Nutrition’s Role in Anxiety Disorders: Evaluating Mental Wellness

Kalea Wattles, ND:

Anxiety disorders are the most common mental health disorders affecting both adults and children, and associated panic attacks can come on quickly and feel distressing. Both anxiety and panic disorders may severely impair a patient's ability to function in life. While in some patients, mental wellness may be challenging to cultivate and maintain, clinical strategies that include nutrition interventions may have significant impacts.

Kate Henry:

There's a critical balance with nutrition where you can't be nutrient deficient; that's a story in its own, which we'll get to in a minute. But we tend to think a lot about the western diet being inflammatory or causing a lot of oxidative stress. That's true, but if you have enough antioxidants in your blood and you balance those, you can buffer a lot of the effects of the foods that you may be eating that are maybe a little bit more inflammatory. So I am always looking for, is this person getting enough antioxidants? Are they getting enough omega-3s? Are they getting enough of the nutrients that we know impact mental health?

Kalea Wattles: 

On today's episode of Pathways to Well-Being, we're talking with Dr. Kate Henry about functional testing, including testing for nutrient deficiencies that can help pinpoint the root cause of anxiety. We're so delighted to have you on the show. Welcome, Dr. Kate.

Kate Henry:

Thanks so much for having me. I'm excited to talk about this really important topic.

Kalea Wattles: 

Well, this is certainly a very important topic, and we know that anxiety disorders in the US are common, affecting approximately 40 million adults every year, and concerns about mental health remain elevated three years after the onset of the COVID-19 pandemic. In fact, 90% of US adults believe that our country is facing a mental health crisis. So I know this is an area where you really focus in your practice; do you find that more patients are coming into the clinic with the specific goal of supporting their mental health? Or are you asking about mental health during your routine wellness visits and kind of happening upon a need for support?

Kate Henry:

Absolutely, it's both, of course. So since COVID, there's certainly been an increase in the number of people who I think know they need to upskill around tools for managing mental health disorders or actually just eliminating their symptoms. And we know that based on the data, so at the height of COVID, 40% of US adults reported that they had symptoms of depression or anxiety that met the clinical threshold for diagnosis. Normally that number is 11%, so that was a huge increase. And as of last year around this time, that number had only come down to 33%. So it makes sense that we're seeing more of this. And we're seeing more of it come in, I think in part, because maybe we're getting a little more comfortable talking about it because so many of us are affected. However, I understand that it feels like a crisis, and that's borne out by the numbers too, because according to the American Association of Medical Colleges, we're facing a shortage of mental health providers. So at the same time, we have more of us than ever with these symptoms, we've got a shortage of the people who we would typically expect to be treating them, psychiatrists and therapists. For example, right now you guys live in a county, those of you who are listening, half of you don't even have a psychiatrist in your county available to see you if you needed one. And that shortage is gonna get worse. So we're going to, in the next 10 to 12 years, be short about 30,000 psychiatrists in our country. And so there's reason to hope, because there are other providers who can help with this, and this is what we're gonna talk about today. It takes a team approach. If you use nutrition, mindfulness, and general health principles, you can heal depression and anxiety. And so I want you to feel hopeful; while it feels like it's a lot, and maybe it feels like you said this word, Dr. Kalea, a crisis, there are so many things we can do. And that's what we're gonna talk about today.

Kalea Wattles: 

Beautifully said. Well, I think using the functional medicine model, we're really equipped to address those mental, emotional, spiritual concerns that bring patients into the office saying, "I need some support." So when you're working with patients in the clinic, what are some of the tools or techniques that you are using more in a primary care setting to help screen for and to diagnose mental health disorders?

Kate Henry:

Absolutely. So I think the gold standard in both the research and clinical practice is something called the GAD 7 questionnaire. And it's just seven questions asking about the symptoms of anxiety. Do you feel nervous and on edge? Are you irritable? Do you have trouble relaxing? Do you find it's hard to sit still? Do you tend to think on a loop, have a hard time with worrying or feeling afraid, like something bad might happen? And then we ask people to rate that on a scale. How often is it happening and how much is it impacting your life? Now that's one way, it's one way to screen for the typical symptoms of anxiety, but there are other ways. And part of that is by doing a really thorough intake, which you guys at Institute for Functional Medicine teach so well. So in the practice that I helped to found, we make sure that we're doing a very in-depth intake, symptoms, head to toe, history, birth until now, and we do an 80-data-point nutrient analysis of people's diet. So we catch everything, because our job is to help treat the root cause of mental health disorders. And finding the root cause requires a medical detective approach, which means you need all the clues in front of you to do that. So our intake is designed to do that. So we're not just relying on one questionnaire, but we're looking at the whole person. The last thing that we'll do is have people take something called a brain health assessment. What it's screening for is symptoms associated with differences in blood flow and metabolic activity in different parts of your brain. And that can be really helpful for our clients who come in already knowing they have anxiety but not knowing why and maybe feeling some shame about it. I think a lot of our clients hesitate to have conversations about mental health issues because they feel like it's based in their personality or their willpower. And if we can say something to them like, "Here's a part of your brain that seems like it has more activity, and here's what we're going to do to fix it," they tend to feel really hopeful.

Kalea Wattles: 

Well, I love that you highlighted the beauty of a functional medicine intake and how comprehensive it is, looking at all of our body systems, looking at our modifiable lifestyle factors, and then, of course, adding this layer of a laboratory investigation, because we know that a patient's lifestyle factors and their clinical imbalance areas, that can really help to direct our treatment plan and make it more specific and more precise. Of course, we need to talk about labs. I've been waiting for this moment to talk to you about some labs. Are there some functional medicine labs that are your go-tos in your initial investigation to help find those root causes of anxiety and panic attacks?

Kate Henry:

Absolutely, guys. And so if you're a functional medicine doctor listening, these are gonna sound pretty familiar to you, which is why there's so much hope for other providers like functional medicine docs, like nutrition experts to come in and do this type of testing and this type of mental health treatment and assistance. So there are four major categories of root causes when it comes to anxiety disorders—oxidative stress, nutrient deficiencies, hormone imbalances, and immune dysfunction. These are the leading edge of functional medicine where we're starting to understand that if somebody has a chronic health condition, focusing on these four areas can really move the dial with their health. So that's where we start our investigation. So of course we do the basics, which just because they're basic doesn't mean they're not powerful or profound. CBC, CNP, lipid panel, just screening for does the person have anemia? Do they have immune system overactivity? And in fact, when we do a lipid panel, we're looking to make sure the person has enough cholesterol. You'll see with one of our case studies later that low cholesterol is actually linked to psychiatric dysfunction. And so cholesterol under 160 is a red flag for us that maybe something is up with someone's liver or digestion. So we're gonna do the basic screenings, everything your primary care would do at home, but then we're also gonna screen for levels of oxidative stress and inflammation. So looking at things like hs-CRP, ESR, F2 isoprostanes, and we're checking for something called total antioxidant capacity. And we can check for that two ways, either in the blood or in the diet. We'll get into that a little bit more in the nutrient section. With hormone imbalances, I know you talk about this a lot, Dr. Kalea, but really looking at DHEA, cortisol, testosterone, we know cortisol levels are abnormal in people with severe mental health conditions. So starting with those basics and then looking at estrogen and progesterone in somebody who's cycling is also important. And then immune dysfunction. So not just like screening with the CBC and ANA, but also for looking for things like food allergies and environmental allergies and high histamine is critically important for people with anxiety because histamine will change the way someone breathes, and hyperventilation is a major component of most panic attacks. So those four pillars—oxidative stress, nutrient deficiencies, hormone imbalances, and immune dysfunction—that's where we focus our testing beyond the basics.

Kalea Wattles: 

Wow. I feel so aligned with what you're saying because like you mentioned, I talk about these very similar pillars for cultivating reproductive resiliency. And I always say the things that we do to support our fertility really extend beyond into reducing our risk for cardiovascular disease, for Alzheimer's, for all of these chronic diseases, and I think our mental health is so intertwined with all of those factors. So this is really about health promotion and cultivating that resilient health from the ground up. So that was very beautifully said, and you mentioned that there's this nutritional component, and we have some cross-sectional and longitudinal studies that suggest that routine consumption of what we might call a western-type diet that includes many highly processed foods can increase the risk for developing symptoms that are associated with anxiety. So my question to you is, how can poor nutrition, or really a lack of nutrient density is maybe a more specific way to say that, how can that increase our risk for generalized anxiety disorder and for panic attacks?

Kate Henry:

I'm so glad you said that the way that you did. Thank you, lack of nutrient density. One of the things, it's funny, when people come in with anxiety, they're already anxious, and part of what they're anxious about is that they're eating too much of the wrong things. They're like, "I know I eat too much pizza or treats." And frankly, what I'm actually concerned about is that they're not eating enough of the right things. So there's a critical balance with nutrition where you can't be nutrient deficient, that's a story in its own, which we'll get to in a minute. But we tend to think a lot about the western diet being inflammatory or causing a lot of oxidative stress. That's true, but if you have enough antioxidants in your blood and you balance those, you can buffer a lot of the effects of the foods that you may be eating that are maybe a little bit more inflammatory. So I am always looking for, is this person getting enough antioxidants? Are they getting enough omega-3s? Are they getting enough of the nutrients that we know impact mental health? For example, 95% of US adults do not consume enough vitamin D each day, now this is according to the CDC. We know that supplementing vitamin D, 1,600 milligrams a day for six months, significantly improves anxiety symptoms. Now this is a nutrient, the top source of vitamin D in the diet is cod liver oil, and then next is trout, and next is salmon. So if you think about it, it might make sense why many of us are deficient, but starting to screen for these nutrients that we know impact anxiety is really, really critical. And we always focus on the ones that we know most Americans are deficient in anyway. So looking at things like vitamin D, many Americans are deficient in the antioxidant nutrients. So let's take a step back. We talk a lot about oxidative stress and mitochondrial health in the functional medicine sphere. I'm seeing Dr. Kalea smile. If you are listening, she is nodding her head. We are in alignment here. So when we measure total antioxidant capacity of the blood, which is how good are you at quenching oxidative stress and inflammation? And for mental health, this matters so much, cause the brain is an oxygen-hungry organ. Our brain consumes 20% of our oxygen, and it's highly metabolically active, which means it's producing a lot of oxidative stress as a byproduct, a lot of oxidants. And so we need a lot of antioxidants to keep our brain healthy while it does those things. And so things like vitamin E, vitamin A, vitamin C, and zinc are considered some of our top antioxidants as well as some other biomarkers like HDL cholesterol for example. So 84% of Americans have an inadequate intake of vitamin E, 45% have inadequate intake of vitamin A, 46% inadequate intake of vitamin C, 15% deficient in zinc, the list goes on. So we are always screening someone's nutrient content of their diet when they come in. There's a couple ways to do that. We do an 80-data-point nutrient analysis based on at least 24 hours of dietary recall. So you come in, we analyze your diet, vitamins A through K, minerals calcium through zinc, exactly how many milligrams are you getting per day on average. We're also looking at how many omega-3s, how many amino acids, how much total energy. Cause the other thing that plays a huge role in nutrition and mental health is that many people are not eating frequently enough, they're getting hypoglycemic, and it's contributing so much to their depression and anxiety and they haven't put it together yet cause maybe they're not monitoring their blood sugar, maybe they're even trying to cut back on what they eat. And when we normalize their blood sugar and give them a nutrient-dense diet, they heal. And we have evidence later in the podcast for you guys; we're going to show you how this works in real life.

Kalea Wattles: 

Okay. There's a couple things I want to go back and unpack a little bit, but I think this last point that you just made is so important that low blood sugar can feel like anxiety. You get shaky, you get sweaty, you don't feel well, and it's so easy to confuse those two states.

Kate Henry:

Absolutely.

Kalea Wattles: 

The other piece that I just want to highlight because you made this point so beautifully, I think we have a tendency to villainize oxidative stress. But you just told us our brain being metabolically active, which we definitely want it to do, is going to generate some oxidative stress. And this is normal, this is totally healthy in a body that has enough antioxidants, as you said, to quench all of those reactive oxygen species. So I think that we just can start to build this awareness that oxidative stress is not necessarily the bad guy, and we want to do this additive approach of adding these antioxidant nutrients, just like you described.

Kate Henry:

People feel so free, I think, when we focus on getting enough or getting more, because so many people, at least in America, feel like their whole life they've been taught to eat less. Eat less, avoid this, cut that out, so many people come into my clinic feeling afraid. They're like, "I can't eat GMOs or dairy or lectins or gluten." And I'm like, "What are you eating?" We really reeducate people and empower them when we focus on the micronutrient content of their diet because it takes away the judgments, it's pure data, which sounds boring, but most of our clients love it, and they actually get pretty competitive with it, where they're like, "I'm going to get 100% of my B6 today." And it leads them on this journey of discovering true health. Most people don't understand that you need B6 to make all of your neurotransmitters, serotonin, dopamine, GABA. The top source of B6 is garbanzo beans and then beef liver. And you'd have to eat like a cup of those a day to get enough, so that's the reason it's the number one nutrient deficiency in the US. So are we surprised that we have a mental health crisis when 11% of our population is frankly deficient in the co-factor they need to make serotonin, dopamine, and GABA? I'm not. I don't think anybody should be surprised, but that means there's so much hope, because when you correct the underlying broken biochemistry and correct the nutrient deficiency, people just start to heal. Their biochemistry starts to work, and they thrive.

Kalea Wattles: 

Right. I know all of our listeners have now heard you talk about this 80-point nutrient evaluation that you're doing, and they're probably thinking, "How is she doing that? Is this something I can do in my office?" Are you working with a nutrition professional? Will you give us the scoop on how you're conducting that evaluation?

Kate Henry:

So we use the software called Cronometer in our practice, and our RDs do the nutrient analysis. Naturopathic doctors do this as well in our practice, and so any nutrition professional can use this software. And in fact, if you aren't a professional, you can use this at home for free. Now, caveats here, don't track your nutrients if you have a history of an eating disorder or if you tend to get kind of hyper-focused. I would recommend going to a nutrition professional who can actually use this software to empower you and give you data. But in the same way that the CDC runs studies on our population by doing 24-hour dietary recall, so they'll say, "What'd you eat yesterday?" They plug that into the nutrient analysis software, and it will give you a nutrition label of your diet. So it'll say, this is how much B1, B2, B3 that you got, vitamin A, D, E, K. This is how much calcium, magnesium, iron, zinc. This is how much protein, how many omega-3s, how much fiber, how much total energy. We give people that 80-data-point printout the first time they come in for the visit, and we say, “Here’s where you are, here’s where we’re going to get you.” Now for people who it’s safe to track, we have them track long-term, even if it’s one day a week. And so we start to gather data long-term about their consumption of these nutrients. In my opinion, this is what’s really missing in our field, and what I’m really excited that we’re going to start to do better, because a lot of times, so many of us jump to testing right away. We go like, “Well, I’m just going to test all of your nutrients.” The patient walks out of the visit with $300 worth of testing. And for me, that immediately stopped working in clinical practice, because so many of my clients had anxiety, and it would take them three months to go get their blood drawn, because they were afraid of needles. So knowing that there's two ways to assess nutrients, one is intake, the other is blood, we always do both, because that's where you get the most data. And I can't tell you how many people we've found gastrointestinal disorders in who didn't have a ton of symptoms, but they were consuming enough nutrients and they were super-nutrient deficient. And so this is a really amazing clinical tool that people can use in their practice and at home. And so I highly encourage you guys to do this.

Kalea Wattles: 

Super helpful. So it sounds like you're really utilizing a thorough, that comprehensive intake that we've talked about. You are having patients track what they're eating at least for some amount of time so that you can do your evaluation. And this is the perfect lead in because I really wanted to ask you, if testing isn't available for someone, are there aspects of the patient's history or maybe a physical exam? Here at IFM, we teach the nutrition-oriented physical exam. Are there some clues that you can use to help identify potential nutrient insufficiencies without doing testing?

Kate Henry:

Absolutely. And I think for a lot of us, it's before testing. Because again, it could take your client a couple months to go in and get the labs that you want drawn, so it's always such a good place to start. So yeah, absolutely. So let's take a step back. I think a lot of doctors feel comfortable saying, "I could identify a root cause of anxiety if it's a thyroid condition." Most docs in med school are taught about hyperthyroidism. It can cause anxiety, so you're going to do a thyroid exam, and you're going to look at someone's eyes, for example. If they have super dry skin, if they're jittery in the office, you're going to want to check not only for the person's thyroid levels but also urine metanephrines. You want to look at the person's nails. Do they have ridging along their nails? Do they have signs of an omega-3 insufficiency, which is like super dry skin? And even eczema can be associated with this. I am so passionate about this link between two things. We talked about the four categories, so thinking about nutrient deficiencies and oxidative stress. But the other parts of the physical exam that are so important are looking for evidence of hormone imbalances and immune dysfunction. So looking at someone's waist-hip ratio. If they're in a female body, looking for signs of PCOS, cystic acne, hair growth, hair loss, like hair growth on the face, hair loss on the scalp, looking for signs of adrenal dysfunction, losing the outer third of their eyebrow, for example. You guys teach this so well and are keeping this art of a physical exam alive, which I'm so happy about. And so the last aspect of this with immune dysfunction is what I really want to hammer home for folks: check for signs of allergies. So rashes, hives, post-nasal drip, sinus tenderness. Histamine is such a major component of the hidden causes of anxiety, and we are not doing a good job screening for it, certainly not in mainstream psychiatry, but also, we're not putting together the dots a lot of times in primary care, and this is why these clients have had anxiety for years. They finally come to a functional medicine doc and get healed. But we need to start screening for allergies earlier in anybody with a history of anxiety. So including those in physical exam is vitally important. The other aspect I'll throw in here, doing a good cardiac exam and taking blood pressure. So much of anxiety can be linked to hyperventilation, but also checking to make sure that your client is not getting hypotensive and having these episodes where their blood pressure is dropping maybe in response to an allergen and they're having a hyperventilation reaction and it feels like a panic attack, but it could just be their immune system. I really encourage our docs at Sanare to do a very thorough exam that includes those aspects. So we always do head to toe for everyone, that's a given, but focusing on those areas is critically important.

Kalea Wattles: 

Good. It's so fun to talk about making all these connections. I think this allergy component, you're right, I never see anyone talking about this, so that is an excellent takeaway from this episode already. And I also just want to echo how wonderful it is to keep hands-on medicine alive, keep the physical exam alive and well, because there are so many pieces that we can uncover as we become medical detectives, like you said at the beginning of the episode. Well, Dr. Kate, I have been so excited to see the emergence of the field of what we might call nutritional psychiatry, which I think is really connected to everything you've been talking about in this episode. It really describes this relationship between our diet quality and our mental health. And it considers the use of some dietary and nutraceutical interventions to help to address those mental health concerns and potentially improve patient outcomes. You've mentioned several nutrients that you're looking for when you do utilize testing, you've talked about vitamin D, you've talked about doing an omega check, screening for iron status, are there any other nutrients that we should highlight, we really want to think about analyzing in a patient that has a history of anxiety?

Kate Henry:

Totally. I think all of the minerals, including magnesium. So most US adults get about 290 milligrams of magnesium per day, the recommended amount is 350 to 450. Magnesium is one of our most calming nutrients. You can check it using a red blood cell magnesium. And we have really amazing evidence that supplementing magnesium helps people with anxiety. And let me add this point: so much of our research has not focused on women in particular phases of their menstrual cycle. And so there's an incredible paper, which I will make sure you get after this, Dr. Kalea, if you want to put this in the notes. But they studied a couple different interventions with magnesium, and they found that it was most effective in the premenstrual phase of someone's cycle for relieving anxiety. And so part of what we need to do in the research is get a bit better about parsing out when certain nutrients help people. Any B vitamin, pick one, impacts the nervous system. We know that, for example, checking for homocysteine, which at very high levels is neurotoxic, is a really amazing part of a good workup for anybody with a neuropsychiatric condition. So when you check for homocysteine and methylmalonic acid, that that can give you a pretty good idea about someone's folate and B12 status long term. B vitamins are water soluble, which means you consume them and they wash out. They don't tend to stick around for a long time like the minerals, like the fat-soluble vitamins A, D, E, K. Those are easier to measure in the blood, and they're more reflective of whole-body status. B vitamins fluctuate. And so what we do instead is we look at things like homocysteine, methylmalonic acid to tell us, does this person have enough B12 and folate long term? So I would add that those are critically important. I want to talk more about omega-3s if you would like. Promise me we'll circle back. I'll skip over that for now. The other thing I think is important and that doesn't get enough press is vitamin C. And so whether you choose to measure that in the blood or you choose to measure it in the diet, I think it's worth measuring. It's the fifth most under-consumed nutrient in our country according to the CDC and the NHANES study. And there's a couple amazing studies where just 500 milligrams a day for two weeks significantly reduced anxiety. So it's a very safe and food-based intervention. So measuring that is an awesome way to have a profound effect while getting someone better nutrition.

Kalea Wattles: 

Ooh, I love it. And I'm just so excited to hear you talking about adjusting your treatment plan during different menstrual phases; that is precision medicine right there.

Kate Henry:

It also helps you maybe not use magnesium every day. So part of what we talk to people about is, when are you most anxious? And if you have an infradian rhythm that's 28 to 35 days versus a circadian rhythm or along with your circadian rhythm, we can time things so that maybe you don't have to take your magnesium or eat your pumpkin seeds, which are the top source of magnesium, every day, but maybe you do it for the week or two before you start menstruating. And that just feels a lot easier and a lot more doable I think to folks, and it is so much more precise, which is just better medicine.

Kalea Wattles: 

Well, and something that's emerging for me as I hear you talk about this is, when we start to pay attention to those patterns, it also results in this body awareness that I think is so beneficial for so many reasons. And when someone starts paying attention to, “At this phase in my cycle, I feel this way,” wow, that really opens up a whole opportunity for some really devoted self-care right when you need it.

Kate Henry:

Absolutely. And we'll talk about this nutrient in a minute, but probably the nutrient that best exemplifies this time-based supplementation is inositol, which is my number one intervention for panic disorder. So we will get back to this, but I see Dr. Kalea nodding because I feel like yes, you have probably talked about this a lot in your practice.

Kalea Wattles: 

We're going to loop back. I'm not going to forget omegas and inositol; it's on the list. And maybe this will naturally emerge, because I wanted to talk to you about a case from your practice. You've already taught us throughout this episode that a balanced diet that includes vegetables and fruits, those brightly colored rainbow foods, healthy fats, lean proteins, that can help to bolster mental wellness and really help us to manage those daily life stressors. I wanted to talk about a case from your practice, a 30-year-old female named Libby who had some anxiety disorder symptoms going on. Will you tell us a little bit about what brought Libby into the office?

Kate Henry:

Absolutely. And it's so interesting that Libby came in when she was 30, cause the average age of diagnosis with GAD or generalized anxiety disorder is actually 31 years old, which is a bit late compared to when we're seeing people typically diagnosed with mental health disorders. So guys, if you recognize yourself in Libby's case, you are not alone; in fact, you're probably in the majority. Libby came in at 30 years old, and part of what brought her in was she knew she got anxious, she had generalized anxiety, but she also tended to get panic in situations where she was the center of attention or stuck, and she was going to get married in six months. And she called me up and said, "I need to get this under control because I cannot have a panic attack when I am walking down the aisle." I said, "I got you, let's go." So we started with a very in-depth test panel, nutrient analysis, and intake as you've already heard me talk about. But part of what we ran for Libby in her blood work was CBC, CNP, we did a thyroid panel, we looked at her lipids, including cholesterol, iron panel, and a micronutrient panel as well. Now this was in COVID, so we were really blessed that she was able to collect a lot of these either at home or locally. Additionally, we did a nutrient analysis of her diet, which we do for every single person. And so part of what we found for her was that thankfully, she was not anemic, she didn't have issues with her cholesterol, her white blood cells, or red blood cells. She was low in copper, low in manganese, and low in chromium. The hack here guys, I guarantee you, there are 35 million papers on PubMed. Pick any nutrient and type in anxiety disorder, and you're probably gonna find a study that suggests that if people are either high or low, normalizing that nutrient in their blood and in their diet helps with anxiety. Why? Cause the brain is an organ; it's run using biochemistry and nutrition. So most nutrients have evidence for impacting anxiety. For Libby in particular, we were able to replete her with these nutrients really easily with diet and a multivitamin because we chose a multi that had all of these in it, which was really easy. Another way to hit the easy button. I will add here, I wish we had checked her for allergies sooner. We did not include a total IgE or allergy panel, and we should have, but that's what we did for her. Some of the nutrient interventions that we did, we lowered the amount of caffeine and alcohol she was consuming. She had a lot of histamine symptoms. You guys can read this whole case over at the Rupa Magazine, but I'm gonna go through the bullet points for you. A lot of histamine symptoms, she wasn't eating breakfast, consuming a lot of caffeine, and so we put her on a low alcohol, low caffeine, low histamine plan. Now low histamine plans are very tricky. I'm very proud of the way we do this at our practice because we make sure they're nutrient replete, they're easy to consume and people are getting enough nutrients. I think low FODMAP and low histamine plans have the potential to be really restrictive. And so anybody at home who's thinking of trying this on your own, please don't, instead see an RD or functional med person who can help you, a practitioner. That's how we have success with these plans. So that was the workup we did was looking at her diet and her blood. Do you want me to move into interventions?

Kalea Wattles: 

We definitely need to know what you did to help Libby, please.

Kate Henry:

Okay, great. So if you're recognizing yourself, guys, what I want you to hear first is so much of Libby's workup was normal. And so many clients come in being like, "Ugh, I have anxiety, but my doctor told me all my labs were normal." There are still things you can do. Here's what we did for her. First things first, anybody with panic attacks who's in a female body and has GAD is usually getting put on an inositol powder from me, particularly if they've got menstrual issues. So inositol is one of our best studied interventions for generalized anxiety disorder and panic attacks. In fact, it's been studied to be more effective or as effective as SSRIs for reducing anxiety. It has almost no side effects, it has no toxic dose. It used to be considered a B vitamin isomer; now we think it's a glucose isomer. We still can't really figure out what it is in nutrition; we just know it's safe and that it's a nutrient. And so I find people get so much relief so quickly when they start to supplement inositol and make sure that they're replete. Put her on a comprehensive multivitamin that had 26 nutrients, including the ones that she was deficient in in her diet. We designed a diet that was nutrient replete. So we knew every day, she was gonna eat foods that she loved but that hit all of 100% RDA for vitamin D, vitamin E, all the antioxidants, the things we know heal mental health disorders. And she worked really hard with our RDS to do it in a way that she didn't even notice. So she gets to eat like a protein muffin in the morning. We know it secretly gets her 100% of what she needs for that meal, but she just knows she's eating like a delicious chocolate protein muffin. We gave her omega-3s. Now we measure people's dietary consumption of omega-3s to determine how much they need to supplement. So if we can get them enough chia seeds and flax seeds and salmon to hit three grams a day, they’re good to go, they don’t need to supplement. If we can’t, we’ll throw in a supplement. I don't know how you feel, Dr. Kalea, but I have yet to see omega-3 supplementation under 1,000 milligrams to do anything for anyone’s mental health long term. They need to hit at least 3,000 milligrams a day or three grams a day total to start to see results. And this is borne out in the research. We can see that three grams of omega-3s for three months will cut anxiety levels by two-thirds and at the same time, anger levels by two-thirds. Right? Which shocks most people, I think people think of anger as like a choice or emotion that they have no control over. In fact, omega-3s can really help with that. Last thing, because Libby was getting low blood pressure, we put her on some licorice root tea. We gave her some GABA at night to help her sleep; she was having a little bit of insomnia. And we fixed her gut, we did a gut healing protocol with her. She's doing a little bit of glutamine supplementation at night and a little chocolate drink. And we did a ton of mindfulness. So biofeedback, autogenics, mindfulness training to give her the tools she needed to manage these symptoms if they popped up. That was her major fear, "What do I do if I start to get anxious going down the aisle?" So we gave her all the tools to manage it if she did feel anxious, and then we did the hard work of getting rid of the underlying anxiety.

Kalea Wattles: 

Wow. You really put together the all-star treatment plan for Libby. So as you're implementing all of these changes, I think a common question that comes up is, how long do I need to do these things before I start to see some benefit? How do you set that expectation with patients right at the beginning of their healing journey?

Kate Henry:

It depends how sick they are, how long they've been sick, and how complex their case is. But generally with anxiety and particularly panic attacks, it takes under a month, which I'm really proud of. Libby's wedding was six months from when I started working with her. She had no panic attack going down the aisle; in fact, she felt really relaxed. She also was having other issues like yeast infections, hypotension, fatigue, frequent urination, brain zaps that we picked up as part of her intake; those also resolved during this time. And so that all, we did a recheck for her on her symptoms six months later, and so that's the data we have. However, I know she got better much sooner. And you'll see with our next case study, she got better in under two months.

Kalea Wattles: 

Amazing. I have to loop back to inositol because you highlighted this one as one of your favorites. This is one that I really love too, and I use this often for sleep. So I'm just wondering if you dose it similarly to how you do when someone is needing sleep support. I'll dose it at night, but for someone that's having anxiety or panic attacks, are you using inositol throughout the day as well?

Kate Henry:

All day, every day. Yep. So we tend to have them, actually for panic attacks, I find the powdered form works the best. So I have them put the powder in their water, they drink it throughout the day, all day, every day. They can use a little bit episodically if they feel like they're going to get a panic attack, they can use a bit more. And then the goal is to eventually wean them off. So they're going to do maybe a tablespoon of myo-inositol blend in their water, in 32 ounces of water twice a day. Slowly, we're going to walk them down. And again, it depends on like the person, what else they have going on, how you're going to dose this. But definitely during the day, I have not seen it work for generalized anxiety disorder when you only do it at night.

Kalea Wattles: 

Well, I feel so excited about the outcome with Libby and so compelling to hear you say there, you have not yet found a case of panic attacks that you haven't been able to address. So let's give another example, because I know you have another really great case to talk about. And this is Mary, a 21-year-old female who presented with anxiety, and she was having panic attacks while she was driving. So tell us a little bit about Mary.

Kate Henry:

Mary was doing everything right. So Mary had been in therapy for a really long time, she was using all the tools. She was basically a therapist herself, like she had read every book, and she was just tired of the struggle. She just came in and she said, "I want this gone. I don't want to have to fight off a panic attack every time I get in the car. I'm doing everything right. Now it's your job." Which is the exact time we want to see people, right? We're like, "Yes, give us your data. We will fix you." So with Mary, you'll recognize a lot of labs we ran, same things we covered in the very beginning of the episode. So looking for nutrient deficiencies, oxidative stress, hormone imbalances, immune dysfunction, so CBC, CNP, lipid panel, thyroid panel, looking at her hormones, urinary iodine, cause she had a family history of thyroid issues, urine metanephrines, food allergies and sensitivities, ANA. We also checked her hair for lithium. So I am a huge fan of Dr. James Greenblatt. I don't know if you've had him on here yet. He's a psychiatrist who is doing a really amazing job at incorporating integrative and functional practices in psychiatry. I encourage everybody, he has tons of free content; please go follow him. But he is who I learned about the abundance of research on lithium. And low levels of lithium in the hair can be associated with psychiatric, neurodevelopmental, and heart disease. So we screen for those sometimes if somebody has either a few of those disorders or some of them. And then we also, for Mary, ran an EKG for her, because her T4 came back high and she had positive ANA, her mom had Graves. So for anybody who's not medically trained, Graves can cause hyperthyroidism, which can result in anxiety. So we wanted to make sure that she was safe while we sent her to rheumatology and endocrinology to get a bit more worked up. Her T4 wasn't crazy high, but it was high enough for me to start to suspect that that might have been an issue. We also checked her nutrients, and she had suboptimal zinc and she had some food sensitivities. And so we also looked at a nutrient analysis of her diet, and she had low intake of pretty much all the B vitamins, vitamin C, D, E, K. She didn't get enough zinc, calcium, copper, iron, magnesium, you name it. And this is common, guys. You might be listening to this thinking, "Okay, well this person wasn't getting enough nutrients, but I am." This inadequate intake of these nutrients is the rule. I have yet to see someone come in getting 100% of the nutrients they need in a day in America. So you're listening to this and you're hearing about Mary; you may be just like her.

Kalea Wattles: 

I'm struck with the lithium piece because I think that one, it's not super common. Many of us wouldn't think of that. You mentioned that you're not ordering this on everyone, but maybe if they have a history of heart disease or they have this symptom picture, you might actually look into that. And so tell us a little bit about how you move forward in your treatment of Mary.

Kate Henry:

Absolutely. So what we did for Mary was, again, what we do for everyone, and this again, this might sound boring, but making sure that someone has a nutrient-replete diet is the most powerful type of medicine you can do for them. Food is what heals; the body heals itself when you give it the right ingredients and get out of its way. And so that's what we do, and we work really hard to do that. So our RDs met with Mary, we figured out that she and her family really needed to have Oreos every day, so we included those in her diet, just gluten free, I think, cause she was sensitive to gluten. And we made sure that she was really excited about starting to consume more protein and B vitamins, cause she was so low in those. So we built our nutrient-replete diet and then we supplemented around what she wasn't able to consume. We did biofeedback with her. Her heart rate variability was very low when she started with us. And so we did some in-office heart rate variability training, which we can talk about more if you want. We also gave her an inositol, we gave her omega-3s and a multi, so very similar to Libby. But we also, because Mary was getting migraines, we gave her a combination of feverfew that had the PAs removed to reduce the risk of liver damage. So this was a safe supplement with feverfew and butterbur, excuse me, magnesium, CoQ10, riboflavin. And so she took that for two months. She also took some GABA support at night cause she was having a hard time sleeping. And then she took lithium orotate for a month or two at night as well. And this was all while she was waiting to get into rheumatology and endocrinology to work up the ANA and the high thyroid levels that we found. And in the meantime, she got better. So before she even made it to those specialists, cause there's such a long wait list, particularly in our area, her panic attacks, migraines, and stomach issues, which we didn't even cover earlier, all of those got better. And she's now out living her life, working, socializing, having the best time. And she has stayed in remission since then. So this has now been probably about a year and a half that she's been panic attack free.

Kalea Wattles: 

And she's driving. She's driving and she's feeling good and she's out there living.

Kate Henry:

She's driving all over. It's amazing. This is what it means to set someone free. This is why functional medicine is so awesome, all types of medicine. But functional medicine, I think, when we set people free, we empower them to go thrive and then they heal the world. And that's why I'm so passionate about what we do has such a big impact because now she's helping other people rather than being stuck at home. She's full of joy and she gets to spread that joy throughout the world, and that's the medicine our world needs. So that was the small part we got to play in that.

Kalea Wattles: 

Yes. And her case is now informing all of these learners. Will you just really quickly go back to the lithium orotate on her treatment plan because combined with her hair lithium, I think people might be wondering, "Wait, what is that and why did you add that?" Will you just briefly describe why that was added to her treatment plan?

Kate Henry:

Totally. So lithium is a nutrient in the soil, and in America, it tends to be deficient in our soils. Now most of you have heard of lithium maybe as a medication. So lithium carbonate is sometimes used as a medication for people with bipolar at levels like 1,300 milligrams, very large doses. Instead, we gave Mary lithium orotate at 20 milligrams, very, very teeny tiny dose in the nutritional form. So we were just helping replete her a bit of this nutrient that we know is very calming and helps to stabilize electrical activity in the brain. And we give it to people for a short amount of time because your body will store lithium, so you don't need to take it usually the rest of your life. You just take it usually for a month or two, sometimes more. And then oftentimes we'll recheck hair. Blood lithium is not a good indication of lithium stores. It's a really great way to monitor lithium medication because we're dosing that so high, you can see it show up in the blood. You can't really monitor nutritional lithium in the blood, and so that's why we tend to look other places for that.

Kalea Wattles: 

Thank you so much. That's a really helpful clarification. Dr. Kate, you have shared so many gems and insights, and we've learned so much from both Libby and Mary's case. As we wrap up today's episode, what can functional medicine clinicians take away from this conversation to inform their approach to anxiety disorders and panic attacks? I'm sure they're feeling inspired. What's your take home message?

Kate Henry:

You can do it. So you guys are qualified if you are trained in medicine or nutrition to help people with mental health disorders, including anxiety; and in fact, you must. We have a shortage of psychiatrists, and 60% of people currently get their mental health care from a primary care provider in the United States. We need all of us, and you are equipped to help. So by focusing on the four pillars, oxidative stress, nutrient deficiencies, hormone imbalances, immune dysfunction, you can help someone heal an anxiety disorder. We gave you proof today. I want to empower you, go do it.

Kalea Wattles: 

What an amazing call to action to end our episode. Dr. Kate, thank you so much for spending time with us and sharing your passion for supporting mental health. It's been a pleasure to chat with you.

Kate Henry:

Thanks for having me.

Kalea Wattles: 

To join the conversation on this topic, visit IFM's pages on Facebook and Instagram. For more information about functional medicine, visit IFM.org.