To treat patients with sleep disturbances, it’s important to understand how neurotransmitters affect sleep and wakefulness. In this interview, NMJ’s Editor-in-Chief Tina Kaczor sat down with neurotransmitter expert and practicing naturopathic physician Robyn Kutka, ND, to learn more about how GABA, melatonin, histamine, acetylcholine, dopamine, serotonin and lesser-known neurotransmitters are involved in the circadian rhythm.
Kutka shared a wealth of clinically relevant knowledge about neurotransmitters, hormones, stress, and sleep that any practitioner who sees patients with sleep issues can put into practice.
Robyn Kutka, ND, is an expert in naturopathic medicine, hormones and menopause. She uses this knowledge, coupled with her laboratory medicine experience and the latest in scientific research, to develop customized treatment plans designed to address the cause of health concerns. Kutka received her medical education from the National University of Natural Medicine, where she trained as a general practitioner and tailored her studies to receive more focused training in the field of women’s health, completing a 3-year women’s health clinical internship. She has spent more than a decade educating women on the topics of sexual health and romance enhancement in their relationships and continues to advance her knowledge in the field, studying with the International Society for the Study of Women’s Sexual Health and the American Academy of Anti-Aging Medicine.
In addition to practicing at Inspire Your Health in Portland, Oregon, Kutka is the director of clinical services and lead staff physician at Labrix Clinical Services. She serves as an educational resource for providers across the world on the topic of hormone balancing and bioidentical hormones and has shared her knowledge by speaking for organizations including the American Academy of Anti-Aging Medicine, the Association for the Advancement of Restorative Medicine and the Integrative Healthcare Symposium.
Tina Kaczor, ND, FABNO: Hello, I'm Tina Kaczor, editor-in-chief here at the Natural Medicine Journal. I'm talking today about sleep and how various neurotransmitters are involved in the circadian pattern of wakefulness and sleep, and I'm talking with Doctor Robyn Kutka. Doctor Kutka is a practicing naturopathic physician in Portland, Oregon, with a focus on women's health, and in particular balancing hormones and neurotransmitters. Doctor Kutka, thank you so much for joining me.
Robyn Kutka, ND: Absolutely, thank you for having me. I'm excited for our topic today.
Kaczor: Me too, and I want to start with the most basic of questions, because we are diurnal beings, we are not nocturnal beings. My first question is basically what drives us to sleep at night?
Kutka: Great question. I think we think about our circadian rhythm, our circadian Process C, but it's actually a little bit more than that. When it comes to sleep, we have a couple of processes that work together to balance that out and promote our sleep patterns. So we have our Process C, which is our circadian process, that is mostly endogenous. So we think about our body temperature, our melatonin production, but it's adapted to our local environment and our external time cues, so things like daylight, timing of sleep, our timing of meals, work schedule, social interaction, so it can change based on those things.
But then the Process C is balanced with something called Process S, and think a lot of people aren't aware of that. That's our sleep homeostasis, our sleep pressure so to speak. It's this drive for sleep that builds as we wake and accumulates until we start our sleep, at which point it starts to decrease. When we have an imbalance in those 2 systems, that's where we start to see some sleep disruptions.
Kaczor: So when you say it's our drive for sleep, do you mean that's more of our habits and our lifestyle?
Kutka: No, it's more of an internal process regulated by things like some of our neurotransmitters. It's more of a biochemical process. I think a great example of disruption that maybe will help to explain it is when people drink alcohol. We drink alcohol and people think it's helping them sleep. What happens is it disrupts some of the chemical process of this Process S and actually shortens it at the end, and so we end up waking earlier. A lot of people will fall asleep nicely but then they wake up sooner than they want to and it's because we've disrupted our normal process with that.
Kaczor: Oh, okay. So yeah, let's dive right into that. What's going on with the ... What neurotransmitters, I should start there, are involved with sleep? I think the one thing we all know about is melatonin and perhaps serotonin by association, but what are the neurotransmitters involved in sleeping and wakefulness?
Kutka: Oh, definitely, there's several involved in sleeping and wakefulness and some I think we're really aware of and others are newer, they're things we don't typically think about. Just like all of our processes, it's a balance between our neurotransmitters that will help promote sleep. And so we have sleep promoters which are more of your inhibitory neurotransmitters, things like GABA and melatonin. GABA's probably your largest sleep promoter, and those are common to us. We know those, but then there's a couple others like adenosine and galanin that we probably aren't used to talking about.
When we think about wakefulness promoters that's more of our excitatory neurotransmitters, so histamine, acetylcholine, dopamine, serotonin like you mentioned. Serotonin's a little tricky. I think it can really be both a sleep promoter and wakefulness promoter, but then norepinephrine, epinephrine, and then one called orexin or hypocretin is another.
Kaczor: Okay, yeah, we'll definitely come back to the serotonin because that's definitely one that I can see how it can go both ways given what it looks like in the pathway and just feedback from patients from over the years. Let's talk about histamine some more, histamine as a neurotransmitter, because the reason I started here is because I think there's another kind of common knowledge out there, which is Benadryl puts you to sleep and Benadryl's an antihistamine, and so it's kind of nice to have that to hang our hats on, like we know an antihistamine puts us to sleep then histamine must keep us awake. So what's going on there?
Kutka: Yeah, I think you're right in that a lot of people are turning to the over the counter medications, most of which have the antihistamine in there and it's spot on. Histamine is probably our strongest contributor to arousal or staying awake. So using an antihistamine and really blocking that neurotransmitter can help promote sleepiness. But beyond that histamine, also plays a limited role in our muscle tone and control while we're sleeping as well. A lot of our major pharmacological treatments will actually work on histamine to promote sleep, not all but quite a few of them.
Kaczor: Okay, so yeah, let's circle back. Well I was going ask you this. Antihistamine diets are popular. So now they have someone who knows neurotransmitters well on the horn, I want to ask a question and that is, these antihistamine diets, are they helpful for people who have sleep issues, or are they linked at all to the histamine in the brain, or are we just talking more systemic?
Kutka: Great question. There aren't a lot of great placebo-controlled, double-blind studies out there using an antihistamine diet but people who have higher histamine levels, higher stress levels, things like that, there actually could be some breach of integrity to the blood-brain barrier. And so I do think it's worth trying, at least initially trying some form of antihistamine diet, and I'll get back to that. It's not necessarily because we're consuming so much histamine or we're making so much histamine. Maybe it's because we're not breaking our histamine down as well, you know, break down and testing first and seeing what neurotransmitters are dysregulated, but in somebody that for whatever reason has those higher levels of histamine, of course decreasing the amount of histamine that might be coming in per se could be beneficial.
That's more of beneficial I think too for people who are more sensitive to histamine from their foods and that's not going to be everybody. You know, there's a lot of, I don't want to use the hype but I'm going to, a lot of hype around the histamine food plans. I definitely have patients come in and say, "I'm sure I have a histamine intolerance." Well do we really have a histamine intolerance or maybe we have a variant in that enzyme in breaking it down, or maybe we have a nutrient deficiency so that enzyme isn't working at full capacity or as well as it could per se.
If we try a histamine or low histamine diet for people and it's working I wouldn't necessarily look at that as a histamine intolerance. It might be more diagnostic of that's the reason that's they're not sleeping but is it because, like I mentioned, not necessarily a histamine intolerance but maybe they need more of the nutrients to break it down to help support that enzyme.
Kaczor: Yeah, and I do want to get back around to testing but before we go there I just want to hit a couple more of these neurotransmitters that are wakefulness neurotransmitters like that serotonin that you mentioned, which I find interesting because a lot of people take a lot of supplements and drugs to increase their serotonin levels and those same folks can sometimes have sleep issues. How do we kind of tease this apart to know when serotonin should be supported and maybe shouldn't be pushed so heavily with substrates or cofactors?
Kutka: Well I do think that probably goes back to testing but also knowing where any implications that somebody might be lower in serotonin, I'm going to think about that in my postmenopausal women that might be a little lower in estrogen. That's one of estrogen's main roles is to promote serotonin. So if I know that, and I don't want to wait for testing maybe I'm just going to try it and try to get her some relief, you know, try promoting serotonin at that point and see if we can get some relief in the short term and then think about testing later so we don't have to wait for something.
But you're right, I think serotonin's a tricky one where too little and we're not going to get great sleep and too much and that could actually promote wakefulness and decrease our REM sleep. If we think about it, a lot of people will try 5-HTP and when we're giving 5-HTP, that serotonin precursor, we're almost always giving it to people before bed. So clinically I think well, if we give it to them and it helps that's a pretty good indication that they need that serotonin support and maybe melatonin support because, down the road serotonin becomes melatonin, but if we give it to them and it causes them to have more sleep disruptions or irritability on waking or something along those lines I think we've missed the mark there and it probably isn't serotonin that's the issue.
Kaczor: Yeah, so testing might flush that out? Is that what I kind of heard you start with? If they have a high serotonin and low melatonin then obviously there's a conversion issue?
Kutka: Yeah, that would be, I would think of that as a conversion issue or somebody with lower serotonin levels on their testing. Then we'd want to support that. Somebody with higher serotonin levels we probably wouldn't want to support that and that wouldn't really get us where we wanted to go.
Kaczor: Okay, and let me ask you this, is there a role for any of the other neurotransmitters to control the serotonin at all? Is there any play with the others that is involved with controlling the serotonin output into the synapse? Do you know what I'm saying?
Kutka: Oh, I do, yeah, absolutely. I think GABA in general will help to decrease the activity of our wakefulness promoters, so histamine, serotonin, norepinephrine. GABA's going to come in and kind of combat that, whether it's not necessarily decreasing serotonin per se but blocking serotonin messaging in different parts of the brain.
Kutka: I think that's ... yeah, GABA's really huge across the board.
Kaczor: Yeah, yeah, GABA's kind of that mellow you out neurotransmitter, right? That's what we all associate with being calm and the Valium effect.
Kaczor: All right, so let's move on to norepinephrine. There was something that you mentioned in a lecture that you did, and it was that ... You mentioned norepinephrine levels increase most when focused cognitive effort is interrupted. I kept repeating that line in my brain going, "Boy, focused cognitive effort is interrupted." So anytime you're ... I kind of wondered, I went straight to all of our interruptions on a given day, you know, our phone goes off or notifications come up on the computer. It's just such a very busy world that we live in now as far as long we have to concentrate on only one thing. Is that what you mean by that? Is that relevant even?
Kutka: Yeah, no, I think it is. We think of serotonin being elevated as we sustain our cognitive concentration but norepinephrine is going to raise as we interrupt it. So it's kind of ... I call it shiny goldfish syndrome. If you guys have watched Finding Nemo and Dory's all over the place. That's what we're thinking about. And so another way to look at that is our ADHD meds or ADD meds. They're working on norepinephrine and raising and sustaining those levels so that people can concentrate. So we're watching something, we get interrupted and move on to the next thing and we get this increase in norepinephrine. It's really, I think, in a way our body trying to maintain that focused concentration that's lacking there. And so disruption in that system makes it difficult and we see that sustained with medication but I think there's other ways we could do it certainly, but yes, I think you got out of it what I intended there.
Kaczor: Okay, good, good. So basically maybe turning off our phones while we eat or whatever, when we're just trying to concentrate on one thing maybe we should intentionally almost like horses, put blinders on, just kind of focus and not-
Kutka: Oh, absolutely. I think we can extract this really ... I was thinking about it in preparation for today and really we can even extrapolate that to this ... We see a huge lack of mindfulness in our culture and this idea of we're so busy. We go from one thing, to the next thing, to the next thing, and as we're doing that it's keeping us in more of the sympathetic versus our parasympathetic state, and this is really just another way of looking at it doing the same thing. We move from one thing to another, we're increasing those norepinephrine levels. We're in this fight or flight mode all the time, and then that's causing a disruption in some of our neurotransmitters, and we see that extrapolated into our patient base on all those things we do to help them with whether it's deep breathing or 10 minutes a day on their own, or any of the herbs or things that we might be doing. What we're really doing is trying to promote more time spent in that parasympathetic state so we can lower some of these excitatory neurotransmitters and things. So it goes beyond sleep for sure.
Kaczor: Mm-hmm, so what should dopamine be doing in the daytime and in the nighttime? Is there a rhythm for the dopamine, ideal rhythm for it like there is some of the others?
Kutka: Well it's another wakefulness promoter. It doesn't necessarily decrease toward bedtime or anything like you see in some of the others that we talked about, but when we have disturbances in dopamine you'll see some disturbances in sleep. So I tend to think about commonly we see disturbances in REM sleep in our Parkinson's patients or increased sleep disturbances in people with schizophrenia where dopamine is associated. It can definitely help control sleep and wake and as we wake up it actually down regulates melatonin. So I suppose it does have its own little rhythm there. It'll down regulate melatonin just before waking allowing us to wake up and get out of that sleep state.
Kaczor: Okay, so the other one you mentioned that I wasn't familiar with was orexin. What is orexin?
Kutka: It's actually, it's not newer per se but it's newer to us in medicine. It's only been really studied since the late '90s. It's another neuromodulator/neurotransmitter that helps coordinate sleep. When we don't have enough of it, it actually is associated more with narcolepsy. That's what they've studied it in quite a bit of so it's again a wakefulness promoter and it's influenced by a lot of our main energy factors, things like our monoamines, so serotonin, dopamine, norepinephrine, nutrients, blood sugars, leptin, ghrelin. So we extrapolate that out and see that it also coordinates our regulation of energy balance, and sleep, and wakefulness. Our newer medications, not so popular yet, actually work on this system. There's 2 different receptors for orexin. The newer pharmaceuticals, suvorexant, that's actually what's working on this. So it's not necessarily a hypnotic like some of the other medications that we use.
Kaczor: Okay, okay, yeah, and I saw those hypnotics just got an FDA warning for sleepwalking recently, last week I believe.
Kutka: Mm-hmm (affirmative).
Kaczor: Yeah, so yeah, if we can work around them that would be ideal, right, for folks who have sleepwalking issues.
Kutka: Yeah, absolutely.
Kaczor: All right, so we've been talking about all of those neurotransmitters and you had mentioned in your lecture glutamate and how it is involved as an excitatory neurotransmitter but I think it's also involved in GABA production as well. Can you give us a little review about glutamate and how we can either assess and/or balance that?
Kutka: Yeah, absolutely. So glutamate, like our other neurotransmitters, can be looked at in neurotransmitter testing. Not all can but glutamate can be. Glutamate actually becomes GABA when we're thinking about our cycles there. So when glutamate is too high and it's not converting properly to GABA we can actually see some of those insomnia symptoms or even difficulty falling asleep. And so having proper conversion so we have adequate GABA levels to promote sleep is important there.
Glutamate might raise because people are ... I have seen it raised because people are supplementing it or maybe it's in their protein powders and they're not converting it properly, but some people are more sensitive to our glutamic acids in foods, not all but some people are and that could also be what's raising it for people. If they have an issue, again, converting it or don't have the right cofactors to do that then we're going to see imbalances there that are going to promote more of our insomnia versus sleep patterns.
Kaczor: Okay. Let me ask you this because I know you've worked for laboratories in the past and you've looked at a lot of these various neurotransmitter tests results. Is it your opinion that cofactors in larger quantities push these pathways such that so if glutamate was high and GABA was presumed to be low, can we push these pathways just by giving the cofactors or is that not-
Kutka: No, I think that's a fair assessment. In a perfect world where all enzymes work properly without any variance or maybe we don't have any SNPs in them—it's a great environment with low inflammation, low pollution, low toxicity, as long as people aren't malnourished if we work on the cofactors I think we can get a lot of good benefit and good outcomes there but I would always think about making sure cofactors are repleted and optimal before I give any of the amino acid precursors or building blocks otherwise we won't be able to simulate them. And so I think you're right in what you're kind of saying here is that cofactors being the priority. One great example of that is vitamin D. We need vitamin D to make the vast majority of our neurotransmitters, especially serotonin and dopamine. Yeah, here in the Portland area we live in a part of the country where almost everybody's vitamin D is insufficient unless they're supplementing it. So it's a great example of making sure that we replete that before we start giving people building blocks.
Kaczor: Yeah, yeah, and it's an interesting difference between say repletion and mega dosing where you're giving intentionally large doses of P-5-P, Pyridoxal-5-Phosphate, or some other cofactor to make the neurotransmitters. I think that everyone should be aware that's there's a very big difference between those 2, repletion and basically nutraceutical dosing of large amounts of any kind of vitamin.
Kutka: Yeah, absolutely. I think that's a great comment there. The other thing I think about is iron deficiency. You know, we're working with both women and men can be iron insufficient but women in particular if they're menstruating quite often are insufficient in iron. Depending on what labs we're looking at reference ranges aren't going to show that. They're going to look "normal" when really they're considered iron deficient in that we work on repleting. Obviously wouldn't mega dose any iron or anything but repleting that before we give the amino acid precursors as well.
Kaczor: Yeah, that's a great point. Yeah, iron deficiency is pretty common in women's health, especially for cycling women. And it's so important for so many of these enzymes, isn't it, for these enzymes that create the neurotransmitters in the brain?
Kutka: Yeah, absolutely, for that initial step of conversion toward serotonin, toward dopamine. We need iron, we need vitamin D, we need B6, and actually biopterin, tetra biopterin, so we think about it as a methylation step as well.
Kaczor: Yeah, yeah, that's interesting because of course we think of fatigue as a low iron symptom but maybe sleep disturbance could be counted as a symptom as well or just any neurotransmitter disruption really.
Kutka: Yeah, absolutely.
Kaczor: Okay, so I have a question because I have a lot of women in my practice, especially if they're perimenopausal, postmenopausal, they tell me they have this wake in the night, say 1:00, 2:00, 3:00, and they've got a busy brain. One patient called it her monkey mind, turns on inexplicably. She starts worrying about stuff she knows she doesn't need to worry about but it kicks in and she can't turn it off and she can't get back to sleep of course because after that I'm guessing her cortisol kicks in and wakes her up, right?
Kutka: Mm-hmm (affirmative).
Kaczor: What's going on with these women who especially peri- and postmenopausally seem to have this middle of the night wakefulness and the brain just kind of kicks on and won't kick off?
Kutka: Yeah, great question. This is one of my favorite things to work with in practice because 97% of the time it's so easy to fix and get some really good symptom relief here. As we become perimenopausal we start having more anovulatory cycles and of course postmenopausally we're not cycling at all. So we have anovulatory cycles. We're not expecting that egg so then we don't have the tissue hanging around that would express a lot of progesterone.
Progesterone actually works at the GABA receptors, progesterone and its metabolite allopregnanolone. We have 2 different GABA receptors. So progesterone works at one and its metabolite works at the other. So as we become menopausal and we have much lower levels of progesterone overall, those GABA receptors aren't being stimulated as much as they have in the past. We talked about how important GABA is in that sleep promotion, probably the most important neurotransmitter we have there, and it's so calming. It's what things like most of our sleep medications and anxiolytics actually work at GABA receptors. And so for women in that period of life, their body's own anxiolytic has really decreased substantially.
When that happens they're going to have that what you called "monkey mind." They can't turn their mind off and they're thinking about all these things they know they don't need to think about. So as we promote, whether we're going to promote progesterone, or allopregnanolone, or utilize potentially some GABA. That's a tricky one because it's too large to cross the blood brain barrier but whatever we do, if we can promote working at those receptors they can get some excellent relief from their sleep symptoms.
Kaczor: So progesterone or allopregnanolone is usually how you would support those women through that process?
Kutka: Yeah, absolutely. Typically, when we swallow progesterone, we're straying from neurotransmitters a little bit, but when we swallow progesterone the vast majority of it, probably over 90%, is actually metabolized to allopregnanolone. So a tip for these women is to maybe utilize some oral progesterone or sublingual progesterone which will give them a little bit of progesterone and whatever is absorbed through the blood vessels under the tongue but what they swallow in their saliva will work like an oral progesterone. And so they'll get both progesterone and allopregnanolone at the GABA receptors. It can be so beneficial for sleep.
Kaczor: That's a great point because obviously a topical cream of progesterone is just not going to have that same effect.
Kutka: No, it's not, not for most women. Every now and then someone will get enough from that but that sublingual oral really helps, and what's really neat about that too is that it doesn't work as a hypnotic where a lot of the medications that work at those receptors work as hypnotics and they rob us from our deep restorative sleep that we need for muscle building, and hormone regulation, and things. Progesterone doesn't do that, and in studies with about 300 mg of oral progesterone they saw this return to sleep normalcy and the restorative sleep for the women who were suffering from it but it didn't negatively affect women who weren't suffering from insomnia when they took it. So it didn't make them excessively groggy or anything like that. There were no negative side effects with it.
Kaczor: And in interpreting the tests when you see them and women are taking that 300 mg of progesterone say orally, do you see any changes in downstream steroid synthesis? Do you see any more testosterone or anymore estrogens formed in those women?
Kutka: No, and I think 300 mg is probably higher than I would do. It's just what was in the study. But progesterone doesn't become estrogen, or testosterone, or anything like that. So we don't see any either increase in those. It also won't inhibit production of those. The pathways are so different, especially in our postmenopausal population, where they're making those hormones. So no negative or positive effects on other hormones really.
Kaczor: Okay, okay, and so we've mentioned the word testing several times during our talk today but I just ... There's a couple different types of patients, right? There's the ones who don't want to test, and there's people who want to test everything you can possibly test because they really want to see the objective information, and then there's the people in between where as a clinician you're like, "Well, let me just test a couple things and make sure I'm right," or you take a couple shots and you were wrong, and then you test. There's so many different ways of doing this. What I want to know is two-fold, one, what's the basic least amount of testing that's going to get you the most bang for your buck, because a lot of people are paying out of pocket, and then what would be on the flip side those folks who are just all in and they want to go no-holds-barred, they're just like, "Give me the whole package." What can you test and I'm talking saliva, urine, blood? What are the 2 routes to go as far as testing?
Kutka: Mm-hmm (affirmative), oh, great question. I think basic wise there's some serum, blood tests that we want to do really on the vast majority of people who are going to come in with some of these symptoms. At that point we're looking at nothing new but maybe looking at it with a new lens so to speak. So we're looking at somebody's ferritin, their vitamin D levels, we're looking at their CBC, and maybe B12, and folate to really get an idea of how they're using those really important cofactors here. Of course with sleep disturbances I'm thinking about potential thyroid imbalances too, so I would look at those in serum for people and that would be really my absolute minimum. Starting there, maybe doing some stress management techniques and repleting any nutrient deficiencies that we find, and optimizing I should say. I'm sure you and most of the listeners realize that our reference ranges aren't necessarily set to optimal for many things, and so we want to optimize those, not just make them look okay. Then they can better utilize and assimilate what else is going on in their body and whatever else we give them.
But then beyond that, we can look at neurotransmitters in urine, almost all of them. Acetylcholine we don't have a great assay for, some of those newer ones like orexin or adenosine we're not really monitoring that but our main ones that we know that promote sleep and wakefulness can be utilized in an easy spot urine test. It's super simple and the studies that we have on that correlated well to central spinal fluid. You know, yes, we're looking at full body levels there but it's still a reflection of the imbalances in the body and that is correlated well from the literature that we do have at this point correlating that.
And then, of course, from there if we wanted to get an idea on how we're breaking it down there's another test that will look at the metabolites of neurotransmitters. I don't use it a ton but for somebody who wanted to do absolutely everything, you know, we're looking at organic acid testing, and neurotransmitters, and all of their metabolites. But I would also think about hormones in these people as well, particularly our cortisol levels and finding any dysregulations in the HPA axis, so the brain telling the adrenals to work. Those imbalances with cortisol levels will absolutely lead to sleep disturbances and not just having elevated cortisol levels at night but even people with flat line or lower cortisol levels will actually be the ones that typically will report more nighttime wakenings than others.
But then we can look at sex hormone imbalances in our salivary testing as well and get a great look at all of the neuroendocrine influencers that can be resulting in sleep disturbances. That's really the imbalances there that we're seeing that's causing that, not necessarily one thing over the other but an imbalance of those sleep promoters and wakefulness promoters.
Kaczor: So would it be fair to say that if someone was testing hormones they're going a little bit more upstream because the hormones are having such a profound effect on neurotransmitters, so if they had to pick one or the other? Is that accurate?
Kutka: Yeah, I think that is pretty accurate but particularly in I think about it more in women in that period of postmenopausal group or even younger women who are having menstrual cycle disruptions because it's that estrogen promotes serotonin, it promotes dopamine; progesterone promotes GABA. And so our really big players are promoted by our main sex hormones. Yeah, I think that's a fair statement there for sure.
Kaczor: Okay, great. Well we didn't get in the HP axis so now we have something to talk about next time we have an interview. And of course this was great. I really appreciate your time and your expertise. Neurotransmitters can be a pretty confusing topic for a lot of folks so thank you for all the clinically relevant information.
Kutka: Yeah, absolutely. Thanks so much for having me. I hope that it helps with some patients' interactions in the future.
Kaczor: I'm sure it will and next time maybe we'll talk about the HPA axis, and sleep and wakefulness, and until then, take care.
Kutka: Thank you, you too.
Using content to connect with potential patients and grow a medical practice has become increasingly popular. Most practice owners are using some form of content to promote their business including a website, blogs, podcasts, social media posts, and/or email campaigns. In this podcast, the ethical ramifications of content marketing are explored with naturopathic physician and medical writer, Sarah Cook, ND.
Sarah Cook, ND, is a medical writer and a copywriter for the integrative medical community. She holds a naturopathic doctorate degree from Southwest College of Naturopathic Medicine, a certificate in biomedical writing, a professional diploma in digital marketing, and she is a StoryBrand certified guide. Sarah writes website copy, email campaigns, e-books, and other marketing materials—helping clinicians and small business owners create authentic marketing messages to reach more of the people who need them most. Connect with Sarah at www.ndpen.com.
Karolyn Gazella: Hello, I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Using content as a way to connect with potential patients and grow your practice is an increasingly popular trend. Also called content marketing, most practice owners are using some form of content to promote their business. It may be a website, blog, podcast, social media posts, email campaigns. While it's true that content marketing can be extremely effective in growing your business, have you ever thought about what the ethical ramifications might be?
Today I'll be talking with Dr. Sarah Cook, who is a naturopathic doctor and seasoned medical writer. Dr. Cook has worked with us at the Natural Medicine Journal on many writing projects over the years. She also helps doctors with content creation and copywriting through her company, ND Pen. Dr. Cook is here to talk about the ethical pitfalls of content marketing. Thank you so much for joining me, Dr. Cook.
Sarah Cook: Thank you, Karolyn. I'm excited to be here.
Gazella: Well, before we dive into these ethical pitfalls, could you briefly tell us why you think this is such an important topic for clinicians to think about?
Cook: Absolutely. So, like you said, most clinicians are doing something with content. They're putting out content for their business, and most of them aren't really thinking about, "Well, how does this relate to ethics?" at all. And even if they thought about some of these things, they might not know where to go for information or really what precautions they should be taking. And I guess you asked why is it important, and I think it's really because it's just really too bad if they're well meaning clinicians, they're coming from a sincere place of wanting to put good information out to help people, and they make mistakes and just because they're not aware, and so then they end up with unexpected consequences. And so that's really what we want to avoid really just by creating awareness about it.
Gazella: Yeah, it's such a good point because I do agree; I think the clinicians are coming at it from the correct perspective. Now you mentioned unexpected consequences. What do you mean by unexpected consequences?
Cook: So, I mean, I can give a couple of examples of some things that I've seen happen. So for example, there was a doctor who I worked with to help him create his content for a while, and before I started working with him, he had been producing a blog, and one of his blogs, again, he just made a mistake. He found an image online that he thought went well with his blog and he posted that image along with that blog post, completely innocently, not trying to steal somebody else's content and not realizing that this image had a copyright and he was not supposed to use it. And ended up he got a letter in the mail for copyright infringement, and the thing is that the fines for copyright infringement, they're in the hundreds or even thousands of dollars, and so this is not a small thing.
So, one unexpected consequence certainly could be financial. And maybe even worse, I think the other thing to think about is your reputation. Really your reputation is on the line when you're putting content out for your business. And so I can share another example of where I recently saw this play out on social media, and essentially what happened was there was ... I try to stay out of the weeds on these things. I don't get involved, and so I don't have all the details on this, but essentially it was some sort of wellness practitioner, I think a nutritionist of some sort, was creating a lot of social posts and blogging about a concept that actually another better known physician who had written a book about this topic had really already coined these ideas and like I said, written a book about this specific concept, and this other practitioner essentially was promoting the same ideas using the same terminology and not giving credit to that original doctor who had come up with the ideas and had written the book about it.
And what happened, what I saw kind of play out on social media, was that people noticed and really her reputation was slammed for that. And I don't know, maybe ... We don't know. We can give her the benefit of the doubt. We don't know if she went intentionally stealing the ideas or if she just thought that she was putting helpful information out, but the mistake that she made was that she didn't give credit to the original person who came up with those ideas. So, I think that is really maybe even more important than the financial consequences is your reputation.
Gazella: Oh, I would agree. I think that's such a good point. I mean, your whole business model moving forward stands on your reputation, whether or not you get new patients, patient referrals, et cetera, so I would agree. I think that's critical, and I can see that the stakes are high. So what is your direct experience with the ethics of content marketing?
Cook: Yeah, so I mean, I can gratefully say that I haven't really personally suffered these consequences of making ethical mistakes. It doesn't mean I haven't made minor infringements. I'm sure I have, but I haven't been caught. But I've really just been forced to learn some of these concepts over the years of writing and creating content for the integrative medical community just really from being in the trenches and needing to.
So for example, you know very well, Karolyn, when we write anything for a dietary supplement company, we need to be extremely careful about the words that we use so that we don't make any claims that that supplement treats or prevents disease, right? And so that is one thing where writing for a dietary supplement company, they usually have their own lawyers, and they make sure that you're being compliant with your language, but even when I've worked with individual doctors where we might be writing a blog and they have a product that they really want people to know about, but it's a specific dietary supplement, and so now we're in the realm of where we have to be very careful about the words we use. And we can get more into this, but you can't talk about that supplement treating disease. You have to talk about it supporting the structure and the function of the body.
And so for one way, if there's clinicians listening to this and they're thinking, "Well, I'm blogging about this product," one thing I have done with doctors is like if you have any question, go to the company of that product and say, "Look, I'm writing this blog about this product. Is it okay how I'm wording this and what I'm saying?" I think it's always better to ask than to not exactly know if it's okay what you're doing.
So, working with supplement companies, working with doctors is certainly where I have just been in the trenches and having to figure this out as I go. I think the other area is when it comes to email marketing, so collecting people's email addresses, building an email list is huge now as part of content marketing, and the regulations just within the last year, there were sweeping changes in the regulations that actually change what you can ethically do with a person's email address. And so as those changes in regulations rolled out in this last year, any of my clients who I've been helping with their email list, we've had to figure out how to become compliant to these new regulations. So again, a lot of these things are not stuff you can necessarily just Google and find out. A lot of it, for me, has been learning as I go because I have to, and so that's really why I wanted to talk about this subject and make sure everyone else is informed.
Gazella: Yeah, it's such a good point, especially about emails, and it's interesting, I know we're going to talk about unsubstantiated claims, but I started out in the natural health industry in the early 1990s. It was like 1992. I became the marketing director of a very large supplement company, and within a couple of months after getting on the job, the company got into significant trouble with the FDA. Dozens of products had to be taken off the market. We had to change labels and literature, and I have to tell you, Dr. Cook, it was baptism by fire. I had to learn very quickly about structure/function claims, disease claims and how to write about products to keep the company safe. So, yeah, I think that that's such important topics. Now, I want to talk about-
Cook: Yeah, and I really believe, like you said, you then were like all of a sudden you have to learn structure/function. Well, it's like I also think we can learn from each other's mistakes, and so you and I have worked with structure/function a lot, so if we can share some pearls so that other people don't have to go through what we've been through.
Gazella: I know. It's so true, and I do like your advice about contacting the manufacturer because a clinician doesn't have the legal resources, but the larger manufacturers, they have a team of legal people that review content and make sure that the content is safe to publish, so I really like that piece of advice a lot.
Cook: And in my experience, they are happy to review an article if you're writing about their product because it helps them.
Gazella: Yeah, absolutely. And yeah, it's different when you're talking about a product specifically versus if you're talking generically about a nutrient or herb.
Cook: Yes. Yes, absolutely.
Gazella: You have to be a lot more careful. Yeah, lot, lot more careful when you're talking about a product specifically.
So, let's get to the ethical pitfalls of content marketing. What are some of the common pitfalls that you've seen?
Cook: So, I was thinking I would just highlight three so we keep this manageable here, so certainly copyright infringement would be one thing to talk about. Secondly, unsupported claims, which I can get into a bit more what I mean by that, but not being able to support what you say with evidence. And then the third thing, misuse of personal information, and that really comes into play when we're collecting people's email addresses and what we're allowed to do with that personal information. So I think those three things are probably a good place to start.
Gazella: Yeah. I would agree, those are perfect. So let's talk a little bit about that first pitfall. What advice do you have for clinicians to help them avoid copyright infringement?
Cook: Yeah, so honestly, this one probably is the easiest pitfall to avoid if you just have a little bit of awareness. But copyright applies to any content that somebody else has created, so it applies to words, images, videos, and it even applies to ideas, and so the example I gave of where the practitioner had been using these ideas from a book and not giving credit to the author of that book, she wasn't directly copying any paragraphs from that book, but she was copying the ideas, and it's something that's called derivative work. We use that word derivative where it's basically like she's deriving that content, and that is a form of copyright infringement that people might not realize. You don't have to directly copy the words to be infringing on their copyright.
So, derivative work is just something to keep in mind where ... I mean, the point is give credit to the person who came up with that idea in the first place. That's all you need to do. And that really goes across the board for any kind of a word. Any words, written content that you are using from somebody else, it's really just a matter of giving them credit, so either linking over to their website or linking over to wherever it was first published in a different article. Giving credit.
Images. Images are something to think about. Again, I gave that example of where the doctor didn't realize he shouldn't be using that image. You can't just go to Google images and use any image that comes up. Most of those would have a copyright on them, and here's the thing about images: it doesn't have to have that little copyright symbol on there. It doesn't have to have a watermark to be copyrighted. If somebody took the time to design that image on their own and put it on their website, by default, they own the copyright to that image, and you should not be using it without their permission.
So that's something to keep in mind about images, but probably the safest way to go about using images, I would say there's 2 categories of images that you can use without getting permission because you can always ask for permission, but of course that's a hassle, and probably for the most part you don't want to bother with trying to get permission to use somebody else's images. So, really the 2 types of images you can use would be either what's called royalty-free or images in the public domain. Now, I don't know if you want me to go into what's the difference between those, or what do you think, Karolyn?
Gazella: Sure. Let's just, yeah, let's touch on that.
Cook: Yeah, so royalty-free images, the free part doesn't necessarily mean they're free. You can buy these, so websites like iStock, you pay for it, but it's royalty-free meaning that you're getting a license to use it freely. And so some royalty-free images are paid for, like the iStock photos. Some royalty-free images are available for free at sites like Pixabay.com for example. But the point of being a royalty-free image is that they're granting you a license to use that image freely, and usually, I always would double check what the license agreement says, but for most of these, the license agreement says you can use this freely. You do not have to tell where you got it. The word is attribution. When you give credit, you do not have to give attribution. So you don't have to even document where it came from. Most of those licenses say that for royalty-free images.
And then the second category is images in the public domain. And so those are different in that they actually either never had a copyright on them or the copyright has expired, and so they're just in the public domain, again, for anybody to use freely, you do not have to give attribution. So some of the places that you would find those would be on like Wikipedia or it's called Wikimedia Commons, I believe. And that's a nice place if you're looking for more science kind of ... A lot of times you might want to draw a flowchart of the hormones from the hypothalamus down to the ovaries or something, right? That's not something you're probably going to find on iStock Photo, but you might find it in the public domain on like Wikimedia Commons for example.
Gazella: Yeah, that sounds pretty straightforward, and I'm glad that you went into that detail. Now, what about that second pitfall? This is the one that I'm really interested in hearing you talk about. What do you mean by making unsubstantiated claims? Can you give us some examples?
Cook: Yeah, so we can start with what we talked about when we're talking about specific dietary supplements. That's really just a matter of needing to use words that talk about how that supplement supports what we call structure/function of the body. So for example, if you're talking about a certain curcumin supplement, you can't say, "Oh, this treats pain and inflammation in arthritis." You have to just modify your wording and say something like, "Supports a healthy inflammatory response." And again, that is when you're talking about specific supplements, and I'm glad you brought up that if it is just you're generally talking about curcumin, you can be more free in your language.
However, it kind of brings me to the next point about supporting your claims, and that is even if you're just generally talking about curcumin, you shouldn't be making claims that you can't back up with evidence, and so either being able to link over to some study that supports what you're saying, if you're going to say curcumin really is great for knee pain or something, then you would want to be able to link to a study that showed that or be able to at least say, "Look, this is in my experience or what I have seen with my patients," and that's perfectly fine to use as evidence as long as you're clear that that's what you're basing this on, that's what you're basing your statement on.
So it's really all just about being transparent about if you're making a claim, being able to back it up with either research or your personal experience and just being open and honest about that.
Gazella: Yeah. That makes a lot of sense, and I think it's a great reminder.
Now let's move on to that third pitfall. What does misuse of personal information have to do with content marketing?
Cook: Okay, so this really gets into collection of email addresses, and so the thing is, this is a huge trend in content marketing is give away something free. So people call it all different things; they call it a freebie or a lead magnet or a lead generator, but they're giving away maybe like a free PDF download, and it used to be that you could give away this free, really valuable piece of content, and it was just assumed that when somebody put in their email address to download that guide, they're automatically put into your email list of subscribers, and they're going to start getting your regular emails like your e-newsletter or your promotions or anything.
And that actually used to be fine, and there's an email regulation called the CAN-SPAM Act, which has some items in place to make sure you don't spam people with mass emails, but it used to be very easy to be compliant with CAN-SPAM if you were using any regular kind of MailChimp or Constant Contact or any of those things, you were pretty much automatically compliant. It was just required things like having a little unsubscribe button at the bottom of every email.
But here's the thing is that just in the last year, so May of 2018, regulation went into effect in Europe called GDPR, and it totally changed this situation. So, quick disclaimer, I'm not a lawyer, so please, Karolyn, do not take anything I say as legal advice, Okay?
Gazella: That's a great disclaimer. I like it.
Cook: This is not legal advice.
Gazella: I'm going to make that same disclaimer. I'm not an attorney.
Cook: I am not an attorney, but in a broad sense, I think it's useful to understand what GDPR is about because it completely relates to ethically what we do with people's email addresses. So, I want to just broadly tell you what this is. Pretty much what GDPR says is that people should have a say in what you do with their personal information. So, it's really 2 things that we need email subscribers to give us, number 1 explicit consent to email them stuff, so they need to specifically say, "Yes, I want to be on your email list," and the second thing, granular consent. So it means you can't lump everything into a bucket anymore and say, "When you download this guide, you're also going on my general email list." They need to specifically check a box that says, "Yes, I want the guide, and yes, I want to be on your email list," so they need to specifically say they want to be there to be compliant with GDPR.
So, it doesn't mean ... We can still use freebies or lead magnets or whatever you want to call them. It's just a slight variation on how you create that form on your website to collect that email so that you'll be compliant.
Gazella: Yeah, that makes a lot of sense, and clinical practices are used to dealing with personal health information, so as long as they take that same care when dealing with the personal emails I think that ... And it can be confusing. A lot of this-
Cook: But wait. Can I say one more thing about ... I'm sorry. Excuse me.
Gazella: Uh-huh (affirmative).
Cook: One more thing I just want to mention because a lot of people might say, "Well, I'm a US-based business and GDPR is a European law, so it doesn't apply to me," but here is the thing is that GDPR, if somebody in Europe accesses your website, even if you're a US-based business, you need to be compliant with GDPR. And so if somebody sitting in a coffee shop in Madrid, Spain looks at your website and opts in for your guide for smoothies, then you're supposed to be GDPR compliant for that person. And so that ... Oh my gosh, email marketers are doing all different kinds of things, and some are getting really technical and monitoring like, "Oh, if somebody is in Europe and they're on my website, I'll show them the GDPR-compliant form, and if they're in New York and they look at it, I'll show them the noncompliant form."
So you can get into the weeds really fast here, but in my opinion, GDPR brings up an ethical issue that is people should have a say in what you do with their information, and if they want to be on your email list, you should get their permission for that.
Gazella: Yeah, I think that's a good general piece of advice, but I can also see where some of these issues might get a little complicated quickly. Where do you suggest people go for more information if they have additional questions?
Cook: So, that's a great question because I think I mentioned earlier a lot of these things, Google doesn't necessarily get you where he need to go. So, I actually put together a list of resources, at least from what I have, that I can share with your listeners, and so I just put together a resource guide. It has some things of where you can find royalty-free images or images in the public domain, linking over Copyright Alliance is actually an organization that just has really simple to understand information to understand copyright law. I have a link in that guide for where you can find FDA guidance on the structure/function language, and then of course some links to where you can learn more about GDPR.
So, I tried to put together just some things that I have found to be reliable and really useful in that guide, and so I think we're going to share that maybe in the show notes, but you can find it. It'll be on my website, which is NDPen.com/ethics.
Gazella: Yeah, and we'll also-
Cook: Oh, and by the way ... I keep cutting you off, Karolyn. I'm so sorry.
Gazella: Oh no, that's okay. Go ahead.
Cook: I am setting that up to be a GDPR compliant opt-in so that you can see an example of what that looks like, so you can just download the guide and that's it, or you can choose to be on my email list, but I will not just add you to my email list when you download the guide.
Gazella: Yeah, and we're also going to be linking to that guide. On this page of the podcast, there's going to be a link so our listeners can just click over. I mean, from a clinician standpoint, this might be something that you're going to want to share with your office manager or the people who are actually executing your marketing communication plan, your content marketing plan. So, yeah, thank you for doing that free guide for our listeners, Dr. Cook.
Now, I have a question here. With all of these ethical pitfalls, do you think that content marketing to grow a medical practice is worth the risk?
Cook: Yes, absolutely. Oh my gosh. I mean, here's the thing. The chances, if you are going about this from your heart, with good intentions, honestly the chances of getting in trouble for minor infractions of any of these things is so slim. It's so slim that you would ever get in trouble for anything, and yet the benefits of getting your content out there are massive. So, I mean really, if you're putting content out there, it's a way to really show your expertise, it's a way to get ... I mean, all of these integrative health practitioners, everyone has a unique message. Everyone's message is different. They have their own authentic voice and way of sharing it, and you get that out with your content. And really, yeah, creating content takes time, and you might hire some people to help you with all the parts and pieces, but it is a really effective way to promote your business without getting into a massive advertising budget.
So, I mean bottom line is like getting your content out gets you connected with people who need you the most; that's what it's about. It's about getting your message out there and helping people, and I really believe that that content marketing is a solid way to do that and really to just grow a thriving business.
Gazella: Yeah, I would agree with you. I have been a content publisher of integrative health information since the early 1990s, and I really feel that content is king. So, I have a love of quality content just as you do, Dr. Cook. I think that you brought up some really good points. It allows the practitioner to showcase his or her expertise. It can help you distinguish yourself from the competition. So for example, if you have areas of expertise or specialty areas that the doctor down the street doesn't have, you can showcase that, and you can actually target the patients that you want coming into your clinic. You can use content marketing as a referral tool.
There's so many great things about content marketing, and the fact that you highlighted, Dr. Cook, the fact that content marketing helps practitioners help people; it helps a ton of people, so it's not just the patients that they're seeing, it helps a broader audience, and I think that is very much in line from a vision standpoint for most of the practitioners, and that's probably true in the case of the practitioners that you're working with, that they have this mission; they're on a mission.
Cook: Yep. Absolutely.
Gazella: Yeah, I think that this is great. Well, this has been a lot of great information, and we are going to be submitting this podcast for continuing educational credits in the area of ethics, so thank you for helping us out it with that, Dr. Cook.
Gazella: And I hope you have a great day.
Cook: Thanks so much, Karolyn. You too.