadds@yahoo.com or 505-292-8533. 

Website: www.drkeanna.com 

References: 

(1) http://www.iabdm.org/cms/index.php?id=73 

(2) Stillman, PR., “Progress in Dentistry”, Can 

Dent Assoc J, Vol.IV, 1938. 

(3) Harris, Chapin A; “The Principles and 

Practice of Dental Surgery”, 2 nd 

ed, Lindsay and 

Blakiston, Philadelphia, 1845, pg. 259-260. 

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2012 

(4) Torres, H.O. & Ehrlich, A., “Modern Dental 

Assisting”, WB Saunders Co, Phila., PA 1980. 

(5) Wentz, Myron PhD; “A Mouth Full of 

Poison: The Truth about Mercury Amalgam 

Fillings.” Rosarito Beach, Baja, California: Medicis, 

S.C.; 2004. pg. 10. 

(6) Wenig, M., “The rise of dentistry as a 

profession”, Dental Students’ Magazine, Sept. 

1943, pg.18. 

(7) Bremner, MDK., “The Story of Dentistry”, 

Dental Items of Interest Publ., Brooklyn, NY 

1939, pgs 86-87. 

(8) Oral Opportunistic Infections: Links to 

Systemic Diseases. http:/nidcr.cit.nih.gov 

(9) Amar S, Han X. “The impact of periodontal 

infection on systemic diseases.” Med Sci Monit. 

2003; 9(12): RA291-9. 

(10) Li X, Kolltveit KM, Tronstad L, et al., 

“Systemic diseases caused by oral infection.” Clin 

Microbiol Rev. 2003; 13(4): 547-58. 

(11) Genco RJ, Glurich V, Haraszthy J, et al., 

“Overview of risk factors for periodontal disease 

and implications for diabetes and cardiovascular 

disease.” Compend Contin Educ Dent. 1998; 

19:40-5. 

(12) Mattila, KJ, Nieminen MS, Valtonen VV, et 

al., “Association between dental health and acute 

myocardial infarction.” Br. Med. J. 1989; 

298:779-81. 

(13) Matilla KJ, Valle MS, Nieminen MS, et al., 

“Dental infections and coronary atherosclerosis.” 

Atherosclerosis. 1993; 103:205-11. 

(14) DeStefanno F, Anda RF, Kahn HS, et al., 

“Dental disease and risk of coronary heart 

disease and mortality.” Br. Med. J. 1993; 

306:688-91. 

(15) Joshipura KJ, Rimm EB, Douglass CW, et 

al., “Poor oral health and coronary heart disease. 

” J. Dent. Res. 1996; 75:1631-6. 

(16) Grau AJ, Buggle F, Ziegler C, et al., 

“Association between acute cerebrovascular 

ischemia and chronic recurrent infection.” Stroke. 

1997; 28:1724-9. 

(17) Grossi SG, Genco RJ. “Periodontal disease 

and diabetes mellitus: a two-way relationship.” 

Ann. Periodontol. 1998; 3:51-61. 

(18) Offenbacher S, Katz V, Fertik G. 

“Periodontal infection as a possible risk factor for 

preterm low birth weight.” J. Periodontol. 1996; 

67:1103-13. 

(19) Offenbacher S, Jared HL, O’Reilly PG, et 

al., “Potential pathogenic mechanisms of 

periodontitis associated pregnancy complications.” 

Ann. Periodontal. 1998; 3:233-50. 

(20) Offenbacher S, Beck JD, Lieff S, et al., 

“Roles of periodontitis in systemic health: 

spontaneous preterm birth.” J. Dent. Educ. 

1998;62:852-8. 

(21) Scannapieco FA, Mylotte JM. “Relationships 

between periodontal disease and bacterial 

pneumonia.” J. Periodontal. 1996; 67:1114-22. 

(22) Scannapieco FA, Papandonatos GD, 

Dunford RG. “Associations between oral conditions 

and respiratory disease in a national sample 

survey population.” Ann. Periodontol. 1998; 

3:251-6. 

(23) DiMatteo, A. “The Oral-Systemic Link: How 

Much Do We Know?” Inside Dentistry, Tufts 

University School of Dental Medicine, December 

2005 Issue, pgs. 38-52. 

(24) Wentz, Myron PhD; “A Mouth Full of 

Poison: The Truth about Mercury Amalgam 

Fillings.” Rosarito Beach, Baja, California: Medicis, 

S.C.; 2004. Pg.7. 

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33 

Pelvicology: A 

Neuro Muscular 

Skeletal Approach 

to the Treatment of 

Pelvic Conditions 

Marilyn Freedman, 

PT, DPT, CAPP, BCB- 

PMB TM 

Riva Preil, MS, PT, 

DPT 

Introduction: Traditionally the care of patients who 

have symptoms related to pelvic organs has been 

divided between different medical practitioners. 

Gynecologists and Obstetricians treat women 

during their life cycles of reproduction and beyond, 

with a focus on female organs of reproduction. 

Patients with urological symptoms, or males with 

reproductive organ disease are seen by Urologists, 

while dysfunction of the gastrointestinal tract are 

treated by Gastro-enterologists, General and Colorectal 

surgeons. More recently the addition of 

Uro-gynecologists has been an attempt to bridge 

the specialties of Gynecology and Urology. In all 

these specialties treatment is mostly symptom 

driven and treated by dispensing medication or 

doing surgery. Although Physical Therapists in 

most parts of the world have been involved with 

patient care in all of the above fields for many 

years, their unique role in treatment of the neuro 

musculo-skeletal system as it relates to all pelvic 

conditions has only recently been acknowledged. 

Physical Therapists are the “Pelvicologists” who 

bridge the uro-gynecological, colo-rectal fields, 

and as such are beginning to become more 

mainstreamed as adjuncts to those specialties. 

Physical therapists are neuro-muscular skeletal 

specialists, and the role this system plays in 

creating a healing environment for pelvic system 

health is well documented. In order to understand 

this role our approach in this article is to divide 

conditions into two main types of pelvic floor 

dysfunction. These can be classified as 

hypotonicity and hypertonicity of the pelvic floor 

muscles. Hypotonicity implies weakness of the 

2012 

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2012 

pelvic floor muscles which interferes with the 

muscles performing several of their crucial roles. 

Some important functions of the pelvic floor 

muscles are: to support the pelvic floor organs 

(bladder, uterus, rectum) which rest atop the 

sling like pelvic floor muscles; to maintain bowel 

and bladder continence; sexual function and an 

important core support of the body. As women 

age and hormone related changes occur, pelvic 

floor muscles and the surrounding ligaments 

become weaker. In addition, each pregnancy and 

vaginal delivery increases a patient’s likelihood of 

developing pelvic floor muscle weakness. 

Furthermore, research has shown that there is an 

increase in joint laxity during pregnancy which 

may result in altered pelvic floor biomechanical 

alignment i . In addition, birthing position may 

adversely affect the positioning of the pelvic floor, 

especially if previous medical conditions exist. 

Therefore, women with sacroiliac dysfunction 

should deliver in in semi-reclining position (with 

hips supported, flexed abducted, and externally 

rotated), and women with coccyx (tail-bone) 

pain should deliver in squatting, side-lying, or 

upright kneeling position. ii 

Also, facilitated delivery 

with forceps causes more trauma to the pelvic 

floor compared to vacuum extraction assistance. iii 

In addition, in 2002, approximately 25% vaginal 

deliveries are still performed with episiotomies 

despite the fact that this procedure increases the 

risk of sustaining anal damage. iv 

The resulting 

scar may not heal properly or may restrict 

underlying tissue mobility. 

Furthermore, prolonged repetitive straining and 

stress to the pelvic floor such as jobs that involve 

heavy lifting or chronic constipation increase the 

likelihood of developing weakened pelvic floor 

muscles. Several other factors that may 

contribute to hypotonicity of the pelvic floor 

muscles are trauma, infection, radiation, 

chemotherapy, and other co-morbidities that affect 

and weaken muscle and/or soft tissue 

(ex. Muscular Dystrophy, Multiple Sclerosis, 

Parkinson’s disease). 

Just like a weak biceps or deltoid muscle will 

interfere with the ability to lift or carry objects 

normally, so too a weakened pelvic floor will 

interfere not only with general activities of daily 

living, but more specifically with the ability to 

postpone the elimination of bowel and bladder, 

until arriving at a restroom at an appropriate time 

and fashion. The bowel and/or bladder related 

issues that this creates may affect daily activities 

in a very significant way. For example, a woman 

who fears that she might “have an accident” if 

she attempts to participate in a tennis match with 

her friend may choose to remain at home, within 

a short distance to a restroom, watching a movie 

alone. This may negatively affect her socialization 

as well as her productivity at work. In addition, 

another symptom that women may experience is a 

“dropping” sensation in the pelvic floor, as if 

something inside feels like it is descending. This 

is referred to as pelvic organ prolapse, and it 

may involve descent of the uterus, the urethra, 

bladder or even bowel descending onto the 

anterior aspect (front) of the vaginal wall 

(cystocele) or the rectum descending onto the 

posterior aspect (back) of the vaginal wall 

(rectocele) v . 

Fortunately, there are conservative treatment 

methods of the aforementioned conditions. The 

common denominator between all of these 

approaches is management of the symptoms 

through Physical Therapy without requiring invasive 

procedures or surgeries. Like any weak muscle, 

the key to improving core strength, incontinence 

and prolapse related symptoms is by strengthening 

the weak pelvic floor muscles. One way to 

accomplish this is by regularly performing two 

types of pelvic floor exercises, phasic or “quick 

flick” muscle contractions to strengthen the fast 

twitch muscle fibers, and prolonged tonic “holding” 

muscle contractions to strengthen the slow twitch 

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2012 

endurance muscle fibers. Laycock developed a 

four point grading scale called the P/E/R/F 

model. This scale measures Power (0-5 

maximum voluntary strength measurement), 

Endurance (how long can maximum voluntary 

contraction be held?), Repetitions (how many 

repetitions can be performed prior to exhaustion?) 

and Fast Twitch (how many quick contractions 

can be performed prior to exhaustion?). vi 

The 

strengthening can be enhanced by using vaginal 

or anal weights, and gradually increasing the 

amount of resistance as the pelvic floor muscles 

get stronger. Sometimes, individuals do not know 

how to properly use their pelvic floor muscles, 

and they may think they are performing a pelvic 

floor muscle contraction when, in fact, they are 

mistakenly contracting their abdominal or gluteal 

muscles instead. This type of substitution is 

actually counterproductive, because using the more 

superficial prime movers (rectus abdominus and 

internal and external obliques) of the abdominal 

muscles will enhance the opposite role of pelvic 

floor muscles. Contraction of these substitute 

muscles cause the pelvic muscles to relax and 

pelvic contents to descend even further. 

Contraction of the pelvic floor muscles, muscles 

on the other hand will help support the pelvic 

organs and maintain continence. Oftentimes 

pelvic floor exercises are handed out to a patient 

in their Doctor’s office, with little or no guidance 

on correct form and execution. Research has 

shown that abysmally few patients are able to do 

the exercises correctly, most patients bearing down 

with their muscles instead of contracting them. 

When the patient’s symptoms do not improve or 

even worsen, leading to the misconception is that 

this conservative method was not effective and 

that the patient requires a more invasive therapy. 

To ensure correct exercise technique, a 

practitioner needs to give adequate biofeedback by 

inserting a finger vaginally or rectally in order to 

digitally palpate the muscle contraction. 

Ultrasonography is another excellent educational 

biofeedback tool, as is surface electromyography 

(sEMG). It may even be necessary to use 

alternating electric current to simulate a pelvic 

muscle contraction if the above is not enough. 

Helping a patient make the correct neuromuscular 

connection is essential to improve their ability to 

learn how to contract and release their muscles 

effectively. Biofeedback has been proven to be 

an effective approach to treating anorectal 

disorders. vii 

It is sometimes also necessary to 

dispense a home electrical stimulating device, or 

biofeedback unit for use on a daily basis until the 

patient is able to carry out the required exercise 

independently. 

Diet is also an important factor to be considered 

when treating pelvic floor muscle dysfunction. 

Some foods, especially highly caffeinated, highly 

acidic or spicy foods, act as bladder irritants, 

which make it more challenging for a patient to 

control bowel and bladder function. Treatment 

needs to include education about proper foods 

and beverages as well as tracking toileting habits 

with bowel and bladder diaries. This helps the 

individual keep track of the frequency and amount 

of leaks, and it helps them connect particular 

triggers in their diet to the incontinent episodes in 

order to prevent future occurrences. Toileting 

posture and technique play an important auxiliary 

role in all conditions. In case of organ prolapse, 

physical therapists can help guide the individual in 

the proper selection of a pessary, a device that 

may be inserted to support the descending pelvic 

organ during selected activities (ex. exercise) or 

throughout the day. There are many different 

types of pessaries, including platform, gellhorn, 

inflatable, cube, and Smith-Hodge pessaries. viii 

Most importantly these patients need to learn how 

to use their deep core muscles (levator ani, 

transverse abdominal and multifidus) during all 

activities of daily living. Core muscle activity 

needs to vary with the intensity of activity, for 

example using stronger muscle contraction when 

climbing stairs than walking on a floor. Muscles 

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2012 

need to learn how to relax appropriately during 

activities like sitting or lying down; too much 

contraction without appropriate relaxation can 

create a problem of hypertonicity. 

Hypertonicity implies that the pelvic floor muscles 

are tight or overactive, which often is associated 

with pelvic floor pain. There are several factors 

that are associated with hypertonicity of the pelvic 

floor muscles including prior trauma or a genetic 

pre-disposition. Prior sexual or emotional abuse 

may sometimes contribute to pelvic floor 

hypertonicity. Van Der Velde and Everaerd 

performed a study with 45 women who presented 

with vaginismus, a condition making vaginal 

penetration difficult or impossible. Pelvic floor 

muscle and upper trapezius muscle activity was 

measured while the women were exposed to four 

different types of stimuli: neutral, threatening, 

erotic, and sexual threatening. Their research 

revealed that the women demonstrated increased 

pelvic floor muscle and upper trapezius muscle 

activity during film excerpts that were threatening 

and sexually threatening. In other words, these 

women tightened and “held” their pelvic floor 

muscles when exposed to traumatic stimuli, 

demonstrating that sexual and emotional trauma 

can contribute to hypertonicity of the pelvic floor 

muscles (2001). ix 

Stress can be a trigger for 

pelvic floor muscle hypertonicity: in the same way 

that some individuals store stress and tension in 

their upper trapezius muscle, at the top of their 

“core”, so too, others store stress and tension in 

their pelvic floor muscles, at the bottom of their 

“core”. Finally, there can be an insidious onset 

of pelvic floor muscle tightness, without any 

apparent reason for the hypertonicity. 

The symptoms of pelvic floor hypertonicity differ 

from hypotonicity, and they include pain, tightness 

of the pelvic floor, sexual dysfunction and 

dyspareunia (pain with penetration during sexual 

activity in women). Urinary hesitancy, increased 

post void residual and frequent urinary tract 

infections and constipation can also be the result 

of increased pelvic muscle tone. The 

aforementioned symptoms are often accompanied 

by emotional issues such as anxiety and/or 

depression. 

Pelvic floor physical therapy can be very beneficial 

in treating symptoms of hypertonicity as well. 

Following the aforementioned analogy of the tight 

and painful upper trapezius muscle, which requires 

manual therapy, massage, and soft tissue release 

to relax and stretch the tight muscle, so too, 

tight pelvic floor muscles benefit from manual 

therapy as well. Specially trained pelvic floor 

therapists are skilled in performing internal vaginal, 

anal and external muscle massage, stretching and 

manual trigger point release to tender localized 

spots. This approach has been demonstrated to 

be beneficial in decreasing pelvic floor muscle 

spasm and pain. x 

It is only when patients are 

taught how to administer this treatment 

themselves, that they do not become dependent 

on the therapist to treat their symptoms, but are 

able to treat themselves on a daily basis in the 

comfort and security of their own homes. In 

addition, any of the methods of biofeedback 

discussed above can also be utilized to help 

teach individuals with tight pelvic floor muscles 

how to relax their pelvic floor muscles. It is 

imperative to stretch and diffuse tender trigger 

points first, as sEMG administered on its own will 

only train the muscle to relax in its shortened, 

painful state. This “down training” helps people 

who clench the pelvic floor muscles involuntarily 

learn how to “let go” and lower the resting tone 

of the pelvic floor muscles from moment to 

moment in order to facilitate healing of the tissue. 

Use of vaginal dilators, anal dilators or wands can 

help patients perform self massage and stretching, 

especially if it is difficult for them to use self 

digital manipulation for same. At first, smaller 

sized dilators are used, and the individual 

gradually increases the size as their tolerance 

increases and the tightness decreases. 

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2012 

An additional key to managing pelvic floor 

hypertonicity is relaxation training. This includes 

learning how to perform proper diaphragmatic 

breathing. When used correctly this pattern is the 

most efficient and effective way to provide oxygen 

to cells throughout the body; it also promotes 

overall physiological relaxation of the neuromusculoskeletal 

system. An additional approach to 

relaxation training is Jacobson’s relaxation series, 

where the individual systematically contracts and 

then relaxes various muscles throughout the body 

in a specific order. This provides a contrast for 

the individual to learn how to “turn on” and then 

“turn off” muscles, with the ultimate goal of 

eventually “turning off” the overactive pelvic floor 

muscles at will. Dr. Anderson and Dr. Wise 

describe a more finely tuned relaxation concept, 

also developed by Dr. Jacobsen, and known as 

paradoxical relaxation. The paradox is that by 

learning to acknowledge and accept bodily 

discomfort and tension, the tension and discomfort 

stop fighting back, and so release more easily. At 

times, pelvic pain may be due to underlying soft 

tissue and organ restriction. In this case physical 

therapists can perform visceral mobilization 

techniques to facilitate proper movement of the 

internal organs and underlying fascia. This is 

especially important in conditions like 

endometriosis, where there can be diffuse scarring, 

sometimes even after surgery to remove the scar 

tissue. Even years after abdominal or pelvic 

surgery, scar tissue massage can release bowel 

adhesions, improve circulation and reduce tension 

around involved nerve tissue. Conditions like 

painful episiotomy or surgical scarring may limit 

mobility of tissue and or organs and contributing 

to pain. By teaching the patient how to perform 

a self-technique at home, it is possible to avoid 

the kind of symptoms associated with scarring, 

like repetitive bowel obstruction. Proper toileting 

posture and colonic transport self-massage is 

especially beneficial to those who experience 

irritable bowel syndrome, especially of the 

constipation type. This technique is an external 

massage along the direction of the colon to help 

promote peristalsis and normal passage of stool 

through the large intestine. Bowel stimulating 

exercises, usually involving some type of low 

impact activity, core strengthening and abdominal 

exercise are an important addition to the program. 

It has been well documented in evidence based 

practice that there is a strong correlation between 

pelvic floor related problems, respiratory conditions 

and back pain. It is rare to find an adult patient 

who has cystic fibrosis who has remained 

continent. There is a higher correlation between 

patients who have incontinence (hypotonicity of 

pelvic floor muscles) and low back pain than 

patients who have a high body mass index 

(BMI) and back pain. All musculo-skeletal 

systems in our bodies are related, and as the 

pelvis, its contents and structure are supported by 

a substantial musculo-skeletal system, it is 

imperative to take this system into account when 

treating any of the conditions or symptoms related 

to the pelvis. 

Marilyn Freedman has her clinical doctorate in 

physical therapy. She is certified in pelvic muscle 

dysfunction biofeedback and has completed a 

certificate of achievement in pelvic physical therapy 

through the women’s health section of the 

American Physical Therapy Association (APTA). 

Marilyn has over thirty years of experience in 

helping people resolve complex pelvic conditions. 

She has worked with men, women and children 

with pelvic pain, urological, obstetrical, 

gynecological and colorectal conditions. She is an 

adjunct instructor at area physical therapy schools. 

She lectures to professional colleagues and has 

contributed to several publications in her field of 

expertise. Her research interests include 

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2012 

investigating conservative management of pelvic 

pain conditions. 

Contact Marilyn Freedman at 

essentialphysicaltherapy@gmail.com or 

516-829-0960. 

Website: www.pelvicology.com 

Riva Preil is a physical therapist who specializes 

in women’s health and pelvic floor dysfunction. 

She is currently employed in a private Physical 

Therapy practice in New York City, New York. 

Experienced Threat in Women With and Without 

Vaginismus.” Behav Res Ther 39: 395-408 

(2001) 

x 

Hartmann EH, Nelson, C. “The Perceived 

Effectiveness of Physical Therapy Treatment on 

Women Complaining of Vulvar Pain and 

Diagnosed with Either Vulvar Vestibulitis Syndrome 

or Dysesthetic Vulvodynia. Journal of the Section 

on Women’s Health. 25: 13-18. (2001) 

References: 

i 

Marnarch, M. “Joint Laxity and Hormones in 

Pregnancy”, Obstet Gynecol 101: 331-335 

(2003) 

ii 

Boissonnault, J. “Modifying Labor and Delivery 

Positions for Women with Spine and Pelvic Ring 

Dysfunction” JOSWH (26) 2, 9-13 (2002) 

iii 

Johanson, R, Menon, B. “Vacuum extraction 

versus forceps for assisted vaginal delivery,” 

Cochrane Revview , I nCochrane Library, 2001, 

Issue2. 

iv 

Eason, E, Labrecque, M, Marcoux, S. “Anal 

Incontinenceafter Childbirth”. JAMC 166 (3): 

326-330 (2002) 

v 

Abrams et al. “Standardization of terminology in 

Lower Urinary Tract Function”, Neuro Urol and 

Urodyn 21: 167-178 (2002) 

vi 

Laycock, J. “Clinical Evaluation of the Pelvic 

Floor.” Chapter 2, 42-48 in Pelvic Floor Reeducation, 

principles and Practice. (Eds.) 

Schussler, B Laycock, J Norton P, Stanton S. 

Springer verlag, London. 1994 

vii 

Palsson, O., heymen, S. “Treatment of 

Functional Anorectal Disorders: Biofeedback is 

provin its Value Like never before.” Biofeedback, 

34 (1): 21-23. (2006) 

viii 

Laycock J, Haslam J. “Therapeutic Management 

of Incontinence and Pelvic Pain: Pelvic Organ 

Disorders”. London, Springer-Verlag. Pg. 201- 

204 (2002) 

ix 

Van Der Velde, J and Everaerd, W. “The 

Relationship Between Involuntary Pelvic Floor 

Muscle Activity, Muscle Awareness and 

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34 

Activating Our 

Healing Potential 

by Using Our Innate 

Faith 

2012 

Vernon C. 

Barksdale, MD, 

MPH, CPI 

When asked to contribute a chapter on medicine, 

healing and spirituality, I initially agreed, then 

realized I would be walking the line where science 

and spirituality oft share an uncomfortable border. 

We have traveled far in the science of Medicine 

but have yet to come full circle in acknowledging 

the power of the healing process each of us 

carries, except in the most significant health 

challenges, such as cancer treatment. Similarly, 

the faithful in so many religious disciplines and 

spiritual paths often are passive travelers, only 

living the faith when confronted with overwhelming 

challenges that they no longer can ‘will’ to 

resolution or rely on what science has to offer. 

Consider however, that many people got better in 

the days of bloodletting and use of leaches 

despite having active disease. Was it placebo 

effect or the faith that healed? Are placebo 

effect and “faith” in healing closely related? 

Jerome Frank, MD, one of my supervisors during 

training in Psychiatry at The Johns Hopkins 

University, discussed his writings, theories and 

beliefs on the power of persuasion and healing, 

believing that even psychotherapy was somehow a 

process that helped change belief to initiate 

healing. These connections emotionally, and, as I 

eventually learned, spiritually, were powerful 

stimulants to the healing process. There are 

numerous examples in the medical and research 

literature on positive thinking, prayer and placebo 

effect helping patients overcome numerous health 

challenges. There is also personal clinical 

experience of those sad cases where 

demoralization promotes the reverse of healing, 

often leading to negative outcomes or hastening 

the patient’s succumbing to the disease. Even in 

clinical trials we have seen placebo effect 

improving the patient and thwarting our data! 

Current research also documents the conversion of 

emotional states into neurotransmitter substrates 

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2012 

that signal the immune system into action. We 

understand that we have this innate ability to 

convert an emotion into biological changes. Are 

positive emotion and cognition close enough to the 

concept of faith to satisfy our need for scientific 

evidence of the healing power of faith? Is there 

anything else that can be activated by our faith to 

further the healing process or improve the way 

our patients manage their health concerns? These 

are the challenges we face as clinicians as we 

strive to promote health as a part of overall wellbeing. 

Our patients are seeking ways to have a 

holistic experience of life that includes their health. 

We should be champions of their cause, as we 

know how powerful a role lifestyle plays in the 

health of our patients. Genetics may be the bullet 

but lifestyle pulls the trigger that often “wounds” 

us with chronic disease, stress and shortened 

lifespan. To exacerbate the issue, many of our 

chronic diseases have stress-related drivers that 

can foil remission or antagonize symptoms. 

When our patients face health challenges, they 

look for meaning of the event as it relates to 

their life and belief. Often it’s “gut check” time 

at the altar, where now they must seriously apply 

their faith. For many, fear fertilizes the weeds of 

demoralization, causing faith to falter. Negative 

attitudes or beliefs circle about and darken the 

sky of hope. Can we play a role to help 

overcome these obstacles? Often, despite our 

privilege to ask intimate details of a person’s life, 

we rarely explore the details of this struggle, 

leaving the patient to go it alone. We miss this 

opportunity to be an ally and additional source of 

validation of their faith building to assist the 

healing process. We are not unwelcome visitors 

into their personal sanctum if we allow ourselves 

to become comfortable with asking to enter, 

honoring their avocation. 

In his presentation on Spirituality and Healing, 

Herbert Benson, MD of Harvard Medical School 

and Director of the Hypertension Section of Beth 

Israel Hospital reports that many patients believe 

the God of their faith plays a role in their 

treatment response. Most interesting is the finding 

that many believe God is working through their 

doctor to bring them the best that Medicine has 

for their particular challenge. A National Institutes 

of Health-Centers for Disease Control (NIH- 

CDC) study in 2002 found that ~50% of 

patients used some form of religious or spiritual 

activity to promote their health. This included 

praying for themselves to God. Dr. Benson’s 

experiments with the Relaxation Response 

meditation training revealed patients describing it 

as a “Spirituality experience,” regardless of 

religious beliefs. I was also very impressed with 

the consistent finding over more than four years 

of lecturing patients in our Intensive Outpatient 

Program for substances of abuse. Patients 

described “Spirituality” as a personal relationship 

and experience of God, different from rules and 

conventions of “religion.” These findings spanned 

different ethnic groups and faiths. Even those not 

participating in a religion agreed with this 

understanding. I believe many of our patients are 

already “ready” to have some form of spiritual 

activity or belief as part of the healing process. 

Over years of studying with Eastern and Western 

schools of metaphysical and spiritual sciences, it 

has become clear to me that we have an 

underpinning to our existence that is based on the 

belief in a “Great Architect” of our universe, 

creating and sustaining all that we know as well 

as the things we are not aware of yet. The 

simple axiom, to use a mathematics term, is that 

all matter and life are “created” by God without 

need of primordial substance, as It supersedes the 

need for any existing substance to “work” with to 

make reality. All of reality as we know it, seen, 

unseen, is made of God’s Substance. This brings 

an interesting observation: If all particles of matter 

are at their foundation God substance, then the 

infinite intelligence/capabilities of God are an 

innate part of all matter. How can we access it 

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2012 

more efficiently? Do we sometimes access by 

chance when in unique situations where faith and 

belief are optimal and persistent to transcend the 

connection? This God substance is the elusive 

“quantum” particle we are looking for. It is the 

primordial template of living things replete with 

Divine Intelligence even in the most minute 

particle. Thus, we are in essence spiritual beings 

having a human experience. 

The great Yogis and acupuncture healing 

practitioners of the East point to the interface of 

the spiritual and physical beings at the 

neuroendocrine axis and central nervous system. 

The acupuncture meridians are also superimposed 

on this primordial “body.” Perhaps this is why so 

many agnostics and people of faith in our 

substance abuse program all came to the same 

conclusion on spirituality: something they 

experienced independent of the structure of their 

religion, that was personal, a special internal 

connection that made them feel whole and at 

peace. 

We may insist that it is not our role to support a 

belief we may not agree with or understand. 

However, the patient believes anyway and may be 

looking for validation or support that could be 

adding to activating the healing process and 

enhancing it by increasing connection to their 

spiritual side. We can walk a supportive and 

respectful path with our patients who entrust us 

with their well-being. 

We also have good literature on the benefits of 

biofeedback on managing stress and promoting a 

sense of influence over how we respond to 

stress. We can also draw on the success of 

rehearsal by visualization and positive emotion on 

performance. Both support the impact of mental 

processes coupled with positive emotion on 

outcomes. Prayer and meditation can evoke a 

similar experience for the individual. Before belief 

slips too far, they both have strong emotional 

components—not just expressed emotion, but also 

internal feelings of peace, joy, calm, or wellbeing. 

The mental discipline of focusing on a 

thought, especially one that affirms the presence 

of God as part of us and helping us, found in 

prayer, chanting and meditation, also evokes the 

positive emotions noted above. When we access 

this source it helps to promote the healing 

process, reduces stress-related drivers of illness 

pathology and improves coping skills. Small 

studies on prayer for a patient by people not in 

their presence also showed concurrent changes in 

the brain activity even when the patient was 

unaware of the prayer times. Faith in the process 

and what one believes in are paramount to the 

chance for the best outcome. Even use of simple 

word chants as part of Transcendental Meditation 

in Benson’s double-blind studies made a 

difference in changing vital signs with patients also 

reporting a “spiritual experience”. 

We can validate the faith of our patients as a 

tool to help healing by “normalizing” that it may 

exist with them. I learned these questioning 

techniques during my work with substance abuse 

patients and when attempting to clarify patient 

medication adherence. When we inform patients 

that an event is often seen with the patients we 

care for, we “normalize” it for them. This makes 

it easier for them to report their similar experience 

or behaviors, instead of feeling like an outlier, not 

doing the right thing. 

After giving a patient a difficult diagnosis I may 

ask: Many of my patients are upset, frustrated or 

fearful about a diagnosis like this and need a way 

to cope with it. How do you cope with stressful 

or frightening situations where you are not sure 

you are in control of your life? Do you use 

spiritual supports? Do you have family or friends 

you trust with whom you can talk? Then, we do 

what we do best. Listen and the patient will 

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guide you to the place they are comfortable. More 

about this in the FAQ section at the end. This 

normalizing questioning also works when gathering 

substance abuse history. If patients get the 

impression that you often see patients who use 

marijuana to relax or reduce pain, it’s easier for 

them to talk about their use. In these situations, 

patients may disclose that they used to go to 

church, temple or mosque and need to consider 

returning. Well, that may be easier than getting 

them to a disease-specific support group. 

However, if they are turned off by spiritual or 

religious programs, then illness-specific support 

groups, meditation or yoga for stress management 

can be appropriate. You don’t have to be an 

expert but do have some contact information for 

local resources. Alternatively, give them a 

homework assignment to visit such a group to see 

if it fits their needs. Patients rarely ask about 

your faith but often benefit from feeling their 

health provider validates/supports the use of their 

beliefs. If patients ask for a strategy they can use 

for their illness, stress management is always a 

safe bet that can be used for general life issues, 

which then adds to overall health. 

As with any advice and material given to a 

patient concerning these matters, one must 

proceed with a nonjudgmental approach 

respectfully honoring the patient’s belief system. 

This works best if we understand that, at the end 

of the day, we are all made from God substance 

and the palette of different faiths/beliefs may just 

be the Creator’s way of ensuring that there was 

freedom of choice on method of access: “each 

according to his need and faith.” I also instruct 

patients that the use of spiritual or meditation 

resources serves to enhance the healing 

interventions prescribed. They work together, not 

against each other. You as the provider must also 

reconcile any personal belief/faith issues so that 

they don’t interfere with those of your patient. If 

these can’t be reconciled then this approach may 

not be for you. 

FAQS: 

“What if the patient says: “Why do you 

ask?” This question may have a few 

different origins. If you have not explored 

or discussed these issues before with the 

patient they may be wondering what’s 

different with you. Now would be a good 

time to discuss your interest in helping 

them to consider a holistic approach to 

care for their health challenge, to marshal 

any and all resources that they may find 

or consider helpful. If their question is not 

hostile, you can drill down a little to ask 

about their experience with meditation or 

prayer or if they have a formal spiritual 

program or faith and encourage them to 

consider it a helpful coping skill. 

“What if the patient asks: “What would 

you do?” Honestly, what would you do? 

Read the latest literature, consult 

colleagues, seek support from family, read 

a book on living with the illness, or pray. 

Be prepared to have a sincere answer 

besides “follow doctors’ orders”. Honesty 

is a lot better than being too professional. 

If you don’t practice a stress reducing 

program or faith or don’t have a belief 

system, consider referral to support groups 

for their illness. Clarify with them that 

belief is a personal process and what 

works for one may not work for the other, 

but research has shown it can help 

coping and attitude, which is important to 

increase the chance for the best outcome. 

“Is there any tool you use in your 

practice?” If the patient has a belief in 

God, even generically/agnostically, I 

recommend they practice the Golden Key 

by Emmet Fox. I have and do use this 

regularly for stress management, and as a 

scientific prayer to manage challenges. 

You have to try the exercise yourself to 

see if it resonates with you. This is a 

difficult exercise but pays great dividends. 

Alternatively, as a strong supporter of 

self-care, I often put the responsibility on 

the patient to look for inspirational 

scriptures, quotes, invocations, or other 

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2012 

inspiring words they find, as a mantra to 

focus on by repetition to “crowd out” the 

fears/ruminations about their health 

challenge. You may be surprised at their 

creativity, as long as it works for them. 

This can become a practical tool they can 

use for any challenge. Keep a collection 

of these works with their permission to 

help others in the future. The Golden Key 

is generic enough that I have had Muslim 

and Christian alike find it helpful. It also 

may be applied to daily stressors. A link 

is provided at the end of this FAQ 

section. 

“My patient only wants to use their faith 

or natural means of healing and not take 

medication or surgery.” There are certain 

faiths, such as Jehovah’s Witnesses, for 

example, that won’t take a transfusion due 

to their beliefs. Sometimes family in a 

particular faith will extend prohibitions to 

medications in general. I have requested a 

meeting with the local leader or pastor to 

review with the patient my 

recommendations and clarify if they are 

against their faith. Generally, I have 

received the support of the leader for the 

treatment and their prayers that it shall be 

successful. If this is not possible or does 

not support treatment, then you are back 

to discussing the risks/benefits of their 

decision, referral to get a second opinion 

or discharge the patient. I also ask them 

to seek help from a provider who 

practices their faith for a better 

understanding of their needs. 

Vernon Barksdale is Board Certified in Psychiatry 

and is ASAM (American Society of Addiction 

Medicine) Certified in Addiction Medicine. He 

attended Harvard University, majoring in Economics 

and Premedical Science. He matriculated from The 

Johns Hopkins University School of Medicine in 

Baltimore, Maryland with both a Medicine Degree 

and a Master’s Degree in Public Health. He has 

completed fellowships in Psychiatry and Forensic 

Psychiatry. He is a Certified Acupuncture 

Detoxification Specialist, using acupuncture for drug 

detox. He has also taught meditation techniques 

for stress management, conflict resolution, 

relationship enrichment and assistance in spiritual 

development. He is a Certified Physician 

Investigator, having served as Principal Investigator 

for clinical trials of new medications in Psychiatry 

and Internal Medicine. Dr. Barksdale is most 

excited about his parallel and ongoing training in 

metaphysical sciences as they relate to healing 

and attainment of optimal health and wellbeing. 

His training began during medical school and 

spans eastern and western spiritual sciences. It 

has allowed him to understand and utilize the 

interface between the spiritual and physical 

aspects of being for optimal health and success. 

He has worked with shamans and completed 

trainings at schools dedicated to spiritual 

advancement. 

Dr. Barksdale has presented at international 

conferences on topics of medical meditation, the 

convergence of spirituality and medicine to 

synergize the healing process, and techniques to 

increase one’s wellbeing. He has published CDs 

for practical application of meditation techniques in 

daily life for busy people and trainings for 

advanced meditation skills. 

Dr. Barksdale hosted “My Mind, My Health”, 13- 

week series on spirituality, mental health and 

wellbeing on VoiceAmerica.com’s Variety Channel. 

Contact Vernon Barksdale at vbarksdalemd@gmail.com 

Website: www.mymindmyhealth.com 

References: 

The Relaxation Response. Herbert Benson, MD 

with Miriam Z. Klipper 1975 

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2012 

Spirituality and Healing in Medicine Conference, 

Harvard Medical School December, 2004: “The 

Power of Belief and the Role of the Relaxation 

Response in Healthcare”, Herbert Benson, MD. 

Autonomic, Neuroendocrine and Immune Changes 

in MDD [Major Depressive Disorder]—Body-Mind 

Science Addresses Key Questions; Charles 

Raison, MD, Associate Professor, Department of 

Psychiatry and Behavioral Sciences, Emory 

University School of Medicine. Lecture presented 

at Psychiatry Congress 2010. 

Link to Golden Key via Useful Links page at 

www.mymindmyhealth.com 

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