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The Float Zone (local to us, but have great educational info about floating as well)
In this [long-awaited, yet very timely] podcast episode, Dr. Hartman addresses the third pillar of the foundations of Functional Medicine: Stress & Relaxation. What is stress? How does it affect our health, and is it an issue currently in our culture? What are some new scientific insights that are helping us understand the importance of stress on our health, and what can we do to utilize these new insights to optimize our health? Listen in for answers to these questions and lots of resources to help you manage stress and anxiety effectively.
Related Reading: Mitochondria Food Plan Diet
Host [00:00:08] Welcome to Foundations of Functional Medicine with Aaron Hartman, M.D. This is a podcast of Richmond Integrative and Functional Medicine. This podcast seeks to motivate individuals to reclaim their health through education, encouragement, and empowerment by reviewing the basic tenets of Functional and Integrative medicine, as well as discussing new advances shaping the future of healthcare in our country. To learn more about us and keep up to date on other important health-related topics, visit us at www.richmondfunctionalmedicine.com.
Host [00:00:43] The following discussion is for educational purposes only and is not intended to diagnose or treat any disease or disease process. You should always discuss any medical treatments or interventions, as well as changes in your health, with your personal physician.
Dr. Hartman [00:00:58] Stress is something we hear about on a daily basis. “I’m stressed about work. I’m stressed about school. I’m stressed about this versus that.” The term is almost used so much that it no longer has an accepted meaning. Stress is whatever you want it to be. But what is stress? How does it affect our health, and is it an issue currently in our culture? What are some new scientific insights that are helping us understand the importance of stress on our health, and what can we do to utilize these new insights to optimize our health? According to the CDC Report in 2012, life expectancy in the United States was its lowest it has been in a decade, and stress is thought to be the underlying cause for this. According to the American Psychological Association, up to 63% of the Americans surveyed are stressed. Well, what are we stressed about? The future of our country, money, work, the current political state, climate, school safety, our children’s education, social media, and technology.
Dr. Hartman [00:01:57] There is also the new emerging field of study in mind, body, and medicine called the Psycho-Neuro-Endocrine-Immunology. So, what does this mean? Psyche is our mind. Neuro- is our neurological system. Immuno- our immune system, and endo- our hormonal system. So, in this field of study, which you can now study at a Ph.D. level, we learn how our mind, the psyche, affects everything else: our nervous system, our immune system, our hormones, and how all these systems interact with each other.
Dr. Hartman [00:02:28] The word stress is a relatively new word to the English language. Hans Selye is the endocrinologist who coined the term in the 1950s. This is the definition of stress: “Stress is an adaptive metabolic response to an actual or perceived environmental, emotional, and/or psychological threat that results in an adaptive self-regulation. Let’s walk through this definition and discuss each part briefly.
Dr. Hartman [00:02:53] Adaptive: stress is actually good. Our body adapts to external stimuli in a response to them in a fashion that we don’t become dysregulated, and we can continue with our lives. Dr. Robert Sapolsky talked about the natural stress response in animals and uses the zebra as an example of how we are supposed to respond to stressors. After being chased by a lion for 45 seconds of sheer fright and anguish, the herd of zebras goes back to grazing carefree. While, at the same time, their unlucky comrade is being eaten in the background. That is some hardcore adaptation. After the stressful life-threatening event, all goes back to business as usual.
Dr. Hartman [00:03:32] Metabolic: a metabolism or our stress hormones are metabolic regulators are always influx based on our internal and external environment. So, for example, cortisol goes up first thing in the morning upon waking. Epinephrine and norepinephrine, also known as adrenaline, will shoot up with sugar fluctuations in our blood. When we eat, insulin rises as glucagon goes down, and when we have fasted for several hours, our glucagon level rises to maintain our body’s steady-state glucose level. Elevations in epinephrine increase our heart rate and slow down our GI tract while the arteries serving our muscles dilate to increase blood flow to them in preparation to run. These are just a few of the constantly-changing metabolic functions our body does on a second-by-second basis to actual stress like say a threatening person coming towards you or perceived stress like let’s say the job interview you’re about to walk into.
Dr. Hartman [00:04:29] Response: This is what the body does; it responds, and the response is metabolic. This means that it occurs at the level of the cell, so when you feel threatened, and your heart starts to race, the end organ of the heart may be beating fast, but it’s the downstream effects of cells changing the metabolism. Many times, you don’t feel the response because it might not directly lead to sweat, increased heart rate, but instead might lead to decreased digestion capacity and altered neuro transmitters. These are brain chemicals.
Dr. Hartman [00:04:58] Perception: This is the process of getting and interpreting, selecting, and organizing sensor information. It includes the collection of data from sense organs and food to the interpretation made by the brain. The sense organ could be nerves in our stomach, cold receptors in our skin, or the brain’s interpretation of an ongoing or different event that happened to us years ago.
Dr. Hartman [00:05:20] Environmental, emotional, psychological threat: a threat that results from stress can be from a whole host of different sources. All matter and all are important. Our tendency to minimize a threat because “It’s all in your head” is a grave misunderstanding of what a threat is and how our body responds. The reality is that everything is in your head. Everything outside of your cranium is just sensory input. Understanding of this is revolutionizing how you look at things from chronic pain to cardiovascular disease.
Dr. Hartman [00:05:52] Self-regulation: This is the goal to maintain balance. The biologic term for this is homeostasis. For your body to stay in homeostasis or a state of balanced self-regulation, everything needs to be working appropriately. The control center of the brain needs to interpret correctly all of the incoming data and then send out the appropriate response to the heart to speed up or slow down for the body to maintain its temperature either by shifting blood to the skin to cool off or away from the skin to keep warm. Ultimately, this filters down to the powerhouse of the cell, the mitochondria. They need to know how much energy to make for your whole body and the whole-body system to continue functioning appropriately.
Dr. Hartman [00:06:34] Now, on to the brain and the nervous system. Our central nervous system is typically thought of as two distinct but co-existing systems. These are the sympathetic and parasympathetic nervous system. Combined, they are referred to as the autonomic nervous system. These two systems are interconnected though they have different distinct functions. It’s like your heating/cooling system in your home. The brain of the system is the air handler sitting in your closet or attic. It receives environmental input from the thermostats and then connects to your house via the conducting system. When it’s hot, the system goes into parasympathetic mode and tries to cool off things. When cold, it goes into sympathetic mode and tries to heat up things. The effect of the control center, though not directly touching every aspect of your home, affects every aspect of the transfer of heat and cool molecules in the air, which originate in the HVAC system, but systematically travel through the entire home.
Dr. Hartman [00:07:28] An important concept is that all stress is not bad stress. Actually, most stress is good. Athletes stress their bodies to improve performance. HIT, which is a type of high-intensity training that maximally works in both the oxygen-loading aerobic and non-oxygen loading anaerobic aspects of the energy-producing pathways in the cell are activated by this type of exercise. The result is peak athletic performance. Students, as well, stress their minds. They learn new information and create new connections through their focused attention to a topic, and this repetitive practice of focused attention creates new connections in the brain, which, over time, allow them to develop an expertise in a certain topic or field of study. Some people even work better with low-grade stress. We all know some of these people who tend to wait until the last moment to do anything, and just crank it out, in the end, to get things done the very last minute.
Dr. Hartman [00:08:20] But then there’s also bad stress, and that’s what most of us are worried about. Bad stress shifts the metabolism from the building and repairing phase called anabolism to the breaking down phase called catabolism. This is done through different activation on the parts of all the nervous system and results in downstream effects on the cellular metabolism. And there’s all the balance of these two metabolic processes, but in chronic stress, the metabolism is more toward the catabolic, the breaking down pathway, and with this, we see a loss of muscle mass, strength, and resiliency. Marathon runners are a great example of catabolic dominance. Many marathon runners tend to have low muscle mass, low-fat mass, loss of hormonal signaling, and tend to chronic injuries. Whereas, sprinters run the opposite spectrum. They’re training tends to be more anabolic. They tend toward muscle building and quick repair. Ship workers who work at night tend to have catabolic-type illnesses. They tend to have more obesity, more diabetes, more sleep apnea, tend towards more cancer than their day-shift working counterparts. Over time, our organ systems and physiologic systems are affected by these imbalances. Activation of the parasympathetic nervous system tends toward building or anabolism and sympathetic nervous system activation towards catabolism are breaking down.
Dr. Hartman [00:09:39] So, for some examples: in our digestive system, stress results in slow digestion, increased release of stomach acid and enzymes and abnormalities in the composition of our gut bacteria, also known as the microbiome. When under chronic stress, depending on the overall mental, metabolic, emotional, and spiritual condition, we may either have our appetite centers in the hypothalamus of our brain shut down and lose our appetite, or rev up and have an increased appetite. Stress eating is common. What is less common, but suggests graver, more serious health concerns is a loss of appetite and the same conditions.
Dr. Hartman [00:10:16] Proper sleep requires an exquisite balance of the two arms of the sympathetic nervous system and the parasympathetic nervous system working together. We’ve all experienced disruptive sleep due to stress. I won’t spend too much time here since I’ve already written a blog post on this. I will be addressing this in a future podcast. Sleep is one of the pillars of functional medicine. But proper sleep requires balance.
Dr. Hartman [00:10:39] A memory requires both activation of attention through focused activation of the sympathetic nervous system during the day, and then during sleep, a switch to a nerve-fixing, nerve-connecting phase a plasticity where we create permanent memories from the previous day’s events. This is driven by the parasympathetic nervous system, again, requiring a fine-tuned balance between these two symptoms. If it’s not balanced appropriately, we won’t actually form long-term memories when we sleep at night, and we tend to have poorer memory the following day.
Dr. Hartman [00:11:08] Detoxification is a current buzz word in the functional medicine community that requires the same type of balance. At night, while sleeping, our body changes its focus to repair and rebuilding. The organs of detoxification, like the liver, increase their cleaning capacity at work while sleeping. This process is occurring in every cell of the body. This is especially important in the brain cells. During deep sleep, which requires parasympathetic dominance, neurons increase the transport of beta-amyloid out of the cells and work on cleansing these cells. Beta-amyloid is the protein associated with Alzheimer’s Disease, and this may explain the connection with poor sleep hygiene, memory issues, and an increased risk for Alzheimer’s Disease.
Dr. Hartman [00:11:50] Many of our hormones also recharge overnight in preparation for the next day. Around 6 am in the morning, there’s a peak in testosterone production and cortisol production. This requires a well-balanced night’s sleep, which is mediated through a balancing act of our autonomic nervous system. Stress can disrupt this. If everything goes as planned, your major energy hormones are ready for the day. Your cortisol peaks, and you wake up refreshed and ready to go. Melatonin levels are low, so you aren’t groggy, and testosterone is peaking. This testosterone peak is especially important in males. First thing in the morning, glucose levels should be balanced and insulin levels low. All this requires a balance in the sympathetic and parasympathetic nervous system creating this normal daily fluctuation and these hormone levels. Chronic stress erasing all these daily fluctuations and over time causes dysregulation. But there are a few other ways in which stress can have an impact on our underlying health and wellness.
Dr. Hartman [00:12:46] Remember, not all stress is bad, and we actually need some stress for optimal functioning. It’s the daily chronic ongoing and non-willing stress of our modern busy lives that, over time, can result in all the above issues. Eventually, over time, with chronic ongoing stress, the sympathetic overdrive shifts us from a healing, reparative, contemplative way of life to a constant alertness. This can be a slow process over months to years, or it can be instantaneous, like a trauma.
Dr. Hartman [00:13:15] The slow process of creating a chronic state of alertness takes time. As humans, we have the ability to ruminate. Rumination is a low-grade pre-occupation with something or someone that, over time, takes a life of its own. It’s almost like a form of negative meditation that results in all the opposite effects that meditation creates. Instead of being in a post-meditative state of serenity and wellbeing, we’re in a state of chronic activation, feeling like we’re chronically on edge. The idea of stress is only 70 years old, and we’ve only known about post-traumatic stress disorder since WWI, where it was initially referred to as shell-shock. Our understanding is constantly changing, so let’s talk about some newer concepts in this field of medicine.
Dr. Hartman [00:14:00] First, let’s look at technology and stress. Yes, you heard me right. Technology can increase our nervous system perception of stress. Initially, it was just lightbulbs. Older, incandescent lightbulbs mimic the light spectrum of the sun, and so our form of full-spectrum light. Full-spectrum light itself is not a form of over-stimulation to our nervous system. But with the advent of light, we could extend our workdays. Before the advent of this technology, work was limited to most of the population to just the number of hours during the day when we had visible light from the sun. In the summer, we worked longer days, and in the winter, shorter ones. We too often forget the hundreds of years ago, in the middle of the winter, workdays were much shorter than the summer. That was all ended with lightbulbs. But today, it doesn’t stop there. With the advent of computers, cellphones, and now, LED lights, we are being bombarded with blue light. Blue light is a limited spectrum of light that is especially stimulating to our central nervous system, and children are especially sensitive to the effects of this light’s spectrum. Recent research has shown a correlation between computer screen exposure and anxiety. Also included in this are blue light-emitting screens from cellphones. The concept here is overexposure to blue light can cause low-levels of anxiety and stress.
Dr. Hartman [00:15:13] Now, let’s briefly discuss PTSD. Post-traumatic stress disorder was first recognized by the American Psychological Association in 1980. This was largely due to the increased realization of its existence after the Vietnam ware. So, the diagnosis has only been recognized for 40 years, but historically, it has existed for a millennium. Just think about that for a second. We’ve had war the entirety of human existence and only recognize PTSD since the Vietnam War. Understanding of trauma and how it affects the human condition hasn’t stopped with that related to war. We’re now expanding this knowledge to other professionals like police officers, firefighters, or even particular events such as newborn babies spending the first weeks of their lives in an intensive care unit, or even concussions. Concussions can be a form of trauma that acts like a PTSD to your brain. When anything is first discovered, you need to name it in order to study it and understand its existence. One of the first names for PTSD was war fatigue. This entity was recognized during WWI, and the French quickly realized that troops on the frontlines had to be rotated out of the intense frontline every week or two, or they would break down mentally. When this occurred after a bomb event, and the soldiers showed psychological effects, it was referred to as shell-shock. Dating back to the battles of the Greeks and Persians in the 4th Century BC, you read about similar events, but they were always minimalized and related to weakness in the soldier. It wasn’t until the Vietnam War that PTSD was finally given a scientific name and, thus, validity. During this time, as well, we began to realize that the traumatized individual didn’t actually have to have a life-threatening event happen to them. Just seeing death could cause it. The first time this was brought home to me was during my time during the United States Airforce. One of my co-workers who served during Vietnam was nowhere near the frontlines and was never shot at. Part of his job also included zipping up the body bags of the deceased soldiers. Over 20 years later, every night when he closed his eyes to sleep, he would see those young soldiers and his zipping up the bags. The concept of secondary trauma was unknown at that time, so my co-worker was never diagnosed with PTSD, and he suffered its consequences. Today, we’re learning all the nuances of trauma and how it affects individuals. We’re doing better with the military recognizing primary and secondary PTSD as well as different forms of trauma, but we’re still underdiagnosing concussions.
Dr. Hartman [00:17:37] A brain injury can present with all the same cognitive symptoms as PTSD if the cause could be a bump in the road in Iraq, with a head bonk on a metal bar or a soldier falling out the back of a truck hitting his head. We’re still learning about the secondary effects of wave blast and how far certain people can be from the center of a blast and still get a brain injury. I also see this on the civilian side, as well. An extreme example of this was a 35-year-old female patient I saw several years ago. She was at Home Depot looking at some cabinets and forgot that she left one cabinet open. She stood up and hit the back of her head on the back of the open door. The result was six months of mood swings, poor sleep, anxiety, and memory problems. These are all classic symptoms of a concussion or brain injury. The range in trauma induces injury is wide and, at times, requires a clinician for diagnosis. Because of this, it’s often missed.
Dr. Hartman [00:18:27] Another newer understanding deals with the secondary traumas of first responders like police, firefighter, and rescue squad workers. With these types of jobs, there’s a chronic low-grade stress, like, for example, “Will this be that last speeding ticket I ever attempt to hand out.” Then, the acute chronic stress like, “I’m hanging out at the fire station with my friends, and then in one instant, I’m transported to an acute situation where I literally run into a burning building.” Just think about that. “There are guys running out, and I’m running in.”
Dr. Hartman [00:18:56] Within these domains, there are even different levels of severity. The effects of different types of stress on first responders is just now beginning to be understood, and they include psychological effects as well as long-term health effects. Examples are an increased risk for heart disease and cancer in this population versus the general population. Now, we’ll make note that we really didn’t know a whole lot about trauma and first responders until after 9-11. That’s when it was made very real to us that there’s something else going on with these people that at the Twin Towers.
Dr. Hartman [00:19:26] Some newer literature I reviewed in the last several years has dealt with the effects of newborn babies spending the first weeks of life in an intensive care unit. This effects mother-child bonding as well as future attachment. It can also set up the tone for the autonomic nervous system in a state of chronic low-grade fight or flight. This can show up later as behavioral issues, IBS, anxiety, or even in extreme cases, personality disorders. This is especially true in a special needs community where children are constantly in and out of healthcare systems having their life constantly threatened and even having family members involved in this with them. Not only can it traumatize the children, but also the adult caregivers and the parents.
Dr. Hartman [00:20:06] The last example of some of our newer understandings has to deal with a concussion. When I was in college, a head injury wasn’t considered a concussion unless you were knocked out. Now we understand that according to one study, a high school football player may have up to 20 micro concussions in a single Friday night football game. This was detected using a G-force detector in their helmets. I’ve already given an example of a mile head injury causing a post-concussive syndrome, but as recently as three years ago, there was a local rollercoaster in my area that was notorious for giving some of its riders concussions. I even saw a few of these patients, typically parents of kids riding the rollercoaster. It was impressive to me to see firsthand how a simple fun ride could affect brain function. The point of this is that these low-grade physical traumas to the nervous system can result in low-grade and ongoing sympathetic activation that can translate into ADHD, anxiety, memory problems, sleep disorders, mood swings, and the like. Physical stressors can result in long-term and ongoing neurological stressors. With all this information, what is our response? How do we deal with stress or even with the potential for future stress? The answer is this: we maximize our resiliency.
Dr. Hartman [00:21:15] Resiliency is our ability to withstand chronic stress and bounce back after an acute stressor. There are four major ways to do this:
- adequate sleep
- adequate exercise
- proper nutrition
- self-regulatory practices
I will be addressing sleep and exercise in future podcasts, as these are two of the five pillars of functional medicine. I have already discussed nutrition, so I’ll spend a little more time on self-regulatory practices.
Dr. Hartman [00:21:40] These self-regulatory or self-relaxing practices could also partially fall into the sleep and relaxation pillar. This is just another example of how everything is connected with everything else. Prayer, meditation, and self-awareness practices date back to about 5,000 BC in the Indian sub-continent. A great review of modern science behind these practices can be found in Dan Goleman’s book, Altered Traits. This book looks at the current science behind meditation and prayer and how these practices change brain size and function. One such example from his book is how sustained meditation and prayer practices over time result in a bigger hippocampus and a smaller amygdala. This translates into better memory and better emotional control. Dr. Goleman gives an example of a meditative expert who can live 100% in the moment: talk to a mother who has lost a child and cry with her, and then a few minutes later be joyful with a mother who has a newborn child, and then a few moments later, contemplate with a philosopher or physicist. In each state, there’s no dragging of the past emotions to the present versus a typical American who would get cut off in traffic, fume about it for 30 minutes, get to work, and still be mad. This ability to live in the present and not the past experiences centers in the balance between the amygdala and the hippocampus of the brain.
Dr. Hartman [00:22:55] Prayer is a very individualized practice, but just the practice of prayer increases alpha wave activity in the pre-frontal cortex. What this means is that prayer alone will center us and help us to focus. For those who aren’t looking to develop a prayer practice, guided imagery is a way to create a centering effect in our brain wave function and improve our mental clarity and focus. Guided imagery is even now being used by professional athletes and Olympians to improve their cognitive function, focus, and performance. Dr. Andrew Weil has popularized a mindful breathing practice he refers to as the 4-7-8 Technique. This practice focuses on vagal nerve stimulation through controlled breathing exercises. The vagal nerve attaches to most organs, and its activation is a major part of the relaxation response in humans.
Dr. Hartman [00:23:37] There will be links available on the podcast page to our website with free downloads that will help guide you in developing your own self-regulatory practice. This will also include specific techniques for relaxation and improvement in stress reduction and relaxation. For those of you who the above does not resonate, the next section is on technologies that will create similar responses.
Dr. Hartman [00:23:55] Let’s start with sensory deprivation. Sensory deprivation is what’s commonly called float tanks. They are a great way to relieve stress and help your body to detoxify. The Veterans Administration hospital system is currently using this modality to treat PTSD as well as traumatic brain injuries. I’ve personally had a great experience with this technology. My son almost died several years ago. Don’t worry; he’s fine—otherwise, I wouldn’t mention this or ever talk about it, but one of the effects of this trauma to our family was that my wife got PTSD. One day, he disappeared on our property for about ten minutes, and she couldn’t find him. When he eventually showed up, she could not get out of her fight or flight [freeze] mode. She went right into fight or flight when he disappeared and stayed there for hours. Her anxiety flared to an extent that she was in a panic state all afternoon. This happened to be on one of our date nights, so we had a babysitter. When I got home, we went out to the local float tank and did a 45-minute session. [For reference, these are done alone, we had separate sessions in our own individual tanks] At the end of the session, her anxiety was 100% gone, and she was back to her old self. For some, this is a very powerful tool. In others, it’s a basic health tool.
Dr. Hartman [00:24:57] Massage and acupuncture are millennia-old techniques for relaxation that in the past were relegated only to the rich and famous. Now, it’s much more possible for people to get massages. Massage helps detoxify the lymphatic drainage system, and it also helps to relax the automatic nervous system through manual activation of soft tissues. Acupuncture is another one of these old, traditional modalities. Acupuncture works through modulating the automatic nervous system via the meridians. The meridians are the attritional lines you see on the acupuncture chart. These points correspond to low resistance areas on the skin as well as to exit points of the body’s electromagnetic fields. Truth be told, we aren’t 100% sure how it works, but some theories focus on the effects of acupuncture on the peripheral nervous system via low-resistant points of modulation on the skin, now via modulation of the body’s electromagnetic fields. Maybe it’s both. Muse is an interesting type of biofeedback using sound. You wear a device, and if you’re stressed, it picks up your brainwave activity, and through breathing and relaxation, your brain waves start to slow down and regulate. The device picks up this activity and will start to produce calming sounds you get to listen to. This gives you feedback that you’re calming down, and your central nervous system is getting in a better state of relaxation. HeartMath is another type of biofeedback device, but it uses the heart rate beat-to-beat variability as a biometric parameter. Athletes tend to really like the HeartMath. The more artistic people, in my experience, tend to like the Muse better.
Dr. Hartman [00:26:25] Sauna therapy is another time-tested way to relax, especially far infrared (FIR) therapy with chromatherapy or light therapy. Alpha-Stim is another modality I use in my clinic as well as at home, and I’ve had multiple patients have great responses to Alpha-Stim. There are case reports of its use with sympathetic regional pain syndrome, also known as, the old school term is reflex sympathetic dystrophy, fibromyalgia, as well as anxiety, PTSD, and insomnia. I’ve even used it for anxiety-related blood-pressure fluctuations in some of my patients with dysautonomia or POTS. Again, at home, I’ve used it with my wife for anxiety. You guessed it – kids. My son has even used it for some of his stress issues related to some of his history of trauma. If you listened to Episode 1 of the podcast, you learned a little bit about our family, but I didn’t mention that the process had been quite stressful, especially for my wife, who bears the brunt of the issues related to how we built our family. If you want to learn more about that, listen to Episode 1. Needless to say, we use this one a lot. Neurobiofeedback is a great technology for retraining the brain. It’s used for PTSD, anxiety, traumatic brain injuries, and other similar neurological issues. Binaural beats or binaural training is a technology that uses beats to retrain the central nervous system. The corpora quadrigemina is an integrated system found at the base of the back of your brain in the ventral tectum area. That’s a lot of technical jargon for the upper back part of the middle of your brain. The reason this area is super cool is that these four little bumps called the superior and inferior colliculi are where your brain integrates and puts from your eyes and your ears. So, we see as visual and auditory integration are located anatomically side-by-side on your brain. If you’ve ever heard of EMDR, this is a way of brain retraining that utilized eye movements for trauma treatment. Binaural beats also use the auditory part of the system.
Dr. Hartman [00:28:08] Hopefully, this brief summary of stress, its effects on our health, and ways to deal with it has been helpful. The resources I’ve previously mentioned will be available as bonus material in the show notes or as downloads on the website and podcast page. For additional resources and for educational purposes, please refer to the educational tab on our website. We will be continuing to develop these resources as time goes on.
Host [00:28:32] We hope you found today’s episode useful and informative. Please see the show notes on our website at www.rifm2021.flywheelstaging.com. In addition to many other resources and educational materials. We’d also like to invite you to subscribe to our podcast to keep up to date with new episodes. You can find us on Apple podcasts or wherever you listen to podcasts. Please also consider giving us a five-star rating and review so that others can gain access to this information. You can also find Richmond Integrative and Functional Medicine on Facebook and Instagram.