Immune System Resilience and the Environment

Kalea Wattles, ND:
On this episode of Pathways to Well-being, we focus on building resilience and how the environment around us can influence the potential of our immune systems.

Dr. Susan Haddow is board certified in family medicine, integrative medicine, and functional medicine. For 30 years, she has worked primarily in underserved populations, and she has been actively involved with teaching residents for 20 years. She practices integrative and functional primary care in the Hennepin Healthcare system in Minneapolis, Minnesota. Functional and integrative medicine, along with a love of gardening and being in nature, infuse her patient care, resident teaching, and view on well-being. Environmental factors, lifestyle habits, and social determinants of health have a significant impact on patients’ overall health and susceptibility to disease or acute infections. We're so fortunate to have Dr. Susan Haddow with us to discuss strategies for supporting our immune health. Welcome, Dr. Haddow.

Susan Haddow, MD, IFMCP, ABOIM:
Thank you very much. It's an honor to be here.

Kalea Wattles:
We're so excited to talk to you today, and it's always really a pleasure for me to hear how our experienced clinicians are utilizing the functional medicine model in their practice. So I'd love to start out today just to take a moment and hear how you're applying the functional medicine approach with patients in your daily life.

Susan Haddow:
Sure. I'd love to talk about that. I have found myself using the tools of functional medicine on a regular basis. In particular, I just loved the timeline. And then I find that a ton of my work happens in the modifiable lifestyle factors really informed by the clinical imbalances. And I want to say that the clinical imbalances early on were kind of a difficult concept for me to wrap my head around. And we were trained in med school in the body systems, but as I read and learned and studied, the imbalances really echo the body systems to a degree, but the imbalances are built around function, and that makes them so much more rich for me. So different organ systems can sort of cross state lines, so to speak. We talk about assimilation, for example, and I look at the GI tract, of course, that's where we get our nutrients, but we also absorb things through our skin, through our lungs. It's a larger picture.

So my goal as a clinician is to provide, to the best of my ability, up-to-date knowledge, self-care skills, nutritional and natural recommendations, and then drugs and surgery as needed, when they are needed, so that people can have, and be in charge of, their health as much as they choose to be and live their best lives. And then the functional and integrative medicine tool sets have really afforded me the capacity to do that more and more. And I must say also that I think that this approach helps prevent burnout. I don't run out of options. I've hit drugs, I've hit surgery, 30% of people didn't respond to anything, couldn't use that, or even more. And I think it also gives me that opportunity to deepen compassion and deepen relationships. So thank you for asking that.

Kalea Wattles:
Beautifully spoken. And I think returning to those foundational tools, to the matrix, is so empowering when you have these complex patient cases, and you're not sure where to go next, just returning to those foundational tools is so... I'm so grateful that we have those skills. Now, speaking of those foundational tools, of course, in functional medicine, we're always thinking about a patient's timeline. And we know that the early part of someone's life can really impact their health trajectory. And we recognize the importance of those experiences starting with the prenatal environment and maternal health and early childhood experiences. So from your perspective, how might this early life experience influence things like the development of autoimmune disease or allergies?

Susan Haddow:
Let's start with an in utero experience. For example, I work in populations where we have a fair amount of stress and poverty and stuff. And so there's stress, there's depression, there's anxiety. There's a lot of cortisol. There's a lot of epinephrine, and sometimes the nutritional status is not optimal, so that child can be at risk for preterm birth, for neurodevelopmental problems and suppressed immune function. There's enough research to make those connections. And then, depending on the mode of delivery, and I used to deliver babies, but I haven't for over 10 years now, but C-section versus vaginal delivery. How robust of a microbiome inoculation has this person received, or how diminished? We know, for example, that the microbiome influences immune system function later in life. So these antecedents can be pretty significant. And what can we do about those things? And this is where, again, I go back to the basics on those modifiable lifestyle factors.

And I start with food. A lot of my patients live in a food desert. They are on food stamps, or they live paycheck to paycheck. And some of them never received some of that generational cooking and learning about food experience that some of us have that we feel are healthier than others. And now, in the pandemic, so many people are struggling even more for adequate food support. I even start back further than that. And we start with breastfeeding and encouraging all of our pregnant patients to breastfeed. I teach in a residency program, and the residents are all doing lots of prenatal care. And I supervise a lot of that. And we are lucky to have an awesome lactation consultant onsite, which is great. And there's so many good attributes to the breastfeeding, and it gets moms inspired to eat healthier. It's good for bonding. It's good for the developing microbiome. And actually, breast milk is not sterile. And we know that skin to skin work is so important as well for transmitting the good bacteria. And we now know that even the uterus, the intrauterine environment, is not sterile.

There are bacteria in there that are our friends. They're not all E. coli and listeria. So it also encourages bonding, and there's those pre- and probiotics in the breast milk. So that's number one. And the physical environment plays a big effect there too; is there lead in my patient's environment? A lot of them live in old houses with peeling paint. There's an asphalt factory between where I live and where my clinic is. And those kids have higher rates of asthma and allergies. I also was reflecting on this, in the old days, so I've been...I finished my training in 1990, and back then we didn't have the Hib and the pneumococcal vaccines. And we treated a lot of babies for ear infections. We used a lot of antibiotics early on, and we were probably wrecking a lot of microbiomes with very good intentions, and there've been some really excellent studies. There was a 2012 cohort study in the UK of children who had received antibiotics before age one and following them for a bunch of years to see who developed inflammatory bowel disease or not.

And there's a high association of more than two courses of antibiotics as an infant with inflammatory bowel disease. So this just lends so much more data, and this was over a million patients reviewed. Big data to this idea of good stewardship of the antibiotics and trying to maintain a healthy environment in the gut. We know that dysbiosis, this bad gut stuff, is one of the multifactorial contributors to immune dysfunction, along with genetics, environment, and probably things we don't even know yet. So we don't always know the link. Why did somebody develop an autoimmune disease? But there is some very exciting stuff with seeing improvements in both GI autoimmune diseases and non-GI autoimmune diseases with some dietary changes.

I don't know if you're familiar with—I'm not trying to sell anybody anything—autoimmunewellness.com has a great little set of areas in their website of research that's been done with the autoimmune type protocol for eating and going into remission with your Crohn's disease, going into remission with ulcerative colitis, improving, and people getting off of a thyroid medication for Hashimoto's, because they heal their guts, improve their microbiome, and their immune systems can, it seems like there's immune resiliency in that way. Can the immune system heal itself and learn new tricks? Say, "Oh, I don't need to fight that thyroid peroxidase anymore. I can just fight those bad guys when they come in.” So there's a lot of exciting things there.

Kalea Wattles:
Well, I love, of course, that you brought up gut health. We could probably talk about that all day on its own. One thing that is a great fortune to me as a clinician that's somewhat fresh in my career is the ability to pick the brains, if you will, of clinicians who have been using the functional medicine model and really living it. And so selfishly, I'd love to ask you a question returning to the timeline. Sometimes, I find with patients when we talk about those prenatal or even maternal exposures that they almost feel like, okay, now it's my destiny to have autoimmune disease or allergies. So when you are framing those conversations to patients, are you returning to those personalized modifiable lifestyle factors to say yes, perhaps you have a predisposition to something because of those early experiences, but look at all of these things that we have control over. Is that kind of how you're approaching that conversation?

Susan Haddow:
Absolutely. I definitely use that approach, and it gives people hope. I've watched faces light up and say, "Really, I can do something?" Yes, you can. Can we completely a hundred percent reverse it? I've taken to using the dial analogy. We can dial it back a lot, so that instead of having this being so out of control over here, you can make a huge impact here. Like someone whose mom had type 2 diabetes or gestational diabetes when they were pregnant. Are they destined to get diabetes? I'd say they're not destined to get diabetes. You have a lot, gosh forbid you get an autoimmune type 1. That's another story, but there's a lot we can do to help. And that's where, again, I start back with the basics of good eating, and that's one thing I wanted to share in here. We do a bunch of group visits at our clinic, because you can say the same thing over and over to one person, and you do—one person, one person, one person—but it's really fun to say it to eight or nine people at once. And the energy evolves, and the wisdom in the group evolves.

And the effect is larger than the whole, than the sum of the parts. And so, in our groups, we talk about anti-inflammatory eating, and some of my patients have never really thought about it like that. We talk about eating as an opportunity to have an inflammatory or an anti-inflammatory experience. And actually, we ask our patients—we put them in groups—we ask them to write down, what are inflammatory foods? What do you think those are? And people actually get it. Even people you would think, “Oh, there's no way,” whatever, they get it. They know that eating the refined sugars and the high fats and the fried things are not the right way to go. But the support of the group helps them more than me saying, "You need to eat this way." When the group gets together and says, "Yeah, yeah, I found I can finally do this." They'll see someone who looks like them experiencing and growing in that way. And then it's really fun to watch the light bulbs go on with what are my symptoms? How does the food connect? How can I feel better? That's very exciting to me.

Kalea Wattles:
I think you keep tying all of this really back to the matrix, because when I hear you talk about group visits and the added benefit of learning from that collective experience is that community is medicine, that relationship part of those modifiable lifestyle factors. And so I think it just further illustrates how important that foundational aspect of health promotion is. So that is so exciting to hear that you're doing those group visits. We're definitely feeling excited about that as well. And I've heard you talk about gut health and inflammation, and now community. Just very generally speaking, I know this is a tough question to answer, but just very generally speaking, what are the top three things that you recommend for patients to support their resiliency and their immune function?

Susan Haddow:
Well, so, all right, I'm going to sound like a broken record when I say I go back to the basics, but I go back to the basics. I go back to food, but in that first category of the basics, I include food, movement, sleep, and how do we manage stress? Those are like my top things in that first category. And then I look at vitamin D levels, because I think, where I live at least, we're the 44th, 45th parallel here. It's eight hours of sunlight if we're lucky in the winter. So vitamin D and being vitamin D sufficient is crucial to both immune resilience and just in general good health. And then in the time of COVID in particular, I'm going to kind of toss that into this moment, is an immune support package that we've developed, Dr. Parker, Kara Parker[JDM2] , and myself and our pharmacists at our clinic developed a little immune support packet based on the work that IFM put out, and some other readings that we did, and created a seven supplement packet that's about 30 bucks and lasts for about two and a half months, give or take.

And it's not the super high doses, but it's good doses. And it's good for immune support based on research that has been out there. And half of our staff is taking it, a bunch of our patients take it. And when people come in for COVID testing and they're negative, and even when they're positive, we'll say, "Have you heard about these things? Let's try this as a supportive piece." So those are kind of my top three things: sleep, food, movement, stress management all in one, vitamin D levels, and then an immune support packet.

Kalea Wattles
This is the perfect lead-in to my next question, how you brought COVID into the mix, because I would love to hear from you, if someone contracts COVID-19, and they have an acute infection, is it too late to add immune support? Or can they still course correct a bit?

Susan Haddow:
In my experience, it's never too late. You can continue to build some resilience. Now, if you're super sick in the hospital, and I'm not doing the inpatient world right now, that's another area, but I'm in that early exposure prophylaxis prevention place. And yes, you bet. Of course, the earlier you get on it, the better. You get a little sore throat, there's a lot of things you can do to clear out the infection, really, in a couple of days from at least your basic other viruses. But I've seen it work in helping COVID infections too. Let me just share a story of a patient I've had who I thought for sure if he ever got COVID, he would be a statistic of fatality. So my patient is about 67. He's got, how many hands do you have? He's got COPD. He's got polycythemia vera, he's got traumatic brain injury. He's got nerve compression injury. He's on chronic opioids. He's got type 2 diabetes. He's got hypertension, neurogenic bladder. I think that's about it. And he's crabby often. And he smokes.

He said to me one day, I think, he snuck in through all the safety precautions at the front door, and then up in the room, he says to me, "I think I might've had an exposure to COVID." And I said, "Why is that?" And he said, “Well, somebody who I sit near, but not that near, when I go to the bar once a week, has called me and said he was positive." And I went, "Hmm, okay." So we ended up testing him, and he ends up being positive, and my heart sank. And so I used the Eastern Virginia Medical School protocol for early treatment. I put him on ivermectin. I put him on higher dose zinc. I used the quercetin, melatonin, vitamin C, and they're all in there in the doses, so I don't really need to tell all those doses, but he got a little crabbier. Oh, I also put him on a steroid burst because of his COPD, and he was a little wheezy.

He never dropped his oxygen saturation. He never went to the hospital. Two weeks later, he was feeling significantly better. He says, "My crabbiness has improved." And I really thought that this gentleman was going to pass. So I think that just tells you, I mean, I had him on some things beforehand. He was already taking vitamin D and some vitamin C, and he was intermittent with his zinc and intermittent with some things, but he cranked it when I said, "This is what you’ve got to do." So it's not too late. I don't think it's ever too late to do whatever we can do.

Kalea Wattles:
Well, I know that you've been seeing patients who are somewhat in that acute phase of infection. So let's talk about what happens afterwards a little bit. I'd love to hear, from your experience, what you're doing, how we can support patients following the resolution of acute infection. We are hearing the long-hauler syndrome talked about often—how are you supporting patients following their initial illness?

Susan Haddow:
Well, that's an evolving practice for me, even as we speak, I have at, well Kara and I, interestingly in our practice, we've had a lot of people on a lot of different supports at the beginning of this pandemic. And I just went through my patient list the other day, looking at how many COVID-positive patients do I have. I have about 10 that I know of that have been tested in my system so that I can follow them up. And about four of them have been in more of a long-hauly situation. Although a couple of them are after the 12-week situation. So we talk about glutathione, and I use a lot of NAC. I use higher dose vitamin C, as long as there are no contraindications, they don't have active kidney stones and different things, 1,000 milligrams, sometimes 2,000 milligrams, two to three times a day.

It's evolving. I don't have a real standard to reflect on right now, but I was listening to a podcast earlier about this just earlier today. And some people are again using the ivermectin in the long-haul phase and finding some good results. I don't think it's across the board. It's about 75, 80% of people seem to respond to it. That's better than just waiting. And I think the important thing that I have learned from COVID's long-haul thing is that this isn't new, we've had people with Epstein-Barr, we've had people with Lyme and other tick-borne illnesses whose lives were transformed, not for the better, after having contracted an illness. So I think what it may give us an opportunity to do is to extend a little grace to those other people who have been suffering for years.

Kalea Wattles:
Yeah. That's actually interesting that you've mentioned that. I have actually seen that emerge as well, that people who have chronic repercussions of other viral illnesses are saying this actually isn't new. And while of course it's not positive that this is now emerging again, it is somewhat helpful. And the medical community at large is starting to acknowledge that this is something that's real and looking into solutions. And so, in that way, it's been beneficial to some.

Susan Haddow:
Yeah. And I think the scale with which it's happening now is the thing that's been the real eye-opener.

Kalea Wattles:
Yeah. Well, it sounds to me like so many of the things that you're discussing as being beneficial are helpful in large part because they help control our inflammasome. And we love at IFM to talk about how even things like time and nature can really influence someone's exposome and inflammasome. And I know that in your personal life, you love gardening and being out in nature, and that that's something of value to you. And an area where we have started to look into the research is this whole concept of the microbioscape, and this equilibrium between humans and our natural interactions. So what guidance do you have for really getting patients to do more time in nature, to get more of that natural exposure? How do you make these recommendations in real life?

Susan Haddow:
In real life, in real time, well, I tell you, I'm lucky to live in a city where the city planners, many years back, believed in green space. So it's hard to walk into a neighborhood and walk more than eight to 10 blocks and not hit a park. And most of the parks have some little climbing things or playground-y stuff or sandbox-y stuff, or a baseball lot or basketball courts. So it's not too hard to find a space. So I definitely spend time talking to people about, what are their activities? Do they feel safe enough to go out and play or take walks in their neighborhood? Do they have community activities, sports, or things like that? We talk about gardening in the city, people love to do that. They also like to just go out, and we have the Mississippi river nearby, and there's walking parks around there.

So I suggest and make sure people know about all the free things that there are to do to get out and do some forest bathing of sorts, get out there and breathe with the trees, get your hands dirty and know that it's actually good to do that, be in the dirt, pull some stuff out of the ground and clean it off and snack on a carrot, for example. We have a lot of community gardens around town, and actually there's a couple of things, there's Urban Ventures for children, and they take them out in canoes, they take them out on the lakes, and they're all very, very affordable and often with a scholarship type thing through the city.

There's the Urban City Kid Farm, that's up along what we call our Greenway. It's a big bike path that you can bike around the cities here for over 40, 50 miles. And they even sell their vegetables on the green path at certain times of the week in the summer. So there are a lot of opportunities for structured and unstructured outdoor time, even in our urban environment here. There's a lot of pavement, but there's a lot of green space to keep with our friendly old friend, bacteria friends.

Kalea Wattles:
I think you've touched on a really important topic here. And it's something that I know is dear to my heart and really important to IFM as an organization, which is about, there tends to be a cost perception of functional medicine, that it won't be accessible. And you've just highlighted a number of ways that cost little or nothing to really promote health, getting out in nature, putting your hands and feet in the dirt, spending some time in the forest, these are accessible to most people. And so I think returning to those pieces is so critically important.

Susan Haddow:
And when you remind people of what's available, they go, "Oh, okay. Maybe so." And you just help turn the lights on a little bit.

Kalea Wattles
I know you have experienced working with underserved communities. Do you have any takeaways for us to help clinicians who really want to support these communities in building their immune resilience?

Susan Haddow:
I sure do. I'm going to reflect back for a moment on the group visits, but I do this one-on-one as well. And we talk a lot about stress resilience. A lot of our patients don't have a lot of agency, or don't know that they do until we work with it. So we do things like mindfulness space, stress reduction practice, mind-body practices. I teach people breathing exercises one-on-one, I teach them quick coherence through heart math, if you're familiar with that. And I've had a couple of times where people have a hard time finding a positive emotion to hang on to, to grow. So we search, but we usually can find something. And so one of my big takeaways for my underserved patients is recognizing that they're in a lot of stress, and so how can we help them? And as we help them kind of quiet some of that fight or flight down a little bit, other things bubble up. The capacity to make a change, make a decision, maybe change a toxic relationship.

Maybe finally, I am going to take that training course, or whatever it is, or I'm going to go to treatment or there's a variety of different pathways they might move down. And I feel like we get to educate with that, and really help them understand stuff about themselves. So that's one thing. The other is eating the rainbow. People get that. And I teach that a lot, and thank you, Deanna Minich, [JDM3] for the great tools that you've shared with us for that. Children get it, but my adult patients love it too. They put those rainbow-colored things on their fridge, and they'll do them and see how many veggies they can eat in a day.

I talk about nutrients. We talked about the vitamin D, but I talk a lot about fish oil, vitamin C, D, magnesium, and zinc. And these are all really pretty affordable. And I'm going to tell you, medical assistance will cover a lot of them. I have a lot of people on the medical assistance, and it covers that, which is fabulous. And also, I mean, I'm going to encapsulate it in this last thing to say that we like to educate our patients, empower them, engage and empower—educate, engage, and empower. That is the way I see that because as we educate them with new tools, they feel they have—and they can become engaged in using those tools, people are empowered to make changes, and changes that can be really positive.

Kalea Wattles:
I think as we're coming to the end of our talk together and I'm reflecting on what you've said, a theme that I'm really taking away is that as we're cultivating resiliency, that's whole person health that we would do anyway. Even if we weren't in the middle of a pandemic, this is really about cultivating that resiliency to make us strong, just as organisms, and then inherently, there's a protective mechanism in doing that work. And I've thought about this often, most of my patients are—I do fertility, so most of my patients are preconception, and I've thought all the things I do to support preconception health is inherently supporting the immune system, because we're cultivating resiliency. And that's really what I've heard from you today, talking about all the modifiable lifestyle factors and repleting nutrients and maintaining our stress-coping mechanisms. And so I think it's just a beautiful point for reflection that it's not necessarily all about the immune system. It's about really helping whole people, which is what we do in functional medicine.

Susan Haddow:
Thank you. That's what I like to think of it as too. We're just really trying to be very good whole people doctors.

Kalea Wattles
That's exactly right. Well, it has been such a pleasure to talk to you today. I think you've really highlighted for us things that we can do to take care of our health before we were to get any infections and then to support our bodies during an acute infectious time, and then really what we can do to support ourselves following an acute infection. So thank you so much for centering all of your insights around the functional medicine matrix and the functional medicine model at large, which is so helpful for us too, to make our mental model. It has been such a joy to talk to you, Dr. Haddow. Thank you so much for being with us.

Susan Haddow:
Thank you for your time too. Bye now.

Kalea Wattles:
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