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The 2021 Functional Medicine Year in Review

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Kalea Wattles, ND:
On this episode of Pathways to Well-Being, we’re recapping the functional medicine year in review. IFM’s Director of Medical Education Dr. Dan Lukaczer and the Director of Medical Education Initiatives Dr. Robert Luby will lead today’s discussion on the most prominent topics and takeaways in the 2021 research.

They’ll discuss new opportunities for functional medicine care and highlight the clinical advances, including the latest updates on COVID-19 that practitioners should consider as we head into the new year. Welcome, Drs. Lukaczer and Luby.

Dan Lukaczer, ND
Thank you.

Robert Luby, MD
Thank you, Dr. Wattles.

Kalea:
We have so much to talk about today, but I want to start with, maybe the hottest topic of the year, again, was COVID-19. We had the rollout of vaccines and boosters, the rise of new variants. And, of course, we kept our eye on the impacts of long COVID. For us in our functional medicine community, a big theme was immune resilience, with our annual conference this year even focusing on cultivating resiliency in both our health and our immune system. So, Dr. Luby, I’ll get started with you. As the leader of IFM’s COVID course, what are the important themes that we should be thinking about in terms of COVID-19 and our immune resilience as we head into the new year?

Robert:
Thanks, Kalea. When we developed that COVID course, we had a pretty clear idea of the conditions, the medical diagnoses that gave an individual increased vulnerability to severe infection and poor outcomes. And it was quite evident based on those being mainly chronic diseases, lifestyle-driven diseases, that taking action on lifestyle, making improvements in lifestyle, could certainly be protective from COVID. And now, as this is starting to go into its, really almost the third year now, that is still the case, that making lifestyle changes, addressing those comorbid conditions or those vulnerable conditions, can still make a difference.

I think what’s interesting is over these two years now, some data has accumulated regarding the health of the microbiome. There seems to be signals in the data that if you do have a more diverse, optimal microbiome, you are also more protected from poor outcomes of COVID. And we also know now that COVID itself, if you were to get the infection, can alter the microbiome. And since we know that all five lifestyle factors can improve the microbiota, it’s probably the case that not only is attention to lifestyle factors important for protection against COVID, it’s also probably crucial for recovery and restoration after you’ve gotten COVID.

So I think those are some of the main takeaways, as we haven’t had a vaccine that’s given the results that we hoped for, early ambulatory treatment options that have really made a huge impact. In the absence of those, we are still emphasizing the importance of the lifestyle factors. So that’s how I think we bring the functional medicine model into this, Kalea.

Kalea:
I think that’s brilliantly said. And that’s one thing that I’ve really valued about the functional medicine model as we’ve learned about all of these risk factors for vulnerability and severity of disease. These are things that we’re already thinking about with the functional medicine model. We’re already addressing all those modifiable lifestyle factors. And I want to just dive into this gut health topic a little bit.

Robert:
Kalea, if I could just say something.

Kalea:
Sure.

Robert:
One thing I would have liked to have said is one of our functional medicine principles with the microbiota is “weed, feed, and seed.” And with Dr. Lukaczer’s expertise in gardening, I think he’s going to really take this to new levels.

Dan:
I did want to add to what Robert said, and you know what I’m doing clinically, and certainly along the lines of Robert mentioned, there’s now some pretty good research that suggests that the gut microbiome does alter in patients with COVID-19. And so there’s a couple of things that I think we should be thinking about specifically. We should be thinking about probiotics and prebiotics, on using some of the toolkit items that we have at IFM. I hand those out regularly.

The other thing I would say about that is that, and to some of that research, is that looking at things that we’ve been looking at for the past dozen years, like hs-CRP, we know from some of this research that C-reactive protein can be elevated by a disordered microbiome. So doing those same kinds of laboratory analyses with an eye on, well, what can you do around the microbiome? How can you assess easily, and this is not a perfect test, obviously hs-CRP is not assessing the microbiome specifically, but we do know that a healthy microbiome is less inflammatory. We do know, of course, that we, when we put ourselves more in an inflammatory situation, that we are more susceptible to not only COVID-19 or SARS-CoV-2, but some of the sequelae around SARS-CoV-2 if one does catch that infection. So I think really focusing on inflammation and what we can do around gut and microbiome improvements to decrease inflammation is the takeaway for me.

Kalea:
Great. I’ll follow up on that because a study came out earlier this year that showed this immunological coordination between the gut and the lungs that facilitated SARS-CoV-2 to infect the GI tract. And I’m certainly seeing more significant GI symptoms in patients following COVID-19 infection. Dan, is that something that you’re seeing as well?

Dan:
Yeah, I am seeing that. I can’t say that I’m seeing a great number of COVID patients, but in those that I do see, I am seeing some of that. And I would like to just add, again, a little bit to what Robert was talking about, and when we’re talking about, obviously, these vaccines and boosters and various pharmacological treatments, they are not, unfortunately, and I think we’d all like them to be the panacea, but we see breakthrough infections. And so doing this kind of immune resilience along with those kinds of treatments, I think, is incredibly important.

And just stepping back into overall immune resilience, we want to be looking at some of the other things that we’ve been talking about for almost two years around immune resilience and have on our website around certain vitamins and minerals. You know, talking about vitamin D and talking about selenium and talking about folate and talking about zinc and either measuring those or making sure that an individual is getting that in their diet and or supplementation, I think, are really important things to do in that overall immune resilience.

Kalea:
Yes. Perfect anchoring back into our functional medicine model. So as we’re talking about our modifiable lifestyle factors, this is a perfect time to switch gears and look at the topic of biological aging and lifestyle. We’ve seen good evidence of biological aging as a measure of health and wellness. And I would say that even includes topics like immune senescence and how our immune system is functioning into our older age. And we know that lifestyle modifications can really alter that trajectory. Our friend and colleague, Dr. Kara Fitzgerald, who’s really studied aging, has demonstrated that our lifestyle has the potential to reverse our biological aging. So I’d love to talk to you both about how you’re thinking about biological aging. How you’re talking to folks about this, and what strategies we can implement in the new year to slow our rate of biological aging. So, Dan, I’ll go ahead and pass this over to you if you want to tell us your thoughts on this new and really exciting topic.

Dan:
Well, I think what we talked about in our just past annual conference, an important part of where you’re going, Kalea, and that is Kara Fitzgerald’s study on aging and what she called the—her methylation diet, I believe, and that was published, really showed improvements with a very focused but broad dietary program that highlighted various ways to improve or balance methylation. And so I think that is an important reminder of what we can do too. And what she showed was to actually slow biological aging in the treatment arm versus the standard arm.

And I think that, while I think we need to continue to do this kind of research to prove the point, I think it’s certainly along the same lines of what we have been talking about for quite a while in terms of what she did in that study, which is a very nutrient dense, lower carbohydrate dietary intake with other lifestyle factors that improved biological aging. And it’s not surprising. It’s good to have that kind of research, but it’s not surprising to me. And so it doesn’t—while I refer to that when occasionally, when I talk to patients, it doesn’t really change what I have been, and I think what we all have been, trying to do in that foundation, those foundational, those five foundational factors on the base of the matrix.

Kalea:
Absolutely. And Robert, I’ll direct just this very similar question your way. We see that there appears to be an increase in biological age following COVID-19 infection. How can we talk to people who may have gone through COVID-19 about using those lifestyle factors when they read these studies and might feel a little fearful that they’ve accelerated their aging process?

Robert:
Right. Yeah, for those who are aware of this biological aging concept, that will be very motivating. I think that they will take this information to heart and understand that having had the COVID infection will biologically age you. And at this point, the modifiable lifestyle factors that we know so well in functional medicine are the most certain intervention we can use to reverse biological aging. What I think is important about the group that’s maybe not so aware of the concept of biological aging, and this is probably the majority of our patients, the majority of the world at this point as this is somewhat of a new concept, the opportunities that I see are just wonderful.

For one thing, with regard to methylation and those other epigenetic influences on biological aging, this puts epigenetics on the map and in the lexicon of patients and consumers. That’s the potential I see in the coming future. So that we’re talking about, patients are talking about, how do I change my gene expression? That’s not something that is currently on the mind of most of our patients, but that could be one of the great results of this kind of research. The other thing is if we think back from a patient’s perspective over the last few decades, what kinds of metrics were patients clinging to? It was total cholesterol level, it’s their weight. Maybe it’s even their hemoglobin A1C. And we’ve seen the problems with those not really being as predictive as we hoped for in terms of outcomes. And so focusing on those and whether your cholesterol is going up or down was not as accurate a predictor of your future health as it could be.

So in terms of these biological aging metrics, the measurements that we’re going to have as a result of the circadian clocks and such, these metrics can replace the historical metrics in the minds of patients. And if they are now keeping track of their aging metrics, I think it’s going to be one much more accurate in terms of preventing disease. Much more accurate in terms of reducing or reversing disease, and much more motivating for patients. Cholesterol is not nearly as motivating, and saying, geez, I’m 42, but I have a biological age of 48, I better do something about it, that’s really compelling, much more compelling than any metric we have for patients at this point. So I’m really excited about what it’s going to do to the mindset of the patients, their motivation, their adherence to treatment, their adherence to lifestyle, especially. And then if we switch to thinking about healthcare costs in general, if we get a more effective metric like that in the minds of patients, think about the impact on healthcare costs with more people getting engaged in lifestyle factors, because they know what that’ll do to their biological age. I just see great potential going forward for this biological age research.

Kalea:
Yeah, you reminded me. I was listening to a speaker at a conference earlier this year talking about genetics versus epigenetics. And you reminded me as you were speaking that this particular speaker said, “Genetics is the part of our story that’s written in pen, but epigenetics is the part that’s written in pencil.” And so we can do some editing there based on our lifestyle factors, nutrition being one of them, and how empowering to feel like this part is written in pencil, and if you need to do a little rewrite, you can.

Robert:
Well, for the new generations coming up, they might not know what pens and pencils are. So we might have to change that message.

Kalea:
Indeed. Before we move on, I also just wanted to loop back to the inflammation piece, because Dan, you were talking about inflammation earlier. And I think a theme that’s really emerged for me is this concept of inflammaging, right? And how chronic inflammation that may be triggered by an infection and then lingers on can really accelerate our aging process, and in functional medicine, we’re already inflammologists. So this seems like a real place for functional medicine to shine in terms of really addressing that defense and repair mechanism and addressing long chronic inflammation. So Dan, is this a conversation that you’re having with people, that even aside from COVID, inflammation is a powerful driver of our aging process and something we want to be mindful about?

Dan:
Yep. I think that’s a conversation I probably in one way or another have with every patient around inflammation. Because as you said, Kalea, it’s such an overarching mediator of disease and dysfunction. And so, I think, and we have, and I know we’ll be talking about time-restricted eating and fasting, which is another tool in the toolkit around decreasing inflammation. We have so many ways that we can talk to patients about how stress can cause inflammation, about how increased intestinal permeability can cause inflammation, how our diets can have a significant effect, a pro-inflammatory effect on inflammation, how our connections, how sleep—I mean, we have a lot of ways to decrease inflammation, I think. And so I do talk with patients in various ways, as I say, directly talking about inflammation or indirectly, I may just be talking about sleep, or be talking about a particular nutrient botanical, and I don’t bring up inflammation, but it’s always in the background, it seems.

Kalea:
Well, this is the perfect time to move on and talk about time-restricted feeding or fasting. Dr. Valter Longo, his work on the fasting-mimicking diet was hugely successful at our Annual International Conference earlier this year. And we know that fasting and ketogenic diets and nutritional ketosis, there’s evidence that continues to accrue that these states can really help treat some chronic conditions. So this is really exciting. And I’d love to hear from both of you what you have your eye on in the next year in terms of the upcoming research. So Robert, I’ll start with you on this one. What are you looking forward to learning about in 2022, in terms of our time-restricted eating?

Robert:
Well, to interweave this with the topics we’ve just talked about, the restrictive feeding regimens have been shown to improve the biomarkers of longevity. So I think that’s a real nice synergy there, is as patients get more aware of longevity, of biological aging, the biomarkers there, especially those metrics that they could track, I think there will be even more enthusiasm for and adherence to any kind of a restricted feeding regimen. It’s been shown to improve cognitive functioning in the elderly. So these kinds of feeding regimens are going to catch on for that reason. I think there’s a lot more awareness of cognitive decline and the interest of patients to prevent that and curtail it if they see it starting.

And the other thing, to go back to our microbiota, is time-restricted feeding, other restrictive feeding regimens, change the gut microbiota in a positive way. So this is also not only relevant for COVID, but for all chronic diseases, really, microbiota is informing our inflammation. As Dan just mentioned, if we can improve the microbiota, we can improve inflammation, we can prevent or improve chronic diseases, and restrictive feeding regimens are a great way to do that. I think we’ll see again, if you haven’t gotten COVID yet, it will lower your vulnerability to COVID. And if you have had COVID infection, time-restricted feeding could be the way to get your microbiota back to an optimal state that will help you recover and restore your health.

The other thing I like about it, again from the patient’s perspective is, think about what we used to be able to talk with our patients about in terms of what’s going to help your nutrition. It was calorie counting. It was reducing this food, reducing that food, eliminating these foods. Now we’ve got a whole different portfolio of, hey, you can choose just 14 hours a day of not eating or two days a week of a lower calorie intake or a fasting-mimicking diet. There’s more options for the patient that they can choose from, which could make this more sustainable for them because they have more options instead of just the tiresome and tedious calorie counting. They’ve got options that they can adhere to and sustain, and that they have chosen. So that’s what I’m really excited for with patients, the options and the control it gives them over how they want to prevent chronic diseases, promote their future health, restore their current health.

Kalea:
Definitely an exciting place to explore in our patient population. And Dan, I know you’ve been doing some fasting in a unique setting with your patients, and I’d love to hear a little bit about how you’ve been using some fasting strategies in the clinic.

Dan:
Well, I’m not sure how unique it is, really. I am seeing patients by telemedicine. And so I talk to patients all the time, almost every patient I see, about some form of either fasting, which I define as 24 hours or longer, or time-restricted eating, which I define as just a longer time period that you are not eating between when you go to bed generally and when you wake up. And I think what you may be also alluding to, Kalea, is I’ve been doing shared medical appointments and been doing some fast, specifically fasting and time-restricted eating classes. And I really think that, I would say in the big picture, I think doing shared medical appointments and/or group classes online is just a wonderful integration of functional medicine in a healthcare setting. I think it makes it, while I like classes in and of themselves, I think doing them online makes them so much easier for patients, it’s just so much more convenient. And while I do think there are some things that are lost in, when you’re not sitting together as a group, there is a lot to be gained from doing those group medical appointments online, just in terms of the convenience. So I think that’s definitely, as we all know, a wave of the future, and I’m hopeful that we can continue to accentuate that in the healthcare setting.

I would just add a little bit to what Robert said about fasting and—I think fasting and time-restricted eating are also really important or useful because an individual who starts that, in other words, well, they can start wherever they can start. So there’s no one right way, but if you are doing that for a couple of months, you generally start to see some improvements, either in how you’re feeling in terms of lowering inflammation or weight loss. For many people, it helps with weight loss or improvement, in glucose control, so you—you see and feel changes. And I think not that looking at some of these biological aging, which are very important, but we often don’t necessarily feel that. And I think it’s feeling some of these changes in these time-restricted eating protocols and these fasting protocols is so useful for patients. And as Robert suggested, at least with the fasting regimes, not necessarily the fasting-mimicking diet, which can cost some money if you’re going on one of the programs like ProLon, but going on a longer overnight fast, or doing longer kinds of fasts, doesn’t cost anything. So I think that’s another really useful, as we all know, useful additive program that you can add to somebody’s regime or protocol without increasing their costs.

Kalea:
Fantastic. Well, I liked that you mentioned that some of the improvements we’ll notice, maybe improved sleep or weight loss, but there’s also some things that are happening when we’re fasting that we don’t necessarily see with our eyes. And I’m thinking about improvements to mitochondrial function. And I’m going to use that to loop us into our next topic, which is something that was fairly new to me, this field of osteoimmunology. And research over the last year has really found that mitochondria play an important role in the health of many body systems, which we knew, but including the bones and of course the immune system, and then recent studies have also linked bone health to GI integrity, particularly the use of probiotics in post-menopausal women. And we’ve seen this topic heavily featured in industry headlines. And so I’d love to check in with both of you and see what you’re keeping your eye on in terms of bone health, mitochondrial function, osteoimmunology. So Robert, I’ll turn it your way. Anything that you’re excited to learn more about in 2022 about bone health, the connection between our GI system and our bones?

Robert:
Yeah, I think this is something on which we need to keep our fingers on the pulse. So as you said, it’s been shown in some recently emerging evidence that probiotics will improve markers of bone health, also flavonoids. So dietary approaches and nutraceutical approaches. And this is really important, because a lot of people would argue, there are not satisfactory pharmaceutical options in terms of potential risk factors, the frequency of side effects, and the cost as well. So I think this is a real positive way to bring in some functional medicine principles. And if probiotics are helpful, one would think prebiotics may also be, and maybe the research just hasn’t been done yet. So I think dietary approaches to improve osteoimmunology, as you said, mitochondrial health and all those markers of bone health, are a real thing that we have to keep our eye on. And I think the functional medicine model will have a central role to play in helping patients achieve it.

Dan:
Yeah. Let me just cut in there, Kalea, and add that I think that probiotics may be helpful in other ways that we didn’t realize, as Robert is saying, but if we think back, all of us, or many of us who have been using some sort of stool analysis and looking at beta-glucuronidase and the recirculation of estrogen and with higher levels of beta-glucuronidase and knowing that probiotics can lower that, can lower beta-glucuronidase. And so it has an effect, likely, on estrogen and therefore likely has an effect on bone reabsorption in that way as well. So it’s at some level learning old things in new ways, I think as Robert has alluded to. There are now a number of studies that just came out in the past couple of years that suggest that. So I think it’s another avenue that, again, as Robert said, we need to keep our eye on the ball here.

Kalea:
As we’re talking about the connection between different body systems, we just talked about hormones and mitochondria and bone health, I want to dive into the gut health piece a little bit, because we saw some studies emerge over the last year showing that chronic conditions like IBS and long COVID symptoms, that there seems to be a connection between mast cell activation and all of these chronic conditions. And I’m always looking for new information about mast cell activation, because it’s something that my patients ask me about all the time. And so I’m really excited to see more papers come out over the last year. And I’d love to hear a little bit about what you have found, what your clinical takeaways have been from this admittedly very complicated and intricate topic. So, Robert, any clinical takeaways that we should know about or keep our eye on as we head into the new year?

Robert:
Right, I think this is really problematic to get your clinical mind around, but here’s how I suggest that we look at it in our functional medicine community. Think about the historical parade of concepts that we accelerated into the mainstream, such as the role of inflammation in chronic disease, the role of the microbiome, the role of leaky gut. Now there weren’t at the start, there were not good laboratory measures of that. There were not reliable clinical patterns necessarily that you could rely on. The same is true of mast cell activation syndrome. So we should be comfortable in this uncertain space. It has non-specific symptoms, there’s currently no lab testing that can verify it.

And yet, the way we think about systems biology, we should be up to this challenge, Kalea, as functional medicine practitioners. And here’s the way I recommend that we look at it. We are going to be able to develop reliable antecedents of mast cell syndrome. There are some genetic, there’s some primary and secondary mast cell syndromes, but really, I think the more common thing is mast cells are part of the immune system, and like other branches of the immune system, they get activated or dysregulatory with chronic diseases, with lifestyle changes. So I think what we also need to come to do is to define what triggers mast cell activation in different conditions. What are the mediators of mast cell activation that are recurrent or ongoing in a patient that can be reversed with either lifestyle changes, dietary changes?

So I think what we’re going to do is we’re going to find that even though this seems mysterious right now, we’re going to see some general familiar principles come out of it. We just need to categorize this into what are the antecedents, what are the triggers, what are the mediators? We’ve been through this before with inflammation, the microbiota, leaky gut, and we can solve this mast cell syndrome clinically. So, I think dietary modulation looks like it’s going to be an important thing. There’s already some evidence supporting fiber, onions, turmeric, apples, peaches, things like moringa, chamomile, Brazil nuts, nettle, watercress, galangal. So nutritional approaches will be helpful. I think we’re going to be able to discover and uncover and use more. There’s also now, again, noise in the data that long COVID is often involving mast cell activation. So I think it’s important that we get on this and get on it quickly because we are going to be seeing a lot of patients with long COVID manifestations. I think this is an important contributor just as our previous historical accelerables were. Inflammation is an important contributor in recovering from long COVID, the microbiota, the leaky gut. Well, so too is mast cell activation. So let’s take this on as a community challenge, we’re up to it, we are systems thinkers. There’s going to be antecedents, triggers, and mediators. I say, let’s do it. Let’s lead the charge and be the vanguard of addressing mast cell activation syndrome.

Dan:
Yeah, I would just add onto that of what Robert has just articulated that we have been talking about mast cells for the past 20 years. This is what has become apparent, I think, over the past maybe five years, and the research that’s been going on is that mast cells have a much larger place to play than just thinking about allergies or allergic reactions. And because now there’s good research that mast cells are involved in a variety of other illnesses or dysfunctions, from IBS, to IBD, to migraines, et cetera. So it is, as again, as Robert said, it is trying to bring what we have known for a while in terms of some of those foods. And in terms of some of the kinds of supplements that we have used for a while in terms of stabilizing mast cells, and talking about quercetin and stinging nettles, and what we can do to better understand this syndrome now. Now it’s called a syndrome, mast cell activation syndrome. What we can do to better understand it while we continue to move forward in the ways that we have known that we are moving forward. And we’ve probably been treating, I think, mast cell, although I think it’s much more prevalent now for a variety of reasons. I think we’ve all been treating mast cell dysfunction or mast cell activation for many years and maybe just didn’t know we were treating that specifically.

Robert:
I agree with everything Dan has said. And Kalea, if I may, one more facet of this, in order for the functional medicine community to get their mind around it, I think the mast cell activation syndrome may have a home, if you will, in the structural integrity note of the matrix. There’s some good evidence that it disrupts barriers, microscopic membranes and such. The gut endothelium, maybe the blood-brain barrier, other microscopic structural components of the body. And we may also want to be thinking of this in terms of the spectrum of autoinflammation to autoimmunity, perhaps mast cell activation is one of those components of the autoinflammatory response, especially at that micro-structural level. I think this is something we want to pay attention to, keep our eyes on the research, see if this does bear out, because it’s certainly a principle we would know how to address in our systems thinking, in our functional medicine clinical approach.

Dan:
One other thing I want to add is that Robert brought up Brazil nuts as seeming to have some effects on mast cell stabilization. And that may be because of, we all know there’s a lot of selenium in Brazil nuts, and there’s other research that suggests that selenium may have some mast cell stabilization. And our old friend vitamin D, which seems to be good for everything, vitamin D seems to have some regulatory or usefulness in decreasing mast cell activation. So there are particular vitamins I think we can think about that help with stabilizing mast cells as well.

Kalea:
It’s interesting, Dan, how you just mentioned vitamin D and selenium, full fast therapeutics to help prevent mast cell activation or hyperactivation. And knowing that both of those interventions are also used to lower, potentially, thyroid antibodies. And going back to your point, Robert, about this potentially being an autoinflammatory situation, it makes a lot of sense.

We talked about different factors triggering a hyperactivation of our mast cells, nutrition, lifestyle factors. And so let’s talk a little bit about a new topic, which is polyvagal theory. As we’re thinking about our stress coping mechanisms and how that plays into our chronic health conditions. Dr. Stephen Porges spoke at our Annual International Conference earlier this year, and he really emphasized the importance of autonomic regulation in our health. And this continues to be highlighted by the pandemic. We know that the stimulation of our vagus nerve and our parasympathetic response can really help to offset chronic stressors. Robert, I’d love to hear from you, how are you talking to people about using their vagus nerve stimulation? How can we incorporate this into clinical practice? What should we be looking out for?

Robert:
Yeah. I like to frame this in terms of, you know, patients are very comfortable with physical fitness, aerobic fitness, and this is a way of talking about vagal fitness or parasympathetic fitness. Their vagal tone can be improved. Parasympathetic tone can be improved with regard to—it’s a mediator, to get to our ATM model. It’s a mediator in so many chronic diseases, especially diseases involving pain and inflammation, because poor sympathetic tone or dysregulated sympathetic tone contribute to inflammation. Also, with regard to COVID, the parasympathetic tone, the vagal tone is important in terms of a long-term sequelae of past trauma, social determinants of health, and adverse childhood experiences. It’s certainly a contributor in exacerbating mental health conditions or what we would call mental health conditions. So the way I like to think of it with patients now is in terms of fitness, this can be a fifth form of exercise. If you think of aerobic resistance exercise, flexibility, and balance, well vagal moments could be our fifth form of exercise. I think if we put it in those kinds of terms for patients, they get it, and they can include this in a daily regimen of fitness, vagal fitness.

The other thing I think, it’s obviously closely related to stress reduction, but you can almost think of polyvagal syndrome and polyvagal toning as a sixth modifiable lifestyle factor. We want to pay attention to exercise, to sleep, to nutrition, to stress, to relationships. We can also take time out every day for vagal moments. There’s very simple things you can do to improve vagal tone throughout the day. And that’s how I think we can really bring this into clinical practice, again in an accelerated way that’s going to be very meaningful and will hopefully motivate further research on the topic.

Dan:
Let me just add here, Kalea, I think that was really well said in “vagal moments.” And I think we can have, we often think, or I certainly have in the past often thought about mindfulness and mindfulness practice and mindfulness training and spending 20 or 30 minutes at the beginning of your day or at the end of your day doing that or trying to find the time. But as Robert just said, I think we can find mindfulness moments. It doesn’t have to be the 20 or 30 minutes. One of the main ways that you can stimulate in this idea, the healthy function of the vagus nerve, is through deep slow belly breathing, and you can just do that for a moment. And I think those kinds of things can also help integrate that into your daily lives.

Kalea:
Well, vagal moments and mindfulness moments. So many good soundbites just provided there. As we’re talking about our stress coping mechanisms, I wanted to close out our episode talking about different care models. And Dan, you already talked about shared medical visits and what we’ve discovered over the last year and learning from our subject matter experts is that when we’re in a shared medical visit model, that sometimes that can be a stress reliever for the patient. They build a sense of community. It allows them to share in a more open and engaging way. I would love to talk for just a few minutes about these really emerging forms of care using telemedicine, the collaborative care team, utilizing health coaches. Are there models of care that you’re interested in moving into the next year? Will you be shifting your practice at all? Dan, I’ll hand it over to you.

Dan:
Well, as I said, I am trying to provide more shared medical appointments, because, not only for the reasons that I mentioned, I think it’s a very good way to connect with patients and have them connect with themselves. For me, personally or professionally, I just find it very satisfying to have those kinds of connections with a number of people, 10 to 15 people, and kind of going around the room and sharing experiences. And not just, if you will, lecturing or teaching but having a shared experience. And in that process, what I’ve also worked with or tried to work with is not just the clinician but working with a health coach or somebody who provides that health coaching and does that far better than I in terms of bringing the participants out in and getting what they are interested in pursuing. And it doesn’t have to be if in this group that everybody is doing the same thing is as I mentioned in, when I was talking about fasting, there are many different ways to get up that mountain, and you don’t all have to be going at same speed as long as you are taking that first step. So working with a nutritionist and/or a health coach I think for me is one of the ways that I want to incorporate in the coming year.

Kalea:
Great. Robert, any thoughts about our shifting care teams in the new year?

Robert:
Oh yes. I think this really, in terms of the practitioner, makes the practitioner rethink their model with all the various forms of providing remote care and virtual care. It really asks us to consider different options of our clinical model. And this even goes back to training of medical students, residents, et cetera. We want to be training them to think beyond just the face-to-face patient visit and how can they make a bigger impact on health. What’s so promising about it from a patient perspective, though, and the clinician perspective also is this provides for proactive care as opposed to reactive episodes of care. Usually, you haven’t seen the patient for a while, the patient gets sick, they call you up, they make an appointment, and you’re always reacting. With the kinds of monitoring we can do proactively in providing remote care, it can actually be the clinician or the care team that initiates the touch point because we see something in their data, their trackable data that they’re using, and we can actually be proactive in their health.

Now think of what this does for the patient-clinician relationship or the therapeutic partnership. Currently, we have to rely on patient recall, memory, and quite frankly, their candor in telling us what led to their most recent episode for which they called us up. That’s fraught with all kinds of problems. If we are proactively monitoring them with the wearables and the trackable devices and such, think about—we’re reaching out to communicate with them, patients appreciate that, but it also allows us a much more intimate look into their circumstances, their lifestyle factors. We’re going to say, “Hey, we notice this is going on right now. What’s going on in your life?” And they’ll have immediate recall, they’ll be able to tell us. They’ll be grateful for that. And I think this really has the potential to enhance the patient-doctor relationship and not just the doctor. Of course, this is other healthcare professionals who will be reaching out for these touch points. So I think it has a real, real ability to improve that relationship factor of care in addition to bringing all kinds of other healthcare professionals into primary roles in the healthcare team. And this alone can provide cost savings and more access to underserved, marginalized communities, et cetera. So I see great potential for this. I hope we can steward this movement in those directions, of which I’ve just spoken.

Kalea:
Fantastic. You reminded me about just the emergence of remote monitoring during this telehealth era and how with even blood pressure, or in my practice, I do cycle tracking, and having that engagement between practitioner and patient, as you said, can really deepen that therapeutic partnership. So beautifully said. Well, as we wrap this episode, I wanted to thank you both for spending time with us today. And not only letting us know about the most exciting topics of the year but also sharing your clinical takeaways from a functional medicine perspective. It has been such a pleasure chatting with both of you. And we look forward to reconnecting with this community in 2022. Thanks everyone.

Robert:
Thanks everyone. Happy new year.

Dan:
Bye.

Kalea:
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Show Notes

Kara Fitzgerald’s paper on biological aging in the journal Aging: https://www.aging-us.com/article/202913/