Microbiome with Kiran Krishnan: Rational Wellness Podcast 163

Kiran Kirshnan discusses The Microbiome with Dr. Ben Weitz and the Functional Medicine Discussion Group.

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Podcast Highlights

6:55  Among its other roles, the microbiome is responsible for the maturation and proliferation of immune cells like T cells, B cells, and macrophages, etc… Our bone marrow produces B cells and our thymus produces T cells, which is like producing 15 year olds to defend our country, but in order for them to succeed they must first go through basic training and learn how to fight and get their equipment, which is what the microbiome does. This has been studied in mice without a microbiota and you see very poor and complete attenuation of the development of their immune system. The microbiome also supplies the energetics, like butyrate, and the equipment for the natural killer cells, the macrophages, and the dendritic cells of the immune system that are continuously circulating around looking for pathogenic viruses and bacteria to attack or to use the compliment system to neutralize it. Everthing inside our bodies is covered by a mucosa. This mucosal surface of the inside of our bodies are approximately 4,000 square feet, which would be a really large house to live in. It is in this mucosa where the viruses and bacteria interact with our microbiome and this is where all the sampling and action takes place. 70-80% of our immune system is centered around our gut and in such eubiotic mice, this never develops. 



Kiran Kirshnan is a Research Microbiologist and has been involved in the dietary supplement and nutrition market for the past 20 years, including hands on involvement in university research.  Kiran is a Co-Founder and the Chief Scientific Officer at Microbiome Labs, a leader in microbiome and probiotic research. He is a frequent lecturer on the Human Microbiome at Medical and Nutrition Conferences.  He is currently involved in over 18 novel human clinical trials on probiotics and the human microbiome. Kiran is also on the Scientific Advisory Board for 7 other companies in the industry. Kiran has published clinical trials in peer-reviewed, scientific journals and several global patents in his name.  The new stool test he has helped developed is the Biome FX

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.


Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talked to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.

                                Hi there, this podcast is a recording of our monthly Functional Medicine discussion group meeting, and it’s similar to the normal podcasts, and that it’s basically an interview style, in this case it’s with Kiran Krishnan of Microbiome Labs who sponsored this podcast. And the topic was the microbiome, and we were having an amazing discussion and it went on for about 90 minutes.  Unfortunately, I didn’t hit the record until about 30 minutes in, so I’m going to try to set this up for you so that it’ll make some sense. So I’m going to give some a little introductory remarks to set up the topic, and then just keep in mind that it’ll start with the speaker speaking and I’ll try to help with what he was talking about. So let me set this up. So as I just mentioned, the topic for today is the microbiome, which as many of us know is of crucial importance for our overall health and it’s no accident that many of us in the Functional Medicine world tend to start by looking at the gut as the most important underlying factor or one of the most important underlying factors in many aspects of our health.  Just to be clear, the more than one trillion bacteria, fungi, protozoa, and viruses that live largely along our digestive track, especially in our colon, but also in our small intestines as Dr. Pimentel explained to us last month, but also on our skin, in the vagina, in our nearly every mucous membrane that the body is referred to as our microbiotaThe microbiome is the genetic material of all these microbes. Now, the bacteria and the microbiome are incredibly important for our health as all of us know and we’re starting to learn about some of the importance of the fungi, and there’s even been some interesting data looking at the benefits of parasites. But we’re going to focus on the bacteria today and these bacteria help us to digest our food, regulate our immune system, protect against other bacteria that cause disease, and produce various vitamins, amino acids, short chain fatty acids like propionate and butyrate, and neuro-transmitters among other important substances.

                                The father of functional medicine, Dr. Jeffrey Bland once said, “The relationship between our diet and the trillions of bacteria in our intestinal tract is one of the most important features that regulates the way our genes are expressed.”  We now know that the concept of trying to map out the microbiome so that we can determine which ideal set of specific microbes determines a healthy microbiome is no longer a practical definition.  What I mean by that is we thought at one point that if we simply figured out exactly which set of specific bacteria map out a healthy microbiome, then we could just try to duplicate that, and now we know that it’s way more complex than that. There’s a huge amount of diversity in what constitutes a healthy microbiome and that’s between people living in different countries over the course of their life, and many different factors.  So unfortunately that simple definition is not going to work for us. So given that what are some of the factors that can help us determine if a given patient has a healthy microbiome? Or if their microbiome may be contributing to their disease or symptoms or imbalances?  For example, there’s growing body of evidence showing that having a more diverse microbiome is associated with improved health, and then the lack of diversity is associated with obesity, inflammatory bowel disease, obesity, diabetes, and many other conditions.

So Kiran Krishnan is here to enlighten us on some of these topics. And he’s a research microbiologist who’s been involved in a dietary supplement and nutrition market for the past 20 years, including hands on involvement in university research.  Kiran is a co-founder and the chief scientific officer at Microbiome Labs, a leader in microbiome and probiotic research. He’s a frequent lecturer on the human microbiome at Medical and Nutrition Conferences. He’s currently involved in over 18 novel human clinical trials on probiotics in the human microbiome. And he’s on the scientific advisory board for seven other companies and he’s published clinical trials in peer reviewed scientific journals.  So Kiran, we started off the discussion by me asking Kiran about what are some of the most important components to a healthy microbiome. And he talked about one thing that’s important is that there are certain key stone, super important species. He talked about akkermansia muciniphila, he talked about faecalibacterium prausnitzii, and he also talked about some of the ratios like the Firmicutes to Bacteroidetes and the Prevotella-to-Bacteroides ratio.  And now as the discussion starts, he’s talking about how the microbiome positively affects the immune system and how these microorganisms actually help with the maturity of our immune cells?  So with no further ado, we’re going to go right into discussion with Kiran Krishnan speaking. And I hope you really enjoy this, even though we missed the beginning, there’s some amazing, interesting information that he’s sharing with us.

Kiran:                    Maturation and proliferation come from the microbiome predominantly, right? So we have certain amount of machinery to make immune cells but we’re making baby naive immune cells. And it’s the role of the microbiome to train and mature, and then proliferate those immune cells in order for them to actually do their job. The analogy I give is like, we can make children that are immature and small and tiny, and we can’t send our, 15-year-old without any equipment to war, right?  If we want them to go out and defend the country they have to go through basic training and all the training, get the equipment and all that to actually be able to go and fight. So what our bone marrow and what our thymus is doing is actually producing children essentially, which are ineffective at fighting for us. And then our microbiome trains those soldiers. So without the function of the microbiome, you would not get maturation of those T cells, B cells and macrophages and so on.  And this has been studied extensively in no biotic mice, for example, the germ free mice, right? When you rear a mouse germ-free meaning it has no microbiome, you see very poor and complete attenuation of the development of their immune system. In fact, the amount of immune tissue in the gut, which is where about 70, 80% of your immune tissue exists, that becomes attenuated dramatically. So you don’t even develop all of that immune tissue in the gut.

                                A second part to that first claim is a lot of the energetics that the roving immune system requires in order to continuously circulate through. And then when they find something, attack it, eat it up, use the compliment system to neutralize it or the natural killer cells and their ability to use nitric oxide and all the super oxides, all of that equipment and energetics come from the microbiome.  So the microbiome produces the equipment for our defense cells to kill off viruses, bacteria infected cells and they produce the energy, like butyrate is a really important energy source, macrophages and dendritic cells who are circulating around trying to protect us. So again, that relationship is so intimate and the immune system would cease to exist and function if it wasn’t for the microbiome. Then the claim about the neighborhood watch, I’ve been trying to eliminate the importance of the microbiome for people using what I think are sensible analogy.

                                So think about inside the body, everything is covered by a mucosa. So we used to say that the skin, the outer skin was the largest organ in the body, it’s a huge barrier, it’s protecting us, but the skin is only about two square meters in surface area. The mucosa on the inside is about 400 square meters. So it is way larger in terms of area than the skin. And most people here are from the US, so translation of 400 square meters is it’s close to 4,000 square feet.   So imagine an apartment or a house that’s 4,000 square feet, we’d be pretty happy in that space. All of that is packed in as our mucosa. So a virus or bacteria basically enters through a mucosal layer, whether they’re going into the eyes, nose, mouth, they’re going in through your genital tract or even through the skin, they’re going to enter the mucosa.  So that’s where all the sampling and action takes place. Now, in this mucosa, you’ve got about 40 trillion microbes that already lived there, right? So imagine you’ve got 40 trillion microbes covering the space where new pathogenic microbes enter and it’s a job of the immune system to somehow sift through all of the 40 trillion to find the one or two that might be causing you a problem.  And in fact, to survey those 40 trillion or so microbes that already live in your system, you’ve got about 200 million immune cells that do that job, right? So it’s a 200,000 to one ratio.

Dr. Weitz:            Wow.

Kiran:                    It’s an absolute mind-boggling feat when you think about it. The analogy I give is imagine you’re at a music festival and it’s good to imagine it because it’s never going to happen again, or at least not for another year or more. But imagine where like a really fun music festival and it’s in a pretty big field and there’s 200,000 attendees there. So that’s a lot of people, it’s a big event.  Among that 200,000 attendees, you get word that there may be five that are potentially egregious, that could be toxic and somehow hurt some of the other attendees could bring all kinds of paraphernalia and drugs and really kind of cause issues. And you are the lone security guard in that sea of 200,000 people and it’s your job to find those four or five potentially harmful attendees, it would be an impossible task.  The only way you could do it is if the other 199,995 attendees are also keeping eye for you being a neighborhood watch and can radio you, should they see anything suspicious? That’s the only way you can serve it, that’s what occurs in your body. The sea of microbes that predominate cells, all of the cells in your body, they are the neighborhood watch for their immune system when they sense a new pathogen entering a system, whether it’s in the lung with the along microbiome or your sinus cavities in your gut, anywhere else in the body, the microbiota, the resident microbiota in that space signals to the immune system that something is going on, here you got to come pay attention, right?  That’s the only way the immune system can survey this amazing surface area that is already covered with potentially harmful microbes.

Dr. Weitz:            Somebody asked the question, I guess you had mentioned a Prevotella-to-Bacteroides ratio, and maybe you could explain what that is and its importance.

Kiran:                    Sure. Yeah. And what’s interesting, another interesting thing we’re seeing prevotella and bacteroides are also two file up. And this is not bacteroidetes which is the one we were talking about with firmicutes, this is bacteroides, so it’s very close in name but slightly different. What we’re seeing is that when people consume lots of meat and protein, you tend to start to lose prevotella and then you start to increase bacteroidetes. And again, not to confuse me, but this is not the bacteroidetes we were talking about earlier, this is bacteroides.  And what we start to see in this pattern is the formation of insulin resistance. There’s two things that occur, one is the inability to balance blood sugar levels, and then the second thing is the inability to build glycogen storage. So people that tend to have really low prevotella and much higher bacteroidetes tend to have blood sugar dysfunction, and then also tend to have, like get really lethargic and tired at some points of the day they can’t produce the energy.

                                This is really profound because they’re seeing this more and more in the Western world. And when we do the biome effects test, this is another one of those functionalities that we measure. What’s interesting about when I’ve done a consult, so one of the things that we offer for all of you guys that you should know when you start getting the test done for either yourself or your patients, we offer consults with either our biome effects clinical director, Dr. Sam [Malt 00:14:49] or we’ve got groups within our learning and development team that will go over the test with you so you get familiar with it, right?   But for some practitioners who are friends of mine, I’ve done it myself and they’ll send me their patients test beforehand and I’ll tell them, “Don’t tell me anything about the patient,” in the first few minutes I’m talking to you, I want to guess what they’re coming in to see you about, just from looking at their tests. And so far, I think it’s been five out of five that I’ve been able to guess.

                                And the last three have been this same issue like, are they having glucose metabolism issues? Which they may not know because they’re not necessarily pricking their finger and testing the glucose levels because they’re not diabetic. But the way it cycles is it causes massive drops in blood sugar levels in the middle of the night. Some of these people awakened because of that, they get a panic response, during the day, they have real big swings in energy levels.

                                And then when you encourage them to do a 24-hour glucose and insulin cycle, you see these massive swings up and down throughout the day, and they’re not diabetic, their A1C is may be a little bit of elevated but they’re not completely diabetic. And all of them have this diminished prevotella and really high bacteroides.

                                So that’s another function that dictates like, and it doesn’t have to be obese, like the last two people I talked to about this one was 110 pounds, so she’s not in any way shape or form obese and never has been. But because of multiple rounds of antibiotics and because she has SIBO like condition, she’s basically completely eliminated plant-based foods and she’s very high on the protein and that starts to cause that dysfunction.  So that’s another one that we tend to look at what people in metabolic dysfunction is, how do we bring back that ratio, get that akkermansia up. Between those two things, you’ll start to see a big change, we have a study publishing just on that recently, I’m sorry to keep running on about this, but we have a study publishing recently where we took obese individuals, so these are people, the BMI of 30, 30 to 31 somewhere around there.  So they’re not morbidly obese but they’re overweight. And we did full DEXA scans, we were looking at visceral fat, subcutaneous fat, we were looking at a whole bunch of metabolic parameters. There was a 90-day study, right? And what we did is all we added into their system, and this was a placebo controlled study was a little bit of a prebiotic that we know increases Akkermansia and bifidobacteria as well and then the spores, the spores that stopped the LPS, the leaky gut.

                                It was a 90-day study, we told them not to change anything about their diet, don’t add any exercise in that they weren’t normally doing. So they’re continuing all of the behaviors they normally continued that kept them overweight and kept them gaining weight.  And what we saw in that 90-day period with no changes in diet, exercise or anything was in the group that was getting that probiotic, prebiotic combination. We saw a 38% reduction in visceral fat mass, and that’s a really dangerous fat around the organs. We saw some weight reduction as well but weight is just not a great measure of metabolic activity, but doing the DEXA scan we saw real fat being lost quite dramatically. And we also saw an inching up of their lean mass, so they were putting on some lean body mass, and then we saw all of these beneficial metabolic changes as well.  So that just goes to show without even diet and exercise and those other aspects of it, just shifting the microbiome we can start shifting their metabolic profile. And then if you add diet exercise and all that to it, the results can be quite profound.

Dr. Weitz:            That’s amazing. Can this be used as an adjunct to working with a patient with diabetes or prediabetes?

Kiran:                    Absolutely, yeah. In fact, we’re starting a diabetes, a prediabetes study with UCLA right now on the same principles but in this case, we’re going to have the probiotic, we’re going to have components of the prebiotic but we’re also adding in bitters in fact berberine. And one of the important…

Dr. Weitz:            And natural Metformin.

Kiran:                    Exactly, completely natural Metformin. And one of the things that’s really interesting about it and the professors that we’re working with already have published on some of the mechanism of action of bitters, we have bitter receptors right in the upper part of our GI, right where the stomach dumps out, and then in the lower part of our intestines as well, those bitters trigger things called peptide YY GLP-1, these are transducers or transmitters that actually improve leptin response, increase fat burn by increasing something called cyclic AMP.  So it stimulates all of the cells in your body to start burning fat for fuel, it improves gastric emptying and motility in the gut, and then it dramatically improves the insulin sensitivity as well. So simple thing like that and we know that, you guys all know that prediabetes is going to be one of the biggest health pandemics in the next couple of decades because not only do we have so many diabetics right now in the world, we have four times as many prediabetics as we do diabetics and almost 80% of them are going to become diabetics over the next 10 years.   And when they all become diabetics, morbidity and mortality for all of the chronic conditions increased dramatically with diabetes, including COVID right? The mortality rate for diabetes with COVID is seven-fold, seven times higher than a non-diabetic. And that’s scary because in the US we have lots of adults and even some children who are diabetic.

Dr. Weitz:            Absolutely, get into discussion with somebody about COVID, they go, “Well, it’s only people who have these high risk factors.” And when you look at the American population you’re talking about obesity, we’ve got 70% of people are overweight read in the number of people with diabetes and heart disease and autoimmune or immunological compromise. And then you add some cardiovascular conditions, you’re talking about a huge percentage of our unhealthy population.

Kiran:                    Per CDC data, 60% of US adults have at least one of those chronic illnesses falls under the high risk category, right? Hypertension, diabetes, cardiovascular disease, obesity, 60% or more. So yeah, we have a tremendously high risk population in general which goes beyond just the age factor.

Dr. Weitz:            Right. This should be one of the messages we get out of this pandemic crisis we’re in is we have a really unhealthy society and we’ve got to get do something about improving our overall health.

Kiran:                    Yeah, absolutely. That to me was, I’ve done lots of interviews so far on COVID and the pathology and so on. One of the first interview I ever did, I said, my point was that there is a silver lining here because when you look at this virus it’s developed the capability of taking advantage of our vulnerabilities. And that vulnerabilities, the ACE2 receptor, the ACE2 receptors is expressed in cases of chronic low-grade inflammation, which is a epidemic in our society.

                                And this pathogen has figured out a way to take advantage of that vulnerability. What it tells us is that we should have resilience against these kind of things, and many people do but it’s really painting a picture of how vulnerable we are as a population. Because the thing is, we’ll get through this one and it’s not as bad as it could be as other viruses could be. It doesn’t have the mortality rate as MERS did or the first SARS did, or Ebola does, it doesn’t have 15, 16% mortality rate.

                                But somewhere around the corner, that’s another one of these coming around and it could be as infectious but 10 times the mortality rate. Again, taking advantage of our vulnerabilities, so to me that is really the silver lining in all of this is like, we should realize that as a population, we are ill equipped to handle something like this only because our systems are vulnerable. Our immune system can take care of this kind of virus very easily if we are allowing it to function in the right way.

Dr. Weitz:            So a bottom line for patients who are overweight, a couple of people ask questions about this, what can we do now to help in terms of the microbiome to make it easier to lose weight?

Kiran:                    Yeah, so really important practical things and this is exactly what I do too and I’ll go through swings with my own weight, and I actually just saw my sister the other day and she’s like, “How did you lose?” I leaned down over the last two and a half weeks because I was like, “Yeah, I’m getting a little too pandemic chubby. So I got to lean down.” So what do I focus on when I do that? And what I think will be really effective to start stoking people’s metabolism. Number one is the fasting, right? If you can add in some intermittent fasting and yes, it will be hard for certain people to go 14, 15, 16 hours right off the bat, but you could totally taper them up.  If they can go 12 hours without eating 8:00 PM to 8:00 AM for the first week, have them do that next week, go 8:00 PM to 9:00 AM, start pushing them, right? If they can get to that 14, 15 hour range metabolic changes already start to happen. Akkermansia levels will increase, the microbiome diversity will increase, bifidobacteria levels will start to increase. Those will be profound changes for their microbiome.

Dr. Weitz:            So why will our microbiome flourish when we don’t eat anything?

Kiran:                    Yeah, so that’s a really important question. So part of it is about food utilization. So if you think about it, every meal that you eat takes about depending on your system but it will take eight to 12 hours before you deprecate that part of the meal, right? It takes that long to go through your system. Now, the way the microbiome is organized is there are many community structures that feed off of one another, there are primary digesters of the macronutrients that you take in, and then they produce secondary metabolites.  And then those secondary metabolites metabolized by another group of bacteria that then produce tertiary metabolites. And then another group of bacteria can eat those and produce another set of metabolites. So that’s part of the reason it takes so long, especially when the food gets to the colon for it to start passing through and all of the digestion that occurs in the colon to happen, or at least a fermentation to happen.

                                And the thing is when you have primary digesters, let’s say bacteria A is a primary digester of the carbohydrates that enter in as food products, right? Bacteria A seize the carbohydrates, it becomes really active and it starts digesting those carbohydrates.  When it is active it suppresses the growth and the functionality of vector B, C, and D, right? So it starts metabolizing and then it produces all of these secondary metabolites, its primary food is gone so it becomes, it starts lowering its activity. Then bacteria B jumps on these metabolites and starts producing bacteria B gets to flourish to a certain degree. When its primary food source has gone it pushes goes down the row, bacteria C starts to flourish.

                                So when you give your body time to digest the food and ferment the food completely, you actually get to flourish lots of groups of bacteria. What tends to happen is that bacteria A is digesting its primary food, and then that food is gone then it kind of takes a metabolic risk, bacteria B starts to digest the metabolites. All of a sudden the primary food comes back in, then bacteria A start getting active again, which suppresses this next group of bacteria.

                                So it’s this staircase type of metabolic process, hopefully that’s… I know it’s a little abstract to think about but hopefully that is understandable. So when you give your gut time to actually process all of the food, you get complete fermentation and digestion, and that completeness in fermentation and digestion allows more and more microbes to flourish that utilize different parts of the meal and diet. So that’s a really important thing to understand.  So if we just continuously keep feeding, we’re really only supporting certain categories of bacteria, others get suppressed, they don’t ever have a chance to flourish.

Dr. Weitz:            Would it be even better to fast for three or five days?

Kiran:                    So there can be some diminishing returns if you go too far, and we need more studies on that. There’s a lot of great studies on intermittent fasting, there’s some pretty good studies on 24, 48 hour fastings, but there’s very few studies so far in longer fast, like six, seven, eight days.  I would think that there’s a point in most people’s microbiome where you start losing the benefit and start gaining some dysfunction from that longer fast. It’s probably less typical for us as a species to go that long without eating than it is to go 14, 15, 16 hours. Our ancestors routinely went that long without eating because they didn’t always have food at the ready, they would wait for the hunger pangs to kick in, to motivate them to go out and start looking for food.

                                So I would say you push that, the longest I’ve ever done is about 30 hours. And I could tell for me, and I intermittent fast every day, pretty much and have been for the last three, four years. That 30-hour period was kind of, I could feel was not really producing much more benefit for me. So then I had small food, small meals, I started feeling great.

                                So that intermittent fasting becomes really important, that’s one of the easiest things to implement. If you could start getting some prebiotics into them, the illegal saccharides particular, the ones that we use is in that Mega Pre, the fructooligosaccharides that come from Kiwi especially are really important for increasing akkermansia and increasing bifidobacteria. Bifidobacteria is another group of bacteria that are inversely correlated with metabolic dysfunction.

                                Now, the question is, if I take high doses of bifidobacteria, will I achieve the same thing? In fact, you don’t, you don’t see studies that show high dose of bifidobacteria having metabolic impact. There is one bifidobacteria strain called Blp1 I think that when it’s dead will actually help induce some metabolic improvements. That’s again, one of those special cases where there’s something within that bacteria strain that when it’s killed and it opens up will actually provide a metabolic benefit.

                                So the prebiotic will do a lot more to increasing your endogenous bifidobacteria, giving that metabolic support. Using the spores can be very powerful to megaspores because it stops that leaky gut. So you want to stop the leaky gut, you want to use a prebiotic to increase akkermansia and bifidobacteria, you want to add in a degree of fasting, and then if you can get them to take additional things like resistant starches, that’ll help because one of the really important metabolites in the microbiome that controls body weight controls metabolism are short chain fatty acids.

                                Like butyrate is so important for metabolic health, butyrate is one of the main signals that turns on the cyclic AMP process that causes all of your cells in your body to burn fat. Butyrate also helps with the leptin response and the satiety signaling, so they’re really, really important. If you can just increase short chain fatty acids, you’ll start to see changes in weight.

Dr. Weitz:            Is it beneficial to take supplements in butyrate and short chain fatty acids?

Kiran:                    Yeah, that’s an interesting component of butyrate therapy because what they found is that butyrate is really useful in things like colorectal cancer or really severe colitis when you have inflammation in the large bowel, but when you take it orally, it doesn’t seem to help. So what they’ve started doing in hospitals is they all still do butyrate enemas instead to get it into the large bowel, so it actually has that function. So there’s a big question of whether or not orally supplemented butyrate actually will get to the large bowel where it needs to be, or does it get dissipated and absorbed in the small intestine, or maybe even the stomach.  So that’s the part that’s unsure, increasing your endogenous butyrate is not hard at all. Our study that we published last year showed that when we added the prebiotic and the probiotic in, we increase butyrate production by 150%.

Dr. Weitz:            One of the tricky things about using prebiotics since a lot of us have patients with SIBO and they’re very sensitive to prebiotics and fiber, and it tends to square them up.

Kiran:                    Yeah. That is problematic. So we say with the prebiotic that we use, which are highly specialized oligosaccharides designed to make it to the large bowel so they should not have a lot of bacteria in the small bowel that can ferment it to create the gas and distension, but we tell them to test it. They can go as little as like an eighth of a scoop, mix it into a jug of water, shake it up and kind of sip it throughout the day.

                                We’ve even had some people that go as far as not being able to take it in orally, so then they do prebiotic enema to get some oligosaccharides into the large intestine, which is where the bifidobacteria acclimates are all there, so you can do a retention enema with the prebiotic mix. So that’s one way to start getting it in there. If you can, because if we can’t do it this way, you might try the other way.

Dr. Weitz:            So it’s interesting as some of these probiotics that are dead are actually more beneficial, myself and I’m sure a lot of the practitioners who are listening probably have probiotics in our refrigerators at our office, which we’ve made a big deal out of making sure that they will refrigerated the whole time thinking that we’re providing an extra benefit, because if the temperature gets too high the bacteria will die and these are more potent. Are we really helping our patients?

Kiran:                    Yeah. No, all of that work to try to keep it alive in the room is really all for nothing because the moment they hit 98.6 degrees in the body and pH a one and a half or something going through the stomach, they just obliterated. And we’ve tested that, we’ve tested 40 or so of the top retail probiotics and even the probiotics in the health space and all of them die going through the gastric system.  So the key is then finding ones that have shown studies that the dead versions are actually beneficial. And that’s specialized. Like for example, with rhamnosus GG, when you kill it and you administer it, it has all of these benefits but regular rhamnosus, the generic version of rhamnosus wouldn’t have that same effect.  You kill it, it’s just dead and it’s not really doing anything, you’re going to poop it out 12 hours later. So the metabolic response modifiers, the types of strains that when dead can have specific metabolic effect are very specialized to those subspecies of the strain, it doesn’t translate to the wild type version of this strain.

Dr. Weitz:            With respect to intermittent fasting, somebody asked the question, do you think it’s more beneficial to skip breakfast or to skip dinner?

Kiran:                    Ah, great question.

Dr. Weitz:            What do you think it matters?

Kiran:                    So yes, there are at least two studies that came out that showed that if your fasting window is basically from the afternoon till the morning that, that actually has a bigger impact on weight loss than the overnight to the afternoon fast. So if you’re fast with somewhere around like 12:00 or 1:00 PM all the way until like 8:00 or 9:00 AM, that seems to have a more profound effect on weight loss and fat loss than the overnight to noon fast.  Now that being said, the overnight to noon fast also has benefit, right? The problem I have, and I can’t do the other way around just because dinner becomes such a big important social thing. Whether it’s business related, it’s family, it’s friends, so it becomes really hard to skip dinner, just from the social side of it.

                                And so that’s why for me, I’ve not been able to do that kind of routine, I can do the skip the breakfast very easily. Now, the other advantage for me in skipping breakfast is that I can do my workouts in the morning and doing your workout in a fasted state really amplifies your growth hormone levels, and that has a huge metabolic impact as well. If you can fast through the late afternoon and evening and then throw in a workout sometimes somewhere in that evening period, that’s fantastic but a lot of people find it very hard to skip dinner. There are too many social things surrounding dinner.

Dr. Weitz:            Yeah, actually for me it’s easier because a lot of times I’m busy with patients and I don’t really have time. And a lot of patients want to come in after work, and so rather than eat late, a lot of times I’ll just skip dinner just because it’s easier.

Kiran:                    Yeah, that actually has a bigger impact metabolically than skipping breakfast. But if you can’t skip dinner, then skipping breakfast will help as well.

Dr. Weitz:            Is there ever going to be a probiotic, protozoa or fungus?

Kiran:                    Oh, fungus yes, so we already have saccharomyces.

Dr. Weitz:            Yeah. That’s true. That’s true.

Kiran:                    Well established. We will have, yeah, I believe we will, we’ll have potentially things like amoebas, we’ll potentially have protozoas, we may have organisms that we don’t even know exist yet. When prions became a thing with mad cow disease 20 years ago I was actually still in university and it was so interesting to see my immunology, microbiology professors like losing their minds as to what the hell is this weird alien thing.  Because imagine viruses are really fascinating all themselves, because they’re not even living creatures, viruses are technically not alive because they cannot create any sort of metabolic effect on their own, they can’t reproduce on their own, they’re just like a fatty envelope with RNA or DNA sitting in it or protein envelope with RNA and DNA sitting in it and just floating around.

                                And it just has this mechanism that allows it to bind to certain things, inject its RNA or DNA and hijack the cell. So that in itself is fascinating, then you think about a prion which doesn’t even have that sophistication, it’s just a strand of protein. And this strand of protein, it just so happens the prions that we know of right now are really devastating that’s what created the mad cow disease. So it creates the encephalitis, so basically bus holes in your brain, but it’s this tiny little thing of protein and there’s like no functional way of killing it, that anyone knows it can withstand all kinds of heat, it can withstand all kinds of acid, it’s really mind boggling.

                                So we may find organisms that we don’t even know exists right now that are really important therapeutics within our system. I think the next one’s beyond bacteria and fungus are likely going to be in the parasite family, the parasitic family, just because there’s so much work being done with that already in a fringe world, the helmet therapy and all is considered by many to be like really weird. But the data’s good and they’re showing real progress in certain parts of the world in treating allergies.

                                And when something like allergies becomes more and more of an epidemic in our country, we’ll start having to go towards those types of therapies.

Dr. Weitz:            Don’t we know that societies where worms are endemic have much lower rates of allergies and asthma and autoimmune diseases?

Kiran:                    Yep, absolutely. And there’s a double edged sword that there are certainly some worms that will then create all kinds of other problems down the road, but absolutely. And I think in part, what that speaks to, to me is it speaks to our disconnect from the natural world. So we’ve evolved to have a pretty intimate relationship with all of these organisms in the natural world.

                                And the more we disconnect from them, then the more susceptible we become because we’re missing key links to our function and our phylogenetic tree. And so understanding what those things that we’re missing are, and putting it back into our system, I think will be a really big part of microbiome therapeutics moving forward. We are engaged with lots of very big companies in the world and massive companies. What’s exciting about it and then many people are turned off by massive companies. I totally understand that, but massive companies like Nestle, for example, who’ve spent their whole lives feeding sugar to people and sugar to kids.

                                When you look at their new focus, they’re saying we’re going to de-invest from all of our candy sugar stuff and focus on health wellness and microbiome science. There are companies like Chris Hanson and ADM, Archer Daniels Midland, these are massive billion dollar companies and they’re all seeing the writing on the wall.

                                I get calls from these kinds of companies and I talk to the leadership within those companies, they’re all trying to figure out how do we focus and hone in on the microbiome. They all see the microbiome as like the big thing over the next several decades to really improve health and humanity. So it’s really exciting. I think we’ll see lots and lots of innovations.

                                One of the areas that we’ll start to see more and I’m always advising companies to disrespect is the microbiome modulation. We’re getting to understand more that A, if you have high risk for certain types of cancers, you have certain type of microbiome, there are certain features within your microbiome that are characteristic of that condition.

                                So as we can better monitor and understand and test for those features, we can hopefully modulate features as we go along to fix people’s ecosystems in a very precise way to improve their overall outcomes.

Dr. Weitz:            How does the microbiome change with diet? You mentioned that if we eat heavy meat diet, that that’ll influence the diet one way. And right now in the diet world, we have these really extremes, we have people eating meat only the carnivore diet, we have people only eating vegetables and everything in between.

Kiran:                    Yeah, absolutely, and that to me is one of the scary things in the whole world of wellness and functional medicine is the adaptation of real extreme and exclusive diets. We’re just not designed to function that way. I think one of the things that makes the human species really unique in the animal kingdom is our incorporation of a really large diversity of microbes into our system, which really gives us strong omnivore qualities.  And that omnivore quality actually is a big part of our evolutionary ascent up the ladder, because if you think about other species that we essentially we would be competing with that are obligate carnivores or obligate herbivores, they are very susceptible to environmental and other changes. If you think of a lion is as powerful and ferocious as a lion is, if there’s a drought and the wildebeest levels are low, or its main prey, the lion’s going to starve to death.

                                If a human is in that same drought, we can go and dig for roots and tubers, we can eat insects, we can eat plants, we can eat rodents, we can eat a whole bunch of different things and survive through that. The same with on the opposite end with the lions prey, the wildebeest was an obligate herbivore can only eat plants. And so if those plants are dead and the Savannah is dry, they’re going to die, they can’t just go and eat insects and they can’t just go and catch a muskrat and eat it.

                                So we’ve got this really unique capability of producing tools using these hands, we’re upright, we’re [bi-pi-to 00:44:50], we can move long distances and we can eat lots of different things. Our microbiomes are really designed to do that. So the moment we go to a very exclusive diet especially if we do it for long period of time, it’s going to have a long-term negative consequences. I think short-term, like if you’re really trying to change your metabolism and you’re going to go keto for a short period of time, that could be totally fine.

                                Because one of the big benefits of keto is you’re actually eliminating sugar, and that to me is where you get a lot of the benefits of keto. So you can go keto for a short period of time, but then get those vegetables and the plant-based foods back into your diet. You also shouldn’t be going vegan forever and not getting any complexity in your amino acid profile and so on.

                                So to me, it’s really about much more of a balanced diet and I think that’s how we’re evolved to exist.

Dr. Weitz:            It’s a really big current trend in the functional medicine world as you mentioned to talk about the dangers of eating lectins, the dangers of eating meat, because everybody’s going to get heart diseases. And it seems like everybody’s looking to the specialized diet that subtract certain types of foods as the answer to fixing people with certain types of problems.

Kiran:                    Totally, yeah, and that’s a problem because we’re not talking about enough is how do you build a resilient microbiome that handles all of these things? I mean, you talk about lectins, one of the types of diets have tend to a lot of lectins is the Mediterranean diet, they eat lots tomatoes and all that. It’s one of the healthiest diets ever, there’s more studies on the Mediterranean diet than any other kind of diet and we’re talking huge studies and we’re talking 50,000 patients longevity studies on it.

                                So clearly it has benefit and there’s a way of eating it and there’s a way of preparing it, and the people’s microbiomes are resilient to handle it. We have amazing capability of neutralizing things that are not actually good for us, the anti-nutrients people talk about. If we have a resilient diverse microbiome, we can absolutely neutralize those, we can neutralize glyphosate in our gut, not to say that we should have glyphosate in our food, but just to show the ability the resilience of our microbiome to protect us.

                                So to me and people always ask me, like what is your focus and goal with your microbiome? What do you try to do? And to me, my goal for health is about being resilient, because I don’t want to have to live a really structured control life in order to feel good. Like you talked a lot of people and you go, “How you feeling? How’s your gut doing?” “Oh, I feel great as long as I don’t eat this, this, this,” and they’d rattle off 17 things. “And I feel great as long as I don’t do this.”

Dr. Weitz:            That’s one of the biggest issues of a lot of us in the functional medicine world, we have these patients that come to see us for these severe gut problems. And gluten was a problem, they cut out gluten, they cut out dairy, they cut out this vegetable, we cut out that vegetable, we cut out, they went on a low FODMAP diet, so they cut out all the cruciferous vegetables and then they found out about the next category of foods to cut out and they come in and they’re eating two or three fruits and [crosstalk 00:48:19] anything.

Kiran:                    Yeah, absolutely.

Dr. Weitz:            And your gut has no tolerance to be able to eat these different types of fruits.

Kiran:                    And the thing is the elimination doesn’t do the healing, and that’s the important part that people need to understand. And in fact, speaking of gluten, there’s a really good study on this, and I think it’s fine for people to avoid gluten if they want to reduce the risk for that permeability. But you cannot avoid carbohydrates, you cannot avoid fiber because one of the big studies on gluten they showed that in the first year of gluten intolerant people going on a gluten free diet, their mortality rate almost doubles.

                                And you would think like, wait a minute, that makes no sense. So these are gluten intolerant people, meaning when they eat gluten, they get all this inflammation, they get all this intestinal permeability. Why is it when they go on a gluten free diet, does their mortality rate increase in that first year? And then it tapers off a little bit in second year, but in that first 24 months, their mortality rate almost doubles.

                                So the reason for that is in Western society and in our culture and our society, more than 85% of our fiber intake comes from wheat. So you’re getting all of this fiber, despite getting the gluten that’s also harming you, but you are getting the fiber component. So then also then you eliminate gluten and most people who eliminate gluten we’ll replace it with proteins and fats.

                                So you’re taking out fiber completely out of your diet and then you’re replacing it with fats and proteins. So now the expectation is what I removed the offending thing my gut should be healing. As it turns out, when they look at these individuals, the gut doesn’t heal at all, it stays susceptible and because you increase the intake of other things like fats that can increase endotoxemia, you are actually increasing your risk for other conditions.

                                So what you should do in that case is eliminate the gluten, that’s fine, but you have to replace it with other non-gluten sources of fiber and so on, because that is what drives the repair. Just eliminate, eliminate, eliminate is not going to cause a repair. We need to maybe temporarily eliminate foods that are clearly offending your system, but then make sure we’re getting things in there to provide some diversity, provide some resistant starches, some fiber, all of those things are really important.

Dr. Weitz:            Is there any way that people following a carnivore diet by eating the entire animal, every part of it. Is there any way they can have a healthy microbiome?

Kiran:                    So if they’re eating the entire animal then potentially, and that would include intestinal content. And we see that in hunter-gatherer tribes, right? So in the hands of tribe in Tanzania and the tribes in Papua New Guinea, when the hunters go out and they catch their prey like in, I think it’s in the one in Tanzania, the porcupine is like a delicacy for them.

                                And they’re not doing this often, even though they’re called hunter-gatherers, they hunt way less than they gather, they gather a lot more. But they do go out as hunting parties. One of the first things they do when they capture the animal, is they cut open the intestines and then they eat the intestinal content. Most of these animals that they eat are ruminant to certain degree, they’re picking up seeds and nuts and all that from all over the place.

                                They’re fermenting it in their guts and if you eat that intestinal content, you’re getting all kinds of amazing carbohydrates and resistant starches and so on. So you likely can, if you’re eating connective tissue and you’re getting different forms of collagen, you’re getting some of the glycoproteins from connective tissue, if you’re eating organ meat, if you’re eating brain, if you’re eating liver, you can get diverse enough macronutrient to maintain diversity within the diet.

                                But the unfortunate thing is in the US, when you’re saying, when someone’s saying the carnival diet, they’re just eating a steak and that’s about it. And I’ve met a lot of people like that. I mean, I get to speak at places like the paleo effects like I spoke last year. I met so many people at that show they go, “Yeah, I’ve gone full carnivore.” I’m like, “Okay, what do you eat?” “I eat two steaks a day. That’s it. And sometimes I’ll have a dollop of butter on the steak.”

                                And I’m like, “Okay, well, that’s not a good thing necessarily.” And also it depends on your microbiome in large part, because if you look at it, one of the ill effects of meat metabolism is the formation of TMAO. And there are certain types of bacteria that produce high levels of TMAO.

                                If you happen to be one of those people that have high TMAO producing bacteria, and you eat lots and lots of meat, it’s going to cause heart disease. There’s no if, and’s or but’s about it, the studies on TMAO are pretty clear. But if you happen to have very low levels of those bacteria, you can sustain this for a period of time until those bacteria grow because you’re giving it so much meat. So that’s another kind of catch that whole thing is what happens to the food when it enters your system.

Dr. Weitz:            I know this is kind of going off our topic, but I love to get your take on this TMAO thing, because those of us who are working with patients with cardiovascular risk factors we have found that certain supplements, like L-carnitine, incredibly helpful for mitochondria, for the strengthening the heart, and all need super important nutrients for liver health, for brain health.

                                And it’s really hard to, it doesn’t really seem to make sense, it doesn’t fit with our experience that patients who are eating foods or taking supplements with choline or L-carnitine are really putting themselves at increased risk of heart disease.

Kiran:                    Yeah, because of the potential of TMAO.

Dr. Weitz:            TMAO.

Kiran:                    [crosstalk 00:54:28] of TMAO.

Dr. Weitz:            Yeah. So I think the answer to the TMAO question is more about making sure we have a healthy microbiome than about not consuming L-carnitine or choline.

Kiran:                    Exactly. Yeah, because again, it comes back to that balance issue. So one of the things that we test in the biome effects tests is TMAO producing bacteria.

Dr. Weitz:            By the way, if everybody’s not familiar with this, why don’t you explain that Microbiome Labs is offering a stool test. And how can practitioners find out about this?

Kiran:                    Yeah, absolutely. So  the test is called biome FX, like the letter F and the letter X. It’s a whole genome sequencing test, just to give you a little bit about the difference between what we’re doing and what you have already experienced in the market. We started seeing a lot of issues with accuracy in stool testing. One of the big problems is most of the stool tests, in fact, all of the ones you’ve used use something called 16S sequencing, 16S sequencing if you’re not familiar with sequencing information, 16S is like taking random Polaroids of a single of parts of someone’s body, and then trying to piece it together and identify who that person is.   So it’s a really low resolution inaccurate way of identifying species level for the bacteria in your system. So it tends to have a very high error rate. And what the companies aren’t telling you when you look at your test results, and they’re showing certain bacteria that they’ve picked up, they’re not telling you that they have an algorithm in their bioinformatics pipeline that makes a prediction that this is likely the bacteria we found, it’s not absolute at all.

                                In fact, all of the big microbiome research organizations, the American Gut Project, the Human Microbiome Project have come out and said, you cannot use 16S to identify bacteria to the species level. So we saw that as a big problem, and so we wanted to make that in itself a change. So we started working with the top lab in this space called CosmosID on developing a whole genome sequencing test, which means that we actually have to sequence in bacteria’s entire genome from end to end in order to identify, we’re not looking at just little snippets of the bacteria.

                                So it’s a far more accurate, it’s 99% or more accurate. So you’re getting the most accurate species level information. Now, why is species level information so important? Well, because like we’ve been talking about with the microbiome, it’s really about what does that total ecosystem look like. Outside of the keystone strains you can’t necessarily just pinpoint singular bacteria and their levels as being problematic because everybody at the species level has most of those bacteria different frequencies.

                                And so what we look for is we look for really important trends, well-established trends because in the microbiome, one of the things I say is, it’s not who’s there, it’s who else is there, right? The function of certain bacteria are dictated by what other bacteria are in that environment and what are all of their relative abundances? That’s where the mapping becomes really important. So we can map out functionalities within your microbiome by understanding the species level, relative abundance data, and the best researchers who have done this is led by Rita Colwell.

                                Rita Colwell is the most decorated scientists in this whole world of microbiome mapping, she’s got 60 honorary degrees including a couple PhDs that she first earned and then 60 other degrees, she’s published 800 papers in this space in peer reviewed journals, which is a mind-boggling amount for any researcher doing work.

Dr. Weitz:            Isn’t it the case that the PCR, quantitative PCR testing is actually more sensitive and specific for picking out organisms? And if you go into a hospital and they suspect CDF, they’re not doing a whole genome sequencing stool tests, they’re doing a PCR test, right?

Kiran:                    They’re doing a PCR test and that’s important because the relative abundance of that pathogen compared to all of the other DNA may be really low. So for them, in order to find that bacterial DNA or viral DNA in the case of COVID or any other virus, they need to amplify that bacteria viruses DNA. And that’s what PCR does, the polymerase chain reaction amplifies the DNA. The problem with doing that in a stool test to try to understand your microbiome is it artificially amplifies the volume of that particular species DNA.

                                So it gives you erroneous relative abundance numbers, so we need to be able to get really accurate relative abundance numbers. And the thing is that the sequencing work takes longer, that’s another reason why, if you’re ill with something, they’re trying to figure out what is making you ill, they use PCR because it can be done pretty quickly. You can get PCR done in an hour or 35, 40 minutes.

                                The genome mapping using full metagenomics takes much longer than that. However, CosmosID, the lab that we’re working with are the only lab that are FDA approved to do whole genome sequencing for pathogen identification, because now we’re starting to see some issues with PCR, even in pathogen identification because you might go to a doc, or you might have diarrhea and your doctor, your infectious disease doctor gastroenterologists might say, “You might have C diff, this looks like C diff. So let’s take a stool sample and then we’ll look for C diff.” But they were using the PCR, they will amplify the C diff DNA and they’ll pick it up.

                                Now, C diff may not even be causing you the problem, because C diff may be there but its levels may be low enough that it’s not the one causing you the problem. And the PCR is absolutely focused on that one organism, it’s not like it’s amplifying everything to pick up whatever it can find, it’s going in, honing in on that one organism saying, “Hey, we found some C diff, that must be your problem so we’re going to give you vancomycin all day long.”

                                Well, that might not be the solution, right? So now the FDA and the infectious disease specialists starting to see that PCR may be problematic even in trying to identify an infectious agent, what may be better is sequencing everything that’s there and seeing what is just popped up at the highest that could cause those symptoms. So CosmosID is the only FDA approved lab in the country that can do that kind of work.

                                So we partnered with them to get the best sequencing data. And then our other thing that we focus on the stool test is we want to give you functionality, we want you to be able to tell what your patients microbiome tends to do and tends not to do. It’s not absolutes, there’s no absolutes within the microbiome, but you will have a guide for you to understand where the real issues may be within that patient’s microbiome that you can start honing in on to help.

                                And everything we test actually gives you actionable steps that have references. On lifestyle changes, diet changes, and even supplement changes that can help that particular area. Coming back to TMAO, that’s one of the things we test. So you could eat meat and choline there and L-carnitine all the time and be absolutely fine and it’d be very healthy for you as long as you don’t have really overgrown levels of bacteria that create TMAO.

                                And you may have that because of previous dietary choices, when you bring back balance of the microbiome, then you don’t have that issue. And so one of the things you can do is you could test your patient’s microbiome and say, “Hey, your TMAO levels are really producing bacteria really high, so let’s reduce these kinds of things for a period of time until that comes down, then we can bring them back into the system.”

                                Just another example of that sulfate reducing bacteria. Nobody would have really thought about it or heard of these things within functional medicine, but they’re so important because one of the things that they do is they take sulfate from sulfate rich foods, and they convert it to hydrogen sulfide in the body which then becomes really inflammatory to the bowels. And so many healthy foods are high in sulfates, seafood is high in sulfates, and the leeks and garlic and artichokes, all of these things, high in sulfate.

                                So you might have a patient that’s going, “Doc, I’m eating pretty clean. I’m eating healthy fish in a line caught fish, I’m eating these vegetables. I still have really bad diarrhea…”

Dr. Weitz:            I just had a patient today and she had a flatline SIBO breath test which is usually indicative of hydrogen sulfide.

Kiran:                    Yup, exactly. So, yeah, and then you will know from the bio effects test like, “Oh, okay. It’s because your sulfate reducing bacteria are really high, these categories of foods really are actually counterproductive in your gut. So let’s bring those down over time and you could see all of the recommendations that allow to bring that down, bring that down over time and then rebalance microbiome, then you can reintroduce foods like normal.”

Dr. Weitz:            So how do we order this stool tests and how much does it cost?

Kiran:                    Yeah. So the practitioners you can order, I think we sell them in bundles kits of four, there’s no cost to order them of course because you can order the kits and have it within your practice until you have the right patient to use it on. The price that we charge is 299, we leave it up to you if you want to mark it up above that, but that’s a price that we only talk to practitioners about.

                                So the patients don’t know what the cost of this is. We have a mix of practitioners, some that don’t mark up tests at all but then charge a consultation fee to go through it or some that double the price depending on how they’re set up. So we allow you to decide how to do that. So then the functionality of it is if you have patients coming into your clinic, you can hand them a test, you can either have you or your staff registered the kit for them.

                                It’s a very quick process maybe it takes two minutes and you can either put in the payment and then charge them back, or you can have them take the kit home and have them register it using your code in there and then they will pay for it directly too. So you can manage it however you want, they do this test at home, we’ve got a very painless sampling procedure. That was another thing that we really wanted to improve, we didn’t want people like scooping poop and doing all kinds of stuff.

                                So we have this piece of paper that actually sticks to the toilet seat that has a bowl in it and then you take care of your first void and then we give you a brush, a coring brush, and you kind of core through a few spots in the stool, stick the coring brush in the test tube, close it off, then that’s what you mail back the paper, you can actually just unstick it and flush it. So you’re not dealing with actually managing anything.

Dr. Weitz:            That’s cool. It’s always tricky trying to hold that with [crosstalk 01:06:13] basket.

Kiran:                    Exactly, yeah. And the brush, what’s cool about the brush is we even thought about this like, we don’t want you to get too close to the stool. So the brush actually has a long handle when you first get it and you can actually core through the poop sample. I think we recommend somewhere around like five or six times you core through it.

                                And we use a brush because one of the things we found was you’re not getting adequate sampling of the DNA from the stool when you swab the surface or when you scoop a tiny bit of it. The DNA and the bacteria in the stool is not homogenous, so the bacteria on one side is going to look different than the bacteria and the other side and their relative abundances can change. So we wanted you to be able to go through the whole core of the stool and use a brush with lots of bristles to pick up as much as we can.

                                The more you pick up the more accurate the data it would be. So the brush has a long handle, you core through it a few times, you put it into the test tube, and I think you just off the top of the handle and then screw the cap on it, then you’re just mailing it back in a prepaid envelope.

                                And here’s the exciting part about it is we now have an FDA approved COVID diagnostic in the stool tests, and it’s an actual diagnostic meaning you can diagnose COVID in the stool. And that’s really important because studies have shown that you can actually pick up COVID in the stool for up to two to three weeks longer than you can pick it up in the upper respiratory tract. So you might have a patient that was feeling pretty crummy.

                                And in fact, we just had this with one of our employees, she was feeling pretty crummy and she went and got the nasal pharyngeal test and it was negative. But there’s studies that show, you can get up to 50% false negatives with that test. And so she’s like sitting at home having lots of similar COVID like symptoms and doesn’t know if it’s COVID or not.

                                So we’re having to do the stool test instead and the stool test will come back in about four days for the COVID part. The sequencing takes a little bit longer, but the COVID part comes back faster. And if you had somebody that had COVID maybe a couple of weeks ago, I suspect they did, you could still pick it up in the stool test up to two, three weeks after symptoms go away.

                                So it’s a great way to do that diagnostic, and you can do it at home. You don’t have to go to a testing facility where you’re around a bunch of other people that also think that have COVID and you could kind of keep yourself just safe distance from all of that.

Dr. Weitz:            This has been an awesome discussion Kiran, and I could talk to you for hours.

Kiran:                    Thank you.

Dr. Weitz:            Thank you for being so generous with your time. And so I think we got to most of people’s questions.

Kiran:                    Awesome.

Dr. Weitz:            And I really appreciate it.

Kiran:                    Well, yeah. Thank you so much for the opportunity, I always treasure any opportunity to talk about this with people, because clearly everybody here are the people on the front lines, you guys are the ones making the difference out there. And nothing I do is meaningful until it translates to the work that you do, so I’m always grateful for these opportunities. So thank you, Tanya, so great to see you and thank you for getting this set up for us as well and really enjoyed it, really enjoyed it myself.

Dr. Weitz:            Excellent. And thanks to everybody.

Kiran:                    Yeah. Take care.




Emotional Eating with Melainie Rogers: Rational Wellness Podcast 162

Melainie Rogers speaks about Emotional Eating with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

5:22  Losing weight is difficult, which is why 70% of the population is overweight.  One of the problems is that many people overeat or binge eat for emotional reasons. When our clients are feeling anxiety, they tend to eat carbohydrate foods, which tend to increase the amount of serotonin in the brain.  And while we are in this global COVID-19 pandemic, we are seeing a lot of anxiety and lot of this type of overeating.

7:34  When working with a weight loss client, we have to try to help our clients to understand their eating behavior and then work backwards to try to understand what feelings are triggering their behavior.

9:12  Not everybody who’s eating for emotional reasons have an eating disorder, but many do.  A good acronym is HALT, which refers to eating for the following reasons: 1. feeling hungry, 2. feeling angry, 3. feeling lonely, or 4. feeling tired.  If you do this occasionally, this could be normal, but if you’re doing this two or three times per week and feeling out of control, this is an eating disorder.

10:18  The difference between overeating and binge eating is that if you ate a whole pizza and then felt really full, that would be overeating. But if you did it and felt out of control and great distress by doing it, that would be binge eating.

11:00  One of the best strategies is to sort out what is biological or physiological from what is emotional. If someone skips breakfast and eats very little for lunch, then it is biological to be extremely hungry and to overeat because of that.  If they binge at this time it would be considered a physiological binge. For patients with emotional eating problems it is important to eat consistently throughout the day.

12:20  Eating consistently is important for emotional eaters to break their cycle, but in the Functional Medicine world now the hottest trend is to skip either breakfast or dinner so that you 12-14 hours without eating, which is referred to as intermittent fasting, which is considered to have anti-aging properties. Melainie said that if intermittent fasting works for you and you don’t binge at the end of the day, then continue doing it.  But if you find yourself overeating during that 8 hour window, then that may not be the right program for you. During Ramadan where you fast from sunrise to sunset, they often gain weight, since they tend to overeat or gorge at night. 

15:22  The difference between physiological and emotional binging is that if the client is eating food consistently throughout the day and meeting their nutritional needs and they are still overeating or binging, this is emotional because they are hungry or angry or lonely or tired.  It is important to make clients aware of this.

16:26  Mindfullness is being aware of what you are eating. Paying attention to whether or not you are really hungry.  You should not eat when you are distracted, such as by watching t.v..  It can be helpful to jot down on a notepad how hungry you are on a 1 to 5 pt scale before the meal and how you feel after.  It can also be helpful to write down what you are eating throughout the day, so you are aware of how much you ate.

20:15  The app Recovery Record can be helpful for clients with eating disorders.

20:50  Negative body image can be the motivation for eating disorders, so it is important to work towards having a positive body image or at least get to body neutrality, which means I just appreciate what my body can do for me. I may not love my body, but I’m not beating myself up all the time. It can be very difficult in our society where we are bombarded with imagery around the thin ideal.

23:25  If we eat unhealthy foods, we deplete our bodies of necessary vitamins, minerals, and other nutrients such as protein, which may make us crave more food.  For example, craving sweets could be an indication that we are dehydrated or lacking vitamin C, while a craving for salty foods might mean that we’re deficient in sodium or calcium or magnesium or zinc.  Eating a lot of low nutrition junk food can lead to someone being overfueled calorically, but underfueled nutritionally.

25:40  Eating foods like breakfast cereals that are fortified with vitamins and minerals is not as nutritious as eating real, natural foods like fruits and vegetables that are naturally high in vitamin and minerals and many other phytonutrients that are important and others that have yet to be discovered and appreciated.  We are programmed to seek out variety in food so that we are more likely to eat all of these important nutrients and this can’t be replaced by a poor diet and a multivitamin.  Supplements can be most beneficial when they top off a healthy diet. 

27:21  A lot of people are feeling extra amounts of stress due to the current coronavirus pandemic and are more liable to eat unhealthy, processed foods that require minimal preparation. And such processed foods are actually less expensive per calorie than natural, healthy foods and many people are out of work or making less.  And such processed foods tend to have a longer shelf life if you are stocking up to avoid frequent trips to the grocery store.

29:56  A lot of people are confused about what to eat, since the science seems to be changing and there is so much misinformation on social media around food and wellness.  There are many wellness coaches and diet gurus with very minimal training in the science giving advise about the best way to eat.  We have completely opposite diets–the meat only carnivore diet and the vegetable only vegan diet both being promoted and discussed as the best way to eat, so it is not surprising that so many people are confused about what the best way to eat is.  The diet debate is as polarized as the political debate in the US right now.

32:52  We know that exercise has incredible benefits for mental health, physical health benefits, motility, flexibility, joint stability, bone density, etc.   But high intensity exercise or overexercising can be another form of obsession like an eating disorder.  This can be just as harmful as undereating.   Overexercising can be very harmful and is done for an underlying body image issue, so we need to find out what is underlying the motivation for their behavior. 

36:11  It is not unusual that clients who come to us for weight loss will tend to underreport what they are eating by about 50% because they feel shame and guilt that they have over not being able to do what we have asked them to do. Our job is not to shame them further, but to figure out how we can set them up to be more successful.



Melainie Rogers, RDN is a Certified Eating Disorder Registered Dietician and accredited supervisor in the treatment of eating disorders. She is the Founder and Executive Director of BALANCE eating disorder treatment center™ and Melainie Rogers Nutrition, LLC in New York City. Among her many affiliations Melainie is the founder and recent past president of the New York City Chapter of the International Association of Eating Disorder Professionals (IAEDP), an Advisory Board Member at the Center for the Study of Anorexia and Bulimia (CSAB) and a former Board Member of the Binge Eating Disorder Association (BEDA). She is also an adjunct professor in the Department of Nutrition and Food Studies at New York University. She recently published Redefining Wellness: The Ultimate Diet Free Guide, a free e-book that contains contributions from 150 experts, which can be found on her redefiningwellness.co website.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.



Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.  Hello Rational Wellness podcasters, Dr. Ben Weitz here. Thank you so much for joining me again today. For those of you who enjoy listening to this podcast, please give us ratings and review on Apple podcasts. If you’d like to see a video version, go to my YouTube page. And if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.

                            Today our topic is emotional leading with Melainie Rogers. I think I butchered your name, but there are many-

Melainie:              Oh, that’s perfect.

Dr. Weitz:            There are many reasons why approximately 70% of Americans are overweight or obese. There are genetic factors that make it difficult to get and keep your weight into a healthy range. We may be taking certain medications such as antidepressants that tend to make us overeat. There are various hormonal factors, many of which can be treated. Insulin is secreted when we consume foods with a lot of sugar, and a large insulin surge in response to eating a bowl of breakfast cereal or a doughnut will tend to drop your blood sugar making you crave more sugar.    By the way, I saw an executive from one of the companies that make cereal on CNBC, and he was bragging about the fact that, “Isn’t it so great that Americans now are eating cereal for dinner as well as breakfast?”

Melainie:              No. Wow.

Dr. Weitz:            Anyway, back to sugar and insulin. Every time we develop insulin resistance, so our pancreas needs to pump out ever greater amounts of insulin, which makes us crave more and more sugar, and more carbohydrates, and we end up in this vicious cycle that is hormonally related. In our society, inexpensive, highly processed, and addictive junk food is readily available. Such unhealthy food products have been specifically designed to be hyper palatable and addictive. And there’s aggressive marketing to convince us that eating such foods are good for us. And if we eat such high sugar, high fat, high salt foods regularly, we end up being depleted of necessary vitamins, minerals, phytonutrients. And so this may encourage our bodies to eat more to get those nutrients we need. Of course, being cooped up inside due to the COVID-19 crisis, which we’re currently undergoing with the stress and worries about getting infected and dying, as well as our loss of income, provide additional reasons for unhealthy eating.

                                Melainie Rogers is here to join us today. And she’s a registered dietitian and a certified dietitian and a certified eating disorder registered dietitian. She’s the accredited supervisor in the treatment of eating disorders. She’s the founder and director of BALANCE Eating Disorder Treatment Center in New York City. She’s the founder and past president of the New York Chapter of the International Association of Eating Disorders Professionals. And she is definitely one of the top experts in binge eating and anorexia, et cetera. She recently published Redefining Wellness: The Ultimate Diet Free Guide, which is a free ebook that contains contributions from 150 experts, which can be found on her redefiningwellness.co website. Melainie, thank you for joining us today.

Melainie:              It’s a pleasure, Ben. Thank you for having me.

Dr. Weitz:            Before we start the conversation, I’d like to start with a request or a comment. I know that, looking at some of your work and your blog posts, that you’re used to often speaking to a lot of women who may be more right brain in their thinking about emotional eating. I assume that they are probably a big part of your target audience. But I think most of my audience and myself are very left brain analytical focused. We talk about health and functional medicine. I think it’s important to deal with the emotional stuff, but if there’s a way that we can do it so that limited left brain people like me can understand it, that would be helpful.

Melainie:              Sure. As a left brain person myself, I’m trained in research. So we will definitely talk about the research, and then of course behaviors.

Dr. Weitz:            Very good. Losing weight is very difficult for most people, which is one of the reasons so many people are overweight. I think the latest statistics show in the United States, something like 70% of the population is overweight. I work with a lot of clients who are trying to lose weight and many of them have emotional reasons for why they eat. Can you explain some of the emotional reasons people have for overeating or binge eating?

Melainie:              Absolutely. Not most people, but many people, guys and gals, I know you mentioned women earlier, but for overeating and emotional eating, it’s about a 50/50 split between guys and gals. The reason for that is because we all, male and female, experience emotions, and a driving force behind the key emotion, which is anxiety, is actually our amygdala. Amygdala is a part of the brain that is responsible for that flight freeze response. And that’s the part of the brain that’s responsible for pumping out this feeling of uncertainty and anxiety, generalized anxiety.  What we know from emotional eating, Ben, is that most of our clients or general population, when they’re feeling anxious, they seek out carbohydrates, usually. They don’t usually seek out a chicken breast, right? The reason to that, my clients say to me, “My God, I don’t know what it is. Why am I addicted to carbs or sugars?” It’s not that you’re addicted to carbs or sugars. It’s that carbohydrates, specifically, when you ingest them increase the amount of serotonin in the brain.  Now, many of your viewers may know that serotonin is the chemical that reduces anxiety. So we’re talking about a neurobiological process here, that we call emotional eating, because we think it’s all about emotions, but it’s actually a whole chemical response and a domino effect that leads to overeating. And right now with COVID-19, we’re seeing so much more of this type of eating.

Dr. Weitz:            When we come in contact with someone who’s trying to change their weight, how do you determine what the underlying reasons are? Not everybody is willing or able to actually articulate why they’re overeating.

Melainie:              Absolutely. And a big part of that, too, is that, as a society, we’re not actually encouraged to check in with our emotions, and certainly there’s a gender bias there. Where guys are definitely not at all encouraged to connect with their emotions, they’re encouraged to be stoic and to pull yourself up by your bootstraps and just get on with it. Which that kind of a suppressed emotion just leads to a lot of things going sideways, hence we’ve got guys and gals, but more predominantly guys, who drink excessively, who have sex addictions, who gamble excessively. Those are behaviors that are working sideways; too many underlying emotions, which they really have lack of awareness around.  For us, what we try to do is help our clients understand, or at least start with the behavior because that’s very concrete, and then work backwards to, what’s the trigger around why you would do that? Often, for many people, that’s pulling back the layers to figure out what are those underlying feelings, which make people really scared. People get really scared to think about feelings. It’s amazing, actually, but yes, that’s the process.

Dr. Weitz:            So is everybody who’s eating for emotional reasons, do they all have an eating disorder?

Melainie:              No, not at all. But they probably have disordered eating. So it’s on a spectrum. For many of us at some time, we’re all going to eat out of emotion. A really good acronym that’s often used in the substance abuse world that we’ve adopted in the eating disorder world is HALT, hungry, angry, lonely, tired. The whole quintessential, I roll into bed or I crawl into bed with my pint of ice cream and binge, watch TV, Netflix, or whatever. So that’s emotional eating for comfort. Maybe there’s been a break up, or your boss yelled at, you or COVID-19. So it’s on a spectrum. And doing that occasionally just means you’re normal. But if you’re doing that two or three times a week and feel very out of control and can’t stop it, then by default of the frequency and the severity of it, then it may fall into the criteria of what is an eating disorder.

Dr. Weitz:            And then, what’s the distinction between emotional eating or overeating and binge eating?

Melainie:              Binge eating is when you eat a larger amount of food than other people would normally have. Let’s say you have two entrees for dinner. You eat very quickly, and you feel great distress doing it. It’s one thing to sit down and eat a whole pie of pizza, pizza pie, and be like, “Oh gosh, I’m really overfull. Wow, I ate all that.” But there’s not a distress attached to it. That wouldn’t be considered a binge. A binge is when people feel out of control and feel great distress by what they’re doing.

Dr. Weitz:            Okay. What are some of the best strategies and tips to help patients, clients avoid overeating or binge eating?

Melainie:              Number one thing we find is biological. My job as a registered dietitian is to separate out biological or physiological binges from emotional binges. How I would differentiate the two then is that, a physiological binge is when our clients get up in the morning, maybe they’ve binged the night before and they decide, “Oh, I’m going to skip breakfast this morning.” Or, “I’m not hungry for breakfast.” They get to lunch, and they decide that they’re going to have a tomato and a piece of lettuce, because they’ve got to make up for calories that they consumed the night before. And you guess it, by the time they get to the end of the day for dinner, they’re absolutely ravenous. That’s a physiological hunger.  Then when they sit down to dinner, they don’t just have their steamed chicken breast and a little portion of broccoli that they intended to have, they in fact, go on an outright binge and usually have fried this and fried that and fried this and feel out of control. So that’s a physiological binge. How we try to reduce that is by having people eat consistently throughout the day. That means you have to have a breakfast, you have to have a lunch, you have to have snack, you have to have dinner. Go ahead.

Dr. Weitz:            Yeah, I have to jump in here because this is a constant discussion we have in the functional medicine world. I’ve been working with clients with nutrition for over 30 years now. The big thing we started with was, people skip breakfast, they’re rushing around, they have a snack for lunch and then they overeat for dinner, and that’s why they’re all overweight. And the mantra was, “You have to eat breakfast, you have to eat within so much a period of time of waking up. You have to have small meals throughout the day.” For years we were preaching, “That’s the way to be healthy. That’s the way to balance your blood sugar.” And now the big thing in Functional Medicine is, the way to be healthy is to do intermittent fasting by skipping breakfast.

Melainie:              I know. I know, right. I know. Because it’s the goal of getting a 12-hour break on your body, right? 

Dr. Weitz:            Yeah, or 14 hours or 16 hours, and pressing your eating window into a narrow range It’s funny how it comes full circle, but anyway go ahead…

Melainie:              It’s so funny because… No, you’re absolutely right, because it used to be low fat and then it was no carbs, and now it’s, sorry, intermittent fasting. I don’t really advocate any one diet. What I do for my clients is try and figure out what works for them. But we do know conclusively that if you skip breakfast… Or let’s say you don’t do breakfast, I’m cool with that too. I’ll work with whatever the client wants to do in the sense of guiding them. But if you’re just eating lunch and then you’re eating dinner and you’re binging, I would suggest that you’re just not taking in enough calories for the day, and that’s a physiological binge. Yeah, those intermittent fasters out there, whatever works for you. But if you are binging towards the end of the day, then you may want to have a look at that.  What’s interesting about that, Ben, is that it used to be, “Don’t eat after 7:00 PM.” But I think that went out the window because with our current lifestyle, people don’t usually get to dinner until 8:00 or 9:00. So I think this is the new modification on that, which is just trying to create some kind of gap. But also it makes me wonder that, are people just there for binge eating or grazing through those eight hours that they can eat? During Ramadan, for example, when the Muslims fast for a month, people gain weight.

Dr. Weitz:            Is that right?

Melainie:              Because they starve and then they binge. I’m laughing. I’m sorry. It’s not a laughing matter. But we know that the-

Dr. Weitz:            No, no. I know that you’re laughing out of irony. Yeah.

Melainie:              Yes, out of irony. I mean, we know from the research that the number one way for people to gain weight is by restricting so excessively that they end up being out of control around food. That’s just a physiological fact.

Dr. Weitz:            If that’s the physiological or part physiological-

Melainie:              Yes, binge.

Dr. Weitz:            Then what’s the difference between the physiological and the emotional?

Melainie:              If a client is then eating consistent food intake throughout the day and meeting their nutritional needs, their fuel needs for the day, and they’re still finding that they’re getting out of control with eating and it’s not hunger-driven, we know it’s emotionally-driven. So then that becomes the big question of, what are those underlying emotions? So for people who are overeating it can be, the acronym I used earlier.  Well, hungry, we just eliminate it, because we’re having consistent eating. But now we’ve got angry, now we’ve got lonely, now we’ve got tired. And so it’s important for clients to then have a look at, “Why am I eating right now? I know I’m not hungry.” That brings into play mindfulness, which is just observing your behaviors and not judging, Ben, but just being curious. Like, “Why am I doing this? I don’t want to eat this. I’m not even tasting it.” So helping clients increase that awareness around their behavior.

Dr. Weitz:            What is mindfulness? Everybody throws it around. And when I talk to people, a lot of people are not really sure what it is.

Melainie:              Sure. Mindfulness from the definition or how we operate with our clients is really awareness. Just being aware that, “Hey, I’m reaching for the third or fourth, or fifth slice of pizza, and I haven’t checked in if I’m even hungry because I’m usually disconnected.” If we think most of us are disconnected like this from what our body is needing from a hunger and fullness perspective, that’s our internal regulatory system. Leptin, ghrelin, PYY, all those great feedback hormones are dictating that. What we really want to practice or get back into doing is checking in with our body and saying, “Gosh, I think I’m full. I don’t actually need that extra slice.”

Dr. Weitz:            What’s a practical tip for somebody who’s sitting down and they’re eating. Is there a little tool that they can use to be mindful while they eat?

Melainie:              Absolutely. There’s a lot of different ones. Some of them come back to the oldies but the goodies which is, “Don’t eat when you’re distracted.” And for many of us it’s for dinner anyway, sitting down in front of the TV or the computer and eating, and we look at our plate, “My gosh, gee, did I eat all that? I didn’t even realize it. The plate’s empty, I must have eaten it.” That’s distracted eating. First and foremost, try to reduce the distracted eating. Which means, turn off the TV, shut down the computer, sit there and be thoughtful and notice yourself eating your meal and check in with your body.  For some people, it can be helpful if they have a little notepad and just think, “Oh, how hungry am I?” And use a one to five point scale? “How hungry am I when I go in? How full am I at the end of the meal? So that they have a little bit more data collection that can feel more concrete for them around this process, so it doesn’t feel new and ethereal and not scientific. Those are just a couple of real simple things.  The other thing is when you plate a meal, if you go back for more check in, ask yourself, “Am I still hungry?” “Yeah, I’m still hungry. Maybe I’ve got some mouthfeel going on, so maybe I want some dessert to wrap up,” or something like that. It’s really checking in with yourself.

Dr. Weitz:            Okay. What are some of the other techniques we can use?

Melainie:              Some other techniques to use would be having a look at… Checking in, “Did I eat throughout the day today?” For some people, writing it down can be really helpful as a scientific experiment on themselves. So that-

Dr. Weitz:            You mean write down what they’re eating?

Melainie:              Yeah. Or even if you don’t want to write down what you’re eating, just write down the time that you ate throughout the day. So for some of us, we’re so crazy busy, Ben, and honestly, you can forget to eat. Your introduction earlier was about people who are just on the go, and you can really get delayed in eating consistently throughout the day. So if you even just decide that you’re going to write down what time of the day you eat throughout the day. It doesn’t matter what the food is for now for this example. Then you can just check, “Did I eat lunch?” “Yes, I did.” “Did I have a snack?” “Yes, I did.” “Did I have dinner?”   If on one particular day, you’re overeating at the end of the day and you go back to your notepad and say, “Why am I crazy hungry? Or why am I wanting to overeat right now? Did I eat today?” And you check back and go, “Oh, I forgot to have lunch.” It can happen. It could happen. Or, “I grabbed a snack for lunch instead of a real meal. And that’s why I’m starving right now.” That kind of data collection is important.

Dr. Weitz:            Do you have any apps for doing that?

Melainie:              Yeah, I do, actually. We don’t tend to use apps that have calories, because I find that that keeps everything external. I want clients to get back to their internal regulatory system with those hormones we talked about earlier. There’s a wonderful app we use called Recovery Record. And it’s really about logging what time, what you ate, but also hunger and fullness. Then of course, if we think about hungry, angry, lonely, tired, it can also tap into if there’s any kind of emotional eating going on as well.

Dr. Weitz:            What role does negative body image or body dissatisfaction play in? How can this be overcome?

Melainie:              It plays a huge role. Because usually what happens is that there is a dissatisfaction with your body and a desire to change it, which usually in our society now, which idolizes the thin ideal, that usually means weight loss, or for a lot of us it means beefing up. And so therefore there is usually an attempt to, in the weight loss case, there’s an attempt to lose weight and reduce calories. What we know is that when you reduce calories below a certain amount for an extended period of time, that physiological response we spoke about kicks in and then people end up overeating, they’re fallen off the wagon, they feel despair, they regain the weight plus some. So body image in our current society can be a huge trigger for dieting, weight loss, and weight regain.

Dr. Weitz:            How does somebody get a positive body image?

Melainie:              It doesn’t happen overnight. I would say it’s pretty tough to do in the current society where, Ben, we’re just bombarded with imagery around the thin ideal. What we work with with our clients on is, “Okay, let’s not go from negative body image and hating your body to, ‘I love my body overnight.'” I think that’s almost impossible. What if we just get to body neutrality, which means I just appreciate what my body can do for me? I may not love it. I may still think this about my stomach and my thighs, but I’m not beating myself up all the time. So we work on our clients trying to reduce behaviors that might add to the negative body image, which means unfollow on Instagram and social media accounts that have you comparing yourself to others.  In some cases, we even have our clients take up their full length mirrors and just have the mirror above your head, for example. Because if you can’t view your body without picking it apart, then maybe it’s time to just take a short break from doing that. And then there’s a lot of cognitive challenging of a lot of the thoughts that we all have, some challenging on those thoughts and some reframing of those thoughts to get to at least an appreciation of what your body can do for you.

Dr. Weitz:            Can you talk about how, if we eat unhealthy foods we tend to deplete our bodies of necessary vitamins, minerals, and other needed nutrients, such as, say, protein that may make us crave more food? In one of your blogs, you wrote that craving sweets could be an indication that we are dehydrated or lacking vitamin C, while a craving for salty foods might mean that we’re deficient in sodium or calcium or magnesium or zinc.

Melainie:              Yeah, absolutely. Well, we know that, and you alluded to this earlier, that if you’re eating a lot of what we call low nutritious food, which still has a role in an overall eating plan, but not if it makes up all of the eating plan. So foods that don’t have a lot of vitamins and minerals in them can ultimately lead to someone being overfueled calorically, but underfueled nutritionally, which means they’re deplete in vitamins and minerals. Then I think that blog really just speaks to cravings and how cravings can direct us. If you listen to your cravings, they can direct you in a way of what you might need a little bit more of.

Dr. Weitz:            But it says on that box of breakfast cereal that it’s fortified with vitamins and minerals.

Melainie:              I know. I know. Which is why maybe it could be a good dinner choice. Yeah, I know. Isn’t that crazy? Absolutely. We’re finding that out that the portion of the population that might be nutritionally depleted, even though we do have a lot of fortification, vitamins don’t necessarily, because we’re still doing the research on this, right? They don’t necessarily check all the boxes just as a sole entity. It’s a lot more complicated when vitamin C is detracted from a food source because of all the other elements that play along with the vitamin C, versus a synthesized vitamin C supplement, as we well know. Yeah.

Dr. Weitz:            When vitamin C is found in foods like oranges, there’s all sorts of bioflavonoids and other phytonutrients, many of which we’ve not even figured out what their role is. I’m a big believer in supplements, but supplements are topping off a natural diet. So you’re getting at least a good background of all those phytonutrients that are contained.  Just recently, one of the studies on COVID-19, we’ve seen some positive data on vitamin C, but the bioflavonoids have been shown to be super helpful. I mean, some of the ones particularly that are found in foods that have vitamin C, like hesperidin and rutin. And so I think it’s important that you have a phytonutrient rich, healthy diet with lots of different colors of fruits and vegetables. And then take your vitamin C on top of that, you’re going to get a different response than eating Cheerios that are fortified with vitamins.

Melainie:              Exactly. It’s amazing, Ben, because we’re actually designed to seek out variety in food. And this is the very reason for it. Because prior to us being able to actually identify that there are such things as vitamins and minerals, no one’s got a gauge built into their arm that says, “You’ve met your zinc intake and your magnesium intake for the day, et cetera.” Right? The way that our brains are structured is, we seek out variety of food to make sure that we’re actually getting in adequate vitamins and minerals throughout the day. Which is pretty genius when you think about it. And it can’t be replaced by just a simple supplement, as you rightly said.

Dr. Weitz:            Unfortunately, a lot of people now are stressed, so they’re eating some of these unhealthy foods because they don’t require a lot of preparation. But the reality is, is we really have more time now because people are at home to fix yourself a really good healthy meal with lots of fruits and vegetables and actually being involved in preparing it, and prepping it, and cooking it. It’s actually an important part of getting the benefits and enjoyment out of a meal. I encourage everybody to do that.  Now, on the other hand, I also understand that unfortunately, healthy foods are more expensive. You see at these food banks, you don’t see a lot of fresh produce being put into those boxes. You see boxes of cereal, and packaged foods and things like that. And because those are relatively inexpensive and ditto for junk foods, our fast food industry, which is probably still doing as much business as they were before because you can’t dine in but a lot of people do takeout anyway and it’s fast and inexpensive.

Melainie:              Right. That’s so true. Also there’s a shelf life on those items that you mentioned at the food bank. Those things can be put on a shelf or put in a box, easily and stored, whereas fresh fruit and veggies don’t and they spoil. It’s just logistically a lot tougher. And also what we find with food scarcity is that some of the more socioeconomically challenged areas, particularly I can speak for New York City, anyway, there’s not a lot of grocery stores in certain areas, but there’s hell of a lot of fast food chains in those areas. It’s also access to food. So there’s a lot of factors that play into it.  One other thing, Ben, is, yeah, some people are looking for what’s readily available. And this would be a good time to take the time to prepare some of these more nutritious meals and such. But I think honestly, it also comes down to motivation. I think so many people are feeling so flat right now with so much uncertainty that it’s just stressful. And when stress is high, your motivation tends to go low, which is counterintuitive to what would make you probably feel better. But we know about that, right? Motivation and behavior change is really tough as well.

Dr. Weitz:            It’s interesting that there seems to be more information and ever on food, and healthy eating, and nutrition, and yet, a lot of people are still confused. Can you comment about that?

Melainie:              Absolutely. I think it’s because there’s information overwhelm. They’re confused because, for example, we used to say that butter was bad, and then we went to margarine, and now maybe margarine is bad. So the science keeps changing and therefore consumers can’t keep up, is one thing. And now with social media, there’s such a plethora of information out there, it’s hard to even follow. And there’s so much contradiction out there as well. What my pet peeve is, is all the pseudoscience that is out there on social media.  There was one stat I saw recently, which suggested that between eight to nine out of every 10 comments and information out there on social media around food and wellness is actually bad science or even no science. I mean, I’m a registered dietician. I was medically trained. And so everything that we do is based upon what is the research. So it’s frightening to see a lot of wellness coaches out there who have no training and no understanding of the research spreading incorrect and inaccurate information.  I feel sorry for the consumer, because how can you possibly try to sort through what’s rubbish to fact? Then the facts actually do change as more and more research comes in as well. So it’s tough. I’m glad that I have the training that I have, but it’s still a lot of information to filter through.

Dr. Weitz:            Yeah. If you’re on social media, it seems to me that the biggest trend right now is the carnivore diet, which is meat only. All you eat is meat.

Melainie:              Right. Yeah. So a bit of caveman coming in there, but even caveman used to run around and get their root vegetables and fruits and berries from the trees and such like that. Yeah, it’s just another form of like the Atkins that was around a couple of decades ago, and it’s just the same thing-

Dr. Weitz:            Even more extreme, you know?

Melainie:              Yes, it is very extreme. It’s very extreme. The difficulty with that, and I know there are people who are pro; the difficulty with that, as we’ve seen with any of these eating plans, is that for a while it works for people until it doesn’t because taste fatigue, physiological needs are not met, et cetera. And then-

Dr. Weitz:            Starving the microbiome…

Melainie:              Exactly microbiome, and then people fall off the wagon. Then what’s so beautiful and brilliant about these diets is that when the consumer falls off the wagon, they blame themselves. They don’t look at the diet and say, “This diet was setting people up to fail.” Hence, it just perpetuates itself.

Dr. Weitz:            What do you think about high intensity exercise for emotional leaders? You see people who are obsessed with exercise, especially the gyms are closed, but I’m a gym person and used to seeing certain people at the gym for hours at a time. And that’s another form of eating disorder is over exercising. So how should people who have a tendency towards emotional eating approach exercise?

Melainie:              Exercise in moderation is really great for so many reasons. And you as a chiropractor and sports chiropractic person know this. I have a sports nutrition background as well, Ben. So you know that the mental health benefits, the physical health benefits, motility, flexibility, all of these things, we know exercise is really helpful up to a point. But what you’re speaking to is a behavior of obsessiveness and going above and beyond what actually technically is healthy. In fact, obsessive exercising is very unhealthy.  What we look at with what we do is not just people’s obsession around food, whether it be undereating or overeating, but that obsessive tendency carries forth in other areas. And one of them, as you said, is over-exercising, which can be really harmful. But what’s really interesting about that is that some people overeat, or express their emotions through other ways; over-exercising is a way that people are trying to manage anxiety. It certainly has health benefits and therefore, unfortunately, it’s pretty normalized in our society because it’s like, “Oh, I envy that guy. Look, they’re three hours at the gym.” And it’s like, “Uh-uh (negative), that is so unhealthy.” I wonder about the work ethic, and also wonder about their relationships, because if you’re three hours in the gym, you’re not going to have some pretty happy people at home.

                                What we try to do there is we treat the whole person. So it’s not just about the food. It’s about what is your relationship with exercise? And also what’s driving that, and often it’s a body image underlying piece is driving that. For the guys it might be the bulking up, because there’s an underlying body image issue, which is an underlying anxiety issue. I mean, I’m simplifying these concepts, but for the point of the illustration. So we try to get at the underlying reason that one might be over-exercising and try to pull that back.  Usually what happens is when you reduce, someone who’s an over-exerciser, when you reduce their activity, their anxiety goes right through the roof. Which is exactly what we want to see because then we’re like, “Okay, you’re self-medicating with exercise. So let’s get it, what’s the underlying anxiety about?” In the same way that someone might be drinking excessively, you take the alcohol out of the picture and you’ll see their anxiety going up. So we need to get at the underlying anxiety.

Dr. Weitz:            How about a few tips for those of us who’re working with clients with weight problems? How about the client who’s not being honest with you? You make recommendations for changing their diet and exercise and they come back and four weeks later, no change, haven’t lost a pound, maybe gained a pound and they claim that they’ve eaten nothing all day except a salad and some tuna fish and an apple and they’re doing excessive amounts of exercising. You just know it’s not the case. How do you approach them?

Melainie:              Well, there’s a couple of different things there. First and foremost, we know that for a lot of our clients, because of shame, and they want to be seen as doing the right thing, and they want to not do the right thing. They want to follow your recommendations. They want to please you, Ben, they want to please me. They’re coming in, they’re paying us money. And then they find they can’t. Then they feel great shame about their behaviors. And they also feel shame about the fact that they can’t do what you asked them to do. So they’re not always forthcoming with the reality.  We know with our clients that 50% of what they tell us is either true or not true in the sense of, for our under-eaters, they’ll report that they’re eating a lot more than they are by about 50%. And for our over-eaters, they’ll under-report how much they’re eating by about 50%. So we know that from the get go, that that is part of the shame. Our job is not to shame them further, but to figure out how we can set them up to be more successful. So maybe those goals were too ambitious. Or maybe, actually, this is not just occasional over-eating, but there’s a serious problem going on here that they’re not able to rein in on their own, and they actually need more help and more support around that. And maybe they need more therapeutic support to handle the emotional stuff that’s causing them to overeat and then lie about it.  Then of course, there’s the other piece… Sorry, Ben. The other comment there is, the lessons learned from the greatest loser is that people massively restrict and they’ve lost a lot of weight, even though they still may be in a higher body weight, their metabolic rate shuts down and all sorts of biochemical processes change. And that endures for up to six or seven years; we’ve seen from the research thus far. So-

Dr. Weitz:            What have we seen from the biggest loser? Can you go over there?

Melainie:              Yeah. From the biggest loser where they’re able to do research on people who’ve lost a hundred plus pounds and are able to follow up with them six and seven years later, all of them regain plus some. And what they actually found is that the weights they return to, their metabolic rates never recovered fully to what we would expect a person of their body weight to be. If you-

Dr. Weitz:            Wow. This is almost all of them, you’re saying?

Melainie:              Yes. If you look at the Biggest Loser, which I hate that show but for research I have to watch it. And I was horrified by the shaming and it’s just disgraceful. But if you remember, those contestants were exercising six and seven hours a day plus. So it wasn’t that a lack of exercise was affecting their metabolic rate, which is a common thought in the sports nutrition world, that’s for sure, that exercise will protect your metabolic rate. It’s not true.  Again, I guess what I want to say for our higher weight clients, it’s complicated. There’s so much that we still don’t know because of weight bias actually, Ben. There hasn’t been good research done because assumptions were calories in calories out. We now know that that’s not the case. That it’s much more complicated and nuanced and sophisticated than that. And so our higher weight individual, our clients, we don’t have good research to be able to advise them accordingly. So compassion is really important. And then making those recommendations more baby steps so that they can feel good, and they can feel that they’re succeeding.

Dr. Weitz:            What could you do? Let’s say you’re in with a client and this is somebody who’s trying to lose weight, and you know they’re not being honest about the food they’re eating, how do you coax it out of them? What kind of a conversation or what can you do? So, for example, you’re recommending that they need psychological counseling besides the nutrition coaching that somebody like myself can provide. But how do you even bring that up if they’re not even admitting?

Melainie:          Well, if they’re not admitting that means their shame is too great. Even if you were able to… So here’s the thing, previously, what I guess might’ve    been encouraged is to just say to them blatantly, “I don’t believe a thing you’re telling me and you’re lying because the scale tells me the truth.” So my question to anyone who would approach them in that manner is, A, “Will the client come back?” B, “Did you help that client in the future to seek out help?” What we find is that when clients drop out of treatment, it may take them two years to come back, if at all. And we know that higher weight clients disproportionately don’t seek out help because they’re ashamed about their body and their weights. So shaming is not a way to go.

                                We know that our clients are going to under-report how much they’re eating because they’re ashamed of it. I’m just going to keep that in my mind, but I’m going to work with what they’re willing to talk about. That might be, I’m not going to comment on how much they had for dinner or not. I’m going to say, “Okay, well, did we have that breakfast?” How did you go with trying to get that breakfast in?” Or, “How did you go trying to get that lunch in?” “You know how we talked about having to make sure we get some protein in there? How did you go with that?”  We talk about those one or two, or even three simpler ideas. Because the idea is if we can get food in and by food, I mean, you make sure you get your protein there, make sure you get your fat for satiety, make sure you get the carbs in there. I don’t want low carbs because you’re going to binge on those later. It’s a physiological response. If we can work on what we can add in at the times where there are gaps, then that can also help with overeating later on, even if they’re not reporting that.

                                I had one client that I worked with, Ben, for two years before she admitted that she was binging. I knew she was, but that’s part of her process. It’s like if someone’s drinking alcohol, and you know they’re drinking, but they won’t admit to it because that’s their process; denial. If you think of stages of change; denial, and then there’s pre-contemplation and contemplation. Motivational interviewing and thinking of stages of change with behavior can be really helpful as well.  Also managing our expectations as the clinicians, because we know that if you just follow what I tell you, you’re going to really just see some great results and you’re going to be healthy and you’re going to recover. Then when they don’t do it, it’s really takes away from our sense of accomplishment. And so we have to check our egos as well and pull back and meet the client where they’re at with their process.

Dr. Weitz:            How about when they come in for their first consultation and you’re somebody like me who just is super disciplined, and it’s like, “If this is healthy, then I’m going to do it. I can’t imagine why anybody wouldn’t do that.” You’re meeting a client and you know that they’ve had problems with weight for a long time. They may be told you that. How do you set them up for success? Because I know I’ve had the occasion more than once, unfortunately, of setting them up on a program and asking them to write everything down, and this is going to be so great. We’re all excited, and that’s it. Never saw them again.

Melainie:              That’s right. That’s absolutely right. Because you set them up, you’re like, “We’re going to do this.” Yeah, because it’s overwhelming. It’s overwhelming for them. I think what’s really, really hard is, and I encounter this too, because I’m a registered dietician, so therefore, I know what to eat and what not to eat and all that stuff. I studied it for seven years, and other things. We have to be a little bit careful, Ben, because we bring our enthusiasm for what we do but if our clients were wired in the same way that we’re wired with our interests and our level of passion for this, they wouldn’t need our help. We have to bring it down a notch or two or three.

                                I like to share with my clients occasionally whatever, that I love my Doritos and my glass of wine. And I have to make sure I have my Kit-Kat or my chocolate every day; to normalize it and come down to their level, and to be able to say, “Gosh, I know this is really hard.” And maybe even reflect what other clients struggled with and how they were able to overcome it. Because I think using us as a benchmark… We’re the supposedly expert and we’ve done, hopefully, all this study and clinical practice to get where we are, but we still have to moderate that to help the clients. And maybe their baseline is this. Maybe that’s as good as it’s going to be for them, and they’re thrilled with that because it was better than where they were.   But I hear you and I’ve been in the situation too. Beautiful plan and the client doesn’t come back, or they come in and they’ve done none of it. And that’s when you’re like, “Okay, those goals were way too big and overwhelming. Let’s just start with the basics.”

Dr. Weitz:            Good. Okay. That was great. Any final thoughts you have for our viewers or listeners?

Melainie:              I hope people have gotten out of this today just that, most people are doing the best that they can, and we can definitely help them to take that next step and take it in baby steps. Those extreme diets are usually not exactly what they’re cut out to be.

Dr. Weitz:            How can people find out about your programs and getting in touch with you and your clinic and-

Melainie:              Absolutely. Check us out on our website, which is balancedtx.com. And also we have a free 20-minute complimentary discovery call, Ben, for any callers who want to call in or sign in via our website. If you feel as though maybe you’re struggling or someone you love is struggling and you want to just get a better sense, “Is this disordered eating? Is this emotional eating? Is this an eating disorder?” We can help you sort through that.

Dr. Weitz:            How about practitioners? Let’s say somebody like myself who’s not typically focused on the emotional stuff, is there a way, if I’m working with a client and I’m working with the dietary stuff, can we interface with you and your office on emotional part?

Melainie:              Absolutely. I have a team of therapists and I have a team of nutritionists, so we have the medical piece and we have the psychological piece. Our whole philosophy is, gold standard of practices working collaboratively. So we would love to do that, Ben.

Dr. Weitz:            So as a practitioner, how would I approach that with sending one of my clients too, but making sure that I can continue to work with them on the nutrition part?

Melainie:              Oh, absolutely, that’s essential. Is if our clients come in with any kind of team member that they’ve been working with, our goal is to absolutely insist that they continue to see you because you know them the best. We want to hear from you what you’ve seen and observed so we can then set up the best care package for them with your collaboration and theirs. And then-

Dr. Weitz:            So as a practitioner, would I call or-

Melainie:              Absolutely. Just give us a call.

Dr. Weitz:            Okay. Awesome. Thank you, Melanie.

Melainie:              Thank you so much, Ben.

Dr. Weitz:            Melianie

Melainie:              That’s okay. It’s all good. Thanks, Ben. What a pleasure.

Dr. Weitz:            It was a pleasure for me as well. Thank you.




Fasting with Dr. Daniel Pompa: Rational Wellness Podcast 161

Dr. Daniel Pompa discusses fasting with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

2:37  Some of the smartest doctors in the Functional Medicine field just happen to be chiropractors.  The reason is because we share a major premise that the body has innate intelligence that heals itself if we just remove the interference for this. 

3:13  Dr. Pompa became interested in fasting in the 90s from his involvement with a vegetarian group that was inspired by some books by Herbert Shelton on fasting and he went to some of the seminars. At that time, fasting was not very popular.

4:15  Intermittent daily fasting is where you don’t eat for a period of time that could be 12 or 15 hours or even 24 hours.  Extended fasts are where you go without food for between 2 and 5 days. And there are certain conditions that will benefit from an even longer fast.  Dr. Alan Goldhamer, who I interviewed on episode 116, has patients do a 30 day medically supervised fast.  30 Day Fasting with Dr. Alan Goldhamer: Rational Wellness Podcast 116   

5:36  Dr. Pompa discussed a patient that he fasted years ago for a grapefruit sized tumor for about 26 days. It took that long to reduce the tumor to the size of a golf ball. She was detoxing and her tongue went from coated white to green to black and fuzzy her family had to cross ventilate their house since she smelled so bad.  When you do a 5 day fast, the magic happens after 3 days when you have lost your hunger and you get your energy back. Day four we hit max autophagy, which is when your body eats broken down and damaged cells, organelles, and even DNA and recycles these proteins and nucleic acids. So then you continue the fast one more day for 5 days to really take advantage of this autophagy and then you see a massive rise in stem cells to rebuild and massive rise in growth hormone as well. The benefits of a fast tend to decrease after 5 days, so multiple 5 day fasts is the way to go in order to maximize autophagy and allow the body to heal itself.

9:22  Dr. Pompa prefers to do water only fasts, but he often starts clients with a partial fast, such as using the five day partial fast developed by Dr. Valter Longo, which makes it easy. You just eat what’s in this box, nothing else, for 5 days. You can design such a program yourself and Dr. Pompa in his Beyond Fasting book explains how you can design a partial fast around the foods that you like.

11:12  With a partial fast you get a lot of the benefits of a full fast. You still get autophagy and stem cell production.  It is helpful to work up to a complete water fast by starting with a partial fast that contains between 500 and 1,000 calories, depending upon the person.  But such a fast does need to get the protein levels down to below 15-20 grams per day, depending upon the size of the person.  Many of the studies that look water only fasts do not see as many results as Dr. Pompa’s patients get because they prepare and train for the fast so that their body is fat adapted and ready for the fast, much as you would train to be able to run a marathon. He lays out a seven week program in his book, Beyond Fasting, for how to prepare to do a 5 day water only fast. With a water only fast you get energy divergent where your body uses it’s energy that does not need to help digesting food and this energy can be used to help the body to heal, whether it’s a knee or the kidneys.

14:18   Fasting can actually stimulate the immune system and that could be very helpful during this coronavirus pandemic. Back in the 90s fasting was considered to be harmful to immunity because during a fast you might see a drop in white blood cells, but this is actually part of autophagy and it is getting rid of old white blood cells which we call senescent cells that drive inflammation. Then, a month or so after the fast you will see an increase in the immune system to preventative levels.  With fasting we also see an improvement with patients with autoimmunity.

16:48  To prepare for a 5 day water fast, it is advantageous do a ketogenic diet to get your body to become fat adapted. If your body is fat adapted, you may start having autophagy on day one of your water fast instead of on day three.

18:12  The key to weight loss is to eat less often rather than eating less, according to Dr. Pompa.  If you eat too few calories for too long, your metabolism will slow down and your body thinks it is starving and it will hold onto fat but break down your muscle and turn it into sugar for fuel. Dr. Pompa noted that he eats only two meals per day in a 4-5 hour window and one of these meals he eats until he is a bit beyond full, which signals the body that you are not starving and you can burn fat for fuel.

22:32  For many years it was believed that the key to losing weight and being healthy was to eat breakfast and to have small, frequent meals throughout the day to keep an even blood sugar, so that you didn’t eat too large a dinner.  But by doing this, you never give your body a chance to burn its own fat because you are always feeding it.  And it’s a bit ironic that now one of the keys to losing weight and being healthy is to skip breakfast so that you are doing an intermittent fast. Dr. Pompa pointed out that because of the Dawn Effect, where you get a rise in blood sugar from the morning rise in cortisol, it is easy to have energy in the morning without eating anything. Hunter-gatherers in Africa usually just eat one meal per day. The men are up early and spend all day tracking down and hunting prey and they don’t eat until evening when they come back to the tribe in the evening and they would eat together.  And these hunter-gatherers were lean, ripped, and healthy.

25:48  On the other hand, Dr. Pompa said that if it works better for your schedule to skip dinner rather than breakfast, then that works as well. The key is giving your body time to go through autophagy by not eating for a period of time and it doesn’t really matter what meal you skip. 

26:33  When people follow a ketogenic diet for too long, the body will think it’s starving and will hold onto fat. We have to have periods of feasting as well as periods of fasting. And we should change our diet based on the seasons and environmental changes.

27:43  To measure cellular aging vs biological aging we can use telomere testing.  Telomere testing measures the length of our chromosomes and we now have DNA methylation testing. Looking at your telomere length is like looking at the tread you have left on your tires. To promote better cellular aging it is best not to do low carb or keto for too long.  It’s best not to do too much fasting since stimulating autophagy long term is not good. It’s also not best to do vegetarian all the time or to eat a bodybuilding high protein diet. For short periods, a high protein diet can be healing, but for long term, high protein will age you by stimulating the mTOR pathway. It’s best to alternate periods of fasting with feasting, moving in out of low carbs and higher carbs. The magic is in the change.

30:12  While a ketogenic diet has less fiber and stresses the microbiome, this will actually help to increase bacterial diversity once you come off the ketogenic diet.  By stressing your microbiome, you stimulate change and improvement, much like exercise stresses your system to make you stronger.

34:46  When you follow a ketogenic diet initially you start to burn fat for energy, so you produce ketones and during the first week or so you spill a lot of ketones into the urine and these can be measured with ketostix. But once your body gets used to using ketones for energy, when you become fat adapted, you will no longer spill a lot of ketones into the urine, so you need to measure ketones in blood instead of in urine.


Dr. Daniel Pompa is a global health leader and innovator on a mission to educate practitioners and the public on the origins of inflammation-driven diseases, cellular detoxification, fasting strategies, and diet variation principles.  Dr. Pompa is the host of Cellular Healing TV, and the author of the books Beyond Fasting and The Cellular Healing Diet. His website is DrPompa.com.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.


Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz host of The Rational Wellness Podcast, I talk to the leading health and nutrition experts and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to The Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.  Hello, Rational Wellness Podcasters. For those of you who enjoy listening to The Rational Wellness Podcast, please give us a ratings and a review on Apple podcasts. If you’d like to see a video version, please go to my YouTube page. And if you go to my website drweitz.com, you can find detailed show notes and a complete transcript.

                                Today our topic is fasting with Dr. Daniel Pompa. Fasting is one of the oldest healing strategies in natural medicine. And it’s been advocated for thousands of years by alternative health care practitioners and utilized by almost every religion today that’s around. For years the medical community has essentially dismissed fasting as having no randomized double blind clinical trials, proving that fasting has significant benefits for reducing or curing diseases. But the studies have been accumulating especially on intermittent fasting. And Dr. Valter Longo of USC has been publishing a number of scientific articles and a book that have really been placing the spotlight onto fasting, highlighting some of the anti-aging benefits with his fasting mimicking diet program that involves eating a low calorie diet while eating only food products contained in his ProLon kit. That includes a low protein vegetarian nutrition plan.  Dr. Daniel Pompa is a global leader, and an innovator on a mission to educate practitioners in the public on the origins of inflammation driven diseases, cellular detoxification, fasting strategies, and diet variation principles. Dr. Pompa is the host of Cellular Healing TV, and the author of the books Beyond Fasting, which is going to be the focus of our talk today, and The Cellular Healing Diet. Dr. Pompa, thank you so much for joining me today.

Dr. Pompa:         Yeah, thank you for having me. I love these topics.

Dr. Weitz:            I just think it’s so interesting that I’m a chiropractor. You’re originally a chiropractor So many of the smartest people in the functional medicine world are chiropractors for whatever reason.

Dr. Pompa:         There’s a reason it’s because we share a major premise of the fact that the body has innate intelligence that heals itself and all we can do is remove interference and it does, right? And so fasting is one of those things that harnesses that innate intelligence and allows the body to heal itself, and that’s the magic. That’s why we all unite around that philosophy, honestly.

Dr. Weitz:            How did you get so interested in fasting?

Dr. Pompa:         It was back in the ’90s. I joke because I say it was just me and some natural hygiene society guys that were into fasting. That was a vegan vegetarian group, but they were all really big into fasting and there’s a guy named Herbert Shelton that read a lot of books on fasting and so I would go to the seminars. I was intrigued by fasting because again, it’s the philosophy of the innate intelligence, right? It’s like the body heals itself.   Yeah, I got very sick, so it was something I had to apply to myself but fasting does, it harnesses that innate intelligence and my fascination with it came out of that.  Back then it was very few people are into it.  And now it’s popular, I just had to stick around for 20 more years.

Dr. Weitz:            These trends in natural health world. So what is the definition of fasting? And then what is intermittent fasting? Because those are two terms you hear a lot, and I think there’s some confusion over exactly what fasting includes.

Dr. Pompa:         Yeah. So intermittent fasting daily is where you just don’t eat for a period of time, maybe it’s 12 hours, 15 hours, 24 hours, right? That’s an intermittent fast and you can do it daily. Now, extended fasts are when you take and you go without food beyond that, maybe it’s two days, maybe it’s three. I prefer and always have five-day fasts. And I believe there’s a magic number in that five days. But with that said, there are certain conditions that you will benefit fasting longer.  But there’s also a time to stop fasting and we talk about all those things but extended fasts has different benefits. Some of the same benefits is intermittent fasting daily, where you just do that 15 hours, 18 hours, whatever it is. So some of the same benefits you pick up even at a short fast like that, but certain conditions, certain health aspects, extending it longer is critical.

Dr. Weitz:            Yeah. I interviewed about a year ago Dr. Alan Goldhamer and he-

Dr. Pompa:         Yeah.

Dr. Weitz:            … puts people in 30 days medically supervised fasts.

Dr. Pompa:         Yeah, and there’s a time for that. Back in the day, I took some people through some really long fasts and they definitely have to have more body stores just to put it nicely. Certain tumors, a bit longer fasts. I fasted a woman, it was probably about 26 days, she had a grapefruit sized tumor and man it took that many days to bring it down to it was about a golf ball. And then she fasted like another week after three months and then she got rid of it completely.  But in that time, her first week was horrible. She was detoxing, her tongue went from coated white to coated green to black and fuzzy and her family literally had to cross ventilate the house. They had a fan on one side and they would open the windows and blow it through because she stunk up the whole house, right?

Dr. Weitz:            Wow!

Dr. Pompa:         In the first week, she came in complaining to the clinic everyday. Oh, my gosh. Right? And then after that she came bounding in every day with her reports of healing. So I’ve watched fasting really deep, deal with some incredible things and I’ve watched incredible things happen with the fast. But I learned through that process is shorter, five-day fast. You can achieve the same thing with a lot less pain, multiple five-day fasts. And why five days? Because look, it takes about three days for people to go, “Okay, I can do this. I actually lost my hunger. I actually have energy back.” So I would always carry them at least one more day, right? But again, three days is suffering. So day four was like, “Okay, it’s a good day.” So why not carry an extra day, day five, when they finally feel good to get that healing. Look, I didn’t know a lot of the science back then because there wasn’t any frankly on some of this.

                                Now, we know that some magic happens day four, we hit max autophagy. What autophagy is, is this happens during fast, the body to get energy eats. It’s so intelligent. Here’s that inborn intelligence thing right, that heals the body. It’s so smart, it wants to survive. It will eat only the bad cells of the body. It’s that smart to even know, here’s bad DNA, here’s a bad cell. It’ll take those out and not harm the good cells. So autophagy is the body getting rid of these bad cells and other debris and rubbish that it needs to get rid of. It’ll eat that first. That’s autophagy. So when I use that word autophagy, so think of auto automatic. Phagy as eating, so automatically eating the bad.  So what happens is, is during that this fast, day four we have max autophagy, meaning that all of a sudden the body’s just crushing bad cells, why would you cut it off then? And then day five, we see what we call max stem cell production. Because every time the body gets rid of a bad cell, it doesn’t just go, “Oh, you’re going to have to live without that white blood cell.” No, it stimulates and produces a new white blood cell via of the stem cell production. So about day five, we see this massive rise in stem cells.  And then after that, there’s a plateau effect. So if we do multiple five-day fasts, we maximize the autophagy, we maximize the stem cell production and we also maximize the hormones. We have this massive growth hormone rise that takes place day five. So multiple five-day fasts is how you can shut off autoimmune-

Dr. Weitz:           And a fast for you is water only right?

Dr. Pompa:         Yeah. I do prefer water only.  So you mentioned Valter Longo, right?  I love Valter and his group.  Pleasure to work with them.  I thank God for some of his studies because he really brought what we learned clinically years ago five-day fast is he’s the one that really spearheaded that max autophagy, max stem cell and some others have done that work too.  But so he’s brought a lot to this.  One of his studies was taking five months and this was an animal study, a rat study. Type 1 diabetic rats and fasting them. And really watching the beta cells regenerate because of the stem cell rise that takes place and after month four and five, we would see this the beta cells coming back and they were able to reverse the condition. So more and more studies, very exciting have been done, so I thank Valter for that.  But Valter and I definitely disagree in that I think that again, I train doctors on these topics. And clinically, I can tell you the most powerful still is a water fast.  Now, I still utilize partial fasting and I have for years.  So Valter’s fast where he boxed the foods for five days.  I’m a big fan.  I think it’s easy.  I think it’s a great partial fast, and I’ll explain what that really is because there’s a definition of partial fast.  I’ve used it for many, many years.  And oftentimes the first fast I’ll do with someone is in fact, a partial fast, and then move them to water fasting, which is a little more aggressive in getting rid of bad cells.  So I’m a fan of pure water fast.  But yet, I’m still a fan of partial fasting. Okay, so…

Dr. Weitz:            So partial fast, you’re not getting the same benefits as a full fast.

Dr. Pompa:         Yeah. You’re still getting a lot of benefits, you still get autophagy, you still get stem cell production. We have a way of measuring autophagy, and I talk about that in my book that doing your fast you can measure this in a very simple way. But we don’t see as much autophagy in a partial fast as a water fast.  And Valter really loves the partial fast. I have a lot of respect for him. But again, clinically, I just see, in a lot of the studies, they just put the average person into a water fast. It’s a mistake, you’re going to not see these major benefits. In my book. I have a seven week program. This is what you do five weeks up to the fast. Week six is the fast, week seven is breaking the fast. So it takes you through that whole process.  You don’t just run a marathon, you train for a marathon. So number one, you can finish it. And number two, you get the best result, right? So you don’t just do a fast. My book takes you through how to train for it. So a lot of the studies that just do look at water fasting or taking someone who’s not fat adapted, they’re not able to fast very well. So they’re not getting these benefits that I’m talking about right out of the gate.  So anyways, the bottom line is Valter has made the partial fast very popular, and he even boxed the foods that follow the rules of a partial fast. So what is a partial fast? If you have to get your calories, depending on body size down somewhere between 500 calories a day to 1000. Figure people can do a little more calories. Protein is important. You have to get your protein at least under 20 grams a day. The reason is, is if you have too much protein, it will knock you out of that autophagy. You won’t get any autophagy, so you have to get the protein down.

                                So a smaller person, you might need less protein, even under 15 grams of protein a day. So Valter put those in five boxes. So you have what it is you’re eating. In my book I give a partial fast, you can design it yourself around the foods you like, right? So I talk about that. But yeah, so partial fasting you still get the benefits, you still autophagy, you still get stem cell production. Water fasting, you get something a mass of what I call energy divergent, where your body has so much energy not eating any food, it has so much extra energy that it takes that extra energy and it just doesn’t sit on it and have a vacation. It takes it and all of a sudden the stuff that it wanted to heal, but it couldn’t because you never gave it a break. It takes energy and it starts healing it.  So maybe it was a knee problem from 20 years ago. All of a sudden, you get this knee pain, that’s the body healing it. It will divert these extra stem cells to the knee and start healing it. Maybe it’s kidney pain. Maybe it’s this pain, whatever it is, the body will take that extra energy, utilize its stem cells, and magic happens.

Dr. Weitz:            And of course, right now we’re going and at the time of this recording, we’re going through the corona virus pandemic. And fasting is actually something that can stimulate immunity.

Dr. Pompa:         Yeah, very much because, one of the things that back in the 90s was a criticism of fasting was it lowers your immune system. Because we would do blood tests, right? And you’d see this massive drop in white blood cells. Well, that can’t be good. But clinically, we’d say, “Wow! But we see the opposite.” We see autoimmune which is mean hyper immunity, which is really bad immunity, right? Where your body’s hyper responding, creating inflammation, sick people, people don’t feel well will have autoimmune even if you don’t diagnose, your body’s attacking itself, not good.  We see a lowering of the autoimmunity. And then we see this rise, especially a month or so after a fast of the good immune system would go up. Well, now, one of the Valter studies showed this drop in white blood cells is the autophagy, meaning the body gets rid of these old white blood cells, immune cells that are living too long. We call them senescence cells. They live too long, they cause mishit, they drive inflammation. They don’t work. They’re like union workers. I just insulted somebody out there. I didn’t mean to do that. I met like the bad union workers, the guys that sit around. The PennDOT guys or what are those? Government workers. There’s the word I was looking for, not union. Sorry, union people. My father was a union guy, didn’t mean that. The government workers they get paid anyway, so they don’t want to do anything.  So anyways, there’s probably better analogies out there but insult nobody. I don’t mean that. The point is, is these white blood cells that live too long, they just hanging around causing bad stuff to happen not doing their job. So what we learned is that drop in white blood cells, the body eats those guys out. And when we get rid of those, it stimulates a stem cell and it  creates a brand new white cell that is working and doing its job. So it’s like hiring the good employee again, right? It’s like, bam, doing everything correct. And so that’s how you end up with better immunity.  So right now, with this virus, I’ve recommended people to fast. My kids, they all fasted together, they did a five day water fast, and upregulated their immune system to preventative levels.

Dr. Weitz:            Cool. So, in order to do to get ready for the fast, in your new book you talk about putting people on a ketogenic diet. So what exactly does that consist of?

Dr. Pompa:         Yeah, so chapter one is fat adaptation, becoming fat adapted will get you into this autophagy instead of taking four days to get there, you can get there day one. And in the book I talked about, again how to measure that. We look at ketone levels, glucose levels, but there’s a ratio, but we can get there day one.  So chapter one is how to get your cells using fat for energy, because that will create more autophagy faster, and ketosis is that way of doing it. And then we take each chapter takes you through another step, then we start eating less often and we start doing some of that intermittent fasting. I call it mitochondrial fitness. We stress the mitochondria without eating in periods of time. Again, we’re training it for the fast that’s going to happen. And then I take you through some of my diet variation strategies, which is a whole nother subject, chapters four and five, really, how these various strategies take you to another hormonal level to become this efficient fat burning machine. So when you go without food, your body’s just crushing bad cells. So there’s a process there.

Dr. Weitz:            So in terms of weight loss, I know in your book, you say that the key to weight loss is to eat less often rather than eating less.

Dr. Pompa:         Yeah. Look, when we look at, especially in this country. We look at weight loss, you can’t flip a television on without a morning show anyway, talking about a calorie restricted meal, right? There’s a menu of low fat low calories, right? That is the cornerstone of weight loss still in this country, even though scientifically we know it doesn’t work. Now, when we say that though, people listening will say, “Yeah, okay. I want to believe you, but I restrict my calories, I lose 10 pounds.” And I would say, “You’re right, you do. And if you’re a bigger person, you may even lose 20. Gosh darn it, it works.”  Well, long-term it doesn’t because the weight loss ends up to be more muscle. Even if it’s fat, what happens is it’ll stop at a certain point because the metabolism gets lower and lower. As you restrict calories, the body eventually says, “I’m starving.” And when it says I’m starving, now it will start to use its muscle, break it down into sugar, it’s called gluconeogenesis. And then it will hold on to fat, which is not what you want. So therefore, now you can be down to 500 calories a day that used to work for you. Now you’re at 500 calories a day. And again, remember I said that a partial fast short-term, that’s great. But long-term, it’s very destructive to your metabolism and your health in general. So long-term caloric restriction does not work.   So how when we look at … we talked a little bit about anti-aging, right? You mentioned that I should say. When we look at that, there’s only one thing that really works for anti-aging, and that’s eat less. So you just said caloric restriction doesn’t work. So when we look at countries cultures that live long, healthy, we know they eat less, but they don’t do it the American way of pushing food away eating half your meal, caloric restriction. No, they don’t do that. They eat less by eating less often. And there’s our conversation of intermittent fasting daily.

                                So I typically eat two meals in a day in a very short window four to five hours. So I’m eating less often. At the end of the day, I eat less calories than the average American my age no doubt about it. But if I did the exact same amount of calories, but pushed my meals away, I still ate four meals a day or five meals or even three and I ate half of my meal my body would go, “You’re starving,” because you’re not eating too full. Something magic happens when you eat one meal to full a day.  So I always make sure I eat at least one meal to where I’m literally, even a little bit beyond full. The body likes that because it goes, “I’m not starving and I’ll keep using your fat.” If you start stopping meals and eating partial meals, the body will go, “I’m starving, and then it will start holding on to your fat.” So eat less often and eat too full would be the rest of that conversation.



Dr. Weitz:                            We’ve been having a great discussion, but I’d like to take a minute to tell you about the sponsor for this episode. I’m thrilled that we are being sponsored for this episode of the Rational Wellness Podcast by Integrative Therapeutics, which is one of the few lines of professional products that I use in my office. Integrative Therapeutics is a top tier manufacturer of clinician designed, cutting edge nutritional products, with therapeutic dosages of scientifically proven ingredients, to help patients prevent chronic diseases and feel better naturally.

                                                Integrative Therapeutics is also the founding sponsor of Tap Integrated, a dynamic resource of practitioners to learn with and from leading experts and fellow clinicians. I am a subscriber and if you include the discount code Weitz, W-E-I-T-Z, you’ll be able to subscribe for only $99, instead of $149 for the year. And now, back to our discussion.



Dr. Weitz:              I think it’s so ironic that I’ve been doing this for over 30 years. And when we started, the big key to helping people lose weight was the fact that people rushed out of the house with eating breakfast, and then they would eat too much for dinner. And so for years, the mantra was, you have to eat breakfast. You have to eat within an hour of waking up. You got to have small frequent meals throughout the day.  And it’s just so ironic that now … so before then the key to being healthy was having breakfast, having small meals spaced throughout the day so you can keep an even blood sugar. And now the key is skipping breakfast.

Dr. Pompa:            You know it’s funny as I some years ago, I think it was 2005 was the first time I had the opportunity to go visit this hunting gathering tribe in Africa. And I was still a four or five meal a day person, like you’re saying, right? That philosophy, and I saw something completely different. I saw a tribe, I said, “Where are the men?” They were up and gone at like 4:30 in the morning when it was still cool off in their hunts, tracking down pray, and they’d be gone all day to three or four in the afternoon. “So how do they eat? What do they do?” “They don’t eat at all.” They’re out all day tracking down pray. So oftentimes jogging, running, right? It’s like, “And they do without food?” “Yeah.” And then I noticed the women never eat, even the ones that were gathering. They weren’t eating because they would wait and eat one meal together as a tribe. Now that meal may have lasted three hours, right? They’d start eating and start preparing but, a very European way of eating.  And I was fascinated by it because these people were lean, ripped. Amazing, right? Without disease, it was a pretty amazing experience. It made me question that, like, what are we doing? It’s like, because every time you’re eating, you’re basically not allowing your body to burn its own fat. But like caloric restriction, it works in the beginning. Because if you’re eating five meals a day, your body’s not eating its muscle, it will prevent that. So it maintains the metabolism that way, and people feel that but the problem is, we never give it a chance to burn it’s stored fat, that’s what our bodies are designed to do.

                                So long-term, you want to live long, healthy, eat less, but eat less by eating less often, and that’s what we see very healthy in the Hadza people did this. So were basically short cutting something that works short-term, not long-term. And that was the five meal a day thing. And by the way, eating breakfast in the morning, that’s the most natural meal to skip. And the reason why is because you get something called the dawn effect. In the morning, oftentimes you’re not hungry because your body releases glucose. If you test your glucose, the highest glucose you have all day long in the morning, because your cortisol rises to get you up. That’s what gets you up in the morning. Glucose falls cortisol. So that just means your glucose goes up. And that gives you your energy for several hours after you get up, right? So that’s why you’re not hungry because your glucose is high because of your cortisol level. So that dawn effect of glucose we’re meant to run on, and then again, you can run on that for pretty long time.

Dr. Weitz:            Yeah. I know for me, for some reason, I do better if I have a good breakfast. And if I’m going to skip a meal, I’ll skip dinner.

Dr. Pompa:         I was going to say this. So people always asked me, “Well, which meal should I skip if I’m going to eat two meals?” I said, “Whichever one works best for you and your schedule.” In other words, if eating dinner is important to your family you can’t skip, then eat dinner. Skip breakfast. If for you it’s the other way around, right? And some people for diabetics, I’ll have them skip dinner and eat the breakfast and skip dinner. So it’s whatever works. The key is, is just opening up that time giving your body time to go through autophagy, and giving it time to fast. It doesn’t matter what meal you skip, really.

Dr. Weitz:            When people follow a ketogenic diet or try to follow a ketogenic diet, what are some of the biggest mistakes they make? Why are they not successful? Can’t produce enough ketones? What are some of the mistakes that people make?

Dr. Pompa:         One big mistake is, first of all, I’m not a believer that there’s one diet, you should stay on your whole life, right? That tribe that I spent time with, they were constantly changing their diet based on what foods they have, environmental changes. So in my book, I talk about seasonal variation, how important that is, and weekly and monthly variation. And if you’re low carb too long, the body will think it’s starving, and we need times of feast and we need time to famine. And that balance is emulating these really healthy cultures. So it’s really key for hormone optimization. And that’s really how we age slowly, right? So, I’ve been able to measure my cellular age every way possible. And I spent some time sick some years ago, and my cellular age was much older than my actual age. Now-

Dr. Weitz:            What method for measuring cellular aging have you found to be the most effective or accurate?

Dr. Pompa:         Well, telomere testing has gotten better.

Dr. Weitz:            Right.

Dr. Pompa:         That measures … It’s the biological clock that, protects our DNA and the shorter they get the closer you are to death, simply put. It’s gotten better and better and more accurate, but now that we have DNA methylation testing.

Dr. Weitz:            Right.

Dr. Pompa:         If the given analogy, looking at your telomere length is looking at the tread you have left on your tires. DNA methylation is looking at the parts of the engine, how well are your organs aging, compared to your … Look, I’m a mid 50s, I’ll be 55 this year. I’m getting younger every year at the cellular level compared to my actual age. And I was the opposite. And again, everything I’m saying right now is what I do and how I’ve done it, amongst other things. But you will age according to your cellular health. Honestly, on the outside is what I’m saying.  Right anyways, so diet variation strategies is a anti-aging strategy as well. Shifting your diet is critical. So the answer to your question is one of the biggest mistakes for people is they try to stay in ketosis all the time or low carb, big mistake. And again I’ll throw criticism both ways. Staying vegetarian all the time big mistake. Staying keto, paleo all the time, big mistake. If you want to die sooner, eat a bodybuilding diet high protein diet will age you sooner, right? But eating high protein for short periods is very healing, right? So it stimulates a pathway called mTOR, mTOR long-term is bad for you. Low mTOR stimulation short-term very good for you, that means high protein or high calories that stimulates mTOR.

                                So too much fasting is not good that stimulates the autophagy pathway long-term is not good. So variation, you need autophagy to get rid of bad cells, you need mTOR to stimulate production of new cells. So feast famine, I talked about in my book and how to do feast famine. So when people do ketosis, the big mistake is just staying in ketosis. Big mistake, you need feast, you need famine, you need moving in and out of high healthy carbs, low carbs. The magic is in the change.

Dr. Weitz:            Cool. You also talk about how ketones when you’re following a ketogenic diet helps to heal the gut and helps to diversify the microbiome. But one of the traditional criticisms of the ketogenic diet is that there’s not enough fiber which typically comes from starchy vegetables, beans, grains, seeds, and so that a ketogenic diet tends to starve the microbiome.

Dr. Pompa:         Great question. Let’s make it even more extreme. First of all, with the improved testing on being able to measure the microbiome or like the types of bacteria, the amount of bacteria in our gut, right, we call that the microbiome. That’s not just bacteria, but viruses, funguses, right? It’s all of these pathogens and everything that’s included in our gut.

Dr. Weitz:            Right.

Dr. Pompa:         Okay, so we have better testing to measure. The one thing that we can take away from all of this testing really isn’t what we thought in the beginning we would get, we thought, we’re going to be able to be able to, “Oh, there’s these bad guys, you have this too many bad guys, you have too many this.” It really didn’t turn out like that, it turned out to be diversity. If we look at very healthy people, their microbiome on a test versus unhealthy people, the one thing that stands out is not what type of bacteria, it’s the diversity of the bacteria. The more diversity, the healthier the person.  So the question should be then how do we increase the diversity? Stress the microbiome, honestly, just like how do I get more fit and healthy? Exercise, what’s good exercise? You have to stress your body, right. If you stress it too much, you won’t recover. Not good, right?  And the more the better shape you are, the more you can stress.  So fasting is a stress. When you change your diet, it’s a stress to your microbiome.  So my point is going to be this.  Take a carnivore diet, that’s an extreme diet of eating only meat and fats. Zero fat, okay. It’s caught on out there, right? People are showing their pre blood and post blood tests, you would think eating only meat and fat? Oh, my gosh, their cholesterol must go up. Obviously, it’s the opposite. Their blood test transforms.

                                Now, the challenge that I propose is stay on that diet.  Maybe genetics carry you a year, maybe two. But now all of a sudden, you’re going to see massive changes the other way.  Now, let’s pick on the other side, you have the vegans, right?  So I got on the diet.  I felt great.  Stay on that diet, we’re going to start to develop certain deficiencies. The point is, I love being vegan or vegetarian for a period of time, I love being on a carnivore diet for a period of time. So to answer the question how you increase the diversity of your gut, do those extremes.  So going without fiber for a month on a carnivore diet, it stresses those bacteria, oh, they don’t die, they back up, they get stronger, they get resistant, and then you start eating again. And they’re just they take off and they get four. So we know that the change of diet, the more you change your diet, like the Hadza people, the more diversity you have in your microbiome.  So it’s magic.  It really is.

Dr. Weitz:            Now it’s tricky to change your diet. I know over the years, when if I change from eating more animal protein to suddenly eating more fiber, initially, you start getting GI upset and your enzyme system isn’t ready for that change. So …

Dr. Pompa:         Yeah. To your point, and you know what’s happening because here’s what, your body has to change its microbiome to make the enzymes that it needs to start breaking down. Eventually, it adapts. So the advice is just take it slow. Take it slow. If you just drastically change, your body will catch up, but you’re going to have to deal with symptoms. All right, so if you just go slower, then maybe when you first start eating more meat, you’d have to take some HCL, digestive enzymes, HCl or bile, the body will change its microbial and start producing more bile, it will start producing more HCl. It’s that smart.  It is, but it takes some time.  So your question or your comment really gives an explanation for why the diversity increases because it has to survive.

Dr. Weitz:            Right. So when patients try to follow a ketogenic diet, a lot of people will recommend that they use these urine Ketostix. And that’s a way to measure if you’re excreting ketones in the urine, but some people use those through their whole ketogenic program and that’s not really appropriate, right?  Why is that?

Dr. Pompa:         Yeah. Ben, you’re well read. Yeah, you’re right. And I’ve had good doctors say, “Well, my diet gets you in ketosis in two days.” I’m like, “Really? How are you measuring that?” “Urine.” Okay. You eat more fat in the diet, you’ll start producing more ketones. You’ll see them in the urine. So what happens is ketones, let’s back up. What are ketones? I don’t know how educated you’re listening audience is. But ketosis means that where your cells can use two things for energy, sugar or fat. So when we become fat adapted or going into a ketosis diet, we’re shifting the cells energy to where 95, 98% of the energy is from fat, not sugar, right? So we reduced our carbs down to so low that it has to eventually to survive use fat. When it burns fat, it makes something called ketones because your brain can’t use fat as energy. It can only use sugar or ketones. So when we drop sugar down, it burns the fat. The body uses the fat as energy, and then it makes ketones and your brain uses the ketones.  Okay, so just a little bit of chemistry there. So ketones have a major healing effect on the body for your brain. We know that keto diets would take people out of seizures, neurodegenerative conditions, alters people’s brains wake up. Hugely healing for the brain and the gut. That was one of your questions earlier.   We also know studies the ketones help heal the gut. Again, staying on the diet can create problems, down the road, but by shifting people over into this fat about the diet and making ketones, it’s magic. So the first week or so we see this urine rise up if ketones, and then we see it go away. Well, where did they go? Because now the body’s actually using the ketones and you don’t see them in the urine anymore. So it takes about two weeks for someone to fat adapt to become keto adapted. And one of the telltale signs is you don’t have ketones in your urine as much anymore. So means your body’s finally using. So we can’t use urine as a good measurement. You have to use a little blood.

Dr. Weitz:            Right. So let’s see. How long do you recommend people follow this ketogenic diet?

Dr. Pompa:         Again, it’s different for everybody, and it’s interesting, because one of the things that some of your viewers may be saying is, “I tried it, didn’t work for me.” And, well, that’s just that it works for everybody because the body is meant to go in these ketosis states. But when you’re really stuck in is a sugar burner, you meaning your cells can only use sugar, it’s oftentimes hard to break out of that. It’s very dangerous just to be in that zone, it can lead to cancer and other problems. But what we’ll do clinically, is we’ll take somebody and put them in a keto diet for like, two, three months. They’re hardly getting in whether you’re measuring your blood ketones, and you have to be above 0.5 to say, “I’m in ketosis, right?” And their 0.5, 0.6, 0.3, 0.2, they’re in they’re out, they’re barely in. What’s going on?  We’ll pull them out of a ketone diet after two months, put them on a healthy higher carb diet. Two months later, we put them back into a keto diet. And by the way, when they’re on keto, they’re not feeling good yet, right? They’re just not using the ketones, their brain’s not using them, they don’t feel good. We move them back to a higher healthy carb diet. Now they feel good because they’re using more sugar again. So then, two months later, now we put them back into ketosis. Now their ketone numbers go higher 0.8, 1.2, 0.3. I still feel great, but better, and then we’ll move them out again.  So we’ll do that a few times. And then each time they get more fat adapted, each time they get more grit. So we actually use that variation strategy to help people break through into this phase that everybody should be able to get into. So answer your question, sometimes two months, sometimes three months, sometimes six months, and but I always move them in and out of the state.

Dr. Weitz:            Are there some people based on their genetics and their lab values that maybe shouldn’t do a ketogenic diet? For example, maybe patients who have APOE-e4 variation?

Dr. Pompa:         Yeah. Look at our bodies, everybody can benefit from it. Why? Because it’s survival mechanism. It’s a survival mode. And during survival modes, the body turns off bad genes that have been turned on. it’s called epigenetics. It resets the microbiome, right? You get rid of bad cells, because bad cells don’t adapt to the stress of ketosis. So I believe that it’s a stressor that everybody can benefit. Fasting is the same way, meaning we’re genetically programmed to fast. The problem is today is we’re always in a feast mode, whatever diet you’re on. We always have access to food, it’s not healthy. We’re meant to go through these resets and fasting gives us that reset. Ketosis gives us a reset.

Dr. Weitz:            Right? But what about, let’s say somebody goes on a ketogenic diet, and then you say, do lab testing and you find out that there’s small, dense LDL is shooting up?

Dr. Pompa:         Interesting. So when I am in a state of ketosis, my particle numbers of cholesterol rise up, which I always educate people that total cholesterol doesn’t matter.

Dr. Weitz:            Right.

Dr. Pompa:         Typically, with total cholesterol, you’ll see that drop and triglycerides will drop typically in ketosis, right? But total cholesterol doesn’t matter but the particle numbers and the size do in fact, matter. It sounds like you know that. When I’m in ketosis, I’m in about a 20% group that actually sees a rise in my particles. And yet, all of my inflammation numbers drop dramatically. So I struggled with that for a while, what’s going on? And I found out that there’s 20% of people that that happens. And there’s theories around why that happens. But one of the things is they learned that it’s not a dangerous state, the body’s raising up the particles to carry more cholesterol, and it’s doing … it’s an adaptation mechanism. But the fact is, as my CRP drops, all of my inflammation numbers that we possibly measure drop down, showing that it’s really not an inflamed state, and I’ve done that with some others like myself, who get that phenomena opposite.   So the point is, is when most people go into ketosis, we see a drop in particles. That’s most people, 80% of the people.

Dr. Weitz:            Right.

Dr. Pompa:         But again, I would argue if you stay in that state too long, you could see a shift again, right? So we’re all genetically different. I think that’s the point you’re making. But one thing is, is that we all need variation. I don’t care what diet is best for you. All we need is variation. Now, how long you can stay vegetarian successful without creating certain deficiencies, genetics will determine that. How long you can stay in a carnivore or keto diet without creating problems, genetics will determine that, but we all need change.

Dr. Weitz:            Can you do ketogenic diet and be vegetarian?

Dr. Pompa:         Yeah. No, you can because the key to it is low carb. So and when we look at ketosis, the average with the way to get into ketosis is get your carbohydrates down below 50 grams a day. Now that’s net carbs. What that means is you minus the fiber, so think of it this way, and a cup of blueberries. Let’s say it has 15 grams of carbs and seven of them are from fiber, you minus the seven and you’re left with eight net carbs. So vegetables typically, some of them can have high carbs, but when you minus the fiber, you’re at a much lower net. So it’s very easy to lower your carbs below 50 on even a vegetarian keto. I put people in a vegetarian keto for different reasons. And sometimes I put people on high fat, with a higher meat, so there’s a lot of different ways to do ketosis. You can do ketosis on any diet really, except high carbohydrates.

Dr. Weitz:            Do you lose muscle when you fast?

Dr. Pompa:         No, here’s the funny thing, right? So I told the story in my book. My son, Isaac was like, “I want to put on muscle. Why would I fast?” I said, because you need to get rid of the bad muscle that’s not adapting anymore. That’s why you’re not getting gains in the gym anymore.” And so I gave him a challenge. So he fasted and he lost about eight pounds. Very typical, I would say, I told him you’d probably lose 10. Anyways, and, “Oh my gosh, I’m losing.” I said, you only lost bad muscle, the body’s too smart for that. Now watch what happens the next month. So the bet was that he would put on not only that weight, but he would for the next few months, he would actually gain weight and he did. Because the body, it really gets rid of the muscle cells that aren’t adapting causing problems, inflammation.  You remember, you don’t make gains in the gym. You make gains when you’re recovering. So by getting rid of bad cells via autophagy, the body will recover faster. Arguably his microbiome got better, his assimilation got better. But we even use fasting for people who can’t gain weight and they end up putting on muscle after a fast so typically a month after you’ve gained your your weight back and then some muscle.

Dr. Weitz:            So it’s really about stimulating the body, stressing it and then having the body adapt in a positive way, which is as you mentioned, what happens with exercise.

Dr. Pompa:         That’s right. Yeah, exactly right. Everything is about adaptation. So the key to the stress of fasting is creating a hormone optimization. Because of forcing the adaptation, how does the body adapt? It does it via hormone optimization. So when we look at that day five of a fast, I said, we see this maximum growth hormone rise. Even after one day of fasting, the body raises up the growth hormone and you know why? It’s holding on to its muscle. It knows I need it to fight or flight. It knows it needs the muscle, so it raises a growth hormone, and it stops the loss of muscle, and it only allows the loss of bad tissue.

                                And even your cells become more sensitive to hormones, which carries on after the fast. So I talk about in the book, how to hormone optimize using these strategies, even when you change your diet. Let me give me a great example with exercise because I think all of your listeners can understand this. If you start exercising, you always get a benefit. I don’t care what type of exercise you feel better, whatever benefit is, you feel better, you get a benefit when you start exercising. However, if you still do the same thing over and over again in the gym, it plateaus. Oh, and then now there’s a plateau, you actually start losing things and you’re like, “What’s going on?” Hire a good trainer and he goes, “Oh, you just have to change your workout,” and you start getting benefits again. Why? And then a good trainer changes your even every routine, he changes things, right?

                                So because the moment you change, the body has to readapt and then it does it by hormone optimization. So every time you force your body to adapt that it does you get stronger, you get better. Same with diet. So you start the new diet, whether it’s vegan vegetarian, carnivore, whatever it is, I feel so much better. And then not maybe like this first few days, you know how it is your body shifts around but eventually you feel better. So you become a firm card carrying paleo diet person, right? That says me because it helped me I’m a vegan, and I always will be because it helped me.

                                Now here we are a year later. “Yeah, I’m fatigued.” It’s not the diet because this diet helped me, right. But then someone comes along, convinces you to change your diet. It’s like, “Oh, my gosh, I feel so much better.” Don’t be a card carrier, the magic is the change like exercise, just keep changing the diet, keep changing exercise force the body to adapt, and your microbiome will change. You’ll turn off bad genes. I hormone optimize. All of that happens when you change your diet, just like exercise.

Dr. Weitz:            That’s great. Dr. Pompa, any final words for our audience?

Dr. Pompa:         Well look, at this time, as we said, I would argue all of it starts with mindset, right? It’s like, during this time of this Coronavirus, I’ve told my family, the doctors that I train, this is an opportunity to change our lives for the better. Or you could focus on the fear and your life will get worse. It will, you’ll get more sick, you’ll gain weight, you’ll feel worse, you’ll make less money, all these bad things.  My heart breaks for people who aren’t able to work, but out of these times is a soil ripe for change. You will come out of this stress just like fasting, making less money, being trapped at home, you will come out better, but you have to choose it. You have to think about it now, set the intention that this is an amazing time. Thank God for this time, out of it will come creativity, a job change you needed. You’ll look back if you create these intentions and say, “That was one of the greatest times in my life.”    So even though the adversity is hard now for us, and I believe that they are not minimizing your stress, but you have to change the intention to opportunity in what you can change. And believe me, fasting is another way of changing those intentions and creating new ones, because it just adds that stress. So I challenge you to fast and I challenge you to change your mindset.

Dr. Weitz:            That’s great. And how can our listeners and viewers get ahold of you and find out about your books and programs?

Dr. Pompa:         Yeah. The link is … if you go to it right now, that’s a first book. We really haven’t even have the hardcopy yet. So there’s still one more editing that goes back so you all are getting a special prelaunch right there. So if you go to beyondfastingbook.com you can get that prelaunch, beyondfastingbook.com and you can check it out. And then you can go just to my website drpompa.com. So Dr like doctor. D-R and then P-O-M-P-A.com. So there you go.

Dr. Weitz:            Awesome. Thank you Dr. Pompa.

Dr. Pompa:         Yeah, you’re welcome. Thank you for having me.




Cancer, Incorporated with Dr. Ralph Moss: Rational Wellness Podcast 160

Dr. Ralph Moss talks about Cancer, Incorporated, his latest book, with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

3:45  Dr. Moss shares some thoughts about the current coronavirus pandemic, including that if every particle of coronavirus were visible with a light, we’d be amazed how widespread it is. He likes the medicinal mushrooms, including shitake, maitake, and reishi, for immune system support.  Dr. Moss is intrigued by the concept of Superinfection Therapy, which has been used in the treatment of hepatitis B and C and for the seasonal flu and the concept is that one infection stimulates the immune system that knocks out another infection, such as with a poultry virus that does not cause any disease in humans.

12:29  Dr. Moss discussed the use of the BCG vaccine, which is used for TB, and this shows some effectiveness both as a treatment and for prevention for the SARS-COV-2 virus.

13:56  The areas where there are the highest amounts of fatalities from COVID-19 are occurring in areas with high rates of air pollution.

17:07  Dr. Moss’s latest book is Cancer, Incorporated, which talks about the war on cancer and the drugs and the financial ties between the researchers and the drug companies and the regulators.  One shocking fact is that when we look at some of the new targeted drugs, like the immune therapy ones like Yervoy, which are used for solid tumor cancers during stage four, on average these drugs only extend survival by 3 to 6 months.  On the other hand, some people are completely cured by targeted drugs, such as former President Jimmy Carter, who had melanoma that had spread to his brain.

21:59  These newer, targeted cancer medications tend to have much fewer side effects than traditional chemotherapeutic drugs. But there are a number of questionable ways that they were able to get some of these drugs approved, such as that some of them are approved not because of curing any cancer patients but because they improve some surrogate marker, such as a score on a test. For a drug to get approved for cancer it should either cure you or extend life in a meaningful way or improve the quality of your life.  For example, some drugs are approved because they extend disease-free survival or progression-free survival, which may mean that there is actually no increase in the rate of survival from the cancer.  And these drugs can have a number of uncomfortable side effects.

29:40  Immunotherapy for cancer includes drugs like Yervoy, Opdivo, Keytruda, and Tecentriq, which are heavily advertised to the public.  Cancer tends to confuse and turn down the immune system, so these drugs activate the immune system and they can be very effective in certain cancers like melanoma.  They are also often referred to as immune checkpoint inhibitors. But these drugs are very expensive, costing approximately $150,000 and it may be most effective to take two of these drugs at a time. There’s new drug, Kymriah, a CAR T therapy drug, also an immunotherapy, that costs $475,000 per injection, while the actual cost of production is $20,000.  One of the justifications from the pharmaceutical companies is that they spend lots of money doing research and development for these drugs. But Dr. Moss points out that most of the basic research is actually done by the National Institutes of Health, by the government, paid for by taxpayers. After the taxpayers pay for much of this research, it is then handed over to big pharma, who reap most of the rewards.

35:15  These pharmaceutical companies can no longer be taken to court for price gouging since congress passed the Medicare Modernization Act of 2003. It included in the law that the government, which means Medicare, Medicaid, and the VA could not contest the prices, could not negotiate over the price of the drug.  The sole reason why the same drugs are cheaper in Canada than the United States is simply because they have a universal healthcare system that goes through the government, and the government negotiates those prices down.  This same provision that we not negotiate to lower the price of the drugs was also written into the Obamacare legislation in order to keep the big pharma lobbyists from opposing the legislation and keeping it from passing. When they were passing Obamacare, there were three times as many lobbyists from big pharma and the insurance companies for every member of congress.

40:25  Dr. Moss’s book Cancer, Incorporated highlights how money flows from big pharma to the oncology profession.  A lot of money especially flows to the key opinion leaders, the most influential doctors, the ones whose names show up on the key clinical trial papers. In fact, if you go to a website called Open Payment Data, you can track all the money paid to doctors by drug companies. This database was part of the Obamacare bill and it requires that drug companies have to reveall all the money they give to doctors, universities, and hospitals.


Dr. Ralph Moss is the former science writer and assistant director of public affairs at Memorial Sloan-Kettering Cancer Center. He is known for his Moss Reports which are detailed reports on the most common cancer diagnoses for lay persons and he also provides informational and personalized consultations for cancer patients. Dr. Moss was a founding member of the National Institutes of Health’s Alternative Medicine Program Advisory Council, and of the Complementary and Alternative Medicine panel. Dr. Moss has written a number of books, including his latest Cancer, Incorporated.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.


Podcast Transcript

Dr. Weitz:            Hey. This is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest and cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.  Hello, Rational Wellness Podcasters. For those of you who enjoy listening to the podcast, please give us a ratings and review on Apple podcast. If you’d like to see a video version, please go to my YouTube page, and if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.

                                Today, I will be talking to the medical writer, Ralph Moss, PhD, who has written or edited 14 books and collaborated on four film documentaries related to cancer research and treatment. We will be talking about modern cancer treatment, especially chemotherapy and some of the newer targeted medications. Dr. Moss is a former science writer and assistant director of public affairs at Memorial Sloan Kettering Cancer Center in New York back in the ’70s.  Since leaving Sloan Kettering, Dr. Moss has independently evaluated the claims of conventional and nonconventional cancer treatments all over the world, and he currently writes the Moss Reports, which are very detailed reports on the most common cancer diagnoses for laypersons, and he also provides informational and personalized consultations for cancer patients and their families. Dr. Moss was also a founding member of the National Institutes of Health’s Alternative Medicine Program Advisory Council, and he has served as a peer juror for a dozen medical journals.  Dr. Moss, thank you so much for joining me today.

Dr. Moss:             My pleasure.

Dr. Weitz:            So, I definitely want to focus our talk on your latest book, The Cancer Industry, but before we do-

Dr. Moss:             Cancer Incorporated.

Dr. Weitz:            Cancer Incorporated, okay. Sorry about that. Cancer Incorporated. Before we do, I wanted to ask you a few questions about the current coronavirus pandemic situation that we’re in. At the time of this filming, that’s what’s going on right now in the country, and you can tell from this mark on my nose from wearing a face mask almost the entire day, which is not something I’m used to since I don’t work in an emergency room. I’m in private practice.   So, I know that you’re an expert at cancer, but you’re also an expert at integrative approaches to cancer, and as I think about this pandemic, I think that the way I like to look at a viral epidemic like this is the key, I think, from my integrative functional medicine perspective is that we want to make the host, which is us, very inhospitable to the virus stinking root and growing. I think of integrative cancer care the same way. We want to make the terrain of our body hostile for cancer to be able to take root and grow.   So, from your perspective, what are some of the most important things that we can do to protect our bodies against this coronavirus that’s spreading around the world right now?

Dr. Moss:             Well, as you say, I’m not an expert on this topic with the other 320 million Americans trying to figure out how to survive in all of this, and given my age, and some of other health conditions, I feel personally that my wife and I are at increased risk. So, we’re very vigorously following the standard recommendation, and treating like it is already in our area, although I live in Maine, and we have not been hard hit in the rural parts of Maine, but, of course, if every particle of coronavirus were visible with a little light on it, we’d probably be amazed at how widespread this thing is.  Actually, that’s how we conceptualize it. So, we do take very seriously the need to wear a mask and gloves and all the rest of it. In our community, which is a very small community, the neighbors have gotten together and made a group plan where we’re all in touch via instant messaging, which initially was for helping each other do shopping, and we’ve utilized that, but it also is a way to keep in touch and know if anybody’s gotten sick and where are things then. The first notice we got of the lockdown of the state was through that little informal messaging system. I think this is going on all over the country. It’s very, very good. Oddly, the social distancing has led to greater closeness among neighbors in some parts, at least, and this has been very good.

Dr. Weitz:            That would be a great positive that could come out of this situation is it actually brings the country together to fight this common condition.

Dr. Moss:             No doubt. No doubt. I think history will be rewritten to be pre-COVID-19 and post-COVID-19. I see it as that. Let me just get rid of this call. So, as far as what one could do about it, I think of this in two different ways. One is what can you do personally and then the other one is what can you do society-wise. Personally, I’ve written a blog about mushrooms, medicinal mushrooms.  Why? Because the strengthening of the immune system and the healing healthfulness of the immune system I think is very important. So, the things you would normally do to keep your immune system healthy and keep the numbers in a high normal range would be beneficial, and the most neglected supplement in that regard, I think, are the medicinal mushrooms, which have a tremendous amount of research behind them in Asia, not so much in the US.   People go to my website, which is mossreports.com, they’ll find my blog about this and how you could prepare a soup out of medicinal mushrooms, especially shiitake, maitake, and reishi or oyster mushrooms. Amazingly, almost all of the exotic Asian mushrooms also double as immune modulators. So, I think that’s important.

                                A woman that I knew when I worked as a consultant to the National Institute of Health, Jennifer Jacobs, MD, has put out a blog about homeopathy and COVID-19, which I thought was very interesting. She’s a medical doctor. She’s had 40 years experience with homeopathy. So, I think her word should be taken seriously.

                                Then I think also from a societal point of view, the ideas that have intrigued me the most about potential treatments have been the ones that work on the immune system, and two in particular. I’ve written a blog about one of them. The other one is very much in the news, if people search for it.   The first one is called Superinfection Therapy. It seems like a contradiction of terms to give an infection on top of an already existing infection. This has been used in the treatment of hepatitis B, hepatitis C, and seasonal influenza, flu in Russia from the ’60s to the ’80s. Hundreds of thousands of people who got basically non-disease-causing superinfections were deliberately given this. Some of them were given, for instance, the Sabin oral polio vaccine.   So, what would that do? Well, there’s a funny thing called superinfection where if you have an infection, you give another infection on top of it, sometimes that second infection knocks out the first infection. It’s like they’re competing for the same ground. You could think of it that way.  The other idea is that the superinfection, the second infection stimulates the immune system in a nonspecific way that then enhances your ability to deal with the first one. Whatever the reason is, there’s a lot of potential to this, and it’s been shown in other situations. This may be applicable to SARS type of infections, coronaviruses, and so forth. There’s a petition at the White House. The White House has the petition process and we have started the petition basically to bring this to the attention of Anthony Fauci, who is a big top scientist on the president’s COVID-19 taskforce. So, we’re hoping.   It’s a long shot, but if you get 100,000 signatures on a petition to the White House, somebody in the White House has to respond to it. So, we’re trying. What else can we do, right? There isn’t much more. We’re trying to-

Dr. Weitz:            Just let President Trump know how he could personally make an investment in a company that provides this therapy and you’ll be golden. It will be on every press conference.

Dr. Moss:             My problem in life is I’m always trying to find the least expensive, least profitable treatments. To me, the most effective treatment would be water or something, something that was free.

Dr. Weitz:            Sleep, exercise, right, meditation.

Dr. Moss:             Walk in the pine forest in Maine might be the best treatment. You know what I’m saying is that … So, that’s a treatment that would be incredibly inexpensive because the one that they use in Europe experimentally is a poultry virus. These poultry viruses are very good because they are highly contagious and active, but they don’t cause any human diseases. There’s a couple of them.  So, one of them is currently being proposed as a treatment. We’re not asking for anymore than a fair test initially, like a pilot study, and maybe 10 patients to start, and then, of course, we’ll work through clinical trials, although the clinical trial system seems to be tremendously under stress now for the obvious reasons.

Dr. Weitz:            Oh, sure, but there are actually a huge number of clinical trials that the FDA is allowing without the normal controls because of the situation we’re in. So, actually, the scientific community is very excited about the ability to launch somebody’s treatments.

Dr. Moss:             The other treatment that interests me very much is BCG, bacille Calmette-Guerin, which is the standard TB vaccine.

Dr. Weitz:            They use that for bladder cancer sometimes, right?

Dr. Moss:             Correct. Correct. That was your first use medical, well, repurposed use in cancer, and it’s used at very high level, instilled into the bladder mainly to prevent recurrences of bladder cancer, which are relatively easy to treat, but very difficult to keep from coming back.   So, they use the BCG, instill it, but BCG has many uses. It’s been in literally over a billion people. It’s given to babies. It’s considered, of course, a very safe thing, and it seems to correlate with lower rates of viral infections, but more importantly, BCG is being tried in Europe as a way of actually treating people.  Again, I think the philosophy is almost identical to superinfection theory, therapy in that it makes a nonspecific stimulation of the immune system. That can be enough to help the person in the initial stages to keep that virus from taking over the lungs. So, I think that this is very important.

                                Another one more thing I’ll mention, which is, and it came out, I mean, there was an article about it today in the New York Times, but there have been hints of this all along, which is that the greatest number of fatalities from COVID-19 are occurring in areas with high rates of air pollution.   I thought about this because I, luckily enough, and not by accident, I live in an area with very little air pollution. I mean, we get what blows up the coast from Boston, and maybe Portland, but that’s about it. I mean, so if you-

Dr. Weitz:            So, it’s probably a great idea that the president right now is trying to reduce the fuel emission standards on cars.

Dr. Moss:             Well, nature is carrying out an experiment, which is to reduce air pollution. So, we got the green new deal, but we got in a way we never expected. All the industries shut down. Car manufacturing is all shut down and so forth. So, in a way, I mean, it’s ironic that it took that in order to get us to reduce our pollution of the planet, but I’m not saying … This is more like a longterm thing, but it also points to the fact that the health of the lungs proves critical in a surprise, surprise, in a respiratory disease.   So, whatever you can do to improve the health of your lungs, whether it’s through exercise or through supplements, through walking in the woods, whatever you need to do, that would be a beneficial thing.



Dr. Weitz:                            I’ve really been enjoying this discussion, but now, I’d like to pause to tell you about the sponsor for this episode of the Rational Wellness Podcast. This episode is sponsored by Pure Encapsulations, which is one of the few lines of professional nutritional supplements that I use in my office. Pure Encapsulations manufactures a complete line of hypoallergenic research-based dietary supplements. Pure products are meticulously formulated using pure scientifically-tested and validated ingredients. They are free from magnesium stearate, gluten, GMOs, hydrogenated fats, artificial colors, sweeteners and preservatives.

Among other things, one of the great things about Pure Encapsulations is not just the quality products but the fact that they often provide a range of different dosages and sizes, which makes it easy to find the right product for the right patient, especially since we do a lot of testing and we figure out exactly what the patients need. For example, with DHEA, they offer five, 10 and 25-milligram dosages in both 60 and 180 capsules per bottle size, which is extremely convenient.

                                                Now, back to our discussion.



Dr. Weitz:             Let’s talk about your book, Cancer Incorporated, which talks about the laws and the war on cancer and the drugs that ties between the researchers and the drug companies and the regulators.

Dr. Moss:             Yes. So, I wrote the book. It took me about a year to do this, and it just came out in January. Of course, then overwhelmed by our more oppressing problems, but the cancer problem is not going away, and it will-

Dr. Weitz:            In fact, patients who are currently undergoing some of these treatments for cancer actually at increased risk of COVID-19 infection and having a worse response as well.

Dr. Moss:             Absolutely. Absolutely. It’s a disaster especially for cancer patients, especially people with lung cancer. It’s a terrible situation. What I focused on in Cancer Incorporated, though, is the manner in which these drugs, these new drugs in particular have been presented to the public, and what I see as the corruption of the oncology profession, the leading cancer researchers in terms of approving drugs and getting the FDA to approve drugs that are not really effective.   I was led to this by the speech that James P. Allison of the MD Anderson Cancer Center gave upon accepting the Nobel Prize in December of 2018. He was contrasting a treatment that he invented called Yervoy, which is a immune therapy with all previous drugs I targeted, so-called targeted drugs, and he made a comment that I can’t quote exactly, but, basically, on average that these drugs extend survival by a few months. You push the envelop by a few months.    When I looked into this, I was startled. I hadn’t realized, as critical as I’ve been of the cancer industry, I hadn’t realized that it was that limited. When I looked into this, I found that it was in fact the actual increase in overall survival from these new drugs in stage four cancers. We have to specify. We’re not talking about pediatric cancers or relatively rare kinds of cancer, but on average, for the solid tumors of adults in the final stage, in the stage four, metastatic disease, is I think-

Dr. Weitz:            For those who are not aware, stage four means that the cancer has now spread from the initial organ where it was throughout the other parts of the body.

Dr. Moss:             Correct. So, it’s about 3.8 months. That’s what this clinical trial show. These are the actual benefit on average of all of these targeted drugs that are now the bulk of the drugs that are being approved or what we would call targeted drugs. Even with the immunotherapy, which I do believe in in general terms, it’s really only about five or six months on average.   Now, you hear about people being cured by immunotherapy. This is true. This is-

Dr. Weitz:            For example, former Vice President Jimmy Carter who was diagnosed-

Dr. Moss:             President, yeah.

Dr. Weitz:            Yeah, former President Jimmy Carter who was diagnosed with, I think it was metastatic. What was it?

Dr. Moss:             Melanomas spread to the brain.

Dr. Weitz:            Spread to the brain, and it’s been years now, and he seems to be doing phenomenal.

Dr. Moss:             Phenomenally well. He did have a pinpoint radiation to the brain, but especially in an older person like himself, and he’s I think in his 90s, you wouldn’t expect that to result in a-

Dr. Weitz:            He takes one of these targeted meds or took one of these targeted meds, right?

Dr. Moss:             He took one of the very first immunotherapy drugs. So, the targeted drugs could be divided into precision medicine, let’s say, and then a subset of that would be immunotherapy.

Dr. Weitz:            By the way, these are somewhat of an improvement over the traditional chemotherapy, which were basically drugs that just kill everything and are designed to kill the cancer cells and hopefully they don’t kill you. Whereas these targeted drugs don’t have as many of the side effects.

Dr. Moss:             No. That was the main selling point of that, but I go in great detail in Cancer Incorporated into what these drugs actually do, and the manner in which they’ve been approved. I was shocked by what I found because there’s couple of things.   One is that, now, we’re not talking about fraud here, which sometimes occurs, but I’m no saying that there’s actual making up of data. It isn’t that, okay? So, people can disabuse themselves of that notion. It does happen, but that’s not what I’m talking about. That’s not the general course of thing. What I’m talking about is that most of the time, the drugs are approved by FDA based upon a surrogate marker.  A surrogate marker means I can’t prove to you that the drug actually conveys true patient benefit, but I’ll choose something else like a score on a test or another. I’ll redefine what I mean by benefit, so that I can then get approval. The main scam going on here, and it is a scam, is a drug to be effective, for a cancer drug to be effective in stage four cancer, it basically has to do one of three things.  First of all, it could cure you. That would be great. You take the drug, you have a complete response to the drug, meaning that the cancer disappears, and you live out your normal lifespan. That would be a cure.  Second thing, it could extend your survival in a meaningful way. So, what would that be? Meaning that in the group as a whole, we’re not going to just consider anecdotes, individual cases, we’re going to consider the entire group being tested. They live months or years longer than they would have if they took a different treatment or if they took no treatment or they just have best supportive care. That would be increased overall survival, okay? That’s another palpable benefit of treatment.  The third one would be increased quality of life, but the vast majority of drugs do not cure. They almost never tested for quality of life, very rare or they don’t really extend the overall survival. So, how could it be then? How could the FDA, the Food and Drug Administration or the equivalent agencies abroad, how could they approve a drug without it showing any benefit?

                                The answer is that there are a dozen definitions of survival at the National Cancer Institute dictionary, cancer terms, and they usually substitute something like disease-free survival or progression-free survival. What does that mean? So, it means that between the time that they administer the treatment and the time that they first noticed that the cancer is in fact getting bigger, progressing, spreading to other organs, whatever, that period of time, the progression-free time is longer in the patients who get the treatment than in those who don’t.  So, now, when you read a headline that says, “Such and such drug increases survival in cancer patients,” most often, if you drill down and you’ll read, bother to read the article not just the headline, much less read the actual study that it’s based upon, not just the abstract but the actual study, you find that what they’ve done is they changed the shape of the curve. They moved it over so that some more time elapse between the time the person was first treated and the time that they first noticed the disease is progressing, but they didn’t increase the actual time the patient live.

                                So, I give an illustration on how that could be you. You have two people, patient A and patient B. So, patient A and B, they have the same disease, same stage, same type of cancer. They’re both treated on, let’s say, January 1st. One of them gets the experimental drug, and one of them gets no further treatment, okay?  So, at three months, there’s no sign of further progression in patient A, but patient B is going downhill. The cancer is still growing, it’s still causing a problem. At the six-month point, patient B, of course, is still going downhill. Patient A may detect that patient A actually now has an increase in progression of the cancer, and they both continued downhill from there, and they both died exactly one year after starting the treatment.  So, from a common sense or a patient or a laypersons’ point of view, what exactly was the difference between those cases? They both lived exactly to the day, one year from the time that they started the treatment. It didn’t make any difference. If you take the word survival, I mean, increased lifespan, which I think 99% of people would, it didn’t make any difference.    Did patient A have a better quality of life? That’s debatable? Patient A had a period of false hope, let’s say, a period of six months where she thought that she was maybe going to be cured, but during that time, she was getting this toxic drug. So, she may have spent that time in very, very difficult, uncomfortable or dangerous circumstances.  So, which is better? I don’t know. No one has ever figured that out because I think it depends on the person. Do you want that period of that false hope of six months and you can enjoy that and have a normal … or do you want to just accept your fate, not do anything, and slowly go down? I don’t know.

Dr. Weitz:            You know who benefits from that.

Dr. Moss:             Right.

Dr. Weitz:            The executives and the shareholders of the big pharma company that are making more profits supplying this drug that costs hundreds of thousands of dollars when you’re treating that.

Dr. Moss:             Right, and can have a horrendous side effect. Yes, it’s true that with chemotherapy, one of the most brutal treatments ever invented, chemotherapy, or probably the most poisonous that’s deliberately given to human beings since the bloodletting era or the mercury era, whatever you want to call it.  Yes, you don’t get that kind of … but you get other toxicities, some weird things. Even with the immunotherapy, which as I say, for the highly mutated cancers like melanomas and lung cancers, can be very effective, but the guidebook on the side effects of those new immunotherapy runs to, I think it’s 65 pages of fine print for what can occur following this kind of immunotherapy.

Dr. Weitz:            By the way, which are some of the examples of some of the immunotherapies and how do those drugs work?

Dr. Moss:             Right. So, it’s Yervoy, and Opdivo, and Keytruda, which are heavily advertised to the public, by the way, only two countries in the world.

Dr. Weitz:            Is it Yervoy, the drug that Carter was given?

Dr. Moss:             I believe it was.

Dr. Weitz:            Yeah.

Dr. Moss:             It was either that or, yeah, I think it was or it was Opdivo, but, yes, I think it was Yervoy because that was the first one to be developed, and then there’s Tecentriq, and there’s a few others, okay? The idea is a very good one. It’s based on a very, very important fact that Dr. Jim Allison and others discovered, which is that cancers have the ability to confuse and turn down the immune system.  So, the immune response can be inhibited by the cancer itself. So, it’s like a fifth column within the body that’s preventing your armed forces from being able to act, okay? So, the brilliance of what Jim Allison did, who discovered Yervoy, was to figure out a way chemically to block the interaction of the cancer cell with the immune cell, the crosstalk that goes on between the cancer and the immune system, and to block that, and then the immune system is able to be activated.  This can be very, very effective in melanoma. It’s something like 50% or 60% of the patients, melanoma stage four patients are now having these major responses and durable remissions from this drug. So, I understand the excitement and enthusiasm for it, but through not any fault of Jim Allison, the company, Bristol-Myers Squibb, which owns both Yervoy and Opdivo, set the price of the drug at around $150,000, and if they’re given in combination, which is the most effective way, the price can go up to a million dollars per person.

                                Some oncologists in Latin America analyzed the situation and they said … They were in Chile, country of Chile, and they said only 10% of the population would even be covered through insurance for this type of treatment. Forget about the people who don’t have insurance, but just of the insured population. In Peru, a less affluent country, only 5% of the population would be covered for that treatment.  So, you could be sure that 95% of humanity will be left out of that kind of treatment, that kind of pricing. It’s just out of this world. The height of absurdity came with a different type of immunotherapy called Kymriah. It’s what’s also called the CAR T cell therapy. That drug sells for $475,000 per injection, per injection.  We know from the inventor of that treatment who let the cat out of the bag because he said that the actual cost of production, it’s a living drug, it’s a very interesting drug, but it’s a living drug, he says that the actual cost of production is $20,000. So, 455,000 or about whatever that is 96% is profit.

Dr. Weitz:            Now, is there any justification for that based on the fact that I’m assuming to take a devil’s advocate position a drug company would say, “Look, we had to spend years researching this, and we spent years researching other drugs that didn’t work that we never got paid for.” The cost of running these trials is very expensive, right?

Dr. Moss:             Right. Right, but what most people don’t realize, if we want to talk about fairness, is that the vast majority, I think some people have said 100% of all new cancer drugs are basically researched by the federal government at taxpayer expense.

Dr. Weitz:            You mean, initially, the NIH is doing the basic research.

Dr. Moss:             Exactly. All the basic research of almost all the drugs, the taxpayer pays for to an amazing degree, sometimes up to actually the finished product, which is then handed over to a drug company on the very disadvantageous terms to the government. The taxol famous case of the derivative, the only herbal treatment, well, one of the few herbal, the derived treatments for cancer, Bristol Meyers was given a monopoly on the sale and distribution of that drug for an incredibly small amount of money compared to the billions that they made on it. It was a scandal that actually wound them up in court, eventually, in the old days when drug companies could be taken to court, but the basic-

Dr. Weitz:            Can they not be taken to court anymore?

Dr. Moss:             Not for what we’re talking about because they pay … I mean, for price gouging, and monopoly practices, no, it doesn’t happen, but basically, the drug companies through the corruption of the congress and the FDA, they’d pass the law in 2003 that we live with the consequences are called the Medicare Modernization Act of 2003.   One of the things that this did where they slipped in was that the government, meaning Medicare, Medicaid, and VA could not contest the prices, could not negotiate over the price of the drug. So, it’s like if you go to a plumber and you say, “You can charge me anything you want. Go ahead. Just whatever it is, I’m going to pay it and I have no recourse,” and the public is demanding that you give them that drug because of good public relations and complicity of the media.   So, they got that law passed. They got it passed at 3:00 in the morning by one vote in the senate, and emergency, they called a surprise vote, the proponents of the bill, 3:00 in the morning. A lot of the opponents were not there, and they pushed it through. We’ve lived with the consequences of this-

Dr. Weitz:            By the way, the sole reason why the same drugs are cheaper in Canada than the United States is simply because they have a universal healthcare system that goes through the government, and the government negotiates those prices down. That’s the main reason why-

Dr. Moss:             That’s right. I mean, I’m in favor of a Medicare for all system, but we wouldn’t have even needed a Medicare for all system. All we needed was for Medicare to have the right and the requirement to economize on behalf of the American public by negotiating over the price. It wouldn’t have been perfect, but we wouldn’t see 150, 175,000, much less $475,000 drugs. It would be impossible.  You know why? Because if you look at Great Britain, which has a special committee, they have national health service, so they have a special committee that judges the value of the drug. They have formulas that they work out and everything, but the basic bottom line is that set they will say, “No. We don’t want it.”  It’s not enough of an innovation over the previous drug, and it’s not cost-effective. Invariably, what happens is that the company then comes back and says, “All right. Well, how about half? Would you do half?”  Then they’ll look at it again, they run their numbers and they say, “No. Still no good.”    The company will come back, “All right. We’ll take a quarter,” because 95% of the price is markup. That’s business.

Dr. Weitz:            By the way, these companies just by partially by talking about how much they spend on research and development, and the fact is is these companies spend more money on marketing than they do on research and development.

Dr. Moss:             Overwhelmingly so. Overwhelmingly so.

Dr. Weitz:            That same provision was written into the Obama Care, Affordable Care Act that was written into the Medicare bill.

Dr. Moss:             Yeah, because if you look at opensecrets.org and you can see to the penny how much the drug companies are giving to the different campaigns, so-called of the congress people.

Dr. Weitz:            There are three times as many lobbyists for the pharmaceutical industry and the insurance industry than there are for every member of congress.

Dr. Moss:             Correct. There’s between … because this came out at the time of that bill, the Medicare Modernization Act, but also more recently, the precision medicine initiative, which was Obama’s pride and joy, 1,350 drug company lobbyists were creeping and crawling all over the congress, which is exactly what you said, three times, three lobbyists for each and every member of congress. The money just flows like water, and-

Dr. Weitz:            In defense of the congress people, that’s the system we have. They can’t get reelected unless they can raise millions of dollars.

Dr. Moss:             Well, Bernie Sanders did it. I mean, he didn’t win, but it wasn’t for lack of money. That’s a different issue.

Dr. Weitz:            Right, but that’s an exception. That’s not that easy to do what he did.

Dr. Moss:             There are other countries that have public funding of election that don’t allow that.

Dr. Weitz:            Absolutely. Absolutely.

Dr. Moss:             So, it’s a solveable problem, but the fact is that corruption is always good with people who are going to find an excuse for corruption, but the corruption is there. A big part of my book, of Cancer Incorporated, is concerned with how this money flows to the oncology profession, and I don’t just mean the profession individually, but individual payment to leading what I call key opinion leaders, KOLs, the key opinion leaders within oncology, the most influential doctors, the ones who show up first author, second author, and final author on the key clinical trial papers.   Most of those people are in the pay personally of the drug companies. This is public knowledge. There’s a website called Open Payment Data. It’s run by the Medicare facility. This is one good thing that came out of the Obama era, Obama Care era, and it basically stipulates that the drug companies have to reveal to the penny how much they’re giving to individual doctors, which is amazing because it isn’t just like, “Oh, we gave 10 billion to the oncologist.” No.  You can enter in the name of the doctor, the medical doctor, American medical doctor and see who they took how much from. It’s very interesting because most of the situations that I looked at and I looked at a lot of different clinical trials as you can imagine, it’s a pattern that the key researchers, the key opinion leaders, and many of the other people included in that paper as well, the top people, the top academics, a person taking personal payments.   I want to emphasize they were personal, they call these general payments. What that means is I think that’s euphemism, but what it means when not talking about the money they take for their lab or their clinic to do the research on these drugs, which is questionable in and of itself and undoubtedly you bring $12 million into your institution. You’re going to rise, you’re going to climb up that totem pole. I’m not talking about that.  I’m talking about how much money you took to put your kid through a fancy school or a fancy college or you took for the yacht or you took for the second or third-

Dr. Weitz:            Now, to play devil’s advocate again, I thought it was illegal for doctors to get direct payments from pharmaceutical companies.

Dr. Moss:             No. It’s not illegal, and it never was illegal in oncology. Oncology wrote its own rules, which is called the chemotherapy concession by which they could buy drugs wholesale and sell them to the patients and get reimbursed at retail rates. At one time, that constituted, according to one source, that constituted two-thirds of the income of oncologists in private practice.   The oncologist in private practice makes about, I think the average figure is $367,000, but that means that these people, these individuals were making the equivalent of a million dollars, two-third of which came from the sales of chemotherapy, the chemotherapy concession.   Now, that all changed also with changes to the Medicare reimbursement rules, and so I’m not saying that that’s going on to the same degree as it was because oncology changed from a private practice-centered profession to a group, I mean, to it working for hospitals, basically.

                                This is something else. What I’m talking about is something else. This is, I don’t even know how to describe it. It’s payments for what they describe as honoraria or speakers bureau fees or consulting, different names are given, but it’s money that flows for vaguely defined services right into the pocket or to the account of the doctor who’s involved oftentimes in evaluating the product of that company.   I don’t know how much more clear cut it could be, how much more grazen it could be. You’re evaluating a drug that people are going to make life and death decisions based upon your statements and your evaluations. You’re going to take up to $3 million from the company who produces that drug and then you’re going to make, you’re telling me that you’re going to make an objective evaluation of the efficacy of that drug.

                                I’m saying, again, they stay on the very side of the law by not lying about the results. I’m not accusing them of lying. It’s the interpretation of the results. In other words, it increased survival. Well, it did if you look up survival in the NCI, National Cancer Institute dictionary, and you want to define progression-free survival or disease-free survival as survival, they’re not lying, but the way you spin the results, the way you write it up for New England Journal of Medicine of JAMA Oncology or any of the other big journals, that’s critical because the average person is only going to read the headline of the story.    Some will read down into the story itself. Some may go look at the title or the abstract of the paper. Believe me, very few people actually read the entire paper through with a critical eye, but when you do that, you see there’s no, “There, there.” There’s nothing there. It doesn’t do anything. If they’re going to charge you $150,000, we have nothing. What are they sowing? Oh, the greatest commodity in the history of the world.

Dr. Weitz:            So, Dr. Moss, what are some of the solutions to the situation that we’re in?

Dr. Moss:             How about reforming the congress so that they don’t take any more money for coverage?

Dr. Weitz:            Well, I think there’s a lot of people who’d like to do that. The problem is is since the Supreme Court ruled on Citizens United, there’s no way that we could pass a law, even if we wanted to, because it would be overruled by the Supreme Court. So, the only two choices we have are A, to have a significant change in the Supreme Court, which is very difficult, and seems to be going the wrong direction right now or B, we would have to have a constitutional amendment that would go over the Supreme Court, and we never even passed the women’s rights amendment.

Dr. Moss:             I’m totally aware of that. So, I mean, I can only put forward Utopian solutions.

Dr. Weitz:            No, absolutely.

Dr. Moss:             At this moment, we’re just spinning our wheels. I understand that. I’m not saying that I have a solution that’s a practical thing that could be implemented right now because the problem is so pervasive. It’s so systemic.

Dr. Weitz:            No. I think it’s totally corrupted, all are on politics, and having public financing of campaigns and getting rid of lobbyists, absolutely has to be a goal how do we end up eventually accomplishing it.

Dr. Moss:             Yeah. A couple of chapters were written in conjunction with other individuals who I think I was very lucky to get their input. One of them was the final conclusions of the book, of Cancer Incorporated. I co-wrote or bounced back and forth with Wayne Jonas, who was my colleague at the Office of Alternative Medicine back in the ’90s, and was the director of the OAM office, now National Center for Complementary and Integrative Health. I was an adviser to that committee.

                                So, Wayne and I have kept in touch for decades now. He’s a brilliant thinker and has thought of many of these. Lives in Washington area, has participated in endless discussions at the governmental level. He and I came to the conclusion quite through our own surprise that we felt that the main recommendation we could make would be to nationalize the cancer drug industry.

                                We don’t go as far as to say nationalize the whole drug industry. That wasn’t our focus, and I don’t really know enough about other areas where drug industry maybe is better than it is on oncology, but we feel that it’s actually an impediment to the overall drug development in the United States that the NIH and the NCI already does the heavy lifting in terms of drug development and could do a better job, and by better job, what I mean is that they wouldn’t have the same pressures that the drug industry has to show increased profits every quarter because that’s the imperative of Wall Street, of capitalism.

                                So, we felt that scientists would still do their work. You don’t even need the patent system. You could reward people. You could give them amazing rewards for discovering new drugs and new treatments based upon actual benefit to people. I’m talking about large rewards. You could give 50 million or $100 million to people who discover and effective new treatment. Why? Because you’re ready. Every year, the world is spending about $120 billion on cancer drugs, most of which as we see probably 90%-95% of which is pure profit to the industry, and they’re spinning their wheels.

Dr. Weitz:            So, essentially, what you’re saying, doc, is right now, for those people who don’t realize it, National Institutes of Health does a lot of the basic research, they’re finding out maybe some of the mechanisms, some molecular processes, et cetera, and then that’s all done paid for by the taxpayers done by the National Institutes of Health, and then pharmaceutical companies cherry pick what they see as the more promising research and then do the last steps, and get all the money for the drugs. You’re saying just have the National Institutes of Health just finish the process and take those promising processes and develop the drug and market it, and not have those huge profits to the benefit of the taxpayers.

Dr. Moss:             Correct. I fully and freely admit, I didn’t come up with this idea. What happened was is that in the course of writing the book last summer, an article appeared in JAMA Oncology. JAMA is, for those who don’t know, is Journal of the American Medical Association, advocating exactly this for cancer drugs. I mean, it blew my mind, and Wayne Jonas’ as well because he’s the one who actually brought it to my attention. He said, “Look at this.” We haven’t even gone that far in our thinking.

Dr. Weitz:            Now, one of the immediate objections is going to be, “Well, we know that government can’t do anything well. They’re totally inefficient. The private sector always does things better.”

Dr. Moss:             So, we talk about immune checkpoint inhibitors, okay? Immune checkpoint are the most important advance in cancer treatment in at least 25 years came about by, entirely, by government funding, NIH, National Institutes of Health and National Cancer Institute grant to a salary employee of a public institution. James Allison was a professor of virology and immunology at University of California Berkeley, a public institution, which used to be free, by the way.

                                So, the entire development of the immune checkpoint drugs up until the point where he had to find a private firm to take it over, which eventually wound up to be Bristol Meyers Squibb. So, government-funded, government-run, government laboratory, government-paid, and the drugs were all invented there. I could tell you many other drugs. Adriamycin got developed by the government, had to be handed over to a private company that invent the private company because none of the drug companies wanted to touch it. It wasn’t profitable enough.

                                Taxol, entirely developed within NIH and then NIH funded lab in New York at a public hospital in New York City, which isn’t the case. The government functions very well in the realm of biomedicine, but nothing’s ever going to be public. I’m no saying that some Utopian era is going to dawn if the government … Of course, you always, in life, it’s you go from one set of problems to another one at a “higher level” but there’s still problems. You solve one problem and then you get another problem. I mean, that’s just the nature of reality.

                                So, yes, we will have issues if the government takes over the drug, but you know what? I felt this way when I was consulting for almost nine years for the government. As bad as it was, you still could drag somebody up before a committee and drill them and find out and investigate, and find out where the … There’s that potential for public exposure and disclosure, right?

                                I said about the government runs the website that lets us see the degree of corruption of the oncology profession. It doesn’t happen automatically, but I saw it happen with my own eyes. It can happen.

                                So, it’s always going to be a problem to administer a country of 320 million is never going to be easy, and much less a world with whatever, seven or eight billion people, but at least there’s some disclosure. What goes on inside the boardroom at Bristol Meyers Squibb? We don’t know. I don’t know, and we’ll never know or the boardroom at Memorial Sloan Kettering private institution. You’ll never know.

                                This is kept close to the vest, but one thing you can be sure of with the imperatives of a private corporation, especially a corporation that’s traded on the stock exchange and is competitive with other companies and so forth that their imperatives are profit and growth, and it usually is on the quarterly basis. They’re all racing to show how well they did because Wall Street will react even to one quarter downturn.

                                So, they’re kind of a cancer because they have to keep on growing and spreading and metastasizing, and that’s their imperative. You don’t have the same imperative-

Dr. Weitz:            It’s really the system, not the companies because as public corporations, they’re required to maximize profits, to maximize shareholder value.

Dr. Moss:             Right. Even if they weren’t, they’d still have to do it because who would invest in the company that was lagging? Sometimes you get the best results at privately owned companies, and I own a company, so I’m not saying that companies are necessarily bad, but my son and I, we’re in business together, we could decide, “Oh, well, this quarter, we’re going to focus on doing something that’s not immediately profitable, that maybe it’s an investment in the future or something.”  Nobody, except for our wives, nobody is going to criticize or have any word to say about this, but when you’re a publicly owned corporation, you’ve got the lash of profitability at your back and nothing can stop that. The really interesting thing was they held a meeting that this immune checkpoint inhibitor thing is just phenomenally big. I mean, it’s billions and billions. One drug alone makes, that’s Keytruda, makes over eight or nine billion dollars a year.

                                Everybody wants in on this, and the FDA last year held a meeting, and they brought together whoever wanted to come to discuss the development of new cancer drugs, and it was new immune therapy drugs. This was chaired by Richard Pastor, who’s considered the cancer Tsar in the United States. He’s the most powerful person probably at the FDA.  In the course of the meeting, he listened to the presentations from this company, that company, this company. At the end of the presentation, he said, “So, now, what you’re telling me is …” I’m paraphrasing, “You’re all basically creating the same drug.” They all were creating Keytruda, and Keytruda is another version of Opdivo. What does that mean?  It means that everybody wants in on the $8.8 billion Keytruda market. So, if I could splinter one little thing, I’ll take a cancer, a very, very small portion of that, maybe I’ll just take an angiosarcoma and I’ll run my drug against that drug, and I find that there’s some positive thing. Now, that’s not covered by your patent. I just cut away a little sliver. What can I do with that? The drug could be then extended into other kinds of cancer, become competitive with your big drug or I could sell it out to the highest bidder because even a sliver of the cancer market is worth billions of dollars. It’s so big. Huge market.   So, the head, basically, I call him the head of the FDA, I mean, the top most influential person in cancer in the FDA basically said, “It’s all the same, isn’t it? It’s all the same drug.” So, you got hundreds of companies competing to create a drug that already exists. In fact, it already exists in two forms. There’s no innovation going on there. They don’t want it. Innovation is too risky. It’s much safer to create a me-too drug and then cash in your chips three, five years down the road. That’s what’s going on.

Dr. Weitz:            Thank you, Dr. Moss. I’m going to have to bring the discussion to a close because I am still seeing patients at this time, and I do have a patient coming up. So, maybe you can tell everybody how they can get a hold of your reports, and find out more information about you.

Dr. Moss:             Right. So, our website is mossreports.com, and I’ll hold up a copy of my book, Cancer Incorporated. This book just 250 pages in length, including all the references is available for free as an ebook at our website. So, you just go to mossreports.com/cancerinc or Cancer Incorporated, and you download a copy of the book. We wanted to get this out to as many people as possible or you can get a paperback of it if you choose. That’s not free, but not expensive either.     In our Moss Reports, we have 38 diagnoses of disease, specific reports on different forms of cancer, and we have phone consultations as well. So, we’re busy. We’re active. I’ve been doing this for 45 years. Hopefully, we’ll do it another 45 years.

Dr. Weitz:            Thank you so much, Dr. Moss. Fascinating discussion and a great contribution.

Dr. Moss:             Thank you.

Dr. Weitz:            Thank you.



New Developments in IBS and SIBO with Dr. Mark Pimentel: Rational Wellness Podcast 159

Dr. Mark Pimentel speaks with Dr. Ben Weitz and the Functional Medicine Discussion Group meeting about New Developments in IBS and SIBO.

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Podcast Highlights

9:15  The story about SIBO and IBS is similar to the story about peptic ulcers and H. pylori.  We’ve known about peptic ulcers since the 1980s and then they discovered that H. pylori is the cause of 60-70% of cases of peptic ulcers. We didn’t change the name to H. pylori disease. About 60-70% of IBS is caused by SIBO, but just like there are a bunch of people with H. pylori that don’t have ulcers, there are a bunch of patients with SIBO that don’t have IBS.  There could be narcotics or adhesions as the cause or something else.

10:49  Dr. Pimentel discovered that many cases of SIBO have an autoimmune origin. It starts with a bout of food poisoning related to a bacteria like E. Coli, salmonella, shigella or campylobacter. These bacteria can all secrete Cytolethal Distending Toxin, which can create a response from the immune system, creating antibodies. Those antibodies can cross react with a similar structural protein in the intestinal wall called vinculin and this can damage the ability of the nerves to control the Migrating Motor Complex, which produces cleansing waves that help keep the intestines clear of too much bacteria.  Thus by damaging this normal motility, there is an increased likelihood of bacterial overgrowth of the small intestines.  Dr. Pimentel has also developed a blood test to measure these anti-CDT and anti-vinculin antibodies, the IBS Smart Test. The higher the anti-vinculin antibodies, the more difficult the patient is to treat.

17:15  This cross-reactivity of anti-CDT and anti-vinculin antibodies proves that this model of cross reactivity of antibodies can lead to autoimmunity and in the Functional Medicine world we use this concept of immune cross reactivity to explain how reactions to gluten or dairy or to toxins or to infections can result in autoimmunity. Dr. Pimentel remarked that when he was conducting his Reimagine Study, where he and his colleagues mapped the microbiome of the small intestine, he was surprised that they found that patients who went gluten free but did not have celiac disease, tended to have lower cytokines in their blood and that they were less inflammatory.

20:05  In a recent paper, the ACG Clinical Guidelines for SIBO, you list 6 factors that are important for helping to maintain small bowel ecology and for preventing SIBO.  You talk about 1. hydrochloric acid, 2. digestive enzymes, 3. bile, 4. motility, 5. the ileocecal valve, and 6. the gut immune system.  Yes, acid kills bacteria, but acid blocking medications like PPI use is not necessarily associated with SIBO and Dr. Pimentel’s group did not find really significant changes in the microbiome in patients who took PPIs.  If you have IBS and you’re on a PPI, we didn’t see more SIBO. But if you’re a healthy individual with no GI symptoms, just GERD, and you’re taking a PPI, there is higher risk of getting SIBO.  But because methane organisms eat hydrogen, and because hydrochloric acid contains hydrogen, patients on PPIs had less methane SIBO.  Dr. Pimentel has found that GI motility is the most important factor in preventing SIBO.  The Migrating Motor Complex (MMC) refers to waves of peristaltic contractions that occur when you haven’t eaten for several hours and these help keep the intestine clear of too much bacteria. It is like a dishwasher. This MMC is what gets inhibited by vinculin antibodies or by opiate medications. There are drugs that stimulate this motility, like Prucalopride, Tegaserod or Zelnorm, and even erythromycin low dose can do it.

24:53  When intestinal motility is impaired you can have diarrhea rather than constipation. You would think that without peristalsis, without motility, you would have constipation.  But you can actually have diarrhea, since without the squeezing of the peristaltic activity actively slowing things down, the intestinal contents would just pour through. This is the case with scleroderma, where the bowel becomes thicker and the contents just pour through like water going through your plumbing pipes, since there is nothing holding it back. 

26:08  The Migrating Motor Complex controls the cleaning waves and this is separate from the peristaltic activity that happens when you eat food.  The eating mode is grind three times, four times, then stop and wait, let the food absorb, and then grind a little more, and then let the food absorb. Then keep doing that over and over again. The small bowel moves the food forwards and backwards and forwards and backwards getting it all mixed with enzymes and bile, like it’s mixing it up. Each section of the digestive tract–stomach, small bowel, colon–each section moves differently at a different time and each has separate neural control.  The only time they all come together is during the cleaning wave. The cleaning wave starts at the top of the digestive tract and marches down, squeezing things through in a very straight top to bottom way to strip everything out. Patients who are taking a Proton Pump Inhibitor (PPI). like Prilosec, which are acid reducing medications, the bowel thinks you don’t have as much food in the stomach and it goes to cleaning waves prematurely or sooner than you should.  Because when you eat, you’ve got a lot of acid and all that acid prevents the switch from switching from eating mode to cleaning mode. But when you’re on a PPI, you don’t have that signal. You switch to cleaning mode earlier and you actually get more MMCs or cleaning waves, which may reduce the likelihood of SIBO. There are patients who have neuropathies where they switch to cleaning wave mode when their stomach is full of food, which is not good. People think it happens because they get what’s called a gastrocolic reflex where they eat and then they’re running into the bathroom. But that’s not that meal.  But there are also people who never switch to cleaning mode and then that’s a problem because they never clean.

29:26  The Vagus Nerve. There are a number of prominent practitioners in the Functional Medicine world who talk about the importance of stimulating the vagal nerve to help patients with SIBO by stimulating motility.  The vagus nerve is the electricity coming into the house, but the problem is the wiring that goes to the light sockets and having more electricity going to your house will not fix the wires and not all the lights will turn on. Using a prokinetic is also a way to turn up the energy, so that the lights that are working can be brighter, but the only way to get the other lights working, to fix the motility, is to get rid of the vinculin antibodies.

30:57  Dr. Pimentel and his group have mapped out the microbiome of the small intestine for the first time with his REIMAGINE Study.  The Human Microbiome Project was published in Nature in 2007, but this only mapped out the microbiome of the colon.  But the microbiome of the small intestine is completely different from the colon. The density of microbes in the small intestine is much smaller than the colon, but the small intestine has a much larger surface area, so there are probably more total microbes than there are in the colon.  Unfortunately, the Human Microbiome Project has not yielded one bug, one disease, but Dr. Pimentel’s research looks like it will be discovering a number of one bug, one disease associations in the small bowel, which is very exciting.

33:57  Dr. Pimentel used to think that the bacteria that cause SIBO overgrew up from the colon, but now we know that they are likely already in the small intestine and have overgrown since the cleaning wave is not working. It’s basically E. Coli and Klebsiella and possibly Aeromonas. These are the bacteria that cause many cases of hydrogen SIBO.

35:28  While Dr. Pimentel used to think that there potentially was a different variant of SIBO in different portions of the small intestine, regional forms of SIBO, such as duodenal SIBO and jejunal SIBO.  But his study did not really find that there was much of a difference in the bacterial content as you get closer to the colon, as had been theorized, so there does not appear to be regional SIBO.

37:00  Dr. Pimentel and his group have now reclassified methane SIBO as IMO, which stand for Intestinal Methanogen Overgrowth, since it is caused by methanogens, which are not bacteria, and they are not necessarily overgrown only in the small intestine, but also in the colon.  Dr. Pimentel has been studying the beneficial effects of a non-absorbable form of Lovastatin that reduces methane production. 

38:52  The consensus by experts for the cutoff level for a positive for methane on a lactulose SIBO breath test is 10 and while Dr. Pimentel used to prefer a level of 3, he now feels that 10 is probably a better marker.

40:50  Methane SIBO is often more difficult to treat than hydrogen SIBO and Dr. Pimentel pointed out that this may be because the methanogens that cause it tend to be closer to the surface of the mucosa and drugs like rifaximin may not penetrate as well there. This is why Dr. Pimentel is working on possibly using a version of Lovastatin.  Dr. Sam Rahbar of LA Integrative Gastroenterology and Nutrition has noticed that methane SIBO may also have a coexistence of fungal overgrowth and he has pointed out that this may be one of the reasons that Lovastatin helps, since it appears to have antifungal properties as well.  I suggested that perhaps certain nutritional agents that are known to break up biofilms like bismuth and NAC, which is also a mucolytic agent (breaks up mucus) might be helpful, but Dr. Pimentel feels that there is not enough scientific evidence to know if these might work.  Dr. Pimentel also noted that the organisms that cause hydrogen SIBO, E. Coli and Klebsiella also tend to live in this mucosal layer. And this is one of the reasons that the work that Dr. Pimentel and his group did to sample the bacteria in the small intestine was so difficult. 

44:30  Hydrogen Sulfide SIBO. We think that hydrogen sulfide is causing diarrhea in SIBO patients. Methane causes constipation, hydrogen sulfide causes diarrhea, and hydrogen is just the fuel source for either direction.  Dr. Pimentel usually uses antibiotics to kill the bugs that cause SIBO, but he tries to use as few antibiotics as possible. He uses Rifaximin for hydrogen SIBO and Rifaxmin and Neomycin for methane SIBO and he’s not sure what to do for hydrogen sulfide. He is hopeful to have a new breath test out that will enable us to diagnose hydrogen sulfide SIBO.  He is hopeful that the data on Lovastatin will pan out and they can use that for methane SIBO.  If they don’t respond, they may use natural products like peppermint and berberine and allicin.  If they are positive on IBS Smart test for vinculin antibodies, then he will give a prokinetic.  Once they get rid of the SIBO, they place patients on a specialized diet like low FODMAP, but he prefers the low fermentation diet, because you will have a better quality of life.  He’s not sure if a low sulfur diet might be helpful for hydrogen sulfide SIBO.  He prefers not to use a low fiber diet until after the antibiotics treatment, since if you starve the bacteria, the antibiotics may not work as well.

48:30  Dr. Allison Siebecker and Dr. Steven Sanford-Lewis, two of the top integrative doctors who are experts on SIBO, both treat SIBO successfully by using Rifaxmin or natural antimicrobials and a low FODMAP diet simultaneously and they find that using both simultaneously is more effective. Dr. Pimentel will typicall treat with antiboitics first and then add in the low fermentation diet and often a prokinetic, and Prucalopride or Motegrity is his favorite one to use, though he may use low dose erythromycin because of the lower cost.

56:36  Lovastatin that’s on the market now is designed to be absorbed into your blood to reduce cholesterol. In order for Lovastatin to have the desired effect in the gut for methane SIBO, it will have to be non-absorbed into the bloodstream and slowly released in the gut, so Dr. Pimentel is developing a novel form of the drug, which is not yet available on the market.

59:07  Some patients with SIBO get brain fog and neurological symptoms. This could be caused by D-lactic acidosis, which Dr. Satish Rao has published on. Methane is a gas similar to halothane and isoflurane, which are gases used in the operating room to induce sleep. Methane is also associated with higher blood sugar and higher cholesterol, so methane is clearly a bad actor.

1:00:20  Dr. Felice Gersh, a gynecologist and women health expert in Irvine, California asked since a lot of cases of IBS and SIBO occur in women, how estrogen affects their enteric nervous system and their microbiome?  If you are a woman and you get food poisoning, you are almost twice as likely to get IBS as men. Women have more autoimmune disease. Dr. Pimentel explained that estrogens are growth factors for some bacteria but he does not have the answer yet as to how estrogen impacts the microbiome.

1:04:30  There is a study that shows that spore based probiotics containing bacillis strains performed better than either Rifaximin followed by conventional probiotics or Rifaximin followed by a low FODMAP diet. (Catinean A, Neag AM, Nita A, Buzea M, Buzoianu AD. Bacillus spp. Spores-A Promising Treatment Option for Patients with Irritable Bowel Syndrome. Nutrients. 2019;11(9):1968.)  Dr. Pimentel is excited about the potential for probiotics to be helpful, but most of the probiotic studies are small and we really need a large, well designed trial, like with 500 patients, to really answer this question.

1:06:18  If you have a patient with both SIBO and H. pylori infection, Dr. Pimentel would treat the H. pylori first, since it requires a larger trial of antibiotics and you might wipe out both infections, so you should repeat the breath test after the treatment for H. pylori to see if the SIBO is also gone. Dr. Pimentel is also exploring whether there could be parasites that are stimulating this autoimmune response in the small bowel that leads to SIBO and he pointed out that Giardia has vinculin in it and he is exploring whether that could that trigger vinculin antibodies.

1:10:48  SIBO could affect B vitamin status. You can get an elevation of folate with SIBO, since folate is produced by gut bacteria. You do sometimes see a vitamin B12 deficiency in SIBO.




Here are links to some recent important papers by Dr. Pimentel:

1.Pimentel M, Saad RJ, Long MD, Rao SSC.  ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020; 115(2):165-178.  (This is the paper where methane SIBO is recategorized as IMO.)

2. Leite GGS, Weitsman S, Parodi G, et al. Mapping the Segmental Microbiomes in the Human Small Bowel in Comparison With Stool: A REIMAGINE Study. Digestive Diseases and Sciences (2020) 

3. Pimentel M, Lembo A.  Microbiome and Its Role in Irritable Bowel Syndrome. Dig Dis Sci. 2020;65:829-839.

4. Morales W, Rezaie A, Barlow G, Pimentel. Second-Generation Biomarker Testing for Irritable Bowel Syndrome Using Plasma Anti-CdtB and Anti-Vinculin Levels. Dig Dis Sci. 2019;64(11):3115-3121.



Dr. Mark Pimentel is a Gastroenterologist who is head of the Pimentel Laboratory and Executive Director of the Medically Associated Science and Technology (MAST) program at Cedars-Sinai, which is focused on the development of drugs, diagnostic tests, and devices related to condition of the microbiome, with a focus on IBS. Dr. Pimentel has published over 100 scientific papers and he speaks around the world at conferences, esp. about SIBO and IBS. Here is a list of some of Dr. Pimentel’s key publications: https://www.cedars-sinai.edu/Research/Research-Labs/Pimentel-Lab/Publications.aspx

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.


Podcast Transcript

Dr. Weitz:                            Hey, this is Dr. Ben Weitz, host of The Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest and cutting edge health information. Subscribe to The Rational Wellness Podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.

Okay. Welcome everybody. Our topic for tonight is small intestinal bacterial overgrowth and irritable bowel syndrome. Our special guest at our Functional Medicine Discussion Group meeting tonight is Dr. Mark Pimentel. I’m Dr. Ben Weitz and I’ll start by making some introductory remarks. Due to such a large crowd, I’ll ask everybody to type in your questions and then I’ll try to call on you or I’ll ask Dr. Pimentel the question when it’s appropriate for the discussion. Let’s see. Unfortunately, I guess I have to keep manually admitting everybody as we go. If you’re not aware, we have a closed Facebook Page, the Functional Medicine Discussion Group of Santa Monica.  If you’re not on there, you should join so we can continue the conversation when this evening’s over. I’ll be recording this event and I’ll post it on my YouTube page and I’ll include it in my weekly Rational Wellness Podcast. If you haven’t listened, please check out my Rational Wellness Podcast and subscribe to it. It’s on Apple Podcasts and all the places you can get podcasts, Spotify, et cetera. If you do like listening to it, I’d appreciate if you give me a ratings and review on Apple Podcasts. We have many excellent interviews with many of the top doctors in the Functional Medicine world. We just posted a discussion of testing for COVID-19 with Dr. David Brady.

Tonight, Metagenics will be our sponsor. I’d like to tell you about a few products that they have that are awesome for gut health. CandiBactin-AR, which contains oregano and thyme oils along with sage leaf extract and lemon balm, and CandiBactin-BR, which contains a number of herbal sources of berberine, along with some Chinese herbs. This combo is really awesome for SIBO and many other forms of gut dysbiosis.  It’s been used in a study at Johns Hopkins by Gerald Mullins to be equally as effective as rifaximin, which is the gold standard antibiotic treatment for SIBO. Also, I wanted to tell you about one of Metagenics line of quality probiotics, UltraFlora Integrity. This contains Lactobacillus salivarius UCC118, which has been shown to support tight junctions and reduce intestinal permeability. In other words, it reduces leaky gut. In addition, a study was conducted at Cleveland Clinic that found that this particular strain of probiotic used daily for 90 days was effective in reducing symptoms of SIBO. Anyone who would like additional information or would like to set up an account with Metagenics please call or text our local representative Kaylee Ogaard at (310) 321-8785.

                                                Dr. Mark Pimentel is the head the Pimentel Lab and Executive Director of the Medically Associated Science and Technology program at Cedars-Sinai. He’s a very prolific researcher having published over 120 scientific papers. The Pimentel Lab research is irritable bowel syndrome, the microbiome, and many other gastrointestinal conditions. Irritable bowel syndrome affects 10 to 15% of people in the United States. For many years, prior to Dr. Pimentel’s research, IBS was thought to be a diagnosis of exclusion. Once inflammatory bowel disorders, celiac disease, parasites, and all the other causes of gastrointestinal disorders were ruled out, you were sometimes left with a diagnosis of IBS. Generally, there was not an organic reason for this condition. Dr. Pimentel has many accomplishments. He’s the first researcher to demonstrate that small intestinal bacterial overgrowth is the cause of IBS in a majority of cases and that SIBO could be diagnosed with a lactulose breath test. Dr. Pimentel also pioneered the use of rifaximin, a nonabsorbed antibiotic as a treatment for IBS, especially for IBS with diarrhea.   He’s developed an autoimmune model of IBS being caused by an episode of acute gastroenteritis, which most of us called food poisoning. He’s developed a blood test looking at antibodies to vinculin and cytolethal distending toxin to diagnosis this autoimmune cause of IBS. Dr. Pimentel has discovered that the methane producing organism Methanobrevibacter smithii causes constipation and that lovastatin can inhibit this methane production. Dr. Pimentel and his colleagues have recently renamed the methane version of SIBO as IMO, which stands for Intestinal Methanogen Overgrowth. Most recently with his Reimagine Study, Dr. Pimentel for the first time ever has mapped out the microbiome of the small intestine, a monumental achievement. Dr. Pimentel has really spurred the development of an entire SIBO community complete with SIBO testing, SIBO drugs, SIBO supplements, SIBO podcasts, and SIBO conferences. I hope one day we’ll be able to go to conferences again. But until then, we’ll have to do Zoom conferences like we’re doing now. Most importantly, Dr. Pimentel has given hope to millions of patients with IBS that they might finally be able to feel better and stay better. Thank you, Dr. Pimentel for joining us tonight.

Dr. Pimentel:                     Well, thank you, Ben. It’s a pleasure to be here and thanks for such a broad introduction. I really appreciate it.

Dr. Weitz:                          Before we get started with the discussion of SIBO and IBS, Allison Siebecker called me and asked me to ask you a question, which I’ll ask you in a little bit. I told her I was happy to finally be discussing something other than COVID-19 because I’ve been doing all these podcasts about COVID-19. She told me about your project to use UV light inside the body to kill the virus. I said, “I can’t believe that. I just saw president Trump talking about light inside the body to kill the virus.” You have to tell us about this project. Are you looking to replace Dr. Fauci? I’m just kidding.

Dr. Pimentel:                     Replace Dr. Fauci although he’s disappeared.  We had been working for about three or four years. Dr. Rezaie sort of came up with this notion of using light, Ultraviolet A light, to treat infections. We did a broad array of experiments. Some of this is public information because we presented at the European meeting of gastroenterology that a particular wavelength of light for 20 minutes to 40 minutes will kill most pathogens. Because our research was paused by COVID, one of the applications was to put it in the endotracheal tube to prevent a pneumonia from endotracheal tubes. Then we began to test it on coronavirus. That’s all I can tell you right now, but yes, we’re very interested in what we could do to maybe help save lives. Again, that’s all I can say for the moment, but stay tuned because we’re publishing the work that expresses or goes beyond that abstract at the European meeting. Yeah, just trying something different for the moment because we’re closed otherwise.

Dr. Weitz:                          Yeah. My understanding is, is that this is potentially something that might in the future be able to help with SIBO as well.

Dr. Pimentel:                     It could. We’re looking at ways to apply it internally. One of the bugs that we tested and was presented at the European meeting was C. diff is very susceptible to this light. Stay tuned, we’ve got a lot of things coming from that technology. Very exciting.

Dr. Weitz:                          Yeah, that’s very exciting because C. diff is a very difficult bug to kill. Before we get into some of your latest research, perhaps we can define some terms so everybody is on the same page. Can you explain what is IBS, what is SIBO and how should we rethink of these two conditions?

Dr. Pimentel:                     I’m explaining it just a little different these days. Maybe you’ve heard it from other podcasts, but I think it helps to understand because people are confused. Patients are confused as well because they say, “Well, is it SIBO or is it IBS?” The answer is, yes, because it’s both. The way I explain it now is, if you go back into the 1980s and look at peptic ulcer disease. Peptic ulcer was a ulcer in your stomach and you had pain and so forth and so on. Then they discovered that H. pylori was the cause of that ulcer, but it only caused about 60 or 70% of ulcers. We didn’t change the name to H. pylori disease. It’s still peptic ulcer disease, but H. pylori is the cause of 60 or 70%. Sort of a similar story here. It’s irritable bowel syndrome, and about 60 or 70% of IBS is caused by SIBO, I think. That’s basically how we frame it now. But like H. pylori, there’s a bunch of people with H. pylori that don’t have ulcers and there’s a bunch of people with SIBO that it isn’t IBS. There’s another cause.  There could be narcotics as a cause or adhesions as a cause or something else. Not just IBS and not just this post-infectious autoimmune thing. It’s just how the terminology is used.

Dr. Weitz:                            Okay. Can you explain your autoimmune concept of SIBO?

Dr. Pimentel:                     Yeah. I mean, to me, this is the most exciting stuff, because it may suggest we could be close to a cure if we can cross the next couple of hurdles. But essentially, food poisoning starts the process, it’s like a trigger. People don’t remember. I mean, they don’t remember two days of diarrhea two years ago and they now still have diarrhea. But sometimes you do remember. Sometimes it ruined your vacation or whatever, and ever since then, your bowels have never returned to normal. But that trigger is what trips you into a problem. We now identified that food poisoning, it could be E. Coli, it could be salmonella, shigella or campylobacter, they all share one toxin in common. This is what we sort of latched onto in the 2000s and said, “Well, could this toxin be a culprit?” Because they didn’t have anything else in common, but they had this toxin. We actually created a campylobacter without this toxin and infected rats, and they didn’t get IBS. But the rats infected with campylobacter got IBS. We’ve continued even to this day with that animal model.   Just at this past DDW, we had a huge abstract and presentation, but DDW didn’t happen. But the bottom line is that, toxin, CdtB creates antibodies in your blood that we can detect. Exposure to that toxin creates an autoimmunity to a protein in your gut called vinculin. Vinculin is important for the nerves to kind of connect. With attacking vinculin, those nerves are not connecting properly, the gut doesn’t flow correctly and bacteria build up. That’s how it works. We were supposed to present even more data that substantiates that story to a greater extent about two or three weeks ago.

Dr. Weitz:                            If somebody gets a bout of food poisoning, this is a question that Allison Siebecker asked me to ask you, is there a way to prevent them from this turning into SIBO? Is there some strategy they could use?

Dr. Pimentel:                     Well, let’s say you get food poisoning today. Well, one strategy that we tested in the animal studies was, let’s say you were going on a weekend trip to an underserviced area in an underserviced country to maybe build homes or something as a mission work or other things. And you were there for a short period of time in an underserviced area. If you took antibiotics with every meal, I know that sounds strong, you will prevent food poisoning and you will not get IBS. Our rat studies showed that. We do that in humans for some people who travel to very difficult areas. But I’ll explain another way we use that also. You can prevent. If you have food poisoning today, we used to say, let it go because it’s self-limited, it’s going to go away after a few days. But we now know based on all the meta-analysis and in fact Mayo Clinic did a beautiful 45 minute presentation that proves food poisoning causes IBS. What they found, was the longer the food poisoning, the more likely you were to get IBS and SIBO and all that stuff. [inaudible 00:14:07], then maybe you’re going to help you.   [inaudible 00:14:13] is [inaudible 00:14:20]. For example, now you had food poisoning, it’s gone and you want to [inaudible 00:14:24] to be able to [inaudible 00:14:25]. But the study was only 30 patients, so it wasn’t strong enough or powerful enough to show that it prevented. That jury is out on that, but to be honest….

Dr. Weitz:                          Hang on one second, Mark. I’m going to mute everybody and then unmute you again because I can’t find where she is. Okay. There we go.

Dr. Pimentel:                     Okay. Perfect.

Dr. Weitz:                          Okay. Good. Thanks.

Dr. Pimentel:                     The third thing is the steroid jury’s out, but I wouldn’t recommend steroids because of the side effects.

Dr. Weitz:                          Right. Okay. Then can you talk about the serum test that you developed and now you’re on the second version of it that helps us measure this autoimmune form of SIBO?

Dr. Pimentel:                     Yeah. We developed the first version, but it’s specificity and sensitivity needed some tweaking. The proteins, vinculin and CdtB are quirky, and so they need to be stabilized. We figured out a way to stabilize it, we call it epitope optimization. Now the new generation test is very specific, over 90% specific with either marker, and it’s called ibs-smart. Now ibs-smart helps me a lot in my clinic for anybody with diarrhea. Because, I’ll give you an example, I had a patient in my clinic. She was 19 or 20 years old. Her mother said she wanted her to have a colonoscopy and I would say, “This is 19 years old. You have no blood in the stool.” I did the test, it was negative. Then I said, “Okay, I will scope this one.” It was microscopic colitis. I wasn’t expecting that in a young person. In another case, it was a young man who was 23 years old. His mother has vinculin antibodies over three. So she’s super autoimmune. She said her son is having the same symptoms. I measured the antibodies and the vinculin was high, but not really high enough to be IBS.  Then he said, “Well, I’m going to Southeast Asia in about six months. What should I do?” I said, “Well, you can’t let those antibodies get higher because you’ll be harder to treat.” This is what we see in our clinic, the higher the anti-vinculin, the harder they are to treat. But the amazing thing with this young man was, he was in his early 20s. He’d had a colonoscopy already. He had a CT scan of the abdomen, the ultrasound, stool study. I mean he had a $4,000 workup. That’s his copay. That’s not how much the workup costs. Where he could have had the test and the test would have saved them all that copay because it was positive. We’re using the test not just to make patients feel comfortable that the diagnosis is correct because the test is very accurate, but also to guide prognosis and to save money for patients and for healthcare.

Dr. Weitz:                            It’s kind of exciting for us in the Functional Medicine world, because we see a lot of patients who have these autoimmune conditions and we find that food sensitivities and reactions to toxins and heavy metals and things like that seem to be factors. We’re always talking about this cross-reactivity model and here we have a very concrete cross-reactivity model that’s been thoroughly proven in this particular arena. It kind of gives more credence to that cross-reactivity model that we often utilize to explain how sensitivity to gluten or dairy can lead to autoimmune thyroid disease and things like that.

Dr. Pimentel:                     Well, two things to say on that. First of all, we think that these two markers, anti-CdtB and anti-vinculin, are not markers of the disease, they’re actually causing the disease. That’s the part that I’m really excited about because, particularly in anti-vinculin’s case, if we can get that out of your bloodstream, it’s possible we can cure IBS and SIBO. That part makes me very excited, but it’s also a little challenging to do that. The second part of what you said is, for me to swallow my tongue and say something I didn’t expect to say. Which is that I’ve sort of been on the fence about gluten. I’ve always said, “Well, I’m not sure …” Celiac disease is clear. Gluten sensitivity was always unclear to me. This Reimagine Study that we’re doing, we were supposed to present … It’s public domain now because the abstracts are published, but it was at the meeting, the DDW meeting. People who were gluten free and not celiac, their cytokines in their blood were much lower. They were less inflammatory. I was expecting to see nothing.

Dr. Weitz:                          Interesting, fascinating.

Dr. Pimentel:                     Well, now I have data. It’s not that I need to see my own data to be correct, but it’s more that I have a way of thinking through problems. As we thought through this problem, it’s clear there’s something there that needs further exploration and more objective evidence. But I’m convinced there’s something there in some people. I’m glad you brought that up because I needed to clear the air on my own conscious and say…

Dr. Weitz:                          That’s right.

Dr. Pimentel:                     … something to gluten.

Dr. Weitz:                          Interesting, yeah. Alessio Fasano and other researchers have found that 100% of patients who consume gluten on a regular basis have some evidence of leaky gut and other issues. So that’s interesting. One of your recent papers is the ACG Clinical Guidelines for SIBO. In those guidelines, you list six factors that are important for helping to maintain small bowel ecology. You talk about hydrochloric acid and digestive enzymes and bile and motility and the ileocecal valve and the gut immune system. I thought maybe we could talk about some of those and which ones do you think are most important in the etiology of SIBO?

Dr. Pimentel:                     All of those are what I call classic or traditional notions of what can prevent bacteria from getting in your gut. Yes, acid prevents bacteria from getting in the gut. Well, the irony of that is, we did present it at DDW and this paper is coming out just shortly, that people on PPI did not have too much of a different microbiome in the small bowel. That shocked me also because I was expecting PPI to radically change the microbiome, and it didn’t. There were a couple of small changes, but nothing as remarkable as I expected and definitely PPI was not associated with SIBO. This was a very large group of patients. Acid is funny because acid kills bacteria, but you don’t need much time with acid for it to kill. In five minutes with a pH of one, bacteria are pretty much destroyed.

Dr. Weitz:                          It seems like maybe your group has gone back and forth on the PPI because it actually states in the paper that PPI use is associated with higher risk of SIBO.

Dr. Pimentel:                     Yeah. Okay. Traditional studies had said that, and our paper hasn’t been published yet. Now in the Reimagine Study, we didn’t find SIBO. That hasn’t been published, so we couldn’t put it in there yet. It was only an abstract and they don’t like abstracts for guidelines because it’s not peer-reviewed as thoroughly as a paper. But we didn’t find it. But there’s two things that were happening that’s in the literature. Number one, if you’re IBS and you’re on a PPI, we didn’t see more SIBO even in published literature. But if you a healthy individual with no GI symptoms, just GERD and you’re taking a PPI, there was more SIBO. It’s a little confusing. The third sort of confusing leg of this three-legged stool of acid and bacteria is, methane organisms love acid. They can use hydrogen or acid hydrogen to make methane. People on a PPI had less methane overgrowth because they had less acid. Sometimes no acid is good depending upon if you’re methane, sometimes no acid is bad if you’re … Yes, the thing is confusing.

Dr. Weitz:                            Yeah. Interesting. Then digestive enzymes, I know that one of the things that you think is super important is this migrating motor complex and motility. Allison Siebecker was talking about it and she was explaining how the digestive enzymes and the bile are kind of like the soap as part of this process by which the MMC helps keep the intestines clear. For those, you who are not aware, the MMC is gastric contractions that occur in between eating. When you haven’t eaten for a while, you get these peristaltic activity that helps to keep the small intestine clear of bacteria.

Dr. Pimentel:                     Yeah. It’s like a dishwasher. It washes your small bowel in preparation for the next meal. To me, that’s the most important. Of all the factors for SIBO, not having that wave means SIBO or having a reduction in the frequency. That happens every 90 minutes when you’re not eating. Morphine causes SIBO and morphine’s a potent inhibitor of that wave. Anything that blocks that wave from occurring will cause a lot of SIBO. We think that’s what vinculin antibodies are doing, is that they’re impairing that cleaning wave. That’s based on the research in the animals.

Dr. Weitz:                            What other drugs inhibit that wave?

Dr. Pimentel:                     It’s mostly opiates that do that. Then there are drugs that stimulate that wave, like motility drugs, Prucalopride, Tegaserod or Zelnorm, and even erythromycin low dose can do it.

Dr. Weitz:                            Okay. Last time we talked, we were talking about motility and you explained something that was really fascinating and I think most people are not aware of. Which is that, without normal intestinal motility we’ll actually have diarrhea, not constipation. Can you explain that?

Dr. Pimentel:                     Yeah. It’s a little confusing because even when I train the fellows about motility, people think you don’t have stuff coming out because the gut isn’t moving. But the way that that actually works is, if your gut can actually squeeze and hold things in, that’s active slowing. But for example in scleroderma, if the bowel becomes thicker and can’t move because it’s so thick, it actually just pours through like going through plumbing because there’s nothing holding it back. You can actually have diarrhea if the peristalsis is thick and unable to perform its retaining function. Motility is kind of fascinating because there’s so many ways you can have symptoms based on the lack or presence of motility.

Dr. Weitz:                            Now, is the migrating motor complex, is that exactly the same thing as the peristaltic activity that happens when you eat food or are those separate things with separate neural control?

Dr. Pimentel:                     Yeah, they’re totally separate. It’s almost like you have a switch with two modes. You have the cleaning mode and then you have the eating mode. The eating mode is, grind three times, four times, then stop and wait, let the food kind of absorb and then grind a little more and then let the food absorb. Then keep doing that over and over again. The small bowel moves the food forward and back and forward and back and forward and back getting it all mixed with … Like it’s mixing it up. Whereas the cleaning wave, it starts at the top and goes choo,choo,choo, like marching down, squeezing things through in a very systematic, straight top to bottom kind of way to strip everything out. All the lettuce and things you can’t eat or can’t digest. They’re different mechanisms. Going back to acid, this is a funny part, people on a PPI, the bowel thinks you don’t have as much food in the stomach and it goes to cleaning waves prematurely or sooner than you should.  Because when you eat, you’ve got a lot of acid and all that acid prevents the switch from switching from eating mode to cleaning mode. But when you’re on a PPI, you don’t have that signal. You switch to cleaning mode earlier and you actually get more MMCs or cleaning waves. Again, another reason why SIBO may or may not be associated with acid reduction medication. Was that kind of confusing or …

Dr. Weitz:                          Yeah. Well, what’s the implication of that MMC happening earlier?

Dr. Pimentel:                     Well, in some ways it’s good. But there are patients for example, and this is not that common, who have what are called neuropathies. Where the nerves are irritated and the switch is not in the right position. The last thing you want is a cleaning wave when your stomach’s full of food, because then everything’s just going to go whoosh right to your colon and out. That doesn’t happen very often at all. People think it happens because they get what’s called a gastrocolic reflex where they eat and then they’re running into the bathroom. But that’s not that meal. This event that I’m talking about is very rare. But there are also people who never switch to cleaning mode and then that’s a problem because they never clean. There’s various forms of neuropathy that are out there.

Dr. Weitz:                          We have a slightly different neural control of motility in different parts of the track? Stomach is different than small bowel than large bowel?

Dr. Pimentel:                     Yeah. The only time they all come together is that cleaning wave. The stomach starts, then the small bowel, and then it gets to the colon and the colon sort of holds everything right after that to get everything dehydrated to make stool. Everything kind of activates during that cleaning wave to keep things moving along. It’s integrated only when you’re not eating. But when you’re eating, every part is moving separately and doing things in a different way.

Dr. Weitz:                          A lot of people talk about the vagal nerve, the gut brain connection and the vagal nerve is sending a lot of signals to control motility. What do we know about the importance of the vagus nerve? Is there a way to stimulate it to help with SIBO or motility problems?

Dr. Pimentel:                     Yeah. Stimulating the vagus nerve is a little challenging. There are neurostimulators and other things that could be used, but not well studied in SIBO particularly. Now the problem with SIBO is, the nerves are … It’s sort of like that … What I tell my patients is, “You have electricity come into the house. That’s your vagus nerve. Okay. The wires from the pole are coming to your house, but not all the wires are touching the light bulb sockets.” You’ve got half the lights. You turn on all the lights in the house, but only half are turning on. That’s the problem with SIBO. You could make the wires from the house push more electricity, but it’s not really working terrific. Now, again, that’s what the prokinetic does, is it turns the energy up so that all the light bulbs that do work are brighter and you get a bit of light. That’s why we use a prokinetic to kind of, whatever’s working, make it work better. But you can’t repair the phase until you get rid of the antibody. That’s the way I see it.

Dr. Weitz:                          Okay. Let’s talk about your research mapping the microbiome of the small intestine. This is the first time this has ever been done. What are some of the implications that we’re getting out of this data to help us understanding and treating SIBO?

Dr. Pimentel:                     Yeah. This is super cool because there’s a lot of things we’re learning that would be very important for you to understand today. But about 10 years ago, maybe 13 years ago, the Human Microbiome Project was published in the journal Nature. This was a huge thing because the microbiome was mapped for the first time. What they said was, “We mapped the gut microbiome.” The answer is, no, you didn’t. Because you mapped the stool and you said because you mapped the stool, you mapped the whole gut. What we learned is that, the small bowel in the study that you’re referring to that was just published, is completely different from colon. It’s literally like the sun and the moon. It’s completely different organisms, the different structure of the types of bacteria and so forth and so on. Now, the other thing that is a bit of a fallacy, and this will be easier to understand is, they think because the stool has a size and that it contains a ton of bacteria, oh, that’s really important.   The problem is, the stool is like this and the bacteria is sitting in the center, it’s not doing anything to you. It can’t reach you because it’s got all these other characters in the way. Even though there’s a lot of bugs in there, it’s not a lot of bugs compared … Now think about the small intestine. The small intestine has the surface area of a tennis court. Imagine if you smeared a thin layer of peanut butter across our whole tennis court, how much peanut butter you’d need. We think the small bowel might actually have more microbes than the colon if you consider surface area.

Dr. Weitz:                          Oh wow.

Dr. Pimentel:                     Okay. Then when you add to that, that the small bowel absorbs but the colon doesn’t, it just absorbs water, imagine the chemicals, the bugs in that surface area of a tennis court are giving to you on a daily basis helping, hurting or neutral. We don’t know. And what impact that could have. The Reimagine Study is trying to figure out what bugs and what disease.  Because look, the 13 years since the Human Microbiome Project, zero.  One bug, one disease. Look at C. diff. C. diff was discovered in the 1980s using old school microbiology. But 13 years of microbiome research hasn’t found one bug, one disease. We’re already finding one bug, one association in the small bowel. I can’t talk about that yet because we haven’t published it yet. But it’s fantastic what’s going on in the small bowel in terms of maybe helping diseases.

Dr. Weitz:                          Now we’ve had controversy over where the bugs that cause SIBO come from. Are they overgrowing up from the large intestine or are they in the small intestine and just overgrowing? Has your study helped to answer that question?

Dr. Pimentel:                     My thinking used to be, colon coming up.  My thinking has changed now. It’s, they’re there. You probably all live in LA or I imagine most of you live in LA somewhere-

Dr. Weitz:                          I think most of us, yeah.

Dr. Pimentel:                     We had the drought last year and just before the rains came about two years ago, actually. Burton Boulevard has this beautiful central boulevard of grass, and the grass is Beverly Hills pristine. Then they stopped mowing the lawn just because they wanted to save water. There wasn’t a lick of grass. There was tall weeds, about three feet deep. Not mowing the lawn, the grass couldn’t compete, the weeds worked. Without the cleaning wave, the weeds grow. The weeds are there, they’re just … It’s E. Coli and Klebsiella. That’s what’s causing bacterial overgrowth. Once they get a foothold, it’s hard to flip them out and get the weeds gone. That’s what we think is overgrowth based on the Reimagine Study. It’s E. Coli and Klebsiella, those two characters and a little bit of Aeromonas.

Dr. Weitz:                          Is there such thing as region specific SIBO? Is there duodenal SIBO versus jejunal SIBO?

Dr. Pimentel:                     Yeah. In this study, we mapped the whole small bowel and ironically, it was remarkable that there wasn’t as much of an increase as you get closer to the colon as we had expected based on people just talking. I mean, people talk and they say, “Oh, it must get higher and higher as you get to the colon.” That wasn’t what we found. It wasn’t dramatic like that. As we now get truth, the truth is telling us what the answers are and it’s not quite like that. I don’t think that there’s actually as much regional SIBO as we used to think, but we’re continuing to collect data and I may correct myself in a year if our data suggests otherwise.

Dr. Weitz:                          In your study, I didn’t see methanogens on the list of organisms you found. My question is, did you find methanogens in the small intestine and what about fungus and parasites like protozoa that are normal to the colon?

Dr. Pimentel:                     Yeah. The sequencing we did was for bacteria initially, not for archaea and not for fungus or parasites. But we have all the DNA of all of that and we’re looking through that. In fact, right now my lab had just come back finally, and they’ve been marching through the methanogens in the small bowel, the colon and everywhere, because that’s really important. We’ll have data to share on that hopefully in the next few months.

Dr. Weitz:                          What’s the significance of this reclassification of methane SIBO?

Dr. Pimentel:                     Yeah. The term is SIBO, small intestinal bacterial overgrowth. First of all, it’s small intestine. It has to be in the small intestine, which we agree SIBO is. And then it’s bacterial overgrowth. Methanogens are not bacteria they’re archaea, so you can’t call them bacterial overgrowth. We used to call it methane SIBO, but that’s a wrong terminology. The second part is that methanogens grow in the colon too much as well in these patients, not just the small bowel. We couldn’t say small bowel because it’s both the colon and the small bowel in the case of methanogens. We had to reclassify the term. It’s an overgrowth if it’s a bloom and it’s excessive number of methanogens, but not just in the small intestine.

Dr. Weitz:                          Conceivably, methane SIBO could be primarily in the colon?

Dr. Pimentel:                     It could be. We’re mapping the bowel now and then comparing that to … Again, I’ll be able to tell you more with more granularity that in a few months, but-

Dr. Weitz:                          But of course, if it comes up positive on the SIBO breath test, then that means especially if it occurs in the first 90 minutes, then we know that that’s got to be the small intestine?

Dr. Pimentel:                     Well, methane is different because methane is either there or not. On the breath test, often a methane producer normally hydrogen starts at five and then works its way up over 20, and that’s positive. In methane, it starts at 30 and stays 30. You’re either methane presence or not. It doesn’t really go up that much with lactulose. It’s a different characteristic of the breath test.

Dr. Weitz:                          What should be the cutoff for the breath test for methane? Should it be 10? I’ve heard you mention that perhaps it should be lower.

Dr. Pimentel:                     Yeah. The North American Consensus and the recent SIBO guidelines from the American College of Gastroenterology are saying, for methane, any number over 10 within the first 90 minutes. Then for hydrogen, it’s a rise of 20 within 90 minutes. If you start at five, it’s got to go to 25, and then that’s considered positive.

Dr. Weitz:                          I’ve heard you say perhaps maybe methane at three should be significant.

Dr. Pimentel:                     Okay. This is the problem with consensus. Is that I have my opinion and there’s 20 other people in the room and we have to go along with consensus. The group felt that 10 was a better marker. But let me explain why 10 might be a better marker. When you do research on methane, Dr. Rezaie and I looked at all the breath tests, 12,000, 15,000 breath tests at Cedars over a decade. We looked at, if somebody had three, 90% of the time they went over 10 at some point during the test. Even if we used three, almost all those patients would be over 10 anyway at some point and meet that criteria. It wasn’t so big a deal. But the second part is, if you’re going to give a drug to lower methane, it’s better that it’s 10 so you can see it go down than three, where there’s nowhere to go. We sort of like the 10 now because if we’re going to develop drugs as we’re doing now to reduce methane, at least you have somewhere to go from 10. You don’t have more to go from three. That makes sense?

Dr. Weitz:                          Sure, yeah. Why do you think methane is so difficult to treat?

Dr. Pimentel:                     Yeah. There’s a couple of things about methanogens. Number one, they tend to be closer to the surface of the mucosa or the surface of the human cells. There’s a thick mucus layer where rifaximin and a lot of drugs can’t penetrate, not as well anyways. That’s part of it. The other thing is, they’re not bacteria. We developed antibiotics for bacteria and not archaea. It’s sort of like trying to use antibiotics for yeast and it’s not developed that way, they’re different. That’s why we’re trying to take different approaches. We’re using, as you mentioned in your introduction, sort of a variety or a version of lovastatin which goes into the bug and stops methane production. Then the energy of the bug can’t be produced and the methane is not produced so the constipation gets better. We’re just in the middle of the trial of that drug. We’re super excited to get that done soon.

Dr. Weitz:                            I was just talking to Dr. Rahbar a couple of days ago. He was saying that he sees in cases of methane, he often sees a fungal overgrowth. He said that lovastatin actually has antifungal properties and that could perhaps be one of the reasons why it helps.

Dr. Pimentel:                     Remember, lovastatin comes from Aspergillus, which is a fungus. Aspergillus, didn’t make the lovastatin for human cholesterol. It’s making it to affect things around it. It could be to prevent other fungus from growing there and getting in its way. Certainly in swamps and other places where Aspergillus is prominent, there’s a lot of methane and methanogens which may be intoxicating to the Aspergillus and it wants to block that. Obviously lovastatin has a chemical property that does something to the microbiome which we think is beneficial, but we’ll see. We’ll get some results later this year.

Dr. Weitz:                            Since the methanogens are found in the mucus and it’s one of the reasons why they’re hard to get at, I wonder, would it makes sense to use agents? We have certain nutritional agents that are known to break up biofilms like bismuth, we use certain enzymes, NAC is a mucolytic agent. I wonder if something like that would make sense to break up some of that mucus layer to get at the methanogens.

Dr. Pimentel:                     Yeah. I mean, but the challenge with these things are half-life of the products and how much surface area you have to cover. Because again, we’re talking about a tennis court size area. Yes, we’re looking at all of that actually, but we have to work it in a way that actually is effective in such a large surface area. Stay tuned, I’ll have more things to report in that context. This is all again, coming from the Reimagine Study. Because the Reimagine Study, and I can’t talk about all of this data, but we’re looking at the bugs in the center of the bowel, the bugs in the mucus and the bugs right at the surface. They’re different. As we study the layers, even in the small bowel, it’s pretty remarkable the different bugs. I’ll tell you where the SIBO is, is in the mucus. That’s why it’s hard to get rid of it because it’s in the mucus and that’s where E. Coli and Klebsiella love to live. That may be why we need to get better treatments and they’re coming, we’re working on something right now. It’ll be interesting to see how that evolves.

Dr. Weitz:                          What does your Reimagine Study tell us about hydrogen sulfide SIBO? Right now, our only way to try to diagnose is if we see a flat line of hydrogen all the way through the third hour. Do you think we’re picking up a substantial percentage of patients with hydrogen sulfide SIBO?

Dr. Pimentel:                     Yeah. Well, a new breath test is emerging soon that will be able to test hydrogen sulfide. But we think hydrogen sulfide is causing diarrhea. Methane causing constipation, hydrogen sulfide, diarrhea, and hydrogen is just the fuel source for either direction. Of course the methane bugs don’t like the hydrogen sulfide bugs because they’re eating the same rabbits, which is hydrogen. You either have foxes or you have wolves in the neighborhood because the rabbits are the hydrogen.

Dr. Weitz:                          Right now, what are your current treatment protocols for hydrogen SIBO, methane SIBO and hydrogen sulfide SIBO?

Dr. Pimentel:                     Well, the effective therapies that we use are usually antibiotic therapies. But again, what we’re trying to do is to use as little antibiotics as possible. Because that’s why when we treat … Okay. Let me go through it. For hydrogen, we use rifaximin as first line. There are other things we do if you want to get into it if they don’t respond including peppermint and other natural products that you’ve covered partly in your introduction as well. Then with methane, we use rifaximin and neomycin because there was a double blind study that shows that. Although we can’t wait for the lovastatin data. We’re hopeful that that will show something good. It may not work. If it doesn’t, then we regroup. Hydrogen sulfide, we don’t know what to do with that yet because we don’t have the breath test widely available. Once we get that, we’ll know within months what’s going to be effective there. I’m very sort of excited about that. But once you get control … This is why we do the ibs-smart test.  Because if they are vinculin positive, they got to go on a prokinetic more likely because they really have a motility issue. We’re more likely to give a prokinetic, at least in my practice. Then we try to use diet to try to ward off the overgrowth and prevented it from coming back. That’s also really important. There’re a variety of diets. Low FODMAP, we tend to use low fermentation because it’s better quality of life.

Dr. Weitz:                          When do you kick in a low fermentation diet? Do you do it while treating or do you do when you’re done with treating?

Dr. Pimentel:                     Well, I basically … The reason, and people know this of me, that I don’t do it while treating because of the old mantra of antibiotics back in the ’70s. Which is, starving bacteria, hibernate or form spores, or try to protect themselves by walling off because they’re stressed. Stressed bacteria are not susceptible to antibiotics. I don’t like using the starvation of low fermentation or low FODMAP because it might make it harder to treat. Other people have taken my words and said, “Well, let’s give guar gum, really juice up the bacteria, and then give antibiotics.” I don’t do that, but people have suggested that I said that and I haven’t. But I understand the rationale and maybe it’s helpful, but I haven’t tested it personally. But the bacteria that are fed are going to be more susceptible to the rifaximin or the rifaximin and neomycin. Better not starve before you do the antibiotics.

Dr. Weitz:                          It’s interesting you mentioned guar gum. Because my understanding is, hydrolyzed guar gum is the one fiber that does not really irritate SIBO.

Dr. Pimentel:                     Yeah, I understand that. I don’t know where that came from, but it’s out there and somebody said, I’ve said it, but it wasn’t me.

Dr. Weitz:                          Yeah. I know Allison Siebecker said that she and Dr. Sanford-Lewis normally treat with rifaximin or natural antimicrobials and a low FODMAP type of diet at the same time and find that they get quicker symptom resolution by including the diet at the same time. The concept is, is you’re trying to kill the bacteria and you’re starving them at the same time. You’ve got two different strategies at the same time.

Dr. Pimentel:                     Yeah, that’s true. I do use some other naturals, berberine does help in some patients.  Allicin is quite good for methane sometimes. Again, everything works sometimes and you just got to find the right thing for the right patient.

Dr. Weitz:                          Have you used a different diet when it’s hydrogen sulfide?

Dr. Pimentel:                     Yeah. The opportunity for diets is going to be interesting because a low sulfide diet will actually reduce hydrogen sulfide. But because I don’t have hydrogen sulfide to measure yet, I don’t know how well it works. Once we have this breath test up and running, I think we’re going to get some interesting results as to whether certain diets with low sulfate, for example, could be helpful in that instance. I think it might be, so we may have some tailored diets depending upon the gas profile.

Dr. Weitz:                          When do you think that new breath test will be available?

Dr. Pimentel:                     To be honest, a lot of breath tests are shut down because of COVID. Everything has gotten a bit delayed. I don’t have a timeline for you, but hopefully very shortly.

Dr. Weitz:                          Right. Promotility agents, prokinetics, should these be employed at the same time that we’re treating the SIBO or afterwards?

Dr. Pimentel:                     My routine is after, because that’s sort of how I’ve done it for years. I don’t object to the concept of giving it with the treatment, but here’s the rationale of why I don’t. Is because, back in the early days people were saying, “Mark, are you really giving a prokinetic to a diarrhea patient?” I said, “No, I treat them first. Now they don’t have diarrhea. Then I give the prokinetic.” The patient could suffer with diarrhea if they already have diarrhea and you’re giving them a prokinetic before the overgrowth has gone with the antibiotic. That’s my rationale there. For the constipators with methane, you could argue, you could give them a prokinetic at the same time. Although I sort of do it one after the other, it saves a little money too.

Dr. Weitz:                          What’s your favorite prokinetic these days?

Dr. Pimentel:                     I’ve got to say I love Prucalopride, Rezole or Motegrity it’s called in the US. It’s the most powerful prokinetic I’ve seen on the planet. Now, powerful doesn’t mean isn’t always good. But what I mean is, I start at usually a very low dose, like half a milligram at bedtime to get those cleaning waves going and people don’t have problems with that. It’s not powerful at that dose. You don’t want to start right at the two milligram dose in these patients, because if it’s too strong, they won’t like you for it. Start low and move up as you need to. That’s how I do it.

Dr. Weitz:                          Have you tested LDN or any of the natural prokinetics?

Dr. Pimentel:                     Yeah. I mean, occasionally LDN, and Dr. Rezaie uses LDN a little more than I do. There are prokinetic actions of LDN and anti-inflammatory also properties of that. I think there’s merit in that. You just got to choose what the patient’s going to respond to. I go for the big gun now, the Motegrity, because I think it’s just so superior to everything else. But if I can get away with LDN or low dose erythromycin, it’s cheaper especially for low dose erythromycin.

Dr. Weitz:                          Okay. Why is rifaximin so expensive in the US and are generic versions as high a quality?

Dr. Pimentel:                     Yeah. Well, it’s a complicated answer. Rifaximin is a weird molecule where there’s an alpha beta, gamma and delta form. There’s sort of four … If you make the chemical in your basement, you’re going to get a mixture of four different sort of shaped molecules that are the same molecule, but they bend in a different way. You have to use rifaximin-alpha. The rifaximin from brand name is alpha. The problem with some of the generics, they don’t describe how much alpha versus gamma, beta, delta, and that’s confusing. You might be paying a quarter the price, but you might be getting a quarter of the drug. I don’t know. I think the ones that are branded generic and are available here in the US might have the FDA breathing down their neck if it’s not alpha. But some of the ones from overseas or from other sources may not contain exactly … I mean it’s not toxic, but it may not contain things that you hope and be less effective as a result.

Dr. Weitz:                            What percentage of patients with SIBO do you think end up having recurrences and what’s the best strategy for trying to help when they’re coming back for the second round or the third round?

Dr. Pimentel:                     Yeah. When we did the TARGET 3 Study, which was the rifaximin three treatment trial, about a third of people who got treated and it worked with rifaximin never needed treatment again. That’s amazing. We’re studying that because there’s a term that one of our collaborators from Caltech uses and he publishes on, it’s called hysteresis. Where it’s like a teeter-totter. You’ve got the overgrowth here that’s weighing down, sort of the weeds, but if you get enough of the weeds gone, the totter flips and it’s hard to go back. You see what I’m saying? If the grass is able to grow hardy enough and you’ve got the weeds down far enough, the grass won’t let the weeds come back up. I think that’s true for a third of cases, we can get them to flip and they stay flipped. For some others, the weeds go down and then come up and down and up and we’ve got to keep treating about every three to six months. That’s sometimes frustrating for patients. That’s why we’re trying to look for even better therapies now to try and keep the teeter-totter flipped and growing grass, not weeds.

Dr. Weitz:                            Now, one way we think of it especially in a functional medicine community is, if we want that grass to grow, we give it more grass seed i.e probiotics.

Dr. Pimentel:                     Right. Well, yes. I guess what I’m getting … I don’t disagree with probiotics and I don’t dislike probiotics. I think now that we have Reimagine data and now we understand the small bowel data better and we understand who are the weeds and who are not the weeds … Because we didn’t. We were just giving probiotics. But as you pointed out, this is the first mapping of the small bowel. We were kind of shooting in the dark. Now maybe, there may be an opportunity now knowing what the grass is to give more grass. You’re right, I think that’s the evolution of this over time and maybe there will be something. I’m very optimistic, but we’re learning more every day.

Dr. Weitz:                          Right. Great. I think those are the questions I had. Did anybody have questions? I haven’t seen any typed out. I’m not sure if my screen is even showing them or not, but I don’t even know where they would be.

Dr. Pimentel:                     If you look at the chat bubble at the bottom, I think they’d come up.

Dr. Weitz:                          Okay, there we go. Let me look at some of these questions. Yeah, there’s a bunch of them. Sorry, everybody.

Dr. Pimentel:                     I’ve been doing a lot of Zoom in the last few weeks, I’ve become a Zoom super user.

Dr. Weitz:                          Somebody wanted to talk more about lovastatin for SIBO. Is it currently considered an acceptable treatment or not?

Dr. Pimentel:                     The problem with lovastatin that you would get right now, whose one of the brand names is Mevacor, is that it’s designed to be absorbed into your blood to reduce cholesterol. I want it the other way. I want it not absorbed. I don’t really care about cholesterol. I want it to be sort of slowly moving or released in a different pattern through the gut. The product that we’re testing now is sort of a dual release lovastatin that will release in the gut and won’t get absorbed. That’s what we’re testing because it will have a better effect. The other thing is, what we see in our practice, is to get methane down, we almost have to go to really high doses of lovastatin. Which start to give you body aches and side effects that are typical of that drug. It’s tricky. We do it sometimes and we do get some benefits, but it has to be done in a very particular way. It’s just not like what we’re testing in the big clinical trial right now.

Dr. Weitz:                            I see. One of the questions is, is certain bacterial strains produce methane, some produce sulfate and ammonia. Wouldn’t it be important to keep these bacterial strains in balance?

Dr. Pimentel:                     Yeah. There’s things we know about methane and we’re learning more and more about. Okay. When methane is here, I don’t want to get rid of methanogens because I think there should be a balance. But if your methane is here and normal is here, we just want to get it to here and to keep things in harmony. We’re going to have some data coming out that says, if we can get it here, the microbes start to make the balance come back and it stays here. It’s like that teeter-totter thing again I talked about. Yeah, the goal is not to … That’s why the lovastatin thing is so awesome. Because if it works, we’re basically getting into one organism, taming it a little so that everything grows normally again, instead of this bashing everything with a sledgehammer like in an antibiotic approach. Which is a little more coarse and not fine-tuned. I like where we’re going with more of a finesse touch rather than this sledgehammer approach.

Dr. Weitz:                            Some patients with SIBO get a brain fog and neural symptoms. What do you think is causing that?

Dr. Pimentel:                     There’s a couple of things. You could have what’s called D-lactic acidosis. It’s very uncommon. Satish Rao has published that a few … We’ve checked it a number of times and we find it very rarely. But that’s an extraordinary and sort of encephalopathy or sort of a confusion state that people can get from that. But more commonly, methane, for example, think of methane like halothane and fluorane, isoflurane. Those are gases that they use in the operating room to put you to sleep. Methane is a hydrocarbon like them. We see when the methane is super high in patients, people are more brain fog, more fatigue, more of that. Methane really, I think has an important role. Methane can do all sorts of things. Methane bugs are associated with obesity, they’re associated with higher blood sugar, they’re associated with higher cholesterol. Methane is a weird character. We don’t want it here. We want it nice and normal, and that’s what we’re shooting for.

Dr. Weitz:                            Here’s a question from Dr. Felice Gersh. Felice. I unmuted you, would you like to ask your question?

Dr. Gersh:                            Sure. Where am I? Hang on.

Dr. Weitz:                            I just-

Dr. Gersh:                            Can you hear me?

Dr. Weitz:                            I guess you’re not visual, huh?

Dr. Gersh:                            I can be. Do I need to be for me to …

Dr. Weitz:                            Felice is an expert on female hormones. There she is.

Dr. Gersh:                            Hello. Hi there. Hi there, everybody.

Dr. Weitz:                            Hi there. Go ahead with your question.

Dr. Gersh:             Well, yeah, I’m always bringing in what’s going on with the females and their hormones, because that’s a huge component that’s often left out. As you know, females make up a very high percentage of patients who are diagnosed with IBS. Women are very different in terms of how their estrogen affects their enteric nervous system, the gut microbiome. But the question I have is, about 90% of females these days spend a good bulk of their reproductive lives on either oral contraceptives or what I call similars, progestin agents. What is that doing to their gut microbiome? What’s it doing to their enteric nervous system? How is that impacting all of this? Because there is data published that shows that the microbiome is quite different in women who are on these products. Then of course, the universal event of menopause has many impacts on the gut. I just wanted your comments on the female side.

Dr. Pimentel:                     Thank you. I mean, that’s amazing. Ben mentioned in the beginning this hysterical woman comment, but I think he took it [crosstalk 01:01:55]-

Dr. Weitz:                            I was just kidding.

Dr. Pimentel:                     No, but you took it from one of my … You weren’t kidding because what I’ll tell you is, and this came out in one of my tweets. One of our fellows went to a conference where they were learning how to write the exam, the board exams. One of the senior gastroenterologists said, in 2017, “IBS is a disease of hysterical women.” [inaudible 01:02:18] in the 1980s and ’90s, this is the stupid way this disease was thought of. When Ben said, “Yeah, that’s how it used to be thought of.” It’s literally verbatim of what happened. It’s so wrong because you can’t blame a disease on women. Secondly, it’s not a female disease because men get it also. Those two things, it’s like saying pregnancy is a disease. It’s not a disease, it’s a natural phenomenon. Or these are the crazy things that went on. But let me get to your question. That is, the biomarker, the ibs-smart test measuring vinculin and CdtB.  If you’re a woman and you get food poisoning, you are almost twice as likely to get IBS as men. Women have a tendency to get more autoimmune disease.

                                                There’s more rheumatoid arthritis, lupus, other autoimmune diseases in women. That may be why there’s more IBS in women. It’s super important we figure that out, why is that happening. But it’s very interesting at the same time. But it’s not because of some psychological alteration that women have that they get this. That one I just want to settle that because that’s very frustrating to me that I’ve had to hear that as recently as 2017. The second part of your question is all these hormones. We know estrogens are growth factors for some bacteria. Yeah, I mean, it’s possible that you change the microbiome in the small bowel. Certainly there are studies in the colon, stool, but we’re really interested in seeing what’s going on in the small bowel with estrogen. You’re right, I don’t have the answer yet, but we’re looking at it. We have all the medications of all these patients that are undergoing scope. The only problem with our study, the Reimagine Study, is, they have to have be coming in for a scope for a reason.

                                                More often than not, it’s older folks that come in for scopes rather than younger people who might be on birth control or estrogen replacement. But yeah, and menopausal women, they’re on estrogen replacement. We’re going to address that and I think that’s a very, very, very important question. I have some answers, but not all the answers to your question.

Dr. Weitz:                            Somebody asked a question about bacillus probiotic spores. There’s a study on patients with IBS and apparently this study found that spore based probiotics perform better than rifaximin and a low FODMAP diet.

Dr. Pimentel:                     Yeah. I’m very excited about some of the probiotic studies that are coming out, and this is sort of another example. I’m not cuckooing probiotics studies and I’m not cuckooing this one, I’m excited about it. What I’m saying is that … I’ll give you an example with peppermint. The peppermint studies show peppermint is effective. There’s a double blind study of about 80 patients. But the weird thing about peppermint, when they did a 20 patient study or a smaller study, the p-value was amazing. It was like it was really working. Then they did a bigger study and the p-value is smaller, and a bigger study and the p-value is even smaller. If they did a 500 patient study, would it be statistically significant? This is the challenges that small studies that are positive get published. I’d love to see a probiotic company just step on the gas, put some money down and do a 800 patient study. If it works, wow, they will be … Well, first of all, they all make a lot of money. Which is good for them, I suppose, and that’s the whole incentive for them.  But it’ll help a lot of people if we can get some clarity around this. I love all of it. I want to see it happen and I’m happy to participate in these kinds of trials because I think there’s something there. We just need to do the big trial, the good trial and get a good answer.

Dr. Weitz:                            Somebody asked about, if you have a patient with SIBO and they also have H. pylori how would you treat it? Would you treat the H. pylori first? Would you treat the SIBO first? I’d also like to add in there, to what extent can SIBO be a cause of reflux?

Dr. Pimentel:                     Yeah. SIBO as a cause of reflux is possible. Especially we see that in methane because there’s sort of a double hit with methane. They get gas build up and the colon is slower and the bowel is slower. Everything is sort of building up and then you’re getting more pressure, which means more reflux. Reflux is a combination of two things. It’s this valve at the top holding the acid down, and how much pressure is below your chest and your abdomen that’s pushing acid up. When you have SIBO, that definitely … Now, I forgot the first part of your question.

Dr. Weitz:                          Yeah. If you had a patient who has H. pylori and SIBO.

Dr. Pimentel:                     Yeah, H. Pylori. I would treat the H. pylori first because it’s a larger cocktail of antibiotics and there’s a pretty good chance you could hit two birds with one stone. You might want, in that case, do a breath test after just to see that you kind of got them both.

Dr. Weitz:                          Okay. Interesting. Could there be other gut pathogens that stimulate the autoimmune response besides I guess cytolethal? I guess, could there be things other than bacteria that could be stimulating this autoimmune SIBO response?

Dr. Pimentel:                     Yeah. We’re exploring a lot of different things because there is a Helicobacter, it’s not pylori, that has CdtB. I think its Helicobacter hepaticus. I haven’t looked at this in a while. But Giardia has vinculin in it. If you kill Giardia and it releases all this vinculin, could you form vinculin antibodies? We don’t know. There’s stuff like that that is really ripe for exploration. But your question is right on, we need to look at these other organisms. We have already found some patients and I’m not going to get into the details … Again, it hasn’t been published yet. That do harbor bacteria that makes CdtB. That’s weird, they shouldn’t be there. We’re looking at that and what role that has and how bad their disease is. Or maybe they’re spreaders or they have a tendency to keep these bad bacteria in their gut in a different way.

Dr. Weitz:                          There was a question about anatomical differences. Certainly we know that if there’s obstructions or adhesions that could play a role in SIBO, right?

Dr. Pimentel:                     Yeah.

Dr. Weitz:                          Let’s see. What about your thoughts on a continuous low dose of Xifaxan or natural antimicrobial to prevent relapses? I’d just like to give my input real quick for a second. Is, we sometimes have patients who recover, we do several rounds. Sometimes I have found that a lower dose of one of the antimicrobials that resonates with them, like just a little bit of berberine or oregano that they just take every day, it seems to help manage the symptoms. What about your experience with that?

Dr. Pimentel:                     Yeah, for sure, I have patients who do that or I’ve prescribed that to. The only caution I have, and I’m sure you do this as well, Ben, is that, if they don’t respond like they are magically better and they at least stay better for a few weeks, or if they require this chronicity, I just want to make sure that it’s not an obstruction in the bowel or it’s not something else. Sometimes it’s a cancer or something that’s causing a blockage. I’m a little more aggressive with workup and maybe CT scans and other things just to see that I’m not missing anything. As long as I’m comfortable I’m not missing anything, then I proceed down that road. I think that’s just a point of caution.

Dr. Weitz:                            Yeah, good medicine. It’s always good to be cautious. Why the low fermentation diet? I think we know that. Probiotics, if you’re on birth control and you can’t absorb vitamin B, is vitamin B deficiency common in SIBO? Okay. I’m not sure. Are there vitamin … I guess that’s the question. Do we see vitamin deficiencies in SIBO?  We know the small intestine is how you’re absorbing nutrients from your food. If there’s too many bacteria lining the small intestine, it could potentially interfere with absorption of nutrients.

Dr. Pimentel:                     Yeah. A couple of things there. First of all, let’s start with folate because that’s an interesting one. The folate you get from you comes from bacteria. For example, in dogs, in veterinary world, they can diagnose SIBO by measuring folate. If folate is high in the blood, they think the dog has overgrowth and they treat the dog with antibiotics because he can’t do a breath test on a dog. But in humans, we see a high folate in SIBO quite often. That’s very common. It used to be thought that B12 deficiency could happen in SIBO. I still think we see that, but it’s not as common. That would be one of the B vitamins you’re talking about. What’s interesting is vitamin D, because we actually did a study, this was years ago … We never published it because it was just so profoundly negative. We didn’t see a deficiency in vitamin D and we also did bone scans. We didn’t see any osteoporosis in overgrowth patients, which I was a little surprised with. But this was about a 300 patient study, so quite large.

Dr. Weitz:                          What about if there’s fungal overgrowth at the same time as SIBO? What would you treat first?

Dr. Pimentel:                     Yeah. Generally, I mean, I’ve treated a lot of SIBO with antibiotics and I almost never have patients get worse with rifaximin. I’m not saying it doesn’t happen, I’m just saying it almost never happens. I generally give the rifaximin first. Then if I really think it’s fungal, then I will give the Fluconazole or something of that type for the patient as a backup. But yes, Dr. Rao actually cultures these patients more often but we haven’t been happy or confident with how we would culture yeast at our center yet. As I said, we have the Reimagine data and we’re looking at yeast in the coming months. We’ll be able to have a really clear picture of how many people who have yeast at a microscopic, a molecular level, not culturing. Which is more accurate.

Dr. Weitz:                          I mean, if we see fungal overgrowth on a stool sample, let’s say we have a patient, difficult to treat SIBO patient, not responding, and we see elevated fungal overgrowth on a stool sample. Is that a reason to think, Hey, this might be a case of SIFO?

Dr. Pimentel:                     Yeah, it could be. I mean, it could well be. If they respond to the antifungal, then I think you have your answer. It’s a little indirect because you’re measuring stool and not small bowel, but it may be an indirect way. Then again, as I said, if the patient responds dramatically, which I’ve had cases that respond dramatically, then I think you’ve got your answer. That’s a good thing for the patient.

Dr. Weitz:                          What about the use of elemental diet for patients who don’t do as well with the initial treatment?

Dr. Pimentel:                     Yeah. I used to do a lot more elemental diet when we didn’t have rifaximin and we didn’t have all the more modern approaches which are more effective. Because we’ve done about 3000 patients with elemental diet over the years. I use it a lot less these days, but it’s very effective for hydrogen. For methane, it’s about 50-50. People going into this, I sort of tell them that, “You will hate me the first three days. You will be fine for about seven or eight days. The last three days you’ll hate me more because you wish you were done.” Because it’s hard to do liquid only for 14 full days. But it’s about 80% effective in hydrogen. So very effective.

Dr. Weitz:                          Have you used metronidazole?

Dr. Pimentel:                     Metronidazole, I used … For methane, I use rifaximin and neomycin and sometimes I swap out with metronidazole. I see a question there with nitazoxanide, and that could also be a sub in for neomycin for methane. There are some people who are just using a linear or nitazoxanide. By itself, I don’t do that that often. Sort of because I think rifaximin adds something to that, we give both for methane.

Dr. Weitz:                          We have a question about glyphosate and I guess pesticides as a factor.

Dr. Pimentel:                     Yeah. I mean, all of that stuff is really … The big challenge we have is to understand our food system and our processes that go into producing food in the United States. I can’t tell you how many times I’ve had in my practice people who can’t eat pasta, they go to Italy, and they feel absolutely nothing. They feel perfect and they’re eating pasta every day. If there’s something we’re doing wrong, these are some of the things we’re doing wrong, polysorbate 80 or other agents that are food preservatives, sodium benzoate. I don’t know what we’re doing with all this stuff. There’s something different about the natural food you get in Italy and Europe as compared to here. It’s a quagmire, but I think there’s something wrong.

Dr. Weitz:                          Yeah. Our food system leaves a lot to be desired. We sometimes run some of these food sensitivity panels. One of the things they test is meat glue. Because apparently they glue the meat together. I mean, we really process our foods in all kinds of disgusting ways. Somebody asked about treatment for adhesions.

Dr. Pimentel:                     Yeah. I mean, there’s multiple ways to treat adhesions. I know there’s Clear Passages and other places that do manipulation of the bowel for adhesions, and I’ve sent patients there for that as well. Especially if it’s a single very pinpoint adhesion, that really is quite effective. The problem with surgery is, and for the complex adhesions, it often comes back. Will give it one try, a second try maybe, but after that, it’s futile and they just keep coming back. I hate adhesions and I think it’s one of the worst things I see in my patients.

Dr. Weitz:                          What do you do with it?

Dr. Pimentel:                     Well, again, Clear Passages is one option, so I will refer them there. But in the meantime, if they’re really bad and they’re almost obstructed, they have to go to surgery. I’ve had a couple of patients just in the last two months that struggled with that.

Dr. Weitz:                          Yeah. Okay. Thank you everybody for their questions and joining us. Thank you so much for being generous with your time Dr. Pimentel, we really learned a lot.

Dr. Pimentel:                     Well, I can tell your audience knows a lot because they’re asking some of the amazing questions and some of the tougher questions that I get. Thank you all for knowing so much and asking the right questions tonight because they were very good. Thank you.

Dr. Weitz:                            Great. Thank you. Talk to you soon.



Thyroid Hacks Part 2 with Dr. Ruben Valdes: Rational Wellness Podcast 158

Dr. Ruben Valdes talks about Improving Thyroid Health in Thyroid Hacks Part 2 with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

6:17   Hashimoto’s thyroiditis is an autoimmune condition and it is the main cause of hyothyroidism in the US today.  We do not know if Hashimoto’s patients fare any worse or better than other people if they contract COVID-19.  But patients with diabetes tend to fare less well since many of them are in an immunosuppressed state, since blood sugar spikes tend to cause glycation of white blood cells.  Gycation is when the sugar in the bloodstream sticks to proteins in the retina, to nerves, in the brain, to hemoglobin in red blood cells (HemoglobinA1C), and to white blood cells.  Diabetic patients have more trouble fighting off an infection and diabetes is associated with a worse outcome with COVID-19 infection. 

13:00  At this point we don’t really have much data as to whether patients with Hashimoto’s thyroiditis will fare better or worse with COVID-19 infection, but it’s interesting that some of the key nutrients for thyroid health–zinc, selenium, vitamin D, and iodine if they are low will increase your risk of a worse outcome with COVID-19.  Patients with autoimmune disease will likely fare worse with COVID-19 and viruses like the SARS-COV-2 virus tend to trigger the formation of autoimmune diseases. Viruses can lead to autoimmunity through 3 mechanisms: 1. Molecular mimicry, 2. Bystander activation, and 3. Epitope activation.  1. What molecular mimicry means is that viruses can hide from the immune system by expressing a protein that is very similar to self. It could be similar to thyroid, the brain, the lungs, depending upon the area that the virus is going to infect. This allows the virus to hide from the immune system. Then, when the immune system goes after the virus, it can inadvertently attack yourself.  2. With bystander activation the virus begins to break down the cells it’s infecting, and those cells die and break open, there’s going to be self-antigens that are released as that cell dies, and that’s going to now create a self-attack. The immune system’s going to identify these intracellular antibodies and begin to go after those tissues because they contain that antigen.  3. With epitope activation, which is very similar just to a much larger scale to bystander activation when there’s very diffused tissue breakdown, and when we see things like what happens with coronavirus, this cytokine storm, this huge wave of inflammation to a specific tissue.  So it would not be surprising if one of the sequelae of this COVID-19 is an increase in autoimmune diseases.

19:17  There are various triggers for Hashimoto’s thyroiditis, including viruses. Hormonal surges, such as of insulin or cortisol, can be activating to the immune system.  Cortisol is secreted by the adrenal glands when we are stressed, when we’re in the fight-or-flight, and we know that cortisol initially has an immuno activating effect.  Longer term, cortisol ends up becoming immunosuppressive, which is why cortisone is sometimes used to treat autoimmune diseases.  Stress and cortisol can  shut down some of the areas of our innate immunity and start overactivating our acquired or antibody-based immunity, thus serving as a trigger for the development of autoimmune disease and for the relapse of autoimmune disease.

25:32  If you have an autoimmune patient, such as one with Hashimoto’s, the first thing you should do is metabolic clearing. This involves using an elimination food plan where the foods that are inflammatory for most people, like gluten, dairy, soy, grains, sugar, are removed, combined with a liver detoxification program, which is essentially the 4R program taught to many of us years ago by the father of Functional Medicine, Dr. Jeffrey Bland.  We increase hydration and support the liver detoxification process with the right nutritional supplements. Then if we are dealing with excess cortisol, we will use adaptogenic herbs to support adrenal balance.  Having a diet high in carbohydrate and sugar and eating to excess can lead to recurrent insulin surges and this can also be a trigger for autoimmune disease.  Surges in estrogen, as occurs during the menstrual cycle, in women with PCOS, and each day when women take the birth control pill, increases the risk for Hashimoto’s. Dr. Valdes suggests that a copper IUD might be a better birth control device than the pill.  Even women during perimenopause and the transition to menopause will experience periods of estrogen surges.  This fact that estrogen surges can serve as a trigger for autoimmune disease is one reason why at least 75% of those with autoimmune diseases are women.  And then we also have toxic forms of estrogen (xenoestrogens) from the environment like pesticides, bisphenol A and phthalates, etc. This is also why we are seeing girls in the US beginning to develop adult female characteristics, breast tissue, pubic hair at or around the age of eight or nine, which is unheard of, as compared to our European counterparts, where most of their girls begin to develop their adult female characteristics around 12, 13, 14, even 15, which is normal.  The estrogenic load on both men and women in our society is very high.

34:49  One of the other triggers for autoimmune diseases like Hashimoto’s is heavy metal toxicity, like mercury.  Other common metal toxicities are cadmium, aluminum, and lead. For mercury, we have two forms, methyl mercury and inorganic mercury.  Inorganic mercury we get from primarily amalgams in our mouth, whereas organic, methyl mercury, which we get primarily from fish.  Cadmium comes mainly from cigarette and other tobacco smoke.  Aluminum is everywhere in our society. And even copper, which is an essential nutrient, if levels are too high is dangerous, comes often from copper piping leaching into the water. This is similar to the situation with lead.  Dr. Valdes likes to use heavy metal testing from Quicksilver Scientific, including the Tri-Mercury test, which measures hair, urine, and blood for both organic and inorganic mercury.  He likes the protocols developed by Dr. Christopher Shade, who is the founder of Quicksilver.  To detoxify heavy metals, Dr. Valdes recommends using EDTA for the metals other than mercury and using tons of glutathione and NAC because glutathione has this wrapping effect when the metal is pulled from the tissue, it’ll wrap it, and it’ll make it less damaging for cellular tissue as you detoxify it.   You also want vitamin C, which is going to be immunomodulating. As you clear it, you want to have a lot of zinc. You also probably want to do remineralization because as you’re pulling metals, you’re also pulling minerals, which you want to replenish. What else is pretty important? You want to increase liver detoxification. So, you want to increase your intake of cofactors and milk thistle and all of the things that help the liver push stuff out. So, yeah, you really need a good comprehensive toolkit.  For binders, Dr. Vlades tends to recommend activated charcoal and chitosan and he likes IMD from Quicksilver, which is a proprietary, highly purified silica with covalently attached thiolic (sulfur) metal-binding groups, allowing it to bind metals in the intestines. Dr. Valdes also like to use a liposomal form of EDTA, which helps to chelate our metals and it is also a really good emulsifier and helps to break down biofilms. 

43:53  The next possible trigger for Hashimoto’s could be leaky gut and/or gut dysbiosis. If patients have leaky gut or increased intestinal permeability, undigested food particles and lipopolysaccharides will get absorbed into the blood stream. We need to rebalance the gut by clearing out pathogenic bacteria and rebuilding the microbiome. Antimicrobials and probiotics can be helpful. Fasting for 3, 5, 7, or 11 days and taking bone broth can be a very helpful tool. 

50:13  Biotoxins, like mold toxins and Lyme Disease, can also be a triggers for Hashimoto’s.  22% of the population are carriers of a susceptibility in a gene called HLA-DR/DQ, and for people that are susceptible, what that means is that their immune system cannot identify or create antibodies or transport and present the biotoxin itself. This tends to drive autoimmune disease. The more people are staying inside their homes, often without good air circulation, they are more likely to get exposed to mold and mycotoxins.  When it comes to mycotoxins, the first thing is mold removal from the home, which includes vacuuming, cleaning, and using an Air Oasis air purifier can all help. Formula 409 kills mold and also viruses.  The best binders for mycotoxins are the prescription ones: cholestyramine and Welchol. Dr. Valdes recommends the Richie Shoemaker protocol that focuses on normalizing various immune markers, including the C4A, the TGFB-1, the MMP-9. There’s different steps for each one of those, and ultimately, there’s an intranasal spray called VIP, vasoactive intestinal peptide. That will repair the tissues of the sinuses and of the gut to finalize the whole process.


Dr. Ruben Valdes is a Doctor of Chiropractic and an expert in Functional Medicine. He is the Chief Content and Marketing Officer of Novis Health Systems, a Functional Medicine franchise. He wrote 3 books, including The Chiropractic Entrepeneur, From Diabetic to Non-Diabetic, and The Thyroid Hack. Dr. Valdes can be contacted through Novis-Health.com.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.


Podcast Transcript

Dr. Weitz:            Hey. This is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast. Hello Rational Wellness Podcasters. Thank you so much for joining me again today. Please give us some readings and review on Apple Podcasts. If you’d like to see a video version, you can go to my YouTube page, Weitz Chiro, and if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.

                                Today, our topic is a functional medicine approach to thyroid health with Dr. Ruben Valdes, and this is part two of our interview. In part one in the interview, Dr. Valdes and I spoke about thyroid health, what makes a thyroid misfunction, how to a test for it.  A lot of focus was on diagnostics, but we really didn’t have much time to get into the particular triggers and how to treat them, and with the overwhelming majority of patients in the U.S. having autoimmune hypothyroid, nor did we get to talk about secondary hypothyroidism or how to treat it.

Dr. Valdes:          That’s a mouthful, yep.

Dr. Weitz:            Yes, yes, yes, and I’d also like to remark that at the time of this recording, we’re in the midst of the coronavirus, COVID-19 pandemic. So, that’s providing a background into what’s going on, so I’d also like to ask Dr. Valdes a few questions about that particular topic.  Dr. Ruben Valdes is a doctor of chiropractic and an expert in functional medicine.  He’s the Chief Content and Marketing Officer of Novus Health Systems, a Functional Medicine franchise. He’s written three books including The Chiropractic Entrepreneur, From Diabetic to Non-diabetic, and The Thyroid Hack. Dr. Valdes, thank you so much for joining me again today.

Dr. Valdes:          Thank you for having me, Dr. Weitz. It’s always a pleasure.

Dr. Weitz:            So, how is this coronavirus pandemic affecting you and your practice and how have you been able to pivot?

Dr. Valdes:          Well, I mean, just like everybody, we’re being profoundly affected. Almost overnight, our entire practice has been flipped upside down. Initially, we got a communication from the board saying, “You guys are an essential service. You’re working with high-risk patients, diabetics.” Then the state said, “All non-essential medical services meaning immediate response to COVID-19 needs to shut down.” Then we got another communication from the Department of Homeland Security saying, “Yes, you guys need to stay open.” So, what we’ve done, we were fortunate enough to be partially set up for virtual consultations, virtual appointments, and we just bulked up that side of our practice. So, all of our current patients are being taken care of virtually just like we are doing right now.  This type of Zoom call, we’re providing support. We’re being able to drop-ship their test kits, their supplementation, and that’s really been quite the blessing. I think I’ve been busier the last four or five days than I have been in the last three or four months. So, I feel really fortunate right now that we are in a position where we can help a lot of these patients.

Dr. Weitz:            So, currently, your practice is pretty much focused on the functional nutrition component, correct?

Dr. Valdes:          That’s correct, yes. Yeah, we’re 100% functional medicine right now.

Dr. Weitz:            So, you find Zoom. Is that a good HIPAA-compliant platform? Is that working for you?

Dr. Valdes:          It’s not perfect, but we’re very fortunate that HIPAA laws have become very flexible right now for this very reason, and there was a declaration on this really at the beginning of COVID-19 arriving stateside. There was really a lot of stimulus for doctors to go virtual to be able to take care of their patients this way. So, right now, Zoom’s not a perfect tool. There’s some better, like Spruce is a lot more HIPAA compliant, but the laws around this stuff are pretty flexible right now in order for us doctors to be able to deliver care to our patients.

Dr. Weitz:            Okay. I know a number of other people in the functional medicine space who’ve tried to find ways to make sure that they were compliant with all the rules related to, “Is it okay to treat somebody in another state where you’re not licensed and how does all that work?”

Dr. Valdes:          Yeah, I mean, there’s definitely a lot of laws that go deep into that. Our franchise has worked with probably the best legal firm in the country. They’re out in California, and normally, these things are very, very strict. If it’s somebody from another state, you have to have a physical examination to establish a doctor-patient relationship, and sometimes you have to have a local there, perform the exam, send it to you. Right now, I can’t really speak into that very much because I don’t have anybody at the time that would be outside of my state. So, I do have a few patients from Florida, from the Charlotte practice, and we’ve already had the establishment of a doctor-patient relationship in the past. So, right now, now we believe that we’re pretty much in compliance within our state laws.

Dr. Weitz:            Cool. So, with respect to Hashimoto’s thyroiditis, Hashimoto’s being a cause of overwhelming majority of patients with hypothyroid in the United States is an autoimmune condition, and how does this impact the potential if they contract coronavirus? Are they more or less likely to have a worse response or is it not related at all? We know that patients who have a compromised immune system are more likely to have a worse response. What about somebody with an autoimmune condition like Hashimoto’s?

Dr. Valdes:          Yeah, that’s a great question, and I appreciate you throwing me into the hot water of controversy right out the gate.

Dr. Weitz:            That’s what we’re here for-

Dr. Valdes:          Good. I love it.

Dr. Weitz:            … to solve some of these controversies or at least bring a little bit of light where there is otherwise darkness.

Dr. Valdes:          Yeah, so here’s my position in what I’ve read. I really can’t say… On the side of susceptibility to the viral infection, I don’t feel comfortable enough to have a well-formed opinion yet because number one, this is a completely new virus. It means that none of us have preformed antibodies. So, at the end of the day, that really leaves all of us in a place where we can contract the virus.

Dr. Weitz:            Yeah, I would assume that we’re all probably, if we get the right exposure to the virus, are probably equally likely to become infected. Let’s just assume that. The question is, “Who’s going to have relatively mild symptoms and who’s going to need hospitalization?” Then you hear some patients just have a horrible response and within a day or two, it just overwhelms your body and takes over.

Dr. Valdes:          Yeah, so first, I’m going to talk to you about what I’ve seen, and then I’ll talk about the research around this topic. So, I haven’t seen any of my Hashimoto’s patients contract the coronavirus yet. I have seen some of my diabetic patients already having contracted the coronavirus and for them, it’s very, very ugly. Like every diabetic, we know and we consider them to be immunosuppressed because with spikes in blood sugar, there’s glycation of white blood. So, most of them walk around in a deep or relatively deep immunosuppressed state.

Dr. Weitz:            Okay, okay. I want to stop you there for a second because I don’t think that’s a point that is generally talked about or even considered is we generally think a type one diabetes as an autoimmune condition. Type two diabetes, we generally think of it as a condition related to diet and lifestyle, and we don’t think of it as having an autoimmune component, but can you explain that again? How is type two diabetes impact the immune system?

Dr. Valdes:          Yeah, so it has a huge impact. High blood sugar, when there’s excess sugar in blood, there’s a process called advanced glycation. So, the sugar molecules begin to stick to proteins, to cells, and it really decreases their function. So, whenever a diabetic goes into the emergency room, immediately right off the bat, the attending emergency room physician is going to check them off as immunosuppressed.  They’re going to be treated as an immunosuppressed patient because this advanced glycation affects the function of white blood cells by sugar sticking to the proteins in the white blood cell.  So, for many of them, when their blood sugar is high, we’re talking above 120 and maybe even lower than that. They have a lot of difficulty fighting off infection. Now, the problem-

Dr. Weitz:            So, let me just clarify a little bit for patients or for anybody who’s listening, doctors, et cetera, who aren’t familiar with advanced glycation end products. These are AGEs, and these are components of the sugar molecules that combine with proteins in the body, and when you measure the hemoglobin A1C, you’re measuring one of these advanced glycation end products, which is where the sugar molecules combine with the hemoglobin.

Dr. Valdes:          Yeah, 100%, and think about it like-

Dr. Weitz:            So, that’s a red blood cell, but now you’re seeing the same process also occurs in white blood cells.

Dr. Valdes:          Yeah, it occurs everywhere. When there’s high blood sugar, think about the blood becoming syrupy, full of sugar. So, that’ll stick to the proteins in the retina. In the nerve endings of the retina, there’s proteins there. In the brain, in the peripheral nerves, it’ll stick in joint tissue and in renal tissue. That’s why diabetes is so diffused in its complications because these proteins are being damaged everywhere. So, the immune system is no exception to that process of advanced glycation. So, I’ve seen it already in them. The infection lasts a long time for them. It doesn’t go away. It progresses very rapidly.  In addition to that, we know that people that have diabetes or high blood sugar, when they contract an infection, their blood sugar shoots up and it goes higher because now, there’s inflammation. There’s more insulin resistance. If they’re in a hospital setting, and they were just a controlled metformin-based diabetic, a lot of times in the hospital, the standard is to start injecting them with insulin to bring their blood sugar down. Once they go on insulin, then they’re put on insulin forever. So, it just becomes a very rapidly progressing scenario for them.   So, I can speak on that side with a lot of confidence on Hashimoto’s.  I still don’t have first-hand experience of my patients contracting the illness, but I do have very, very strong suspicions as to what it’s going to look and how they’re going to evolve if they contract the infection.

Dr. Weitz:            It’s interesting just thinking about it. It just so happens that some of the key nutrients necessary for thyroid health, zinc and selenium and vitamin D, which are talked about a lot are also if any of these are low or less than optimal, increase your susceptibility to viral infection.

Dr. Valdes:          That’s right, and to complications from viral infections, and I know that zero patients that have ever walked in through my door coming from a conventional model of care where all that’s done for them is taking Synthroid or levothyroxine, right? None of them come in with high levels of selenium or high levels of zinc. So, the majority of these patients are straight out of the gate just because of nutritional status in a situation where they are at risk for complications or progression of the virus if they were to become infected.  So, in addition to that, if we go into the topic of autoimmunity, then that really opens up the conversation because I think that it’s not about the prevention of the infection, but what’s going to happen to so many of these patients that already having a pre-existing autoimmunity whether Hashimoto’s or lupus, sclerodermis, psoriasis, MS, whichever one of these conditions. We know that viral infections are huge, huge triggers of autoimmunity, hands down, rarely any exception to that rule.

Dr. Weitz:            Interesting because I think that there’s perhaps somewhat misconception that autoimmunity is simply an immune system that’s overactive, which would mean that would be a good thing if you had a viral infection, right?

Dr. Valdes:          You would wish but not really. So, there’s really three main mechanisms to autoimmunity in connection with viruses. One of them is called molecular mimicry. What that means is viruses are very, very sneaky, very sophisticated types of infections, and the way that they hide from the immune system is by expressing a protein, an antigen that is very, very similar to self. It could be similar to the thyroid. It can be similar to the brain. It can be similar to the lungs depending on the area that the virus is going to infect, or it has a preference for infecting.  So, many times when the immune system creates a response to that virus, if the response is very aggressive, like you were saying, very overactive. Then it’s going to go after the tissue. Also, it’s going to go after self because they look very, very similar to the immune system. There’s also something called bystander activation where the immune system whereas the virus begins to break down the cells that it’s infecting, and those cells die and break open, there’s going to be self-antigens that are released as that cell dies, and that’s going to now create a self-attack. The immune systems going to identify these intracellular antibodies and begin to go after those tissues because they contain that antigen. Then there’s another one called epitope activation, which is very similar just to a much larger scale to bystander activation when there’s very diffused tissue breakdown, and when we see things like what happens with coronavirus, this cytokine storm, this huge wave of inflammation to a specific tissue.

                                So, we know that viruses especially when they take hold, they are very immuno activating, and there can be a lot of overlap between virus antigens and self-antigens, and that’s why I’m really, really worried for autoimmune patients, Hashimoto’s patients because we know that if they were to contract the virus, viruses, especially very pathogenic viruses are a huge source of immune activation, and that can mean on the least a relapse of the condition, a reactivation, but on the worst, development of now new autoimmune diseases moving forward, and I think some of the people that are out there talking about this are maybe trying to bring down the tone and create less worry, less concern, less stress but in reality when you really look at the mechanisms of autoimmunity, this becomes very alarming for the population moving forward, not just for what’s going on right now.

Dr. Weitz:            Now, the things you’re talking about, how speculative are they? I could just see the editors from New England Journal of Medicine saying, “Well, there’s really no human scientific randomized trials to show that any of this is truthful.”

Dr. Valdes:          Yeah, well, they’re really not very speculative, and they’re not too far-fetched. They are speculative for this virus in particular because it’s a novel virus. We don’t have enough data. We don’t have enough knowledge, but when you look, and I’ve looked at a lot of reviews of the literature linking viral disease and the development for autoimmunity, and we have class one data. We have the best available studies that have shown over and over that viral infections can be very strong triggers for autoimmunity. So, we know that enteric viruses and children are deeply linked to the development of type one diabetes. We know that viruses like Epstein-Barr and cytomegalovirus are deeply linked to auto immunities of the thyroid and of the brain. Those are well, well documented facts.  It wouldn’t be a surprise to me that with the type of infectivity and pathogenicity that COVID-19 has to the respiratory tract. I would be surprised that we don’t see long-term autoimmune consequences from this infection.

Dr. Weitz:            Okay, cool. Good way to start. Let’s pivot to where we left off in the last discussion, and that’s talking about the triggers of Hashimoto’s and what to do about these.

Dr. Valdes:          Yeah, so Hashimoto’s really like any other autoimmune disease has a pretty extensive number of triggers. We can talk about hormonal surges. If hormones like insulin or cortisol or estrogen are surging, that means spiking day after day. These high levels of hormonal surge can be immuno activating. They can signal the immune system and say, “Hey, there’s too much hormone. What’s going on? Is there a tumor in a tissue? Do we need to go clear it?” So, hormonal surges are big activators.

Dr. Weitz:            So, let’s go into that a little bit. Let’s talk about some of those hormonal surges. So, why don’t we start with cortisol, say?

Dr. Valdes:          Yeah, so one of the biggest known autoimmune activators. Cortisol is secreted by the adrenal glands when we are stressed, when we’re in the fight-or-flight, and we know that cortisol has initially an immuno activating effect, but long-term, unimpressive effect. When cortisol is detoxified or in the liver, it becomes cortisone, and which has a very immunosuppressive effect. When this stuff starts compounding, it can begin to shut down some of the areas of our innate immunity and start overactivating or driving domains of acquired or antibody-based immunity. So, we know that stress is one of the biggest triggers for the development of autoimmune disease and for the relapse of autoimmune disease.

Dr. Weitz:            Now, what about cortisol having lower levels because a lot of us who do like the salivary cortisol testing find that a lot of patients especially with long-term stress just have lower cortisol levels.

Dr. Valdes:          Yeah, and for me personally, clinically, that’s just an indicator that at some point, they had very, very high cortisol levels. Now, I’m not very clear on the mechanisms between the immune system and having low cortisol as clear as I am when cortisol is surging, but yeah, to me, that’s usually an indicator that at some point, this person had very high levels of cortisol and now, they’re shutting down their production or slowing down their production.

Dr. Weitz:            Now, I can’t help but make another comment about coronavirus, because unfortunately, it seems to be on everybody’s mind including my mind, like 23 out of 24 hours a day as much as I try not to, but some of the data seems to indicate that nonsteroidal anti-inflammatory is actually worse than your response, and corticosteroids seem to be potentially somewhat beneficial, and there are some articles showing that glycyrrhizic acid, which is contained in licorice, which helps your adrenal glands to produce more cortisol may actually be beneficial.

Dr. Valdes:          Yeah, very interesting and super confusing too because we know that a chronic stress response reduces your… Sorry about that. Reduces your ability to fight off infection. That’s common knowledge, and right now, the thing that I worry about is people stuck in their house, stressed out of their minds, eating all this crap. If they were to contract the infection, in my mind, it really creates a negative scenario. So, it is confusing to see that there would be benefit from-

Dr. Weitz:            Well, it’s probably about the timing. In other words, if you were to have a surge in cortisol before or at the beginning, that might make it… I’m only speculating here based on some of the stuff I’ve read. But perhaps once you’ve got the virus that’s starting to create this inflammatory situation in the lungs, that can lead to that big cytokine storm that’s creating all this damage to the lung, scarring, et cetera, that sometimes can be fatal. Maybe at that point, using cortisone can help to lower that inflammatory response. So, it’s not always about the exact substance but the timing as well.

Dr. Valdes:          Yeah, that makes a lot of sense. Well put. Well put. Yeah, I mean, that makes sense, absolutely, and in the hospital, right now, I know that what they’re doing for most people, I know a lot of the doctors are not very comfortable yet with the hydroxychloroquine and the Z-pack. Apparently, it’s a pretty aggressive combo, especially for heart. So, I know that for the most part what they’re doing is albuterol to the lung, which is just an anti-inflammatory cortical steroid. So, it makes sense. If at that point, probably the main thing is driving down inflammation in the respiratory tract.

Dr. Weitz:            Yeah, so anyway, so cortisol surges that will… How does that affect Hashimoto’s now?

Dr. Valdes:          Yeah, so we know that-

Dr. Weitz:            Sorry to get you off track, doc.

Dr. Valdes:          No, all good. So, we know that when cortisol is surging, it’s activating, it’s spiking, it can be immunoactivating. It seems that whenever there’s a preponderance of hormone over time or repeatedly over time, it can signal the immune system to activate. We suspect it’s probably part of just innate immunity, the way that the immune system would clear tumors. Probably when there’s continuous urgings of specific hormones, there seems to be signaling to the immune system that there’s a problem with this tissue.

Dr. Weitz:            So, if you have a patient with high cortisol levels that seems to be triggering their Hashimoto’s, how would you treat that?

Dr. Valdes:          Great question. So, it’ll depend a little bit. Really, we like to go three pronged with it. Classically, we’ll use adaptogens. Whenever we have someone that’s autoimmune after we’ve done metabolic clearing, which we like to do with almost every autoimmune patient-

Dr. Weitz:            What is metabolic clearing?

Dr. Valdes:          So, metabolic clearing is a combination of an elimination food plan where we remove most of the foods that we know are problematic for the immune system in most people.

Dr. Weitz:            Which would be what?

Dr. Valdes:          So, it would be things like gluten, dairy, soy, grains, sugar obviously, some of the key things we know to be very inflammatory and immunoactive.

Dr. Weitz:            Okay.

Dr. Valdes:          We combine that with liver detoxification. We improve nutritional status. We clean out the gut a little bit, and that’s what we mean by metabolic clearing. We increase hydration significantly to be able to eliminate metabolites, xenobiotics, all of the things that-

Dr. Weitz:            So, essentially, you’re talking about one of the pillars of functional medicine approach as originally taught to us by the father of functional medicine, Dr. Jeffrey Bland, using a 4R or the 5R program.

Dr. Valdes:          That’s correct, yeah. So, we really liken and find a lot of value in initiating every autoimmune or almost every… There’s some patients that won’t tolerate it, and we can talk about that, but almost every patient that we take on, we to start them on there because it’s such a broad… It covers so many pieces, and one of the things that it does, it helps people eliminate excess hormones during that period of time. So, if one of the things is they’re having surges of insulin or of cortisol or estradiol, their overall hormonal levels are going to decrease by detoxification. So, that’s one thing. Another thing is we want to induce things that can have a direct effect.

Dr. Weitz:            Well, I’ll tell you what. Let me stop you there because we went into the cortisol. Why don’t we talk about the surges of insulin and what we can do about that?

Dr. Valdes:          Yeah, so those are probably the easiest to talk about because most of the time, those are 100%… I don’t know why this keeps going off.

Dr. Weitz:            What happened?

Dr. Valdes:          Can you hear those notifications or am I the only one hearing them?

Dr. Weitz:            Yeah, I don’t think I’m hearing them, doc.

Dr. Valdes:          Okay, sorry about that. So, insulin is 100% connected to dietary intake for the most part. So, people that have a diet that’s very high in carbohydrates, people that have a diet that’s high in starches and sugar, people that just eat in excess and eat way more than they should be eating are going to be experiencing recurrent insulin surges. Now, if on top of that the patient has mechanisms of insulin resistance, if they’re secreting excess glucagon, if they’re having high cortisol, which will also drive high blood sugar, then those things can worsen the insulin spikes. So, initially, we want to also in the elimination diet make sure that we’re keeping their carbohydrate levels and their sugar intake as low as possible, and then in other stages of the treatment, we’re going to go into some of the mechanisms for the insulin surges themselves. Is that clear?

Dr. Weitz:            Yeah, sounds good, and then estrogen surges. Why would somebody have estrogen surges?

Dr. Valdes:          Yeah, so two specific times of life. One of them is women that are on the pill for-

Dr. Weitz:            Birth control.

Dr. Valdes:          … birth control. Whenever they consume their birth control pill, they’re going to have an estrogen surge, and they’re going to detoxify it, eliminate… Their estrogen level’s going to drop. The next day, what do they do? They take it again. So, it resurges, and it’s interesting because we tend to see… When you see younger adult females in their 20s or 30s, almost always there seems to be a connection too with birth control. So, that’s a common place where you’ll see estrogen surges. Also in-

Dr. Weitz:            Hold on a second. So, are you saying there’s a connection between birth control and Hashimoto’s?

Dr. Valdes:          Yeah, yeah, and there’s a lot of research on that. Just a search in PubMed will show you that it’s been linked historically with birth control therapy.

Dr. Weitz:            So, if you have a patient with Hashimoto’s, what is your advice if they’re on birth control and you detect it. They’re having an estrogen surge.

Dr. Valdes:          Well, that’s going to depend. I mean, if they are wanting to-

Dr. Weitz:            In consultation with their gynecologist.

Dr. Valdes:          In consultation with their gynecologist. Most of the time, like an IUD might be a better. An IUD, copper primarily now-

Dr. Weitz:            Because there’s been a lot of problems with some of these IUDs.

Dr. Valdes:          Correct. There are, and there’s really problems with most forms of birth control then. Some women might be having really big issues with their menstrual cycle. They might have PCOS. They might have all these issues, and they have a lot of bleeding and sometimes, there’s a consideration for an IUD with estradiol to offset that. So, in conjunction with their OBGYN provider, I would probably recommend a copper IUD as a preferred method, but I know that’s… I mean, you’re putting me super in the hot water today. It’s an extremely controversial topic, but that would probably be a preferred route. Now, do understand that a lot of people go on birth control, and not everybody develops autoimmunity. So, there’s other factors.

Dr. Weitz:            Of course.

Dr. Valdes:          There has to be other potential immune triggers. Sometimes, there’s genetics that are predisposing. So, it’s not a general rule of thumb, but if we were to speak generally, we know that this causes estrogen surges, and estrogen surges are known to be potentiators of autoimmunity and then to add to that, perimenopause and menopausal females also experience estrogen surges during that period. So, there also can be, and there is a surge in the demographic information of people that develop autoimmunities later in life. There seems to be a prevalence, and really, one of the reasons why I think that this is also so much more common in females than it is in males.

Dr. Weitz:            Right, and this is often referred to as estrogen dominance.

Dr. Valdes:          Correct.

Dr. Weitz:            Then of course we have the toxic forms of estrogen from the environment like pesticides and bisphenol A and phthalates and on and on and on.

Dr. Valdes:          Oh, yeah. I mean, we can spend an entire day there, and it’s really crazy. From even the stuff that’s put in food, like estrogen is directly and purposely placed on food. We are seeing here in the U.S., girls that are beginning to develop adult female characteristics, breast tissue, pubic hair at or around the age of eight or nine, which is unheard of, and we look at our European counterparts. Most of their girls begin to develop their adult female characteristics around 12, 13, 14, even 15, which is actually normal. So, the estrogenic load on our population both female and male is incredible. It’s incredible.   So, yeah, from toxic forms from nutritional forms, and the worst part about it is our body could potentially get rid of some of this stuff, but when you throw in all the other chemicals over 700,000 toxic chemicals every day to each and every one of us, the toxic burden is so high that if we’re not doing things very purposely, very actively for our detoxification pathways, most of us are vulnerable to this estrogenic bombardment.

Dr. Weitz:            Okay, good. So, let’s move on to some of other triggers for Hashimoto’s.

Dr. Valdes:          Yeah, so I mean, there’s so many I can mention off, and then we can go into whichever ones, but there’s toxins like mercury, one of the biggest ones, permeability issues in the gut, food sensitivities, viral infections, which we spoke about.

Dr. Weitz:            Okay, so why don’t we start with toxins?

Dr. Valdes:          Okay.

Dr. Weitz:            So, we’ve got heavy metals, mercury. Are there other heavy metals or is mercury the main one that you-

Dr. Valdes:          No. There’s definitely more. Cadmium, aluminum, lead really tend to be the biggest ones. I’m sure there’s more, but those are the ones that I tend to see more frequently. Mercury, two forms, methyl mercury and inorganic mercury. One, we get from primarily amalgams in our mouth unless you were a kid playing with the stuff that was inside of your thermometer, which I unfortunately did, and-

Dr. Weitz:            Same here unfortunately.

Dr. Valdes:          And then methyl mercury, which we are getting primarily from fish. Then cadmium, the main source in humans is cigarette smoke and tobacco smoke, and aluminum… I mean, it’s everywhere from cans-

Dr. Weitz:            Ubiquitous.

Dr. Valdes:          It’s ubiquitous. There’s also a form that’s rarely talked about, which is copper, and copper is an essential nutrient but at the degree and amount that we’re being exposed to it, it’s actually very toxic to both us and our environment.

Dr. Weitz:            Especially since we’ve switched over to copper piping for a lot of our plumbing.

Dr. Valdes:          Correct, yeah.

Dr. Weitz:            We went from lead, which obviously is problematic to copper.

Dr. Valdes:          Which is slightly less problematic but still problematic, and when we look at the world of cognitive disorders, it’s a big, big player in that, and then aluminum, cadmium, lead, mercury. Yeah, I think those are the main ones that we tend to really pay a lot of attention to.

Dr. Weitz:            So, the preferred testing, you use serum. Is it provoked urine? Is it hair?

Dr. Valdes:          We like to use just for practicality and for accuracy as far as what we’ve seen, we like to use Quicksilver Tri-Mercury with blood metal. So, we run blood metals, but then mercury because of its… It really behaves in a way that it’s very unique in its differences between methyl and organic or inorganic mercury. We like to have the Tri test, which will check hair, urine and blood for mercury.

Dr. Weitz:            Now, is the Quicksilver metals test, is it simply a serum test? Is there some reason why doing the Quicksilver metals test is better than just running serum metals through LabCorp or doing it NutrEval, which includes serum metals?

Dr. Valdes:          Well, I mean, one of the things that we like is that it’s very comprehensive, so it includes a lot of different metals together with essential minerals, which are also metals. Things like zinc and copper and all those will also be. So, we do it primarily because of convenience. I don’t know. In that side, in the blood metal side, I can speak in to the mercury side, and there’s definitely huge benefits to run-

Dr. Weitz:            No, I can see the benefit of doing that Tri metals test.

Dr. Valdes:          Right, yeah, but as far as the blood metals, nothing really that would stand for me. As a preference, it’s just the convenience of having all of those metals tested together.

Dr. Weitz:            Sure, good, and then when you find the metals, what do you do? Let’s say you have an elevation of whatever, mercury or cadmium or specific protocols for each one. Is there a general metals detox program you do?

Dr. Valdes:          Yeah, I mean, again, we do like the protocols that have been created by Dr. Shade who is the founder of Quicksilver, and there’s differences. A lot of the metals that are non-mercury metals are going to require on top of everything else, they require EDTA to be able to emulsify them and bring them out. Now, if you do EDTA with mercury, you actually push it further into the tissue. So, you make the patient worse. There’s definitely a lot of different specific things. You always want to have a binder that will catch the metal in the gut. You always want to have tons of glutathione and NAC because glutathione has this wrapping effect when the metal is pulled from the tissue, it’ll wrap it, and it’ll make it less damaging for cellular tissue as you detoxify it.   You also want vitamin C, which is going to be immunomodulating. As you clear it, you want to have a lot of zinc. You also probably want to do remineralization because as you’re pulling metals, you’re also pulling minerals, which you want to replenish. What else is pretty important? You want to increase liver detoxification. So, you want to increase your intake of cofactors and milk thistle and all of the things that help the liver push stuff out. So, yeah, you really need a good comprehensive toolkit.

Dr. Weitz:            So, for binders, do you do a combination binder? There’s a number of things that are on the market or do you use specific binders for specific metals?

Dr. Valdes:          Yeah, I mean, most of the time, I activated charcoal, and I like chitosan. Those are my two really big ones. There are some combination ones out there. If they’re in stock, hey, it’s convenient. I’ll use them. Also, IMD, which is a very specific gut binder can also be beneficial especially when dealing with mercury.

Dr. Weitz:            What is IMD?

Dr. Valdes:          I’m not sure what the letter stands for, but it’s just a binder. That’s why it’s called IMD, and it’s just a little bit more specific for toxins that bind to the lining of the gut.

Dr. Weitz:            And then sodium EDTA, what form is that in? Are you talking about a nutritional supplement or intravenous or-

Dr. Valdes:          Yeah, well, we use nutritional supplements. We use it in an oral liposomal liquid, but intravenous can be very, very beneficial, and actually, I found a tremendous amount of benefits for EDTA, and we can talk about breaking down biofilms in infections, breaking down and emulsifying viruses in the respiratory tract, which is an interesting application to talk about right now, but EDTA is a really good emulsifier. So, when things are sticking, it works like a soap to release things. A liposomal form is very absorbable, so we tend to like it.

Dr. Weitz:            Okay, interesting. Yeah, I think what you’re referring to is that some infections, bacteria, viruses that get into your system may form a biofilm, a protective coating that protects them, and it’s more difficult for your body to get rid of it, but viruses… I know bacteria do this, but viruses do this as well?

Dr. Valdes:          No. Viruses don’t form biofilms, but viruses can be… This comes from some of the studies around Monolaurin and laurisidin. EDTA has no research that I’ve seen on application, but things that have an emulsifying effect have the potential of removing viral load or lessening viral load. So, that’s why I think it’s very interesting. It could be an interesting application to play around, and don’t take this as a medical recommendation. This is just a curious mind because seeing we do use it clinically for a lot of sinus infections, we’ll put it up there with it as a nasal spray with things like MARCoNS or very aggressive bacterial infections, and it works at emulsifying the biofilm. So, my suspicion, my clinical interest is that EDTA could have a very similar effect with viral infections also.

Dr. Weitz:            Okay, so let’s move on to the next trigger for Hashimoto’s. So, we already covered to some extent food sensitivities, insulin, cortisol, estrogen surges, dysregulation, and we talked a little bit about heavy metals. What would be another common one?

Dr. Valdes:          Yeah, so a huge one, and this is the thing that everyone talks about obviously is the gut and increased membrane permeability issues in the gut.

Dr. Weitz:            By the way, sorry to keep interjecting, but non-stop, I have this coronavirus thing on my mind, but I just recently read an article that it turns out that more than a reasonable percentage of patients… I forgot exactly the number that the infection will actually start with gut symptoms. So, it seems to actually get into the gut to begin with, and then obviously somebody who has a leaky gut would potentially be an easier route into the rest of the system.

Dr. Valdes:          Absolutely, yeah, absolutely, and out of the COVID-19 prevention and treatment manual, they showed that for some of the patients that were presenting gut symptoms, they showed the value of a high-caliber probiotics, something like VSL#3 and high levels of acidophilus specifically is what they talked about in the publication. So, absolutely, absolutely.

Dr. Weitz:            Would you mind sending me a copy of that that I put in the show notes?

Dr. Valdes:          Yeah, absolutely. I posted the whole manual on my LinkedIn page. So, if you just go to Dr. Ruben… I’m happy to send it anyways, but that’s a quick way of getting it.

Dr. Weitz:            Okay, sounds good.

Dr. Valdes:          So, yeah, absolutely. There’s a mechanism there. For those that are not familiar with leaky gut, in 2020, you should, but leaky gut, medically, that’s not a medical term. When we talk to a gastroenterologist or whatever, they call it increased membrane permeability, and it is a thing. It is a diagnosis. Our gut is the only tissue in our body that is one-cell layer thick. So, it’s very thin. It’s designed for absorption and filtration, and those cells are held together by proteins that gates, have a gating mechanism for specific things that are larger that can be absorbed to be, let’s say, decided upon like the Panama Canal, and things can go up to a certain stage and then permeate through, or they can be rejected and go back into stool, into the bolus.   So, people that have increased gut permeability will absorb things that shouldn’t be absorbed. It can be undigested food particles, which are a problem because just like viruses, some of the surface antigens in food can create molecular mimicry. It can create confusion for the immune system. Lipopolysaccharides, which are these proteins that are produced by bacterias, which are very, very inflammatory, they can absorb viruses. They can absorb a lot of things that are not supposed to go into the bloodstream creating this chronic activation of the immune system, driving some of the autoimmune pathways.

Dr. Weitz:            Okay, cool. So, what do we do about problems with… How do we identify problems with gut health and then what do we do about them?

Dr. Valdes:          Yeah, so there’s a lot of things that drive gut permeability. One of them, and I rarely hear people talking about this, but it’s just the amount of food that we eat and the frequency with what we eat. It’s crazy. In America, we eat a lot, a lot, and all the time, and what happens is every time there’s food going through this one-cell layer of tissue, it’s damaging. It’s creating some abrasion. So, something that’s incredibly effective for leaky gut is fasting. Stopping eating. We preach this stuff all the time. The body has the ability to heal, to repair itself. So, going on a fast 3, 5, 7 days, or 11 days, and something that makes that easier is having something that’s densely nutritious, something that has a lot of collagen. Something like bone broth can be a very, very useful tool for a fast in repairing the gut. So, that’s one of my preferred.  There’s also people that need specialty stuff. So, if we test, and we find that there’s a nasty infection like Klebsiella, Clostridium, an overgrowth, an imbalance. We need to go in there and begin rebalancing that microbiome, get rid of the stuff that might be driving inflammation, that might be driving some of the breakdown of the cell tissue.

Dr. Weitz:            So, how would you handle that? Are you talking about using anti-microbials?

Dr. Valdes:          Yep. We would use anti-microbials that would be specific to the sensitivity of the pathogen or the dysbiotic fungus or bacteria that we would find. If there is a suspicion of an enterovirus, which most of the time we don’t really have a test for, for viruses in the gut, but a lot of people have viruses in the gut. Here’s a place where your lurasidone and potentially your oral EDTA would also have a great benefit in helping get rid or decreasing the viral load in the gut. So, just another little tool.

Dr. Weitz:            I know some of the PCR stool tests now include some viruses, a limited number.

Dr. Valdes:          Yeah, some do. I’m still interested in seeing a little bit more data on PCR, but I think there’s a ton of promise there for sure.

Dr. Weitz:            Oh, yeah, we pretty much switched over to using the GI-MAP from Diagnostic Solutions-

Dr. Valdes:          Nice. Very cool. Very cool.

Dr. Weitz:            … which is a PCR-based stool test. So, next trigger for Hashimoto’s, what would be the next thing? So, we did heavy metals. We did food sensitivities. We did insulin, cortisol, estrogen. What would be the next one?

Dr. Valdes:          Yeah, so we can talk briefly about one that’s very common, but rarely spoken about, and we got into this a little bit the last time, but biotoxin illness. We know that 22% of the people, the population are carriers of a susceptibility in a gene called HLA-DR/DQ, and for people that are susceptible, what that means is that their immune system cannot identify or create antibodies or transport and present the biotoxin itself. So, a domain of their immune system becomes chronically active.  Now, if you ask the developer of all of this stuff, Dr. Ritchie Shoemaker, he will tell you there’s not enough data yet to confirm that this is a driver of autoimmune disease. Possibly, I don’t know. I haven’t spoken to him in a long time, so I don’t know where he’s standing right now on this, but clinically, we see an immense amount of people that have these susceptibilities that move on to develop autoimmunity, and when they are autoimmune, these tend to be big triggers.

Dr. Weitz:            So, by biotoxins, the main one you’re talking about is mold mycotoxins?

Dr. Valdes:          Yeah, mold mycotoxins is the most prevalent one, but there’s also Lyme disease, which is becoming more and more prevalent.

Dr. Weitz:            Most people put that in the infection category.

Dr. Valdes:          Well, it is both infectious and biotoxin because initially, when you’re bitten by a tick, you get a Borrelia infection, but the Borrelia is a biotoxin-producing organism just like mold or just like specific types of blooms or just like MARCoNS. Microorganism, some of them can produce these nasty biotoxins. So, some people that are non-susceptible do a great job at getting rid of the infection and getting rid of the biotoxin. Some people that are susceptible can get the infection, and they might be treated for the infection, but the biotoxin illness will linger on and stay around. So, it falls into both categories and right now, actually, this is a pretty interesting and controversial subject.

                                I interviewed somebody yesterday about this because all of us are being forced to stay indoors and for a lot of people, they’re now indoors with their other enemy, which is mold, and they don’t know about it, and for a lot of people, potentially about 20% of our population, they’re going to begin to become sicker and sicker from being indoors. Buildings, structures are not built the way that they once were in the past. There was a lot of focus on air circulation on being able to move the air from the outside-in, and that’s one of the things that really can get rid of these biotoxins.  Sunlight gets rid of molds, and now, people are living in homes being in building structures that have poor air circulation. So, the longer that we are indoors, the sicker a lot of our population and the people that you and I see are going to be coming back outdoors.

Dr. Weitz:            Which is interesting because actually part of it has to do with the construction, trying to make your home more waterproof ends up reducing the air circulation.

Dr. Valdes:          Correct.

Dr. Weitz:            Then you end up with moisture that builds up within the walls that can contribute to the mold.

Dr. Valdes:          Absolutely, yeah. Yeah, I mean, there’s so many little things to that, from the way that your windows are flashed to the angle of the roofing. If one little nail goes in the wrong place, it’s like crawl spaces are a problem. Basements are a problem. Sump pumps are a problem. There’s so many things that can really contribute. Even in the best-built home, this is a problem that can really affect any and all of us.

Dr. Weitz:            So, I think this is going to have to be our last point.

Dr. Valdes:          No problem.

Dr. Weitz:            Once again, we’re running up against the time clock because I do have a patient coming up. So, your preferred method of getting rid of mycotoxins and Lyme?

Dr. Valdes:          Yeah, so mycotoxins or first thing is removal. So, remove the person from the environment that is making them sick or change the environment. Remediate the environment.

Dr. Weitz:            Which right now is really hard when you’re supposed to stay in your house.

Dr. Valdes:          Right, absolutely. It’s incredibly hard. So, for when that can’t be the case, there is a protocol. I’ll send it to you. There’s two things that have been shown effective in killing mold. Formula 409 is fantastic. Nothing else can kill the stuff. So, using that stuff on your house, which is toxic, so I don’t know. Go to the backyard for a little bit. Vacuuming, cleaning, all that becomes important. There’s also something called Air Oasis, which can actually kill the biotoxins. It’s also effective for killing viruses in the environment too.

Dr. Weitz:            I just had somebody show me an air filtration system that also puts out hydrogen peroxide and then claim that that helps get rid of mycotoxins.

Dr. Valdes:          Absolutely, yeah, absolutely. I mean, they’re not hard to kill. So, for the time being, that would be the best strategy for Lyme, which you mentioned the only way of removing the exposure really is if you have the active infection is doxycycline or an antibiotic that will get rid of the infection. I’m not very familiar with natural methods that can get rid of Borrelia. For the toxin, unfortunately, the only binders that we have documented success with are cholestyramine and Welchol, which are both prescription binders.

Dr. Weitz:            These are for the mold?

Dr. Valdes:          Yeah. This is once the toxin is in the body.

Dr. Weitz:            Okay, the mycotoxins.

Dr. Valdes:          Then you bind it. You bind it with a binder in the gut to get rid of those.

Dr. Weitz:            Those are both prescription meds?

Dr. Valdes:          Those are both prescription. There is some promise around okra seed and chitosan has the shape where it would bind the toxin, but unfortunately, most of the chitosan out there is not enterically coated, so by the time it reaches the gut, it denatures, and it doesn’t make it to the bile where is where we would bind the toxin. So, for the time being, cholestyramine and Welchol are really the only thing, and I research this all the time. There’s some people out there saying that they have a binder that would do this or that but in reality, they are ineffective. So, that would be the main thing and from there, it’s a very streamlined protocol where you begin to normalize each one of the immune markers, the C4A, the TGFB-1, the MMP-9. There’s different steps for each one of those, and ultimately, there’s an intranasal spray called VIP, vasoactive intestinal peptide. That will repair the tissues of the sinuses and of the gut to finalize the whole process.

Dr. Weitz:            Those are basically part of the Ritchie Shoemaker protocol?

Dr. Valdes:          Yes, correct.

Dr. Weitz:            Okay. Excellent, Dr. Valdes. Tons of interesting information. Once again, we could have gone on for another hour, but I think this’ll give everybody a lot of things to think about. So, for the listeners and viewers, how can they contact you and find out about seeing you or visiting one of your offices, real or virtual?

Dr. Valdes:          Yeah, so the best way right now is www.novis, which is N-O-V-I-S.health. So, no .com, just .health. Novis.health. That’s our main site. We’ve actually have bulked it up. We’re releasing a new site on Wednesday. So, we’re very excited about that. People will be able to book their virtual consultations right on the site.

Dr. Weitz:            Awesome. Thank you so much.

Dr. Valdes:          Thanks, doc. Have a great day, and thanks for all your awesome work.

Dr. Weitz:            Thank you.



Testing for COVID-19 with Dr. David Brady: Rational Wellness Podcast 157

Dr. David Brady discusses Testing For COVID-19 with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

8:13  People with chronic diseases like obesity, hypertension, coronary artery disease, and a host of chronic conditions fare more poorly with COVID-19.  And in the US we have a lot of people with one or more of these chronic conditions and it would be good if we took this opportunity as a wake up call and to turn our public health policy and our health care system to focus on reducing obesity, diabetes, hypertension and other chronic diseases.

10:50  This virus seems to have a big cardiovascular component that distinguishes it from the seasonal flu.  We are seeing endothelial inflammation, changes in hemoglobin structure, changes in the ability to perfuse tissues with oxygen while still being able to get rid of CO2, the happy hypoxia thing, the COVID toes, and the micro-coagulations. Some of the emergency rooms are prescribing blood thinners routinely to cut down on the clotting that we are seeing in patients with COVID-19.  Functional Medicine practitioners are putting many patients on fish oil, nattokinase, and lumbrokinase prophylactically.

12:45  There is some amazing data on the benefits of some natural agents like vitamin D and zinc helping with COVID-19.  Dr. Brady has gotten calls from doctors at ICUs in major hospitals in New York and Massachusetts about the best procedure to a high dose IV vitamin C drip and about blood ozone and UV treatments. And the vitamin D level has turned out to be the best predictor of who has a very bad outcome and who does okay when exposed to SARS-COV-2.  When there are no effective drugs, doctors and patients have turned to natural agents like vitamin D and botanicals that help to strengthen the immune system. The most effective drug for COVID-19 at this time is Remdesivir, which did not reduce mortality, but reduced the length of the hospital stay by 2-3 days, while zinc when added to hydroxychloroquine and azithromycin reduced mortality by 49%!  And Remdesivir costs around $5000 per month, while zinc will cost you about $20.  We know that nutrients like quercetin, resveratrol, and ECGC from green tea can block viral docking and penetration into the cell. We know that zinc, vitamin D, high dose vitamin C, and botanicals like elderberry, astragalus, and andrographis have antiviral properties. And melatonin can reduce the potential for having a cytokine storm.

18:53  Testing for the SARS-COV-2 virus, which is what causes COVID-19, includes the nasopharygeal swab which is stuck all the way in the back of the nose and then twisted around, which is then analyzed through pcr testing, which amplifies the DNA, which is the gold standard. A number of labs are offering this test, including Diagnostic Solutions, which Dr. Brady works with. There are rapid tests using the np swab and then placing the swabs into an expensive machine from Abbott or several other pharmaceutical companies, which then gives results in 15 minutes, these do not use pcr, so they are less accurate. There are also tests using an oral swab or saliva, including some at-home tests, but these tests are not as good at getting enough viral load and therefore are not as accurate.  The original CDC test didn’t work very well because it only targeted two end proteins on the virus. Diagnostic Solutions Lab (DSL) developed a pcr test that used these two end proteins along with the spike protein and an envelope protein that has now become the standard. The literature coming out of China indicated that you can find the virus in the GI tract for up to 6 weeks after recovering, so DSL has developed a stool test for the virus, which has advantages in that the patients can do it at home and mail it in, so you don’t need a healthcare worker in PPE to get the sample.  In fact, DSL has been running the nasopharyngeal swab tests for the virus, stool tests for the virus, and IgG and IgM antibody testing and they have been correlating these tests to better internally validate their tests and to understand this disease.

30:25  When it comes to the accuracy of testing for the virus, doctors often ask about the sensitivity and the specificity of the testing.  PCR molecular targeting methods used in such testing has virtually 100% sensitivity and specificity, but the limiting factor is getting the proper sample to test as well as the progression of the disease and the level of the virus in the tissue being sampled.  If the person performing the nasal swab doesn’t do it optimally, you may not have virus in the sample. And it depends where the patient is in their disease process. The viral load is highest on symptomatic people in the first five days of symptoms, and then it starts trailing off. So it depends when during their condition that you perform the test. The test may have 100% analytical validity, but the clinical validity may be lower for the reasons just mentioned.

36:06  The difference between the rapid testing and the PCR testing for the virus is that the rapid testing is not amplifying the DNA, so you need a lot more viral load in the sample to see it.  If a rapid test is positive, you can trust it, but there may be a of of false negatives. These rapid tests are meant for point of care diagnosis, like in an ER or an ICU.  Such tests won’t be a good way to say screen NBA players before games because if they are infected but not symptomatic and don’t have a high viral load, you won’t be able to catch most of these cases. And such tests won’t work that well for screening patients coming into work because the machine for testing is expensive, there are few available to buy and you can only load one sample at a time.  And it takes 15 minutes to get results and then you have to wait 5 minutes for the machine to reset before putting another sample in.  This makes it impossible to test 100s of employees in less than many hours, such as at a meat packing plant, or even 10 employees at a restaurant, since even that would take a few hours. If they are not symptomatic and are infected but have a relatively low viral load and they are likely to be a false negative.  Here is a paper discussing PCR vs rapid testing for the virus, as well as the proper technique for performing the nasopharyngeal swab: Laboratory Diagnosis of COVID-19: Current Issues and Challenges

40:04  Antibody testing also has this mix of blood spot, quick tests as compared with a blood draw and using a quality ELISSA antibody kit.  The rapid antibody tests are lateral flow tests and they are almost like a pregnancy test for HCG where you pee on it an it turns a color. It has poor sensitivity and requires a high level of antibodies.  When it comes to antibody testing, there is also a possible issue of cross-reactivity with antibodies formed to other coronaviruses, such as SARS and MERS, and 229E and OC43, which are two of the coronaviruses responsible for the common cold.  On the other hand, the original SARS from 2003 and MERS  are not around any more so you are not likely to see a lot of false positives to them.  The serum PCR molecular testing for antibodies is much more targeted and exact by nature, so it will be more accurate than the rapid testing.  On the other hand, we are still studying this new virus, SARS-COVID-2, and trying to determine what exact level of IgM means that you have an active infection, what exact level of IgG antibodies confer immunity, how long these IgG antibodies will stick around for, etc.  We have pretty good evidence that infection with SARS-COVID-2 does result in antibodies in most patients: Antibody responses to SARS-CoV-2 in patients of novel coronavirus disease 2019.  

47:01  After an infection with SARS-COVID-2 or any virus, IgM antibodies are the first to form usually after the first week of infection, while IgG antibodies will typically form about 2-4 weeks after infection.  The serum or plasma antibody tests are more accurate than the rapid tests using blood spot.  Here’s an article discussing this: Antibody Tests in Detecting SARS-CoV-2 Infection: A Meta-Analysis.  This article from the Journal Of Infection shows the peak of IgM antibodies after 3 weeks and then fading with IgG antibodies peaking after 4 weeks and continuing: Profile of specific antibodies to SARS-CoV-2: The first report.Here is another article showing when IgM and IgG antibodies form after SARS-COV-2 infection: Serological and molecular findings during SARS-CoV-2 infection: the first case study in Finland, January to February 2020.   


Dr. David Brady can be contacted at his website https://drdavidbrady.com/ You can check out the website for The Fibrofix book that he wrote at https://www.fibrofix.com/ You can get information on the swab, antibody, and stool tests for COVID-19 from Diagnostic Solutions at https://www.diagnosticsolutionslab.com/tests/covid-19-sars-cov-2

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.


Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.  Hello, Rational Wellness Podcasters, Dr. Ben Weitz here again today. Thank you so much for joining me.

So today we will be discussing some of the controversies and confusion about testing for COVID-19 with our special guest, Dr. David Brady. So when we talk about testing, we’re referring to both testing for the virus and testing for antibodies to the virus that causes COVID-19, the SARS-COVID-2 virus. There seems to be quite a bit of controversy over how necessary testing is, how accurate it is, what type of testing is most helpful.  And when it comes to antibody testing, whether it’s valuable or not, do antibodies provide protection, how accurate is it, I’ve asked one of the brightest people in the functional medicine world and someone who is involved with developing some of these tests, including I think the only company that has a stool test for the virus, Dr. David Brady. Dr. David Brady is an internationally known speaker, doctor of chiropractic, naturopathic physician.  He’s also a professor at the University of Bridgeport. He’s the chief medical officer for Designs for Health, and also for Diagnostic Solutions Lab. Dr. Brady’s a prolific writer, having published a number of scientific papers. He’s contributed chapters to numerous textbooks. He’s written a number of books, including his latest is the Fibro Fix published in 2016. Dr. Brady, thank you so much for joining me today. 

Dr. Brady:            Hey Ben. Thanks for having me on again. And I think you’ve been trying to lasso me to do this for about four… I don’t know, at least four weeks, maybe six. But with COVID craziness, it’s just been difficult, but here we are.

Dr. Weitz:            Yeah. Good. And by the way, the information on testing seems to be developing by the day. But before we get into our discussion about testing, you have another title. You are the chief myth buster about bogus concepts circulating through social media related the COVID-19 in the functional medicine world. And you’ve recently spoken out about a number of myths including whether immune-strengthening herbs like elderberry can increase the risk of cytokine storm. Are there any myths that you’d like to comment about now, because there are quite a number?

Dr. Brady:            Oh, it’s quite a minefield, as you know, Ben. And I don’t know if I’m the chief myth buster but at some point I’ve-

Dr. Weitz:            I’ve given you that title.

Dr. Brady:            Yeah, thank you. I’ve had enough sometimes and I’ve used a graphic a couple of times with some blog posts I put out there, or some social media posts with some guy pulling his hair out, just because I couldn’t take it anymore, and I couldn’t answer the same question via email 200 times in a day. So I put something out. Yeah. A lot of it started with that, “Stop your elderberry, and vitamin D, and vitamin A. It’ll cause a cytokine storm,” thing. And then, “Don’t take ibuprofen, but this is fine.”   Then the latest thing I kind of flipped out about a little bit was everyone just comparing it to the flu, and the lethality numbers, without contextualization on a whole lot of other ramification and factors of what’s going on with SARS-COV-2 as compares to seasonal influenza. It’s just staggering to me that even healthcare providers, practitioners who supposedly have had some schooling in epidemiology, and infectious disease, and laboratory diagnosis go off on some of the tangents that they go.  But I know these are strange times and it’s a very charged subject, and there’s a lot of raw emotions. And it’s something none of us have ever lived through before. So we’re all going down our little rabbit holes sometimes.

Dr. Weitz:            It is true and it’s amazing how even discussions about health seem to break down along partisan line, which you wouldn’t think that that would be the one topic which partisanship would have no role to play. 

Dr. Brady:            No, these days nothing’s off the table when it comes to that, unfortunately.

Dr. Weitz:            Yeah. And when you talk about the numbers, you’re hearing recently all the numbers are inflated, and people who really have died of some other cause are being labeled as dying of COVID. And we’re doing that to purposely inflate the numbers. And why would we want-

Dr. Brady:            That goes back to the way Medicare constructed the billing and things like that. But a lot of that is taken out of context. And I don’t know if any of that’s going on. But I’ll tell you one thing, Ben. I live in a small town in Connecticut. We have 80 dead people in my town. They’re not statistics, they’re not made up COVID deaths. I don’t remember the last time 80 people in my little town in Connecticut died in six weeks. Okay? Not through seasonal flu, not through calling the diagnosis something it’s not. I’ll tell you what doesn’t lie. Body bags, they don’t lie. So I’ll just leave it at that. 

Dr. Weitz:            I’d also like to make a comment, which is that it’s easy to say, “Okay, this person who now is being labeled as dying of COVID-19, really died because they had heart attack, or really died of complications related to some other disease, usually a chronic disease.” But it’s never the case that when someone dies, they die of one thing. There’s always complicating factors. And when someone dies, we don’t say, “Well, this person died 40% from coronary artery disease, and 30% from diabetes, and 20% from hypertension.” We give it a diagnosis, the one that makes the most sense. And that’s what’s being done here. And I don’t think there’s anything sinister going on.  I’d also like to say it’s not the case that Bill Gates is not the evil genius along with a number of other well known people in the epidemiological world, who are trying to force us into mandatory vaccines and a bunch of other- 

Dr. Brady:            Well, listen. I don’t pretend to know every potential sinister plan out there because all kinds of organizations with power, regardless of what side of the political spectrum they come from, what their agendas may be, the ones that have been around a long time and are successful probably all follow the same adage, which is never let any crisis go to waste. So I’m sure they’re all trying to further various agendas. But that’s sort of above my pay grade. I just look at the science, I look at the data we have, I look at what’s happening in front of my face, and try not to go off on conspiracy theories, agendas, political bents.  Hey, I’m not saying anybody who has various opinions along those lines are wrong. I’m not saying public authorities have handled this all correctly. We can have reasonable debate on how to respond to a pandemic like this. There’s different approaches, different opinions, but there’s some core things that are reality, and that is that this is a serious condition. There’s lots of dead people. And it’s not the seasonal flu. It’s not the same. It’s not impacting society and the healthcare system in the same way. Who knows about all those other things. We’ll probably know a lot more in retrospect down the line. And then there’s a bunch of stuff that we’ll never hear about because we don’t get told everything. 

Dr. Weitz:            Right. Well, one thing we do know is that people with chronic conditions, like patients who have hypertension, who are overweight, who have diabetes, who have coronary artery disease, who have a whole host of chronic conditions fare much more poorly with this disease. And I think it would be nice if we put some real focus on doing something about our society that has all these chronic diseases, because if we had a healthier society, whatever condition we could frank, whether it be this particular virus or any other situation, we’d be a lot better off if we had a much lower chronic disease burden. And so, I think that that’s something-

Dr. Brady:            Yeah, there’s no doubt about that. And those are some lessons that we better learn from this. I mean, as a modern culture, we tend to have very short memories. But there are some big lessons that come out of this, and I hope it’s not just the functional integrative kind of healthcare providers that have this imprinted or maybe solidified in their mind, because they’ve kind of been in this camp to begin with. But I hope more conventional people, more people with regulatory responsibility, public health care policy and so forth, realized this is a wake up call.  It doesn’t matter what pandemic comes next or what have you, we better get a healthier population. And the obesity and the dysglycemia, and the diabetes, and the hypertension, and the cardiovascular disease. By and large, most people, talking to my colleagues now. I’m not on the front lines in the ICU in critical care medicine, but I have a lot of friends who are, and most of the people… Now, there’s definitely exceptions to this, but most of the people that ended up on ventilators are in those categories I just named. Although there are some that were perfectly healthy athletes who are 30 years old who are now not breathing anymore and they’re dead.

                                Right now we’re trying to mind those genes, find those different constellations of different patterns of snips, and metabolome issues and things like that to try to, in the future at least, be better at predicting who are those odd docs that if they get exposed to SARS-COVID-2 or even a related virus that’s got some of the sinister characteristics of it, are likely to go down that slippery slope and down into a severe immune overreaction, acute respiratory distress syndrome, cytokine storm, and what have you, and be really susceptible of dying of this, because there are certainly those people. We know some of those genes and snips already. We know some general patterns, but there’s a lot more to be harvested and learned.

Dr. Weitz:            Yeah, no, this virus definitely seems to have a cardiovascular component that’s quite different than the seasonal flu.

Dr. Brady:            Oh yeah. I mean it’s not just the respiratory virus. In fact, it has the ability to get into all kinds of cells, and not just cells with ACE-2 receptors. Because of the furin cleavage sites on the spike protein it can get into almost any tissue. It has an affinity for a highly or densely populated ACE-2 receptor tissues in GI mucosa, cardiovascular tissue. But you’re seeing now, the vascular biologists are having a field day with this trying to figure out what’s going on with all this endothelial inflammatory function changes, changes in hemoglobin structure, changes in the ability to perfuse tissues with oxygen while still being able to get rid of CO2, the happy hypoxia thing, the COVID toes, the micro coagulations. I mean, it’s a really nasty player. 

Dr. Weitz:            Yeah. No, blood clotting seems to be a major factor. And I’ve talked to a couple of docs who are working in the emergency rooms, and I know in Los Angeles, and I’m sure in some other areas, they’re using blood thinners as just a normal part of the usual treatment. 

Dr. Brady:            Yeah. Sure. We’re using them as well. We have lots of patients on fish oil, nattokinase, lumbrokinase, baby aspirin a day. I mean, we’re looking at all those things as well, for sure. 

Dr. Weitz:            Yeah. It’d be nice to see if nattokinase or one of the other natural blood thinners could have the beneficial role if used prophylactically. 

Dr. Brady:            Yeah. I don’t think it’s going to hurt. A lot of us with all of these therapies, even the front line therapies, by and large, we’re going on a rational hypothesis, known mechanism of action, what we know about the pathogen, and throwing stuff at it and seeing what happens.

Dr. Weitz:            Certainly we’re seeing some amazing data already on vitamin D and zinc among other nutrients. 

Dr. Brady:            Yeah. And you know what, Ben, I never thought I’d live to see some of the stuff I’ve seen in the last couple of months. And I think we all can say that. But I never thought I’d have doctors from ICUs in New York, major hospitals, calling me, tracking me down on my cell phone to ask me what I thought about the best procedure to do in a high-dose IV vitamin C drip. I have a hospital from Massachusetts call me about learning more about blood ozone and UV treatments, The stuff in the media and all over the place with vitamin D and zinc and elderberry and all this.  It’s kind of interesting, when the proverbial stool matter hit the fan in society, I think people amazingly queued up pretty quickly. Hey, there’s no magic bullet pharma agent to save me here. And they saw the richest country in the world’s healthcare system basically be reduced to, “If you get sick with respiratory symptoms, don’t come here. Don’t come to your doctor’s office. We can’t see you. We’re not going to see you. We may talk to you on the telephone, but you need to stay home and basically live or die. And if you get really bad, call 911 and they’ll bring you to the emergency room. You’ll probably end up in an ICU and die there.”  So they figured out, hey, I’m on my own. We’re back to the old days. I need to figure out how to help myself. And what did they turn to? They turn to all the stuff that supposedly doesn’t really work. Well, you know what? It turns out the data’s showing it does work, okay? So you see this stuff, like you said, in the biggest, most solid predictor we have right now to determine who goes to a very bad outcome and who does okay when they’re exposed to SARS-COVID-2 is their vitamin D level. Imagine that, right?

Dr. Weitz:            Yes.

Dr. Brady:            People I went to high school with, I’ve never heard from since, are emailing me, “Should I stop my elderberry? Might I have a cytokine storm? And what is this thing about zinc ionophores?” I’m like, “Do I live in bizarro land here?” But there’s such an opportunity here for folks like us in the tribe that your podcast goes out to. I think it’s changed people’s perception for the long term. Not everybody. But I think a much larger segment of the US population now is thinking, “You know what? I’d better proactively take care of myself a little bit better, and maybe there is something to taking vitamin D, and maybe there is something to supporting my immune system. Maybe some of these natural agents and botanicals and things like that, which we were told that’s not real serious therapy, maybe they are.” Right?

Dr. Weitz:            Yeah. No, it’s amazing. Couple of days ago I read that study coming out of New York City where they had two groups of patients where they got hydroxychloroquine and z-pack, and one group got 50 milligrams of zinc taken twice a day. And-

Dr. Brady:            Major difference in the outcome.

Dr. Weitz:            49% reduction in mortality. 49% reduction in mortality.

Dr. Brady:            Yeah. Hydrochloroquine and chloroquine, of course, big function is as a zinc ionophore. It transports zinc into the cell, and zinc is very toxic- 

Dr. Weitz:            Without the zinc, they didn’t get that outcome.

Dr. Brady:            Exactly.

Dr. Weitz:            You’re talking about a supplement that’s going to cost you 20 bucks. And in contrast, we have an antiviral drug like remdesivir, which is supposedly the most effective drug we have so far, and its effects for like $5,000 a month are that the hospital stay will be reduced by two or three days, and no improvement in mortality. And we have a natural substance like zinc that’s reducing mortality by almost 50%. That’s pretty amazing.

Dr. Brady:            Yeah. Admittedly, we don’t have great retrospective long term outcome studies on any of the drugs. I mean-

Dr. Weitz:            Sure. Yeah. No, there was no placebo control group, but-

Dr. Brady:            Yeah. But we do have lessons learned from SARS in 2003 from MERS. We have lessons learned from other Corona viruses, like various influenza viruses. And there’s really good data out there. There’s animal data, but there’s human outcome data on things like quercetin and resveratrol, and EGCG on blocking, viral docking, and penetration into the cell on zinc, on vitamin D, on high-dose vitamin C, and right on down the line, on botanicals like elderberry, astragalus, and so forth.  So we are using these things. We’re not saying, “Hey, they’re a cure for COVID-19.” We’re not. But the more we can look at what we know about this virus, what we know in lessons learned from related viruses, and we can use different types of mechanisms of action on top of one another. Some block the virus from docking to the cells. Some block it from penetrating the cells. Some block RNA replication. Some change the pH in the exosomes where the viruses hang out.   Some things up-regulate the immune system with better NK cell function, or change cytokine patterns. Or something like melatonin. Who would have thought? Everyone thinks of it as a sleep thing. In functional medicine, we know at higher dose and things, it’s been used as an immune modulator. But even at the low doses, people use it for sleep. It directly targets NLRP3, which is that first domino that falls in cytokine storms.  I have most of my patient base on melatonin at night right now, just like a three milligram dose even if they don’t have sleep problems. Just in case they get exposed to SARS-COVID-2, we’re lessening the likelihood, it appears, that they would have that cascade effect into cytokine storm. So it’s interesting times. 

Dr. Weitz:            Yep. Let’s get into virus testing.

Dr. Brady:            Sure.

Dr. Weitz:            Some of the tests that are available, we have this nasal swab that you have to stick all the way into the back of the nose, and then it’s sent for DNA reverse transcription, polymerase chain reaction testing. We have some rapid tests that require getting a machine from Abbott or a few other companies that can return results in as little as five minutes. And that’s the test being used daily at the White House. We have a new saliva test developed by Rutgers University, that doesn’t require using a swab at all. We have a new home test from LabCorp.  Diagnostic Solutions, which you work with, has a stool test. How accurate are all these tests? What are the relative benefits of one test over the other? 

Dr. Brady:            Yeah. Well, I wrote a pretty detailed article that’s about to publish in the next edition of Townsend Letter, and it will also run an NDNR, Naturopathic Doctor News and Review, where I kind of go through exactly those things you just asked because there’s a lot of details and there’s a lot of nuances. And unfortunately, when a lot of this stuff gets reported in the media, they like to reduce things to 32nd sound bytes that the average lay person can digest. And unfortunately, it’s hard to reduce the very complicated and nuanced subject with immunology, laboratory medicine. I mean, these are not just easy things. So yeah.

                                I mean, the way the tests break down, they break down into two major categories generally. One is diagnostic testing for COVID-19. And to start off, a lot of mixing of terms in the media, COVID-19, a lot of people call it the COVID-19 virus. The virus is in COVID-19. The virus is SARS-COV-2, novel Corona virus 2, whatever you want to call it. But it’s not COVID-19. COVID-19 is the clinical presentation and syndrome, which is a respiratory dominant disorder, that you see that’s killing people, okay? So-

Dr. Weitz:            COVID-19 is the name of the disease, not the name of the virus.

Dr. Brady:            Exactly. So SARS-COV-2 could cause, in some people who are exposed to it, COVID-19 but not all. So the first testing bucket we’ll create here is to diagnose COVID-19. These are tests that are generally done in reserve for people who are symptomatic or there’s some clinical suspicion on the part of a healthcare provider that they may have COVID-19, okay? These are samples that are done generally, and according to FDA, the only laboratory diagnostic tests for COVID-19 is on a respiratory sample. So these are generally taken from the respiratory tract somewhere.   The data’s kind of emerging, shifting, and things, but from what we know, the most convenient sample that has the best sensitivity, and reproducibility, and capture viral load is called an NP swab, a nasal pharyngeal swab, which is those really long kind of Q-tips that you have to stick along the septum, nasal floor, all the way back to where it hits the pharynx and twist it around a little bit. So, from the side, you’re going back all the way to about where the ear is.  Patients don’t love it. It kind of feels like someone’s sticking a big Q-tip in your brain. You can’t collect them by yourself because you just won’t let yourself do that, okay? But they are definitely, at least what the literature shows so far, superior to trying to collect and get a viral load on an oral pharyngeal swab through the mouth to the back of the throat and brushing the tonsils, or just an oral swab, or saliva, or a nasal swab. So these at-home tests are not nearly as good because the sample is just not as good at getting enough viral load to be detected in the laboratory.  But these are done on a respiratory sample, and generally, most of them, the very good ones are not the rapid test. These involve PCR, so polymerase chain reaction. So it’s an amplification of the DNA. The limiting factor in these tests is really the collection, is getting enough viral load on the swab, or sometimes if there’s people in ICUs on ventilators… We’re actually doing testing on bronchial alveolar washings, and sputum, and different things like that, direct sampling from the lungs. You get the biological sample. You do a PCR process to greatly amplify the DNA that’s in there, to have a better chance of finding the virus. So it greatly increases the sensitivity on the test. And this is done through genomic sequencing and just normal PCR molecular method.

                                The original CDC tests that had a lot of controversy about it, that didn’t work very well, at least in the initial iteration, the CDC decided not to use the World Health Organization’s developed tests. They developed their own. This test molecularly targeted two nuclear capsid or end proteins on the virus. For whatever reason, it turned out it wasn’t very good at targeting those. I’m not sure where exactly it was in the process. But then, the FDA released a emergency use authorization appealing to the private sector to start developing some tests.   At DSL, we pivoted to this very, very early in the game because we’re a molecular shop. We’re a quantitative molecular. We have a whole really highly skilled team that does just this kind of work. We’ve applied our molecular skills to things like GI map and other types of testing that we do. But we pivoted and we developed a PCR quantitative real-time PCR based test on respiratory samples, to hit four different targets on the novel Coronavirus. So two end proteins, the same as the CDC test, but also a spike protein and an envelope protein.  Many other people followed that line, but there were remarkably few labs in the US that were able to do that very quickly. You had some major US academic medical centers of excellent pathology labs that were able to do it. And then your Quest and LabCorp, and some of the really, really big biotech firms. DSL was in that first group of 30 in the country that got the FDA EUA validations in and cleared to do the testing. So we’ve been doing it from very early for major hospital systems, a lot of the drive through centers for different states and municipalities. So we have a lot of data collected on doing that kind of testing.

                                We very early also applied that to testing stool because we were looking at the literature coming out of China and out of other countries showing that you can actually find the virus through molecular methods in the GI tract, generally before you can find it in the respiratory tract. And if someone does get respiratory COVID-19 and they recover, we can find the virus in the stool for up to six weeks after they’ve recovered and are asymptomatic. So that brings up the idea, are they shedding it intact in the stool and could they be a fecal oral transmitter of this?  So everyone was sort of obsessed with the nasal droplets and the aerosolization and all of that, which they should be in respiratory sick people. But what about these people who never got respiratory symptoms or who have recovered from respiratory symptoms? If they’re shedding it in the fecal matter, we still have a transmission problem with them. So we pivoted, we started doing that, and we were very successful at applying the same quad target to it. And we talked to FDA about it and they were really intrigued by it for community surveillance.  Now, they don’t consider it a diagnostic test for COVID-19 because it’s not on a respiratory sample. But some of the advantages are you don’t need a healthcare provider all garbed up in PPE trying to get a respiratory sample on a symptomatic patient. You can dropship a kit, let’s say, to people, have them collect it without exposing anyone else, to get the data on it. So then we started looking at things and other researchers where.  Is this just viral RNA shedding in the stool? Is it intact virus? Can you do viral cultures on it? Can you actually transmit the virus this way? So really interesting.  Then down the line now, what we’re doing, we’re the only lab in the country, that we know of at least, doing this on stool. So FDA has been actually referring a lot of the groups and units and academic centers doing fecal microbial transplants to us to screen their transplant material before they introduce it into a patient because they don’t want to be introducing SARS-COVID-2 through a fecal microbial transplant. So we’re doing a lot of that, and we’re doing a lot of…    Now that the medical centers are opening back up for elective tests, there are elective procedures and surgeries and things like that, we’re doing a lot of pre-screening of patients that are going in for other surgical procedures, for colonoscopies, and things like that, using stool and using respiratory samples when necessary, and combining with antibody testing because the other bucket of testing is not looking for the virus per se through molecular targeting, but looking for antibodies that the immune system, in someone who has been exposed, has developed to the SARS-COV-2. 

                                So, as far as I know, we’re the only lab that are doing the molecular PCR diagnostic testing on respiratory samples, plus the antibody testing, plus the stool testing. So we’ve been trying to correlate all this data with clinical information because that’s what’s important in the long term to better understand the testing. And not only the analytical validity, but the clinical validity. So we early on were doing a lot of antibody testing before we even commercialized it, before we released it for doctors to be able to order.  We were very early in diagnostic testing, very earlier, the first in stool. We were not the earliest ones in the game in antibody testing, even though we’d probably been doing it as long as anybody, because we were waiting to get really rock solid validations in data. We were testing antibodies very early on, on hospital staff, medical staff, in these large hospital systems to help the hospital determine who in our medical staff may have been exposed, have developed immunity, who may have active infection, even if they’re not symptomatic, even if they’re negative on swabbing. If they have really spiked high IGMs, we need to maybe pull them off of the service lines.  So we were able to get clinical data, NP swab data, antibody data, and in some cases stool data all on the same subject, to be able to try to at least internally validate some of those things, which has been interesting. We’re continuing to do that, because it’s going to take a lot longer to fully understand, particularly the antibody patterns. 

Dr. Weitz:            Maybe you could speak for a minute about the accuracy of the testing for the virus, and then we’ll get into the antibody testing afterwards.

Dr. Brady:            Sure.

Dr. Weitz:            When it comes to accuracy, people are concerned about, it’s often broken down into sensitivity and specificity. And then, the other way to understand it is, do you have false negatives or false positives? Maybe you could just explain those. And then, what level of accuracy do we have with these tests? 

Dr. Brady:            Well, most PCR, molecular based testing, they’re using now usually two, three, or in our case, four targets. If there’s viral load on the sample, the NP swab, the OP swab, the lung washings, whatever, if you have enough viral load that’s above the lower limit of detection, for whatever the lab process is, those PCR molecular targeting methods are almost bulletproof. They’re 100% virtually on sensitivity and specificity. You can trust a positive call on them, and you can trust a negative call from the standpoint of, there wasn’t viable virus above the lower level of detection in the sample.  The problem though is more difficult than that. The analytical validity is extremely high, but the limiting factor is the collection of the sample, and the progression of the disease. We have a lot of people out there now, because a lot of healthcare providers were thrown into action in things they’re not used to doing. Like someone said, if you think SARS-COVID-2 is a problem, Wait till you get to the ICU and you get intubated by a gynecologist.  So a lot of people are doing stuff they’re not used to doing, including trying to collect these samples when they’re not really good at it. And it’s variable when the virus is in different places in different people. For instance, we know on classic nasal pharyngeal swabbing, the viral load is highest on symptomatic people in the first five days of symptoms, then it starts trailing off. So if you’re doing the NP swab at day three of symptoms, you’re much more likely to get a good viral load on that swab, on the same subject, than if you did it on day 10. So that’s a variable.   Are you getting enough virus on the sample? Because the lab can be 100%, but if the sample doesn’t come in with enough virus, then you have a problem. You can’t find what’s not there, or what is below the lower limit of detection. So it’s a difficult thing to answer, and a lot of doctors immediately we’re throwing out, “What’s the sensitivity and specificity?” I’m not sure they really understood what they were asking, particularly when it comes to antibody testing, because there’s two different answers to that always in any laboratory process. There’s analytical validity and there’s clinical validity.   The analytical validity, like sensitivity and specificity, is if something is there in the sample, what is your likelihood of finding it? Or when you flip it around to specificity, what is your likelihood of not finding it if it’s not there, or what’s your likelihood of identifying it inappropriately? Right? Well, even in antibody testing, which is way more loosey goosey than the PCR molecular testing, most of these different kits that labs are using, the analytical validity of specificity and sensitivity is up in the mid 90s to virtually 100%.

                                So if the antibody that you’re targeting is there, they’ll find it, and if it’s not, they won’t. And if you didn’t have it that way, you would never be able to sell an ELISA kit. It’s just that’s the way they roll. What most practitioners really want to know is clinical validity. What is the likelihood, if the person has what I think they might have, that the test shows positive? And what is the likelihood, if they have it, that it shows negative? Or you can flip it around, that they don’t have it and it shows positive, what have you.  That’s a whole different kettle of fish, with antibody testing in particular, because this is a novel virus. This is a new pathogen. Nobody has studied this out retrospectively. With antibody testing, you really want to know, tightly, in a controlled study, what is the clinical history of each subject? Do they have all the clinical manifestations, let’s say, of COVID 19? It would be nice to know, do they have a positive PCR on a respiratory sample or not? And then, you need to do antibodies, IgG, IgM at different stages, at two days, at seven days, at two weeks, at eight weeks, at six weeks, and do those. Nobody’s had time to do those studies.   Some people are trying to patch that together, but there’s been organized studies that have been able to be done yet to really report true clinical validity numbers. So everyone’s throwing analytical validity at you, and they’re 100%, or they’re 95%. It sounds impressive, but it’s not really that impressive because it’s the only thing it could be if you’re in a CLIA-certified lab, using an ELISA kit that’s valid, and particularly one that has IVD status with FDA. So the clinical, the analytical, very, very different, and the media has no idea what that all means. And then-

Dr. Weitz:            Now, on the virus testing, what about the quick test versus the PCR test?

Dr. Brady:            Yeah. I was just going to get into that.

Dr. Weitz:            Okay.

Dr. Brady:            Let’s take the PCR diagnostic testing first.

Dr. Weitz:            Okay.

Dr. Brady:            We talk about the rapid testing. Rapid testing, by its very nature, and design, and intention, one of the reasons it’s rapid is because it doesn’t involve the PCR step. It doesn’t involve amplification. So since you’re not amplifying the DNA, you need a lot more viral load in the sample to make it pop on the radar of the test. So rapid tests are good, and they have their place, but they’re really meant for point of care diagnosis, like in an ICU or in an emergency room with something very symptomatic, high viral load. You do this rapid test, put it in the machine. And if it tells you it’s positive, you can trust the positive. The problem is there’s a lot of false negatives because if you don’t have enough viral load, it will be negative. The other downside of this test-

Dr. Weitz:            Right now, the way they want to use it is, “Hey, how can we screen these people as they go into work, into the meat-packing plant, into the White House, before they play their NBA game?”

Dr. Brady:            Yeah. Well, if you’re talking about like NBA players and stuff, they’re still subject to false negatives because if they don’t have a high viral load, they’re not very symptomatic, but they’re a carrier. You’re not going to catch them on those tests, likely. But it’s not good for population-wide surveillance for a couple of reasons. One is you need the high viral load. So it doesn’t have the sensitivity of the PCR-based molecular test.  The other downside is the throughput is terrible. You’ve got to put like one sample in at a time, and they say, “Oh, results in 15 minutes.” It’s one sample at a time on the machine, and then you’ve got to wait like five minutes on a reset to put in another sample. So you’re doing one sample every 20 minutes. When we’re doing our PCR tests on these arrays and multiplexers, we’re doing hundreds of tests at a time, same time. So the throughput is just not realistic for now-

Dr. Weitz:            So you’re saying it’s not practical, say, for a meat-packing plant, or even a restaurant with five or 10 employees to test everybody on one of those before they come to work every day.

Dr. Brady:            No, they’re really point of care with really clinically sick people to confirm a diagnosis type of test. And they’re very good for that. But they’re not good for what they’re not good for. The other thing is you need the right piece… You alluded to this before, you need the right piece of equipment with the right kit. So it’s almost like having the right laser jet or the right inkjet printer and have the right cartridge. The wrong cartridge doesn’t play nice in the other person’s machine. So it’s very proprietarized. So you’re in Apple world or you’re in Mac World. You’re an Abbott land, you’re in Roche world, whatever.   And if you don’t have that machinery already, first of all, it’s very expensive, and it’s hard to get your hands on if you don’t already have it because of what’s going on. So there’s a lot of limitations. No one ever talks about this in the media. Same thing with that saliva test. And, hey, listen, I’m a Rutgers guy, alma mater. So [crosstalk 00:39:15]-

Dr. Weitz:            I saw one of the doctors from Rutgers and he said there were more viruses in the saliva than there were in the nasal discharge.

Dr. Brady:            Yeah, I mean, there’s definitely more persistence of it in the GI mucosal cells. I’m not sure about the saliva, but we know inherently in the lab, saliva’s harder to work with and concentrate and target things like viruses than a swab. But that is a useful test.  But again, I think it falls into the same bucket as these rapid tests.  You really need a higher viral load.  I’m not sure of the exact throughput capabilities on that saliva test because it’s a onesy. It was just developed in an academic lab. It’s not really been commercialized in a scaleable way.  Same thing in those antibody tests.  You have different kind of variations and stripes.  A lot of the testing, like where you’re from, remember when they tested LA and they said it was like 4% of the population was IgG

Dr. Weitz:            Yes.

Dr. Brady:            … and New York was 20%, they were using these rapid antibody tests that were basically what are called lateral flow tests. They’re almost like a pregnancy test for HCG where you pee on it and it turns a color. It’s like a reagent test. They have very bad sensitivity. They need high viral load or high antibody load in that. So high viral load translates to high antibody load, particularly early on in the phase with IgM, and then later after seroconversion and IgG. But then IgGs fall as well. So they’re really also these sort of point of care. It will not be a diagnostic test for COVID, but it can help confirm a diagnosis. Let’s say you’re in an ICU-

Dr. Weitz:            These are the tests where you prick your finger, you get blood spot.

Dr. Brady:            Those are blood spot. Those are different. So the blood spot tests are kind of the next stage. And they also suffer from lack of sensitivity. You need much more antibody load for those to be viable.

Dr. Weitz:            Aren’t the blood spot the lateral flow or not?

Dr. Brady:            It depends what methodology they’re using with the blood spot.

Dr. Weitz:            Oh, I see. I see.

Dr. Brady:            They can take a blood spot, solubilize it, and then try to do an ELISA process on it, or they can a lateral flow [crosstalk 00:41:31]-

Dr. Weitz:            Oh, okay. I see.

Dr. Brady:            But just think about it, it’s kind of intuitive. If you poke your finger and put blood on a blotter paper and it dries, the lab’s got to get it back, solubilize it, get enough of that sample, be able to viably test it. You don’t have the pristineness of the sample and the sensitivity that you would if you did traditional phlebotomy into an SST tube, spun it down, separated the serum, and sent it to the lab.   Now we’re doing our antibody tests. You don’t even have to do the spin down. You can pull it into a lavender tube and just do it on plasma. It’s equally as good. But they’re definitely better than the blood spot ones. But I understand why people want the convenience of a finger stick. It’s just, there’s a yin and yang. There’s a price to pay, and that’s sensitivity. So-

Dr. Weitz:            Do we know what the sensitivity accuracy of the blood spot, the rapid flow tests are?

Dr. Brady:            Once again, we’re talking analytical validity versus [crosstalk 00:42:33]-

Dr. Weitz:            Okay. Okay.

Dr. Brady:            So it’s hard to say at this point.

Dr. Weitz:            I’ve heard 50 to 70% thrown around, but-

Dr. Brady:            Well, yeah, but that’s analytical validity. When you’re talking about an ELISA done on a quality kit with a quality kit, with a good internal laboratory validation, you’re talking 95 to 100%-

Dr. Weitz:            I see.

Dr. Brady:            … on those. So it’s different. And then, there’s issues of cross-reactivity with other Corona viruses, other SARS viruses. Let’s say, when ELISA antibody testing, what did they build the kit to find antibodies to? Now, most of the ELISA kits are meant to find antibodies that are made by the human immune system to nuclear cuspid or end proteins on the virus. The reason they build it to that is because that has the most surface presence on the virus. So if you’re targeting something where the virus has more of it on the surface, your sensitivity goes up.  But one of the things that happens on sort of a ubiquitous thing on the surfaces, your sensitivity goes up, but your specificity can go down a little bit. So there is some potential, theoretically, for cross-reactivity on those tests to other common Corona viruses. Well, I shouldn’t say common, relatively common. They’re still not very common, like 229E and I think it’s OC43. I wrote it down here. But when they’ve looked at that, they really haven’t seen that. So most of the published studies, and I pulled some of them here, show a very high specificity using pre COVID blood samples.  We tried to use samples as controls that were available that were collected before we knew SARS-COVID-2 was around, and we’re not getting cross reactivity. Some of the other ELISA kits are built to the spike protein. They have the ability to cross react a little bit more with original SARS from 2003. But we don’t think that’s around. So it’s kind of moot. So I think you’re not going to get a lot of false positives from cross-reactivity to common influenza viruses or the original SARS on the antibody test. But the antibody tests are a little bit dicier in that there’s not as much uniform quality control for a couple of reasons. One, PCR molecular-

Dr. Weitz:            Keep talking. I just have to turn the music down that popped on.

Dr. Brady:            Sure. 

Dr. Weitz:            Yeah. Go ahead.

Dr. Brady:            PCR molecular is just by nature much more honed in and targeted, and exact in its nature. Think about testing, in immunology testing, it’s a little more fuzzy around the edges. And individuals have a great deal of variability in how they react to a pathogen, how much antibody they produce, how much IgM, and when they convert to IgG, how much IgG they maintain around for lengths of time, what their viral load was to begin with.  Ben, if you get exposed once to SARS-COVID-2 and you harbor it in some way, whether you go on to become clinically symptomatic or not, you’ll develop a certain amount of antibody titer to it. But if you’re a healthcare provider in the hospital every day, and you’re getting exposed to this virus repetitively, you’re going to develop a much higher viral load, whether you’re symptomatic or not, and therefore a much higher antibody titer. So to try to answer questions on what exact level of IgG confers immunity, what exact level of IgM means you have an active infection, there’s different kits, there’s different methods, there’s different individuals, there’s different viral loads. It’s impossible.  So, over time, as the methodology coalesces to a gold standard, and then they can follow people over many subjects over many time intervals after exposure, then you can learn these cut points and dial them in like we know about Epstein-BARR virus. This is a brand new virus. So doctors are asking the same questions that they would ask with a virus that we’ve been studying for decades and have all kinds of retrospective data on to a brand new virus. When in many cases labs, immunologists, everybody’s kind of shooting in the dark, doing the best they can, but they haven’t had the benefit of time to answer the kind of questions that the doctors think you should have. I don’t know-

Dr. Weitz:            Generally speaking, what do we know about… IgM are the first antibodies that form, and then they fade away and we get these IgG antibodies, which are generally considered to be the longer term protective ones. So how long after infection, on average, do the IgM antibodies form with SARS-COVID-2 virus? And then, how long did they last for, and when did the IgG antibodies form?

Dr. Brady:            Well, I mean, once again, they’re still trying to dial a lot of this in, but fundamentally-

Dr. Weitz:            Right. But what do we know so far?

Dr. Brady:            Fundamentally, Corona viruses aren’t new, okay? This is a particularly nasty one because of some novel properties of it. But it’s a-

Dr. Weitz:            By the way, 20% of colds are caused by Corona viruses.

Dr. Brady:            Exactly. So we know how Corona viruses operate. We know how our immune systems react to them. We have the benefit of lessons learned from SARS and MERS and things like that. So there’s no reason to think that there will be some really atypical, bizarre reaction of the human immune system that defies what we know about immunology. So basically, if you’re exposed to the virus, and you have a viable viral load, and whether or not you develop overt symptoms or not, you will start to rapidly develop IgM antibodies.  And depending on your level of exposure, your level of viral load, your IGMs will come up to a point that will be easily detectable through any of these type of laboratory methods. Now, over time, over a couple of weeks, you will get serial conversion of IgM to IgG. So your IgM spike first, then they will come down. The IgG titers will go up, and they’ll be much higher in the beginning, and then they’ll gradually trail off. Then they’ll stay at a lower level on a persistent basis, and that’s your learned long-term immunity.  Let’s say the rapid tests or the lateral flow tests, they’re pretty good at finding that initial high IgM spike, and they are probably still pretty decent detecting that initial high IgG after seroconversion is early. But then as you lower down that IgG titer, you need more resolution or sensitivity in the test to find the low levels of elevated IgGs that are characteristic of a long-term sticky immunity, if you will. And that’s what most clinicians want to do. They want to test someone who isn’t sick right now, who thinks they may have been exposed in January, or had a family member exposed. Do I have protection?  You want to find that relatively or comparatively low level of IgG elevation, which the rapid, linear flow, and all those tests, blood spot tests are not nearly as good at finding as the ones that are done on conventional phlebotomy, either plasma or serum, using a really good quality ELISA kit. So it really depends what you’re looking for. I’ve done a million media interviews on news, national news, local news, regional news, all that, particularly when we were…

                                We were one of the first companies in the United States to do broad-based employee testing on the workforce at Designs For Health because we’ve had to keep all of our manufacturing plants running 24/7 during this because we can’t make enough stuff. It just gets ripped through. So we needed a very healthy workforce, and so we turned to DSL to do all the antibody testing. It generated a lot of media, so I was on a lot of interviews about this. And even if you try to explain some of these nuances, they don’t have time for it, and they don’t want to know. It was like, “No, I don’t want to know. We just want easy answers here.” How do you take something that is complex and has all these nuances, and make it like a binary answer and something really simplistic? It’s hard. 

Dr. Weitz:            But essentially, part of what you just said to me was, you hear in the news, “Well, we don’t really know if you develop antibodies. We don’t really know if you do develop antibodies, will you be protective?” Essentially, what you said to me is, and correct me if I’m wrong, that our immune systems generally work similar to the way they do with other viruses. One of the main ways that we fight viruses is to produce antibodies over time. Depends on the person, depends on the infection and everything else. But generally speaking, we develop antibodies, and generally speaking, these antibodies are protective over time. 

Dr. Brady:            There’s no reason to think, when someone has IgG titers to SARS-COVID-2, that they would not have some significant amount of immunity. They would highly be unlikely to be infected again anytime soon with it. We have not seen that. You saw some reports out, like South Korea, something about reinfection. It turns out, in peer review, it was not really the case. We don’t have evidence of that. I can’t tell you a hundred percent that won’t emerge. But we don’t think so. And even with lower levels of persistent IgG to SARS-COVID-2, it’s likely you would have a persistent immunity to it for at least the near future.  This is an RNA virus. By nature, they kind of change around a lot. But this has a very complex large genome, and it has a sinister property of a lot of self reparative mechanisms to the genome of the virus, which means, over time, it doesn’t mutate as much and lose virulence. So that’s the bad news. It’s likely to maintain the characteristics it has now. It’s not likely to be burned out by the heat. All those things.

                                On the other hand, if you develop immunity to it, that really means that we’re more likely to have that immunity persist. But we don’t know if a year from now it’s changed enough. Like influenza, even with the vaccine talk, I don’t think… Honestly, I hope I’m wrong, but I don’t think there’s a magic vaccine coming to cure us, because this is an RNA virus. And if they develop a viable vaccine to this that sticks, that’s the same over time, it will be the first time they’ve done it in history.  They don’t have a vaccine for AIDS. The vaccine for influenza is not like polio or MM…You have to get it every year because they’re guessing what new variant may come, and they get it wrong sometimes and get it right sometimes. But this is not easy. When they tried to develop a vaccine for SARS1, I’ve talked to some of the researchers. Every time there was several different efforts, highly funded, every one of them failed. And the ones I know of that I talked to people involved in it, every time they gave the vaccine to animals, it killed them all. So they basically stopped trying.  Now maybe they know more now. There’s brilliant people. Hopefully they can develop one that’s safe. Who knows? But I’m not holding my breath, honestly. I think it’s a lifesaver that they throw out to the public to feed them. But I’m not sure that it’s really all that viable, at least in the near term. And I don’t think there’s a magic drug coming along that’s just going to eradicate the virus because we’re not good with antiviral drugs to begin with.

Dr. Weitz:            We were talking about the antibodies, and another piece of evidence that the antibodies are protective, is we’ve been using convalescent plasma therapy, which is taking antibodies from patients who were infected, and using it on patients who are sick. And they’ve been getting some pretty good results with that. So that’s more evidence that antibodies are protective. And then, the only problem with that, it’s not really scalable if you take antibodies from one person and give them to one person. You can’t help a lot of people. But they’re trying to develop those antibodies in a lab and- 

Dr. Brady:            That may be helpful. They can have a form of immune modulatory or immune therapy based on this. And, boy, that whole area has progressed so much. That may be the answer, but who knows? But it’s interesting, when I was doing media too, an interesting phenomena, you had a lot of public health authorities, governors, even all the way up to the top saying, “Oh, antibodies are our ticket to understanding this, to knowing what the penetrance is in the population, and to getting people back to work safely.” and all that.  Then all of a sudden, it started having it spin. Oh, we don’t know about this antibody stuff. Oh, a lot of the tests aren’t any good.  And I’m like, “What flipped the public narrative?” And I really do think that public health and regulatory authorities came to grips with the reality. As people started getting antibody testing done, they realized that they were developing two segments of the population, those with IgG antibodies and those without. So what were they to do with the partition population? One set of rules for the people with antibodies and another set of rules for the people without?  What about the people that found out they have IgG antibody titers to SARS-COVID-2? Did they start telling the public health officials, “We’re not following your social distance stuff. We’re not wearing masks, because we have immunity”? Basically, what do you do with the population where… Do you give them immunity cards, non- immunity? I don’t think they even wanted to deal with that complexity. And they started messaging, “Well, we’re not sure we can trust antibody tests.”

                                Listen, we’ve been using antibody testing in medicine forever. This isn’t new. So there’s ways to figure this out. With antibody testing, it was different than PCR, because PCR molecular testing, you had to have a lab with really good molecular talent, really high level of scientific complexity, and you had to be able to take in samples that had a pathogen that’s infectious. So you had to have a BSL-3 lab. Now most of these labs aren’t BSL three labs. They don’t do molecular work, particularly in the integrative functional space. So they were just sitting on the sidelines.  Meanwhile, all their normal testing dried up. At least for a month, nobody was doing all salivary cortisols, and stool tests, and organic acids. No one was doing that. So then when the antibody opportunity came around and they said, “Hey, well maybe we can get back in the testing game and get some revenue coming in. Let’s do SARS-COVID-2 antibodies because, you know what, you didn’t have to develop that in your lab from scratch with the methodology. You just had to buy a kit and follow the instructions.

                                Now, I oversimplify that because when you get the kit, you still have to follow the instructions right. You have to prepare the samples right. You have to have consistency. So you should do your own internal validations on how you work the kit. But the heavy lifting was done by the big biotech firms that make the kits, submit the validations on the kits to FDA, and do that work for you. So, basically, a lot more people can get in the antibody testing game in PCR kit. So that’s where you saw all this explosion of antibody testing.  If a lab didn’t have a lot of experience in antibody testing or immunology testing, didn’t have supply lines created or supply chains to get the good kits, the only kits they were able to get are were the cheap, less quality kits, mainly out of Asian countries. And the labs that were higher complexity, had these other supply chains, were getting the American and German kits, and they’re a little bit different in their quality.  So I understand the argument, “Hey, we’ve got to worry about the antibody quality throughout the labs.” I get that. It’s definitely more of a question than the PCR testing, but I think there wasn’t really much of a choice. They had to turn to the public sector to just turn on the engine to get the testing capacity to be able to really do enough tests to really get an idea of what’s going on in the population.

Dr. Weitz:            I’ve got one more speculative question. We know that this cytokine storm, it happens when things go bad with patients who are infected. Is there any screening test that can give us any idea about the likelihood that somebody is going to have a cytokine storm? And I’m thinking, are there inflammatory markers, tests of antioxidant status, or even measuring cytokines, that can tell us whether we’re more likely to have an inflammatory situation, oxidant storm, a cytokine storm?

Dr. Brady:            No. I get the question. And we thought about that immediately because we have a cytokine test called cytoDX. And it looks at inflammatory and anti-inflammatory cytokines. But we never positioned it as a screening in that way because we are not sure that the ranges in the sensitivities or the normal ranges of the inflammatory cytokines are set in a way that would somehow screen someone to have an event that didn’t occur yet. Like is there just a mildly elevated pattern of some of these inflammatory cytokines, or the ratio of inflammatory to anti-inflammatory cytokines that would be somewhat predictive of who’s going to go down that pathway?  It may be, but we have no way to really test it because we don’t know who’s going to go there. And then once they go there, we don’t have the data on them before they went there. So it’s a really cool thing. The ranges and the normalities were never established or set with that kind of mindset. So when they go into a cytokine storm or when it starts, if you did a cytoDX, the inflammatory cytokines would be off the chart. But we can’t accurately say that before that ever happened or before they were exposed to SARS-COVID-2, that their anti inflammatory cytokines would be above the normal range. So those are things to be worked out.

                                What we’re mining now, we’re trying to get buccal swabs of people that we know in the ICUs went down into respiratory distress syndrome, and through our genomic insights platform in OPUS23, and all the AI and machine learning, we’re trying to pick apart what is the exact pattern in constellation of snips. And we’re looking at ACE-2 receptor snips. We’re looking at cytokine snips. We’re looking at a whole bunch of different snips to find out what is the golden pattern. And maybe it’s not just snips, it’s snips plus metabolome markers.  So we’re looking at some of that stuff, but once again, we don’t have the time and the number of samples in the right sequence with the clinical histories. It’s really hard to put together, but we’re looking at that. I’m having a little bit of brain freeze on his name, but there’s a researcher, I believe he was at Duke or one of the California institutions, that is the go-to expert on cytokine storm, even before COVID happened, right. People tended to go into a cytokine storm, particularly people with certain auto immune disorders and so forth.  His most accurate predictor of cytokine storm are people that have elevated ferritins, like up in the 4, 5, 600s. And we know it’s an acute phase reactant, early reactant. And it’s not really indicative necessarily of their iron status. It’s sort of a lab artifact as an acute phase reactant. But I read some of his work. Even advising some of the ICU physicians to do just a serum ferritin. And if the serum ferritin was really high, really watch this patient and maybe even use TNF alphas or immune modulating medications on them to stop them from going into that.

                                But it’s a very good question, Ben. And I don’t know. I think our life raft here, beyond vaccines and beyond some direct therapeutics, is to get better at predictive using omics, genomics, proteomics, metabolomics, what have you, to be able to find those canaries in the coal mine. Who are the ones that might go down the cytokine storm pathway, and to be more aggressive with them? And on the flip side, just have better understandings of standards of care when they do get there, because there’s a lot of speculation now that they were treating the COVID-19 like any other viral pneumonia and what they knew how to treat it. And it turns out it’s very different, with the happy hypoxia and the CO2 going off, but the oxygen not profusing, they were getting really silly kind of reactions from patients, and they were very, very quick to ventilate them, and now they’re thinking that was a mistake, that they created more lung damage and worse outcomes by putting people early on ventilators when they shouldn’t have.  So maybe they learn more, I’m sure they will. And then drug combos, whether it’s azithromycin and chloroquine, or whether it’s these antiviral cocktails combined with this and that. We’ll see. I’m sure they’re going to figure out better ways to treat it even if it’s not curative.

Dr. Weitz:            Excellent. Thank you so much, David.

Dr. Brady:            Okay. Thanks, Ben. Appreciate the time.

Dr. Weitz:            Any final words? How can people get a hold of, I guess, the practitioners, can find out about the Diagnostic Solutions Lab testing?

Dr. Brady:            Yeah. They can just go to DiagnosticSolutionsLab.com and then click on COVID testing, and you get all the different options, whether it’s stool antibodies and what we’re doing with the NP swabs and the diagnostic testing. And then, I put that link on for you to share in your resources for this podcast interview, but I put a link to some other really good resources like the FDA site on serum antibody testing, and the different kits that have been approved, and their different sensitivity and specificity, and coefficients of confidence intervals and all of that if you want to look at it.  I put something up about, everyone’s talking about different strains of COVID or of SARS-COV-2. There’s no different strains of SARS-COV-2. There’s different isolates, different isovariants, but there’s yet to be a different strain of SARS-COV-2. A different strain means there’s something enough different about the virus and its structure that it behaves different functionally. They haven’t had that. We’ve seen variants or differences in some of the genomics, but that’s really an isoform or an isolate, not a strain. So that’s bad nomenclature. So that’s unlikely to affect antibodies, PCR targeting, anything like that. Then I just put a couple of other resources that people may like to see on false positives, false negatives, why they may occur, why they may not. 

Dr. Weitz:            Excellent. And those will be in the show notes, if you go to drweitz.com. Also, if you’d like to see a video version of this podcast, go to my YouTube page. And if you enjoy this podcast, if you could go to Apple podcasts and give us positive ratings and review, I would certainly appreciate that. Thank you, Dr. Brady.

Dr. Brady:            Okay. Thanks. Appreciate it.



Cardiologist’s Perspective on COVID-19 with Dr. Howard Elkin: Rational Wellness Podcast 156

Dr. Howard Elkin provides his Integrative Cardiologist’s perspective on COVID-19 with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

7:25  While many of us think of COVID-19 as a respiratory infection, it tends to have a significant effect on the heart, the blood vessels, the kidneys, and on blood clotting and this is part of why it’s so lethal and distinguishes COVID-19 from other respiratory tract infections, like the seasonal flu.  At least 20-30% of patients with COVID-19 tend to have an elevation of troponin, which is an enzyme that indicates injury to the myocardium of the heart, such as when patients have a heart attack.

8:48  A lot of patients with COVID-19 have elevations of D-dimer, which is related to the fact that they have increased blood clotting. Normal levels of D-dimer are zero and we’re seeing levels as high as 3,4, or 5000, levels that are unfathomable.  This is leading to blood clots being formed rapidly and we are even seeing reports of patients in their 30s and 40s dying of strokes from blood clots.  The actor, Nick Cordero, age 41 had to be hospitalized for two months, ventilated, placed into a medically induced coma and have his leg amputated from COVID-19 and is still having some complications. Doctors and researchers are still trying to understand what is going on in these cases of COVID-19. When patients are in the ICU, intubated, in end stage disease, they can develop DIC (disseminated intravascular coagulopathy) where you get fibrin split products that cause small thrombosis throughout the body in the legs, the kidneys, etc.  DIC typically occurs when patients have sepsis or acute respiratory distress syndrome.  But it is highly unusual to see such clotting in patients in their 30s and 40s.

11:50  Some patients with COVID-19 end up with low oxygen levels and for some patients what is happening is that the iron is being liberated from the heme group in the bloodstream. This free iron ends up feeding the normally inactive bacteria that we all have in our bloodstream and these bacteria grow and secrete toxins which leads to sepsis and this hypercoagulable state.  What’s not clear is what is causing what.  We’ve learned that these patients don’t respond the way that other patients with acute respiratory distress syndrome (ARDS) that can result from more typical bacterial or viral pneumonias.  More typical cases of ARDS usually respond to positive end-expiratory pressure (PEEP) which involves using a ventilator to force more oxygen around the body, but patients with COVID-19 often don’t do as well with PEEP and may do better with a C-pap machine or just oxygen or being placed on a prone position.

15:04  What can we do from a natural prospective to prevent blood clots?  We should make sure to include fish oil in our daily supplements and it would be a good idea to combine some vitamin E in the form of mixed tocopherols or tocotrienols can help to protect the omega 3 oils from oxidation, both of which have a mild blood thinning effect.  Also omega 3 is a natural anti-inflammatory and we want to reduce the likelihood of having a cytokine storm if we do get infected with coronavirus.  Garlic and ginger are also natural blood thinner and can also be helpful. On the other hand, we might not want to thin the blood out too much in case we need to do surgery on these patients. 

18:00  Patients with existing hypertension, heart disease, and diabetes have an increased risk of being hospitalized or of dying from COVID-19.  If you have pre-existing heart disease or diabetes you have 2-3 times the risk of dying from COVID-19. Patients with kidney failure are twice as likely to die if they contract COVID-19. Obesity is also a risk factor for a worse prognosis and unfortunately, 40% of Americans are obese and 70% are overweight, so Americans are particularly vulnerable to a poor prognosis. Patients with hypertension are vulnerable to a worse prognosis and in the US we have 80 or 90 million people with hypertension and most of them do not even know it. Most of them are not adequately treated to the current standards. Blood pressure of 131/81 is considered hypertension and it should be 120 over 70 no matter if they are 20 or 80 years of age.  Diet and exercise are the most impactful lifestyle changes.  When it comes to hypertension, the first thing to look at is whether or not you are a salt retainer. Unfortunately, there is no test for this, but if you tend to collect edema, swelling of the ankles or if you’re African American or Mexican American, then you may be a salt retainer and you should try reducing your sodium intake. But sodium is essential for nerve and muscle function and sodium should not be vilified the way it has been as the cause of all hypertension. Dr. Elkin prefers not to prescribe diuretics, which help you get rid of sodium.  In fact, we should be more concerned about sugar for the heart than salt. And sugar competes with vitamin C and it weakens immune function.  Unfortunately, many people who have been forced to stay home because of this COVID-19 pandemic are finding that they’re baking cookies and eating more candy and other desserts to deal with the stress.

26:31  Certain nutritional supplements can be beneficial for patients with hypertension, including potassium, magnesium, fish oil, CoQ10, and quercetin, which can also be beneficial for fighting COVID-19, since it is a zinc transporter. 

28:19  Since patients with chronic disease and who are obese have a worse outcome with COVID-19, it would be nice if as a nation we used this moment to create a focus in our public health programs or policies or with our health care system to focus on using diet and lifestyle to reduce obesity and reverse this chronic disease burden.  This would lower our healthcare costs and make people more productive.

32:22  We have seen a number of disappointing studies with hydroxychloroquine and azithromycin, but yet some folks are posting on social media that it is the cure-all, it has been touted by President Trump, and some on social media are alleging that there is some sort of conspiracy to keep doctors from using it.  Dr. Elkin noted that he has had patients asking for a prescription for these two drugs in case they get sick with COVID-19.  There was one study in New York City that used hydroxychloroquine and azithromycin along with 50 mg zinc twice per day that did get excellent results but this showed more about the benefits of zinc than of hydroxychloroquine.  Hydroxychloroquine is a drug for malaria that has also been used in certain autoimmune disorders.  But it has some potential cardiovascular side effects, including arrhythmia in about 20% of patients. It can prolong the QT interval, which is something that is measured on an EKG. Azithromycin also prolongs the QT interval, so combined you are looking at 30-40% of patients potentially getting arrhythmia from taking this drug combination, and this arrhythmia can lead to sudden death.

39:27  Does taking certain commonly used blood pressure medications–ACE receptor blocking agents or ARBs (angiotensin receptor blocking drugs) (such as Losartan) make COVID-19 better or worse?  We know that the coronavirus attaches to cells and gains entry through the ACE2 receptors.  This has led some to speculate that taking such medications might make the infection worse.  There are ACE-2 receptors in the lungs, the heart, the kidneys, etc. which is why these drugs work so well.  But ACE inhibitors and ARBs are the most commonly used agents for hypertension because you can take them once per day, they work well, and they have few side effects.  They also have utility in heart failure, kidney disease, and in diabetes, so we use them a lot. To take all these patients off without any real evidence that they’re bad, could really make matters worse, because what we don’t want is more heart disease, or kidney disease. So, the American College of Cardiology, and the American Heart Association, have both come out with statements saying, there’s no real evidence that it does make it worse, despite the theoretical information that we have, and they may even be beneficial.  And the worst thing you want is out of control hypertension, heart failure, or kidney disease and then get infected, and have to deal with more problems.


Dr. Howard Elkin is an Integrative Cardiologist and he is the director of HeartWise Fitness and Longevity Center with offices in both Whittier and Santa Monica, California. He has been in practice since 1986. While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for exercise, diet, and lifestyle changes to improve their condition. He also utilizes non-invasive procedures like External Enhanced Counter Pulsation (EECP) as an alternative to angioplasty and by-pass surgery for the treatment of heart disease.  Dr. Elkin has written a book, From Both Sides of the Table: When Doctor Becomes Patient, that will soon be published. He can be contacted at 562-945-3753 or through his website, HeartWise.com.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.


Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts, and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.  Hello Rational Wellness podcasters, Dr. Ben Weitz. Thank you so much for joining me again today.

Our topic for today, is to take a look at the COVID-19 pandemic from the perspective of an integrative cardiologist, Dr. Howard Elkin. Especially since we know that COVID-19 affects the cardiovascular system in a significant percentage of patients, we’ve seen numerous reports that patients with existing hypertension, diabetes, and coronary heart disease tend to fare more poorly with COVID-19.  But we’ve also heard about patients with COVID-19, who end up with damage to their heart, including myocarditis, and cardiomyopathy. And these are often in patients who never had any heart disease, and we’ve even seen reports of younger patients in their 30s, and 40s, with blood clots, and even dying of strokes. We’ve also heard of some of the drugs being utilized, like hydroxychloroquine, causing arrhythmia.

Dr. Howard Elkin is an integrative cardiologist, with offices in Whittier, and Santa Monica, California, and he’s been in practice since 1986. Dr. Elkin does utilize medications, and performs standard angioplasty, and stent replacement, and other surgical procedures, but his real focus in his practice is to employ natural strategies for helping patients, including recommendations for exercise, diet, lifestyle changes to improve their condition.  He also utilizes other creative, non-invasive procedures like external enhanced counterpulsation, as a non-invasive alternative to angioplasty, and bypass surgery for the treatment of heart disease. Dr. Elkin has written a book, From Both Sides of the Table: When Doctor Becomes Patient, that will soon be published. Dr. Elkin, thank you so much for joining me today.

Dr. Elkin:              Thank you. I’m delighted as always to be here with you, Dr. Weitz.

Dr. Weitz:            And I’m sporting my pandemic beard here.  And as we’re filming this, since the topic is talking about patients with COVID-19, I wanted to start off by asking you a personal question. How has this pandemic affected you, and your practice?

Dr. Elkin:              Well, I think it affects everyone. As far as it’s affected me, clearly my outpatient business is down a little bit.  Maybe about 20, 25%, which is better than most.  I’ve made a real effort to keep us running, because so many patients, while I’m a cardiologist, these are the patients with higher morbidity, and mortality. So my emphasis has been to keep these patients healthy, and build their immune system so they don’t end up being a statistic.  So, it’s changed the volume that I see. But it’s also given me a chance to really focus on my own health, and basically, slowing down and smelling the roses kind of thing, so it’s actually been uplifting in a way.

Dr. Weitz:            Good. Excellent. One more question before we get into the COVID patients is, I’ve heard reports that there are a drastically decreased number of patients coming into the hospital with heart attacks, and other cardiovascular issues, and this may be partially because patients are afraid to come into the hospitals, because they’ve been told that they should stay away, or they’re afraid they’re going to come into contact with patients with COVID-19. What have you seen in that regard?

Dr. Elkin:              You’re absolutely correct on this. In fact, studies have shown in France, and also Spain. And we don’t have quite the data yet on New York, but heart people presenting with what we call a STEMI, which stands for ST-Elevation Myocardial Infarction. It’s a term used for a particular type of heart attack, that basically, it’s a total blockage, or occlusion of a vessel. And we need to get in there right away to intervene, in order to save a life, and to also minimize the size of a heart attack.  Now, the number, it’s been reported by the Cardiology Society, is that the number of STEMIs has decreased, anywhere from 60% to 80% in the last couple of months. That’s huge. I still take call about two to three times a month, and I’m in charge of the STEMIs when I’m on call, and the first week we had a lockdown, I had three cases. It was very, very busy. And that was at the very beginning of March.  Since then, I get almost no calls at all. And that’s just, I think, an exemplary of what we’re talking about. People are staying home, they’re afraid to come in, which of course, is not a good thing.  So we’ve been warned, from the American College of Cardiology, that we’re going to have an onslaught of cardiac cases in a few weeks, because people can’t stay home for so long, right?  I mean, this is a heart attack.  But I think it’s fear, people not wanting to leave their home.

Dr. Weitz:            Yeah, I know that unfortunately, some of these patients who might have come in with less severe disease now, might come in closer to end stage disease.

Dr. Elkin:              Absolutely. That’s my fear, and why I’ve blogged about it, I’ve written about it, I’ve been vocal about it on social media. It’s like, we’re open, we want to remain open. We want to be there for you as a source, so that we don’t have to deal with end stage disease.

Dr. Weitz:            And in California, where we practice, even though LA has had more in cases in some of the rural parts of the state, our hospital capacity has been not even close to being challenged. So, our hospitals now are starting to, I believe they’re going to start welcoming in patients for elective procedures. So hopefully that will help in that regard.

Dr. Elkin:              Right. Our hospital has just released that, in the last week or so. I actually did an elective angiogram on a patient. It wasn’t elective, he actually needed to have it done.

Dr. Weitz:            Right. A lot of people don’t realize, I talked to people about elective surgery, and they go, “Oh, you mean plastic surgery?” No. We’re talking about a huge number of important, medically necessary procedures, but they’re just not being done, because the priority has been to keep the ICUs open for COVID patients.

Dr. Elkin:              Right. I walked into my hospital’s lobby yesterday because I had a patient, I was doing a cardioversion, which is when you actually shock a patient’s rhythm back into normal, and the lobby is like nobody’s there. It’s so quiet. I’ve never seen a hospital so quiet. It’s surreal. It’s really surreal.

Dr. Weitz:            Yeah. So, while many people think about COVID-19 as a respiratory infection, it tends to have a fairly significant effect on the cardiovascular system. And in fact, its effect on the heart, the blood vessels, the kidneys, and on blood clotting, is often what leads to its lethality. And this distinguishes the coronavirus from other respiratory infections, such as the seasonal flu, doesn’t it?

Dr. Elkin:              Absolutely. And, this is so evolving. A few weeks ago, we thought… I didn’t really think about it as a cardiac problem. But, in the last few weeks, we’re seeing it really is quite a bit of cardiac involvement. In fact, at least 20% to 30% of patients, depending on what you read, tend to have an elevation in troponin, which is an enzyme that we look for, to detect injury to the myocardium of the heart. And that’s what we measure when people come in with a heart attack. And we follow that, we trend it. So we’re seeing a lot of these patients are having elevated enzymes, which does portend a bad prognosis. In fact, the mortality of people with elevated troponin levels, regardless of whether they end up having a heart attack, it just adds insult to injury. So if you see elevated troponin, it’s not a good sign.

Dr. Weitz:            I understand a lot of these patients have elevations of D-dimer, which is related to the fact that they have increased clotting. And I’ve talked to some physicians who are working in emergency rooms, and they’re telling me, I don’t know if this is done everywhere, but they’re starting to routinely put patients on blood thinners when they are admitted for COVID-19.

Dr. Elkin:              Yes, our hospital is doing the same. So D-dimer is a chemical test, and what it detects is basically venous thrombosis clots. And, a normal level zero, right? We’re talking levels as high as three, four and 5,000, which is unfathomable. You’d never see that before, even in someone that’s had a vein clot, or pulmonary embolism. So the numbers are astronomical, and then, doctor interventionalists that are intervening with people with strokes, they’re saying that the clot is being formed as they’re intervening.

Dr. Weitz:            Wow.

Dr. Elkin:              Actually seeing more clot being laid down, which, I can’t imagine that.

Dr. Weitz:            And I guess that’s what’s explaining why we’ve seen reports of patients in their 30s, and 40s, dying of strokes from blood clots. And then we heard about that actor, Nick Cordero, who had several strokes, had to have his leg amputated, and is still having some serious problems after being in the ICU for a considerable period of time. What is going on with this clotting, and what’s going on in the blood vessels?

Dr. Elkin:              We’re not quite sure, what the chicken, and what’s the egg in this case. First of all, a lot of people with end stage disease, they’re intubated, they’re in ICU, they’re not doing well. They develop this entity called DIC, disseminated intravascular coagulopathy. And so, what happens, you have these, and the end product is something called fibrin split products, and they cause all these little small thrombosis everywhere. Kidneys, legs, everywhere. But that’s just part of the problem. That’s end stage. When you see DIC, usually I’ve seen it in people that have sepsis, or acute respiratory distress syndrome, which of course, is common in these patients.

But now we’re seeing young people, like you say, with strokes, or these thromboses, and part of the problem is, we’re not quite sure why is happening. But we know that these people kept saying to themselves, “This can’t be a stroke, I’m only 30 years old.” Right? And so, they are not seeking immediate, or prompt attention, which is really bad. Because this is something that’s treatable. Just like what I do, as an interventional cardiologist, I intervene, I go in there, and I do a thrombectomy, and then put a stent in. The same thing can be done and a stroke center, which, my hospital is one of them. So, these patients should not be staying home if they have any sign, or symptom of a stroke, at any age.

Dr. Weitz:            Now, there’s been some discussion in the literature, how this actually ties in with the breathing problems patients are having, which was originally thought to be typical, to acute respiratory syndrome, and now they’re realizing it has more to do with low oxygen levels. And some of the data is showing that what’s happening, is that iron is being liberated, free iron is is being liberated from… The heme isn’t able to hold the oxygen, and the iron group is dislodged from the heme group, and is floating free in the bloodstream, and I heard one discussion about this.  So, if you have more iron in the bloodstream, it turns out our blood, which most people think is sterile, is really not sterile. There’s a lot of bacteria floating around in there, but the bacteria are not really active. Partially because they need iron to actually grow, and reproduce, and flourish. And now there’s free iron is leading to these pathogens in the blood growing, and creating toxins, and that this might be part of the process that’s leading to sepsis, and some of these other coagulable situations.

Dr. Elkin:              I agree on that. And this is new information. We’re just really reading about it. Again, it’s the chicken, and the egg thing. what’s happening first? And when I think of sepsis, having been around ICUs for many, many years in my training, and also as a practitioner, I think about, usually bacterial infections of any matter, or form, and then the end result is sepsis. But you do see it, and viremia, and it seems to be common in this virus, in which it’s overwhelming.  The body is breaking down, okay? The body is breaking down, and like you say, the heme is being stripped from the red blood cells, with the lack of oxygen. We’re learning so many things, and people need to understand this virus, it’s fickle. It can mutate, it can do all kinds of strange things. We don’t have a handle on it. And so, like, for example, ARDS, we’ve known about that. We’ve treated it for years, acute respiratory distress syndrome. We see it in any type of bacterial, and/or viral pneumonias.  But, usually it responds favorably to this thing called PEEP, positive end-expiratory pressure. Okay, but now we have found that these people with COVID-19 are not a homogeneous group. And some really don’t do well with high levels of PEEP.  Actually it can lead to oxygen toxicity, and other problems.  And that some of them behave more like high altitude sickness.  And some of them may need a C-pap machine, or different treatments. A lot of them are being put in a prone position, on their stomach, right? Because they can aerate more lungs. We’re just tip of the iceberg here. That’s why it really is learning process.

Dr. Weitz:            So from a natural perspective, if patients are being given blood thinners when they get into the hospital, if I wanted to do what I can, from a natural perspective, to decrease my chances of having a poor outcome if I do get infected, does it make sense for me to consider taking a natural blood thinner, like natto kinase, or maybe increasing my normal intake of fish oil, or garlic, or vitamin E, which may mildly thin the blood out?

Dr. Elkin:              Well, that’s a great question. So what do we do? Can we do anything prophylactically? First of all-

Dr. Weitz:            And preventatively, yeah.

Dr. Elkin:              Preventatively, right. You know the study that came out about a year and a half ago, that’s saying, “Low dose aspirin in the general population of over age 50, really isn’t something we recommend.”

Dr. Weitz:            But that’s because it might cause more bleeding.

Dr. Elkin:              Right. And I’ve adhered to that principle, even before the study came out. So now we have a different thing. I would say, yeah, first of all, I definitely am a firm believer of… What’s some things you mentioned? Like garlic…

Dr. Weitz:            Fish oil.

Dr. Elkin:              To me, anybody over the age of 40, and maybe even younger now, deserves to be on fish oil. That’s my number one go to supplement.

Dr. Weitz:            And see, fish oil is a natural anti-inflammatory, and we know part of the acute respiratory distress syndrome, where you get this cytokine storm in the lungs, you get a lot of inflammation. Fish oil probably could be beneficial in that regard, too. So maybe a simple solution is just up the normal amount of fish oil you’re taking.

Dr. Elkin:              Right. Ginger, garlic, they’re also natural blood thinners. Vitamin E. I usually like mixed tocopherols. These are all things that we can be doing. I haven’t recommend… I mean, my big thing is fish oil.

Dr. Weitz:            Yeah.

Dr. Elkin:              That’s a great question, because we don’t have the answer. We don’t want to thin it out too much, because what if you have to do surgery on these patients, or an intervention? Then we’ve got other issues on our hands.

Dr. Weitz:            Right.

Dr. Elkin:              But, these are the questions that really need to be answered.

Dr. Weitz:            Yeah. And yeah, I’ve increased my fish oil, and added one of those supplements that has the extracts from the fish oil that decreases inflammation, the inflammatory response modifiers. And, anytime I take fish oil, I always throw in some vitamin E, and the preferred source I’ve been using the last six months is the tocotrienols now, because the data seems to be pretty robust for that.  So, we know that patients with existing heart disease, and diabetes, et cetera, high blood pressure, have an increased risk. So, what can these patients do prophylactically to, besides, we’re talking about the blood thinner thing, what else could they do to make sure that they’re most likely going to have the best possible outcome?

Dr. Elkin:              And by the way, this is probably the most important question anyone can ask, which is what I’ve written about, blogged about. First of all, keep your appointments with your practitioners. Because-

Dr. Weitz:            And, I should say, besides losing 50 pounds, getting your blood pressure totally under control, and doing all those things to have perfect health. But what can they do in his short term?

Dr. Elkin:              Right. Okay, so, you’ve mentioned it already. Let me just give you a little bit of a rundown of the numbers. If you have preexisting heart disease, you’re twice as likely to have a negative result, I mean death. Your increase of mortality are doubled. I’m sorry, three times. You’re three times more likely. Same thing with diabetes. So, diabetes and preexisting heart disease are your two biggies. Kidney failure, twice as likely to die. And then the next one is obesity, which is, as you know, about 40% of the American population is obese, and about 70% are overweight. So we’re not dealing with a healthy crowd to begin with.  And that’s what I’ve been talking about. Use this opportunity to improve your overall health. If you’re hypertensive, get your blood pressure down. I’m really strict on that one, because, the numbers now are incredible. It used to be 70 million and now there’s 80 or 90 million people in this country with hypertension. Most of them do not know it. Most of them are not adequately treated, at least according to the standards that we’re looking for. So it’s really-

Dr. Weitz:            And according to the current standards, and the way you see the literature, what constitutes, what number of systolic diastolic blood pressure constitutes hypertension? And what is the ideal range that they should be in?

Dr. Elkin:              Right. I always tell people that the ideal blood pressure, whether you’re 20, 30, 60, 80, or 100, is always 120 over 70. And that doesn’t mean I try to get that in everybody, but that’s the ideal. But the standards now, which have been present for about a year and a half, is that anything above 130, on the systolic range, and above 80 on the diastolic range is considered hypertensive. So if you’re 131 over 81, that’s considered hypertension.  Now, does that mean I try to get everybody to that number, that’d be ridiculous, because patients would be on three or four medicines, they’d have to see me every three to six weeks. But, I do pick and choose.  On younger people, people that are really proactive about their health, people that really want to get to optimal. Yes, we will do our best to get that way. There’s so much you can do with lifestyle. People think that we should go straight to medicines, and I don’t tend to do that, when I see a new patient, unless the blood pressure is off the wall.

Dr. Weitz:            So what are the most impactful lifestyle factors that we can utilize?

Dr. Elkin:              Well, it always boils down to diet and exercise, right? I mean, because most of these patients are overweight, overstressed, and they don’t exercise on a regular basis. Same thing with diabetes.  So, for me, an ideal diabetic should be in the non-diabetic range.  I have many diabetics that start off with high A1Cs, I get them to being a pre-diabetic.  Then I get them below 5.7, and they’re really a diabetic, but we’ve got them very well maintained, and it can be done. It’s work but…

Dr. Weitz:            What are the most impactful dietary factors, A, for heart disease, and B, for diabetes?

Dr. Elkin:              Okay. 

Dr. Weitz:            Why don’t we start with hypertension?

Dr. Elkin:              Right. Then it always comes down to this topic about salt, right? I mean, just this age old problem that’s been going on for years. And, if you are a person with normal blood pressure, you do not have to worry about salt. Okay? It’s just unnecessary. If you have blood pressure, hypertension, it really is going to depend on whether or not you’re a salt retainer. Though there’s not a test that shows whether or not your salt retainer, but, if you tend to collect edema, or swelling of the ankles, if you’re African American, or Mexican American, these people tend to have a higher incidence of hypertension.  In the Caucasian group, it really depends. I am not overly strict about sodium, unless they have heart failure, kidney failure, liver failure, or they fall into those groups. Also, kidney failure is a very big one, and you have to be very careful about sodium with them. The average hypertensive, I very rarely give diuretics, which help you get rid of sodium. And I don’t super restrict, I just say, “Use a prudent diet.” I mean, you should be-

Dr. Weitz:            And of course, there’s a balance between sodium on one end, and potassium, magnesium, calcium on the other.

Dr. Elkin:              Right. People have to understand that sodium is not to be vilified. I mean, it’s important for nerve and muscle function, and it also helps create balance of the body fluids. So it’s essential for life, so I think that’s been over-emphasized. It’s actually been shown, I did a recent reading on this, that sugar, believe it or not, sugar is actually not good for the heart. I don’t know… For us in functional medicine, it’s not major surprise, right? But the emphasis has really never been on sugar.  In fact, some of these… On What the Health, was a documentary that came out a couple years ago, which is… I won’t go into my thoughts about it, but sugar was minimized, as far as any mal-effect at all on the body. So, it’s crazy. But back to the preventative stuff you were saying, I’m sorry.

Dr. Weitz:            By the way, the easiest way to weaken your immune system, is to eat a bunch of sugar.

Dr. Elkin:              Right. And I didn’t know this, but in my research, that sugar actually competes with vitamin C for your immune system. And so, my thing is, why would you want sugar to compete? And why would you want sugar to win? Because it will.

Dr. Weitz:            Yeah.

Dr. Elkin:              I mean, I’ve had patients who wrote on Facebook, “Wow. Since this pandemic, I’ve stayed at home, I’ve gained 15 pounds, and I’m baking bread and chocolate chip cookies.” It’s like, “You serious?” People are doing this. I mean, I drive by this [inaudible 00:24:51] place, I never stop out there, but on the way to work. And it’s packed.  Or I was at CVS, getting some razor blades, about two weeks ago, and I just happened to happen to walk by the candy aisle, it’s like almost everything is gone. These poor kids are at home because they’re not in school, and the parents are probably trying to shut them up, and giving them candy. Terrible. So those are the kinds of things. Sugar is very deleterious to your health, and is the last thing you want if you’re trying to build, or optimize your immune system.



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Dr. Weitz:             Are there any particular supplements that patients with hypertension might take at this point?

Dr. Elkin:          Yes. First of all, I do use, even though I don’t normally supplement with potassium, I don’t think you normally have to, if you eat adequate fruits, and vegetables. I sometimes will add just a little bit of potassium, because that can help lower blood pressure. Magnesium, so I’m big on minerals. I’m big on minerals. I have a product that has olive leaf extract in it, which has been shown in a population of patients have been effective. It’s also anti-carcinogenic. CoQ10 can be helpful. These supplements have small, but potentially cumulative roles.

Dr. Weitz:            Right.

Dr. Elkin:              So, I really try to… Fish oil, CoQ10, those two are much.

Dr. Weitz:            Of course, quercetin is a product that could be potentially beneficial for COVID-19 patients, because it’s a zinc transporter, but that also potentially can help with hypertension.

Dr. Elkin:              Right, exactly. So, minerals, there are things you can do. So, I add them. Plus, because of my standing as an integrative cardiologist, a lot of people come to me because they don’t want to go on medications. They’ve been to three or four doctors, they’ve all put them on medicines, they’ve had side effects. They don’t like it. So they’ve heard about me, and they come to me for that reason. So, these are the people I like to work with. But, it’s always gonna start with lifestyle, number one. We’ll add the supplements, and do my best to avoid going on medications. Lots of times you need it, because, again, to stay out of the hypertensive range, you may need to add pharmaceuticals. But it’s not my go to, at least initially, unless you’re really, really high.

Dr. Weitz:            It would be really nice if we utilize this opportunity. If we look at the fact, I’d be curious when we’re done with this, if we see how well the American public has fared with the COVID-19 infection, compared to other countries. But given the fact that we are, I believe, still the number one country in terms of rates of overweight, and obesity, and I’m sure we’ve got to be close to the top on diabetes, and we know heart disease is just rampant, as well as these other chronic diseases, we could use this as an opportunity to focus on trying to get our society healthier. And that would be a great thing for the health of our nation going forwards, and would also be beneficial for every other possible reason, in terms of lowering our healthcare costs, and even making people more productive. I think we should try to seize this opportunity to focus on what we can do to reduce the chronic disease burden.

Dr. Elkin:              And I could not agree with you more. And I really laud some of the things that you are personally doing. I mean, you have these Tuesday afternoon Zoom sessions, that people can dial in, and talk, actually share their thoughts about COVID-19. And, I mean, that is a great move. I just put together my own supplement, which is really basic, called ImmunoWise, to help boost the immune system. It’s very basic. It’s got the proper dose of vitamin C, and zinc, and I’m blanking now. But it’s got quercetin, but it’s a nice supplement, in one bottle. If you take three day, it’s going to help with your immune system.

Dr. Weitz:            That’s great.

Dr. Elkin:              So, we’re doing things, and I’d like to think that a lot of our colleagues are doing the same, taking that opportunity. And also to reassure patients, they don’t have to have negative outcomes, even if you have a heart problem.

Dr. Weitz:            By the way, I don’t know if you just came across the bulletin boards. There is a pre-print of a study from hospitals in New York, and they utilized zinc along with hydroxychloroquine, and it turns out that the patients who were taking zinc did remarkably better in terms of mortality rates, and being released from the hospital, or not ending up on a ventilator. And the dosage of zinc was actually quite high. They were using 50 milligrams of zinc, twice per day. So, that’s 100 milligrams of elemental zinc.

Dr. Elkin:              Right.

Dr. Weitz:            And I think that’s interesting that now you have traditional hospitals utilizing essentially a pharmaceutical dosage of zinc, and getting incredible levels. So, I think it’s interesting to see that some of these natural substances can be quite powerful.

Dr. Elkin:              And I think this is, again, why this is such an important learning process. We really don’t know. I avoid this whole hydroxychloroquine, chloroquine Z-Pak thing. We can talk about it. We probably should, because, I mean, I see these posts on Facebook, and I want to just scream, because these people are obsessed about who’s right, who’s wrong, why they’re right. It’s like, “You guys.” I say-

Dr. Weitz:            Just make sure when you take your hydroxychloroquine, wash it down with some bleach.

Dr. Elkin:              Right. Exactly. Yeah.

Dr. Weitz:            And inject some Lysol right after that.

Dr. Elkin:              Right. I saw this cartoon of our president, and he’s getting erect, and getting an enema. Oh boy. So anyway-

Dr. Weitz:            So yeah, why don’t you talk about… So hydroxychloroquine, or chloroquine. These are drugs that have traditionally been used for malaria. And there are some reasons to see that they may be potentially of benefit.  Even though, if they are effective, they’re certainly not going to be the cure all.  And, one of the benefits of hydroxychloroquine is that it helps as a zinc transporter. Unfortunately, it has a lot of potential side effects, and maybe you can talk about that.

Dr. Elkin:              Right. So, hydroxychloroquine, which has been used, like you say, for a long time, it’s also used in certain autoimmune disorders, rheumatologists use it for-

Dr. Weitz:             Lupus.

Dr. Elkin:              Lupus. Rheumatoid arthritis. I had a patient that was on it for briefly, for mixed connective tissue disease.  She was followed by a rheumatologist at UCLA, and had problems.  Here’s the thing.  The success stories are basically very anecdotal.  There’s a lot of observational studies, and I understand, it’s a new disease, basically, we don’t have a lot of data.  But some people are jumping to, “Oh wow, they’re using this in Inglewood, a hospital in Inglewood with great successes.” It’s like, okay, I would not take that as gospel.  But anyways, so here’s what we worry about.  It can prolong the QT interval. What is that? The QT interval is something we actually measure on a routine EKG. It has to do with your electrical… It’s resetting your electrical setting, electrical activity between beats. So you have a depolarisation, electrical impulse, and then the heart contracts. Then it has to relax in between beats, for the next one. So it’s electrical activity that can be… The certain part of the cardiac cycle can be prolonged, electrically, as a result of these drugs.  We’re talking about at least 20% or more of patients on these drugs will develop QT prolongation. Now, if you add azithromycin into it, which is not benign, like people think it is, then you’re probably magnifying that by double. You probably double it. So the two in combination, can really prolong QT interval. Why would you care? Because QT prolongation could lead to malignant arrhythmias. There’s one that we look for called torsades de pointes, which means a twisting of the points in French, and I’ve seen it, and it can be deadly. I mean, this is what can lead to sudden death. So, these patients really have to be monitored. I’ve had people ask me, “Can I have a prescription for hydroxychloroquine just in case?” I said, “Are you serious?” They said, “Just in case.” I’ve actually had people ask me this.

Dr. Weitz:            Yeah, just go to the pet store, and get the kind you use to clean your fish tank. You see how that worked out for them.

Dr. Elkin:              Right. Right. Exactly. So-

Dr. Weitz:            I’m referring to somebody in the news, who consumed that, unfortunately, didn’t have a good outcome.

Dr. Elkin:              Yeah, yeah. He thought it would… Amazing. So anyway, another reason to be concerned is because these patients are in ICU, they’re critically ill to begin with. Like I said, about 20% of them are going to have elevated troponin levels, if you look at the new data coming out. So, I don’t know. I would not want to give this to someone with an elevated troponin level, who’s already at higher risk of arrhythmias, right?  And then you’re going to potentially worsen that. So, these people that are so pro that combination, because it works, it’s worth… And a doctor in New York, who I don’t know this doctor, I’m sure you’ve heard about him. He’s said it work in every patient he gave it to.

Dr. Weitz:            I seen that report, too. Yeah, so I’d like to make a couple of comments about the hydroxychloroquine. One is, in the functional medicine world, people have jumped on this. I don’t know why, but somehow, there’s people especially tend to be attracted to conspiracy theories, and they think that we have this drug that works, but the medical establishment is telling people not to take it, because they want to force everybody to get vaccines.  And, I think it’s clear that we really don’t know if it might work. And, I certainly wouldn’t jump on it. And I think there’s an alternative. And then, number two is, there are folks in the natural medicine world, who have figured, “Since hydroxychloroquine may be of benefit, I’ll just give the patients quinine water.” And unfortunately, the amount of chloroquine in quinine water is so low, that there’s no way. If chloroquine, or hydroxychloroquine has a beneficial therapeutic outcome, then the amount in quinine is going to be insignificant. So, forget that idea.

And one of the main things that hydroxychloroquine seems to do is, it increases the ability to get zinc into the cells, they call it a zinc ionophore, and because the cells tend to repel the zinc, and in this recent study in New York, it turns out that the patients on hydroxychloroquine really had few benefits compared to the patients who were taking hydroxychloroquine and zinc, which really what that study shows is that zinc is a real benefit, and that hydroxychloroquine is just getting it into the cells.  So, those of us in the natural world use 250, to 500 milligrams quercetin each time you take the zinc, and that’s a natural alternative to getting the zinc into the system. And then one other potential benefit to hydroxychloroquine, is once the coronavirus gets into the cells, it gets put into an endosome, and then it gets pushed out of the cell, where it could spread. And, that that endospore requires an alkaline environment, and the hydroxychloroquine creates an alkaline environment, so it may suppress the ability of the virus to spread. But there’s an actual agent known as Chinese skullcap, that can also do the same thing. So you can combine quercetin and Chinese skullcap with zinc, and you’re probably going to get the same benefits without having any arrhythmia.

Dr. Elkin:              That’s interesting. That’s new to me, because I’m familiar with skullcap. It’s an actual anti-inflammatory, but I’ve never seen it in that context. But it’s interesting though, these… And like you said, I think- 

Dr. Weitz:            That was pointed out to me by Dr. Peter D’Adamo from the Eat Right for Your Blood Type, who I did a podcast with a few weeks ago. I wanted to ask you about one more set of drugs that are used for heart disease. So, we know that this novel coronavirus, they say it’s novel because we don’t have any immunity to it. So, this coronavirus tends to attach to, and gain entry into our cells through ACE-2 receptors, which are found in the lungs, and virtually on almost all the tissues of the body. And so, there’s been some speculation that certain common drugs for hypertension, like ACE inhibitors, and angiotensin response blockers might increase the risk of worse infection. What’s your perspective on this?

Dr. Elkin:              Okay, I’m glad you mentioned that. First of all, so there are ACE-2 receptors in the lung, in the heart, in the myocardium, in the kidney. I mean, they’re all over. But, that’s also probably why they work, why they’re so effective in blood pressure. But, so, this started off as an observational study. And I don’t even know if it was in vivo or in vitro, in China, when they noticed this, and it does make sense, right? I mean, if it’s the same port of entry, the virus enters the cell by attaching to an ACE-2 receptor, does it make it worse?  And then, the big thing about that, is that okay, well, ACE inhibitors and ARBs are the most commonly used agents for hypertension, and it’s certainly my practice, because generally you can do them once a day, and they are well tolerated with very little side effects.

They also have utility in heart failure, and renal conservation, people that are diabetic, so we use them a lot. To take all these patients off without any real evidence that they’re bad, could really make matters worse, because what we don’t want is more heart disease, or kidney disease. So, the American College of Cardiology, and the American Heart Association, I think, have both come out with statements saying, there’s no… And there’s truly no real evidence that it does make it worse, despite the theoretical information that we have. Some people say, I don’t know if you’ve read about this, that there actually may be some improvements.

Dr. Weitz:            Absolutely. And you can think about that, right? If the ACE inhibitors are blocking the ACE receptors…

Dr. Elkin:              Exactly. So, I have not taken anyone off of ACE or an ARB as a result of this information. I’ve had many phone calls. I’ve heard about this, but I have dissuaded them from changing. Plus, when you change blood pressure medications, and let’s say you have something, a combo that’s working, you’ve got to start all over again, with a different class of medications.

Dr. Weitz:            And the worst thing you want is out of control hypertension, and then get infected, and have to deal with more problems.

Dr. Elkin:              Right. Or heart failure, or worse, even kidney failure.

Dr. Weitz:            Exactly, exactly. Okay, so I think those are the main topics I wanted to cover. Is there anything else you wanted to tell the listeners, and viewers?

Dr. Elkin:              [crosstalk 00:42:38] Just one that’s interesting, I don’t have the answer to this.

Dr. Weitz:            Yeah.

Dr. Elkin:              But I want to hear your opinion, as well. This whole thing about testing.

Dr. Weitz:            Yes.

Dr. Elkin:              Should I be tested? Should I not be tested? And then you’ve got, again, the same kind of protagonists, and antagonists in the social media world, saying, “Oh, no.” So, what we look for, and I want to really get your opinion is, we want a test to be 100% sensitive, and 100% specific. 

Dr. Weitz:            And that doesn’t exist in the real world.

Dr. Elkin:              It doesn’t exist in the real world. So, if I am a true negative, that means I definitely don’t have the virus, or never had it, or [inaudible 00:43:13]. So, there’s loopholes, and as far as testing is concerned, it does not clearly confer immunity, and we don’t know how long immunity really will last.

Dr. Weitz:            So are you now talking about antibody testing, or virus testing?

Dr. Elkin:              Yeah, yeah. Not so much the nasal swab. We know that the nasal swab will be… If the nasal swab is done correctly, and these centers know how to do it.

Dr. Weitz:            By the way, it was just approved, I think either this morning, or yesterday, using saliva, a home viral test using saliva where the patients spit into a tube, and send it in. It’s been tested in New Jersey for a couple of weeks now. That was now approved as a new way to test, and that’s going to be a game changer for… We don’t have to worry about having enough of the swabs, it doesn’t require the same reagents, you don’t have to have somebody in a hazmat suit, with full PPE, worried about sticking a swab down someone’s nose, and being uncomfortable, and everything else. So, testing for the virus-

Dr. Elkin:              You’ve got to go way up there.

Dr. Weitz:            Yeah, this is going to be a big game changer as far as that goes.

Dr. Elkin:              So the antibody testing, there’s no perfect test. If you’re going to have it done, and I did have it done, you want to check… Even though I don’t think there’s anything that’s truly FDA approved yet, that takes a while to happen. Okay? You’ve not going to have FDA approval in such a short time period.

Dr. Weitz:            Well, what’s been happening is, is there are tests on the market that haven’t gotten any recognition at all, but there’s somewhere around, I don’t know, 80, 90 tests, maybe more, on the market that have been given emergency approval by the FDA. Meaning, hey, you guys have some data, it looks like you guys have done some thorough testing. We don’t really have time to investigate all the details, but go ahead, and put it on the market. It looks like you guys are doing a good job to start with. And so, I would certainly use a test that at least has emergency FDA approval.

Dr. Elkin:              Right. And I chose one that does both IGM, and IGG, and it’s quantitative. So, my test was negative. I maybe will repeat that in three months. There’s no set pattern as to when you do it. So, we don’t have the answers. There’s no perfect test. There probably would never be a perfect test. But, we will learn more about testing as we learn more about this virus.

Dr. Weitz:            Well, so there’s two types of tests. There’s one test where you prick your finger, and it’s called a blood spot test. And then there’s tests where they take serum. And the serum tests are decidedly more accurate. So, the blood spot tests are some ways in the 50% to 70% rate of accuracy, sensitivity, and specificity. And whereas, the companies that have done a good job with the serum tests are somewhere in the 90% to 100% range.

Dr. Elkin:              Correct.

Dr. Weitz:            So, I would go with a serum test, rather than a blood spot test. The blood spot tests are the ones where you get the results in 10, 15 minutes. The serum tests, unfortunately you have to send it in to a lab, and get it back.

Dr. Elkin:              Right.

Dr. Weitz:            But I’d like to make a comment about whether antibodies are protective. Now, it’s good to be cautious. It’s good to be careful. It’s good not to get ahead of the research. And it’s easy for people to extrapolate, make all kinds of claims that aren’t accurate. So, I applaud the medical establishment for being very careful, and saying, “Hey, we don’t know for sure if antibodies are protective.”  But, we know that the way our immune system fights against viruses, any virus, is to create antibodies. And this virus is, in many ways, similar to other viruses. And we know that our bodies do mount antibodies, and for the most part, not 100%, not in everybody, but generally speaking, I’d like to say that I think if we looked at the preponderance of evidence, even though we don’t have 100% proof yet, antibodies are going to be protective.  That’s the way our body works. If antibodies were not protective, a vaccine will never work, nothing’s ever going to work. Herd immunity won’t work. The whole point of herd immunity is everybody builds up antibodies. A vaccine is to synthetically stimulate your body to form antibodies. So, I know everybody’s being cautious, and fine. But, I’m not saying I have proof for this, but I think methodologically, it makes sense that antibodies are going to be protective.  The proof we do have is that they’re using convalescent plasma therapy, which is taking antibodies from patients who’ve been infected, and we’ve seen really good results. Also, they did a study with rhesus monkeys, and for antibody production, I guess, rhesus monkeys are fairly predictive. And they gave the rhesus monkeys the coronavirus, the COVID-19. They tested positive, they got over it, they tested negative, then they reinfected them with COVID-19, and they did not get infected again.

Dr. Elkin:              Right.

Dr. Weitz:            Because they had the antibodies. And I understand we’re being cautious about making these recommendations, and I think it would be foolish for somebody to say, “Hey, I had a positive antibody test, I’m going to run around without a mask, and infect everybody else, and not worry about anything else.” Because we can’t say 100%.

Dr. Elkin:              It’s like you’re having these COVID-19 parties. I agree with you. I [inaudible 00:49:17].

Dr. Weitz:            I think for the most part, we should think that antibodies should generally be protective. Don’t you agree with that?

Dr. Elkin:              Absolutely. And it always goes back to your immune system. People think, they want to think, and I’m not going to try to politicize this by any way, matter, or form, is that a vaccine is like a magic bullet. A magic pill. Americans, we always want that magic pill or bullet, which doesn’t really exist. Now vaccines can be effective, but you’ve got to remember about, if you look at just the flu vaccine, just that simple, little flu vaccine, about 50% of people do not respond favorably to it. Why? Because they’re obese, diabetic, hypertensive heart disease, renal failure, and they can’t mount an adequate immune response.  When we give you a vaccine, we’re really giving you the antigen, we give you an attenuated form of the virus. We’re dependent on your body to form antibodies. And if your body isn’t healthy, you’re not going to have the same response. So it still boils back to the lifestyle, the kind of stuff that you and I talk about all the time.

Dr. Weitz:            Absolutely. Excellent, Dr. Elkin, I really appreciate it.

Dr. Elkin:              [crosstalk 00:50:22].

Dr. Weitz:            I enjoyed the discussion. For those who don’t know, Dr. Elkin’s on the west side, in my office on Tuesdays. And I believe you are probably the only integrative cardiologist on the West Side of LA right now. So, patients should take advantage of the ability to see Dr. Elkin, in Santa Monica.  And, I also wanted to say to our listeners and viewers, that in addition to this podcast showing up on Apple Podcasts, where if you give me a positive rating and review, I would really appreciate it. But it’s on Spotify, it’s on all the other places you get podcasts. And there’s also a video version on YouTube. And also, if you go to my website, drweitz.com, you can find a complete transcript, and detailed show notes. And then how can listeners and viewers get a hold of you, Dr. Elkin?

Dr. Elkin:              The best place, probably through my website, www.heartwise.com. I’m also on Facebook, at HeartWise Fitness & Longevity Center. I’m also on Instagram. So, I’m all over social media. So, I’d be glad to talk to, meet anyone. Clear pleasure.

Dr. Weitz:            Excellent. Great. Thank you. I’ll talk to you soon.



Keto Green with Dr. Anna Cabeca: Rational Wellness Podcast 155

Dr. Anna Cabeca discusses her Keto Green Approach to Diet with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

4:55  The Keto Green 16 diet allows you to get results in 16 days. Dr. Cabeca also recommends doing a 16 hour intermittent fast. And in numerology 16 means willpower, intuition and transformation.  The Keto Green diet is a super low carb diet that puts you into a fat burning state, into ketosis by eating mostly healthy fats and quality proteins and lots of dark, leafy green vegetables that help to alkalinize your system. Other keto diets tend to put you into an acidic state, which has a catabolic effect on hormones and can lead to an inflammatory state.  This program helps to balance our master hormones: cortisol, insulin, and oxytocin. These help us to balance our sex hormones: progesterone, estrogen and testosterone and even DHEA. Measuring and keeping our urine pH in an alkaline state will help to manage our cortisol levels and our other hormones.

12:24   Does testing urine pH really make a difference in our health when the pH of our blood stays in a very narrow range no matter what we eat.  Also, certain portions of our body thrive on an acidic environment, like our digestive tract and the vagina, among other areas.  Dr. Cabeca pointed out that when we do a urinalysis we always measure the pH.  If a patient is really sick in her clinic, she would draw out arterial blood and measure the gases to see what their pH is and if it slightly low, she will give IV bicarbonate to quickly resuscitate them and get them balanced.  Our body works hard to maintain this metabolic balance and if we become slightly more acidic we will pull minerals like calcium and magnesium from the bones to increase alkalinity, which can promote osteoporosis. Emotions and stress can also play a role in this metabolic balance. Laughter, a walk on the beach, fun with friends can make you more alkaline as measured in your urine. Incorporating dark green leafy vegetables, sprouts, herbs, and Dr. Cabeca’s Mighty Maca Greens powder can also lead to more alkalinity.

17:52  A traditional ketogenic diet often seems to revolve around eating a lot of meat and Dr Cabeca has an omnivore plan that includes meat and fish, but she also has vegan and vegetarian plans as well.  All her plans are dairy free. Dr. Cabeca has been wearing a continuous glucose monitor and finds that by following her Keto Green diet her blood sugar stays in a narrow range with no peaks or valleys.  She is even able to eat Keto-Green chocolate mousse, made with avocado and cocoa and only 3 grams of carbs.

20:35  Some might question why it matters what women eat when it comes to hormones, since once they hit menopause, their hormones decline fairly dramatically.  But if we balance our blood sugar, that can help with hormone balance.  And blood sugar control is important for brain health. In order for our brains to use glucose, women need some estrogen, so after menopause it is better to have your brain run on ketones rather than on glucose. This is one reason why the ketogenic diet is so beneficial, since it shifts us into using ketones for energy.  This need by the female brain for estrogen to use glucose may be one of the reasons why older women are so much more prone than men to Alzheimer’s Disease.  The ketogenic diet also helps reduce weight gain, anxiety, insomnia, and fatigue that are neurological symptoms of endocrine imbalances that occur with menopause.



Dr. Ana Cabeca is a triple board certified OBGYN, in Integrative Medicine and in Anti-aging and Regenerative Medicine as well as an expert in Functional Medicine, menopause, and women’s sexual health. She specializes in bio-identical hormone replacement therapy and natural alternatives, successful menopause and age management medicine. And Dr. Cabeca has just  published her second book, Keto Green 16. Her first book, The Hormone Fix, was a USA Today bestseller in 2019. 

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.


Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, DrWeitz.com. Thanks for joining me, and let’s jump into the podcast.  Hello Rational Wellness Podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, I would appreciate it if you can give me a ratings and review on Apple Podcast. If you’d like to see a video version, please go to my YouTube page. And if you go to my website, DrWeitz.com, you can find detailed show notes and a complete transcript.

So our topic for today is the ketogenic diet with Dr. Anna Cabeca. So we are going to talk about Dr. Cabeca’s version of the ketogenic diet and how this can help to balance our hormones, help us to lose weight and promote our overall health. Dr. Anna Cabeca is Triple Board-certified OBGYN. She is also an expert in integrative and functional medicine. She specializes in women’s sexual health and helping women with the changes of menopause. Dr. Cabeca will soon be publishing her second book, Keto-Green, will be coming out very shortly. And her first book, The Hormone Fix was a USA Today bestseller in 2019. And she also has a podcast that she recently renamed The Girlfriend Doctor Podcast. Dr. Cabeca, thank you so much for joining me today.

Dr. Cabeca:         Thanks for having me. Good to be with you again, Dr. Weitz. Thanks.

Dr. Weitz:            As we’re filming this, we’re still in the midst of this coronavirus, COVID-19 pandemic. So just on a personal note, how is this affecting you and your family and your endeavors?

Dr. Cabeca:         Initially, it started off a little bit rough because I had a daughter studying in Holland, and she was in her third year of university. She was studying in Holland, admist weekend travels and everything else. And so when all this started, I was looking at the research, trying to understand what’s going on. And I’m well connected and spoken internationally with some of the medical societies. One of my dear friends, a founder, Dr. Francesco Marotta of the ReGenera Medical Society of Italy. And I reached out to him and got a hold of him, and he’s like, “Bring her home right away.” And so that ignited some panic, that ignited some PTSD because, Ben, my story, we lost a child and the fear that, “Oh my God, would we lose another child? I can’t get to her in time.”  All of that really triggered me. So I had a really rough start till I got her home. And then just all the principles of practice that I teach of really just, again, just foundational disciplines and principles, I incorporated that. And I will tell you, we are doing better than ever. We are doing better than ever. And definitely, I’m in line supporting my medical colleagues and my clients and my patients on a daily basis. But as a family and personally, feeling strong, resilient, and grateful for every day that I have here.

Dr. Weitz:            That’s great. That’s great. You can get lost in fear. You spend all your time watching the news and get depressed, or you can try to remake yourself and make something good out of a tough situation.

Dr. Cabeca:         Yeah. And I think that’s it too, looking for those silver linings and just being very conscientious and bringing back to that family dinner time, which has been certainly a bonus of us. Now, we’re a household of five women and two female dogs.

Dr. Weitz:            So the question I have is, how do you eat while wearing a mask?

Dr. Cabeca:         I know, not in our house, which is so cool. Gosh, wearing this mask continuously, when I go out, it just brings back those flashbacks to operating in the operating room, wearing a mask and having a runny nose and being like, “I can’t freaking touch anything. This is terrible.”

Dr. Weitz:            I’m not used to wearing a mask at all, and right now I have the mark of the mask, which is this red mark across the bridge of my nose from wearing an N95 mask and not knowing exactly how to properly fit it. So, how do you come up with the name Keto-Green 16? Where does 16 come from?

Dr. Cabeca:         Well, 16 is actually, it’s a fun. The science is, number one, I wanted the shortest amount of days that I could get the maximum amount of results. I’m all about efficiency, quick results. Those are quick wins that keep us compliant, especially as women and me and around my age, I’m 53 years old and 53 with a 12-year-old, Ben. I’ve got to keep my hormones healthy. And so especially again, time efficient everything out. So 16 days, that was the number that stuck in my head, and I really felt committed. And then I dug in, there’s some great research studies that looked at 16 programs that got results in 16 days, so I felt like I didn’t have to do a 21-day, a 40-day program, and that was the first thing.

And then also I wanted 16-hour intermittent fasting. So the 16’s also 16 hours intermittent fasting and really working for that for the 16 days and staying committed to that. So again, I was just like going off on the number 16. I’m like, “How many key food ingredient types?” And I just wrote it down, lo and behold, 16, 16 key food ingredient types. And then I was like, “Well, how about for high intensity exercise? How many minutes can I get away with? Okay, 15, but 16.” And so I just kept going. And then I did some research and someone actually told me, he said, “Well, do what the number 16 means as far as numerology or angel numbers and something like that?” And I was like, “I have no idea.”  And it’s willpower, intuition and transformation. I’m like, “Oh, perfect.” And then there’s one other bonus is like, how many 16-day diet plans have you failed? Probably none because there really aren’t any.

Dr. Weitz:            Got to be the first.

Dr. Cabeca:         So that’s a good track record.

Dr. Weitz:            Yeah, absolutely. So how does this program help us balance our hormones?

Dr. Cabeca:         Well, this is all part of being, our hormones-

Dr. Weitz:            Well, maybe you should explain what your program is.

Dr. Cabeca:         Oh yeah, that’s a good point. So beyond the 16. The Keto-Green plan, and this is where it comes into the key parts of hormone balancing. And the dog in the background is just proof in pudding that I am home with my animals. The 16 Keto-Green comes from understanding what is happening, how we can master our physiology in the menopause time period. Now, again, pre-menopause, post-menopause, men do fabulous, but women have the toughest time in the peri-menopause, in this menopausal transition. And I experienced it myself. And as a gynecologist, I’d love to say that it’s all about progesterone, estrogen and testosterone and even DHEA.  But the truth is that it’s really about these major hormones such as cortisol, insulin and our master hormone, oxytocin. And so the Keto-Green way is about getting into ketosis, getting into that fat-burning state through healthy fats, good quality proteins. But the key part, and this is where keto dieters make a mistake that they are eating very acidic foods leading an acidic lifestyle for too long and that really creates a catabolic effect on their hormones and they can get into trouble, inflammatory diseases, etc. So you have to do it right and there in comes the green aspect, which is the fiber again, because keto dieters are constantly constipated and have that issue. Many of them, not all. Again, there’s right way and wrong way-

Dr. Weitz:            And that’s because for those who aren’t familiar, ketogenic diet is a super low carb diet. And when you take a lot of the carbohydrates out, you tend to remove a lot of the fiber.

Dr. Cabeca:         Right, exactly. And so we want to add that fiber back in the form of low carbohydrate, dark leafy greens that are micronutrient rich, so that helps to balance cell membrane health. Now, even so we see fabulous results right away because we’re improving cell membrane health. But it’s not just about what we eat, that alkalinizing component is also the thoughts we keep, the way we live. When we manage cortisol, we have more of an alkaline urine pH. When we’re more cortisol driven, we have a more acidic urine pH. So my alkaline approach really does require a little self-assessment tools such as checking urine pH for pennies a day, just check your urine pH. It makes a huge difference.  So the Keto-Green, Keto Alkaline way is this. And where it transformed my life was when I was 48, experiencing my second menopause, let’s say. Because I’d been diagnosed at 39 with infertility and early menopause. reversed it, had a baby at 41, that 12-year-old that I’m now homeschooling. Blissfully. So blissfully homeschooling. It’s not my forte, Ben, it is not my forte. I was 48 and I was spiraling down and that’s when like brain fog, memory loss, I gained 20 pounds overnight without doing anything different. Our patients would come in and say that to us. “Dr. Anna, I’m gaining five, 10, 20 pounds and I’m not doing anything different.” And as a young confident physician, highly trained, I would think in my mind, “Really? How is that possible? How can that be possible?”  And then it just freaking happened to me. So of course I dug into the research to understand why, very humbly so, and a silent apology out to all my patients I doubted. However, I always did the backup work on hormones and everything. Really it does happen, without doing anything different, I gained 20 pounds overnight. And having been well over 240 pounds at one point in my life and losing those 80 pounds, keeping them off for like nearly a decade, that rapid weight gain, I was like, “I’ll be 300.” So that’s where I really started doing keto. And it’s low carbohydrate, higher fats, high protein, and just restricted the carbs. And I certainly I’ve put patients on these types of programs in the past.

And as I started experiencing, not so much keto flu, but keto crazy, I was irritable, I knew something was up with my neurotransmitters and my hormones and that this transition period of menopause creates a more vulnerable time period, and likely because of our decrease in our natural progesterone, yet my hormones as a hormone expert were dialed in. Dialed in, pretty optimized, and that’s why I say it takes more than hormones to fix our hormones. And so as I discovered why, I started checking my urine pH, I was so acidic. I was so acidic. Now, we’re not talking blood pH as you know, but urine pH, this is another vital sign for us. And so that was an aha moment for me where I’m like, “Okay, let me add in the greens.”  But that also as, I started testing every time I went to the bathroom essentially to get more alkaline in, it started to improve. But I noticed the days that when I woke up and I walked outside, did a nice leisurely walk in nature and, or did my gratitude journaling in the morning, I was more alkaline all day. And so that’s when I researched like, “Why? How does stress or cortisol cause this?” And that’s a physiologic effect of cortisol, is urinary acidification. So here we can use urine pH testing to manage cortisol, our lifestyle and our nutrient base. And this is where we really see the needle moving.

Dr. Weitz:            Now, this alkalinizing urine thing is something that’s fairly popular in the Functional Medicine world, and the traditional medical world severely criticizes it. Now, criticisms are because the pH in the blood stays in a very, very narrow range between 7.35, 7.45, never really changes, doesn’t matter so much what you eat at all. And in fact, it can’t change because you would die if it got significantly off. And big parts of our body actually thrive on an acidic environment like the digestive track and the vagina, etc. So does it really matter what the pH of your urine is, if the pH inside the body is different?

Dr. Cabeca:         Yeah. And this is that beauty of this discovery. And I want to say too, as far as medical, I think at some point physicians, the medical societies realize how important pH testing was because it’s on all our urine test strips. Every time you go to the doctor, we dip, definitely an OBGYN, we dip your urine, pH is always on there.  At some point we forgot.  We stopped looking at it when like we pass renal physiology in medical school and we don’t look unless we go back to nephrology. But in this conversation, as I started discovering this with myself, I went to a nephrologist and spoke with him, even though again, renal physiology, it was a long time ago.  This is where I really dug into it. Now, we know, because like if someone came into my operating room or my clinic and they were really, really sick, I would put a needle in the radial artery right here at the wrist, base of the wrist and draw out arterial blood gas, not even venous. Arterial blood gas as closely delivered from the heart as possible, the most oxygenated blood. And we know if that is slightly high, slightly low, and it’s typically slightly low when they’re crashing, that little difference, they are crashing and we’re going to give them bicarb like baking soda, essentially. By that, we’re going to do IV bicarbonate to quickly resuscitate them and get them balanced.

How do they get there? That is a metabolic imbalance. Certainly there’s a metabolic imbalance between potassium, magnesium conversations across the cell membrane. And how do we maintain that? We maintain it so specifically to keep us alive, so we will rob Peter to pay Paul to keep that mineral balance, to keep that alkaline balance in our blood from, what? Minerals. Where do we get those? Bones. So who are more likely to be osteoporotic? Those with acidic urinary pH. So the urinary pH, just like our pulse and our blood pressure now becomes a vital sign that helps us do our Nancy Drew detective work. Maybe for you it was Hardy Boys, for me it was Nancy Drew. Nancy Drew detective work.

When I did karaoke the other night, oh my gosh, my urine pH was eight. It was so much fun. That laughter, the walk on the beach. But stress, thinking about the coronavirus, thinking about someone who’s sick and I have no control over, I quickly are able to gather my thoughts to say, “I am the only one who can upset myself.” That’s the tragic situation. But I can choose how to react, and that’s where we create, and it talks about this in the Bible, through faith, these practices. That we create the peace that surpasses all understanding.  And that was it for me, as I created that alkalinity aspect into my life, I was still perimenopause, I was still this single mom, two kids with one in high school, one in middle school.  And then my young one in her first years of elementary school.

None of that had changed. I was still the breadwinner. I was still cycling down burnout from my business, but I had this peace, and that enabled me to go from burnout, foggy brain, struggling with my relationships, unable to like remember my kids’ names, let alone write a blog, to I’m now writing and publishing two bestselling books, another additional two online programs and having a community of over 300,000 people that I serve blissfully to help support them during this time, because I’ve been to hell and back. I’ve been there and I know what works, and this Keto-Green way for me and how important it is fine tuning our physiology, and how much control we have as being our own physician, listening to our internal physician, our intuition too. That has just transformed my life, and I know many others’.

I love it. I love Detective Drew, it’s so cool, so much fun. And right now running some group medical visits with Keto-Green 16, that’s what my clients said. They said. “Thankfully, I’m checking urine pH, I’m seeing where my mind is stressing me out, and quickly gaining control of it with your spiritual practices, going for long walks, doing these things as well as nourishing their body with the greens, adding in supplemental like Mighty Maca greens, adding in the sprouts and the herbs that are all so alkalinizing and powerful. They said they just felt so much better having something positive to focus on. And it really did. It took them out of fear-based thinking and they had fabulous results.

Dr. Weitz:            So your version of the ketogenic diet, how is it different than a traditional ketogenic diet? Traditional ketogenic diets, even though they’re supposed to be moderate or lower in meat, they often seem to revolve around meat with every meal.

Dr. Cabeca:         Yeah. Well, with Keto-Green 16, we have the omnivore plan, which also has, it has meat, fish and also some vegan options certainly. But also we have a 16-day vegan and vegetarian Keto-Green plan. All my plans are dairy free because I’m dairy free, if I can’t have milk, neither can you. That’s not why, but because it’s one of the most common food sensitivities. You can optionally add something, but yeah, it’s pretty much eliminated. And they’re gluten free, grain free for the most part. And so that really does help with insulin sensitivity. So what I’m thinking about with my Keto-Green plan, it is what want to eat, the healthy fats, the good quality proteins and the plentiful fiber and dark green leafies. But it’s also when we’re eating, we’re not snacking anymore.  Monitoring blood sugar, one thing I’ve done, you’re going to love this, Ben. You know FreeStyle Libre, the 14 day blood sugar monitor?

Dr. Weitz:            Right.

Dr. Cabeca:         Over the past year, as soon as I found out about this, I was like, “Oh my God, I got to get one.” It’s like there’s toys. I know you’re like that in chiropractic, “Oh, what’s this gadget?” And you don’t need a monitor, you just use your smartphone and you can just see, “Here, I’m an hour or so after my Keto-Green breakfast, my blood sugar is 85.” And you can see there’s… I don’t know how well you can see that, anyone who’s listening, but this is the last eight hours. There’s no peaks, blood sugar stays… This is 24 hours, blood sugar stays really, really stable. And that’s eating two or three healthy Keto-Green meals per day.  And even my Keto-Green chocolate mousse, my avocado chocolate mousse, it’s a fabulous a feast, but it’s like three grams of carbs and done with avocado and cocoa. So we can have these fun things and keep our blood sugar stable, which creates insulin sensitivity. And keto, we’re looking for that, but then there’s the different ways that you can do it. The key component is that we are really focusing on balancing our hormones and creating not just the right nutrient combinations, because like adding fermented foods and digestive support is critical to my plan, that’s not thought about in general keto, but also it is the lifestyle factors that we put in that makes this plan so powerfully successful.

Dr. Weitz:            Now, women, once they hit perimenopause, menopause, their hormones decline and they decline fairly dramatically. So what difference does make what they eat?

Dr. Cabeca:         Oh, see, this is so important. Thank you. You’re teasing me, I know This is so beautiful, because look, this is what I found out too. I had to think, “Well, why am I having the brain fog? Why was I experiencing in the brain fog?” And no one talked about this. No one has talked about this. I needed to understand, I’m always like, “Why do research? I don’t know if this about me. I did research with the US Navy and exercise physiology before I went to medical school.

Dr. Weitz:            Oh, cool.

Dr. Cabeca:         Yeah. So I loved it, hyperbaric medicine, physiology, and then I was the physiology mentor in medical school. So I wanted to understand why, the mechanism of action, like “What the heck is going on here?” It blew my mind when I figured this out. First of all, I knew that once I got Keto-Green, I had clarity, my memory was back, I was sharp and it wasn’t like this caffeine clarity, kit’s this calm piece, like I mentioned, I call it energized enlightenment. Not only did I lose that 20 pounds within weeks, but I had this clarity and this peace. I created amazing relationships with my children. Like I said, able to write and create the programs that I have, but I needed to understand why.

And so what happens during this time, yes, we’re declining progesterone and declining estrogen, what’s really key, why the brain fog when our hormone levels are shifting? It’s because gluconeogenesis in the brain is an estrogen-dependent phenomenon. In other words, for our brain to be able to use glucose, we need some estrogen on board. Now, as our ovarian function declines, it’s really a sharp decline in progesterone, also precursor to estrogen. When we add stress, brain fog. A sharper decline of our neuroprotective hormone because cortisol steals away progesterone, that also estrogen and testosterone suffer.

Now, what’s really amazing is why don’t men experience this to any notable degree that I’ve heard explained anywhere? Well, number one, men have 10 times as much testosterone which converts to estrogen, and according to research that I found, in men’s brain, there is six times as much, up to six times as much circulating estrogen because number one, you don’t rely on ovaries for estrogen production, go figure. We rely predominantly on ovarian function, so when this ovarian function declines and we don’t shift to go… We have to shift when we are in this perimenopause. That’s why I say, getting Keto-Green in the perimenopause and beyond is absolutely necessary for us.

It is absolutely necessary to get into ketosis because we can shift to use ketones for fuel, which is actually preferred by the brain and ketones are to the brain. I like to make the example of glucose is to gasoline as ketones are to jet fuel. And that’s what it feels like because use of ketones in the brain is not hormone dependent to any degree that I’m aware of. And that creates this clarity, this memory. And part of this may be an explanation as to why women have 2.6 times as much Alzheimer’s as men, 2.6 times as much Alzheimer’s because our brain as estrogen declines, is it’s suffocating a little bit, it’s starving because it’s not getting the glucose, the fuel it needs as readily into the cells.

But ketones, yes. And that clarifying point was for me, another aha moment to understand, and yet when we look at the curves, now, we’ve been studying the brain and we can look at glucose utilization in the brain, that drop in glucose utilization in the brain follows our decline in progesterone. So 35 to 55, that period of neuroendocrine vulnerability, and the big problem is how that manifests clinically. Our patients come in saying, “Dr. Anna, I’m having brain fog, I’m having PMs, I’m gaining weight, I’m having hot flashes, I’m irritable, I hate my husband two weeks out of the month.” I was like, “Don’t say that because it’s more than two weeks, it’s your husband. If it’s only two weeks, it may be your hormones.”

And so this during this time, but it’s anxiety, it’s insomnia, it’s fatigue. So these are neurologic symptoms along with the endocrine symptoms such as the irregular cycle, the ovarian cysts, the irregular uterine bleeding, which often leads women to get hysterectomies and their ovaries out, which is going to worsen the problem. The uterus is a victim. Sometimes we still need to remove it, but we always want to address the underlying reason why we need that hysterectomy to begin with, and address the underlying reasons. Not enough to say, “Well, I had heavy periods, that’s why I had a hysterectomy.”  Well, why did you have the heavy periods? And that is certainly my husband, my pet peeve with my profession, my colleagues and my profession, but also my patients, you’ve got to ask why, you’re responsible for your body.

Dr. Weitz:            And that of course is the Functional Medicine approach and how it’s different than traditional medicine is asking why, let’s find the underlying reasons, let’s see what we can do to get your body to work the way it knows how to work instead of overwhelming it and just fixing the problem with a drug or a surgery that certainly can be lifesaving in certain circumstances, but if it’s not needed and we get to the underlying cause, that’s a better way to go about it.

Dr. Cabeca:         Yes, absolutely.

Dr. Weitz:            Now, everybody focuses on estrogen and progesterone, and you talk a lot about some other hormones like oxytocin, most people don’t really give it much attention. Why is oxytocin so important?

Dr. Cabeca:         It is the most powerful hormone in our body. Oxytocin is absolutely the most powerful hormone in our body and it is actually the most alkalinizing hormone. As acidifying as cortisol is, Oxytocin is alkalinizing. I want to give an example of how this plays out. I had a client age 67, she’s been following my online magic menopause programs for the last few years. So she’s very comfortable checking her urine pH, and here she is in Northern New York and as soon as this COVID quarantine hit, she was distanced from her daughter and her grandson and she’s locked in with her husband. I’m not exactly sure which was worse.

But she said that she was really struggling, she was struggling on getting alkaline, nothing shifted, just worried and watching the news and she goes, “I’ve been working on it though.” And she said, “Dr. Anna, I have to share with you this though.” She goes, “My grandson was turning two and I wasn’t going to be able to be there with him for his birthday, and so my daughter had us do a Skype virtual birthday party for him, and I got to see him eat his cake and open his presents. And he just laughed and giggled at me and oh my gosh, it just made my day.” And she goes, “Dr. Anna, I couldn’t wait to go run to the bathroom and check my urine, and sure enough, I was like a pH of eight. I was so alkaline.”

And she goes, “Yep, the power of oxytocin.” Absolutely. That is the power of oxytocin. That is really what we live for, and we need more oxytocin in our life now more than ever, it really does help us manage cortisol and overpowers the negative physiologic effects of chronic stress. So the more we can get oxytocin, the better. Now, I know it from a personal, and this is again, I didn’t study this, I had to research it. I didn’t learn this in med school, I didn’t learn this in residency there. All I knew about oxytocin in residency, certainly love bonding hormone, the hormone to help us breastfeed, to help moms breastfeed, and the hormone that we give IV during labor, Pitocin is oxytocin. Pitocin to increase the speed of labor contractions.

And so that’s where my knowledge had sufficed up until I hit that deep, dark, bottomless pit of depression and anxiety and grief. And as a result of PTSD and trauma where cortisol was winning and fear based mentality beyond everything I knew. I lost a child, so thinking, “Oh my God, checking on my other children, are they breathing at night? What’s going on?” Not sleeping for three hours a night. And then we knew, my husband I knew that when couple’s lose a child, they have an significantly increased risk of divorce, and we didn’t want to be that couple. We wanted to stay together forever, that was our vows. And we went to counseling, we did this, we did that and yet we divorced.

And so because predominantly, I felt nothing. I couldn’t feel love, I couldn’t feel connected. I felt disconnected, and all the other symptoms that chronic PTSD, I mean PTSD-ers, like I’m going to say, we’re going to be… I prefer post-traumatic growth. Now, I’m in a totally post-traumatic growth stage or post-traumatic resilience stage, but I didn’t know that at the time, I didn’t know what was happening under the surface. And so the physiology of that disconnect, the physiology of that divorce was the oxytocin-cortisol disconnect. And so when cortisol goes low and oxytocin is low at the same time and cortisol is suppressed and oxytocin is low, that feeling is that feeling of isolation, of a loneliness.

And this is what now I see it everywhere, I no longer feel love, I no longer feel connected. I know I love my husband, I don’t feel love for him, something’s wrong. And also oxytocin seeking behaviors intuitively, and you see this in, and I’m not going to say midlife crisis, I hate that term, but binging or shopping or the midlife crisis or sex seeking, those are often oxytocin seeking behaviors because there’s this bottom-down disconnect. And those of us who have had trauma or adverse childhood experiences, we know that in the menopause, and I would say in the andropause too, we get a flare up of the symptoms.

And so once you’re aware, that’s why this education is so important that you’re giving and that we’re sharing today too, is that when we’re aware of this, we see it, and then we can say, “Okay, well, let me just give this a try. What if I empower oxytocin and master oxytocin in the most helpful ways through loving, kind gestures, maybe playing with a pet, doing karaoke with your friends, having virtual birthday parties, whatever it is. And how does that make us feel?” That’s what we want at the end of our lives anyway, that we loved well, we lived well and we’ve looked back on the hard times of our life and saw how much grace and kindness and love was still there.

Dr. Weitz:            That’s great. Can your program be effective for women who are taking hormones?

Dr. Cabeca:         Absolutely, yeah. And even in men too. In the study, we had one man, in fact, he came along with his wife, because I was looking at postmenopausal women, and so in 16 days he lost 30 pounds and he had high blood pressure, his blood pressure had run, I have to look at the numbers again, but like 150, his diastolic was 100. And so his diastolic got down to 70 and it was weaned off, started to wean off his blood pressure medicine. So yeah, men do really, really well too on the program. I have a whole men’s chapter this time for you guys, Ben, in Keto-Green 16.

Dr. Weitz:            Cool. And of course, following a program similar to yours, a ketogenic diet could potentially be helpful for reducing inflammation and that could be helpful at this time of Coronavirus because people who do get infected who don’t do well, they get into this state of high oxidative stress, inflammation in the lungs and that’s when they tend to go downhill.

Dr. Cabeca:         Ketones can be protective, plus, we’re getting insulin sensitive. There was an article and actually I was just reviewing this today and I know you’ll love it, I’ll put the article in the footnotes. It was published by Journal of Neurology in 2006 and it looked at the Avian Coronavirus Infectious Bronchitis Virus undergoes direct low pH dependent fusion activation during entry into host cells. So what they said, a more basic environment was protective, so hence that alkaline environment is more protective. And so again, that why that is so critical and why our smokers have more trouble because they’re more acidic in the lung and they get increased viral replication.  And I think that’s really a critical component. So both the Keto and the alkaline aspects are really important. And granted, again, stomach pH, very acidic, vaginal pH, naturally acidic. And if not, definitely use Julva, a little plug for my cream, but other areas of the body more alkaline. So again, consider urine pH, a thermostat, a thermometer just measuring how well are you doing.

Dr. Weitz:            Yeah. That’s actually one of the proposed mechanisms why hydroxychloroquine or chloroquine might have some benefit is that it tends to alkalinize that endosomes and a virus needs that endosome environment to be acidic to be able to reproduce. Not that I would recommend that, but the other thing that chloroquine does is it’s a zinc transporter, but of course-

Dr. Cabeca:         That’s why zinc is beneficial.

Dr. Weitz:            Yeah. The issue though is getting zinc into the cells, so the best combo is to add quercetin with your zinc, because that’s a natural zinc transporter.

Dr. Cabeca:         Okay. I didn’t know that. That’s awesome. I’m doing it all; quercetin, zinc. Mighty Maca has quercetin, turmeric, resveratrol, green tea extract, Cat’s Claw. It’s all in my Mighty Maca Plus Formula. I’m drinking that too.

Dr. Weitz:            Well, green tea is also a zinc transporter too, also helps with that.

Dr. Cabeca:         Awesome. And zinc too for hair loss by the way. You know my stress related hair loss, zinc helps with that too. That’s the reason I’m doing it, really. Again, I’ve been okay. If I get sick… No, no, I’m just kidding, I don’t want the hair loss.

Dr. Weitz:            And zinc can help thyroid function and testosterone levels too in men who are low in zinc.

Dr. Cabeca:         Yes, absolutely.

Dr. Weitz:            So besides following the Keto-Green diet, you also recommend some nutritional supplements for women and men?

Dr. Cabeca:         Yeah. And I think that’s definitely where we certainly agree. For me, I would say, if I want my clients to leave with two things by my own prejudice, because it helped me on my journey, reversed my infertility and helped my hormones, my Mighty Maca Plus. Over 30 superfoods, everything we’ve just mentioned is in here. The Maca, Peruvian Maca, which is interesting too with the altitude sickness. We haven’t looked at Maca with altitude sickness, but it grows in the high alps. And I know in Peru, I haven’t researched this, but when I was in Peru, if you have altitude sickness, do the Maca, do the cocoa leaves. That was one part.  So I wonder if there’s something with this altitude sickness and also like how they’re saying the heme oxygenation, if that improves heme oxygenation because Maca only grows, the pure Maca and the one I use, grows in the high altitude.

Dr. Weitz:            Yeah. Now, they’ve been discarding the typical protocols for ventilation because they’re not working and they’re saying that this is much closer to altitude sickness and using some of the medications that are traditionally used for that, it seems like they might have more efficacy for the type of respiratory problems that people are having. So that’s an interesting thought.

Dr. Cabeca:         I know. I’m curious about that. So with Mighty Maca Plus too, we talk quercetin, Cat’s Claw herbs, turmeric, resveratrol, green tea extract, 30 superfoods. So that’s one. And then Omega-3 fish oils, always supporting cell membrane function, and a probiotic, but I use the fermented foods. So if we need to, we can add a probiotic on top of that. I definitely think it’s beneficial as we get older. I monitor myself, but I probably will do a probiotic once or twice a week now because I am doing fermented foods on a regular basis as part of my nutritional combinations. And also I think that the other thing I use, I definitely in the perimenopausal, postmenopausal woman is a bioidentical progesterone. So my PPR Cream progesterone with Pregnenolone, both neuroprotective hormones.

And then of course I added in some anti-aging ingredients into my formula just because anyway, because I can, and it’s for me. And that’s a really big one, I think sometimes gets overlooked. We want to support the adrenals so that’s bottom up and we want to support top down and just progesterone deficiency. Certainly, I think in post-menopause we should be doing a little bit of progesterone at bedtime, at least five or six nights a week. And certainly, it helps men to have sleep issues. So again, a little bit goes a long way. And that’s part of my supplement regimen amongst vitamin C and zinc, those are our core supplements.

Dr. Weitz:            Cool. So I think that pretty much takes us to the end of the discussion unless you’ve anything else that you’d like to bring up? I’m sure there’s a lot of, a lot of topics we could add in.

Dr. Cabeca:         Well, I think definitely that’s a big thing to know is that, again, when we get Keto-Green, we’re mastering insulin sensitivity and we are working on these alkalinizers and in a very short amount of time following this plan my Keto-Green 16 Plan, we’re going to see fabulous results. And again, it’s all about discovery. And I want to let clients know, no matter if you have five pounds to lose or 200 pounds to lose or you’re dealing with diagnoses like I was, I was 39 dealing with an infertility diagnosis and an early menopause diagnosis. But let me just tell you, that we can reverse these diagnosis, diabetes, high blood pressure.  We’ve seen just amazing results and quickly and it is about us claiming our power back. And I say this very wholeheartedly, the answer is not finding a vaccine, the answer is in creating a resilient, healthy community and being inhospitable to invasions of any sort.

Dr. Weitz:            That’s great. So how can viewers, listeners get ahold of you and find out about your program and how can they get your book that’s going to be coming out? Can they pre-order it?

Dr. Cabeca:         Yeah. Anywhere books are sold, I definitely encourage calling your local bookstore, leaving a message, getting that order in there.

Dr. Weitz:            Amazon’s got enough orders.

Dr. Cabeca:         Yeah. But certainly it’s available, Amazon, Barnes and Nobles, Books-A-Million and all the Indie Booksellers. It’s published by Ballantine Penguin Random House. And we have book bonuses at my website, just enter in your receipt number, whether it’s from an Indie Bookstore, a local bookstore or anywhere else, and you guys can just snapshot that receipt or enter that receipt number and get a bunch of extra book bonuses too.

Dr. Weitz:            And what’s your website?

Dr. Cabeca:       dranna.com. Like DrAnna, D-R-A-N-N-A.com.

Dr. Weitz:          Cool. Thank you.

Dr. Cabeca:         Thank you, Ben. Thank you.



Thyroid Hacks with Dr. Ruben Valdes: Rational Wellness Podcast 154

Dr. Ruben Valdes talks about Thyroid Health and How to Improve it with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

4:08  Thyroid hormone is the master hormone and is the only hormone that is received by cells at the nuclear level.

5:40  The thyroid produces the inactive form of T4 which then has to be converted into T3, the active form.  In severe cases of Hashimoto’s, patients can go through a thyroid storm when the body starts destroying the thyroid and all the stored thyroid hormone gets released and they end up with too much of the active form of thyroid hormone, T3.  They may get strong palpitations and they will get very hot and this is very damaging to the other organs in the body.  Therefore, you don’t want too much of the active form of thyroid T3 floating around the blood stream. It is much safer for the body to produce T4, the inactive form, and let the various tissues convert the T4 to the active T3 form as needed. 60% of the thyroid hormone conversion takes place in the liver, 20% in the intestines by our gut microbiota, and the other 20% in various tissues thoughout the body like the skin and bones.

8:26  There are various nutrients that are required for synthesizing thyroid hormone, and then for this T4 to T3 conversion, including iodine. The thyroid always needs iodine but taking too much iodine can make Hashimoto’s worse.  It can be an immune trigger and taking a high dosage, like 12.5 or 25 mg found in Iodoral, can be especially dangerous. Diagnosing Hashimoto’s can be tricky since sometimes the patient can be negative for TPO and TGB antibodies and there is a third set of antibodies, alpha and beta tubulin, which are measured as part of the Cyrex Array 5, which is the multiple autoimmune reactivity screen. Alpha and beta tubulin are structural cross fibers that are found in different tissues, including the brain and also the thyroid, though it is much more rare than TPO and TGB.

14:02  Dr. Valdes has a standard thyroid panel that he likes to run that includes the following: 1. TSH, 2. Total T4, 3. Free T4, 4. Total T3, 5. Free T3, 6. Reverse T3, 7. TGB antibodies, 8. TPO antibodies, 9. Thyroid binding protein, 10. Thyroid binding globulin, 11. Alpha tubulin, 12. Beta tubulin. It is important to compare Total T3 to Free T3.  For example, if your Free T3 is in range, say 2.4, which is on the high end of the range, but their total T3 is 71, which is on the low end. This indicates that not enough of the T3 is bound, which indicates an issue with thyroid binding protein. If you don’t measure reverse T3, then you will not know that some of your free T3 is actually reverse, inactive T3.

17:20  Most traditional MDs usually just run TSH and TSH is important and a high TSH will drive thyroid gland hypertrophy and can even drive thyroid cancer.  So it is important to suppress TSH.  Dr. Valdes likes to see TSH between 1 and 1.5, which is a bit extreme, whereas most experts look at normal as being between .4 and 4.0 or 3.5. 

20:58  Reverse T3.  When the body is converting T4 to T3 it removes one of the 4 iodines from the carbon ring.  It is supposed to remove the iodine from the outer ring, but if it removes an iodine from the inner ring, then it becomes an inactive form of T3 known as reverse T3.  You can have a patient that has a high T3 but yet feels badly, their hair is falling out, they are tired, and they’re moody.  High cortisol, chronic stress, chronic inflammation, and infections will drive cortisol up and impair liver detoxification, which can result in forming more reverse T3 when the T4 to T3 conversion is happening in the liver.

25:19  Dr. Valdes said that his experience is that when you just place patients on Cytomel, which is just T3 alone, patients may feel amazing for the first few months and then they start to tank because they develop thyroid resistance.  Dr. Valdes likes to use GTA Forte from Biotics as the preferred thyroid medication, which is actually a nutritional supplement.  It is a glandular with some added cofactors, including the minerals zinc, copper, rubidium and selenium, and the antioxidant Superoxide Dismutase.  Dr. Valdes pointed out that Armour thyroid has a portion that is synthetic, so a purely glandular product like GTA Forte is to be preferred.  He also likes the prescription product Nature Throid.

33:40  Thyroid Binding Globulin.  If you have a high Total T3 and a low Free T3, this indicates an overproduction of thyroid binding globulin (TBG). TBG usually follows Sex Hormone Binding Globulin (SHBG).  Dr. Valdes then likes to run a DUTCH test, which is a Dried Urine Hormone test to look at how well they are metabolizing or clearing their estrogen.  If they are not clearing their estrogen or metabolizing it safely, then you need to address metabolism and detoxification issues.  If it’s a male, DUTCH can tell you if they are aromatizing some of their testosterone into estrogen, and if so, is it primarily estrone, estradiol or estriol.  You also want to see if men are overconverting their testosterone into estrogen.

36.55  The underlying causes of Hashimoto’s thyroiditis (primary hypothyroid) can include HLA DR-DQ susceptibility to biotoxins, heavy metals, leaky gut, chronic infections, insulin surges, estrogen surges, cortisol surges, food sensitivities.  Which direction to pursue will have to do with the history. 

40:55  Dr. Valdes does a very detailed history on every patient and he uses the Living Matrix software that uses the history taking model developed by the Institute of Functional Medicine.  This model helps him to see which direction to go when trying to discover the underlying, root causes of the thyroid problem.  Should he focus on defense and repair, assimilation, communication, their energy system, or the structural integrity of their organs? Then he will use detailed testing to help zero in on possible causes based on the history. 

42:54  If he suspects biotoxins, like mold, Lyme, cauatera, bloom, spider bites, and snake bites, he will run a HLA DR-DQ.  Lyme starts out as an infection but the Borrelia produces a biotoxin. Other markers are C4A, TGFB1, MMP9, and VEGF, which are part of the Richie Shoemaker protocol.  Dr. Valdes does not find the urine mycotoxin tests that helpful.



Dr. Ruben Valdes is a Doctor of Chiropractic and an expert in Functional Medicine. He is the Chief Content and Marketing Officer of Novis Health Systems, a Functional Medicine franchise. He wrote 3 books, including The Chiropractic Entrepeneur, From Diabetic to Non-Diabetic, and The Thyroid Hack. Dr. Valdes can be contacted through Novis-Health.com.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.


Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.  Hello, Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to our Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcasts and give us a ratings and review. For those who’d like to see a video version, you can go to my YouTube page, Weitz Chiro, and if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.

Today, our topic is a Functional Medicine approach to thyroid health with Dr. Ruben Valdes. The thyroid is the master regulatory gland and it’s found in the front of the neck below the Adam’s apple. The thyroid produces three main hormones, T4, T3 and calcitonin.  Calcitonin plays a role in regulating blood calcium levels. T4 and especially T3, which is a more active form, affect metabolism, appetite, gut motility, heartbeat, breathing rate, the mitochondria and many other functions in the body. Too little thyroid production, hypothyroidism, including Hashimoto’s autoimmune hypothyroidism, which accounts for 90% of cases of hypothyroidism in the US, can result in weight gain, a lack of energy, brain fog, feeling cold, constipation, hair loss, infertility, et cetera. Too much thought production, hyperthyroidism, including autoimmune hypothyroidism called graves, will speed up the metabolism and cause weight loss, hair loss, et cetera.

 The traditional medical treatment for hypothyroid is to prescribe synthetic T4 thyroid hormone, also known as synthroid, and that’s pretty much the extent of the treatment. Occasionally, some T3 may also be prescribed as well, but there is never any attempt to figure out the underlying causes for the thyroid to determine why this thyroid stopped functioning properly. Similarly, for the traditional medical approach, in cases of Hashimoto’s thyroiditis, there’s virtually no focus on the autoimmune condition that’s causing the thyroid to malfunction, with all the focus being on reducing TSH levels using thyroid hormone, but from a functional medicine approach, we want to discover some of the underlying triggers and causes for hypothyroid and correct these. When there is autoimmune thyroiditis, we need to look for some of the reasons why our immune system has gotten so out of balance and make some changes so we don’t see a continued destruction of the thyroid gland.

Our goal today is get a better understanding of what some of the mechanisms of hypothyroid are, including autoimmune, how to properly analyze and improve thyroid health with the proper thyroid panel, and then figure out some of the root causes and how to correct them using a functional medicine approach. Dr. Ruben Valdes is a doctor of chiropractic and an expert in functional medicine. He’s the Chief Content and Marketing Officer of Novus Health Systems, a functional medicine franchise. He wrote three books, including From Diabetic to Non-diabetic, The Thyroid Hack, and his newest book is Awakening from Alzheimer’s. Dr. Valdes, thank you so much for joining me today.

Dr. Valdes:          Thank you so much for having me, Dr. Weitz.

Dr. Weitz:            Dr. Valdes, can you explain, what’s the role that the thyroid plays in our metabolic functions and our overall health?

Dr. Valdes:          Absolutely. Thyroid hormone is what I like to call the master hormone. It’s the only hormone that is received at the nuclear level. You know that every other hormone has receptors on the surface cell of the wall, whether it’s insulin, testosterone, estrogen, cortisol, you name it. They’re all received and affect the outer membrane of the cell. Thyroid hormone, specifically activated T3, is the only hormone that makes it all the way in through the cell wall and stimulates nuclear activity. If you remember, obviously DNA is what lives in the nucleus of the cell, so it initiates transcription and translation. Everything in our body is dependent on transcription and translation, from our ability to grow hair, to our ability to grow nails, to our ability to produce cells to repair, to regenerate, to produce oil in our skins to regulate our metabolism. Everything is DNA dependent. Imagine what the consequences long term of having your master hormone become disordered, diseased and dysregulated are and can be.

Dr. Weitz:            Interesting. The thyroid produces the inactive form of T4, which then has to get converted into T3, which is the active form. I wonder why the body has set that up? What’s the evolutionary advantage of producing an inactive form that has to be converted into an active form? Wouldn’t it be easier if the thyroid just produced the active form of T3?

Dr. Valdes:          Well, that’s a great question actually, and a very smart question. The reason why that would be catastrophic is because what would happen is the moment that that active hormone is immediately released from its origin site, the thyroid, everything around it would immediately absorbed and uptake this very critical master hormone. We actually see that in very severe cases of Hashimoto’s, when people are going through something called thyroid storm. When that happens, there’s very aggressive, very active destruction of the thyroid, and all of that stored T4 and the little T3 that’s stored is released, and you’ll see a lot of metabolic activity centrally. They’ll get very, very strong palpitations. This will get very, very hot, and it just puts all this tissues that are around the thyroid in danger. The body being as brilliant as it is, is going to first create primarily the inactive form so it can be bound, transported, converted, and then taken to the sites where it’s actually needed.

Dr. Weitz:            Cool. Where does most of the conversion of T4 to T3 take place?

Dr. Valdes:          60% of that conversion happens at the liver by an enzyme called 3,5 deiodinase.  Another 20% is happening in the lining of our guts, primarily by our gut microbiota, and then another 20%, which is not really very effectable, or alterable, happens at the level of our bone and skin, and other peripheral tissues. Now, when you look at a panel and you look at where their total T3 levels are, sometimes it can be a dead giveaway. People that normally would have, or typically would have very, very low levels of T3, I’m talking maybe in the 70s or less, almost always you can immediately assume that that’s liver, right, because when it’s gut that 20% usually won’t drive it that low. Sometimes the levels themselves can immediately begin to tell you where some of these under conversion patterns might be happening, even before you look at the rest of the lab work.

Dr. Weitz:            Interesting. What are some of the nutrients required for synthesizing thyroid hormone, and then for this T4 to T3 conversion?

Dr. Valdes:          Yeah, so nutritionally, the thyroid always needs iodine and this is such a controversial topic, as you already know, because for patients with Hashimoto’s thyroiditis, and Hashimoto’s thyrotoxicity, iodine becomes extremely toxic.  As a matter of fact, it can be an immune trigger that makes the Hashimoto’s worse, right?  There’s all this information out there and all these people talking about, “Hey, low thyroid. Take iodine,” and they’re unfortunately making the primary reason why they have hypothyroidism worse, crazily.

Dr. Weitz:            In fact, in certain Functional Medicine circles, very high dose iodine supplement called Iodoral at 12.5 or 25 milligrams, whereas the average dosage of iodine in the diet’s supposed to be about 150 micrograms, which is what you usually see in a multi, they’re promoting the use of these super high dosages of iodine.

Dr. Valdes:          Yeah, and it’s very, very sad. It’s very sad to see because before that… it’s not a wrong intervention. It can be a good intervention, but at the right time. Way before somebody would jump on that wagon, being primary hypothyroid, meaning they have Hashimoto’s disease, we first have to confirm that the immune system is going into remission, that it stopped its attack on the thyroid, so then the thyroid can utilize that nutrient effectively. If you’re uptaking those high doses, you’re getting a surge. Those surges are very, very immuno activating, and you’re making the primary condition worse. There is a time and a place for an intervention like that. It just has to be done at the right time.

Now, we can speak a little bit, as we move forward, about secondary hypothyroidism, which is not that commonly talked about, meaning the gland itself is healthy, but there’s other factors in the body that are ultimately influencing how effectively and successfully that gland is creating hormone, and how the body’s converting the hormone. For those patients, if it is confirmed that in fact it is not Hashimoto’s, then we have to talk a lot about how many people are tested, and since they test negative for TPO or TGB, they’re told, “No, you don’t have Hashimoto’s,” when in fact the majority of them actually do. We’re now even discovering and learning about a third form, about a third set of antibodies that are more rare, but that can also be diagnostic of Hashimoto’s disease called alpha and beta tubulin.  The prevalence of true secondary hypothyroidism is actually very small 3 to 4%. For those patients, iodine intervention right off the bat might not be a good… might not be a bad idea, but for the majority of people, if you’re not going into that level of depth, then you’re actually placing the patient at risk of having… re-triggering of their autoimmunity.

Dr. Weitz:            That’s interesting. That’s the first time I’ve heard about these two new antibodies to look for autoimmune thyroid.

Dr. Valdes:          Yeah.

Dr. Weitz:            Can you repeat what those are again? Where is that testing available?

Dr. Valdes:          Yeah. They’re called alpha and beta tubulin. Alpha and Beta tubulin are cross fibers, structural cross fibers that are found in different tissues. They can, at times, be found in the brain. They can be found in other areas of the body, but they’re very prevalent in the thyroid. The best place to run those is through an RA-5 from Cyrex Labs. They’re included in their multiple autoimmune reactivity serum.

Dr. Weitz:            No wonder I’ve heard of it. Okay.

Dr. Valdes:          Yep. Yeah, so they’re in there and we’re now learning that it is a rare form, and it can act very similar to thyroglobulin, which clinically we tend to see people with elevated thyroglobulin antibodies that have autoimmune thyroid tend to have a more severe version of the problem than just the TPO antibody itself, because TPO is just attack on the enzyme which alters hormonal production, versus TGB is actually going after the structural components of the thyroid. When those patients are under attack, their ups and downs are a lot more severe. The severity of the condition tends to progress very rapidly.  Patients with alpha and beta tubulin tend to present more like TGB than TPO. Interestingly, I had a case of this recently in a young girl, and 31, losing her hair, her hormones all over the place, very dry skin, always cold.  We ran the classic 11 markers and everything looked good. I was like, “You look fine.” Her TSH at 1.8, her TPO, TGB normal, everything else normal, but it looks so much like Hashimoto’s.  We dug deeper and it came back positive for alpha and beta tubulin. It was interesting.

Dr. Weitz:            Interesting.

Dr. Valdes:          Yeah very.

Dr. Weitz:            Why don’t we go through testing now? Why don’t you tell us what your standard profile is? You mentioned 11 standard tests that you do.

Dr. Valdes:          Yeah. For most patients, we’ll run the classic TSH, T4 total, T4 free, T3 total, T3 free reverse. We’ll run both antibodies, TGB, TPO. We’re going to run thyroid binding protein, sometimes sex binding protein, and then if necessary, alpha and beta tubulin. That puts us at 12.

Dr. Weitz:            Right.

Dr. Valdes:          If we don’t run the sex binding globulin, that’ll put us at 11.

Dr. Weitz:            Now, it’s become a standard in some of the functional medicine circles to just run a panel that includes free T3 and free T4. What does adding a total T4 and total T3 give you?

Dr. Valdes:          Well, it tells us a lot. I don’t know who would do that and why because thyroid binding protein is a very important player. You want to know, even if the T3 levels look good and they’re in the functional range, it’s like, okay, great, you have enough free, but you really can’t make assumptions based just on that. Number one, you really want to know how much of that hormone is actually bound anyways. Having a comparison of total T3 to your free T3 is going to speak into how well your thyroid binding protein is binding. Let’s give you an example. What if your T3 is in range, I don’t know, at 2.4 on the high end of the range? You’re like, okay, this is good. Their symptoms are going to be okay, but you look at their total T3 and they’re 71. Right? There’s a problem right there because your total T3 levels are low, and there’s probably some type of issue with thyroid binding protein where not enough of it is bound.

Yeah, you’re having enough to three, but your overall production and conversion is crappy. Right? I want to know that. In addition to that, we can never assume that all that free T3 is active, because part of that free T3 that’s being counted is actually reverse T3 that’s being reported just this T3. When you look at your total T3 value, that includes active and reverse T3. It’s all bundled in the total T3 count. When you look at free T3, you’re getting active and you’re getting reverse. You don’t know, just by looking at free T3, that all of it is active together. I would say to a certain extent, it is a disservice and it takes us back to the very thing that we’re trying to get away from in Functional Medicine, which is just dealing with symptoms, which is the whole conventional approach. Our idea is to get a full picture of everything that’s going on with that patient, with that pattern in order to be able to promote health to the highest level.

Dr. Weitz:            Right. Traditional doctors a lot of times just run the TSH. That’s all they’re really concerned about.

Dr. Valdes:          Yeah. I mean, let’s be fair, that’s important. A high TSH is going to drive hypertrophy in the gland. It can drive cancer. Yeah, they’re trained in pathology. They’re trained in disease. Suppressing TSH is, in fairness, important. It’s a good thing. However, baby, If we begin to talk about the things that also matter, like quality of life for these patients, the elimination of the very symptoms that took them into their doctor’s office in the first place, right?

Dr. Weitz:            Right.

Dr. Valdes:          The things that they actually want help with, they’re untouched by just looking and treating their TSH. Yes, it’s a very incomplete picture and on top of that, most doctors are utilizing the reference range which, pardon my French is absolute garbage.

Dr. Weitz:            What range do you like to use for TSH?

Dr. Valdes:          Well, I’m a little bit of a Nazi. I like it to be one to 1.5, and that’s not really…

Dr. Weitz:            That’s extreme.

Dr. Valdes:          It is extreme. Yeah, it is extreme. Most of the time they’ll say from point A to 2.3 is acceptable. If somebody is above the age of…

Dr. Weitz:            Most traditional doctors have a range of up to four or 4.5.

Dr. Valdes:          That’s right. Yeah, and by the time someone’s anywhere close to four, their life is collapsing, man. They feel so terrible. They’re being told… and I see it all the time, they’re like, “Yeah, my thyroid was checked and I was told I was good. Go home. Don’t worry about it.” Until you go up that extra fraction of a point. “Wait, now it’s time to put you on a drug for the rest of your life,” which, surprise, surprise, is the number one selling drug in America. Synthroid and Levothyroxine.

Dr. Weitz:            Yeah. What about when patients get older? I heard one prominent functional medicine doctor say that once you’re past 60 and you… TSH up to 10 is still okay.

Dr. Valdes:          Okay, wow. Yeah, I find myself challenged by that statement. Absolutely. As we age, there’s a lot less concern about that range. Normally, I’m typically pretty comfortable with patients around the age of 65 being three, 3.2, I’m a lot less strict, and primarily because now you begin to enter the risk of arrhythmia’s and cardiovascular stuff. Yes, allowing that range to be broader and less strict in people that are older is most of the time okay. 10? I don’t know that I would ever be comfortable with. I would honestly have to see the research that would support that, but up to date, I haven’t seen studies that would support allowing a TSH to be that high again because of the risk that that poses to the thyroid around nodulation, and that’s a risk that will be present until somebody is 80 or 90.

Dr. Weitz:            Right. You mentioned reverse T3. Let’s talk about reverse T3 and what the significance is.

Dr. Valdes:          Yeah. Reverse T3 is like an isomer. That means a mirror molecule. When the enzymes that create the conversion into T3 are working, sometimes they’re working very rapidly, and they’re going to remove the wrong iodine from the ring. T4 is called T4 because there’s four iodine around the ring. Normally, if my memory doesn’t fail me, the iodine that we want to remove is on the fifth carbon, but sometimes if the iodine on the third carbon is removed, it creates this mirror molecule. The problem with it is that it looks identical. It’ll be bound to protein. It’ll be transported, but it can’t fit in the nucleus. It can’t fit on the receptor, so making it ineffective, an ineffective, inactive form of T3. There’s a lot of people that, for one reason or another, too much of that conversion goes the wrong way and they start over making this reverse form of the hormone.

Now, a lot of times, you might look at their total T3 and you’re like, “Wow, it’s 120, 125. This is fantastic,” and you look at them and they look like garbage, right? They’re exhausted, their hair’s falling, they’re tired, they’re moody. Their husband or their wives are ready to kick them out of the house, and it’s because it’s because when you dig deeper, more than 20% of that total hormonal conversion is becoming this inactive form. There’s a lot of things that drive that. The most common, historically, is high cortisol. High cortisol, chronic stress, chronic inflammation, infections will drive cortisol up, and it’ll impair or alter phase one, phase two detoxification pathways. It can also alter gut inflammation, gut microbiota, also altering the conversion into reverse T3. Yeah, definitely a very important piece to look at.

Dr. Weitz:            If you see an alteration, do you look at the T3 to reverse T3 ratio? Is that how you analyze it?

Dr. Valdes:          Possibly I mean, if I’m going after symptoms and you’ve had those patients where you’re like, they need to start feeling better yesterday, right? Because we want them in care. This is the patient that’s been to six other doctors and nobody’s been able to help me feel better. That’s the patient where you take that approach. You want to increase their free T3 right out the gate as much as possible. However, for a long term strategy, for a long term plan, again, we have to go back to the entire panel and just make sure that things balance out the way that they need to.  Reverse T3 is always going to be there and it’s not a problem as long as it represents less than 20% of their total T3.  Yes, I would say absolutely.  Looking at that ratio, especially initially, to clear symptoms is going to be very valuable, but down the road, you always want to look at the entire cascade of fibroid conversion, clearing, transport.  You want to look at all the pieces to have a sustained recovery.

Dr. Weitz:            I’ve heard a few docs talk about this reverse T3 and this reverse T3 ratio and say that when that’s out of whack, they basically add T3 to the patient.

Dr. Valdes:          Yeah, and I have mixed feelings about that for numerous reasons. A lot of the T3 that’s out there, like Armour Thyroid and Cytomel specifically… Cytomel and I don’t get along.

Dr. Weitz:            Yeah, Cytomel is specifically T3 because Armour is basically a combination of T4 and T3, and maybe T2 and T1 as well because it’s coming from desiccated pig thyroid, right?

Dr. Valdes:          Yeah, absolutely. My experience has been that when you supplement or when you replace primarily T3 and only T3, the first two to three months the patient is going to have this… it’s like they come back to life. They’re like, “My god, this is amazing. You’re the best doctor in the world,” and then all of a sudden they start tanking. They start tanking and keep tanking and keep tanking. What I have learned is that they begin to develop thyroid hormone resistance, almost every single time, and that’s one of the reasons why Cytomel is no longer prescribed willy-nilly. When that thing came out originally, It was like, “Cytomel for you. Cytomel for you.” That’s gone away. It’s rare that you would see rarely any patients, and when I have somebody that comes into my office, they’re like, “Yeah, I’m on Cytomel.” I’m like, “Man, your doctor’s probably from the 19th century.” The problem with it… yeah. The problem is that the body, again, did this, designed this…

This was designed very specifically from conversion to T4, to binding, to transport, to delivery into the cell. There’s something. I’m almost sure that at some point, we’re going to find that there’s probably some type of tag or something that’s going on the hormone once it’s converted to gate it or allow it through the membrane. I haven’t seen that yet, but I have a feeling that as we continue to learn more about this, and we continue to learn more about Transcriptomics, I’m almost sure we’re going to find some type of tag that is placed on that hormone once there’s conversion. I think that’s really what it boils down to. We always need to go back to conversion. Conversion is the key. If we’re just replacing T3, it can be very beneficial to get the patient out of the dump for that initial two to three month window, but over time they’ll start getting worse because of thyroid hormone resistance. The nucleus will stop uptaking it.

Dr. Weitz:            What form of thyroid medication do you find most effective?

Dr. Valdes:          Yeah, so we’ve used GTA from Biotics for a long, long time. It’s tested, and one of the things I like about it is that it really is primarily T4. It does have a little bit of T3, T2, T1, but it is primarily T4. In addition to that, I’ve also…

Dr. Weitz:            You’re saying, instead of a prescription medication like Synthroid, you’re using a nutritional supplement?

Dr. Valdes:          Yep, absolutely.

Dr. Weitz:            Wow.

Dr. Valdes:          Patients love that for many reasons. I still haven’t seen…

Dr. Weitz:            Now, the critique probably is going to be, “Hey, this is not really standardized. You can’t count on this like a prescription medication.”

Dr. Valdes:          Yeah, I mean, if… I’ve heard that a few times, and if you go to Biotics, they will literally stab you if you make a statement like that because it is very standardized. We know very, very well what the dosage that’s going into that patient consistently, and we see it be consistent over time. We can see it both in the way that they respond to it clinically and through their labs.

Dr. Weitz:            What is this product? Because I’m not familiar with it.

Dr. Valdes:          Yeah. Biotics has something called GTA.

Dr. Weitz:            Right.

Dr. Valdes:          They have simple GTA-Forte and GTA-Forte II. It was just…

Dr. Weitz:            I’m assuming this is a glandular product.

Dr. Valdes:          It is. Yeah, it is primarily a glandular and they’ve added a few cofactors that are also important for transport conversion. It’s a very, very good product.

Dr. Weitz:            Now, why would this be better than an Armour?

Dr. Valdes:          There is a portion of Armour that is synthetic and when you run… anytime, when you run into a synthetic, you’re going to have transport and conversion.

Dr. Weitz:            What part of Armour is synthetic? I thought it was…

Dr. Valdes:          No. Part of the T4 in Armour is actually synthetic. From my understanding, and in addition to that, it’s also my understanding that there are some binders or fillers in the encapsulation. I can only speak into my clinical experience with both products, what I’ve seen, and historically I’ve seen a much better result from GTA. There’s also another one that is prescription called Nature Throid. I’ve also seen very comparable results from Nature Throid to GTA. Those are the two-

Dr. Weitz:            Nature Throid and WP Thyroid is another popular product.

Dr. Valdes:          Correct. Yeah. Clinically, they’re the two that I’ve seen the best outcomes with historically, as far as thyroid hormone replacement.

Dr. Weitz:            Now have you actually taken patients off of Synthroid and put them on this product from Biotics?

Dr. Valdes:          You’re funny. Legally…

Dr. Weitz:            Sorry doc, didn’t mean to put you on the spot there.

Dr. Valdes:          The answer to that is threefold.

Dr. Weitz:            You and I are both doctors of chiropractic and we don’t prescribe medication.

Dr. Valdes:          In conjunction with their prescribing physician, the answer to that question is absolutely yes. 97 or 98% of my cases come off of Synthroid or Levothyroxine and permanently to then utilize a bio identical or a glandular.

Dr. Weitz:            This product from Biotics, it contains T4 and T3.

Dr. Valdes:          Yes. Yeah. It just, it just follows thyroid composition, right? The thyroid is roughly 92, 93%, depending on the research. Then there’s a small percentage in there of T3, so that’s exactly what you’re gonna find in the glandular product.

Dr. Weitz:            What kind of dosages are you typically using for this product?

Dr. Valdes:          Yeah, so when you look at the equivalent there’s GTA single is the equivalent of about a 0.33 Synthroid or Levo. You can kind of play around with that if they’re on 0.75 and if they’re on 0.50, you can play around with that dosing. It’s also always very important to understand that a glandular is going to convert better and transport better than a synthetic every single time. And so sometimes the equivalent has to be a little bit lower on the glandular side in comparison to the synthetic side. From there, they have the GTA-Forte, which is basically two times stronger than the GTA basic. You just double that. It would be 0.66, which in reality is the equivalent of a 0.75 functionally.  They have the GTA-Forte II, which doubles the strength. I think they add a little bit of copper into that one. I’m not super in love with that. We get so much copper exposure from environment, from water from food, that I don’t really tend to find that I need to be giving these patients more copper especially, because of how prevalent copper has become.

Dr. Weitz:            Copper piping-

Dr. Valdes:          Yep.

Dr. Weitz:            … leading to copper in the water.

Dr. Valdes:          Yep, yeah. And then in the food too. Most people really need to be on a ton of zinc to redox the copper out of their body. I’m never a fan of throwing stuff at people that has more copper, especially because of all the work that I’m now doing on the cognitive side of things and finding copper is such a huge player in cognitive decline. So yeah, most of the time I’ll stick to either GTA, GTA-Forte, and then I’ll dose two capsules. One capsule based on where they are with their synthetic.

Dr. Weitz:            Okay. You mentioned thyroid binding globulin as far as the testing, and I don’t think most practitioners pay a lot of importance to this marker. Maybe you could talk about that for a minute.

Dr. Valdes:          Yeah, so it is and can be a very important marker to look at. When you start seeing ratios of total T3 and 3T3 that are off. Example a person that has a very high total T3 and then a free… Sorry, yeah, high total T3 and a low 3T3, then you know that there’s probably going to be an overproduction of thyroid binding protein. That’s the time that you might want to go and check it. Most of the time it follows sex binding globulin, so they either rise or drop together. They respond to the same factor. A male that’s estrogen dominant, you’ll see that they’re going to have higher sex binding proteins, higher thyroid binding proteins. A female that’s estrogen dominant, you’re gonna see the same thing. Then you start kind of seeing more of the endocrine picture of this unique patient.  It’s not a determining mark, but it can be a very indicative marker of the overall picture of what’s going on with that thyroid. I like to have it, I like to see it instead of just going back to it and running it at a later…

Dr. Weitz:            If you see a higher load thyroid binding globulin, so if the binding globulin is high, what do you think and what do you do?

Dr. Valdes:          Yeah, most of the time you want to think estrogen. When I see it, the next step that I take is I run a DUTCH test, which is the Dried Urinary Hormone test. The DUTCH test will tell me if they’re aromatizing, they’re over converting… If it’s a male over converting their testosterone into estrogen, which type of estrogen is predominant estrone, estradiol or estriol. It’ll also show me the metabolites. A lot of people, whether male or female, might not be producing a ton of estrogen, but they might be having a problem clearing estrogen. If you don’t look at the metabolites, you don’t have a clear picture of what’s going on with estrogen. All of a sudden estradiol is maybe on the low end of the range, but you look at their metabolites and they’re accumulating, they’re bio accumulating, and these metabolites have effect.  They’re doing the same thing that estrogen would be doing. All of that stuff is really important because now we begin to talk about clearance and detoxification issues, or we talk about hormonal production issues, or we are now jumping into adrenal issues with the HEA and pregnenolone steal and all of those things, so the picture just keeps getting broader as to why this person is having that symptom that every thyroid person has, but the reasons why they have it are very unique to them.

Dr. Weitz:            Interesting. Let’s go through some of the underlying causes of hypothyroid especially of Hashimoto’s autoimmune. And then how do you work it up, and what do you do about it?

Dr. Valdes:          Yeah. So we are very keen on testing. We do believe you know that just to test as much as we can, as much as we can and I’ll give you an insight of how my brain works. When you look at primary hypothyroidism, Hashimoto’s. 97% of cases that are hypothyroid are Hashimoto’s. There’s going to be varying severities. Recently I had a kid 19 years old, most of his hair had gone, eyebrows gone, fatigued out of his mind, moody, gaining a ton of weight, very rapid, very severe progression. Then you’ll see this female that the problem started when they were 23, and they’re now in their 50s, they’re still somewhat lean. Their energy weans and waves but for the most part is good. So all of that is already speaking into the severity of the immune triggers.

Most of the time when somebody is progressing very rapidly, it usually will be things that make the immune system insane, right? We’ve been looking a lot into the world of biotoxin illness. People that are HLA DR-DQ susceptible to some of these bio toxins, because these people can’t clear the thing that is making their immune system bananas. Certain heavy metals also have the ability to drive the immune system bananas too. Especially in people that might be genetically susceptible to autoimmune disease. From there, if you take it a notch down, almost always you’re going to be looking at gut. The gut, if it’s super permeable, they’re going to have that molecular mimicry mechanism, and that’s just going to be driving this thing like a bat out of hell.

From there, then we can go into the infections layer, we can talk about viruses, we can talk about Epstein-Barr, we can talk about all that stuff that predispose to a baby born, C-section, no breastfeeding, whatever, you know, that type of stuff? Pregnancy being another huge trigger, I would say almost right below that. And from there the rest of the factors from, insulin surges, estrogen surges, cortisol surges, food sensitivities, lesser toxic exposures. The reality is to be able to really assess what is driving the immune system to do what it’s doing, it’s impossible to do without really testing the crap out of the patient. That’s one of the biggest barriers for a lot of patients into care, and also for a lot of doctors in being able to deliver.

Dr. Weitz:            You mean because the testing is expensive?

Dr. Valdes:          Exactly, yeah. Because it can be very expensive. we can talk about this some other time. But that kind of took us back to the drawing board. And it’s how do we redesign this functional medicine model, so we’re not placing the patient in front of exorbitant costs, and we can get them into care successfully and affordably. That’s kind of… As doctors, we have to think about that, as much as we don’t want to, we have to think about that, and how to really deliver highly successful care.

Dr. Weitz:            Right. So your first layer obviously depends on the history and everything else, but is to look at… If I understand what you just said, is to look especially at toxins. Is that first things you start to rule out?

Dr. Valdes:          Yeah, so it depends. Let me let me explain myself. Every patient that comes into the practice is going to go through a software called the LivingMatrix. The LivingMatrix was developed in partnership with the IFM and Cleveland clinic’s, and it’s a very rigorous process of gathering-

Dr. Weitz:            IFM is the Institute of Functional Medicine. Yeah.

Dr. Valdes:          Yeah, exactly. And so, this is the tool that’s now being used to publish studies like the promise study and all that.

Dr. Weitz:            As a way to organize their history.

Dr. Valdes:          Correct. Once I gathered data, I see the health history timeline, that converts into the functional medicine matrix. It tells me, it begins to tell me what are the areas that this patient is having major difficulties with? Is it defense and repair? Is it assimilation? Is it communication? Is that their energy system? Is it structural integrity of organs? Once I see that I can begin to make the best decisions I can about their testing. Again, this will also help me understand the severity and the velocity of the progression. When I see defense and repair issues, when I see assimilation issues, when I see communication issues, and this person went from zero to 60, in five minutes, I’m immediately thinking either biotoxin or metals, right?  Because it’s one of those things that just drives the immune system bananas.  If I’m seeing defense or repair assimilation, but the progression is going slower, then I’m kind of shifting my thinking a little bit.  I always want to come in with the most likely diagnostic test, and that’s kind of my entry point. From there, I continue to test based on those initial findings.

Dr. Weitz:            How do you test for toxins? What kind of studying do you do?

Dr. Valdes:          Yeah, so if it’s going to be biotoxin, the first layer is running a test called HLA DR-DQ. It’s a genetic test.

Dr. Weitz:            Biotoxin we’re talking about like mold?

Dr. Valdes:          Correct, yeah. Mold, Lyme, ciguatera, bloom. Rare certain types of spider bites or snake bites.

Dr. Weitz:            You consider Lyme a toxin, isn’t that more of an infection?

Dr. Valdes:          It’s both. Yeah. When you get bitten by a tick you, you contract the Borrelia infection. But the Borrelia infection produces a biotoxin, and that’s what makes people very sick. In Lyme, when you look at people that get Lyme, 22% of them can go on to develop post Lyme syndrome, which is that long term drawn out disease that people can get. That’s very consistent with mold. That’s very consistent with MARCoNS, which is multiple antibiotic resistance stuff in the sinuses. That’s very consistent with people that are exposed to Ciguatera toxin in deep water fish. We’re learning that for this percentage of the population that have these genetic susceptibilities. These things are huge deal. They’re a huge deal, because what happens is HLA DR-DQ codes for the antigen presenting cell.  That cell that’s going to bind the antigen and then present it to the immune system. What happens is the site where biotoxins would bind to is misshapen. Biotoxins are very small, they’re smaller than point three microns, they can’t bind so the immune system can never clear the toxin. The body’s very smart, it’s going to still try and get rid of it, so it’ll go through the liver, it’ll be pushed through the bile. But bile emulsifies it, reabsorbs it and it goes back into the body and it just keeps circulating in the body. There’s a very specific domain of the immune system that becomes chronically activated because of these toxins. Markers for that are C4A, TGFB1, MMP9, VEGF. That part of the immune system just starts going… We are learning that this category of patient is incredibly susceptible to not just Hashimoto’s really any and every autoimmune disease in the spectrum of autoimmune disease.

Dr. Weitz:            For those who are practitioners who are listening to this, you may recognize that I… believe you’re talking about like Ritchie Shoemaker’s Protocol?

Dr. Valdes:          That’s right. Yeah, absolutely. Yeah. I had the privilege of learning from Ritchie Shoemaker. Two years ago, he had a kind of like, really cool workshop down in Miami and I got to meet him and learn. Brilliant, brilliant dude. I really believe that his work is on the tip of the arrow for what we’re going to be doing as Functional Medicine doctors in the next 20 years because of this understanding of transcriptomics, and how signaling into our genetics is really what drives health or disease.

Dr. Weitz:            Can we screen for mold without doing these markers? What if we just did like a Great Plains urine mycotoxin test or something like that?

Dr. Valdes:          Man, you’re going to get me in all kinds of trouble. Well, there’s a lot of people that promote these tests like that however, unfortunately when we look at the hard data, there’s really no major validity to that type of approach. And it pains me to say it because there’s a great practitioners that live and die by it, and I hate being that guy that, but when we look at… 

Dr. Weitz:            The urine mycotoxins testing is not accurate you’re saying?

Dr. Valdes:          I mean, I’m not saying that, I’m saying…

Dr. Weitz:            There’s no science to back it at this time.

Dr. Valdes:          No, there is some science, it’s just the clinical relevance. The type of assumption that we can make based on that data is not very solid. Let me say that a different way. You could be living in a home that’s full of mold, but if your genetics do not make you susceptible to that exposure, the reality is it’s not really a major threat, for the most part because you have the ability to clear it. So…

Dr. Weitz:            Right, but this is a way to test your body excreting these mold toxins. No?

Dr. Valdes:          I’m going to kindly turn down my response on it simply because the validity of those tests is just not all the way there. And…

Dr. Weitz:            Those serum markers that you mentioned are indication of the body having this inflammatory reaction?

Dr. Valdes:          Yep. One of the things is the problem with molds is the toxins that they produce, number one. The toxins they produce are 0.3 microns small. No test that’s out there currently, yet has the ability to detect these particulates, even though we know they exist, we know they’re there. First step, from a clinical point of view, if I’m going… If me, this is my thought process. If I’m going after an autoimmunity, I need to know if this person has the predisposition, the genetic factors that would make them vulnerable to this problem?

Dr. Weitz:            Okay.

Dr. Valdes:          If they are, then there’s more important questions to answer than if they’re peeing fungal metabolites right?

Dr. Weitz:            Okay.

Dr. Valdes:          There’s more important questions to answer that.

Dr. Weitz:            Okay, I don’t want to go too far down the mold rabbit hole. I realized we could spend another hour on that. Let’s move on. How about nutrient status? Which are some of the most important nutrients, and how do you test for these?

Dr. Valdes:          Yeah, I’ve actually gotten away a little bit, and I want to get your opinion on this too, because I’ve kind of moved away a little bit from testing nutrient status for a few reasons. One of them is I’m going to be supplementing and replacing most nutrients that are going to be important therapeutically. There is value to that. There is a lot of value in understanding nutritional status, because there can be issues around absorption, around transport. Because of the cost, I’ve opted to prioritize some of the more heavy hitting tests initially, before jumping into that especially because I am going to be intervening with a very broad spectrum set of nutrients.

It’s kind of give and take. Now, to the defense of that, let me say that a lot of people that have Hashimoto’s, all autoimmune diseases have little families, they’re called serotypes. The two closest family members to Hashimoto’s disease are celiac and pernicious anemia. With celiac, there’s going to be a ton of nutritional deficiencies because of absorption issues, and with pernicious anemia, you’re going to have methylcobalamin, methylfolate absorption issues. So it’s like, there can be. If my concern level is heightened this person is developing more autoimmunities, I have a suspicion of celiac, I have a suspicion of pernicious, probably, I’ll go down that route. Outside of that I look at organic acids from the DUTCH test, which is going to give me all of their B metabolites.  I’m going to look at other neurotransmitter precursors too that are important to me. I’ll look at vitamin D, and I’m always going to work with the fat soluble vitamins A, D, E, K in addition to the rest of them. I don’t know, that’s kind of how I handle it. Are you currently doing full nutritional testing?

Dr. Weitz:            We do include some nutritional testing. We’ve got a bunch of serum markers in one of our initial panels, and then some of the patients I’ll have them do like a NutrEval. I have found it to be helpful. I had one patient recently that has Hashimoto’s and the zinc was really a high marker, and also had a genetic SNP that made it difficult to absorb zinc. Even though zinc was already in the diet and in the multi… I might have been hesitant about really beefing up the zinc, and really beefing up the zinc for this patient made a huge difference.

Dr. Valdes:          Excellent. Yeah, well, that’s truly cool to hear. Let me rephrase that. We do test metals, both nutritional minerals and heavy metals. We do that through Quicksilver. For a nutrient like zinc, I would have data but I was thinking more like… Oh, and we also check for-

Dr. Weitz:            Selenium, or vitamin D, or…

Dr. Valdes:          Right. Well that we check through serum. We also get glutathione metabolites through urine. So yeah, I think that to a certain degree, we [crosstalk 00:53:12] do get a lot of them just not all of them.

Dr. Weitz:            You do some nutrients through serum?

Dr. Valdes:          Yeah. Well, I mean, yes, we do some of the basic nutrients vitamin D and the…

Dr. Weitz:            Right. Iron is super important for thyroid.

Dr. Valdes:          Right. Iron and Ferritin, the works, of course.

Dr. Weitz:            Yeah, okay. I think we’re closing in on an hour and I have a patient coming up so-

Dr. Valdes:          Okay.

Dr. Weitz:            … I know there’s a lot more we could talk about, but I think we’re gonna have to bring this to a close in the next couple of minutes. Where should we go to end this?

Dr. Valdes:          I don’t know, man. I think we-

Dr. Weitz:            I know there’s a ton stuff still to talk about, but…

Dr. Valdes:          Yeah, I think that maybe two things. If you and your audience like the conversation, we can continue it. We were starting to talk about the triggers of Hashimoto’s and how to go about those. We didn’t really dive into secondary hypothyroidism if that would be something of interest for your-

Dr. Weitz:            Okay, why don’t we plan to do a part two, and we’ll go into those things.

Dr. Valdes:          Excellent. Would love to be back if your listenership is excited about this stuff.

Dr. Weitz:            No, I think so. I think you’ve really delivered some good, interesting takes on some of this information, so I think it would be helpful. Let’s give your information about how listeners and viewers can contact you and find out about some of your programs that you offer. For practitioners, you’re also… have this functional medicine franchise that’s-

Dr. Valdes:          Yeah, that’s correct.

Dr. Weitz:            … available.

Dr. Valdes:          Yeah, so our company is Novis Health for consumers and patients dealing with hypothyroidism. We have two centers currently on our way to have four before the end of the year. Very excited about that. We deal primarily with hypothyroidism and some other metabolic disorders. Our website is www.novis.health. We are beefing that site up big time to become an authority site pretty soon. Then for doctors, our mission and our belief is to have functional medicine available to everyone that needs it. We want a functional medicine facility in every corner, just like we have these days massage and all those things. We want to make it available. We know that the main hospital systems are never going to make that happen, so it’s up to us to join forces and really all drive in the same direction.  One of the things that frustrates me a little bit about Functional Medicine is that everybody wants to be a voice and everybody wants to be heard as a provider, and that’s super important to become that expert, to become that celebrity. But we can only succeed long term to the degree that we’re unified and all fighting for the same thing, and that’s really what we’re trying to do. We’ve built very strong business models around our doctors in order to make sure that they can do what they love doing, which is taking care of their patients, taking care of their practice, having freedom of time, having freedom of practice, having financial freedom. If you’re interested in that it’s novishealthsystems.com. Very successful model for those that are wanting to really grow and expand in the world of functional medicine.

Dr. Weitz:            Excellent. Thank you, doc.

Dr. Valdes:          Thank you. Have a great day, and thank you for having me.