Past Lectures

Thursday
January 13 2022

Thursday, January 13, 2022, 12:00 PM 2:00 PM

Virtual Event Broadcasting live
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Past Lectures

June 14, 2023 | When Your Patient Wants Their Immune System ‘Boosted’, Part II Panel Discussion with:

M. Patricia George, MD, National Jewish Health
Elizabeth Devon Smith, PhD, National Jewish Health
Lata Shirname-More, PhD, Instructor, SKY Breath Meditation and Healing Breaths, Art of Living Foundation
Gary Soffer, MD, Yale University School of Medicine

Good morning, everyone. Welcome to this special edition of Denver Allergy Rounds. Of course,

the continuation of the William Silver's Integrative Allergy Immunology Respiratory Wellness program,

the second part being our panel discussion today. Hopefully, you were able to join us

last week for our excellent discussion presentation last week by one of our panelists today, Dr.

Gary Suffer, who we'll introduce here in just a minute. Briefly, as we heard a little bit about

last week, but just to remind us all, the Integrative Allergy Immunology Respiratory

Wellness program, or AIR, if you didn't catch the acronym there, really is an effort, of course,

led by Dr. Silvers, who we're happy to have join us again today. I think everybody enjoyed

getting together with you and seeing you last week, Bill, so welcome and thank you for joining

us. Thank you for your support of this program, of course, now in its third year. It meant to

really shine the light, I think, on an area of medicine that doesn't always get a lot of attention

and help us all integrate into our practices, integrative medicine in a variety of different

ways. I think very often what we found over the last few years of being involved with the program

that there's a lot of different ways that integrative medicine can fit into our practice.

It's not always obvious. It might not always seem like integrative medicine, and so that's part of

one of the goals of the discussion today is to try to help us all see where we can include

integrative medicine, where we can promote it, I think, and how it can really be a benefit for

ourselves and for our patients, so certainly look forward to that discussion. Also, a very practical

often way to find resources or to help connect people who are looking for certain things,

certain resources for their patients, so feel free when we get to the question and answer session

and the discussion among the panel, if you have a very practical question that seems mundane perhaps

or how do I do this or what's a good source for that, please do jump in and ask those questions

because those are very useful and practical things for sure. With the Zoom session in this

format, I believe you should be able to raise your hand and we'll be able to unmute you or

you'll be able to unmute yourself, but when we get to that, feel free to chime in with questions as we

after we introduce the panelists here, and so I apologize for not introducing myself. I'm B.J.

Lancer. I'm one of the pediatric allergists here. I'm in charge of the fellowship program and

have been working closely with Aimeen Wang and Flavia Hoyt and, you know, Jess Huey as well,

both on the Denver allergy round side of things and then also coordinating the integrative medicine

panel. So I'll be moderating today and it's my pleasure to introduce our panelists. So first up,

you recognize of course from our session last week, Gary Suffer received his medical degree

at Tel Aviv University in Israel and completed training in pediatrics, pediatric allergy and

immunology both at the Children's Hospital at Montefiore in New York at the Albert Einstein

College of Medicine and then he did a second fellowship in integrative medicine at the

University of Arizona, a program which we heard about of course last year and certainly one of

the reasons why he's here with us for this session this year. Interested in food allergies,

mind and body medicine, eczema, asthma, of course environmental allergies and a variety of other

conditions. Gary, wonderful talk last week and thank you for joining us. As many folks know,

my interest is in food allergy as well and I think there are some interesting ways and some

variety of different aspects of tying together potentially integrative medicine or integrative

techniques into a food allergy practice and if you maybe want to touch a little bit on some of those

areas and where we could be thinking perhaps of how to benefit our patients when we're food

challenging or you know just taking care of food allergy in general. Yeah, you know there's lots

of aspects to integrative medicine but I think one of the most powerful ones is how we change

the experience of a disease, not necessarily the disease course itself. You know I think BJ,

I deal with a lot with food allergies, probably not as much as you, but I have kids who are coming

in who don't even pay mind to their food allergies. They're safe, they're careful,

they carry their EpiPen and then that runs the spectrum to kids that I'm seeing with you know

as severe as avoidant restrictive food intake disorder which is a you know I call it up and

coming but it's a much more prevalent food eating disorder that we're seeing more and more now

and so how do we support the kid? How do we create an environment that they're both cautious and smart

but not paralyzed by fear and I think integrative medicine gives a lot of space for that whether

that's with mind body medicine or other mental health support services that we have. You know

we just published it just came out published a paper on the role of child life in the in the

allergy and immunology clinic and I see that you know I see that very much as integrative medicine

because we're really thinking holistically about the person. We're thinking holistically about the

patient. The other aspect of this that I think is really important to mention is that I once

asked an integrative practitioner how she takes care of kids and she said I always treat the

parents first and you know I think I've surprised but pleasantly surprised a number of parents

by suggesting that they get mental health support during this process as well and the

transformation just by the parents themselves getting that mental health support both in the

parent and the child has been incredibly meaningful and has really allowed us to do food challenges

and rule out food allergies. So you know those two aspects changing the experience of the disease

and then really supporting the parents and their own struggles really come from integrative

medicine and I think we can everybody can apply it whether you have an integrative medicine

background or not. Yeah I think absolutely you know child life specialists are hugely valuable

in so many different ways and Destiny if you're if you're joining us thank you and thank you to

all of your colleagues for the help that you provide. We have an art therapist as well and

that can go along you know dovetail nicely with the child life role to help you in those situations

there's a lot of different folks in that arena that can be tremendously helpful as a therapy

and as a you know variety of techniques that can really help make the challenge more successful

and you know hopefully help you avoid more less foods for the child which is of course

always our goal to avoid less than more. So thank you Gary and thank you again for joining us

from Yale. We wish you were here in person again this time but of course we can't

take that time as much as we'd like but thank you again for joining us.

Next up on our panel is Dr. Patty George she is a pulmonologist and pulmonary

hypertension program director and head of the pulmonary hypertension section

here at National Jewish Health in addition to helping build the pulmonary hypertension program

to achieve national accreditation through the pulmonary hypertension association. She's an

ultra-cyclist. She built a non-profit team PH Phenomenal HOPE which partners with endurance

athletes partners endurance athletes with people who live with pulmonary hypertension to raise

awareness about the disease, supports patients through an unmet needs program for financial

assistance and in educational programs and support groups and as well as funding research awards

for young investigators in the field. That in and of itself is impressive

and certainly something we'd love to hear more about but Dr. George also has a passion for

building teams and taking on complex problems as you can see already. Her academic interests

include optimization of metabolic health in people with heart and lung disease to help

improve better and through all of those things together and work in the pulmonary hypertension

clinic how do you integrate that metabolic health and breathing program into you know that the

clinical setting and and how do you see this you know fitting in here at National Jewish and

and could it how does that differ over compared to other standard of care? Yeah absolutely so

thanks so much BJ for the introduction and thank you so much for letting me be on the panel and

join you guys. This is a big honor to be a part of this and I really enjoyed the talk last week.

So we have you know how would I say it so 50% of patients that we see or over 50%

right around there at National Jewish Health are overweight or obese and no matter what their

lung disease so I see people mainly with pulmonary hypertension of various types. The most common type

I see by the way that all of us see is pulmonary hypertension due to left-sided heart disease which

is one of the complications and in certain people of metabolic syndrome insulin resistance

type 2 diabetes etc. So standard of care is okay I come in I prescribe medications see you in

whatever period of time oh and by the way for your obesity and diabetes follow up with your primary

doctor who might be treating their sugar elevations with glipizide and obesogenic medications

and you should eat less and exercise more go do that well that advice doesn't really work

if it did we wouldn't have the epidemic that we have and so in patients who have metabolic

syndrome and insulin resistance well we've started a program where we actually can educate them on

the what they can do to help reverse this disease so there have been papers published on usage of

things everything anything that you can do our approach is anything that you can do to help lower

people's need for insulin either endogenous insulin that their own body makes or even worse a type 2

diabetic giving themselves exogenous insulin which just is more obesogenic and worsens the problem

anything you do to lower it is helpful so it starts with you know solid nutritional advice

eating real food getting away from ultra processed foods avoiding starchy carbohydrates eating good

quality carbohydrates and perhaps even limiting them and then working with patients with a

program designed to you know for people who really want to put their diabetes into remission

sometimes we'll even approach you know use a ketogenic diet approach like putting people

into nutritional ketosis or intermittent fasting or you know a variety of of the above and so

we found some success when we actually address the metabolic syndrome and give people a different

nutritional strategy with they come back having lost weight and having and being able to breathe

better and no it won't reverse their pulmonary fibrosis or their pulmonary arterial hypertension

but it might help reverse HEPF we actually have clinical studies when we just completed when

we're about to start looking at this in patients with heart failure with preserved

ejection fraction so therapeutic nutrition might actually have a role not only in improving symptom

management but maybe actually in disease reversal in as much as whatever disease is associated with

that insulin resistance in patients with pah there's also a high association of type of diabetes and

insulin resistance and those who have it have worse outcomes than those without insulin resistance

was data published years ago and so you know really looking at this i think is important

i would love all pulmonologists to check a hemoglobin a1c and a lipid panel but that's

part of my mission in life i guess to to change the world so that's how we got started with the

metabolic health program merely diagnosing and giving medications without addressing the pillars

of health underneath diet you know nutrition movement sleep and mental health is kind of

scratching at the surface certainly certainly challenges you know like you said to just say go

out and exercise doesn't help anybody we need to be better partners in that so thank you for all

of your work in that area and of course thank you for joining us today perfect segue into our next

speaker dr elizabeth who goes by devin smith as a licensed clinical psychologist and her background

uh in research and treating psychological factors unique to chronic illness and health concerns

plays out very often in in the sleep realm so sleep of course is critically important and perhaps

at the center of almost everything we do i'm going to throw that out there uh and and so she's worked

in a variety of medical settings oncology primary care cardiology pulmonology infectious disease

sleep medicine and currently is an assistant professor here at national jewish health

endeavor and focusing on sleep so you know for those of us who might have been up late last night

or or uh trouble getting up this morning you know is that insomnia and you know how can we improve

our sleep if uh you know quickly just give us some key pointers to help us on the right path

yeah sure so thanks for the introduction um so like you mentioned i've worn a lot of different

hats um you know i've done a lot of different things as a psychologist but um most recently

over the past five years or so i've been in the sleep world um and really being in the sleep world

has shown me that it's it just filters out into everything you know medical psychological um and

so i see a lot of people that have chronic health issues um including allergies and so

sleep is sensitive to stressors um as we all know um insomnia you know diagnostically you have to

have regular and consistent sleep issues for a period of time um you know either trouble falling

asleep staying asleep and it has to be impairing your life in some way and so about 10 of the

population meets criteria for insomnia is what research shows but um poor sleep health is is

much higher so um there's been some research that i've seen that up to 50 of the population

has some sort of insomnia symptom at least once a week and so a lot of us do have trouble with

sleep um you know either the quality of our sleep sleep regularity uh timing of sleep those are some

factors that play into just general sleep health um and so when it comes to having people improve

sleep uh the treatment that i do is called cognitive behavioral therapy for insomnia or cbti

and it is considered the quote-unquote gold standard for insomnia uh i wish it treated

everyone it does not um you know some research varies up to 70 to 80 percent of people respond

but people who are what we call short sleepers so sleeping uh much less than six hours maybe four

or five hours a night they tend to not respond as well to cbti and some emerging research suggests

that you really do need a medication on board for those people um but that said within cbti

one of the biggest things that i recommend is stop spending so much time in bed so that's one of the

tenants of cbti and that sounds very backwards because when i when people come in they're having

trouble sleeping and i ask them to spend less time in bed without the rationale in the background

behind that it sounds very counterintuitive but in theory you have to retrain yourself to associate

the bed with sleep and so by getting on a regular schedule spending less time trying to sleep and

more time actually sleeping you start to promote better sleep habits and so the the first thing

that people can do is track their sleep for a couple of days there's some great apps out there

um you know insomnia coach is the the go-to recommendation that i like for patients

but if you track your sleep for a few days you can get what's called a total average sleep time

so let's say that you're sleeping on average six hours a night really you should be only spending

or scheduling six and a half hours per sleep whereas people are often scheduling a whole

lot more and that leaves a lot of space for for disrupted sleep and so probably going to bed a

little bit later waking up a little bit earlier it's going to consolidate your sleep and and

show some pretty significant improvements and so it's pretty cool to see that process when people

are consolidating their sleep and and the strategies are working um but routine is really

key for sleep like it is for so many other things so there's a the that's the biggest

recommendation that i have um with sleep but i'm happy to answer more questions you know it's my

wheelhouse right now so our our high school or college habits of sleeping until you know noon

on the weekends are maybe not the best approach to help our sleep habits is that right it's

it's tricky so i mainly work with adults but with with kids and adolescents so the circadian rhythm

is delayed and so that's what uh if anyone knew dr lisa melzer you know she delaying school start

times to more closely match our uh you know kids natural rhythms was really helpful um so it's hard

when school start times are so early um to not catch up on that sleep on the weekends but yes

in an ideal world you wouldn't be playing catch up you would just stick the wake time is one of the

most important parts of of maintaining good sleep to be honest because the timing of the

light really sets your circadian rhythm so our teenagers you know when we think there might

just be being lazy and trying to you know sleep more than they uh should be there are actually

probably following some in some cases some good probably yeah then some even a little better than

yeah there we go uh finally our our last panelist uh thank you for joining us uh dr

more uh is a phd scientist and has her mba as well she is retired which is perhaps her greatest

accomplishment at this point and coming out of retirement to join us for the panel we appreciate

that you uh doing that of course um but she's been here at national jewish health uh recently

and for the last several years in a role as the manager of finance and operations for the

environmental and occupational health sciences division here and many of you may recognize her

for the work that she did in implementing one of the wellness initiatives and a very valuable

session on meditation and if you could tell us a little bit more about what that was and and why

why it was something that you uh you know really put a lot of effort into and and uh you know

offered us all here that opportunity and why that's so important okay thank you so much for

including me on this panel and thank you for the introduction so you know our patients and all of

us have stress stress is responsible for a lot of health disorders and we can look at stress as an

imbalance of the autonomic nervous system but another way of looking at stress is an imbalance

of energy so uh it's too much to do and not enough energy to handle the things we want to do

so one way to uh manage stress is to either reduce what the workload or to increase our energy level

and these days it's really impossible to introduce our work so the only way to increase

is is to balance stress is to increase our energy and there are four ways in which we can increase

our energy and our panelists some of our panelists had already referred to that

eat nutrition proper food sleep and rest exercise and the third source of energy

is the breath and fourth source of energy is a competitive mind so the breath is the most

underutilized source of energy and why do we and how does the breath work so when

when the mind is under stress it has certain tendencies number one under stress the mind

wanders a lot second the mind vacillates from the past to the future and when it is stuck in the

past it also experiences certain emotions for example you may start with really great memories

nostalgia but it also experiences emotion negative emotions such as guilt regret

or and when it is lost in the future it may start off with you know excitement anticipation

expectation but it also starts has negative emotions let's just worry anxiety and the more

the mind vacillates from the past to the future the more stress gets accumulated in a nervous

system and the mind does wander a lot a harvard study published in science showed that the mind

wanders 49.9 percent of the time and when it wanders it's unhappy so they did a survey of

2500 people they gave them an app and asked them three questions what are you doing right now

where is your mind right now and how do you feel right now and 49.9 percent of the time

people responded that the mind was elsewhere and they were dissatisfied so wandering mind

is an unhappy mind unhappy mind another tendency of the mind is is that it is negative bias

it has negative bias for example if i give you 10 compliments and say one negative thing what are

you going to remember likely that negative comment right and also you cannot manage the mind with

your mind how successful are you in getting rid of that stubborn thought the more you try to get

rid of it the more it gets stuck in your mind isn't it so you need something else other than

the mind to handle that mind something more tangible and here is the breath that comes into

play so how does the breath affect the mind so the breath is is is both involuntary as involuntary

and voluntary we can control our breath right second the breath is always in the present moment

yeah and that breath and emotions are are linked for example when you have

when you're angry you have a certain pattern of breath when you feel sad you have a certain pattern

of breath when you don't feel well you have a certain pattern of breath so every emotion has

a corresponding pattern of breath and the reverse is also true right so most of the time you know

we are our emotions are driving us but we also have the ability to change the breath to manage

the emotions so that's where the breath you know has the power to change the mind change

emotions calm down the mind and once the mind is calms down then you are able to get into a more

meditative state of the mind which is a very restful phase so i have been practicing this

particular breath-based meditation called SKY which stands for Sudarshan Kriya Yoga and

this particular breath practice uses specific cyclical rhythmic patterns of breath

to bring the breath to bring to calm down the body and mind and it all not only calms down the mind

but it also energizes the mind it becomes being about alertness and it's taught to this

organization non-profit organization called the Art of Living and I have been a volunteer instructor

for this practice for more than 15 years and practicing it myself for more than 20 years

and the effectiveness of this particular sky breath meditation has been shown

in a number of studies effectiveness of this technique to handle stress and stress related

disorders have been shown in open and random trials and in and in as well as in

um healthy populations and those with um with um compromised health conditions

and it is something you practice truly uh lifelong it seems right it's not a

something you master and you are you are done but much like you know many of our careers it is

a practice for for quite some time right it's something yes yes and it's easily practiced it's

it's a it's um it can be learned in eight hours three hours two hours session each day for three

consecutive days it's offered in the community post post pre-covid it was offered in in person

but post-covid it's on online this foundation organization is present in 150 countries

um around the globe so people around the globe are practicing this technique it's easily learned

and once you learn the practice the the home practice the daily practice is only for 20

minutes but we recommend additional five minutes of rest so it's easily done um it's it's a low

cost um and and easily practiced and very effective

definitely uh you know an important part of integrating all of these

pieces for for health and wellness and uh so uh but as folks in the audience if you have questions

and want to either type those in or raise your hand and we can unmute you please feel free to

do so um starting off with one kind of question i think that uh gary really touched on last week

but uh perhaps an unanswerable question or a challenging question for us but you know there

are a lot of different ideas and we've talked a lot about a lot of different pieces but you know

what does integrative medicine mean to you or how do you define it or what other terms do you think

of in relation to integrative medicine that will help help us all kind of piece it together or see

it in a different light brands whoever anyone who wants to jump in first feel free

for me you know integrative medicine is ultimately taking the best of what kept people well for

thousands of years and integrating it into modern conventional medicine and so that's different for

different people for some people it might mean yoga and meditation for other people it's exercise

and nutrition but there are so many components that promoted health and kept people healthy

for for you know generations that were just not utilizing in the in the clinic space um

you know to me it's it's about finding the least invasive ways of doing that and so that

for me that doesn't mean lab tests it doesn't mean supplements or herbs although there i think there

is a place for supplements and herbs in select situations and um but but really just starting

at the basics starting at the most evidence informed and starting at you know the again the basics

i would go ahead okay i would echo that you know integrative medicine is bringing the

best modalities uh from different traditions that have been shown for centuries to be

effective in um in managing stress managing health yeah

i often tell my patients that we forget our head and our bodies are connected so you know from a

psychological perspective often what impacts one will impact the other so you know it's really

important to consider both pieces yeah and as i mentioned before um you know if we make a

diagnosis of a rare lung disease that requires complex medication and being able to take that

medication or taking it on time and all this that disrupts someone's lifestyle perhaps

and these other pillars aren't in place they're not sleeping um they're not using the right

nutrition they're you know they're they're eating ultra processed foods or whatever and so their

energy levels are depleted they're not managing stress they don't have like that meditative or

tech you know mindfulness techniques or they um aren't moving their bodies like if you're not

doing those things the medicines um sure they'll work but are they really going to work as well

and are they really going to take them all the time because if you feel crummy no matter what

you just have to address that whole patient whole person

absolutely um linden i send your message we'll see how we can make this work hopefully it goes

well but sadhana has her hand raised and i think you should be able to unmute yourself now sadhana

okay great um this is a question for dr patty george and the metabolic program in general

how do you address the challenges with the differences in cultural cultural differences

in diet restrictions in their diet and such um i'm sure you get sort of a diverse patient

group so how would you address those challenges yeah absolutely um and the people that mainly

address this and i want to just give credit to jenna milliron who's our nurse practitioner

and dia qualcar who's our who's also a nurse practitioner and they really manage and run

this program but oftentimes they'll be introduced to it through me um or through my colleagues like

dr kim and and others and so you know that's where it becomes not a um one diet for everybody

you know it isn't necessarily the keto program or the plant-based program or

whatever so i i think that a lot of it is working on these general principles

um of educating somebody as to what is in this case inducing hyperinsulinemia and insulin

resistance and what would that person be willing to do to dial back on that so um you know so

different cultural diets can potentially be you know it's all about how would i say it um

embracing what the person is doing and seeing what might be movable for them so people can

for example somebody might come in with a value system that says i want to be plant-based purely

vegan for the environment for you know kindness for its others all of that kind of thing so

that we can do a plant-based low carb low starch program um somebody may come in and they may not

be ready or wanting to change the actual content of what they eat hopefully we can shift them off

ultra processed foods that in and of itself makes a huge difference cell metabolism study by holland

colleagues will just it's a really classic study that can make a huge difference to people with

weight loss if we can make that shift and or maybe implement something like intermittent fasting

you know some sort of program if they're eating at night um while they're suffering from insomnia

and they haven't seen devin yet uh we try to get them you know fasting at night you know so there's

it's all about trying to assess what are the movable things that we can do with each person

and that's why it's not a here's a handout follow this plan believe me we have handouts but we

really try to tailor it to each specific person gotcha thank you

gary that brings to mind uh you know when the the early introduction guidelines for the prevention

of food allergy came out you know there's perhaps language that we weren't used to seeing quite so

often uh and and seem to maybe out of place for you know infants when we're trying to feed them

peanut butter but you know that language was there you know in accordance with you know your

family practices and customs and and have you seen that play out you know in different patient

populations or uh you know what do you think about that kind of approach and and how do we

maintain you know this this early introduction idea as something that's just natural and part

of a normal diet as opposed to medicine right we're not making trying to medicalize this

eating you know essentially uh thoughts on that at all yeah i really think cultural sensitivity is

incredibly important here because i have a group of patients from certain areas that aren't even

familiar with tree nuts so it's not even in their parent it's not even in their their mindset to get

these foods into their children's diets but because they're living in the american culture now it

becomes so important that they introduce it and so that sensitivity becomes incredibly important

you know the other aspect that's maybe that's also cultural in many ways is when i talk about

food allergy to integrative medicine communities and early introduction i show the foods these are

all part of the anti-inflammatory diet tree nuts fish soy all of these foods are incredibly

important for a healthy diet so the earlier that we're introducing them the less allergies that

we're preventing you know we're shifting them towards a healthier diet overall so it's you know

they're inherently linked

thank you jerry um lennie up next with your question you're unmuted now so you should be able to

speak okay great thank you um i have a question i'm sorry i missed a year ago a description of

the program at arizona but i heard the lecture last week and i heard the discussion here

and it's clear that there are a lot of sort of you know common sense practical and information

evidence informed aspects of integrative medicine that are useful for patients

but i guess i'm a bit of an institutionalist after i was on the abai i spent about 10 years on the

cmss which is the council of medical specialty societies so i'm wondering why the integrative

medicine community hasn't put together a professional organization but then maybe could

have the internists and pediatricians within that professional organization once a curriculum is

defined apply to the abim and the abp to be a subspecialty of practice within these two

disciplines because certainly institutionalizing if you will this aspect of integrative medicine

would be helpful and clearly having specialists in this area could help pulmonologists could help

allergists could help sleep specialists could help cardiologists based on their on their knowledge

so i was wondering if there's been any effects or any kinds of organized approaches to try and

bring integrative medicine into a more defined institutionalized medicine so that the benefits

of this kind of approach and thinking could be standardized and applied to all the other aspects

of pediatrics and internal medicine that we have with all of our disciplines so i don't know who

would be able to answer that i probably should have had the discussion with bill silvers over the years

about this but i think thinking about where integrative medicine could do its best work

might be through this kind of institutionalization if you will so you know there's there's two parts

to your answer there is a greater move towards institutionalization there's actually a board

certification that you can take controversial in in some aspects to be quite transparent but there

is a board certification that you can take then there is different organizations like the academic

consortium of integrative medicine which yell is a part of and a number of major institutions

are part of but ultimately the goal is to bring integrative medicine to to the to the groups

themselves so for example both major allergy organizations have subcommittees on integrative

medicine the i'm a pediatrician so i you know i i work with the american academy of pediatrics

on and their executive committee on integrative medicine and i as well as the academic pediatric

association so apa and pas i'm co-chairing the subcommittee on that so so yes there is a move

within the integrative medicine community to institutionalize it as a specialty but ultimately

the goal is to find the space within the actual specialties themselves like allergy and immunology

like pediatrics and bring it there right that's probably a admirable you said there's a board

certification is that under the abms is it a certified you know certificate of qualification

from it is not under the abms because um look ultimately you know ultimately there's there's a

lot of pushback for this specialty right and and some of it is well founded and some of it isn't

absolutely not um and so we've you know i've struggled at my own institution to to to bring

this uh integrative medicine historically has always just had an uphill battle bringing it to

certain publications or certain journals is challenging every aspect of bringing this

specialty out there is challenging so there is it is through a separate um board certifying

organization i don't know it offhand um i can certainly google it for you and put it in the

chat but um but you know it's not without the a concerted effort to to make this as valid and

as um institutional as you put it um as possible yeah no but maybe the way to overcome all the

pushback would be to have a discipline that's well defined and and and going up to the same

kind of rigor than all the other specialties and subspecialties of medicine might fit

i i agree with you in many aspects but i think it's it comes from both directions um you know

i i can only tell you my personal experience but when i publish just sort of a general allergy

article my review comments are you know there but a few when i publish an integrative medicine

article in a in a conventional journal i get pages and pages of comments um my writing is

not different my research isn't different the background isn't different so you know it needs

to come from two places which is by the way what makes what bill is doing so incredible and so

special um and it's important to shout him out right now because he is bridging that gap he is

actively that's good but um the number of responses to your writings is not a measure of what's

legitimate or what's not legitimate in the field uh you get a better sense of that by applying

the same kind of rigor that all the other aspects of medicine have apple applied and there's no doubt

in my mind that integrative medicine can achieve that kind of thing but you sort of have to play

within the white lines of the playing fields that we have in medicine so i understand your difficulties

and i i sympathize with them uh and i think that there is legitimacy to this kind of approach

across the board uh but i think that um getting it standardized in a way that

makes it more acceptable there's always going to be some people that you're not going to

that you're not going to win over with this kind of approach and there's always going to be people

who maybe you're not aware of it'll be brought into the the whole realm but doing it within the

standardized framework uh is probably something that um you don't have to worry about whether or

not you're uh you're getting the right kind of response or whether the response is uh genuine

or not i don't know i'm not trying to be difficult i'm trying to see where your next steps forward

might be with this whole discipline and i think it's worthwhile uh but perhaps following the route

i just mentioned while it might be difficult might be in the long run maybe a good way to go

i have a question so it seems like a lot of people probably use this approach of integrative medicine

without really realizing it and so do you feel like it's the term itself that's polarizing you

know the responses that you get i think i i think yes i so you know andrew weill who's one of the

founders of integrative medicine likes to say is the goal of integrative medicine is to lose the

term entirely that it just ultimately becomes medicine and so that's that to me is really

the approach is not so much as defining ourselves but really integrating ourselves into common daily

practices uh if anyone else in the audience has a question here before we head towards wrapping

up in the last few minutes here but you can raise your hand and uh langdon will get you unmuted so

you're able to ask the question or feel free to type those in the q a you know i think that is a

kind of a nice uh thought here towards the end gary certainly a um you know a neat idea that we

that this becomes just part of medicine right we don't need a special term anymore uh certainly a

good goal uh dr servers hi there well nice to uh nice to see you virtually and i'm very appreciative

of the uh of national jewish taking on this uh program and of the panelists participating in it

because i think that uh gary uh and lanny's lady's question and gary's response you know

really touches at the heart of what we do you know i have all often said that you know a uh

a good physician practices holistically but uh whoever practices holistic medicine

you have to ask exactly what they do and look with some you know uh uncertainty about that

and the same thing as we discussed uh uh in sidebar after our our conference last week

is that the term integrative medicine is kind of becoming uh um questioned itself because anybody

who practices good medicine practices in an integrative fashion as we're discussing and

anybody who practices integrative medicine you know you ask yourself again what exactly are they

focusing on um and the the whole term cam which is started out as complementary alternative medicine

um you know we're trying to uh um adopt whatever complementary approaches that are valuable

into our orthodox practices but we're trying to uh to identify whatever practices are alternative

or not within the uh the evidence informed and sounds like no longer evidence-based but

evidence-informed um practices uh you know you have to identify that and as we're talking about

you know what the culture is uh to accept these people within the medical model but not to shun

them because they don't uh adhere to what our approach is so i think that that lanny's question

is very valuable and to do we institutionalize integrative medicine and i don't think so myself

i think that the approach to integrating uh all of these approaches nutrition exercise

sleep management and especially stress management you know um within our practices within every

patient that we see uh another line of mine is that you're only as good as your last patient

you know whatever your uh uh your past profile is and you have to address what that patient is so

lanny i appreciate your question and gary i appreciate your uh response in terms of uh of

presenting all of the you know in terms of presenting an integrative approach that all of us

can can take it's not really i don't think also a separate specialty um but having this discussion

among the panelists uh uh i appreciate the contributions of each of them but you have to

see uh what the patient wants to do you know as dr george points out you know the the exercise

and the metabolic syndrome is not just for those who are obese but every patient should be adopting

a certain exercise regimen and we haven't touched today so much uh on the nutritional

approach to our patients beyond food allergy etc but yeah nutrition should be part of every

allergy immunology prescription and especially the the stress management part

uh beyond breathing i mean the breath of life uh so i think that i'm very appreciative of your

having this discussion and uh and i uh i hope we continue to discuss this until

as gary says integrative becomes just our our uh comprehensive holistic so to speak

approach to each and every one of our patients so thank you all very much

and thank you bill for your for your leadership and your help and your amazing uh you know

come back and recovery it is great to have you uh you know joining us once again so thank you

michael nevin does a question in the chat asking about the opportunity perhaps to get some of the

resources and articles that were reviewed last week and uh yes we will uh certainly do that there

there should be a place to put that on the website where we have the link

and then other ways as well that was on my list of to-do's this weekend but i didn't get there

yet but i there are certainly some great articles you know one on that nutrition front uh just to

raise the light of which we'll get out there the uh kind of the immune supportive diet

publication from the dieticians and others from the european academy but that will be one other

highlights that you want to pick out maybe especially on the nutrition front

i i think that article was excellent and a great summary um if we're thinking about mind body

medicine galen marshall wrote an excellent review on on the role that was published in

annals maybe two three years ago i think um and and then there's other smaller articles

that i mentioned throughout that i'm happy um if there are specific ones that you want i'm happy

to send them your way uh as we uh you know begin to wrap up here a chance for uh each of the

panelists to chime in one more time and uh if you have any parting thoughts for us words of wisdom

or recommendations thoughts suggestions please share them as we uh you know head back into the

real world and try to incorporate what we've learned uh here last week and again today and

um you know first just thank you all again for joining us i hope you enjoyed it and thank you

for you know helping us uh going to move this area along and uh we appreciate your insights and all

the work that you do you know here at national jewish as well as of course uh on the east coast

gary but uh thank you all and thank you for joining us if you have further questions

you can certainly type those and we can try to follow up on those uh but uh panelists parting

final thoughts i just want to express immense gratitude to to dr silvers and to the team at

national jewish um everybody who helped organize this and work with me um it's it's such an

opportunity and such a privilege to be able to do this and to talk about a subject that i love that

you know as mentioned before it doesn't always have the the space and so to create that space

is just um amazing i'll second that and uh echo was equally enjoyable having you join us here

it was a lot of fun to see you and uh you know comments of course from all over folks who joined

us for the lecture last week really appreciating your you know your take on things and the

approach to integrative medicine some very useful things that folks found they may you know who are

not maybe at all you know interested in integrative medicine or even aware of it or thinking about it

you know uh really kind of brought to light some ideas for him so i think that is incredibly useful

and uh you know we'll see that of course coming up many years down the road i'm sure

i just want to thank you for including me i really enjoyed your talk gary i i replaced my amazon uh

multivitamin after your talk so um i've been i've enjoyed being a panelist and i encourage

the providers on here ask your patients about their sleep because a lot of your

patients are probably struggling um and there's referrals available out there

absolutely couldn't agree more having learned from lisa melzer

certainly appreciate the importance of good sleep

yeah one of the approaches i sometimes take with patients first of all i'm really honored to have

been with this group and um sometimes when i see somebody that i'm sitting with somebody in the

clinic i have to think well what would what what are the what are the practices we ourselves as

docs and nurses as nurse practitioners should do to heal heal ourselves right like doctor heal

thyself and um you know there's a lot of this stuff that's rolled into these pillars of health

i'm like taking notes from the co-panelists here of okay all right i'll do this i'm going to give

up my screen time no i'm just kidding all that kind of stuff meditative techniques all this stuff

really really works and um i think when we think about those things uh what we would do to heal

ourselves um and oftentimes we make these nutritional changes right because traditional

advice doesn't work so when we do these things let us also offer that for our patients and if

we're not doing it for ourselves we need to dial in on that too of course

yeah and i put that thought um and you know one of the comments that dr sofa made in his talk last

year that last last last week was you know patients and people are looking for this they

are not looking for evidence people are thronging to this alternative phase modalities for healing

themselves so so thank you for including me on this panel and listening to you know the

the practice that i have been teaching and doing myself

and for consider and i think what i think that if the medical community can be more open to

integrating these modalities and doing more research to get gathering the evidence so that

they can be more that they can be validated and they can be offered to patient populations

yeah and and thank you for your uh you know years of leadership and giving us that opportunity for

meditation and then teaching you so many folks here at national jewish that uh technique and

certainly valuable uh and uh you know important for us to think about as we move on uh so once

again thank you to all of our panelists thank you dr silvers for your uh of course uh tremendous

support uh lani thank you for joining in the questions today and always throughout the year

and uh thank you for to everybody for joining us and uh i appreciate the opportunity to to

moderate and have this chance to talk uh so we will see you again next year for our uh next

installment of the integrative medicine series until then we have one more uh denver allergy

rounds left so we will wrap up at the end of the month uh with the last wednesday with our

botanist and our uh spring late spring grass walk so we look forward to seeing you for the

lecture portion and the in person for those of you who are here in denver and can join us those

details will come with the with that talk but uh once again thank you everybody for joining us and

have a great day

you

June 6, 2023 | When Your Patient Wants Their Immune System ‘Boosted’

Gary Soffer, MD, Assistant Professor; Director, Integrative Medicine Program, Yale University School of Medicine

Wonderful. I'm so excited to see all these faces and Dr. Silvers joining us. So we're

really excited for today's Denver Allergy Rounds. We have our special Willem S. Silvers

Integrated Allergy and Immunology Respiratory Wellness Program at National Jewish Health.

This is our third year. So, and the theme of this is integrating lifestyle recommendations

with nutrition, exercise, and stress management to enhance overall well-being. Really excited

for this program because we invited both faculty and fellows from the National Jewish University

of Colorado, Children's Hospital Colorado, and also the Integrative Medicine Committees

at both the college and the academy. So thank you and welcome, both in person and on Zoom.

Let's see. So just to give some background, this is our third year. So in 2021, Dr. Galen

Marshall kicked us off with evaluating integrated approaches to allergy, immunology, respiratory

patients. What is the evidence? And then we had a following wonderful panel discussion

looking at the present state of allergy, immunology, respiratory medicine, and future potential at

National Jewish Health. We had wonderful colleagues at National Jewish to include Dr. Plum, Galen

Marshall from the University of Mississippi, Dr. Meltzer, Jennifer-Morin Darmes, and Dr. Tabby also.

Then following that, we had Dr. Randy Horowitz, who is the Medical Director at the Andrew Weill

Center for Integrative Medicine at the University of Arizona College of Medicine, and he gave a

wonderful presentation called The Guide for the Perplexed. We followed this up with a nice panel

discussion that included Dr. Horowitz and his colleague, Dr. Neyman, who is a sleep specialist,

also our own National Jewish, Dr. Todd Olin, and Dr. Tabby joined us again for a second year.

And I'd like to just give a few words here because we have Dr. Bill Silvers here today.

He's, as you all know, is an Allergist-Uminologist, was a Clinical Professor of Medicine at the

University of Colorado School of Medicine, and a former National Jewish Fellow. So he has been

committed to National Jewish Health through this inspiring lecture series, which is titled the

William S. Silvers Integrative Allergy, Immunology, and Respiratory Wellness Program.

And the goal of this series is to inspire medical professionals to learn and share

new techniques that will help them provide the best integrative care for their patients.

As I mentioned, former fellow, remained committed to National Jewish Health,

and he's a well-known advocate for patients and treating the patient as a whole patient, right?

Not just as a sum of its parts, and it's a combination of traditional, complementary,

and alternative medicine. He's also been named a top doctor by 5280 magazine multiple times.

He's highly respected in Allergy and Immunology, also sports medicine and integrative medicine,

and has committed a lot of his efforts to bioethics and humanities. And he's been a

long-standing advocate for integrative medicine, and through this series creates his educational

legacy that we hope to continue in the future. And we're really grateful for presence today,

his accomplishments, and for sponsoring this annual series.

So with that, I'm going to turn it over to my co-chair for Denver Allergy Rounds,

Dr. Jessica Hui, and she will introduce our speaker today. So for this year, we have a series

of a presentation by Dr. Gary Soffer, and then also a panel series with our both National Jewish

and Dr. Soffer. Thank you.

All right, so we are pleased to have Dr. Gary Soffer here as our guest speaker this morning.

So he pursued a pediatrics residency and then fellowship in Allergy and Immunology at Albert

Einstein College of Medicine, Children's Hospital at Montefiore. Then he completed a second fellowship

in integrative medicine at the University of Arizona. So he's currently on faculty at Yale

in Allergy and Immunology, and is also the director of integrative medicine.

So he recently first authored a paper in Jackie and Practice on safety considerations for natural

products commonly used by allergy patients. And I did read it yesterday, and I thought it was

such an important article, and really all of us should read that after our talk if we haven't

already, as you know, we advocate for safety and success of our patients. So with that,

please welcome Dr. Soffer. Okay, so I'm going to be talking about, you know, in my clinic,

quite a bit, especially in integrative medicine, this question comes up a lot. How do I boost my

immune system? And so we're going to we're going to talk about it, talk about what it means. And

then, you know, there's a nuance in the title that we're also going to talk about, which is

evidence-informed rather than evidence-based. And I want to touch on that, too. My goal today is

really to give you an overview of what integrative medicine is, at least what my vision for integrative

medicine is, because it's quite heterogeneous when you go out there. But how I practice it,

and how I hope to spread it, you know, spread the word in a meaningful way throughout our field.

So I have no disclosures. So about me, this was mentioned before, I did a residency in pediatrics,

I did my fellowship in AI, and then I did an additional fellowship in integrative medicine.

And this was a two-year sort of hybrid online didactic fellowship, but it's really the major

one within the field of integrative medicine, if anybody's ever entrusted in it. And so that gives

me a lot of hats to wear. And I, you know, I get a lot of questions about a lot of different things.

And so I think the first hat that you're probably least familiar with is the integrative medicine hat

that I wear. This is actually, if you're familiar with the guy named Paul Stamets, who's my

colleges, this is a mushroom hat out of Transylvania. It's the most integrative medicine hat I can find.

So what is my definition of integrative medicine? So my definition is it's really the best of what

kept people well for thousands of years combined with what the best of what keeps people well now.

And it's really seeking the least invasive ways of making people feel better. And that may mean a

lot of things to a lot of different people. But yeah, and then we'll go through what the differences

between alternative versus complementary versus integrative in a minute. But integrative medicine

is unique and distinct. And so we have this huge toolbox to work from. We have lots and lots of

different modalities that we get to choose from. And there's different ways of organizing it.

There's different ways of looking at it. The NCCIH, which is the NIH's branch of integrative

medicine, has done it this way in the past. And I really like this because it's probably as best

as you can do, but understand that none of these are siloed. And so you have biologically or

nutritionally-based therapies, and that can include diet, nutrition. It can include vitamins

and herbs. You have mind-body interventions. These are by far my favorite. Meditation, yoga,

biofeedback. Then you have manipulative or biomechanical therapies, massage therapy of

osteopathy. I'm sure some of your colleagues are osteopaths. And then you also have chiropractic.

You have energy and spiritual, and that might be prayer, faith-based. It might also include things

like reiki, which I hope some of you are at least familiar with. And then you have entire

alternative medical systems. So you have traditional Chinese medicine, which acupuncture falls

underneath, but it's a whole system of medicine. You have Ayurveda, which is traditional Indian

medicine. And you have naturopathy, which is also another set. And let's go through some definitions

so we're really clear what each of these mean. So alternative medicine is if non-mainstream

practice is used in place of conventional medicine. So that means I help direct the

integrative medicine program at our cancer center. That means if my patient decides to forego

chemotherapy and goes to another country and gets IV mistletoe, that is alternative medicine.

Complementary medicine is if a non-mainstream practice is used together with conventional

medicine. So that means they're getting their conventional chemotherapy, but they're also

seeing a practitioner out in the community. And that might mean a naturopath. That might mean

acupuncturist, whatever it means. What makes integrative medicine unique and special and why

we need it more in hospitals is it brings together conventional and complementary therapy

in a coordinated way. So we're having conversations. We're talking about this.

And so each of you has the opportunity to practice it just simply by asking the patients,

are you on any herbs or supplements? That's integrative medicine because you're coordinating

their care. Are you seeing an alternative practitioner in the community? That's integrative

medicine. And so there's varying degrees at which you can practice it, but there's space for everybody

in the room to practice it. Some other definitions that often get used, and I just want to clarify

what they are, is holistic. This is really nonspecific. It's really used to indicate that

therapy addresses the whole person. I think often, and I think it's why I was so attracted

to allergy, often as allergists, we really do treat somebody as a whole person, sort of the

nature of the field because we're dealing with so many systems at once. Naturopathic. So this is an

alternative medical system that came from traditional practices and uses a lot of lab

testing and supplementation, but they go to a four-year school. Some of them even do residencies.

There's naturopathic colleges, and you have to get a degree, and this is when you see ND at the end

of their name. And then homeopathic, because I feel like people use homeopathic really quite

synonymously with it. This is also very specific practice where you take certain tablets that,

I'm not going to go into details, but have been highly diluted down, and there's a concept that

like treats like, so you give something to somebody that might worsen the symptoms actually in a very

highly diluted amount. It's so diluted, it's past Avogadro's number. If you guys remember what that

is, that means past the point of nothingness basically. I do want to say a word on functional

medicine. This would probably be the most controversial part of my talk if I was in

front of a group of integrative practitioners. Who in the room is familiar with what functional

medicine is? Is there a similar term? Okay, so functional medicine is, let me try as PC is about

this as possible. They focus on what they see as nutritional deficiencies, and the way they do that

is they use a lot of unvalidated lab testing, or they use unvalidated parameters for those labs,

so they might see CRP differently than we see CRP. And there's a heavy reliance on supplements,

and there's also a heavy reliance on diet and nutritional changes. They do use quite a bit of

extrapolated evidence to make their conclusions, and as you know, one functional practitioner told

me, if you're not comfortable with that, you're not going to be comfortable with functional medicine,

so I told her I wasn't comfortable. And the training is a little bit elusive. There's one

major group that does it, but it's a certificate program, and it's really for all licensed health

care professionals, so PTs, OTs, RNs, PAs, naturopaths, MDs, and it's often associated with

integrative medicine because you see a lot of people practicing both, but I see it as distinct

as do most of the leaders at University of Arizona who are at the forefront of integrative medicine.

Okay, so who are these patients? So these are not patients that generally abandon conventional

medicine. They're mostly female, higher education, higher income, they tend to have chronic illness,

they have greater body sensitivity, so how observant people are of physical signs and symptoms,

and overall they actually have better health, and they have a strong sense of ultimately being

responsible for their own health, which means they want to be autonomous, and that's why they're

seeking things out. What drives these patients? So poor prognosis, again, autonomy, and maybe

cultural values. You know, I did my training in the Bronx, and there was a heavy reliance on what

my grandmother recommended. Belief systems, as we all know, Jehovah's Witnesses, and blood

transfusions, and other things. Then of course we all know the conspiracy theories and medical myths

that are out there that drive patients. And actually, you know, I always put this one there

because it's actually meaningful, is attending group support. And I actually see this quite

a bit with my oncology patients, even though it's within the cancer center. They're doing

these group support visits, and they have a lot of questions about a lot of things that they've

read and seen. So where are they getting their information from? 65% are getting them from friends,

48% from family, and only 21% from media. So despite what we think, that patients are getting

their information from the internet or something like that. It's actually coming from people they

really trust and people that they're close to. And then conventional care is some person in a

white coat they've never met or heard of beforehand. So keep that in mind. You know,

they don't know you, not yet at least. So this is how we look at evidence, right? We've all seen

this. What are the measures of evidence? And, you know, obviously we always want to go for meta

analyses or systematic reviews, but there's not a lot of space for that in integrative medicine.

I can go into why, but I won't. But, you know, we just don't have it. And so this leads us to

this idea of evidence-informed medicine. And if that's a concept that makes you uncomfortable,

just think back to COVID, where everything was evidence-informed. I mean, you know, you couldn't

buy zinc lozenge to save your life. You know, so keep in mind, you know, that's the same thing we

used. And luckily with COVID, we had a lot of money and a lot of resources and a lot of interest

funding it. We don't have that in integrative medicine. And so the process is much slower,

but the concept is very similar in that sense, that we rely on what we have and we do it in a way

that uses this model. Okay? So this is the Kathy Kemper model. Kathy Kemper is a pediatrician who

really was at the forefront of pediatric integrative medicine. She came up with this model,

and it's a model that we should use throughout medicine, but really focus on an integrative

medicine. We ask ourselves, is the therapy effective and is the therapy safe? Now I've

changed it to, is the therapy not a burden? Because I think there are things that are safe for patients,

but may actually create a good amount of burden for them, whether it's a false sense of hope or

spending a lot of money on things that may not get them any better. And so where integrative medicine

shifts from conventional care is that if the therapy is maybe not effective, it doesn't create

a burden for the patient. We tolerate it. We give it space because if you're one patient,

you don't care about a hundred patients. You don't care about a study. You care about what makes you

feel better. And if that, I always say in integrative medicine, I love the placebo effect,

you know, and so do my patients. And so this model allows for more individualized treatments,

greater flexibility and management, getting it wrong a few times, trying different approaches

versus stepping up therapy, greater shared decision-making, more patient autonomy, and

again, being okay with the placebo effect. I love the placebo effect. And by the way,

if you look at any allergy study, the placebo effect is massive. So don't convince yourself

that you're not using the placebo effect every single day. I recognize it also can allow for the

misrepresentation of data. We see that. It also allows for the application of extrapolated evidence

as though it's legitimate. We see that. And that's what I was talking about before.

So then I have my, you know, AI hat and, you know, I identify as a big A person, little I person,

and I'm going to dive into the eye here and I'm going to do it with as much humility as possible.

I may get it wrong a few times today, but I think it's important to have this conversation.

And I hope you can forgive me. I do it with a lot of humility, but I hope you forgive me if I get

it wrong. So all of my hats, what did that lead me to? How I spent my pandemic? Well, at least

initially. So lots of questions about elderberry, lots of questions about boosting my immune system,

what vitamins I should be taking. And you could see why this is so confusing. There's about a

million products on the market about boosting the immune system. Again, I obviously don't endorse

or recommend any of these products whatsoever, but you can see why this is so confusing for people

because it's everywhere. And I don't have to tell this room what a boosted immune system means,

right? Allergies, autoimmunity, cancer, sepsis, severe COVID, right? I don't really want a

boosting immune system. This is the comic break for me to take a sip of water. It's not really

that funny. Okay. So what is really our goal? We want to support balance, a balanced immune system,

homeostasis. We want appropriate responses to appropriate things. We want immune regulation.

We want decreased immune senescence, decreased immune aging. And then we want the least invasive

ways of doing this. And we want evidence-important management of being able to do it.

And so back to these pictures, these herbs, these supplements, what are they? What do we know about

them? And so when I approach this, I start by thinking about what is my goal as an integrative

practitioner? And I think herbs and supplements have a place in some areas. But what I think

most patients are asking me is what pill can I take? And we're using the conventional paradigm

to fit what is really traditional medicine. And that doesn't always fit. That doesn't always make

sense. I think a lot of times patients are looking for that edge or that quick fix. And we've really

entered a world where we believe that pills fix things. And as I explained to my patients,

oftentimes when they come in on tumor pills and explain, I'd rather you eat it because nobody's

grandmother made a curry in a veggie capsule. Right? So food is always the first step for me.

So my concerns with herbs and supplements is twofold. The truth is, is that I actually

believe in their pure form, most herbs and supplements are quite safe. And I think if you

look at most studies looking at them, where you have very controlled herbs and supplements,

what you're giving the patient, the safety data tends to be very, very good. But the issue really

becomes how they're regulated in the United States. And so the short answer is not well.

So there was an act in 1994, there was a big push to start regulating supplements. You can thank

Mel Gibson for that not happening. If you want to ever watch the most disturbing video, watch

Mel Gibson supplements video from like 1994. It's hilarious. I wish there was time for me to show it.

So what came of this act of this big act supplements can be marketed without testing

efficacy. Safety does not need to be proved before marketing. The burden is on the FDA to

prove that the product is unsafe. And I know that the FDA does not have the resources to prove that

many of these products are unsafe. There's no standards that are required for manufacturing.

Structure and function product claims are allowed. Label claims do not need extensive evidence,

and FDA approval is not needed for marketing claims. So in profound contrast to the medicines

that we're giving our patients every day, there's really no oversight. And so what does this lead to?

So this was a recent publication in JAMA, and it looked at select dietary supplements marketed

to support or boost the immune system. And they looked at the 30 top dietary supplements from

Amazon that were available, 17 of which had inaccurate labels. 13 had ingredients listed

that were not detected. Nine had additional substances. And so deglycentrisated licorice

is safe, but deglycirizim is what gives you hypertension. So if you're getting the wrong

product, it comes with a lot of risk. I do want to say that when you talk about supplements and

when you're looking at supplements, the best approach to take is making sure that there are

third party verification. So NSF or USP are really good ways of going about it. None of these had the

third party verification. So again, there are safe products on the market. You have to be really,

really careful about what's out there. And so again, I apply this model to how I approach my

patients when they come to ask me how to boost their immune system or how to support their immune

system. Is the therapy effective? Maybe. I don't know. Is the therapy not a burden? The therapies

that I'm going to go through now are all not a burden to the patient. They're all safe. They're

all non-invasive. And we'll talk about it. And we'll talk about some of the evidence that supports

it and some of the immune evidence that supports it. And again, this is evidence informed. And I

may be extrapolating data a little bit, but when it's safe and when it's not invasive, I'm much

more comfortable with that. So how I recommended my patients support their immune system and why.

We always, always, always start with nutrition. And maybe Hippocrates said, let food be thy

medicine. We're not really sure. But we'll give them credit still. But there are over 30,000 peer

reviewed articles published on the relationship between diet, inflammation, and health outcomes.

Obviously, I'm not going to go through all of them. But what do we know about this standard

American diet, right? It's an unlicensed photo. So it's rich in total fat, saturated fat, refined

sugars and processed foods and ultra processed foods, which is the new term, needs to disturb gut

epithelial barrier function, pro-inflammatory microbiome composition, low grade inflammation,

you see activation of PLR4, activation of NB. High intake of fast food. So this

is just bringing it back clinically. High intake of fast foods is linked to development of allergic

disease in adolescents. And it's obviously increased mortality of UCM patients on this sort of diet.

And so when we bring it to the immune system, this to me is probably one of the most exciting

lenses to look at food from an immunologic standpoint. This is called the Dietary Inflammatory

Index. It was a validated measure that was developed in 2007. And there have been a number

of articles that have come out since then. And what they do is they take 45 pro or anti-inflammatory

foods, nutrients or food components, and they score them based on what they do to blood work.

So you get one point if you have increased IL-1 beta, IL-6, TNF alpha or CRP, or if you have

decreased IL-4, IL-10. I'm obviously building IL-4 because I'm in the room of allergists,

and that's a little bit uncomfortable for me, but that's okay. And then the opposite is true,

you decrease points if the opposite is true. And so what did they develop? They developed

essentially what we already know, but it's really nice to see it proved through science,

which is that pro-inflammatory foods are saturated fats, trans fatty acids and cholesterol from a

million products. One caveat on that is that pasture-raised grass-fed beef does not seem to

fall into that same category of cholesterol from a million products. It actually has quite high

omega-3 content from the grass that they're eating. And then anti-inflammatory foods, the foods that

we want people to use to support their immune system are fruits, vegetables, especially garlic,

spices like cumin, oregano, whole grains, fatty fish, teas. I really try to transition my patients

from coffees to teas. I try to transition myself from coffee to tea, not going so wrong.

Flavonoids and then dietary fibers. And so what are the clinical outcomes from looking at this?

So a higher dietary inflammatory index score is associated with higher rates of obesity and type

2 diabetes. During pregnancy, it's associated with a higher risk of asthma and offspring.

Cardiovascular diseases, it creates a higher risk and you see higher rates of depression in

adolescents who have high DII scores. And then a 23% increased all-cause mortality comparing

highest versus lowest dietary inflammatory index categories. And so the Mediterranean diet, which

is everybody in the room familiar with Mediterranean diet for the most part?

Mediterranean diet's a little bit distinct from the dietary inflammatory index, but it has a very

good dietary inflammatory index. And the Attica study, which is one of the largest studies looking

at diet nutrition, they didn't look at the immune system too much, but it was over 3,000 Greek folks

and 20% had lower CRP based on their diet, 17% lower IL-6 based on their diet. And then the big

nurse health study that we all know about showed lower CRP, IL-6, ICAM-1, BCAM-1 and increased

telomere length based on adherence to the Mediterranean diet. So the better you were

adhering to the Mediterranean diet, the better your scores were.

This was a cool study that was just published in Cell recently, looking at food fermentation.

Specifically, they compared patients with high fiber diets with high fermented food diets. And

we know high fiber diets are really quite healthy for you and good for you. But within the high

fermented food diet, they actually saw even more increased microbiome diversity, and they saw

decreased inflammatory signals and activity as well. So fermented foods are great.

And back to my point about pills, because we always want to bring this back clinically,

is this paper was published recently, and it showed that nutrient supplementation, so taking

any sort of pills for the prevention of viral respiratory tracts, infection in healthy subjects,

didn't work. It didn't work. So nutrient supplementation to prevent viral respiratory

illnesses just didn't work. And then the second study that was published in Cell,

didn't work. So again, I'm not sure pills are always the answer.

So this is a great article. I hope everybody in the room reads it, especially the fellows. This

was just recently published in Allergy. This is called the Immune Supportive Diet in Allergy

Management and Narrative Review and Proposal. This was written by some very high level people.

I think Karina Venter was on it, or Mary Brush, one or the other. Sorry if they're on here. I

apologize. But really just giving a good idea of what could potentially prevent atopic disease

in your patients, what sort of diet, and it gives really good and directed advice.

This is just the food pyramid for the anti-inflammatory diet, vegetables and fruits,

grains, whole grains pasta, beans and legumes, and then moving up from there,

but always focusing on vegetables and fruits for your patients. So that's how I want you to

bring it back to the clinic. That's how I want it to show up for patients.

So next topic is meditation. I love meditation because lots of good evidence, not very invasive.

What is meditation? So John Cabotin, who's a very famous meditation teacher, actually created one

of the most standardized courses for meditation, allowed meditation researchers to be a lot more

consistent about how they study meditation. But he describes it as the awareness that emerges

through paying attention in a particular way on purpose in the present moment and without judgment

to the unfolding experience from moment to moment. So that's a lot of words. It just means paying

attention. It just means paying attention to a specific point and allowing whatever comes up

to come up and bringing your attention back to that point. And so that might be the breath.

It might be a mantra. It could be a hundred things. There's 80,000 different types of

meditation out there. So, you know, but that's the general principle of it is just bringing

your attention back to something specific. So meditation and health. Expert meditators,

these are people who have been meditating their whole life over 10,000 hours. You see a 23%

decrease in all-cause mortality. It's pretty impressive. Improved cardiovascular health,

improved sleep, improved cognition. All of this is likely dose dependent.

What do we know about meditation and immunity? So this stuff is starting to get interesting. It's

starting to emerge right now. One study doing this MBSR course, that's the course I described John

Kabat-Sinn in patients with ulcerative colitis showed a significant increase in IL-10. As we

know, IL-10 is a regulatory cytokine that helps create homeostasis and balance within the immune

system. Another study looking at a different mind body training program, but it was a double

blinded randomized controlled trial, also found a significant increase in IL-10.

This was a study done a number of years ago, really interesting look at CD4 counts in HIV

patients. It was a randomized controlled trial of 40 patients and they did a mindfulness based

cognitive therapy, which is a type of psychology similar to CBT, but they did two and a half hours

a week over eight weeks. These were all patients on treatment for over five years.

Most of them had undetectable viral load and within the study group, they had a significant

change in their CD4 count. So these were completely controlled patients, well established,

and they showed a significant increase in their CD4 count. It's very cool stuff.

This was a very small part of a much larger study. They really didn't go into the details of it,

but still interesting nonetheless and I think important to mention that in a group of patients

who did an eight week MBSR course versus a weightless control, all patients were vaccinated

at the end of eight weeks for flu and then the titers were drawn at four and eight weeks. There

was a statistically significant difference at the eight week mark for the meditation group,

so they were having nicer vaccine responses.

This to me is probably the most exciting and emerging evidence on meditation and its role

and they're starting to get cell transcription factors in gene expression. This is a study

looking at young breast cancer survivors who did a six week mindfulness awareness practice

and they showed a significant decrease in expression of 19 pro-inflammatory genes that

were all associated with chronic stress. They based this on a prior study and they showed a

dose dependent meaning how much you actually adhere to the meditation practice, a dose dependent

decrease in IL-6, but interestingly there wasn't really a change in plasma markers of cytokines and

so the question becomes like with the study before, do you have to wait a little bit longer

to see if there's a big change in the plasma markers and I don't think they really waited long

enough. There's another study looking at expert meditators. Again, these are people who have

meditated for over 10,000 hours versus non-meditators and they showed a decreased

expression of pro-inflammatory genes, so there's a change in histone diacetylase which led to

changes in RIPK2 and COX2 expression as well, so changes in inflammatory expression.

When you're bringing it back to the clinic, again, what does meditation mean and this is

Jack Kornfield who's a very famous meditation teacher and he says a good meditation practice

is anyone who develops awareness or mindfulness of our body and our senses, of our mind and our

heart, and it doesn't really matter which kind you choose. Again, there's 80,000 different types.

To me, it's really about creating a practice, about a sustained practice. You're doing the

same thing every day, so I love that patients are going on comm apps and listening to like a different

meditation every day, but it's really about this daily sustained practice that you're doing that's

similar each and every day because sometimes the comm app could just sort of be entertainment,

you know, or a distraction, and so there are tons of options. There's books, there's apps,

there's videos, there's websites, and there's large organizations that are committed to teaching

meditation. It's really just about picking one and sticking to it for eight weeks and seeing what it

does for you. Nature. I love nature. So what do we know about nature and just overall health?

Less green, the higher risk of morbidity and mortality. Green space exposure is tied to

decreased depression and anxiety, ADHD, infections, cancer, decreased risk of preterm birth,

type 2 diabetes, and cardiovascular disease, and this all started with this study in 1984,

and it was a very cool study where they took patients as retrospective. They just looked

at patients who were sitting in a room that was overlooking a parking lot and patients that were

overlooking trees, and what they found is, and they're all post-colycystectomy, what they found

is that the patients who were overlooking the trees had a shorter post-operative hospital stay.

They had fewer negative evaluations from nurses, and they required fewer analgesics. So very simple

intervention, again, that has a profound and meaningful change, and by the way, the business

guys in the hospitals love this study. And so there's lots of proposed mechanisms about why we

see these different health outcomes. Obviously, there's a mental health aspect of it, of just

being in nature and enjoying it, but there's also other aspects of it. Over here, there's

different active ingredients that plants actually release, and we call these biogenic volatile

organic compounds, and plants are releasing them all the time. They're produced by marine

and terrestrial vegetation, and it's really quite interesting what they do to their body.

So terpenes and terpenoids, which are really the major BVOCs out there. So one study showed that

the limonene had decreased TNF-alpha, IL-1-beta, and IL-6 within macrophages.

1-H-cineal has TNF-alpha and IL-1-beta, leukotriene B4 and thromboxane B2 decrease in monocytes. And

if we're looking at animal studies, gamma-terpenine shows decreased TNF-alpha and IL-1-beta in mice.

And then in humans, alpha-pinene, which is another one, actually acted as a

low-dose bronchodilator, like a slightly active bronchodilator. And then there was one study

looking at 1-H-cineal as a supplement, and it showed some benefit in asthma as a double-blinded

randomized control trial. Not something I recommend. It actually does have some side effects,

but just important to note, instead of taking supplement, go hiking.

Forest bathing is a really, really cool technique. It combines meditation and

nature exposure and mindfulness. And there's a study out of Japan that's really studying this

the most, and they found increased NK cell levels and activities in patients who are doing this

forest bathing. They showed decreased inflammatory cytokines like TNF-alpha, IL-6, and IL-8, and

decreased CRP just from these nature bathing experiences. And so how do we get it into our

clinic? How do we get our patients out here? In Denver, I'm sure it's not hard, because I feel

like it's part of the culture out here to be outside and to go out into the mountains.

Connecticut and certain urban areas around us, it's a little bit harder. There's a great website

called ParkRx, so park prescription, that has lots of resources about how patients get outside.

And then Shinran Yoku is actually the Japanese name for forest bathing. This is a great little

book on different techniques that you can use with patients. I got it for, does anybody know

about thriftbooks.com? Probably shouldn't be advertising up here, but I got it for $3

on thriftbooks.com, so it's accessible to patients. Yoga, I think we all know about yoga. What we don't

know is that yoga really extends well beyond just the bending and the poses and the breathing

techniques. It's a much more holistic practice, but when we study it, we really focus on what we

call asanas, which is the postures and the poses. This was a study of 30 healthy women that didn't

eat just regular Hatha yoga class, and they actually showed no differences in the plasma levels of IL-8,

MCP-1, or TNF-alpha, but when they did culture whole blood stimulation, they did see changes

in cytokines. And then they looked at PBMCs and showed decreased TLR2 expression, but actually

not TLR4 expression. So interesting, promising, we need more. This is a study of 200 breast cancer

survivors. It's in a 12-week randomized controlled trial. They did a twice weekly yoga class, and they

did show plasma differences. They showed significant decreases in IL-6, TNF-alpha, IL-1 beta,

three months post-treatment, but not immediately. And so that goes back to the point that I was

making before, is that

A Guide for the Perplexed, Part II Panel Discussion with:

Randy J. Horwitz, MD, PhD, Medical Director of the Arizona Center for Integrative Medicine
Rubin Naiman, PhD, FAASM, Clinical Assistant Professor of Medicine at University of Arizona Center for Integrative Medicine
J. Tod Olin, MD, MSCS, Director, Exercise and Performance Breathing Center, National Jewish Health
Jinny Tavee, MD, Chief, Division of Neurology and Behavioral Health, National Jewish Health

Good morning, everybody. Welcome to our final Denver Allergy Rounds to round out this academic

year. We have a really exciting session today that is part of the William S. Silver's Integrative

Allergy and Immunology Respiratory Wellness Program. This is our second part of our two-part

series this year. We had a wonderful lecture by Dr. Randy Horwitz, who is one of our panelists

today and today we'll be having a multidisciplinary panel discussion with two internal panelists and

two external who I'll be introducing. I want you to talk a little bit about Dr. William Silvers.

He's been a committed partner to National Jewish Health through his inspiring lecture series,

this wellness program, and now, as I mentioned, it's in its second year. He was a former allergy

immunology fellow at National Jewish Health, and he's a well-known advocate for treating the whole

patient through a combination of traditionary, complementary, and alternative medicine.

He's been named a top doctor by 5280 magazine multiple times. He's highly respected in allergy,

asthma, immunology, and likely known to many of you, as well as sports medicine and integrative

medicine. He is the son of Holocaust survivors and has committed much of his efforts to bioethics

and humanities. His lecture series is a prime example of his wish to further education to

anyone willing to learn and to share the knowledge of integrative medicine. For Dr. Silvers,

who has retired, his retirement is not the conclusion of his service to the community,

but an opportunity to support the issues he cares about in a new capacity. We thank him very much

for helping to create this wonderful respiratory wellness program. We're grateful for his

accomplishments to the medical community, including sponsoring this annual lectureship.

I do want to make a special note that many of you may have heard that Dr. William Silvers was

recently injured. There was a request that he does have a CaringBridge website,

and that any well wishes should be sent there rather than in the chat box. I will input that

link into the chat box for everyone to have. So to orient everyone for this panel session,

I will be introducing each of the panelists and then asking them a question. So we have

four panelists today. We have Dr. Randy Horowitz, Dr. Ruben Nyman, Dr. Ginny Tavi, and Dr. Todd

Olin. Then we would love to open it up to the group for an interactive Q&A. You can enter

your questions into the Q&A or chat box, or you can unmute yourselves or raise your hands,

and I can call on you. All right, so to get us started, so we'll start with Dr. Randy Horowitz.

He is the medical director of the Center for Integrative Medicine and a professor of medicine

at the University of Arizona College of Medicine. So before medical school, he completed his PhD

in molecular immunology. He also completed two fellowships, one in allergy and immunology and

the other in integrative medicine. He's triple board certified in internal medicine, allergy

and immunology, and integrative medicine. He's well published in integrative medicine, and in 2012,

his first textbook, which was titled Integrative Rheumatology, was released. He's been elected as

the founding chair of the American Board of Integrative Medicine, and in 2021, he was awarded

the Physician of the Year Award by the American Board of Integrative Medicine, and we're very

pleased to have Dr. Horowitz join us for this very early morning session for him in Arizona.

So a question for you, Randy, is what would you tell allergy immunology specialists is the greatest

gap in our approach to patient care, and how does the Angie Weill Center for Integrative Medicine

address that? Yeah, thank you very much. I'd like to preface by sending Bill and his family our

best wishes for a speedy recovery, and he is, as you said, a pioneer in integrative allergy.

So the two biggest gaps in my view, I went from allergy immunology to integrative,

I think the first would be time. I think that in allergy, I mean, when I was a fellow, some

docs would see 40 patients in a day, and that's just the antithesis of integrative medicine.

I think we have the luxury of time in integrative medicine, and I think having longer appointment

times in allergy immunology would help. I think a lot depends on why you went into medicine. I

wanted to connect with people, and I think that the extra time gives me a chance to know my

patients rather than as a list of diagnoses, and maybe the other one connected is tunnel vision.

I think that everyone in allergy immunology is a physician, and while you have expertise

in allergy immunology, and that's why patients are coming to see you, you have a fund of other

knowledge that the lay public lacks. Even your views on diet and exercise, which can always

impact immune health and can impact allergy and immunology, and I think limiting yourself to just

giving advice on allergy immunology, you have SAR, here's something you can use in your nose,

it's okay, that's why patients come to see you, but there's a lot more to medicine, a lot more

that you can give your patients. So I think time and tunnel vision, the two T's, may be

one of the biggest gaps that we're facing. Fantastic, and hopefully we'll be able to

delve into that a little bit more. Our next panelist is Dr. Ruben Nyman, who is a psychologist,

clinical assistant professor of medicine at the University of Arizona Angewell Center for

Integrative Medicine, and also the director of New Moon Sleep, LLC, which is an organization

that offers a range of sleep services and trainings internationally. He completed his

MS in rehabilitation counseling at the University of Arizona and his PhD in clinical psychology

at Alliance University in San Diego. He's a fellow in the American Academy of Sleep Medicine,

and by merging scientific with psychological and spiritual approaches, Dr. Nyman has become

a leader in the development of integrative approaches to sleep health. He's authored numerous

works on sleep blogs for the Huffington Post, and has presented on various topics to include

sleep and dreams, stress, psychological aspects of illness, and consciousness.

So a question for Ruben, can you describe some of your work as a pioneer in the development

of integrative medicine approaches to sleep and dreams? Thanks, I like to be muted in the morning

so I don't wake people up, you know, it is early here, and so thank you for inviting me,

and thanks for having me also. So let me begin by saying that sleep medicine, which is actually

50 years old this year, has made tremendous progress, especially in the arena of understanding

and treating sleep apnea, but that's not the case with regard to insomnia. I think we've done a lot

of work that's ended up with symptom-suppressive medications, and I think the main problem here is

we don't really get what sleep is. We make presumptions about what sleep is, and let me

just say, I think a lot of my perspective was influenced by something very fundamental in Dr.

Weil's approach. I met Dr. Weil 30 years, more than 30 years ago at Canyon Ranch, and I was

taken by the fact that as a physician, he was profoundly sensitive to psychological factors,

and I think the body-mind connection has been really a critical underpinning in all of integrative

medicine. So the point I want to make is that with all of the progress we see in sleep medicine,

we've learned a tremendous amount about sleep, about how sleep looks in the brain and in the

body, but we've essentially forgotten the sleeper, we've forgotten the person, and there's a really

obvious kind of benign neglect of the experience of sleep. Now that's associated with what I

consider the excessive medicalization of sleep. We tend to look at sleep today in terms of its

correlates in the brain and in the body. We look at sleep in terms of its measurements, in terms of

its numbers and concepts around activity in neural networks, and this always reminds me of Gregory

Bateson's advice that the name is not the thing, and I would add that the number is not the thing.

Sleep is not what goes on in the brain. It's an important correlate. The other piece of this

misunderstanding of sleep is that both professionally and among consumers, we tend to define sleep

negatively, and what I mean by that is not that we define it badly, but we define it in the same

way we define health. We think of health as the absence of disease. We define it negatively. What's

health? It's not disease. It's not illness. We define sleep negatively. What is sleep? Well,

it's not waking, right? It's not awareness. It's not consciousness, and the technical definition

of sleep in the field of sleep medicine is non-REM. True sleep is NREM, non-REM. What is sleep? Oh,

it's not dreaming, so this really obscures the critical question of what sleep is,

and I think we need to reconsider that, and that takes us to the fundamental

aspect of an integrative approach, and that's about recognizing that sleep is a consciousness

issue. Now, that may sound obscure to you, but we live in a wake-centric world, and what I mean by

that, wake-centrism is similar to ethnocentrism. We have this inherent bias about how we look at

consciousness, and the bias is we believe that waking, what we're all doing now to varying

degrees, right, we believe that waking is the gold standard for consciousness, and we see other forms

of consciousness, specifically sleep and dreams, as being secondary and subservient, so we try to

leverage waking to get to sleep, and this is really important, so we see this, for example,

if you're familiar with cognitive behavior therapy approaches, CBTI approaches to insomnia,

this is the standard of care for treating insomnia, and it works well, but not that well.

Somewhere between 25 and 40% of patients don't benefit from it. Even patients who do don't

exhibit any significant change in the quality of their lives, so it's an important step,

but what we fail to recognize is that we need to understand and manage our thinking in order to get

to sleep. I think the CBTI is being a helpful process for getting us to bed. We need to change

our thinking to get ourselves to bed in a healthy way, but in order to get to sleep, we need to let

go of thinking, and this is the consciousness issue, and if we believe waking is everything,

we fail to recognize that we need to relinquish waking to get to sleep, and I'll summarize,

I think, the heart of this by saying that the bridge, the natural bridge from waking consciousness

to sleeping consciousness is dreaming, and I would say sleep medicine's greatest shortcoming today

is around the fact that they don't recognize the importance of dreaming. They certainly

consider REM sleep, which is the physiological manifestation of dreaming, but there is virtually

no regard for the experience of the dreamer, the personal experience of the dreamer,

and work I've done anecdotally with thousands of patients, the best way to help people to get

from waking to sleep is to remind them that dreaming is the bridge, to consciously allow

them to move into dream consciousness, and I'll say one other quick thing. There was a question

in the chat about how to deal with chronic fatigue and long-call COVID, and I just want

to emphasize that this is anecdotal, but something I've observed over the last 35, 40 years,

I believe there is a critical connection between dream loss and chronic fatigue. I should mention,

and I've done some publication around this, that we as a culture are at least as dream deprived

as we are sleep deprived, and what sleep medicine does is it includes dreaming as a subset of sleep,

so it doesn't differentiate between sleep loss, technical sleep loss, and dream loss.

When we look closely at it, we can easily argue that much and possibly most of what we consider

sleep loss is dream loss, and you probably know that one key feature of dreaming is a loss of

muscle tone, what we call ramatonia or sleep paralysis. That loss of muscle tone looks like

fatigue, and one possibility, and again, this is based on anecdotal observations, is that when we

don't sleep sufficiently, we're sleepy during the day. When we don't dream sufficiently,

we get dreamy during the day, and there's a rebound, there's an attempt on the body and

the brain's part to reinstate that essential loss of muscle tone, so low-grade ramatonia may be

a key factor in fatigue. I encourage all of my chronic fatigue patients and sleep patients

to redevelop, I would say, a personal relationship with dreaming, so let me leave it at that.

Yeah, that's fascinating. I do like that, relinquishing your awake for sleep.

So, for our next panelist, Dr. Ginny Tavi is an associate professor and neurologist at

National Jewish Health. Dr. Tavi serves as the chief of the Division of Neurology and Behavioral

Health. She's a neuromuscular-trained neurologist with a special interest in peripheral neuropathy,

neurosarcoidosis, and evidence-based complementary alternative medicine practices.

She is actively involved in research studies evaluating the effects of integrative holistic

therapies on chronic neurological diseases and has led meditation retreats for patients,

physicians, and U.S. Marines returning from the Gulf War through the Wounded Warriors program.

Dr. Tavi, thank you so much for being here today, and a question for you is, as a neuromuscular

specialist, what have you found to be successful in terms of integrative approaches?

Thank you, Eileen, for having me, and to Dr. Silvers. We are thinking of you. You're a beautiful

and inspiring spirit, but ever since I attended my first integrative medicine conference sponsored

by the University of Arizona in 2008-2009, I've incorporated three major things in my approach

to integrative medicine with my patients, and I saved them for the last five to ten minutes.

This is something that everyone can do no matter what your specialty is, and you have spent maybe

45 minutes to an hour already with the patients, so you can see, are they a marathon runner who

knows how many calories they take every day, or do they live in a food desert and have never been

exposed to any kind of healthy choices? And so, at the end, you can kind of tailor what you think

they would be able to participate in, but the most important thing, of course, is eating. We all eat,

and we can all make a decision at the grocery store, at the restaurants, and when we open the

fridge, and I always push for increased protein, chicken, fish, lean cuts of red meat if you

absolutely have to have it, and nuts, fruits and vegetables, five servings every day of fruits and

vegetables, and then cutting your carbs. You can have good carbs like fruits, but cutting gluten,

and some patients don't understand, well, what is gluten? I still have people ask me that,

and so I said, well, just cut all bread, pasta, and not gluten-free cookies, not gluten-free

pretzels, but just no carbs, and of course drink more water every day. The second thing is about

exercise, doing something every day. Pick something you like, or you can tolerate,

because if you don't like it, you're going to quit. The number one month for joining a health

club is January. The number one month for quitting a health club, February. So, it doesn't matter if

it's Zoom, or what is it, that it's not Zoom, it's this thing where it's the dancing, the jazz

hands, or whatever, or it's running or swimming, but try to do 150 minutes a week, or a day,

I'm sorry, 150 minutes a week, and then number three would be mind-body therapies, and in many

cases, I think that this would be one of the most important things, because mind-body therapies,

such as meditation, tai chi, qigong, yoga, can help you understand what's going on, it calms you down,

it's been shown in clinical studies to reduce blood pressure, to reduce the sugar issues with

diabetes, and to improve overall health, and it also just makes you feel better. We've done

meditation studies in patients with ALS, in diabetic neuropathy, in multiple sclerosis,

and generalized neuropathy, and they comment on how it has changed their life.

I had one patient, and you can engage, if somebody has a lot of anxiety, sitting meditation is not

going to be the best, and the reason why is they're going to be in their mind, they're going to be

running around in their heads, and you have to get out of your head, and that's the point of

meditation. You're not always just thinking about what's going on, you're kind of just letting things

be, and so I tell them to do movement meditation, so again, yoga, tai chi, qigong, I had this one

CEO who I said, you know, why don't you do tai chi, he had some brain issues, and he says,

I don't do tai chi, you know, I do competitive skiing, I don't do that kind of thing, right,

I said, well just try it, I do the 24 short form, the yang style 24 short form, so six months later

I see him, he now teaches the 108 long form in Chicago, so and he said it did make a difference,

and I did have dinner with an allergist actually, so it's not just for patients, I had dinner with

an allergist a couple months ago, and you know, he's in private practice, he has a very successful

practice in western Colorado, but it's stressful, especially with COVID, you know, in when we're in

major academic centers, it's easy for everyone else to tell us what to do, but when you have

your own practices, you have to decide how we're going to do this, how do we get patients in,

and how do we keep it safe for everybody, and it was just very, very stressful, he's got kids,

and he started doing meditation, and he said it made a huge difference in his life, so this is if

I feel like the patient is going to be open to that, I'll talk to them about it the very first

time I meet them.

Fantastic, Jenny, I definitely took some notes for that one, and last but not least, we have Dr.

Todd Olin, who's associate professor and a pulmonologist specializing in exercise medicine

at National Jewish Health. Dr. Olin is the director of the National Jewish Health Exercise

and Performance Breathing Center, he has published in the area of pediatric airways disease, as well

as in the airway of high-performance exercise limitation. He is specifically interested in

helping children and adults exercise safely and comfortably, whether sick or well, fit or obese,

toddlers or Olympic-level athletes. He has invented two novel therapies for exercise-induced

laryngeal obstruction, which is also known as vocal cord dysfunction, a condition for which he's

considered a global leader. He also sees the value of working with sporting bodies to promote

population health and works with multiple local and national sporting bodies.

So question for Todd, as a pulmonologist with unique expertise in exercise medicine,

how does integrative medicine impact your approach to exercise and breathing?

Thanks, thanks for having me and well wishes to Bill also. I know Bill has,

we've worked on projects together and he's actually come to visit our exercise lab back

in the day. So kind of thinking through this, so I'm not a psychologist, although now like I've

picked up the title here at National Jewish of the Pulma Psych somehow, which I don't know if

that's like a blessing or a curse, but I think that it does reflect at some level or another,

the fact that we're thinking about a little bit more than just the airways when we're treating

people. And I think the biggest way that this enters my life as a clinician is just this

concept of if you're going to enact some sort of behavioral change, like be it in the form of like

taking a medication or learning a new way to breathe, which is what we spend a lot of time

doing, you have to meet people where they're at. And as part of that, you have to understand

a little bit about their psychology, a little bit about how they receive information, how they

process information, how they give information back to you so that you can have this, I don't

know if a closed loop is the way of thinking of it, but just to optimize communication.

And so we actually, as part of our exercise program with a lot of the patients, sort of

resource dependent, we'll have psychologists meet as many people as possible, but there's

really specific goals. And sort of goal number one is it's actually to at a professional level,

really digest the information that I just gave you is how does this person need to

have the information in order to learn or to sort of optimize adherence with whatever

therapy that we're giving. And, you know, are there other sort of red flags on the

behavioral health side or just sort of signals that we need to address in order to optimize

the overall health broadly defined of the patient. And then at a more specific level,

when we're so for those of you that aren't really familiar with what we're doing clinically, what

essentially what we're doing is for for athletes that are struggling to breathe during exercise

in whom the upper airway is for reasons we don't totally understand becoming obstructed. We teach

different breathing techniques to essentially undo the obstruction. And it's this really empirical

approach that we've developed. And if we don't understand the molecular mechanisms behind things,

but as part of the teaching, what we're doing is we're using a laryngoscope as biofeedback

while we're teaching athletes and they can see what's happening in their throat. And then we can

individualize the the different respiratory retraining therapies that we're using. And

at first, and again, this is just totally empiric, but I kind of stumbled upon the complimentary

side of things and the integrative side of things. We just used to think this was a totally

biomechanical thing. And I think in a lot of the world, it still is viewed as just a

biomechanical thing, like the vocal cords in the way, get it out of the way. And what we found is

that you can you can try to implement the same biomechanical techniques in two different people

and get two really different results. And so then, and this was just sort of empirically with a

camera down somebody's throat. And the observation to sort of a self-proclaimed idiot was that,

well, gosh, it's that same thing to two different people. And I didn't get two different results,

or I got two different results. So therefore, there must be something else going on. And

sort of the first thing that we stumbled upon was, well, there's probably something like

behaviorally going on. And so because in the old days, especially with athletes, and I kind of

was born and raised in an athletic family in the 70s and 80s, right? So my first thought was,

oh, well, people aren't dealing with stress well, like broadly defined, or they're cracking under

pressure. And there's a little bit in the literature about this, whether or not that's

totally correct is a different issue. And so I would push on the stress button, both diagnostically

and therapeutically. Diagnostically, in the old days, and I mellowed in my old age, I used to really

just kind of talk trash when people are on the treadmills, as like kind of a feeler to see like,

is this going on? And I would say things like, oh, come on, man, like, you're never going to be

running a 415 mile if you're getting tired at this point, or, you know, just kind of trying to get

under people's skin in a way that I knew that I could. And then we would see different things

with the camera. And then therapeutically, sort of the revelation of this, I am embarrassed to say,

probably took about two years was, well, shoot, if I can mess people up by sort of inducing stress

maybe I could actually use that therapeutically if I reverse things. And so we, over time, what

happened was we developed this whole sort of behavioral curriculum. And it was a little bit

performance psych-ish with a lot of feedback from behavioral health experts, both in general psych

and performance psych about, you know, hey, like, maybe we could implement this as we're implementing

a biomechanical respiratory retraining strategy to then optimize the implementation. Well, later,

we would get the same phenomenon of, gosh, we're saying the same things to two different people,

and we're still having variable results. And so we got more and more refined to sort of understand

the different tactical things that were involved in different sports, because we had this revelation

of, wow, we're teaching MMA fighters the same thing as the swimmers, or the distance runners,

and the breathing's not the same in any of those things. And then at some level, you know, you just

wake up and you're like, wow, that's really stupid. We have to think about that. And so we've developed

a number of different domains that we now proactively address. You know, there is this

biomechanical domain of respiratory retraining, but there's also this domain of figuring out

ways to hardwire it so people don't have to think about it, dealing with sort of the sport-specific

issues, the sort of the behavioral health issues, and then the social issues that are involved in

different teams. And so it's a little bit, you know, refining the people that are part of the

problem or part of the solution outside of the patient. And so there's a lot of structure to it

now, but it's just really empirical approach, but it sort of brought me into the sort of the holistic

kind of integrative side, if you will, I think kind of really, really, really broadly defined.

But I didn't kind of come at it actively from that perspective initially,

just kind of stumbled upon it from being stupid over the years.

That's a great depiction of your journey, and I do like the term pulmo-psych, so I'll be sure to

use that from now on, Todd. So we do have some questions in the chat. The first one, I think,

is open to any one of our panelists. It's kind of a chicken or the egg type of question, but

it's regarding the impact of the practice of integrative medicine, complementary

alternative medicine on therapeutic adherence. So the question is, does the practice of

integrative medicine often attract patients that are more motivated for therapeutic recommendation

adherence, or is it the approach of integrative medicine that results in patients having

vested interests in therapies and therefore greater adherence?

Well, I'll take the first stab. I think that this is one of the attractions of integrative medicine,

at least personally. The patients are so highly motivated. They seek you out as an integrative

medicine practitioner, and I think that's just, I think it's wonderful. I mean, integrative medicine,

if you haven't figured it out yet, is a consumer-driven movement. Consumers want this.

They want a comprehensive evaluation of their overall health, their practices,

and I think that their motivation is through the roof. And sometimes it's a little difficult

because it's got to be tempered with your own personal beliefs. For example, if someone comes

in with their usual wheeling suitcase full of supplements and botanicals, it's often difficult

to say, you know, I don't really know the evidence for this. Do you see a personal benefit from this?

And most patients will say, I don't know. Why did you start this? I saw it on TV. A neighbor told me.

Is it helping you? I guess so, because sometimes it's a little difficult to temper in that enthusiasm

for natural therapies. But by the same token, patients listen to what you say, and the idea

in integrative medicine is to partner with your patient. Most practitioners in integrative medicine

are enthusiastic supporters of integrative medicine, and to get a patient who is aligned,

it's really a nice blend. And the fun part about integrative medicine is that each patient is

different and you meet the patient to partner. So they may not believe everything you say. They may

not go for all your recommendations. However, they will listen to them and you can have a discussion.

And obviously, when it's outside your belief system, it can get a little tough. I mean,

you can get some emotions that run high, but the same token, patients are coming to you for your

advice because you have some expertise in this area. You're not the police. You're not their mother.

You're not their best friend. You are the provider of advice, and you're giving it from a learned

standpoint. So I think patients respect that. The internet has evened up the playing field.

Back when I was a kid, my mom put pediatricians on a pedestal. I mean, they were next to God.

Everything they say was the word. Their tablets came from tablets in a religious standpoint. But

the truth is, the internet has evened things up. So I learn as much from my patients as they learn

from me. They bring in articles and instead of saying, I don't have time to read that,

or I didn't see that, or that's a bunch of crap, I say, show me the articles. Let me learn.

We had no problem learning when drug reps used to come into our center and they used to show

all the graphs. We had time for that. But suddenly, when a patient brings in an article from a

non-medical journal, people discount it. So I'm going tangentially. But one of the fun parts,

the fun aspects of integrative medicine is that your patients are so highly motivated.

When they come into your appointment, they say, I've been waiting for this appointment for so long.

When was the last time? Well, in allergy, you get that all the time during allergy season.

They've all been waiting for appointments long. But this is true enthusiasm to share ideas. So

I think that's one of the real benefits of integrative medicine.

Can I add something to that? I think with regard to addressing sleep issues in integrative medicine,

so many patients I see have been through the wringer. They show up after years of reliance

on sleeping pills and other approaches. And what's happened is there's been an erosion

of what we call sleep self-efficacy. I think a less technical term would be people lose faith

in their own ability to sleep. And I think an integrative approach, which clearly,

Brandy, as you're saying, has a lot of regard for the individual for partnership. We're not looking

at imposing sleep on people. We're recognizing that it's a capacity they have. It's about restoring

their sense of their own ability to sleep. So that kind of partnership, I think, is really

attractive to people when they've lost faith in their own ability.

Fantastic. All right. So I actually have a directed question now for Dr. Olin. Are you

able to provide some examples of specific breathing exercises which may help with anxiety

and or stress in addition to alleviating upper airway obstruction?

Maybe. So I'm like the ultimate skeptic in things. And again, I kind of stumbled upon this world just

from like the hammer that I used on a lot of different nails was just this camera down

people's throats when they're running or biking. And so what we came up with was a

So what we came up with was ways of opening the throat. And we could just see that happen

in real time. And then sort of the feedback that we also had was on exercise performance. And so

sort of to build off of the last question, sort of my common denominator is that people come in

because they want to do what they want to do, whether that's like a performance or an end goal

or chase somebody around. And then they have a specific diagnosis. As far as the techniques

related to anxiety, to me, that's a little trickier for a couple of reasons. One is

it's not really why people come to me. I might have the gut feeling that that's part of the issue,

but there's going to be this totally bizarre selection bias for people that have that and

are running. And I worry about biases in a lot of ways. I think it might really be shadowing

who's coming to see me in the first place anyway. With the evidence around breathing techniques,

there's actually, I'm trying to think of the physician's name. He's based at Harbor, UCLA,

and he has some sort of podcast and a book, I think. And it's something about the scientific

skeptic, and essentially what he does is rate different things. And I think that the idea around

breathing techniques, whether it's like breathing in through your nose or intentionally slowing down

or using sort of meditative type approaches to breathing, I think the idea is probably at a

scientific level is that you're doing something with autonomic tone, and it's not related at all

to whether or not the airway is open. For example, if you personally breathe out for several seconds,

for me, I'm like, yeah, if I've got a camera down your throat doing that, it actually closes the

glottis to a large extent. But it probably makes people feel better, but I can't measure

why they feel better. And I can't tell if they're saying they feel better because

they're just trying to make me happy or they actually feel better, which are, I think,

not the same thing. And a lot of people are pleasers, and so they want to give me positive

feedback as if they think that'll help me sleep better or something. So at the end of the day,

I don't know. However, I would argue that there's something autonomic. If the metrics are autonomic,

if you can use a breathing technique that's doing something maybe like, you know, this is off the

top of my head, something with our interval or, you know, heart rate in general, that is probably

a reflection of increased vagal tone, that maybe that's going to spin off and have a result

as it relates to anxiety. And this is totally hypothetical in my mind right now, and I don't

know the literature that well in this area. But my instinct is that that would be your technique.

It might be like in through the nose, in out really slow through the mouth, you know, as we see in a

lot of meditative type breathing. But my instinct is if you did anything to sort of change autonomic

tone in a way that you were sort of a little more vagal, you might have an increased benefit

for anxiety. So kind of a roundabout answer, like the short answer is I don't know.

Fantastic. Thank you. This is a question in response to a follow up to yours, Jenny,

your comment about the skeptic patients, skeptical patients you had. So what are some strategies to

addressing skepticism to alternative medicine for patrons who are not as motivated, or may think

that suggesting alternative medicine may implicate that part of their condition is, quote unquote,

in their head, unquote. So that's a great question. And I think that the first thing is to talk about

their actual medical diagnosis and offer conventional testing and treatment. You know, if somebody even

if somebody comes in with fatigue, you want to make sure that their B12 level is okay. Looking at

their white count, are they anemic? And so they know that you're taking them seriously. So that's

And so they know that you're taking them seriously. So that's number one. The second thing would be

to offer literature. Now, there are going to be some patients who are going to be very health

literate, like my engineers who bring in their blood pressures graphed very carefully throughout

the day. And then there are going to be some people who are not so health literate, but at least you

can just abbreviate that some people are going to be like, well, give me the reference, I'm going

to look that up online. Or if you just say, yes, there was a study of a few years ago that showed

that Tai Chi helped with balance. Sometimes that's good enough. But I think that the third

is probably the most important one. It hits home for CEOs or patients who are on disability.

It is personal stories, right? It's like the story of my patient with Tai Chi. It gets people's

attention to like, hmm, maybe I should try that. You know, for food, I tell patients about, you

know, one woman who was over 300 pounds, she had diabetic neuropathy, is very painful. So I put her

on a medication that helps with both weight loss. It's part of a weight loss drug and pain,

topiramate. And then I put her on my diet, you know, just not my diet. It's the diet, you know,

it's gluten free, proteins, fish, chicken, all of that. And then six months later, she came back to

me. She goes, Dr. Tabby, I lost 100 pounds. I lost you. And so I said, okay. But when you tell

stories like that, it hits home with them and they'll be more willing to do it. And then,

of course, you just have to look at them, engage them and respect their personal thoughts about

what some people dismiss as woo woo. But I think that if you stick with things like

nutrition, exercise, sleep, meditation, these things are free, right? You're not selling them

anything. And most of them are just common sense. If I can add one thing, that was a wonderful

answer. I saw on the question to suggesting that a patient's condition is in their head.

When did being in their head be a pejorative term? Do lung cancer patients, are they told it's all

in your lung? For some reason, being all in your head has a negative connotation. I tell my patients,

I wish it was all in your head, we can do something definitive and you have control.

I think it's difficult to just categorize patients as being psychosomatic, it's all in your head.

But I tell patients that they can exert more control. And I don't know, as a psychologist,

Ruben has an opinion on that, about medical conditions in people's heads.

Yeah, I think it's all in our heads. The whole mind-body thing, I think, has been oversimplified,

this notion that the body and the mind are one, I think is actually mistaken.

Clearly, I look at it as a relationship. I'll tell you, from a sleep perspective,

when we look at what goes on in the brain during REM sleep, it's actually an out-of-body experience.

Traditionally, across the world, people believe that the soul left the body during sleep. But

there's actually a disconnection between executive function and lower limbic functions, particularly

hippocampal functions. And in a sense, our psychological self, the part of us we call

eye, is no longer confined to the body. And so, given that, our experience isn't restricted to

sensory channels, to eyes, ears, nose, touch, and so on. So, from the perspective of the mind,

it's an out-of-body experience. But from the perspective of the body, something really

interesting happens in sleep. When the mind is away, the body kind of goes wild. We talked

earlier about ramatonia. There's a loss of muscle tone. The mind isn't moving the body.

But there are also what we call autonomic nervous system storms. And these have baffled

sleep scientists for years. In fact, they've often referred to as hell breaking loose during sleep.

What happens in an ANS storm is there's this profound dysregulation of cardiac activity,

of respiration. Brain waves go wild. Body temperature bounces up and down. And it's

baffled people. But actually, rather than thinking of it as a chaotic reaction,

it's probably a reset that's going on. The body is shaking off. From the body's perspective,

it's an out-of-mind experience. The mind is no longer there. So, the body shakes it off.

The other thing that happens is, independently of the content of the dream during ram sleep,

there is a clear sexual activation. Men get erections and women lubricate. So, again,

when the mind leaves the body, the body gets an opportunity to basically shake out the tension

of the day. And I think of the body and mind relationship as a mixed marriage. It's an

essential connection. But they need time apart. They get that time apart during ram sleep. And

as I said earlier, I would call it an epidemic of ram sleep loss that has an impact on this connection.

So, as a psychologist, I think of things being in the mind as being very, very critical. Everything

has a psychological component. Even if it's strictly biological, the way we look at it,

the way we experience it has an impact on it. Yeah, that's great. Thank you. So, another

question I think we can open up to the entire panel, but what are good resources we can use

to learn more about ways to incorporate evidence-based integrative medicine components

into our practices? I know some of you have written books, so.

Yeah, I think generally it's difficult because if you look at integrative medicine journals,

the ones dedicated to integrative medicine, the research, how do I put this, it's not the most

robust research. And I don't like to categorize things as this is integrative, this is not. It's

all part of the practice of medicine. I think textbooks are a good starting point. I mean,

I mentioned in my last lecture that you can do a fellowship, you can take courses online,

take them from university or reputable-based authorities that at least reference materials.

So, I think the canonical textbook in integrative medicine is Integrative Medicine,

edited by Dave Rakel. The fifth edition is coming out in the next few weeks. And it's heavily

referenced and it's got enough wiggle room, but I think that's a good place. I think the

natural medicine database, if you're interested in learning about supplements and botanicals,

and again, I think this is recorded in my last lecture, natural medicine database, the same

people who put out pharmacist's letter, Jeff Jelen maybe, those people, I think it's now,

it was combined with natural standards, so it's pharmacologists at Harvard. And they're looking

at very good, it's very well annotated, it's got good references, and it may be a good starting

point. So, if you're considering, just like if you're considering dipping your toe into

integrative medicine, you don't have the experience, pick an area that you're really

passionate about, whether it be nutrition or botanicals or supplements or mind-body medicine,

and then learn as much as you can about it from these reputable sources and introduce things very

slowly. But I think that's a big challenge if you're looking for current research, because if

you're a double-blind, placebo-controlled, randomized trial person, you're not going to find it.

None of the people that make the supplements or that do a lot of integrative research have the

resources to put in what a drug company might. So, again, to double back to your question,

I think, Rachel, I think there's some good online sources, and I think courses put on by universities

or other accredited organizations are a good starting point.

That's wonderful. I was just going to throw in sort of my side kind of coming up from the other

angle of rather than introducing it with people, it's certainly in the athlete world, the amount

of totally ridiculous voodoo out there is so high, and frankly, totally dangerous sometimes.

There's actually a supplement that a lot of athletes used in the 90s that had meth in it,

right? And it was sort of discovered because all these people start failing doping control tests.

I wonder sort of on the other end, as the provider, to just be kind of curious and ask why people are

doing things, and you'll lose them in a heartbeat if you recommend that they stop all these things

that they're taking with almost like religious fervor. But at the same time, to get them to

question it too, because like Ginny talked about the power of the anecdote, it takes on like this

religious level in the sporting world where like, you know, X, Y, or Z person did this one thing,

and then like thousands of people start doing it with like absolutely nothing behind it other than

like Tom Brady ate, I don't know, lobster one day or whatever. And so we're going to always

eat lobster on Tuesdays of odd numbers, months with the wax and give a spoon.

So but I think the biggest thing is be curious, meet them where they're at,

ask questions, don't judge upfront. But over time, there is this need to like rein it in,

but you won't be able to do that in a single visit. It takes a relationship. And that's where you kind

of the psychology blends into it, you need to meet people where they're at before you can really enact

change. Wonderful. And that theme of partnership keeps flowing through this panel. I did

post a link to Dr. Horowitz's past lecture and also last year's program. Another question that

I think is kind of two part, you know, for those who do integrative medicine also incorporate into

the practices. So the question is for physicians trying to incorporate integrative medicine into

practices, when should they consider that referral to providers specializing integrative medicine,

and which patients would benefit the most from seeing a provider who focuses in this area?

I think this will be an interesting question for all panelists to answer, both from the perspective

of those who get incorporated into their own practices, and also who have specialized

integrative medicine clinics. So whoever wants to start us off.

Well, I can start. So we do get a lot of referrals. And it's interesting, we get phone calls too. So

our department and most of them get directed to me. Someone will say my patient's on a supplement,

what do I do? What is this supplement? Things like that. And I think the referrals,

I guess when to refer, I'm trying to think about it from the other end.

Some of the referrals I get are very simple. Please look at my patient's supplements and

botanicals and get them off this junk. I get a lot of those. This patient needs a

more appropriate diet. So I'll get a lot of those. I would say that I think about 75, 80% of my

referrals are self-referred by these motivated patients. And the other patients are the other

patients I get are people who come from subspecialties or other areas. I mean, I don't

usually get endocrinology referrals for a diabetic diet, but I will get them even from allergy

immunology. Is there any better supplement than this? My patient refuses to take corticosteroids,

any other option other than nebulized cromolin or something. And so we'll often go in that direction.

I guess my advice would be, we don't mind seeing patients with simple questions. It's nice.

When someone comes in with that wheeling suitcase, we have to go through all the

supplements with them. It would be nice to say a simple question or two, just like you would

consult anyone else. If there's areas you're not well-versed in, I mean, most people are well-versed

in the conventional aspect, but we study mind, body, exercise, nutrition, supplements, botanicals

in those areas. Yeah. And I think we get referrals because people know that we're open-minded, but

we're not that open that our brains are spilling out. I mean, you still have to keep your sense

about you and say, this is appropriate. This could be dangerous, as was mentioned. There's no real

evidence for what's the risk-benefit ratio. So I think the referrals, if you have an

integrated person at your center or a department, they go the whole panoply from everything to a

single question. I would add that with regard to sleep, most of my referrals are self-referrals.

And I think because the field of sleep medicine is relatively young, it really hasn't opened up to

a lot of the alternative integrative approaches. A lot of referrals that I get have come from

integrative medicine practitioners, but most of them are self-referrals. And what I notice is

these are people who find that some of their personal values are not respected in conventional

sleep medicine. I get a lot of referrals from people involved, for example, in yoga practices,

yoga nidra, which are yoga sleep practices. People with traditional religious perspectives

who believe in dreaming, who believe that sleep is not simply the absence of waking, but that it

takes them somewhere. So the contradiction or conflict between their personal beliefs

and the sort of restricted, hardcore scientific brain-focused beliefs of sleep medicine, I think

often will cause people to look for alternatives. And I've written extensively about the fact that

we throw the baby out with the bath water, that there's so much we can learn from traditional

perspectives, yogic perspectives, Hindu perspectives, Tibetan Buddhist perspectives,

mystical Christian, mystical Kabbalistic Jewish perspectives. There's interesting writings about

sleep that go back thousands of years. And I think the more we come to understand sleep from

a scientific perspective, the more consistency we see between that. And I think we need to be open

again to recognize that sleep can't be fully defined scientifically, and we need to extend

deeper regard for the personal experience of sleep. I think integrative medicine is also helpful for

patients with chronic illnesses, where we've done everything to look for a primary cause that can

be corrected. And we've thrown every conventional medication at them, you know, gabapentin, pregabalin,

and they're fat and they're goofy and they're tired and they hate taking the medications.

And so the next step is, and I always integrated the first part, but you know, many of these

patients have already seen other individuals and they've just had many different medications

thrown at them. So I think that's a role that integrative medicine can help patients with

chronic illnesses, especially pain, given the opioid crisis now. And I worked with an integrative

medicine doctor when I was in Chicago and she was great, you know, and I understand about the

supplements. I've seen it when they come in and they put them all out on the counter. I've never

heard of them. I can't pronounce them. And so we just have to find a happy medium, something that

has literature behind it and to let them know, gosh, we care about you. And if you don't have

any experience, I think that's a great reason for a referral to integrative medicine to say, look,

we've tried everything here. Let's get you to somebody who knows a little bit more about,

you know, something that can help you. Can I add one other piece? I keep thinking when

we refer to supplements about melatonin, you might know melatonin is the best-selling

over-the-counter supplement in the United States today. It has been for a long time.

And if you look at the literature, it's really clear that melatonin doesn't work and it's really

clear that it does work. And there's so much oversimplification about this. Big Pharma doesn't

like melatonin because there's evidence that it doesn't work. And there's such naivety about it.

Many patients come in and say, well, I've tried melatonin and it doesn't work. And I ask, well,

what did you try? What kind was it? Was it pharmaceutical grade? Was it time released?

What was the dosage? The most common answer I get is, I don't know. And so I think it's just a

question of becoming better informed. And I'll say something I think we all know.

Healthcare medicine is as much an art as it is a science. And we need to base it as much as we can

on science. But there's this really critical artistic piece. And so we draw from our histories,

our experience, our knowledge. And melatonin maybe is emblematic of a lot of supplements.

It works for some people some of the time under certain circumstances and not for others.

And so we have to keep our minds and hearts open to that perspective.

Great. These are fantastic points made. So we have just a couple more minutes. And I want each

of the panelists to have a chance to have some closing remarks. And if you're able to,

we do have a couple questions that went unanswered. But one of them, if you want to close out with

your comments on this, is what advice can integrative medicine offer to traditional clinicians

working to help patients become better partners in their care? So that partnering

as a theme for this panel. And we can start with Abba. We'll start with Todd.

That's a good question. I think the number one thing is just to have curiosity. I don't

think it's reasonable to say that every complementary approach is going to hold water at the same time.

I think the likelihood that traditional medicine practitioners are right about every problem 100%

of the time is unlikely. And so just to always question yourself as to what are you doing that's

working? What are you doing that's not working? What gaps do you have in your own practice? Where

can you look to other resources for things that might fill a specific niche that you had? And

I think all four of us on this panel are really different in terms of what we do in practice.

But at the same time, I think we're really similar in the sense that we're dealing with

people that have problems that want to fix their problems. And you just have to kind of find a way

to get them the solution that they're looking for. And some of it's already out there and some of

it's not already out there. Yeah, I'll just add a really quick comment. And that is I'm so pleased

that National Jewish has an enthusiastic approach toward integrative medicine and an

open-minded approach. And I think cultivating this interest, and you don't have to drink the Kool-Aid,

but you have to open your mind up to other approaches other than pharmacologic approaches

or surgical approaches when appropriate. And I think the most important thing you could do is

cultivate that passion. So among fellows who show an interest, cultivate it. Let them do some CME

in integrative medicine. Let them do a patient slot or two of extended two-hour appointments,

and let them address something they're interested in, like nutrition with a patient. Again,

having an institution like this who puts on a panel like this shows that you're on the

right track. And I just think nurturing the next generation of physicians is most important.

Jenny, we'll go to you next. So I always tell patients, this is what I can do,

right? I'll do the diagnostic testing. We'll go over that, and then we'll do some conventional

treatments. But this is what you can do. And then that's when we talk about the nutrition and the

exercise. And together, you're going to feel better. I may not cure you, you know, this is

a chronic illness, but things are going to get better.

I'd like to add something about the spiritual piece, which I think, again, Dr. Wilde emphasized

from the start, from the emergence of integrative medicine. From a sleep perspective, sleep and

dreams are the roots of the tree of waking life. And just like the roots of the tree, when we tend

to look out of the tree, we forget that there's as much of it underground as there is visible.

And how critical that is as a source of grounding, communication with other trees, if you will,

a source of nutrition, of nourishment. And I think there's a tendency with healthcare in general,

certainly with sleep medicine, for people to become OCD. Everybody's trying to do the right

thing, all the right things. There's so much information, there's so many steps. And people

often are attempting to do the right thing in the wrong way. The critical piece about sleep and

dreams is remembering that there is as much value in letting go and not doing and trusting, and

really surrendering as there is value in all the activities and the diets and the supplements and

the exercise that we can do. It's complementing that. And again, it's extending trust to our

nature, to all of the wisdom that has been a part of who we are over evolution. So trusting

ourselves, trusting our body, trusting the night, trusting sleep, trusting dreams.

Wonderful. Well, I really want to thank all four of our panelists,

Randy, Reuben, Ginny, and Todd. This was really a fantastic panel. I wish we could go on for an

additional hour. We've ranged in topics from kind of philosophical approaches to concrete,

actionable steps and resources. Partnering with patients has been a big theme. Education,

the next generation of providers is also another wonderful theme. So I want to thank the audience

for joining us and also particularly Dr. William Silvers for making this wonderful program on

respiratory wellness and integrative medicine possible. Thank you, everyone. And I hope you

have a wonderful rest of the week. And thank you for joining us for Denver Allergy Rounds.

March 9, 2022 | Integrative Medicine: A Guide for the Perplexed | Randy Horwitz MD, PhD, FACP

Randy Horwitz MD, PhD, FACP is the Medical Director of the Andrew Weil Center for Integrative Medicine, and a Professor of Medicine at the University of Arizona College of Medicine.

Can this guy make you healthy?

So I met him in the mid 1990s while becoming interested in what we called CAM, Complementary Alternative Medicine at that time, seeing that a number of patients were not satisfied with the traditional medicine and were seeking alternative providers promising allergy relief and allergy elimination with unsubstantiated methodology, trying to be competitive with we trained allergists. So I view integrative medicine along the way as incorporating complementary approaches with evidence bases into our traditional orthodoxy, addressing the whole patient, mind, body and spirit. And Randy is uniquely qualified to help us share these perspectives on lifestyle, nutrition, exercise and stress management in the care of our patients. So while Maimonides had authored the first treatise on asthma, and if I can, I'll just show again, as I did last year, the Maimonides treatise on asthma, it's a book that Henry Klayman had given me that was given to his mother, an eminent allergist, Leonie Klayman.

He passed that on to me a number of years ago, and I shall pass this volume on to the Henry Klayman collection at the University of Colorado Straus Health Sciences Library on the third floor. You ought to get there sometime if you haven't yet. Maimonides also wrote the Guide for the Perplexed in 1190 in the 12th century, which seeks to reconcile Aristotelianism with rabbinical Jewish theology by finding rational explanations for many events in the text. It was written first in Arabic, later translated into Hebrew. So while some of this terminology may seem like Greek to us, perhaps Randy Horowitz can help enlighten us and guide us along the way to our wholesome approach to our patient care in 2022. Randy, I love the title of your talk, and I look forward to you joining us.

Thank you very much.

Sure. It's my pleasure. My pleasure, Bill, and what an honor. Guide to the Perplexed with apologies to Maimonides, I guess. Let me start by saying I have no financial disclosures. I am certainly open to it, though, if anyone on the call wants to make an offer. Let me say a word about Bill and how honored I am to give this lecture that is presented in his honor. When I joined the fellowship in integrative medicine, it was about two decades ago, about 20-some odd years ago, and I'd heard about integrative medicine and Andy Weil, and I came on from a pretty conventional background. Andy is a pioneer in integrative medicine, as Bill said, but Bill is really a pioneer in integrative allergy. When I got into the field and started looking, his name popped up again and again and again, and he wrote seminal articles about integrative allergy. While I'm honored to give this lecture, I'm also honored to know Bill because he is a pioneer, and pioneers have to put up with all the derision and they have to confront their colleagues about integrative medicine with different views, so I salute him. This picture is from the 2016 nutrition conference we put on, and that was when I first met Bill face-to-face. Before I start my talk, I just want to give you a personal aside as to how I got interested in integrative medicine.

I had already been to graduate school, medical school, residency, and fellowship in allergy. This is a picture of me and my sister. That's me with more hair. That's why I'm not recognizable in the picture, but I grew up in Chicago, and I had childhood asthma, but as an infant, I had frequent URIs and LRIs. These infections were severe. I was on antibiotics most of my early life. I was hospitalized quite a bit, and in Chicago, the docs, the pediatricians didn't know what to do, so they heard about a new doc at Mayo Clinic who was working studying the immunoglobulins of kiddies with decreased resistance to infections. I was sent to Mayo Clinic starting at maybe five or six years old and annually following up with my doc there, who was Dr. Bob. My doctor was Robert Good. He's regarded by some as a founder of modern immunology.

I guess in the late 60s, he led a team that did the first bone marrow transplant between non-identical people who weren't twins, so allografts. I think a boy who received his transplant from his eight-year-old sister. He taught me about immunology, so probably he loved to teach, and probably from the age of six or seven, I was one of the youngest people that wanted to be an immunologist. Every year on follow-up, he would teach me more about immunology,

but what he really taught me was you have to think outside the box, and he used that phrase quite a bit, and it stuck with me all these years. I got to Allergy Fellowship, as Bill said, with Bill Busse and Rob Lemanski and Bob Bush, and there again, they were emphasizing thinking outside the box. These guys are as straight-laced as you can imagine. If you know Bill Busse, he doesn't deviate at all, but we knew, for example, people with SAR, seasonal allergic rhinitis or chronic rhinosinusitis, we had to get a corticosteroid into the nose. We wanted to localize it rather than using systemic. There was no Flonase, no beclomethazone. Nothing was available commercially, so what did we do? Well, the fellows suggested chopping up prednisone tablets on a mirror and having patients snort them, but it was kind of in vogue around that time, but that was shot down.

Here's what we did instead. Fluticasone was available as flow vent, so we would take a flow vent MDI, and if you're older or this looks familiar to you, we'd slap a baby bottle nipple on the end of it and cut off the end of that baby bottle nipple and have patients put that in their nose and give a few sprays. We didn't know the exact dose to use. We didn't know the potential side effects. It was wide open, and yet that was, again, an example of thinking outside the box, and it worked. It worked well until the commercial products came along, and yeah, there were side effects and bleeding and things like that, but overall it worked pretty well. In addition, when I was both an allergy fellow prior to having nebulized corticosteroids for kids, we used Intual extensively, which is still available as a nebulizer, and when I got into fellowship in integrative medicine, I learned the story behind Chromalin. Roger Altunian, who is pictured here, almost by himself, pushed for this drug and tested it, in fact, on himself, terrible guinea pig allergies, and so he would test compounds from this plant, Amiviznaga. It's called the Kala plant. His grandma used to give it to him for his terrible asthma, and it worked, and so he said there's got to be something in there, tested over 600 compounds on himself until he isolated the chromones that became Chromalin sodium. So it's an interesting story, and I urge you to read it if you're interested in a fact. I mean, he even designed the spin that was used for the powder dispersion. Spinhaler's a little propeller, and he was in the RAF, and that's how he came up with that design. It's a fascinating story. Again, this pervasive theme of being able to think outside the box is, I guess, what drew me to integrative medicine. So in this talk, I want to give you a few things. I want to dispel some myths because I don't know if I'm preaching to the choir or a hostile audience, but let me tell you my view of integrative medicine, and then the second half of the talk, I'm going to give you resources in case you want to learn more or incorporate some integrative medicine options or patient choices into your practice. I want to stimulate thought, and we've all been zoomed out here quite a bit, so I'll try not to be boring. Last year, Dr. Marshall did discuss specific interventions for allergies and asthma. He mentioned some supplements, botanicals, mind-body interventions, which he's big on. I'm going to give you a general guide and our view of integrative medicine, and the reason I want to dispel myths is because in many medical centers, here's how integrative medicine is viewed. This is how many people see us, and Andy Wile, when he started the programs at our clinic, has to be right in the midst of internal medicine.

My clinic, I'm surrounded by rheumatologists, endocrinologists, ID docs. We're just right in there. We're truly integrated at the medical center here. Let me start with, I'm just going to give five myths and explore them a little. Myth number one, integrative medicine is CAM, complementary alternative medicine, with WACOs using unproven therapies. This is a myth that's commonly held, and let me address all three areas, complementary alternative medicine, WACOs, and unproven therapies. Let me start with our definition of integrative medicine, so we're all on the same page. In our view, integrative medicine is healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. We explore with patients aspects such as nutrition, exercise, stressors, go into mind-body a bit, and of course, we deal with their medical condition as well.

We emphasize that therapeutic relationship between the practitioner and patient, that bond that's needed in order to affect either behavioral change or mind change, a change in outlook.

What we do is inform by evidence and make use of all appropriate therapies. When I discuss options with a patient, I will discuss conventional and less conventional options, and we'll put them all in a bucket and try to eliminate some biases and talk about the pros and cons. The first myth, we are not complementary alternative medicine docs. If you want, you can say we bridge the gap between conventional medicine or orthodoxy and complementary alternative medicine. We're certainly educated in those areas. It's nice to be able to discuss the options with patients because patients are doing all this research on areas that you may not be familiar with, so it behooves us to at least

know as much as the patient if we can. Let me talk for a second about basic principles of integrative medicine. Again, that partnership between the patient practitioner is really important, and that's one of the reasons I went into medicine. I had a basic science background, but I wanted to connect with people and help people one-to-one. Facilitating the body's innate healing abilities, that homeostatic urge for the body to heal, what's blocking it in certain patients? Why do some patients react a certain way to a viral infection and others do not? Going beyond the pathophysiologic explanations, there could be other reasons as well. We need to reject conventional medicine nor embrace alternative medicine uncritically, and I'll talk about this more in a second, but that's really important. Our foundation is conventional medicine.

Good medicine is grounded in good science, but it's got to be open to new paradigms. Otherwise, we just stagnate. We have to be open-minded and open to new paradigms, including integrative medicine and other options. Last year, Dr. Martian talked about psycho-neuroimmunology. Bob Ader, Nick Cohn, who did the pioneer work in psycho-neuroimmunology, they were going out on a limb, but they were open-minded and looking at other options for how the immune system can react using neurologic methods. They were open-minded pathways. We focus on promoting health and preventing illness as well as treating disease because it's really easier to promote health and to prevent illness, much harder to treat disease.

So if we can get a patient and team up with a patient and prevent illness, that's the best option. My personal view of integrative medicine, just a few biases, I think it's a philosophy of patient care. When people ask me about it, it's not replacing a drug with an herb. It's not taking away sabas and giving a patient an incantation when they get tight in terms of their breathing. It's a way to approach patients and a way to approach patient care. I don't think there's a specific specialty of integrative medicine, which is sacrilegious, seeing as how I sat on the board of integrative medicine. I think it kind of transcends. I don't think that there's a unique specialty of integrative medicine. We have in our fellowship representation of all different fellows from pathologists to emergency department physicians to family practice docs to cardiothoracic surgeons. There's no specific specialty. Again, it's some of the tenets and philosophies that you can incorporate, and the same for allergy and immunology.

As Dr. Marshall explained last year, I also subscribe to the WHO definition of health. Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. The thing that's interesting about this, it was adopted in the late 40s, even though it's up every year for voters, it's never been amended. Obviously, the rest of the world is way ahead of us. The way we explore integrative medicine, we obviously deal with the patient's health issues.

That's what brought them in, but as I said earlier, we talk about their nutrition. What diets are they following? Is it a standard American diet, the sad diet? There is more and more evidence that nutrition impacts overall health, but also allergy and immunology. We talk about exercise, physical activity. What are they doing to keep their body in good shape? We talk about stressors. Everyone has stressors these days, particularly with the pandemic. That's an area we explore. We talk about the nature of their relationships with people. Have they had many relationships, short-term, long-term? Why or why not? What about many relationships? What do those people have in common? What's a common thread? We get to know the person. I think that's really important because there is a lot of heterogeneity, as I'll mention in a minute. We talk about medications and supplements. We do have the occasional patient that wheels in a wheeling suitcase full of hundreds of supplements. I personally tend to be a minimalist, but I think there's botanicals and supplements that can be really helpful for asthma and allergic rhinitis, allergic diseases.

Among the modalities that we use, obviously conventional medicine is our foundation, but as I said, we do address nutrition, recommend diets depending on the person's needs, botanicals, vitamin supplements, manual medicine. I'm not a fan of chiropractic personally, but osteopathic manipulation I like. Mind-body modalities, of course, they're essential. Exercise, traditional Chinese medicine, yeah. If you're familiar with Xiumin Li's work, her earlier work with Hugh Sampson at Mount Sinai, there's some wonderful compounds that show efficacy against both asthma and allergic rhinitis and maybe even food allergies. Of course, pharmaceuticals as well.

If you look at this list and you say, well, conventional medicine, check. The other ones, not so much. If you want to start introducing this, pick an area, say nutrition at the top of the list. We know that maybe from Jim Stein's work at Wisconsin that the MESA study that was a multi-ethnic cohort that showed that persistent asthmatics had a higher cardiovascular disease event rate than non-asthmatics. So that puts our patients with asthma at higher risk.

That's a good place to start. Learn about nutrition and learn about cardiovascular risk and advise patients. You may not be a primary care doc, but you're a doc. We all went through medical school and had the capability to, if not learn about this, then master these areas.

The modalities come in handy. What about the patient who refuses corticosteroids for themselves or their kids? For some reason, they feel that they're poisoned. You spend time trying to educate them and explain them, but what if they say, I understand, but I don't want to. What are your options? Chromaline is a good option for many people, but are there other options? Again, I think that these modalities, I've worked with them for a couple of decades in our clinic and I'm comfortable with them, but certainly didn't start that way. Just like with any new area that you're exploring, we're all capable of doing this. It's nothing that requires anything more than time and attention.

Okay. Let me address the wacko part of it. Okay. This is not an integrated medicine doc. I don't care how he advertises himself. Someone who's hawking weight loss products that have no evidence basis and any cardiothoracic surgeon that gets up there and is pushing double cheeseburgers, although it appeals to me at some basal level, it certainly is not indicative of an integrated medicine doc. I think in politics aside, just looking at the TV show and the attitude, it's a bell-shaped curb in every field and integrated medicine is no different.

You have people at each end that are in the fringes and here is one. This is not an integrated medicine doc. The people that I admire, some of the pioneers in the field, Dean Ornish in the upper left, he did the whole systems approach to reverse cardiovascular disease, including diet, meditation, exercise, and it was shown to be effective. It did reverse cardiovascular disease. Deepak Chopra, a little fringy for some people, but the importance of meditation, Ayurvedic medicine, John Kabat-Zinn in the lower left, he westernized his Buddhist meditation process and called it mindfulness-based stress reduction.

He was at UMass in Worcester and they didn't allow him to use the word meditation when he started his program because it wasn't acceptable culturally, so he called it mindfulness-based stress reduction. Excellent program, set up an eight-week program, and actually for the first several years, he had only chronic pain patients referred from orthopedics, so helped with chronic pain. And Rachel Naomi Remen, who people may know, pediatrician, but also an integrative cancer medicine specialist started Common Wheel, has written many books on the subject. She is a wonderful person and role model. I think one of the problems when we teach students and residents, residents say, you know, I can bring this up and I can understand it, but I bring it up to my older attending and they just don't want to look at it or have other complaints. They say that even if I see value in considering non-conventional therapies, they lack the gold standard studies necessary to allow me to make good clinical choices.

So this is a common complaint and, you know, we all know, we're all medical professionals here, we all know that I could make a talk here and I could put up slides that will talk about the benefit of X, Y, and Z. Every time you see a talk, someone is cherry-picking papers and a lot of times there's pro and con, but you won't often see that in papers. I think my response to this is that there's many levels of evidence. There are people that you encounter that swear by the double blind placebo controlled trial. So be it. I mean, it's almost a fundamentalist religion with the evidence-based medicine who worship that. All I have to say is when I look at those trials, I'm astounded. Let me give you an example. When I trained and maybe when Bill trained, there were two types of asthma, extrinsic and intrinsic. That was it. Now, pathophysiologically, we've determined that there are a dozen or more phenotypes or endotypes, if you will.

Our older studies that we regard as cold gold standard were likely done with heterogeneous populations. These people had different types of asthma, maybe even different pathophysiology, and yet we're lumping them all together. It works that way even today in rheumatologic studies when you have rheumatoid arthritis, which is grossly heterogeneous, and we're grouping people based on a few lab tests and a few physical symptoms. It's important for treatment options, but if I were to use wild type mice in my basic science graduate studies, I'd be laughed out of the program, and yet that's what we're doing with our studies now. So that's my push for personalized medicine. So how do we answer the lack of gold standard studies?

Well, we use a sliding scale of evidence. The greater the potential that a treatment has to cause harm, the stricter the standards of evidence it should be held to in terms of efficacy. So if you are recommending chemotherapy for a patient that has potential to kill, you better be damn sure you have the right agent and the right dose. But what about recommending breathing exercises for a patient or meditative practice? Not so much. Again, I guess you could hyperventilate with breathing studies, so maybe you can pre-medicate with albuterol, but these things have value, and the point is you have to assess the risk-benefit ratio of everything that you recommend, even in integrative medicine. Does that mean we should accept everything? No. You have to maintain some degree of critical thinking and objectivity. I think Ernest Hemingway said it best for writers, but I think it holds for docs as well. Most essential gift for a good writer is a built-in shockproof shit detector. Everyone has to define their own line in the sand.

What are you comfortable with based on the evidence? Personally, I mean, I'm not a big energy medicine person. I don't understand it. I mean, hands-on work, very important, but other people that I know recommended patients love it. Homeopathy, I got to tell you, homeopathy has worked for a few of my patients with multiple chemical sensitivity who are taking, whether it's a mind-body intervention, I don't know, but not really my forte, but again, it's not like you're drinking the Kool-Aid here and accepting everything. We're not a cult. You are free to pick and choose areas that you believe in, that you feel are important.

Second myth, integrative medicine ignores or convinces patients to eschew conventional therapies. Nothing could be further than the truth, at least the way we practice it. I am writing many prescriptions for pharmaceuticals. There are people that I know that will, some people who teach Pateko breathing or things like that, will take patients off their short acting beta agonists and use other techniques, breathing techniques. Yeah, that's not me. I don't favor that, but I also write prescriptions for exercise, for diet, for whole systems.

In our clinic, even when I was a fellow in our clinic, both Andy Weill, who was my attending then, and myself, we would spend hours convincing patients to accept chemotherapy for Hodgkin. Someone would come with a malignancy and say, they don't want to use chemo, it's poison. Well, yeah, it's poison. You need that poison, and we give it in graduated doses. I have patients who don't want to take CT scans because of the radiation that's going to kill them. I have patients who don't want to take inhaled or systemic corticosteroids, and so I spend a lot of time educating them, giving them my view, and laying out the whole process. If there are patients who won't, you can adapt a little. CT scan, okay. Right after the CT scan, we can pump you full of antioxidants that will minimize damage, whether perceived or actual.

I think that conventional therapies are kind of our foundation, and we don't take patients off their medications. That's just ridiculous. Another myth, integrative medicine is a fad that's dying off. Well, actually, nothing could be further than the truth. As Bill alluded to, this is a consumer-driven movement. Americans, this is from the NIH, the National Center for Complementary and Integrative Health. Americans spent $30 billion out of pocket, and those numbers go up each year. This is consumer-driven, and most people get a benefit from this, or you wouldn't see this year-to-year repetition or increase. There's something that they're getting from complementary health approaches that they're not getting from conventional health approaches, and maybe it's time to expand a little, expand our view or our vision. Among the biggies, people take natural products, supplements. Even the people, when I talk to our local medical groups, our Pima County Medical Group, and these people are a little older and a little more rigid, they don't really care much for integrative approaches, but I ask them how many people here take vitamins, and all the people my age and above are raising their hand, and I say, why? What's the evidence? What are you doing? By the way, there is some good evidence for that. I don't want to diss it, but people are using what we consider complementary health approaches in large numbers, and I think it's nothing to ignore. I think that breathing techniques are great, meditation, especially during the pandemic. In addition to just looking at NIH figures and the general population, look at clinics that are well-known. Mayo Clinic has a section of integrative medicine, and here's Brent Bauer's book. Cleveland Clinic has integrative and lifestyle medicine. They also have a functional medicine clinic that's a little different that I'll tell you about in a few minutes, but they have their own section of integrative medicine.

The Osher Center at Harvard, they focus a lot on research, but they also have a clinical center for integrative medicine, and in fact, if you look at the US, specifically in the world in general, there is an academic consortium for integrative medicine and health, and I think that Colorado, yep, UC Health is a member, so there's over 75 medical centers and universities that have dedicated programs for training, research, or patient care, and this has been expanded. It was the US when I was involved in the consortium, then North America, and now it's the world. There are people all over the world, medical centers that are joining this consortium, so I don't think that this is specifically just consumer-driven. I think at least the catalyst was the consumer drive, but I think now it's being adopted and accepted by medical centers and clinicians all over. Maybe reflective of age, maybe younger people are clued into this, but in any event, it is certainly pervasive now, and I think that's a good thing.

Myth number four, integrative medicine is easier than regular medicine. Oh, that's why people go into it. I don't have to prescribe drugs. I can just say, go meditate in a corner. Well, I'll tell you the truth. I think it's more difficult having done both strict conventional medicine and integrative. It's much harder to do integrative medicine. In our clinic, in my clinic, I see cancer, inflammatory bowel diseases, asthma, rheumatologic diseases, cardiovascular, food sensitivities. All the conventional allergists who say you have a food sensitivity, go see integrative medicine. Chronic fatigue and the chronic fatigue of this era, mass cell activation syndrome, there's an asterisk there because I stopped. We were getting overwhelmed, and the lab was yelling at me because I was ordering a serum tryptase and F2 alpha E4 urinary studies and never getting any positives. I'm afraid that there are websites that list if you have this symptom, if you're fatigued and get occasional sore throats, you may have MCAS see your doctor and a little overwhelmed, but that's a different lecture altogether. But back to the issue of being easy, a lot depends on your location. I'm doing general integrative medicine. I specialize in allergy, but I see all comers. In a large city, you can refer to an integrative oncologist, integrative gastroenterologist, rheumatologist, because there's plenty in big cities. But in most places outside the big cities, you need to do that work yourself.

So if I see a patient with rheumatoid arthritis, I have to know what's the current standard of care for RA beyond just an internist knowledge. Are supplements or botanicals efficacious? Do that research. Will they interact with the standard therapies, particularly the biologics? Is there any evidence? And I think it's a challenge. It keeps you learning. I mean, this is lifelong learning, and I love doing that. And after a while, once you've seen a few dozen RA patients, it becomes easier. But again, it's a steep learning curve. So again, if you're in the Midwest and you're doing it all yourself, you're a one-person shop, it becomes more difficult than conventional medicine.

Telemedicine will certainly help. And we have a pilot in New York City that we're doing and expanding to the state of New York where we'll get multiple specialties doing telemedicine, but it's just a pilot now. Integrative medicine is easier in one regard. I went into integrated medicine because I wanted to connect with patients. I had that need to the physical connection. And if you're familiar with the Beckman study, this was a study done by visits to internists. The physicians would listen to the patient concerns for 18 seconds before interrupting.

And in fact, it's interesting because in over two-thirds of the visits, the patient was interrupted by the physician before they could even say why they were there. I think that ability to focus on the patient that I enjoy in integrative medicine is one of the biggest rewards, if I could digress for a second. When I was an allergy fellow, they showed us this from Jim Lee, who is the chair, I don't know if he still is, chair of allergy and mail. He had a whole article about how to get through a 15-minute visit, how to separate it. An open-ended inquiry about patient concerns. Give it a minute. Ask the status of the asthma. There's another minute. Spend three minutes on the physical exam. Wow, that's a luxury. I mean, back then as an allergy fellow, they were teaching this to us as it was the gospel. Now I show it to integrated medicine colleagues.

They get a good laugh out of it. When I started in integrated medicine, I used to hurry through intakes, how to get that review of systems, H&P, there's other patients waiting. It was on my agenda, not the patient's. Integrative medicine changed my focus. I'm working for the patient rather than for a coder right now. What does that patient need from me? Do they need the physical exam? Maybe they don't this time. Maybe they need someone to tell me about the stressors that may be aggravating their asthma or allergies, maybe something else in their life. I guess it depends on how you want to connect with the patients, but yeah, this makes me cringe now to look at this. Okay, the last myth. Many of my therapies recommended will kill my patients.

Yeah, if you don't think about this when you're in conventional practice, then you're perhaps short-sighted because yeah, it's a thought that goes through our mind. When I started in this field back in let's say 2002, there was a big, at the quadruple AI meeting, there was an extra session on complementary alternative medicine. Steve Strauss was there, he was the head of NCAM at the NIH and he was giving lectures. I saved some of the slides from the talk that was given about dangers of integrative or CAM practice. Here's a couple. They would go through medicinal herbs. I left off the name of the doc who presented this. That's not important, but garlic, for example. I mean, I use it now as an anti-infective. It's not great for cholesterol.

It's certainly not used as an antithrombotic and the interaction here should not be taken prior surgery or prolonged bleeding time. Maybe it will. Certainly in people on warfarin, I'm really careful with supplements, but I remember when the same type of talk was given at an international meeting and a whole bunch of people burst out laughing and they were surgeons from Rome and they said if they tell their patients to stop eating garlic, they would not go to them and they haven't had problems. I mean, sure, there's a theoretical risk, but it really isn't. You can find case reports of someone taking 20 grams a day of allicin supplementary tablets or something that maybe will have a bleeding issue, but it's really not that common. I mean, if we go to the extreme and the same talk, chamomile, really chamomile, chamomile tea to relax, give it to my patients all the time. Maybe it does cross-react with ragweed and birch. I have ragweed and birch allergies. I get oral allergy syndrome when I bite it into an apple. I personally don't have any problem with chamomile tea. I think it just goes to extremes. The problem is with these talks, the people that are teaching these talks often teach it, but they have no experience with it.

These are people, I mean, if I raise my hand and I say, well, what have you seen in your experience with garlic or chamomile? Well, I don't know. I read about it here. It's a big difference. You guys may as well have grand rounds with a gynecologist teaching about allergic rhinitis. It's the same thing. If you're not doing and working with it, you're relying on case reports, chamomile tea anaphylaxis. Seriously? I'm sure it happens now and again. Hell, chicken soup anaphylaxis happens. Come on, you got to be a little reasonable about this. One area to look at that won't kill your patients, mind-body medicine. This is the type of therapy that most patients in my experience can benefit from. The New York Times, are my allergies all in my head? I'll give you another quote from William Osler, and actually Bill and I should not be using Osler as an example. He was a terrible misogynist, but I'll use this quote anyway.

Authors agree that there is, in a majority of cases of bronchial asthma, a strong neurotic element. If you're old, like me and Bill, sorry Bill, I'll put you in my category, but if you're older, you remember when hereditary angioedema was hanging, hereditary angio-neurotic edema. Mercifully, we took the word neurotic out of there, maybe reflecting the fact that we're all neurotic to some degree. The mind-body connection is hugely strong. You guys in Colorado know it better than anyone at National Jewish. Here's Murray Peskin, who probably in the 40s or 50s was a medical director of the Children's Asthma Research Institute in Denver, and maybe that became National Jewish. I'm not sure, but his big contribution, at least the mind-body literature, was that he noticed that kids with most severe asthma improved markedly as soon as they were removed from their homes and hospitalized, long before the treatments had a chance to work, and it led him to publish that we should consider parentectomy, a change in the environment for severe asthmatic kids that didn't improve with other treatments. He attributed the success of a parentectomy to both removal of allergens from the environment, but also removing kids from psychological conflicts they might have had with their parents. I want to shift gears for the last few minutes and talk about how can I learn about integrative medicine. If I've tantalized you or gotten you angry, either way, here's how you can learn more. I think there's four key ways you can learn on your own. Tough, but we've been doing it for years. You can learn through courses, meetings, or even a fellowship if you're really motivated. If you want to self-learn and grab a textbook, you have to get Dave Rakel's. Rakel's integrative medicine is the Harrison's or Nelson, if that's still around, for pediatrics. This is the textbook for integrative medicine, and I think I have one of the first editions. I think Bill contributed to that. I've contributed to this. The fifth edition, don't buy the fourth. The fifth is coming out this year, and it's a worthwhile investment. There's other textbooks as well. The one on the far right, integrative rheumatology. Obviously, unless you're a rheumatologist, may not appeal to you, but I just wanted to advertise the fact that Andy Weil, this is the Oxford University Press Integrative Library, and Andy Weil set this up with Oxford University Press. Well, many, many different specialties are represented. They're very affordable, so medical students can afford them. Instead of the 80 or 90 dollars, they're about 30, and they're really good books.

You can learn through government sites on your own as well. So this is what used to be NCAM, the National Center for Complementary and Integrative Health. They have areas on their information for healthcare providers. You can learn more about it. There are many university sites, so I think University of Maryland has them, where they are just storehouses of information. This is Sloan Kettering's site, which is very helpful for patients and practitioners. I think Barry Caslet set it up some years ago, and you can look up, search up different herbs if you're interested, if a patient asks you about it, mind-body therapies. This one I just called up a pine bark extract. So this is, in case you're familiar with Pycnogenol. Pycnogenol is a French marine pine bark extract that probably has one of the best and only studies done on kids with mild to moderate asthma, and it's a double-blind placebo-controlled trial. So if you want to learn more about pine bark extract and its use in pediatric asthma, you can start with a site like this. They also have an app called About Herbs that they put out, and I think it's free. It's Sloan Kettering. Information is well researched. If you're looking for an independent site, natural medicine database is huge. These are the same people that put out the pharmacist's letter and things like that. They do a good job, combination of that group and I think the Harvard group. Natural medicine, it's a really nice site. It's a subscription site, but it's not that expensive. You can check for interactions. You can put in the name of a particular ailment. You can put in allergic rhinitis, and you'll find a whole list of herbs. It's so well annotated with articles both in vitro, animal, and human clinical trials. It's a really nice resource, and so I certainly

recommend that. If you decide that you have reached the limits of self-learning and want to go on to courses, the medical world's catching up to you. Medical schools are adding integrative medicine courses. That's well known. University of California at Irvine got a $200 million gift from the Samwellys. Now, in addition to naming the medical school, they demanded that they start teaching integrative medicine. It was interesting because a lot of conservative medical schools were up in arms, but I don't know whether it was jealousy because they didn't get $200 million or not. UC Irvine has many, many programs to teach incoming medical students an integrative approach.

Remember, our goal is not to build integrative medicine into a separate specialty. It's to truly integrate, and as Andy Weil says, we want to make ourselves obsolete. We want these tenets, these philosophies to be incorporated, and then it can just be called good medicine and not be separated as conventional or integrative. If you shop at Walmart, you will know about Alice Walton's Whole Health Institute in Bentonville, Arkansas. She's building a medical school.

It's far beyond building. It's an integrative medical school, and they're just getting approval now, and it's going to have an integrative focus as well. So this is the wave of the future.

We have courses at our own center that you can log in. You can search for us. We have a lot of online education and courses. I think that we have Introduction to Contemplative Care. For free, you can sample, but it's live, but there's pain management, perioperative care. I'm working on a COVID module now, and we're doing an ID module. So there's a lot of courses that we offer. They're CME courses, so you can even use the CME money for it. It's not just about us. The Academy of Integrative Health and Medicine has courses. The Academy is another group that has a fellowship and courses. Well, I just took a screenshot, the board review courses, but also there's Mimi Guineri. She's an integrative cardiologist talking about approaches to cardiovascular disease.

If you're into botanicals and supplements and want to learn from a great teacher, my buddy Tarone Lodog, who is the physician, has a hands-on course that she teaches in New Mexico, as well as distance learning. She is an amazing teacher, and she was an herbalist before she went to medical school, so it's an interesting approach. Meetings are another source of information. As I showed you a picture of Bill from our nutrition conference that we have annually in the pandemic, we switched to a virtual summit, and we have one coming up May 6th. It's a one-day session, and these are kind of debates, and we have different topics. I am moderating the immunology section with two physicians, with two MD, PhDs, people that do research in immunology. The question I'm posing to them is, what is the deal with immune boosting? Is it really possible to immune boost or modulate the immune system at a whole body level via supplements or other activities, or is it just a lot of marketing hype? There's also talks about the microbiome and psychedelics for psychiatric issues and mental health, so it should be an interesting short conference for one day. If you're into big conferences and want to be somewhere in person, the consortium that I talked about, all those medical centers from around the globe, get together in Phoenix in May.

It's about a three-day conference, poster sessions, plenary sessions, breakout sessions, and you get to meet people who are practicing integrated medicine from around the world at academic centers, so it's got a lot of science and a lot of experiential activities as well. Final thing I'll talk about, integrated medicine fellowships, and this requires a commitment. Often it's a thousand hours or two years, but most of these are not in person. Many of these are distance learning, as is ours. I got the list from the American Board of Physicians Specialties in the US, ABPSUS, and they run the American Board of Integrative Medicine. I just took some screenshots. There's ours in Arizona, but there are fellowships all over. Again, most of these, I'll show you about ours in a second, but Maine, Massachusetts, Michigan, depending on where you are, some of these have a focus on research, but they all have clinical opportunities.

The Academy of Integrative Health and Medicine has their own fellowship, and it's a thousand hours. It's a distance fellowship as well, and I think they may have a residential week. They're kind of unique in that they get together people, psychologists, dentists, people from all different realms of healthcare come together and learn integrative approaches.

There are functional medicine fellowships. Functional medicine, a little different from what we do, more biochemically based and using a lot of lab tests. It's a little different approach, but certainly their approach to patient care is similar to a degree to an integrative approach.

Functional medicine is the clinic they have at Cleveland Clinic, Mark Hyman, who is another big name in the field, runs this. Our own fellowship, we have physicians and NPs, PAs, and PharmDs. It's a thousand hours, about 10 hours a week, three residential weeks where you come to Tucson for a week and learn some hands-on techniques, osteopathic manipulation, things like that. We've had over 2,100 fellows and graduates in our program, and it's very popular. We had to add on an extra program, so the movement is not going away.

If you do a fellowship, one of the advantages is you can get board certification that is gradually being accepted at many medical centers around the country. You can go to the ABOIM website if you want to learn about this. You have to take a test, and it's good for eight or 10 years. I'm going to end there because I see my time is just about up, and I'd be happy to entertain any questions. Let me stop sharing.

Well, thank you, Dr. Horvitz. From the pediatric side, I can share with you that the story of the Parentectomy is alive and well. That is one that we have not forgotten. That has been shared with us as fellows, and the story of that lives on from Carrie, which did merge into become part of National Jewish. It's a good story and important to share something I think we dream of many, many times, but certainly would help, but not something we...

I just wanted to convey that integrative medicine is accessible, and it does not have to be rigidly that you have to follow every single tenet or philosophy. As Eileen shared in the chat, if you have questions, you can raise your hand. We can unmute you, or you can type your questions, and we'll read those. While folks are getting set up for that, I just wanted to share the website for the integrative allergy immunology respiratory wellness program, which has information about the events like the lecture today, a reading list, and we'll post the links and a lot of that useful information that you shared in your talk. We'll put that on the website as well. You can watch last year's lectures, and then a quick announcement that for the next panel, which was planned for April, has been moved to June 1st, so that information will be coming, the email and will be on the website as well. So June 1st is the new date for the panel discussion. Randy, thanks for a nice talk on making the integrative medicine. It's also a science with a nice presentation, and I just wanted just a comment. I read a book recently called Breath by James Nestor, and it is an excellent book, especially for asthma specialists or any other factor thing that you talked about today, and I was finding it's a very fascinating thing how the oxygenation he was talking about can improve the stress-related factors in multiple diseases, so I was kind of interested in a book on that I read some time ago.

And the other thing I wanted to make, just like my personal, because just like you guys, I've practiced more than 40 years, and I had only one case of chamomile tea, anaphylaxis actually, you know, it came to my patient. I was really wonderstruck, and she just bought the tea.

I brewed the tea in the microwave in my office, and just put a drop and spit, and she was positive, and I checked for ragweed, you know, just for other things. So it can happen occasionally, but it is not very common, as you mentioned, but I just want to mention that. Yeah, thank you for that, and Nestor's book I recommend highly as well, and we have a podcast, and I think Andy Weil interviewed Nestor. It's available on Apple podcasts or on our website, but yeah, it's a great book. I recommend it. So one of our adult allergy immunology colleagues, Dr. Glantz-Sawford, has a question that I'll read from the chat. Self-directed mind-body medicine practices seem daunting to

patients, and she's not familiar with psychiatrists, psychologists, or integrative medicines. Medicine physicians who do this, and importantly, also are they covered by Medicare, Medicaid, and can you discuss the costs and how many sessions typically folks need and what's covered? Yeah, it's integrative medicine. I think that's the most difficult part is reimbursement, and reimbursement now most integrative medicine is not reimbursed.

Most physicians that we train are already under contract at a medical center to many different insurance companies, and they tweak their practice a little where they will see a patient for an extended period or discuss nutrition, physical activity on multiple appointments, and in that way they get the regular reimbursement. In our case, we are members of Medicare because we are at a group practice at the university, but no one else accepts integrative medicine, so it's self-pay, and so kind of our self-pay patients kind of fund our clinic, and there's a big demand. We make it a point to go out and do community work. We have access, we take Medicaid, and we do a number of free visits as well to make it so it's not just an exclusive concierge type medicine, but that's the biggest challenge right now, and I think we had a primary care clinic in Phoenix, and what we did was a hybrid model where patients would pay, we would take insurance, but they would pay a membership fee as well, and that would supplement that, but I think you've hit on something when it comes to cost. When we go out in the community and we go to underserved areas, and I should mention this to everyone, there is a whole group called I Am For Us, I Am the Numeral Four and Us. It is a whole nationwide group devoted to integrative medicine for the underserved, and I Am For Us has an annual meeting, and they talk about unique ways that you can introduce and use integrative medicine in the community, the underserved community.

A lot of people, when we went to rural areas, these people needed conventional medical care, and we got to talk to them about nutrition, nutrition for their kiddies, things like that, but they were in need of regular conventional medical care, so anyway, I digressed a little, but yeah, that's a tough one, and clinic appointments, they vary. At our telehealth pilot in New York, the doctors are charging anywhere from $300 for an hour session to $900,

so there's a huge range depending on where you are in the country. It's a big problem. We have an integrative psychiatry program here at the U of A, and they train fellows and they also see patients, and that program does take insurance.

One more question here. If you could comment on the types and validity of allergy tests that are not done or not ordered by allergy specialists? You mean the alternative allergy tests?

The weird ones? Yeah, I can tell you about a few. So, Gary Soffer, who's an allergist who went through our program, he's at Yale, he and I just wrote a, just wrote, it was last year, we wrote a brief article or an editorial, I forgot what journal, about IGG food testing. That's a biggie. IGG food testing, we were obviously opposed. I hope I'm speaking to people who are of the same mind, and that's a tough one because Everly Well and all these companies

that are online are giving IGG food testing to patients, and they're coming in with IGG food tests and may as well have a dark board. I'm seeing all the patients who fail those kind of tests. So, those tests are the most prevalent, the IGG food testing that give me the headaches the most, but there's weird tests out there. There is applied kinesiology, which is called muscle testing, and here's what they do. They will have a patient take either a food or, this is vitamin C, have the patient hold vitamin C in one hand, and they will test muscle strength in the other, and they'll test it at baseline. Then they'll have a patient hold different foods, and if the patient has less strength in that area, they'll say, oh, you're sensitive.

You can't take that supplement or that food. There is live blood cell testing. This is where they take a sample of your blood under, I don't know whether it's a dark field microscope or a play school microscope, whatever, and they'll say, oh, you have candida overgrowth. I can tell from your blood, and you have to explain to patients, if you had candida they saw in your blood, you'd be in an ICU now. You wouldn't be walking here. So, there's a lot out there, and again, it's not like you're saying, I'm integrated medicine, and I say, yeah, I don't agree with that.

You look at the evidence and decide what you're comfortable with. Was that the question?

I think so, yeah. One of my answers is always, you know, I don't like to get my medical care and group on, but that's certainly one place you can get some of those IgG tests. I mean, things have changed. I've got to tell you, when I was an allergy fellow, and I don't think I'm giving away any secrets or anything, when a patient would come in insisting they had a food allergy and it was clearly a sensitivity, we would automatically refer to psych. We'd say, you know, you're in the right church, the wrong pew, you have to see psychiatry, and now we deal with these people. I think food sensitivity is huge, and I tell patients, I wish we had a test for food sensitivity. I mean, it's my biggest desire, but I say the symptoms are so diverse, the pathophysiology is so diverse, and you're unique. So elimination diets, that's what we use. Is it far-fetched? No. Is it integrative? Yeah. Is it complementary? Yeah. Is it conventional?

Yes. So, yeah. It's the reintroduction part, you know, trying it again, that is so important to remember, especially in pediatric patients. Exactly, and it's an art in medicine. I mean, you can look at food rotation diets, you can pick whatever elimination and re-addition that you want, but in the end, it becomes art, and you kind of do one-on-one with a patient.

Absolutely. Well, I think that is a wonderful reminder and point for us to end on today. Dr. Horowitz, thank you so much for joining us, and we look forward to having you back virtually, of course, on June 1st for the panel discussion, and we hope you all can join us. Thank you all, and thank you again to Dr. Solvers and the Integrative Allergy Immunology Respiratory Wellness Program, and to all the folks who helped make this possible and put this on today. Thank you. Thank you, everyone. Thank you.

Integrating Lifestyle Recommendations with Nutrition, Exercise, Sleep and Stress Management to Enhance Overall Well-Being

Download the Reading List Here

Lecture: Evaluating Integrative Approaches to Allergy-Immunology-Respiratory Patients: What is the Evidence?

Gailen D. Marshall, Jr., MD, PhD
The R. Faser Triplett Sr., MD, Chair of Allergy and Immunology
Professor of Medicine, Pediatrics, Pathology and Population Health Science
Chief, Laboratory of Behavioral Immunology Research
The University of Mississippi Medical Center

Welcome, everyone, to a really exciting Denver Allergy Rounds.

If some of you were able to join us for the Colorado Allergy in Asthma Society, Dr. Galen

Marshall really kicked it off with a fantastic talk that I thought was just very eye-opening.

It talks about the concepts, the implementation, and the data behind integrative medicine in

our specialty.

And so we are kicking off the National Jewish Part.

We have a two-part series in the William S. Silvers Integrative Allergy Immunology Respiratory

Wellness Program, where we'll be focusing on the integrating lifestyle recommendations

with nutrition, exercise, sleep, and stress management to enhance overall well-being.

And we actually have a very special introduction by the president and CEO of National Jewish

Health to kick off our two-part program today.

And so welcome, Dr. Salem.

Good morning, and thank you for joining us.

We're proud to be hosting the inaugural Dr. William Silvers Integrative Allergy Immunology

and Respiratory Wellness Program.

Bill has graciously ensured that for this and future years, we could bring you the latest

in integrative medicine as it relates to AIR, or Allergy Immunology and Respiratory Medicine.

Each year, this lectureship will have the ultimate goal of inspiring medical professionals

to learn and share new techniques that will help them provide the best integrative care

for their patients.

Bill is a former Allergy and Immunology Fellow at National Jewish Health and is a well-known

advocate of treating the whole patient through a combination of traditional, complementary,

and alternative medicine approaches.

He has been named a top doctor by 5280 magazine multiple times.

His accomplishments are numerous, and he's highly respected.

He is the son of Holocaust survivors and has committed much of his efforts to bioethics

and the humanities.

We are appreciative of his accomplishments in the medical community, including sponsoring

this annual lectureship.

We thank each of you for joining us, and we hope you enjoy this inaugural two-part series

on integrative medicine with a lecture by Dr. Galen Marshall this morning and a panel

discussion moderated by Bill this afternoon.

Now, please help me welcome Dr. Galen Marshall, who is Chair of Immunology and Allergy and

Professor of Medicine, Pediatrics, Pathology, and Population Health Sciences at the University

of Mississippi Medical Center.

He will be speaking on evaluating the evidence of integrative approaches to treating allergy

immunology and respiratory patients.

Welcome, Dr. Marshall.

I want to thank everyone for this.

William Silvers and I have been friends for more years than we haven't, and when he first

approached me and then BJ Lancer approached me on behalf of National Jewish about doing

this inaugural lecture, I jumped at the opportunity, both because it's something that I'm passionate

about and believe in very strongly, but also because of my desire to honor William and

all the great things that he has done that you just heard something about.

The whole idea of this is based upon the concept, and I have no relevant disclosures for the

lecture, about the issue of health.

National Jewish, I have known and respected for many, many years.

It's gone through various and sundry iterations in terms of name, but I remember a time when

health was prominently in the name as was one of the short parts in the name.

And I think that all of us as health care providers are interested in what this word

really means.

I think it's important for us to understand that it doesn't simply mean the absence of

discernible disease or pathological process.

I told the story last night about a patient who would come to see the doctor and she came

in complaining of not feeling well.

I just don't feel well, doctor.

I'm tired, I'm achy, I have trouble thinking straight, I can't hold attention.

I don't know what's wrong.

Can you help me?

And this doctor, being a very well-intentioned health care provider, takes a thorough history,

does a good physical exam, orders what would seem to be appropriate laboratory and procedural

analyses, gathers all those data, finds no clear abnormalities, and then comes back to

Mrs. Smith and says, good news, Mrs. Smith, there's nothing wrong.

Well, that's probably not very helpful to Mrs. Smith because clearly there was something

wrong and the fact that we're not able to discern a specific disease process does not

equate to the fact that she is healthy.

It is in fact a state of persistent physical, emotional, intellectual, social, and spiritual

wellbeing, and that wellbeing becomes the important component of it.

It cannot be achieved or maintained by pharmaceutical interventions alone, and in modified forms

can still be achieved by individuals who have significant comorbidities such as physical

or psychological challenges and comorbidities.

So people that have really serious illnesses, they might be congenital, they might be living

with cancer, they might be a person living with AIDS, these people can still be relatively

healthy as they work toward and embrace the concept of wellbeing.

When you talk about stress and health, stress and health is considered to be excessive stress.

It's been shown to be a factor in causing or worsening most chronic and many acute diseases,

particularly those with inflammatory pathophysiology, and they can manifest in mental fashions such

as anxiety and worry, depression that can even add to despair, or somatic complaints

such as allergic disease, asthma, autoimmune and other respiratory diseases, heart disease,

diabetes, cancer, et cetera.

The clinical definition of a stress response is not just the event.

The event would talk about, well, I'm under a lot of stress.

What that really means is that you're being exposed to a stressor.

It's the psychophysiological response to the event that defines the true stress response.

This can be acute, I'm under a lot of stress, that's the classic fight or flight response

with the representative physiologic changes that come from a combination of HPA,

hypothesis of pituitary adrenal axis, and autonomic nervous system interactions,

which will typically rapidly resolve as the stressor and stress response abates.

This can actually oftentimes be helpful.

Individuals, for example, that like to do lots of exercise, a few crazy people you might

know that like to put a big rubber band around their waist that goes attached to the wall

and then jump off a bridge called a bungee cord experience.

Well, for some of us, that would not be a pleasant experience.

With me, as you would see it bounce back up, you would see my lifeless body bouncing back

up because I would have died from the pure fear of jumping off that bridge.

I don't like high places.

For some people, they really enjoy that and watching people, particularly those in areas

like Colorado, where they have lots of areas to do really neat things in hills and mountains

and skiing and hiking and so on.

People go to adventure movies, people read scary novels because they enjoy being stimulated

and excited and even challenged emotionally, but within the context that this is self-limited

and that they will get better eventually.

In contrast with chronic or excessive stress, oftentimes manifest with the patient saying,

doctor, I'm really stressed out.

This can result in anxiety and depression, which in limited amounts are understandable,

but then it can become more chronic and evolve to things like worry, even despair, et cetera.

From a physiological standpoint, particularly endocrine and immune, this constant stimulation

that can occur can lead to what we know to be immune exhaustion that have clinical consequences

as a result, and this is typically maladaptive.

So a chronic stress may not be excessive for some people and excessive stress might not

be particularly chronic.

That's something that has to be looked at and evaluated with the individual patient.

If you hear this in the background, there's a thunderstorm out the way.

I don't think this is God necessarily validating everything I'm saying, though I suspect that

probably most of it is okay.

Major factors that actually impact the nature, magnitude, and the duration of this stress

response include outlook, and there's literatures for each of these that are very well-defined.

The idea of being optimistic versus pessimistic.

Optimism is a mitigating factor, a coping factor for individuals that have chronic excessive

stress, and those who have a pessimistic outlook are actually more susceptible to less significant

amounts of stress in terms of intensity, duration, or even the nature of it.

A social support system is a very important thing.

The idea that none of us are islands under ourselves, we're seeing a lot of this.

I don't know if you're seeing it in your offices, but we're certainly seeing it in our clinics

of individuals because of the COVID pandemic who have been isolated, who have been torn

away from their social support system, and it has had definable adverse clinical effects.

Unfortunately, many of the mental health care professionals indicate to us with an appropriate

evidence-based alarm that the consequence of this may not be short-lived, but may in

fact be much more significant in our patients now and in the future as we return back to

the interactions that we've had before.

I would challenge you, just as an aside here, is to watch out for this sort of thing, and

I'll even give you a tip here in just a second of how you might want to do it in your clinical

setting.

What's been shown in the literature to be the best is the nuclear family, and given

the diversity of our nuclear families in our society today, there does not appear to be

a particular discrimination about the nature of it, but it's the idea that there is a parent

or a sibling or a significant other that composes that nuclear family, and it becomes very important.

Fraternal organizations are important.

I don't know about you, I'm already tired of virtual, national, and even regional meetings.

I've been to Denver multiple times, and I am delighted to be here with you all today,

but I'm really quite sad that this has to be done virtually, and that I can't be in

the same room with you, reading your faces, letting you read my face, I guess you get

to read mine a little bit, but reading your faces and being more personally interactive.

Fraternal organizations actually do matter, and community as well.

All of these have been challenged greatly in the last year because of the pandemic.

And then the third area is a belief system, which is the basis of spirituality.

This is not, and I emphasize, this is not necessarily an organized religious tradition.

A belief system occurs in all human beings.

We find something that we believe in, we find something that we trust in, and that becomes

an important component of what we know as spirituality, which is another way of saying

is the inner self of the individual.

The idea of, doctor, I'm not stressed.

They come in and we ask the patients of this and they say, you know, really, I'm not stressed.

Our society has been subject to increasing types, intensities, and duration, as we've

just discussed.

The pressures of life, such that are coming from finances, strained relationships, fear

of dangers that can be natural dangers or manmade dangers, and a loss of hope in the

future.

Recent studies and polls that have been done suggest that all these are at a heightened

level in our societies that haven't been seen since the time of the Great Depression.

Up to 75% of all office visits to physicians, that would include you and me, are stress-related.

And the question is, do we as clinicians, number one, appreciate that fact, and number

two, do we even consider assessing that fact, and number three, do we have any sense of

what to do about it?

The goals in caring for patients with allergy, asthma, immune, and respiratory diseases is,

of course, to achieve and maintain clinical control.

There are very few of these illnesses that we can, quote, cure, unquote.

Some we would like to say that we can, but most of the time, we're shepherding the patient

along until the illness either resolves or remits on its own with the medications that

we've had to help control them.

I remember, and I'm old enough, and my friend Dr. Silvers and some other senior members

on the call that I have seen, remember the time when inhaled steroids were brand new,

completely brand new, and the excitement we had because of the normalization of airway

function and the idea of, oh, we are altering disease.

Here is a disease-modifying therapy because now these people are staying out of the emergency

room.

Now these people are not having symptoms, and all they have to do is use their inhaler

a couple of times a year.

And then several studies were done, and we all learned about it that when patients stopped

these medicines without much time in between, they began to move back toward the mean of

their original symptoms, indicating that these were controllers, not disease modifiers.

And the fact is, is that for probably 95% of the illnesses that we care for right now,

that's really a fact.

Achieving and maintaining clinical control, having that conversation with our patients

is a very important thing.

Managing the side effects of the disease itself and or the therapy that's there, improving

and maintaining quality of life.

Medical drugs and therapies have been approved now based upon measures of quality of life.

That's certainly not trivial, and in the final analysis, it's why patients ultimately come

to see us.

They want their quality of life maximized, considering the comorbidities that they are

experiencing.

How can the mind actually adversely affect the immune system through stress, anxiety,

depression, and worry?

Let's look at a little bit of this.

In anxiety, depression, and asthma, there's a well-known association since antiquity.

Maimonides, in the 12th century, famously talked about the idea that stress can have

an impact on the respiratory organs.

In adult asthma patients, panic disorder occurs in 6% to 24% of patients.

In pediatric adolescent asthma, anxiety disorder is present in a third, and depression is present

in anywhere from a third to two-thirds of asthma outpatient.

Now, do I mean major depressive disorder?

Absolutely not, but depressive symptoms that can have impact on what they do about their

illness as well as physiologic effects on the illness mechanism itself are increasingly

evident and therefore increasingly worthy as targets of therapy.

So what I want to show you here is a study that one of my fellows and I did and is in

for publication that we finished recently, in that we took an instrument called the DAS

21.

DAS stands for depression, anxiety, stress, score, and it's a 21 question.

So that's the acronym that's given.

And this gives you an idea.

I didn't ask.

It may not be big enough for you to see, but it asks pretty straightforward questions.

It's one page.

It can go from zero.

I don't have any issues with it to three, and we gave this and continue to give this

to all of our asthma patients along with the ACT at every visit, and it has been validated

as a repeated measure of the individual's level of depression, anxiety, and perceived

stress.

There are in fact established cut points for varying degrees of dysfunction in each category.

Nothing significant, mild, moderate, or severe.

And we have discerned multiple patients over the last year and a half that we've been using

this that we find have severe evidence of anxiety or depression and have been referred

to mental health professionals for management.

And guess what?

It has helped those individuals in the control of their asthma.

What we looked at was simply to ask the question, it was a very straight up question, since

we had the data between the DAS21 scores and the ACT scores, was there a correlation between

the two?

ACT score is a good measure of clinical control of the illness.

So in these 231 individuals, there was a moderate association inverse correlation in the total

score between the higher the DAS21 score, the lower the ACT.

It was true for depression, it was true for anxiety, and it was true for stress.

All these sub-measures in this DAS21 itself, highly significant association.

We looked at a couple of divisions based on gender.

In females, it was even more associated in the group that we had.

In males, interestingly enough, the overall score was significant, barely so, but there

wasn't much correlation in the males that we studied.

Now, I don't know if that's unique to Mississippi males.

It was a small sample size.

It is something we're continuing to accumulate data from and will certainly do follow up

with this as we go more and try to delve into why there may be a difference in the male

about asthma control and DAS21 that there are in females.

We also looked at racial differences here.

Our practice is about a 50-50 Caucasian African-American practice, and there was no real big racial

effect here.

This was true across the races that we see in our clinic.

So the idea of what stress does with asthma, there's certainly direct effects through this

chronic HPA activation with inflammatory responses there, the stress hormones, catecholamines

and cortisol, and the stress hormone receptors that are altered, this can all have impact

on asthma symptoms, but there are indirect effects as well that may be a bit more social.

There's evidence of as people are stressed, they tend to smoke more.

As people are stressed, they tend to eat more and many times exercise less, and therefore

they become overweight and obesity becomes a problem.

And of course, there is this inverse relationship between level of stress and willingness to

adhere to therapies.

All of these can have an adverse effect and increase asthma symptoms.

These can physiologically, and it becomes important because what you automatically see just in

this cartoon here is that there's no single approach.

You can't give a molecular approach only to this.

You can't give a social approach only to this.

You need a combined approach that utilizes the entire healthcare team.

And here's a little plug for this afternoon is that you're going to have some, and these

are people that I've just met recently, you're going to have some outstanding individuals

giving perspectives about these issues from how they deal with it and show you as a provider

or someone who is sort of a synthesizer of your thoughts, the complexity of this in

terms of its multifaceted approach to managing this.

Addressing the role of stress in patients with allergy, asthma, and respiratory diseases

requires an integrative approach.

And just as a little quick recap from last night, we define integrative medicine, the

World Health Organization does, as a system that puts the patient at the center and addresses

the full range of physical, emotional, mental, social, spiritual, and environmental influences

that can affect a person's health, both good and bad.

The therapeutic role is to treat the whole patient using whatever evidence-based therapy,

be it conventional, complementary, and alternative, oftentimes called CAM, that addresses the

patient need.

Now, it's important to point out that integrative medicine may well utilize CAM as it's appropriate

for the individual patient, but the terms are not synonymous.

It's very important that I would suspect to begin with, most of us practice integrative

medicine.

We just don't call it that.

Most of us are using therapies that are off-label uses.

If you take care of someone with chronic urticaria, you likely have used an H2 blocker in those

individuals.

There is no FDA-approved indication for an H2 blocker in chronic urticaria.

It's an off-label use.

It is a complementary use of a therapy to achieve a therapeutic goal.

Some of you may have used Plaquenil in these individuals.

Again, there is no FDA-approved use of Plaquenil, and in point of fact, the literature for it

is fairly light, but it's something that's commonly done because it's been passed down

from provider to provider to provider for decades because it works.

It works in these more severe, chronic, spontaneous urticaria patients, and I could give many

examples of this, and you could think of examples in your own practice that you may have learned

from your clinical mentor, you may have learned from your partners, you may have seen it emerge.

If you are a fellow, you learn it from those that are teaching you now, and it becomes

the style of medicine, but yet it's something we do every day, as long as it's good for

our patient.

Integrative medicine is something that we all practice.

Humans in this concept, though, are defined by the components of body, mind, and spirit.

Some people use the word soul, but others use the word spirit.

This is not related to what religious organization do you belong to.

It's far more than that.

It's the original personalized medicine, and the approach to care is recorded from the

history.

Hippocrates, as recapped by Sir William Osler in the late 19th century, famously said, it

is far more important to know what person the disease has than what disease the person

has.

That becomes, with that mindset, becomes important because we'll take those extra few minutes

to talk with our patient.

We'll take those extra few minutes to listen to our patient, and amazingly, that's what

they're looking for more than just about anything else.

They're not just looking for a prescription.

They're not just looking for a procedure.

They're looking for understanding and validation of their illness by you and me, their health

care provider.

What about the usefulness of this in allergy, asthma, and respiratory care?

What is the evidence that go along with it?

Let me give you just a little bit, just a comment.

This comes from the Cochrane group, and so we all do Cochrane database analyses that

are very interested, and the idea of the evidence-based medicine triad, now I know that the new fancy

term that we all want to use is precision medicine-based, but they're not unique here.

Precision medicine-based may be part of this external evidence, so it may be more molecular,

may be more pristine, and may potentially, and I emphasize potentially because we're

not sure yet, be more individually applicable, but along with it will still be the individual

clinical expertise.

I do not believe that we're going to be replaced by a computer anytime soon, that artificial

intelligence is going to be a great tool for us, but it's going to augment what we can

do.

It's not going to replace it, and then equally important in this triad are the values and

expectations of patients.

We have to ascertain those to be able to utilize our expertise by taking advantage of the best

external evidence to present the highest level of evidence-based medical care that we can

provide.

What about some of the neuroendocrine immune interactions and allergen asthma?

This is a cartoon that presents that.

As we are experiencing the stressor, it's our perception of the stressor that has an

impact, so it can be cognitive or non-cognitive perception, has an impact through the hypophysial,

pituitary, adrenal axis, and the autonomic nervous system to produce these stress hormones

that have impact on various elements of the immune response, lots and lots and lots of

data on this at not only the organismic and cellular, but the molecular level as well,

with the attendant impact on these immune cascades that can alter immune balance, that

can increase immune exhaustion, and result in increased inflammatory disease risk or

activity, and that can be in allergy, asthma, immune, as well as respiratory diseases.

This is a study that we did back in the 90s.

It's 20-something years old.

It's still cited today, and the reason what it was is that it introduced the idea of

immune imbalance being the consequence of chronic stress, where prior to this time in

the 90s and before, most of the literature looked at it in the context of its impact

on infectious disease, implying that it was immunosuppressive, and certainly chronic stress

can be immunosuppressive, but it can also be dysregulatory.

This was looking at a TH1, TH2 imbalance that occurred in first-year medical students four

weeks before and the day after they were taking their block exams, and these young people

were classified on the basis of taking a daily brief test called a Hassles Scale, and it's

exactly what it sounds like.

It assesses how much they perceive their life events to be a big hassle for those, and those

events with a high Hassles Score four weeks before, their ratio was already suppressed

compared to those with a low Hassles Score, but the impact of the acute event, this was

when I was at the University of Texas at Houston, and in those days, the first-year students

had all their exams on one day, and it was typically on a Monday, so they had been studying

like crazy since the previous Friday, hadn't slept, hadn't eaten very well, were very stressed

out, as well measured, and the impact is that in those that were in pretty good shape four

weeks before, they had a significant decrease in their immune balance, and there was a further

immune balance even in those that were already altered before.

We also looked later on, using a questionnaire called a perceived stress scale, 40 is the

highest score.

The higher the score, the higher the perception of stress, and saw an inverse relationship

between this and regulatory T cells.

A regulatory T cell that is defective allows hypersensitivity illness to express itself.

That's a very simplistic statement.

I really don't realize there are a lot of complexities to this, but this suggests the

relationship that you would see and would also suggest the clinical observation that

you can make is that what we used to see clinically, in fact still see, is after medical

school exam blocks, after step exams, our patients that are medical students that have

asthma, that have immune, that have other respiratory-type illnesses, we see more of

them in clinic in that time after that, representing those that have excessive levels of stress

in their life.

This little cartoon that was published by Edith Chen and Greg Miller in Brain Behavior

and Immunity now some years ago still is a classic cartoon because it shows that paradigm

that I've been using here in the context of an asthma patient impact on the adrenal glands

with these impact of these profiles that have a downstream effect on both the mast cell

as well as the eosinophil driven by the host response.

The new information that's being generated looks at the ILCs as well, and not surprising

the early information suggests that when they're exposed to these stress hormones, they do

exactly the same thing.

ILC2 is enhanced, ILC1 and ILC17 are relatively suppressed.

Immune effects of stress on immediate and late-phase skin test responses.

This is a study that we did with our colleagues at Ohio State University, the real giants

in the field of psychoneuromunology, Jan Kiko Glaser and her husband, the late Ronald Glaser,

who were dear friends of mine, Jan's still alive and well, she's still a dear friend

and Ron was a great friend till the day that he passed.

But the study they did is there was a test developed to look for the effects, physiological

effects of acute stress, and it was developed in Trier, Germany and was called the Trier

Panel Discussion: Integrative AIR: Present State of Allergy, Immunology and Respiratory Medicine and the Future Potential at National Jewish Health

Moderated by:
William Silvers, MD, Allergist/Immunologist
Clinical Professor of Medicine, University of Colorado School of Medicine

Panelists:
Kristen Holm PhD, MPH, Marriage and Family Therapist
Associate Professor, National Jewish Health

Gailen Marshall, MD, PhD, Allergist/Immunologist
Professor, The University of Mississippi Medical Center

Lisa Meltzer, PhD, Pediatric Sleep Psychologist
Professor, National Jewish Health

Jennifer Moyer Darr, LCSW, Clinical Social Worker
Pediatric Behavioral Health, National Jewish Health

Jinny Tavee, MD, Chief, Division of Neurology
Associate Professor, National Jewish Health

So we started last night with an excellent talk from Dr. Galen Marshall about integrative

medicine, followed up by another excellent talk this morning, also by Dr. Marshall.

And now we have the luxury of having a panel discussion with some of our own folks here

Jewish that do different aspects of integrative medicine every day in their practice, as I'm

sure most of our attendees do as well. So first I'd like to introduce Dr. William Silvers.

Many of us know him as Dr. Bill Silvers. I'll just tell you a little bit about him and then

he'll kind of take over from there, just giving us a little bit of background and sort of his

vision and help moderate today's panel as well. So Dr. Silvers is a clinical professor of medicine

at the University of Colorado School of Medicine and a faculty affiliate at the CU Center for

Bioethics and Humanities. So many of our fellows have probably interacted with Dr. Silvers in the

clinic, helping learn from him as I did, as I was fortunate enough to do as a fellow myself.

He's a graduate of Indiana University and the Indiana University School of Medicine.

He then trained in internal medicine at Emory University Hospitals in Atlanta, Georgia,

and did his fellowship here at National Jewish in allergy and clinical immunology.

Thereafter, he actually helped start an allergy clinic at Hadassah Medical Center Hebrew University

in Jerusalem, Israel, and then one year as an emergency medicine physician in Aspen, Colorado.

After returning to Denver, he founded Allergy Asthma Colorado in 1981 and had consultation

clinics in Bale and Aspen. He has since retired from private practice in 2016 to pursue other

interests and we've heard him speak on many topics related to integrative medicine as well as

a special interest in marijuana, especially with its recent legalization. He's just a wonderful

person to have around broadening our scope of allergy and just medicine in general.

Before I pass the virtual microphone over to Dr. Silvers, I want to just say thank you again

for sponsoring this session. Thank you to all of our panelists for being here and for helping us

inaugurate this wonderful session. In terms of housekeeping, we're going to have

questions in the Q&A if you can, so reserve the chat for comments, but the questions,

if they come in through the Q&A, that will let us keep closer tabs on the questions in order to ask

the panelists when it's time and also in order to be able to record them in case there isn't enough

time to answer everything, we can get back to you after the fact with answers. So without further

ado, Dr. Silvers. Thank you very much, Flavia. Great having superb fellows like yourselves as I was

having the pleasure of attending at the allergy clinic at CU. Thank you for allowing me to do this

and I'd like to show you a book that Henry Klayman gave me in 2004. This is the medical writings of

Moses Maimonides, treatise on asthma, and it was given to his mother, Leonie Klayman, who was an

eminent allergist in New York City by Murray Peschkin, and I shall give this to the University

of Colorado Health Sciences Library where they have a Klayman collection on the third floor.

It's called the Strauss Health Sciences Library, named after the benefactor Henry Strauss, who passed

away just this last couple of weeks, who gave his library of integrative medicine texts, many of them

from the Far East, to the University and it's housed right next to Henry's collection. Also,

you can pick up, if you wish, Henry's haikus and Galen, I'd just like to share with you the first

haiku of Henry in 2012-13, the trouble with atheism, there is nobody to blame or to thank.

As Galen spoke about last night, the famous saying variously attributed to Cerulean Mosler,

perhaps Hippocrates, definitely Maimonides in his treatise on asthma, the good physician

treats the disease that the patient has, the great physician treats the patient who has the disease,

and this has been passed on through the years. Bella Schick had said, first the patient, second

the patient, third, fourth, fifth the patient, and then maybe comes the science, we must do everything

for the patient. And Henry Klayman at the Aspen Allergy Conference, in addition to his classic,

less is more, said the patient is always right. We may not understand how and why, but that's our

job. So I'm appreciative to National Jewish for my training, to the University of Colorado,

for the clinical appointment with the Allergy, Clinical Immunology Division, to mentors along

the way, Henry Klayman, Steve Dreskin, Chuck Kirkpatrick, Hal Nelson, my colleagues in the

Colorado, and in the Aspen Allergy Conference founded by Jack Sellner, another mentor and

ultimate inquisitive physician scientist. I'd like to say, BJ Lanzer, that if I can

quote from your email last night after Galen's talk to the Allergy Society,

BJ wrote, many times tonight I thought to myself, I do that all the time. And that he thinks that

the former NJ Fellows will come away from this recognizing that many of the things we do could

be called integrative medicine, but we may not see it that way, because it's just how we, quotation

marks, grew up. And in our training, there was nothing alternative about it. So hopefully this

program will help further integrate the talents, the commitments, and the resources

at National Jewish, our nation's leading respiratory hospital, patient by patient, body, mind, and

spirit. As we begin, I'd like to thank Michelle Mosco of the development for hearing my initial

thoughts and shepherding this through from the beginning, to BJ, Flavia, Eileen for moving this

forth, Michael Salem, the CEO president of National Jewish for his introduction this morning,

a lot of people involved here for the success, Langdon Crawford and Audiovisual, the panelists,

and all the attendees today. So I thank you for this opportunity. And BJ, at all, please take it

from here. Thank you, Bill. And thanks for using that quotation. I meant all those words, certainly,

and I think that is absolutely true. Thank you for bringing us all together and creating this

opportunity. In addition to the thank yous and welcomes, especially also want to welcome

our various guests, both the folks who normally join us from Denver Allergy Rounds, thank you for

all of your attendance along the way. Special welcome to folks from the Quadii and the college

from the integrative medicine committees. Those folks, we're happy to have you join us along with

the Aspen Allergy Committee. And then our former fellows from the adult and pediatric sides over

the many years. So we're happy to come together in this way. And as a history major, it's been

great to hear so much different historical pieces. And I'm excited about the things we're going to

talk about today. As it was last night at the Colorado Allergy Society meeting, it's once again

my pleasure to introduce one of our panelists who has been our speaker and probably needs no

introduction any further. But Galen Marshall is obviously the perfect person to kick off this

whole session with his career over the years, focusing on so many different aspects of what

we can now call integrative medicine, but has had other names over the years. And that's a good

reminder for us all as we kind of look through these things. But Galen is, of course, professor

of actually many things at the University of Mississippi Medical Center and is the editor of

the Annals of Allergy, for which I've had the pleasure of working with him in that capacity,

among many, many other achievements and accolades. But Galen, as we've heard from you over the last

evening and this morning, I think I'd be really interested to hear what you would say is kind of

the biggest gap in our approach to patient care as allergy and immunology specialists

and where we should focus to fill in that gap. BJ, thanks again. And again, thanks for the

opportunity to participate in this inaugural event. I hope it goes on for many, many years

because it's an outstanding way to help bring us together and to teach us more about it.

And what I didn't say and what some people may not even realize is that I started life as a basic

scientist and actually went to medical school with the idea that I was going to be a basic

scientist in a clinical or rather in a basic science department, stick an MD on the end of my

name after my PhD, go back to the lab, and that would be the end of it. As a freshman, I went to

University of Texas Medical Branch in Galveston and as a freshman back in 1980, it was a new

experiment of bringing freshmen into a clinical setting as first year students instead of waiting

to the traditional third or fourth year. They put a stethoscope on my hand and they changed my

life forever. My passion for research never went away, but now my passion for making that research

relevant to the sick and the suffering individuals suddenly took the center stage in my life. And

then as we've evolved the idea of saying, well, why not prevent disease instead of treat disease

whenever you can? I think in allergy immunology, now I was privileged to be trained by Phil Lieberman,

one of the phenomenal allergist immunologists that people know and Phil is a second father to me and

has been ever since the days in his clinic where he beat me up with some regularity, but always

with that kind Lieberman smile. It was amazing you could get beat up that bad and then turn around

and say, can you beat me up a little bit more because I really learned a lot from that. But

till this day, Phil and I smile about that. But what I remember was the very idea of that, in fact,

science and art of medicine are a continuum, not categorical. Unfortunately, I believe, and it's not

unique to allergy immunology, but as allergist immunologists, we are mired in it. And I think

have the opportunity to get out of it and lead our other colleagues is that we've been caught,

whether it's from the science at the meetings and more and more desire to have scientifically

sound arguments and P values that matter. I'm not making fun of any of that, but on the other hand,

still be told to be compassionate and care for people and listen to them and spend time with them

when every minute we're spending time with someone, particularly those individuals in

community practice who don't have the buffer of a university salary. They don't have the buffer of

fellows to actually help them rather than to hinder them. They have every moment they spend

with one patient because of the way insurance is. It's something they're not spending with someone

else, and it costs them money. Now, the good news is that those that are really dedicated,

and that's the overwhelming majority of the people that we practice with around the country

and literally around the world, they askew that idea because the patient still is at the center

of what they do. But as we move forward, as rules and laws change, as technologies become

more complex and the need to understand deep science becomes more necessary for proper

prescription to these patients, that challenge is still going to be there. That tension is going to

get greater, and I think we have to recognize the tension. We have to embrace it, and we have to

be active as we look at and see what new things that do will enhance what we do and what will

take away from what we do, and we examine everything. We keep the good. We discard the bad,

and by doing that, my belief is that 20 years from now, when William and I are probably not

practicing, we may or may not still be breathing. We probably won't be practicing 20 years from now.

Those of you that are will still be able to do it with the love and compassion that you

show for your patients now, but with a technology that will be routine to you that we now only dream

about, and the key is that that art and humanism of medicine remain as the technology develops.

That's what I see, BJ, as the greatest challenge that we're facing. Wonderful. Thank you, Dr.

Galen. I get the pleasure of introducing Dr. Ginny Tavi, who is an exciting addition to

National Jewish Health of recent has already made great strides, and it's just fantastically

impressive. Dr. Tavi is Chief of Neurology and Associate Professor at National Jewish Health.

She is a neuromuscular trained neurologist with a special interest in peripheral neuropathy,

neurosaccharidosis, and evidence-based complementary alternative medicine practices.

She's actively involved in research studies evaluating the effects of

integrative holistic therapies on chronic neurological diseases and has led meditation

retreats for patients, physicians, and U.S. Marines returning from a Gulf War through the

Wounded Warrior Program. She's also very humble, but she did not include this, but she's also

authored a patient-centered book titled The Last Day of Suffering, Five Steps to Health and

Happiness that includes specific instructions on nutrition, mind-body therapies, and exercise.

So a talented woman in a great addition to National Jewish. Dr. Tavi, I have a question

for you to start off this panel, which is, what does your integrative approach look like

in your practice as a neuromuscular specialist? So first of all, thank you very much for having

me on this program today. I really enjoyed the grand rounds this morning, but I wanted to make

it clear. I always start out with conventional treatments for my patients with chronic neurologic

disease, although I do have a holistic approach that's very simple. I stick to three basic

tenets, nutrition, exercise, and mind-body therapies. These are free or just the cost of

routine food. They don't make you fat or goofy, and they're widely available.

The first thing that I always talk about is nutrition. Food as medicine is a concept that

the Chinese have been using for thousands of years, right? Now, it's the easiest thing to do

to change your life, and it's the easiest thing to market to your patients. They may not be in the

acupuncture or yoga, but everybody eats, right? And so what I tell them is, number one,

make sure you try to get five servings of fruits and vegetables a day. I just did it this morning

with a patient, and I was just like, no way I can do this. So I said, in the morning, have

bananas, blueberries. That's two. You have some salad at lunch, and then you have an apple,

and then some kind of vegetable for dinner. That's five. That's CDC and American Heart

Association recommendations. The second thing is to increase your protein, and the third is to cut

gluten. Now, there's certainly not enough information to say that it's pro-inflammatory,

but I mean, if you just stop the carbs, right, bread and pasta, this does not mean gluten-free

pretzels or gluten-free cake. That means no bread or pasta, and you will lose weight and you'll

feel better. And with all the other changes, you can improve your health. The second recommendation

is exercise. For many of my patients, especially those with neuropathy, that's their only saving

grace, right? And so I tell them, I don't care what you do. It could be Zumba. It could be

jazzercise, right? Just make sure you try to get 150 minutes per week. That's the recommendation

for patients with metabolic syndrome. Many permutations on how you want to do this, but 150

minutes per week seems to work. Many patients also ask, how much is too much? How much can I

exercise? Well, I tell them the two-hour rule. The two-hour rule was written by Matt Sutlip,

who was the head of physical therapy at the Cleveland Clinic, and he told me that this is

the most important rule of exercise. My surgical friends love this, but let's say you do elliptical

for 20 minutes, okay? Two hours later, you should feel refreshed or neutral. If you feel tired or

worse, that was too much. Go back and change that, and patients love that, right? And then the final

recommendation is mind-body therapies, and this includes meditation, Tai Chi, yoga, and Qigong.

So Tai Chi is a Chinese martial art. You know, you've seen Cloud Hand, these 90-year-old women

in Hong Kong in the park, right? Qigong is very similar. It's not in self-defense, but it is a

type of Chinese exercise with deep breathing. You know, I do have one disclosure. My mother is a

Buddhist monk, and we built her a temple in the rainforest of southern Thailand. She teaches

meditation to people from all over the world for free. I pay for that, but anyway, meditation is

so important, not just for our patients, but also for everybody. I mean, I think technology

has gone beyond what we can handle, right? Do you have any people check their work email after hours?

Just get over 80%, and I would venture to say it's even higher post-COVID, right, or in this COVID

setting. So this not only helps you with calming you down, but it reduces stress, right? And we

know from Dr. Marshall's excellent talk this morning what stress does to our neuroendocrine system,

to asthma, and to so many other disorders. But it also, what I tell patients is it gets you out of

your head. So you're not always like this, thinking about your disease, thinking about other drama

that we all carry around, right? And you know that we have 60,000 thoughts a day. That's the

average, and most of those thoughts, over 90%, are about ourselves, right? So meditation is very

important, and we've actually done clinical trials. I've imported my mother for a couple. We did

meditation for neuropathy, more for sclerosis. Right now, I just submitted a paper looking at

yoga breathing for patients with ALS, and it did help. I'm sorry, Dr. Marshall, the p-values

weren't good. It was a pilot study, wasn't hard for efficacy, but it did look good. They didn't

change for an eight-month period. They're FDC, which is pretty amazing. And then I'm in the

middle of a study now looking at telachigong for patients with diabetic neuropathy. So it works.

Talk to your patients about this. Just five minutes at the end of your visit. It can increase

your patient satisfaction scores by 30%, according to an organ health sciences survey. So mine are

now about 50%. Just kidding. But the patients do 55. So the patients do love it, and they think you

care. And that's half the battle, right? Just making sure that they know that you care about

that. So thanks again. Thank you, Jenny. So I now have the pleasure to introduce Dr. Lisa Meltzer.

Dr. Meltzer is a professor of pediatrics at National Jewish Health, and she is a licensed

clinical psychologist and is certified in behavioral sleep medicine by the American

Board of Sleep Medicine. She's actually also a co-author of a book. So she wrote

Pediatric Sleep Problems, a Clinician's Guide to Behavioral Interventions, and she has treated

pediatric sleep issues for almost 20 years. Her program of research examines the impact of chronic

illness on pediatric sleep, the objective and subjective measurement of sleep, and the impact

of changing school start times on health outcomes. She's also very modest, and she recently received

Natalie V. Zucker Award to help promote females in research for a study with melatonin itch and

sleep. And she also happens to be my office neighbor here at work, and so has been helpful

with my own personal questions regarding my children and their sleep, or lack thereof at times.

And so my question for you, Dr. Meltzer, is just about sleep in general. What is its role? And

I'm a little nervous to ask the next question, but does sleep really help repair mind and body?

So as well, I'd like to say thank you for having me. And the short answer is yes, it does. The way

that Dr. Tabby says the most important things are diet and exercise. Sleep is that third pillar of

health that is often not discussed, but everyone sleeps, or in many cases, everyone doesn't sleep.

But sleep is a critical health asset that everyone needs to be getting every night.

And so in the same way that you need to eat fried fruits and vegetables a day,

you need to go to bed and wake up at the same time every day and have that consistent sleep

opportunity. Sleep impacts every aspect of health and well-being. So we know that when you fall asleep,

the brain cleans itself, right? There's a lot of, I would explain it from a biological standpoint,

but I'm just going to say the brain cleans itself overnight while we're sleeping of all the gook

that it builds up during the day. Our muscles recover during the sleep. Our immune regulation

is functioning during sleep. We know that if we sleep deprive you and expose you to virus,

you're more likely to get sick than had you been well rested and had sufficient sleep duration.

So sleep is really critical. And we are, unfortunately, a society that believes sleep

is for slackers. And when we have a lot to do, what's the first thing to go is sleep.

On the flip side of that, you have the impact of everything that happens all day on sleep. So people

who are extremely stressed and don't use all of your mind, body relaxation techniques that

my previous and next speakers are going to be talking about, but that makes it more difficult

to fall asleep. You know, checking work email after work is bad. Checking work email in bed

is really bad, right? So having that clear separation and having a bedtime routine is so

essential across ages. Again, I work with Peds, but you need a bedtime routine no matter how old

you are. Your body needs to be able to separate daytime from nighttime. And it really is so

important to be aiming to get a sufficient amount of sleep every night. And then it's

important to consider what happens if you are sleeping enough and things still aren't going

well during the day. We need to evaluate the quality of sleep and recognize the underlying

sleep disorders that are very common. So sleep apnea in particular is something we need to be

aware of. There's a lot of movement disorders during sleep. You know, for our allergy kids,

especially the itchy ones, they're itching all night. So it doesn't matter how many hours they

sleep. They're having brain arousals every time the itch sensation kicks in. So if that's not

well managed, their sleep quality is not good, which is going to impact their ability to heal

and feel well during the day. And when you're not sleeping, then your ability to follow through on

all those treatment recommendations may be impaired because your ability to think clearly

and remember and follow through is definitely impaired. So again, back to the simple answer.

Sleep is a critical health asset and is really important for every aspect of

physical and emotional well-being.

Thank you, Lisa. And having had the pleasure to work with you as both a colleague in pediatrics

here as well as a mentor for some of my projects, I can attest to the tremendous work that she has

done both for our patients here at National Jewish as well as throughout the community.

Her work on school start times is truly impressive. That's, I think, just like moving

a mountain to change school start times. So I am impressed. As someone who did not sleep

last night, thanks to patients coming in, I'm happy to introduce another one of my colleagues

in pediatrics, Jennifer Moyer-Darr, who is a licensed clinical social worker. She has

been practicing for over 20 years as the manager.

The night before the lecture and panel discussion, Dr. Marshall gave a presentation to the Colorado Allergy and Asthma Society.

AIR Presentation CAAS, April 2021: Using Integrative Medicine for Allergy-Asthma-Immunology Practice

Gailen D. Marshall, Jr., MD, PhD, FACP, FACAAI, FAAAAI

First of all, I'm absolutely delighted and honored to help kick off

this inaugural session for my dear friend, Dr. William Silvers. I've known

him since we were both younger. I was trying to think this afternoon how

long we've known each other, and I can honestly say I think I've known him

longer than I haven't, at least certainly from a professional standpoint,

and I've had the greatest of respect for what William does, what he has done,

the passion he has for his patients. He's always looked for the very best

that he could do for his patients, and integrative medicine is something that

just grew out of that. In regard to what B.J. was saying about Phaser

Triplett, Triplett was the first

allergist immunologist in Mississippi who was trained formally as allergy

immunology, started the Mississippi Allergy and Immunology Clinic, which is

now the Allergy Asthma Immunology Clinic in Jackson. They have eight providers

in that group. They're very helpful to us in our training program. Our fellows

love them, and in fact, three of our former fellows are their partners now,

so we have a very great relationship. When Dr. Triplett passed away,

his family honored me in 2012 by endowing our Phaser Triplett senior chair,

and I'm the inaugural holder of that chair, and I've been very blessed with

the benefits it's provided. We've been able to do and promote some very good

research as a result of that, and I'll actually show you a little bit of that

tonight and again tomorrow. Let me just give a word or two of introduction

about this as we get started. I've been involved, probably in integrative

medicine, really came at it in a little bit different way in that I got

involved in some basic sciences that related to a field called psychoneuroimmunology,

and again, I'll have more to say about that tomorrow morning in the lecture

and a bit tonight, but from that grew into the whole idea of the idea of

patient-centeredness. As BJ mentioned, I did my Allergy Immunology Fellowship

with Phil Lieberman in Memphis, and from the first day I met Phil,

it was very clear that this brilliant, scientifically sound individual still

kept the patient at the forefront of what he did, and he instilled that in me

as many of my other clinical mentors did as well, and so I was looking for

ways to exercise that and getting involved in the idea of integrative medicine.

I began to see patients, particularly in the late 80s and the early 90s,

who began to come to me and tell me about things that they were interested

in using to make their allergies or their asthma better, and some of these

related to things that I thought were kind of off the wall, actually,

until I decided to sit and listen to them, and I was amazed at the consistency

that I heard from many of my patients and actually began to ask questions

and found there were a lot of them that really engaged in this,

but what I want to make sure that you understand tonight is that neither

tonight or tomorrow morning will be as an advertisement for complementary

and alternative medicine techniques.

For the majority of people in this call, that will not be something that you will

actively promote or engage in.

What I want to do is to really focus on what integrative medicine means,

what it is, and how from that may flow some of these other modalities,

and to point out, I suspect that many, if not most of you on the call,

if you are patient-centered in what you do, you're already practicing integrative

medicine in some form or fashion in your practice.

So I invite you to be skeptical of what I have to say, but try not to be cynical.

Keep an open mind, look at the evidence, see what's presented both tonight

and again tomorrow morning.

If you can, I've been very impressed in seeing the pedigrees of the folks

that will be on the call for the panel discussion tomorrow afternoon,

because I don't know all of them, but I'm very impressed with them.

I've taken the time to read some of what they've done, and I think that you can

come away from this tonight and tomorrow changed in your thinking,

changed in your thinking of the idea that you can put feet to what I hope is true

for all of us, that we want to do what the very best is for our patients,

and we want to do it as individually or collectively as necessary.

I don't have any relevant disclosures for this lecture.

I have a bunch of disclosures, but nothing applies to this lecture.

Let's begin by talking about health, that word.

Health is a state of complete physical, mental, and social well-being,

and is not merely the absence of disease or infirmity, and that's a WHO definition.

It cannot, therefore, be attained or maintained solely by pills or procedures.

Physicians and other healthcare providers, too often, we allow patients to come to us

expecting to walk away with some form of a remedy, and the remedy is either thought

of as a prescription or something that we have done to them.

It involves the initiation of maintenance of homeostasis, a word that all of us

learned probably in public school and certainly when we were in college,

and it can be influenced by multiple non-physical components,

such as the outlook of the individual.

Are they optimistic?

Are they pessimistic?

By the provider-patient relationship, which can include the entire healthcare team,

all of us who practice, whether we're in academia, whether we're in community

practice, all of us know that our staff can make us or break us,

and so the whole team becomes very important in relating to our patients.

And then the recognition of the relationship between spirituality and health.

I'll have some words to say about that as well.

There are some major challenges in Western society that are related to our health,

that are not going away, and in fact, if anything, are getting worse.

Chronic disease is increasingly prevalent.

This is the follow-up or the fallout, if you will, or the fact that we can keep

people alive that 50 or 75 years ago would have died much earlier in their life.

It very much translates to someone in my generation.

I turned 70 this last year, and I never believed that I would be 70 because it

seems like it was 10 years ago when I was just getting out of training in my 30s.

Time flies.

Time flies, particularly when you're having fun, and I've been blessed with that

very much, but hypertension, cardiovascular disease, diabetes,

metabolic syndromes that come from that, cancer, and even allergy and asthma,

which has increased in prevalence almost 30% in the last couple of decades.

Unfortunately, Mississippi, if you look this up for all four of these,

Mississippi is number one per capita in negative outcomes for all four of these

major illness categories, so we live and breathe this every day in this state

with our patients.

Most, if not all, chronic disease have an inflammatory and immune component.

I'm an immunologist by training.

This is my lecture, so I can say that.

Now, whether other people might disagree with it, but think about it.

Think about all the different categories of diseases that we know about,

we learned in medical school, maybe we take care of today.

How many of them don't have something to do with an immune or an inflammatory

component?

We live in an increasingly obese and sedentary society, and those go hand in

hand, and obesity, as I know we all know, is itself an inflammatory condition.

There are lots of adipokines that have negative impact on the outcomes in our

patients.

There are increasing levels of societal stress, come from economic challenges,

come from environmental challenges, and even come from philosophical challenges.

Those of us, again, who are older can remember a time where the idea of agreeing

to disagree or civil discourse was something that was most common, and the idea

of yelling and screaming and the overwhelming passions that seemed to so much

characterize the discourse and the political process today were exceptions, not

the rule, and it seemed like in many ways that has flipped.

Recent studies that have been published have indicated this is a major stressor

for most Americans, regardless of what their philosophical or political views

are, and it is something that I believe very strongly has the potential to have

very significant adverse health effects.

Western medicine is increasingly technology-driven.

That's a good thing, but unfortunately, the bad thing is that it's often minimized

the whole-person approach of body, mind, and spirit, so the idea would be to try

to return to some sort of balance using our technology, using it as well as we

can wherever we can, but also reminding ourselves that we're treating individuals,

not biochemistry numbers, and certainly not a bag of physiological manifestations.

Now, I want to share with you this Hippocratic Oath.

This is a version of a Hippocratic Oath that was actually written by the dean of

the medical school at Tufts and recited at the 1964 Tufts commencement, and I want you

to get this from the concept of an integrative medicine perspective.

I swear to fulfill to the best of my ability and judgment this covenant.

I will apply, for the benefit of the sick, all measures which are required, avoiding

those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is an art to medicine as well as science, and that warmth,

sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will remember that I do not treat a fever chart or a cancerous growth, but a sick human

being whose illness may affect the person's family and economic stability.

My responsibility includes these related problems if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

This had a major impact on me when I first saw this probably 20 years ago, and I've kept

it with me, I've shared it with medical students, I've shared it with residents, and it is something

that I believe very passionately as a clinician and as a physician scientist, it's important

for me to believe and to adhere to.

So what about this term integrative medicine?

My stars, if we had time and it was in a live audience, I would stop and I would ask people

to tell me what they thought this meant, and there would be a variety of things.

But what it does, again, a WHO definition is it puts the patient at the center and addresses

the full range of physical, emotional, mental, social, spiritual, and environmental influences

that affect a person's health.

Again, this is not my definition, this comes from the World Health Organization.

The therapeutic goal is to treat the whole patient using whatever evidence-based therapy,

be it conventional, complementary, and all alternative that addresses the patient's needs.

Now it's important to understand that while CAM, complementary and alternative medicine,

CAM can be a component of integrative medicine, it is much more.

Integrative medicine is much more than just using CAM.

If you get nothing else out of tonight's talk, if you say, I had enough and I wanted to watch

some television or whatever, if you can get that statement correct, that integrative medicine

is more than CAM.

CAM is a component, but it's not even a fundamental component, if you hear me out through the

rest of this evening.

Medicines are defined by the components of body, mind, and spirit.

Some people like to use the word soul, but they're interchangeable and I'll show you

this in just a second.

It is in fact the original personalized medicine.

This approach to care has been recorded from the earliest medical history.

Hippocrates famously said and was recapitulated by Sir William Osler at the end of the 19th

century, it is far more important to know what person the disease has than what disease

the person has.

With that mindset, there are other things that came from Hippocrates and others, such

as let food be the medicine and medicine be the food, in other words, that diet is important.

I think we know that walking is man's best friend, exercise is important, and a wise

man should consider that health is the greatest of human blessings and learn how by his own

thought to derive benefit from his illnesses, in other words, an optimistic outlook.

Others had thoughts as well, Mamanides, a famous Egyptian physician, famously said the

success of relieving the patient depends upon an intimate knowledge of the total patient.

He also had some things to say about respiratory disease, mental suffering impedes well-being

and adversely affects the respiratory organs.

Integrative medicine principle is focused on the patient and has been that way from

antiquity.

I've done these talks and done this sort of writing and so on long enough that I've

had patients say, well, sure, it was easy for Hippocrates, it was easy for Mamanides,

they didn't have anything else.

Number one, that's not true.

They had a lot of things that they used.

Were they effective?

Maybe certainly not like they are now with what we have choices while, but it wasn't

just that they could only do this.

It was a component of this as the central part of their medical practices.

What about complementary and alternative medicine or CAM?

Let's talk just very briefly about the basics.

Complementary means used together with conventional medicine.

Alternative means used in place of conventional medicine.

You can have complementary, which is what most of the therapies are, they're add-ons

rather than alternative that's used when something is not there.

However, it's important to understand that what is considered to be complementary alternative

medicine continually changes.

The National Center for Complementary and Integrative Health, which used to be the National

Center for Complementary and Alternative Medicine in CAM, says newer therapies that are proven

to be safe and effective become adopted into conventional health care.

Let me ask the question, and obviously there's no one to respond to this, so it's a rhetorical

question, all of mine are going to be denied.

How many people have at least dabbled in the idea of treating vitamin D deficiency or insufficiency

in asthma?

How many people are aware of the fact that vitamin D levels tend to be lower in our African

American colleagues when you keep our patients, when we keep all other parameters controlled,

their numbers will tend to be lower.

And asthma, all things being kept level, asthma in an African American tends to be worse and

more difficult to control, more severe, et cetera, compared to other racial counterparts.

So is there a relationship between those?

The literature is full of that question.

How many of you use H2 blockers along with H1 blockers in the treatment of chronic urticaria?

And I dare say for the clinicians in the audience, the overwhelming majority do.

But interestingly enough, there is no FDA approved indication for the use of H2 blockers.

It's something that's done sort of as standard of care and common, but it's therefore a complementary

medicine therapy.

Hydroxychloroquine in chronic urticaria, many of you, if not most of you have put patients,

at least in the past, on Plaquenil and gained control in chronic urticaria that before we

have the choices of some of the monoclonal antibodies.

And now if your patient's insurances are like my patient's insurances, a lot of time the

insurance company says no until they fail these other things.

So the idea of using these are in fact complementary and alternative medicine.

There's not an herb in this.

There's not a yoga in this.

There's not acupuncture in this.

This is complementary and alternative medicine at its heart.

Now don't think I'm making fun of that stuff.

I'm not.

I'm going to come to it in just a minute and show you some of the evidence that would suggest

that it might be useful.

What about allopathic medicine attitudes toward complementary and alternative medicine?

Generally the best you can hope for is neutral.

They tend to be negative.

There are very few advocates relative to critics, but I think this not only may change, I think

it's beginning to change.

Ignorance and what I mean by ignorance is I don't mean this as a derogatory term, but

ignorance of the process because it's not commonly taught.

I do the lectures on complementary and alternative medicine at our medical school, in our medical

students.

They get one in the first year and they get a second one in the second year.

One is in microbiology in the first year and the second one is in pharmacology in the

second year.

That's it.

I will tell you that our school is in the minority.

If you go through all the medical schools in the U.S., there are a large number of them

where there is no formal education in complementary and alternative medicine.

There are possible reasons for this attitude as well.

Some suggest that it's not evidence-based and in some cases they've got a case, particularly

if you get online and see what are the latest, newest things to use to treat that are complementary

and alternative.

One of the big things is, well, there are a whole bunch of different things, different

kinds and so on, but an issue is that if you look at it online, almost invariably, not

100%, but almost invariably somebody is trying to sell you something.

It might be a probiotic.

Probiotics are real big right now and, in fact, there are a lot of really good research

going on.

If you looked and did a Medline search, PubMed search, rather, shows you how old I am, say

Medline, a PubMed search, because I did it this afternoon and looked and simply put in

the word probiotic and allergy.

There were 667 articles published within the last five years on that topic alone.

Of that number, about 590 of them are in primary English language.

I say that because in Europe and Asia, the use of complementary or alternative medicine

is actually higher in the public than it is here in the United States, but the English

literature is even more robust in how probiotics as a complementary or alternative therapy

is actually being used to manage allergic disease.

The other is the worry about it could be potentially dangerous, either because it's directly toxic.

Some of the folk medicines and herbal therapies that are, particularly from other countries,

their quality is not controlled.

There have been reports of evidence of toxic compounds, mercury-based compounds, pesticides,

et cetera, found in these, but the other, I think that even more concerned that the

average provider might have is the concern that if a patient decides to embrace complementary

and alternative medicine, that she or he will withdraw from taking effective therapies,

maybe because it's too expensive, maybe it's because they like the natural approach or whatever.

So there is a genuine concern about the withdrawal if somehow it's perceived that the provider

is promoting the idea of complementary or alternative medicine in the management of their illness.

There's also the possibility of a negative impact on the physician-patient relationship

because the patients may decide to self-treat or they may actually seek alternative providers,

naturopaths, homeopaths, et cetera.

That I know of, there are four natural paths in Mississippi that are registered and they're

interesting individuals. They're very nice people. They're very interested in the health

of their patients, but their approach, of course, lacks the scientific rigor that the things that

we would do, but their patients swear by them and they swear by them because they say that

they feel better and some of them are patients who have asthma, some of them are patients who

have chronic urticaria, some of them are patients that have recurrent infections, which makes you

wonder if they have immunodeficiency but typically are not really worked up for that,

and these individuals do take good care of them at least from the interaction with them and the

listening to them and the putting them at the center of what they do. What about caring for

patients with allergy and asthma? Of course, we know they have a high level of morbidity

and a very low level of mortality, but it's not zero. The care that we give is aimed primarily

at quality of life to minimize or eliminate symptoms, maximize the activities of daily

living, athletics, scholarship, et cetera, and we make ourselves feel good about this in that we

have objective measures that we seek to normalize. We want their FEV1 to be normal. We want their

hive count to be low. We want their rhinitis symptoms to resolve. All of these things are

things that we're aimed at, but what the patient wants to do is they want to feel better and they

want to be happy about themselves to go about what they want to do on a regular basis.

A word or two about spirituality and health, and I think this is an important thing, particularly

in the premise that I'm giving that they are related. Spirituality is the way people find

meaning and purpose as to how they experience their connectedness to self, others, or the

significant or sacred. It is a universal human characteristic. It is not, let me say it again,

it is not specifically associated with any religious tradition. An atheist has a spiritual

side according to this concept. One's relationship with the transcendent can be expressed through

attitudes, habits, practices, and can be manifest certainly as religion, but also in the arts,

in humanism, cultural beliefs, and practices. It is in fact the inner life of a person, and this

was put together by an oncologist named Puchinsky and published back in 2012, a very nice paper that

he wrote about in the idea of medical spirituality issues. This is an interesting thing that goes

along with it because here was a study that was done now quite some years ago, but they took a

group of college graduates beginning at time zero, and they followed them. They measured with the

Minnesota multi-phasic personality inventory optimism pessimism scale. They determined that

a person was either optimistic, sort of in the middle, or pessimistic, and they simply looked at

all cause mortality over the next four years. You see here that the end for this was almost 7,000

individuals, and the relative risk of dying early in the pessimistic group was in fact

about 46%, a 1.46 relative risk for earlier mortality. Now, how much are we talking about

death-wise? You're talking about a survival difference of about 0.95 compared to about 0.91,

so you'd only talk about 4%. But 4% of 7,000 people is a lot, and 4% of 323 million population

in the United States is a lot more. We look at this, and in fact, 4% is more than the individuals

who have died from COVID-19 in the last year. In terms of the population of the United States,

and certainly the population of the world, that percentage is lower than that.

What about stress, anxiety, depression, worry? Can the mind impact disease activity? I think we

know an association between anxiety, depression, and asthma. In adults, asthma panic disorder

occurs in 6% to 24% of patients. In pediatric adolescent asthma, anxiety disorders are present

in a third, and depression is present in as much as two-thirds of asthma outpatients,

and the decrease in pulmonary function can correlate with anxiety or depression scores.

These are classic studies, but there is nothing that's been published to suggest that these are

not as true today as they were when they were first published. I want to take you through a case,

and we're going to go through this as a clinical case to show you the point that I have about how

things other than just the, quote, standards of care that we offer can be a benefit to a patient

if we keep that patient at the center of our concern and care. This is a 25-year-old African

American male PhD molecular biologist who presents with a chief complaint of chronic cough,

mild dyspnea, and fatigue. Began approximately three months ago, within six weeks of moving

to Denver from Jackson, Mississippi, JSU, to begin his postdoctoral fellowship, supposed to be at his.

History of asthma began at age two, which spontaneously resolved by age nine. He was

accompanied by allergic rhinitis symptoms, which have continued throughout his life.

He moved to an older apartment with three other roommates, and within days, cough developed

always worse when he was in his apartment. He discovered that the previous tenants had three

cats. He had gone to the University Health Center and was diagnosed with bronchitis. Now, hopefully,

the University of Colorado Health Center doesn't do this, but Jackson State University Health Center

does this because this is based on a patient that I actually saw, University of Mississippi. Most

university things tend to underdiagnose asthma unless they ask the right questions, and he was

given the classic generic cocktail, Cipro for 10 days and prednisone for five days,

advised to continue his over-the-counter daily for ticosone nasal spray and fexafinidine.

His symptoms improved significantly by day three. Of course, thank you, prednisone, and he stopped

all of his medications by day six. Within a week of completing the prednisone, the cough had returned

even worse than before, especially at night, waking him from sleep. He wheezed only at the

end of forced expiration during coughing paroxysms but was now concerned that his cough could be

asthma since his brother's asthma started as a cough some years before, so he sought subspecialty

care. He had some other historical information the review systems was negative except for

admitting mild depression from loneliness after moving from the mid-south to Colorado

and anxiety about beginning studies at a new school. He acknowledged a desire to develop

new friends and become involved in a local church as he had been in Mississippi. His physical exam,

he had a mild cough throughout the exam, especially was talking and deep breathing.

Pertinent negatives, he had a clear skin, no tracheal sensitivity, no wheezing. His pertinent

positives were boggy turbinates and allergic shiners, oropharyngeal cobblestoning, and midfield

and in-expertory wheeze on forced expiration only. His barometry, his ratio was down a bit

at the bottom of normal, his FPV1 was 81% predicted, and he had some significant

reversibility after bronchodilator administration. His allergy skin testing wasn't an allergist

office, so he had to get allergy skin testing, was positive for oak tree, ragweed, cat dust mite,

both DF and DP, and aspergillus species. So his diagnosis was cough secondary to asthma,

which was defined as moderate persistent. His combined seasonal and perennial allergic

rhinitis, and it was complicated by chronic stress and existential challenges leading to

increased anxiety, worry, and depression. The medications he was given was a Budesonide inhaler,

two pups BID, started on 10 milligrams a day of Montelukas, Vexifinidine, one a day continued,

and the fluticasone, which was already using. His viral control measures were the typical for

dust mites, dehumidifiers, and dusting and vacuuming in his bedroom while wearing an L

air filter mask, and the discussion with his patient was to establish his interest in being

referred to student counseling service for anxiety, depression, assessment, and management,

and to a local youth adult pastor for spiritual counseling. So let's talk a little bit about some

of the integrative therapies for allergy and asthma that have been used, that are being used,

and a little bit about why they might be useful. First is diet and nutrition. Diet is a modifiable

factor. A Mediterranean diet demonstrated protection from wheezing independent of exercise

and obesity. Children and adolescents eating fast food more than three times a week had an

increased risk of severe asthma. Rhino conjunctivitis and asthma, while those who had more than three

servings of fruit a week were less likely to have severe asthma. What about herbal-based therapies?

There's some basic information about the herbals that may be of use to you. It's one of the fastest

growing segments of the health care industry, and some people would put health care industry

in quotes. 2001, these are U.S. numbers, $4.2 billion was spent for herbs and botanical revenues.

Estimated that says 12, that's supposed to be updated in 2019, which was the last year,

$12.8 billion had been spent. Used for virtually all categories of illness, for therapy,

for supplemental, to promote health care, or for prophylaxis itself to actually prevent.

People will come in telling you that, I take X herbal preparation to keep myself from getting

asthma, and therefore I don't need my inhaled steroid. Now, that patient's going to have to

have some counseling, that patient's going to have to have some discussion, but we as providers need

to take note of the fact that that patient is saying that their symptoms are fine. Are they

poor perceivers, or has their asthma somehow changed from the last time that we saw them?

The mechanism of effectiveness can range from the placebo effect, the expectancy that this is going

to work, to a pharmacological effect. There are some bases for increasing popularity of the herbals.

Again, dissatisfaction with the allopathic approach, the health care team that's spending

and less time with them as individual patients, or the pharmaceutical choices that they have,

the concern about the potential side effects. I don't know about you, but I do spend some time

with patients that are new onset asthma and rhinitis. When I prescribe either intranasal

or inhaled corticosteroids, it's not uncommon to see their eyes get a little bit big because of the

steroidophobia, and it still extends into other health care providers as well. Then, of course,

many of these meds are not cheap, even with the copay and pharmacy programs that many people have.

Fear of side effects of the conventional therapies themselves,

control issues over maintaining their own health. Many of our patients, more so, particularly in the

younger population, they're not very good at coming in and saying, Doc, what do you want me to do?

They can come in. They're educated individuals, and they have educated themselves, perhaps

erroneously, with internet best things. WebMD, which is generally okay, sometimes is not.

They'll know, and it's not uncommon for them to come in, and it's clear they've read it.

Some of them will actually bring the article with them that they've downloaded from the

net, or they'll show it to you on their device, because if you express any sort of skepticism to

them, because it's on the internet, it must be true, is not a completely unrealistic attitude

that many of our patients have. The perception of safety and effectiveness, that combination there,

that balance is oftentimes not there, particularly if the patient has some unrealistic expectancy

of effectiveness that the first dose should essentially take care of their problems.

And then the appeal of the natural approach. It's hard to get around that one, because they,

the idea of being natural, but I think, again, this is where engagement with them in a discussion

becomes important. The key is, though, that takes time, and it may be time that not all of us either

have or are willing to spend with the patient who has this approach. What about physical activity?

In exercise and asthma, Cochran review of physical training for asthma showed good exercise

tolerance and improved maximum oxygen uptake. Quality of life is significantly improved for

those exercising with asthma, and four out of five reviewed studies and mirroring models demonstrate

reduced remodeling and airway inflammation with low to moderate aerobic exercise.

Exercise and asthma are a positive thing. They do not create the problems that many people think,

and in fact, most of us, I think, would encourage our patients to do asthma,

but I raise the question, how many of us bring it up in the conversation?

If the patient doesn't mention it, do we mention it? Do we say,

do you get any exercise unless we're asking about exercise and symptoms? We ask them if

they get good exercise. It's a stress manager. It can help their lungs develop increased muscle tone.

It's a good cardiovascular therapy. There's very little downside to a good exercise program

in patients except those with the most severe forms of asthma. Indeed, the current state of

research here published in the current opinion analogy and clinical immunology review a couple

of years ago, strong evidence that it is safe, no excess risk for exacerbation, and consistent

improvements in symptoms and asthma-related quality of life. Now, more research needs to be

done. Most of us will promote swimming because I was trained that swimming is the best exercise

for an asthma patient. It keeps their airways hydrated. It's good cardiovascular training.

There's very little downside except that if somebody is, their asthma is unstable,

you don't necessarily want them trying to be swimming out in the deep end where they

might get into trouble. Walking, cycling, et cetera, there's not a lot of work in children

compared to adults, and then there's not been good work to look at the mechanism of action

for the positive impact of exercise on asthma. Does it reduce airway inflammation? Is the airway

hyperreactivity related to cardiometabolic changes? And what about the respiratory muscle changes?

Are they better because they can breathe better? Are they better because they have less airway

obstruction? Or is it some combination of that? Allergists are aware of the strong evidence in

favor of physical activity. This is a very important point. This is a study published in the

WAO journal of 280 clinicians, European primarily clinicians, who had been in practice for

quite a while. Let me back up on that. I'm sorry. For quite a while. I'll get that right in a minute.

What they showed was they were looking at different things that they agreed with and agreed that there

was good evidence, not much evidence or negative evidence, psychological well-being, helping in

weight control, reducing asthma risk, improving asthma control, reducing incidence of allergic

rhinitis, and improving rhinitis control. While the evidence is not particularly strong there,

what you see is that allergists tend to be aware of this evidence of them. What you see is that

it is less than of it being aware. There's a lot of them being unaware, but it still shows you

that we've got work to do to demonstrate to our colleagues that just a good exercise physical

activity program has a positive benefit to allergic and asthmatic disease. Also, promote

physical activity is important in overall care. If you look at this, they all agree that that's true,

but being aware of what its benefit is, is still lacking. What about yoga and asthma as a physical

exercise? The literature has variability regarding the therapeutic effectiveness of yoga in patients

with asthma, but when used as an adjunct to standard asthma treatment, there were significant

improvements in quality of life stores. Some studies also demonstrated improvement in pulmonary

function tests, and here was a simple study that was done and published of a group of a very small

study, only 20 individuals, 12 women that were participating in yoga for 10 weeks, twice a week

for an hour that had mild to moderate asthma compared to eight standard of care, and they

took the St. George's respiratory questionnaire given before and after. If you see this with yoga,

their score went down. As the score goes down, that's a good thing for the St. George's. It is

a good thing. Lower scores is good. Upper scores is bad. In the control group, the symptoms

improved in the treatment group, their activity improved in the treatment group, the impact of

asthma on their daily life decreased in the group, and the total score decreased, which was considered

to be a positive thing. The implications for clinical practice for yoga, in particularly yoga

forms that include breathing exercise, seems to be more effective than usual care for alleviating

asthma. Non-yoga breathing exercises seem to be an effective intervention at least for improving

patient-reported outcomes in some asthma patients. Complex yoga or yoga breathing interventions can

be considered, sorry, can be considered ancillary interventions or alternatives to other breathing

exercises for asthma patients interested in complementary interventions. I wonder how many

of us ever even ask our patients if they participate in yoga, and then the ones that

tend to do that a lot are these providers who already would also ask their patients about or

would prescribe for them breathing exercises to improve their respiratory muscle function.

That's a question for us all to think about. Acupuncture, this is a study that was published

in the Annals a few years ago looking at its potential for seasonal allergic rhinitis.

It was a fairly small study. This is out of Australia, and what they did was had ended up

by going down through here. They had 88 versus 87 randomized into a real acupuncture versus a sham

acupuncture. I think probably everybody knows acupuncture uses the meridians and their acupoints

that are necessary to be needled. It's a very well-described exercise or activity that's done

by a trained professional. Indeed, in Mississippi, and I suspect it's this way in most states,

they have a board and actually have to pass a board exam to be able to practice acupuncture

in the state. What they got were weekly treatments, three times a week for four weeks. They

had various dropouts you see here, and then they did follow-ups weekly for four more weeks,

and then analyzed with an intent-to-treat analysis in the two groups. What this is important to show

you was the grass pollen. This is done over a three-year period of time. The grass pollens

were fairly low after treatment one. They were increasing, so they were moving into the grass

season. You saw this peak right about the time they had the fourth treatment, and then it had

one dip, but then tended to vary and was still there in the follow-up period of time. What they

showed in the red is the sham group, the blue is the actual acupuncture group, was that there's

a substantial decrease in the weekly medication score that persisted after the actual intervention

was stopped for the four-week follow-up period. The sneezing score was blunted, only statistically

significant right in this area here, but it was blunted throughout the regimen after about week

two in the acupuncture group versus the sham group. What about psychological and spiritual-based

interventions? The psychological stressor sources, there's a lot. This is Juan Soledon's

figure that was published in his paper late last year in the Annals. Stress perception,

stressful life events, conflicts, history of physical or sexual abuse, anxiety-depression

symptoms, caregiver anxiety, family chaos, infrastructure, intra-familial violence,

home insecurity, community levels, neighborhoods, stress-violent crime, gun violence, poverty,

school stress, peer stress, racism and discrimination. The result of this increased

asthma incidence, increased asthma symptoms, increased emergency department hospitalizations,

missed school days, poor academic performance, decreased asthma symptom control, and decreased

adherence to therapy. All of these are things that happen. Here's an intervention that Laurie

Burt from U-Mass did now published now almost a decade ago, but it's still

used in a more practical way than this was done pragmatically. This was a mindful-based stress

reduction study in an active group with 42 versus a weekly healthy living course where they watched

videos and talked about things for good health, living, diet, exercise, et cetera. It was eight

weekly two and a half hour sessions. That's certainly not pragmatic for a clinician,

but I'll show you in a moment something that's a whole lot less than that. Mindfulness training

is to learn to recognize and discriminate between components of experience, including thoughts,

feelings, and sensations such as dyspnea to develop a non-reactive awareness of the

experience and sensation so you don't panic and you don't go nutso when you begin to feel

a little shorter breath, an anxiety reaction which is not uncommon for our patients even if

they try to hide it. The meditation with focus on control breathing to control and slow down

their breathing and stretching to develop personal spatial awareness during their movement.

In result of MBSR is to reduce perceived stress and the disease-related stress in symptoms,

and it was practiced for these individuals after the completion of this training session

for eight weeks. They practiced for 30 minutes a day, six days a week for a year,

and here's what they found. The red is the active group. The blue is the control group.

These were not well controlled asthma patients. Only seven percent of them were well controlled

and remember that it was an eight-week process, so from the time of study entry at 10 weeks,

there's not really much of a difference here, but by six months there's a very strong difference,

a much higher percentage of controlled asthma patients that persisted to 12 months after

initiation of the study which was not there in the control group. Looking at their overall asthma

quality of life score, there was a reasonable increase in both of them that sort of persisted

up through six-month period of time, but then got even better. Remember these folks are practicing

30 minutes a day, six days a week, and they continue to do that throughout the 12 months

of the study compared to these folks that are back to standard of care. They're essentially

finished at the end of that, and then the last one of these is looking at the perceived stress

score which is exactly what it sounds like. It's a questionnaire that gives you an idea of how much

stress the individual perceives that they're under. Not much difference in the first six months,

but now that was blunted, it went down, and it stayed down for the 12 months in the active group

compared to the control group. So let's go back to our case for a moment. He was followed up one

month later, and the symptoms had essentially abated. The cough was gone, the dyspnea had

resolved, the fatigue was much better, but was still having some trouble sleeping due to anxiety,

depression, and social struggles, but he was not waking up or using his short-acting bronchodilator

agent. He had become active in counseling at the student counseling office and was now involved in

a young adult church group. He was using the medications as prescribed. His repeats barometry

now showed an FBB1 of 103% with a ratio of 92. It was suggested that he continue counseling

his medications and begin allergen immunotherapy for tree dust mites and cap.

Most of you know this fellow. My dear friend and hopefully all of yours, Richard Weber,

the president of the college back in 2013, was quoted as saying,

The opportunity for allergists in the immunology portion of their practice

is that it encompasses the entire human body, requiring a holistic approach of looking at the

whole person rather than just a small part of their anatomy. Patients want physicians who take

a holistic approach, which places allergists in an excellent position for the future. So in this,

this is my last slide of how I believe that we should consistently work as it relates to

our patient in an integrative approach to allergy and asthma care, regardless of whether you have

any intention of learning more about and getting involved in some of these complementary alternative

medicine therapies. And hear me out. First is our typical conventional assessment. We all do this

pretty well. History and physical exam, review our medications, including asking people about,

do they take herbals or other things that would be considered CAMP? Because many of those people

won't think of them because they're not prescription medicines. Questions about their diet, their

activity, exercise, lifestyle choices, appropriate labs or procedures. We all do this and I think we

do it pretty well. We could do more with asking people about CAMP, but I think the other ones are

done reasonably well. But what about a psychological assessment? Do we look for or ask them about

underlying psychosocial stressors? Is everything going on in school? Are there any problems at

home? Are you having any relational issues? Is there issues related to perceived stress, worry,

anxiety, or depression? And then a spiritual assessment. This is the one that makes people,

again, when I'm in audiences looking at people, it makes people squirm the most. But allow me to

tell you what I'm asking. I'm not asking you to ask them if they go to church or synagogue

or mosque. I'm asking you to ask them about their assessing of their meaningfulness. Do they think

their life is worthwhile? Are they satisfied with their life? Do they have aspirations or are they

just sort of discouraged and sitting there? Look at their non-cognitive behavior. See what they

look like as well as what they say to look for evidence of existential disturbance or crisis.

And then from that, you can construct a comprehensive management program that is sensitive,

respectful, and non-judgmental in its approach, and that may include conventional or CAMP

interventions. And if not, you may be able to appropriately refer them. As this case that we

described tonight was to a ministering staff member, if that is the tradition that the

individual wants to follow, a list of these people in most towns and cities is available.

You don't have to participate in the religious tradition at all or the same one, but you can

help link them up with that. There are psychologists that are very capable of this. We're hoping to

desensitize and decriminalize the word psychosomatic because the word psychosomatic

simply means mind, body, and like it or not, we cannot disconnect that connection. And I end

with that, and thanks everyone very much for your attention. I will hand back the share,

and if there are any questions in the time that we have left, I'll be happy to answer. Thank you.

Thank you so much, Dr. Marshall. That was wonderful. And anyone for questions,

you're welcome to unmute yourself and ask them directly. If you prefer to ask them in the chat,

you can do that too. Hi, this is Dr. Murtekrishna from Fort Collins. Thank you, Dr. Marshall,

for a wonderful summary of this excellent program. And you see these patients in allergy

practices, for example, self-climbed foot allergies, or as you mentioned, one of the

cases somewhat not exactly that respiratory symptoms, but not related to asthma, skin

conditions, a lot of GI symptoms, and there is a lot of self-climbed, you know, the gluten

sensitivity in the last 10 years or so. So when we evaluate as physicians, traditional, you know,

allopathic medicines, we go through some of the basic investigations that you mentioned briefly,

and it becomes negative when we tell the patient, of course, then we just leave it at that level,

because they don't have a real disease. And they may have one of these things that you discussed

today in our lab. So I think if there is a, you know, somewhat of a clinic or referrals where

we can make these patients go because in regular allergy practices, you will not be able to handle

their, you know, anxiety or depression or other nutritional problems they have or something.

So if there is a clinic where these patients can be referred, otherwise they'll look for some other,

you know, CAM or alternative medicine themselves. So can you comment on that?

At some places, these clinics are available where we can refer these patients to check it out?

I think that's a superb question. Thank you very much for asking that question. I tell the story

when I give this talk, particularly in the medical school, I tell a story of Mrs. Smith comes to see

me, and she says she doesn't feel good. And so I asked her what's wrong. Well, I'm tired all the time.

I get short of breath easy, I ache, I hurt and so on. And so I'm a good doctor, and I'm medicine

trained. So I'm also doing my internal medicine stick along with her. And so I take a good history,

I examine her, I do the appropriate testing, everything comes back normal. Am I being a

kind physician when I walk back into our, I bring her back to the office later on and I say, Mrs.

Smith, good news, there's nothing wrong. Well, Mrs. Smith wouldn't have come to see me if there

wasn't something wrong. Clearly there's something wrong. The fact that I can't find it doesn't make

it unreal. And the fact that it may not fit into the category of the disease that we talk about

is in the same thing. Some of you may know, and apparently from what I saw at the beginning,

this is going to be really interesting next month, as you're going to talk about COVID vaccines and

so on. There is an NIH research opportunity announcement that we have responded to with our

colleagues at the Mayo Clinic about a condition that many of you would have heard of as long-haul

COVID, but is also now called post-acute sequelae of coronavirus infection or PASC.

And we are in collaboration with all three of the Mayo campuses. We form a four-institution

network that is looking at this and we have a standard way. We take these people that are

symptomatic and we're very conservative in that number and that unlike the Europeans who don't

really diagnose this for 120 days, we diagnose it generally after 30 days and even there's some that

maybe they're just not that we can get an early start on. But one of the components of this is

not just the organ specific, the chronic cough or the exercise and tolerance with breathing,

et cetera, but it's what's called a central sensitization syndrome. And these are the

nondescript symptoms like profound fatigue and brain fog and myalgias and arthralgias. And

for those of us who are old enough when chronic fatigue syndrome was chronic fatigue and immune

dysfunction syndrome, which was that way for about 10 years in the 90s, they called it CIFIDS and

immunologists saw a lot of CIFIDS patients. I did because nobody knew what to do with them

and they had these nondescript illnesses. I think that what my experience has been with these

individuals that has been so helpful is the candor of telling them, I don't know what's

wrong with you, but clearly I acknowledge that something is just by validating their illness

and not immediately passing them off to the latest mental health professional. They may

well ultimately end there and a fair percentage of them do, but they would not to ultimately

pass them off. On the other hand, not to be to the point where we're spending $20,000,

$50,000 of laboratory money getting reams after reams after reams of normal data. Then we found

an abnormal one and feel compelled to go after it and never really give them anything that's better.

What's being reported in the COVID associated past patients is that with supportive care,

truly supportive care, many of these people ultimately get better. The minority of them

after three or six months, the minority of them are still symptomatic. You're not helping everyone.

The NIH study is to do deep phenotyping of these individuals because the next research opportunity

announcement that will be out probably at the end of the summer, beginning of the fall will be

related to interventions and what they're trying to do for this. What you describe,

I believe is much, much more common than we acknowledge. What these individuals will

typically do if we're dismissive of them is that they will seek out the alternative providers

and they will land in the natural past office, they will land in the homeopaths office,

they will land in the chiropractor's office without any musculoskeletal individual. These

individuals very often, they come out of those offices just delighted. Thank you, doctor. You

have saved my life because you're listening to me. The one thing that I would say is that we have

to invest enough into being willing to listen to the people. I do not believe that you have to spend

two hours with the patients. You can have a defined 20 to 25 minute interaction with them

and it's amazing how well they'll walk out of there because you have validated

that you agree that they're ill. You just haven't been able to tell them yet the exact etiology.

That's my approach to that. Thank you.

Thank you, Dr. Murthy. Any additional questions for Dr. Marshall?

If I could, Galen, thanks very much for giving us this review and putting the patient in the center

and also for your seminal work with the stress and the immune responses. I just got to say that

it was given your paper talking about skin testing being improved with the new skin

it improved with patients through the MBSR program that I did a program

at the Denver Botanic Gardens with a instructor from Boulder from the Naropa Institute actually

who had trained in Boston at UMass with John Kabat-Zinn, et cetera, that you're talking about

the MBSR mindfulness-based stress reduction. As I told the fellows at the Journal Club at

CU, I haven't taken a sleeping medication since then because the breathing and the medication

is so helpful. I just wanted two questions. One is besides MBSR, which is a significant investment

of time, are there other recommendations that you give your patients regarding breathing,

relaxation exercises, stress reduction techniques that they can easily take with you? Number one.

Number two, to the physicians, do you have references online that if people come in

with a concoction of all kinds of supplements that they can look up

what the safety efficacy, the value is, et cetera? To answer the first one, a teaser for tomorrow

morning will show you some data from something called a behavioral activation that is a one-hour

training that can be done in the office. The patient takes that home with them and they use

it. It's based upon MBSR, but it's different from MBSR. They've now gone to the University of Toledo,

but they were at our place for some years. I still collaborate with one of them there, a fellow

named Matt Tull. Matt and his wife Kim Gratz, who are both clinical psychologists, develop this.

The value of it is that it's so pragmatic. The real value of it is that again,

behavioral activation is a little bit different than mindfulness-based stress reduction in that

what they're doing is that they're catching themselves though in the moment. They are,

if you will, calming themselves down and it involves breathing. It involves stretching. It

is an immediate abbreviated form, I guess, that some people would acknowledge based on yoga,

but it works very well for our patients. I think the key is one of the things that we do

is that really early on in people, particularly in somebody that we might think have, for example,

vocal cord dysfunction, maybe they have defined asthma, but clearly their exacerbations are

coming more from VCD. One of the things we'll do is contract with them to agree that they're

going to delay the use of their reliever for a minute. We teach them that same galactic pull

that everyone knows where there's sort of a counter pull. We go through the thing about

Charlie Harson, the leg, and these are Charlie Harson, the retinoid muscles. While that's a

little, I think the purest particularly in Denver probably might jump on me a little bit, it works.

In a high percentage of these individuals, when they begin to realize that in fact it's anxiety

that has brought on these attacks and it is put there where they can see it and understand it,

it's absolutely amazing. It's almost transformative of them. Then they engage in this.

Doesn't cost them any extra money. It's something they can do repeatedly and we've seen over and

over the ACT scores improved substantially in these individuals, particularly because their use

of short-acting bronchodilator goes from almost daily to virtually zero. The second one is that

yes, there are several websites that exist that give people good information and that the docs

can use. Bill, you might be better equipped to give all the current information. We have it

available to us, but I guess I've done this long enough now and I also look at it in the literature

to see if there's stuff that's new in these areas. When they come talk to us about it,

I can give them information and then direct them to what's available. This is something that

the integrative medicine committees for both the college and the academy should be pressing

their boards for. This happened for a little while, fell out of vogue for a while and hopefully

come back again. If we're going to ask our colleagues to become more educated about these,

we need to be able to provide them the resources where it's readily available for them to

access that information.

Yeah, I might just say that for my colleagues here,

there are two online resources, I think. I would go to number one and to send patients to would be

the National Center for Complementary Integrative Health at the NIH. That's classic and

evidence-based, et cetera. The other one that is more detailed to supplements, I'd recommend that

you at least put in your, as an arrow in your quiver if you're confronted with patients coming

in with certain supplements that you're not familiar with, is the naturaldatabase.com. It's

the National Center for Complementary Medicines and it's put out and it's vetted by the same

people who do the pharmacist newsletter. We had explored them for the Academy years ago and then

for the college and they've got all these people in these little cubicles looking at the data,

et cetera, and they have nice safety efficacy profiles of all of the supplements. There's a

free version that's simple and then there's a paid-for version that the Academy may still have. The

college had it at one point, the Academy then picked it up. I don't know if it's back to the

college or the Academy now, but one of our two major societies has that as a, or at least as of

last year or so, has that as a member benefit and you don't have to pay for anything.

I'll try to find out which one has it before tomorrow morning, actually. Those are two

resources, I think, that are valuable to direct patients toward and to search out yourself for

the questions that may confront you.

Thank you. That was wonderful. I can't think of a better way as an introduction to

the William Silver's integrative allergy immunology respiratory wellness program.

I do hope that everyone who can, can join for tomorrow's sessions as

BJ had previously shared. If you need any of those links, please reach out to us

at the Colorado Allergy and Asthma Society or directly through BJ in his email.

Before we adjourn for this evening, any additional questions or comments?

Please, those that can attend tomorrow, enjoy those sessions. Otherwise, we look forward to

seeing you in May on the May 11th for the next session of the Colorado Allergy and Asthma Study.

Thank you, Dr. Marshall.

Great pleasure. Enjoyed it.