In conversation with Dr. Amy Price Neff of Mindstream Integrative Medicine
Founder of Framework Allen Penn and Dr. Amy Price Neff explore her unique experience and perspective on hot and cold exposure—and the ecosystem of benefits associated with its practice—through the lens of a centering question of her medical ethos: what do people really need?
Dr. Amy Price Neff is a native Tennessean who grew up in Memphis. She thanks her father, a biologist who worked in medical research, for facilitating her early interests in immunology and cell biology. After completing her undergraduate work in Neuroanatomy, she went to medical school at UT Memphis. Amy did her residency in the Department of Family Medicine at the University of Virginia where she focused on community mental health and access to care for the un-and-underinsured and a lot of good ensued as a result.
The first time Dr. Amy went to a sauna, it wasn’t in the locker room of a gym. It was in Germany, and was wonderfully social. It struck a chord in her, even without any ‘this practice will make you feel better’ caveat, and it drew her back regularly. Even though she couldn't necessarily link ‘medical care’ to her affinity to the heat, the practice simply made her feel good. She says that’s what she finds beautiful about practicing medicine—new awareness of how to look at what is making us feel good and prescribe it.
Fast forward to her work today—Dr. Amy is always centered on the question, ‘what do people need?’ She’s led educational conversations regarding chronic disease and the role of lifestyle practices like sauna and cold plunge at Framework—and has prescribed regular usage to her patients, several of whom are now Framework members. She continues to study Ayurveda as well as deep inquiries into the microbiome, cancer metabolism, nutrition, mindfulness, medications and the mind, autoimmunity and the clinical questions that come up in daily practice at MindStream Integrative Medicine—a full spectrum integrative medicine and primary care practice.
We spoke with Dr. Amy about her unique experience and perspective on hot and cold exposure—and the ecosystem of benefits associated with its practice. Read on.
Allen: When did you start first thinking about hot and cold exposure as a medical treatment? Is there sort of a patient experience or a prototype that comes to mind where you said, ‘let me actually try this out with a patient and suggest something?’
Dr. Amy: What brought me to hot and cold was just an awareness through training that I've done in integrative medicine and in cancer care—an awareness that warming the body is very healthy. There are studies that show when you heat somebody's core temperature up and hold it there for 90 minutes, it's as good as any medication. We have other more popular tools, like a ketogenic diet. Psychedelics, ketamine—other ways of heating the body. It’s one time and it's durable. When we're talking about being practical, and feeling better, and what's acceptable to people, heat exposure seems like a low hanging fruit. One thing about the relevance and the validity of any treatment we offer has to be something that people would do. Until I met you and Framework came into existence, I didn't really have a place to direct people. It felt like a heavy lift to tell people to get a sauna for your home—that's not an acceptable option for people and it was never lost on me and all of those trials. I've read that the social aspect of sauna is very important, too.
Allen: Lifespan and healthspan.
Dr. Amy: That's right. When people have risk factors for heart disease or neurodegenerative disease, dementia—they want to know what they can do. We talked about nutrition, we talked about movement, but a huge option that shows up is talking about hot—in particular—and then cold. Another group that's come up more recently is people that have been ‘biohacking,’ or just using growth hormone for a variety of longevity and or pain indications. I always have a little bit of pause supplementing people with hormones, right. There are protocols that have demonstrated the use of heat as a way to naturally raise people's growth hormone levels, and that's always going to be a more interesting option to me than a pharmaceutical.
Allen: What are the things that you believe most strongly or think resonates the most with patients and people you talk to about it with? What's your go-to, quick-hit list of benefits for folks like when you think about why hot exposure is good for you? Why is cold plunging good for you?
Dr. Amy: At the end of the day, it's about stretching that rubber band of the nervous system. When you go into heat, your body has to adapt and you're doing it in such a way that you control the adaptation. We can choose to get out, right? In heat, there's all kinds of things that are happening to your cardiovascular system. The body is scrambling a little bit to dilate blood vessels. It's lowering your blood pressure, it's releasing proteins and chemical messengers from the cells because the system is a little bit stressed—it starts to ‘clean house.’ It's like, ‘you're underperforming? Get out.’ And the cells that are getting that directive—those are pre-cancer cells or actual cancer cells. Cells that just are using energy, not necessarily helping to kind of lift the load. Similarly with cold plunging, anyone taking those first couple of steps into the tank knows that there is a kind of a core, grounding experience of doing that. So much about illness or health is about your nervous system's resilience. And for it to also be social, where you get encouraged? You're able to stretch that nervous system rubber band in a really beautiful way.
Allen: It’s the proverbial, ‘if you could take this pill, everyone would be taking it.’
Dr. Amy: It would be the blockbuster of blockbusters. This isn't a passive thing though. For me to invite patients, which I do often, to go do this hard thing? It’s a little different than ‘go and take this pill.’ Inviting people to move from passive into active is really hard. We get into these controlled experiences that—for years now, we've attempted not to make anything ‘too much.’ But we need to want to get up to the edge, and open up the window of tolerance—which you have to work at.
Allen: How would you describe the ‘I want to to get out,’ feeling that someone doing an exposure might have—whether that means they’re too hot or they’re too cold? What's kind of going on under the hood of our bodies as we move off that ‘regular’ 72 degree temperature?
Dr. Amy: We live on an Earth with seasons, nothing is ever static. I move the metaphor—what people eat now, for instance, is nothing like what people were eating when our genes developed.
Allen: They probably didn't have protein in their water, for example.
Dr. Amy: They didn't! And in the same way, the environment that our genes adapted in was not 72 degrees. Now, are we gonna argue that 72 degrees is comfortable? No—because it's nice.
Allen: As I like to say, we have 50,000 years of human history and 50 years of age HVAC history.
Dr. Amy: I grew up in Memphis in the ‘80s with no air conditioner—it was hot. And oddly enough, one could do it, right. It wasn't great, but it was possible and I'm not saying like we shouldn't cool people—
Allen: —but maybe not 24/7 365.
Dr. Amy: That's right. This is a pretty new concept in the healthcare literature about thermo-neutrality and inflammation. When studying animals in a thermo-neutral environment, it has been shown that all inducing illness can take is to simply to keep animals at the same temperature. It's fascinating. Clearly, there was some reason that we adapted to be able to tolerate heat and cold. A couple of terms come to mind—one is hormesis, or ‘stressor,’ which is within the realm of what one can handle. A stressor that pushes you towards your edge, and then you bring it back, right. In a sauna, that stress is heat stress. All kinds of ‘members’ of the body are on the job to raise and lower different mechanisms within us to preserve our thermal neutrality. All of that cellular machinery, it's available and meant to be used. The intelligence of our design is such that, when we let it work, it's actually cleaning house. It's taking care of things. When we're just at ‘static,’ whether it's the same food coming in, or the same temperature coming in, then the system decays some—or decays more rapidly. We need these little mini-stressors regularly to buff and polish all the systems.
Allen: What else would you equate [good stress, or hormesis] to that is more commonly discussed?
Dr. Amy: People need a mission and a purpose. And we feel best when we've accomplished something. Kind of in the same way, with cold, I'm going to just admit that there's so much to the mystery of the body that can't be explained—the literature, the scientific research, it's all trying to catch up with this. But I think in the same way that we were designed to kind of be able to go without food for a period of time, we're designed to be able to tolerate periods of cold or periods of hot. It's because of the design or perhaps the conditions that were always around. It's something that, instead of thinking of it as a negative, the body was like, ‘if that's what we have to do, how do we make it part of thriving?’ For instance, when people fast, fasting is hard. But as you get through it, there's this arrival of something wonderful. There's a reason that culturally, things like fasting were baked into every society on the planet. There's a reason that things like sauna have been around for centuries. It's because it offered more than just what was happening in the moment.
Allen: One piece of evidence to that is, when you start cold plunging or using sauna, the second and third, and fifth and 10th time feel easier than the first. It's clear that you're building some adaptation and some strength around that. Much is the same as the first time you do a workout, or go for a jog.
Dr. Amy: It makes me think about the performance athletes, and how over time they develop efficiency. The difference between me and me—or mortal and Olympian—isn't effort. It's the efficiency. As we train ourselves into these spaces, we're gonna push ourselves and then ease up. Not overtrain.
Allen: You’ve said something to the effect of many of the best studies about the health benefits of heat have come out of Finland. Those are not solo experiences—those are group experiences. I'd love to have you kind of expound on the benefits of that.
Dr. Amy: Sauna aside, just being able to connect socially is associated with lower all-cause mortality. It's not something that we normally prescribe medically. But if we could put it in a pill, everybody would be taking it. Sauna is a social experience that can be arousing—even if you don't feel like being around people, what I want to name here is that it doesn't have to be a conversation. Simply being near one another, our nervous systems are co-regulating, or regulating our nervous systems together. We do that passively. For example, maybe the grocery store clerk is upset about something and you can kind of sense your own kind of regulation in response. People in a sauna are doing something hard on their own—
Allen: —and because everyone's working, you get to kind of draft off of that, benefit. We're all working together, or maybe we're experiencing this as pleasurable or maybe we're experiencing it as a sense of accomplishment or a thing to be pushed through. But you're literally and sort of metaphorically not alone.
Dr. Amy: Exactly. There's a camaraderie that can come. The sauna culture in Finland, the saunas available, they're a governmental benefit to people. From my personal background and care of clients in the past—the sauna equalized socio-economic differences. In my imagination, it's like, there's a corner sauna. And on your way home from work, you can just stop in there. What kind of person stops in the sauna, four to seven times? And if you go that much, and you have that incidental contact with people, you're seeing people that much, over time, over years…those interactions may form really deep bonds that couldn’t happen in some artificial setting.
Allen: Even if it's a different set of people each time, if you're having those positive interactions, maybe you start to look forward to that. ‘What kind of interesting people or interesting conversations do I get into today?’ And all of a sudden, you've injected something that otherwise maybe feels like it's a chore or feels like a thing you're doing because you should into something that's pleasurable and desirable.
Dr. Amy: A lot of people might have that same feeling about their gym experience. There are very similar attributes to that—maybe at the gym, you notice somebody's like really nailing it and you don't even have to say anything, but if you just kind of appreciate it. Similarly, you can imagine an OG-member in the sauna and a newbie comes in and they share their top tips or offer some kind of support. It's beautiful. We've mechanized our way out of a lot of incidental contact, so building that back in is critical.
Allen: That was one of my reactions. Everything that has happened along the way from the internet through to the pandemic-related changes have kind of pushed us in that direction—less public spaces. When you can get your food and your groceries delivered, and your house is your office, and you're doing workouts online, there're great efficiency benefits at the cost of human interactions.
Dr. Amy: With a lot of things that I recommend people do that are hard, we're kind of stacking up the reasons of ‘why this is worthwhile,’ so that hopefully after a few experiences, that feedback loop starts to form. One thing I love about sauna and cold plunge is, let's say there's a day where I'm just kind of low energy, feeling depleted. These are the experiences that in certain ways are passive, but energizing. I always know if I work out, I'm gonna feel a lot better. But there are days where I just really don't have it in me—so sauna is a really good option. Then there are people that, because of a joint injury or some other variable, are just not able to move. There's great evidence that sauna is a surrogate for a workout. It might be easier to talk yourself off the couch to go sit in the sauna—and then maybe by the time you're there, you can sit in the cold water as well. That may get your own motivation up and then the exercise follows, because you've kind of taken the first step with something that's a little more intermediate. And it's not sloppy seconds. You actually did some stuff. I've never left a sauna experience not feeling like I didn't do anything.
Allen: A lot of folks ask, ‘what's the right way to do this? How often, what temperature, how many times a week?’ Any ‘musts’ that jump out to you, or are you pretty relaxed on this?
Dr. Amy: The first step, especially for people that haven't done much sauna or cold plunge, is to go and experiment. Remembering—this is a stressor, but it’s one that’s voluntary. I remember bringing my dad here, and he was in there for five seconds and he was like, ‘perfect.’ He had no interest in a longer, cold plunge. Cool—he did it. And then he was in the sauna for a long time. So once you gain experience feeling comfortable, maybe then you’re ready for something more challenging. Speaking to sauna: In the related studies, the ‘dosage’ was at least four times a week, for at least 20 minutes. In the literature, they describe different phases of adaptation that you go through if you're in the sauna that long. It’s an effort! You can imagine, to stay in an 180 degree environment for that long does invite one to go inward, right? It can be really beautiful. 20 minutes, four to seven times a week.
Allen: One of things I found funny when first getting into this space was that people have been jumping in cold water and building fire-heated pits that effectively were saunas for hundreds, thousands of years—and we know and have a lot of suspicions of how good they are for you, but not as much of the data that we're used to in many other areas of medicine on exactly, what, why and how.
Dr. Amy: It’s coming at a beautiful time where what’s consumer-driven will end up spurring more of that data. People do these things, and it makes them feel better, right? These are cultural practices that have been going on for hundreds, if not thousands of years. So, what's going on behind the curtain? Whether it's fasting, or sauna, or cold plunge, or other practices that cultures have championed. There are aspects of well-being behind them that warrant a closer look based on the results people are seeing. It's cool—we're catching up.
Allen: We often talk about these practices in this preventative health manner presuming that you're looking to stay healthy over its use in a more therapeutic manner. Can you talk about what you've learned about the use of temperature exposure and cancer treatment?
Dr. Amy: Absolutely. Metabolically, the ‘stress’ of the sauna makes our entire system sit up and go, ‘underperforming cells—time for you to go.’ The experience weeds out underperforming cells that are at risk for becoming cancerous. Cancer is a mitochondrial disorder. Sauna is your mitochondrial challenge. Early and often, doing things that just help your body clean house, is the way to go. It's like opening the door of a closet that's organized.
Allen: Essentially, temperature exposure is still in the preventative bucket—and the idea is that some of the best things we can do to broadly create an environment in our body that is less predisposed to cancer?
Dr. Amy: Whether it's heart disease and the atherogenic particles, neurodegenerative disease and the development of these amyloid plaques, cancer and the mitochondrial dysfunction that leads those cells to no longer play by the rules, and metabolic diseases of the liver and endocrine system like diabetes and fatty liver disease. These are all things individuals develop over time based on their genetic vulnerabilities. This is a tool that's going to hit all of those vulnerabilities. Specifically in the cancer world, and more specifically through the traditional Chinese medicine lens, cancer is a cold disease. One of the ways that we treat cancers—without sounding off-base—is to warm people. Warming therapies. Bringing that idea into an eastern realm of like science—some places in the world where when they give chemotherapy, they do it in a sauna. Those same tools that press the capacity of a cell to tolerate something. But just imagine if you’ve got to take chemotherapy—it's a cell damaging undertaking, and it's systemic, so we want to deliver the lowest-possible, effective dose. The cancer cells are vulnerable to drugs like platinum-based chemotherapy because they damage the DNA. Well, if you give that thing to a cell that is already stressed, that's a really good thing. Healthy tissue tends to be able to withstand that—so what better way to give people chemo than in a sauna, while they're exercising, or in a fasted state? Anything that speeds up blood flow and opens up the blood vessels is going to improve the ability of that drug to actually make it to the target tissue.
Allen: Is this something that's happening broadly? Or is this a new idea?
Dr. Amy: One of the barriers to doing things like this is that our current delivery system for cancer care is really locked into an overarching theme called ‘standard of care.’ I appreciate the fact that developing protocols and guidelines and studying people—it's an enormous undertaking. It's a very common kind of limitation of our current medical research body, which is that they don't fund research on nutrients like vitamins. You know, practices like the ones at Framework wouldn't necessarily be funded because there's nobody to pay for it. But these practices have been around for a long time, and there's an emerging field of metabolic oncology. Thomas Seyfried PhD, Dom D'Agostino PhD, and Nasha Winters, ND are people of note.
Allen: So not only is the US lagging in overall sauna adoption as a day-to-day preventative practice, but we’re also lagging in this area of pairing it with other therapies.
Dr. Amy: Things like hot exposure are really low risk for harm and should be more broadly embraced. When you bring these questions up in the clinical setting, I think that a couple of things are at play. You've got a busy doctor who hasn't been trained in it, who really doesn't have the time to entertain the conversation. Sometimes the best answer that you can get is often, ‘I don't know anything about that, I can't recommend it.’ Which can feel like a shut door for a lot of people.
Allen: It’s really encouraging to hear that hopefully, temperature exposure is becoming more popular in the US as more people are doing this. That we can continue to connect the dots on these two things more. Before we hop into the sauna and take a plunge ourselves, do you mind sharing what you’ve been up to at your practice?
Dr. Amy: My practice Mindstream Integrative Medicine—right down the street—is a full spectrum medical facility. We take care of people from nine months of age and older and we play in the sandbox of Western medicine. Everything that happens in that traditional setting can happen at Mindstream—wellness visits, physicals, and the like—but we've expanded our toolkit. We're very curious about the things that work, and we bring that curiosity to the clinical setting. We're trained in ketogenic diets for mental health, we have a gym that we opened recently, and we are just increasingly adding to the repertoire of things available. We follow effectiveness.
Allen: Which is a little bit of a wild statement, amazingly, in the medical field.
Dr. Amy: Yeah, it seems crazy, doesn't it. A lot of things that don't get adopted in traditional practice happen because there's no time. That's the thing we're trying to weed through and you know, and just say, ‘hey, if time is the only barrier, then we just have to get more curious about how to fix that.’
Strengthen the foundations of your health, one exposure workout and practice addition at a time. Sign up for a session or a Framework Fitness class today. Teach a cool class and want to offer it at Framework? We’d love to hear from you.
