Being on the faculty of the Institute of Functional Medicine is a rewarding part of my professional life. On Sunday, I returned from an intense weeklong meeting with other members of the faculty and leadership of the Institute for Functional Medicine.  I’m excited to report that we brought the Functional Medicine Health Matrix (for diagnosis and treatment) protocol to a new level. One of the things that is so exciting about this is that this proceeds from the same structural premise found in THE age-old Eastern approaches to health.  Thus, the Matrix is a marriage of the old and the new and has significant treatment implications. While the new Matrix will not be rolled out for a year to new practitioners, faculty physicians, such as myself, will be using the new Matrix immediately. We anticipate lowering health care costs and improving health outcomes to our patients using this new Matrix.
 
In addition to the faculty and leadership meeting, I attended a Functional Medicine Detoxification Education Module, which featured the latest data regarding chemical and environmental toxicity [we are all facing increased levels of toxicity], and various protocols to detoxify ourselves.

Let me start by acknowledging what is well known: Manic Depression or Bipolar disorder can be a devastating illness. Affecting at least 1% of the population, it can, untreated, result in suicide, ruined careers and devastated families. Bipolar disorder is often accompanied by alcohol and drug abuse and addiction, criminal and even violent behavior. I acknowledge this, because I do not want to make light of the burden this illness places on people’s lives, their families and communities.

On the other hand, the history of the world has been influenced very significantly by people with manic depression (see my website www.wholepsychiatry.com for details)-from actors and actresses (Patty Duke, Jim Carey and Robin Williams) to Politicians (Winston Churchill, Theodore Roosevelt) to astronauts (Buzz Aldren), media mogels (Ted Turner) and perhaps even well known religious figures.

It seems clear that for at least some people with Bipolar disorder, there is an increased sense of spirituality, creativity, and accomplishment. It may be that having bipolar disorder holds great potential, if one is able to master or effectively channel the energies, which are periodically available, to some higher task. This would of course presume the ability to abstain from harmful drugs and alcohol, to have good character, and at least some supportive relationships and community networks.

It might be helpful to consider a reconceptualization. Perhaps instead of it being a disorder, we can think of people with bipolarity as having access to unusual potency. This potency will find a way to be outstanding-either in a destructive way, or in a constructive way. If such a choice is presented to the person, perhaps it can open some doors.

I will be discussing this and other aspects of bipolar disorder on Wednesday, August 4th @ 12PM Eastern time in my free virtual teleconference.

In a previous blog, I talked about how many doctors and patients do not know the full story about their drugs or medical treatments because of a widespread problem involving unpublished or biased clinical trials. Here is an update on what is happening.

As I mentioned, frequently, medical journals or pharmaceutical companies that sponsor research will report only positive results, leaving out the non-findings or negative findings where a new drug or procedure may have proved more harmful than helpful.

“A new review of research about this problem points to hidden or misleading studies for all sorts of conditions, including depression, Alzheimer's disease, type 2 diabetes, menopausal symptoms and cancer”, said Beate Wieseler, deputy head of the Institute for Quality and Efficiency in Health Care (IQWiG) Drug Assessment Departmentresearchers at in Germany.

Much of that problem arises from financial conflicts of interest when pharmaceutical or medical device companies fund the studies, according to Wieseler and her colleagues.  They pointed to past research showing an association between industry sponsorship and positive outcomes or conclusions in studies.  The FDA currently does not disclose much of the information it receives from companies when deciding what drugs or devices to approve for market. Now Wieseler and her colleagues want a global system to register trials and make public all research results for drugs or other medical interventions.  They detailed their findings in the April issue of the journal Trials.

"It's been shown that reporting bias is associated with all sorts of funding – government funding, department funding, industry funding – but the worst source of bias is industry-funded," said Kay Dickersin, an epidemiologist at Johns Hopkins University in Baltimore.

The FDA's European counterpart, the European Medicines Agency, has also considered its own steps toward more disclosure. "The agencies understand that there's a need for more transparency," Wieseler said. "There is increasing understanding that the public should have access [to clinical trial data]."
But regulatory agencies still have not decided how to balance the need for public access against the desire by companies to keep commercial information or trade secrets confidential, Wieseler noted.

As a post script…

In the above we see the overlapping territory of medicine, government, and politics. I encourage people to be proactive in improving and protecting their health. Here is an opportunity to do so.

There are over 900 'new to nature' chemicals in our environments, in our blood, and many are even in the blood of unborn children. Now, following the heightened concern regarding bisphenol A (in clear plastics, such as baby bottles), the FDA is beginning to set its sights on Triclosan. Triclosan is an antibacterial preservative used in "76% of liquid soaps and 29% of bar soaps". Aside from soaps, triclosan is also used in toothpastes, cosmetics, shoes, socks, workout clothes, and many personal care products. Triclosan has been detected in the urine of 75% of Americans, 60% of US streams, and persists in the environment for at least 40 years.

"Animal studies have shown that triclosan alters hormone regulation" according to the FDA, and there is no benefit to using soaps containing this chemical. Despite the fact that the European Union will prohibit its use in products that come into contact with food beginning next year, the FDA states that it "does not have sufficient safety evidence to recommend changing consumer use of products that contain triclosan at this time." The last time I checked, we were part of the animal kingdom. It seems reasonable to conclude that there is a possibility that this chemical is part of the cause of the national epidemic of hormonal dysfunction (e.g, hypothyroidism). While the FDA is advising no change in regulation or consumer behavior until there is evidence that triclosan is harmful to humans, such studies could take years. Additionally, studies which can determine the synergistic effect of this chemical in combination with other new-to-nature concoctions will, in all likelihood, never be done.

Given the facts that a) animal studies show an effect of triclosan on thyroid function (reduction in thyroxine, testosterone and sperm counts in rats), b) triclosan is toxic to aquatic animals and plants and c) there is no benefit to using the product , I advise you to seek out products that are free of triclosan.

These products can be found at IKEA, the Body Shop, Whole Foods and Trader Joes (read the labels!).  Brands that do not use triclosan include Ivory, Tom's of Maine, Listerine Essential Care, Peelu, Weleda, Toxic Free Basics, Aveda, Clean Well, LUSH, Nature's Gate, Vermont Country, Paul's Organic, Dr Bronner's Magic Soaps, MiEssence, The Natural Dentist.

For more information, visit http://www.fda.gov/forconsumers/consumerupdates/ucm205999.htm

Yours in health,
Dr. Robert Hedaya

If you are reading this, you are probably a parent, a teacher, or perhaps even a teen yourself. In any case, you feel confounded by unpredictable and volatile behavior, emotions which seem to arise like tornados from out of the blue, and a parade of identities which seem to change as fast as a runway model’s wardrobe.  What causes all this chaos and confusion? In this article I will summarize some of the new research findings, which shed light on this most vibrant phase of life in the teen brain.

The structure of the brain

I often describe the overall structure of the brain as an ice-cream cone with two scoops. The cone itself is the most primitive part of the brain, called the brain stem. It controls basic functions such as alertness, breathing, blood pressure, and body temperature. Sitting on top of the cone sits the first scoop-the emotional brain (called the limbic system)- which is involved in hormonal control, memory, as well as automatic (and usually unconscious) emotional reactions. The second scoop is the conscious, thinking, planning, brain (called the cortex).

If we look deeper, or microscopically, into the brain, we see that there are millions of nerve cells, which, like streets and highways, are connected to each other. If you visualize a map of the United States showing all the highways as well as primary and secondary and even tertiary roads you can get a feel for a few things. First, not only are there many, many roads, but they seem to converge on certain points we call cities, towns, and neighborhoods. In the brain these points of convergence are called nuclei. One of the major nuclei in the brain is called the amygdala. This nucleus controls rage, fear, and sex. It also tells us (before we are consciously aware) whether a situation is safe, exciting, or dangerous, and our body reacts (again, before we are aware) immediately to this unconscious reflex. This assessment of the situation is based on early childhood experiences.

The Changing Teen Brain

During the teen years, under the influence of massive new hormonal messages, as well as current needs and experiences, the teenager’s brain is being reshaped, and reconstructed. Information highways are being speeded up (a process called myelination), and some old routes, closed down (this is called pruning); some are re-routed and reconnected to other destinations. And above all, old information highways are making lots of new connections to other highways, and other cites and towns (this is called sprouting).  It’s a massive construction project, unlike anything that occurs at any other time in life. In such as situation, things rarely flow smoothly, and surprise destinations thrive. This reconstruction explains why the personality and stability that was evident just a year or two before adolescence recedes, and suddenly new perspectives, and reactions abound.

One of the important things to remember is that what a teen does and is exposed to during this critical time in life, has a large influence on the teen’s future, because experience and current needs shape the pruning and sprouting process in the brain. So if a teen is playing lots of video games, this will shape the brain in such a way that they might become an excellent fighter pilot, but becoming an accountant or researcher will be less possible. Being the class clown will help make a good sales person later on, and running for class president will develop brain skills that are needed to run a business or take on a management position. Being exposed to drugs, computer sex, or violent movies, will also shape the brain and future of the adolescent, laying down the seeds of addiction and interpersonal conflict.

A Changing Brain Means A Changing Identity

Because of all the change that is occurring in the brain, as well as in their social and academic world, teens have a deep need to define themselves, to clarify who they are, and what they stand for. As they are losing their pre-adolescent identity, they are desperate for a new identity. This search can have constructive or destructive aspects to it. Often the new identity is supplied by their peer group, for better or for worse. Because the teen doesn’t know clearly what they want or what they can do, they like to try many different things. This helps them discover what works for them, what feels right, and who they are becoming. The parent-teacher role is to allow and encourage safe exploration.

The constructive approach to identity formation, which should be supported by parents and teachers, is to try new hobbies, take new classes, get involved in new organizations. Supervised exploration of new territory should be encouraged.  Teenagers need guidance not unrestricted freedom. They need novelty, but within bounds.

On the other hand, one common, easy, but non-productive way to define one’s identity, is to do or be the opposite of what the parents are, and to become involved in non-supervised activities. Mom and Dad like going to Shul, so I will sleep late on Shabbat. It is inevitable that there will be a clash and limits will be tested. I advise parents to make the limits reasonably narrow. It’s better for an adolescent to argue over whether they have to go to shul, than whether they can stay out with friends until one AM.

Undeveloped Brain Territory
One part of the teen brain that is undeveloped until the mid-twenties lies in that second scoop of the ice cream cone. This is called the pre-frontal cortex (PFC). This part of the brain, when fully developed, is in a constant dialogue with the emotional brain (the limbic brain). In the adult, the PFC and the limbic brain are in balance, each one inhibiting the other. So when an adult has an emotional reaction to being cut off by a speeding car, the PFC part of the brain says-“Hey, stop, and think about your desire to go speeding after that car. You might get a ticket, you might cause an accident, your insurance rates will go up”. For the teen, however, the PFC is undeveloped, and the emotional brain (including the amygdala mentioned above) rules the moment, until the PFC is developed in the mid-twenties. The teen thinks: “This is going to be exciting!”—if he thinks at all.   Auto insurance companies figured this one out long ago.

Sharing your PFC

One highly effective way for parents and teachers to help teens develop the PFC is to make sure they have some ‘skin in the game’, and to make them deal with the consequences of their actions.  This takes some thinking ahead (a PFC function) on the part of the adults, about the new freedoms and responsibilities that their teen will have. In the case of driving, for example, it is useful if the parents prepare the pre-adolescent with the idea that they will have to save up some money to pay for a car, insurance, gas etc.  If the teen ever gets a parking or speeding ticket, they need to know that they will pay for it. Letting the teen know this in advance, is in a sense, loaning the teen our frontal lobe functions.

Nutrition, Drugs, Alcohol and the Teen Brain

One of the most overlooked and problematic issues for teens is nutrition. The amygdala and other areas of the brain undergoing myelination (to make those connecting superhighways operate really fast) require healthy fats. That means fish oils. My grandfather from Aleppo some how knew that fish was brain food. Modern research has shown this to be true. High levels of these omega 3 fatty acids are associated with less depression and suicide, and many other health benefits too numerous to mention here.

Also, extremely important for the growing teen is making sure the brain gets enough zinc. Zinc makes the mood regulating chemical, serotonin, function properly. If there is too little zinc, often there is too much of the novelty-seeking chemical, dopamine, and even the overstimulating, anxiety-producing chemical, glutamate. Getting enough zinc is a challenge for teens because their growing bones take much of the body supply of zinc, leaving the brain in short supply. This shows up as irritability and moodiness, as well as zinc spots (white spots) on the nails. Giving the teenager a zinc supplement (enough till the nails clear) and a B50 complex can make a very significant difference in moodiness as well help clear up their skin. Add some fish oil capsules and you have some good support for the teen brain.

What doesn’t help the teen brain at all, are alcohol and drugs. For many reasons, including the fact that the teen brain is changing at such a rapid pace, new experiences that are pleasurable (e.g., music) very quickly become habits. Thus the teen will become addicted to substances much more easily than an adult will. Alcohol and drugs cause a Swiss cheese like change in the brain, so that some areas function normally, and others, like the holes in the cheese, under-function to a large degree. This change occurs throughout the brain, but the PFC is markedly affected, (where they are most undeveloped.)

Every Teen is Unique

Remember every teen is different and requires a different approach. If your teen is a responsible and diligent student, and has well adjusted peers, you might be more than willing to send them to college or on a teen tour. On the other hand, if they are showing more signs of impulsivity, which means an undeveloped PFC, they might not be ready to be on their own, with the unrestricted freedom. Strive to see what the best qualities of your teenager are—where their uniqueness lies—and help them find it. It’s the best you can do for the teen you love.

The New York Times had a front page article on May 12th, 2010 entitled: "Doubt is Cast on Many Reports of Food Allergies".

The article reviewed a government report on the concept and prevalence of food allergies. From the NY times report (I have not read the article, as it is not available yet) there are some valid points (e.g., a food allergy must involve the immune system, certain food reactions are not true allergies, such as lactose intolerance). However my concern is twofold:

a) The NY Times summary of the article, and perhaps the publication itself, seem at this point to ignore IgG food allergies, (which are delayed) and only focused on IgE food allergies

b) The NY Times summary of the article, and perhaps the publication itself implies that many labs are of poor quality. I would agree that many labs are of poor quality, but lets be clear that this quality issue is an industry-wide problem and applies to standard laboratories such as Quest and LabCorp as well. As an example, two articles in the Journal of Clinical Endocrinology and Metabolism (about 6 years ago and 2 years ago) showed clearly that there was only one laboratory in the country doing accurate Vitamin D testing.

I know for a fact, because I routinely send in split samples to different labs, that there is at least one food allergy (IgG) lab that is reliable – ImmunoLabs. (I have no financial connection with them.) I also know that two food allergy labs, which I tested for reliability, were highly inaccurate and unable to explain their inaccuracy to me.

Delayed food allergy testing by a reliable laboratory is a very useful test when one is dealing with many chronic illnesses that have an inflammatory component. These diseases range from arthritis, osteoporosis, diabetes, cardiovascular disease, neuro-degenerative diseases, to psychosis, chronic fatigue, fibromyalgia, obsessive-compulsive disorder, and mood disorders. The list of disease states that have an inflammatory component is quite long.

I am concerned that the New York Times article, and perhaps the actual publication, (yet to be released) will inhibit people form addressing one of the major pathways for inflammation-the gut and diet. Estimates are that 60% of the immune tissue in the body surrounds the gut. We are constructed this way for a very good reason-each meal we eat represents a potential antigenic assault on the body.

Sincerely yours,
Robert Hedaya, M.D., D.F.A.P.A.

As I mentioned in part I of this blog, there is a strong association between insulin resistance, diabetes and mental health.

Caught and treated early, insulin resistance is reversible in >90% of patients, and there is a clear improvement in well-being associated with this reversal.  To get to the foundation of the problem, you must do a diagnostic work-up, to identify and deal with the layered factors which promote insulin resistance and diabetes. Factors to be assessed include:

a)     Cortisol-levels which are too high, (as might be the case in anxiety disorders, mood disorders, and psychotic disorders) cause insulin to be elevated, and increase appetite. Cortisol can be reduced easily enough by either supplements or medications, as well as psychotherapeutic methods (e.g., biofeedback, certain therapies, body work etc)

b)     Female and male hormones-low levels of testosterone result in lowered lean body mass (therefore lower metabolic rate), lower energy and vitality. High levels of estrogens (e.g. with potent birth control pills) can also cause weigh gain, albeit in a different pattern of distribution.

c)      Stress-many people over eat when tired, angry, frustrated, bored, lonely; Becoming mindful of your sense of hunger before eating, can, over time, reduce unconscious habitual stress eating. Identifying the situations which make you stressed and problem solving them when possible can help reduce stress eating. Keeping a daily log  (what you ate, when you ate it, and situations in which you over-ate) will definitely raise consciousness

d)     Lifestyle-getting adequate sleep (7-9 hours for most people), moderate exercise 4-5 times per week will reduce the tendency to eat highly processed foods in an out of control manner when you are tired.

e)     Inflammation and toxins: inflammation due to infection, or toxins in your environment can cause weight gain, as a hormone called Leptin can rise to unusual levels. Irvingia Gabonensis has been shown to help reverse leptin elevation and therefore help with appetite reduction and weight loss.

f)       Nutritional deficiencies (e.g., chromium, vanadium, thiamine) can lead to trouble handling carbohydrates in the body.

g)     Caloric restriction-the hardest part of the program is to reduce calories, but with the above measures, perhaps a support group (e.g. weight watchers, over-eaters anonymous, food addicts anonymous), you can do it.

Yours in Health,

Dr. Hedaya

Insulin resistance is a fully reversible condition in which the cells of the body become insensitive to the insulin signal, which itself is designed to take glucose (sugar) out of the blood and into the cells (for energy). If insulin resistance becomes severe enough, it progresses into type II diabetes. Diabetes is more difficult to reverse, and is associated with frequent urination, increased weight, increased thirst, and a host of other problems.

The connection between obesity, insulin resistance, diabetes and mental health problems is no longer questioned. There are number of reasons for the association, including the use of psychotropic medications which cause weight gain, and promote the metabolic syndrome; the social stigma associated with obesity and the lifestyle changes associated with diabetes; and inflammatory activation due to poor diet, high insulin and glucose levels, which in turn changes brain neurochemistry.

A recent study (McIntyre et al.  brain volume abnormalities and neurocognitive deficits in diabetes mellitus: points of pathophysiological commonality with mood disorders?: Adv. Ther. 2010 Feb;27(2):63-80. ) reviewed the literature on brain changes in type one and two diabetes, and concluded that the brain areas which are affected in mood disorders and DM diabetes mellitus, significantly overlap. The association is so compelling that one article in 2007 (Ann. Clin. Psychiatry; 2007 Oct-Dec;1994):257-64) was titled: “Should Depressive Syndromes Be Reclassified as “Metabolic Syndrome Type II”. The association with diabetes (and obesity and insulin resistance) extends beyond just mood disorders, to anxiety disorders, and major psychiatric syndromes such as bipolar disorder and schizophrenia.

I was thinking about the high rate of fractured families and the lack of community in the US, when I began to look at the issue from a different perspective. Fractured families may not be pathological from the planet’s point of view. The earth’s limited resources, or at least the way we are using them, cannot sustain the increasing numbers of human inhabitants. These days, it is clear that the tide has changed; we are not living in a time of easy expansion, which has been present for years. We are now at a point where resources are becoming scarce, air is polluted, water is polluted, and we are over-fishing the seas. It’s inevitable that human expansion has to slow down.

That means fewer children, and or more wars and famines. One way that comes about experientially is for our younger generations to have a harder time getting jobs, making enough money to support a marriage and a family; to find their way in the world. Consequently, they have fewer children, less affluence, a harder time establishing a career,  and may feel a sense of failure when they compare themselves or their achievements to those of their parents.

Without this global perspective, this situation can be experienced and misinterpreted as personal and familial failure. But it’s useful to realize that the tide has turned, and our young children are swimming upstream—more than the baby boomers were, and certainly they are swimming against a strong current, compared to the post-World War II generation.  A diminishing numbers of young people will establish large successful families; those who are able to do so will be in the minority.
Nature will have its way. Nature is fracturing the over-grown human social structure, with all the political and socio-economic changes associated with that. It is hard.

My hope in writing this is that people can recognize the rebalancing aspects of nature which are involved, rather than blaming themselves-- attributing the frustrations in achieving goals to be purely personal and familial failure, or  the result of psychological shortcomings.

Insomnia, an all too common problem, is usually attributed to stress, depression, anxiety, alcohol or caffeine use, poor sleep hygiene, restless legs syndrome, and sleep apnea. Hormonally, thyroid abnormalities, and unusually low levels of melatonin can cause insomnia as well. While all of these syndromes should be considered in evaluating insomnia, the role that PMS and female hormones (progesterone, estrogens) play in insomnia is rarely discussed.

Background

In healthy women sleep disturbances occur twice as often as they do in men. Insomnia is also often more common in the 1-2 weeks before menstruation begins (the luteal phase of the cycle), when compared with the first half of the menstrual cycle. The sleep regulating role of female hormones looms even larger in women with PMS (also known as PMDD, premenstrual dysphoric disorder), and women in the post-menopausal and postpartum phases of the reproductive cycle.

The most common finding in studies of healthy menstruating women is a reduction in dream sleep (REM sleep) in the luteal phase of the monthly cycle. REM sleep usually occurs at the time of the night when body temperature is lowest, but progesterone raises body temperature, thereby (presumably) reducing REM sleep. It is possible that variations in progesterone (which acts in some ways like valium acts, at the GABA-a receptor) and its metabolites may affect sleep quality directly, or via affects on body temperature. In sum, it seems that progesterone, the hormone that rises to very high levels (in the second half of the cycle) to prepare women for pregnancy, helps women fall asleep better, and stay asleep better (but dream less).

Melatonin, the ‘sleep hormone’, seems intimately involved with the female hormonal axis. Surprisingly, receptors for female hormones and melatonin both occur in the same areas of the brain, and melatonin is even found in human ovarian fluid! The relationship between melatonin, while very relevant, is clearly complex. In some studies progesterone and melatonin oppose each other, and in other studies they support each other’s actions. Estrogen, on the other hand seems to reduce melatonin action.

Women with PMS

In women with PMS, disturbances of sleep are very common in the second half of the menstrual cycle (as compared with the first half of the cycle), and dream sleep is reduced. Studies have documented that women with PMS have lower levels of progesterone toward the end of the cycle than their healthy counterparts, and I have seen this in my own practice. Lower levels of allopregnenolone (a breakdown product of progesterone which helps block anxiety) are also found in women with PMS, as well as lower GABA receptor activity levels. GABA is calming, and reduces anxiety.

Abnormal timing of melatonin secretion in PMS has also been documented and it is possible that this is related to reduced availability of serotonin during the second half of the menstrual cycle. Reduced serotonin could result in less melatonin production, and could be the result of increased inflammation in the body, since it is known that inflammation blocks serotonin production in the brain. Inflammatory mediators (TGF-beta-1 family) are involved in processes that control development of the ovarian follicle, the cradle of the egg.

This is pretty complex stuff, and we are far from understanding all or even most of the interactions, but clearly the data indicates that many body systems intersect between the reproductive and sleep cycles.

What can be done?

Despite the lack of clarity about mechanisms, insomnia associated with PMS is quite treatable, if a careful evaluation is done.

If you think you have PMS, carefully track your menstrual cycles and moods on a graph for three months. Get your female hormones measured several times during the first half and second half of your cycle, using blood samples or saliva samples, being sure to measure the pituitary hormones (FSH and LH) in your blood at least once in each half of the cycle.  Measure your melatonin in the second half of your cycle via saliva testing, and journal what you are eating during that time of your cycle. Also journal whether or not you notice more aches and pains during that period of time, as this indicates an inflammatory component, which lowers brain serotonin. This approach will help you be sure it is PMS and help shed light on what to do.

Some women with PMS benefit from light therapy with improved mood, perhaps via its effect on biological rhythms, improved timing of adrenal output, or melatonin release. Sleep deprivation (sleeping from 3-7 AM) seems to normalize circadian rhythms and REM sleep, as well as improve mood during the second half of the menstrual cycle, however this treatment was only studied for short, one-day periods of time. Selective serotonin re-uptake inhibitors (SSRI’s) are also effective in treating PMS.

Progesterone supplementation is very often useful if you have documented progesterone deficiencies, or estrogen excesses. Melatonin levels can be measured at night, and melatonin can be effective in alleviating the insomnia of PMS. Dietary changes may be indicated if aches and pains (which indicate an inflammatory process) are a significant symptom, since reduction in inflammation increases the brain’s ability to make serotonin and melatonin, and maintain a good mood, and low levels of anxiety.