Managing Chronic Stress in Patient Care with Dr. Susan Blum

Let’s face it, folks – we are all grappling with various levels of stress right now. As if chronic stress wasn’t already a top contributor to general health ailments and chronic disease, now add stress from social isolation, the pandemic, and political strife to the list. That’s why we are so grateful to welcome Dr. Susan Blum MD to New Frontiers. Dr. Blum has worked in preventative medicine as a chronic disease specialist for nearly two decades and is the founder and director of Blum Center for Health. Her focus is on supporting patients in their recovery from autoimmune and immune-related conditions, and now educates and coaches patients through mind-body medicine tools and behavior modification to rebalance their autonomic nervous system and downregulate the stress response. Together, we talk about her personal journey dealing with stress, how she approaches the topic with each patient, and why this is one of the most important considerations for your clinical practice as we navigate the current and post-pandemic era. Let us know what you think with a comment, rating, and share! ~DrKF

Managing Chronic Stress in Patient Care with Dr. Susan Blum

Chronic stress continues to be pervasive with more and more individuals struggling under the overwhelming weight of stress at home, at work, with the COVID pandemic and heightened political tension. In this episode of New Frontiers, Dr. Blum explains to me why if you’re bathed in stress, you’re effectively shutting your immune system down. Together, we discuss why clinicians should be focused on educating our patients about the role of stress management not only as a fundamental tool for immune resilience during this pandemic, but also as an integral aspect of a patient’s lifestyle prescription.

In this episode of New Frontiers, learn about:

Dr. Kara Fitzgerald: Hi everybody, welcome to New Frontiers in Functional Medicine where we are interviewing the best minds in functional medicine and of course today is no exception. I’m really excited to be sitting with my dear friend, colleague, and mentor Dr. Susan Blum. And we’re going to be talking about… well, we’re going to be talking about a lot of really interesting stuff. You know her in her work in autoimmunity and gut work and work in arthritis and she’s a functional medicine doc. But today, we’re going to be kind of looking at this through the lens of stress, of chronic stress, of inadequately addressed autonomic overdrive. So before we jump in, I just want to give you a little bit of Dr. Blum’s background. She’s an assistant clinical professor in the department of preventative medicine in Icahn School of Medicine Mount Sinai.

She’s been treating, healing, and preventing chronic diseases for nearly two decades. Preventative medicine and chronic disease specialist, she’s founder and director of Blum Center for Health in Rye Brook, New York and she’s got a great, very bright, multi -specialty team of physicians, nurse practitioners, nutritionists, and health coaches, all providing cutting edge functional and integrative medicine services. In fact, my team has visited her clinic in Rye Brook and we’ve had really some fun times together. We joined their rounds, I think they joined our rounds, we have a virtual rounds, they have an in-person rounds. And it’s been really nice to collaborate with her on a lot of different levels.

You are likely familiar with her best-selling book, The Immune System Recovery Plan. She published that in 2013, she’s got a good four step program, she’s used this to help thousands of patients recover from autoimmune and immune related conditions without medication. We talk about that as well as the book she published in 2017, Healing Arthritis, on our first podcast and if you go to the show notes, you’ll see my conversation with Dr. Blum there. And look at both books. In fact, so I don’t forget, I want to just mention that my mom quotes you all the time. “Dr. Blum said… ”

Dr. Susan Blum: Okay, now that is the best endorsement that there could be, okay?

Dr. Kara Fitzgerald: All the time.

Dr. Susan Blum: So I’ll take everybody’s mom, that’s great. Thank you. Thank her for me.

Dr. Kara Fitzgerald: Absolutely, absolutely. So she’s a member of the Medical Advisory Board for the Dr. Oz show, she’s on teaching faculty for the Center for Mind-Body Medicine. And she’s lectured throughout the world and she has a particular interest in global trauma and training programs. She approaches medicine and her life, and I know this because she and I connect often from this whole body perspective, incorporating all facets of wellness into every aspect. She co-founded the Organic Farmer, a grab and go functional food and juice eatery with delivery available nationwide. That’s so cool. I’ve observed this grow over time. Maybe we’ll have a second to see how that’s doing.

And she practices what she preaches. She starts her day with a meditation, she takes a walk with her pup, and she just does a lot of good work not just for her patients but herself too. So welcome again to New Frontiers Dr. Blum.

Dr. Susan Blum: Oh, that’s such a nice intro. Thank you so much.

Dr. Kara Fitzgerald: Absolutely, my pleasure. It’s just lovely to be with you again.

Dr. Susan Blum: I know, I miss you too. We’re all virtual. We’re all sort in our silos in a way. So it’s nice, it’s great to connect.

Dr. Kara Fitzgerald: Yeah, it is, it is. We’re recording on Zoom so we get to actually look at each other today because it has, it’s been a long time. So you’ve got a lot of focus on the gut because you’re thinking about the immune system. And now you’re really thinking, of course, we’re in the midst of COVID and you’re really thinking about that stress influence. You always have but now more than at any time previous I think it’s central to your thinking as underlying a lot of the chronic conditions that you’re seeing come to your practice and specifically you’re interested in the autonomic nervous system and its involvement versus HPA. Or not versus HPA but in addition to HPA.

Dr. Susan Blum: In addition to.

Dr. Kara Fitzgerald: Yeah. So talk to me about this evolution in thinking and where you’re going with it.

Dr. Susan Blum: Okay, great. So first, thank you for having me here. I’ve been practicing functional medicine for like 20 years which is just amazing, I’m a long hauler, I guess. We’ll use it in that term. But I’ve been taking care of people for a really long time. I have patients that I’ve been taking care of for many, many, many years. And recently, and this past year I’ve sort of been working and my practice has been moving in this direction of having this annual visit where I really… having people come in for a 90 minute review of everything and it’s really struck me that… I mean, this is sort of multi-level is how I ended up, like why I’m so interested in this in this moment.

But a lot of it is in my clinical practice, I’m really seeing these people that I’m treating their gut every year. And the SIBO just won’t go away. And why am I doing another gut box or more herbs and what is still going on if the eating’s okay, the diet’s changed? And so there’s this piece to really trying to understand what’s driving it. And then the other big thing that comes along with that is that I’ve been doing… and I know you’ve done DUTCH tests on here. And so for the past year or two, I’ve been doing a lot of DUTCH tests.

And I love it. For someone who loves the pathways, the biochemistry person in me, it’s just so cool to see all that. But the thing is that it’s only one part of the story. And so what I’ve been thinking about lately-

Dr. Kara Fitzgerald: Let me just throw out for people who aren’t familiar with the DUTCH, we have a ton of content and lots of webinars and posts and all sorts of stuff on the DUTCH. But you’re speaking specifically about the cortisol evaluation, the four point cortisol and the cortisol awakening response, right?

Dr. Susan Blum: Yeah. So you really get a great adrenal cortex assessment of all the corticosteroids. All of them. Actually not aldosterone, which I almost said mineralocorticoid, that’s different. But the rest of the corticosteroids are there. But coming back to my own sense of there’s really something going on here, and then COVID hit. And we’re talking about stress and my opening with everybody is, “How are you doing? What’s going on?” But the reality is that I’ve been thinking about that even up till now because I’ve been sitting with everybody, pondering why are people not fully healing? We are upstream medicine, let’s go upstream. Why is the gut not… the ecosystem not completely healing? What’s still pushing it out of balance? There’s this ecosystem and I believe in the finish what you started. And how are we really going to help someone get to that place where they’re really in balance and they’re just living their life and they don’t need to treat dysbiosis again? And-

Dr. Kara Fitzgerald: I just want to say, because I know you and for anyone who might be thinking, I kind of want to nip this in the bud, that you do know the latest technology and you are looking at the latest probiotics and interventions and pharmaceuticals when appropriate and herbal combinations. The evolution of our…

Dr. Susan Blum: Oh yeah, I’m using medications-

Dr. Kara Fitzgerald: So you know all that and it’s there.

Dr. Susan Blum: And prescriptions, I’m rotating different herbal combinations. So what I want people to understand is you’re treating this. So what I’ve come to understand and because I’ve been doing this a long time, I won’t call myself old but what I’ve learned is that there’s this stress component that is driving a lot of dysfunction or perpetuating some of the imbalances. Oh god, the cat’s here, sorry.

Dr. Kara Fitzgerald: I can see him in the reflection. That’s so cute.

Dr. Susan Blum: Yeah. And so it must be close to her feeding time. And so what I’ve come to realize and also I do a lot of trauma work with the Center of Mind-Body Medicine. I just gave a talk on the autonomic nervous system and I’m reading all this information and I’m thinking, “If you asked… ” And I’ve told this story before, I was giving a lecture for 250 people and it was health professionals and I asked everybody in the audience, “Who here knows that stress is important for their health?” Everybody raised their hands. And I said, “Okay, now, who is actively incorporating that into their practice every day to mitigate how stress comes into your body? Because there are stressors and then there’s how stress comes in and how it comes in and changes our physiology. And who’s practicing something to mitigate that?”

And only like a third of the people raised their hands and these are all of us who know it. And so what I found myself doing this past year with COVID as well as me catching up with all my patients and really looking at their history and how I’ve been taking care of them all these years, is digging in to stress. And so that’s really why I thought to talk about that with you today because I’ve been exploring not just the effects of cortisol which is what we are good at in functional medicine, we do cortisol. That’s why I brought up DUTCH. We understand cortisol, we understand ACTH, HPA axis and how it works and how to assess it and how to treat it, what herbs to use.

We’re in a good way, so to speak, with assessing that. But there’s a whole other system that we don’t talk about-

Dr. Kara Fitzgerald: Yeah, that’s right.

Dr. Susan Blum: And so I’ve just been reminding myself and so I wanted to remind everyone here that there’s another system that’s a big player and that both of these systems, the HPA axis as well as the autonomic nervous system, have direct effect on the gut, on the gut lining integrity, on the gut microbiome, on motility. And what do we talk about in SIBO all the time about motility and everybody’s busy saying, “Okay.” What about norepinephrine that’s being secreted into the tissues in the gut lining? It’s affecting motility. And so there’s all sorts of interesting effects. And so I don’t think we do as good a job as we can in the world of functional medicine in addressing this.

So I’ve been really exploring in my own practice and in my own mind like, “Okay, how are we going to assess this? How am I going to make this part of every visit with everybody and really help them understand and stress with them, stress stress, help them drill into that?” Because people don’t want to do it. They would rather you give them a pill even in a functional medicine place. And so they don’t always want to go there. And how do we help people really realize that you have to go here?

Dr. Kara Fitzgerald: Right. I want to underscore that point. And I actually have a couple thoughts. So we’re going to talk about-

Dr. Susan Blum: Yeah, that was my little rant. So now it’s your turn.

Dr. Kara Fitzgerald: Well on our show notes, folks, I’m going to link to an image of the autonomic nervous system and its involvement in all of our organ systems. Actually if we can specifically find one that’s gut focused-

Dr. Susan Blum: Oh yeah. I have a whole bunch of slides, we can do that.

Dr. Kara Fitzgerald: Perfect. Yeah, I want to just put, so people can get a roadmap to the significance, just a reminder, a lot of folks are clinicians so this is going to be… obviously this is familiar to you but you’ll just have a visual reminder of-

Dr. Susan Blum: Yeah, and I can talk about it a little bit too.

Dr. Kara Fitzgerald: Okay. Perfect. So we want that. And I just want to say my own a-ha around stress because I play a good game around stress and what I’m doing. I know the drill. I have some good self-care habits, I need more self-care habits. But one of the things that a-ha’d me profoundly regarding stress was this research that I’ve been doing into DNA methylation. And one of the ways that we assess biological age like really how old is your body. It may not have anything to do with chronological age, it could be a lot younger or a lot older. But the most rigorous way we assess that is learning at DNA methylation patterns and that’s the first thing that we looked at in our study. We checked biological age and as I’ve been researching and writing about it, the really amazing thing is that 25% of those sites, those DNA methylation sites, are related to stress, a full 25%, boom.

And the other piece that’s interesting is that when you actually pull the thread of what’s going on with some of these genes involved, you see the early life stress experience, the in-utero stress experience, you see mom, you see inherited stress experiencing changing epigenetics. They’re the same genes that then are linked to cognitive decline, cardiovascular disease, et cetera. It’s pretty nuts. And aging. So I mean that was the big bucket of water, the ALS challenge, that really moved me like, “Oh my god, this is everywhere.” So needing more than lip service. So that was a little-

Dr. Susan Blum: No, totally. Needing more than lip service and coming back to children, the adverse childhood events studies, those are those ACES studies on trauma in children. And-

Dr. Kara Fitzgerald: It’s profound.

Dr. Susan Blum: I’m sure it changes their whole methylome and methylation as one of the mechanisms of how they end up having an increased risk of autoimmune disease and we know that trauma has a big effect on long term health and so where really people are studying all of these mechanisms. But in this moment, though, as people here listening and everyone listening are clinicians or they’re taking care of themselves, but there are a lot of clinicians and I think that… well, we always teach, do yourself first. So you have to work with yourself first. And I will say, I’ve had a lot of trauma in the past 10 years and with my kids, all sorts of things. My daughter-in-law suddenly died New Year’s Eve last year. So we’re going on her annual thing this year.

Dr. Kara Fitzgerald: Oh my gosh.

Dr. Susan Blum: And I’m just stating that for the record because I have had reflux all year, me. And I’m doing everything right. And I meditate. But there’s all sorts of other aspects of helping hook into the autonomic nervous system that I want to… so maybe there’s personal aspects of this and my son had… I had a traumatic brain injury kid like 10 years ago. There’s all sorts of ways that I’ve had my own personal experience with how stress and trauma have affected my own health. And so I do know that and maybe that has informed me and why I’m so passionate about it. But I see it now, you know once you see something, you can’t unsee it?

Dr. Kara Fitzgerald: Mm-hmm (affirmative).

Dr. Susan Blum: And so I see it in all my patients now. And so I’ve really been able to make some really good inroads into really repairing and restoring health, finally, with people that are going with me on that journey. And really working on helping them find tools to rebalance either the autonomic nervous system which is a little different than just practicing meditation. So autonomic nervous system has two branches, sympathetic, parasympathetic. Sympathetic is the fight or flight, so we talk about the fight or flight response. And sympathetic are adrenergic nerves that release norepinephrine. And the nerves bathe all your tissues, they innervate your lymphoid organs and all your GALT, it’s everywhere and it releases into tissues.

It doesn’t synapse directly with T cells and B cells but there are receptors on T cells and B cells and it releases just generally and diffuses away throughout the whole lymphoid tissue and into the gut lumen. And interestingly, norepinephrine when released from… so sympathetic nerve innervates every smooth muscle. Because it’s automatic, the autonomic nervous system. And it innervates all your tissues. And so that’s sympathetic, I’ll come back to that in a second and then parasympathetic is acetylcholine, it’s released from the vagus nerve. Actually, there’s more nerves.

So everything starts in the brain stem and the vagus nerve actually travels through the lungs and the diaphragm and down the back, the dorsal, into all the gut and all your tissues too. So it heads down throughout the body, the vagus nerve is called the wanderer, vagus. And that’s the parasympathetic nerve and when it’s engaged, it really triggers parasympathetic’s relaxation system. And parasympathetic actually helps with motility whereas sympathetic freezes the gut.

Dr. Kara Fitzgerald: Sure. Well if you think about it, if you’re fleeing from a tiger, you don’t want to be digesting your food, right?

Dr. Susan Blum: Right. And so it freezes that, it shunts the blood, vasoconstriction. Heart rate, blood pressure, everything goes up, and shunts the blood to the periphery to the muscles so you could run. And so that’s sympathetic nerve and parasympathetic. So when you think about autonomic and we think about treating it and we think about how we help understand how we can help ourselves balance the system, it’s really about you don’t want to be stuck on and you don’t want to be stuck off. Stuck off is called the freeze response in trauma. And so you don’t want to be stuck off either. It’s too much parasympathetic, it’s almost like a POTS, too much parasympathetic. And so you want to have the system, it’s just like everything else, you want to have it turn on when you need it, turn off when you don’t.

Resiliency, on/off, balance. And this is, again, in my old age that I’m really about ecosystem imbalance. It’s not just you can’t just force things, you have to help people find a way to bring the body into balance and the power and the importance of the autonomic nervous system in driving the ability of the body to be in its most resilient balanced state is really important. And so engaging parasympathetic, that’s why breath work is so powerful because when you take a deep breath and you open the bases of your lungs, you tweak the vagus nerve through the diaphragm and it engages parasympathetic. So the sympathetic nerve terminals that end up in the gut, I was reading, this is like the most fascinating thing, you know about the whole thing about iron and siderophores. You know how we talked about that?

So dysbiosis, gram negative rods, those bad bugs that make lipopolysaccharide that we don’t like, they need iron to live and they gobble up iron and they make these siderophores. But our bodies hold on to the iron with lactoferrin and transferrin and it doesn’t let it have it. But what norepinephrine does is it frees up the iron to be gobbled up by the gram-negative rod and so it promotes without… it doesn’t directly stimulate them, it feeds them. And norepinephrine released into the gut lumen will increase dysbiosis. And so there’s just this fascinating stuff. And cortisol has its own direct effects on dysbiosis as well. So both of them are going to really be important.

Dr. Kara Fitzgerald: That’s fascinating, yeah.

Dr. Susan Blum: It’s really awesome. And so we have to do something about it and in functional medicine we’re really trying to help everyone and here we are with… and both norepinephrine and cortisol shift the immune system to TH2 which for those people just understanding TH1 and TH2, TH2 is… these are just T-helper lymphocyte cells that promote humoral immunity. So antibody production. And TH1 is more the T-lymphocytes, the helper cells, that promote cytotoxic T-cells. And that’s more anti-viral. And so if you’re pushing to TH2 which is good for bacteria maybe worms, there’s all sorts of… and it’s more allergy, when you have really TH2 dominant, it’s always like one is pushed at the expense of the other one. And so-

Dr. Kara Fitzgerald: Sure, yeah. And let me just throw out to give some color to that. So adult-onset allergies are huge. I mean, in severe allergies-

Dr. Susan Blum: Huge.

Dr. Kara Fitzgerald: We’re not talking a delayed hypersensitivity to dairy where you’ve got the sniffles. We’re talking up to full anaphylaxis and that’s because digestion is shut down and so these large proteins are foreign to the gut. So the immune system, our ability to break stuff down, if we’re in sympathetic is really inhibited and it becomes problematic. And layer into that, antacids, the acid blocking therapy and you just sort of turn the volume up on that big time. But that’s a really good point.

Dr. Susan Blum: And so here we are and everybody’s taking herbs and zinc and vitamin C and we’re doing all this reporting and great stuff we’re all posting and we’re trying to educate our patients about good supplements to take during COVID. But if you’re walking around and bathing your immune system in catecholamines and if you’re really in an “on” sympathetic state in addition to an “on” HPA axis state, cortisol and norepinephrine, both of them, you’re going to really be shifting your body away from being able to fight the virus. And so I just want people to really wake up to the importance of this. You and I, we’re upstream medicine people. And at the end of the day, we have to address this. And so coming into clinical practice then, this is a conversation to have with everybody, every, every, everybody. And I make sure to make time for it and this is also where health coaching comes in to really help people and to give people resources and hook them up with what they need. But our job is to educate people so that they understand how this is affecting them.

Dr. Kara Fitzgerald: So you see folks failing, you’ve done all the sophisticated intervention-

Dr. Susan Blum: Wait a minute. I don’t want to say they’re failing.

Dr. Kara Fitzgerald: Yeah, yeah, yeah. Sorry, sorry, sorry. That’s strong but-

Dr. Susan Blum: Really what happens is we’ve gone from they were a mess and I always use football analogies. My father raised girls before he finally had his fourth son and so we did a lot of football but if you’re moving the football down the field, somebody comes in, we move the football all the way to the five yard line. But there’s something that is causing them to keep getting recurring symptoms like something is just not… we’re not finishing it. It’s like the finish what you started. People are feeling so much better. I mean, they’re still coming back, otherwise I would have lost them a long time ago. So we’re really helping people feel better and better.

But they’re still having relapses and there’s just something that still is causing them to relapse. They’ll do good for a while and then they’ll relapse. And so yes, now you can finish what you were going to say. But I just wanted to clarify, I didn’t mean to make it sounds like they’re failing. It’s just this is me going, “Why are they relapsing again? I haven’t seen them maybe for a year and now they’re back because they’re having symptoms again.”

Dr. Kara Fitzgerald: Yeah. So I’m thinking about your own journey because you shared the facts that you were struggling with reflux and, I mean, you’ve just had some really significant trauma over the last decade. But in your patients, just in general, what are some of the things, what are some of the clinical pictures that are going to flag you towards autonomic nervous dysregulation besides just, “Okay, you’re 90% better but this really refractory 10%,” but what else?

Dr. Susan Blum: Good question. So what do people look like that have a catecholamine imbalance, right? And so you know when somebody comes in who’s really fatigued? So you’ve got someone you’re working up fatigue. There are people who have a low energy, low mood fatigue. They’re just flat. Really low energy, low mood. Catecholamines are really important nerve transmitters. You’re doing the work-up for fatigue and you see they have adrenal fatigue and you’re talking to this person, we have relationships and you’re interviewing them and you see that they’re depressed, low energy, you really might want to think about catecholamine depletion as an issue, like low catecholamines because the sympathetic system has been burnt out from you have adrenal fatigue, you have burnout from cortisol, you can also get burnout from catecholamines.

Dr. Kara Fitzgerald: Mostly you’re leaning on norepinephrine or are you thinking about epinephrine, dopamine, I mean-

Dr. Susan Blum: Yeah. You need to measure all of them. And so clinical is the first thing. So you have a sign about it clinically if they’re low. And so it’s very hard to evaluate it clinically. And so I think my two main ways I would do that is in organic acids. You can get the HVA and VMA which are the metabolites of dopamine and norepinephrine/epinephrine. And if the metabolites are really low and sometimes one’s high and one’s low which is a different thing which we can talk about in a minute. But you can definitely get that. I mean, I do organic acids on everybody. So I’m always looking at VMA and HVA. A lot of times I see it’s high.

And so you can see if it’s high, they might be just having a high output situation. So right there you can see if it’s high, you can see if it’s low. If they’re both low you can look at there’s nutrients that are important, B6, copper, vitamin C, you need COMT to be working, catechol-O-methyltransferase. So you can do more work to assess the system into giving the vitamins, certainly they need to see if it would pick up. But if they have fatigue and they have low mood, you can think catecholamines. And one of the ways, the things I do as a conventional doc, is I’ll do a 24-hour urine for the metanephrine and the normetanephrine which are… it’s just 24-hour urine for the catecholamines.

Dr. Kara Fitzgerald: Yeah, and those are additional intermediates beyond… actually VMA and HVA, I think are really at the end of the road in those-

Dr. Susan Blum: Right. And then normetanephrine and metanephrine, I think that’s actually straight from epinephrine and norepinephrine.

Dr. Kara Fitzgerald: And they’re in between, yeah.

Dr. Susan Blum: That’s the one that you measure if you think someone has a pheochromocytoma. I mean, that’s the classic, in medicine, where you’re looking for high output catecholamines.

Dr. Kara Fitzgerald: Because of a tumor.

Dr. Susan Blum: Because of a tumor. Thank you. And so, yes, you can do a 24-hour urine conventional medicine or you have do a 24-hour urine which is actually helpful because you can look at total output that way. And so you can do a screening that way. And then in terms of people who are, you can tell how stressed they are, think of the people who are having palpitations, think of the people who are having… they’re telling you they’re not sleeping, their heart rate’s up, they’re having a lot of anxiety. They could be in just a high output catecholamine state. And seriously, you can’t give them really medication for that. It’s stress stuff so sure, we could do CBD and teach them… and we’re going to talk about mind-body medicine because that’s really important. But I’m saying in terms of functional medicine, it’s not we have a blocker for the adrenergic receptors. You have to really help people practice something to turn off their stress response. Which brings us to mind-body medicine and I will say that-

Dr. Kara Fitzgerald: Let me just ask you, so as you’re talking about blockers, of course, I’m thinking about Mother’s Little Helpers, Valium and the benzos and so forth that some clinicians would turn to. It just made me think of addiction because, obviously, that’s going to be a huge concern with going in that direction to manage stress. And I mean, are you seeing in this population, addiction happening as well?

Dr. Susan Blum: Not really.

Dr. Kara Fitzgerald: Okay.

Dr. Susan Blum: But look, my population, I’m in a suburb of New York City. So-

Dr. Kara Fitzgerald: And I don’t mean addiction like Valium, maybe…

Dr. Susan Blum: Oh, like I’m taking my Xanax and I can’t stop.

Dr. Kara Fitzgerald: No, or just eating too much or just like using a compulsive behavior to mask over the sympathetic overdrive? I’m watching TV or I’m addicted to-

Dr. Susan Blum: I would say yes, sometimes, for sure. I actually had a patient yesterday who I’ve been seeing for several years. And she is just like wired up and anxious and worries about everything and stressed about everything. And she’s definitely just taking Xanax every night to sleep. And she expresses that she’d like to get off of it. But she just can’t. And that sometimes she works herself up into palpitations and I did her organic acids and she definitely has high both. She’s high for both. And so I think she’s got a high output sympathetic drive. We made a plan for how she’s going to address that and so somebody like that and so was there a part two to your question though? Because I don’t want to move on-

Dr. Kara Fitzgerald: No. But well my new part is I’m curious how you’re approaching this but I know we’re going to get there so just keep-

Dr. Susan Blum: Yeah. Well because for someone like that, so I do whatever I can… I try everything and so I did actually, for her, what we did was have her taking CBD in the late afternoon at 4:00 before she gets into the evening to see if she doesn’t need it because a lot of it’s behavior modification. We talked about what her evenings are like, she’s got little kids at home. By the time she lands in bed, she just needs something, she’s like all wired up. And so starting the wind down, some of it’s just about real good old fashioned behavior modification which really coaches are great… and I’m having her follow up with my coach to make sure that she gets ongoing feedback to keep her going with that.

And she already messaged that she tried it yesterday and it was great. Taking something earlier to blunt the acceleration of her anxiety as it heads into the evening. And so, yes, behavior modification, I think, this is where some GABA, the pharma GABA chewables and some theanine and CBD to help people start some of that relaxation process into the evening. And winding down at night for her. The morning meditation, I tend to work with people with more morning meditation or morning practice. But for her, she needed something to manage her evening-

Dr. Kara Fitzgerald: Well, as a mom with a toddler, it’s funny. I have a neighbor who’s got two toddlers and I saw her the other day and she’s absolutely looks beautiful. She’s been just engaged in all sorts of good self-care but I was talking to her about it and she said to me, “Yep.” She was talking to me about the clean diet and all of this and it was great. But she goes, “By the way, Kara, I’m not giving up my wine.” And that was-

Dr. Susan Blum: Well right. And I have found a lot of my patients during the pandemic, they did that for a little while. But now they’re all back. They sort of pulled themselves back up by their bootstraps. But I do want to say, lately I’ve been enamored with heart math.

Dr. Kara Fitzgerald: Okay, good.

Dr. Susan Blum: And the reason why I want to bring that up is because one of the things I really like about it, so the thing about autonomic nervous system, heart rate variability, this is like sympathetic hard wiring into the-

Dr. Kara Fitzgerald: Can you just define it, talk about what heart math is and just a little definition.

Dr. Susan Blum: Yes. Okay, it’s been around for a long time. And heart math is a biofeedback gizmo that you can do to help even out your heart rhythm. And it turns out that when you’re stressed, so your autonomic nervous system is very central to running your whole heart rate and your heart rhythm. And there’s something called entrainment that happens where your heart rate variability… it’s actually where it’s more variable but in a really good way. It’s even and variable. And that’s a sign of relaxation actually and that when you’re not in this rhythmic state, and you have low heart rate variability, it’s just sort of very erratic, your heart rate. It’s not an EKG, it’s like a different kind of measure. Your EKG is fine, this is just some other kind of a way of measuring your heart rate.

And so what you can do is it’s like an exercise, it’s a little gizmo you get, you put it on your finger and Bluetooth it to your phone and you just follow the instructions. And you do it like 10 minutes, And they ask you to imagine something that makes you feel good. So it helps you make the connection between how you feel and your body’s sympathetic nervous system. And so you can see the rhythm as it’s telling you to think good thoughts or gives you different prompts. And the computer on the gizmo will respond to how you’re doing and give you prompts. And you practice and with practice you end up helping your heart rate get into that really good stage of heart rate variability. And when it’s in that good stage, you know your sympathetic nervous system is smooth and more in balance. The sympathetic nervous system, which is this automatic, we always thought it was automatic in that past, your heart rate.

We know that we can actually have an influence. And so how do you take something voluntary and influence something we thought was involuntary? And there’s that place where that intersects. And so that’s one of the reasons I like heart math for this idea of the people with the autonomic imbalances because they really… and for people who need a gizmo. There are people who just, the idea of meditation… and I say the word meditation but there’s so many apps out there. You just have to plug in and listen to someone tell you what to do. It’s like breathing exercises or other visual things, imagine where the tension is in your body. There’s all different ways to promote a relaxation response through these mind-body medicine tools like guided visualization and imagery. But the gizmo thing is an interesting way to really work, to really get a direct intersection into the autonomics.

Dr. Kara Fitzgerald: Yeah, that makes-

Dr. Susan Blum: Does that make sense?

Dr. Kara Fitzgerald: Sense. Oh yeah, it’s great. Well because you had opened up our conversation with a little provocative comment around needing something more than meditation. I can’t remember exactly what you said but-

Dr. Susan Blum: Yep, some people do.

Dr. Kara Fitzgerald: This supplies a little bit more information. Yeah, I’m wearing an Oura ring these days, which I really love. And this tracks heart rate variability too and I like having it except that it’s passively tracking it where heart math, we prescribe the inner balance app with the earbuds.

Dr. Susan Blum: Yeah, that’s what it is. The inner balance app.

Dr. Kara Fitzgerald: And one is actively engaged in it for those sessions. You’re just really actively participating in your own transformation and thinking about gut where we started this conversation and we’ll surely circle back, I mean, one could track those two. And I’m sure you’ve had people track their heart rate variability, their response to heart math, and their SIBO symptoms or IBS and-

Dr. Susan Blum: Absolutely. My gut people, once I get them practicing, and meditation’s fine too for them. Not everybody really needs real hardcore intervention for the autonomic. Sometimes really meditation is enough or the app that they start practicing every morning or knitting or something that brings you to this moment and involves breathing. And so you have to be in this moment and you have to be doing deep breathing in some way. And so it could be yoga and it could be just yoga pranayama, it could be stretching and breathing every morning. I try to really figure out what’s going to work for each person. You don’t have to do heart math. And so depending on how somebody’s particular circumstance, it’s a prescription. You have to help figure out what’s going to work best and you take into account that person and whether they are resistant, they’re like, “I can’t do meditation.”

I personally love meditation and I’m actually (taking) this new Tibetan meditation course. And I have this guy I turn on on my laptop every morning for 10, 15 minutes and I’m following new instructions and it’s sort of fun to do something different. But you have to find some way every day of engaging parasympathetic, you have to. And it’s not enough to go workout and it’s not enough, necessarily, to just read a book. I mean, you might turn off the sympathetic if you read a book but you really want to actively engage parasympathetic. And especially if you know that stress is having an effect on your health.

And I would say from a preventive medicine perspective, you have to prevent it from having an effect on your health and especially right now we’re all living in the land of we’re making sure we can fight viruses really good, you have to make sure you’re not living in sympathetic and you’re not living in high cortisol land as I say to my patients. And so I guess I just really want to encourage people to also measure… cortisol might look fine. But they might actually be in sympathetic and the adrenals, when you do the DUTCH, it actually looks fine. So when you do the DUTCH complete or any kind of organic acid, you take a look at that VMA and HVA and the person’s symptoms. Is this your insomnia people, is this your menopausal woman who’s getting hot flashes all the time?

There’s all sorts of reasons why this might be something that… and sometimes you might change much of what you do other than really make it clear that you think this is contributing to someone’s symptoms, for yourself and for the patient. And then find tools, every clinician needs tools in their toolkit for how to prescribe or refer them to someone who can help them. And so, I think that we educate. What do we spend all our time doing in our clinical visits is educating. And so my job is to connect those dots for people. I really want to educate you about this is what I think is going on. And we really have to do something about this.

Dr. Kara Fitzgerald: Yeah, right, right. And I guess I’m thinking of some of my patients who’ve been with me for the long haul and they might not have either achieved the goals quite that they’ve set out. I’m thinking of one woman who was impeccable with all of our interventions, took the train to New York City every day, is a lawyer and raising kids, single mom. Pretty tough existence.

Dr. Susan Blum: Yeah, there is no way she is not having stressors. So this is the thing you have to understand, everyone has stressors.

Dr. Kara Fitzgerald: And so for her, it was more that… I mean, she ended up just moving into the city, that was her stress release because she didn’t have to do that massive commute anymore and now she can walk to work and that was the game changer for her. So the last straw for her was she couldn’t lose weight, her numbers were fabulous, her inflammation was beautiful, her diet was dialed in, et cetera. But she just hung on to her pounds because of just the stress overdrive.

Dr. Susan Blum: You know you can’t lose weight when you’re bathing yourself in high cortisol for sure.

Dr. Kara Fitzgerald: Right. And so that was the turnaround. So it’s brainstorming unique to whatever the situation is.

Dr. Susan Blum: Look, I’m not saying we should blame stress for everything. That’s certainly an easy out, “Oh, it’s just stress.” And I’m not telling anyone to do that. But it’s part of the matrix. It’s part of where we go. Actually, I’ll put it more as a mediator on the matrix. It’s a… yeah?

Dr. Kara Fitzgerald: Well I think it is. I think we pay it good lip service. I mean, it is, it’s on the matrix, it sits in the middle, the mental-emotional piece. Or at least it’s central to the matrix and influences all of the nodes but no, I think-

Dr. Susan Blum: But are we doing good enough in our treatment?

Dr. Kara Fitzgerald: No, I agree with you. I don’t think you’re shirking your responsibility as a functional medicine deep thinker. I mean, you know how to practice medicine really well and this is where you’re landing.

Dr. Susan Blum: Thank you. I’m just-

Dr. Kara Fitzgerald: You know how to do it.

Dr. Susan Blum: I’m just clarifying for people that, in this moment, this is what I felt like talking about today because I have done everything else and I know how to do everything else.

Dr. Kara Fitzgerald: Well let me ask you …

Dr. Susan Blum: And I have to do this too, it’s just do this too. It’s like you have to do this also. That’s all.

Dr. Kara Fitzgerald: Well I have a couple questions for you, I do want to ask about COVID because what you started our conversation with was that if you’re bathed in stress, you’re effectively shutting your immune system down. Not only that, but in the gastrointestinal tract, and I’m sure if we go scour the literature, we’ll see it elsewhere where we’re liberating iron for microbe proliferation if you’re in sympathetic-

Dr. Susan Blum: And we’re decreasing motility-

Dr. Kara Fitzgerald: Overdrive.

Dr. Susan Blum: So for you SIBO people, we’ve got a problem with that.

Dr. Kara Fitzgerald: So we’re not able to fight anything going on in the gut. But you also sent an interesting… actually a really cool paper to me about stress being an essential mediator to virally induced autoimmunity. And I thought that was very compelling. So, again, we always pay a lip service to stress. But these authors were hypothesizing that, in fact, we’re anxious about viruses. Of course we’re very anxious right now about COVID, we’re seeing long haul patients in our practice, people who aren’t able to completely clear COVID and they’ve got just a basket of pretty terrible symptoms. And this hypothesis is pretty compelling that you sent me.

Dr. Susan Blum: Yeah and this is what you and I have been dealing with all these years in terms of autoimmunity and stealth viruses and chronic infections and why are we living in a world of we have an epidemic of autoimmunity and we have an epidemic of chronic infections. And we don’t even know how to measure half of them, we can’t even find them. I have this one patient that comes in, she’s actually a biologist who travels around the world looking at soil in like third world countries for the microbes. She ended up with mixed connective tissue autoimmunity because she had terrible pain and inflammation. No one ever figured out anything about it and it was after one of her trips, she came home and was never the same. And I’m like, “You picked something up in Africa. I can’t figure out what it is. I know that’s what happened.” There’s just something. I tested everything that I could find in the lab that we test for and I could never find the infection.

I’m definitely not actually saying I think this was stress. I do think some people have a genetic predisposition, perhaps to why can’t some people clear out viruses and others can? And maybe it comes back to methylation and childhood trauma. I mean, I don’t know. Maybe there is some defect in general immune cellular immunity which is what helps get viruses out and then the TH1 system. But it is true that stress will not help this.

Dr. Kara Fitzgerald: Yeah, that’s right.

Dr. Susan Blum: And so if we’re trying to just help people fight what we think are the self-infections that they’re still struggling to clear out as part of the we got to help your immune system. And this is actually step two in my first book, The Immune System Recovery Plan is all about the effect of stress. And in that book, I talked about, for infections, you have to have a healthy immune system. You’ve got to do everything you can to help the immune system clear it out because we can’t always find the infection and treat it. And your podcast is called Frontiers, I think the final frontier in medicine, or one of them, certainly we can all say we have our own favorite one, is that we don’t know how to treat viruses. Here we are. Viruses invade the immune system, they live, they persist in our body and we don’t have any antiviral medication that works.

Dr. Kara Fitzgerald: Yeah, or very limited. That’s right. Interesting hypothesis you mentioned.

Dr. Susan Blum: And with autoimmunity and now this long haul COVID, I’m worried about it too.

Dr. Kara Fitzgerald: Sure. But to tie it back, as one of the papers you sent over to me, folks, I will link to all of these papers on the show notes. But this one is Temajo and Howard. They say an intrinsic prerequisite to autoimmunity is viral illness, is… excuse me, stress is an intrinsic prerequisite to viral triggered autoimmunity. So I just want to circle us back there. So we may not have a great arsenal at addressing viruses but we can improve resilience.

Dr. Susan Blum: We can improve resilience, I love that word. And that’s sort of where I say to my patients where we do the history and it’s so clear for autoimmune people that stress was the last trigger before this all happened. And I think of stress as the camel’s back. So we have all the antecedents, they’re set up, perhaps they’re all set up, there’s a microbiome issue where they have an infection or something. But then some big stressor comes on, autoimmunity started after their parent died after a long illness. The autoimmunity started after there was a death and something major happened, a trauma, and then they got sick.

And so I think that that’s why I love that article because that’s one of my favorite sayings is the stress is the straw that broke the camel’s back. And then out it came. And if we believe that viruses are the root of all autoimmunity, which I don’t know that we know that now, but if that’s true then what it means is we have to do everything we can to keep our immune surveillance and our resiliency and our immune system functioning at its tippy top.

Dr. Kara Fitzgerald: Yeah, that’s right.

Dr. Susan Blum: And in order to do that, you have to understand where you’re at with your stress system and how it’s functioning, are you in hyper drive, are you burned out, on either system. And there’s two systems, there’s autonomic system and there’s the HP axis. Don’t forget about the autonomic nervous system.

Dr. Kara Fitzgerald: That’s right. I agree with you. Really good. So what else do I… okay, so I wanted to ask you a little bit about what some of the interventions… you’ve practiced good self-care in stress management. But you also live a big life, you have a big practice, you do a lot, you’ve written books, we were just talking about-

Dr. Susan Blum: I know, I’m exhausted thinking about it.

Dr. Kara Fitzgerald: I know. Sue-

Dr. Susan Blum: And I don’t always do good, that’s what I’m saying. I’ve had episodes of health issues that I keep writing books about. So I had episcleritis and some arthritis in my hands. That was after my son’s… the head injury, he had the traumatic brain injury and so all the stress that, for me, I developed inflammatory and some joint pain. And so that I had to embark on. So, what happens is, under times of stress for myself, and this is true for a lot of people, you fall off the wagon and I stopped meditating every day and I wasn’t doing all the things that I needed to do. And so I have to say during this pandemic, I have been on my cushion every morning. I really have made this huge commitment to my meditation practice which I’ve been doing for 25 years.

So I’m a long term, thankfully, meditator. But on and off, right? And so I have had to really, really take myself in hand and make myself because I knew with the trauma… and so we had a big family trauma a month before COVID. And then we slipped into COVID. And so it’s been tough, it’s been really tough. And then, of course, I’m running a business and the whole medical practice and I had to pivot and try…

Dr. Kara Fitzgerald: You had a big brick and mortar..

Dr. Susan Blum: I had a really big year. As I like to say, I’ve been in a blender for the year. And it’s been really tough. And so I did EMDR with a therapist. I love EMDR for trauma-

Dr. Kara Fitzgerald: We’ll link to a page about EMDR

Dr. Susan Blum: I went and got myself… I went back to an old therapist I used from when I needed her before. And I started doing that before lockdown and then we continued telemedicine and actually she sent me the buzzers and we were doing it from home. And so I said, “Susan, you’re not going to get sick again.” And I did acupuncture which is amazing as an option for balancing the HPA axis and balancing the autonomic nervous system. I think acupuncture is a great way, let someone help you.

So I did acupuncture like consistently through the whole thing. I think I broke it for a couple months in the hardcore part of the pandemic. But my acupuncturist is really, really safe and so I’m back to seeing her again. I did acupuncture, I did EMDR, and had a therapist to support me. And I made sure I stayed on my cushion and meditated and got out in nature at least twice a week for two hours in the preserve, twice a week. As well as just walking. But I had a couple of solid pandemic buddy girlfriends. So this is me. This is like I stepped it up big. And honestly my reflux, I stopped drinking coffee and sparkling water. Two things that I was living home then and drinking too much coffee and too much sparkling water.

And I’m intermittent fasting so I was drinking coffee on an empty stomach and I just stopped that. And actually my reflux is better. So I don’t know if that was so much stress related all though I’m sure it still was. Even with all that, I still ended up having reflux but I did a stool test and my stool test was pretty much fine. I have a history of SIBO in the past, mild, and so I was afraid it came back but it didn’t but I was at risk. And so I took it all very, very seriously and I did all those things. And I’m okay. So my reflux is now under control but I had to stop drinking coffee. And who knew that mineral water, which I then, because I was home, was drinking all day during the pandemic, the bubbles, that that would have a big effect.

Dr. Kara Fitzgerald: It’s a really difficult time.

Dr. Susan Blum: It’s a really difficult time and so I talk about myself but you said, “What are the things?”

Dr. Kara Fitzgerald: No, people want to know. In fact, if you can send us a link to the meditation work that you’re doing, I’d-

Dr. Susan Blum: Oh yeah, there’s this really, really cool-

Dr. Kara Fitzgerald: People will be asking about that.

Dr. Susan Blum: Really cool, it’s a Tibetan Buddhist. So yeah, my cousin is one of my angels and so she’s a Buddhist monk and so she sent me this course and said, “Do this.” And I said, “Okay.” So because, in the past during times of intense stress, it did end up affecting me more. This time I worked really hard and I really am okay. But maybe this is why I feel passionate about this message right now. But also I’ve seen reflected everyone’s… I’m not alone. We have a collective trauma right now. And not only… and I do all this trauma work for the Center of Mind-Body Medicine. I mean, we’re at Marjorie Stoneman Douglas in Florida and after the shooting and all the wildfires, we were in all sorts of places where people really, really stressed. And so we all just have to find our own tools that work for us. And so the kinds of tools that we do are, so like I said, you can get outside people.

So there’s EMDR, there’s all sorts of other techniques therapists have. I like somatic experience therapists. They help you work through how your body might be holding stress and trauma. You have given me a really good website to this… I’ve got to find the name of it, Kara, what was the name of that one? Where is that?

Dr. Kara Fitzgerald: It’s DNRS.

Dr. Susan Blum: Yeah. And so there’s various programs. So the simplest thing is to teach your patients to ask them what they want to do. What do you like? And as a clinician, I think you should just try things yourself because if you have your own practice and you learn for yourself that this is so important for you, it’ll help you share that with people.

Dr. Kara Fitzgerald: So yeah, there are many tools out there. I think you’ve just mentioned a handful of really good ones. And then just simple at home stuff like breathing, as you said, or just a simple meditation. There’s so, so, so many resources. But we are…. yeah.

Dr. Susan Blum: No, I was just going to say the main thing is you need to make a time every day and a place where you’re going to do it, it takes 60 days or something to make a new habit. Whatever that saying is. You need to just create a new habit. And so you wake up in the morning, I get my green tea, and I go sit. And so maybe for you it’s at night, or maybe it’s at 4:00. Whatever works for you, but you need to set a specific time every day and you need a place because then you could put stuff there and you just go and sit. And it just is more inviting and it makes it easier. And so I think you have to create this habit. And so whatever it is you decide to do when you’re sitting there in your meditation corner, whatever app you use, whatever you choose to do there, I think you need to have a time and a place and do it consistently, whatever it is.

There’s Calm app, there’s Insight meditation, there’s Headspace, there’s all sorts of apps that people use, there’s online meditation classes. We have meditation classes our teachers teach at Blum Center. We have regular time slots for our patients for free. They can just log in and do it. And so I think we all just have to walk our talk and then it’ll be easy to teach it or to help people know what to do.

Dr. Kara Fitzgerald: Yeah. And I think now is definitely, definitely the time, as we’re-

Dr. Susan Blum: And now is the time. We’re all home.

Dr. Kara Fitzgerald: Months into the pandemic.

Dr. Susan Blum: And we’ll be home another three or four months.

Dr. Kara Fitzgerald: For over a year.

Dr. Susan Blum: Right? How long do you think we’ll be home? Summer, right?

Dr. Kara Fitzgerald: Yeah.

Dr. Susan Blum: Late spring.

Dr. Kara Fitzgerald: Well and so beyond that, beyond our immediate impact, of course, we’re seeing the impact of the other countries and the food shortages and all of that whole massive economic hit which we’ve been talking about here at our practice because we’ve been thinking about how we should donate. I mean, there’s just been so much trauma here in the US. I mean, political trauma and then we go headlong into-

Dr. Susan Blum: It’s huge.

Dr. Kara Fitzgerald: Yeah. Layers and layers and layers. This is was the absolute appropriate conversation for us to be having today.

Dr. Susan Blum: I think because you know how I was saying we don’t know the long-term repercussions of COVID in terms of persisters, long haulers, people who got it and have some persistent symptoms. I mean, autoimmunity is an epidemic now but we could really see because really serious chronic inflammatory diseases spike in the next year or two. Especially as people are coming out of this collective trauma and stress that they’re all experiencing.

Dr. Kara Fitzgerald: That’s right. And we are already seeing an increase in autoantibodies associated with COVID, unequivocally it is. And so-

Dr. Susan Blum: And there’s plenty of smart minds out there talking about… you amongst others, all the articles you’ve written which have been great, co-written with people about ways to support immunity. But I just wanted to highlight this so that people don’t forget the importance of this too.

Dr. Kara Fitzgerald: Well very lovely to connect with you on this. And it actually felt really good to have this conversation. I felt like I’m in a nice parasympathetic place.

Dr. Susan Blum: Exactly.

Dr. Kara Fitzgerald: A gentle conversation.

Dr. Susan Blum: You know what? It’s just like real talk, it’s real talk which is my new motto.

Dr. Kara Fitzgerald: Lovely, lovely to have you as always.

Dr. Susan Blum: Thank you. Lovely to be here.

Dr. Kara Fitzgerald: To be continued. Thanks so much for joining me today, Dr. Blum.

Dr. Susan Blum: Thank you, Kara.

Dr. Kara Fitzgerald:  And that wraps up another amazing conversation with a great mind in functional medicine. I am so glad that you could join me. None of this would be possible, through the years, without our generous, wonderful sponsors, including Integrative Therapeutics, Metagenics, and Biotics. These are companies that I trust, and I use with my patients, every single day. Visit them at IntegativePro.com, BioticsResearch.com, and Metagenics.com. Please tell them that I sent you and thank them for making New Frontiers in Functional Medicine possible.

And one more thing? Leave a review and a thumbs-up on iTunes or Soundcloud or wherever you’re hearing my voice. These kinds of comments will promote New Frontiers in Functional Medicine getting the word on functional medicine out there to greater community. And for that, I thank you.

Susan Blum, MD, MPH an Assistant Clinical Professor in the Department of Preventive Medicine at the Icahn School of Medicine at Mount Sinai, has been treating, healing and preventing chronic diseases for nearly two decades. A Preventive Medicine and Chronic Disease Specialist, Dr. Blum is the Founder and Director of Blum Center for Health in Rye Brook, New York, where she leads a multi-specialty team of physicians, nurse practitioners, nutritionists and health coaches, all providing cutting edge Functional and Integrative Medicine services.

In her first best-selling book, The Immune System Recovery Plan (Scribner; 2013), Dr. Blum offers her four-step program, which she has used to help thousands of patients recover from autoimmune and immune-related conditions without medication. Dr. Blum’s second book, Healing Arthritis (Scribner; 2017) offers a ground-breaking approach to helping arthritis sufferers reverse and heal this condition.

Dr. Blum is Board Certified in Preventive Medicine and Certified in both Functional Medicine and Integrative and Holistic Medicine. She is a member of the Medical Advisory Board for The Dr. Oz Show, the Institute for Integrative Nutrition, and is Senior Teaching Faculty with the Center for Mind-Body Medicine in Washington, D.C. and teaches throughout the world in their Global trauma and training programs.

Dr. Blum approaches medicine—and her life—from a whole-body perspective, incorporating all facets of wellness into every aspect. Following her passion for nutrition, she co-founded Organic Pharmer, a grab-and-go, functional food and juice eatery, with delivery available nationwide, and puts these principles into practice by beginning each day with a 20-minute meditation, a green smoothie made from the contents of her garden and a walk on her country road with her dog, Trixie.

New Frontiers podcast: Arthritis – exploring oxidative stress, microbes, gut permeability and more with Dr. Susan Blum

Book: Healing Arthritis, by Susan Blum

Book: The Immune System Recovery Plan, by Susan Blum

Stress & Viruses paper: The mosaic of environment involvement in autoimmunity; Temajo and Howard

Autonomic Nervous System *slide deck

Soft Belly Meditation

Fully Being: Comprehensive course from Tsoknyi Rinpoche (Tibetan Buddhism)

DrKF FxMed Resources

DrKF FxMed Clinic: Patient consults with DrKF physicians

Clinician Professional Development: DrKF FxMed Clinic Immersion

DrKF FxMed Nutritional Residency Program