THE RELATIONSHIP BETWEEN STRESS AND MÉNIÈRE’S

First published in Spin Issue 105 (2021)

Stress is known to both trigger and exacerbate symptoms of Ménière’s, and stress reduction is one effective way to help manage the condition. Living as we are through a global pandemic, life for many of us has never been more stressful. But why does stress trigger Ménière's? And what if anything can be done to help manage it?

Stress activates the fight or flight response releasing stress hormones and increasing inflammation in the body. Fight or flight is the bodies way of responding to imminent danger, traditionally fleeing a lion! Fight or fight diverts energy to the muscles and brain, away from the gut, immune system and reproductive organs, so we can think and run faster. This works fantastically when stressors are brief.

But modern life, not to mention living through a global pandemic, can keep us chronically stressed. When fight or flight is switched on permanently the immune system is permanently disrupted, inflammation increases, blood sugar is imbalanced, digestion is switched off, food reactions develop and stress hormones affect fluid balance. For a few days or weeks we may be OK. But when this goes on for months or years we become vulnerable to disease. This chronic inflammatory state leads too many modern diseases. We now know that inflammation and oxidative stress are the driving force behind Ménière's disease too. So how can we reduce stress and inflammation to help manage Ménière's? You can’t necessarily reduce the stress in your life but you can reduce your bodies reaction to it. Let’s find out how.

The food we eat, our microbiome (gut bugs), immune system and stress response are intimately linked. What we eat can have a positive or negative effect on all of these responses. Thats why food can be both stressor and saviour.  Food is the information which tells our cells how to behave. Food can increase or reduce inflammation, fluid balance, blood sugar, stress levels, hormone levels, improve or harm digestion. So what can we do about it?

1. Eat a rainbow of vegetables

Veg is anti-inflammatory. Veg feeds good bacteria in the gut, boosting the immune system and lowering inflammation. The more diverse the veg you eat, the more diverse your gut bacteria, the lower inflammation, the healthier you will be. A healthy microbiome also sends happy signals to the brain lowering stress hormones. So try new veg. Aim to eat half a plate of rainbow veg at each meal.

2. Drink more water

It’s easy to turn to tea, coffee and booze when we’re stressed, making us more dehydrated. But dehydration is stressful for the body increasing stress hormones which affect sugar and salt concentration and fluid balance in the ear. Increasing water can decrease stress hormones which affect fluid balance in the ear. Ideally drink filtered water.

3. Reduce or eliminate caffeine

Caffeine can increase the stress hormone cortisol making us feel even more anxious. Caffeine also dehydrates and affects sleep. Reduce it gradually to avoid withdrawal symptoms. 

4. Find alternatives to comfort eating

Ironically the food we turn to for comfort can stress the body further, destroying the microbiome, and increasing inflammation. Yet we all do it. A slice of cake to cheer us up, a pizza, glass of wine. Once in a while this is no problem, but the pandemic has meant many of us are reaching for the biscuit tin more often. For example rather than suppressing feelings with food reach for the phone, read, dance, practice deep breathing, take a walk, enjoy nature or learn to meditate. Any absorbing activity that requires intense concentration and distracts can help reset the stress response.

5. Improve sleep hygiene

Sleep disorders are associated with Ménière's. Sleep is essential for the body to heal and repair itself.  It only takes one night of poor sleep to increase inflammation, stress and hunger hormones, making us more sensitive to stress and inclined to overeat inflammatory comfort foods. A regular wake and bed time and sleeping in total darkness can improve sleep quality, decreasing stress hormones which affect fluid balance in the ear.

6. Switch off the screen

We are being constantly bombarded with negative news stories keeping Covid top of mind and stress levels high. Stress before bed can also stop us sleeping well. Blue light from devices also acts like sunshine on the brain, disrupting sleep hormones. So switch off the news and devices, particularly late at night. Watch once earlier in the day rather than checking your phone every hour.

7. Practice gratitude

It’s easy to worry about every little thing especially at the moment, even if you don’t have Ménière's. Research shows focusing on the things you do have, rather than the things you don’t, can help reset the stress response. Try to think of 5 things you’re grateful for each night

Eg The delicious beef stew, the beautiful sunset, my comfortable bed, the call with my grandchildren, the walk in the park etc.

Let’s hope that by the time you read this the pandemic is over, but regardless, stress management is essential to help manage Ménière's symptoms. To recap, you can reduce inflammation by eating more vegetables and increasing your water consumption. Reset the stress response by sleeping 8-9 hours a night, switch off the news and practice daily gratitude. But please don’t stress about trying to do everything on this list! Choose one thing that strikes a chord and do it daily.

There is still a lot to be learned about Ménière's. But we do know it is a condition driven by inflammation and oxidative stress. Learning to manage stress can be one of the ways to help reduce inflammation, either yourself at home, or sometimes clients need further support in clinic.

Beyond stress, dietary and other lifestyle factors can also increase inflammation and trigger and exacerbate symptoms. In my practice I use a Functional Medicine approach to identify biochemical imbalances underlying disease to help manage symptoms.

REFERENCES

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D’Avila C, Lavinsky L. Glucose and Insulin Profiles and Their Correlation in Ménière’s Disease. International Tinnitus Journal. Vol 11, No 2, 170-176 (2005) 

Ishiyama G. Oxidative Stress in the Blood Labyrinthine Barrier in the Macula Utricle of Ménière's Disease Patients (2018) Sep 3;9:1068

Kim S. Relationship between sleep quality and dizziness. March 7, 2018. Plus One. 

Kitahara T. A Two-Year Randomized Trial of Interventions to Decrease Stress Hormone Vasopressin Production in Patients with Ménière's Disease-A Pilot Study. PloS one, 2016. Jun 30;11(6):e0158309. 

Knox G. Menière’s disease: differential diagnosis and treatment. The American Family Physician. 1997 Mar;55(4):1185-90, 1193-4 

Manzel A. Role of "Western diet" in inflammatory autoimmune diseases. Current Allergy and Asthma reports. 2014 Jan;14(1):404 

Naganuma H.  Water may cure patients with Meniere disease. Laryngoscope. 2006 Aug;116(8):1455-60. 

Sanchez-Sellero. Caffeine intake and Menière's disease: Is there relationship? Nutritional Neuroscience. 2018 Nov;21(9):624-631. 

Scuto M. Nutritional Mushroom Treatment in Ménière's Disease with Coriolus versicolor: A Rationale for Therapeutic Intervention in Neuroinflammation and Antineurodegeneration. International Journal of Molecular Sciences. 2019 Dec 31;21(1):284. 

Sbeih F. Newly Diagnosed Ménière's Disease: Clinical Course With Initiation of Noninvasive Treatment Including an Accounting of Vestibular Migraine. The Annals of Otology, Rhinology and Laryngology. 2018 May;127(5):331-337. 

Sharon. Treatment of Menière's Disease. (2015) Apr;17(4):341.

Wu V. Approach to MD Management. 2019. Jul;65(7):463-467. 

Yanguas J. The complexity of loneliness. Acta Bio Medica. 2018 Jun 7;89(2):302-314.

Yeo N. Stress and Unusual Events Exacerbate Symptoms in Menière's Disease: A Longitudinal Study. Otology & Neuratology. 2018 Jan;39(1):73-81

THE LIMITATIONS OF A LOW SODIUM DIET AND HOW TO OVERCOME THEM

As a Nutritional Therapist with Ménière’s I use food and lifestyle to manage my own and my clients’ symptoms. I am constantly asked about the low sodium diet guidelines. I can see how a low sodium diet can be helpful for people when first diagnosed, but clients often come to me as they are frustrated with the restrictive nature of this approach.

Standard guidelines for Ménière’s management are to keep sodium levels between 1500 and 2000mg of sodium per day. This is about half what the average person consumes. It is widely believed that salt restriction works by reducing fluid balance, thus stabilizing the endolymph in the inner ear, as an increase in endolymph is believed to be the main cause of Ménière’s. However, the latest research suggests that this is only half the story.

I believe this approach can work in the short term, but anecdotally some clients find sodium restriction stressful and restrictive in the long run. Much like calorie counting, counting sodium can take over your life. It can stop you enjoying food. It can make eating out stressful at best, or impossible at worst, and can make following recipes difficult. One of my core beliefs is that food should be enjoyable and not stressful. As stress is also considered a major trigger for Ménière’s and its reduction essential for the management of the condition, any guidelines which add to stress levels are not helpful.

Focusing purely on low sodium foods can also mean we restrict healthy foods and instead turn to unhealthy processed foods marketed as ‘low sodium’ options. Processed foods also come with an ingredients list that includes sodium content, which makes them an attractive option if you’re counting sodium. I see many clients scared to eat natural, nutritious, anti-inflammatory foods like fish or olives who instead turn to ‘low sodium’ potato chips, deli meat, cheese, instant mash or french fries, thinking they are better for them. This approach can lead to people avoiding anti-inflammatory foods which could help manage symptoms better and replacing them with foods that are inflammatory, devoid of nutrition and that could actually worsen their condition.

The latest research shows that Ménière’s Disease is actually an immune mediated condition. All immune mediated conditions, including Ménière’s, are driven by the same underlying factor: inflammation. This inflammation can lead to changes in the endolymph and eventually damage to the ear in people susceptible to Ménière’s. This means that thousands of studies linking inflammatory foods with autoimmune conditions can now be applied to Ménière’s too. Salt in itself has been found to be inflammatory, but inflammation can be caused by many other foods, infections and lifestyle factors. To successfully manage the condition it is important that we remove the underlying trigger of the inflammation causing the condition. It is clear that salt removal alone does not do this.

The Western diet is now believed to be inflammatory, high in processed and prepackaged food, and devoid of nutritious fibre, healthy fats and nutrients. These have been replaced with cheap sugar, salt, and artificial ingredients. As the Western diet is adopted in more and more countries, a rise in immune mediated diseases follow. This is why immune meditated conditions and Ménière’s are now considered to be Western diseases. If you don’t eat a Western diet, you’re a lot less likely to get an immune mediated condition.

Manufacturers add salt because it is a cheap way to make food taste good and to make us eat more and therefore buy more. Not surprisingly, processed food accounts for 75% of sodium intake in the Western diet. So what’s the solution?

A WHOLE FOODS APPROACH

A whole foods diet is naturally low in salt, and also naturally anti-inflammatory. But what exactly is a whole food? A whole food is a single ingredient, so no ingredients list is required. For example, plant based foods such as broccoli, almonds and oats, or animal based foods like salmon, eggs and chicken, are all whole foods. They have not been manufactured in a factory which means they are unprocessed and free of additives, artificial ingredients, sugar, gluten and of course salt.

I believe focusing on eating whole foods is a far more positive approach than focusing on salt restriction. It is much more positive to focus on what you can eat rather than what you can’t – it puts the focus on health rather than on disease. As a real world approach, it is much less stressful and easier to stick to. For example, in a restaurant it’s much easier to order a meal of fish and vegetables, or a chicken salad than to estimate the sodium content of every dish on the menu.

Eating an unprocessed diet is nutritionally better for us for many reasons. Not only is it higher in nutrients, fibre, protein, and healthy fats but an unprocessed diet cuts all manner of Ménière’s triggers - MSG, gluten, sugar, dairy, salt - in one fell swoop.

Unprocessed foods are also the richest sources of potassium, the nutrient that balances out sodium in the body. So eating an unprocessed diet gives the body the ratio of nutrients it needs naturally. More importantly, an anti-inflammatory diet can help reduce some of the inflammation triggering Ménière’s much more effectively than focusing on low salt alone.

A whole foods diet also re-educates your taste buds – so fruit tastes sweet, and the tiniest amount of salt tastes salty. This makes it increasingly easy to stick to as your taste buds change and you begin to crave natural foods over processed foods, which increasingly taste manufactured and unnatural.

For context, the average person consumes 3500mg of sodium per day. Significantly, processed food accounts for approximately 75% of our sodium intake. It therefore follows that if you eliminated processed food from your diet completely you would instantly knock 2625mg off your daily sodium intake, reducing it to 875mg per day – way below the aforementioned 1500-2000mg guidelines for Ménière’s.

Obviously eliminating all processed food from your diet is a drastic step, and as we’ve shown would actually be overkill in terms of meeting the Ménière’s Guidelines for sodium. It’s possible to meet these guidelines with smaller and more achievable methods. Aiming to eat whole foods 80% of the time and keeping processed food for an occasional treat should get your sodium levels down to the safe range. If you cut out most of the processed food in your diet, you get to stop counting salt – so you may still even be able to get the salt mill out occasionally!

RECOMMENDATIONS

If your existing approach of counting salt is working for you then please don't change it. But if you find it stressful and restrictive then try following the following recommendations:

• Cook from scratch with whole foods 80% of the time, so you can remove the stress of obsessively counting sodium

• Continue to avoid very salty foods such as salted nuts, crisps and bacon

• Make processed food an occasional treat

• Focus on quality foods without ingredients lists (and therefore salt)

• Avoid foods with ‘low sodium’ claims. They’re likely to be highly processed and inflammatory.

• Once symptoms reduce you may need to occasionally add a little salt to food. In which case use a mineral rich unrefined pink himalayan salt.

• Ensure you drink adequate water as dehydration can also affect fluid balance. Aim for 0.033 liters of filtered water per kg of body weight per day.

SUMMARY

Following an anti-inflammatory diet will naturally reduce salt, without the hassle of counting sodium.

Reducing salt can help manage the symptoms of Ménière’s for some people. However I believe that salt reduction is one small part of a much bigger picture. I feel that the guidance is too narrow and could be reframed in a more positive and beneficial way. Also, the guidelines have been in place since 1931 and don’t take the latest research on Ménière’s into consideration.

Counting sodium levels can be stressful for people in their daily lives, and as stress is a major factor in Ménière’s this is not helpful. Not only that, but a focus purely on low salt can actually push us towards eating inflammatory foods which while being marketed as ‘low sodium’ may actually worsen our condition. In choosing processed, inflammatory foods, you’re by default neglecting to eat anti-inflammatory foods which could in fact help manage the condition far better.

I believe a focus on whole foods, as opposed to salt restriction is a more positive, relaxed and pleasurable approach, putting the emphasis back on health rather than disease and on what we can eat, rather than what we can’t. Whole foods reduce salt in a natural and healthy way, improve nutrition and reduce inflammation immeasurably. A whole foods diet is increasingly easy to stick to, both when eating out and cooking at home. A low salt diet alone will not significantly solve the root cause of Ménière’s, that being reduction of the inflammation that’s driving the increase in endolymph in the ear. Whereas eating an anti-inflammatory diet can help manage the symptoms and potentially even the root cause of Ménière’s over the long term.

To remove the need to obsessively count your salt intake, you simply need to cook from scratch 80% of the time. This means using ingredients without ingredients lists as much as possible, and focusing on quality not quantity. Cooking from scratch doesn’t need to take long either, despite what food companies would have us believe. It takes seconds to scramble an egg or make a stir fry, and minutes to cook a piece of salmon or chicken. Keep processed foods for special occasions and when you do choose some try to avoid products that contain ingredients that are unfamiliar, unpronounceable or are five or more in number. Remember that a processed diet is inflammatory, whereas a natural whole foods diet is anti-inflammatory.

Only once symptoms have reduced permanently can a small amount of high quality salt be occasionally added to your food. The key is to listen to your body.

When I was experiencing Ménière’s symptoms, there was something I called the ‘danger zone’. This was when my tinnitus was constant and at its loudest and I was generally feeling dreadful and exhausted. I knew that feeling like this meant it was not the moment to take any risks with my diet. But now that I haven’t experienced symptoms for a long time, I know that I’m out of the danger zone, and can allow myself to add the odd bit of salt to my food from time to time. For you, being out of the danger zone could mean that your tinnitus is low or barely perceptible and you feel energetic and positive again.

Unfortunately there is no one trigger for Meniere’s. Diet is one of several factors which can increase inflammation. Diet, infections, medications, lifestyle and genetic factors can all play their part. We are all individuals after all, and Meniere’s is complex so each person will have a different mix of triggers. This is why diet is not a cure, but can be a safe approach to try to see if it works for you too.

REFERENCES

Bischoff S. Intestinal permeability – a new target for disease prevention and therapy. BMC Gastroenterology. 2014; 14: 189.

Bruderer S. Population-Based Study on the Epidemiology of Ménière's Disease. Audiology & Neurotology. 2017;22(2):74-82

Caulley L, Quimby A, Karsh J, Ahrari A, Tse D, Kontorinis G. Autoimmune arthritis in Ménière's disease: A systematic review of the literature. Seminars in Arthritis and Rheumitism. 2017 Nov 29. pii: S0049-0172(17)30691-1.

Dahan S, Segal Y. Dietary factors in rheumatic autoimmune diseases: a recipe for therapy? Nature Reviews. Rheumatology. 2017 Jun;13(6):348-358

Fasano A, Shea-Donohue T. Mechanisms of disease: the role of intestinal barrier function in the pathogenesis of gastrointestinal autoimmune diseases. Nature Clinical Practice. Gastroenterology and Hepatology. 2005 Sep;2(9):416-22.

Frejo L. Clinical Subgroups in Bilateral Meniere Disease. Frontiers in neurology. 2016 Oct 24;7:182

Frejo L, Martin-Sanz R, Teggi R, Trinidad G, Soto-Varela A, Santos-Perez S et al. 2012 et al. Extended phenotype and clinical subgroups in unilateral Ménière’s disease: A cross-sectional study with cluster analysis. Clin Otolaryngol. 2017 Feb 6

Foster C. Optimal management of Ménière’s disease. Therapeutic Clinical Risk Management. 2015; 11: 301–307.

Gazquez I, Soto-Varela A, Aran I, Santos S, Batuecas A, Trinidad G, Perez-Garrigues H, Gonzalez-Oller C, Acosta L, Lopez-Escamez J. High Prevalence of Systemic Autoimmune Diseases in Patients with Ménière’sMénière’s Disease. PLoS One. 2011; 6(10) e26759

Greco A. Ménière’s disease might be an autoimmune condition? Autoimmunity Reviews. Volume 11, Issue 10, August 2012, Pages 731-738

Haase S, Wilck H. Sodium chloride triggers Th17 mediated autoimmunity. Journal of Neuroinflammation. 2018 Jun 30. pii: S0165-5728(17)30512-X

Hammer A, Schliep A. Impact of combined sodium chloride and saturated long-chain fatty acid challenge on the differentiation of T helper cells in neuroinflammation. Journal of Neuroinflammation. 2017; 14: 184.

Konijeti G, Kim N, Lewis J. Efficacy of the Autoimmune Protocol Diet for Inflammatory Bowel Diseases. Inflammatory Bowel Disease. 2017 Nov;23(11):2054-2060

Manzel A. Role of "Western diet" in inflammatory autoimmune diseases. Current Allergy and Asthma reports. 2014 Jan;14(1):404

McKenzie C, Tan J. The nutrition‐gut microbiome‐physiology axis and allergic diseases. Immunological Reviews. 28 June 2017

Myashita T, Inamoto R. Hormonal changes following a low-salt diet in patients with Ménière's disease. Auris, Nasus, Larynx. 2017 Feb;44(1):52-57.

Richardson B. The interaction between environmental triggers and epigenetics in autoimmunity. Clinical Immunology. 2018 Nov;196:72-76

Sbeih F, Christov F. Newly Diagnosed Ménière’s Disease: Clinical Course With Initiation of Noninvasive Treatment Including an Accounting of Vestibular Migraine. The Annals of otology, rhinology and laryngology. 2018 May;127(5):331-337.

Sharon J. Trevino C. Treatment of Menière's Disease. Current Treatment Options in Neurology. 2015 Apr;17(4):341

Willebrand R. The role of salt for immune cell function and disease. Immunology. 2018 Jul;154(3):346-353.

Yeo N. Stress and Unusual Events Exacerbate Symptoms in Menière's Disease: A Longitudinal Study. Otology & Neuratology. 2018 Jan;39(1):73-81

Dietary triggers of Ménière's (which aren't salt)

While the true causes of Ménière's are still unknown, research shows that triggers are many and can vary by individual. As a Nutritional Therapist with Ménière's myself, I feel it is my duty to give you the latest research in the hope that it can improve your symptoms, even just a little. 

It takes on average 17 years for the latest scientific knowledge to filter down into mainstream medicine. This glacial pace of adoption, combined with the fact that nutrition isn’t part of conventional medical training, means that your doctor may not be providing you with the latest advice. I’m not here to replace your doctor – just to try to plug that specialist knowledge gap.

MÉNIÈRE’S IS AN AUTOIMMUNE DISEASE

The latest research suggests that Ménière's is on the autoimmune spectrum, in which case a similar dietary approach would be beneficial. As with Ménière’s, the causes of autoimmunity are many and vary by individual. 

An autoimmune disease is where the body mounts an inflammatory attack against a foreign invader, usually a food, virus or toxin. Then the antibodies dispatched to destroy it also attack the harmless cells of the labyrinth (the inner ear) causing damage and increased fluid known as endolymph. Your immune system is attacking your nervous system. Autoimmune diseases are western diseases, meaning they stem from a western diet and lifestyle. Three foods commonly trigger this mechanism:- Sugar, Gluten, and Dairy.

1. SUGAR

Refined sugar is one of the most inflammatory foods we can eat. Eight times more addictive than cocaine, it sends your blood sugar flying up, only to come crashing back down again, like a kind of blood sugar rollercoaster. The hunger and shakiness which follow make us reach for yet more sugar, which sets the rollercoaster in motion again.

The International Tinnitus Journal believes that high blood sugar may be one of the main causes of Ménière’s Disease. In 2014 the American Journal of Otology & Neurotology found that hearing loss in Ménière's fluctuates with insulin levels (insulin is the hormone released when we consume too much sugar). The higher the insulin, the worse the hearing loss. In fact 94.2% of Ménière's sufferers had abnormal blood sugar results when tested. But once put on a ‘Low carb (this means low sugar, as all carbs are broken down into sugar by the body), high protein’ diet to stabilise blood sugar, 92% of patients achieved control of their vertigo.

You’ll know if you have problems with blood sugar as you’ll crave sweet or carby foods, have energy slumps after eating and may also have fat around your middle, as excess sugar is converted to tummy fat. If you develop Ménière's symptoms late morning, late afternoon or in the middle of the night, then a blood sugar crash may be the problem, as these are the times when blood sugar is at its lowest.

LAURA’S LOW SUGAR RECOMMENDATIONS

• Gradually reduce refined sugar (chocolate, cakes, cereal etc) to an occasional treat.

• Reduce refined carbohydrates (cereal, bread & pasta) to 1/4 of your plate. All carbohydrates are converted to sugar by the body. In fact a slice of wholemeal bread spikes blood sugar more than a snickers bar! 

• Eat a palm sized portion of protein (meat, fish, nuts, seeds, yoghurt, pulses etc) at every meal or snack, as protein helps stabilize blood sugar. This is the reason a Snickers spikes blood sugar less than bread - it contains nuts.

• Eat every 4 hours as going longer without food will cause you blood sugar to fall and could trigger an attack.

LOW SUGAR ALTERNATIVES

• Switch to 70% dark chocolate. Place a small square under your tongue and let it melt to get a big chocolate hit without the bloody sugar rollercoaster. 

• Switch your toast, or cereal to scrambled eggs or an omelette.

• Keep a bag of almonds and an apple in your bag for a blood sugar friendly snack

• Artificial Sweeteners also spike blood sugar.

2. GLUTEN

Gluten is the protein in wheat, barley and rye, commonly found in flour, bread, pasta and most processed foods. It is hard to digest so many people are sensitive to gluten. This sensitivity to gluten is believed to trigger inflammation which is the gateway to autoimmune diseases, including Ménière's. 

GLUTEN SENSITIVITY IN MÉNIÈRE’S

You are 6 times more likely to be sensitive to gluten if you have Ménière’s. Ménière's symptoms may indeed be the only symptoms that manifest. This means you may not have digestive issues which are commonly associated with gluten sensitivity, such as bloating, gas, constipation or diarrhea. Gluten sensitivity can also cause brain fog, fatigue, poor memory, joint pain, headaches and anxiety. 

In 2013 the American Journal of Otolaryngology proved that a gluten free diet can improve Ménière’s symptoms, with symptoms reappearing again with the reintroduction of gluten containing foods. Dr Datis Kharrazian, a Functional Medicine doctor has also seen that strategies to manage autoimmunity, such as removing gluten, benefit those with Menieres.

LAURA’S GLUTEN FREE RECOMMENDATIONS

• Eliminate gluten from your diet for 3 weeks - This is the best way to see if gluten is an issue for you. Then reintroduce gluten and see how you feel. If you feel worse you’ll know that gluten is causing inflammation in your body and you should avoid it from now on.  

There are tests a nutritional therapist can do to see if your immune system is reacting to gluten, however an elimination diet is more reliable and far cheaper. I believe everyone with Ménière's should rule out gluten sensitivity before taking more drastic measures. 

NB: Gluten must be consumed for 6 weeks prior to a celiac test, so make sure to get tested for celiac before removing gluten for good.

GLUTEN FREE ALTERNATIVES

• Look for healthy alternatives which are naturally gluten free such as brown rice, quinoa, gluten free oats, oat cakes, rice cakes, sweet potatoes, rice noodles, rice wraps, buckwheat bread, buckwheat pasta and buckwheat crackers. 

• Try to avoid the gluten free aisle as these foods tend to be highly processed and full of sugar and other highly processed inflammatory nasties. 

• For baking use almond flour,  coconut flour, buckwheat flour or chickpea flour.

• Eat more veg - it’s anti-inflammatory! Aim to eat for 5 different coloured veg daily.

3. DAIRY

The protein in cow’s milk is eight times the size of protein in human breast milk, so many people find it hard to digest. In fact 75% of the population are dairy intolerant. As with gluten, this means dairy can lead to inflammation, autoimmune and inflammatory conditions such as Ménière’s.  In 2018 The American College of Nutrition found that Ménière’s symptoms were relieved with a milk free diet and reappeared with its reintroduction.

Other signs you may have a sensitivity to dairy are IBS, joint pain, headaches, migraine, acne, congestion, sinusitis, postnasal drip, ear infections, bloating and gas. Dairy containing foods (cheese, milk, yoghurt or ice cream) may also be your comfort food of choice, as the foods we are exposed too most often are the ones we tend to develop sensitivities too.

LAURA’S DAIRY FREE RECOMMENDATION

• Eliminate dairy for 3 weeks, then reintroduce it noting any symptoms as described above. Both gluten and dairy can be removed at the same time, but make sure to reintroduce them at least 3 days apart so it’s obvious which food caused symptoms.

  
  DAIRY ALTERNATIVES

• Switch cow’s milk to hemp, rice, almond or coconut milk.

• Switch yoghurt or ice cream to coconut, cashew or GM free soy.

• Instead of butter use olive oil, coconut oil or ghee for cooking (ghee is safe as the undigestible proteins have been removed.)

• Eat plenty of greens such as brocolli and kale, as well as nuts and seeds. Calcium is far more abundant in these anti-inflammatory foods than in dairy, contrary to popular belief. 

START A FOOD DIARY

It would be far too much to expect anyone to remove all three foods at once. Life with Ménière’s is overwhelming enough!  Keeping a food and symptom diary can help you see which of these foods you’re eating most often and if any are triggering symptoms. Symptoms can take up to 3 days to appear so this is why a diary is invaluable. This will help you work out what to focus on first. You may need to do it for a few weeks to notice a pattern. For information or help on how to do this then do get in touch. 

CONCLUSION

Sugar, gluten and dairy are the most common foods to set up the inflammation which leads to Ménière’s disease in susceptible individuals. Foods we are sensitive too trigger inflammation, the gateway to autoimmune disease and Ménière’s. 

The science is clear: once inflammation is reduced by removing these foods, you can stop and eventually reverse the damage of most autoimmune diseases, if you catch them early before permanent damage has been done. Unfortunately, if you don’t tackle the root cause the unchecked inflammation may also lead to further autoimmune conditions. That’s why uncovering your own root cause is so important.

This article originally appeared in the September 2018 edition of Spin magazine

REFERENCES

The American Autoimmune Related Diseases Association: https://www.aarda.org/diseaseinfo/menieres-disease/

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Carraccio A et al. Non-Celiac Wheat Sensitivity Diagnosed by Double Blind Placebo-Controlled Challenge: Exploring a New Clinical Entity. American Journal of Gastroenterology 107, no 12 (Dec 2012): 1898-906. 

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Gaby A. Integrative Approaches to Ménière’sMénière’s Disease. Vol 8, No 2 Integrative Medicine. Apr/May 2009. 
Gazquez I, Soto-Varela A, Aran I, Santos S, Batuecas A, Trinidad G, Perez-Garrigues H, Gonzalez-Oller C, Acosta L, Lopez-Escamez J. High Prevalence of Systemic Autoimmune Diseases in Patients with Ménière’sMénière’s Disease. PLoS One. 2011; 6(10) e26759

Hadjivassiliou M, Grünewald R, Kandler R, Chattopadhyay A, Jarratt J, Sanders D, Sharrack B, Wharton B, and Davies‐Jones G. Neuropathy associated with gluten sensitivity. Journal of Neurology, Neurosurgery & Psychiatry. 2006 Nov; 77(11): 1262–1266. 

Kharrazian D. Why Isnt My Brain Working? Elephant Press LP, USA. 2013 

Lavinsky J, Wolff M, Trasel A, Valerio M, Lavinsky L. Effect of hyperinsulinism on sensorineural hearing impairment in Ménière's disease: a cohort study. The American Journal of Otology & Neurotology. 2014 Jan;35(1):155-61. doi: 10.1097/MAO.0b013e3182976f5f. 

Riente L, Bongiorni F, Nacci A, Migliorini P, Segnini G, Delle Sedie A, Ursino F, Tommasi S, Fattori B. Antibodies to inner ear antigens in Ménière’sMénière’s disease. Clin Exp Immunol. 2004 Jan; 135(1):159-163.

Yoo TJ, Shea J Jr, Ge X et al. Presence of autoantibodies in the sera of Ménière’s disease. Ann Otol Rhinol Laryngol 2001; 110:425–9.

Ménière's and Vitamin D

Are you taking vitamin D to help your Ménière's? A recent study which came out last month by the 'Medical Hypothesis Journal' found that Vitamin D supplementation may help improve the symptoms of Ménière's.

This is because Vitamin D helps regulate the immune system, reduce inflammation and heal a leaky gut (the root cause of autoimmune conditions). 

The benefit of Vitamin D in autoimmune conditions has been widely researched, but this is the first study specifically looking at the benefit of Vitamin D in Ménière's.

Vitamin D is one of the most common deficiencies in the UK, due to our lack of sun and increased use of suncream. This deficiency is also believed to partly explain why autoimmune conditions (and I believe Ménière's symptoms too) are worse during the winter months for some.

What to take? 

I'd recommend the BetterYou DLux spray. This peppermint flavored spray is absorbed directly into your bloodstream. It comes in 3000 IU and 1000 IUs.
You can buy it in Holland and Barrett, Waitrose or Ocado. Spray it under your tongue or onto the inside of your cheek.

How much vitamin D should I take?

If you have never had your vitamin D levels checked I'd recommend taking 3000 IU per day. However people with Ménière's may need up to 4000 IU per day initially, but I'd only recommend taking this much if your vitamin D levels have been tested first. For a maintenance dose, I'd then recommend 2000 IU per day.
 

How to get tested?

Your GP will sometimes test vitamin D levels for free, BetterYou offer vitamin D tests here, or you can be tested by your Nutritional Therapist.

Sleep hygeine tips for Meniere's and autoimmunity

Getting enough sleep is crucial when you have Ménière's disease. The immune system only works properly when we sleep, so healing and regeneration of the inner ear won’t happen if we aren’t getting enough quality sleep. 

Sleep deprivation and the stress it puts on the body can trigger attacks and exacerbate symptoms. Poor sleep also increases our stress hormones, spikes blood sugar and increases inflammation (believed to be the root cause of Ménière's and autoimmunity).  

It comes as no surprise then, that sleep disorders are much more common in those with Ménière's (ref). Certainly in clinic, most clients I see struggle with sleeping well to some extent. If you have Ménière's, or another autoimmune condition you should aim for 8-9 hours of quality sleep a night. But you may need more initially if you are severely sleep deprived. 

Sleep hygiene is the first step towards recovery from Ménière's. Here are 5 ways to achieve it:-

5 sleep hygiene tips

1. Total darkness

Light and dark determine our circadian rhythm, the bodies internal body clock which tells us when to sleep. For this reason, our bodies are incredibly sensitive to light, particularly at night.

For total darkness try using a sleep mask or ideally fit blackout blinds or thick curtains. Use velcro if necessary to ensure blinds are fitted close to the wall.

2. No devices 90 minutes before bed

Looking at your phone, iPad or laptop before bed is the equivalent to looking at the sun. This is because the blue light they emit sends a message to the pineal gland in the brain telling it to stop making melatonin, the sleep hormone. 

Ideally, switch your device off 90 minutes before bed and leave it downstairs when you go to bed. Most smartphones now also have a ‘night shift’ function which allows you to shift the colour spectrum away from blue light towards warmer red tones which have less of an effect on melatonin. 

TV also emits blue light, but this is less damaging as we sit further away. Ideally turn the TV off 30 minutes before bed.

3. Caffeine before noon

Caffeine reduces the time we sleep, our quality of sleep and increases the time it takes to fall asleep. It can also cause us to wake up at night needing the toilet. Caffeine reduction is also beneficial in Ménière's as caffeine can affect the endolymph and increase stress and anxiety which can also trigger Ménière's attacks.  Ideally, keep caffeine to before noon.

4. Create a bedtime routine 

Adults are no different to children. Having a bedtime routine that you use most nights helps the body wind down naturally for sleep. For example:

• Noon - Stop drinking caffeine 
• 9.30 pm - Devices off
• 10.30 pm - TV off and do something relaxing - stretching, meditation, bath or shower, read next to a dim light. 
• 11 pm - Lights out - Try setting an alarm to remind you to go to bed

Going to bed and waking up at the same time each day also helps re-set our circadian rhythm. For this reason, if you need to catch up on sleep it’s far better to have a quick nap later in the day, rather than sleeping late in the morning.

5. Contain worries

It’s easy to find yourself worrying when you have Ménière's. Anxiety can also cause attacks and disrupt sleep so take steps to reduce worries before bed. 

For example, avoid the evening news or difficult conversations at night. Instead, a relaxing book, bath or shower, deep breathing or short meditation before bed can do the trick. Research shows practicing gratitude each night can help us feel less anxious, making sleep easier to come by. Simply write down 5 things that you are grateful for before going to bed each night. 

References:

Bruderer, Bodmer, Stohler, Jick,  Meier. Population-Based Study on the Epidemiology of Ménière's Disease. Audiology & Neurotology. 2017;22(2):74-82.

Kim, Jeon, Hong. Relationship between sleep quality and dizziness. 2018. PloS One2018 Mar 7;13(3):e0192705. 

Sharon, Trevino, Schubert, Carey. Treatment of Menière's Disease. Current Treatment options in neurology. 2015 Apr;17(4):341

Yeo, White, Ronan, Whinney, Curnow, Tyrrell. Stress and Unusual Events Exacerbate Symptoms in Menière's Disease: A Longitudinal Study. 2018

Microbial Diversity and AIDs

Diet diversity mirrors microbial diversity in the gut. This means the more fruit and veg you eat, the more diverse your good bacteria and potentially the better your autoimmune condition. This is because beneficial bacteria help the immune system to work.

Take Miguel Toribio-Mateus' '50 foods in 7 days' challenge to see how well you're doing.

COULD DIET BE ONE OF THE CAUSES OF MÉNIÈRES?

This article was originally published in SPIN magazine, May 2018.

Four years ago, I began suffering frequent debilitating bouts of tinnitus, deafness and vertigo, and was eventually diagnosed with Ménière’s disease. As a Nutritional Therapist, I have been naturally drawn to researching the links between diet and Ménière’s. We all know that salt can be a trigger for Ménière’s, but I wanted to know what, if any, other dietary triggers existed.

Through this research, I have found that various types of food can play a significant role in the occurrence of Ménière’s symptoms. I have since made a number of dietary changes that have transformed my quality of life. For example, since excluding gluten from my diet, I’ve noticed that if I accidentally eat any, an attack follows within a few hours. Whilst the changes I’ve made are far from being a cure for Ménière’s, I can happily say that I’ve been largely symptom-free for over twelve months.

In the course of my investigation, the relationship between Ménière’s and gluten was among the most significant that I discovered. So, I’m excited to share my findings today, in the hope that I may help others with their own Ménière’s symptoms.

WHAT IS GLUTEN?

Gluten is a protein found in common grains such as wheat, barley and rye. These grains are contained in bread, pasta, cereal, cake and most processed foods. Wheat, in

particular, is a staple of the modern western diet. It is eaten in some form at almost every meal, making it the most consumed grain on the planet.

Given this ubiquity, it’s easy to imagine that we’ve been eating gluten forever. The reality is very different. In evolutionary terms, gluten is a very recent addition to the human diet. It was first introduced ten generations ago, when farming replaced hunter-gathering and humans progressed to a predominantly wheat-based diet. Whilst ten generations sounds a long time to us, it’s not long enough for the human digestive system to adapt to such a fundamental dietary shift.

Moreover, around fifty years ago all commercial wheat was genetically modified in order to increase yield. This had the unfortunate side-effect of making wheat even harder for our bodies to digest.

So what evidence is there that removing gluten from your diet could help with Ménière’s?

1. GLUTEN SENSITIVITY IS MORE COMMON IN PEOPLE WITH MÉNIÈRE’S

You are six times more likely to have a sensitivity to gluten if you have Ménière’s. In a 2012 study by US journal The Laryngoscope, 56.9% of the Ménière’s community had gluten sensitivity. Moreover, the same study found that many people with Ménière’s suffer from digestive symptoms that seem to correlate with episodes of vertigo.

Gluten sensitivity can also cause symptoms beyond the digestive system (only one in eight gluten-sensitive people suffer digestive issues). The inflammation gluten sensitivity causes throughout the body can lead to headaches, memory loss, joint pain, swelling, brain fog, ear infections, vertigo, tinnitus and hearing loss.

2. IF YOU HAVE MÉNIÈRE’S YOU ALMOST CERTAINLY HAVE LEAKY GUT

In a 2017 study by the American Journal of Otolaryngology, 100% of symptomatic Ménière’s sufferers had a leaky gut. Leaky gut is when holes appear between the cells of the gut wall, allowing undigested food, toxins and microbes into the body via the bloodstream.

Once in the bloodstream, the undigested gluten is seen as a foreign invader. This triggers an immune response, which over the long term may lead to Ménière’s in susceptible individuals.

3. MÉNIÈRE’S SYMPTOMS MAY BE CAUSED BY GLUTEN-BASED VITAMIN DEFICIENCIES

A study in 2010 found that leaky gut caused by gluten sensitivity can also hinder nutrient absorption, leading to multiple vitamin deficiencies which may exacerbate Ménière’s

symptoms. In particular, deficiencies in vitamin B12, B6 and vitamin D were found in gluten sensitive people. These deficiencies have been linked with anxiety, tinnitus, dizziness, nausea, and vertigo.

4. MÉNIÈRE’S IS LIKELY TO BE AN AUTOIMMUNE DISEASE

A growing weight of opinion believes that Ménière’s is actually a type of autoimmune disease. A systematic review in 2011 found that autoimmune diseases are far more prevalent in the Ménière’s population. Autoimmune-antibodies have also been discovered in Ménière’s sufferers, suggesting a role for autoimmunity in the development of Ménière’s Disease.

An autoimmune disease is where the body detects a foreign invader and the antibodies dispatched to destroy it also attack harmless tissues and organs by mistake. The American Journal of Gastroenterology has shown that gluten sensitivity, and its effect on the gut, is a primary cause of many autoimmune diseases.

5. LOSS OF BALANCE AND HEARING CAN BE TRIGGERED BY GLUTEN

Tinnitus, vertigo and hearing loss can also be triggered by gluten sensitivity. Gluten sensitivity has been shown to cause the body’s immune system to attack its own brain tissue.

In 2012, A Professor of Neurology at Sheffield Teaching Hospitals NHS Trust discovered that gluten antibodies can attack the cerebellum, the part of the brain responsible for balance, causing vertigo and nausea. Gluten antibodies can also attack the temporal lobe, the part of the brain responsible for hearing, causing tinnitus and hearing loss.

SUMMARY

Studies show that Ménière’s sufferers seem to be predisposed to gluten sensitivity. Gluten sensitivity can trigger the immune system to attack its own tissues, which in turn can trigger Ménière’s symptoms.

In my opinion, ruling out gluten sensitivity as a trigger for symptoms is a must for everyone with Ménière’s. Unfortunately, there is no reliable test for gluten sensitivity, so the best way to do this is to eliminate gluten from your diet for three weeks and then reintroduce it to see if symptoms return.

That said, we are all individuals, so Ménière’s triggers will vary from person to person. Therefore I strongly recommend you work with a health professional to develop a personalised plan before removing gluten from your diet, or making any other dietary changes.

Laura is a Registered Nutritional Therapist DipION MBANT CNHC and runs a nutritional therapy clinic focusing on Autoimmunity including Ménière’s. She offers complimentary support which works alongside conventional medicine. For more information or to contact her visit www.laurafishernutrition.com.

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