ICU – “I SEE YOU” PODCAST
Diet and Nutrition for Vestibular Patients
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For many people with vestibular disorders, what they eat and drink can trigger dizziness, vertigo, nausea, and other symptoms. The good news is that certain dietary modifications can help you manage your symptoms. Figuring out what to eliminate from your diet can be tricky, though. Not only are triggers different for each person, but you also have to be aware of maintaining a balanced diet, and you want it to taste good too. In this episode hosts Cynthia Ryan and Kimberly Warner are joined by guests Dr. Jessica Lieffers, RD and Alicia Wolf of the Dizzy Cook to discuss diet and nutrition for people with vestibular disorders.
This podcast is a co-production of the Vestibular Disorders Association (VeDA) and Unfixed Media.
ABOUT THE GUESTS
Alicia Wolf is a cookbook author, recipe developer, and Vestibular Migraine advocate. She was diagnosed with Chronic Vestibular Migraine in 2016. Originally a self-taught chef, she honed her skills by attending culinary immersion programs in Dallas, TX and France. Alicia’s recipes have been featured by Yahoo!, PARADE, mindbodygreen, and on local morning shows like Today and Good Morning Texas. She is a Vestibular Disorders Association Ambassador and her advocacy work for vestibular migraine has been highlighted by Healthline, American Migraine Foundation, Miles for Migraine, and Self Magazine. Her first cookbook, The Dizzy Cook, was published February 2020 and has been considered an Amazon Bestseller in the Pain Management category. Her new cookbook, The Mediterranean Migraine Diet: A Science Based Roadmap to Control Symptoms and Transform Brain Health, was created in partnership with her neurologist, Dr. Shin Beh. Both books are available almost everywhere books are sold. https://thedizzycook.com/
Dr. Jessica Lieffers is a Registered Dietitian and an Associate Professor of Nutrition and Dietetics at the University of Saskatchewan. She has published more than 50 peer-reviewed research articles in various areas of nutrition and dietetics. She also teaches in the BSc Nutrition program at the University of Saskatchewan and supervises Masters and PhD students in nutrition. Jessica has been also living with a vestibular disorder since 2018 and brings both professional and patient experience to this podcast.
Hosts:
Cynthia Ryan, Executive Director of the Vestibular Disorders Association (VeDA) https://vestibular.org/
Kimberly Warner, Founder and Director of Unfixed Media https://unfixedmedia.com/
This podcast is a co-production of the Vestibular Disorders Association (VeDA) and Unfixed Media
ADDITIONAL RESOURCES FOR DIET AND NUTRITION
Clinical Practice Guidelines Meniere’s Disease https://www.entnet.org/quality-practice/quality-products/clinical-practice-guidelines/menieres-disease/
Lifestyle Interventions and Meniere’s Disease (Cochrane Review – Plain Language Summary) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015244.pub2/full#CD015244-abs-0002
More information about dietitians:
USA
https://www.eatright.org/about-rdns-and-ndtrs
https://www.eatright.org/find-a-nutrition-expert
Canada
https://www.unlockfood.ca/en/Articles/About-Dietitians/What-is-a-Dietitian.aspx
https://www.dietitians.ca/Find-a-Dietitian
TRANSCRIPT
VeDA uses otter.ai to create machine-generated transcripts. This transcript may contain errors.
Cynthia Ryan
Welcome to the ICU Podcast where we explore the vestibular experience through conversations between patients and the health professionals who care for them.
Kimberly Warner – Unfixed Media
During this podcast, we invite patients to share their stories and healthcare professionals to ask questions. So they are equipped to better care for and truly see the invisible challenges faced by their patients. I’m Kimberly Warner. And
Cynthia Ryan
I’m Cynthia Ryan. And we are your hosts on this journey of discovery. Welcome, everyone, to another episode of the ICU Podcast. I’m Cynthia Ryan here with Kimberly Warner, your hosts and we are excited today to talk to Alicia Wolf and Jessica leafers. about diet and nutrition in, in managing the stimulator disorders, I want to I want to pause before we get started. And just let everybody know I have a personal announcement. I am a new mother of two kidneys. And for those of you who are watching the our YouTube channel, the video of this, you may see some disruption in the background. And I apologize in advance. So but I will if they do come I will introduce them all to you. So anyway, let me tell you a little bit about what we’re gonna do today. So I don’t know about you guys, but I like to eat probably too much and I’m pretty picky about my food. I like food that’s full of flavor, and the occasional or let’s be honest, sometimes more than occasional alcoholic beverage that can be pretty nice. However, it for many people with vestibular disorders and in particular manures disease and vestibular migraine, what they eat can trigger dizziness, vertigo, nausea, and other symptoms. The good news is that certain dietary modifications can help you manage your symptoms. Figuring out what to eliminate from your diet can be tricky though not only are triggers different for each person, but you have to be aware of maintaining a balanced diet and you want it to taste good, too. So today, we’re talking to Alicia Wolf, otherwise known as the Dizzy Cook, about the role diet and nutrition playing in managing her vestibular symptoms. And just Jessica leafers, who is a vestibular patient as well, and also a registered dietitian and nutrition researcher. And Jessica is going to talk to us about what to watch out for when making changes to your diet. So welcome to Alicia and Jessica.
Dr. Jessica Lieffers, RD
Thank you for having me. Yes.
Cynthia Ryan
And let me tell you guys a little bit about Jessica. So Jessica is a registered dietician and associate professor of nutrition and dietetics at the University of Saskatchewan in Saskatoon, Canada. That’s fun to say. She’s published more than 50 peer reviewed research articles in various areas of Nutrition and Dietetics. She also teaches in the nutrition program at the University of Saskatchewan. Sorry about that.
Dr. Jessica Lieffers, RD
You got it.
Cynthia Ryan
Dieticians and supervisors, Masters and PhD students in nutrition. She’s on the board of editors for the Journal of the Academy of Nutrition and Dietetics here in the US. Jessica’s been living with a vestibular disorder since 2018. And she brings both her professional and patient experience to this podcast. Kimberly I’ll pass it off to you.
Kimberly Warner – Unfixed Media
Okay. Welcome, Jessica. We’re so happy to have you here and thank you for having me. Yeah. And welcome Alicia. This is going to be such a an amazing conversation. Most of you already know about Alicia wolf, the incredible Dizzy cook. She is a cookbook author, obviously, recipe developer and vestibular migraine advocate. She was diagnosed with chronic vestibular migraine in 2016. Originally a self taught chef she honed her skills by attending culinary immersion programs in Dallas, Texas and France, which is amazing. Her first cookbook the Dizzy Cook was published February 2020 and has been considered an Amazon bestseller in the pain management category. Her new cookbook the Mediterranean migraine diet, a science based roadmap to controlling symptoms and transforming brain health was created in partnership with her neurologist Dr. Shin Bay. Both books are available almost everywhere books are sold. I have both of them and I use them all the time. My hands down favorite recipe is the enchilada with the tomatillo green salsa says it’s a win. We are so happy to have you guys here. Thank you, Alicia to you for joining us with your childcare duties 24/7. A lot of people know about you, but some don’t. So can you tell us a little bit about your vestibular history and how you discovered that managing your diet, improve those symptoms and maybe touch on the elimination diet too.
Alicia Wolf – the Dizzy Cook
Yeah, so I was diagnosed. I think I’m Coming up on eight years with chronic vestibular migraine and now we probably think I had an element of triple PD and with that, as well, but back then it wasn’t being diagnosed as often. And I was diagnosed after about seven months of just feeling totally dizzy, unstable. I felt like I was walking on marshmallows or that I that I was moving when I wasn’t. I had periods of vertigo as I went without treatment. A lot of the doctors just kind of brushed me off and they kept giving me steroids and telling me I would feel better eventually and I never did got misdiagnosed, a lot was told it was just anxiety and stress. Until I finally went to the Mayo Clinic in Arizona. I did two full days of vestibular testing there, as well as I had already had an MRI previously from a really bad vertigo attack. And the doctor came in he said you had vestibular migraine and I said, Well, no, i How can I have a migraine attack without a headache. And that’s when he explained vestibular migraine to me, but he was an EMT that really specialized in perilymph fistula. So he told me that I would need to see a neurologist or neurotology just to have the proper treatment. Luckily for me, my current neurologist is an expert in unexplained dizziness. And about the time that I left Mayo was the time that his office called me that they had an opening for an appointment for me. So I went to go see him, he did a few of his own tests, and he confirmed my diagnosis with Spieler migraine. So after having two doctors confirm this, I finally accepted it as my diagnosis even though it was so hard for me to wrap my head around the fact that I could have these symptoms of dizziness, light sensitivity, vertigo, this off balance feeling. Sometimes I felt like my head would just pop off and float away. And they were constant for me, I mean, unrelenting 24/7. And it was so hard for me to wrap my head around the fact that that was actually a migraine attack, because all I was ever told, you know from the media, and all we see is that migraine just means a really bad headache. And so this opened up a whole new world to me of trying to figure out how to manage this, this type of migraine with very few resources at the time. Now it’s becoming a lot more talked about a lot more diagnosed, a lot more commonly diagnosed, there are more treatments that are coming out for it. So it’s very exciting to see the evolution since I was diagnosed versus the history of it. But back then there wasn’t a lot to do, especially regarding women who wanted to try to get pregnant. At the time, the new anti CGRP meds were just in the beginning stages, they were just coming out. And they were definitely not being prescribed for people who are trying to conceive, even now I don’t think they’re recommended. And so my doctor and I worked on some medications and lifestyle changes that could potentially bring down those 24/7 symptoms of dizziness and vertigo and all that all those other things for me. And a part of that was to look at my sleep hygiene. So like how much I was sleeping, my hydration, but then also to look at my diet. At the time he he recommended or he mentioned that elimination diet was out there. There was this famous book called heal your headache that had been written. And he said, You know, there’s not a lot of scientific evidence for it. But it could be worth a try considering you are trying to go the more natural route with treatments. So he had seen very successful patients, but he thought it was you know, a good thing to try if I want it to. And so that’s when I started down this path of trying to figure out an elimination diet, how to cook for it, how to eat for it. And for someone like me who has experience with cooking in the past, it was very difficult. I went to the grocery store I started reading labels and not just looking at the front of the label, which was Oh healthy. All these things buzzwords and actually looking at the ingredient list on the back and trying to understand what those ingredients meant, and how it could potentially trigger some of my attacks. So through this process, I remember very vividly, I was doing this elimination, it was very difficult to change my eating habits, because at the time I was having caffeine every single morning with oat milk or not actually not milks in it, and almond milk. And I was eating a lot of nuts thinking I was doing something really healthy for myself, I had heard that nets were really good for brain health. I was also eating a lot of yogurt in for breakfast in the morning. And I had to eliminate all of that. And as I went through about two months on this diet, I remember very vividly having dinner one night, I thought, oh gosh, I’m not even feeling like that much better. I’m just going to try yogurt with my dinner and see how that goes. And as I was sitting at the table, I ate yogurt. And about an hour later, if not a little bit more, I started to have a very severe vertigo attack. And it occurred to me that I had an experienced vertigo attack in months. And ever since ever since starting this elimination diet. And so it was hard for me to see that even though I was dizzy every single day, I was still having an improvement, because I had not had those vertigo attacks, which were totally disabling. And so it’s kind of hard for me to see like the forest through the trees type of thing. Because I was so focused on my daily symptoms, and I didn’t realize like the improvements that were coming along from combining everything else. So that to me was a very clear indicator, oh, maybe there is something to this diet. And I’ll give it a little bit more time. So about I wanted to play say six to seven months in was when I really started to have totally Dizzy free moments during the day. And that turned into totally Dizzy free days. So about that time when I was having like more Dizzy free times, I wasn’t completely symptom free, but I felt more comfortable reintroducing foods. So I started to keep a journal of every food that I was reintroducing, and I was able to bring back a lot of foods like avocados, onions, lemons, and limes, and that sort of thing that that is normally recommended to stop on the elimination diet, I mean elimination diet. But I did find some larger triggers, which were things like certain nuts, yogurt, and certain protein powders actually. And I can’t tolerate caffeine at all. Unfortunately, it’s it’s just too much for me. So even some decaf options really get to me. So I found all of that out through the elimination diet, there were just a handful of things. And it really did help me to kind of calm down my brain and bring down those some of those symptoms for me. So in my mind, it was totally worth it. And I still carry a lot of those that those things from it like reading labels into my life. Now that I’ve reintroduced foods, what I’ve sort of transitioned to is this new Mediterranean diet way of eating, which is less restrictive. But I still avoid you know, a lot of my major triggers, I will check them every once in a while to make sure they are still food triggers for me as food triggers can change throughout the years and with certain treatments and everything like that. But overall, my big ones still tend to remain and they really do lower my migraine threshold. So I still avoid some of those but I focus on incorporating certain foods into my diet now to help me with my brain health. So things like that are high in omega threes. I focus on using olive oil a lot in my cooking, as well as just making sure my blood sugar stays stable throughout meals too. So always making sure my meals are pretty well balanced with the protein, a carbohydrate and lots of fiber and a little bit of fat too. If I do eat sugar now I always try to do it with a larger meal so that I’m not you know, spiking my blood sugar too. So I just try to be mindful of stuff like that throughout not skipping meals, that sort of thing. And it does make a big difference.
Cynthia Ryan
Wow. Wow, there’s so much information there and call out how cool it is that your doctor said there’s not much evidence to support this. You know diet for Management of vestibular migraine but let’s try it you know that that he was open to trying something without a lot of evidence that it kind of puts the power in your hands to control you know your your symptoms
Alicia Wolf – the Dizzy Cook
is what I love about my about my neurologist is he is always a very creative thinker especially with meds and like none of the medications I’ve ever been on and treatments they’ve all been very new. Like I started to mA eyedrops was a big thing for me and no one was talking about it at the time. And he was using it very creatively based on one very small study. And it’s it’s helped me it’s helped a lot of my migraine friends. It’s the same thing with some of these neuromodulation devices. He really likes to just give them a try and see if they help people and so while I see some doctor saying there’s no evidence for that, you know, I see a lot of his patients improving because they’re trying different things. Right. Right had
Dr. Jessica Lieffers, RD
a similar experience with that with with Botox too. We just tried it on for my headaches. I had Vestibular neuritis, and now I have triple PD and cervicogenic dizziness, and we just gave it a try. And bingo. I couldn’t walk better. And and it’s been a it’s been so amazing for my symptom control. So again, similar experience to Alicia had a similar thing with with Botox too, as well. So, Jessica,
Cynthia Ryan
why don’t you tell us a little bit about how you got into into nutrition? You know, how did you become interested in working with nutrition? Because I believe, correct me if I’m wrong, it predates your vestibular problems. Is that right? Yeah,
Dr. Jessica Lieffers, RD
it does. So I I’ve been a dietitian, since I believe it’s I think it’s 2007. I was a dietitian. So I didn’t know what I wanted to do my undergraduate degree, I was like, I want to do science and health, something in that area. And I took an undergraduate first year nutrition course. And I was I was hooked on it. I love the science of it. I loved learning about how all the foods we eat contain different nutrients and how those nutrients have different impacts across our body too, as well. It was very practical information that I could incorporate into my own life. And I just loved loved learning about about food and nutrition. And I also really loved the different practice areas that dietitians can work in too. So some of them will work in hospitals with with inpatients so they might work with outpatients. But some some of your listeners may not know dieticians, also managed food service operations too, as well. So big hospital food service operations, they do that too. And they also work in the community and public health to try to help optimize the nutrition of, of groups of people as well too. So and then they also do research as well. So I just love the diversity of the career and all the different things you could do with it. It was it was really, really fun. So I took that one course and I knew right away that I wanted to do nutrition so that that was how I how I got into it. So I’ve been a dietitian for many years. I don’t I don’t do one on one counseling with patients I am going to focus in a in a research and academic practice. So I teach and I teach undergraduate nutrition students I supervise graduate students I also do nutrition research too as well. So I started thinking a little bit about nutrition and vestibular disorder maybe about 18 months ago after my condition started becoming better managed I was like Oh I wonder what’s out there just kind of my curiosity of it and I just started doing some searches on it and I I just found out there wasn’t a lot out there but I got quite curious about it and both from my own experience and also just reading about other people’s stories as well to became interesting interesting to me to do that. So that’s kind of how I how I how I come here today.
Cynthia Ryan
Thank you
Kimberly Warner – Unfixed Media
I’m really looking for Jessica to hear I’m assuming early on you probably discovered Alicia his work and how that’s been implemented into your life so I’ll say that but I’m I’m Alicia since we know you as the Dizzy cook some of us would love to hear how that started because I mean I hear you are Dizzy already and then you’re like Oh, I’m gonna just I’m gonna write a book. How did that start? And then but I also am also interested because you know we talked touched on the Mediterranean diet and the elimination diet but tell us to since you’re such an advocate for us all around food, how you as a dizzy Cook, implement cooking as a healing process to or eating As a mindful practice, because I know that’s also part of this and not just the nutrients.
Alicia Wolf – the Dizzy Cook
Yeah, so in. So let me just start from the very beginning, I, when I graduated, college, I got dumped. And all my girlfriends, you know, in Texas and Oklahoma, everyone gets married very young here. And all my girlfriends were had very serious boyfriends. And they were always going out on dates and stuff like that. And so I, I moved to Dallas finally, got a job and watch design. And my, my way of bringing myself comfort when I was home alone, was to make myself dinner. And I figured, well, you know, I am by myself, I have this extra income now that I can spend on myself. And so I would go and try out new foods and just go to the grocery store, Hey, I’ve never cooked with mussels before, what’s that like? And so I would rely on a lot of like, the famous Cookbooks You know, things like Julia Child’s and I know garden. And Smith and kitchen was a favorite blog of mine back in the day. And you know, even Martha Stewart great, great classic recipes, and would just kind of make myself something new all the time, every week, I would try to experiment with a new food that I had never tested before. And so that’s how I got exposed to cooking with a wide variety of foods. And okay, I like the flavor of this. I don’t like the flavor. This, I know how to cook this best. This is the way I like it could fast. And so that really taught me a lot about cooking and grocery shopping from the very beginning. Once I got dizzy, that became a lot more challenging, because a lot of us who live with this, understand that going to grocery stores, it can be very triggering the just amount of lights that are around you this overstimulation and it takes all of your energy just to go to the grocery store. I will say that 2020 changed a lot of things for us with grocery store pickup. That’s something that I wish I would have had back in the day. And I think it’s really been amazing for a lot of people with chronic illness,
Dr. Jessica Lieffers, RD
too, as well. Yeah, the
Alicia Wolf – the Dizzy Cook
only thing I hate is they never pick out the best produce. And so I hate that, but
Dr. Jessica Lieffers, RD
I’m a substitution. Substitution. What were you thinking? But yeah, no, I was, especially when I was really really dizzy. i Yeah, it was wonderful having someone come to my door with with groceries.
Alicia Wolf – the Dizzy Cook
I mean, I think that has made the cooking process a lot easier. And in the long run. It was something I had to learn how to do again. And so when I lost my job, I kind of lost who I was as a person, all I was identifying with was this like sick, Dizzy person who couldn’t be the same person that she was before. And so the one thing I tried to do every day and I worked on this with a therapist, she asked me to write a list of all the things that I enjoyed to do in life. And cooking was a top one. And so it was something I tried to focus on something that brought me joy every single day. And so if you’re sitting there fighting with insurance companies all day trying to get into doctors trying to manage you know, getting on their cancellation list. I mean, it’s exhausting. And so the one thing that I did for myself was tried to make a meal go back to those, the what I did before after college and everything when I was feeling very lonely, which was make myself a meal that I hadn’t tried before, which in this case was using these migraine friendly ingredients. So how would I make my favorite recipes but make them work for this new diet. And so I spent a lot of time on my stool, which I recommend for everyone with this tubular disorder he’s trying to cook. I always started the dinner with a mocktail, even if it’s just like sparkling water with fruit or something like that, and in a wineglass just because that made it feel it kind of set the tone, like okay, this is going to be a relaxing event. This is not going to be nice dressing, just trying to get dinner on the table. And so when I thought of it like that, and I planned out more time in my day to really go through the process and put on music and enjoy it. It became very much a comforting experience for me and it made me feel like I could reclaim my life a little bit because I knew for the most part, if I put these ingredients together, I would have a delicious meal at the end of the day and they’re worth all these on knowns like there is with migraine treatment, like, you think you should try these meds and they’ll work and they’ll just make all your symptoms go away. But that often doesn’t work for us. Whereas with ingredients and a good recipe, you can put all those things together, and chances are, it’s going to turn out really good for you. So that’s how I loved to approach it. And it really became more of a mindful practice for me rather than a stressful thing. Now, of course, there are some days where you feel so sick. And that’s when I kind of like lean on to meals that are really good for freezing or meals that you can prep ahead. But trying to plan out meals for at least like five days, even if I was using leftovers was was really, really helpful for me. And I noticed it made a difference just cooking more at home, in the way I felt. As far as like mindful eating, I will say that, you know that that comes kind of after you have to take things like one day at a time. And I’m still learning new things like I’m sure Jessica is going to share with us today. I’m currently working with a dietitian, myself, but just learning new things about how to get new, more protein in your diet things I think we all struggle with how to balance that blood sugar, that sort of thing, and to start to incorporate that now that I have a good solid foundation of what works for me and what doesn’t try to focus more on those types of things to fine tune and help me feel a certain way I’m in my cooking education. A part of me or a part of what I’ve done in the past is go to culinary intensive program in France. And the reason why I wanted to do that was to not only just learn about new, like French cooking techniques, but also to learn about the way that they approach dinner time and gathering their ingredients for food. And it’s very much a thoughtful process like how they go to the market and talk to each of the vendors who are experts in what they do. And they care very much about what they’re selling you. You have a cheese guy you have a lamb guy you have you have a guy for strawberries I mean there’s a guy there’s a guy you know who who’s growing this stuff himself a very much cares about it. And I think in the US we get so used to places like Costco and I love Costco don’t get me wrong. But, you know, it’s, it’s always nice to get to know your food on a little more personal level. And it makes it a little more enjoyable to to have those things in you take a little more care and preparing it when you do that. When you know
Kimberly Warner – Unfixed Media
you’re making me think of, I’m just realizing, and this is sort of accidental, but like I said at the top of the show, I love your green tomatillo salsa. Yeah, one of my veggie beds, has tomatoes, jalapenos, cilantro, and shallots. I ended up buying so many of those because I would make that salsa like constantly was a way that I may have already had the ingredients here with me be was getting to be more mindful with the ingredients. And now I have a gazillion frozen jars of it in my freezer for the winter. So really cool. You know, that’s even take that mindfulness with food. It’s another step and even think, you know, it’s not that hard to grow these ingredients. Yeah.
Alicia Wolf – the Dizzy Cook
So I grow a lot of my own herbs now because I got tired of spending $2 For a little thing of basil. I mean, it does save you a lot of money if you can grow that stuff. Yeah.
Dr. Jessica Lieffers, RD
Mindful eating has actually been added to Canada’s Food Guide, even for the overall health overall population because it’s, it’s decided it’s so important for healthy eating. The new food guide focuses on what to eat and how to eat. But that part of the How to Eat part is the mindful eating piece. So that’s really important that it’s been, I think it’s really great. And leash, I loved your examples of how you were doing that. And Kimberly, too, and I it’s just, it’s so it’s so good that we’re talking about this more and that it’s been more becoming more common in the in our population, we still need to do it more. But I think I think it’s great that it’s starting to become involved in some of our national guidelines. It’s
Cynthia Ryan
so easy to for me, you know, I eat lunch while I’m at my computer, you know, and I know and I’m not thinking about it, you know, I’m just I make a bowl and I eat what’s in the bowl instead of you know, if I’m sitting and being mindful about it. I can stop when I get full. Or many of us in front of the TV and we’re not we’re not thinking about it. So yeah, I love that. Well I still
Alicia Wolf – the Dizzy Cook
have days like that too. I mean, don’t get me wrong.
Dr. Jessica Lieffers, RD
Like romantic foods also really linked to quality of life too, as well too. So it can really bring us pleasure or connection enjoyment that connects us to our culture too, as well. So I’ve been really thinking that food is so important. It’s such a central part of our lives, and it can really help us to, to heal and to be well, too. Yeah,
Cynthia Ryan
Jessica, earlier we were, we were talking about how there’s not a lot of literature out there about the role diet plays in managing the stimulus symptoms, specifically, but we can also expand that to health and other chronic conditions in general, can you maybe share from your research experience, what you know about the about what is known in research about diet and nutrition? In
Dr. Jessica Lieffers, RD
Vestibular Disorders? Yeah, so there were a few things that so again, about 18 months ago, I started kind of diving into this a bit more, as I mentioned before, so again, there’s not there isn’t a lot out there on on diet and vestibular disorders. And doesn’t really surprise me a lot. Because I mean, a lot of people have trouble getting help. And, you know, there’s not a lot of health care professionals working in this area, not as many as we need. So get didn’t really, really surprise me. And there, from what I could see to this, there is no one really focusing in specifically on on this area. It’s, it’s, there’s people who are doing work in this area, but it’s often part of other studies, or they may be doing it, they’d have focused on something else. And they had no diets, some information about diet somewhere. So I found it’s kind of scattered in different places. So I’m not going to talk about everything today. But I’m going to focus on a couple things about your talk about migraines, because Alicia has really done a lot of work in that area. And she’s She knows a lot about it. So I’m gonna leave that with her. But I will talk about a couple of things. So the first thing I want to talk about is, is vitamin D, actually. So vitamin D and BPPV. So vitamin D is is a fat soluble vitamin. Have you heard of it before? You heard of it before? Yeah, so it’s linked to a lot of different health IGE issues ranging from it’s mostly for bone health, a lot of the work on vitamin D, but it’s also been linked to other things like of healthy immune system, dental caries, too, as well. So it’s a, it’s, um, it’s a nutrient that we we have trouble getting in our diets. It’s not in a lot of different foods, it’s in sort of fatty fish and egg yolks. And fortified milk is kind of the main sources, it’s in a few other places too, but it’s not in a lot of different foods. A lot of people do have to use a supplement to to get it but it has been, you know, when you type in kind of diet and vestibular disorders, or diet and dizziness, that’s like probably the top thing that comes up. I don’t know if you’ve seen that before in any of your other searches. Yeah, so
Kimberly Warner – Unfixed Media
especially, I was surprised to see why.
Dr. Jessica Lieffers, RD
And I think it’s because what they’re saying is it may be linked to low vitamin D levels in the blood and also to it’s also especially been linked to recurrence of BPPV to from from what I could see. And so at some studies have found that vitamin D supplements can actually be maybe be beneficial for some people with low vitamin D levels to and vitamin D is really important for calcium regulation. And the otoconia are the crystals are made out of calcium. So that’s why there’s that link there between between those two so so I think for people who have BPPV are especially recurrent and they may be worried about their vitamin D levels is something you can get your doctor to check really easily to as well and is it is something that can be corrected with with with supplements, but again, it’s something to talk to your doctor about too, as well. So that was sort of the first thing I wanted to talk about there with with research again, we can’t talk about everything, but that was something Vitamin D has gotten a lot of press lately too. It’s it’s kind of the sunshine vitamin. But again, we know that too much sun exposure isn’t a good thing. So that’s why we have to go with supplements oftentimes to or foods but again, it’s not and a lot of different food sources. Eggs also contain some vitamin D as well too. Okay. All right. So any questions about that or? Yeah,
Alicia Wolf – the Dizzy Cook
go ahead can really Oh, well, I was just gonna say it’s really important for migraine as well to have good levels of vitamin D. So we did a blood test for myself before knowing what to prescribe because you I think a lot of patients just go out and they think, oh, I need to get vitamin D. But often you don’t know if you’re low or if there is such a thing as taking too much too. Exactly. So that’s an important blood test to get.
Dr. Jessica Lieffers, RD
I just want to talk about that too much piece of Alicia too. That was really glad you brought that up. So anytime you you take supplements, anytime anyone take supplements, and it’s just something to think about each nutrient that we that we that we have available that we need, has different we call the dietary reference intake. So those are the amounts that are needed for sort of general health and they have different, those are sort of our benchmarks of what we want to, to consume. So there’s, there’s two, couple of things I want to talk about there with every nutrient, there’s usually a recommended dietary allowance, I’m not certain about that need sets needed to meet 97 to 98% of the needs of the of the population, or the adequate intake, if there’s not enough data to calculate a recommended dietary allowance, then then they use the adequate intake, which is sort of the amount that the general healthy population and that he had sex group needs. And then every nutrient also has a tolerable upper intake level too, as well. And so and that’s the level where that’s the maximum level where there’s not going to be any harm, but taking that nutrient. So if you start going above that tolerable upper intake level, for different nutrients, there’s a potential for harm as well, too. And this becomes really important when you’re taking when you’re taking supplements as well, too. So, again, making sure that that if you are going to take supplements, it’s always important to talk to a doctor or dietitian about it. But making sure that you’re you’re below that that tolerable upper intake level too, as well. So something to keep in mind with that use.
Cynthia Ryan
I love to hear Alicia that you and your doctor were so consciousness to blood test before you started working with supplements, because I know you talk a lot about the supplements that that you’ve used. Yeah,
Alicia Wolf – the Dizzy Cook
and I don’t know, maybe Jessica can talk to this too. I don’t mean to get too much off topic. But there are some blood tests that don’t work when it comes to supplements. And like magnesium is one that I see for that because it’s not, when you’re measuring magnesium, at least for migraine, it can’t factor in what is crossing your blood brain barrier. It’s just measuring the amount of magnesium in your blood. So that is I think where people get tripped up is they’re like, Well, I’m not low on magnesium according to my blood tests, but they don’t really understand that you’re not trying to get magnesium, for your blood, it’s for your brain, basically.
Kimberly Warner – Unfixed Media
That the magnesium threshold is pretty easy to figure out yourself. That it’s you know, as a laxative,
Alicia Wolf – the Dizzy Cook
that’s what my doctor sent
Kimberly Warner – Unfixed Media
me a blood test, right? You just need to be mindful of your own body.
Dr. Jessica Lieffers, RD
So yeah, I think every nutrient is going to be measured. There’s different ways to measure different nutrient status levels. And and I think it’s just to talk to your doctor dietician, they can advise on which which ones are going to be relevant, relevant for you. Move on to manures disease really quickly, I don’t have a lot to say about that. But I could just say that there isn’t a lot of data on the low salt diet that that is commonly recommended. A recent a recent position or sort of clinical practice guidelines and also some reviewed articles, I’ve just said that the the evidence for the low salt diet is really limited. I’m not saying people shouldn’t follow it, because it does help a lot of people. But I’ll just say that there’s not a lot of randomized control trials on that on that specific dietary recommendation. So, again, we know that it does work for a lot of people. And at something that’s, you know, can be really helpful. And the most recent clinical practice Scott is from 2020. For manures disease did did recommend that as a as a as a therapy. So it’s something that isn’t is important there. But there isn’t a lot of evidence on that. Unfortunately, it’s because it is so commonly recommended. But we do know that it does help lots of people. So it’s about saying not to have it, but I’m just saying that the research data is is limited in that area. Sorry, is just crazy to
Cynthia Ryan
- Yeah, there we have it’s included in the clinical practice guidelines. We have tons of anecdotal data of people sharing that it makes a difference in their symptoms and yet no one’s doing research on it. Yeah, so it’s just weird to me that this is how medicine works.
Dr. Jessica Lieffers, RD
Shocking actually, like I found that to be quite shocking as well too. But yeah, it’s it is something that does work for so many people and it’s IT people should Keep trying it. But there is not a lot of evidence on it. Yeah. Well, just from clinical trials,
Cynthia Ryan
yeah. Give a shout out to there are several books out there about from patients about their experience with veneers and a low salt diet. So, yeah, you can, you can get more information on VITAS website about that we actually have an article on diet, dietary considerations for vestibular disorders with some references to books.
Dr. Jessica Lieffers, RD
I think you had a Facebook Live last year too, if I remember from a low salt diet too, as well.
Cynthia Ryan
Yes, yes. Yes. I remember with one of the authors. Yes.
Dr. Jessica Lieffers, RD
Yeah. Okay. And then the last Can I talk? I’ll talk about keto. One more area is, yeah, okay. So the last story I want to talk about is research on people’s experiences with food and diet, people with vestibular disorders, in their experiences with food diet, this is probably the area that I’m most interested in myself, um, it ties into some of my other work that I do. And a lot of these studies, they either use surveys to get information from people, or they’ll do what’s called qualitative studies. Do you guys know what qualitative studies are? You heard of those before?
Cynthia Ryan
A little bit, but it would be great if you could explain for our listeners, okay.
Dr. Jessica Lieffers, RD
So what they are is they’re studies that don’t collect information on participants using numbers, they collect info, that would be quantitative study, so it’s more numerical. But they collect data more on people’s experiences, perspectives, and behaviors and motivations. And they collect the collected information using words. So things like interviews and focus groups, and also observations too, as well. So they’ll go in, and the sample sizes are usually really small, they’ll maybe interview five to 30 people somewhere in there, and they get really, really rich data on those topics. So get a few. And this can be really helpful to generate new research ideas, as well as helpful to for developing supports for people who live with different health conditions too. And I think this is where we could, I’m interested in this area as well, too. So there’s been a few studies that have looked at, you know, people having trouble with some of the stuff we’ve talked about today. So acquiring food, food preparation, activities, shopping difficulties, a bit, a little bit on that, but nothing that’s focused on food. It’s all been kind of dabbled in other studies, too. So it’s been a little bit on that. And challenges also with with social activities, too, as well. So eating in restaurants, too. I know, I’ve been overstimulated in many restaurants before, Alicia, I don’t you probably have been to as well, like. So and then another part of some of this workers that I found really interesting was that there were I found four articles that provided that said that more than more than 50% of their the nice ones use surveys, but they had more than 50% of their survey respondents said that they either did diet changes or received a diet intervention to manage their vestibular which I think as a, as a dietitian, this really interested me a lot that there’s so many people who are using this, this tool to do that. And we don’t really know a lot about people’s experiences using that we have Alicia, you’ve done a lot of you’ve, you’ve shared your story. So well. And I think what people have really, really learned from it, vinyl, there’s lots of probably there’s lots of other stories, too, that that people would have as well about making those those diet changes. And you know, I think I think that’s something that I think we’re missing in our, in our literature, I think that could really help us develop some, some some better supports too, as well. So I can
Alicia Wolf – the Dizzy Cook
give you lots of feedback from my DMs, if you I hear at all
Dr. Jessica Lieffers, RD
what we need to I think, you know, we need to start. And that’s great. I know, there’s lots of stories out there, but I think getting them getting them out there. And then the peer reviewed literature is important too, as well. Yeah. Yeah. Well,
Cynthia Ryan
I love that, you know, we have research that is patient focused. That’s great to hear. So so, you know, on this similar topic, you know, we’re talking about supplements. And Alicia, I know you you talk about supplements a lot in your blog, and also gut health. Do you want to kind of dive into that a little bit? Yeah.
Alicia Wolf – the Dizzy Cook
So God are Well, let’s start with the supplements. So I initially got a sheet of supplements to try from my neurologist. So like, I think a lot of us do, like here, take these and it will, you know, let me know how you’re in six months. The thing about what they recommend is they are doing it based on research studies. And so I found out that magnesium oxide was often being read commended, because that was the type used in migraine studies. That was interesting to me because as I started researching different types of magnesium, I found that that can often like stimulate bowel movements a lot more than other types of magnesium. So I started looking at different types of magnesium. And I wrote an article for my website about it initially just kind of researching different types and did a little small group with some of my migraine friends to look at the the benefits of maybe using magnesium three and eight. And if it could help us with some of the symptoms like brain fog, I published this on my website. And with like the literature, this very limited research on it, for other patients with cognitive issues, and how they sought benefits with it there. And as well as like our own experiences of testing this out. And what was interesting is, out of all the supplements I tried, that was probably the one that I saw the quickest benefit with and because I wasn’t having caffeine in the morning, often I would feel really sluggish when I woke up. And I don’t know if that’s a like not caffeine thing or a vestibular thing, maybe both. But I noticed that when I use magnesium three and eight in the morning, that that really helped sort of clear my brain and give me a little more energy. And so published on my website, what’s interesting is I’m starting to see more people recommend it now, as well as things like magnesium glycinate. So I actually take a combination of three different magnesium because I found that works best for me. So I think sometimes with these recommendations, looking to see what works best for you. And even different types of supplements can be helpful because one brands magnesium is going to be have a different makeup than another brands, magnesium. And so I’ve seen patients take one type that they don’t tolerate well, and they switch to another type. And that can be very effective for them. So just because someone recommends or your doctor recommends supplements for you, you know, it really is what works best for you. So you kind of have to take it for a little while see if you see a benefit. I will say it’s you can’t just take things for like a week and expect it to have to have this big, clarifying moment, it generally takes about like three to four months to notice a difference on anything you take, whether it’s medication, supplements, diet changes, that sort of thing. And to kind of work and see if you’re seeing a benefit from it. And then you can always take it away to see if Okay, is this actually working for me? Or is this just giving me really expensive P? You know, and that’s it, you kind of have to do. So there are supplements that I’ve continued, because I see a big benefit from the things like my combination of magnesium and their supplements that I’ve stopped taking. So stop taking so much riboflavin even though that was recommended migraine prevention, just because I wasn’t seeing a huge benefit from it anymore. I’ve had bad reactions to certain supplements that have been recommended for migraine too. So it’s just like I said, it’s important to see what works best for you. As far as the gut health component, that is something I’m still learning, like I said, I am working with a dietitian now and when I decided to work with a dietitian was because I had had two kids right in a row. And I had very complicated pregnancies and C sections and everything like that. So I have been on antibiotics a lot, I have been sleep deprived, I have not always been able to eat the way I would like to and so that in turn can you know do not create a great environment for your gut health. I’m also very sensitive to certain strains of bacteria. So certain types of probiotics don’t work? Well. For me, it’s the same thing. I can’t tolerate yogurt for very, very well. So we’re kind of looking into that I’m trying to figure out what tests I actually need and what tests are a little woowoo for me and that I don’t want to spend that kind of money on so going down that route has been very interesting. But I know at the at the heart of it is like eating a very very diet can be very important. I can tell just because
Dr. Jessica Lieffers, RD
I mean the gut microbiome is not is not my focus of my any of my research, but I know a little bit a little bit about and I can so it’s there’s been an explosion of interest in this in the past 10 to 20 years. It’s burst and And I will say information on this topic changes daily. So, even I don’t even like reading papers from a couple of years ago on this, because I don’t know if it’s even relevant anymore. So basically, our gut microbiome is made up of trillions of bacteria in our GI tract, especially in our lower GI tract. And it’s been linked to a lot of different health issues, including mental health issues. So depression has come up gastrointestinal health, cardiovascular, health, diabetes, so much more so. And the effects from the gut microbiome can happen through a lot of different kinds of pathways in the body. So just knowing that and we’re learning more about this every single day, I wouldn’t be surprised. And again, that there might be a link, eventually discover a link to distributor disorders to as well as something I don’t think we’ve got any research on that yet. But or not much. But I wouldn’t be surprised. That’s, that’s a pure speculation. For me,
Kimberly Warner – Unfixed Media
there is a great book by Ed Young called I contain multitudes. Did you read that one? Jessica, I haven’t read that book. Excellent. And he does, he touches on so many different disorders that are, you know, that have sort of microbiome precursors to those disorders. So highly recommend it, it’s called I contain multitudes. And I read it like eight years ago, and I feel like they even remember something about dizziness in there, but I can’t quote, don’t quote me on that,
Dr. Jessica Lieffers, RD
ya know, it’s, it’s changes so much, it’s a really, really hot area right now. And the big thing with the gut microbiome, Alicia, maybe you’ve heard this from your dietitian, too, is fiber is really, really important and getting a variety of fiber. So we want kind of a lot of diverse fibers, because the fiber, the bacteria feed on the fiber, and they digested they produce what’s called short chain, fatty acids, and those have a lot of different effects in the body. So basically, eating lots of different kinds of fiber, which is found in plant based foods. And we know that a lot of just the general public doesn’t get enough fiber anyways. So this is something that you know, is really important. Fiber is found in whole grains, vegetables, and fruits, legumes, nuts, and seeds as well, too. So those are some some sources of fiber too. So yeah, the gut microbiome is a really, really hot area right now. I
Cynthia Ryan
know I’m jumping around here a little bit, but you you just mentioned whole grains and Whole Foods. Can you talk a little bit more about the role that holds play healthy diet?
Kimberly Warner – Unfixed Media
Yeah, you’re talking about that. This because I’m aware of, I don’t want to keep you guys for so long. But I know we really want to get to blood sugar, and I know that those are really connected. So maybe include some of your understanding around balancing blood sugar and why that’s important for vestibular patients. Yeah,
Dr. Jessica Lieffers, RD
so different. Blood sugar can have a lot of different impacts potentially, on the severe patients, we know that low blood sugar for pretty much anyone can cause you to be become dizzy or get headaches. Just not feel well, I know for me, I get I get those kinds of things too, if I don’t eat eat enough food. And we know that it’s really important to make sure that we have stable stable blood sugars throughout the day. So and also to familiars, disease, it could be really important too, as well for people that really make sure their food intake is balanced throughout the day, too. So whole foods are foods that are pretty much as close as possible to their natural states. So basically, if you think about picking a tomato off a bush or that kind of thing, those are those are Whole Foods and we know whole foods are really really rich in vitamins and minerals and fiber as well as and then. And then those are in contrast to more Ultra processed foods or highly processed foods, which are foods that are really are they’re they’re high and added salt, sugar and fat, and they’re very shelf stable too, as well. So they taste really good, but they’re not they’re not very good for us. So it is really important that we get a lot of a lot of whole foods that are in our diet and we know those whole foods have have blood sugar, I mean have have fiber in them, that can really help especially the fruit vegetables and fruits, a whole grains that can really help slow down absorption of, of sugar in our body. And it can cause us to have that nice sort of stable blood sugar. If we eat something that’s high in simple sugars, which is like table sugar or foods like candy, baked goods, that kind of thing. Those can cause our blood sugar to spike. And then and then and then we get that we get a sugar low after and we don’t feel well too, right. So those are things that we want want to avoid. So some things to help balance our blood sugar is to make sure that we eat breakfast. That’s a that’s a really important recommendation for balancing blood You’re getting off to a good start of the day. And this can help regulate your blood sugar throughout the day as well to focusing on complex carbohydrates, so those foods that are in love those whole foods are those those on those foods that are minimally processed. So you know, vegetables and fruits, whole grains, legumes, that kind of thing. Those are, those are foods that that can help they take longer to digest, because the sugar molecules in them are in big strands. And so the body takes a long time to digest those. And those can help keep our blood sugar more stable, too, as well. And those are good. I mentioned some of the foods. And then I just
Cynthia Ryan
said, I’m sorry to interrupt. I just wanted to share something that I think is kind of funny. My husband recently told me that popcorn is considered a whole grain. Yes,
Dr. Jessica Lieffers, RD
yes, it is. It is. So a shame Canada’s previous Food Guide popcorn was was a whole grain and they’re listed in there. So that’s that is true. So that’s yes. So that is a good thing. I mean, sometimes they can get we can add a lot of fat and on Oh, yeah, I do. Like a less healthy choice. But But popcorn itself. Yes, air pop popcorn is a is a whole grain, too, as well. And then I think too, when when blessing want to say about balancing blood sugars is to make sure that you eat frequently, as well, too. So having three meals, I get a couple of snacks a day too. And then making sure meals have sort of half your plate is vegetables, a quarter of it is a is a whole grain product or a grain product and then a quarter protein. And then and then snack should be a couple of different food groups, you should have a complex carbohydrate with a with a protein ideally a bit too, as well. So those are some things that can be can be really helpful for balancing blood sugar, too. I hope that answers your question.
Kimberly Warner – Unfixed Media
Yeah. Okay, so I want to let’s talk about hyper vigilance because we’ve just spent an hour talking about like, do this. Try not to do that. Consider this, maybe do this. And of course, many of us vestibular patients are perfectionist and that contributes to the dizziness we found. So how do you navigate all of this information and still remain chill?
Alicia Wolf – the Dizzy Cook
Think it’s probably best, someone who’s trying to navigate this herself too, I think it’s probably best to focus on one thing at a time. So for me I is what I see a lot of people have an issue with is they’re trying to combine different diets when they’re trying to do an elimination diet. So instead, okay, if your goal is to find if you have migraine food triggers, then focus on that for now. And then the other stuff, you can figure it out later. It’s the same thing with with if you’re focusing on you know, just trying to make small changes, like Jessica said, eat breakfast every day. So that’s can be one goal is just okay, I’m going to just focus on having breakfast every day. And my breakfast is not going to you know just be oats, but it’s going to be I’m going to add an egg to that. Or I’m going to you know, make this turkey sausage or to get in some protein in the morning or add cottage cheese or whatever works for you. I think making those small changes. And once you get comfortable with that adding something else in is really an effective way to go about it. Because for me on the Elimination Diet initially, it was very overwhelming. And so my first my first goal was to just try to figure out reading labels and find products that I really liked that would help make my cooking easier. So once I had those products sound, I could shop very easily I didn’t have to think about it, read labels every time and that sort of thing. I could just go grab what worked well for me and go from there with the recipes. I also think meal planning is a highly effective tool for people with these disorders. So I try to make at least three new meals a week and then incorporate meals that are going to work for other nights of the week too. So those are things like I will do a lot of slow cooker chicken or so prefer pull pork and so I’ll use that chicken one night and do tacos with it and then the next day I’ll do a salad with it or I will put it in you know make functors or I will use it for a soup or something like that. So I’m getting two different dinners with one way of cooking and so that cuts down on thought on my time cooking and it also gives me variety to do which
Kimberly Warner – Unfixed Media
brings the joy to which seems like one way to counteract the vigilance is to have joy with it, whatever that looks like, because food should be
Dr. Jessica Lieffers, RD
fun, should be fun.
Alicia Wolf – the Dizzy Cook
It should be fun. And that’s the other thing, too is I will see a lot of people get wrapped up in is this causing me trigger? Is this? Is this a trigger for me? Or is it? Am I just having symptoms all the time. And so I always tell people like to not focus on trying to figure out triggers in the moment, you just try to figure out, how do I eat the best during my day, that’ll make me happy. And so a lot of times, like with thanksgiving, where we have holidays coming up, right. And so people are really worried about what they’re going to eat. So I tell them to pick out, you know, a few recipes that will work for you make something send something to do someone else who’s going to be cooking at that meal, and then allow yourself like a little bit of fun. So whether that is, you know, whether that is chocolate cake, or a high sodium item, or something like that, or if it’s red wine, that’s what your, you know, fun food is and you enjoy that. And then you are mindful of the other things you’re doing. So you have
Dr. Jessica Lieffers, RD
the 8020 rule to Yes, a thing that they often say is, you know, 80% of time eat healthy and then splurge on that, that other 20% or 9010, or whatever you choose. But yeah, don’t want to restrict yourself from not having those those fun. Favorites, right? Yeah.
Alicia Wolf – the Dizzy Cook
Yeah, maybe one glass of wine works better than two. Or maybe you choose the cake. And so the wine or you know, whatever it is.
Kimberly Warner – Unfixed Media
If you feel kind of crappy the next day, it’s like you just kind of I know the symptoms. It’s not, you know, cause for freakout, it might happen. And that’s okay. So that’s really cute.
Cynthia Ryan
Yeah, this is such a huge topic. I mean, we’ve covered a lot, but there’s, yeah, I didn’t even get to everything that we wanted to talk about. We’re gonna have to have another conversation another time. Yeah. Thank you so much for sharing your experience your expertise. And, and for more information, obviously, go to the Dizzy cook.com.
Dr. Jessica Lieffers, RD
Right. I just make one plug to I just want to say if anyone has any nutrition questions to do seek out a you know, don’t be afraid to seek out a registered dietitian as well to, um, you can look for the Academy of Nutrition and Dietetics. Or you can talk to your primary care provider as well, too. If you have any questions about nutrition, because nutrition can be really hard, can be really hard and confusing. There’s a lot of a lot of mixed messaging out there. Everyone knows about food. Everyone has an opinion on foods. So yeah, don’t be afraid to talk to a dietician. Any questions?
Kimberly Warner – Unfixed Media
Jessica, if you have any links that you’d like to share, we can include that in the YouTube
Dr. Jessica Lieffers, RD
description too, I can share a link for the Academy of Nutrition Dietetics find a dietitian page and also for some pages in Canada too, as well dietitians of Canada and unlock food.ca as well to
Alicia Wolf – the Dizzy Cook
make sure you go to their website to and like look at them before to make sure like their views kind of align with yours. And it because there’s a lot of like Instagram dieticians out there now who are not the best at advice. Perfect.
Dr. Jessica Lieffers, RD
What’s the dietician, what I would suggest is talking to them getting a sense of it’s going to be a good fit, you may need to talk to a few different ones like like physiotherapist or doctors to you know, sometimes the first one is not not the one you end up working with, but they all have different areas of expertise that that. So, so, but I know for many people, a dietitian could could be a valuable care team member as well.
Kimberly Warner – Unfixed Media
Great. Well, thank you all this has been such a great conversation. I can’t wait for part two. Thank you.
Dr. Jessica Lieffers, RD
Thank you. Great to be here.
Cynthia Ryan
Thanks for tuning in to ICU this month. We hope
Kimberly Warner – Unfixed Media
this conversation sparked new understanding of the vestibular journey. And for all of our patients out there leaves you feeling just a little more heard. And a little more seen. I see