We’ve talked a lot about the “gut-brain” axis.  But did you know there’s also a “gut-skin” axis?  And did you know that researchers have been aware of this connection for more than 100 years?  Of course, this early work was forgotten for about 90 years, and it has only received increasing attention in the last decade.  It’s an exciting area of study, and it gives us new strategies for naturally treating skin conditions like acne (vulgaris and rosacea), psoriasis, eczema, dermatitis and others.

And in this episode of Revolution Health Radio, we cover:

2:24  Does the Gut-Brain-Skin Axis hold the secret to naturally get rid of acne?
8:23  The latest study validating 100 year-old research connecting stress, leaky gut, and acne
12:20  Why these ancient gut remedies also treat skin conditions
17:59  Could leaky gut be the hidden cause of acne?
20:55  How to break the vicious constipation-acne cycle
26:00  Why rush-hour traffic can cause low stomach acid, gas, and bloating
29:40  “The first place I look when someone comes to my practice with skin conditions”
34:48  The specific Gut Healing Protocol to naturally eliminate skin problems… for good
40:00  What foods to eat – and not eat – to get rid of migraines (and clear your skin)
44:12  The telltale signs you have low stomach acid… and what to do about it

Links We Discuss

• The Gut-Brain-Skin Axis – Back to the Future? (Full Text Study)
• The HCL Challenge Instructions

I write a lot about diet and nutrition, and there’s absolutely no doubt that the food we eat is one of the most important factors that determines our health.

But it’s a mistake to assume that food is the only consideration that matters when it comes to health, and that all health problems can be solved simply by making dietary changes. Unfortunately, this seems to be an increasingly common assumption in the Paleo/Primal nutrition world these days.

I see a lot of people in my practice that have their nutrition completely dialed in, but don’t take care of themselves in other ways. Maybe they don’t manage their stress, they don’t exercise, or they don’t sleep well.

Even if this person eats a perfect diet, are they really healthy?

And what about the person who doesn’t eat particularly well, but sleeps like a baby, gets a massage a couple times a month, has a lot of fun, spends lots of time outdoors, and doesn’t have any health problems?

What is health?

Moshe Feldenkrais, the creator of the Feldenkrais Method, defined health as “the ability to live your dreams“. I think that’s an interesting way to look at it. Using the examples above, it’s entirely possible that the person with the perfect diet but the rest of their life in shambles is less healthy than the person who doesn’t eat that well but takes care of himself or herself in other ways.

If you were to embrace Feldenkrais’ definition of health, how would you live your life differently? Would you put more time and energy into perfecting your diet, or would you spend a little more time focusing on the areas of your life that you tend to neglect? Which path would take you closer to being able to live your dreams?

In a previous article, I argued that the biggest obstacle to optimal health is our mind. The more patients I work with, the more convinced I am that this is true. From the article:

What I’ve observed in myself, in working with patients and in almost 20 years of meditation practice is that each of us has a significant blind spot or area in our lives where we lack awareness and insight. As a crude analogy, let’s call this a weak link in our chain and assume that the chain represents health.

Most of us invest the majority of our time and energy strengthening the parts of our chain that are already strong. These stronger links are where we feel comfortable and confident, where we can operate safely within the bounds of who we think we are.

And this is where the problem lies. No matter how much we strengthen the links in our chain that are already strong, if there’s still a weak link the chain as a whole isn’t stronger. It can break just as easily.

A better approach, of course, would be to focus our efforts on the strengthening the weak link. But that is much, much harder to do. Why? Because it usually requires us to step out of our concept of self and challenge our very identity. It asks us to grow and evolve and shine the light of awareness into the dark corners of our psyche. This isn’t something that happens overnight. It’s not as simple as popping a pill or eliminating nightshades from our diet. It’s a life’s work.

Yes, it’s important to pay attention to how much omega-6 fat you eat. Yes, it’s best to minimize phytic acid consumption by soaking nuts. Yes, it’s wise to avoid excess fructose, especially if you have digestive problems. These finer points of nutrition do make a difference.

But optimizing nutrition is only one variable in the equation of health. And if all of our attention goes there, at the expense of other variables that are also important (like sleep, exercise, stress management, pleasure, etc.), our health will suffer. That’s why only 4 out of my 9 Steps to Perfect Health are explicitly related to food and nutrition.

There’s more to life than health

In the same way that there’s more to health than food, there’s more to life than health.

I’m sure some of you have a friend or acquaintance that eats well and takes great care of themselves, but they’re a wreck in their personal or professional lives. Maybe they’re in a toxic relationship, they have a job that they hate, they can’t get along with co-workers or friends, or they feel lost, empty and unfulfilled.

And maybe you know someone that has struggled with a chronic illness for years, but has deep, rewarding relationships, meaningful work, a sense of purpose, and a rich, vibrant life.

Of course we all want to be as physically healthy as possible. There’s nothing wrong with that pursuit. But the cold, hard truth is that not all health problems are solvable. As much as we’d like to believe otherwise, we don’t have full control over all of the conditions of our lives.

What we do have control over is how we relate to ourselves and these conditions. In my opinion, this – more than anything else – is what determines our happiness and sense of well-being.

It’s possible to be physically healthy, but live in a constant state of struggle and dissatisfaction. Likewise, it’s possible to be ill, in pain, or physically disabled and be happy and at peace. I wrote about this in more detail in a previous article, Living with Chronic Illness: The Power of Acceptance.

I’d like to end this article by asking you two questions:

1. What aspects of health do you tend to ignore? And how does that keep you from living your dreams?
2. What areas of your life – beyond your health – could use more attention? How would addressing those areas bring you more happiness and peace?

Please leave your answers in the comments section!

One of the most hotly debated subjects over the past few years has been the cause of the obesity epidemic, and along with that, the best strategy for weight loss.

Some folks (Atkins, Taubes, Eades, etc.) believe that carbohydrates are to blame. Others (Ornish, Campbell, Esselstyn, Fuhrman, etc.) believe that fat is the problem. More recently, researchers like Seth Roberts and Stephan Guyenet and clinicians like Dr. Sharma have raised awareness of another hypothesis, called the food reward theory, which holds that the consumption of highly palatable foods leads to overeating and weight gain. And Paul Jaminet and others have argued that micronutrient deficiencies, toxins and infections may play a significant role in the obesity epidemic.

Here’s what I think: the most accurate answer to “why do people get fat?” and “what’s the most effective weight loss strategy?” is: “it depends.”

Separating cause from mechanism and effect

One of the biggest mistakes often made in this debate is the confounding of cause, mechanism and effect. A classic example is the assumption that if reducing carbohydrate or fat intake leads to weight loss, then the original weight gain must have been caused by excess carbohydrate or fat consumption.

While it’s tempting to make such an assumption, the logic is faulty. It’s kind of like saying “Advil cures headaches. Therefore, headaches must be caused by Advil deficiency.”

Let’s look at some definitions.

Cause: something that brings about an effect or a result

Mechanism: the fundamental processes involved in or responsible for an action, reaction, or other natural phenomenon

Effect: an outward sign

Obesity is an effect. Insulin resistance, leptin resistance, lipotoxicity, disruption of the mesolimbic dopamine reward pathway and inflammation of the hypothalamus are presumed mechanisms. Excess consumption of carbohydrates, fat, highly palatable food and food toxins (wheat, seed oils, liquid fructose, etc.), exposure to environmental toxins (chemicals), stress, infections, etc. are presumed causes.

Say we do a study on obese people and we observe that they eat a lot of carbohydrates and are insulin and leptin resistance. It’s easy to assume that the chain of causality worked like this: normal weight person eats high-carbohydrate diet, becomes insulin and leptin resistant, and then becomes obese.

But again, this is faulty logic. There’s no proof that A (high carbohydrate intake) was what led to B (insulin and leptin resistance) was what led to C (obesity).

In fact, we could disprove that theory simply by observing another individual or group that eats a very high carbohydrate diet, but does not develop insulin or leptin resistance and obesity. Guess what? Such individuals and groups most certainly exist. There goes that theory.

Likewise, we could also disprove this theory by observing people that are insulin and leptin resistant, but don’t become obese. Such people do exist, and I’ve written about them in my series on diabesity here.

A more rigorous approach

How have we developed our theories on obesity and weight regulation? It seems to me they come from a blend of personal experience, belief and facts. And I think it’s time to become more rigorous about keeping them separate. Here’s an example of what I mean:

Personal experience: I lose weight on an low-carb diet, therefore low-carb diets must be best for weight loss.

Belief: carbohydrates are responsible for the obesity epidemic, via their effects on insulin.

Fact: many cultures around the world eat high-carbohydrate diets and are exceptionally lean.

Those who’ve lost a lot of weight on a low-carb diet have a tendency to become convinced that their wife, friends, family, plumber and everyone else will also lose weight following the same diet.

From this personal experience, a belief is formed. And once we believe in something, we have a remarkable ability to filter out any evidence that might contradict that belief.

This is especially true if our reputation or financial livelihood is tied to said belief. As Upton Sinclair famously said:

It’s difficult to get a man to understand something when his salary is dependent upon him not understanding it.

When a belief like “carbs cause obesity” is shared between enough individuals, it becomes a meme. Once that happens, it is accepted by most as fact – regardless of whether it has any scientific basis. Hence we had the idea for decades that eating fat makes you fat, and now the more recent idea that eating carbs makes you fat.

There’s no single cause (or treatment) of obesity

Perhaps one of the reasons it’s so easy to confuse cause, mechanism and effect and personal experience, belief and fact is that obesity is an incredibly complex disease. Just how complex is it?

Click on the Obesity Systems Influence Diagram below to find out.

Click image for larger version

Wow. That should give you a rough idea of how many variables are potentially involved in weight regulation. Now you know why it has been such a challenge to come up with a single, unified theory of obesity.

That said, of all of the hypotheses advanced to explain the mechanisms behind obesity, I think the food reward theory is the most inclusive.

However, as even its proponents would agree, it doesn’t tell the whole story because there are people and groups that eat large amounts of highly palatable foods that do not become obese.

My opinion is that the modern lifestyle (i.e. food and environmental toxins, stress, poor gut health, infections, micronutrient deficiencies, sleep deprivation, etc.) interfere with hypothalamic hormonal regulation, dopamine signaling, leptin and insulin sensitivity at the cellular level, glucose metabolism and a range of other mechanisms that lead to obesity.

This is consistent with the observation that obesity is extremely rare or nonexistent in traditional cultures that do not consume modern foods and do not live a “modern” lifestyle.

But even this theory is incomplete, because there are people fully exposed to the modern lifestyle that do not become overweight or obese. This suggests that genetics, and perhaps other undiscovered factors, also play a role.

We’re not robots

Humans are not robots. We’re living, breathing, dynamic organisms influenced by varying genetics and environmental conditions.

Anthropological evidence combined with modern research has helped us to reveal the basic template of a species-appropriate diet. However, it has also shown us that humans can thrive on a wide variety of macronutrient ratios and foods within that basic template.

This is not a belief. It’s a fact, supported by the evidence as a whole. Ignoring the evidence doesn’t make it go away. Believing passionately in something doesn’t make it true. Experiencing something personally doesn’t make it fact for everybody else.

19th century philosopher Charles Peirce said:

The state of belief is a calm and satisfactory state which we do not wish to avoid, or to change to a belief in anything else.

And Tolstoy said:

I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives.

Recognizing this basic human trait, philosopher of science Karl Popper advised every researcher to earnestly try to discredit their own hypotheses.

That is no easy task, and it asks a lot of us. Yet intellectual rigor, emotional maturity and personal integrity are characterized by the capacity to question our own beliefs, no matter how deeply cherished they are or how much is at stake.

I sometimes wonder why we’re all so sure of ourselves. It helps me to remember that at every point in history scientists (and the general public) were convinced they had the right answers. At one time the world was flat, the earth was the center of the solar system and disease was caused by foul humors and could be cured by bloodletting.

Nowadays we look back on those fallacies with a smirk. But are we so arrogant to assume that our great-grandchildren won’t do the same?

The truth is, there’s far more we don’t know than we do know.

Of all the 9 steps, stress management is probably the most important. Why? Because no matter what diet you follow, how much you exercise and what supplements you take, if you’re not managing your stress you will still be at risk for modern degenerative conditions like heart disease, diabetes, hypothyroidism and autoimmunity.

I see this every day in my practice. I have a lot of patients that are following a “perfect” diet, and yet they are still sick. Stress is often the cause. (I’ll define stress more clearly in a moment.) Yet as pervasive as stress is, many people don’t do anything to mitigate its harmful effects. The truth is it’s a lot easier to make dietary changes and pop some pills (whether drugs or supplements) than it is to manage our stress. Stress management bumps us up against core patterns of belief and behavior that are difficult to change.

I suspect this is why all of the articles I’ve written about stress management are among the least shared on Facebook and Twitter and have elicited the fewest comments. I think many of you may feel defeated or overwhelmed by stress. I understand this. Stress management is hard. It asks a lot of us. It forces us to slow down, to step back, to disengage (if only for a brief time) from the electric current of modern life. It asks us to prioritize self-care in a culture that does not value it.

While I feel your pain, and still struggle with stress management myself, I’ve got to lay down some tough love here. If you’re not doing some form of regular stress management, you will sabotage all of your best efforts with diet, exercise and supplements. Stress management is absolutely crucial to optimal health and longevity. If most health conscious people spent even half the amount of time they spend focusing on nutrition and exercise on managing their stress, they’d be a lot better off.

I’m going to suggest several strategies for stress management at the end of the article, but first let’s define stress more explicitly and learn more about the harm it causes.

What is stress?

Hans Selye, the famous physiologist who coined the term “stress”, defined it this way:

…the nonspecific response of the body to any demand made upon it.

The prominent psychologist Richard Lazarus offers a similar definition:

…any event in which environmental demands, internal demands, or both tax or exceed the adaptive resources of an individual…

At the simplest level, then, stress is a disturbance of homeostasis. Homeostasis is the body’s ability to regulate its inner environment. When the body loses this ability, disease occurs.

The adrenals are two walnut-shaped glands that sit atop the kidneys. They secrete hormones – such as cortisol, epinephrine and norepinephrine – that regulate the stress response. Because of this, the adrenals are what determine our tolerance to stress and are also the system of our body most affected by stress.

Most people are aware of the obvious forms of stress that affect the adrenal glands: impossibly full schedules, driving in traffic, financial problems, arguments with a spouse, losing a job and the many other emotional and psychological challenges of modern life.

But other factors not commonly considered when people think of “stress” place just as much of a burden on the adrenal glands. These include blood sugar swings, gut dysfunction, food intolerances (especially gluten), chronic infections, environmental toxins, autoimmune problems, inflammation and overtraining. All of these conditions sound the alarm bells and cause the adrenals to pump out more stress hormones.

Adrenal stress is probably the most common problem we encounter in functional medicine, because nearly everyone is dealing with at least one of the factors listed above. Symptoms of adrenal stress are diverse and nonspecific, because the adrenals affect every system in the body. But some of the more common symptoms are:

• Fatigue
• Headaches
• Decreased immunity
• Difficulty falling asleep, staying asleep and waking up
• Mood swings
• Sugar and caffeine cravings
• Irritability or lightheadedness between meals
• Eating to relieve fatigue
• Dizziness when moving from sitting or lying to standing
• Digestive distress

How does stress harm the body?

The short answer is “in every way imaginable.” It would take books to explain the full effects of stress. And those books have been written. Check out Why Zebras Don’t Get Ulcers by Robert Sapolsky and When the Body Says No: Exploring the Stress-Disease Connection by Gabor Mate for a more thorough investigation. I’m just going to summarize here.

When stress becomes chronic and prolonged, the hypothalamus is activated and triggers the adrenal glands to release a hormone called cortisol. Cortisol is normally released in a specific rhythm throughout the day. It should be high in the mornings when you wake up (this is what helps you get out of bed and start your day), and gradually taper off throughout the day (so you feel tired at bedtime and can fall asleep).

Recent research shows that chronic stress can not only increase absolute cortisol levels, but more importantly it disrupts the natural cortisol rhythm. And it’s this broken cortisol rhythm that wreaks so much havoc on your body. Among other effects, it:

• raises your blood sugar
• weakens your immune system
• makes your gut leaky
• makes you hungry and crave sugar
• reduces your ability to burn fat
• suppresses your HPA-axis, which causes hormonal imbalances
• reduces your DHEA, testosterone, growth hormone and TSH levels
• increases your belly fat and makes your liver fatty
• causes depression, anxiety and mood imbalances
• contributes to cardiovascular disease

These are all well-documented in the scientific literature, and the list of health problems caused by stress goes on. And on. In fact it’s not a stretch to suggest that stress contributes to all modern, chronic disease.

But most people don’t need much convincing of this. You’ve witnessed the negative effects of stress firsthand, every day of your life. So the question is, what do you do about it?

How to reduce the impact of stress

There are two different approaches to reducing the impact of stress, and both are important:

1. Reduce the amount of stress you experience.
2. Mitigate the harmful effects of stress you can’t avoid.

Reducing the amount of stress you experience

Reducing stress means just what it sounds like: reducing your total exposure to all forms of stress, whether psychological or physiological. Of course it’s never possible to completely remove stress from our lives. But even in the most stressful of circumstances, it’s still possible to reduce stress.

The first step is to avoid unnecessary stress. This often seems obvious, but it isn’t. It’s easy to overlook habitual patterns of thought and behavior that cause unnecessary stress above and beyond the stress we can’t avoid. Here are a few guidelines for how to avoid this kind of stress:

• Learn to say “no”. Know your limits, and don’t take on projects or commitments you can’t handle.
• Avoid people who stress you out. You know the kind of person I’m talking about. Drama kings and queens. People who are constantly taking and never giving. Limit your time with these people or avoid them entirely.
• Turn off the news (or at least limit your exposure to it). If watching the world go up in flames stresses you out, limit your exposure to the news. You’ll still find out what’s going on, and still be able to act as a concerned citizen. But you’ll have more time for yourself. I stopped getting the paper years ago, and don’t even have TV. And believe it or not I’m still well-informed. The difference is I get to choose what I’m exposed to.
• Give up pointless arguments. This is especially true for useless internet debating. There is obviously a place for discussion and debate, and working towards change. But have you noticed that most arguments don’t lead to change? In fact, they tend to have the opposite effect – each side becomes more defended and entrenched in their worldview. Find other ways to get your point across, learn to listen with empathy, and don’t waste precious time and energy trying to convert fundamentalists to your religion.
• Escape the tyranny of your to-do list. Each day spend some time in the morning really considering what needs to be done that day. Drop unimportant tasks to the bottom of the list. Better yet, cross them off entirely. The world will go on.

The second step in reducing the amount of stress you experience is to address any physiological problems that are taxing your adrenals. These causes include anemia, blood sugar swings, gut inflammation, food intolerances (especially gluten), essential fatty acid deficiencies and environmental toxins. If you have one or more of these conditions, it’s probably best to get help from a skilled practitioner.

Mitigating the harmful effects of stress you can’t avoid

Obviously there are times when we just can’t avoid stress. Maybe we have a high-stress job, or we’re caring for an ailing parent, or we’re having difficulty with our partner or spouse. In these situations it’s not about reducing stress itself, but about reducing its harmful effects.

How do you do that? There are several different strategies:

• Reframe the situation. We experience stress because of the meaning we assign to certain events or situations. Sometimes changing our perspective is enough to relieve the stress. For example, being stuck in traffic can be a “disaster” or it could be an opportunity for contemplation and solitude.
• Lower your standards. This is especially important for you perfectionists out there. Don’t let the perfect be the enemy of the good. Let good enough be good enough.
• Practice acceptance. One of my meditation teachers used to say “All suffering is caused by wishing the moment to be other than it is.” Many things in life are beyond our control. Learn to accept the things you can’t change.
• Be grateful. Simply shifting your focus from what is not okay or not enough, to what you’re grateful for or appreciative of can completely change your perspective – and relieve stress.
• Cultivate empathy. When you’re in a conflict with another person, make an effort to connect with their feelings and needs. If you understand where they’re coming from, you’ll be less likely to react and take it personally.
• Manage your time. Poor time management is a major cause of stress. When you’re overwhelmed with commitments and stretched too thin, it’s difficult to stay present and relaxed. Careful planning and establishing boundaries with your time can help.

In addition to everything I’ve listed above, one of the most important things you can do to manage stress is to bring more pleasure, joy and fun into your life. This is the subject of Step 9, so I’ll just mention it briefly here.

Stress management practices and techniques

All of the stress management tips above are important, and can make a huge difference in your health and well-being. However, there’s a certain amount of stress in modern life that is simply unavoidable for most of us. That’s why it’s so crucial to have a regular stress management practice.

There are a lot of options here, of course. Things like exercise, yoga, tai qi, qi gong, a walk on the beach, etc. can all relieve stress. I’ll just share the practices I’ve found to be most helpful for myself and my patients over the years.

Meditation

In spite of the fact that I’m listing it here, I don’t consider meditation as a “stress management” technique – although it can certainly have that effect. Meditation is an awareness practice. Through meditation we learn to witness our thoughts, feelings and sensations and dis-identify with the story we tell ourselves about them. We learn to stay present to our lives even in the face of great difficulty or pain.

Contrary to popular belief, you don’t have to be able to “relax” to meditate. Sometimes we are relaxed during meditation, sometimes we are quite agitated. We don’t meditate to manipulate our feelings, but to learn to observe them without reacting to or “becoming” them.

One of the books I often recommend to people who’d like to learn more about meditation practice is Opening the Hand of Thought, by Kosho Uchiyama. You may also want to check out Don Matesz’s recent article, 10 Reasons Why I Practice Mindfulness Meditation, for more on the benefits of meditation practice.

Mindfulness-based Stress Reduction

Mindfulness-Based Stress Reduction (MBSR) combines mindfulness meditation and yoga to cultivate greater awareness of the unity of mind and body, as well as of the ways the unconscious thoughts, feelings, and behaviors can undermine emotional, physical, and spiritual health. It was developed by Jon Kabat-Zinn at the Stress Reduction Clinic at the University of Massachusetts Medical Center in 1979.

Through clinical research at the University of Massachusetts and elsewhere, MBSR has been shown to positively effect a range of autonomic physiological processes, such as lowering blood pressure and reducing overall arousal and emotional reactivity. MBSR is offered as an 8-week intensive training in hospitals and medical centers around the world. It is also offered as an online course, and can be done via home study with books and audio recordings. MBSR is particularly effective for anyone struggling with chronic illness or pain.

Rest Assured

Rest Assured is a program for healing insomnia naturally. However, the way this is accomplished is by maintaining a greater state of relaxation and ease throughout the day. We can’t run around all day in a state of constant hyper-arousal and expect to fall into a deep and peaceful sleep at night. The body doesn’t turn on and off like a light switch. This is why sleep medications have become ubiquitous. They’re the equivalent of hitting yourself over the head with a sledgehammer so you can fall asleep.

The Rest Assured program contains simple exercises that coordinate breath and movement. Many of the exercises can be performed in as little as 3-4 minute throughout the day, while some take 20-30 minutes and can be done when you have a little more time – or while you’re laying in bed before sleep. I’ve found these to be incredibly helpful myself, and my patients have as well.

So here’s my request. If you found this article to be helpful, please share it on Facebook and Twitter (you can use the FB & Twitter icons at the top of the post), or email it to someone you care about. Stress management is one of the most important things we can to do protect our health, yet it’s often the first thing that slips through the cracks in a busy life.

Let me start by saying that I’m a fan of intermittent fasting. I think going for extended periods without eating was probably normal for humans throughout most of our evolution, and I’ve seen enough evidence to convince me that it can help with everything from weight loss to improving insulin sensitivity to boosting the immune system.

Martin Berkhan at Leangains and Paul Jaminet at Perfect Health Diet both write extensively about the benefits of intermittent fasting, so I’m not going to cover that here.

Instead, I want to talk briefly about when intermittent fasting might not be a good idea. I haven’t arrived at this notion through combing the research literature, but through direct experience with patients in my clinical practice.

In the last few months I’ve had a few patients come to me with several months of low-carb, paleo nutrition and intermittent fasting experience behind them. When I had them test their blood sugar with a glucometer, we discovered some very erratic patterns. They didn’t just have high fasting blood sugar in the morning, as is typical with low-carb dieters, but they had high levels or a “yo yo” pattern throughout the day.

I tested the cortisol/melatonin rhythm in two of these patients, and it was off in both of them. Why would this be? It’s possible that the blood sugar ups and downs they’re experiencing are exhausting their adrenals. Or, that their adrenals were already under stress and the repeated cortisol secretions necessary to bring their blood sugar back up when it drops created further stress.

As an experiment we decided to have them try eating regular meals, and even more frequently than normal (i.e. every 2-3 hours). Guess what? Their blood sugar normalized within a few days, they started sleeping better and other symptoms improved. I’ve only re-tested cortisol rhythm in one of these patients, but it was back in the normal range after three weeks of eating more regularly.

So how could intermittent fasting normalize blood sugar in some people, but throw it off in others? I’m not sure, but as I said above, my guess is that it has a lot to do with their adrenal status when they begin fasting. There’s a complex relationship between blood sugar and hormones like cortisol, glucagon, epinephrine, norepinephrine and growth hormone. While it’s true that balancing blood sugar can bring the hormones back into line, it’s also true that hormonal imbalances can throw blood sugar out of whack.

I’ve heard anecdotal reports from some that intermittent fasting was rough on them when they first started, but after sticking with it for quite a while it had the desired effect. It’s possible, of course, that if these patients of mine had simply kept going their blood sugar and insulin sensitivity would have normalized. But three of them, at least, had been doing it for six months or longer before they came to me – so I think it’s unlikely that another few months would have made the difference.

As usual, I’d love to hear your thoughts on this.

Over the last several years I’ve come to believe that chronic stress – and the cascade of changes it causes in the body – is second only to diet as the primary cause of modern disease. This isn’t just my opinion. It’s supported by mountains of scientific evidence as well as a basic understanding of evolutionary biology and human physiology.

The problem is, nobody wants to hear this. I think it, um, stresses us out to know that stress is so harmful. It’s interesting to note that whenever I write an article about stress, like this one about how stress makes you fat and diabetic, the response is decidedly lukewarm – especially compared to the popularity of articles about diet.

Diet is important. I think you all know how I feel about that. But here’s the thing: it’s not enough. Even if your diet is perfect, stress can still destroy your health.

In fact, I see this in almost all of my patients. Most people I work with already have pretty good diets. Sure, there’s almost always room for some tweaks, but overall they’re doing better than 99% of the population. Yet they are still struggling with chronic health problems – some of them quite severe.

Without exception, these folks have cortisol problems. Either their cortisol is high, low, or the rhythm is out of whack. Remember that cortisol is a hormone that is released during the stress response. Like insulin, we need it in small amounts to function properly, but too much of it can wreak havoc on the body.

Why? Because our bodies aren’t set up for chronic stress. We evolved to deal with a series of acute, short-term stressors. Stress causes the release of cortisol and other hormones. The purpose of these hormones is to prepare our bodies for either fight, or flight. This involves mobilizing stores of fat, protein and glucose to give us the energy we need to deal with the threat.

This all works well if we actually do fight, or run away, because these activities discharge the hormones and the extra energy produced by the stress response.

But these days, we don’t have the chance to do that. The stress we experience is chronic, not acute, and more often than not it’s not something we can fight or run away from. One of the disadvantages of our big brains is that we’ve developed the capacity to stress ourselves out simply by imagining potential threats. Worrying about our financial future or driving in traffic produce a similar hormonal response to what getting chased by a lion would have triggered for our ancestors.

But in our case, those hormones just keep pumping out and building up, and fat, protein and glucose keep getting mobilized without any discharge. And what happens when cortisol builds up and fat and sugar are too abundant? Modern disease happens. Obesity, diabetes, heart disease, depression, anxiety, insomnia, gut disorders, autoimmune diseases, allergies and nearly every chronic, modern health problem is directly related to the changes in our body caused by stress.

I’m sure you don’t need me to tell you that stress is harmful. Duh. The question you’re probably more interested in is, “what can I do about it?”

It’s pretty clear that for most of us, reducing stress isn’t a viable option. At the simplest level, stress is what happens when the demands of life exceed our ability to deal with them. Those demands can be physical, emotional or psychological.

Raise your hand if you ever feel the demands of modern life exceed your capacity to deal with them. Yeah, that’s what I thought. That’s probably why people feel disempowered when they read articles like this. But that doesn’t mean we can’t take steps to mitigate the harmful effects of stress. Stress management – not stress reduction – is where we need to focus.

Stress management may very well be the most important thing you can do to improve your health and prevent disease. Yet most of us don’t do it anything about it.

When I talk to people about the importance of stress management, I usually get a nod of the head and an answer like “yeah, I know I’m really stressed out and I need to relax more.” But I can tell they’re not taking it seriously. It’s almost like I suggested they put up their Christmas decorations a little earlier, or they wash their car more often, or something like that. “Yeah, I know I should, but…”

Yet these are the same people that are taking 23 different supplements, following a strict diet and exercising every day at 6:00am. Clearly lack of motivation isn’t the issue.

So why are we so resistant to managing stress? Because the truth is, it’s far easier to change our diet and take some pills than it is to manage stress and transform the way we live.

If stress is what happens when life’s demands exceed our body’s capacity to deal with them, then we have two options. The first is to reduce the demands. In today’s world, this just isn’t practical for most people. The second option is to increase our body’s ability to deal with the stressors we face. Everyone can – and should – do this.

How? There are two ways, both important. First, we can learn stress management techniques and make lifestyle changes that increase our buffer against stress. Second, we can use supplements and herbs to support the hypothalamic-pituitary axis (HPA), which governs our stress response. I’ll discuss specific strategies for both in a future article.

In the first part of this series on diabesity, we “got under the hood” to look at the underlying mechanisms of both obesity and diabetes. We’ve now moved on to discussing the environmental and lifestyle risk factors that drive these conditions. In the last article we learned about the top 3 dietary causes of diabesity. In this article, we’re going to see how stress can independently cause both obesity and diabetes.

A huge – and I mean huge – amount of research over the past two decades shows that stress causes both obesity and diabetes in a variety of ways. Studies also show that stress makes it hard to lose weight. This is one reason why some people just can’t seem to lose weight no matter how well they eat or how much they exercise. I believe stress is one of the most important – yet most often ignored – factors driving the diabesity epidemic.

Stress is a bigger problem than you think

Hans Selye, the famous physiologist who coined the term “stress”, defined it this way:

…the nonspecific response of the body to any demand made upon it.

The prominent psychologist Richard Lazarus offers a similar definition:

…any event in which environmental demands, internal demands, or both tax or exceed the adaptive resources of an individual…

Most people only think of psychological stress when they hear the term “stress”. When asked what causes stress, they might say things like losing a job, having a fight with your spouse, driving in traffic or getting audited by the IRS.

While it’s true that psychological challenges like this are major stressors, what many people don’t realize is that stress is also caused by physiological challenges, such as:

• insomnia
• chronic infections
• inflammation
• autoimmune disease
• environmental toxins
• dieting
• too much exercise

Even if your levels of psychological stress are pretty low, any of the conditions listed above can provoke a chronic stress reaction in your body. And as we’ll see in the next section, chronic stress can make you both fat and diabetic.

10 ways stress makes you fat and diabetic

When stress becomes chronic and prolonged, the hypothalamus is activated and triggers the adrenal glands to release a hormone called cortisol. Cortisol is normally released in a specific rhythm throughout the day. It should be high in the mornings when you wake up (this is what helps you get out of bed and start your day), and gradually taper off throughout the day (so you feel tired at bedtime and can fall asleep).

Recent research shows that chronic stress can not only increase absolute cortisol levels, but more importantly it disrupts the natural cortisol rhythm. And it’s this broken cortisol rhythm that wreaks so much havoc on your body. Among other effects, it:

• raises your blood sugar
• makes it harder for glucose to get into your cells ¹
• makes you hungry and crave sugar
• reduces your ability to burn fat
• suppresses your HPA-axis, which causes hormonal imbalances
• reduces your DHEA, testosterone, growth hormone and TSH levels ²
• makes your cells less sensitive to insulin
• increases your belly fat and makes your liver fatty
• increases the rate at which you store fat
• raises the level of fatty acids and triglycerides in your blood

Each one of these consequences alone could make you fat and diabetic, but when added together they’re almost a perfect recipe for diabesity.

Our bodies aren’t made for chronic stress

One of the reasons chronic stress is so destructive is that our bodies didn’t evolve to deal with it. We’re set up to handle short-term, acute stress fairly well. In paleolithic times, this might have been caused by getting chased by a lion or hunting for our next meal. In fact, this type of stress may even be beneficial for our bodies because it improves our ability to react to the challenges of life.

What we’re not adapted for, however, is the chronic, unrelenting stress that has become so common in modern life. This type of stress provokes feelings of hopelessness and helplessness – what psychologists call a “defeat response”. And it’s the defeat response that leads to increased fat storage, abdominal obesity, tissue breakdown, suppression of the immune system, and all of the other effects I listed above that directly cause obesity and diabetes.

A closer look at insomnia, dieting and exercise

I’d like to take a closer look at three often stressors that can make us fat and diabetic: insomnia, dieting and exercise.

More than a third of American suffer from insomnia, with 42 million prescriptions for sleeping medications filled in 2007. Several studies show that sleep deprivation elevates cortisol and makes it more likely that you’ll get fat and develop diabetes.

A very recent paper showed that restricting sleep to 5 hours a night for just one week significantly reduces insulin sensitivity. Another study earlier this year showed that even one night of sleep loss increased appetite in young, healthy adults. Sleep restriction is associated with impairment of carbohydrate tolerance, and research has shown that a loss of 3 hours of sleep each night causes a weight gain of 4-5%.

It’s estimated that between 50-60% of Americans are dieting at any given time. That’s a huge number. And while it may seem counter-intuitive that dieting contributes to obesity and diabetes, it makes perfect sense when you understand that dieting is a stressor that disrupts our cortisol rhythm.

A 2001 study showed that “cognitive dietary restraint” (translation: stressing about food or doing overly restrictive diets) raises your cortisol levels. Studies have also shown that caloric restriction – as is common in low-fat diets – increases cortisol levels. And a recent study reported on by Stephan Guyenet at Whole Health Source found that caloric restriction is especially harmful when combined with sleep deprivation.

Finally, although not common in the general population, too much exercise can also predispose you to weight gain and diabetes by raising cortisol levels, breaking down muscle tissue and increasing fat storage. This is especially true if cortisol levels are already elevated or disrupted by other stressors like gut infections, insomnia, food toxins or psychological factors.

It’s not uncommon (in the paleo/fitness subculture, at least) to encounter someone who eats well and exercises their brains out, but cannot lose weight. In fact, several of my patients fall into this category. They are often surprised when I tell them they need to exercise less if they want to lose weight and recover their health. What they may not realize is that cortisol is a catabolic hormone. It breaks the body down.

While this might sound like a good thing for those trying to lose weight, it’s not. Muscle tissue is metabolically active and actually helps us lose weight. A reduction of lean muscle tissue may drop a few pounds in the short-term, but it will predispose you to weight gain in the future by impairing your metabolism. (This is another reason why caloric restricted diets, which break down muscle tissue, don’t work in the long-term and even make things worse.)

So if you’re struggling with weight or blood sugar control, don’t diet, get plenty of sleep and take it easy with exercise. You’ll be a lot better off.

We’ve already talked about how blood sugar imbalances and poor gut health can lead to hypothyroidism and Hashimoto’s. The harmful effects of adrenal stress complete the triad.

The adrenals are two walnut-shaped glands that sit atop the kidneys. They secrete hormones – such as cortisol, epinephrine and norepinephrine – that regulate the stress response. But these hormones play other crucial roles, many of which are directly related to thyroid health. In fact, as we’ll see in this article, proper thyroid function depends on healthy adrenal glands.

Most people are aware of the obvious forms of stress that affect the adrenal glands: impossibly full schedules, driving in traffic, financial problems, arguments with a spouse, losing a job and the many other emotional and psychological challenges of modern life.

But other factors not commonly considered when people think of “stress” place just as much of a burden on the adrenal glands. These include blood sugar swings, gut dysfunction, food intolerances (especially gluten), chronic infections, environmental toxins, autoimmune problems and inflammation. All of these conditions sound the alarm bells and cause the adrenals to pump out more stress hormones. In this context, stress is broadly defined as anything that disturbs the body’s natural balance (homeostasis).

Adrenal stress is probably the most common problem we encounter in functional medicine, because nearly everyone is dealing with at least one of the factors listed above. Symptoms of adrenal stress are diverse and nonspecific, because the adrenals affect every system in the body. But some of the more common symptoms are:

• Fatigue
• Headaches
• Decreased immunity
• Difficulty falling asleep, staying asleep and waking up
• Mood swings
• Sugar and caffeine cravings
• Irritability or lightheadedness between meals
• Eating to relieve fatigue
• Dizziness when moving from sitting or lying to standing
• Gastric ulcers

Weak adrenals can cause hypothyroid symptoms without any problem in the thyroid gland itself. In such cases, treating the thyroid is both unnecessary and ineffective, and addressing the adrenals themselves is the key to improving thyroid function.

The most significant indirect effect the adrenals have on thyroid function is via their influence on blood sugar. High or low cortisol – caused by any of the chronic stressors listed above – can cause hypoglycemica, hyperglycemia or both. And as we saw in a previous article, blood sugar imbalances cause hypothyroid symptoms in a variety of ways.

But adrenal stress also has more direct impacts on thyroid function. The following five mechanisms are the most important.

1) Adrenal stress disrupts the HPA axis

By now many people have heard of the hypothalamic-pituitary-adrenal (HPA) axis. It’s a complex network of interactions between the hypothalamus, the pituitary and the adrenal glands that regulates things such as temperature, digestion, immune system, mood, sexuality and energy usage – in addition to controlling the body’s reaction to stress and trauma.

Countless studies show that chronic adrenal stress depresses hypothalamic and pituitary function. And since these two organs direct thyroid hormone production, anything that disrupts the HPA axis will also suppress thyroid function.

Studies have shown that the inflammatory cytokines IL-1 beta, IL-6 and TNF-alpha, which are released during the stress response, down-regulate the HPA axis and reduce levels of thyroid stimulating hormone (TSH). Another study showed that one single injection of tumor necrosis factor alpha (TNF-alpha), an inflammatory peptide, reduced serum TSH, T3, free T4, free T3 and hypothalamic TRH for 5 days. TNF-alpha was also found to decrease the conversion of T4 to T3, reduce thyroid hormone uptake, and decrease the sensitivity of the thyroid to TSH.

2) Adrenal stress reduces conversion of T4 to T3

We discussed under-conversion of T4 to T3 in a prior article. Remember that although 93% of the hormone produced by the thyroid gland is T4, it is inactive in that form and must be converted into T3 before it can be used by the cells. The inflammatory cytokines I listed above not only disrupt the HPA axis, they also interfere with the conversion of T4 to T3.

The enzyme 5′-deiodinase catalyzes the conversion of T4 into T3 in peripheral tissues such as the liver and the gut. Both Th1 and Th2 inflammatory cytokines – IL-6, TNF-alpha, IFN-gamma and IL-1 beta – have been shown to suppress the conversion of T4 to T3. In patients without thyroid illness, as levels of IL-6 (a marker for inflammation) rise, levels of serum T3 fall. And injections of inflammatory cytokines into healthy human subjects resulted in a rapid reduction of serum T3 and TSH levels, and an increase in the inactive reverse T3 (rT3) form, while T4 and free T4 levels were only minimally changed.

3) Adrenal stress promotes autoimmunity by weakening immune barriers

The GI tract, lungs and the blood-brain barrier are the primary immune barriers in the body. They prevent foreign substances from entering the bloodstream and the brain. Adrenal stress weakens these barriers, weakens the immune system in general, and promotes poor immune system regulation.

As we discussed in my previous article on the gut-thyroid connection, when these immune barriers are breached large proteins and other antigens are able to pass into the bloodstream or brain where they don’t belong. If this happens repeatedly, the immune system gets thrown out of whack and we become more prone to autoimmune diseases – such as Hashimoto’s.

4) Adrenal stress causes thyroid hormone resistance

In order for thyroid hormone circulating in blood to have a physiological effect, it must first activate receptors on cells. Inflammatory cytokines have been shown to suppress thyroid receptor site sensitivity.

If you’re familiar with insulin resistance, where the cells gradually lose their sensitivity to insulin, this is a similar pattern. It’s as if the thyroid hormone is knocking on the cell’s door, but the cells don’t answer.

While there’s no practical way to measure receptor site sensitivity in a clinical setting, the research above suggests it is decreased in autoimmune and other inflammatory conditions. A perfect example of this in practice is the Hashimoto’s patient who is taking replacement hormones but still suffers from hypothyroid symptoms – often in spite of repeated changes in the dose and type of medication. In these patients, inflammation is depressing thyroid receptor site sensitivity and producing hypothyroid symptoms, even though lab markers like TSH, T4 and T3 may be normal.

5) Adrenal stress causes hormonal imbalances

Cortisol is one of the hormones released by the adrenals during the stress response. Prolonged cortisol elevations, caused by chronic stress, decrease the liver’s ability to clear excess estrogens from the blood. Excess estrogen increases levels of thyroid binding globulin (TBG), the proteins that thyroid hormone is attached to as it’s transported through the body.

When thyroid hormone is bound to TBG, it is inactive. It must be cleaved from TBG to become “free-fraction” before it can activate cellular receptors. (These free-fraction thyroid hormones are represented on lab tests as “free T4 [FT4]” and “free T3 [FT3]“.)

When TBG levels are high, the percentage of free thyroid hormones drops. This shows up on labs as low T3 uptake and low free T4/T3.

Aside from adrenal stress, the most common causes of elevated TBG secondary to excess estrogen are birth control pills and estrogen replacement (i.e. Premarin).

Balancing the adrenals

Here’s the tricky thing about adrenal stress: it’s almost always caused – at least in part – by something else. These causes include anemia, blood sugar swings, gut inflammation, food intolerances (especially gluten), essential fatty acid deficiencies, environmental toxins, and of course, chronic emotional and psychological stress.

When they exist, these conditions must be addressed or any attempt to support the adrenals directly will either fail or be only partially successful. With that in mind, here are some general guidelines for adrenal health:

• Avoid or at least greatly minimize stimulants
• Stabilize blood sugar (via a moderate or low-carb diet)
• Practice stress management and relaxation techniques
• Have fun, laugh and make pleasure a regular part of your life
• Avoid dietary causes of inflammation (refined flours, high-fructose corn syrup and industrial seed oils in particular)
• Ensure adequate intake of DHA & EPA

Specific nutrients such as phosphatidyl serine and adaptogenic botanicals like Panax ginseng, Siberian ginseng, Ashwagandha and Holy basil leaf extract are also helpful in modulating the stress response and supporting the adrenals. However, these are potent medicines and should be taken under the supervision of a trained practitioner.

Excerpted from Sciencedaily.com, 9/4/08

In an effort to better understand how chronic stress affects the human body, researchers at the Yerkes National Primate Research Center and the Department of Psychiatry and Behavioral Sciences, Emory University, have created an animal model that shows how chronic stress affects behavior, physiology and reproduction.

According to lead researcher Mark Wilson, PhD, chief of the Division of Psychobiology at Yerkes, “Chronic stress can lead to a number of behavioral changes and physical health problems, including anxiety, depression and infertility.”

Via the animal model, the researchers found corticotropin releasing factor (CRF) is a key neurohormone involved in stress response. Wilson explains, “CRF is located in several different brain regions, serving different functions. Its release is important for our ability to adapt to every day stressors and to maintain our physical and emotional health.”

In response to stress, CRF levels rise; CRF levels decrease when the stressor no longer is present. Chronic stress, however, increases the length and volume of expression of CRF in areas of the brain associated with fear and emotion, including the amygdala. Such chronic stress changes the body’s response, and the resulting increased expression of CRF is thought to be the cause of such health-related stress problems including anxiety, depression and infertility.

In Part I and Part II of this series, we examined drug-free alternatives to treating depression including exercise, psychotherapy, light therapy, St. John’s Wort and acupuncture. We have learned that all of these treatments are at least as effective as antidepressants in the short term, and some (exercise and psychotherapy) are more effective in the long-term. All of these treatments have far fewer side effects, risks and complications than antidepressants. In fact, the only “side effects” of exercise and psychotherapy are positive ones: improved physiological and mental health!

Today we will look at other lifestyle-based approaches to treating depression without drugs. As I mentioned in the previous article, because 70% of research is funded by drug companies, many of these non-drug approaches have not been studied as extensively as antidepressant medication.

Nevertheless, there is enough data from clinical and epidemiological studies to support the following strategies – especially since they are superior to antidepressants from a “cost/risk – benefit” analysis. In other words, though some of the approaches I will propose in this article have not been exhaustively proven according to the standards of Western science, there are several lines of evidence supporting their effectiveness and without exception they have beneficial side effects and improve the quality of patient’s lives.

What’s more, all of these approaches can be combined together along with the treatments mentioned in the two previous articles to obtain the maximum effect. Based on the available evidence which we have extensively reviewed, these non-drug treatments should without a doubt be the first line of defense (as well as the second, third, fourth, etc.) in treating depression.

Nutrition

At some point in the future, I hope to dedicate an entire post (or perhaps more) to the subject of nutrition and depression. I personally believe that inadequate nutrition is a significant contributing factor to the continuously rising rates of depression in this country. Consequently, I also believe that proper nutrition can be one of the most effective treatments for depression.

For now, I will go over what I feel are the most important aspects of nutritional causes and treatment of depression, and hopefully address the subject in more detail later.

SUGAR

Diabetes is correlated with higher rates of depression. In 2005, researchers discovered a positive connection between higher levels of insulin resistance and severity of depressive symptoms in patients with impaired glucose tolerance, before the occurrence of diabetes. Based on these findings, it was suggested that insulin resistance could be the result of an increased release of counter-regulatory hormones linked to depression; however, this has not been confirmed.

Sugar can increase fasting levels of glucose and can cause reactive hypoglycemia. Sugar can also cause a decrease in your insulin sensitivity thereby causing an abnormally high insulin levels and eventually diabetes. Based on the study results above, this is one mechanism by which sugar could contribute to depression.

There is no doubt that increased sugar intake leads to hormonal changes that can lead to emotional instability. Therefore, people who are depressed (and all people, in fact) should significantly decrease their sugar consumption.

OMEGA-6 / OMEGA-3 RATIO

Anthropological evidence suggests that the intake of omega-6 (n-6) and omega-3 (n-3) polyunsaturated fatty acids (PUFA) during the Paleolithic era was roughly equal, whereas the present n-6 to n-3 PUFA in western countries has ben estimated to be between 10 and 25 to 1. The n-6 to n-3 PUFA imbalance has been due mainly to the increase in vegetable and seed oil use and the rise in consumption of processed foods (which contain these oils).

Two major studies have provided direct evidence for the role of the n-6 to n-3 PUFA ratio in depression. The studies found that depression is associated with significantly decreased total n-3 PUFA and increased n-6 to n-3 PUFA ratio (Maes et al. 1996; Maes et al. 1999) . A supporting study carried out in 1998 also found a significant depletion in total n-3 PUFA, and in particular DHA, in the erythrocyte membranes of depressed patients.

Epidemiological data show the trend in decreasing dietary n-3 PUFA consumption and the increasing evidence of depression, both over time and between nations (Hibbeln et al. 1995). Further investigation suggests that the significance lies in the increase in n-6 to n-3 ratio, rather than simply low n-3 intake alone, as these two fatty acids compete in binding to enzyme systems that produce chain elongation and further desaturation. A diet high in n-6 fatty acids prevents the incorporation of n-3 PUFA into cell membranes and phospholipids (Spector et al. 1985).

All polyunsaturated fatty acids – including n-3 PUFA – have been shown to make lipoproteins more vulnerable to oxidative damage (Reaven et al. 1991), and oxidative damage is a significant risk factor for heart disease, cancer and many other conditions. As mentioned above, n-6 consumption actually prevents the incorporation of n-3 into our cells. Therefore, rather than increasing our consumption of n-3 PUFA to treat depression, as is often suggested, it makes more sense to dramatically decrease our consumption of n-6 PUFA. This will help our bodies to incorporate the small, but adequate amount of n-3 PUFA we get in a whole-foods based diet. Avoiding n-6 PUFA (primarily found in vegetable and seed oils, and in animals fed vegetables high in n-6 like pigs and chickens) will not only alleviate depression, but also benefit our health in many other ways.

VITAMIN D

In a 1998 controlled experiment, Australian researchers found that vitamin D (400 and 800 IU), significantly enhanced positive affect when given to healthy individuals. Forty-four subjects were given 400 IU cholecalciferol, 800 IU cholecalciferol, or placebo for 5 days during late winter in a random double-blind study. Results on a self-report measure showed that vitamin D3 enhanced positive affect a full standard deviation and there was some evidence of a reduction in negative affect. The authors concluded: “vitamin D3 deficiency provides a compelling and parsimonious explanation for seasonal variations in mood” (Landsdowne & Provost, 1998).

In another study in 1999, the vitamin D scientist, Bruce Hollis, teamed up with Michael Gloth and Wasif Alam to find that 100,000 IU of vitamin D given as a one time oral dose improved depression scales better than light therapy in a small group of patients with seasonal affective disorder. All subjects in the vitamin D group improved in all measures and, more importantly, improvement in 25(OH)D levels levels was significantly associated with the degree of improvement (Gloth et al. 1999).

According to the Vitamin D Council:

If you suffer from depression, get your 25(OH)D level checked and, if it is lower than 35 ng/mL (87 nM/L), you are vitamin D deficient and should begin treatment. If you are not depressed, get your 25(OH)D level checked anyway. If it is lower than 35 ng/mL (87 nM/L), you are vitamin D deficient and should begin treatment.

Recommended intake is up to 5,000 IU per day of vitamin D through exposure to sunshine and/or supplementation. See this article on vitamin D to learn to calculate how much vitamin D is produced given a certain amount of exposure to sunlight, and to learn more about vitamin D supplementation. It is important to remember that D works synergistically with A & K2, so if you increase your intake of D you must also increase your intake of A & K2 to avoid D toxicity.

Finally, I’d like to share with you a comment I received from a reader about how he/she has cured depression with nutritional intervention. Note that I endorse just about every suggested step, with the exception of the significant increase in n-3 intake. Based on the evidence above, I suspect that his/her improvement was a result of the decrease in n-6 PUFA more than it was the increase in n-3 PUFA.

Following the reader’s advice will not only relieve depression, it will dramatically improve all aspects of your physical, emotional and mental health.

Adequate sleep and rest

Recent studies have definitively linked insomnia with depression and increased suicidal behavior. A research abstract that was presented on June 12 at SLEEP 2008, the annual meeting of the Associated Professional Sleep Societies, found a link between poor sleep and suicidal behavior among children and adolescents with depressive episodes. 83.8% of the depressed patients in the study had sleep disturbances, and there was a significant association between suicidal behavior and the presence of sleep complaints.

Another recent study confirmed the persistent nature of insomnia and the increased risk of subsequent depression among individuals with insomnia. According to the study, 17% – 50% of subjects with insomnia lasting just two weeks or longer developed a major depressive episode reported in a later interview.

Other research has indicated that insomnia can cause depressed mood and adversely affect endocrine function (Banks 2007).

Most Americans are chronically sleep deprived. The foundation’s 2001 national “Sleep in America” poll reported that almost seven out of 10 Americans experienced frequent sleep problems, and that most were undiagnosed. The same poll in 2003 found that 67 percent of older adults had frequent sleep problems and only one in eight had been diagnosed.

This alone could explain the epidemic increase in depression over the last several decades. But when sleep deprivation is added to other factors such as increased intake of n-6 PUFA, increased stress, the use of antidepressant drugs, the breakdown of family, community and other social support structures, it isn’t difficult at all to understand why so many of us are depressed.

The American Academy of Sleep Medicine (AASM) offers the following tips on how to get a good night’s sleep:

• Follow a consistent bedtime routine.
• Establish a relaxing setting at bedtime.
• Get a full night’s sleep every night.
• Avoid foods or drinks that contain caffeine, as well as any medicine that has a stimulant, prior to bedtime.
• Keep computers and TVs out of the bedroom.
• Do not go to bed hungry, but don’t eat a big meal before bedtime either.
• Avoid any rigorous exercise within six hours of your bedtime.
• Make your bedroom quiet, dark and a little bit cool.
• Get up at the same time every morning.

Stress Management

An increasing amount of evidence (along with common sense) indicates that chronic stress directly contributes to depression. Please see my recent article for more information about this.

I am not aware of any well-designed clinical trials examining the effects of stress reduction on depression. However, logic dictates that since stress is a cause of and contributing factor to depression, managing stress is an important aspect of treating depression.

One study published in 1995 showed that meditation can improve mood. Another small study demonstrated that mindfulness-based cognitive therapy (MBCT) significantly improved depression and reduced relapse. A series of studies and case studies have shown that biofeedback can also be effective for depression and mood disorders.

The reality is that there are many ways to manage and reduce stress, from yoga to meditation to mindfulness-based stress reduction to progressive relaxation techniques. The important thing is not which method you choose, but that you commit to something and do it on a regular basis.

Prayer & Spiritual Practice

You’re not going to see much scientific research into the role of prayer and spiritual practice in treating depression. Nevertheless, for as long as people have been “depressed” they have used their relationship with God, nature, a “higher power” or whatever guiding principles they embrace to get through difficult times.

People who are depressed often feel isolated, alienated or alone. A strong faith in God or in the interconnectedness of all life can re-establish a sense of belonging and support. Prayer and spirituality can also re-frame the depression one is experiencing in a larger and less “personal” context.

In my previous article called The Heart of Depression, we examined how cultural, religious and spiritual beliefs in these traditional societies provide a context in which symptoms of depression and other mental illness can be understood outside of the label of medical disease or pathology. Possession and rites of passage are two examples of such contexts.

The words and labels we use to “frame” our experience have tremendous power. In the U.S. today, depression is viewed as a sickness that must be cured, as a pathology, as a “biological disease”. There is little doubt that the people who seek treatment for depression are suffering. But should psychological and emotional suffering always be viewed as “something to get rid of”?

Great religious and spiritual traditions from around the world view suffering as an avenue to greater understanding of oneself, life and God. Suffering can be viewed as a signal drawing our attention to issues in our life that need to be addressed.

Spirituality and prayer can help people who are suffering to understand their experience in a more empowering and self-validating context than what is offered by mainstream medicine. When one views their suffering as an opportunity for growth and evolution, rather than as a disease requiring treatment with drugs, it is far more likely that lasting, positive change will occur.

In the next and final article (for a while, at least) in my series on depression and antidepressants, I will summarize everything we’ve covered so far and offer my recommendations for treating depression holistically.

In the first article in this three-part series on treating depression without drugs, we established that several non-drug treatments are at least as effective in treating depression than antidepressants – with few, if any of their side effects. Specifically, we learned that both psychotherapy and exercise compare favorably with antidepressants for treating even serious depression in the short-term, and are both more effective than antidepressants in the long-term.

Today we will examine three other drug-free treatments for depression: light therapy, St. John’s Wort and acupuncture. In the final article, we will look at lifestyle-based treatments such as nutrition, adequate sleep and rest, stress management, pleasure and bibliotherapy (prayer or spiritual practice).

Light Therapy

Researchers at the National Institute for Mental Health are credited for the idea that perhaps more people are apt to become depressed during dark, dreary winter days than on bright, crisp spring days because they are not getting enough light. Since then, people around the world have begun to use “light therapy” to overcome Seasonal Affective Disorder. However, light therapy is also being used to successfully treat major depression at any time of the year.

Beginning the day sitting in front of a fluorescent light box that typically emits about 10,000 lux units of light has helped many people who might otherwise struggle with depression throughout the day. Bright light has been shown by numerous studies to act as a specific antidepressant in depressed patients. In a recent meta-analysis of published studies on light therapy and depression which appeared in the April 2005 issue of the American Journal of Psychiatry, the authors found that bright light treatment for nonseasonal depression is efficacious, with effect sizes equivalent to those in most antidepressant studies.

Once again, as was the case with both exercise and psychotherapy, the combining light therapy with antidepressants was no more effective than light therapy alone.

In contrast to exercise and psychotherapy, bright light therapy does occasionally have some side effects, including headache, eye strain, nausea and agitation. But these are very mild when compared against the side effect profile of antidepressants.

It is very important to note that some psychotropic medication (and psychotropic herbs such as St. John’s Wort) may increase sensitivity to light, so light therapy should probably not be combined with St. John’s Wort or antidepressants.

Some critics of light therapy have pointed out that it could be a placebo and there is no way to prove otherwise. It is not possible to keep someone from knowing whether they are being exposed to very bright light or the placebo (dim light). Therefore the “blind” is broken and patients will know whether they are receiving the active or “inert” treatment. Could it be that the positive effects of bright light are simply due to the assumption or expectation of the patients that they will improve, rather than a result of the bright light itself?

Sure it is. But perhaps a more important question is, “does it matter?” If we use Antonuccio’s criteria for evaluating a potential treatment (i.e. 1) first do no harm, 2) cost-benefit analysis) then it becomes clear that light therapy compares very favorably with antidepressants even if it is “merely a placebo”. As you will know if you’ve been following my blog, antidepressants could also be referred to as placebos because they have been shown to be no more effective than placebo in treating depression. The criteria for whether a drug gets approved or not by the FDA is that it must outperform placebo; otherwise, it is simply considered a placebo itself.

Although light therapy may have some side effects, they pale in comparison to those of antidepressants and, unlike antidepressants, light therapy poses no significant risks or long-term complications. A typical light therapy device costs between $200-$300, so over the long-term it is much more cost-effective than medication. Finally, light therapy is just as effective as pharmacotherapy for treating depression.

When all of this is taken together, light therapy is superior to antidepressants – even if it is a placebo.

St. John’s Wort

St. John’s Wort (Hypericum) is an herb that can be used to make tea, or the “active ingredients” with the herb that can be extracted and put into capsules. In Europe SJW is widely prescribed as an antidepressant, but in the U.S., it is available over-the-counter.

St. John’s Wort has repeatedly been shown to work as well as or better than antidepressants in double-blind, placebo-controlled studies. For example, compared to Paxil, depression scores fell more (56.6% vs. 44.8%) and side effects were less (Szegedi et al. 2005). Similar results were found for Prozac (Schulz 2002). A comparison with both Zoloft and Celexa found St. John’s Wort again performed as well as the antidepressant drug without as many side effects (Gastpar 2005; Gastpar 2006).

While St. John’s Wort is clearly as effective as antidepressants, the number of adverse effects is ten times less – being essentially equivalent to taking a placebo. The most common adverse events (1 per 300,000 treated cases) concern reactions of the skin exposed to light (due to potential increased photosensitivity caused by SJW and other psychotropic substances).

Please do note that St. John’s Wort is contraindicated for concurrent use with certain medications, including antidepressant drugs, coumarin-type anticoagulants, the immunosuppressants cyclosporine and tacrolimus, protease and reverse transcriptase inhibitors used in anti-HIV treatment and with certain antineoplastic (cancer) agents.

However, these potential interactions can be easily avoided with proper supervision from a health-care professional who is experienced with the use of St. John’s Wort.

Once again, to be accurate we must point out the possibility that St. John’s Wort is merely a placebo. If it is roughly as effective as antidepressants, and antidepressants are themselves placebo, then it follows that St. John’s Wort may also be a placebo. However, the same analyses that we used for light therapy applies here. The question is, how does St. John’s Wort compare against the primary treatment for depression – antidepressants? As we have seen, SJW is just as effective as antidepressants with only a fraction of the side effects, so there is absolutely no reason not to choose it over a synthetic antidepressant.

Before we move on to acupuncture, nutrition, rest and other lifestyle-based treatments for depression, I want to briefly discuss the criteria we’ve used so far for evaluating the effectiveness of a treatment. As I’m sure you’ve noticed, I am primarily basing the determination of the effectiveness (or lack thereof) of a treatment on well-designed, placebo-controlled, double-blind scientific studies.

I obviously have great respect for this method of inquiry and it has led (and continues to lead) to many important advances in medicine. However, it must be pointed out that this standard of proof has limitations. For example, 2/3 of medical research is funded by pharmaceutical companies. This means that the lines of investigations most often pursued in scientific research are those that are likely to lead to new therapies that can be monetized by the drug companies. There is little incentive for a drug company to dedicate research dollars to a study on how nutrition affects depression, unless there’s a product they can imagine marketing based on the study results. The result is that there are relatively few studies evaluating the effect of nutritional intake on depression.

Another limitation of double-blind, placebo-controlled research is that it is difficult (if not impossible) to maintain that standard with treatment modalities that depend on the unique interaction that happens between a practitioner and a patient. Western science is often skeptical, of course, that this interaction that occurs influences the treatment in any way. They do not understand how the interaction could influence the treatment, and what Western science does not understand, is often dismissed as “new-age fluff”.

What is remarkable about this is not just the arrogance of such a position, but also the ignorance it demonstrates. Over the last two decades, research into the placebo effect and growing understanding of how the nervous, endocrine and immune systems are inter-related have proven beyond a shadow of a doubt – according to the most rigorous Western scientific standards – that the interaction between a doctor or clinician and their patient absolutely influences the outcome of the treatment. In fact, many studies have shown that this interaction may be more important than the treatment itself; or, perhaps more accurately, the interaction is the treatment.

With this in mind, it becomes clear that the efficacy of acupuncture as a treatment for depression – or anything else – can never be accurately measured in a double-blind, placebo-controlled study. As much as Western science hates to admit this, we are not machines that respond in entirely an predictable manner given the same circumstances. There is no way to “standardize” the interaction that happens between an acupuncturist (or any healing professional) and a patient, because each person and, therefore, each relationship is unique.

Acupuncture

Considering all of the caveats above, can acupuncture help with depression? According to the Cochrane Database Systematic Review (the gold standard for medical research reviews today), “there is no evidence that medication was better than acupuncture in reducing the severity of depression.” In many of the studies they reviewed, acupuncture and electro-acupuncture either cured or remarkably improved depression scores, performing just as well as synthetic antidepressants.

However, it must also be noted that the studies were few in number, often poorly designed and did not have enough subjects to draw definitive conclusions. The authors of the review concluded that there was “insufficient evidence to determine the efficacy of acupuncture compared to medication”.

And of course, we always have the issue of placebo. It is possible that the benefit the patients are receiving comes from the interaction with the practitioner and their expectation that they will improve – rather than as a result of the needles themselves.

Once again, though, if we evaluate acupuncture based on a “cost-benefit” analysis, it compares very well against antidepressants. It has been shown to be at least as effective as medication in many studies as noted above, and the side effects are minimal when compared with antidepressants. Acupuncture has also been shown to be effective in treating other conditions that may occur alongside of depression, such as pain and stress.

Stay tuned for the third-part of this series which will consider lifestyle-based treatments such as nutrition, adequate sleep and rest, stress management, pleasure and prayer.

In the last few articles in my series on antidepressants and depression, I have presented evidence demonstrating that – despite popular belief – depression is not caused by a deficiency of serotonin in the brain.

However, this of course does not suggest that depression is completely divorced from biochemical processes in the body. The brain is a “living orchestra” of complex, interconnected systems that are in continuous relationship with one another. Everything from the food that we eat to the chemicals we’re exposed to in our environment to the hormones we produce effects the functioning of the brain.

This will likely come as no surprise to you. It’s simply common sense. But as you may have noticed, in the world of scientific research common sense must first be proven according to the established standards of scientific proof before it is accepted.

Such has been the case with the link between stress and depression. I’ll wager that if I asked ten people on the street whether chronic stress caused depression, probably all ten of them would say “yes”. However, scientific proof of the causal link between chronic stress and depression has only begun to emerge over the past few years. It has been known for much longer that depressed people have elevated levels of cortisol (an indicator of chronic stress), but it was not known whether those elevated levels were the result or cause of depression.

In 2006 Ardyfio & Kim published a study indicating that chronic hypercortisolemia (elevated cortisol levels in the blood) causes anxiety-related behavior in mice. These results suggest that elevated cortisol levels may contribute to the symptom profile of depression rather than simply being a consequence of it.

Ardyfio & Kim’s study also confirmed the results of other studies which suggest that while acute stress is adaptive (helps us adjust to our changing circumstances), chronic stress has detrimental effects on the brain and behavior. Indeed, chronic stress has been linked to a wide variety of modern diseases, including (but not limited to) heart disease, cancer, diabetes, autoimmune disease, irritable bowel syndrome and fibromyalgia.

In a more recent study published in 2007, work stress was demonstrated to precipitate diagnosable depression and anxiety-related disorders in previously healthy, young individuals. The authors point out that stressful work conditions predict poor mental health, and that currently as many as 40% of people are exposed to work stress. (That’s funny, I would have thought the number to be closer to 100%).

The relationship between psychological job demands and the risk of depression and anxiety was graded; in study members exposed to high psychological job demands the risk was two times higher than in those with low demands. The combination of multiple work stressors conferred an even higher risk, especially in men.

Once again, this probably does not come as a surprise to you. It makes sense that high stress at work may cause depression and anxiety. But, believe it or not, this is relatively recent news to the mainstream scientific establishment.

Finally, in a study published today, researchers have shown how cortisol (one of the stress hormones) regulates brain neurotransmission in both the short and long term and enables neuronal connections to adapt.

In the short term, cortisol increases the mobility of receptors found on the surface of neurons, thus allowing synaptic connections to adapt more effectively to the demands of brain activity. The stress hormone might be considered as an “alarm” that mobilizes the receptors for action. This behavior is adaptive, as it helps the organism (us) prepare and mobilize for action when faced with stress (a threat).

However, in the case of prolonged stress (which is the type of stress most prevalent in modern life) cortisol actually reduces synaptic plasticity. Lack of receptor mobility contributes to a lack of adaptation, which of course, is bad news for us.

The relevance to all of these studies to our recent discussion about depression and its treatment is this: stress is likely a significant contributing factor to depression for most people, and stress-management should play an important role in the treatment of depression.

Stress-management strategies are drug-free, non-invasive, cost-effective and have a wide range of beneficial “side effects” such as happiness, relaxation, improved sleep, more energy, improved libido, increased productivity, and protection from the legion of diseases that have been linked to stress.

In short, there is absolutely no reason not to include stress management in your treatment regimen for depression, or in your daily life even if you are currently healthy and free of disease.

There are many ways to reduce stress, including meditation, prayer, gentle movement (yoga, tai chi, Feldenkrais), exercise, deep relaxation techniques, spending time in nature, listening to music. What’s most important is that you find something that works for you and stick with it.

Mindfullness-Based Stress Reduction (MBSR), created by Dr. Jon Kabat-Zinn, is a very successful approach that has been clinically proven in well-designed studies to reduce pain and stress and improve health. I recommend his book Full Catastrophe Living, as well as the CD recordings of the techniques.

I also recommend a system of gentle movement and breathing exercises called “mini-moves”. Although they are marketed as a treatment for insomnia, the creator (Michael Krugman) of the system believes (quite correctly) that the best way to cure insomnia is to manage daytime stress successfully. You can download the “Secrets of Sounder Sleep” audio here. They are very simple and can be performed in as little as 5-15 minutes at a time.

I’ve used both of these systems myself with great success.

Next week will be the final article in the depression series (for now): drug-free alternatives to treating depression. Until then…

There’s no doubt that optimal nutrition plays a significant role in supporting our health and well-being. But nutrition, as important as it is, obviously isn’t the only factor that influences our physiology.

Over the past several years, an increasing amount of research has focused on the role of emotions, behavior and beliefs in contributing to both health and disease. In fact, an entirely new discipline called “psychoneuroimmunology” (say that three times fast!) has emerged to study the connection between the mind and the body. In short, what has been revealed is that the separation we make between “the mind” and “the body” is largely an illusion. Mind and body exist in a continuous and interrelated web of connections that is only now beginning to be discovered by western science.

But though the idea that our thoughts and emotions can directly influence our physiology is new to modern biomedicine (just ten years ago it was dismissed by most physicians and researchers as so much “New Age” fluff), it has been deeply ingrained in our cultural paradigm for centuries. It is embedded in our language; consider the phrases “worried sick” or “scared to death”, and you’ll know what I mean. I’m sure all of you have had the experience of becoming ill after a particularly stressful period at work, or feeling moody and perhaps depressed while you are physically ill. These are both prime examples of how interconnected our mental and emotional health is.

In their book Feeling Good Is Good For You, researchers Carl J. Charnetski and Francis X Brennan set out to review the emerging evidence that pleasure can boost our immune systems and lengthen our lives. According to the authors,:

If stress is the antithesis of pleasure, then it follows that pleasure is the antithesis of stress. And the best way to fight stress, say Charnetski and Brennan, is with pleasure. Our bodies secrete chemicals called endorphins when we experience pleasure. Animal research has revealed, for example, that endorphin levels are up to 86 times higher after animals experience multiple orgasms! But endorphins are also released, albeit at lower levels, in more mundane daily activities such as playing with a pet, watching a funny movie, listening to our favorite music, visiting a favorite place or connecting with loved ones.

The chemicals released when we experience pleasure do more than counteract stress hormones and improve mood. Consider these additional effects:

• They improve immune function by producing an antibacterial peptide
• They enhance the killer instincts and abilities of various immune components, including B cells, T cells, NK cells, and immunoglobulins.
• They enable certain immune cells to secrete their own endorphins as a way of improving their disease-fighting capacity

Charnetski and Brennan examine several “pleasure inducing” experiences that have been scientifically proven to promote health and well-being.

• Music
• Touch
• Pets
• Humor
• Positive attitude and insight

Most of us are already aware of the healing power of those things listed above – at least on some level. But in this culture, there is also an overwhelming reliance on medicine, surgery, diet and other physiological interventions to treat disease. Though we may pay lip service to the idea that stress causes illness and pleasure can prevent it, how many of us actually attribute the same importance to listening to music or watching a funny movie as we do to taking a pill? The lesson in this book is that our thoughts, beliefs, emotions and behavior are all capable of inducing the same physiological changes in our bodies as foods, supplements, pills and even surgery are.

If you doubt that this is true, consider the placebo effect. It has been proven over and over again that pharmacologically inert substances like sugar pills can have identical or even greater therapeutic effects than drugs in certain cases. Even more impressive are the trials that have shown that sham surgery (when small incisions are made to convince the patient they have had the operation, but no surgery is performed) is at times as effective as the actual surgery.

Clearly this points to the power we all have to heal ourselves. If only the suggestion or belief that we will heal is enough to induce the physiological changes that lead to healing, without the presence of any “active” pharmacological substance or surgical intervention, then clearly our thoughts, beliefs and emotions have the potential to be powerful medicine.