Around 30.3 million Americans (9.4%) have diabetes, with another 84.1 million diagnosed with prediabetes, which leads to Type 2 within five years if left alone. But it’s well-documented that conventional treatment, involving medication and monitoring, isn’t quite up to the curing challenge.

Dr. John Heary reports that many patients and practitioners are turning to the functional medicine approach, which eliminates serious side effects from medications and naturally controls Type 2 diabetes.

Understanding the Cause of Diabetes

Unlike Type 1 diabetes, which is an autoimmune condition that can’t be reversed, Type 2 diabetes develops over time and becomes more likely to manifest in people as they age.

While researchers haven’t pinned a singular cause, they have noted that consuming lots of sugar leads to inflammation and insulin resistance, leading to Type 2 diabetes. Genetics can play a role in the likelihood of it developing. However, it’s largely driven by environmental, nutrition, and lifestyle factors.

In its early stages, insulin production is high. The pancreas aims to compensate for high sugar intake by creating more insulin, fueling glucose into the cells and reducing/normalizing blood glucose levels.

Eventually, the pancreatic beta cells cease to function and aren’t able to produce insulin, so the levels fall permanently. At this point, insulin injections are necessary.

Despite its scariness, this is avoidable through the functional medicine approach.

Why Conventional Treatment Methods Aren’t Effective

Under conventional rules, practitioners wait until patients have full-blown Type 2 diabetes before starting treatment. Next to nothing is done to change the course of the chronic disease.

Plus, the medications used to treat Type 2 are fraught with severe side effects like:

• kidney dysfunction
• nausea
• fatigue
• liver dysfunction
• weight gain
• hypoglycemia
• rashes

Last but not least, conventional diet guidelines for those with Type 2 diabetes are outdated. They promote high carb intakes and demonize dietary fats. And this is despite the fact that research shows this approach doesn’t work for this disease and could even make it worse.

Using Functional Medicine to Treat Type 2 Diabetes

Functional medicine flips standard treatment methods on their heads, helping patients eradicate the threat before it becomes a full-blown problem.

Upon determining the driving prediabetes and diabetes elements, functional medicine practitioners construct a plan to address the identified factors.

Diet has shown to improve diabetes symptoms in just one to eight weeks, provided patients follow the plan and choose foods that don’t spike their blood sugar. Such foods often include high-fiber, plant-based morsels, healthy fats, proteins, and nuts. Shunning refined grains, sugary sweets, and fried foods is the main concern here.

These practitioners will prescribe an exercise plan, too. This will meet the individual’s unique needs and ensure their insulin receptors are as healthy and sensitive as possible.

Stress reduction is also on the functional medicine plan. Activities like yoga, meditation, and deep breathing aren’t just great for mental health, but they’re also fantastic for reducing the symptoms of prediabetes and Type 2.

Functional medicine aims to address diabetes aggravators (e.g., poor diet, lack of exercise, toxins, and stress) to ensure the body is better able to use insulin and reduce the chances of developing the disease.

It often starts with fatigue.

There’s a noticeable increase in thirst and hunger. Vision becomes blurred. Sores are slow to heal, and infections become much more common.

Then there’s the inflammation. And Dr. John Heary says that commonly with type 2 diabetes, it’s internal. Since inflammation was first linked to diabetes, the extent of its role in chronic disease is still being studied. Inflammation also plays a prominent role in thyroiditis, when the thyroid gland becomes significantly swollen.

Inflammation in these two commonly associated disorders is often difficult to manage and can become quickly debilitating — but it can be treated effectively. Here’s how.

Type 2 Diabetes and Thyroiditis Explained

Of the over 37 million people in the U.S. who have diabetes, upwards of 95% have type 2.

With type 2 diabetes, the level of insulin one’s body needs to not effectively produced or the body doesn’t adequately use insulin, a hormone that controls the level of sugar in one’s blood. Insulin is created by pancreatic cells.

Often insulin has an impact on the body’s tissue, especially if one is considered obese. That’s because fat cells are capable of creating the type of chemicals that may lead to inflammation.

In thyroiditis, abnormally low or high levels of thyroid hormones lead to the thyroid gland information. Just as the pancreas plays a vital role in creating insulin, the neck’s thyroid gland is responsible for controlling metabolism and how the body grows.

About 20 million Americans have a form of thyroid disease, and 60% of those are not aware they have the condition.

Inflammation’s Role in Type 2 Diabetes and Thyroiditis

Inflammation is a key driver and symptom of both type 2 diabetes and thyroiditis. Researchers have long focused on the inflammatory pathways that often lead to type 1 and 2 diabetes. In fact, most evidence shows that the course of type 2 diabetes is fundamentally dictated by pathways of inflammation.

The different forms of thyroiditis all feature inflammation to some degree. For example, with Hashimoto’s thyroiditis, one’s immune system damages the thyroid gland leading to swelling. Types of viral infections lead to gland inflammation in De Quervain’s thyroiditis.

In general, thyroid disease is commonly associated with different diabetes forms.

Treatment Options Target Inflammation

Treatment plans targeting type 2 diabetes and thyroiditis often center on controlling resulting inflammation that quickly turns chronic. Since many cases of type 2 diabetes feature inflammation as the direct result of obesity, focusing on nutrition is often key.

Antioxidants and other nutrients that are anti-inflammatory, including a range of vegetables, fruits, and fish are integrated into diets.

Depending on family history, medications such as pioglitazone and liraglutide may be used to control both conditions. With type 2 diabetes, the first essential step is usually finding a medication to manage the resistance to insulin, but diet and exercise also play a strong part.

With thyroid conditions, hormone therapy is typically used with the gland is underactive and medications are more common with overactive thyroid glands. Other options include radioactive therapy and surgery.

The key to treating both type 2 diabetes and hypothyroid is to find the underlying root causes of the disease. Once you find out the underlying cause then you can put an effective plan into place in order to reverse the condition through lifestyle changes, nutrition, diet, and supplements.

Too many people see prediabetes as a steppingstone to type 2 diabetes. But this shouldn’t be the case. Instead, individuals should see it as a motivator to lower their risk factors and retain a diabetes-free life.

While it’s easier said than done, Dr. John Heary says that making critical lifestyle changes is the key to avoiding the onset of type 2 diabetes. Everything from drinking more water to increasing exercise to losing fat allow people (whether they’ve received a prediabetes diagnosis or not) to live a healthy, happy life for years to come.

Losing Extra Weight (and Keeping it Off)

Extra weight greatly increases the risk of developing type 2 diabetes. Visceral fat (i.e., excess weight around abdominal organs), in particular, is associated with inflammation, insulin resistance, prediabetes, and type 2 diabetes.

Thankfully, studies show that losing just 5% to 7% of weight can lower the diabetes risk in those who are overweight, obese, or have prediabetes. Greater weight loss, however, leads to increased benefits.

Individuals should speak to their doctor about setting realistic bodyweight targets and timeframes, ensuring they lose fat safely and effectively. Practitioners can also advise on the best ways to keep the weight — i.e., continuing these newfound lifestyle changes forever.

Increasing Physical Activity

Regular exercise helps people lose weight, decrease blood sugar, and enhances sensitivity to insulin, which regulates blood sugar levels. The more active you are, the less likely you’ll experience type 2 diabetes.

Generally speaking, adults should aim for at least 30 minutes of moderate to vigorous aerobic exercise on most days, totaling 150 minutes per week. For resistance training, two to three times a week is enough.

At the end of the day, it’s all about limiting the time spent inactive (like sitting at a computer or watching television).

Consuming Plant-Based Foods

Plant-based foods offer untapped access to minerals, vitamins, phytochemicals and carbohydrates — all of which are important for a healthy, balanced diet.

Carbohydrates include sugar, starches, and fiber. The former two provide energy, while the latter isn’t digested/absorbed by the body. And it’s the fiber-rich foods below that lower the risk of diabetes and aid weight loss by slowing sugar absorption, decreasing blood glucose, managing heart health, and interrupting the absorption of fat and cholesterol:

• Legumes (beans, lentils, chickpeas)
• Fruits (peppers, tomatoes, apples, oranges, etc.)
• Leafy greens (kale, spinach)
• Broccoli
• Cauliflower

Drinking More Water

Many beverages come with high sugar contents, so sticking to water is ideal for preventing type 2 diabetes. The sugar found in sweetened fruit juices and soda has been linked to two varieties of diabetes in adults — type 2 and latent autoimmune diabetes (LADA).

One study of 2,800 participants discovered that those who drank upwards of two sugary beverage servings every day had a 20% increased risk of type 2 diabetes, and 99% increased risk of LADA. Therefore, individuals should increase water intake and cut down on sodas.

In Summary

All patients hold the power to prevent type 2 diabetes. It lies within our grasp through the implementation of lifestyle changes. By embracing healthy habits and making conscious choices, we have the ability to significantly reduce the risk of developing this chronic condition.

Through regular physical activity, maintaining a balanced diet, managing stress levels, and prioritizing quality sleep, we can create a foundation for long-term health and well-being. Remember, the steps we take today to prioritize our health can pave the way for a vibrant and diabetes-free future.

While being diagnosed with an autoimmune condition in childhood can be distressing, an early diagnosis may be better in the long run, especially for conditions that worsen over time when left untreated, like Hashimoto’s disease.

Since Hashimoto’s thyroiditis (HT) impacts hormone production in the hormone-producing thyroid gland, its early detection in children is important to minimize its symptoms and especially its impact on hormone-driven childhood development. Fortunately, HT is treatable with nutrition, dietary supplements and if needed hormone replacement medication that can be taken long-term without harmful effects.

Dr. John Heary explores below some of the risk factors, symptoms, and treatment options for children diagnosed with Hashimoto’s.

Symptoms of Hashimoto’s in Children

Although Hashimoto’s is most commonly detected in middle-aged women, children, including newborns, may also be diagnosed. As an autoimmune disease, Hashimoto’s is caused by the body’s immune system mistakenly attacking healthy cells.

Symptoms of Hashimoto’s can vary greatly from person to person depending on the severity of the diagnosis and how far the disease has progressed, as well as other genetic and environmental factors. Some children with only a mild case of the disease may exhibit few or no symptoms.

Hashimoto’s is most commonly associated with hypothyroidism, in which the thyroid gland does not produce sufficient hormones to meet the body’s metabolic needs and regulate bodily functions. The symptoms of HT are largely similar for children and adults, and some of the most common are:

• Chronic fatigue
• Mental fog
• Constipation
• Dry skin
• Fluid retention
• Weight gain
• Depression
• Decreased body temperature
• Bodily aches
• Facial puffiness

In rare cases, children and adults with Hashimoto’s may develop a goiter, a visible swelling on the neck due to an over-enlarged thyroid gland. As childhood is a period of rapid growth and critical development, children specifically may also experience a slowed growth rate, stunted physical development, and cognitive disabilities.

Risk Factors

As the cause of Hashimoto’s is thought to be a combination of genetic and environmental factors, children with a family history of autoimmune diseases or hypothyroidism may have an elevated risk of developing Hashimoto’s.

Since being diagnosed with one autoimmune disease often increases the risk of developing one or more others, one of the biggest risk factors for Hashimoto’s in children, as in adults, is having a preexisting autoimmune condition, such as vitiligo, diabetes, multiple sclerosis, celiac disease, Addison’s disease, and rheumatoid arthritis.

By the same token, Hashimoto’s can also increase a child’s risk of being diagnosed with another autoimmune condition. It is therefore recommended that children with autoimmune disorders get regular blood tests and medical exams to detect the development of any co-occurring conditions.

Girls and women are also significantly more likely to develop the disease than boys.

Treating the Disease

While there is no known cure or effective prevention plan for Hashimoto’s thyroiditis, the condition can be effectively treated with lifestyle changes, dietary changes, and nutritional supplements and some people may also need hormone replacement medication to regulate a patient’s levels of T4, or thyroxine. Most individuals are able to take this medication safely long-term.

After starting treatment, patients will require several doctor visits and blood tests per year to monitor hormone levels and assess the need for treatment plan changes. Given the vital role that hormones play in physical and mental maturation, these tests are extremely important during the formative childhood years to decrease the likelihood of developmental abnormalities.

In addition to medical interventions, dietary changes may also help to control Hashimoto’s disease. Some patients may find that their symptoms flare after consuming gluten, dairy, or sugar and choose to limit or avoid these foods. Some examples of diets that patients may be advised to follow are:

• The Paleo Diet, which focuses on eating foods that early humans would have hunted or gathered and avoiding processed foods.
• The Anti-Inflammatory Detox Diet, which centers around fresh, whole foods and an abundance of fruits and vegetables.
• The Low Glycemic Index Diet, which aims to avoid foods that cause a spike in blood sugar.

As these diets can be difficult and restrictive to implement, it is important to seek medical guidance before making any drastic changes to a child’s diet. While going gluten free has been shown to help mediate certain autoimmune symptoms, finding what works best for each patient will likely take time and experimentation.

Conclusion

While Hashimoto’s thyroiditis is most commonly diagnosed in adults, children can also develop the condition, especially when they have a personal or family history of autoimmune disease or hypothyroidism. If left untreated, Hashimoto’s can cause developmental complications in children, but simple medical intervention can help monitor the disease and limit its progression.

Like all things once considered alternative, functional medicine is quickly becoming mainstream.

That’s fueled by demand. About six in 10 U.S. adults have a chronic disease, which includes everything from lung and heart disease to diabetes. Four in 10 of those adults have two or more such diseases.

Dr. John Heary explains that such prevalence has led to a sharp rise in those seeking functional medicine care as a more comprehensive approach to treating complicated and long-lasting conditions. In 2020, there were around 40,000 professionals practicing functional medicine in America. In 2010, there were just 5,000 practitioners.

Part holistic treatment and wholly personalized, functional medicine focuses on identifying and treating the root causes of a particular disease — and managing care based on those multiple factors. It also represents a sea change in how the world approaches medical care in the 21st history.

How Functional Medicine Works

Though it was formally named in the early 1990s, functional medicine’s roots run deep. Holistic and integrative medicine has been practiced in some form for thousands of years.

Functional medicine’s central tenants reflect its ancient roots. Broadly, it explores the potential root drivers of different chronic illnesses and considers a body’s whole health rather than separating it into different components to identify and treat conditions.

Several different factors may be at play with chronic disease. Stress, gastrointestinal imbalance, a dysfunctional immune system, and poor diet are among the most common causes of illness that inform treatment approaches used in functional medicine.

Functional medicine practitioners believe that an array of underlying causes — hormone imbalance, inflammatory imbalance, stress-inducing toxic emotions — can contribute to such chronic diseases as arthritis, auto-immune conditions, and obesity.

Core Principles

There are different forms of functional medicine, but it generally adheres to a handful of core principles. The first step for practitioners is getting a thorough understanding of a patient’s unique biochemistry, taking into account environmental and genetic factors.

Armed with an awareness of treatments that are centered on the patient rather than the disease itself, functional medicine explores ways to balance key elements within the mind, body, and spirit, as well as how balance is essential to long-term positive health.

Functional Changes

Depending on a patient’s needs, functional medicine takes a wide range of approaches to improve physical and mental health.

These may include pinpointing needed changes to lifestyle, such as better sleep and more exercise, revamping a diet to eschew processed foods in favor of whole foods. Nutritional deficiencies and hormonal imbalances, in addition to family health history, often guide additional treatment approaches.
This information is informed by longer visits with functional medicine doctors compared to shorter appointments with traditional doctors.

Functional medicine doctors are also more inclined to use treatments such as nutrition, dietary supplements, herbal medicine, and acupuncture as part of a treatment plan for chronic disease, especially if traditional techniques have not been able to manage an illness.

That’s part of the personalized experience that comes with functional medicine. Each patient is addressed individually and comprehensively, and treatments are unique. Chronic illnesses impact each person differently, and the causes are often just as complex and unique as the disease itself.

Chronic diseases affect approximately 40% of the population in the United States, but traditional disease-based medicine is not very effective at treating chronic conditions. Dr. John Heary reports that many of his patients ask how functional medicine can be used to heal the body of chronic disease?

Functional medicine is helpful for treating chronic illness for two reasons: it identifies the root cause of chronic and comorbid conditions and provides a whole-body solution to resolve them. Functional medicine will integrate nutrition, exercise, sleep patterns, stress management, mental health, and any necessary medications to treat the individual, not just the symptoms.

Below, more details on how a functional treatment approach to chronic disease can help heal the body.

Functional Medicine to Heal Chronic Disease

The integrative and holistic approach of functional medicine is the most effective course of action for individuals suffering from chronic diseases. Most chronic illnesses present with a variety of comorbid conditions, and the identification of the root cause of those conditions in combination with a whole-system approach to treating them is the hallmark of effective functional medicine.

Identify the Root Cause

Functional medicine’s ability to heal people suffering from chronic disease lies in part in its focus on identifying the root cause of the disease and not just treating the symptoms of it.

For example, chronic diseases can be caused by toxin exposure, poor diet, obesity, infections, and more. Rather than just (ineffectively) treating the symptoms of the disease, functional medicine practitioners will work to identify the root cause, correct it, and alleviate at least some of the disease severity to give patients a better quality of life.

Practitioners will consider countless factors as they get to know a patient: stress levels, nutrition, activity level, sleep habits, mental health, social influences, genetics, and more. This whole-body approach with relevance placed on both internal and external factors allows for a fuller understanding of the disease processes and individualized treatment.

Treat the Individual, Not the Symptoms

With a systems approach to treatment, functional medicine practitioners are able to design an effective treatment program that works for the individual. By targeting the entire person, and not just the symptoms of disease, healing can begin and the patient can find relief from the illness that has been affecting them.

To heal the body with functional medicine, there will be many strategies used. They will be pulled from alternative medicine practices as well as traditional Western medicine. Functional medicine practitioners will look at the following:

• Testing for food sensitivities
• Providing methods for stress management
• Assessing nutrition
• Examining sleep habits
• Improving activity levels
• Conducting lab analysis and/or diagnostic imaging
• Recommending acupuncture
• Encouraging therapy and health coaching
• Evaluating genetic influences
• And more

A well-rounded, full-patient approach to chronic disease is the best way to produce effective results that not only alleviate symptoms but treat the cause of the disease as well.

Final Thoughts

With a combination of traditional medicine and alternative/holistic approaches, functional medicine practitioners can do more for individuals afflicted by chronic disease. This integrative branch of science-based medicine may be the way of the future for much more than just chronic disease.

Hashimoto Thyroiditis is, unfortunately, a disease that afflicts many but is in the minds and awareness scope of very few people. Dr. John Heary of Medina provides an overview of this condition so that afflicted patients may have a better chance of understanding Hashimoto Thyroiditis.

According to an article published in association with the VA Medical Center of Mather, California, Hashimoto thyroiditis can be defined as a type of autoimmune disease that eradicates thyroid cells through antibody-mediated processes of the immune system.

Hashimoto Thyroiditis Explained

In short, Hashimoto thyroiditis is an autoimmune disorder. It is the most common cause of hypothyroidism. It is most commonly seen in women 20-60 years old. What this means in a nutshell is that the body’s natural defense system against invading viruses and other harmful substances malfunctions, in a sense, and begins attacking normally working parts of the body instead.

In the case of Hashimoto Thyroiditis, the immune system specifically stages an attack on a gland in the neck, shaped like a butterfly, which is called the “thyroid.”

The thyroid then becomes inflamed or irritated. Thyroid cells are killed during an autoimmune attack. There may be a surge of thyroid hormone released into the bloodstream during an autoimmune flare up. This may create hyperthyroid symptoms such as an increased heart rate, heart palpitations, and anxiety. These surges may occur sporadically. The majority of the time the patient will experience hypothyroid symptoms. This is called “hypothyroidism” when the body is unable to produce adequate amounts of thyroid hormone.

Common symptoms of Hashimoto thyroiditis include:

• Rough texture to the skin
• Over-average fatigue
• Weight gain that cannot be otherwise explained
• Dry Hair or hair loss
• Swollen thyroid (throat area)
• Eye puffiness
• Stiff joints
• Constipation
• Cold sensitivity
• Low heart rate
• Depression
• Extremity swelling

How it is Diagnosed

This disease is diagnosed, most commonly through bloodwork. The two antibody that need to be tested are TPO, thyroid peroxidase antibody and thyroglobulin antibody. Only one of these antibodies needs to be positive to be diagnosed with Hashimoto;s Thyroiditis. They may also test the actual function of the thyroid to see if it is working properly. Your healthcare provider will usually check the function of your thyroid gland by testing the TSH, thyroid stimulating hormone. They may also test the T4 which is one of the hormones that the thyroid gland produces.

How Thyroiditis is Treated

Most doctors don’t treat the Hashimoto’s directly. They will usually treat the effects of the Hashimoto’s which is usually a hypothyroid. The most common treatment for hypothyroidism are medications such as levothyroxine and Synthroid.

This is called T4 hormone therapy. Their goal is to get the TSH back into a normal range. Many times the TSH goes back to normal with the medications but the patient still has the same symptoms. This is because there are other factors that need to be considered and addressed.

If Hashimoto Thyroiditis is treated with too much of this synthetic hormone, it could cause other adverse side-effects.

Other types of treatment that have proven effective are functional medicine and nutrition. This type of treatment is very effective. The first step is to get comprehensive lab work done including a complete thyroid panel.

Conclusion: Is There a Cure for Hashimoto Thyroiditis

Technically, Hashimoto thyroiditis is not curable. At least that’s what the majority of conventional doctors state. When treated correctly, I have found that the majority of patients respond well and they start to feel better. The key is to find the root cause as to why the immune system is flaring up and attacking the thyroid gland. Once we figure this out then we can put a plan in place to the thyroid and immune system working correctly.

Exercise and proper nutrition are key to maintaining a healthy body and mind, and they can also minimize the risk of developing diseases. Dr. John Heary of Medina discusses below more on the risk factors of a sedentary lifestyle, and how to improve overall health with proper nutrition.

A healthy balanced diet can help to reduce harmful additives such as fats, sugars, and salt. This in turn improves heart health and reduces the risk of diabetes and cancer. Regular exercise helps to combat a sedentary lifestyle, the risks of which include obesity, heart disease, and mobility issues.

The Impact of Poor Nutrition

Our bodies need a wide range of vitamins, minerals, and essential nutrients to keep our internal systems functioning and healthy. However, for some people, especially those from poorer economic backgrounds, the freedom to be able to choose nutritionally rich and healthy foods can be limited.

Foods that have a low nutritional value are often cheaper to afford, but these items often carry a higher amount of fats, sugars, and salt. Excessive consumption can lead to people becoming overweight, bringing with it a whole host of health complications, being at risk of diabetes, and even heart disease.

How Nutrition Can Reduce Health Risks

Eating a healthy and balanced diet can reduce the risk of a whole host of diseases, such as diabetes, cancer, and heart problems. A diet rich in fruits and vegetables and free from salt, sugars, and saturated and trans fats is key to maintaining good health at any stage in life.

How Much Sugar is Too Much Sugar

The recommended amount of sugar is 10% of a person’s overall food intake. However, many adults exceed this, sometimes even by consuming just one item of food alone! According to the World Health Organization (WHO), halving this again to a total of 5% can greatly increase health benefits.

What About Salt

Adults should aim to only consume 5g (0.17oz) of salt per day in their diet. Reducing salt intake helps to protect against heart disease, hypertension, and strokes.

And Fat

While fat shouldn’t be excluded from a diet, it is important to get the right fats. Trans fats and saturated fats have a much higher risk of causing heart disease and cancer, whereas other fats when consumed in moderation are a healthier choice.

The Risks of an Inactive Lifestyle

Over 80% of all of the jobs within the United States are classed as sedentary, meaning that they do not involve active labor and most work is completed while sitting or standing still.

Out of work hours, less than 25% of people will engage in at least 30 minutes of vigorous exercise per day.

This inactivity can lead to further health complications including issues with joints, cardiovascular problems, and more. In fact, 9% of all deaths worldwide have inactivity as a contributable cause.

The Benefits of Exercise

Reducing Weight

Regular exercise in conjunction with a healthy diet can reduce weight and the risk of obesity. This leads to greater overall health, reducing problems with mobility and cardiovascular function which can be exacerbated by carrying excess pounds.

Decreased Blood Sugar Levels

Exercise lowers blood sugar levels and helps to regulate the body’s supply of insulin. This can help to prevent metabolic diseases and type 2 diabetes. For those already suffering from diabetes, it can help to manage the condition alongside medical treatment.

Healthy Cardiovascular System

Getting the blood pumping through the body during exercise helps to promote a healthy circulatory system, which can prevent heart diseases and lower the risk of a heart attack. It can also lower cholesterol and blood pressure levels.

Reduced Cancer Risk

Exercise has been proven to help to protect against various forms of cancer. These include colon, breast, uterine, and lung cancers, which can often be both aggressive and fatal.

The Perfect Mix

It is worth noting that although a healthy diet and exercise both have their benefits in reducing many health problems and medical conditions, they are far more effective in conjunction with each other rather than just focusing on one factor alone.