RHR: Addressing Complex Chronic Illness, with Sunjya Schweig

In this episode, we discuss:

• The increasing rates of complex chronic illnesses, including autoimmune, Lyme and other tick-borne diseases, and long-haul COVID
• How the journey of people living with chronic illness is often invisible to others
• What struggles the conventional medical system faces in properly addressing complex chronic illness 
• Why Functional Medicine is a better approach to identifying and treating these conditions
• How the California Center for Functional Medicine and the Functional Medicine Research and Technology Center are working to change the patient experience and transform the lives of people with chronic illness

Show notes:

• California Center for Functional Medicine website
• Functional Medicine Research and Technology Center website
• The Invisible Kingdom: Reimagining Chronic Illness by Meghan O’Rourke
• The Lady’s Handbook for Her Mysterious Illness by Sarah Ramey

Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. Six in 10 Americans suffer from a chronic disease, and four in 10 Americans suffer from multiple chronic diseases. And these numbers are fairly similar in other industrialized countries around the world. But they don’t reflect the growing percentage of Americans who suffer from complex chronic illness. These are conditions like Lyme disease, autoimmunity, chronic inflammatory response syndrome, mold illness, chronic fatigue syndrome, fibromyalgia, long COVID, and so many others.

I wanted to invite Dr. Sunjya Schweig on the show to discuss this topic with me. As you may know, I co-founded [the] California Center for Functional Medicine (CCFM) with Dr. Schweig in 2014, and we ran that clinic together for many years until I left to pursue other opportunities a couple of years ago. Dr. Schweig has continued to run and grow CCFM. It’s one of the largest Functional Medicine clinics on the West Coast. He has a wealth of experience in treating complex chronic illness, [and] in particular, Lyme disease. It’s an area that he specialized in for many years. As you’ll learn on the show, his wife suffered from Lyme disease and was diagnosed with it shortly after Sunjya finished his residency in Santa Rosa. He has specialized in treating patients with Lyme [disease] for many years, and [it’s] a prime example of a complex chronic illness that is not well-served by the traditional medical system.

We talk about the shortcomings of the conventional approach to these kinds of conditions [and] why so many people who suffer from them feel invisible, both in terms of [how] these conditions are often under the surface and not visible to people in the outside world, and also [how] the lab results often don’t reflect what’s really going on under the surface. That can be incredibly frustrating and challenging for people that are dealing with them. We talk about how the Functional Medicine model differs when it comes to looking at these conditions from a more systems-based, interconnected perspective, [and] the innovations that Dr. Schweig and his team are making at CCFM on [everything] from a collaborative practice model, to being able to collect meaningful data using wearables and other trackers and visualizing [those] data for actionable insights. [We also talk about] some of the things that his nonprofit, [which is] dedicated to exploring all these topics, is working on, and just [a] fascinating discussion on how we can improve patient care for people [who] are suffering with these kinds of problems. Which is a lot of people, as the statistics I shared at the beginning of this show suggest. I really enjoyed this conversation, [and] I think you will, too. Let’s dive in.

Chris Kresser:  Dr. Sunjya Schweig, [it’s a] pleasure to have you on the show and connect with you again. It’s been a while.

Sunjya Schweig:  Yeah, thanks, Chris. Great to be here. Great to speak with you again.

Chris Kresser:  I’m excited to talk about complex chronic illness. That’s not something most people are excited to talk about, but you and I like to talk about [it] because it’s a big problem. Even in the course of my career, I’ve seen an uptick in the number of people [who] show up in the clinic with, not just chronic illness, which we know is very prevalent. Six in 10 Americans have a chronic disease, [and] four in 10 have multiple chronic diseases. But the number of people showing up with very complex, sometimes mysterious and difficult-to-treat chronic illnesses seems, at least anecdotally and empirically to me, to be on the rise. I think that’s been your experience, as well.

Sunjya Schweig:  I definitely agree with that. We’re seeing bigger numbers of people, we’re seeing broader swaths of different populations, [and] we’re seeing more intensity and level of chronic illness. The complexity seems to build. Our practice [sees] a lot of folks with complex chronic illness, but it does seem like that load is becoming more and more of a burden on the individual, on homes, communities, [and] society. There was an amazing quote, I don’t know if you know the book by Megan O’Rourke, The Invisible Kingdom, but she said, “To become chronically ill is not only to have a disease that you have to manage but to have a new story about yourself. A story that many people refuse to hear, because it’s deeply unsatisfying, full of fits and starts, anger, resentment, chasms of unruly need.” There’s that juxtaposition of these people suffering, but then there’s our society, not just in the medical system, [though] there are huge problems there with how it meets people, but just our society at large is not really set up for this. It’s not really set up for hardship and grief and complexity and struggle. We have a very achievement-[oriented society]. Win, be the smartest, be the best, be the richest, win the Super Bowl, win the World Series. [It’s] a very achievement-oriented society. So the place for these people, as they try to navigate through a variety of societal systems, [is] super hard. [It’s] super, super difficult, on so many fronts.

People Living with Chronic Illnesses Are “Invisible”

Chris Kresser:  Absolutely. You mentioned something that, I think, is one of the most challenging aspects for people who are struggling with chronic illness, which I have myself. That’s what brought me to Functional Medicine, as you know and as many of the listeners know, is the invisibility of it. If you have an injury, [say] you broke your leg [and] you’re in a cast, everyone knows what’s going on there and that your mobility is going to be a bit limited, and they interact with you accordingly. There are even other chronic illnesses and chronic diseases [that] have a more visible element or acute diseases. But with some of these chronic illnesses, they are invisible to most people, except maybe [the] people who are closest to those folks who are suffering from them.

I would say that invisibility exists in two ways. One [is] just from a visual standpoint. Being able to look at someone and not know that they [are] really, really suffering. Not just [suffering] a little bit, [but] barely getting by. [They’re] that debilitated. On the surface, if they’re out at the grocery store or interacting with people at a party, you wouldn’t necessarily know that. And there’s a unique impact that has, I think, on people. Then the second quality of invisibility is in the lab work. They might go to their conventional physician and get the basic markers that you get in a physical, [like] blood sugar, metabolic function, cholesterol panel, etc. All of those are going to be normal. The doctor says, “Everything’s fine. I’m not sure what’s wrong with you; here’s a [selective serotonin reuptake inhibitor] (SSRI).” That can be really disempowering and discouraging, because they feel completely unseen by people around them and completely unseen by the medical establishment that they’re interacting with.

Sunjya Schweig:  Yeah, disempowering, disheartening, I would even go so far as to say traumatic. These people are somewhere in the spectrum of previously [knowing] a “normal life” where I could wake up in the morning and I kind of knew what my body was going to be doing. Maybe I was either having a great day, or maybe I partied the night before, or maybe I traveled and have a little jetlag, and I feel a little tired, and my brain is not working great. But hey, tomorrow, I’ll be back in action. So many people with these complex chronic illnesses wake up in the morning and they literally have no idea what to expect. They might try to get some things done and try to achieve parts of their function, and then they get slapped down. They don’t know where that line is [that] they can’t cross before they have a flare. This push-crash phenomenon. And yeah, [to] your point, then they do their best. They seek medical care, they go to their primary doctors, they go to their internist, they go to their specialist, and the higher up the ladder they go in academia seeking out these smarter and more expert people, unfortunately, the experience becomes more and more difficult and more problematic.

Many doctors, I think, are wonderful people, and they’re doing their best to help so many people during their days. But the factors, which you go into so much in your work, are so many—time, resources, tests that aren’t testing the right thing, or have the wrong interpretive range on them, [so] people are captured in the “normal range,” and [the doctor] said, “Okay, nothing’s wrong with your test.” But then we look at those tests, and we say, “Well, actually, that’s not normal.” There’s a functional range that we might use, and you’re not in that normal range. If we get all these different pieces of the puzzle lined up into those ranges, then maybe things start to play along as a symphony should. But yeah, the trauma of that experience and the trauma of people seeking care, going to these doctors, and hoping, hoping, hoping, hoping and getting let down and not getting answers and not getting better. This is something [that] you know personally, and I know personally. I have some personal chronic health issues, but I’ve also seen my wife go through Lyme disease. For a decade, we had no idea what it was, and we were going to all the specialists. So we’ve both lived this reality. I think that’s part of what makes us so passionate about what we’re doing. We know what’s at stake, and we know how important this is.

Chris Kresser:  Absolutely. I had the same experience. An example that comes to mind is [that] I would often refer patients with iron overload to hematologists, and they’d have a ferritin of 600 [ng/mL], which is [even] out of the lab range. We’re not talking about functional ranges. [They’re] clearly out of the lab range, and their iron saturation [would] be 75 percent, which is [also] well out of the lab range. These folks go to the hematologist, and the hematologist would dismiss them and say, “Hey, there’s nothing to do here. There’s nothing wrong.” I’ve had a lot of time to reflect on that, [and] I think part of the issue is [that], most of the time, those specialists are seeing people at a much later stage in the disease process. They’re seeing people with cancer, they’re seeing people with severe blood disorders, [and] they’re seeing people with ferritin levels at 1500 [ng/mL] who need emergency phlebotomy as a treatment. When that’s your day-to-day experience as a clinician, and somebody comes in who’s at an earlier point on that spectrum, it doesn’t land in the same way. I’m not excusing it, because I think they should still be paying attention to that. But in an effort to make sense of how a hematologist [would] send somebody away with a ferritin level in the six hundreds and iron saturation of 75 percent, the only way that makes any sense to me is that person doesn’t get onto the radar because they have so many other more severe and urgent cases that they need to deal with.

The Struggles of the Conventional Medical System

Chris Kresser:  This highlights [that] one of the biggest issues in the conventional system is that it’s primarily disease management, and [it waits] until the problem becomes so severe that it’s almost too late to intervene, or at least it’s going to be much more difficult to reverse. This is one of the issues [we’ve addressed] together and you continue to [address] at [the] California Center for Functional Medicine—the question [of], “Where do you even start? How do you make sense of these kinds of pathologies and patterns that are so poorly recognized?” They’re not even recognized, in many cases, until years later. I know you’ve fought so hard for so long on the Lyme disease front, as an example. This is something that you have personal experience with, it’s something that you have a ton of clinical experience with, [and] it’s something you’ve seen a shift in from the early days [when] chronic Lyme [disease] wasn’t even allowed to be discussed in any conventional medical context. Maybe we could use that as a microcosm/macrocosm for highlighting some of these issues. Because clearly, there are people who are listening to this, no matter what, who either have been affected by chronic Lyme [disease], are affected, or will be affected.

Sunjya Schweig:  Yeah, you’re right. Lyme disease has been a big area of focus for me across my career, and my wife was diagnosed with Lyme disease the year I finished my medical training at the UCSF Santa Rosa Family Practice Residency program. I entered my chosen career of private practice in Functional Medicine thinking it [was] going to be helping keep people off of drugs, keeping them healthy, and working on lifestyle pieces and optimization. And [I] immediately went down this rabbit hole of [an] unbelievably complex, severe illness, for which not only is that problem A, but problem B is that there’s a war going on in the medical field about what is or isn’t happening with this condition.

I have a huge respect for science and for my mentors and the specialists who I’m trained to rely on, and all of a sudden, what I was doing was at odds with what they were saying. The complexity and the fear and the uncertainty and the wish that, “Gosh, I know what I’m doing is real, and these people need help. At the same time, I have no backup. I’m out on a limb here.” Fortunately, that’s changed, but it’s absolutely not over. [There are] organizations like the Bay Area Lyme Foundation, [which] I serve on the Scientific Advisory Board [for] and have received some generous funding from. We’ve managed to do some really fun research in collaboration with Johns Hopkins, looking at botanical medicines for a variety of tick-borne diseases and showing efficacy in a test tube lab model. The [Centers for Disease Control and Prevention] (CDC) has, over the years, ratcheted up there. It used to be, “Okay, we think there [are] 30,000 cases of Lyme [disease],” and then they said, “Actually, it’s probably 10X that. It’s probably in the 300,000 range this last year.” This [past] year, they said, “Oh, actually, it looks like there [are] about 495,000 new cases of Lyme disease in the [United States] alone.” We still think that’s an underestimate, but at least we’re starting to approach some more realistic numbers. We know [from] the research of Johns Hopkins’ Dr. Aucott [that], assuming somebody gets Lyme [disease] and they get decent treatment, which standard treatment [is] ideally two to three weeks of antibiotics, based on the [Infectious Diseases Society of America] (IDSA) CDC recommendation, if they get that treatment, anywhere from 15 to 35 percent of those people will still then go on to have chronic illness and ongoing symptoms that did not resolve. The mainstream thinking is that’s what they call post-treatment Lyme disease syndrome. Maybe it’s inflammatory, maybe it’s autoimmune, etc. We know pretty conclusively that the bug persists, and that’s been shown with amazing research in the primate model [by] Dr. Monica Embers at Tulane.

The science is stacking, and there’s no longer a question of what is or isn’t happening. We’re [still] left with this tidal wave of ego and infighting around how we move forward, but there [are] people getting better help. The diagnostic tests are completely lacking. We still can’t test and say someone does or doesn’t have it, definitively. The load of what this sets people up for with chronic illness is incredible. We see that in autoimmune [disease]. You talk about this a lot, right? A huge uptick in our society with autoimmune illnesses for so many different reasons—evolutionary mismatch, hidden infections [are] a big driver of that, we talk about Lyme [disease] and Bartonella, [we’re] seeing that in COVID[-19] now, we’re seeing that with parasites, [and] we’re seeing that with other viral infections. Huge. One of my favorite books is this $250 super thick textbook that I have on my shelf called Infections and Autoimmunity. [The] chief editor was Yehuda Shoenfeld, one of the global leaders on this work. We talk about gut and microbiome imbalances, toxin exposure, [and] inflammatory drivers of a variety of different immune system dysregulation processes going sideways.

Now, we think about COVID[-19] and long COVID and, gosh, I mean, [it’s] so intense. [It’s] really scary and disheartening, what’s happened over the last couple of years and how many people are still struggling with long COVID. I think there’s also a little bit of a silver lining there, because here’s this condition, which I think is more accepted and [it’s] more understood that, “Oh, wow, this can actually happen.” We don’t know why, right? There’s a lot of debate. There [are] multiple pathways that we think are involved, and there’s debate still on [whether] there [could] or could not be [a] persistent virus. I think there can be. That’s been shown in a variety of really impressive studies in a variety of different tissue reservoirs. Certainly autoimmune, microclots, mitochondrial dysregulation, central nervous system dysregulation, [and] gut dysregulation. All these factors that we think about in Functional Medicine. And the upside to it is that it’s bringing new people to the table. It’s bringing people to the table who say, “Gosh, I don’t understand it. A person still is invisible. I can’t tell from the outside what they’re experiencing, but it seems to be pretty real. It’s happening all over the world, and it’s happening to hundreds of millions of people.” So there’s a little bit of rekindling of some curiosity and some scientific push, which, I think, in turn is going to transform the experience of other folks with [myalgic encephalomyelitis/chronic fatigue syndrome], Lyme disease, [and] autoimmune [disease]. I think we’re going to get some really interesting answers out of it. So there’s a little bit of a silver lining there of some movement happening on the global scale, which I’m sure you’re seeing, too.

Chris Kresser:  I mean, it’s been well established within the context of other viral illnesses that they’re triggers for autoimmune disease and a lot of other pathologies. So it was not as big of a leap, perhaps, for scientists, even in [the] mainstream medical establishment, to see that [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] is a prevalent virus that’s affecting a huge percentage of the population. It shouldn’t really be a surprise, given what we know about other viruses, that it’s triggering ongoing symptoms, particularly immunological symptoms. So I’m with you; I think that was easier to accept or [required] fewer leaps of understanding or faith that people had to take to get there. What’s difficult to piece out now is the research on the prevalence and incidence, and how to do that properly. It’s really tricky.

Sunjya Schweig:  Yes, [I] agree.

Chris Kresser:  I think Lyme [disease] and autoimmunity and long COVID all highlight the theme that we were talking about earlier, which is the invisibility aspect. With Lyme [disease], just starting with the nature of those infections, they are known as stealth infections, right? Stealth pathogens. They’re known that way because of their ability to evade the immune system.

Sunjya Schweig:  Not even their ability, that’s their deal.

Chris Kresser:  Their central characteristic. That’s what makes them [what] they are. They can switch forms. I mean, it’s amazing.

Sunjya Schweig:  Switch forms, move around. It’s incredible. Almost all of our standard tests are blood tests. We’re pulling a sample from that one compartment, and then we’re running it through a machine to say, “Okay, yes or no?” Ideally, the question would be yes or no, is this bug there? But really, the only question we can ask reliably is, has your immune system seen this bug as a problem? It’s an indirect test. The Lyme bacteri[um] is classically known to very, very quickly get out of the blood compartment and hide out in tissues and areas of the body that are very poorly surveilled from an immune system point of view. It just acts like it’s not there. The immune system can’t figure it out, and it goes into this hyperinflammatory, chronic low-grade inflammation state that doesn’t show up on tests. And the bug doesn’t show up on the tests either. [It] really [is] a master of deception.

When I give talks on this, I will sometimes present this tree of life [where] the upper, outer leaves and branches of this 4.8 billion-year evolution are primates and humans. And down at the very base of that tree are the ancestors of today’s spirochete bacteria. They literally have been around for forever. They’ve just been watching us evolve, and their capacity to evade our immune system hideout persists, like you said. These persistent pathogens [are] actually pretty beautiful. It’s pretty amazing, right, when you can get past how much of a crap show it is. It’s pretty incredible what they can do.

Chris Kresser:  Absolutely. I’ve had Lyme disease myself, as you know, and I’m fascinated by it. And I say this with complete sensitivity to how devastating it can be for people, and even fatal, so I’m not making light [of it] in any way. But I think it is important to have an appreciation for just how sophisticated these organisms are and just how much experience they have at evading mammalian immune systems. Not only their longevity and how long they’ve been on the planet, but as microorganisms, [their] evolutionary life cycle is so much shorter so they can adapt and learn so quickly. If you read any of these books, which explain the mechanisms that these organisms employ, you can’t come away from that without a deep respect and appreciation for what we’re up against. [We’re] lucky that they need to keep us alive in order to propagate, because if not, we really don’t have the level of defense [against it] that we need.

It strikes me [that] the first level [of] invisibility starts here, even before we get to labs or cultural attitudes about it, or medical attitudes about it. The very nature of these pathogens is rooted in their biology. And then, like you said, for so many years, if somebody had Lyme disease, took antibiotics, [and] went back to [their] doctor three months later and said, “Look, I feel exhausted all the time. I’m breaking out in sweats and my muscles are achy, I can’t exercise anymore, joint pain is moving around, [and] I feel like I have the flu all the time.” The response, as you pointed out, was, “Well, it’s not Lyme disease anymore because you had it. We treated you, [so] that’s over. The CDC says so, [and] all the guidelines say so. Here’s some ibuprofen, or whatever.” And these people have suffered and are still suffering for years [or] decades as a result of that misunderstanding. Also, I think [there’s] a little, I’m going to say it, hubris. There’s a lack of humility in these cases, where we’re so sure that we have the answers [that] we’re unwilling to get curious. If you’re in that position [and] you keep seeing people come in, the better clinicians [do] evolve their understanding and start asking questions over time. But [for] those who were perhaps just following the CDC guidelines and sticking to [them], there were a lot of missed opportunities there to help people.

Complex chronic illness is on the rise, and the conventional medical system isn’t properly equipped to deal with it. In this episode, you’ll learn how Dr. Schweig is using the collaborative-care model and comprehensive tool kit of Functional Medicine to create a better path forward for patients facing these conditions. #chriskresser #functionalmedicine #CCFM #FMRTC

Sunjya Schweig:  Absolutely. I’m a generous-minded and generous-hearted person, so I always think that people are generally doing their best, especially when it comes to doctors. But I have seen patients blown off and dismissed and told chronic Lyme [disease] doesn’t exist. “You never knew about a tick bite, so you couldn’t have Lyme [disease],” or, “There’s no Lyme [disease] in California, so flush that tick down the toilet.” Which is total hogwash. Fifty-four out of 56 of the counties in California have the Lyme-carrying tick, and in 46 of those counties, that tick has been shown to have the Lyme bacteri[um] inside of it. It’s here and it’s all over the [United States]. I think that doctors need to be better informed, but there [also] needs to be curiosity, there needs to be tenacity, and there needs to be more time. These doctors are pushed up against the wall, they don’t have time, they’ve got to move people through super [quickly], and there’s not a lot of respect for the biochemical individuality that we think about in Functional Medicine.

There’s a lot of problems around algorithms. [What] we’re taught in Western medicine is very algorithmic. It’s a set of variables, X plus Y equals Z. You look for signs and symptoms, which is X, you do some lab testing and corroborate the evidence, which is Y, and based on X plus Y, you conclude that a patient has a disease, Z, and that dictates what your treatment is. It’s pretty cookie cutter. The best minds will get curious and try to work through that, but for those who don’t have the capacity or start getting defensive or there’s pride involved or hubris, like you [said], yeah, I think they shut down and they give up a little bit. There’s an incredible book called The Lady’s Handbook for Her Mysterious Illness by Sarah Ramey, which has some really incredible quotes in there. I might even read one. Is that okay, if I read one [really quickly]?

Chris Kresser:  Sure. Yeah, absolutely.

Sunjya Schweig:  So she goes to the doctor’s office and she says, “The following scene is unfolding in an office in your town every day. Perhaps right now at this very moment. Jane Doe crosses her ankles in the waiting room, absently turning the pages of People magazine. She looks around often, now at the oversized clock, now at the receptionist, now at the generic watercolors on the wall. ‘Ms. Doe,’ a flat voice calls out, ‘Dr. Bowels will see you here.’” He’s a GI doctor. “‘Second door on the left.’ Jane takes a seat in the doctor’s office, regarding the diplomas on the wall. On the desk stands a life-sized replica of the human intestine tract. When Dr. Bowels bustles in, he introduces himself as he looks over her chart for what is clearly the first time. ‘Now Ms. Doe,’ he cheerfully says, ‘What can I do for you?’ The interaction begins very seriously, a furious scribbling of notes, a furrowing of the brow, a lot of nodding. The usual diseases are ruled out and Jane confirms that she has been tested twice for everything under the sun. Her primary symptoms are severe constipation, distension, and pain in the lower left quadrant of her abdomen. As the doctor pages through her thick medical file, Jane takes the opportunity to share some of the stranger non-bowel symptoms that she’s experienced—aching in the bones, fatigue, itching, unexplained gynecological symptoms, memory problems, lower back pain. But the words are scarcely out of her mouth before she wishes that she had kept her addendum to herself. She can see the red flags rising behind his eyes and the note taking slowly tapers off. Before she knows it, where once Sherlock Holmes scribbled furiously, hot on the trail, bent on solving her mystery, he now leans back in his swivel chair, tip of his pen in the corner of his mouth, checking his watch. His look is saturated with understanding, for he has solved the case. ‘What we have here is not a rare tropical disease, Watson. What we have here is an unhappy woman badly in need of an antidepressant.’”

Chris Kresser:  Wow, yeah, a lot to unpack there. First of all, women do tend to be more affected by these conditions, for reasons that we don’t understand. And that has been sort of weaponized in a sexist way for so many years. Women being told it’s all in their head, whether we’re talking about [irritable bowel syndrome], or autoimmune disease, or chronic inflammatory response syndrome, or any of these conditions. That’s often the routine, exactly what you just described. This, to me, highlights another huge shortcoming of the conventional approach, and [how] Functional Medicine makes so much more sense. It’s the dualistic, Cartesian model of looking at the body, where every part is separate and not related to the whole. If you go to the doctor and you complain of a bunch of different symptoms, they’re going to refer you to [a] doctor [for each body part] to address those particular complaints. If you have [gastrointestinal] issues, you see the gastroenterologist for that. If you have muscle aches and fatigue, you might see a rheumatologist for that. If you feel cold all the time, they might refer you to the endocrinologist [to] check your thyroid. And none of these people are communicating.

Sunjya Schweig:  No one’s talking to each other.

Chris Kresser:  No one’s talking to each other.

Sunjya Schweig:  No one’s going to conferences and learning from each other.

Chris Kresser:  In a perfect world, the primary care provider is supposed to be playing that quarterback role and making all the connections. But they’re not trained to look at the body from a systems perspective, as we do in Functional Medicine.

Sunjya Schweig:  And they get seven to 12 minutes per visit.

Chris Kresser:  Impossible. Even if you have that perspective, it’s just, from a physics perspective, impossible to do that. And yet, the majority of people now have these syndromes that are complex, chronic conditions that are driven usually not by just one factor, but a number of different factors. If you were to map it out on paper, the roots of conventional medicine assume it’s a linear cause and effect relationship. There’s A, and that leads to B, and maybe that eventually leads to C, but you imagine there’s a straight line going from left to right. What it really is, [is] just like a tangled ball of yarn.

Sunjya Schweig:  Yeah, totally. I say that all the time. [It’s] like trying to tease parts of a ball of yarn. Totally.

Chris Kresser:  I think one of the biggest issues is, that’s the reality we live with at this point. And arguably, it was always the reality. The body is a complex ecosystem. It was never really amenable to being characterized by a linear cause and effect relationship. But I think these newer, complex chronic illnesses are even more indicative of that. Can you talk a little bit about that, from the perspective of how Functional Medicine differs and why it’s a better model to address the challenges of our current moment?

Why the Functional Medicine Approach Is Better

Sunjya Schweig:  Yeah, and I think there [are] nuances within Functional Medicine, too. You sent out an email talking about root cause versus pleiotropism, which I thought was super on point and fascinating. [In] Functional Medicine, we always talk about looking for the root cause. Looking for what the driver [is]. We tend to take a lot more time with our patients, we tend to be a lot more curious, we respect the biochemical individuality of each person’s body, [and] we look at the placement of that body within their exposome. Everything that they’re being exposed to, from the time they are in their mom’s womb, or even before. What made that sperm and that egg? All the way up through to the moment they die. How do those things affect their health? All [that] counts. It’s like [if] you have this huge spider web and you pull over here, it’s going to jiggle over here. Or the ball of yarn, or the layers of the onion. We talk about these things, right? We’re always trying to do as deep of a dive as we can and look at all those factors and hold space for all those factors to be involved. Meaning, okay, you might have some bugs, you might have some dysbiosis, you might have gastrointestinal inflammation or imbalance, or breakdown of barriers across the body, whether it’s gut or lung or skin or brain. But you’re also drinking water that you’re exposed to, you’re breathing air, [and] you’re eating food. All those core inputs are what speaks to ourselves and our epigenetics and turns genetics, which is on and off, to either drive or retreat/heal from disease. And then [there’s] community, and psychospiritual, and all these different aspects that are critical for health. It’s incredibly complex.

I would [also] say [that it’s] extremely gratifying to work in this field and to have this huge tool kit, which is invisible to a lot of mainstream primary care specialist doctors. Patients come in and start to cautiously tell us about what they’re experiencing, because they’re worried that they’re going to be met with some resistance. Instead, we’re right there with them and we’re saying, “Yep, that makes sense. Okay, yeah, I can see where that started to turn things sideways. And oh, but what about this? It seems like you started having X, Y, and Z after that, and here’s why that could happen.” The connections and this idea of [a] primary focus on lifestyle, which is what you speak about so eloquently all the time in your books, it’s such a great resource for everybody. Also, this [idea of] patient and provider as collaborators, so it’s not top-down. It’s not, “I’m the doctor, you’re the patient, [and] I’m going to tell you what to do. And if you don’t do it, I’m gonna kick you out of my practice.” It’s the opposite of that. I’m constantly learning from our patients and understanding how things affect different people on an individual basis and what their experience is. We have 25-plus years doing this, and it’s about curiosity, as I mentioned, and it’s about tenacity. We don’t give up. We are going to be digging, looking at all body systems, [and] doing [the] first round of testing. If that doesn’t show anything, [then] we have second, third, fourth, fifth, [and] sixth rounds of testing. Tests are still imperfect. I always tell my patients that. It’s more about what your experience [is], what’s happening to you, and what your response to any treatment [is]. It’s like you’re tapping on a beehive and you’re listening. What did I do and what’s the outcome? And from there, we plot our path.

One thing that we’re doing at CCFM as well as at our new 501(c)(3), the Functional Medicine Research and Technology Center, is trying to build this new care ecosystem that is better equipped to deal with the data, deal with the experience of people struggling with complex chronic illnesses, and that can capture and bring visibility to that experience. Part of that is just [talking]. It’s just [your] history and what’s happened to you and what’s happening to you now. But a big part that we’re playing with is really being careful about capturing and mapping other data. [Doing] symptom tracking in a structured way, so that we can look at those trends and see patterns over time, generate insights, [and] do some cross-tabulation between, okay, here’s where this treatment started and here’s what happened to your symptom load. Also, [we’re utilizing] wearable data—looking at heart rate variability, resting heart rate, sleep metrics, and being able to, again, correlate that to the patient’s experience, what their symptoms are, and then also their trajectory. I think there’s a really amazing opportunity here to move healthcare in general, but specifically, the work that we’re doing with people with complex chronic illnesses, to move that into the future of medicine and to really start to harness that digital exhaust that we’re all giving off.

[I love following] my mentor, Daniel Kraft, on Twitter. He talks about that. We’re giving off this incredible load of data that we can and should start to harness and start to visualize back for provider use and for patient use and for the benefit of wellness and wellness programs. We did this with our firefighter wellness programs and first responder health optimization programs. Visualizing [those] data [and] putting [them] onto a dashboard brings visibility to the experience and the trajectory, and helps us elucidate what’s working [and] what’s not working. [It] also enables a whole care team to be involved with the care, which is so critical. We need the doctors, we need the nurse practitioners, [and] we need the [physician assistants], but we [also] need the health coaches, we need the nutritionists, we need the admin support, we need the social workers, [and] we need a social aspect to this care where people can invite their friends and family to be part of their journey and their data and see along with them what they’re experiencing. I could go on [about] this for a while, but I’ll let you jump in if you have any thoughts or questions.

Chris Kresser:  I’m sure anyone who’s listening is tracking these differences. It’s night and day, really. You have, first of all, a paradigm shift. Perhaps most important as a starting place is the different way that we look at things from a Functional Medicine perspective, as a systems-based approach. We look at the interconnectedness of the body and the mind. We look at [how] all those various [body] parts that you were referred to [separate] doctor[s] to see about in a conventional system [are] connected, and we’re able to make those connections. When we’re working up a patient who comes in and complains, “I have all these diverse symptoms,” we can often trace that back. Okay, it could be a gut health issue. That could lead to all those different symptoms. Or it could be an infection. Over time, that perspective, I think, shortens the learning process dramatically. You can get to at least a working hypothesis so much [quicker] that way than with the more linear, segmented, and disconnected route. You could very well spend 30 years in that system and never really reach the destination and the answer, as a lot of people can attest.

And I would say that [the] same web of interconnectedness extends to how clinical care happens. As you pointed out, it’s not just a linear relationship between [the] doctor and patient and that’s it, and everyone else is just there in the background, playing a support role. There are multiple providers playing multiple roles, all of which are very important, sometimes even more important than the relationship with the doctor. That’s really what it takes at this point, I think. And I know you agree. We set things up that way for a reason. That’s what it takes to deal with these complex chronic conditions that we’re facing now. You can’t map an outdated reductionist system on top of these extremely web-like interconnected, complex, pattern-based illnesses and expect that to work.

Sunjya Schweig:  Absolutely. I remember being so excited and fascinated as you were going through your journey a number of years ago, when you were building the [ADAPT Functional Medicine] Practitioner Training Program, and then later building the [ADAPT] Health Coach Training Program. We’d have these conversations, and I would learn from you about how you were learning about learning theory. How do people learn? How do we optimally convey information? What size chunk of time, duration of a recorded video or of a meeting, or whatever it is? We get to the point where our brains are full after too long, and we’re not absorbing anything. So how do we break that up? How do we make it experiential? How do we really bring [people] in? Watching you go through that and learning from you was really interesting and fascinating for me, because it showed me [that] when we’re working with our patients, we’re asking a lot of them. We’re giving them this new model. I’ve been guilty of overwhelming people. [They say,] “I can only handle so much at a time. I think a lot of what you just told me is really valuable, but I missed most of it because I’m trying to just track number one and number two,” both from the to-do’s on the lifestyle reboots, but also on lab testing, and all the things we ask folks to do.

So [our goal is] getting them the help [they need], [and giving] them the step-by-step approach where they can make incremental progress, they can become empowered, [and] they can see that, if I do my 30-day autoimmune nutritional reset, or if I do my 30 days of breathing exercises, or my 30 days of meditation, or my 30 days of movement, or my 30 days of improving my sleep hygiene, [then] there is this outcome that happens, and that’s on me. I can control that, and that helps reset inflammation in all these different body processes where then everything else works better, all the treatments that we then try.

That engagement and that collaboration is one of my favorite things about what we do. When we see patients in follow-up after a visit, it’s not about, “Did you do X, Y, and Z that I told you or asked you to do?” It’s more about what happened when you did it. Our patients are so engaged, and [we’re] constantly learning from them as we make our way through these worlds.

The Work That CCFM and FMRTC Is Doing

Chris Kresser:  One of the things that frustrated me, [that] I know you’ve been working a lot on at CCFM and also through the 501(c)(3) and that’s a general interest of yours, is [that] our ability to collect data is ahead of our ability to make sense of [the data] and to present [them] to patients in a meaningful way. Even as clinicians, to be able to quickly visualize [them] and turn [those] data into actionable insight that we can use and have it be something that the patients can own themselves and take with them into future medical interactions or health contacts. I think there’s a lot of interesting opportunities with blockchain and how that’s being applied to this, and [with] new data visualization tools and things like that. What’s your sense of that? Because that is potentially one way of addressing this overwhelm of too much information, [where they] can’t make sense of it. If it existed in a form that was easier to take in and that people had ownership and control over, I think it would be easier.

Sunjya Schweig:  Yeah, and that is a thorny problem. It’s the problem of our time. We have the ability, like you said, to gather all [these] data, and the doctors don’t have time to dig into [the data] and mine [them] for insights. We’re working hard on that and trying to find ways to serve the patient. It’s got to be simple, actionable, and on point. It [needs to be] the right piece of data at the right time, at the right level of simplicity or complexity that helps them achieve better outcomes. On the flip side, on our end, it has to be deep and complex and nuanced and manipulatable, and we have to be able to play with it and compare and contrast different things and interventions. So, it’s an evolution right now. My favorite thing right now is just [getting the] data flowing in, playing with [them], and asking questions [about them]. We’re working right now on version three or four of a data visualization dashboard. Doctor Omar Shaker has been working with me for a number of years building dashboards. We’re coming up with a simple overall score that is a compilation of a variety of factors. It’s a [combination] score of their overall symptoms and of several metrics on a wearable device that we think are most important. Those include heart rate variability as a marker for nervous system setpoint, resting heart rate as a marker for resilience and overall capacity on the organism, movement/steps, even though those are a little messy, and one global marker for sleep. Not deep sleep, REM sleep, [or] light sleep, but just how much sleep. I don’t trust all the algorithms on some of these devices, but the raw data [are] really helpful.

What I like to see is, okay, put these devices on people, and if they want to look at their app every day, or once a day, or twice a day, or 10 times a day, or zero times a month, that’s fine. Either look at it or don’t look at it; I don’t care, but just keep it on. What we get is a super interesting data stream that we can look at and make predictive responses to, but also make sense of in retrospect. I’m going to do a little screen share. I want you to look at a couple of things with me as I talk through this. [It’s] a couple of really interesting cases. Here’s this 25-year-old young man, [with] complex chronic illness, chronic fatigue [syndrome], Lyme [disease], [and] tick-borne infections. He’s super fatigued and [has] low motivation. We said, “Okay, well, we’re kind of feeling a little crunch on options. Let’s try some escitalopram (Lexapro), as an antidepressant.” [We] started him on it here, and what we see is his heart rate variability (HRV) just tanking. Then we started to see this compensatory rise or increase, which would be a worsening, of his resting heart rate, and this big dropout in his deep sleep, and he wasn’t feeling very good. He was feeling more tired, more out of it. So that doesn’t look right; let’s stop. And sure enough, [when] we stop it, he reverts back to his baseline.

It turns out that his brother, who also has a complex chronic illness, had been on Lexapro for years prior to his using an Oura ring. [These] data for his brother [are] going back three years. So based on brother one, we said, “Okay, let’s stop the Lexapro for brother two.” And sure enough, right when we stopped it, [his] HRV [climbed] way up to the absolute highest point that he’s had in [the] three years since he’s been tracking.

Chris Kresser:  For [the listeners], because [they] can’t see this, it’s not a small difference. It looks a little bit like a hockey stick at the end of the graph there.

Sunjya Schweig:  Yep. This is all anonymized that we’re looking at, but I’ll double-check with these patients in particular and see if we can post some screenshots because I think it’s just fascinating, fascinating stuff.

Chris Kresser:  Absolutely.

Sunjya Schweig:  And then also deep sleep for brother number two came way up. So [there’s] a lot of physiological metrics. Now, there [are] data in literature showing that SSRIs fractionate sleep. But again, just seeing this physiological response there was great. Here’s a zoom in of that. This is a super interesting case. A 35-year-old female [with] severe [inflammatory bowel disease], Crohn’s [disease], and she went on a diet reset. [She] started eating [only] meat and [vegetables] and felt horrible. [Her symptoms] got a lot worse. [She had] way worse constipation, global worsening of all her symptoms, and after about 10 days, she said, “Okay, I can’t stay on this diet. I feel so bad, I’m going back to my previous diet.” But what we saw, even though she felt horrible, is this paradoxical improvement in her HRV and an improvement in her resting heart rate, telling us that even though she was feeling terribly and there was more inflammation and cytokines, her body was telling us from an internal point of view, that [it’s] a good thing. [The body is saying,] “I want that. That’s going to help me be more reset as an organism.” So we looked at this, and we said, “Wow, okay. Let’s just put as many symptomatic management pieces in place [as we can]. Let’s make sure you’re not constipated. Let’s work on mast cell. Let’s work on your gut. Let’s try to really calm down so that we can try to go back on this type of nutritional intervention and see if that will help us hold your gains.”

These are just a couple of insights that help us. We were able to show, when we worked with firefighters and first responders, that just the first two pieces of our six-month program, [which are] a 30-day, Whole 30, Paleo template reset, and [getting] people moving, tripled their HRV as a cohort. The number one and two ways [firefighters] die are suicide and cancer. So, [from] brain inflammation, full body inflammation, immune dysregulation, [and] trauma. Lowering that load is pretty important. So again, that’s kind of what we’re nibbling at. As we match that to symptoms, I think it becomes very interesting. During [the] COVID[-19 pandemic], a couple of my favorite research groups and studies that were coming out [included one from] Dr. Ben Smarr, down at UC San Diego. He did the Oura ring [temperature] predict studies in collaboration with UCSF. [Another was by] Jennifer Radin, down at Scripps. Different work, different papers, but both showing that if you marry the physiological wearable data with patient-reported symptom tracking data, things really start to kick into gear and become really powerful, and even potentially predictive.

Chris Kresser:  I love those examples because they’re opposite in some ways. In the one case, the data confirm the subjective experience of the two brothers. And then [in] the other case, [the data] contradicted it. The challenge with treating various complex chronic conditions, as we’ve both experienced, is [that] sometimes when you make a positive change, you can feel worse before you feel better. It’s always been a very difficult situation because as a clinician or as a patient, it’s hard to know whether the feeling worse is part of the road to feeling better, or it’s just feeling worse.

Sunjya Schweig:  Right, exactly.

Chris Kresser:  And we didn’t really have any objective tools to help answer that question.

Sunjya Schweig:  They’re invisible, right? These people have an invisible illness and their trajectory is invisible. So yeah, just pulling back the curtain a little bit and starting to see what’s happening inside the body is incredibly valuable.

Chris Kresser:  We’re not quite there, where we have the Star Trek tricorder [and] we can just move it around next to the body and know exactly what’s going on. But it’s a step in that direction. Metagenomics and our ability with shotgun sequencing to see precisely what’s in the microbiome has led to some pretty important discoveries about the bacteria that are most important, like Akkermansia, which wasn’t even on the radar 20 years ago. Because it’s an anaerobe, and it doesn’t survive oxygen, and it’s much harder to work with in the lab. But we’re able to see these things now that we weren’t able to see 20 years ago, at least outside of a rare [type] of research setting.

The same is true for all these different things that you’re sharing. It’s definitely encouraging, [and] a huge step in the right direction. I love that, through your foundation, [you’re] spending a lot of time figuring out not just how to collect these data, which is an important first step, but how to make sense of them and how to make them useful for practitioners and patients. [It’s] exciting times.

Sunjya Schweig:  How to transform chronic illness care, that’s our mission.

Chris Kresser:  Absolutely. Tell people, if they’re hearing this and they want to come to the clinic and work with your team, how to find out more.

Sunjya Schweig:  We welcome any and all levels of participation. If you’re an individual or you have a family member who’s struggling with complex chronic illness, this is where we spend our lives, and we would be honored to try to help you on your journey to recovery. Even if you’ve seen naturopathic doctors [or] you’ve seen Functional Medicine providers with some benefit but you’re not all the way where you need to be, the level of experience and complexity that we bring is really valuable to a lot of people. And it’s what we love doing.

So, patients, you can find us at the California Center for Functional Medicine, which is www.ccfmed.com. If you, on the flip side, understand this world of chronic illness and you have resources, whether [that’s] expertise or time or energy, or you’re able to provide any level of financial support to help us transform healthcare through research, education, and innovation, please go to www.fxmedresearch.org. You can read more about what we’re doing, you could donate there, [and] you could drop us a line if there’s anything you think you might be able to help us with. There’s so many amazing, smart, dedicated, hard-working people out there [who] we would be honored to collaborate with. So please reach out.

Chris Kresser:  One question that we used to get all the time, especially because the clinic is called [the] California Center for Functional Medicine is, “Do I have to live in California? Do I have to come to the clinic in person for all the visits?”

Sunjya Schweig:  We’re a fully virtual clinic at this point, with satellite physical offices. We have [a] nurse practitioner, Megan Anderson, in Colorado. Many of us have licenses in many states, and we continue to accumulate licenses as needed to serve patients as our population grows. We can pretty much help folks anywhere within the [United States]. It’s a little bit harder internationally with logistics. I do anticipate going back to a hybrid of in-person and virtual as we move through, and hopefully, continue to stabilize, the COVID[-19] pandemic.

Chris Kresser:  Great. I wanted to highlight that because so many people have trouble finding someone in their local area and don’t understand that this works pretty well virtually. We’ve been doing it for years. I started out in 2010 offering some portion of visits virtually. Sunjya has been doing that for a long time. All [of] the practitioners have been working that model. It’s easy for clinicians to order tests and send people to [laboratories] where they live, or a lot of the test kits are drop shipped directly to the patient, which makes no difference at all where you live in that scenario. It’s really easy to do this way, and it’s been done this way for a long time. So [that’s] good to know.

Sunjya Schweig:  Yeah, it’s how we built the practice when we started in 2014. When we launched it together, it was built with this virtual backbone.

Chris Kresser:  Absolutely. Well, thank you, Sunjya. It’s been a pleasure to connect with you, and I know this will be helpful to so many listeners. And thanks, everybody, for listening. Keep sending your questions to ChrisKresser.com/podcastquestion and head over to ccfmed.com if you’re interested in getting some help. I can’t recommend Sunjya and his team more highly. It’s an incredible clinic, and you’ll be in great hands. [I] highly, highly recommend it.

Sunjya Schweig:  Thanks so much, Chris. It’s been a pleasure to be here today.

Chris Kresser:  [The] pleasure is mine. All right, everybody. [We’ll] see you next time.

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