Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!

A patient came in with weight gain nobody could explain. Every test came back fine. Shiv K. Goel is a board-certified internal medicine and functional medicine physician. This episode is based on his article “How relationships affect health, seen from the exam room,” published on KevinMD. He treats the people in a patient’s life as part of the same picture as sleep, alcohol, and diet. A difficult supervisor and plain loneliness count as stress the way a marriage does. He is careful to say that a hard relationship does not cause disease. It changes the load the body is carrying, and that load shows up physically. You will hear what he rules out first: thyroid disease, anemia, diabetes, and sleep apnea. You will also hear what a flat cortisol curve tells him about long-running stress, and the questions he asks when nothing turns up. He is not a marriage counselor, and that referral belongs to someone else. He closes with two questions, one for physicians and one for everyone else.

This episode is brought to you by ModMed.

Welcome to your new AI-Powered Practice from ModMed. We’re transforming specialty care by embedding AI Assistants across your entire workflow. Our all-in-one platform of EHR, patient engagement, practice management, and RCM helps reduce repetitive work while keeping you firmly in control.

Trained on de-identified data from nearly a billion patient encounters, this isn’t just smarter software. It’s a new way of working for specialty medicine, more efficient and more connected to the patient experience.

Start building your AI-Powered Practice at modmed.com.

VISIT SPONSOR → https://www.modmed.com/

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Shiv K. Goel, internal medicine and functional medicine physician. Today’s KevinMD article is “How relationships affect health, seen from the exam room.” Shiv, welcome back to the show.

Shiv K. Goel: Thank you for having me, Kevin. I’m excited to talk about this topic.

Kevin Pho: All right, so in your article, you open with a case study about a patient, so let’s talk about that particular patient and case study to jumpstart our conversation. What happened?

Shiv K. Goel: Yes. First of all, for those who don’t know me and are listening for the first time, I’m Dr. Shiv K. Goel. I’m an internal medicine physician practicing in San Antonio, and I moved into functional medicine later on. The example I use is one of my patients, and I have changed the identifying details, because I had been seeing the same kind of patient quite often. I felt as if I was treating their bodies, but over 20-plus years in my career I realized that I was usually treating their relationships. The body was just where the evidence started to show up.

The patient I talk about in this article had unexplained weight gain. That is what triggered this piece specifically, because her workup was completely clean. There was no other underlying issue causing her to start gaining the weight. It happened around the same time that things started to change in her home and in her life, and that caused more stress, and that led to the weight gain.

And I told her story rather than lecture, because people recognize themselves in a story, not in a mechanism, not in the numbers.

The subject does not really come up. We don’t usually go to the doctor for a 15-minute visit and tell them, because a lot of the time we ourselves don’t know what’s happening. We don’t say, “Hey, I’m having a relationship issue which is causing the weight gain.” We only identify with the symptoms, with what we are having, and most of the time we do not relate it to the issues we’re dealing with.

Kevin Pho: So you’re saying that a lot of the physical manifestations that sometimes you see in the exam room can be traced back to whatever problems that they have with family and their other relationships. What are some common relationship issues that you see manifest as physical conditions in your exam room?

Shiv K. Goel: So first let me talk about the idea that people should understand: how a relationship affects health, and in what way. A relationship could be any kind of relationship. It doesn’t have to be just a marriage. With my patient, it was her husband. But I usually see people such as adult children who have a strained relationship with their parents. People caregiving for aging parents, or special needs children. Children who require special care, who require support, and the relationship between them and their caregiver, their parents, which causes stress.

Employees under a chronically difficult supervisor or a boss, or a one-sided friendship that quietly drains someone for years. And it could be between anyone.

It has a lot to do with how you feel in your home, in your workplace, and in your life. The environment which surrounds you: Do you feel safe there, or do you always have to brace yourself to be in that environment, to exist in that environment? And that is what matters here.

A lot of people have a habit of people-pleasing. Or you can say a hypervigilant kid, who is always bracing himself that something wrong is going to happen. And loneliness, which is another kind of epidemic happening, can be just as clinically significant as those relationships are. And that doesn’t mean every relationship. I mean the relationship which affects your environment to grow in a more vital, more authentic way of yourself. That’s what I meant by relationship. It could be any person, situations, your home conditions, or anything.

So relationships affect health. What I meant by that is they are a part of a person’s health environment, the same category as sleep, alcohol, or diet are, because they affect our body, so they are not separate. And I’m not saying a difficult relationship causes disease, not that every difficult relationship ends up with a disease. I’m saying it changes the load your body is carrying, and that load shows up physically.

The line I keep coming back to is that some relationships are like a medicine. They help you grow. They help you feel better. You feel loved. You feel secure. You feel like you belong. And some relationships are like a diagnosis. They create issues in your body.

So a relationship can look emotionally warm on paper sometimes. Everything looks perfect, but at your home it is not. The nervous system responds with consistently higher sympathetic activation. It is like bracing itself all the time. And it doesn’t have to do with what people think a relationship means, only romance, or husband and wife. It shows up in any form: parents, coworkers, your work conditions, your living situations, any kind of relationship it can be.

Kevin Pho: So give us an example of the types of questions you ask in your exam room to go deeper into the relationships that your patients are experiencing that could lead to some of their physical symptoms. Give us an example of the type of questions you use to approach this issue.

Shiv K. Goel: Yeah, that’s a very good question, Kevin. First of all, I just don’t assume that it is a relationship causing issues. I don’t know about that yet. So the most important thing is that first I need to understand and rule out what is happening with the patient.

I run some blood testing first, if they have weight gain or if they have high blood pressure or any kind of thyroid disorder. So, making sure that there is no other underlying issue happening with them, such as any endocrine issue like thyroid disease, or anemia, or diabetes, or sleep apnea. People who are obese have a tendency to have obstructive sleep apnea. So those are the red flags.

Then I look for whether they have other endocrine issues such as adrenal insufficiency or Cushing syndrome. I check their blood test, CBC and their lipid panel, their urinary free cortisol, late-night salivary cortisol, just to see even if at the late night their cortisols are still very high. So that gives me an indication that they are in some kind of stress. I don’t know that stress yet. So that could be anything, the stress.

And then I order them a four- or five-point salivary cortisol curve to understand their HPA axis there. What is the cortisol level in the morning, mid-afternoon, evening, and at the bedtime or midnight. And there’s good research about this topic, how stress and how allostatic load affect your health and everything underlying it.

Now, recognizing the pattern is not easy, because a lot of the time people don’t share it directly. So you have to ask the questions which help them. Give them some leading questions. Suppose a patient came in with a weight gain, this patient. So I ask about their sleeping issues, if they’re having any insomnia, any anxiety issues. When did they actually all start?

There is always a specific period of time, or around this time it started to happen, and you can take it about a couple of months here and there. And what was happening in their life at that time? Any event happened? A lot of the time people have someone died in the family. I had a patient whose father died, and then after a month, her brother died, and then she underwent a surgery. She had one stress after another in her life, while she had a very stressful personality to begin with. So all those things give you an idea about what could be the issue.

If somebody got laid off from the work around that time, somebody going through a divorce at that time. So I’m not saying that everything is related to relationship, and that’s why you have to do the proper workup to understand that they are not, because stress could be multifactorial as well. It doesn’t have to be that people have a divorce happening at the same time while they’ve got laid off from the work, and then they have to do something else too, and their lifestyle stress as well.

So you have to see what is it that is affecting them the most, and then you have to work on each one of them. You can’t heal the relationship, but you can help them understand what is happening to them.

Kevin Pho: You mentioned measuring cortisol levels several times a day. Tell us an example of what you do when those numbers come back, what you do with the results.

Shiv K. Goel: OK. And here I would be kind of a bit cautious, because when we talk about adrenal health, I don’t use the word adrenal stress, or chronic adrenal stress, which a lot of people use. I use an HPA axis overload, which is very definable.

So suppose somebody, I ordered a four-point cortisol test, and I found out that their morning levels are either very low or very high. And then their afternoon levels. Like, I had a patient just a few days ago, his morning cortisol level was two, which is very low. Number two, when usually people have eight within half an hour, eight to 15 or something. And then it jumped a little bit in the afternoon to about four or five. Then in the evening, it again crashed down to one.

So that shows there is something off. His DHEA level was also super low. So that tells me that it’s a flat curve, as if your adrenal gland is so burned out, like your HPA axis is not supporting it. And that can happen over a long period of stress.

Now, if somebody comes in like this patient which I brought up. So she had elevated cortisol levels in the morning, which goes up a bit and then comes down. Her evening and midnight levels were still very high, and especially in the evening time, it goes further up. So that gives me an idea the patient is in a very high stressful situation.

Usually, in normal people, we have a kind of a curve. In the morning, it goes up, and then it goes further high in the mid-afternoon or something. And by the evening, the body starts to relax, because it’s like a time to go home, relax, and it comes down. Especially at the bedtime or midnight, you will find it level at around four or five. But if there is an almost flat curve, whether it is too elevated or whether it’s too low, both are indicators that there is something going on in your HPA axis. Either you’ve been under a lot of stress for a very long time, or even recent.

Kevin Pho: Now, once you alleviate the stress, and it could be whatever is causing the stress, relationship issues, do you measure these cortisol levels serially to see whether alleviation of your stress is improving your cortisol levels?

Shiv K. Goel: So my role here, I’m not a marriage counselor. I’m not a relationship solver. I refer them to the therapist who can help them. My role is to help them understand, because many times people don’t understand what is going on in our life. It’s just that we’re just not feeling good. And these issues we don’t discuss with even our doctors, with physicians, with our friends, because they are very intimate, but this is where our health starts to decline. So I help them understand the issue.

My goal is to help my patient. Relationship is something they have to work on, and this is their decision. I can help them, refer them to a therapist, a marriage counselor, or whatever. A lot of the time people are in bad relationships because they have no out. They don’t feel secure. They don’t see that there is a second option that they can do. A lot of the time financial dependence is there.

As you know, in medicine we know the Takotsubo syndrome, in which you have a dilated cardiomyopathy, severe, and in 80 to 85 percent of the cases, they have seen that it is preceded by some kind of a life event, whether it’s a death or a divorce or something which leads to this event. They still don’t know exactly how it happens. So relationship, or anything, has a bigger part.

So once I start them on any kind of a plan. I usually try, the only way to bring their cortisol level down is for them to first acknowledge it and try to work on things such as your sleep timing. Have a consistent sleep time. At least you should have six to eight hours of sleep.

If they are working, like this patient. She was working also, and she was a teacher, and she also had to take care of her two kids, those who are less than five years of age. So you are breastfeeding, you are taking care of your kids, you are working. On top of that, you had a relationship issue which you didn’t want to admit. Because of how things changed the moment her husband’s shift changed from night shift to morning shift, she started to gain weight. She was so scared.

Before, it was working perfectly, because the husband was out in the nighttime, and she was out in the daytime, so they were hardly seeing each other, and that had been going on for six years. So one year ago, things changed, and those are just the clues. Usually, you will have to just put two and two together, but it’s only after you rule out every other disease, every other situation, every other condition, then you can see, OK, that way it makes sense, because the stress could be not just because of her husband but also because of her kids or because of her work. She was dealing with multiple things.

But usually what I have seen is that what affects people the most is where they have their biggest emotion attached to, where they feel secure. You can deal with multiple things in your life as long as you feel secure. You feel that you’ve been wanted, you are loved.

And to answer your question back, so yes, we do repeat their levels. Usually I repeat them after 12 weeks, because it takes time for your body to respond. If you are going to bed at the same time, I start them sometimes on magnesium. If they are perimenopausal, their progesterone is low, so some progesterone, optimizing their hormones, helping them go to bed on time, avoiding the light or television two hours before, at least getting 10 to 15 minutes of sunlight in the morning. A few things we change in their habit which can help maintain their circadian rhythm.

Then some exercising, and it doesn’t have to be heavy, just simple jogging for 10 to 15 minutes. So it clears your mind, because a lot of the time, when these relationship issues are happening, they go into a kind of chronic anxiety state, a depressive state. And that’s when they start gaining more weight also. They don’t want to go out. They feel that people are going to ask, that they are being judged. And so it creates a vicious cycle. One thing leads to another, and to another, and they get caught up in the situation.

So it is important that they should be heard, and they should know that we all go through this tough time in our life. The stress is something we all are carrying in different forms. But we can deal with the stress. Stress is not something which overtakes us.

A lot of the issues I see, a lot of patients, they have a cumulative stress for years and years in their life, not just because of relationship. I just touch it because I came across a few of those patients, but I see the patients have been carrying it. They grew up in an environment which was not safe. A mother or a father was a drug abuser or alcoholic, and didn’t have a good upbringing, was neglected. They started to have this bracing about everything, because they feel insecure in that environment. Then when they grow up, in the school they go, sometimes you get bullied in the school. Then you grow up, you have to compete to survive. You have to go to the best college. You started dating, you have issues there. It’s an unending cycle.

We can check, like, somebody has high blood pressure. Usually what happens in 10-minute visits, people do it: “OK, blood pressure is high, let’s give you some medication, metoprolol, amlodipine or something, and send you home.” Nobody really checks, and if you go to a nephrologist, they can check all your urinary metanephrine levels, seeing whether you have a renal hypertension or not, or renal artery stenosis, and rule out, “OK, well, this is nothing.”

So let’s say idiopathic hypertension. Idiopathic is, you’re not born with the hypertension. There’s something happening in your life. But that is where, when you have ruled out the thing, you have to ask, have one step, and most of the time people reveal it themselves. It’s just that we don’t have a lot of time. We heard it and get it from there, like, oh, it’s not our business. So that thing is not our business. It’s not our business to fix their relationship, but it is our duty to tell them what is happening, what is causing this.

You can refer them to the right people. You can give them some simple tips. If not more, there are so many YouTube channels, or so many things out there which you can give them the reference to. I go a bit ahead of it because I practice in a more integrated, holistic way. But for those people who don’t have time, and I understand in traditional medicine, you can just refer them. Have something ready for the people, just some breathing exercises, some meditation, some self-awareness work, or have them maintain a diary.

Most of my patients, I tell them to create a journal. At any time any thought comes into their mind, write it down. Writing something down gives people a perspective to things happening in their life, and that has helped, I think, a lot of people, and I think that’s why I decided to write this article.

Kevin Pho: We’re talking to Shiv K. Goel, internal medicine and functional medicine physician. Today’s KevinMD article is “How relationships affect health, seen from the exam room.” Shiv, as always, let’s end with your take-home messages to the KevinMD audience.

Shiv K. Goel: So for my people out there, if they remember one thing out of it, just remember that our body keeps the score long before the mind admits that it is scoring.

One question for tonight for everybody: Ask yourself, who do you brace yourself around, or in what situation? And one question for the physicians: What’s changed in your patient’s life lately?

A healthier model of medicine is one where a clean lab panel opens a conversation instead of closing it.

People can find more of my writing at my blog, drshivgoel.com, where I write, and I also have a YouTube channel where I speak about it, Vitality Metrics with Dr. G, and I’m starting a new series on healingthespirit.com.

Kevin Pho: Shiv, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Shiv K. Goel: Thank you for having me, Kevin. Thank you so much.