Plant Based Diet for Diabetes with Dr. Cyrus Khambatta: Rational Wellness Podcast 144

Dr. Cyrus Khambatta discusses how A Plant Based Diet Benefits Patients with Diabetes with Dr. Ben Weitz.

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Podcast Highlights

3:12:  Dr. Khambatta was diagnosed with Type I Diabetes when he was 22 years old and he developed 3 separate autoimmune conditions within a 6 month period of time.  Dr. Khambatta developed Hashimoto’s hypthyroidism, Type I Diabetes, and Alopecia universalis, which is why he has no hair.  He followed his doctors’ recommendations to follow a lower carbohydrate diet with 100-125 grams of carbs per day.  He started eating more peanut butter, eggs, chicken, fish, olive oil, and reduced his intake of carbohydrates, including fruits, starchy vegetables, and whole grains.  Not only was he having trouble controlling his blood glucose, but his insulin use was gradually going up as well, from the mid 20s, to the mid 30s, to 40-45 units per day.  He decided to try a plant based, high carb, whole food, low fat diet, with the help of Dr. Douglas Graham.  He started eating 5 to 6 times the number of grams of carbohydrates per day and his blood glucose fell within the first 24 hours and he cut his insulin use by 40%!  This led Dr. Khambatta to get a PhD in Nutritional biochemistry from UC Berkley in order to understand what was going on in his own body.  He claims to have dug up over 100 years of information from scientific researchers that document how a low fat, plant based, whole food diet can help maximize insulin sensitivity and enable people with both Type I and Type II diabetes and prediabetes to get the same results. This led him and Robby Barbaro to see up the Mastering Diabetes coaching program to educate people about the benefits of the plant based diet for diabetes.

11:55  The recommended diet for those with both Type I and Type II diabetes can be quite similar, according to Dr. Khambatta. There are three components to a plant-based diet that are beneficial for those living with diabetes: 1. Low fat, 2. Plant based, and 3. Whole food.  Dr. Khambatta recommends that no more than 10-15% of calories should be consumed as fat because low fat will improve insulin sensitivity.  You should eat as much plant material as you can, but you should avoid processed and packaged food products, even if they are plant based. You should stick with whole fruits, vegetables, whole grains and legumes and avoid plant based burgers and soy ice cream and crackers and chips, etc.

14:26  If you consume too many calories, you will store the excess energy as gylcogen and then as bodyfat.  But if you avoid refined carbohydrates and you eat a whole food plant based diet, it is very rich in fiber and water and this creates bulk, which fills you up and makes it hard to eat excess calories. Fiber is very important for slowing the breakdown of the food into sugar, for creating bulk in our stool, and helps feed our microbiome and promotes the production of butyrate by our microbiota.

36:04  Insulin resistance is a complex topic, but Dr. Khambatta feels that the research shows that eating both fat, esp. saturated fat, and/or protein increase insulin resistance, as compared to eating carbohydrates.


Dr. Cyrus Khambatta has a PhD in Nutritional Biochemistry and he has coauthored a number of peer-reviewed scientific papers and he is the co-host of the annual Mastering Diabetes online summit.  He is also the co-author of a new book along with Robby Barbaro, Mastering Diabetes, which was just released on 2/18/2020.

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.


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, thank you so much for joining me again today. For those of you who enjoy listening to our Rational Wellness Podcast, please go to Apple Podcasts or wherever you get your podcasts and give us a ratings and review. Also, if you’d like to see a video version, go to my YouTube page, and if you go to my website, you can find detailed show notes and a complete transcript.

Today our topic is, The Prevention And Treatment Of Diabetes With A Diet And Lifestyle Approach.  Type 1 diabetes is an autoimmune condition that usually starts in childhood or in the teenage years and is marked by damage to the ability to produce insulin, and requires taking insulin injections for the rest of their lives.  But 90 to 95% of those with diabetes have Type 2, and this is a condition that results from diet and lifestyle and is entirely preventable. One of the biggest questions is, which diet and lifestyle factors are the most effective for this task? For example, is it more effective to follow a lower carb diet, which as Dr. Brian Mowll recommends, who we spoke to in episode 139?  Or is it more effective to follow a higher carb, lower fat program such as Dr. Cyrus Khambatta, our guest today advocates? This is a very important topic because diabetes and prediabetes are epidemic and the prevalence continues to increase in the United States and around the world.  9.4% of adults in the US are diabetic and at least 87 million people in the US have prediabetes and rates are climbing, especially among children and teens. Dr. Cyrus Khambatta has a bachelor of science in mechanical engineering from Stanford university in 2003 and a PhD in nutritional biochemistry from UC Berkeley in 2012. He’s coauthored a number of peer-reviewed scientific papers. He appeared on the Forks Over Knives’ documentary and he’s the co-host of the Annual Mastering Diabetes Online Summit, and he’s coauthored the soon to be released book, Mastering Diabetes With Robby Barbara. There you go. Is it available right now?

Dr. Khambatta:                 It’s available for pre-sale right now and it’ll be available on February 18th for everyone.

Dr. Weitz:                         Okay. And he’s also a nutrition and fitness coach and he’s been living with Type 1 diabetes since 2002. Dr. Khambatta, thank you for joining me today.

Dr. Khambatta:                 Thank you so much Dr. Weitz. I really appreciate the opportunity to be here today.

Dr. Weitz:                          Excellent. So maybe you can start by telling us about your personal experiences living with Type 1 diabetes and eating a plant-based diet.

Dr. Khambatta:                 For sure. I was diagnosed with Type 1 diabetes when I was 22 years old, I was a senior at Stanford university at the time and I was just trying to graduate and move on with my life, and I started to feel really thirsty, like incredibly thirsty where I was drinking about one to two gallons of water per day, and my energy levels were just terrible, very little energy. So I picked up the phone and I called my sister and she’s a doctor of osteopathy and I said, “Hey Shanaz, here are my symptoms, what am I experiencing?” And she said, “Cyrus, you are explaining Type 1 diabetes to the T, go to the health center right away.”  And I was like, “Shanaz, I don’t have Type 1 diabetes. What are you talking about?” And she said, “I don’t have time to explain, just go.” So I didn’t know anything about biology, I didn’t know anything about medicine at that point. I just thought that diabetes literally had something to do with old people and cake. That was it. So here I am, I’m like 22 year old guy, I’m athletic and I’m like, “I’m not overweight. I don’t understand what’s happening.” So I checked myself into the health center and while I’m there, they checked my blood glucose and it’s over 600. My brother goes, “Anybody’s blood glucose is supposed to be between 80 and 130 on a given day.” And mine was basically six times higher than it needed to be. And I didn’t know what that meant, but they basically looked at me and they said, “We’re taking you to the ER right now.”

So we go to the ER together. When I checked myself in there, they basically put me into a room. They gave me an IV of saline in one arm to hydrate me, and then they also gave me an IV of insulin into the other arm and they started to control my blood glucose and bring it down using insulin. While I was in the hospital for 24 hours, they pieced together my health history, and they helped me understand that I now had developed, not one, not two, but three autoimmune conditions within a six month period. So the first autoimmune condition was Hashimoto’s hypothyroidism. So I developed Hashimoto’s about six months prior and I was taking a synthetic thyroid supplements, was taking Synthroid and that was supposed to solve that problem.  Then a couple of months later, I developed alopecia universalis, which is why I have no hair, I have no eyebrows, I had no eyelashes, I had no ear hair, no hair, nothing, I’m gone. And then in addition to that, I developed Type 1 diabetes. So all of those setting within a six month period and all three of them were autoimmune. So the doctors looked at me and they were like, “We’ve never ever seen somebody that has these three conditions before.”

Dr. Weitz:                          But actually autoimmune conditions do tend to group together. Having one autoimmune condition increases your risk of another.

Dr. Khambatta:                 No questions asked, you’re absolutely correct. And I’ve gone on to learn over the course of time that there’s actually different types of autoimmune conditions that cluster together. So Hashimoto’s, hypothyroidism, Type 1 diabetes, celiac disease, they all cluster, but I didn’t know that at the time, all I knew was that I’d felt thirsty and I needed some help. And the doctors were basically telling me, they were like, “Well we kind of know what to do and we kind of don’t know what to do.” So I got discharged from the hospital 24 hours later with a blood glucose meter, test strips, two different types of insulin, syringes, carbohydrate counting guide and a life alert bracelet that basically said, “If something happens to me and you find me passed out on a field, call 991.” So I got really nervous really quickly because-

Dr. Weitz:                          Yeah, that’s pretty scary.

Dr. Khambatta:                 Yeah, exactly. So I followed the advice of my doctors at the time and they basically said, “Listen, we know how to treat Type 1 diabetes because it’s pretty classic and there’s a safe way to treat it and that is, to eat a low carbohydrate diet.” So I said, “Great. Let’s do this.” So I started eating more peanut butter, more eggs, more chicken, more fish, more olive oil, and I was trying to reduce my intake of carbohydrate rich, anything, whether that was fruits or starchy vegetables or whole grains. And by doing so it was supposed to make my blood glucose more controllable and it didn’t. It definitely did not.

So maybe I did a low carbohydrate diet terribly incorrectly, but I was trying to control my carbohydrate intake to be about 100 to 125 grams per day, which falls within the low carbohydrate classification. And not only was my blood glucose hard to control, my insulin use was going up over time, started out in the mid-20s, and then it creeped up to the mid-30s, and before I knew it, it was 40 to 45 units per day. And then in addition to that, I also just started to feel very tired and my joints and my muscles were starting to hurt and I couldn’t be as athletic as I wanted to be. And having grown up as an athlete, a soccer player, weightlifter, and just like generally, very active, as soon as my mobility got compromised, I got really frustrated.

So I started looking for more information, I got introduced to this idea of eating a plant-based diet and I said, “Heck, I’ll try it out. Let me do it.” So under the guidance of a nutrition professional named, Dr. Douglas Graham, he helped me transition to a plant-based diet, literally overnight, cold turkey. Now, I don’t really recommend transitioning cold turkey overnight, but I happened to do it just because that’s the situation I was presented with. So I switched over to a plant-based diet and Dr. Weitz, I can’t even tell you how incredible it felt for the first week. Within 24 hours, my blood glucose went from being relatively high and difficult to control, I hit six hypoglycemias within 24 hours. So my blood glucose began to fall and it began to fall rapidly.  And as a result of that, I had to back off on the amount of insulin I was giving myself so that I wouldn’t drive myself more hypoglycemia. Over the course of one week, I’d cut my insulin use by 40%, which is mind boggling, but the beauty was that I was doing it by eating five to six times the number of grams of carbohydrate per day. So that was really where this light bulb went off in my head when I was like, “Wait a minute, I had been told up to this point that carbohydrates equals more insulin, but now I’m eating way more carbohydrate energy and my insulin use is going down, so there’s like they’re moving in opposite directions. How is that possible?” So that’s when I got really interested in studying it at the PhD level, so I went to UC Berkeley. I enrolled in a PhD program there and I got to try and understand what was happening inside of my own body because it was a fascinating experiment.

Dr. Weitz:                          Well, it certainly is counter intuitive.

Dr. Khambatta:                 Oh, it’s fascinating. Yes, absolutely perfect..

Dr. Weitz:                          We basically, carbohydrates, pick a carbohydrate, rice is essentially a long chain of glucose molecules together. And when you eat a carbohydrate like rice, it gets broken down over a period of time, faster or slower depending upon the carbohydrate, into glucose, and if the issue is glucose, it certainly makes sense that eating more carbohydrates is going to raise your blood glucose.

Dr. Khambatta:                 That’s exactly So the overall philosophy of eating more carbohydrates equaling more glucose, equaling more insulin, it makes perfect sense. From like if you step backwards and draw it out on a piece of paper, it makes perfect sense, but my personal experience went exactly opposite to that. And so that’s where I either thought to myself, I was like, “Either I’m a fascinating “N” of one experiment, and what’s happening inside of my body is I’m a genetic anomaly or what’s happening inside of my body is actually applicable to other people living with Type 1 or maybe even other people living with any other form of diabetes.”

So that’s why I went to school and that’s why I tried to educate myself about it so that I could answer that question. Then while I was there, I was able to dig up almost 100 years’ worth of information, from the 1920s and beyond of experiments that scientific researchers have run that mimic exactly what I had gone through myself. And there’s a whole collection of information that really highlights the power of a plant-based diet, especially a low fat, plant-based whole food diet in helping to maximize insulin sensitivity and really enable people living with Type 1 and Type 2 diabetes and prediabetes to see the exact same results, which is higher carbohydrate and take less insulin demands, less insulin biological requirements.  And that’s when I started to say, “Oh, wait a minute, I’m not special. I’m really not special. I just happened to be one person that experienced something that has already been documented for over 100 years.” And so we set up the Mastering Diabetes coaching program to teach people living with all forms of diabetes, how they can also transition to a plant-based diet so that they can achieve incredible similar results.

Dr. Weitz:                          So how should a diet for somebody with Type 1 be different than somebody with Type 2 diabetes?

Dr. Khambatta:                 It doesn’t necessarily have to be that different. At the basis of what we teach, and the basis of all of the scientific investigations that I’ve been involved in in the past 15 years, is that there’s three components to a plant-based diet that are really going to be beneficial for people living with diabetes. Number one, low fat. And when I say low fat, I basically mean approximately 15% of total calories as fat or maybe even a little bit less, somewhere between 10 to 15%. Number two, plant-based, meaning eat as much plant material as you possibly can. You don’t have to go 100%, but it does the further you can increase your plant intake, the better.  And then number three, whole food. And I want to put a focus on whole food too, is very important because as you know yourself, there’s a lot of plant-based packaged products that are now available on the market. There’s plant-based burgers, there’s soy ice cream, there’s crackers, there’s chips, there’s cookies, there’s enchiladas, there’s burritos, you name it.  And we don’t actually recommend eating more of those products even though they’re technically plant-based.  We’re talking about literally eating more fruits, more vegetables, more whole grains and more legumes.  So when you eat a low fat plant-based whole food diet, what ends up happening is that in a low fat environment, when the total quantity of that is quite low in your diet, that enables glucose metabolism to function very efficiently and then enables insulin to become very effective at signaling glucose to enter tissues.

And so to answer your question, you say, “Well, how would a diet for somebody with Type 1 be different than a diet for somebody with Type 2?” The answer is, it doesn’t necessarily have to be. As long as you’re eating a low fat, 10 to 15% of your total intake as fat, plant-based, whole food diet, then what we find is that people with Type 1 diabetes, Type 2 diabetes, people with prediabetes, we’re all doing the same thing under the surface.  And that same thing is we are maximizing insulin sensitivity.  And when you maximize insulin sensitivity, then effectively you allow insulin to do its job very effectively.  So small amounts of insulin can then usher or signal large amounts of glucose to get inside of tissues and that helps keep your blood glucose controlled very well.

Dr. Weitz:                         Isn’t the amount of calories really significant? Isn’t insulin essentially the hormone that allows us to store extra energy?

Dr. Khambatta:                 Yes.

Dr. Weitz:                         In other words, if we consume more calories, calories being a measure of energy, than we need, then we can store some of that energy as glycogen or as fat, and that insulin helps to stimulate that, right?

Dr. Khambatta:                 Yes. So insulin is actually a pretty misunderstood molecule, and what you’re saying is actually very true. So think of insulin as being basically the single most powerful anabolic hormone in your body. And when I say anabolic hormone, I mean, anabolic is a term given to like growth. It stimulates synthetic processes. So insulin is more powerful at stimulating synthetic processes than is testosterone, than is estrogen, than is growth hormone, than is IGF-1, you name it. So insulin’s role in your body, its primary function in your body, is to signal to tissues that glucose is available in your blood.

So when insulin is present, it’s a high energy signal that basically says, “Hey, liver, Hey muscle, would you like to take this glucose up? There’s glucose in the blood, go get it.” And then glucose, if the tissue say, “Yes, okay, no problem,” then glucose can get inside of those tissues. But insulin also has a number of other effects. Insulin can signal amino acid uptake from protein and insulin can signal fatty acid uptake from fatty acids. Insulin can signal cholesterol uptake.  Insulin can also promote DNA synthesis, RNA synthesis, glycogen synthesis. It can stimulate DNA repair. I mean, it’s literally endless what insulin is capable of doing.

But everything that insulin does is synthetic by nature or building by nature. And it also shuts down catabolic processes, meaning it shuts down the oxidation of fatty acids, it shuts down the oxidation of glucose. So it’s basically simultaneously turning up synthetic processes and minimizing or impairing catabolic processes, etc. So to answer your question, if you eat excess calories, does that stimulate an excess insulin production and then increased fatty acid synthesis or increased glycogen synthesis? The answer is absolutely, no questions asked.  So it’s very important for somebody living with any form of diabetes to be very cognizant of the amount of calories they’re consuming and to not over-consume calories.

And one of the things that’s actually very beneficial about a plant-based diet in particular that I’ve learned over the course of many years is that, when you eat a plant-based diet, it’s actually relatively challenging to overeat on calories, just naturally. And the reason for that is because when you’re eating a whole food plant-based diet, the whole food plant-based diet is incredibly fiber rich and is incredibly water rich. And if you add fiber and water together, you end up creating this thing called bulk, this substance called bulk. And there have been many experiments that have been performed over the course of time. And there’s a woman named, Barbara Rolls, who’s the pioneer of this branch of biology.  And what she has shown is that the single most satiating aspect of food, of all food is bulk. So when you consume foods that are fiber rich, that also are pre-packaged with a ton of water, then it’s actually, it fills you up quickly, and as a result of that, you don’t take very many bites before your digestive system signals up a neurological signal to your brain that says, “Hey, I’m getting full, slow down.” And as a result of doing that, you end up not actually taking on too many calories, it’s a natural break to prevent you from taking on excess calories.

Dr. Weitz:                         It doesn’t seem to match with my experience.  From what I’ve seen, people who tend to be overweight, tend to overeat carbohydrate foods. Rarely do people gorge on chicken or eggs–they’re eating bowls of pasta and chips and bagels and those are the typically the foods that lead people to be overweight.

Dr. Khambatta:                 The types of carbohydrate that you’re talking about are actually refined carbohydrate foods. You’re talking about chips and cookies and crackers and pastas and cereals and carbohydrates, sorry, carbohydrate-rich food that has gone through a manufacturing process in order to become a thing that you buy at the grocery store. And you are absolutely correct.  Refined carbohydrate foods can be very addictive because food manufacturers play games with those foods and when they put them into a package, they add natural flavorings to them such that they make them hyper palatable and it makes it much more likely that as soon as it hits your tongue, it sends a dopamine signal into your brain, sorry, your brain generates dopamine, which then gives you a happiness signal, which then makes you want to eat more.  So the nice thing about eating a whole food plant-based diet is that when you’re eating potatoes, potatoes don’t have that same hyper palatability, they’re tasty, and they’re filling and they’re filled with fiber and water. And as a result of that, they fill you up without making you feel like you’re addicted to wanting to eat more and more and more.



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.

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Dr. Weitz:                          Now, don’t carbohydrates break down into sugar more quickly if they’re consumed alone versus if they’re consumed with protein and/or fats because the proteins and fats take longer to digest, you’ll get less of a blood sugar response from eating that meal, isn’t that the case?

Dr. Khambatta:                 I’m very glad you asked me this question because this is a highly misunderstood topic and the answer is true but also true but. If you eat a carbohydrate-rich food, like let’s take for example, sweet potatoes. You eat sweet potatoes and you also eat the sweet potatoes with a protein-rich food. Give me an example of a protein or fat-rich food.

Dr. Weitz:                          Salmon.

Dr. Khambatta:                 Perfect. You eat it with salmon. So you eat the two of those foods together, they basically go in your mouth, they travel down your esophagus, they get into your stomach and then they get into your small intestine. Now, once they get into your small intestine, the lipid soluble components are actually absorbed into your lymph system quickly. So effectively, what that means is through the walls of your small intestine, the lipid soluble components being fatty acids plus cholesterol, they get absorbed through the walls of your small intestines, they get put into your lymph and then they get put into your blood and they circulate as chylomicrons.  These chylomicrons basically are just delivering fatty acids, “Here, you want this fatty acid, go for it. Take it, take it, take it.” Once that lipid absorption starts, that lipid absorption process has a whole bunch of complex signaling mechanisms back up to your brain that then signal back down to your digestive system. So there’s a two way neurological pathway that happens as soon as lipid-rich food gets into your mouth.  So one of the things that happens is that your brain gets a signal from your digestive system that there’s lipid present in the food, and your brain then sends the same signal back to your stomach and it slows your gastric emptying rate.  So it actually slows down the rate at which your stomach passes food into your small intestine. So there’s a pyloric sphincter at the base of your stomach and that pyloric sphincter basically just like closes and its harder to open.  So as a result of that, you actually have like a small, a minor traffic jam of chyme or undigested food material inside of your stomach.  And that’s actually a good thing because what it does is like you said, it slows down the absorption.  So carbohydrates is slowed down as a result of that, and it basically evens down blood glucose response. That is a true statement.

Well, let’s do the opposite now, suppose you just ate the sweet potato by itself and there wasn’t any salmon to come along with it. Does that mean that the glucose from the sweet potato would be present in your blood and it would cause a blood glucose spike?  And the answer is, yes and no, depending on the situation.  So I’ll give you two different scenarios.  If you were to eat a sweet potato and you ate that sweet potato and it went into your small intestine and it got absorbed through the walls of your small intestine and the glucose is put into your blood.  If the glucose cannot get outside of your blood and into tissues, then it’s going to get trapped inside of your blood and you’re going to see a high blood glucose value and you’re going to see that quickly.   The reason that that would happen is if you already are living with insulin resistance, if you’ve eaten the diet that has made you insulin resistant such that your liver and muscles are not accepting of glucose. So if you’re already insulin resistant to begin with, you eat that sweet potato, if you check your blood glucose and it’s going to be high.  If you had eaten yourself into insulin sensitivity and you’ve reversed insulin resistance using your diet, then as soon as the glucose molecules from that sweet potato get inside of your blood, they have an exit route and they can get inside of your liver and they can get inside of your muscle, and that’s going to prevent your blood glucose from going high. The glucose will get inside of your blood and I’ll get out of your blood very quickly and that will keep your blood glucose from going too high.

Dr. Weitz:                          But let’s say I don’t have insulin resistance, but because I’ve been eating a lot of carbohydrates, I have plenty of carbohydrates, my muscle glycogen, my liver glycogen is filled with as much glucose stored as glycogen as it can handle, so I have plenty of glucose and now this is an excess glucose that can’t go anywhere.

Dr. Khambatta:                 There’s a couple of things to think about.

Dr. Weitz:                          In other words, can’t it be the case that it’s not just that we’re not sensitive enough insulin to utilize it, but that there’s just an excess of glucose.

Dr. Khambatta:                 I mean, sure. You can always eat a diet that has an excess amount of carbohydrate and/or glucose energy, that is absolutely possible. And that is most likely going to happen when you’re overeating calories, period, end of story. But if you’re not overeating calories and you just happen to be, let’s just say your calorie requirement for a daily basis is 2,500 calories, just for the sake of argument. Let’s say you’re eating a diet that contains 2,500 calories, so you’re not overeating. If the majority of your energy was coming from carbohydrate. And when I say the majority, I mean, like 70% or sometimes even more, does that mean that you run the risk of glucose overload, of carbohydrate overload and that’s going to cause your blood glucose to go up?  And the answer is, it depends. If you are insulin sensitive, if you truly are insulin sensitive, then you can eat a dramatically high carbohydrate intake, 70 to 80% or even higher, and you will not get glucose overload. Glucose will not get trapped inside of your blood, it’ll easily get imported into glucose, sorry, into your liver and muscle, and that will prevent against high blood glucose values.

Dr. Weitz:                          But can’t my liver and muscles have all the glucose they can use? Can’t they be filled up?

Dr. Khambatta:                 The answer is yes. Yes and no. Glucose is present in your blood at all times, and glucose gets inside of your liver and gets inside of your muscle.

Dr. Weitz:                          But there’s a limit to how much glucose you can store, right?

Dr. Khambatta:                 There’s a limit to how much glucose you can store, absolutely. There’s no question about that.

Dr. Weitz:                          And after that, it turns into fat, right?

Dr. Khambatta:                 Well, let’s think about it this way. Glucose can get inside of your liver and it gets inside of your muscle and it can get stored as glycogen. And on average, you have approximately about 1800 to 2000 calories of glycogen at any given time. So let’s say for now, you ate a dinner that was carbohydrate rich and you topped off your glycogen stores inside of your liver and muscle, and you’re full of glycogen and that’s it. Then you go to sleep, you wake up in the morning, your glycogen stores are now less than they were when you went to sleep. So you’re actually burning glycogen in the middle of the night while you’re sleeping.

Dr. Weitz:                          Okay. But let’s say I wake up and my glycogen stores are still full.

Dr. Khambatta:                 Okay. My point is that that doesn’t happen.

Dr. Weitz:                          It doesn’t happen?

Dr. Khambatta:                 No. So glycogen is a temporary storage tank that you can always fill. You can put more glucose into the glycogen repository, but it’s not like glycogen is a stagnant structure and that as soon as you put stuff in, it’s full and then it stays full for 24 hours. Glycogen is constantly being depleted at all times, 24 hours a day. Right now, you are going through your glycogen stores and so am I. We’re sitting in a chair, we’re not doing anything because glycogen is a fuel tank. It’s just that like if you were to go exercise, you would burn through your glycogen stores much quicker.  Right now your glycogen stores are decreasing, so that means the next time you go eat a glucose-rich meal or a carbohydrate-rich meal, you now have some space to put more glucose back into that glycogen storage tank. So I think what you’re trying to get at is-

Dr. Weitz:                          Let’s say I have this much space but I take this much glucose.

Dr. Khambatta:                 For sure. So you can have a small amount of space and you can take on an extra amount of glucose and yes, that can be a problem. But the question really becomes, is that clinically relevant? And the answer is, if you’re eating a refined carbohydrate diet, you will find two things that are happening. Number one, glucose gets into your blood much quicker than it would if you’re eating whole foods, no question. Number two, it can actually create insulin resistance inside of your liver in particular. So you’ve got hepatic insulin resistance, and as a result of developing hepatic insulin resistance, now you have a traffic jam of glucose that’s present in your blood so your glucose can go higher.  And then like you said, also some of those glucose when it gets inside of your liver, if it’s insulin resistant, boom, now, all of a sudden your liver says, “You know what, let me convert this into fatty acids.” And then it does this conversion of glucose into fatty acids, DNL. However, DNL is actually, it’s a last resort mechanism and it doesn’t really happen as efficiently as most people believe. So we can go into that in detail in a little bit.

Dr. Weitz:                          This is also why you often see people who overeat refined carbohydrates have fatty liver.

Dr. Khambatta:                 No questions asked. Absolutely, 100%. So you’re on the ball about the fact that refined carbohydrates are not healthful foods by any stretch of imagination. So you don’t recommend eating them, I don’t recommend eating them, nobody from the functional world, the plant-based world, we all agree, everyone’s like, “You know what, refined carbohydrates is not an ideal option.”

Dr. Weitz:                         How much does glycemic index matter?

Dr. Khambatta:                Ooh, good question. The glycemic index is important-

Dr. Weitz:                         By the way, for the listeners who are not aware, the glycemic index is a measure of the rate at which a carbohydrate food gets converted into sugar in your system.

Dr. Khambatta:                Exactly right. It’s the speed at which a carbohydrate-rich food gets converted into glucose.

Dr. Weitz:                         You get a big spike or is it a slow gradual release.

Dr. Khambatta:                So the glycemic index is important for people, let’s say you’re eating a plant-based diet and you tend to be eating high, you’re on the glycemic index.  Does that mean that that’s bad for you?  Does that mean that it’s going to-

Dr. Weitz:                         You’re having a lot of white potatoes?

Dr. Khambatta:                 The answer is if you are living with insulin resistance to begin with, if your liver has accumulated a sufficient amount of insulin resistance over the course of time, if your muscles have accumulated a significant amount of insulin resistance over time, then when you eat high glycemic index foods, those high glycemic index foods will get absorbed into your blood, the glucose is going to get into your blood quickly. And it’ll get trapped inside of your blood and it will absolutely cause the glucose spike. If, again, the name of the game is reversing insulin resistance. If you have or have become insulin sensitive through many lifestyle factors, including a low fat plant-based food diet, including frequent movement, including maybe some intermittent fasting.

If you do all those and you do those on a daily basis and you have become tremendously insulin sensitive, then when you eat a high glycemic index food, your blood glucose does not spike, absolutely does not spike. One other thing that I also want to say about the glycemic index and I think is slightly deceiving is that, the glycemic index is basically a measurement of how quickly an individual food metabolizes to glucose inside of your blood. So white potatoes as an example have a higher glycemic index and then does beet-

Dr. Weitz:                          Sweet potato.

Dr. Khambatta:                 Or a sweet potato. Now, when you put a meal together, generally speaking, you’re probably not eating just one food in isolation. Some people might do that, but if you’re putting together a meal, you might have a little bit of salmon, you might have some white potatoes, you might have some broccoli, you might have some wild rice in there. So the glycemic index of each one of these foods matters.  And then when you actually eat the meal together, you’re getting a combination of glycemic indexes, which is going to slow down the rate of absorption of all material that comes from that food.  So the glycemic index is important in isolated situations when you’re living with insulin resistance or when you’re only eating one food at a time.  And the glycemic index is also something that you can change literally, by changing the way you cook a food or by changing the temperature at which it’s served.  So it’s a helpful indicator, but it’s also slightly not that helpful.

Dr. Weitz:                          Right. For example, if you were to cook those white potatoes and then you were to eat them cold, you get an increase in the resistant starch.

Dr. Khambatta:                 That’s exactly right. So the glycemic index then gets lowered as a result of that, even though it’s still the same white potato.

Dr. Weitz:                          Is that something that you employ in some of your strategies?

Dr. Khambatta:                 What? To lower the glycemic index in particular of a certain foods?

Dr. Weitz:                          Yeah. Using say, resistant starches or, you know.

Dr. Khambatta:                 We don’t directly employ that because we don’t necessarily find that it’s necessary. So we are a huge fan of resistant starch because resistant starches, very helpful at blunting of glycemic response, no questions asked. But people can get resistant starch also from eating slightly unripe bananas, they can get it from. Tell me, what other foods are high in resistant starch that you know of?

Dr. Weitz:                          Jerusalem artichoke.

Dr. Khambatta:                 Yup. I think certain types of beans are also high in resistant starch if I’m not mistaken.

Dr. Weitz:                          I think so.

Dr. Khambatta:                 Yeah. So they’re helpful for sure.

Dr. Weitz:                          And then we got the fiber. That’s another big factor in this whole release of carbohydrates, right?

Dr. Khambatta:                 Exactly right.

Dr. Weitz:                          If you talk about whole food, whole grains, you’re talking about foods that are higher in fiber.

Dr. Khambatta:                 Absolutely. Fiber is such an important molecule for a bazillion reasons, but at the upper end of your digestive system, the presence of fiber slows down the rate at which glucose enters your blood. So it blunts your glycemic curve after you eat a meal. By the time fiber gets into your large intestine and then becomes a food for your microbiome, your microbiome can secrete cellulase, break it down into cellulose, and as a result of that… Sorry, break down the cellulose into glucose, and as a result of that, they can metabolize those glucose units and use them to create short chain fatty acids like butyrate, which is going to help not only your small intestine, but other tissues as well.  And then also fiber tends to block your stool, which is a good thing. So yes, fiber is a magical molecule in 1,000 different ways. And again, when you’re eating a plant-based diet, especially if it’s coming from whole foods, then you can dramatically increase your fiber intake without even trying.

Dr. Weitz:                            So insulin resistance seems to be a very complicated and confusing concept when you really get into it. I read several recent papers and it seems like even the top researchers are a little confused about exactly what results or how it results in changes in insulin resistance.

Dr. Khambatta:                 Yes. So over the course of time, insulin resistance has become a more complex topic than I think, even researchers had once believed it to be. And so as a collection of medical professionals, I think the answer is, we don’t know everything that contributes to insulin resistance, but we absolutely do know certain components of food and certain nutrients that are more influential in creating insulin resistance. And we know certain types of nutrients can also reverse insulin resistance at the same time. So if you really look at the types of… What we’re trying to understand here is very simple. Are there specific components of your food that block the action of insulin? That’s what it boils down to.

So are there certain nutrients that you can find in either animal-based foods or plant-based foods or both that when you eat them, the action of insulin is decreased? And if the answer is yes, then those foods are going to contribute to the development of insulin resistance because insulin resistance is at its core, a reduction in insulin signaling and an inability or reduced ability of insulin to do its job. So the question really becomes, well, what nutrients in food are impairing the insulin signaling pathway inside of your muscle and out of your liver. Now, there’s been investigations as far back as 1920s to try and answer this question, and they’re still ongoing today.

And what many of these investigations have found is that, lipids as a general class of molecules are definitely, they can impair insulin signal. So lipids refer to like fat rich molecules, but not necessarily all fat rich molecules are going to impair insulin signal. The most problematic are saturated fatty acids. Now, what ends up happening is that when you eat a food that’s rich in saturated fatty acids, the saturated fatty acids, they can get inside of your liver and they can get inside of your muscle and they can directly slow down the action of insulin inside of those exact cells. So there’s a whole collection of intracellular mechanisms that are initiated when cells uptake saturated fatty acids, and that leads to insulin receptors that are less functional than they were before the saturated fatty acids came in.

So if you have a meal, there’s just some, actually some phenomenal research here that’s been done in Type 1 diabetes in the last couple of years, that takes individuals and they feed them either a meal that’s high in saturated fatty acids or a meal that’s high in protein or a meal that’s high both. And what they find is that over the course of the next three to five hours, insulin signaling is impaired dramatically. And as a result of that, people with Type 1 diabetes who eat either a fat-rich meal or a protein-rich meal or both end up with an increasing need for insulin as much as 65% increased need for insulin over the course of the next five hours.

And that is an indicator again, that saturated fat as one type of molecule can impair the insulin signaling pathway and can alter the biology of your liver and muscle to make it such that those tissues have a difficult time responding to insulin.

Dr. Weitz:                            Do you recommend eating the same types of foods throughout the day or do you recommend for example, eating say, less starchy carbohydrates at night, or maybe more fats, having nuts or things like that?

Dr. Khambatta:                 We have found that over the course of time, that eating certain types of foods at certain times of the day can be very helpful at controlling your blood glucose. So I’ll start out with the morning. In the morning hours, we recommend eating a fruit-centric meal, for a number of reasons. Number one, fruit-centric meals at the beginning of the day, can actually… It’s easy to prepare for breakfast, they don’t require much preparation from like a logistical stand-

Dr. Weitz:                            What would a fruit-centric meal look like?

Dr. Khambatta:                 Suppose I were to put together a fruit bowl that contains two bananas and one mango. That’s it. Two bananas and one mango, or it could be two bananas, one mango with a tablespoon of flax seed drip on top of it. Very simple. If you were to eat that in the morning hours, what we find is that number one, it keeps your blood glucose nice and controlled. Again, assuming that your overall diet has made you insulin sensitive to begin with, and if you are insulin sensitive, then metabolizing that fruit rich meal is very simple. Number two, it keeps you full for two to three hour period until lunch rolls around.

And number three, we also recommend people to exercise in the morning hours, if they can make that happen because it’s a simple way to get your day started and it makes sure that you do it. And so having fruit bracketed with your exercise either before, during or after, is something that’s very helpful at giving you a ton of energy so that you can actually go perform exercise.

Dr. Weitz:                          Do you recommend eating the fruit and then exercise or vice versa?

Dr. Khambatta:                 It’s a personal choice at that point. It depends on the type of diabetes you’re living with, to be quite honest. For people living with Type 1 diabetes, we absolutely recommend eating something before you exercise, and then giving yourself like under-dosing on insulin just a little bit, to have a little-

Dr. Weitz:                          Yeah. You don’t want to take a chance of hypoglycemia.

Dr. Khambatta:                 Exactly, right. For people living with Type 2 diabetes, they have a choice. If they want to eat breakfast before they exercise, go for it, if they don’t want to eat before exercise, they can exercise in the fastest state, it’s no problem. Now, some people choose not to have a fruit-centric breakfast and they instead want to eat something that’s a little more savory. So in that situation we recommend having something that’s containing either beans or quinoa or some rice and some vegetables. So if they want to go for a more savory dish, totally fine as well, both of them are going to give you a good glycemic response.  Then when it comes to lunchtime, lunchtime is our favorite meal for increasing the intake of starchy carbohydrates.

Dr. Weitz:                          It’s interesting. I would say, the most calming carbohydrate-centric meal, you hear people eat is oatmeal with fruit.

Dr. Khambatta:                 Yeah. Oatmeal with fruit, that’s a great example. You can absolutely eat oatmeal with fruit. We’ve got no problems with that.

Dr. Weitz:                          Okay.

Dr. Khambatta:                 How was that? So when lunch rolls around, that’s your opportunity to eat slightly more starchy carbohydrates. So we recommend eating, you can either eat potatoes or squash, you can have some corn at that meal, you can have some more fruits at that meal if you want. You can even eat some whole grains at that meal as well. And we find that people who do that in the middle of the afternoon or for lunchtime are able to keep themselves full for a three to four to five hour period until dinner rolls around, which prevents them from overeating and trying to eat more refined carbohydrates. And their blood glucose response is actually because starchy carbohydrates slow down the glucose response and not necessarily get you a high blood glucose size, it takes time for that to unfold.

So if you put the starchy meal in the middle of the day, then over the course of three to four or five hours or so, you get a nice distribution of glucose coming into your blood, feeding your brain properly and keeping you energized. Then by the time dinner rolls around, we actually recommend eating things that are more what I would consider to be fluffy. When I say fluffy, I mean, more green leafy vegetables, more mushrooms, more non-starchy vegetables. And then having some legumes as well. At that time of the day, we don’t necessarily recommend starchy vegetables, because we find the people who’d start your vegetables in the evening hours sometimes can find their blood glucose to go high and/or stay high in the middle of the night, and then that can be problematic and it can drive your A1c value higher.  So it’s like fruit and/or whole grains in the morning, starch and whole grains in the middle of the day, and then more vegetables and fluffy material towards the end of the day. It’s a simple way to think about it

Dr. Weitz:                          Are there nutritional supplements that can help patients with diabetes?

Dr. Khambatta:                 Nutritional supplements that can help patients with diabetes?

Dr. Weitz:                          Are you not a supplement guy?

Dr. Khambatta:                 No, not a huge supplement guy. Truth be told, we sell a tea, it’s considered a supplement, I guess you’d call, and it’s made of this stuff called amla, which is Indian gooseberries, and Indian gooseberries have tremendous anti-diabetic properties. And so that’s something that we encourage people to incorporate into their diet as well. So ours is called Amla Green because it’s basically amla berries mixed with green tea. But it’s not required by any stretch of imagination, so something that’s very helpful.

Dr. Weitz:                          What about herbs like cinnamon or berberine?

Dr. Khambatta:                 Yeah, for sure. There’s plenty of anti-diabetic medicinal herbs. So there’s cinnamon, which is like controversial as to whether it actually helps [inaudible 00:45:46] management, then there’s berberine, then there’s fenugreek, then there’s gymnema sylvestre, then there’s bitter melon. And we love all of these things. Sometimes they can be hard to find. And so again, if people want to incorporate them into their diet, green light, absolutely love them, but they’re not necessarily required, it’s not necessarily a core component of managing diabetes approach.

Dr. Weitz:                          What is the best type, amount and frequency of exercise for patients with diabetes?

Dr. Khambatta:                 Okay. 30 minutes per day, six days a week. And when I, when I want you to exercise, I’m asking you to do a couple of things. Number one, I want you to get a good distribution of cardiovascular movement versus resistance movement. So when I say that, it’s hard to put specific numbers on it, but if I were to tell you to distribute your activity between approximately 50% cardiovascular movements and 50% resistance movements, that makes sure that your cardiovascular system is in check and that makes sure that you’re also putting a significant stress on your muscles to keep your bones strong over the course of time.

Dr. Weitz:                          Is it okay to do an hour of exercise a day?

Dr. Khambatta:                 For sure. 30 minutes minimum. Absolutely. Sorry, didn’t mean to confuse. 30 minutes minimum, no question. And then I also want to make sure when you’re exercising, that you’re exercising significantly hard enough and fast enough that you cannot talk to someone else, that you cannot answer a phone call and that you cannot sing your favorite song.

Dr. Weitz:                            Some level of intensity.

Dr. Khambatta:                 Exactly right. What types of recommendations do you have in general for exercise?

Dr. Weitz:                            I like to seem amount and frequency. I think it’s best for diabetics to exercise every day as you just mentioned. I think seven days a week if possible to help regulate your sugar and your insulin in accordance with your exercise. I think resistance training and cardiovascular exercise are equally important as well as incorporating some stretching and balance training even though those are not necessarily for blood sugar control, they’re still beneficial for health.

Dr. Khambatta:                 No doubt. 100%. And exercises is… I think in this world of nutrition, we’d like to talk about food a lot of the time. And I’m actually glad you brought up the exercise topic because exercises is something that is, it’s such a powerful insulin sensitizer. It’s hard to put into words, exercise has so many tremendous benefits, not only for your glucose metabolism but also for your brain, for your bones, for your connective tissue, for your muscles. It can improve the health of your thyroid gland, it can improve your mental health. It’s endless what exercise can do. And teaching people how to move their body on a daily basis is something that I think can become very addicting and something that we are huge proponents of.

Dr. Weitz:                            What about the effects of stress on blood glucose?

Dr. Khambatta:                 Yeah. Stress can be a doozy on your blood glucose. When you get stressed either like in a traumatic situation or whether there’s some baseline chronic stress, that can increase your cortisol levels as one type of hormone. And that cortisol can go signal to your liver and it can basically, it can significantly impaired glucose metabolism. And as a result of that, if you’re living in a high stress environment and that’s chronic, blood glucose can absolutely go up and it can make it such that your medication requirements can increase. And simply by, just like you’re saying, literally stretching your body, taking a mindful practice, relaxing, going outside and going for a walk, these are all simple things you can do that have a physiological effect on your blood glucose level.

Dr. Weitz:                            Yeah. If you’re having trouble with that morning fasting glucose number and it’s higher than it seems like it should be based on their diet and everything else, definitely look at stress

Dr. Khambatta:                 For sure. No questions asked.

Dr. Weitz:                            Do you ever address adrenal function or measure adrenal function as a way to look at salivary cortisol levels?

Dr. Khambatta:                 No, actually we don’t. Feel free to educate me on that. I’d love to learn a little bit more.

Dr. Weitz:                            You can measure your cortisol levels through the saliva and you can just fit into little tubes and you can measure them multiple times a day. What’s common is a four-part cortisol test. And now we have the cortisol awakening response where you’re actually measuring your cortisol as soon as you wake up and then 30 minutes later after you get out of bed, and then three other times during the day. And then you plot it out, you get a plot as to what happens with your cortisol curve.

Dr. Khambatta:                 That’s phenomenal. And where can you get these cortisol kits from?

Dr. Weitz:                            Oh, there’s a number of companies. Genova is a common popular company that people use. Great Plain labs, Dutch Lab testing, but-

Dr. Khambatta:                 Very cool. Yeah, I think that’s actually a very important component of monitoring your diabetes health because, even if you don’t have diabetes we live in the modern environment, which we live in, it’s stressful.

Dr. Weitz:                            Yeah, absolutely.

Dr. Khambatta:                 Whether you’re sitting in traffic, whether your internet connection went down, whether your phone is working, whether your boss is breathing down your neck, these are all mildly stressful enough. And when they count down one on top of the other, before you know it, you now are living in a state where you’re like, “I’m exercising, but how come my chronic disease went up? How come my hypertension is gone high? How come my cholesterol’s gone high?” And sometimes the answer is stress.

Dr. Weitz:                            Chronically high cortisol levels, or you can reach a point of burnout and then you have chronically low cortisol levels. A cortisol flat line is correlated with the worst prognosis for cancer and other chronic diseases. So, those are important. Yeah. And then of course we have sleep.

Dr. Khambatta:                 Sleep, sleep, sleep, sleep, sleep, sleep. Yes. There’s this interesting statistic that losing one night of sleep… I’m sure you’ve heard this. It says something like losing one night of sleep puts you at the functional equivalence of somebody who’s had, I think it’s like four beers. So if you don’t get sleep one day and then you go try to drive a car in the next morning to go to work, you’re effectively driving with the same level of mental capacity as if you had four beers. As far as diabetes is concerned, losing even one night of sleep, it has a dramatic effect on insulin resistance in the next morning. You can measure it.

You can actually see how your blood glucose levels are rising and how insulin has become less effective. So imagine if you’re in a position where you’ve become an insomniac or maybe you’re not sleeping enough or maybe the quality of your sleep has gone down. You’re doing everything else, you’re getting a plant-based diet, you’re exercising frequently, you’re doing a mindful practice, but yet you’re not sleeping properly. That unto itself can cause blood glucose to go up and it can frustrate you.

So addressing sleep is something that’s absolutely important and there’s many specific techniques that you can utilize to try and get yourself to go to sleep and stay asleep. And that’s something that’s there’s this research actually that’s actually linking sleep deprivation over the course of many years to cognitive decline, so increased risk for Alzheimer’s and dementia.

Dr. Weitz:                            Absolutely.

Dr. Khambatta:                 Right. And so sleep has profound effects not only for diabetes but also just for your brain health, for your heart health, for kidney health, you name it. All of these tissues require sleep in order to fully function at their optimal.

Dr. Weitz:                            Absolutely. Just as important as unregulated blood sugar is for brain health and Alzheimer’s risk.

Dr. Khambatta:                 Absolutely. And type three diabetes, no question.

Dr. Weitz:                          Right. Good. Okay. Any final thoughts for our viewers, listeners?

Dr. Khambatta:                 Yeah, I would say in this world of nutrition, it’s easy to get caught in between different ideologies. One nutrition expert can say go eat a ketogenic diet, the other nutrition, “Oh, I listened to that guy, he told me a plant-based diet. Oh, I listened to that guy who told me to eat a paleo diet.”

Dr. Weitz:                          No, I mean, we are so polarized in the nutrition world, it’s kind of like our politics. You’ve got carnivore diet and then you’ve got complete opposite.

Dr. Khambatta:                 Exactly right.

Dr. Weitz:                          Yes. More information and people are more confused than ever.

Dr. Khambatta:                 Than ever before. Exactly right. So the thing that I like to focus on is, rather than like spending your time getting frustrated by the differences, try and find the commonalities because there are some serious commonalities that I think unite every single health professional or most health professionals, and those are the commonalities that are really important. So just like you said, number one, sleep. Please go to sleep, stay asleep and improve the quality of your sleep. Number two, move your body. Please move your body on a daily basis.

Number three, do whatever you can to minimize your stress levels because chronic stress is a real doozy and it can increase your level of chronic disease. Everybody’s going to agree on this. Number four, vegetables are good for you. Everybody would agree that eating vegetables is good for you. Eating vegetables isn’t sexy. People aren’t like, “Oh, I can’t wait to go home and eat lettuce and broccoli.” Right?

Dr. Weitz:                          Yeah. Not everybody’s going to agree quite as much on unlimited fruit, but definitely vegetables.

Dr. Khambatta:                 That’s exactly right. People will not agree on unlimited fruit, that’s what we have seen and the research that we’re privy to. And our results show that it’s not about unlimited fruit, but about fruit is not your enemy. Right? And so increasing the quantity of fruit in your diet is something that can be tremendously beneficial for many tissues in your body, and it can help you control and reverse insulin resistance. And then another thing that we would all agree upon-

Dr. Weitz:                          And you also don’t think it matters if you… because you mentioned having bananas, it doesn’t matter if you have berries versus bananas versus grapefruit.

Dr. Khambatta:                 Yeah, it does not matter what type of fruit you eat. And there’s this common misconception that like bananas as an example are a high-glycemic fruit. Bananas are actually not a high-glycemic fruit. Just as one example, bananas are actually medium glycemic. There’s only really one fruit that’s high glycemic, and that’s a watermelon. All the other fruits, pawpaw, mangoes, strawberries, peaches, pears, plums, nectarines, you name it, those are all medium to low-glycemic even though-

Dr. Weitz:                          Part of it depends on how ripe they are.

Dr. Khambatta:                 Even in the ripest state, a banana as an example, a ripe banana is not technically considered a high-glycemic food, which is crazy because if you look at its placement on the glycemic index, you’ll actually find that it’s in the medium category. But point being is that no, we don’t differentiate between the types of fruits because again, your ability to eat fruit is dependent on if you are eating an insulin sensitive diet, an insulin sensitizing diet. But to get back to what I was saying, one thing that we all agree upon as well is that packaged and processed refined foods, there’s not a single health professional that I know that’s saying go eat more refined foods.  You would agree, I would agree, every single health professional says, “Okay, fine, let’s eat more natural foods because that’s actually going to improve your overall health.” And then another thing that we would agree upon, this could be the final one is that there are many ways to eat to reduce your dependence on pharmaceutical medications. And the goal is not to eat a diet that enables you to take a pill to live, instead, we as a community of healthcare professionals, regardless of our ideology, are trying to help you use food as a substitute for pharmaceutical medication.

And if you approach food from that perspective, then I think you’re going to be pleasantly surprised by what you find and that whether you’re going high fat, low fat, high carb, low carb, high fiber, low fiber, like you can experiment around to find something that feels good for you and it gets you good results. But the goal is to try and minimize your dependence on pharmaceutical medications and live as free of pharmaceutical medications as possible, and do it in a way where you’re eating real food as much as possible, and that’s going to have lasting, lasting benefits for every single tissue in your body.

Dr. Weitz:                            Awesome. How can our viewers find out about you and your programs and your book?

Dr. Khambatta:                 Cool. Thank you for asking that question. We wrote this book, Mastering Diabetes, hopefully you can see it on the screen here. And so this book basically is 400 pages long with 800 scientific references inside of it. And we’ve scoured the literature to really understand what is insulin resistance, and how can you wrap your head around it. And it also has a go-to manual for exactly what you can do today to start improving your health and become the most insulin sensitive that you’ve ever been.  You can get it on Amazon, you can get it on Barnes and Noble, you can preorder it right now. It’s going to go live on February 18th.

Dr. Weitz:                            I’ll make sure to put a link in the show notes.

Dr. Khambatta:                 Thank you. Thank you for doing that. And then if you’re also looking for more information, we have a coaching program for people with all forms of diabetes, go to masteringdiabetes.org. You can learn about it there and you can see if this approach is something that resonates with you. And we have tremendous success with our clients and we’d love to be able to help you out if diabetes is something that’s [inaudible 00:59:38]

Dr. Weitz:                            Awesome. Thank you.

Dr. Khambatta:                 Thank you.



How to Heal From a Traumatic Brain Injury with Dr. Kabran Chapek: Rational Wellness Podcast 143

Dr. Kabran Chapek discusses How to Heal from a Traumatic Brain Injury 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

2:17  Dr. Chapek just published a book, Concussion Rescue: A Comprehensive Program to Heal Traumatic Brain Injury, which he wrote partially while riding public transportation to and from work each day, so he dedicates this book to bus route 532.

3:07  Traumatic Brain Injury involves a blow or jolt to the head and minor traumatic brain injury is actually major cause of mental health issues that is often overlooked as a cause. A concussion is a form of mild traumatic brain injury where there is a loss of consciousness.  The standard protocols for treating such injuries have not improved at all in 20 years.  There are many others who have a brain issue, such as dementia, memory problems, depression, anxiety, etc. and this can be due to a past brain injury.  Mild traumatic brain injury is one of the silent causes of mental health issues and nobody knows about it.

4:40  Even the NFL, which is supposedly focused on reducing head injuries with their current concussion protocol, but they are not doing anything about the many minor slaps and blows to the head that do not involve a concussion but that are cumulative and can result in Chronic Traumatic Encepalopathy (CTE).  CTE is the condition highlighted in the movie Concussion and it cannot be diagnosed with a CT scan. This has even led some football players to retire early to avoid permanent brain injury.

8:37  A whiplash car accident can result in a brain injury without ever hitting your head.  This is because the skull has many sharp, bony ridges and the brain is soft as butter.  During a whiplash accident, you can have a shearing of the neurons between the cerebrum and the brain stem as the heavier cerebrum slushes forwards and then backwards in relation to the brain stem. and you also get a secondary injury from the cascade of inflammatory mediators and oxidative damage that results from this. A chronic inflammatory state can result, leading to damage to the brain over months and even years.  Dr. Chapek sees patients coming to see him at Amen Clinic with complaints of depression or ADD and a SPECT Scan finds that they have structural damage to their brain and sometimes it takes repeated asking (up to 10 times) during the history taking till the patient recalls hitting his head or some other trauma to his head.  Once this is determined, the patient is placed on a program involving diet, lifestyle and nutritional supplements to heal the brain and the depression and other symptoms often resolve.  Even though it may be years later, you can still heal your brain.

15:38  Dr. Chapek, as part of his evaluation of patients, besides taking a careful history, will use an online cognitive tool, WebNeuroIt measures attention processing speed, memory, and then emotional states of depression, anxiety, emotion identification, and it’s simple and somewhat objective. It is validated and correlated with MRI.  At Amen Clinic they also do SPECT imaging, which is like 3D imaging of the brain. 

20:27  If a patient has had an acute head trauma, then they should go to the hospital and get a CT scan to rule out a brain bleed or major damage.  Most of the time this will be negative. MRI is best for looking at the brain vasculature and for looking for amyloid plaque in dementia.   After a head injury or concussion, it is good to do a CT or MRI first to rule out severe injury and then if it is negative, do a SPECT scan to pick up mild traumatic injury.  Here is a good paper explaining the utility of doing both types of scans: Clinical Utility of SPECT Neuroimaging in the Diagnosis and Treatment of Traumatic Brain Injury: A Systematic Review.

22:00  Dr. Chapek also likes to do some lab testing including looking at nutrient status. He likes to assess serum zinc, RBC zinc, copper, vitamin D, B12, homocysteine, inflammatory markers, hs-CRP, and lipids (cholesterol).  If any of these nutrients are low, it is harder to heal from a brain injury.  He does not like total cholesterol levels to go below 150, since a healthy brain needs plenty of fat and cholesterol.  The medical profession is a bit overzealous now trying to drive LDL levels down as low as possible using statins and the new PCSK9 inhibitor drugs and this may be sacrificing the brain for the heart.  Having a good vitamin D level is important for healing from a brain injury.  Vitamin K is also important.  Dr. Chapek also measures the Omega 3 index and the Omega 3:6 ratio.  Hi likes his patients have at least 3 gms per day of EPA and DHA.  Dr. Amen completed a study demonstrating the benefits of omega 3s and other nutrients for NFL players after head injuries and had them take 3 gms of Omega 3 fatty acids (fish oil), Gingko, Vinpocetine, Acetyl-L-Carnitine. NAC, alpha-lipoic acid, Huperzine A, and phosphatidylserine in a formula and also a multiple vitaminReversing brain damage in former NFL players: implications for traumatic brain injury and substance abuse rehabilitation. They experienced a 70-80% improvement in cognitive symptoms. 

31:41  25 to 50% of people with brain injury have damage to the pituitary gland, your master hormone gland.  Thus various hormone levels can be affected in head trauma, such as thyroid, adrenals, growth hormone and testosterone in men, and estrogen and progesterone in women.  Dr. Chapek said that we can measure IGF-1 and IGFBP3 levels first thing in the morning in order to monitor growth hormone levels and he said that a good target level for IGF1 is over 200.  This is very controversial now in the anti-aging community where lower levels of IGF-1 are considered better for anti-aging purposes, by Dr. Valter Longo and others.  But Dr. Chapek feels that there should be a balance between lowering IGF-1 levels with fasting and raising IGF-1 levels for growth and regeneration purposes for the neurons in the brain.

36:59  In Dr. Chapek’s book, Concussion Rescue, he talks about a first aid kit for the brain.  There’s a study of active service members in the battlefield who were getting exposed to IEDs. Those who were immediately given N-acetylcysteine (NAC) 86% recovered within a week, whereas only 42% of those who did not get NAS (received a placebo) recovered within a week.  Amelioration of Acute Sequelae of Blast Induced Mild Traumatic Brain Injury by N-Acetyl Cysteine: A Double-Blind, Placebo Controlled Study  NAC is a precursor to glutathione.  In this study, the soldiers were given 4 gms immediately and then 2 gms twice per day for 4 days. Then 1.5 gms twice per day.  This is why NAC is one of the ingredients in Dr. Chapek’s Concussion Rescue first aid kit.  Vitamin D (5000 mg) and vitamin C (1000 mg)  are also part of the program.  We can also use liposomal glutathione under the tongue and even topical gluatione is worth a try, such as to the back of the neck. Curcumin (500 mg) from turmeric is also part of the first aid program.  Omega 3 fats. MCT oil powder or capsules to enhance the brain’s utilization of ketones for fuel.  Branch chain amino acid powder.  Infrared light to the back of the neck can also be helpful.  Exogenous ketones can also be helpful.

43:01  They used to use IV corticosteroids for spinal cord injuries until the CRASH trial published in 2005 study showed it increased mortality, so they stopped doing this.  Inflammation is part of the way the body heals and it is best to dampen but not shut down the inflammatory process.  It is not clear if icing the brain is helpful or not.

45:48  The ketogenic diet appears to be the best diet for healing the brain after trauma. It has been shown to help with other neurological conditions and Dr. Chapek’s clinical experience is that the keto diet helps the brain to heal.  He recommends no more than 30 gms of carbs per day, which requires eating a lot of fat with each meal by adding mayonnaise, avocados, and coconut oil, and by eating those fat bombs.   It can be difficult to digest this much fat, so taking some ox bile can help with digesting them. 

48:50  Sleep is also very important for brain healing, but patients after head trauma often have trouble sleeping and getting into deep sleep.  You don’t necessarily need to do eight hours of sleep straight. But you need at least a four hour chunk to get several cycles of REM sleep to get that restorative sleep. Growth hormone is released during deep sleep.

50:53  Dr. Chapek pointed out that high intensity interval training is another way to increase growth hormone production. 

52:14  Brain training can also be very helpful, including meditation, which strengthens the frontal and temporal lobes of the brain.  Neurofeedback can also be helpful. And there are online brain training games like BrainFitLife that was developed at Amen Clinics, where Dr. Capek works.  There is also Brain HQ, Cogmed, and there are many other brain training programs available. But it is important to train different areas of the brain, so if you’ve been doing cross word puzzles for 30 years and you are really good at them but you are not so good at math, then do some Sodoku.

54:50  The structural alignment of the cranial bones and the spine is also very important to insure the cerebro-spinal fluid flow through the spinal cord and brain, as well as insure blood flow and neurological flow to the brain and spinal cord.  This is where Chiropractic and Osteopathic medicine can play a role in brain healing.

56:00  Hyperbaric oxygen can also be very helpful to push oxygen in for healing of the brain and for the brain to be more metabolically active.



Dr. Kabran Chapek is a Naturopathic Doctor and a staff physician at Amen Clinics and the author of a new book, CONCUSSION RESCUE: A Comprehensive Program to Heal Traumatic Brain Injury. Dr. Chapek is available to see patients at Amen Clinics Northwest in Bellevue, Washington and the phone is 425-250-9564. Amen Clinics has a website where their custom nutritional supplements are sold, BrainMD.com.  Dr. Amen offers a number of online courses for both patients and practitioners at Amen University.

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.


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 Podcast listeners. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please give us a ratings and review on Apple podcasts or wherever you get your podcasts. Also, 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.

Our topic for today is Healing From Concussions and Other traumatic Brain Injuries with Dr. Kabran Chapek. Our focus will be on using a functional medicine approach to help patients heal from either resent or a past traumatic brain injuries.  A traumatic brain injury, which may or may not include a concussion is caused by sudden damage to the brain, caused by a blow or jolt to the head. Common causes include car or motorcycle accidents, falls, sports injuries, and assaults among many other types of trauma. According to the CDC, there are over two million new head injuries in the US per year. Dr. Kabran Chapek is a naturopathic doctor and a staff physician at Amen Clinics and the author of a new book, Concussion Rescue-

Dr. Chapek:        Hey, there it is.

Dr. Weitz:            … A Comprehensive Program to Heal Traumatic Brain Injury. Dr. Chapek uses a functional and integrative approach to the treatment of patients with traumatic brain injuries, Alzheimer’s and dementia, PTSD and anxiety disorders.

Dr. Weitz:           Dr. Chapek, thank you so much for joining me today.

Dr. Chapek:        Oh, it’s my pleasure and an honor to be here.

Dr. Weitz:           Excellent. So I’d like to start the interview by asking, how did taking a bus to work help you write this book?

Dr. Chapek:        No one’s asked me that. That’s awesome. I’m a busy guy. And also, it’s there’s always something you can do. So riding bus route 532, from Edmonds to Bellevue just is like, I had the time and it’s focused time. It’s like I get the most done. And so I devote this book to bus route 532.

Dr. Weitz:           Soon, we’ll be able to do that when the driverless cars come in. We’ll get to sit back and read and work on our-

Dr. Chapek:        Can’t wait.

Dr. Weitz:           Good. Okay, how many more books will get published?

Dr. Chapek:        Right.

Dr. Weitz:           We’re just going to get people reading them.

Dr. Chapek:        Yeah.

Dr. Weitz:           So can you explain what traumatic brain injuries are? What’s the difference between a traumatic brain injury and a concussion? You refer to traumatic brain injuries as a silent epidemic in your book.

Dr. Chapek:        Yeah, so concussion is just a form of mild traumatic brain injury. So when we talk, we’re talking TBI, traumatic brain injury. A concussion is all the treatments are going to be pretty much the same, as far as this is concerned. Of course, severe brain injuries like life fighting to the hospital. That’s a severe brain injury and needs a different approach than what’s in this book. Really, the book is targeted for those who have had a concussion and haven’t gotten better. And those people who have some other brain issue whether it’s dementia, memory problems, depression, anxiety, and it may be due to a past brain injury, you just didn’t know about it. So those are the two.

And then, in my past 12 years working in mental health, one of the major causes of mental health issues is mild traumatic brain injury, and nobody knows about it. And that’s why I call it the silent epidemic because like you said, there’s millions of Americans going to the ER every single year, the number has actually gone up, even though death rates have gone down. The number of people suffer, and part of it, there’s more people, but the solutions haven’t gotten better. The standard protocols haven’t changed a bit in past 20 years. Well, not much.

Dr. Weitz:            Right. And we can look at the NFL as an example of this because everybody knows about concussions but really, the movie Concussion came out, it talked about a condition called traumatic … Was it chronic?

Dr. Chapek:        Chronic Traumatic Encephalopathy, CTE.

Dr. Weitz:            Encephalopathy, exactly. And so this is a condition that doesn’t require a concussion. It can occur from a series of lower level blows that lead to damage to the brain that actually was only discoverable after slicing the brain up and looking at it with a microscope and conventional CT scans didn’t show anything. And so therefore, even current NFL protocols, which are all focused on when the patient has a concussion are still not really addressing some of these milder forms of brain injury that become chronic and overtime get worse and worse.

Dr. Chapek:        Mm-hmm (affirmative). Yeah, absolutely. I think that’s the key that we had. Brain injuries are cumulative, whether it’s from a concussion or subconcussive hits to the head. There’s a study done on football or high school football players, these kids and just playing high school football showed cognitive changes and brain injury on fMRI, functional MRI. It’s like, oh my God.  So these bright, young future leaders and contributors to society are damaging their brains by playing high school football, most of them are not going to become professionals and even if they do, some are actually starting to not say, you know what, I can’t remember who it was but there’s a really talented I think he’s a 49er. He decided not to go on because he didn’t want to suffer brain injury.

Dr. Weitz:           Yeah, I remembered he like retired at age 25 or something like that.

Dr. Chapek:        Yeah. And so this is starting to happen. Pop Warner, parents are pulling their kids out. And I think it’s really smart because they’re recognizing damages cumulative these … we’re seeing these retired athletes, these heroes who are now some of them, like Dave Pear, publicly said, “I regret ever playing football,” even though he missed his career and because he had dementia at age 50.

Dr. Weitz:           Wow.

Dr. Chapek:        The rest of his life totally changed. He has anger problems, memory problems, depression. And that’s like a delayed reaction. So some people think that’s one of the common myths of brain injury that I had this car accident. I was fine and then a month later, why is did this person change?  Why are they angry now?  Couldn’t have been the car accident because it was so far away. But actually, it was a delayed like, swelling slowly increases. There’s chronic inflammation that is under the hood, like you can’t see it.  Inflammation under the skull. That’s part of why it’s the silent epidemic because, just President Trump not to take politically into this, politics into this, but then.

Dr. Weitz:           Talk about a brain injured person.

Dr. Chapek:        Oh, my God. Don’t get me started there, but that’s not what I meant. I meant like he made comments about minimizing. Did you hear about that? Minimizing the veterans who had–had there was a missile strike?

Dr. Weitz:           Yeah. He said they just had a headache or something.

Dr. Chapek:        Yeah, he said, “Just a headache.” These are valuable. These are service men that are putting their lives on the line. So what if it might have been, might not have been? Let’s at least take it seriously and assess them. And let’s not take a chance with their precious people, our brains like that’s who we are, God.

Dr. Weitz:           Absolutely.

Dr. Chapek:        So it’s frustrating.

Dr. Weitz:           We mentioned car accidents. Isn’t it the case that you can have a whiplash injury, never hit your head on a window and still have a brain injury?

Dr. Chapek:        Yes, exact great point. You can have injury from it’s just it’s acceleration deceleration. And it’s horrible, think Shaken Baby Syndrome. Severe brain injury lifetime of disability potentially or death from just shaking a baby. Their brain is so soft. This is why, it’s as soft as butter. The skull has many sharp bony ridges and it’s really hard. So there’s nowhere for the swelling to go.  And it’s like, you can look, you can Google this. But brains if you take a brain out fresh brain, put it on the table. It’s a pile of goo in a few hours.

Dr. Weitz:            Right.

Dr. Chapek:        So the brain is very vulnerable. We’re not designed to hit our heads, in the movie Concussion, rams, they have some spongy bone, woodpeckers, there’s some shock absorber. But humans, no. We’re like the last people to-

Dr. Weitz:            And part of what happens in a car accident is the car is moving at a certain rate of speed and then suddenly stops. And so what happens with the neck is that the body moves forwards the head stays back because it doesn’t weigh as much. Then the body stops and the head moves forward. So you get this deceleration acceleration, injury that occurs at the shearing of the muscles and deaths etc in the cervical spine. But within the skull, you also have this differential between the weight of the skull and the weight of the brain. And you can also get this shearing between the … with the cerebellum and the cerebrum and the brain stem, which is fixed. And so you can get this diffuse brain injury that can occur from a whiplash without any damage that had.

Dr. Chapek:        Great description. Yeah, perfect. Exactly. And so that’s the primary injury, damage to the neurons, breaking of the tissue, stretching of the axons. And then there are secondary injury, and that’s like the cascade of inflammatory mediators, the oxidative damage. It’s like rusting from the inside out, free radicals are produced, Calcium is released, exciting mitochondria, they burn out is what happens and become very … There’s like this glucose spike and then drop and so there’s this metabolic deficit. This hungry organ, this brain that uses 20 to 30% of calories in our diet all of a sudden has less glucose and it’s damaged. So that’s secondary injury, that chronic inflammatory state. It’s like a fire that hasn’t been put out. It continues to smolder for months and sometimes years is where we want to intervene.

Dr. Weitz:            Right. And sometimes patients come into your office, and they don’t even realize it. They’ve had a brain injury.

Dr. Chapek:        Right. That’s key to assess them thoroughly. Now, four out of 10 patients who come to Amen Clinics, because we do brain imaging, we can see that they’ve had an injury, but they’re coming for some other reason. They’re coming for ADD, depression.

I had a patient, we’ll call him Jeremy. And he was 21 when he came in, he’s this jazz drummer, this really bright kid. But on the inside, he was suicidally depressed every single day of his life from age 14 to 21. He’d seen some great therapists, tried every class and medication and was still suffering. He was referred by one of really good therapists in Portland. And he’s been smoking pot every day just to feel better, bad relationship. He was dating a girl who was borderline and a lot of difficulty. And so when we came in, came in from depression, treatment resistant depression. We scanned his brain and he had clear evidence of brain injury. Damage to his left temporal lobe, left frontal lobe.

And it was asymmetrical the type of imagery we do is called SPECT, S-P-E-C-T. It’s functional, looking at blood flow versus MRI, which is structural. We showed him the scan and nowhere on his history had he listed a brain injury. So I said, “Jeremy, have you ever …” This is what you have to do is think back so we minimize it. “Have you ever fallen out of a tree? Have you ever dove into a shallow pool? They were falling off a log? Fallen off your bike? Ever been in a fight?” “No, no, no.” “Have you ever played contact sports?’ And his mom was there said, “Oh, remember you started playing football and you’re about 13 years old. And you’re matched up against the coach’s son who was already six feet tall and you were the scrawny little kid whose got pounded every day and would have headaches.” At that time he was diagnosed with ADD, started having trouble in school and started having depression, which started the next year.  And so by putting him on a program to help him heal his brain, he started to feel better within the next several months, the depression lifted and he’s about to graduate from the Berklee School of Music in the next, this is two years later and broke up with the girl, not smoking pot, doing good.

Dr. Weitz:            That’s great. I saw where in your book you described asking patients sometimes up to 10 times during their initial consultation if they’ve had some sort of brain injury because patients so often don’t remember or don’t connect the dots.

Dr. Chapek:        Right? We think if I didn’t go to the ER, if I didn’t lose consciousness, it must not have been that bad.  It couldn’t be contributing, so that’s one why people don’t and also there’s amnesia.  And we just forget and so it’s like the same with when you’re looking for mold in a home while doing functional medicine you have to ask specifically, or if you are looking for toxicity, because we tend to not think about it. This is the same for brain injury, it’s really helpful to ask your patients or to think back in your life. Okay.  Have I actually and as I started working at Amen Clinics, when I first scan my brain didn’t look so good.  I was like oh crap. Don’t show Dr. Amen my scans.  I need to get this, I need to heal this.  And what must have happened oh, I did fall.  I never lost consciousness.  But I did fall off my skateboard a few times. I fell out of trees, the real active kid. And I can tell you my story about how hoping to heal and improve my brain and re-scanning later, but it is possible to actually improve even if it was many years later, you can actually heal from that fact.

Dr. Weitz:            Right. So we were talking about history, which is first part of a workup for somebody with a traumatic brain injury, or one of these other conditions like ADD.  Does your initial paperwork include some assessment of cognitive function?

Dr. Chapek:        Yeah. Great. In addition to the history, yes we do. We use WebNeuro. This is a cognitive tool. It’s web based and can be repeated. We like that so-

Dr. Weitz:           You logon to the internet and a patient goes out the questionnaire online?

Dr. Chapek:        Yeah, measures attention processing speed, memory, and then emotional states of depression, anxiety, emotion identification, and it’s simple and somewhat objective so that can be repeated three months later how are we doing?  Six months later, how are we doing? And it’s less invasive.

Dr. Weitz:           Why do you like that questionnaire better than so many others?

Dr. Chapek:        It’s validated. It’s also correlates with MRI.

Dr. Weitz:           Okay. 

Dr. Chapek:        They have it correlate to a database. There’s other good ones out there. But the other reason I like it, it’s not just cognitive function, it also does affect or take into account emotional states.

Dr. Weitz:           Okay.

Dr. Chapek:        Because sometimes it’s hard to tell if the memory problems or attention problems are actually due to depression or anxiety or how much is playing in there and that can get missed.

Dr. Weitz:           Right? Good. If you can send me a link to that, I’ll put it in the show notes.

Dr. Chapek:        Happy to.

Dr. Weitz:           And then so we have history, we have some this form of cognitive testing, and then do you typically do an MRI or a CT scan?

Dr. Chapek:        Sometimes. We like SPECT imaging for picking up more subtle changes. We actually have the SPECT scanners in all of our clinics.

Dr. Weitz:           Now what exactly is a SPECT scanner? Do you use an MRI or it’s a completely different machine?

Dr. Chapek:        It’s more like a CT scanner.

Dr. Weitz:           Okay.

Dr. Chapek:        How it works is a patient is injected with a little bit of radioactive isotope.  We use technetium.  It’s about equivalent radiation to a head CT scan. So think about the difference, and then so they’re injected, then you lie on the table and it’s not really a die but the technetium goes to the brain to the most active parts and gets fixed there and then emits a signal which is picked up by the camera as it spins around their head. So a CT camera radiation in taking a picture. This is like the brain emitting a signal and picked up by a camera that spins around the head. So there’s no tube that you go in like an MRI, it’s more just goes around the head and it’s … Most hospitals have some form of SPECT imaging for heart studies and for brain studies. It’s similar to PET differences being PET is much more radiation and is mostly looking for amyloid and different glucose metabolism in the brain.

Dr. Weitz:           Amyloid would be more beneficial for a patient with Alzheimer’s?

Dr. Chapek:        Right. And we say yes or no for Alzheimer’s, Parkinson’s, but the thing is with PET, it’s none. It’s less specific. It tells us less about what else is going on. Yes, it answers a question beta amyloid. So if it’s negative, that’s very reassuring and helpful.  But if it’s positive, that could be amyloid due to past brain injury, could be due to Alzheimer’s dementia. It’s based on history, where a SPECT imaging, you can see it’s like a 3D image of the brain. And you can tell, “Okay, the temporal lobes damaged or the frontal lobes damaged?  Is it the cerebellum? Is it the limbic system? Is there a lot of depression associated with limbic activity?” And in that way, for example-

Dr. Weitz:           Can you do it without the contrast material?

Dr. Chapek:        No, not the SPECT.

Dr. Weitz:           Okay.

Dr. Chapek:        So that’s that. If people can’t do radiation or get a needle, an injection, then it’s very small needle but still, some people have needle phobia.

Dr. Weitz:           I just worry about that stuff. I know there was a report that the MRI contrast with gadolinium that the gadolinium tends to build up in the brain.

Dr. Chapek:        Yes. So this is radiation. So in 150,000 scans, no reactions.

Dr. Weitz:           Oh, okay.

Dr. Chapek:        Because it’s just radiation and sailing. There’s no actual die, although it feels like that. So that’s hopefully helpful.

Dr. Weitz:           That’s good. Okay. So typically at a hospital, they’ll do a CT scan, what are they looking for there?

Dr. Chapek:        So if you’ve had a concussion, you do want to go to the hospital, go to the ER, make sure there’s no brain bleed, especially after concussion. If you have slurred speech, can’t stay awake, you keep passing out. There’s many warning signs, but and you’re looking for brain bleed. So Liam Neeson, his wife, Natasha Richardson. She was skiing on the bunny Hill at Mount Blanc, a couple of years ago and fell, hit her head waved off the emergency personnel said, “I’m fine, I’m fine.” But then the next day she had a massive brain bleed. So I think it was a subdural hematoma and died, so sad.  We need to we need to rule out the worst. CT scan is still important for that. But basically it’s just looking for a brain bleed or major damage. It’s mostly negative and it’s not sensitive at all picking up mild traumatic brain injury.  In fact, there’s a study done in the journal PLOS One in 2013, I believe that looked at 2400 patients who compared SPECT to MRI and CT and found that SPECT imaging picked up mild traumatic brain injury and 94% of the cases that was missed in MRI so it’s more sensitive, but MRI is useful and looking at vasculature and dementia. And the two together is actually a helpful combination.  Clinical Utility of SPECT Neuroimaging in the Diagnosis and Treatment of Traumatic Brain Injury: A Systematic Review.

Dr. Weitz:           Cool. So what type of lab testing can be beneficial and working up patients with traumatic brain injury?

Dr. Chapek:        Love doing labs, love doing labs looking for nutrient deficiencies because oftentimes there are like zinc deficiency, vitamin D. And if you’re low, it’s been shown in many studies it’s harder to heal.

Dr. Weitz:           How do you test zinc deficiencies? Do you do one of these nutrient panels like the NutrEval or the micronutrient test, are you doing serum or red blood cell?

Dr. Chapek:        We just do serum because there’s more research on serum. But I like if I’m really concerned, I’ll do serum and RBC zinc, red blood cells zinc too, because serums outside the cell, RBC is inside the cells. It’s nice to know both. And if someone’s low in serum zinc, they’re low, for sure. But I do like the other panels as well. It’s just for screening, we’ll do serum zinc and we want the levels to be closer to 100 or above. And that copper ratio we want copper to be around 100 or below high copper associated with inflammation although you do need some copper as well. And we do, so we look at nutrient deficiencies.

Dr. Weitz:            You look at the zinc copper ratio?

Dr. Chapek:        Mm-hmm (affirmative). Yeah, zinc copper ratio.

Dr. Weitz:            And you want that to be what?

Dr. Chapek:        I think greater than 1.3. But I don’t calculate it. I want serum to zinc to be around 100 or above and copper around 100 or below, essentially.

Dr. Weitz:            Okay.

Dr. Chapek:        So I keep it simple. And then I look at vitamin D, zinc, copper, B12, homocysteine, inflammatory markers, hs-CRP, look at the cholesterol. Actually want cholesterol to not be too low. High cholesterol is associated with heart disease, low cholesterol associated with brain disease.

Dr. Weitz:            Right, so what level cholesterol is associated with brain disease?

Dr. Chapek:        Below 150.

Dr. Weitz:            This is for total?

Dr. Chapek:        Total. Thank you. Total cholesterol below 150 is associated with suicide and homicide.

Dr. Weitz:            And what about LDL? Is there a cut off for that as well?

Dr. Chapek:        I don’t know the answer for that one. I just don’t total. It’s a good question.

Dr. Weitz:            Okay.

Dr. Chapek:        But usually the LDL is what makes it go a little higher or too low.

Dr. Weitz:            What I’ve seen LDL below 60 I think is problematic with lowered brain function.

Dr. Chapek:        Perfect. Now, thank you for telling me that. It’s good to know. And it’s like their brains are 70% fat by dry weight.

Dr. Weitz:            Yes.

Dr. Chapek:        And we need that fat the brain loves it, it loves cholesterol. So it does well with cholesterol so a higher fat, lower carbohydrate diet.

Dr. Weitz:            And I do think in cardiovascular medicine today there’s, we’re a little bit too overzealous in trying to drive that LDL as low as possible. And now that we have some of these new PCSK inhibitors that can be added to statins, people are celebrating getting the LDL down to 40. And I think we’re overzealous on that not looking at some of the negative effects of that.

Dr. Chapek:        Yes, sacrificing the brain for the heart.

Dr. Weitz:            Exactly.

Dr. Chapek:        That’s so sad. Well, sometimes I can get cardiologists and primary care Doc’s to lower the stat and if we talk about the brain and the heart, and it’s like, tell them hey, we need I understand risk factors. And there’s more benefits beyond just cholesterol lowering effects of statins that are preventing heart attacks. But come on, do we really need it to be 100 total cholesterol, can we just go up to 150, 160 and see if memory improves at that point because a lot of people are having memory problems from too low cholesterol.

Dr. Weitz:           Yeah. And vitamin D is very important, right?

Dr. Chapek:        Oh my gosh, it’s a real key, like it’s going to be hard to recover from brain injury. If vitamin D is deficient. There’s certainly studies to show this. If your vitamin D levels are low prior to injury, then you’re going to have more post concussive symptoms. These are animal studies, but I think they do apply to humans because there’s a number of human studies. Giving vitamin D after injury helps in the recovery process, especially progesterone and vitamin D or other things with vitamin D, because it’s neuro anti-inflammatory.

Dr. Weitz:           Right, and essentially, vitamin D is a hormone, even though it’s not often referred to as that and the interesting thing is, a common recommendation is just go out in the sun and it makes a lot of sense that our body make vitamin D from the sun, but my clinical experience is even practicing in Southern California where we have plenty of sun and even patients who are going out in the sun, often present with very low vitamin D levels.

Dr. Chapek:        Fascinating. So even I was hoping maybe at least you’d have good vitamin D patients but not the case.

Dr. Weitz:           It’s amazing. You would think nobody would be deficient in vitamin D in Southern California and they are. And by the way, for most patients, it’s not easy to bring their levels up to what I consider most functional medicine doctors consider a therapeutic level which is say 50 to 70 or 60 to 80 nanograms per milliliter and we often find we have to go to five or 10,000 units per day to that level.

Dr. Chapek:        You have to work hard at it. I agree with you. Vitamin D is key. Vitamin D is key. Yeah, absolutely.

Dr. Weitz:           We’re big on vitamin K too.

Dr. Chapek:        Vitamin K is important. Yeah, absolutely.

Dr. Weitz:           That works synergistically with vitamin D, uses arterial calcification, important for bone and …

Dr. Chapek:        Are you checking Omega-3 index?

Dr. Weitz:           Absolutely. Yeah.

Dr. Chapek:        I think that’s a great one. And we’ve been doing that I think it’s also helpful because, you can actually measure your Omega-3 to 6 ratio course. And Omega-3 is important anti-inflammatory but also helping heal the the cell membrane and the neurons. So that’s another key aspect.

Dr. Weitz:           Yeah, they’ve been some really good studies on the higher dose Omega-3s for brain injuries right?

Dr. Chapek:        Absolutely, yeah.

Dr. Weitz:           What dosage level do you like for Omega-3s?

Dr. Chapek:        Minimum of three grams, EPA DHA calculated not just total Omega-3, but EPA DHA three grams a day. That’s what we used in the NFL study. So we had 30 NFL retired players, we had them take three grams of Omega-3, they took Ginkgo fossa title searing Acetyl-L-Carnitine. NAC alpha-lipoic acid, Huperzine A, and anthocyanins in a formula with a multiple vitamin. That’s it for supplements and three grams of Omega-3.

We had them exercise, lose weight if they needed to. They ate a … they were treated for sleep apnea, many of them had sleep apnea. And some were given hyperbaric oxygen. And then after six months, believe it was 70 to 80% improvement in cognitive symptoms. So again, that testing before and after attention, memory, processing speed, less anger, less depression, and their brains look better. We could prove this, we could actually document on their scans terrible, and then better.

Dr. Weitz:           Wow! Awesome. When was this study published?

Dr. Chapek:        This was in I believe, 2013, 2014.  I’ll find it and you can put a link if you want to on that.

Dr. Weitz:           Yeah, that would be great.  I’d love to do that.  So I know we’re going to get into supplements in a few minutes a little more, but since we’re on the Omega-3 thing, some practitioners recommend focusing on DHA when it comes to the brain.  And there’s a number of supplements on the market now, including a prescription one that’s mainly DHA. What about using more DHA than EPA or you find the balance better?

Dr. Chapek:        I find the balance better because and I think a little bit of it depends on where you’re at in the process. If it’s acute brain injury, a higher EPA, chronic brain injury you’re trying to rebuild, probably more DHA. My rule of thumb is at least three grams total EPA/DHA, higher EPA to DHA, but at least 1,000 of DHA because that’s what’s been shown in many of the studies for memory and dementia.

Dr. Weitz:           And is there a target you like to hit on either the Omega-3 index or the Omega-6 to 3 ratio?

Dr. Chapek:        We try to shoot for eight to 10. In the studies in around the world, there’s less schizophrenia, less depression if the Omega-3 index is higher like in Japan, so that’s where we’ve shoot. What do you shoot for?

Dr. Weitz:           I like eight to 10 as well. I like to try to get the six to three ratio below four ideally below two. Two is really difficult.

Dr. Chapek:        Yeah, I haven’t seen that very often.

Dr. Weitz:           Yeah, I keep mine below two but I have to take six to eight grams of EPA/DHA.

Dr. Chapek:        Wow, that’s awesome.

Dr. Weitz:           So hormones are often affected by brain injuries. Why is that?

Dr. Chapek:        25 to 50% of people with brain injury have damage to the pituitary gland, your master hormone gland, and it’s because it’s like an upside down ice cream cone. It’s very boldness at the bottom and is surrounded by the sella turcica this very bony ridge, so same idea with this-

Dr. Weitz:           This is inside the skull?

Dr. Chapek:        Deep inside the skull. And so with that acceleration deceleration injury, or a hit to the head and especially a concussive blast injury which many veterans come back with, it can penetrate and damage and hit that pituitary gland. So especially it happens in concussive blast injuries, but also in our football players.  They damage the pituitary fully or partially and if that pituitary is damaged, we will have deficiencies in thyroid hormone, there’s less TSH produced, growth hormone, testosterone, estrogen, progesterone in women, low adrenal function. The top two being growth hormone and testosterone in men, estrogen, progesterone in women. And these hulking guys, these football players 20 to 30% of them have deficiencies in testosterone and growth hormone.

Dr. Weitz:           Yeah.

Dr. Chapek:        I was trained by Dr. Mark Gordon endocrinologist out in your neck of the woods, who’s really done a lot of good work with the veterans and military folks on how to assess and treat for hormonal deficiencies and that really enhanced healing for people. It’s like we need the nutrients for decreasing inflammation. We need the hormones for growth and healing and really accelerating that. Putting the brain into a healing environment where it can heal.

Dr. Weitz:           How do you assess growth hormone levels?

Dr. Chapek:        IGF-1 and IGFBP3.

Dr. Weitz:           Okay.

Dr. Chapek:        First thing in the morning. That’s really the best and if there is a-

Dr. Weitz:           What the target for IGF-1.

Dr. Chapek:        Over 200.

Dr. Weitz:           Over 200?

Dr. Chapek:        Mm-hmm (affirmative).

Dr. Weitz:            Interesting.

Dr. Chapek:        Yeah. According to quoting, Dr. Gordon and there’s this debate between IGF one right.

Dr. Weitz:            I was going to bring that up right now for people don’t know. Actually in a functional medicine in anti-aging world, we have Dr. Valter Longo from USC. And he’s been finding that lower IGF-1 levels are associated with greater longevity.

Dr. Chapek:        Mm-hmm (affirmative). It’s like a tug of war. Of which it’s low. Oh, no, it’s high. So that growth hormone folks, anti-aging folks, high levels, and then it’s the low calorie diet folks, low levels. And I think it’s like there’s this in between, that’s-

Dr. Weitz:            Absolutely.

Dr. Chapek:        It’s like the same in the bones osteoblasts and osteoclast. You don’t want too much. And then the brain there’s APP gene. So this is the Dr. Dale Bredesen’s work and this is his whole theory cannot condensed into the APP gene.

Dr. Weitz:            Right, exactly. We have this just like in the bone where you have this balance of osteoblasts cells that are producing new bone and osteoclast cells which are clearing away, broken down junkie volume and you need this balance. Same thing in the brain, we used to think you had all the neurons you were ever going to have for the rest of her life. And it was just a question of holding on to as many as you can. But now we’ve learned that there’s a turnover of neurons throughout our life, and that we have this neuro, we have production of more neurons and a breakdown of neurons and we need that balance as well.

Dr. Chapek:        And what it’s not one thing that causes that to shift. It’s putting all of them together. It’s the diet, the supplements, the hormones, no toxins, healthy thinking, and that’s what will create that healthy balance between the two verses tons of growth hormone or really low calorie diet. We need to put them together to actually … It is not one thing that heals the brain, it’s a multitude.

Dr. Weitz:            Absolutely. And just to add something to this discussion, because right now you go to an anti-aging conference and it’s pretty much all you want to lower growth factors, you want to lower IGF-1.  The first study that actually showed a reversal of the aging time clock….  That’s one of the new things in anti-aging medicine, it’s they have these biological methylation time clocks.  So Dr. Horvath from UCLA and some other doctors have come up with these ways to measure longevity.  And the first study that was actually shown to show a reversal of one of these aging clocks was utilizing growth hormone and DHEA.

Dr. Chapek:        No kidding. There you go. You get on these tracks and-

Dr. Weitz:           There’s got to be a balance and I totally agree with you on that. In your book, Concussion Rescue, you talk about a first aid kit for the brain. When someone sustains a head injury. Can you talk about what that is?

Dr. Chapek:        Yeah. So I got to tell you about a little bit of science to help it make even more sense.

Dr. Weitz:           Lot’s of science, we love the science.

Dr. Chapek:        Theodore Roth is this undergraduate student at Stanford, and he got to implant an intracranial microscope into the mouse skull. And watch what happened when he hit these poor little mice and cause a concussion and never been seen footage. This is in the journal Nature 2013 where you actually saw oxidative damage, saw the microglia the resident macrophages are immune cells in the brain swell and try and eat up the the damaged tissue, fill in spaces and gaps, saw the tearing and ripping of the vessels and permeation of fluid where it shouldn’t be.  And he didn’t stop there, though. He then applied glutaraldehyde to the mouse skull, which is thinner than the human skull, and saw if applied immediately, there are 67% less cell death. If applied, within three hours, there was 50% less cell death. So there’s this window of time in which to act. And so why are we just standing on the sidelines watching and hoping players get better and in your car, you have a car accident? I hope I get better. Why aren’t we doing something immediately?

In the journal PLOS One 2013, there’s a double blind placebo controlled trial with 81 active service members, they were in the battlefield and an IED would go off, they’d run to the medic or be carried to the medic and then immediately give them either NAC or placebo and the group that got NAC, 86% of them recovered from concussive syndrome after a week, whereas 42% recovered after a week.  Amelioration of Acute Sequelae of Blast Induced Mild Traumatic Brain Injury by N-Acetyl Cysteine: A Double-Blind, Placebo Controlled Study

Dr. Weitz:           That’s amazing.

Dr. Chapek:        Yeah, just NAC. N-acetylcysteine precursor to glutathione.

Dr. Weitz:           That’s one of the most amazing traditional compounds.

Dr. Chapek:        Isn’t it? There’s so many studies on it and we need to be using it. So I can tell you the dose that they used in this study. Four grams immediately they met it gave them four grams, and then days one through four, they were given two grams twice a day. Days five through seven they were given 1.5 grams twice a day. Pretty pretty high doses, and then they stop.

Now, if it was my patient, or my family member or myself, I would take it ongoingly 1.5 twice daily after that, it wouldn’t hurt and I would take vitamin D, I would take vitamin C. This first aid kit outlines all of those and the specific doses.

Dr. Weitz:           Changing glutathione being being used topically on the back of the neck?

Dr. Chapek:        That would be cool. If it penetrates and gets in, the back the neck makes sense when carried in.

Dr. Weitz:           That’s what you put in your book, right?

Dr. Chapek:        Yes.

Dr. Weitz:           Yeah.

Dr. Chapek:        Uh-huh (affirmative). And also light therapy to the back of the neck.

Dr. Weitz:           Okay.

Dr. Chapek:        Possibly, too.

Dr. Weitz:           So is that you are talking about like infrared or what type of light?

Dr. Chapek:        Red light, infrared light. I think that’s helpful.

Dr. Weitz:           Though, is that helpful by itself or it works synergistically to help get the into the glutathione into the tissues?

Dr. Chapek:        It’s just by itself, it would work. So both glutathione and red light. Topical glutathione is worth a try. I would always do topical plus oral NAC because we still don’t know. There’s various companies out there. Is it good what you’re taking or not and it’s not widely available. But if you can get some good quality glutathione topically or IV even better, or nebulized, I would do it.

Dr. Weitz:           And of course now we have Liposomal glutathione and it’s available for oral usage.

Dr. Chapek:        My kids hit their head, Liposomal glutathione under the tongue immediately. I give them NAC, vitamin D. I just carry this around with me.

Dr. Weitz:           So go through your whole first aid kit. So it’s NAC, glutathione, go ahead. What are the rest of them?

Dr. Chapek:        Curcumin because turmeric from turmeric it’s from the spice and it’s not only anti-inflammatory, it does something special, it opens up the aquaporins so when there’s swelling, there’s nowhere for the brain to go against inside of the skull so that can cause damage and sometimes it delayed damage. So that is an important one. Vitamin C doesn’t get enough respect, antioxidant vitamin C.  Vitamin D of course. Omega-3 fatty acids. MCT oil, because like I said there’s a spike and then drop in glucose metabolism. And so MCT oil will help feed into the ketone production and then provide an alternative fuel source. There’s a study where they had a patient in a coma, either gave them IV glucose to just try and overcome that low glucose metabolism, or not.  And if they gave them IV glucose, their utilization of ketones for fuel from their brain was 16%.  And it went to zero.  So they were actually their brain was trying to use those ketone bodies.  So we want to enhance utilization of ketones for fuel into the brain by MCT oil and branched chain amino acids useful for recovery after I go for a run, but also for healing the brain from brain injury.

Dr. Weitz:           Cool. Awesome. I know for spinal cord injuries, they’re still protocol where they use IV prednisone.

Dr. Chapek:        Yes. Great point.

Dr. Weitz:           Haven’t they also experimented with like, ice water in the veins or something like that.

Dr. Chapek:        Yes. Right. Now this is a great, great point. And as I’ve been thinking about this, and trying to understand how best to approach healing the brain from brain injury, I looked at the literature, and there were many failures. There’s been over 35 large scale trials that have all failed to find the one thing that cures a brain from brain injury. They used to give corticosteroids which makes sense, lower inflammation throughout the body. This was done for 30 years, up until 2005 when they did the CRASH trial, and they said, “Okay, what is this actually helping?”  More people died who were given corticosteroids.  So they stopped. It was a standard of care until 2005.  We don’t want to just totally slam down inflammation.

Dr. Weitz:           Right.

Dr. Chapek:        The brain is more complicated and has many other mechanisms that are trying to heal.

Dr. Weitz:           The inflammatory process is part of the way the body heals. It’s sending those those immune cells to the area, and we want to dampen it down, but we don’t want to stomp it out.

Dr. Chapek:        Exactly. Well said. The ice water thing, I just was talking to someone the other day about this certainly saves lives. In surgery, they cool the brain in the body so that they can decrease the swelling and edema and that now there’s those caps like the ice caps, possibly to help with healing. And I don’t know.

Dr. Weitz:           Those for chemo to reduce hair loss.

Dr. Chapek:        Yeah, and when I was writing the book, I’m open to looking at new literature. But when I was looking into this, all of the studies showed it didn’t help.  It didn’t help.  And I don’t know if it’s maybe too powerful like the corticosteroids it actually decreases inflammation too fast and too much or maybe they’ve done more research and figured out maybe it is helpful.  Maybe I need to relook it.  I’m open to that.  But at least when I looked at it before, wasn’t helpful.

Dr. Weitz:           You mentioned MCT oil. What do you think about the exogenous ketones?

Dr. Chapek:        I think they can enhance the ketogenic diet really well, and I think they should be used. I mean, they should be part of the first aid kit. All right, put those in mind KETO//OS, and I have those little packets, and that’s what I’m going to do if I ever hit my head or my family members, because at least the brain will be getting some ketones.

Dr. Weitz:           Right.

Dr. Chapek:        Your listeners probably know.

Dr. Weitz:           Which brings up what’s the best diet for healing from a brain injury?

Dr. Chapek:        The ketogenic diet’s really popular right now.  It’s a fad, but it has been around a long time since the ’20s for seizure disorder. And it’s essentially restricting carbohydrates to less than 30 grams a day net carbs, which isn’t much.  A couple of apples.  And so if you restrict that the body will be forced to burn fats for fuel, which can get into the brain much easier. There’s fewer steps to use for fuel ketones, and that’s why it’s called a ketogenic diet. And so it’s been studied for various neurological problems, brain injury, there’s a few studies they’re working actually right now, on a study in humans with the ketogenic diet, which is going to be done this year. It’s certainly safe.  And it’s been studied for other neurological conditions.  And I think it really helps.

I had a patient who was an airline pilot, who had been knocked out in a bar in Australia and couldn’t fly back, cognitively impaired and he wasn’t able to work for two years. So I was working with him ongoingly.  He’s now able to go back to work just this year recently, which is awesome.  But for a while there, he just was overwhelmed and many people with brain injury can’t take something well, many of our patients, they get overwhelmed by the protocols. He’s like, okay, what’s the one thing I can take? I can’t do all this.  And I said, Let’s forget the supplements let’s do the ketogenic diet.  And so he got into that.  His energy improved, his sleep improved, he started feeling better and then he could add in the supplements again, and now like I said, he’s going back to work now.

Dr. Weitz:           That’s awesome.

Dr. Chapek:        I was a key for him.

Dr. Weitz:           Yeah, so your keto, your recommendations for the ketogenic diet is 30 grams of carbs?

Dr. Chapek:        Mm-hmm (affirmative). Yeah, 30 grams of carbs a day. I recommend doing it for three months and reassess. Is it working or not, give it a good try. It’s hard.  I did it myself after recommending it for people. It took me three weeks to figure out what the heck to eat and to get it figured out.

Dr. Weitz:            It’s actually hard to get the level of fats up.

Dr. Chapek:        Mm-hmm (affirmative). It really is, and a couple tricks that I tell people, you do have to push the fats, you have to add fat to each meal. It’s not just like eating a fatty steak or eating eggs that have fat you have to add fat to each meal, mayonnaise, avocados, coconut oil, eat those make those fat bombs. And I had a hard time digesting all that fat.  Honestly, I got a little nauseous.  So I took Ox Bile, bile salts, and that helped me be able to digest all that fat and then I did much better.

Dr. Weitz:            Right. Yeah, it’s true. Our bodies enzyme systems are adapted to the types of foods we need. If we change that diet and suddenly add a bunch of fat. It’s not ready for that.

Dr. Chapek:        Mm-hmm (affirmative). Exactly. That makes sense.

Dr. Weitz:            So you mentioned sleep, what part does sleep play and healing from brain injuries?

Dr. Chapek:        It’s hard to heal without good sleep. I would say it’s nearly impossible to fully recover without good sleep. Sleep is needed for the brain to restore and heal is when you’re in deep sleep, there’s like lip channels that open and help the brain detoxifying.  In deeper stages of sleep, you produce those hormones that you don’t otherwise like growth hormone, testosterone. And also the brain just needs to get into those deeper stages to really heal and restore. And it’s one of the curses of brain injury that nearly 30 to 70% of them, people with brain injury have sleep problems, and that’s what they need to heal, but they can’t sleep and they’re tired. Oh, it’s like the lights are flickering, and they’re like the neurons are on but not all the way on. They’re firing and not firing. So during the day, they’re tired at night, they can’t sleep. And a lot of people can relate. A lot of people have sleep problems.

One of the recommendations in the book and that we talked about will help anyone to see problems whether it’s turning off the screen an hour before bed. That’s a big one. Not having light in your room, turning the clock around, making sure it’s dark and quiet and cold just for sleep and sex, only the bedroom is just for sleep and sex only.  And that’s not that you have to sleep eight hours solid or doesn’t count. You can do chunks at time. But ideally like a four hour chunk, at least once a night is what I recommend, because you need a couple of REM cycles to really get that restorative sleep. And then you can go pee or wake up, whatever, but go back to sleep. So take away some of that stress and pressure and perfectionism around perfect sleep, doesn’t have to be that but just getting good rest waking up feeling somewhat rested.

Dr. Weitz:            Yeah, and one of the things you point out is growth hormone is often released during deep sleep. And that’s one of the reasons why sleep is so helpful.

Dr. Chapek:        Right? Absolutely. It’s very hard to produce growth hormone without deep sleep. And interval training is another way if people are trying to increase their growth hormone, you can increase it almost 500% if you do really intense interval training, and that will last for a couple of hours.

Dr. Weitz:            For people aren’t familiar, what it what exactly is interval training?

Dr. Chapek:        Oh yes. So interval training is in a nutshell going fast then going slow, sprinting and then moderate pace, sprinting and moderate pace. One easy protocol actually learned from Dr. Mercola was you do a 90 second warm up 30 second sprint 90 second moderate, 30 seconds and you repeat that eight times 20 minutes and you’re good and so a sprint can be doesn’t have to be running. It can be I often do the recumbent exercise bike on the gym or you can run you can go run a block, jog a couple blocks, run a block, jog just fast even walking fast walking slow walking.

Dr. Weitz:           I heard Peter Attia on his podcast and he was saying he likes to use 10 seconds blasts. He says you can really only go run all out for 10 seconds.

Dr. Chapek:        Yeah, that makes sense. It makes sense.

Dr. Weitz:           Anyway, I think as long as you get that intensity up, and-

Dr. Chapek:        Yeah, that’s the key.

Dr. Weitz:           … your weekly routine, you’re good.

Dr. Chapek:        Intensity is key.

Dr. Weitz:           So what about brain training as part of the recovery process?

Dr. Chapek:        Brain training is a real key and I like to think about it in stages. So first we reconnect the wire, so to speak. So we’ve got the chemistry right with the nutrients, the diet, the sleep, structural integrity, and then retraining the brain, so we can do meditation. There’s a pilot study showing that an eight week meditation training course improved fatigue quality of life in patients with brain injuries, which is huge because it’s so hard for anyone to meditate, myself included is the most hardest thing I’ve ever done, but it really strengthens the frontal lobe and the temporal lobes, which is focus and memory. And also-

Dr. Weitz:            It really should be the simplest thing. It’s really just calming your brain.

Dr. Chapek:        I know, but it’s frustrating. It’s so simple, but so hard and it’s so good for the brain. And then there’s more advanced brain training, like neurofeedback, where you have wires connected to your brain to understand the electrical activity, you work with a coach who can coach you on areas that specifically for you that are weak that need to be strengthened and doing a series of this. So you can do brain games on like an app. So we have BrainFitLife at Amen Clinics, which has brain training games, there’s brain HQ, there’s cogmed, which you work with a psychologist on, there’s many programs improve working memory. There’s lots of different brain training programs out there. Any of them are good, some are better than others. And part of it’s cross training, training areas that you’re weak in. So talk with dementia patients about this a lot like, you’ve been doing crossword puzzles for 30 years, you’re really good at them. But you’re not so good at math. So let’s do some Sudoku.

Dr. Weitz:            No, I find the same thing with patients coming in with musculoskeletal complaints. And the ones who are like super flexible, love to do yoga all day long. And they hate doing strength training, which is what they need.

Dr. Chapek:        That’s exactly what they need.

Dr. Weitz:            Usually you’ll find what you’re really good at is what you’re not going to get much benefit from. And you’re not as good at. If you’re super flexible, you’re probably going to do better at focusing on more strength training. And if you’re super tight and have very low flexibility, you’re probably going to get a lot more benefit out of yoga, which you probably don’t like to do because you’re not good at, but that’s an indication that that’s what you need.

Dr. Chapek:        I’d love to talk with you about the structural piece, because that’s an area that you’re more of an expert in than I am, but I recognize the importance of early on because, a in Naturopathic Medicine. Philosophy is looking at the whole person treating the cause and making sure that structural alignment is there.

Dr. Weitz:            Right.

Dr. Chapek:        I did miss this for a while. It’s like we have to have structural alignment so the cerebral spinal fluid and blood flow can be going to the brain and so in the book I talked about NUCCA or Upper Cervical Chiropractic, Atlas Orthogonal and Dr. Scott Rosa’s work, functional neurology, neuro cranial restructuring. It’s like little balloons up the nose. So just making sure that craniosacral, making sure that the that the bones are in alignment, the tissues in alignment, so that everything works properly because you can’t supplement that away, right.

Dr. Weitz:           Absolutely, yeah. No, it’s probably an under discussed part of the Functional Medicine approach.

Dr. Chapek:        Cool.

Dr. Weitz:           So let’s see. One more thing you also mentioned the benefits of hyperbaric oxygen.

Dr. Chapek:        So that’s something that I recommend people do either early or late. And I like to layer it in because of the cost and the time involved. But hyperbaric oxygen is essentially a chamber, like you’ve seen divers go into after they go deep and then they have the bends to push oxygen in and push nitrogen out. The same idea can be used for stroke and brain injury and other conditions, but essentially, you’re under pressure, oxygen is pushed to the deeper structures and it can help the brain to become more metabolically active and to heal.  And so you need to do a series of treatments 40 at least to start all in a row if possible. And 1.3 to 1.4 atmospheres, so that’s the pressure in the chamber, it doesn’t have to be a ton. That lower pressure over time that seems to really help heal. And if I had one magic bullet, the one thing that I could do to help people heal from brain injury, it would be hyperbaric oxygen.

Dr. Weitz:            A lot of the athletes are using it. I know LeBron James has one that he uses regularly.

Dr. Chapek:        Oh, he does.

Dr. Weitz:            Yeah. What do you think about ozone, which is another way to add deliver oxygen to tissues?

Dr. Chapek:        I’m not as familiar with ozone. I guess I’ve thought of it mostly for treating Lyme, infections and things like that. It’d be interesting to look at though, interesting.

Dr. Weitz:            I mean, if hyperbaric oxygen works, and essentially it’s adding the oxygen into the brain, I would think that ozone would be beneficial as well.

Dr. Chapek:        Yeah, There’s NAD, IV NAD would be-

Dr. Weitz:            Yes.

Dr. Chapek:        So a lot out there.

Dr. Weitz:            Nicotinamide riboside.

Dr. Chapek:        Right. Energize into the … especially if there’s almost all patients with brain injury have fatigue, some element of fatigue.

Dr. Weitz:            Mitochondrial support, yeah.

Dr. Chapek:        Exactly. Their mighty mitochondria, those energy producing cells, and they need some help. So there’s ketogenic diet, antioxidants, NAD, hyperbaric oxygen. The key really is not just one thing, but putting the pieces together.

Dr. Weitz:            Absolutely. And from a functional medicine approach, one more thing I would suggest is gut health because of the gut brain connection, which is crucial.

Dr. Chapek:        Absolutely agree with that. And a lot of people actually will start having food allergies after brain injury. And it’s like, why is that? The brain is injured the Vegas nerve can be … there’s less peristalsis, there can be constipation and leaky gut. And so it makes sense what you’re saying that we need to have healthy gut so that there’s less inflammation in the gut, there’s less inflammation in the brain. So …

Dr. Weitz:            Great.

Dr. Chapek:        Love it.

Dr. Weitz:            Thank you Dr, Chapek. It’s been a great discussion, any final thoughts you have for our listeners? And then if you could tell us how patients can get ahold of you and find out about seeing you or finding out about your programs and as well as your book.

Dr. Chapek:        Great. No, it’s been an honor to talk with you. Really, it’s been great. And the one thing I’ll leave you with is that it’s never too late to heal the brain from injury to at least try. Even if it’s been many years. It’s never too late. And three, go back to the drawing board. Your brain is your most precious asset. Let’s really optimize it. So whether it’s think back, have you had any head injuries? Have you had any concussions? Could that be contributing to your issues today, or your patient’s issues? Or have you not recovered from an injury? Those are the two things to think about, and that it’s not too late for you. Even if you’re in your ’60s, ’70s, ’80s we can always improve our brain. And that’s so important because that’s who we are. Our brains are who we are and that’s so precious.

So that’s why I wrote this book and you can find it on Amazon. Wherever books are sold. There’s an Audible version and we’re coming out with the program next week. We filmed me doing a set of the video series on the book Concussion Rescue, which people can watch.

Dr. Weitz:            Cool.

Dr. Chapek:        And that’s it. BrainMD, which is where we sell supplements and stuff and also Dr. Amen’s books. And there’s Amen University is what it’s called.

Dr. Weitz:            Okay.

Dr. Chapek:        Where I’m at Amen Clinics Northwest. So you can just Google that. Amen Clinics, Northwest, we’re in Seattle. And we see patients from all over the country. People come in from Idaho, Alaska, California, wherever, and I do collaborate with other Amen Clinic doctors. So someone does an evaluation in New York with Dr. Sood or Dr. Grin, I will sometimes do a consult with their patients if they need me to, so happy to help.

Dr. Weitz:            Awesome. Thank you Dr. Chapek.

Dr. Chapek:        My pleasure. Great to meet with you.



Challenging the Low FODMAP Diet with Angela Pifer: Rational Wellness Podcast 142

Angela Pifer Challenges the Efficacy and the Research Behind the Low FODMAP 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

This discussion with Angela Pifer is based on the following two articles that she wrote and which were published in September and October 2019 in Today’s Practitioner that critically assess the benefits and the research that supports the low FODMAP diet for patients with SIBO: 

Part 1: The Pervasive Misunderstanding of What The FODMAP Diet Does And Does Not Do

PART 2: The Pervasive Misuderstanding of What the FODMAP Diet Does and Doesn’t Do


4:00  Today Angela Pifer is going to set the SIBO community straight about the low FODMAP diet and what the studies actually show about it.  There are a number of problems with this diet, including that patients get stuck on it for too long a period of time. 

IBS is a chronic gastrointestinal condition that is marked by abdominal pain or discomfort, diarrhea (IBS-D), constipation (IBS-C), or alternating of the two (Mixed IBS). 

SIBO refers to an overgrowth of the bacteria in the small intestine and it is usually secondary to another condition, such as hypothyroidism reducing motility leading to bacterial overgrowth.

The low FODMAP diet is a diet low in fructo-oligosaccharides, disaccharides, monosaccharides, and polyols.  It reduces the fiber and starches in food that tend to cause an increase of water into the small intestine and bloating and distension. The low FODMAP diet was created for people with IBS and the SIBO world adopted it and it does tend to calm symptoms in patients with SIBO.  But it’s supposed to be an elimination diet and not a long term diet.  It’s best to start challenging the patient with the different FODMAP groups after the first month or so to see which foods they can tolerate and which foods they react to.   

10:26  The low FODMAP diet is supposed to help starve out the bacteria from the small intestine by not providing the food that these bacteria need to eat.  But the studies don’t actually show this and when you look at before and after lactulose breath tests with these patients, the test results do not change.  We do not see patients with SIBO have their SIBO go away after being on a low FODMAP diet for months.  We have to learn from that.  Studies that look at patients who are positive for methane SIBO based on a lactulose breath test and symptoms and we put them on a high FODMAP diet, say 50 gm of FODMAP, and the methane does not go up and when we place patients on a low FODMAP diet, say 7-9 gm of FODMAP per day, and methane levels conversely do not go down.   In fact, Angela asserts that if a patient has methane and constipation, then such a low fiber diet, like the low FODMAP diet, should be contraindicated because it will make them more constipated.  She pointed out that it is a bad idea to just put everyone with SIBO or IBS on a low FODMAP diet.  It is more restrictive than many patients need.  While it is likely that all patients with IBS or SIBO will need to modify their diet in some way, this low FODMAP diet is too extreme for what most patients need.  But if you have a patient who has severe symptoms and can’t tell what they are reacting to, it can be a good idea to put the patient on low FODMAP for 3-4 weeks to settle things down and then challenge each of those food groups separately and see what you can add back.

18:00  There are three studies that showed a reduction in breath hydrogen with a low FODMAP diet, but these studies were poorly done. They didn’t perform the lactulose breath test the proper way.  There is supposed to be a proper low fiber diet the day before followed by a 12 hour/overnight fast.  Then you are supposed to drink the lactulose solution with the SIBO breath test and then breath into tubes every 15-30 minutes for 3 hours, during which time you are required to be fasting. Any increase in hydrogen or methane gas after 100-120 minutes is considered to have occurred in the colon, where you are supposed to have fermentation of fiber leading to gas production and this is not considered indicative of SIBO, which is a condition that occurs in the small intestine. These studies did not have the subjects do the proper test prep and in some cases the subjects involved performed the lactulose breath test all day long and they were eating while they were doing the test, which makes the results completely invalid.

20:18  There are three studies that showed a change in hydrogen gas on the breath test, but there were a lot of problems with these studies.  When you really look at these studies, you see that they didn’t use the lactulose breath test in the way that it was validated for. The first study is called, “A low FODMAP diet is associated with changes in the microbiota and reduction in breath hydrogen but not colonic volume in healthy subjects.” The group that were described as eating the high FODMAP diet were not really eating high FODMAPs, but were on a low FODMAP diet with the addition of taking an oligofructose supplement. The low FODMAP group were supplemented with maltodextrin, which is a starch made from corn, rice, potatoes, or wheat, and which should not be included in a low FODMAP diet. Essentially, rather than testing low FODMAP vs high FODMAP, this study compared low FODMAP plus maltodextrin vs low FODMAP plus fructans in healthy subjects.  The participants in the study were normal and were not suffering with SIBO or IBS, which are the group of patients we are interested in. The subjects did not fast for 12 hours or follow the proper food prep the day prior to the breath test that are needed for the SIBO breath test to be considered valid. 

23:05  A second study that found a change in breath hydrogen is Randomised Clinical Trial: Gut microbiome biomarkers are associated with clinical response to a low-FODMAP diet in children with the irritable bowel syndrome. This study only had the children follow the low FODMAP or the high FODMAP for 2 days. And the breath test was conducted over 8 hours rather than the 3 hours that is the standard way to conduct the test.  To insure that the hydrogen gas is being produced in the small intestine, there must be a positive result in an increase in breath hydrogen or methane gas within the first 100-120 minutes.  And they were eating while conducting the breath test, which also violates the recommended test procedure.  The results from this study cannot be considered valid.

24:39  The third study that found an increase in breath hydrogen gas with the low FODMAP diet is Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome.  In this study, the subjects only followed the low or high FODMAP diet for two days, which is too short a period of time to really determine if there could be a change in the level of bacteria in the small intestine.  But the food they fed them was incredibly unhealthy. The low FODMAP group were fed rice flakes, lactose free milk, tea, rice, bread, margarine, orange juice, an orange, rice, pasta and lemonade with sugar. They were also given snacks of hot chocolate with lactose free milk, and chocolate muffins.  This is not representative of a healthy version of the low FODMAP diet.  But they didn’t do the proper food prep required for the breath test to be considered valid and they collected data for the lactulose breath test over 14 hours while they ate instead of over 3 hours while fasting. The results cannot be considered valid. The high FODMAP group was also given high fructose corn syrup soda and gum with sorbitol, a sugar alcohol.  And there is a study that shows that if you combine sorbitol gum and high fructose corn syrup, it exacerbates symptoms by swiftly delivering malabsorbed carbohydrates to the colon.

28:36  There is one other study that is often quoted that saw a change in breath hydrogen, which was by Mcintosh et al. called FODMAPs alter symptoms and the metabolome of patients with IBS: A randomised controlled trial, published in Gut in 2017.  They claimed to have seen a change in breath hydrogen levels when comparing baseline data to post intervention data, but while there was a very small difference but it did not reach statistical significance.  So at this point we do not have a single valid study that demonstrates that a low FODMAP diet lowers hydrogen or methane levels in patients with SIBO using a lactulose breath test.

30:31  If you have been on a low FODMAP diet for a long time and it has helped to manage your symptoms, that’s great. But even if you still have SIBO, then it doesn’t make sense to continue to have such a restrictive diet that negatively affects your microbiome and provides a lack of nutrients.  You have to understand that if you eat something and you have a symptom flare, it doesn’t mean that your SIBO is growing or that it is getting worse.  You should pick your five favorite foods, other than garlic and onions, and see if you can try a tablespoon of something and slowly build up your ability to tolerate these foods again. Your enzymes that enable you to digest these foods have become down-regulated because you haven’t eaten them in while.  This is where adding some digestive enzymes, like Intolerase by Vita Aid, can help to break down those starches and indigestible fibers.  You should go slow and trickle the foods back in.  You have to get past the mindset that because you have SIBO you have to be on such a restrictive diet, with all the anxiety and food disorder type of behavior that accompanies it.

37:07  If the low FODMAP diet has not been shown to be effective for curing SIBO, are there any other diets that have been proven to be effective for SIBO, such as the Specific Carbohydrate Diet (SCD) or the GAPS diet?  Angela said that GAPS has a lot of fermented foods, so it is not good for SIBO and while SCD has some research behind it’s efficacy, it is more for Ulcerative Colitis that it is for SIBO.  Angela prefers to find the food groups that the patient is reacting to, like fructans (onions, garlic, leeks), or fuctose, or lactose, or sucrose, and see which is the most problematic and pull these out for 3-4 weeks and then test them back in. Restricting our diet down to 7 to 9 grams of FODMAPs per day is not going to starve our SIBO out.

41:25   Angela suggests that doing a more conventional elimination style for 3-4 weeks for SIBO patients rather using a highly restrictive low FODMAP diet and then testing back those foods will likely to be more effective.




Angela Pifer is one of nation’s foremost Functional Medicine nutritionists in Seattle, Washington with a focus on Gastrointestinal Disorders like SIBO and IBS. Angela is known as the SIBO Guru. Her website is SIBOGuru.com and she has launched a gut prescription recipe site, Simply SIBO and a FODMAP-free line of bone broths, Gut Rx Gurus Bone Broth.

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.


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 enjoying listening to our Rational Wellness podcast, please give us a ratings and review on Apple Podcasts or wherever you listen to the podcast. Also, if you’d like to watch 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 the low-FODMAP diet with SIBO Guru, Angela Pifer. The low-FODMAP diet is often touted as a beneficial diet for patients with small intestinal bacterial overgrowth, commonly found in 60% to 80% of patients suffering with irritable bowel syndrome, one of the most common gastrointestinal conditions. Irritable Bowel Syndrome, or IBS, is marked by stomach pain, gas and bloating, constipation, diarrhea, alternating of the two, as well as a host of other symptoms. Small intestinal bacterial overgrowth is a condition marked by having higher concentrations of bacteria in the small intestine than normal, and treatments often include a low-FODMAP diet or a similar diet such as a specific carbohydrate diet, a GAPs diet, or Nirala Jacobi’s SIBO biphasic diet, in order to starve the bacteria. Since these bacteria eat fiber as their food. Some studies, Angela is shaking her head now, some studies, and some practitioners are claiming at a low-FODMAP diet, may be all the treatment that’s needed for six patients. Of course, Angela is going to set them right today. Or they may combine the low-FODMAP diet with antimicrobials, motility agents, probiotics, and other treatment protocols.

Angela:                 Yes. Which I wholeheartedly agree with. Yes. And not to starve them out with a FODMAP diet. 

Dr. Weitz:            Our guest today, Angela Pifer has recently published two articles warning that we may be mistaken about what the research shows about the low-FODMAP diet, but the benefits of the low-FODMAP diet are, and what are the dangers of the low-FODMAP diet, especially followed for a long period of time. Angela Pifer is one of the nation’s foremost functional medicine nutritionist with a practice in the state of Washington and her practice is focused on functional gastrointestinal disorders, especially SIBO and IBS. She is known as the SIBO guru and she’s launched a gut prescription recipe site, GutRX Guru and a FODMAP free line of Bone Broths, GutRX Gurus Bone Broths, of course, if we don’t need the low-FODMAP diet, I guess we don’t need-

Angela:                I know. We’ll talk about that in a second.

Dr. Weitz:            But that’s great.

Angela:                The take home message is I know FODMAP, I think I’m going to switch with that.

Dr. Weitz:            Angela’s recently published two articles, part one and part two. The pervasive misunderstanding of what the FODMAP diet does and does not do. And these are the basis for the discussion we will have today.

Angela:                Yes, please.

Dr. Weitz:            Angela thank you so much for joining me.

Angela:                Of course. Of course. Thank you for having me. I appreciate it.

Dr. Weitz:            So today we’re going to set the SIBO community straight.

Angela:                We’re going to set anybody that thinks about the FODMAP diet straight, and the use of FODMAP and what the studies actually show because, oh my gosh, the amount of conjecture. And I think wishful thinking that is happening online and even how some people are implementing this in their clinic leaves a bit to be desired. I think people are getting stuck on this long term. It’s causing a lot of anxiety. Just taking a group of people who already have IBS or SIBO that are dealing with chronic presentation symptoms feeling socially isolated already because they can’t just go eat whatever they want and they have to deal with that.

Now they’re on an even more restrictive plan, which causes more anxiety and stress. And we’ve got to figure out as clinicians why we’re so quick to jump to this study, when, excuse me, sorry. Why we’re so close to quick to jump to this diet, when we start to really dissect the studies. I think it’ll make a little bit more sense. But we’ve got to be mindful that we’re not just putting people on this as we’re thinking clinically, Oh, I’m going to starve out the organisms or I’m going to drop histamines or I’m going to favorably alter the microbiome, because none of those have been proven. In fact, they’ve all been disproven, as we start to look at the studies. So-

Dr. Weitz:            So, just to make sure everybody’s on the same page, including people listening who are not that familiar with IBS or SIBO. How about if we define some terms, can you basically define what is IBS? What is SIBO? And what is the low-FODMAP diet?

Angela:                Yeah, absolutely. So IBS, there’s multiple presentations within IBS, but it, depending on, there’s ROME criteria for actually diagnosing it, but it’s a chronic nature of symptoms in irritableness, diarrhea or constipation or a mixed presentation. And there’s very specific criteria that somebody would look at for diagnosing that. Oftentimes it’s a diagnosis of exclusion. Everything else has been cleared off. It’s not that, here’s what you have. Sometimes it’s been perhaps used as a catchall. You’ve got chronic symptoms, but we haven’t figured out what it is, you have IBS.

SIBO is a small intestinal, I like to say, bowel overgrowth because it’s not all bacteria that can be overgrown, but basically SIBO is an overgrowth of a microbiota within the small intestine.  And for people moving through life and trying to consume a normal diet, some of what they are eating might ramp symptoms up and cause bloating and gas. And sometimes it can be debilitating if it is ramping up another condition that they have, somebody has a hyperthyroid condition, which might slow motility, which might affect the microbiota and build up in the small intestine. All of that is kind of making things worse than that feedback. So it’s a very complex condition, it’s secondary, it’s never a primary, so it’s always there because of something else that’s happening.

And when we look at something like the FODMAP diet, which the FODMAP diet is fructo-oligosaccharides, disaccharides, monosaccharides, and polyols, they are the fibers and starches within the foods that we eat that are known to cause an osmotic shift if eaten in larger amounts within the small intestine so they can cause water movement and fluid moving into the intestine, rapidly moving things causes some bloating and distension and not feeling so great.  And then with SIBO, as it moves through, not only can you get the osmotic shift.  But if you have an overgrowth of organisms in the small intestine, you can have those organisms be able to break down some of those indigestible fibers and consume them.  And they basically off gas and that fermentation produces gases. And now we’ve got a bloat going on as well.

So when we look at the FODMAP diet, the FODMAP diet was really created to help people with IBS.  And the SIBO world, shall we say, readily adopted it because pretty much everybody with, most people with SIBO, also have IBS symptom presentation. And so it can very quickly for, I’d say the majority of people with SIBO, calm symptoms down. The problem is, is that as we look at the FODMAP diet, the way that it is supposed to be used is as an elimination diet.  It’s not meant as a, oh, you have IBS or SIBO, here’s your diet, thank you for coming. They should not be stuck on this long term. There should be a three or four week elimination diet where you ramp down the loads of all those FODMAPs and then on the end of that you’re going to start challenging the different FODMAP groups to see which ones you react to. That’s how it’s supposed to be used. It’s not being used that way. So I’ve been in practice about 16 years now. Long time… I can say, maybe seven, eight years focusing on SIBO. I am as guilty as all the other clinicians. As all of this kind of came into being, we use the FODMAP diet. When I first started, everybody who went on that had SIBO, and that’s just what we did.  As a matter of fact, when somebody walks through the door, we can calm your symptoms down. People feel better at least from getting that calmed down. But the longer and longer you’re in practice treating SIBO, the more and more people you see that have been on the FODMAP diet for two months, six months, two years. I had somebody a month ago come to me, that came to me that had been on it for seven years. And more often than not, when you run a SIBO test and you have a test back when to compare it to, their numbers are similar. So if you’re on a diet that’s supposedly starving out anything like the FODMAP diet is supposed to, a lot of people think that it’s going to starve out the organisms because you’re not sending those fibers that they can break down and consume and produce that gas with…

Dr. Weitz:            Logically it makes sense, you have this bacteria, the bacteria eat fermentable fiber, if we eat foods that are high in fermentable fiber, it’s going to feed the bacteria, the bacteria will grow and we’re trying to get rid of the bacteria, so.

Angela:                 It makes sense. But unfortunately, or fortunately, as you look at it, when you actually look at the studies, it’s not what the studies are showing. And clinically, as we step back. If we ignore the studies. As clinicians, again, we’ve all seen the person that had been on this for two months, six months, two years, seven years, and they still have SIBO. So if the diet treated, if the diet starved anything out, wouldn’t that be all they needed? Wouldn’t that be the fix? It might take them longer to start things out, but that’s not what we see clinically. In fact, I would love any practitioner to talk with me about, oh I just put somebody on a low-FODMAP diet for six months and their SIBO test is negative, here we are. We just don’t see it. So we have to learn from that and we have to look at the studies as well.  So when we actually look at the studies around the lactulose breath test and using a FODMAP diet. So the lactulose breath test, would you like me to explain that one for just a second?

Dr. Weitz:            Sure.

Angela:                 Just to make sense for people. So basically what we’re trying to figure out is, do you have too much gas production in the small intestine? Thereby we can identify SIBO. That overgrowth in the small intestine. What we have is, studies where they put people on a high FODMAP diet, and they put people on a low-FODMAP diet and then they tested their breath test prior to putting them on it and after they put them on it. And we’re starting to, are there any changes? So when we look at methane production. It’s really interesting because as we start to think about, this makes sense, if we put somebody in a low-FODMAP diet, it’s going to start things out.

We should see after someone’s on a FODMAP diet, we should see methane go down. We should see hydrogen go down. So when someone has SIBO and they have an overgrowth of organisms in their small intestine, the gas production is hydrogen, methane or hydrogen sulfide. Right now we have the ability to test for methane and hydrogen. The hydrogen sulfide test is in the works. Hopefully it will be here soon. When we look at the test, when somebody with SIBO is put on a high FODMAP diet and that’s going to be 50 grams of FODMAP a day, to understand where the average person, is basically going to consume around 20 to 24 grams of FODMAP a day. So at least twice what the average person is consuming. You take somebody with SIBO, you give them 50 grams of FODMAP a day in a diet for three weeks or six weeks, depending on the study.

Methane does not go up. So what we know of methane is that when methane is present, transit time slows down. So if we’re feeding more and more FODMAP, that should be feeding more and more methanogens or the archaea that actually produce methane, which means we should see more and more slow down. We should see a bigger niche created for those organisms to grow up to larger numbers producing more methane. We just see that go up and we don’t. So three weeks on a high FODMAP diet or six weeks on a high FODMAP diet and methane doesn’t go up. Conversely, on a low-FODMAP diet on seven to nine grams of FODMAP a day, which is extremely low, methane doesn’t go down at all. It’s not statistically significant.

Dr. Weitz:            Now could this be?

Angela:                What?

Dr. Weitz:            Could this be because what happens with methane is you have these methanogens and the methanogens eat the hydrogen. So it’s a secondary factor. So if the low-FODMAP diet reduced the food for the hydrogen eating organisms, couldn’t it just take a longer period of time before the methanogens were secondarily affected by starving out the hydrogen organisms? In other words, could it be that you just need a longer period of time and could that correlate with why practitioners sometimes see that treating methane SIBO is more difficult and often takes a longer period of time?

Angela:                 I don’t see that for methane taking a longer period of time. I think you just have to be really specific about how you’re treating it and from the start support motility. I don’t wait until after treatment to add in motility support. And there’s other things to do with that I think to make that a little bit more effective. What I would say is that we need longer studies. We need standardized-

Dr. Weitz:            And we need better studies.

Angela:                 … longer studies. But feeding studies are incredibly difficult because how do you control for population, feeding them all the same thing. It’s incredibly expensive. What would be the benefit? Some of the studies looked at a FODMAP diet for two days. What are we supposed to do with this?  So, we definitely need longer studies. I would say clinically when we see patients come in that have been on a low-FODMAP diet for, again two months, six months, two years, they still have SIBO.  Methane does not go down.  In fact, I find, and many practitioners find it’s, and it just is, the FODMAP diet is actually contraindicated. If somebody has methane because you’re basically likely going to make them more constipated by pulling the fiber that’s keeping them regular. So, putting somebody on a low-FODMAP diet is probably not a good idea when somebody has methane production. And I’ll, if we could back up for a second, because I have a bone broth company that has, it’s low-FODMAP ingredients. People who have SIBO and people who have IBS, will likely need to adapt their diet in some way.

What I’m cautioning people about and downright saying don’t do it, is that everybody with IBS and everybody with SIBO does not need to go on this diet full force, even as an elimination diet. Where this diet shines a bit more is when somebody has symptoms that are so deep irritating all over the place, they don’t know what they’re reacting to. And then, great, let’s do the elimination diet three to four weeks, settle things down, challenge each of those groups separately and see what you can add back in. That’s a really good use of that diet, but blanketly going out and saying everybody has to be on this and then insinuating, perhaps with all the info that’s online that we just can’t get away from at this point, or even clinicians still doing it, saying, well, we need to starve things out with this.  And it makes people really worried. Really freaked out about anytime they eat and they get a symptom, SIBO’s getting worse. But when we look at methane, if you produce, or if you, pardon me, feed them, 50 grams of FODMAP a day for three weeks or six weeks, nothing doesn’t go up.  SIBO’s not getting worse. So we need to look at these studies to gather that info. There’s actually three studies that showed a change in hydrogen, but when you really look at those studies, they didn’t use the lactulose breath test in a way that it was validated for. So, well actually-

Dr. Weitz:            I was amazed to read your article where you broke this down. Anybody who’s treated patients with SIBO, anybody who’s had SIBO who’s seen a reasonable practitioner, especially somebody in the functional medicine world, knows that there’s a specific protocol you have to follow before you take the lactulose breath test, you do it for two or three hours. It’s very specific in it. The timing is very important because you want to make sure that if there is gas that it’s being produced in the small intestine. And these studies, it’s amazing how poorly they were done.  They were doing, having them do the breath tests like all day long. They were eating at the same time. It’s unbelievable.

Angela:                 It really is. So they’ll actualize the breath test. I mean, basically you can see lactulose, as the substrate, this fermentable sugar that we don’t really absorb and you breathe out a tube at 15 or 20 minute intervals over a three hour period. And as that moves through the small intestine, if there’s an overgrowth, you’re just going to have a little bit of production because your small intestine is not sterile.

But as that moves past the overgrowth, you’re going to get a larger fermentation reaction, more gas production, and that’s going to cross your intestinal track into the bloodstream. Exchanges in your lungs and comes out your breath. It’s fascinating. But the crux of it is, it was only validated when you do a 12 hour food prep, basically eating chicken and rice, reducing the fermentation that is always going on in the large intestine so you can get a clear read in the small intestine and then you follow that 12 hour food prep with a 12 hour fast basically, again, to decrease the colonic fermentation. When we’re looking at the test time range, to diagnose you. But we’re looking at the 100 to 120 minute mark with the task, not three hours in, because it’s in the colon at that point.

So the three studies that looked at this, I mean one was so interesting, it’s called “A low FODMAP diet is associated with changes in the microbiota and reduction in breath hydrogen but not colonic volume in healthy subjects.”  So first of all, healthy subjects, they ate their habitual diet, their regular diet for seven days. They were provided 24 hours worth of food, which is a standard package.  So at least they’re all doing the same thing.  Right?  It wasn’t low-FODMAP. They did the lactulose breath test the next day and then they took the group as a whole, divided it in two.  The low-FODMAP group, they were given maltodextrin, which we see repeated in other studies where maltodextrin is basically a starch made from corn, rice, potatoes, or wheat.

Dr. Weitz:            Why do they add that?

Angela:                They’re just calling it a control, I guess they feel like, basically it’s a polysaccharide if we’re worried about the FODMAP diet that would be in there. But basically they’re considering that as a control. Nobody really knows why. We’ve seen it in other studies. It doesn’t make any sense issues.  So I don’t even know that it’s a comparison. And then the high FODMAP diet group was on a low-FODMAP diet, but then supplemented with oligofructose, which is basically a fiber supplement. So they weren’t even put on a high FODMAP diet. And then they follow that. And then the whole group was given 24 hours worth of food, which was low-FODMAP, and then they did a lactulose breath test. Just at that point, I don’t even know what we’re testing. Like none of this makes sense. But what the problem is, is that when you read the study title and even if you probably look at the summary on PubMed, it all looks like a low-FODMAP diet is responsible for reducing breath hydrogen.

But when you actually look at the study, you can’t even compare the baseline because it wasn’t low-FODMAP. They didn’t do or implement the instructions for the test that made it a validated test. So to speak to that, when we start to look at actual studies on FODMAP diet, some of them actually offer a high FODMAP diet versus low-FODMAP diet just 50 grams in and around for a high FODMAP and seven to nine grams in and around for the small, excuse me, for the low-FODMAP. And then they compare them over a period of time. That’s really the right way to do it. Others, they basically put everyone on a low-FODMAP and put them on starch or FLS or GOS, which is fiber. Or they basically do a low-FODMAP and a high FODMAP, but then add more fiber, there’s nothing standardized within it, it just doesn’t make a lot of sense.  The other study that saw a change in hydrogen was called Randomized clinical trial: Gut microbiome biomarker, excuse me.  My goodness. Gut microbiome biomarkers are associated with clinical response to a low-FODMAP diet in children with the irritable bowel syndrome.  So they looked at 33 kids, and they basically had them follow the diet for two days. Then they did a wash out period for five days and then they cross them over and it was typical kid diet or a low-FODMAP diet just two days.  But when they did the lactulose breath test, they actually sampled for over eight hours. And then some of the kids up to 15 hours while they ate.  So again, we can’t really draw a lot of conclusions from these tests. We have a third study that kind of hits something very similar.

Dr. Weitz:            Completely invalid.

Angela:                Yeah.

Dr. Weitz:            And this comes to scientific studies and people can cite scientific studies and a lot of times people are trying to make a point, maybe they’re just repeating a citation that somebody else cited and they never went and read the actual paper. And at most they looked at the summary and this goes to show you how just looking at the abstract or the summary of the study is often not accurate. So if you really want to be scientifically accurate, you’ve got to read the whole study and look at how it was done to see if it’s really valid.

Angela:                 And I think this next study that I’d like to talk about really speaks to that because you have to dig a little bit deeper to figure out a couple of items here, which I, once I found the study, another study on this, I thought it was just fascinating. So the third study that showed a change in hydrogen is Gut microbiome biomarkers are associated with clinical response to a low-FODMAP diet in children with the irritable bowel syndromeThis is one of the studies by Shepherd, the two Shepherds out of Australia. She’s basically the creator of the FODMAP diet. And then Monash University, she had an association with them and they’ve got a great app for FODMAP.  So to give them a bit of a shout out there. This study is cited so often. I see this all the time. So basically they had 15 healthy subjects, 15 people with IBS, and they either ate a low-FODMAP diet, nine grams a day, or a high FODMAP diet, 50 grams a day for two days only. This is why it’s like, who looks at anything for two days?

Dr. Weitz:            Yeah, two days, so short. Two days.

Angela:                 So they followed a seven day washout period where they ate their normal diet, and then they cross them over and did the two day diet intervention, which is, you want to have a crossover, make sure there’s no differences between the groups. Food was provided, which is fantastic because then you really get the standard effect. Everyone has fed the same thing. What do we see? So for the low-FODMAP diet, they fed them rice flakes, lactose free milk, tea, rice, bread, margarine, orange juice, an orange, rice, pasta and lemonade with sugar. So really not healthy. Who’s going to stay on that long term? Incredibly whites, nothing, where’s the fiber? Where’s the vital nutrients? Where’s, nobody got an orange in there.

Dr. Weitz:            By the way, I read your article and then I read this study, it’s even worse than that. On top of all that, they gave them snacks containing hot chocolate with lactose free milk, and chocolate wheat muffins.

Angela:                 Yes.

Dr. Weitz:            To both groups.

Angela:                 Yes. Yeah. Really not healthy. Really not healthy, right? So what they found was that there was a change in hydrogen. So what’s interesting, so both groups have higher hydrogen levels and response to the high FODMAP diet. So this is healthy in IBS groups, but the IBS group had higher levels than the controls. So as you did deeper into this, they didn’t do a proper food prep and they didn’t fast for the lactulose breath test. They collected data for the lactulose breath test over 14 hours while they ate. And then they also didn’t control for timing of the meal, so they didn’t feed everybody the same thing at the same time. So I thought that might’ve just been a little bit of an outlier. But what’s so interesting about this that the high FODMAP group was given high fructose corn syrup soda.  And they were also given sorbitol gum with sugar alcohols. And there’s a study that actually shows if you combine sorbitol gum and high fructose corn syrup, it exacerbates symptoms by swiftly delivering malabsorbed carbohydrates to the colon. There’s a study on this.

Dr. Weitz:            Wow.

Angela:                 I know, so you can’t, so for the group and the high, people with IBS are already going to be sensitive to that osmotic shift, probably more so than the healthy individuals. And now you give them high fructose corn syrup and sorbitol gum in there, quicker to malabsorb, quicker to have bloating and excess gas and shift things and kick things up. So again, it’s not just the study, but you have to really get in, look at the point by point. Well, what did you feed? What’s different here? What do we have to question?

Because we can’t just take this at face value at all. There’s one other study that saw a change in hydrogen and that was, which we’ll probably talk about a few times here because the study again is one of those that cited everywhere. It’s FODMAPs alter symptoms and the metabolome of patients with IBS, a randomized controlled trial. And that was by Macintosh et al. They claim to have found a difference with hydrogen levels. But when you actually look at the study, there’s no statistical significance when comparing baseline data to post side intervention. There’s none. So we’re done. They went on to have a big discussion about it, but there’s no statistical significance. So I don’t know why they kept talking about it.

Tell you how I really feel. I know. So at this point right here, we have no study that backs up a low-FODMAP diet, lowering hydrogen levels or methane levels and people with IBS or people with SIBO. None. It’s not even controversial, there’s just none there. If you actually look at those, they didn’t do the lactose breath test right. There’s no data to confirm. That’s all we have.

Dr. Weitz:            It may or may not work. We just don’t have proof that it does.

Angela:                Yeah, and so far it’s pointing towards no, clinically we don’t see it. And when we actually look at the studies where they implemented it properly at three weeks and six weeks, there’s no change to hydrogen and there’s no change to methane.

Dr. Weitz:            And because this diet removes lots of healthy foods like broccoli, avocado, we could go on and on about all these healthy foods that are being removed from your diet.  And because we know that there’s a negative effect on the microbiome, then what you’re saying is we should all stop using the low-FODMAP diet in patients with SIBO.  What about the ones who say they’ve gotten results with it?

Angela:                I’d say this, if you have been on a low-FODMAP diet for a long time and your symptoms are managed with it, I get it. I really get it. What I want to connect with that person with, because I have so much empathy for people not feeling well.  On one hand, obviously there’s some things to figure out because they still have SIBO with SIBO, otherwise they wouldn’t be reacting that way or there might be some other things that we can add to support them that isn’t just restrictive diet.  Additionally, for that connection piece, if we know from the data and again, seeing people on this forever not getting better, in terms of lowering the hydrogen and methane loads on a breath test.

When you eat and have a symptom flare, I know it’s not fun, but it’s not SIBO growing in a Petri dish.  SIBO’s not getting worse.  So what we want to do is basically, pick your five favorite foods that aren’t garlic and onion because those ones are hard to include back in, and see if you can try a tablespoon of something. Really the unfortunate part of expanding off of a really restrictive diet is that you have to do it really slow, and methodically and it takes time. Rebecca Coombs, love her, she shared a story one time where, it took her, I think about four months to introduce pumpkin again, where she would try a tablespoon of pumpkin, did not go well. Waited a month, tried it again, did not go well and it took her until the third month or fourth month for finally for her system to say, all right, it’s not so bad.  So, I think that’s kind of the unfortunate part. This isn’t somebody on, reacting a little bit to dairy and gluten and they eat it on occasion and they don’t quite get a flare up. These are people that if they have, and for a lot of them, if they have a cup of potatoes are going to be down for three days with their symptoms flaring up.  So for some people just depending on where they’re at, they’re going to have to go very slow with the reintroduction.

Dr. Weitz:            What’s happening? Why can’t they tolerate these foods anymore?

Angela:                So, what I consider is that when we were back as hunters and gatherers and running around and looking at things seasonally, we’re going to upregulate or downregulate digestive enzymes based on what we’re consuming on a regular basis. So seasonally, because it doesn’t make sense to me to make a bunch of digestive enzymes to consume certain plant foods that aren’t going to be, if they’re not around all the time.  So, when we’re really pairing somebody down, and having them consume little variety and a lot less food, it takes a little bit to start to reintroduce foods to get their body to start to acclimate to that a little bit. I think there’s some support out there that we had that can really help them introduce things a little bit more easily. There’s some really great, Intolerase by Vita Aid is a really great digestive supplement that was made for SIBO that can help with all those different starches and indigestible fibers to help break those down a bit more. So, I think too, maybe to explain it too, if you haven’t had, let’s say non-SIBO people, just healthy individuals running around.

If you haven’t eaten beans in a year and a half and you go have a cup of beans, you’re going to have probably some gastric distress from the gas production. But if you eat beans on a regular basis, your body will get used to it and acclimate.  So I see that with FODMAP, like the more and more we restrict, the first couple of forays into expanding foods.  If they do it too fast, they react.  So we just go really slow as we trickle that food in, as we start the expansion.  But it’s also getting past the mindset because the mindset has been, I have SIBO, I have to starve this out.  Every time I have a reaction, it’s SIBO growing in a Petri dish and I’m making this worse. I’m never going to get better. I need to restrict.  And that whole mindset, I mean that’s why I basically, there was a whole, at the SIBO symposium last year, there is a full tract on anxiety and food related disorders based in and around SIBO.  Because everybody’s restricting a lot. And I think unnecessarily for a big degree.

Dr. Weitz:            I wonder if we could make use of low dose immunotherapy in such a situation to start getting your body be able to tolerate some of these foods.

Angela:                Possibly. Possibly. I think. 

Dr. Weitz:            It’s interesting how these enzymes are really specific to the exact types of foods that we consume.

Angela:                And that’s where I think something, honestly, like Intolerase comes in. It’s a really broad spectrum, covers a lot of bases in terms of some of these ingestible fibers and stuff. We can do that. If we can go, tablespoon worth the food. Give it a couple of days, double it, give it a couple of days, double it. If all that’s going well, then we can start to increase some of those loads for people and just start to get their body used to it a bit more.  And breed some confidence for the person too, which I think is really important. Cooking grains longer, adding more water, cooking them longer, understanding that if you cook something like rice.

Dr. Weitz:            Using a pressure cooker.

Angela:                I love it.

Dr. Weitz:            Soaking grains, overnight-

Angela:                All of that can help.

Dr. Weitz:            The lectins.

Angela:                Yes, yeah, I think that can help. I’d say also-

Dr. Weitz:            The deadly lectins.

Angela:                Mm-hmm, I’d say that also if you’re, so some people know too, if you cook rice as normal in water on the stove when you boil that and then cool it, you create resistant starch. And so you might do fine as you eat that cooked initially, but if you keep it in the fridge day after day, the more you heat and cool that the more resistant starch is created and that might be a little bit of a key that person reacting more and more as they introduce that.  There’s different types of white rice too. If you don’t do well with Jasmine rice, it doesn’t mean rice is out. There’s different rices and you might do well with another type.

Dr. Weitz:            Depending upon whether they’re higher in amylopectin or-

Angela:                Yep, exactly, exactly.

Dr. Weitz:            If the low-FODMAP diet hasn’t been proven to be effective, are there any other diets that have been proven to be effective for SIBO?

Angela:                No, not to date.  So, basically we’ve got the low-FODMAP diet, we’ve got the SIBO specific food guide, which basically combines the FODMAP and SCD, and then the Bi Phasic is implementation of the SIBO specific food guide, where the groups of foods are phased in at different times. So we don’t have any studies. 

Dr. Weitz:            So really no research to back up the Specific Carbohydrate diet or the GAPS diet, either one of those.

Angela:                Gaps isn’t often used because gaps has a lot of fermented foods in it. And so I think people shy away from that a little bit with SIBO, a lot with SIBO. Who am I kidding there? They really shy away from it.

Dr. Weitz:            But Specific Carbohydrate?

Angela:                SCD actually has some fairly good studies behind it, but not for this.  It’s more related in and around to ulcerative colitis and some other things, but not specifically for SIBO. So and I’ll say there’s, different practitioners have a different way of getting a patient from A to B.  I’m not trying to get in the way of that. I’m trying to have a discussion on what we’re trying to do with the low-FODMAP diet.  And I see so many patients come to me having been on this for so long and it’s almost like you see their shoulders go, huh, when you say, I give you permission to eat, please go eat.  Because I’ve even had people come to me and they said, “Oh, you’re probably going to, I’ve been cheating, you’ll probably going to tighten up my diet.”  And I’m like, “Go eat whatever you want.”  Of course it’s going to be healthy and we’re going to work on it, but I give you permission to eat.  What are the next five foods you want to try?  Let’s do it methodically with purpose. Let’s start to expand.  Give them something to look forward to. So many people expanded with their diet and they’re better for it. They’re not worse.  SIBOs not getting worse. They’re better for it because they have better endurance, they get better emotionally. They’ve got more nutrition coming in.  It’s all positive.  It’s not ever going to be a negative with that.  So we just have to look at this from that perspective.  I’d say again, if you’re working with a practitioner and you’re listening and they really love the SCD, or they really love a FODMAP or the SIBO specific or Biphasic, and they have an in and out plan, that’s fine.  But the in and out plan is three to four weeks. It’s not, you’re going to be on this for four months or five months or this is just the diet you do because you have X, Y, and Z.

So I would challenge the practitioner you’re working with and ask them why they’re choosing this diet, how long you’re going to be on it, what is the plan and when are you going to start expanding your diet? If you can get all of that in writing, the three to four weeks of a regroup could be fine based on what they see. I think it’s, again, the elimination diet as a whole for a FODMAP diet to me is really reserved for people that just cannot figure out what they’re reacting to and through conversation with your clinician, we’re not able to pick it out off the top of their head because it sounds like you’re reacting to everything. Great case for an elimination diet, but for the rest of the groups, then we look at fructose and lactose and it’s just the sucrose, even for some, we reverse engineer it. You don’t have to pull everything.  Fructans are probably the one, like garlic and onion and leeks. Those are the ones that usually are suspect. And the problem is of course, is they’re looking, onion is in everything. If they’re trying to eat out and that would be the first thing that we look at and have suspect about for people reacting and then fructose and lactose.  So it’s not that you have to just pull everything.  We might learn a little bit from the FODMAP diet and what people are less likely to react to, and what we can gravitate towards.  That’s great.  But the whole idea that we have to restrict down to seven to nine grams of FODMAP a day and stay on that to starve something out is ridiculous.

Dr. Weitz:            Essentially, you’re suggesting that we do something like a conventional elimination diet. We just pick two, four, six, eight foods, something like that, eliminate it for a specific period of time, and then try to test them back in and bring those foods back.

Angela:                 I am suggesting that, but that’s also what the studies are suggesting.  Time and time again, the studies are suggesting this is a three to four week diet plan. This is not a long term diet. We need longer studies on this. This should never just be put, have somebody put on long term. So this is the study, is in their commentary and summarizing their investigation study after study after study, says this is a three to four week plan.  So I am suggesting that for people that have more deep irritating symptoms, that from this three to four weeks as an elimination diet pull everything, and then there’s really good, Kate Scarlata has info on what to challenge.  There’s people online that have found what to challenge. You can get that info for free. I really recommend that you do this with a practitioner.  However, not only that, all the effort you put into doing this over a month, if you’re not realizing, oh, X, Y and Z are actually high in FODMAP, they’re just not on any list. You want to make all your efforts count. So work with somebody as you do this because it’s fairly restrictive.

Dr. Weitz:            It’s pretty much what I do. But I typically do it for four to eight weeks rather than two to three weeks, but.

Angela:                Three to four weeks is usually the timeline that is recommended within the studies, and enough time to let symptoms settle down because again, this isn’t food sensitivity. We all learned the elimination diet way back when as pulling gluten, corn, soy and wheat, eggs, all of that. And then some, but that was more sometimes a month, sometimes two months. It was more like a month, month and a half.  But we’re calming down the immune response as well as we challenge that.  We’re getting kind of a reset button on that.  So for this, this is really more what’s ramping up symptoms, osmotic shift and maybe the bloat response from that fermentation piece. 

Dr. Weitz:            And isn’t it interesting that gluten and dairy and soy are some of the same foods in the low-FODMAP diet too that you take out.

Angela:                Yeah. Yup. It definitely is. Definitely is. The other thing I would say I think is really interesting and maybe to make the point here. I’m in the clinician group on Facebook for SIBO and we’re often discussing cases and points and it comes up time and time again that if there’s a pediatric case of SIBO, you completely throw the SIBO test out, ignore it, and you basically fix the foundational parts, clean up the diet, probably dairy and gluten free.  Support the child nutritionally and see and try to figure out really what’s stirring up the emotional piece, what’s adding, where’s the stress coming from.  We ignore it because we don’t want to over-treat and that’s that. I mean that’s said by everyone, Mona, Lisa, Shiva, everyone. So as we start to look at all this, which I will heartedly, I don’t work with a ton of pediatric cases, but I wholeheartedly agree with that. But I feel like we should have also be doing that in adults. So if somebody comes to me with five SIBO tests in a row, I still set them aside.  We look at everything else.  What else could it be?  Let’s start with the basics.  Let’s clean things up.  Let’s settle things down.  Let’s work on motility.  So many people aren’t doing that and then wrap back to that and see if we even need to treat.  So, I think we just don’t want to jump the gun.  I think we get again this, when you have a way of testing for SIBO, that’s fairly easy, fairly affordable for some or most, and you get these test results back and you’re like, aha, that’s it.  Well, it’s secondary. You still haven’t figured out the root cause of it and you can very quickly throw an antibiotic at it or herbals at it and put them on a low-FODMAP diet, which might make them feel better, but now they’re stuck on the low-FODMAP diet and SIBO’s maybe not fixed. So, we still want to look at what set this up and treat from that perspective. The other thing that I think is very interesting to me about the FODMAP diet and how quickly people are quick to jump on it and talk about it online and use it, is that we’ve got this idea that if you put people on this low-FODMAP diet, it’s going to cherry pick and reduce the specific species that are causing IBS or SIBO.  And again, in the studies that’s just completely unfounded.

There was one great study that found that a low-FODMAP diet made the microbiota more dysbiotic and I loved what they said in their work because the way that they said it is it, it made the microbiota more dysbiotic in a group that already has been shown to have a dysbiotic microbiota. So it’s another study, dysbiosis is causal and IBS, although there’s no direct evidence to support this, being kicked around so much in the studies, then the effect of a strict low-FODMAP diet might be counterproductive. So what are we doing? It’s just really interesting. The one study I mentioned earlier about the hydrogen, altering hydrogen where they didn’t see any statistical significance in pre and post data, FODMAPs alter symptoms and the metabolism of patients with IBS, a randomized control trial.

That study again is one of those foundational studies within the SIBO rule that’s been cited so much. And they found no statistical significance when comparing their baseline data and their posts, diet intervention data with the microbiome.  But again, they had a page and a half of summary because then they went on to actually just compare their post intervention data.  So we can’t, we’ve got to look at these studies and this is the one study that actually kicked my whole, wait a second, what the hell is happening?  You got to be kidding me, moments because this one study again that everybody talks about, it’s always cited wherever on everybody’s stuff is they found no statistical significance with hydrogen. They found no statistical significance with the microbiota. They actually said alpha and beta diversity were the same when you compare the pre and post test.  They also, and this is the study that kicked off the whole conversation around histamines because what they claimed in their study was that there was an 8 fold decrease in histamines when people follow the low-FODMAP diet versus the high FODMAP diet. And I was looking at that to write an article off of it and there’s an asterisk on the data for the histamine piece.  And I was like, wait, what?  You can do that?  You can put an asterisk on stats.  So if you read it, what they had to do to get a correct… the statistical significance was that basically I think they started out with like 37 people. They went down to 34 people when they were looking at histamines. That didn’t tell us why a few people were discarded.  And then there was no difference between pre and post data for histamines.  So they only looked at the post data for low-FODMAP and high FODMAP and they had to adjust that subject group down four more times for age and gender, and IBS subtype to actually see a difference between a couple of people. And so-

Dr. Weitz:            Wow.

Angela:                I know, and then you back up and you kind of, you look at what they actually did to test histamines and they did a single point. You’re in test first thing in the morning, which for histamines, for urine histamines we look at a 24 hour collection because histamine is up and down all day long. So they didn’t test it correctly.  There was no difference in pre and post data. That citation is in 50 other studies that the low-FODMAP diet alters histamines.  And then whenever you look at those other studies, they make that citation and go into everything that’s happening with the immune system because we know that it lowers histamine.  It’s all complete conjecture because that study didn’t show it. So it’s really, it was absolutely interesting. I sent it to all my colleagues. I sent it to a friend who’s a colleague who’s a gastrointestinal doctor. Like am I seeing what I think I’m seeing? And he’s just like, “Oh my God, this makes no sense.” So it’s just interesting. It’s interesting, it’s really sad, I mean if you go online and search for FODMAP and histamine, you get a hundred thousand plus results. It’s just everywhere. And it’s, I don’t know what to say.  And when we actually look at the study, it doesn’t show it.

Dr. Weitz:            And its being recently embraced by conventional gastroenterologists now too?

Angela:                 Yes.

Dr. Weitz:            The ones who are involved with diagnosing and treating SIBO.

Angela:                 Yes, and that’s where, I think it’s really, it’s like it’s fortunate unfortunate. I saw the about shift with the GI docs. It was like at the front of, maybe it was like two years ago at the start of the year.  They all thought SIBO was crazy, at the end of the year. I don’t know what conference it was presented all of a sudden SIBO exist, and the FODMAP diet is great.  And that’s not for all of them.  I’m sure there’s lot of them that still think it’s crazy.  But enough of them are treating that, it’s just here’s the test, here’s the antibiotics, here’s the FODMAP diet.  Thank you for coming.  And your GI doc is not who you see on a regular basis. I hope it’s not.  That means you got a lot of gut stuff going on.  Ulcerative colitis patient, you’re going to see your GI doc a lot.  It’s just is what it is.  But for the most part, that’s not where you go for primary care.  And so, are you going to even see them again in six months?  Now you’re stuck on that diet because you’re supposed to follow this.  There’s not a lot of follow through or follow up with that.

Dr. Weitz:            I think Dr Pimentel’s research has been very influential and we know that IBS is the most common gastrointestinal condition. And though, I’m sure a lot of GI docs feel like, wow, we’ve got all these patients with IBS and we don’t really have a lot of tools right now. And so, maybe now we have a strategy that makes sense.  We have a diagnosis, we have a drug that goes with it, and we can throw in a diet too.

Angela:                 Yeah, yeah. It’s true. It’s true. It’s true. And then they again, in the IB, and the study is looking at FODMAP and IBS, they’re showing that about 40-45% of people will improve on a FODMAP diet, again, as an elimination diet.  So it’s not everybody, but that’s a pretty big chunk that somebody can make a difference with a handout.  But then, how long are they following it, and what issues come from that?

Dr. Weitz:            Okay, awesome. Thank you, Angela.

Angela:                Yeah, of course.

Dr. Weitz:            We’re going to shake up the SIBO world a little bit.

Angela:                I hope so. I hope so. Thank you for having me. It was a great conversation, and I hope to continue it.

Dr. Weitz:            Good, good, good. And so how can listeners get a hold of you and find out about your programs and your products?

Angela:                Best site to reach me through is my website, siboguru.com. And then my bone broth is definitely out there, a gutrxbonebroth.com and everything’s linked for my website, so you can just come through me and find info there.

Dr. Weitz:            Awesome. Thank you.

Angela:                Thanks Ben.




Epigenetics and Cellular Detoxification with Dr. Ashley Beckman: Rational Wellness Podcast 141

Dr. Ashley Beckman discusses Epigenetics and Cellular Detoxification 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

4:42  Epigenetics is the study of how certain mechanisms like diet, lifestyle, and behavioral choices can switch our genes on or off.  We have a lot more control over our future and our genes are not our destiny.  In fact, according to Dr. Beckman, they are our greatest opportunity.

5:50  Cellular detoxification is a detox program specific and targeted to our genetic predispositions and our constitution our detox needs.

7:15  To determine our genetics and our epigenetics, Dr. Beckman prefers to determine our genes with a testing company like Apeiron Genomics rather than using 23andMe or Ancestry, since these companies are generally selling your data and now offer a limited number of genes.  Apeiron Genomics uses a large number of genes and provides actionable reports with recommendations for diet, exercise, supplement, and lifestyle tendencies and it does not sell your data.

12:22  Dr. Beckman explained that her patient who gets tested through Apeiron Genomics receives various categories of their tendencies.  For example, they get an insulin resistance score based upon about approximately 20 genes, which gives them a score of the likelihood of developing type II diabetes.  This can provide motivation for people to be mindful and makes changes in their diet and lifestyle, esp. if they have a high propensity for developing insulin resistance and diabetes.

23:22  Looking at your genetic tendencies can help you tailor your detox program to be more effective. Dr. Beckman said that she had been doing Dr. Schultz’s detox programs since she was a kid and did them seasonally. She eats very clean and uses clean products and doesn’t use plastic and doesn’t buy plastic bottled water, etc., but when she did the Great Plains toxin test, she was one of the most toxic folks they had ever tested. She was in the top 75-95% of the highest levels for 15 different toxins, like BPA, MTBE, and perchlorate.  She also learned from her genetic testing that she does not make or process glutathione much at all. So now her detox program involves precursors for glutathione and also binders to soak up the toxins to get rid of them, like fulvic and humic acids and modified citrus pectin, which are more effective than charcoal. For testing for toxins, she likes to run the organic acids, the mycotoxin, and the environmental toxin tests. She also likes the Quicksilver Mercury Tri-test, which is a combination of serum, urine and hair mercury testing.  She may also run a fuller heavy metals screen.  She may also run a GI Map stool test or a Gut Zoomer test.

34:25  Dr. Beckman combines the genetic testing and what shows up in the labs to tailor the detox program for each patient.  She will do a preparatory phase prior to starting the detox and if the person cannot tolerate toxins well based on the genetics, then this phase will be longer.  She will start patients with certain foundations, like optimizing nutrient levels and making sure their bowel is functioning properly and that they are not constipated and ideally pooping twice per day.  If they are constipated, the toxins will recirculate instead of being eliminated.  Dr. Beckman will also give them some nutritional formulas to support the lymph, the kidneys, and the liver.  She likes CellCore Bioscience products, including their HM-ET Binder product, which contains extracts of humic and fulvic acid, and their Biotoxin Binder, which contains humic and fulvic acid and also molybdenum, broccoli sprouts, and yucca root, as well as some products from Designs for Health and also from Quicksilver.  She likes to get her patients off eating gluten, dairy, and refined sugar.  She also works with her clients on breathing and also with dealing with stored grief and sadness and other emotions, including with acupuncture, meditation, and visualization.  Dr. Beckman works out of offices in both Beverly Hills and Malibu and she can work with clients through the phone and her website is DrAshley.com.


Dr. Ashley Beckman is a Doctor of Chinese Medicine and a licensed Acupuncturist and herbalist. She received her doctorate in Healthy Aging and Longevity and wrote her thesis on Epigenetics, the study of how our genes are affected by our diet and lifestyle.  She specializes in healthy aging, epigenetics, pain management, fertility, detoxification, headaches, stress reduction and facial rejuvenation.  She also co-founded Golden Path Alchemy, an organic skincare company based on the principles of Traditional Chinese Medicine.  She can be reached through her website, DrAshley.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.


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 another discussion on important functional medicine topic. For those of you who enjoy listening to the Rational Wellness Podcast, please go to Apple podcast and give us a ratings and review that will help move us up the rankings and help more people find the Rational Wellness Podcast. If you’d like to see a video version of our podcast, 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.

Our topic for today is Epigenetics, and Cellular Detox with licensed acupuncturist, Dr. Ashley Beckman.  Our genetics are the DNA code that we inherit from our parents and these direct the activities of our cells and our DNA code does not change over time. Our DNA code is a sequence of nucleotide basis known as adenine, cytosine, guanine, and thymine. I know that it’s kind of scientific jargon, but it’s the specific sequence of these A, C, G and T bases. This is the code that provides the instructions for our cells to make specific proteins that trigger various biological functions in our body, including the production of insulin, for example.  The definition of epigenetics, epigenetics is a set of triggers and switches that turn our genes off or on, and so epigenetics doesn’t modify the genetic code, but it modifies the expression of our genes. And our genes, our epigenetics is based on a whole series of factors including environmental factors, diet, lifestyle, and our exposure to toxins. Such toxins that have been shown to be drivers of epigenetic processes include heavy metals, pesticides, diesel exhaust, tobacco smoke, bis phenolate, mycotoxins, radioactivity, as well as hormones, bacteria, and basic nutrients. Some of our genes get switched on and get expressed and other of our genes get turned off and do not get expressed.

The other part of our discussion is about detoxification and detoxification is how we get rid of toxins that we’ve been exposed to over our lives and then may be stored in our cells, our organs, and even our bones. This occurs naturally on a daily basis, but we can also stimulate the detoxification process by doing a detoxification program, which often involves some form of fasting combined with taking specific nutrients to support delivery detoxification pathways to support cellular detoxification, and to support the various forms of elimination, including the digestive track and it facilitate sweating another form of elimination such as by using infrared sauna.

Dr. Ashley Beckman is a licensed acupuncturist and herbalist and a doctor of Chinese medicine practicing in Los Angeles. She received her doctorate in healthy aging and longevity and wrote her thesis on epigenetics. The study of how our genes are affected by our diet and lifestyle as I just mentioned. She specializes in healthy aging, epigenetics, detoxification, pain management, fertility, treatment of headaches, stress reduction, and facial rejuvenation. She also co-founded Golden Path Alchemy, an organic skincare company based on the principles of Traditional Chinese Medicine. Dr. Beckman, thank you so much for joining me today.

Dr. Beckman:                     It’s a pleasure to see you and be here today.

Dr. Weitz:                           Good. Let’s start by giving some definitions. I know I’ve gone into it some, but why don’t you explain what epigenetics is?

Dr. Beckman:                     Sure. Epigenetics is the study of certain mechanisms such as diet, lifestyle, behavioral choices that we have like exercise and these different factors we have in our different … in the way we live. And basically these can switch our genes on or off. One thing that I really like about this is that we have a lot more control over our health destiny than what we have been known to believe in the past. So many people just believe if something has been passed down to you by your parents, that you’re destined to get this and more likely doomed to get it.  And so people just really focus and are scared for their future. And I love this theory of epigenetics because we really have a lot more control than people had thought before.

Dr. Weitz:                           Right. Our genes are not our destiny.

Dr. Beckman:                     No. And I say they’re our greatest opportunity.

Dr. Weitz:                           Great. The other part of our discussion is going to be about cellular detox. Maybe you could explain what is cellular detox?

Dr. Beckman:                     Sure. The word detox gets thrown around all the time and people equate this with a three day juice cleanse that they picked up at a juice bar. And especially as someone coming from Chinese medicine, you really need to tailor things towards someone’s constitution. Even on the detox level, we have to know how the body is and even some genetic predispositions and how we detox, like how our phase one and phase two pathways are wired, so that we can actually tailor a detox specific to that person. Some detox that you pick up, like I said, like at a juice bar or even off the shelf at Whole Foods, it’s not going to be exactly what you specifically need.  And so a cellular detox really we want to get in, make sure that you’re targeting all the areas that really need to be addressed and taking the right supplements. And then kind of what you were speaking about, all the other lifestyle factors that accommodate what is needed in a detox with, from mindset to some fasting, the right foods and the right supplements. Something that’s very targeted and actually effective.

Dr. Weitz:                           Okay. With respect to epigenetics, how do we find out what our epigenetics are?

Dr. Beckman:                     Well, so the main way is you basically … what I do with patients is you take someone’s raw genetic data, so you get a test. There are various ones out there. I have utilized raw genetic data that people have already received from somewhere else, like 23andMe or … there’s a various amount of companies now.

Dr. Weitz:                           Ancestry.com, so why don’t we talk a bit for a minute about which is the best one to use?

Dr. Beckman:                     Sure.

Dr. Weitz:                           Because for a while I heard that 23andMe was providing the most amount of genes and then they change the way they do their testing, so they actually provide fewer genes. What do you think is the best company to use if we have a choice?

Dr. Beckman:                     Sure. I use a company called APEIRON and that’s the company that I’ve actually trained with and studied with. They do not store your data and it’s actually extremely private. Your name is not associated with the bar code on your test. That is something because they will never sell your data. And I think that that is actually one of the most important pieces right now.

Dr. Weitz:                           And you’re referring to the fact that 23andMe and Ancestry, the way they make a lot of their money is by selling your data to be used for research by Big Pharma and others?

Dr. Beckman:                     Yes, I believe that that’s accurate. I think a lot of the companies out there are data mining companies and where you get in exchange your raw genetic data. But at the same time I caution anyone who has not done that already to pick another company that does not work in the same manner.

Dr. Weitz:                           Do you mean for privacy concerns?

Dr. Beckman:                     For privacy, and the thing, this whole area is very new and nobody really knows what they’re going to be doing with gathering all this genetic data. I think privacy is of utmost concern. And sometimes I tell people, “If you want a little bit more privacy you could also maybe use a different name when you send it in,” things like that. But at the same time, my number one choice is to tell people to use another company that doesn’t do that and the one that I’m secure with is APEIRON.

Dr. Weitz:                           Okay. How do you use this APEIRON to find out about your genetic code and your epigenome?

Dr. Beckman:                     Sure. It’s the same as the little swab that you do, and the cheek swab, you send it in and then about six weeks later you’re given your raw text file. And then, so what I do is I take that information and put it through a program and then also go through it with this long Excel sheet that I have that has a lot of different of the expressions and what they can mean and what they’re significant for, for different health reasons. Then I compile this report and I go over that with my clients. And it looks at different factors, so it looks at the foods that you eat, supplements, athleticism, hormones, the way you detox and sleep patterns. Those are main areas of epigenetics.

Dr. Weitz:                           When you take the results from that test, what exactly are you getting? Are you getting a genetic code? Are you getting the epigenome? Can you explain?

Dr. Beckman:                     I’m sure. It’s the genetic data, so it’s your genetic blueprint and it is grouped in certain … it’s put in certain groups to test a variety of the SNPs together. When you’re looking at something-

Dr. Weitz:                           Can you explain what a SNP is?

Dr. Beckman:                     That’s basically just like the single nucleotide morphism. It’s the little genetic codes for each area, but what we do is we look at the ones, so you … Sorry, you need to look in a grouping of things. It’s not that great to single out one genetic code and say, now you have this. You know what I mean? We look at a group together usually-

Dr. Weitz:                           What software do you prefer to use?

Dr. Beckman:                     I use the software from APEIRON. And then I pair that with, like I said, this kind of like long Excel sheet that then I dive deeper into which one is the norm and which one is the exception. And so then it gives you some more probabilities of how this might express in your system. This is all just the genes and then

Dr. Weitz:                           How many genes are you analyzing with this software?

Dr. Beckman:                     Oh, shoot! I would have to look it up. I don’t remember.

Dr. Weitz:                           Okay.

Dr. Beckman:                     I’ll look it up so you can put it in the notes though. But it’s very comprehensive.

Dr. Weitz:                           Okay. And then how does this help us?

Dr. Beckman:                     For example, one of my favorite areas is it gives an insulin resistance score. This is a probability that you might have, based on your genes, of your probability of having an issue or developing type 2 diabetes. It basically, for me, and especially because I’m very passionate about getting people to reduce their sugar consumption and because I think that it has such long lasting effects, but a lot of these clients have a high insulin resistance score, so … And they might not even know that. They could be someone, though that tends to be eating a lot of starchy carbs and things like that and is not really that cognizant of how much sugar they’re eating.  And so when I see this in someone’s report, to me it’s a really big push for them to start being mindful of that and to change that. Because that’s, as you probably see with your clients as well, prediabetes is so rampant and most people in their 50s and 60s and unfortunately now children are getting prediabetes at much younger ages. And so it’s something we can completely prevent.

Dr. Weitz:                          Which gene or genes are the ones that most commonly code for insulin resistance? Do you know those offhand?

Dr. Beckman:                     I don’t know them offhand, but I have-

Dr. Weitz:                          Okay.

Dr. Beckman:                     Do you want me to give? I have them right here. Okay, so the thing about the genes that’s kind of … so okay, this grouping is actually about 20 genes that we use to look to-

Dr. Weitz:                           20 genes for insulin resistance, okay.

Dr. Beckman:                     Yeah. This is one thing that I think is very important and I touched on a bit, it’s these grouping of genes. Often we hear about one specific gene all the time, but it really is how they work together. That’s one thing I really like about this company too, like is that it’s never just one gene and then you create this whole idea around it.  We hear about these famous genes, sort of from certain people and I think a lot is built on that-

Dr. Weitz:                           Some of these genes are now being referred to as diseases. “I have MTHFR”

Dr. Beckman:                     Right, exactly. And there’s actually a kind of a little joke that a friend of mine who’s another Functional Medicine doctor said. He just, it’s kind of like, no one would know that unless you recently went to a Functional Medicine doctor and you were told you now have this terrible disease that you need to change all these things.

Dr. Weitz:                           Or they could have gone to Dr. Google or Dr. YouTube.

Dr. Beckman:                     Yes, I know the amount of people actually that talk to me and ask about it, again, I just say actually we look at a bit of a grouping of a lot of genes to see how big of an impact that might be for you.  But that’s just one of them. You know what I mean? There’s a whole lot that are, like I said, they are getting well known.

Dr. Weitz:                           When a patient has … How do you determine how significant these genes are? Let’s say you have one copy, which means you’re … or heterozygous or two copies, which means you’re homozygous or you could have multiple copies of one, multiple versions of one copy of these different genes. How do you know when it really matters? And then do you need to wait until they have positive testing in terms of a fasting glucose and Hemoglobin A1C, et cetera?

Dr. Beckman:                     No. One thing that I like about this is that they give us clues. They give us areas to focus on. There are certain genes that have more weight than others. That’s why these ones, it is true, the ones that are more well known have more weight. But again, it’s still the grouping. Let’s say you have one that is more weighted and more significant, but then you have three that are totally normal. Then that average is your risk down a little bit less than if you were just looking at that one gene, because you do need to look at them together. I mean, the genetic code doesn’t work independently and genes don’t work independently unless it’s something very specific that has a genetic, very specific genetic disease where there’s one …  When you have that switch on one specific thing that it actually creates a very specific pattern or disease in somebody. But those aren’t as common as these groupings creating a probability, if that make sense.

Dr. Weitz:                           Let’s say they have an increased risk for insulin resistance, but they actually have a fasting glucose of 80 and a fasting insulin of three and their Hemoglobin A1C is 5.0. What do you do with that?

Dr. Beckman:                     This is one other thing I love. I love having this and then backing it up with data. I love using even regular lab tests and then Functional labs to basically get a better idea of what’s actually happening right now. Because the genes give you your blueprint and some of your probabilities; your lifestyle, your emotions, your exercise habits. Those are what really can turn things on and off and make significant change. When you have some of these probabilities and then you look and see what their Hemoglobin A1c it’s, it’s steadily creeping up and creeping up, then this person needs to make significant changes so that they can revert back to somebody who doesn’t have those extra probabilities or increased probability of getting the type two diabetes.

Dr. Weitz:                           Does everybody who has some of those genes that code for increased insulin resistance, do they all need to follow a low carb diet?

Dr. Beckman:                     Well, so again, I would say I like to look at them individually. Certain people constitutionally, according to Chinese medicine do better with some starches and grains. A lot of people don’t, especially if there’s some sort of autoimmune issues happening, things like that. I personally don’t think anybody does well with refined sugar. I mean, that’s not any type of news, but my main thing is really getting people just cognizant of how much sugar they’re getting, that they’re not even realizing. Most people never flip something over and read the label.  I tell everybody if there’s double digits, 10 grams of sugar in something, you should not be eating it. And then I give them an amount per day, so a max of 25 grams a day. My goal, like I said, is I don’t want people really having much sugar at all. There’s no benefit of having refined sugar. It actually is just more detrimental. And people, once they get it out, they start to feel better and it has a long reach, I believe in their health span in multiple ways.

Dr. Weitz:                           Right, okay. Give us some other examples of what you get from doing the genetics. And then explain how epigenetics factors in here.

Dr. Beckman:                     Sure. The epigenetics part really is … that is not tested in kind of what you’re getting with the raw genetic data. The raw genetic data shows you what areas you could focus on, so like, which foods would be helpful to silence some genes that might create a problem or the same. It talks about supplements, so sometimes certain supplements would be toxic to somebody if they take too much. But for example, a lot of people were taking a lot of vitamin E for a long time as an antioxidant. It’s one that can be toxic for a lot of people if they take too much of it. It actually shows that-

Dr. Weitz:                          Vitamin E?

Dr. Beckman:                     Yes. But it shows that in the raw genetic data. Some of those are pretty interesting. And then also checking the types of the B vitamins to take, for vitamin D. It shows, which is pretty interesting if people can get the benefit from the sunlight and absorbing it or if they’re not someone that actually can absorb much of the D from sunlight. Because I’m sure as you’ve seen with some of your patients, some people can absorb it really well and some people don’t. Even though they’re in the sun all the time, they’re still deficient.

Dr. Weitz:                           I’m amazed in Southern California how many people get exposed to sun all the time and their vitamin D levels are low.

Dr. Beckman:                     Right. Yes.

Dr. Weitz:                           I think it’s more common than not.

Dr. Beckman:                     Yeah. And a lot of people think … they just think that, and actually I was one prior to testing it is I just thought there’s no way I’m in the sun constantly. And you know, the first time I checked, I think I was at 19 and I literally-

Dr. Weitz:                           Very low

Dr. Beckman:                     … always in the sun because I love sun. I’m just not someone that actually absorbs it from the sun, so I need the supplementation. That’s one thing that I really love again is I’m sure you go by this too, is test, don’t guess.

Dr. Weitz:                           Absolutely.

Dr. Beckman:                     We assume all the time these things that we hear and have known for a while, but they’re not always accurate.

Dr. Weitz:                           Yeah. We occasionally get people with modest amounts of supplementation that their levels shoot up, but more common, it’s really hard to get the levels up. And sometimes doing modest supplementation, like 1000 or 2000 milligrams of vitamin D doesn’t do anything. And it’s not unusual that we have to go to like 10,000 a day to get up to those target ranges that we’re trying to hit, like 50 to 70 or 60 to 80 or something like that, nanograms per milliliter.

Dr. Beckman:                     Right, yeah. And that’s not something from, sort of, in the natural medicine world, we have not heard that. We just thought, if you’re out in the sun and the right hours of day without sunscreen, you’re fine. And as you know, vitamin D is one of those precursors that it’s implicated in over 200 genetic processes. It’s crucial on so many levels that it’s actually in an optimal range.

Dr. Weitz:                           Yeah. And of course we can measure vitamin D receptors and whether people are going to respond and produce vitamin E or absorb the vitamin D that they take in.

Dr. Beckman:                     Yep.

Dr. Weitz:                           How does genetics, how does that change a detox program?

Dr. Beckman:                     Sure. I can give an example of myself for one. I’m someone who, since high school had been doing detoxes. I studied Dr. Schultz’s products, got into that. And since you’re from LA, right, or you’re in LA. I’ve been doing Dr. Schultz’s products since I was a kid. I’ve been obsessed with detoxes since I was little and I did them seasonally. All of that.

Dr. Weitz:                           And what did most of these detoxes consist of?

Dr. Beckman:                     Sorry. Okay, so it’s like a bowel, kidney, liver detox with herbs and just raw foods. It was five days, but I would say–

Dr. Weitz:                           For five days you eat raw foods and you take a series of supplements in pill or tincture form?

Dr. Beckman:                     Yeah, tinctures, pills and tea. And I did this for years. Well, I wouldn’t say I loved it, but I love detoxing. And so I really thought that I was just cleaning everything out. It was great. And then I even did these things for preconception planning. I’m a huge fan of preconception planning, checking for heavy metals, things like that. And I had my daughter almost eight years ago now, but I thought I did all this to clean myself out. I recently did some testing with Great Plains Lab. I love their organic acid tests, their environmental toxin tests. And it turns out on my environmental toxin test, it was one of the most toxic they’d ever seen. No, it was terrible.  And, and I mean, granted, I live in LA, so there’s that factor, which is very big. But I literally have … I don’t use plastic ever. I don’t use any … ever buy bottled water, only grass fed meat. I’m one of the cleanest people that you would come across. Like I said, I even created my own skincare company because I was concerned that a lot of the things were stored in plastic when they had essential oils and-

Dr. Weitz:                           What kind of toxin showed up and where do you think you got these from?

Dr. Beckman:                     Well, basically almost, I think it was 15 out of the ones that they tested were all 75 to 95%. That means that I was in the highest group possible.

Dr. Weitz:                           Right, what kinds of toxins were these?

Dr. Beckman:                     They were still the ones from the plastics, so the Bisphenol A, the ones that have … they are all with the gasoline, very high. And that makes sense because I live in LA.

Dr. Weitz:                           Okay. Like MTBE and-

Dr. Beckman:                     Yeah. The MTBE was very high, the perclorates, high. That again is from the air generally and the rocket fuel, believe.

Dr. Weitz:                           Which was dumped into the water and-

Dr. Beckman:                     Yeah. And that’s the thing, but I-

Dr. Weitz:                           Still found in Colorado River where we get some of our water in Southern California.

Dr. Beckman:                     Yeah. And again, those things aren’t filtered out with filtered water. I mean, not everything can be. I mean, again, it depends on your system that you have, but a lot of the organophosphates from pesticides, things like that. And that’s the thing that was shocking to me-

Dr. Weitz:                            That might be a good marketing strategy. Get your rocket fuel water.

Dr. Beckman:                     I know. And it seeped into the groundwater. I mean, it’s terrible. And you know, you do everything you can, right? I mean, I buy organic products, but then I still eat out at restaurants. And I tell this to patients too. I mean, the meat is not grass fed out. And generally the fruits and vegetables aren’t organic, unless you’re really going for that. That’s the thing is that I know a lot of it is because I live in Los Angeles, but the main factor which came back to my genetics is that I don’t process or make glutathione like much at all.  I had never taken any precursors for glutathione. I’d never taken glutathione. I was doing these traditional detoxes that were still very strong, but they didn’t actually work for my system. I had also gone to the process where I was doing IV glutathione and it made me so sick within about five seconds. I realized that something was … that pushed toxins into my system and they were recirculating and then I felt sick instantly.

Dr. Weitz:                            That’s one of the things that can happen when you do a detox is a lot of these toxins may be stored somewhere in your body. And if you use a strategy that helps remove some of these toxins, they may not get all the way removed. They may come out of storage into circulation and then that can create a lot of detox reactions like you’re describing.

Dr. Beckman:                     Right. And so now the products I use are very different and they go into soak those up so that you basically … my whole goal is to really minimize any detox reactions that people have. And I think a lot of the things that we used before, if your body and detox pathways weren’t prime to deal with that, that’s where everyone’s getting really sick and nauseous and headaches and those are just minimal side effects. It’s really important to do a detox properly and prime the pathways, and have the binders in there that will soak it up properly.

Dr. Weitz:                           Okay. So you’re saying your detox now that you’re doing involves binders and what are some of the substances involved in binders?

Dr. Beckman:                     I use some products that have fulvic and humic acids. I like them a lot. The way that they have been described to me is that they are much more effective and powerful at soaking up things beyond an activated charcoal because the activated charcoal does not have enough energy left in it to actually go in and soak a lot of that.

Dr. Weitz:                           Activated charcoal is one of the most common substances being sold as part of a binding product or separately. And in fact charcoal is right now being used in many consumer products. You can find-

Dr. Beckman:                     It is. Charcoal lemonade.

Dr. Weitz:                           Exactly.

Dr. Beckman:                     And charcoal toothpaste is everywhere.

Dr. Weitz:                           Yeah.

Dr. Beckman:                     I have changed what I’ve done-

Dr. Weitz:                           Those two, what other substances do you find effective for as binding agents? What about modified citrus pectin?

Dr. Beckman:                     Yeah, I like that. And it’s-

Dr. Weitz:                           Cilantro.

Dr. Beckman:                     Yes. And it just depends the … everyone is a little bit different, so some people can handle one type and other people can’t. Some people are so sensitive and so bound up that they basically really need something super gentle. And sometimes I start people off with the homeopathic detox so I can go drop by drop because there are patients that are that sensitive. There’s a wide spectrum, but I think that it’s really important to prep the body before dumping it, like getting all these toxins just dumping into your system without anywhere to go.

Dr. Weitz:                           How long should a detox program take?

Dr. Beckman:                     I would say always customize the patient kind of, so that’s why I like the testing because we want to see if there’s mold exposure, what the viral load is, possibly what the bacteria situation is, what’s going on with the gut, fungal issues, metals, parasites. So it all depends.

Dr. Weitz:                           How do you determine what testing to do and what testing is … Do you have a standard screen or does it depend on history?

Dr. Beckman:                     Yeah, it depends on history. I pretty much always run the organic acids test with Great Plains. I love the mycotoxin test if they have anything positive on the oat. I love the environmental toxin test to see what’s happening there. Some sort of heavy metal testing, I use the Mercury Tri-Test a lot from Quicksilver.

Dr. Weitz:                           Okay, so that utilizes a combination of serum, urine and hair mercury testing?

Dr. Beckman:                     Yes. And then still if they need to check for other metals, can do a metals test. Let’s see what else I love. I mean, I add in the genetics so that we can put that piece in there. And then sometimes like a GI-MAP for stool or to see what’s going on in the gut or as a Zoomer test, Gut Zoomer test.

Dr. Weitz:                            Okay. Just out of curiosity, what’s the approximate cost of that genetic test you’re talking about?

Dr. Beckman:                     The genetic test varies based on kind of how many areas you want to look at. People can get, let’s see like-

Dr. Weitz:                           Just ballpark.

Dr. Beckman:                     All right. Like $1,000.

Dr. Weitz:                           Okay. Now they can get a 23andMe or Ancestry for $100.

Dr. Beckman:                     Yes.

Dr. Weitz:                           Is it that much better?

Dr. Beckman:                     Well, I just think that 23andMe is sort of fluff. It’s not actual information that you can utilize much for your health. That’s what I’m thinking, but it has … it’s like, do you turn red when you’re drinking? Do you have-

Dr. Weitz:                           No, but even if you get the raw data, there’s not enough genes there?

Dr. Beckman:                     No. They’ve changed it a bit and there are less, but there … I mean, yes, the raw data on itself is good, but you are giving up your privacy, which I 100% think is not a good idea.

Dr. Weitz:                           I agree. But I doubt there’s any privacy in our society since they’re monitoring every phone call, every email.

Dr. Beckman:                     I know. If someone really needed to, they could link up everything that you … if they were really trying to find that out for you.

Dr. Weitz:                           Your phone is monitoring every place you’re going. Your phone right now knows that you’re talking to me, where you are. I mean, yeah.

Dr. Beckman:                     I know. It’s so scary. You could talk about something your phone’s off and then that’s all your Instagram feed, Facebook feed, you know everything. It’s true there really is no privacy.

Dr. Weitz:                           Absolutely. I got in my car this morning and my phone says it’s 13 minutes to Gold’s gym. How do you know I’m going to Gold’s gym, right?

Dr. Beckman:                     I know. It’s pretty scary.

Dr. Weitz:                          How does the detox program … you were talking about epigenetics changing your detox, so give me a little more meat on the bones there about how you change the detox according to epigenetics.

Dr. Beckman:                     Basically what I do is, I mean I have a program that I use with a lot of people, but what gets tailored is what we focus on first based on what shows up in their labs and then with their genes. If there’s somebody that can process toxins better, then they might not need as much time in the prep phase. Or if there’s somebody who tends to be more sensitive to metals, then we might need to work on that a lot longer.

Dr. Weitz:                           What’s the prep phase?

Dr. Beckman:                     Sorry, so that’s where we … Certain people need certain foundations, so that would be where I would put in certain vitamin deficiencies that they might have or just optimizing some of their nutrient levels so that they’re prepared to start a detox. And then again, and this part is a bit traditional. We still want to make sure that the bowel is functioning really well. If someone’s constipated, you have to get that under control before you start anything.

Dr. Weitz:                           Number one, you want to make sure somebody is not deficient in nutrients. How do you determine that? You do some sort of nutrient panel?

Dr. Beckman:                     Yes, I can do a nutrient panel. The organic acid test does have part of that in there utilized as well. There are special tests you can do in addition to just see. The SpectraCell has a micronutrient deficiency panel, which can be good if people like that. I use the organic acid one quite a bit.

Dr. Weitz:                           Okay, so you’ll beef them up with some nutrients first to get them ready for the detox?

Dr. Beckman:                     Yes. Then we look at their bowel and make sure that, like I said, they’re not constipated. Make sure they’re going to the bathroom twice a day as ideal.

Dr. Weitz:                           Because if they’re constipated, they’re going to be recirculating the toxins, correct?

Dr. Beckman:                     Yeah. And that happens a lot with estrogens and different toxins and things like that. And then we make sure we look at the lymph, the kidneys, and the liver. I have special supplements for that as well.

Dr. Weitz:                           How do you look at those?

Dr. Beckman:                     Sorry, not look. I just mean address-

Dr. Weitz:                           Okay, so you give them supplements to make sure those are working properly?

Dr. Beckman:                     Yes. Yeah. And then we figure out what-

Dr. Weitz:                           What do you give him to make sure the kidneys are functioning properly?

Dr. Beckman:                     Let’s see. There’s some different herbs that, sorry … There are some herbs that I use. I like some homeopathic tinctures too. You mean which specific herbs?

Dr. Weitz:                           I was just curious. You have some kidney formula you like to use in some-

Dr. Beckman:                     I use CellCore products a lot. I really like them. They have a great kidney-liver formula. And then, I mean, I’ve used other ones in the past too. I also use some products from Designs for Health. They have some great detox packets that are super simple and altogether. And then they have some that are spread out, individual products.

Dr. Weitz:                            Okay. Yeah, go ahead. So you support lymphatic’s, the kidneys, the liver?

Dr. Beckman:                     Yep. Then we need to make sure too what’s going on with the gut. We need to see if there’s any intestinal permeability to make sure that we’re working on the lining. I check, if there’s someone who has a lot of autoimmune or food sensitivities, we need to make sure that’s a big factor. See if they need to eliminate some foods just temporarily, if it’s making things worse. Often I see a lot of issues with gluten, dairy and sugar. Nobody really likes to hear that, but initially I just ask if they can try to go off things for maybe 30 days minimum to just see if we can get some information down as well from what they’re putting in their body.

Dr. Weitz:                            What’s a specific food regimen you put them on? You eliminate gluten, dairy, and what else did you say?

Dr. Beckman:                     Refined sugar. And then-

Dr. Weitz:                            And refined sugar. Are there other things or just those three?

Dr. Beckman:                     It all depends on the person. If there’s somebody who already has a lot of issues, we need to see what would be specific for them. Some people think they’re totally healthy and they don’t feel anything from food, so they … it’s a big deal for them to just get off of sugar. I work with the client to see where they are too. But if someone who-

Dr. Weitz:                           Get them off of caffeine and alcohol as well while they’re doing the detox?

Dr. Beckman:                     Yes. The caffeine is less of an issue for me. If someone can get off all those other things and they still want one cup of coffee a day, usually I say that’s okay. But-

Dr. Weitz:                           Especially if it’s organic.

Dr. Beckman:                     Yeah. And I then love Purity and Bulletproof Coffee. I at least send them to ones that are mycotoxin free and tested. And just, yeah, it’s all about, to me, making healthier choices and swaps too. If I can get people to just make some better choices in their life, get off the granola and yogurt, they start their day with that has 25 grams of sugar, get them onto something that’s healthier. I think those are all big wins and can take them a long distance.

Dr. Weitz:                           Yeah. Or their Count Chocula cereal.

Dr. Beckman:                     Oh yeah. Or even cheerios. There’s better things to do. There’s all these … We have to pick our battles, right? And food is a really one that people like grip on and hold tight to or they have, again their favorite cup of coffee with sugar and cream. And so if I can get them to switch to a healthier version of that, then I feel like I’ve had a good win. And that they will benefit greatly. Because again, I say to people, we often have to look at our daily habits cause it’s in our daily habits where we see some of these really big things that make a big difference, so we can change those. It’s very important.  And even hydration. Many people still just don’t drink enough water. And these are core foundations that if you don’t have sleep, hydration, good food and exercise and some form of meditation, it’s hard to build a base from that.

Dr. Weitz:                           How do you know if somebody is drinking enough water and how much water is enough?

Dr. Beckman:                     I look at their caffeine intake for sure. A lot of people are drinking way more caffeine than water, so that’s my first area to start with. I still do go by the half your weight and ounces. I know some people say that works, some people say it doesn’t. I think it’s a good barometer just to start with. Most people though are drinking so little water that I tell them to just double what they’re doing. And honestly for a lot of people they’re drinking two glasses of water a day. Then I say, drink four and that seems like a stretch for them, but it’s not a huge stretch. If I tell someone that’s drinking two glasses to then go to half a gallon, that doesn’t make any sense to me, and they don’t do it. Sometimes it’s baby steps and-

Dr. Weitz:                           Try to meet them where they are and get them to make changes that are reasonable.

Dr. Beckman:                     Exactly. Again, those are some of those things that are in the beginning part of a detox and the prep phase, is really just getting their foundation solid and then getting them prep so that we can then start addressing the things that are more pertinent and causing more damage, I guess I would say. Like the gut bacteria, the fungus, any sort of mycotoxins, viruses, bacteria … sorry, parasites and then metals we do last usually.

Dr. Weitz:                           Okay, so then-

Dr. Beckman:                     It can be awhile.

Dr. Weitz:                           Right, so multi-phases of this program?

Dr. Beckman:                     Yeah. And it’s based on the lab testing to see what’s there. We want to a lot … for people in general, we have things where basically a big host for a lot of different organisms. And so to think that they’re not all living in us I think is sort of inaccurate. It’s basically something’s high. You know, we have viruses that just lie dormant and then they get activated. Basically if we can create our system to be a good environment, then it’s kind of the best shot we have. And then [crosstalk 00:43:16] up things that are creating damage.

Dr. Weitz:                           Let’s do a couple of sample detox programs. Let’s say the person tests high in mercury. What’s your preferred protocol for that?

Dr. Beckman:                     I do use a lot of Quicksilver products and CellCore products. They have really great binders for pulling out heavy metals. CellCore has something called HM-ET, which I really love. But again, this is the thing. This is all done after months of preparation. You don’t just go in and start trying to pull out heavy metals, which is what everyone wants to do. And that’s where people feel really sick. And another thing is heavy metals can reside inside parasites. If you don’t kill the parasites first, then you could be pulling out all these heavy metals and then you haven’t even addressed the parasites and then you could be releasing more metals that you thought you’d cleaned up.

Dr. Weitz:                            Get rid of parasites and clean up the gut, get rid of nutritional deficiencies, show the body up that way, support the basic organs and then go for the metals and the other toxins?

Dr. Beckman:                     Yes. Yeah.

Dr. Weitz:                            Do you incorporate glutathione in that detox protocol for mercury?

Dr. Beckman:                     I do. I do use glutathione even earlier in the phase to just start helping support the liver, helping it support what already is there before we’ve really started to detox. Sometimes using a precursor like NAC, just it depends on how the person is and what they can handle. A lot of clients have had so many bad issues with taking really strong chlorella, things like that. I just have to be careful with … I tend to get a lot of patients who are really sick and really toxic, so it’s just seeing what works for them and creating something that has the minimal side effects.

Dr. Weitz:                            How long does it typically take to get rid of mercury?

Dr. Beckman:                     Kind of depends on the levels and it can take a year, but that’s the whole thing. You know what I mean? That’s at the end. I wouldn’t just target mercury and it would be so rare that nothing would come up before then. I mean, that actually wouldn’t happen. Like, you know what I mean? No one would just have a mercury issue. I’ll just say.

Dr. Weitz:                            Okay, so what’s your protocol for mycotoxins, which is for mold?

Dr. Beckman:                     Right. Again, I do use CellCore products for that. And so I love the mycotoxin test, because then you can see exactly which ones are the strongest. And again, you still have to really prep the body first, of course, which we talked about. And then in Chinese medicine too, like we want to see what’s happening with the lungs. We want to support. Sometimes I use some other herbs that are kind of like a lung support. Yeah, I know the mold … that’s the thing about mold is it can go everywhere and anywhere, so that’s why it’s extra detrimental. But a lot of people, a big part is from inhalation. I work on a bit with stored grief and sadness with the lungs and we want to make sure just to always addressed the emotional issue of things.  And detox is stir up a lot, because they deal with lungs, they deal with liver, which is related to anger and resentment and depression. A lot of people have some issues with that. We just want to make sure that we’re addressing the emotional side of things as well as the physical.

Dr. Weitz:                            Okay. How do you address the emotional side of things?

Dr. Beckman:                     Well, I love acupuncture and if someone’s not local or not getting acupuncture on the side, there’s visualizations with color that support each organ. And as with Chinese medicine and this people know, the emotional side and the physical side, they’re intertwined. When we’re treating a physical condition, we want to also address the emotional aspect of that. One of my favorite things again is acupuncture, meditation, and then some visualization.

Dr. Weitz:                            Okay. I think that’s pretty good. Everything is-

Dr. Beckman:                     Yeah, we covered a lot.

Dr. Weitz:                            Yeah. I think we covered a lot. Any other specific things you’d like to make the listeners aware of or talk about?

Dr. Beckman:                     No. My main thing is that, and this is what I talk about with my clients every day, is you have a choice every day. You choose what food you put in your body, you’re choosing what products you put on your body, you’re choosing some of the thoughts you have, the way you live or lifestyle. And it’s so crucial for us to be mindful of what we’re doing that everything that we’re doing is either feeding our body or doing something that’s going to make it harder and possibly leading to disease down the future.

We have so much control and I think we forget that. And I see our body as a machine and what we’re doing and putting into it as fuel, and we want to be putting the best quality fuel in it. And you know, we have these beautiful bodies and so we just need to take care of them and you get to do that.

Dr. Weitz:                           All right. How can listeners and viewers get a hold of you and find out … how can they contact you?

Dr. Beckman:                     Sure, my website’s, drashley.com, and that’s D-R-A-S-H-L-E-Y.com. And I always offer a complimentary call if someone wants to just see if we’re a good fit to work together.

Dr. Weitz:                           And so you can work with them by phone?

Dr. Beckman:                     Yes.

Dr. Weitz:                           And if they’re in the Los Angeles area, where’s your practice?

Dr. Beckman:                     I’m in Beverly Hills and in Malibu.

Dr. Weitz:                           Okay, great. Thank you Dr. Beckman.

Dr. Beckman:                     Sure. It’s always fun.

Dr. Weitz:                           Thank you.




Integrative Pediatrics with Dr. Joel Warsh: Rational Wellness Podcast 140

Dr. Joel Warsh discusses Integrative Pediatrics 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

2:26  Dr. Warsh sees Integrative Pediatrics as blending the best of Western medicine with holistic and Functional Medicine.  Dr. Warsh got frustrated with the regular system and was frustrated that the only treatment in most conditions is pharmaceutical medications.  He has found that there are many situations where you don’t need a medication and some dietary changes or a nutritional supplement might be better. If the child is sick with a virus, then an antibiotic isn’t going to help and might make them worse, and this is a great time to use a natural approach. On the other hand, if there is something serious going on, your child may need an x-ray or an antibiotic or may need to go to the hospital.

6:07  A cough is a common symptom of a cold or a flu.  The best way to prevent colds and flus is to focus on what Dr. Warsh calls the SEEDS of health: Sleep, Exercise, Environment, Diet, and Stress.  These are the foundations of health.  When your child first gets a tickle in their throat or a low grade fever before they get really sick, that’s a good time to use vitamin D, vitamin C, elderberry, or some essential oils or colloidal silver to help their body fight it off.   

10:27  Dr. Warsh generally finds most herbs to be safe for children and certainly much safer than many pharmaceutical medications.

12:51  Homeopathy is extremely safe for children, as it is for adults, and can be very effective at times.

17:15  Fever has benefits and helps the body to fight off illness and there is not much risk of harming the child until it gets to 104-105 degrees.  Taking Tylenol or ibuprofen should only be done if the child is extremely uncomfortable or has severe ear pain, but not to lower the fever unless it is 104 or higher. Taking these medications will actually increase the length of your infection. It’s also a good idea to double check the temperature by getting a second thermometer, since some of these thermometers can be inaccurate.  If the fever continues for a month or longer, then you should go the hospital for a full workup.

21:23  Diet is important and Dr. Warsh is a moderate on diet and tends to avoid extremes. He feels the focus should be on eating healthy, whether that includes meat or not. You should eat the rainbow of different colored vegetables and remove the sugar, preservatives, food coloring, and crap out of your diet. If you eat meat, it should be grass fed and sustainably produced.  Fish should be wild and not farmed. You should eat as clean as possible.

23:45  Toxins can play a significant role in the health of our children. We live in Los Angeles and we are surrounded by toxins in the air, food, and water.  Toxins lead to inflammation and it’s one of the reasons children are getting more and more sick.  It is playing a role in the rate of chronic diseases, such as asthma, ADHD, autism, rheumatoid diseases, lupus, and eczema, which are epidemic now. According the CDC, 10% of kids have mental health problems, 7% have anxiety, and 3% have depression and toxins are playing a role in these conditions.  You should have an air filtration system in your house. You should get a reverse osmosis filtration system for your water and you should avoid tap water. Avoid using chemicals to clean your homes and use baking soda, vinegar, and essential oils.  It’s good for kids to get exposed to germs and to play in the dirt, since it stimulates our immune system and our microbiome. Kids that play in the mud and live on farms and in rural areas have lower rates of allergies than kids that live in the city.

29:40  We used to have kids avoid peanuts and common allergens when they were young, but the rates of allergies skyrocketed and now it is recommended that we purposely expose kids to peanuts and other common allergens at six months, since this leads to a lower rate of allergies. The thought process has completely changed. On the other hand, with a little older child who has a lot of allergies or asthma or eczema, the first thing to do is to have them clean up their diet and remove gluten and dairy.

32:17  While serum food sensitivity testing can be helpful, it can be difficult to get kids to have blood drawn and it can be a big expense, so tries to work with the diet first and see if using an elimination diet can resolve symptoms.  But in some cases, food sensitivity testing is warranted and can be helpful.

33:51 Dr. Warsh finds that for eczema, calendula, coconut oil, shea butter, and castor oil are all good to use on the skin, and fish oil can be helpful. Vitamin D and E are beneficial and eating some turmeric, such as in a smoothie, and quercetin and bromelain can also helpful. 



Dr. Joel “Gator” Warsh is the Medical Director of Integrative Pediatrics and Medicine Center in Studio City in Los Angeles, California. Dr. Warsh is certified by the American Academy of Integrative Medicine. He has published research in peer-reviewed journals on topics including childhood injuries, obesity, and physical activity. He has been featured in documentaries, podcasts, and articles, including Broken Brain 2, Dr. Nandi Show, CBS News, LA Parent, Dr. Taz Show, and many others. You can learn more information about Dr. Warsh by going to IntegrativePediatricsandMedicine.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.


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, please go to Apple podcasts or whatever podcast app you use and please give us a ratings and review. Also, if you’d like to see a video version, go to my YouTube page. If you go to my website, drweitz.com you can find detailed show notes and a complete transcript.

Today our topic is integrative pediatrics, which means incorporating holistic and functional medicine along with conventional medical care when providing health care for children. This means using nutrition, nutritional supplements, and various natural healing methods and avoiding prescription meds except when absolutely necessary. There is also a focus on promoting health and preventing illness rather than just treating sickness.

Our special guest is Dr. Joel Warsh. He’s an integrative medical practitioner who’s certified by the American Academy of integrative medicine. Dr. Warsh started the Integrative Pediatrics and Medicine Center in 2018 in Studio City in LA County of California. Dr. Warsh has published research and numerous peer review journals on topics including childhood injuries, obesity and physical activity. He’s been featured in various documentaries, podcasts, and articles including Broken Brain 2, Dr. Nandy show, CBS news, LA parent, Dr. Taz show and many others. He has an upcoming pediatric summit and also a online course, so watch out for those. Dr Warsh, thank you so much for joining me today.

Dr. Warsh:           Thanks so much for having me. I’m looking forward to it.

Dr. Weitz:            Great. What is integrative pediatrics and is it commonly accepted by mainstream medicine?

Dr. Warsh:           It’s a great place to start. The first thing is I don’t think there is a specific definition of integrative pediatrics. I think everybody defines it a little bit differently. But to me it’s blending the best of Western medicine with holistic or alternative medicine. It’s not that you’re picking one or the other, it’s doing whatever you think is best on that day.  What got me into integrative medicine in the first place was just being a bit frustrated with the regular system and really only having pharmaceutical medications to treat everything. My wife is very holistic minded and I had seen some of her friends go to natural paths after being adopters for many years and they would get better. I was like, “There’s got to be something else. What else is there to learn?” That’s what really spurred me to start learning about functional medicine and homeopathy and supplements and then blending those two together.

Because what I found is that a lot of times you don’t need a medication. Parents definitely want to do something when their kid is sick. But a lot of times if it’s a virus then really an antibiotic or another medication isn’t the answer and isn’t going to do anything, it might even make them worse. It’s a really good time to see if there’s something natural that you could do.  But also you want to have that Western side as well because maybe something natural isn’t the right thing to do in a situation where there’s something serious going on, you need to go to the hospital, you need an x-ray, you need an antibiotic. That’s where blending those two together are important.

Then for your second question, it’s not very accepted in regular Western medicine yet. I think it’s moving in that direction. There’s definitely more focus and discussion around prevention and some of the natural modalities are starting to be accepted. Acupuncture is probably the best example of that where it used to be woowoo and crazy and now you see it everywhere with the opioid epidemic and you see it in hospitals. Slowly some things are moving into Western medicine, but it’s not fully accepted by a lot of practitioners yet.

Dr. Weitz:            I think one of the issues is that if you’re going to use preventative, nutritional, integrative medical approaches, it takes more time. The current medical model based on insurance companies controlling things makes it very difficult.

Dr. Warsh:           That’s correct. Number one, with the system as it is today, it’s really hard to spend 45 minutes or half an hour or an hour with a patient, which sometimes is really what you need to go through and get an extensive history. It’s oftentimes a lot easier with a cough or a cold to say, well, just take this antibiotic and then you cover yourself and get them out the door. That certainly is a part of it.

But the other part is there’s a lot of training involved and even learning about natural medicine. You really need to have a lot of communication with your patients when you’re using something natural because things can progress pretty quickly. If you have, let’s say a cough for example it’s a really good example. You have a cough, patient comes in and they’re totally fine, then that might be a great time to do something natural, but you have to be in really good communication because that could change really quickly. They could get pretty sick and then the natural remedy isn’t the right tool that time. Might need an antibiotic.  That Western model where you might have four or five, 10,000 patients in your practice or however many you have, it doesn’t necessarily work as well for natural medicine because you really need to have that good communication to know when you have to step up the treatment to something that’s more Western.

Dr. Weitz:            You brought up a cough and that’s a common symptom of flu. Right now we’re in the midst of cold and flu season. What can be done from your perspective in preventing and treating children with colds and flus, besides giving antibiotics, which probably shouldn’t be indicated at all, since these are caused by viruses?

Dr. Warsh:           That’s correct. For me, what I always focus on with patients is the prevention. We always talk about the foundations of health. A term that I coined was the seeds of health. Sleep, exercise, environment, diet and stress. These are the big factors that we really need to think about because nowadays we have almost forgotten about these basics. Whether you look at Functional Medicine or Ayrevedic or all of the other modalities, this is the foundation of all of those but in Western medicine we’ve forgotten a lot about it.  Certainly if you go to the doctor, they might talk to you for 30 seconds about physical activity or making sure you can exercise. But that’s not really what we mean when we talk about the foundations. It’s really setting up a good lifestyle. You might need a 30 minute or hour discussion with a nutritionist or a health coach just about a child’s diet really making those major changes overall.

That’s really where to me it starts and it starts with those checkups or the well visits where you discuss a little bit more about these foundations. Because if you have a good foundation then you’re not as likely to get sick. We know this, this is not woo woo, this is not alternative medicine. This is Western medicine. There’s plenty of studies where they took viruses and they put them into nodes of patients. Some that were stressed, some of them were not stressed, some that were sleep deprived, some of them were not sleep deprived.  Anytime these foundations are not there, you’re much more likely to get sick. That comes into play with something like the flu. We know this because what happens when you have a test and you’re studying? You’re going through, you’re really stressed. Five minutes after you’re done studying and your body calms down after the stress, you get sick. It’s common knowledge.  We just need to remember this common knowledge is things that we used to talk about and get back to the foundations just like diet. Because we’re literally built of what we eat. If we don’t eat healthy and we don’t have the nutrition then our body doesn’t have those building blocks for our immune system to fight off the infection. That to me is the key overall, is really thinking about the seeds of health and the foundations and setting yourself up for success.

Then when you first get sick, before you really know what’s going on, you start feeling that little bit of tickle in your throat or a little bit of a low grade fever, that’s a great time to try to really do some great view and support. It depends what the situation is, but things like vitamin D, vitamin C, elderberry, essential oils, all sorts of things can be helpful that first three, four hours. If you get some of that stuff in your system, then hopefully your body’s able to fight it off a little bit better before you get really sick.

Dr. Weitz:            Do you have a favorite formula? Should we just hit the vitamin C? Should we hit the vitamin C, vitamin D and the elderberry?

Dr. Warsh:           It’s hard because with kids especially, it’s always been… Anybody it’s going to be different and unique to each patient. With kids, every age group is very different. It really would depend on how old the patient is because obviously a newborn or a two month old would be very different than a 15 year old. You’re very limited with the babies and that’s why I think this advice is very cautionary in terms of you really need to speak to your practitioner before doing any of this stuff, especially with a baby. Because it’s a completely different scenario with one month old who is sick than a 15 year old who says, yes I have a little tickle in my throat.  But in general for the older kids, I think a good multivitamin is going to be helpful. Vitamin D will be helpful. Vitamin C, elderberry. Some people like colloidal silver. It depends on what the scenario… But we’re talking about flu and those are some things you can think about.

Dr. Weitz:            Okay. Do you recommend a high dose vitamin C for that type of situation?

Dr. Warsh:           Usually. I mean it depends and there’s so many different formulations out there, but I’ve used Metagenics before with patients that I have in my office. It will depend on the age, but I don’t usually… Each patient is different so it’s hard to say what the dose would be. But yes, a good dose of vitamin C at least once or twice is going to be helpful.

Dr. Weitz:            Are herbs safe and effective for children?

Dr. Warsh:           I think so. I think to me this is one of the biggest misnomers out there. I think it’s a little bit funny when having discussions with my Western practitioners about this, because these are things that have been used for thousands of years and we call it alternative, but really Western medicine is what’s alternative. That’s the thing that’s been around only 50 years or a hundred years or however long you want to go back.  Sometimes you hear things like, “Oh, you’re going to get… You’re going to try peppermint oil with a child. That’s so dangerous. How could you do that?” That makes me laugh because comparing it to the Western treatment which… Look, everything has risks, right?

Everything has risks, everything has side effects. Everything could possibly have an allergic reaction. When you have a 10 year old who has a little bit of sniffles and you’re trying a little peppermint essential oil, that versus using over the counter cough syrup, the medication has a list of known side effects this long. We don’t even look at it and it’s like, it could cause death, could cause allergic reaction, all these hundred things.  These are known risks versus maybe one child at some point somewhere had a reaction to some not so good herb that was made improperly or had some contaminant. Which one is at more risk? To me it’s crazy and again there’s certain situations where certain herbs and natural things are not safe for sure. Of course that’s true. That’s where we need good science and we need good research and we need good practitioners to know what are the right things to use when.

But in general, for a child who’s not severely ill, a natural item, a natural herb, a natural supplement is almost always going to be way safer than the medication. There’s so many risks to every medication. For whatever reason we’ve forgotten that because you see on the news that anything bad happens with the essential oil or homeopathic, but realistically, if we use our brains for one second, we know that that’s not true. But that’s why the practitioner’s important. You can’t just use the herb because it might be serious. You have to go see a Western doctor, make sure there’s no pneumonia going on, then that’s a good time to try the natural thing.

Dr. Weitz:            What about homeopathics? Do you like those for children?

Dr. Warsh:           That’s a… It’s an interesting topic and I think homeopathy of all the modalities is probably the most controversial, I would say. Just because it’s not used that commonly in Western society. It’s very commonly used in Europe and in other countries. But it’s not that commonly used here. Philosophy is a little bit counterintuitive to anyone who has a scientific mind.  For those that don’t really know, basically using very small diluted doses, using like to cure like or to work with like and so, if you have something that causes… You have a cough, you give something that might cause a cough or stimulate a cough to try to help the body balance. Some people are extremely into this and think it works amazingly, I don’t think it’s all hooey. I think there’s very minimal risk and if you work with a trained homeopath that knows what they’re doing and it seems to work for you, then there’s no reason not to try it.

It’s far and above the safest modality out there. I think really the big question for most people is, does it really do anything or are you just wasting your money? That’s a question that each person has to decide on their own. But you talk to people who take homeopathics and work with homeopathics and most of them love it. Say it works amazingly, say it works better than most medications.  I think if it’s done correctly with somebody who’s trained in it, then it’s reasonable. Just going to the store and picking up a random homeopathic, is that going to work? Maybe, maybe not. But again, it’s safer and if it helps even a little bit, avoid using a medication, then that’s a good thing.

Dr. Weitz:            I agree that homeopathics are super safe. They’re typically using a product that’s so dilute. All there is is the original energy of the original substance in there. On the other hand, looks like our government is said to be banning homeopathy pretty soon here.

Dr. Warsh:           I mean, there’s always discussion about that. I don’t know… Who knows whether it’s actually going to happen or not.

Dr. Weitz:            Well no. Apparently the FDA now has made a ruling that homeopathics are going to have to be approved as drugs. No homeopathy companies have the money to do that type of study to prove this. Homeopathy has been banned in England. This started in Australia, there’s actually a movement to try to ban homeopathy around the world.

Dr. Warsh:           I mean it’s a tough fight because it’s not the same as Western science and so anything that’s different and that can be proven that way has its issues with-

Dr. Weitz:            No, I think what you’re referring to especially is the fact that when you take a homeopathic formulation and you dilute it another hundred times, it’s considered to be more stronger, more powerful. The more you dilute it, the more powerful it gets supposedly. That’s one of the parts of homeopathy that seems very counter to Western scientific thought.

Dr. Warsh:           It is, it’s very different. But then again, the interesting part to me is things like allergy shots and stuff like that where it’s a fairly similar concept where you’re giving very dilute minute doses of something to help the body and immune system create a tolerance to it. It’s so hard because energy is such a foreign concept and it’s like, oh, this is all crazy we’re talking about energy.  But then again, you talk about the moon and how the moon affects the tides. We’re obviously all made of energy and particles and so there is some definite science there. I just don’t think we’re smart enough to understand everything yet. I think it’s frustrating that we’re not open to these discussions, especially when things are safe. I think we need to spend more time studying these as opposed to just thinking they’re crazy because they’ve been used successfully for so many generations in so many places. Just to ban to me is not the answer, is to study it more thoroughly.

Dr. Weitz:            The reason why it would be getting banned is most likely because it’s competition with medications. Since we’ve been talking about colds and flus, I’d like to bring up the concept of fever. What do you think about the whole concept of fever? Typically parents have a kid with a fever and right away they’re rushing for Acetaminofene or other medications to bring the fever down.

Dr. Warsh:           Sure.

Dr. Weitz:            But fever actually has a lot of benefit. It’s part of the way the body fights off an illness.

Dr. Warsh:           For me, that’s a big part of discussion in my office all the time. It’s probably one of the top three most common messages and texts that I get from parents all the time about fever in their kids. A little bit of is education about it. I think it’s a great topic to bring up because it’s so important to recognize that fever is beneficial. Fever is not the thing that we should be worried about. Fever gives us an indication that our kids are sick or that we’re sick.  A fever in and of itself, unless it’s super high, is not really dangerous. It’s pretty hard to get a fever high enough that it’s dangerous to your brain. Once you’re getting over 105 that’s pretty high. But in general, unless you’re talking about a newborn baby in the first few months, when a child first gets a fever, you don’t necessarily need to do anything about that.

It’s not the fever that the doctor is worried about. It’s the fever and the symptoms. I am much more concerned about a child with a 101 fever who’s lethargic, having trouble breathing than a kid with a 104 that’s running around and playing. If the reason to use Tylenol, Motrin, Acetaminophen and ibuprofen would be because your child is extremely uncomfortable.  If your child has a 102 fever, a little bit of congestion, then the reason your body is raising your temperature is to fight off the infection to make an inhospitable environment for the infection that way it kills it faster. There are plenty of studies out there now that those who take Motrin, Tylenol, it does increase the length of your infection by a little bit as well. Is it really damaging to children? It’s probably not super damaging, but any medication can have side effects.  Certainly over a million kids, one kid takes Tylenol, it’s going to affect that kid pretty severely. But here and there using medication, it’s not going to be a huge issue, but use it when you need it. Just because your kid has a little sniffles in a 101, to me that’s not a good time to use Tylenol. It’s if they’re miserable 104, if severe ear pain, something like that, it’s a good time.

Dr. Weitz:            You’re saying 104 would that be the cutoff for when you think fever might be high enough where it could cause brain damage?

Dr. Warsh:           Based on the research that I have seen and what we learn in residency, it’s above 105 where you start to worry. I mean when you’re getting into 106, 107 that’s when it’s pretty high. But the reality is most of the time when you have a temperature that high, it’s the thermometer that’s off. It’s not actually the temperature that’s that high. If you’re getting a really high temperature, my first advice always parents, get a second thermometer and make sure that that’s correct.  If it is correct and the child is very miserable, lethargic, other symptoms, you get seen right away. There’s no question. If you have above a 103 that getting to a higher fever. You don’t necessarily have to rush to the emergency department unless there’s other symptoms, but if it’s staying above 103, it’s been 103 for a day or two, 103 with symptoms, that’s more indicative of a bacterial infection. Something to get seen for. 100, 101 fever, kids okay. Little cough, a little cold. Usually a virus is going to last three to five days. You can watch that.

If you’re ever worried, always safest to go to see your doctor, go to urgent care. No doctor is going to be upset if you give us a call and say, “Hey, my kid’s got a fever of 101. I’m pretty sure they’re fine, but I just want to get their ear check.” Absolutely reasonable. The only caveat to this whole thing that I’m saying is for a baby. In the first couple of months, two, three months, any baby with a fever, that’s a much bigger deal. That’s something they get seen right away. Especially in the first month to month and a half, you want to be going to the hospital for that because babies get sick much more quickly and they can’t tell you how sick they are.  A little bit of a fever can turn into something very serious very quickly. That’s why standard of care in America is first month, month and a half a fever. You’re going in the hospital getting a full workup.

Dr. Weitz:            You mentioned diet. Right now there seems to be more information about diet than we’ve ever had and yet there seems to be more and more confusion. It seems like the diet debate is as polarized as a political debate. We have the carnivore diet on one side, we have the plant-based folks on the other side and everything in between. So where do you stand on diet?

Dr. Warsh:           For me, I’m in between. I, for the most part when I talk to diet about families is eat whole foods, eat real foods, try to eat as healthy as you can and have a variety. We’re in LA, so there’s lots of people that are vegans and vegetarians and I’m totally fine with that. You can be very healthy and never eat any meat and that’s fine for most people. There are some people that they get fairly sick if they don’t have any meat, they need some other nutrients. That I’ve seen it before.  But in general, for almost every kid, if they want to be vegan or vegetarian, that’s fine as long as they’re making sure to get a very diet for that. But I think the more important thing is not to worry about dieting, it’s to think about eating healthy. Eat your fruits, eat your vegetables, eat the rainbow, all sorts of different colors. Get out the crap out of your diet. Get out the sugar, get out the preservatives, get out the packaged foods, the things with fancy coloring and big logos.

Any of that stuff in the middle of the supermarket is generally not going to be good for you. I’m big on telling my patients to read labels. I think it’s super important for them to learn and for the parents to really turn the box over, look at the back and see what’s in there. If there are words on it that you don’t know, it’s not going to be good for you. Don’t buy that. If it says almonds, peanuts, cashews, coconut oil, it’s generally going to be a lot better for you.  I’m more of a peaceful in between thing where I think a little bit of everything is fine. When you’re going for the meats and fish, if you’re going to go for that, then you just want to think about sustainably produce, grass fed meats, not having farm raised fish, Just as good a quality as you can that you can afford. I don’t know if we’re going to go into talking about toxins next, but I think toxins is a big issue that we’re dealing with. I think trying to eat as clean as you can afford is very useful.

Dr. Weitz:            Sure. Let’s hit the toxin issue. We live in a big city, Los Angeles, and like most big cities, there seems to be tons of toxins in the food, water, air, et cetera.

Dr. Warsh:           Yes. It’s one of the big issues. That to me, the environment piece is where I think about toxins for families. That’s absolutely a core foundation that everybody needs to start thinking about because we are surrounded by toxins and toxins are in everything. Unless you’re planning to move to the mountains or go somewhere way out in the country, this is going to be something that you’re going to have to deal with. The good news is human bodies are amazing and we have great filtration systems. Our liver and our kidneys do a great job for the most part. We can handle a fair amount of toxins, but at some point it overflows.

At some point there’s too much inflammation. That to me is one of the big reasons why we’re seeing children getting more and more sick. There have been statistics that I’ve read up, almost 50%, adults certainly around 50% chronic disease and kids somewhere between 25 and 50%. That number has skyrocketed in the last 50 to a hundred years. Used to be three to 5%. The only thing that’s changed is our environment. Genetics can’t change that fast. I mean maybe they’re small little things, but in general it’s our environment. What has changed? It’s the chemicals that we’re surrounded by all day and all the things that you mentioned.

Dr. Weitz:            When you say chronic diseases, what diseases are you referring to?

Dr. Warsh:           Everything. Asthma, ADHD, autism, rheumatoid diseases, lupus and eczema, everything. We’re seeing more and more kids with something. I mean every other kid seems to have an allergy. Every other kid seems to have asthma. Every other kids seems to have something. I mean there’s also all the mental health diseases as well go into that category as well. I think the CDC statistics are 10% of kids have mental health disease, 3% have depression, 7% have anxiety. It’s staggering numbers of children have something, that has to have some part to do with toxins.

Let’s go through a couple of big ones and talk about some tips and solutions because I think this is a big one. To me, environment with diet are the two big pieces that we have a big ability… We have a huge ability to change those things around us. Not everything, but there are certainly small changes that you can make at home for free today that can make a big difference in your kids’ lives.

Number one, the air that we breathe. Our air. We’re certainly surrounded by in LA, lots of chemicals and toxins. You have some control over your house so you can get an air filtration system. You can put a bunch of air cleaning plants in there, aloe plants, snake plants, things like that. It does make a big difference overall. We’re breathing all day, lots of breaths every day. If you are decreasing the toxins even a little bit, that’s going to make a big difference.

 Second, you have the water in your house. You can get a filtration, reverse osmosis or some sort of filtration system. The water that we get in LA is not the best. If you’re going to drink any tap water, which probably isn’t super recommended, but if you’re going to then filtration system is going to help at least to some degree, in filtering out some of those chemicals and toxins around your home.

Go through your closets and think about all the things that you use as cleaners. Look at the labels. We’ve been so trained to think about we need to kill 99.9% of bacteria. We need to kill everything and we’re surrounded and we’re made of germs. You probably don’t want to stick your hand in the mud and eat it, but we don’t need to use all these harsh cleaners all the time. You know how grandma’s always used to use baking soda, vinegar, essential oils. That does a great job for the most part, maybe not for some crazy stain, but for your daily cleaners get rid of all that expensive stuff and just go back to the basics.

You don’t have to kill every single thing. There’s a lot of research now in the allergy world where kids that live Brooklyn farms that live in the mud have much lower rates of allergies than kids in the city. The theory is that we’re too sterile, we’re not being exposed to the germs and then that leads us to having more and more allergies. It’s just an interesting theory to think about because we think about sterilization as being best, but it’s not necessarily.

Dr. Weitz:            Absolutely, hand sanitizer. What you’re saying is it’s really beneficial for us to get exposed to germs and microbes. It helps prime our immune system and it stimulates our microbiome, which is so important for overall health.

Dr. Warsh:           Think about babies. What do they do in the first couple of months? They put everything in their mouth. That has to be biologically relevant. Otherwise, if we were dying and babies are all dying from touching all these bacteria, then we wouldn’t have this reflex to take every single thing and put in our mouth and put our hands in her mouth. It’s very logical that that’s one of those things that’s been selected for, but you’re touching your environment around you. You’re getting exposed to some of those bacteria, then your body’s getting used to it.  Again, you don’t want to go beside someone with the flu and wipe your hands all over their cough and then put that in your mouth. That’s not very smart, but in general, we’re talking about just your general daily life. We don’t have to be sterile everywhere. This isn’t… We’re not living in a hospital.

Dr. Weitz:            In fact, just the opposite. We’re now seeing this huge increase in autoimmune diseases and a hygiene hypothesis seems to be one major reason why, which is the fact that we’re not playing in dirt and getting exposed to germs and bacteria as much as we used to.

Dr. Warsh:           Right. For just general allergies, when we were growing up, it was don’t eat the allergenic foods. Wait until you’re older. Don’t give them peanuts until they’re one or two. And then allergies skyrocketed. All the new research came out that said, expose your kids to it early. Give them peanuts at six months. Try this because the earlier you do it, the lower your allergies are. Even in the regular Western science, the thought process has been completely changed to exposing things earlier. I think to me there hasn’t been as much research on the other topics. I think you can infer that would apply to everything else as well.

Dr. Weitz:            What is some of your favorite natural treatments for kids with allergies and asthma and eczema?

Dr. Warsh:           For allergies, eczema, anything really with autoimmune disease, I think number one, again, so going back to the foundations, absolutely important. Number two is talking about diet. Thinking about the allergenic foods. We know that the number one and two things always are gluten and dairy. If you’re going to pick one thing to think about, if your kids eat a lot of wheat or dairies, try to pull those out of their diet for a month and see what happens. It’s not the easiest thing to do, but you’re going to get the most bang for your buck. You can always just start there. You can see if you can take that out and see if the symptoms improve. It’s crazy how often they do improve.

Dr. Weitz:            Now do you get skeptical parents saying, “Isn’t this just a scam now I’m supposed to avoid gluten?”

Dr. Warsh:           Sometimes. But honestly I think the information’s been out there enough and there have been enough people who have seen significant benefits that people don’t necessarily think it’s a scam. I think the bigger issue is usually with the toddlers. They only eat this. They only eat bread. They only pasta.

Dr. Weitz:            Right.

Dr. Warsh:           Taking that out of their diet means they’re going to eat nothing. That can be hard but if you really have difficulty, sometimes working with a nutritionist can be helpful to see if you can think about things. But most kids don’t starve themselves. If you don’t have it around or you provide other things, they might not eat for a couple meals, but they’ll usually eat eventually if they get hungry enough.  Sometimes it just takes them some tough parenting to hang in there. You’re doing this for your kid and it’s not easy, but it can be helpful. Sometimes it’s just, okay, well we eat pasta every day, so let’s move it to once a week. You have to meet people where they are. It’s very different working with kids than adults because sometimes you just have to do whatever works. When we’re talking about supplements or anything like that, not every kid is going to take it. You have to be careful about what you use and work with the family to use something that they’re actually going to take.

Dr. Weitz:            Do you ever do food sensitivity testing to have it on black and white paper that they have issues with certain foods?

Dr. Warsh:           Definitely. I think a big thing again is different for kids and adults is you really have to be sensitive to blood work with kids. Because it’s a big deal for some kids to take them, give them a poke and get a whole bunch of tubes of blood and send off testing. You have to really think about what is the utility of this test and is it going to be very helpful or helpful enough to warrant the cost and the poke and everything like that.  In some cases it definitely is warranted. I’m big on trying to do whatever we can do first without doing any blood testing. If it’s not improving, you’re not getting better or something is serious, then that’s a good time to do it. Sometimes patients come to me after they’ve been through the whole medical system and they really want to do it and then that’s fine, then we’ll do it then.

It really just involves a lot of discussion and going through the pros and the cons of doing food sensitivity testing because there’s lots of great testing and information you can get out there, but it’s certainly not perfect. You would just, I think want to make sure that patients understand the utility of it and the benefit of it, but sometimes it can be super helpful.  You might come back and have things you would never think of that you’re sensitive to. Sometimes pulling those things out makes a big difference. Sometimes pulling them out makes no difference. Other times you’d send sensitivity testing and everything comes back normal. It just depends. You have to take it with a grain of salt, but when you’ve tried everything else and nothing’s working, then sometimes getting more lab information can be very helpful to push you in a direction to try something else.

Dr. Weitz:            What are some of your favorite nutritional supplements for allergies, asthma, Eczema?

Dr. Warsh:           That’s a good question. Each of those are a little bit different, but for general inflammation, let’s say which-

Dr. Weitz:            Okay, pick any one of those that you want to address.

Dr. Warsh:           Well for eczema, I would say the rashes, lots of creams and lotions that are natural are great. Calendula cream is really good. Coconut oil, Shea butter, Castor oil, fish oil tends to help with the skin rebuilding. Almost everybody is deficient in vitamin D these days. So you can probably just take some vitamin D and E that’d be safe. Turmeric is really wonderful too. That’s something to consider. I always try to get people to eat it as opposed to just taking a supplement if they can.  If you can get some smoothies in with your kids and maybe throw some turmeric. When you’re talking about allergies, things like quercetin and bromelain can be helpful to that kind of stuff.

Dr. Weitz:            Okay, good. You mentioned autism. Do you treat kids with autism?

Dr. Warsh:           Definitely. That’s a statistic that we’re seeing in skyrocketing numbers. Used to be 100 kids with autism, then it was 150, then 140. I’ve seen numbers now as low as 130 to somewhere within 140. It’s becoming very prevalent. Certainly have a fair amount of kids in my practice with autism.

Dr. Weitz:            Why is it becoming so prevalent?

Dr. Warsh:           I don’t think we know. We have no idea why it’s becoming so prevalent. Logically it’s the chemicals, toxins, things we’re exposed to, but they’re… I don’t think there is one thing that is the reason, because I don’t think autism is one thing. It’s a term for a group of diagnoses or a group of symptoms that we give a diagnoses to. I think there are multiple different causes.  My guess and assumption is, because this is becoming so prevalent, we’re going to have a lot more research on this and autism is going to turn into five or six or 10 different things. Because sometimes you’ll see it be a chemical ingestion. Some led toxicity, some sort of toxicity, and you take that toxicity out, the kid gets back to 100%. Other times it’s maybe the environment that they’re in. Most of the time we have no idea.

Dr. Weitz:            Have you used low dose immunotherapy for autism or other conditions?

Dr. Warsh:           Every once in a while I have used it, but in general I send off to other practitioners that specialize in that. We have a pediatric naturopathic doctor in our office and he takes care of a lot of the children that have any developmental disorders. He has a very interesting background history. He’s a toxicologist, he had children that had developmental issues and so he went back to naturopathic school and this is his passion. A lot of the patients will see him for more of their natural medicine and then see me just for their regular medical treatment.

Dr. Weitz:            You mentioned that certain psychological conditions like depression and anxiety are on the rise and really common. What’s your approach for seeing kids like that?

Dr. Warsh:           First thing really is to get a really good history, go back and really see where this stems from, how long has it been going on for, and then to really see how serious it is. For me, anything with mental health, it’s really important to have a good team. I think of myself as the captain of the team and make sure from a medical standpoint we’re not missing anything.  Once you go through the history then thinking about doing the blood work just to make sure that we’re not missing sleep or not missing a vitamin issue. Make sure that their sleep is okay, make sure they’re connected with the right team. If they need a psychiatrist, a psychologist, a nutritionist, whatever it is, having them connect with that team. Then for me, I’m thinking about the medical standpoint and because I’m an integrative doctor sometimes thinking about the integrative health and what we can do from a foundational perspective, and what we can potentially do from a supplement perspective to try to boost that.

It depends because if somebody is severely depressed, that’s not going to be necessarily the right time to do a supplement. They got to go, they got to get their psychology or psychiatry evaluation and then we can work on natural methods to try to help or work in conjunction with the practitioner. To me that’s really important. I think that’s where a lot of people in the natural world don’t do a great job. Is you have to know your limits and stay within your lane and it’s not a good time to start something natural. If something is severe, like someone’s suicidal, that’s not a good time to say, “Okay, well let’s think about some [inaudible 00:38:21].” Or, “Let’s think about some magnesium.” Those are great things to do but maybe not right now.

Dr. Weitz:            Well, how do you work up a kid with say anxiety?

Dr. Warsh:           Usually it will start with… Depends again, because each kid is different so it’s going to be very much dependent on their history and what they’re telling me because some of the tests that we might do would be diet testing, like you said. So sensitivity testing. Sometimes it’s going to be nutrient testing. Sometimes it’s going to be stool testing. Sometimes it’s going to be metal testing. It just depends on when you go through their story, you hear what other symptoms they’re having along with it. Then you think about where do I think is going to be the best bang for my buck.  A lot of times it’s going to be nutrient testing in that case because you’re thinking, maybe there’s a B vitamin deficiency, maybe there’s a D deficiency. Those kinds of things are what goes through my mind with someone with [inaudible 00:39:14].

Dr. Weitz:            Do you have a favorite nutrient panel you like to use?

Dr. Warsh:           I use Genova usually, but they’re-

Dr. Weitz:            [inaudible 00:39:18] NutrEval.

Dr. Warsh:           NutrEval, yes. I like that one. It gives you a lot of information. You get some toxins with it as well. It’s pretty extensive and in general it does a pretty good job of matching up what I’ve seen with other just basic quest or lab quest or lab core workup. It’s not super expensive and generally a lot of insurances will cover at least a portion of it. To me that’s the one I like. They’re easy to use, but there’s a lot of good ones out there.

I think that the bigger key is to think about something that’s going to give you a more broad panel than what you’re going to be able to get from your regular Western lab. I think it’s important to get that a lot of this testing is validated and it’s really good testing, but it’s not something you can necessarily do even from the Western perspective just because… With insurance it’s not medically necessary stuff. They’re not going to cover it. It becomes really risky when you’re trying to run a lot of these tests through your insurance because they usually don’t cover it or they might say they’re going to cover it and then not cover it.

For a lot of my patients, I feel it’s a little safer to say, just go do this test. You know exactly what the cost is going to be and you’re going to get this huge panel. That’s what we do, but not everybody can afford that. Sometimes you just do whatever you can do with [inaudible 00:40:32]. You can do a lot of great stuff through the regular testing too, but you just not going to do nearly as extensive of a workup.

Dr. Weitz:            Right. I think one thing you’re pointing to is this issue with insurance and testing is if you have a patient, you send them to your standard quest or lab core and you do say… You put together say 20 different markers for vitamins and nutrients and they get covered by insurance, fine. If they don’t get covered, the patient could end up having a huge bill. Whereas Genova puts this panel together and say the most it’s going to cost him is 400 bucks and that way you know you’re going to get a lot of info and they’re prepared okay. It’s going to cost me at most 400 bucks. I can handle that or I can’t.

Dr. Warsh:           It’s really important if you’re going to go to your regular pediatrician or regular doctor that you have a discussion about the lab work because it happens all the time where we’ll send… Even just the regular stuff, you send them vitamin D and they won’t cover it. There is… I think people don’t get this. We don’t know. As a doctor, we have no idea what they’re going to cover. You can call them, you can talk to your insurance person. “Oh yes, we’re going to cover it.” Then five months later they send you a bill and say, “Oh, actually by the way, we’re not going to cover it. It’s going to be $1,000 for this one test.” Then the fighting starts.

Usually they can work with the patient and send in a letter or do something with the insurance to fight it and change up the codes or whatever it is. But there is no way, absolutely no way to know. Every insurance is different, every plan is different. Every time it’s different. Basic testing, which should obviously be covered sometimes isn’t covered. It’s just how it is and there’s no way to know that. That’s why when you’re doing these extensive things, as you say, sometimes it’s better just to, if you can afford it just to send the panel because you know exactly what the cost is going to be.

Dr. Weitz:            Right. Great. I think this has been a really good discussion. Any additional thoughts or issues? Is there anything you’re really excited about right now in your field of integrated pediatrics?

Dr. Warsh:           I’m really excited that I think people are starting to become savvy to this and are very interested in learning more about holistic and alternative modalities. Kids are getting sicker and sicker and so people are starting to seek this out on their own. Parents are starting to take health into their own hands and to seek out additional information. I’ve seen this when my practice exploded so quickly. We just opened a new practice where I am, I used to be in Beverly Hills and now I’m over here. People are flocking to this because-

Dr. Weitz:            You’re in Studio City as I mentioned.

Dr. Warsh:           Yes. They’re so excited to be able to discuss alternative modalities. They don’t want just that. Most people don’t want just natural, they want both, but they want someone who’s open to that. The more patients that want it, the more practitioners are going to learn it. To me, I just had a baby and I want him to be healthy and grow up healthy. This is one of the reasons why I’m working on so many other projects on the outside. We’re working on a summit, which is going to be hosted… Well, you can find on integratedpediatrics.com.

We’re working on a wellness care which is basically a course that’s going to go through many different modalities like [inaudible 00:43:56], homeopathy and how those work in with Western medicine and also going through the major conditions, things that we talked about. Like asthma, inflammation and talking about both sides and here’s the Western treatments and here’s some of the alternative treatments and here’s some things you can think about.

Because a lot of parents don’t even know, I could go to a acupuncturist or Chinese medicine doctor for this condition. So just making people think a little bit more about it because if that’s the thought process, I think more Western doctors are going to start to learn this because we need to work as a team. We’re all on the same team, us, chiropractors, acupuncturists. We’re all on the same trying to get kids healthy and adults healthy and hopefully practitioners are going to know where their acupuncture and the yoga studio is as opposed to where their cardiologist is. Right now that’s not the case. We know where our GI referrals are. We know where our allergy referrals are, but you don’t know where your health coach is, where your chiropractor is. If we work together, we’re going to have much healthier patients.

Dr. Weitz:            Just for practitioners out there say who are caught up in our current healthcare system. They’re a pediatrician, they’re taking insurance, racing from room to room, they’d love to talk to their patients about some of this natural stuff. How do you make it work? If you don’t mind talking a little bit about how do you make it work financially? You’re in Los Angeles, there’s a lot of rant, you’re taking insurance. We know insurance is not paying very much. You’re under pressure to see a lot of patients. How do you make it work?

Dr. Warsh:           I think it’s a matter of building up the office in a certain way and using technology to its fullest so that you can cut some of the costs that you have. For me, number one-

Dr. Weitz:            You are a provider for most insurance companies?

Dr. Warsh:           We take the major PPOs. I think the one thing that’s been really helpful is being involved in the American Academy of pediatrics in the background of the business side and seeing what a lot of practitioners do. Just having systems in place. It’s a big conversation so it’s going to be hard to [inaudible 00:46:03].

Dr. Weitz:            I understand.

Dr. Warsh:           But just having systems in place that cut out a lot of the redundancy and having a lot of staff so that way it can keep the costs down to a place where you can do things. I do a lot of other projects on the outside too, so it’s a mix of the two together. Just having other practitioners in here as well. So keeping my costs of rent and things like that down because one of the things that I wanted to do was have a integrative practice actually. So we have a naturopathic doctor in here, a nutritionist in here. A lot of them are renting space from here so it keeps my rent really low.

Dr. Weitz:            Do you charge a concierge fee on top of the insurance?

Dr. Warsh:           We have a small one. A lot of the… Whether it’s an integrative or not, most of the many practices now that are private practice are having some small administrative fee. It’s not a huge thing but these are things that are being charged anyways throughout the year. You’re charging for forms, you’re charging for access after hours, you’re charging for things that insurance doesn’t cover.  Whether integrative or not, most private practices at this point are moving to the hybrid model where they have some small fee that covers the little things. 100 bucks, 300 bucks, whatever it is for the year for the family. It just covers those little things so that families don’t have to come in, 20 bucks for this form and 20 bucks for the vaccine form and 20 bucks for this. They just pay it at the beginning. That gives you a big chunk of… a little chunk of change that can sustain you to buy your supplies and then you don’t have to worry as much. Then the insurance covers the rest.

Dr. Weitz:            Okay, great. How can patients get ahold of you and find out… be able to see you and find out about your programs?

Dr. Warsh:           Sure. You can either go to integrativepediatrics.com. That’s going to be the website we’re working on that right now to get all of these summit and course together, but my website for the office, integrative pediatrics and medicine.

Dr. Weitz:            Okay, great. Thank you, Dr. Warsh.

Dr. Warsh:           Thank you so much for having me. It was a fun time.



Reversing Diabetes with Dr. Brian Mowll: Rational Wellness Podcast 139

Dr. Brian Mowll discusses Preventing and Reversing Diabetes 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

3:08  Type II Diabetes is more a condition or dysfunction than it is a disease, while Type I Diabetes is a classic autoimmune disease, that usually begins in childhood.  Type I diabetics develop auto antibodies against either the insulin producing cells of the pancreas or insulin itself or against some other part of the blood sugar control system leading eventually to pancreatic destruction. They cannot make insulin and need to be on insulin for life. Prior to the discovery of insulin in the 1920s, Type I Diabetics were unable to store energy and they would lose fat and muscle and waste away and eventually die. Insulin is lifesaving for these patients. Insulin is a hormone secreted by the pancreas that allows us to take excess glucose and store it as energy.  What happens in Type II Diabetes is that the cells become resistant to insulin and our glucose levels in our blood go higher than normal.  The fat levels in our blood as triglycerides and cholesterol also become elevated. Type II Diabetes can cause a lot of damage in the body is the leading cause of adult blindness, lower limb amputation, kidney failure, which leads to dialysis, sexual dysfunction in both men and women, peripheral neuropathy leading to numbness, tingling, and pain in the feet and toes and sometimes the hands, autonomic neuropathy leading to gastrointestinal paresis, and dementia and Alzheimer’s Disease.  The term Type 1.5 Diabetes is sometimes used, but there is confusion about this. It is sometimes used to refer to when Type II Diabetics burn their pancreas out and become insulin dependent. Other people use Type 1.5 Diabetes to refer to LADA, which is Latent Autoimmune Diabetes of Adulthood, which is similar to type I but it happens later in life, tends to progress slowly, and may not lead to total pancreatic destruction. Some LADA patients may not need to be on insulin. There’s another condition called MODY, which is a mutation that leads to high blood sugar that is also sometimes referred to as Type 1.5.

9:20  Some of the reasons why Type II Diabetes is so prevalent today include poor diet, processed and refined foods, including sugar, flour, hydrogenated oils, and industrial seed oils, like corn, canola, safflower, cotton seed, and soybean oil.  These all drive metabolic dysfunction. And then there are all the additives, preservatives, and other chemicals in our food supply, as well as sedentary lifestyles.  Also, stress, poor sleep and toxins can block insulin receptors, leading to weight gain and visceral fat stored around our organs, which can lead to diabetes.  Gut dysbiosis and hormone imbalances can also be contributing factors.

12:58  To properly assess patients with prediabetes or diabetes we should monitor both blood sugar and insulin levels.  Dr. Mowll recommends that patients get a glucometer, such as the Precision Neo by Abbott, and start checking their sugar levels regularly.  Besides glucose, we should measure Hemoglobin A1C, which is a measure of damage to hemoglobin in red blood cells by elevated blood sugar. Most people think of it as a measure of blood sugar over the last three months but it is really a measure of glycation damage to proteins from sugar, which essentially carmelizes them.  When we see damage to those cells, we know there is likely damage being done to the lining of the blood vessels and to the kidneys and to the brain and to the other parts of the body. Dr. Mowl said that he likes to picture creme brulee, which is made by putting some sugar on the top and heating it up with a blow torch, forming a hard crust. That’s what happens to our cells in our brain, in our kidneys, on our blood vessels. And that’s what leads to a lot of the complications of diabetes.  Normal Hemoglobin A1C is below 5.6, but ideally it should be below 5. Hemoglobin A1C at 5.7-6.4 is considered prediabetes and at 6.5 it indicates diabetes. We should also monitor insulin levels because if the body is keeping glucose levels down with high insulin levels, that’s not good either.  High insulin is also inflammatory in the blood stream.  In order for the body to degrade a lot of insulin, it uses insulin degrading enzyme and that’s the same enzyme that degrades amyloid plaque in the brain, so high insulin can increase amyloid plaque buildup in the brain, leading to Alzheimer’s Disease.  While the lab range for normal for fasting insulin is large, such as 0 to 21, the functional range is 2.5 to 6.  If it’s above 6, it is elevated.  We can assess insulin resistance with the HOMA-IR score which is computed by multiplying your fasting glucose times your fasting insulin and dividing by 405 and it should be close to 1.  If it is above 2, that indicates insulin resistance.

24:51  The Glycomark Test is another type of calculation that estimates insulin resistance using triglyceride levels along with fasting glucose.

26:03  Insulin resistance is when our cells stop responding properly to the hormone insulin. Under normal circumstances, when we eat glucose and other carbohydrates, it triggers insulin release. But even fat and protein will stimulate some insulin release, though nowhere as much as carbohydrates. Insulin stimulates us to store extra energy in the liver, in our muscles as glycogen, and in fat cells.  What happens in insulin resistance is that if the muscle cells don’t respond to the signals from insulin to store glucose as energy, then glucose will build up in the blood stream, hyperglycemia, which is the hall mark of diabetes.  The vegan community claims that fat in the diet causes insulin resistance, but that is not true. Fat in the blood stream, in the liver, and in the muscles, which results from eating too many carbohydrates, is completely different than fat in the diet.  If somebody were to eat only a thousand calories per day of only fat, they’re not going to build up fat in their organs because they are going to use all of that fat as fuel. Fat in the organs (not fat in the diet) is one of the causes of insulin resistance, along with chronic inflammation. When we eat a lot of carbs, we secrete a lot of insulin and that down regulates the insulin receptors. Also, toxins, such persistent environmental pollutants, can cause insulin resistance.

32:23  Dr. Mowll recommends for most patients with diabetes or prediabetes to follow a low carb, though not necessarily a high fat, diet.  Even the American Diabetes Association, which has tended to promote a lower fat, higher carb diet with a focus on vegetables, whole grains, and fruit for diabetes over the years, says that carbohydrates by a long stretch have the greatest impact on blood glucose levels and blood insulin levels.  For the first time this year, the ADA even recommends that taking a lower carb approach is a viable option for diabetics.  Dr. Mowll recommends that his diabetic patients start with 75 grams of carbs per day, which is about 300 calories from carbohydrates per day, which usually ends up being 10-15% caloric intake.  Dr. Mowll means net carbs, which means that if a food has 15 gms of carbs but if 12 of those grams will come from fiber, then there is only a net 3 grams of carbs.  Fiber doesn’t really have any net effect on blood sugar.  The rest of the diet will consist of protein and healthy fats.

39:09  Carbohydrate foods that are lower on the glycemic index, slow burning carbs, are better for blood sugar control.

40:37  Intermittent or prolonged fasting can be helpful when implemented into a nutrition program at the appropriate time.  Dr. Mowll said that he does like his clients to eat a meal within an hour and then not eat again till the next meal, say 3-5 hours later and not eat in between. This period of not eating allows your system to reset and your glucose and insulin levels to fall back into line.  He does not find that grazing works well for most clients. When Dr. Mowll starts with a new client he does like them to eat a small meal within an hour of waking up to help with blood sugar regulation.  A 24 hour fast can also be helpful at some point in their program,  but it can be tricky if the client is taking medication or insulin and it is best to heal any thyroid or adrenal problems prior to doing this.

44:30  Dr. Mowll has developed some specific subtypes of Type II Diabetes, which facilitate different treatment strategies. Type O is over insulinized and these are patients that produce too much insulin and they’re insulin resistant and tend to be overweight and have an apple shape.  Type I is the insulin subtype and these patients are under insulinized. They tend to be normal weight or thinner and they don;t produce as much insulin as they’re supposed to when they eat. Type S is the stress type and this stress can come from lack of sleep, from gut dysbiosis, from mental or emotional stress, from chronic pain, from hormonal or other imbalances, or from chronic infections.  Type H is a hormone imbalance that affects blood sugar and that can be sex hormones or thyroid or adrenal hormones.  These categories can help guide the patient care.

48:42  There are various nutritional supplements that can be helpful with patients with prediabetes or diabetes.  Some of the most beneficial supplements are things that we find in our food, like omega 3 oils, vitamin D, chromium, zinc, and magnesium.  It is best to get these from our food, though supplementation can be helpful as well to get the optimal amount.  There are also herbal, botanical based supplements, like cinnamon, berberine, and turmeric or curcumin that can be very helpful.  EPA and DHA, which are omega 3 fats from fish oil, should be at a dosage of one and six grams per day. Eating fish is helpful, though there is risk with fish due to the mercury and other toxins contained.  Dr. Mowl recommends a vitamin D level of between 40 and 70 ng/mL, so typically it means supplementing with 5,000 IU per day and sometimes up to 10,000 IU per day. For people with diabetes, there’s a clear connection between vitamin D and insulin sensitivity and blood sugar regulation.  It is also a good idea to add some vitamin K2 with higher dosages of vitamin D.  Dr. Mowll also finds chromium picolinate or polynicotinate important for glucose regulation, so he recommends a supplement of between 200 and 1000 mcg per day. Dr. Mowll also likes to use vanadium at 20 mg for a short period of time since it can have insulin-like effects on the cells and he has seen it helpful for blood sugar regulation, esp. in patients who don;t make enough insulin.  Magnesium is beneficial. Berberine is an alkaloid compound found in goldenseal and other flowers and it acts in several different ways to improve glucose utilization and insulin sensitivity.  Berberine has many of the same mechanisms of action of metformin and can be used synergistically with metformin and allow a lower dosage.  Too high a dosage of metformin can be stressful on the gastrointestinal system and it can deplete vitamin B-12 and CoQ10, which doesn’t happen with berberine.  Dr. Mowll like green drinks and chlorella, which can be very detoxifying and energizing.



Dr. Brian Mowll is the founder and medical director of SweetLife Diabetes Health Centers. He is a master licensed diabetes educator and is certified to practice Functional Medicine by the Institute of Functional Medicine. He organizes the highly successful annual Diabetes Summit and consults with clients worldwide as The Diabetes Coach and you can find more information about the Diabetes Summit and his Mastering Blood Sugar course and you can down his free Blood Sugar Manifesto at his website, DrMowll.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.


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, please give us a ratings and review on Apple podcasts or wherever you get your podcasts.

Our topic for today is the prevention and treatment of diabetes. 90 to 95 percent of those with diabetes have type two. Diabetes and prediabetes are epidemic and the prevalence continues to increase in the United States and around the world. 9.4% of adults in the U.S. are diabetic, as many as 15% in some of the states, and this equates to approximately 30 million Americans ,and 87 million people in the U.S. have prediabetes with some estimates quite a bit higher, especially since many people do not know that they have this since at this stage there may not be any symptoms. And rates are especially climbing among children and teens. At least one out of three, and possibly as many as one out of two Americans have diabetes or prediabetes.

And diabetes is a particularly nasty disease.  It significantly increases your risk of heart attack and stroke. Diabetes is the number one cause of chronic kidney disease and kidney failure, and it accounts for 60% of all lower limb amputations. Diabetes frequently results in diabetic retinopathy, which can cause vision loss and blindness. Diabetes also increases the risk of various other eye problems including glaucoma and cataracts. One of the most common complications of diabetes is diabetic neuropathy, whose symptoms include tingling, numbness, and or pain in the extremities, especially in the feet and legs. Diabetes also significantly increases the risk of cognitive decline as well as the risk of falls in older people. And the biggest tragedy is that diabetes is largely preventable.

Dr Brian Mowll is the founder and medical director of SweetLife Diabetes Health Centers. He’s a master licensed diabetes educator and certified to practice functional medicine by the Institute of Functional Medicine. He organizes the highly successful annual diabetes summit and consults with clients worldwide as a diabetes coach. Dr Mowll, thank you so much for joining me today.

Dr. Mowll:           Thank you so much for having me. Excited to be on the podcast.

Dr. Weitz:            Excellent. Can we begin by explaining … Perhaps we can begin the discussion by explaining what type two diabetes is and why is it so prevalent today?

Dr. Mowll:           Yeah, that’s a good question. You just did a good job of laying out some of the statistics and facts and some of the scary things about diabetes. You’re right, it is the leading cause of adult blindness, lower limb amputation, kidney failure, which leads to dialysis, causes sexual dysfunction in men and women, leads to other hormone imbalances. There’s common issues with thyroid disorders and we see other complications like dementia and Alzheimer’s disease and, as you mentioned, both peripheral and autonomic neuropathy, so that leads to gastrointestinal issues from the autonomic neuropathy and we see lower limb, even sometimes in the hand, usually in the feet and toes, numbness, tingling, pain, sometimes very severe pain, resulting from diabetes and the difference between type one and type two, which will help me to kind of talk about what type two is, is really night and day. They’re a totally different disease.

In fact, I oftentimes wish they didn’t have the same name. Type I is a classic disease. It’s an autoimmune condition where usually sometime in childhood, I’ve seen as young as under a year to as old as late teens, they will develop auto antibodies against something in the blood sugar regulation system. It could be the insulin producing cells of the pancreas or enzymes that are involved in insulin production or insulin itself, but some sort of auto antibody against the blood sugar control system often leading to pancreatic destruction. The pancreas, the organ that makes insulin, which controls blood sugar, gets destroyed, and therefore people with type one diabetes need to be on insulin for the rest of their lives. Before insulin was discovered in the 1920s or at least isolated and formulated in the 1920s, there was no cure or even treatment really for type one diabetes.

And what happens there is people waste away. Essentially, they can’t store energy, so they lose all their fat, they start to lose all their muscle mass, they become almost like cachectic like a cancer patient would, and eventually wither away to nothing and their organs start to malfunction. In those cases, insulin is life saving and they need to be on insulin for the rest of their life. Type two diabetes, completely different. Type two diabetes is more of a condition or a dysfunction than it is even a disease. And what happens in type two diabetes is we make plenty of insulin, but our cells become resistant to it. Again, insulin is a hormone made by particular cells called beta cells in the pancreas, which helps us to store energy, in particular glucose. We release insulin when we eat or when our glucose levels in our blood start to get higher than what is considered normal, and we take that sugar and we store it away for later use.  And that’s the role of insulin. When the cells don’t respond to that hormone anymore, though, we can’t store away that extra fuel, so the glucose levels in our blood go up. Also the fat levels in our blood typically go up, so we see high triglycerides, which ultimately leads to high cholesterol. We see high glucose, which leads to all sorts of problems, and damage that we talked about earlier.

Dr. Weitz:            I guess there’s even a diabetes type 1.5, I was talking to another doctor about.

Dr. Mowll:           Yeah, type 1.5 is kind of a slang term, but there are other forms of diabetes. So I try to steer away from that, because there’s not a lot of agreement on what it actually is.

Dr. Weitz:            Oh, okay.

Dr. Mowll:           Some people use type 1.5 to describe people who have type two diabetes and their pancreas burns out, and then they become insulin dependent, which I would call insulin dependent type two diabetes, but other people use it to describe what’s really known as LADA, L-A-D-A, Latent Autoimmune Diabetes of Adulthood, and that is a condition where it’s similar to type one, it’s an autoimmune manifestation that affects the blood sugar regulation system. Again, there’s about four or five different antibodies that can be affected here and different mechanisms within that, but oftentimes leads to destruction of the pancreas. The difference is it happens later in life, so typically past the age of 20, and it’s much more slowly progressing and may not lead to total pancreatic destruction. We have a lot of LADA clients, for example, who don’t need to be on insulin. You can just maintain good blood sugar with a low carb diet and exercise and so forth. But that’s oftentimes described as type 1.5. There’s another thing called MODY, which is a sort of a mutation that leads to high blood sugar. And there’s other things that sometimes people call type 1.5, but I think the big one is this LADA condition, which is an autoimmune diabetes that instead of affecting kids, affects adults and shows up just a little bit differently.

Dr. Weitz:            Okay, cool. And so why is diabetes so prevalent today?

Dr. Mowll:           Well, yeah, that’s a good question. And let’s say type two diabetes, for sure. I think type one diabetes is probably on the rise slightly as well, but not nearly the epidemic that we see in type two diabetes. And again, if we, I like to look at type two diabetes as a spectrum. We look at it almost like a spectrum dysfunction where we can put along that spectrum obesity, we can put along that spectrum metabolic syndrome, which is elevated blood sugar, elevated lipids, high blood pressure, overweight, and there’s other factors that can be looked at as well. Then I would say even dyslipidemia, which is just elevated cholesterol or triglycerides or abnormal lipids. PCOS, which is polycystic ovarian syndrome, is also related to this. Prediabetes and type two diabetes. To me, that’s a spectrum there and it doesn’t necessarily … You don’t necessarily get all of them and it doesn’t necessarily progress that way, but to me these are all a cluster of problems that are related to the same thing.

And ultimately, type two diabetes is the pinnacle of that. It’s sort of the ultimate metabolic disaster, where our lifestyle and our environment come together to create this perfect storm, which leads to metabolic breakdown. If we want to get more specific on that, poor diet, processed, refined foods, including sugar and grain-based foods as well as fats. We see things like hydrogenated fats, which have kind of been phased out, but most of us grew up eating a lot of those. And we still see refined vegetable oils, quote unquote vegetable oils, industrial seed oils, like corn, canola, safflower, cotton seed oil, soybean oil and so forth, these are highly processed, refined fats that can drive metabolic dysfunction. And then all the additives, preservatives, and other stuff that’s jammed into our food, we see more sedentary lifestyles.

People aren’t moving the way that we used to move. We have more sedentary jobs. We don’t get as much physical activity as we used to get in our evolutionary history. We have more stress, we’re getting poor sleep, we have more toxins in our environment, which end up blocking insulin receptors and leading to weight gain and visceral obesity or fat stored around the organs, which can lead to diabetes. We have gut dysbiosis and dysfunction hormone imbalances, and the list goes on and on. All of these things are part of this group of contributing factors and causes that lead to this metabolic sort of perfect storm, which ultimately can put us along that spectrum of gaining weight, becoming insulin resistant, which I mentioned earlier we can talk more about, and then ultimately leading to prediabetes and type two diabetes.

Dr. Weitz:            Okay, cool. Which lab tests do you think are most beneficial for patients to screen for potential diabetes or who already have existing diabetes?

Dr. Mowll:           Well, there’s really two problems in prediabetes and type two diabetes. The first is high blood sugar, but the second one is high insulin levels or hyperinsulinemia. For sure, you should be checking your blood sugar, and I actually recommend that everybody goes out and gets an over the counter blood sugar meter. I recommend one by Abbott called the Precision Neo, N-E-O. It’s relatively inexpensive, you can get it at any drug store. You don’t need a prescription and you can check your blood sugar whenever you want, after meals, first thing in the morning, before you go to bed, and it gives you some realtime feedback. It’s a great tool. I always say it’d be nice if we could measure every test that way, if we could check our thyroid function with a pinprick, if we could check our cardiovascular markers with a pinprick, it’d be, and it was cheap enough, affordable and easy to do, we’d have a lot more awareness when it comes to biomarkers.

So anyway, we have that with glucose, so let’s check it. Secondly, there is a test called hemoglobin A1C, which is sort of the … Becoming the standard, not quite the standard yet, but becoming the standard in type two diabetes management. It’s not a perfect test, but it’s a really good test, and essentially we describe it as sort of an average of your glucose over the past three to four months. What it really measures is damage to red blood cells, hemoglobin, done by elevated blood sugar. There’s a certain of these A1C receptors on hemoglobin and red blood cells that can be glycated, and when it gets glycated, it means there’s sugar molecules bound to them. And when it gets above a certain percentage, we know that the sugars are running too high, actually causing damage to those cells.

And the problem is when we see damage to those cells, we can extrapolate that and say, “Well, good chance there’s damage being done to the lining of the blood vessels and to the kidneys and to the brain and to the other parts of the body,” which are at risk when it comes to high blood sugar. Hemoglobin A1C is a much more stable marker. Normal, if anybody wants to go get one, is 5.6 or less, 5.6% or less. We like to see it around five. Most of our clients will end up with an A1C between 4.8 and 5.5 percent. Diabetes is diagnosed at 6.5 or greater, and prediabetes is 5.7 to 6.4, so that’s the hemoglobin A1C. As far as …

Dr. Weitz:            I’ve heard you describe the glycation, which not everybody is familiar with, as caramelizing the proteins.

Dr. Mowll:           Yeah, so glycation is what the hemoglobin A1C test measures on the red blood cell, but other cells can get glycated like brain tissue, like the lining of our blood vessels and you’re exactly right. What happens is that high, that sugar, that elevated glucose circulating around the bloodstream acts as an oxidant and your audience has probably heard of oxidative stress, which is like rust on a bumper or the browning of an apple when you take a bite out of and leave it on the counter, that oxidation glycation is similar, but instead of oxygen, it’s glucose doing the damage. It binds to certain protein molecules along, in those cells. And yeah, caramelizes it like we like to picture creme brulee, they put some sugar on the top and heat it up with that little blow torch and it forms that hard crust. That’s what happens to our cells in our brain, in our kidneys, on our blood vessels. And that’s what leads to a lot of the complications of diabetes.

Dr. Weitz:            That’s pretty scary.

Dr. Mowll:           Yeah, pretty nasty.

Dr. Weitz:            Do you recommend a glucose tolerance test where you challenge them with sugar and then measure the glucose again?

Dr. Mowll:           It’s an interesting test and I think it can be really helpful. If people have diabetes already, I don’t recommend doing it typically because, essentially you’re … It’s like somebody who you know has celiac disease saying, “Well, let’s have you go eat a whole loaf of bread and a bowl of pasta and just kind of see what happens.” It’s kind of mean, right? So I don’t typically recommend it for people who have diabetes, but if you are in the prediabetic range or your blood sugar, let’s say you go in and have a fasting blood sugar test, and normal by the way is around 76 to 92. Mid-80s is kind of perfect, so let’s say you come back and the test is 99 or 103 or something like that, then you may want to consider going and having a glucose tolerance test done. What you do there is take about a, it’s usually a 75 gram load of glucose, which is like a sugar syrup that you drink, they check your blood sugar before and then they’ll check it at intervals after that. Usually it’s 60, 90, 120 minutes.

You can also check insulin. So I mentioned a few minutes ago the other thing that happens with type two diabetes and prediabetes is elevated insulin levels. You can also check insulin as part of a glucose tolerance test. It’s called an insulin response test. And you would, again want to check fasting and then you can see what happens to your insulin levels. Sometimes the glucose levels look okay, so fasting glucose is okay, maybe it goes up a little bit too high after that glucose syrup. The threshold to diagnose diabetes at that point is 200, so that’s really high. If you do the glucose syrup and your blood sugar goes up to 180, they say you’re prediabetic, not type two diabetic, but that’s still very, very high. Maybe it goes up higher than it should and then comes right back down. You may not know you have a significant problem, but if you check the insulin, sometimes what you’ll see is maybe fasting, it’s normal, but when you take that glucose load, it shoots up super high. The insulin post glucose challenge should not really ever go above 30, and sometimes we’ll see it go up over a hundred …

Dr. Weitz:            Wow.

Dr. Mowll:           After a glucose challenge, and so what’s happening there is the body’s keeping the blood sugar down, but it’s doing it by releasing like a surge of industrial strength insulin in order to keep the blood sugar down, and that’s not okay, because that insulin causes us to store fat, particularly around the organs and in the liver, it causes us to, it’s inflammatory, so it circulates in our bloodstream inflaming the blood vessels. High insulin levels needs be degraded and it’s degraded by an enzyme in the brain that also degrades amyloid plaque. When we’re degrading all that insulin, we don’t have that enzyme to degrade amyloid plaque, so we get plaque build up in the brain, which is one of the main links to Alzheimer’s disease. High insulin, even without high blood sugar can be a huge problem. And so that’s why, if you’re going to do that test, I would also test insulin at the same time.

Dr. Weitz:            And when we look at fasting insulin, what is the optimal level? Because the range is actually pretty big for the normal, quote unquote.

Dr. Mowll:           Yeah. The way I explain it, a lot of people don’t realize, but that test is not a functional test. Most doctors will not order an insulin test to evaluate metabolic health or diabetes or prediabetes. They’re essentially ordering it when they order it, because they suspect an insulinoma. And insulinoma is basically a tumor on the pancreas that causes the excess release of insulin. That reference range is really tied to insulinoma, not to functionally healthy insulin release. We have to apply a functional range to that. And we do this in other things too, like thyroid. Sometimes there’s a functional range. We do the same thing with triglycerides. When people, when doctors evaluate triglycerides, they’re oftentimes evaluating for cardiovascular risk, not metabolic health. We have a functional range with triglycerides as well. But the functional range for insulin fasting is 2.5 to 6. That’s the range that we use.  And so when it gets above 6, that’s elevated. There’s a calculation you can do called HOMA-IR H-O-M-A-I-R. It stands for Homeostatic Model of Assessment of Insulin Resistance, and you multiply your fasting glucose times your fasting insulin and divide it by 405, and what happens there is it gives you a number, it should be close to one. Once it gets up over two, it’s starting to get elevated and what you’ll see is if you have a fasting glucose of 85 and a fasting insulin of 5, that puts you pretty much right at 1. Once that starts to grow, either the glucose or the insulin, your HOMA-IR score goes up and that’s what many researchers use to assess insulin resistance in research studies.



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                                                Now, back to our discussion.



Dr. Weitz:            Are you familiar with the GlycoMark Test and is that a useful test?

Dr. Mowll:           I like it too. That one uses triglycerides and glucose, so if you don’t have a fasting insulin test, you can do that one. I can’t remember the exact formula or the reference ranges, but it’s similar. I think there’s a multiplication then you do like a, you have to use the log function I think on the, on your, on your scientific calculator, which most smartphones have, but it’s pretty cool and it’s, yeah, it’s good. I like it. And basically, it’s a similar theory. The difference is instead of looking at insulin, you’re looking at triglycerides, which is kind of a surrogate for insulin resistance. What we find is the more insulin resistance, the higher the triglycerides go. Most of our clients, after they do some care with us, their triglycerides are down between like 40 and 70, and if they have triglycerides in that range and a glucose under a hundred, they’re going to have a good GlycoMark. Once that triglyceride level starts getting up around a hundred or higher, that GlycoMark’s going to get elevated.

Dr. Weitz:            You just mentioned insulin resistance several times. Can you explain what insulin resistance is.

Dr. Mowll:           Yeah, so I mentioned it earlier, but I didn’t really dive into it too much. We make this hormone insulin, which actually is an energy preserver really. When we eat food, if we eat extra calories that we can’t necessarily burn or utilize at this time, we store them. And insulin is the hormone that’s largely responsible for that storage. What happens is in the presence of when we eat food, glucose in particular triggers the biggest insulin release, but fat will at some level, protein will at some level. When we eat those foods, we release this hormone insulin, it kind of opens up storage. Storage in the liver, storage in the muscle, storage in the fat cells, for extra energy, and we take whatever we can’t burn or use at the time, we sock it away for later use, so to speak.

And what happens in insulin resistance is for one reason or another, and we can get into some of those reasons, our cells don’t respond properly to that hormone. We describe it as like insulin is a key that opens the door that would allow the glucose to get into the cell, if we’re talking about glucose, and if that key doesn’t open the lock, like somebody stuck some gum in there or it’s an old lock and it’s just jammed, then the glucose can’t get into the cell through that door. It has to go look for another door, and fortunately there are many doors on the cells, but the more and more insulin resistance there is, the less doors open and the less we’re able to get glucose into the cell. Eventually it starts to build up outside the room, in this case, and that’s high blood sugar, hyperglycemia, and a hallmark of diabetes.

There are many causes for that insulin resistance. And one of the things I like to caution people is you’ll hear a lot, this is the cause, that is the cause. From the vegan community, we often hear, “Oh, it’s too much fat in the diet. That’s what causes insulin resistance.” Well, that is just absolutely not true. What they’re doing there is conflating this idea of elevated fat and fat in the liver contributing to insulin resistance, which is very much true with fat in the diet. And they’re two totally different things. Fat in the bloodstream and fat in the liver and fat in the muscles is completely different than fat in the diet. Somebody who eats, let’s say somebody were to eat a thousand calories a day of only fat, they’re not going to build fat in their organs, they’re not going to have extra fat floating around in their bloodstream, because they’re going to use all that fat to fuel their body.

It’s not fat in the diet, it’s fat stored in the organs and fat stored in the muscles and fat floating around the bloodstream, which can be one of the causes of insulin resistance. We also have to look at chronic systemic inflammation. That is in fact I think the main driver of insulin resistance. There’s too much insulin. My friend, Dr. Jason Fung uses this as his main cause, which again, I think that I have a little bit of a problem looking at it as the cause, but it is a cause, when you over consume carbohydrates or just over consume food in general, we release these surges of insulin and the way he described it as like an alcoholic becomes desensitized to alcohol, somebody who smokes becomes desensitized to nicotine, drug addicts become desensitized to whatever drug they’re doing. We become desensitized to insulin, and that does happen.

There are studies showing we down regulate insulin receptors when our insulin levels are high, so that’s a cause. We have to also look at toxins. Certain toxins, environmental pollutants, POPs and other chemicals that are found in plastics, in our food supply, in our water supply, in our air, will actually interfere with insulin signaling at the cell level. There’s a lot of different things that can cause insulin resistance, but the bottom line is that lock gets gummed up, the key doesn’t open the lock, the glucose can’t get in to be burned for fuel and it builds up in the bloodstream.

Dr. Weitz:            Interesting. Yeah, I’d like to touch on the toxin thing, but I just wanted to mention, I just opened up an email from Tom O’Bryan and he’s speaking at a diabetes summit and I thought, oh, it must be Dr. Mowll’s diabetes summit and it’s called the Mastering Diabetes Summit. I started looking at it and there were a number of talks about how the ketogenic diet is the worst thing in the world, and I thought, I don’t think that’s his summit.

Dr. Mowll:           Not mine. No, no, no, no. Those are, they’re friends of mine who run that, but they’re heavy duty vegan advocates. Basically they teach plant-based, ultra low fat diet, keep fat grams under 30 a day, which is basically no fat, and eat a lot of fruit. I found that that doesn’t work very well. I’ve had a lot of clients who have tried that and failed spectacularly with it, so it does help some people. There are certain genotypes, phenotypes, whatever, that seem to respond well to a low fat diet. But the large majority of our clients, and I don’t teach a high fat diet by the way either, but the large majority of our clients seem to do really well with a low carbohydrate approach and avoiding processed, refined foods, moderating protein, moderating fat, and getting plenty of exercise, and then supporting the body systems to make sure the body’s functioning optimally.

Dr. Weitz:            When you talk about a low carb, what is the best diet for most people with diabetes?

Dr. Mowll:           Again, I found that a low carb approach makes sense. Carbohydrate foods, in particular, starch and sugar, drive the production of insulin, which is known as a fat storing hormone. I mean, even the ADA and the American Association of Diabetes Educators say throughout their information and they’re very, very conservative, that carbohydrates by a long stretch have, or by a long shot, have the greatest impact on blood glucose levels and blood insulin levels.

Dr. Weitz:            But traditionally, the ADA has tended over the years to promote a whole grain type of lower fat approach until recently.

Dr. Mowll:           Yeah, I’m not saying that they’re pushing low carb, but they do say that carbohydrates have the greatest impact on blood sugar. There’s a little bit of a disconnect there. They have, you’re right. In recent years, they have started to warm up to low carb. This year, in fact, they’re even saying it’s recommended as a viable path, but they tend to go with this idea that diabetics deserve to eat what everybody else eats. That’s sort of their general mission or general approach to nutrition when it comes to people with diabetes. And so they look at it as there’s medications, so there’s no reason for you to suffer and not get to eat cheesecake just because you have diabetes. As ridiculous as it sounds, that’s their general approach. But getting back to the main question, I’ve found, doing this for over 15 years, that …

Dr. Weitz:            By the way, what do we mean by low carbs?

Dr. Mowll:           Right. Carbohydrate foods are foods that are higher in starch and sugar. All foods have carbohydrates, fat, and protein, so there is no one … Even a white potato is not purely carbohydrate. There’s a tiny bit of protein in there and a little bit of fat. They all have all three, but like a white potato is mostly starch. Starch is long chains of glucose. If you’ve ever seen a lap pool and those lane dividers, they have those little buoys that are all chained together, that’s kind of like if you imagine those as glucose molecules, that’s what a starch molecule looks like.  And that’s what’s in a potato, that’s what’s in pasta, that’s what’s in breads and things like that.  When we eat those foods, we have an enzyme called salivary amylase in our mouth that immediately starts to break those apart into sugar molecules, into glucose molecules.  Sugar, on the other hand is a simple molecule and there are different types of sugars, but table sugar, like white sugar, that people sometimes put in their tea and coffee or honey, for example, is basically a combination of fructose and glucose.  Glucose is what we measure in the blood when we measure blood sugar. Fructose is an altogether different molecule that does not raise blood sugar, but gets shuttled to the liver and ultimately, typically stored as fat in the liver. When we eat table sugar, we’re eating about half fructose, which goes to the liver and gets converted to fat, and about half glucose, which gets absorbed into our bloodstream and either gets used in the cells for fuel or gets stored. And again, the hormone that’s in control of that is insulin. Anyway, what’s a good amount of carbohydrate?

Dr. Weitz:            Yeah, like for example…

Dr. Mowll:           You measure carbohydrate in grams, right?

Dr. Weitz:            Yeah, I saw one recent paper where they were recommending a low carb diet that had 45% carbohydrates.

Dr. Mowll:           Right, exactly. So, a 2000 calorie diet, 45% is what like I don’t know, 800 calories, that’s 200 grams of carbs. That’s a lot of carbs. And the average American consumes about two to 300 grams of carbohydrate a day, and sometimes more, sometimes up to four or 500, so the average American is eating a lot of carbohydrate. And so you can see why we get these problems, because it creates these surges of insulin, leads to insulin resistance, fat storage, and all sorts of other things. We usually start at about 75 grams of carbohydrate, which is about 300 calories from carbohydrates a day. That ends up being around 10 to 15 percent of caloric intake and oftentimes will go lower. It’s really, we talk about eating to the meter. We have our clients check their blood sugar. We’ll dial in their macronutrients, starting with about 75 grams of carbs. We put together a protein recommendation and then fill the rest in with healthy fats and, then we do it in a way that’s healthy, non-refined, non-processed as much as possible, and make it accessible and doable for people.

But 75 grams is probably a good starting point. One last thing I’ll mention on carbs is there’s some confusion around net carbs, diabetic carbs, and so forth. We do recognize net carbs. Net carbs is, they’re still listing fiber as a carbohydrate on the labels, I believe. And so if there’s a, let’s say there’s 15 grams of carbs in something like an avocado, but 12 of those grams come from fiber, fiber doesn’t really have any net effect on blood sugar. Maybe a little bit, but not much, we generally subtract those out. An avocado, if it’s got 15 grams of total carbs, but 12 come from fiber, we would call that three net carbs. And that’s how we would count that food.

Dr. Weitz:            Do you find it helpful to look at glycemic index or glycemic load of carbs?

Dr. Mowll:           A little bit. I mean, if you’re eating a lot of carbohydrates, yes. If you’re maybe in the prediabetic range or you’re sort of like pre prediabetes and just, it’s on your mind a little bit or you’re like a marathon runner or an athlete that where you’re eating a fair amount of carbohydrates for fuel. I do think it’s best to eat slow carbs, so carbs that break down more slowly don’t raise your blood sugars quickly. Those would be things like …

Dr. Weitz:            Legumes…

Dr. Mowll:           Or like, yeah. Legume … Beans and legumes, certain grains, if you want to eat grains, like barley, for example, is lower on the glycemic index than something like rice would be, although I generally recommend steering away from grains. There are certain fruits like berries which are considered low-glycemic. Even apples are lower glycemic if you stick with a smaller apple or a half of an apple. You can probably get away with that. Grapefruit and some citrus lemons and limes are low-glycemic. They don’t have a ton of sugar in them. And there’s other foods like that, so you can pull up a glycemic index chart. I generally recommend sticking with the low-glycemic category, not the moderate or high glycemic categories.

Dr. Weitz:            Okay. What about intermittent fasting or fasting? And I know that for years we were preaching everybody needs to eat within an hour of waking up and then you should have a small meal or snack every three hours throughout the day, and now it’s really popular, especially in functional medicine, anti aging and wellness circles to do some version of intermittent fasting, and frequently this involves skipping breakfast.

Dr. Mowll:           Yeah, I just saw today that Dr. Oz is recommending everybody skips breakfast in 2020 now, so you know it’s hit the mainstream at this point. But yeah, intermittent fasting can be an effective strategy, and there’s many different ways to do intermittent fasting. It doesn’t just have to be skipping breakfast, but it can be a very effective strategy. When I start a new client, we actually have them eat something within an hour of waking up. I’m not a big fan of grazing, unless you’re like a vegan and you’re eating just a ton of leaves and plants and that’s the majority of your diet, like a gorilla. A gorilla will eat actually a high protein diet, but they get most of their protein from leaves, but they’re just eating like pounds and pounds, like 50 pounds of spinach a day, you know?

If that’s what you’re doing, then great, but other than that, I recommend eating all your food within an hour and then having like eating blocks. You might eat from 8:00 to 9:00 AM and then from noon to 1:00 and then 7:00 to 8:00 or 6:00 to 7:00 or something like that. And then don’t eat in between. That’ll allow your system to reset itself, your insulin levels can fall, your glucose can get back in line, your body can function normally for a little while and then you can eat again. There is a time and a place for intermittent fasting and I do recommend it a lot once we get deeper into a treatment plan with our clients, and it can be very helpful to allow insulin levels to come down. It probably is not really going to have significant longterm benefits.  Like I haven’t seen a lot with stimulating autophagy and cell repair and things like that on a, tacking on four hours to nighttime fast, but it can help with hormone fluctuations and can help to resensitize our cells to insulin when you’re kind of early in the process. I think a longer term fast can be even more beneficial, and after you fast for about 24 hours …

Dr. Weitz:            Like 24 hours or 48 hours or …

Dr. Mowll:           Yeah, 24 hours, you’re going to kind of burn through all your glycogen stores, so you’re going to deplete all your stored sugar, and so that’s when you really start to tap into your fat stores. The body starts to release more growth hormone after 24 hours, which helps to maintain lean body mass and starts to upregulate fat burning. You really start to gain some additional benefits past the 24 hour mark. Of course, a lot of our clients are on medications, they’re injecting insulin, so having them do a long fast can be really difficult in the beginning, so we don’t typically do that right out of the gate, but at some point along the way we do. And for someone who’s a little bit healthier, someone who has maybe the early signs of prediabetes or something, doing some extended fasting can be really helpful. The only time I don’t recommend doing that is so there’s a known thyroid issue that’s not being managed well or adrenal fatigue or adrenal dysregulation, those people fast, like long fast, can put a lot of stress on the body and so I think it’s best to heal those areas before we do long fasting.

Dr. Weitz:            I understand you have come up with some specific subtypes of type two diabetes as a way to change, modify your treatment strategies.

Dr. Mowll:           Yeah, so I know we’re a little short on time, so I’ll run through it pretty quickly, but there are four subtypes essentially of type two diabetes, and the first is a type O, which is over insulinized, and those are the people that we’ve mainly talked about today. They produce too much insulin, they’re insulin resistant, we can test insulin levels, it’s high, they tend to be overweight, maybe not obese, but at least overweight or have some visceral adiposity, like that apple shape. That’s the most common of the subtypes, but there are three others. The second one is I, which is the insulin subtype and it’s under insulinized. These are folks who have type two diabetes, it’s not type one, it’s not LADA, there’s no autoimmune issue here, but they’re under producing insulin, and there’s a variety of reasons for why that can happen.

They tend to be either normal weight or thinner, on the thinner side, and we check their insulin and it’s actually low and we do an insulin response test like we talked about earlier, and they don’t release insulin as much as they’re supposed to when they eat. Those folks either need to be on a little bit of insulin or oftentimes we can help to sort of revive the pancreas to make more insulin again, and there’s different strategies that we use for that. There’s two other subtypes which are almost completely ignored. The third one is a type S which is a stress type. A lot of people don’t realize the connection between stress and high blood sugar, but it is a very potent connection, and that stress can come from lack of sleep, it can come from gut dysbiosis, it can come from mental, emotional stress, it can come from a loss of a loved one or divorce or separation or move or some other type of major life stress, major life event. It can come from chronic pain. It can come from a hormone or a number of other imbalances in the body, like chronic infection in the blood. These types of stressors will cause our adrenal glands to make extra cortisol and adrenaline, which raises our blood sugar. And that can ultimately lead to adrenal dysfunction, but in the meantime, we get a prediabetes and oftentimes type II diabetes.

And so we have clients where their insulin is normal, their blood sugar is high, but it doesn’t look like a normal diabetes case. What we find out there, they’ve dealt with a tremendous amount of stress or they’ve just got this chronic pain that’s just always nagging them, driving stress into their system, and once that’s handled, oftentimes their blood sugar will come back down into the normal range. The last type is type H, which is a hormone imbalance, and that can be sex hormones like testosterone or estrogen, progesterone, or more commonly, it’s related to thyroid and adrenal hormones. Not to be confused with type S, this is where the adrenal dysfunction is the primary thing. It’s not that there’s chronic stress or there’s something that we can pinpoint there that we can handle, it’s actually the hormone imbalance itself. Hypothyroidism is oftentimes at the root of this, but we see adrenal dysfunction as well, and other things. There are a few other things that can show up like mitochondrial dysfunction and toxins as we mentioned, but those are the main four subtypes that we classify. And when we sort of look at a new client, we’ll sort of think about those four as we create a care plan for them.

Dr. Weitz:            I can see how those could be really useful. We are a little bit short on time. I’d like to make the last question about which nutritional supplements can be beneficial as part of an adjunct to your care for patients with diabetes or prediabetes.

Dr. Mowll:           Yeah, great question. And I break supplements into two categories. So we look at nutrient based supplements and botanical, herb based supplements. The nutrient based supplements are things that we would normally find in our food, things like omega-3 oils, vitamin D, chromium, zinc and so forth. And then magnesium. And then there are herbal or botanical based supplements, which are things like cinnamon, berberine, turmeric, curcumin and others. For me, the nutrient based supplements are kind of a cornerstone. We want to eat a good diet, we want to use food as medicine, and then sometimes we can supplement to sort of fill in the gaps. Most people I think need and can benefit from some omega-3 support. We just don’t get those healthy omega-3 in our diet as much as we should. And there’s risk with fish today, even though I recommend eating fish.

So good omega-3 supplementation I think is important. Somewhere between one and six grams of combined DHA and EPA per day. And you can check the label, the bottles. If the bottle doesn’t tell you how much EPA and DHA there is in the fish oil, then don’t use it. Make sure it tells you how much is in there and then add those two up. EPA plus DHA, DHA, excuse me, and those should add up to a thousand or more per day. And there are certain ways of tweaking that depending on what we’re trying to accomplish. I also recommend vitamin D for most of our clients. You can check, obviously vitamin D, 25 hydroxy on a blood test, it should be around 40 to 70, maybe a little higher is okay, and if it’s not at least up in that range, then supplement with some vitamin D3. Typically we’re doing 5,000, I use per day, sometimes up to 10, and sometimes as little as 2, but somewhere in that range, I think is really helpful. For people with diabetes, there’s a clear connection between vitamin D and insulin sensitivity and blood sugar regulation.

Dr. Weitz:            Use vitamin K with the vitamin D?

Dr. Mowll:           Yeah, especially if we get up into the higher doses, I think it’s important to do some K2 in particular. You can get vitamin K1 through a lot of foods, but vitamin K2 is hard to find. If we’re up over 5,000 units of D, we’ll definitely add in some vitamin K2 as well.  I like chromium. Chromium is important for glucose regulation and glucose tolerance.  Most people don’t get enough chromium in their diet, so you can supplement anywhere between 200 micrograms up to a thousand micrograms, if you’re trying to really make an impact on your blood sugar of chromium per day, I think that can be helpful.

Dr. Weitz:            And in which form?

Dr. Mowll:           Yeah, either picolinate or polynicotinate. Both of those have good research behind them and seem to be effective.

Dr. Weitz:            And do you like vanadium as well?

Dr. Mowll:           Vanadium is a little trickier. It’s a metal salt and it can be toxic at certain levels, so I use that one short term. I’ll use maybe 20 milligrams of vanadium short term. I think it’s milligrams, milligrams or micrograms. I can’t remember, but we’ll use that one more short term. I’ve seen supplements with 50, 100, I think it’s milligrams of vanadium and that …

Dr. Weitz:            Yeah, I think it’s milligrams.

Dr. Mowll:           Yeah. That, I think there’s some caution there. So I’d be a little bit careful with pushing the vanadium up too high, but vanadium sort of has insulin like effects on the cells, and there are some studies that show vanadium supplementation can sort of act as insulin and help to reduce blood sugar. I’ll use vanadium more in people who don’t make enough insulin and it can be helpful in some cases. Magnesium, really important for many, many reasons. Good blood sugar health is one of them. And then on the herb front, berberine can be really effective. Berberine is a alkaloid compound found in golden seal and other flowers. It acts in several different ways to improve glucose utilization and insulin sensitivity. And it’s one of the most effective compounds we have. Cinnamon can be good as well, especially if you’re eating carbohydrate and you want to lessen the impact of carbohydrate on your blood sugar system, taking some cinnamon at meal time can be really helpful.

Dr. Weitz:            Berberine is kind of a natural form of metformin and can also be used synergistically with metformin, correct?

Dr. Mowll:           Has many of the same mechanisms of action as metformin, yeah, absolutely. Metformin does not derive from berberine. It’s a different chemical structure altogether, but they do have similar mechanisms of action.

Dr. Weitz:            Yeah. And they can actually be used concurrently, right?

Dr. Mowll:           It can, yeah. You have to be a little bit careful. Usually what we’ll do is sort of balance, like if somebody is maxed out on metformin, we’re not going to max them out on berberine also, but oftentimes we’ll do like a little transition where we’ll work with their doctor to back down on metformin and increase the berberine and that can help them, it can be less of a stress on the kidneys and less stress on the gastrointestinal system.  Metformin is really hard on the GI track, it depletes vitamin B-12, it interferes with vitamin B-12 absorption and interferes with the production of coenzyme Q10, so I don’t like to see people maxed out on metformin for too long if we can help it, even though it’s a pretty safe drug.  If we can help to replace some of that with berberine or something else, it can be helpful.

Dr. Weitz:            Great. Any other herbs?

Dr. Mowll:           Well, I like green drinks and I like chlorella.  Chlorella is a, basically an algae that’s pretty high in iron. It has some protein. By weight, it’s high in protein, and it’s very detoxifying.  It’s very energizing, it’s got a lot of chlorophyll.  I like to do some chlorella and I love to do green drinks, which is like basically powdered vegetable and fruit extracts. Usually they’re very low carbohydrate, very low calorie and can give you a nice burst of energy. And I actually like to use those as sort of a multi, because they … It’s kind of plant medicine. It’s got all sorts of vitamins, minerals, nutrients, phytochemicals that we don’t even, necessarily haven’t even identified yet and certainly haven’t put into pills. I like to use food as medicine whenever possible and a green drink is a great way to do that.

Dr. Weitz:            That’s great. Awesome. I think we’ll wrap there. Can you tell our listeners how to get a hold of you and find out about your programs?

Dr. Mowll:           Yeah, so probably the best way, I have my own podcast called Mastering Blood Sugar. I’d love to have you on there doc, maybe sometime here in the future, but Mastering Blood Sugar, you can check out Apple, we’ll be starting … Or iTunes, we’ll be starting our next season here relatively soon, and for other information, just go to drmowll.com, that’s D-R-M-O-W-L-L.com. I have a resource on my website called the blood sugar manifesto, which is free to download and it’s basically got all my best advice in there, some information about supplements, diet, exercise, stress management, sleep management, all those things are included. If you want to get some good free information, go to drmowll.com and download that blood sugar manifesto.

Dr. Weitz:            This has been a great podcast doc. I got a lot of good information. I have a ton of additional question, so if you’re up to it, maybe we could do a part two at some point in the future.

Dr. Mowll:           Yeah, I would love to do that. Maybe a little bit of a deeper dive. It’d be great.

Dr. Weitz:            That’d be awesome. Thank you so much.

Dr. Mowll:           Okay, doc, thanks for having me on.



Men’s Health with Dr. Matthew Cavaiola: Rational Wellness Podcast 138

Dr. Cavaiola discusses Testosterone Replacement Therapy and Men’s Health 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

3:47  To understand what a low testosterone level is, we need to look both at lab tests and at patient symptoms. The symptoms that a male patient with low testosterone may present with are fatigue, libido problems, difficulties putting on muscle mass or losing body fat, sleep disruptions, as well as a variety of others. Then serum total and free testosterone levels are run and we look first at total testosterone levels. But the lab reference ranges usually huge, with normal being from 150 or 250 to 1100.  Because of this huge range, Dr. Cavaiola feels that many men are undertreated.  If a patient has a total testosterone level of 250 or even 400 and they have many symptoms, then there can still be a justification for treating with bioidentical testosterone replacement therapy.

6:38  Free testosterone may be even more important than total testosterone, since it is the bioavailable proportion of testosterone that can be utilized by the body. The free testosterone is that portion of the testosterone that is not bound up by carrier proteins like Sex Hormone Binding Globulin (SHBG) and albumen or that has not been converted into other substances, like estrogen or dihydrotestosterone (DHT).  Therefore, we need to measure both total and free testosterone and we also need to have adequate levels of free testosterone. But after we put a man on testosterone replacement therapy, it’s not as accurate to measure free testosterone any more, so it is more important at that point to mostly monitor levels of total testosterone.  However, Dr. Cavaiola does still measure free testosterone along with total testosterone, as well as estrogen, DHT, and SHBG.

9:58  Dr. Cavaiola monitors estrogen levels in men because of the negative side effects that can result from higher levels of estrogen. He usually focuses mostly on total estrogen levels (combination of estrone (E1), estradiol (E2), and estriol (E3)) and he wants to see that level below 100 but above 30.  In fact, a small amount of estrogen is important for bone protective effects, for libido, and even for erectile function.  Dr. Cavaiola pointed out that estrone is partially a measure of exogenous estrogen exposure from pthalates in plastic and other environmental toxins that have an estrogenic effect.  He does not focus as much on progesterone levels in men.

14:40  Let’s take the case of a young man, say 35 years old, who comes to see Dr. Cavaiola complaining of symptoms characteristic of low testosterone levels but does not want to take testosterone.  After taking his history, examining him, and measuring all his hormones, Dr. Cavaiola will start with diet and lifestyle and usually wants to clean up the gut first.  He will often run a complete stool analysis through Genova and food sensitivity testing through Great Plains Lab. Leaky gut and dysbiosis of the microbiome can have a negative impact on hormone levels.  From a lifestyle perspective, men should not smoke, not drink to excess, and minimize exposure to environmental toxins.  Smoking marijuana is not favorable for testosterone levels, so you should minimize this. Exercise is beneficial for raising testosterone levels, esp. strength training.  Dr. Cavaiola also recommends such men follow an anti-inflammatory diet, which avoids dairy, gluten, sugar, corn, and soy.

23:05  Dr. Cavaiola has found that some of the commonly recommended nutritional supplements, like tribulus and maca, do not appreciably raise testosterone levels.  However, he has found American ginseng to be helpful in raising testerone levels.  Boron has good research that it can lower Sex Hormone Binding Globulin and unbind it from testosterone.  SHBG levels tend to rise with age in men.  Stinging nettle root may also be effective for lowering SHBG and also DHT levels.

26:35  Let’s take the case of a 35 year old with low testosterone who is willing to take a pharmaceutical approach but does not want to start taking testosterone replacement.



Dr. Cavaiola is a Naturopathic Doctor who also holds Master’s degrees in both Human Nutrition and Acupuncture. He specializes in men’s health and testosterone replacement therapy and his practice is Conscious Human Medicine in Santa Monica, which he shares with his partner, Dr. Hashemi. His website is ConsciousHumanMedicine.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.


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 are enjoying listening to our Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcast or whatever podcast app you’re using and give us a ratings and review. That way more people will find out about the Rational Wellness Podcast. Also, if you go to my YouTube page, you can find a video version and if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.

                                                Our topic for today, is the use of bioidentical hormone replacement for men, with Dr. Cavaiola. As men age, their testosterone levels tend to decline, approximately 1 to 2% per year after age 30 or 35, depending upon the study. Though it’s not clear that is inevitable, since some older men do not experience this decline. We’re also seeing a society-wide decrease in both testosterone levels and sperm counts in the US.  Much evidence points to the cause being endocrine disrupting substances in our environment, like bisphenol A, phthalates, PCB, pesticides, glyphosates, as playing a role in reducing these male hormones.

                                                A study in the Archives of Internal Medicine in 2007, found that lower levels of anabolic hormones, which includes testosterone, DHEA IGF-1, in men over age 65, is associated with increased mortality over a six year period. [Relationship between low levels of anabolic hormones and 6-year mortality in older men.However, it’s controversial these days whether having higher IGF-1 levels is better or worse for longevity. There are some studies recently, that have shown that having lower IGF-1 levels, is associated with improved longevity. [ROLE of IGF-1 System in the Modulation of Longevity: Controversies and New Insights From a Centenarians’ Perspective]  Men with low testosterone levels may have a number of significant symptoms, that are associated with a lower quality of life. Including decreased sexual desire, erectile dysfunction, reduced strength, reduced muscle mass, reduced bone density, insomnia, and cognitive dysfunction among others.  The question we would like to answer today is, should such a man be prescribed androgen hormones like testosterone and DHEA? And what are the possible negative and positive consequences of taking male hormones like testosterone, besides the ones your body naturally produces.

Our special guest is Dr. Cavaiola, who is a Naturopathic Doctor. He also holds a master’s degree in both human nutrition and acupuncture. He specializes in men’s health and testosterone replacement therapy and his practice is Conscious Human Medicine in Santa Monica, which he shares with his partner, Dr. Hashemi. Dr. Cavaiola, thank you so much for joining me today.

Dr. Cavaiola:             And thank you for having me, very much appreciated.

Dr. Weitz:                  Excellent.

Dr. Cavaiola:             Great introduction.

Dr. Weitz:                  I appreciate that. So let’s start by defining, what do we mean by low testosterone levels?

Dr. Cavaiola:             So those testosterone levels, there’s basically a clinical definition and more of a symptomatic definition. So when a male patient comes in and sees us in our clinic, essentially, we evaluate the patient. First of all, understanding what’s happening with the patient overall, symptomatically, right? And again, you mentioned some of the symptoms that oftentimes are associated with low testosterone. The picture that they might present with is, I have fatigue, I have difficulties with libido, difficulties putting on muscle mass or fat deposition or weight gain, those types of things.  Sleep disruption, a whole variety of other things. So when they come and see us, it’s important to first of all, understand the root cause.  As Naturopathic Doctors, it’s important for us to get to the root cause of people’s problems.  So that is important for us, so okay, let’s understand the symptom picture and at that point in time, you may recommend some lab work.  And so once we run lab work, the labs can come back and the lab values, the reference values range for total testosterone, from 250 to 1,100.  So that’s a huge, huge range, so a lot-

Dr. Weitz:                 So these are serum levels, you typically do serum-

Dr. Cavaiola:             Correct, yes. So there are different measures of testosterone, there’s different applications, there’s different lab methodologies that you can use to evaluate testosterone.  Serum probably is the gold standard and one of the best, and kind of the most easily used for insurance purposes as well.  So we typically use serum levels and when a total testosterone level comes back between 250 and 1,100 it’s a huge range.  So part of the problem that we’re running into, is that a lot of times men, depending on where they fall along that scale, they’re being undertreated.  And a lot of times because as long as you’re above 250, if you’re 251, you’re considered normal, right?

Dr. Weitz:                  Sure, and some of the labs say the bottom range is 150 or it changes sometimes for age ranges.

Dr. Cavaiola:             Yes, exactly, so really, we need to be looking at the entire picture and that really is the key. So if a patient comes in, their levels are 400 and they feel like, they just feel awful, then there is a potential clinical reason for using testosterone for that patient. So we both look at the lab values, which again, the lower end of the scale is 250. So clinical definition of hypogonadism or low testosterone is anything below 250. Although we need to be looking at the clinical picture, plus the labs for the majority of our patients.

Dr. Weitz:                  Okay, so what about free testosterone levels? Are lab measures accurate? I know there’s some controversy about that.

Dr. Cavaiola:             Yeah, I mean, I think free testosterone levels are accurate and that free testosterone, if people listening out there don’t understand the differences between total and free testosterone. Basically what you have is a total pool of testosterone that’s being released from your testes essentially, and also to a lesser degree, your adrenal glands, which we’ll talk about, I’m sure, in a little while. But your free testosterone basically is the proportions of your testosterone that is not either bound up to carrier proteins, one of the major ones is called sex hormone binding globulin, HSBG, albumen or being converted into other things.  Things like estrogen, things like DHT, those are the primary things that testosterone oftentimes is converted to interest blood stream. So the free testosterone is basically the bioavailable proportion of testosterone that can be utilized by the body. It’s very, very important, so although you may have a normal total testosterone, whatever considered normal is, you can have a lower proportional level of free testosterone. And that’s problematic because that really is what’s doing the magic in the body. So we want to have adequate levels of free testosterone, so we need to measuring both total and free.

                                  So what there is, there is controversy about free testosterone because if we do put a man on testosterone replacement therapy, which we’re going to talk a lot about today, free testosterone increases, at that point in time, it’s not as accurate to measure. Basically, at that point in time, we want to be just looking at the total testosterone because essentially, we’re increasing exogenous levels, endogenous levels of testosterone by injecting testosterone. So it’s the free testosterone levels are going to go up.

Dr. Weitz:                  Okay, so you’re saying, looking at free testosterone levels is not as helpful, why is that again? I don’t quite understand, so-

Dr. Cavaiola:             So free testosterone is important when you first running it-

Dr. Weitz:                  Oh, after you start adding testosterone.

Dr. Cavaiola:             Right, so essentially what’s happening is, if you’re injecting or using some other type of application of testosterone, you’re taking in hormones into the body, right? So it’s asking the body to raise both your total testosterone and your free testosterone levels. So you’re not getting an accurate representation of really what’s happening inside the body. So really at that point in time, the free testosterone is relatively negligible in terms of measuring, we do it anyway, just to kind of see what’s happening overall, with the entire picture, but not as important at that point in time, rather than the collecting of the baseline numbers.

Dr. Weitz:                  Right, unless of course, you don’t see an increase in free testosterone because a lot of it’s getting bound up.

Dr. Cavaiola:             Absolutely, yes, bound up or being converted to other things. So yes, in that case, like I said, we do want to see the entire picture holistically and as people who don’t just prescribe testosterone and get them in and get them out of our practice. We really want to understand what’s happening overall with the hormone picture. It’s really, really important for us to understand what’s happening with estrogen? What’s happening with DHT? What’s happening with SHBG? And then what’s happening with the patient overall?

Dr. Weitz:                  And do you also look at estrogen and progesterone?

Dr. Cavaiola:             Yeah, absolutely, estrogen more so than progesterone. There’s some docs out there that really love to run progesterone levels, haven’t found-

Dr. Weitz:                 Yeah, I’ve even heard some docs prescribe progesterone for men in certain circumstances.

Dr. Cavaiola:             A few of them do, yeah and really from a clinical standpoint, we’re always more concerned about estrogen because of the negative side effects that it can have. There are less side effects associated with progesterone in men and maybe necessarily not as many men need progesterone compared to women.

Dr. Weitz:                 Right, so when you look at estrogen and you basically focused on the estradiol or do you into total estrogen?

Dr. Cavaiola:             We look at total estrogen in our practice and really, it’s really important. Some people just look at estradiol or estradiol alone. And what we’re seeing actually is, estrone (E1), is a relatively potent form of estrogen. For your listeners out there, there’s basically three types of estrogen. You have estrone (E1), estradiol (E2), and estriol, which is E3. And essentially, estriol is negligible, it pretty much doesn’t exist, it’s in very, very small amounts. Estrone and estradiol in the body, they both have similar effects in men and women. Obviously women have more estrogen than men and vice versa. So essentially, what we want to be seeing is not very high levels estrogen total. And you had mentioned earlier the fact that we are taking in more and more exogenous, meaning outside of our body, estrogen nowadays, right?

Dr. Weitz:                  Right.

Dr. Cavaiola:             We’re being bombarded by it all throughout our environment, it really is scary. And so estrone sometimes is a measure of, not estradiol, of our exogenous estrogen exposure. So for instance how much plastic water bottles we’re drinking out of. So plastic of course contains phthalates, that we’re taking into our body, we’re ingesting orally and then basically, get trapped into our body, so-

Dr. Weitz:                 And by the way, it’s almost impossible to avoid plastic, you can avoid plastic water bottles and then you have some fish and find out it’s got microparticles of plastic in it.

Dr. Cavaiola:             Absolutely, everything, we’re turning into a plastic society, unfortunately and there’s no, about one person on this earth at that point in time, who doesn’t have plastic in their body.

Dr. Weitz:                 Absolutely, and you pick up a cash register receipt, it’s coated with bisphenol A, which is one of the hardeners for plastic and yeah. Do you look at DHEA levels?

Dr. Cavaiola:             We do, so as part of our routine baseline analysis for our patients, we’re looking at total and free testosterone, both types of estrogen, DHT, DHEA, cortisol, SHBG. Those are the primary things we’re going to be looking at for our patients. So yes, we look at both DHT, dihydrotestosterone, which is a by-product of testosterone and DHEA. Now DHEA is interesting, it’s an adrenal hormone, by cortisol and DHEA is interesting because I mentioned earlier in the podcast that basically, you have two major sources of testosterone from the body. It’s from your testes and also a little less from your adrenal glands. And you are going to get a little bit of production from adrenals in the form of DHEA converting into some of the other androgens kind of systemically.

Dr. Weitz:                  Right, on the estrogen levels, isn’t it important that the estrogen stay at a certain level? Like if the estrogen gets too low, that’s not ideal and then-

Dr. Cavaiola:             Absolutely.

Dr. Weitz:                 What level are you worried about? What’s the range you like to see the estrogen at?

Dr. Cavaiola:             Very good, it’s a great question. And what we like to see is, the total estrogen, that’s the combination of both estrone (E1) and estradiol (E2), being less than 100. That’s our kind of cut off point, our more a danger zone if you will, I suppose. But like you mentioned, if estrogen goes too low, we can also have effects. So men need estrogen, men need a little bit of estrogen for bone protective effects, actually for libido a little bit. We need some estrogen for natural libido and for our erectile function. So estrogen shouldn’t be lowered and bottomed out, in fact, I’ve seen clinically, when we do that, men run into problems down the line. So we want the estrogen between roughly I would say probably 30 total and 100, that’s kind of our cut off points.

Dr. Weitz:                 Okay, that sounds good. So, let’s start with how you would handle a younger man, maybe a 30-year-old, maybe 40-year-old, who comes into your office and has symptoms of lowered testosterone. Let’s say you evaluate him and maybe in one case they have low total and free testosterone and what would tend to be your approach in handling this patient?

Dr. Cavaiola:             So first of all, I will just back up and I think it’s important to mention to your audience that we are seeing younger and younger men coming into our office with low testosterone. It is no longer an old man’s problem. We really are seeing men in their 20s, 30s and 40s, who have low testosterone. So although our testosterone relatively peaks in our 20s and starts to decline after, like you mentioned around the age of 35, we are seeing men who have low testosterone at a younger and younger age. Again, primarily due to environmental factors. However, when a patient comes in during their 30s or 40s, how we approach the patient is, first of all understanding again, the hormones in totality.  Let’s understand all of the hormones, what’s going on from a holistic perspective? And then saying to a patient, “These are the options, we can start you on testosterone replacement therapy, we can start you on something that might be helpful in raising your testosterone levels outside of testosterone, or some combination thereof.” And then I’ll also explain to the patient that if they are interested in fertility, testosterone has the capabilities of lowering your fertility levels. So we can talk more about that in a little while, but basically, if you take exogenous testosterone, essentially it shuts down your own production of sperm and testosterone, so-

Dr. Weitz:                  So let’s take the case of a guy, 35-year-old guy and he says, “Look, I don’t want to take any testosterone. I don’t want to take any pharmaceuticals.”  What’s your diet and lifestyle approach?

Dr. Cavaiola:             So diet and lifestyle is crucial. Obviously we want to be cleaning up the gut, a lot of times as Functional Medicine practitioners, we start with the gut, we start with diet. It is so, so vitally important to look at the gut as the root cause of so many problems that we have.

Dr. Weitz:                  How do you analyze the gut and how do you clean up the gut?

Dr. Cavaiola:             Great question, so a lot of the times, we look at a stool analysis, look for particles and look for things that might lead us to believe that there’s what we consider intestinal permeability. We also do food sensitivity testing in our office as well, which can give you clues as to what’s happening internally.

Dr. Weitz:                 What type of stool test and food sensitivity testing do you tend to use?

Dr. Cavaiola:             So are you asking for brands, or are you asking for-

Dr. Weitz:                 Sure, yeah, you can talk about brands or-

Dr. Cavaiola:             So typically, I don’t know it’s allowed in this podcast or not.

Dr. Weitz:                 Yeah, there’s no CEUs.

Dr. Cavaiola:             Right, right, so a lot of times we’ll run a Genova stool analysis, comprehensive stool analysis, CSA. And then we really like Great Plains food sensitivity test.  And so what’s important is getting these clues as to what’s happening.  If the gut is permeable, what we are seeing nowadays and also looking at the microbiome to some degree, we’re seeing more and more correlations between microbiome health and also hormone levels in the body and if you can clean up the gut by repairing the holes that had been punctured into the gut, I suppose you could say, tightening things up, so proteins are not leaking into the blood stream.  And also, improving the microbiome, improving the health of the microbiome, that can actually help hormones levels long term. And then from a diet standpoint and a lifestyle standpoint. First of all, lifestyle, it’s important that men do not, they don’t drink to excess, they do not smoke, they minimize their environmental exposures because that really is a key nowadays, more so than a lot of other things and-

Dr. Weitz:                  What about smoking marijuana?

Dr. Cavaiola:             So smoking marijuana is controversial, there’s some people who say it does lower testosterone and some people who say it doesn’t.  I’m in the camp of, if we can do whatever we can to maximize our hormone levels and kind of what the research says, then we should be doing that. I would say, if you do that, don’t do it to excess.  How much are you doing to begin with?  I think that’s part of the battle.  If you’re drinking every single day, you’re going to have lower testosterone levels, most of the time, right?  If you’re smoking every single day, a pack a day or a half a pack a day, it does cause lowered testosterone levels. So those are things we can be doing from a lifestyle standpoint, an actually-

Dr. Weitz:                 Yeah, I tend to think that the marijuana, I’ve seen enough evidence that it certainly, there’s a fair chance that it may lower testosterone levels.

Dr. Cavaiola:             Yes and there’s actually a new study out and kind of there were studies before this too, but actually it linked it to testicular cancer as well in men. So that’s not favorable for marijuana unfortunately. But yeah, and then the other thing, exercise is another thing that’s very, very important to help to raise testosterone levels. There’s a lot of I guess you could say, controversy in terms of understanding what the best types of exercise are for men to raise testosterone levels. And we don’t really know what the gold standard is at this point in time. As long as guys are getting out there and moving their bodies and doing strength training. Strength training has been shown to raise testosterone levels, it doesn’t matter-

Dr. Weitz:                  Wait, hasn’t heavy resistance training been shown to be the most beneficial?

Dr. Cavaiola:             Yeah, I mean strength training, heavy strength training has been shown to be beneficial, as has mixed training as well. So resistance, as well some kind of cardiovascular aerobic training. And one thing that I really love recommending for patients is HIIT training, high intensity interval training, which has actually been shown to be very helpful. Not only to raise testosterone levels, but also to essentially help with a lot of cardiovascular, metabolic parameters too. And from a diet standpoint, we always start, obviously we only have a certain amount of time for our podcast, we could go on and on and on about diet and nutrition. But I think starting with an anti-inflammatory diet would be the best way to go for the majority of people.

Dr. Weitz:                 Which basically, is what?

Dr. Cavaiola:             So an anti-inflammatory diet would primarily be things-

Dr. Weitz:                 There’s many diets that people prescribe as anti-inflammatory.

Dr. Cavaiola:             Yeah, absolutely, so if somebody out there is listening, who has never started on any kind of dietary program before, what we oftentimes recommend is avoiding the four or five big guns. That’s what we call them. So something like dairy, gluten, sugar, absolutely, notice how close I got to the camera. Sugar and corn and depending on who you are-

Dr. Weitz:                            Soy, yeah.

Dr. Cavaiola:             Yes, absolutely, so soy has been show to essentially kind of mimic estrogen in the body and to also unfavorably lower testosterone levels. So that would be a good starting point.



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:                  Besides doing those things, you’ve cleaned up the gut, you’ve got their diet doing better, they’re doing exercise, are there any specific supplements that you have found to be beneficial?

Dr. Cavaiola:             Yeah, I mean, there’s a ton out, there’s a gaggle of products out there, that claim to raise-

Dr. Weitz:                  Which ones work?

Dr. Cavaiola:             So things like tribulus, that has gotten a lot of press. Tribulus, Maca, some of these things. And having covered this a bunch of times in presentations and research, they don’t have any real benefit in men on raising testosterone levels. It may help from a libido standpoint, from a symptomatic standpoint, but they don’t really cause any major bumps in testosterone levels. Now, one herb that I very much like, is ginseng. I talk about it all the time, I used to teach at Bastyr University in California and my students would just get sick and tired of me talking about ginseng because of great it is for raising testosterone levels.

                                                But it also really is an all healing kind of thing, that’s what the prefix ANX means to begin with, all healing. It has really, really great effect on the human body. I would like American ginseng from the perspective of raising testosterone levels. Korean ginseng and Siberian ginseng can also be helpful as well, but American ginseng is really, really great for raising testosterone levels.

Dr. Weitz:                            Yeah, I personality have found Maca to be beneficial, especially if they get sufficient levels. I think just taking a couple of capsules is not enough, but if they can get a substantial amount, like several tablespoons. And then what if they have reasonable of decent total testosterone, but low free testosterone? Let’s say it’s related to high sex hormone binding globulin.

Dr. Cavaiola:             Yeah, so interesting question, there are some things out there that we’re recommending now, to be able to… What we’re trying to do is we’re trying to encapsulate the testosterone from the SHBG. SHBG as opposed to something like albumen, which is another carrier protein in the blood. SHBG, once it binds onto testosterone, it does so very, very strongly. It doesn’t want to let it go. So as men get older, believe it or not, their SHBG level goes up and that really is a problem because it binds on more to free testosterone.

                                                So that’s a problem, so what we want to do is, we want to encapsulate that, we want to get that SHBG off of the testosterone. And so, to do that, one mineral that’s been shown to be able to do that is boron. Boron has some pretty good research on helping to basically kick off the free testosterone from SHBG. And some other minerals, magnesium, zinc and then of course, a good diet and exercise have also been shown to do the same thing.

Dr. Weitz:                            Dr. Geo Espinosa, who’s an expert on men’s health, I had a personal communication with him, he recommended stinging nettle root and I’ve been trying that on some patients and we seem to see some effectiveness.

Dr. Cavaiola:             Great, great, also a great product and it also can actually help to possibly lower DHT levels in men too, so that’s-

Dr. Weitz:                            Oh, okay, good, good, good. So now take the same 35-year-old, who’s willing to try some pharmaceuticals, but maybe doesn’t want to get on testosterone because he’s thinking about having a family.

Dr. Cavaiola:             Ah, got you, yeah, so very important factor. First and foremost, I will say that if a man, even in their 30s starts on testosterone replacement therapy and wants to have a family at some point in time, testosterone replacement or the effects of testosterone replacement on fertility are reversible. So it is not permanent, it does take three to six months, roughly speaking, to basically get the body to start doing its own thing again, from a sperm production. However, it is reversible. Now, there are some things you can do to come back at, let’s say if the guy is on testosterone, what we’ve also been shown to be helpful is something called HCG, human chorionic gonadotropin, it’s a mouthful.

                                                HCG, it’s actually a hormone that’s typically found in highest amounts in pregnant women. Both men and women have some, to a certain degree. What’s interesting about HCG is it basically is an LH agonist, meaning that, LH is a hormone produced by your pituitary gland and LH is the signal to your testes to produce testosterone. So the sub units of HCG look like LH to a certain degree and it actually causes your body to produce a little bit of its own.

                                                And in doing so, helping to raise sperm levels. So HCG can be used in combination with testosterone to help to improve fertility. That being said, if the guy says, “No, I don’t want to do either one of those things.” You can take HCG solo to raise testosterone and help with sperm production, or there are some pharmaceuticals out there, something like Clomid, which has been shown to be helpful. A lot of docs are becoming privy to Clomid, to be able to raise testosterone levels and sperm counts, so interesting.

Dr. Weitz:                            Yeah, I know Dr. Howard Elkin, he was discussing this with me and he often will recommend for that type of patient a combination of Clomid and HCG.

Dr. Cavaiola:             Yeah, good.

Dr. Weitz:                            When they use HCG, how long do they use it for before they see an effect?

Dr. Cavaiola:             So it’s not going to be as immediate necessarily as testosterone. It’s going to take a little while longer, but at the same time, and it’s not going to be to the same degree that testosterone works. You’re going to get a small bump in your testosterone levels as opposed to taking exogenous testosterone. It just doesn’t work as well, but you can usually notice an effect probably in about a month, a month to a month and a half I would say.

Dr. Weitz:                            Okay, since we talked about these endocrine disrupting substances, do you ever try to get rid of those with some sort of a detox?

Dr. Cavaiola:             Yeah, absolutely, so detox is crucial. Especially if we find that your estrone levels are high. We’re like, “Well, there probably is some kind of exogenous estrogen coming into the body, right? So how do we get this out of the body? That’s crucial, and I’m sure you practice and work with your patients a lot in terms of detoxing. And a lot of people think of detox as this weird, magical fufu kind of thing. And it’s not just about drinking juice on a daily basis, it’s really about purging the body of harmful chemicals. And especially if there’s, you basically have four main ways of getting rid of stuff from your body, whatever that is.

                                                Sweating through your skin, poop, through your intestines, getting it purged from your liver, and also through your breath, and through your urine, five major ways. So you have to get it out of your body. So first of all, you need to mobilize and then you need to get rid of it as well. So if you have, let’s say you have a bunch phthalates stored in your fat tissue. First, you need to purge it from that fat tissue, you need unglomp it from your adipose, so one of the main ways to do that is heat. And we use Far-infrared sauna in our practice, to be able to do that.

                                                So it heats at a deep level, Far-infrared sauna and purges those phthalates out, to be able to be excreted through your feces or your urine. So you need to make sure those, what we would emunctories are open, so that you can get rid of them, right? So you need to be pooping properly. You need to be urinating, you need to be drinking water, which a lot of people just do not drink enough of. I would say 80% of our patients come in and they don’t drink enough water. So water and making sure that you’re eliminating properly are really crucial for getting rid of that stuff once you’ve unlocked it.

Dr. Weitz:                            Okay, do you ever consider the factor of sleep in terms of testosterone levels?

Dr. Cavaiola:             Absolutely, so sleep is crucial for so many things in your body. And one of the major things is helping to recharge. Recharge the battery once you’re sleeping, that’s what sleep is all about. And what we oftentimes see is patients who are chronically sleep deprived or who work night shifts and people who just are stressed out to the max. Why that’s important is that basically, it’s a stress on your body. Any kind of stress like that prevents you from basically recharging when you’re sleeping and secondarily, it kills your adrenal glands. And the adrenals are, like we mentioned earlier, a portion of the testosterone that you’re going to release on a daily basis. So we need to make sure that your adrenal glands, and you’re sleeping properly, absolutely. So eight hours sleep a night or whatever it is that you use as your litmus test for the amount of sleep that you need, is really crucial to be able to heal.

Dr. Weitz:                            Okay, so now you have a man, who has hypogonadism, i.e. low testosterone and he’s interested in taking the recommendation to get on testosterone. What’s your preferred type of testosterone you like to utilize?

Dr. Cavaiola:             Great question, so first and foremost, we use something called bioidentical hormone replacement therapy. So bioidentical, meaning it’s like the hormones that are found in your body, so what’s great about bioidentical hormones as opposed to synthetic hormones, is that your body takes them in and recognizes them as cell. So it doesn’t really have to do anything with it, doesn’t have to synthesize it or be overly processed by your liver, takes it in and can utilize it right away. It’s like, “Oh, thank you so much for these extra hormones, they’re very much appreciated.” And so there’s different applications that you can use of testosterone, we’re going to typically prescribe something called testosterone cypionate, C-Y-P-I-O-N-A-T-E. Cypionate, that’s derived primarily from soy and yam, mostly yam, not as much soy, which is a problem for some people. And so what we do is-

Dr. Weitz:                            And this is something that you take by injection.

Dr. Cavaiola:             Yes, so there’s different applications, there’s injections, there’s creams, and then there’s pellets. So we found that creams are helpful to a certain degree, it is in daily application, so getting people to be compliant on it is always a problem and making sure that people are doing enough of it, is also a problem. And making sure there’s no transference where there’s kids in the family, or transferring to a partner is not going to be a problem. So they work relatively well, but again, you need to be doing enough of it to make sure that you get a benefit.

Dr. Weitz:                            And where do you tell them to apply it?

Dr. Cavaiola:             So typically, you can apply it twice a day or mostly at night time.

Dr. Weitz:                            And to which part of the body?

Dr. Cavaiola:             So you’re going to apply it to non hairy skin. It’s just best easily absorbed when it’s on non hairy skin. And there are some doctors out there, that say to apply it to the gonads, to the testes, please don’t do that. It’s just you’re applying testosterone to an area that’s very androgen sensitive to begin with and we’ve seen a lot of people end up with prostate problems or further atrophy in their testes because of it, so don’t do that. And so the other thing is, we can also do pellets as well, pellets are a small little amount of testosterone and plant it under the buttox of the skin.

                                                It’s a minor surgical procedure and essentially, we’ve seen that unfortunately, it should last between three to six, depending on how much they put in. And we see a lot of times what ends up is that men get a lot of huge dose at the beginning and not as much at the end. So they feel great at the beginning, or they actually have too much onboard at the beginning and they kind of have some negative side effects and then not as much in the beginning, they feel like crap.

Dr. Weitz:                            So you had [inaudible 00:35:27] testosterone cream, what particularly product do you like to use, AndroGel, do you use compounded products?

Dr. Cavaiola:             That’s a great question, so some of the pharmaceutical derived testosterone products out there, first and foremost are messy, they’re expensive and they oftentimes don’t work because they don’t have very much in them. So you need to use gobs and gobs of it to get clinical benefit. As opposed to something like a compounded version of testosterone that we get from a compounding pharmacy, where we can specify how much testosterone we want per milliliter or per gram. So that we can make sure the patients are getting enough, that really is crucial.

Dr. Weitz:                            Okay, so what about AndroGel?

Dr. Cavaiola:             So AndroGel, I’ve had patients who have been on it and they come in and they say, “This doesn’t seem to be working.” And when you run the lab test, it verifies that. Their testosterone levels are not, they’re not really seeing a large increase in their testosterone level, nor are they getting any better. And that really is the worst thing, it’s a double whammy. So what we oftentimes recommend is bioidentical form of testosterone, that we can better control and the patients get more of a clinical benefit.

Dr. Weitz:                            So what percentage of your patients are on topical versus pellets versus injections?

Dr. Cavaiola:             So patients who come see us, the majority of them, 90%, 95% are on injections, about 5% are on creams.

Dr. Weitz:                            How often do they inject?

Dr. Cavaiola:             Injections typically vary depending on who the person is. If they have very, very low levels of testosterone, sometimes they’re injecting weekly, most of the time they’re injecting weekly. And if they are somebody who utilizes it very quickly, you can only really understand this if you start a patient on testosterone, they don’t really notice a benefit or they’re bottoming out towards the end of their injection cycle. Meaning six days or seven days. We sometimes do injections twice a week, which does help a lot of patients. So it’s typically twice a week to weekly.

Dr. Weitz:                            Does taking testosterone increase or decrease cardiovascular disease? I saw one paper that showed increased coronary artery plaque that resulted from taking testosterone from one year. This was a JAMA article.

Dr. Cavaiola:             Yeah, that JAMA article and unfortunately, the JAMA article was, I think you’re speaking of the article in the for frail older men. And so this was the study that came out and there was a subsequent study that came out as well, that kind of had a similar finding. And what we’re seeing is, that was in frail, older men, who were people in the VA system, VA healthcare system. And you are partially correct, the research says that there’s a slight uptick in the risk of having a coronary artery event, if during the first part of testosterone replacement therapy in older, frail men, I will just say that.

                                                Now, there’s been subsequent studies that have come out, that have completely debunked this and basically said, “Uh, uh, not true. Basically, yes, there is a small uptick in your risk at the start, but overall, testosterone has a positive benefit for cardiovascular health. And it’s a positive benefit for metabolic health and its positive benefit for so many other things, including like you mentioned earlier in the introduction, for lowering all cause mortality. That is the key, and improving quality of life as you age.” So the study, if you really break it down, and look at the percentages, actually, what they showed was, the men who were in the testosterone replacement group, was a smaller group than it was the non.

                                                And actually, the proportions were actually lower than for the people who had cardiovascular events. It was actually lower in the testosterone replacement group. So you need to know how to crunch the data, you need to look at the data and really analyze some of these studies a little bit closer, so you can understand what’s happening and we don’t want this to get a bad rep and it did, unfortunately. For three to five years testosterone was all over the place, there was lawyers, who were having a field day with this. There’s commercials on TV of, “Did you have coronary artery disease, have you been on testosterone replacement?” So it really scares people and we need to kind of put the positive spin on things to say, “This was in one population group only.”

Dr. Weitz:                            There’s actually an interesting relationship between testosterone and cholesterol, isn’t there?

Dr. Cavaiola:             Absolutely, so there’s been so studies that have come out, looking at this. The fact that testosterone improves cholesterol markers, just by doing that and that alone, not even dietary modification, testosterone lowers LBL, it raises HDL levels and it can lower total cholesterol as well, so-

Dr. Weitz:                            And actually, if you lower your cholesterol levels too low, cholesterol is actually the backbone molecule that your body uses to make testosterone.

Dr. Cavaiola:             Absolutely, so all these would come see us, who have been chronically, they’re put on statin medications and they’ve been on them for five, 10, 15, 20 years even. Oftentimes we see these guys with low T and low thyroid function and low everything production because cholesterol, like you mentioned, is the backbone, it’s making virtually every hormone in the body. So it’s really, really important.

Dr. Weitz:                            Yeah, now we know that testosterone increases red blood cell production, so hematocrit levels go up. So how do you handle this?

Dr. Cavaiola:             Great question, and so really, I would say this doesn’t happen to every single patient and-

Dr. Weitz:                            How often does it happen?

Dr. Cavaiola:             I would maybe 10% of the time. One out of every 10 patient you’re going to run into some kind of difficulties with this. And really, it-

Dr. Weitz:                            And what hematocrit level, is it hematocrit that you monitor for this?

Dr. Cavaiola:             Yes, yeah, I don’t know the exact values right now, while we’re speaking. But what I would say, is making sure that it’s within the reference range, that’s really important, right? And of course, monitoring things over time, that’s why it’s really important for us to understand the patient to begin with, what are their hematocrit levels to begin with, baseline, and then measuring every three, six months, so we can understand what’s happening with the patient. We want to do our due diligence, we want to be ethical, we want to make sure the patient’s safety is protected at all times.

                                                So when, and this does happen, there is a risk for hematocrit causing the blood to become sticky. When it becomes sticky, there’s a risk of cardiovascular events, that’s what we’re concerned about or throw in a clot, that’s basically what can happen, right? And so, what we do in these particular cases, is basically have the patient undergo a routine phlebotomy. Have them give blood and usually their hematocrit levels come down pretty quickly.

Dr. Weitz:                            Right, does taking testosterone increase or decrease the risk of prostate cancer?

Dr. Cavaiola:             Well, it depends on who you are. If you have preexisting prostate cancer, testosterone replacement therapy is not necessarily the best idea for you, that preexisting. However, how many men out there know that they even have prostate cancer to begin with because it’s such a low grade, slow growing cancer, that oftentimes we just don’t even know until it’s clinically diagnosed or diagnosed by a biopsy. However, the research basically shows that testosterone actually has a prostate protective effect, than it does causing prostate cancer.

Dr. Weitz:                            So let’s say a man comes in to see you and as part of your screening, testing, you do PSA levels, what level PSA would you be concerned about whether or not you should put him on testosterone?

Dr. Cavaiola:             So I don’t want to speak on behalf of every single patient who comes in because of course you always want to look at [crosstalk 00:43:48] patient, right? But I would say anything less than four, which is kind of the cut off point, would be kind of worrisome at that point in time.

Dr. Weitz:                            Right, let’s say you had a guy a three and a half.

Dr. Cavaiola:             I wouldn’t be concerned probably, and again, given if there was no symptomatology and you did a prostate exam and everything was normal, there was nodules or masses found, we’d be less concerned.

Dr. Weitz:                            Okay, and so you have a man with prostate, chronic stage, would you ever consider administrating testosterone?

Dr. Cavaiola:             I would highly consider it, yes. Would I necessarily do it all the time? No. I mean, I think there may be some other ways that we can raise testosterone levels, rather than doing testosterone replacement therapy.

Dr. Weitz:                            Would you ever do it?

Dr. Cavaiola:             I think this is something to kind of consider on a case-by-case basis, with each particular patient, depending on the severity of the case. If it’s a stage on or in C2 kind of situation, you’re probably not going to be as concerned than it was if it’s metastasized to the bone, that’s just not a good sign.

Dr. Weitz:                            Right, when you administer testosterone, do you ever recommend certain supplements at the same time to make sure that the body processes the testosterone optimally?

Dr. Cavaiola:             Yeah, I mean, in the way of preventing side effects or…

Dr. Weitz:                            Yeah.

Dr. Cavaiola:             Okay, yeah, I mean, certainly there are some products out there that can be used. For instance, there’s a product called Chrysin, which is essentially derived from the plant passionflower and that has been shown to be helpful to lower estrogen levels. So sometimes we do Chrysin alongside of testosterone replacement to help to mitigate the effects of estrogen on the body.

Dr. Weitz:                            Okay, good, excellent. So I think that’s a wrap for today.

Dr. Cavaiola:             Wonderful.

Dr. Weitz:                            Any final thoughts you have, and then give us your contact information, so patients out there can find out about you and your services.

Dr. Cavaiola:             Thank you so much, yes, so I think what I would say to wrap it up is, if you are struggling with the symptoms of low testosterone or if you think you have it, do not be afraid to talk to somebody about it. I think so often it’s the case where we, as men, do not go see doctors because we’re afraid of what we’re going to find out. We’re going to think that we’re less of a man if we have low testosterone or we’re scared of doctors. Whatever the reason is, please go see somebody about it, go see somebody, who’s going to look at you and understand your case and really take the time to listen to you. That really is crucial and that’s what I would leave you with today. And so, don’t wait before it’s too long, before it’s too [crosstalk 00:46:44]. Okay, so if you are interested in kind of more of our services, you can visit our website at www.concsioushumanmedicine.com C-O-N-S-C-I-O-U-Shumanmedicine-

Dr. Weitz:                            How did you come up with that name?

Dr. Cavaiola:             It’s really important to us, if you kind of look at, break it down in terms of the name, of course medicine stands by itself. But we are passionate about all of us becoming more aware of who we are as human beings and our health. Being conscious, being present and it’s important for us, as well, as practitioners to be conscious. We don’t want to just blindly see people, who come into our office and just give them supplements and send them on their way. It’s about a two-way street, it’s about having great relationships with our patients, being human.

Dr. Weitz:                            Excellent.

Dr. Cavaiola:             Yeah.

Dr. Weitz:                            Thank you Dr. Cavaiola.

Dr. Cavaiola:             Thank you so much for having me today, very much appreciate it.

Dr. Weitz:                            Excellent, I’ll talk to you soon.



Thyroid Health with Dr. Fiona McCulloch: Rational Wellness Podcast 137

Dr. Fiona McCulloch discusses How to Improve Your Thyroid Health 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  The thyroid is a butterfly shaped gland in the neck that is responsible for the metabolism of every cell in our body.  The thyroid is running the show for how our brain works, how our immune system works, and how all the rest of our hormones work.

4:25  The thyroid produces mainly T4, the inactive form of thyroid, that then gets converted into T3, the active form, in the cells in different parts of the body.  These tissues then convert T4 to T3 as needed.  While it occurs throughout the body, it does occur more frequently in certain organs, including the liver and the gut.  But it even happens in our fat cells and if you expose a fat cell to cold, that fat cell will then start producing T3 in order to generate heat and energy. It becomes hyperthyroid inside that fat cell.  This is also why when people are hypothyroid they feel cold all the time and their basal body temperature gets low.

7:58  Testing for thyroid function should include not just TSH, but also free T4, free T3, reverse T3, and the anti-thyroid peroxidase (TPO) and anti thyroglobulin (TgB) antibodies.  Dr. McCulloch will also sometimes measure the thyroid stimulating antibody (TRAb), aka TSI, to screen for Grave’s.  It is common in medicine to only measure TSH, which is the hormone that the pituitary gland makes that tells our thyroid to make mostly T4.  But we know from research that if a patient is hypothyroid and you correct their TSH to 1.5 to 2.5, there may still not be a difference in their energy expenditure compared to people who have never had a thyroid problem. In such cases, their thyroid is producing T4 but the body is not converting the T4 to T3 very effectively.  There are a number of possible reasons for this, including stress, nutritional deficiencies like iron deficiency, and there are also some genetic mutations/polymorphisms in the gene encoding one or more of the D1, D2, or D3 iodotyrosine deiodinase enzymes that help to convert T4 to T3 and these can be a factor in hypothyroidism.  Dr. McCulloch said that if you have a patient who is not converting T4 to T3 (their T4 is at the higher end of the range, such as 19, and the T3 is at the lower end, such as at 3), and you have fixed their iron, improved their sleep, worked on their adrenals, their stress levels, and their diet, and they’re still not converting T4 to T3, then you might suspect one of these genetic polymorphisms.   

16:22  With respect to elevated TPO antibodies, this is an indication of autoimmune hypothyroid, and if they are also symptomatic, such as having brain fog, fatigue, weight gain, etc., then we should be concerned about this, esp. if the TPO antibodies are above 50.  You should look at their cortisol levels, their stress, and their sleep.  You should also check their levels of iron, vitamin D, zinc, selenium, inflammation levels (HsCRP), blood sugar, and look at CBC for signs of infection.  It is also a good idea to minimize iodine intake, such as avoiding kelp. If the person has lost a lot of weight recently, this can cause the body to lower thyroid output.  You should also look at the gut and remove any dysbiosis or yeast overgrowth.  Then you might want to use a natural desiccated thyroid supplement, such as Armour thyroid or Nature-throid in the US or in Canada the product available is ERFA.  The natural desiccated thyroid contains both T3 and T4, as well as some T2, which plays a role in cholesterol metabolism.

25:48  Iodine is an important component of thyroid hormone and the typical thyroid nutritional support product and the typical multivitamin will contain 100 to 200 mcg of iodine, but some Functional Medicine doctors are recommending iodine in the 12-25 milligram range (thousands of micrograms).  Both Dr. McCulloch agree that super high dosages of iodine usually cause a flare of the antibodies and of symptoms in patients with Hashimoto’s and does not help.  Most of the scientific literature also supports this view, including the data on various countries that have supplemented the diet with iodine, such as iodized salt, that while rates of hypothyroid goiter conditions have gone down, rates of autoimmune hypothyroid have gone up. Here is one paper: Effects of increased iodine intake on thyroid disorders.  In fact, Hashimoto’s is named for an area in Japan where there is more of this iodine intake.  On the other hand, there are cases where the ingestion of halides, which are elements in the same column of the periodic table that compete with iodine for absorption, including flouride, bromine, and chlorine, and these can also cause some thyroid aggravation.

31:15  Reverse T3 is an inactive form of T3 that the body can make from T4, so it is important to measure this.  Some practitioners will look at an elevated reverse T3 or look at the T3 to reverse T3 ratio and will recommend taking higher dosages of T3, but Dr. McCulloch feels that this is ignoring the wisdom of the body and can cause heart palpitations and arrhythmias and the patient not feeling well. First, we need to understand that reverse T3 does not compete with T3 and we should try to figure out why the reverse T3 is being formed.  New research indicates that reverse T3 may have some beneficial functions in the body, such as stimulating the immune system during periods of starvation or illness.

33:35  Patients who lose a lot of weight in a short period of time will often see a decrease in their thyroid function. This is because feels like it’s in a famine situation and it wants to conserve its fat reserves for survival. The body will tend to deactivate thyroid hormone and convert T4 into reverse T3. Exercise can increase the metabolic rate, so make sure that such weight loss patients are doing regular exercise, including resistance exercise.  In some cases, such patient may benefit from taking a low dosage of natural desiccated thyroid for a limited period of time to help them get their system reset and get past that plateau of weight loss resistance.

37:17  Patients who benefit from thyroid support will usually also benefit from some adrenal support as well. Dr. McCulloch finds the herb Ashwaganda a really good adaptogenic herb that can help both patients who need some calming and also those who need simulation of their adrenals. She also finds that stabilizing their blood sugar is very important, since if their blood sugar dips, their body will increase the cortisol levels.  To avoid an afternoon blood sugar and cortisol spike, Dr. McCulloch recommends a healthy lunch with a serving of protein the size of their palm, 2-3 cups of veggies, some healthy fat, like 1/2 of an avocado or a handful of nuts or seeds. She likes to see the carbs low and slow, like a 1/2 cup of beans or of sweet potato.

40:14  The thyroid has a huge effect on the liver including regulating cholesterol production.  The liver normally gets rid of cholesterol through the bile, but with hypothyroid, the bile flow slows and cholesterol gets reabsorbed through the liver again.  So a low thyroid may be the cause of high LDL, since in hypothyroidism the LDL receptor is reduced by around 50%, which suppresses the uptake of LDL.  The thyroid can also affect liver enzymes and increase the risk of fatty liver through the way that it regulates the liver’s glucose metabolism and sensitivity to insulin.  And fatty liver can reduce thyroid hormone conversion, so there can be a negative compounding effect.  If a patient has fatty liver, Dr. McCulloch recommends intermittent fasting, alpha lipoic acid, N-acetylcysteine, phosphatidylcholine, and vitamin C to reverse it, along with the proper, low carbohydrate diet.



Dr. Fiona McCulloch is a Naturopathic Doctor and founder of White Lotus Integrative Medicine in Toronto, Canada, serving thousands of women with hormonal conditions. Dr. Fiona’s best selling book, 8 Steps To Reverse Your PCOS, offers her well-researched methods for the natural treatment of Polycystic Ovarian Syndrome (PCOS). Dr. McCulloch is available to see patients and can be contacted through her website, DrFionaND.

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.


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.   Hello Rational Wellness Podcasters. I would really appreciate it if you could go to your podcast app, Apple podcasts, or wherever you listen to the podcast and give us a ratings and review. That way more people will find out about our podcast. Also, if you go to my YouTube page you can find a video version, and if you go to my website you can find detailed show notes and a complete transcript.

Today our topic is the effect of thyroid health on metabolism. 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 known as thyroxin, and especially T3, triiodothyronine, which is a more active form affect metabolism, appetite, gut motility, heartbeat, breathing rate, the mitochondria and many other functions in the body too. Too little thyroid production, what we call hypothyroidism, including Hashimoto’s autoimmune hypothyroid, which counts for 90% of cases of hyperthyroid in advanced countries like the US and Canada can result in weight gain, a lack of energy, brain fog, feeling cold, constipation, hair loss, infertility, et cetera. Too much thyroid production, hyperthyroidism, including Graves’ autoimmune hyperthyroidism will speed up the metabolism and cause weight loss, et cetera. Today we plan to dig deeper into how thyroid works, how it affects our metabolism and the interaction between thyroid and liver health, with our special guest, Dr Fiona McCulloch.

This will be my second time getting to chat with the beautiful Dr Fiona after she made an appearance on Rational Wellness last year in episode 65, in which we focused on Polycystic Ovarian Syndrome. Dr Fiona McCulloch is a Naturopathic Doctor and founder of White Lotus Integrative Medicine in Toronto, Canada, serving thousands of women with hormonal conditions. Dr Fiona has written a best selling book, 8 Steps To Reverse Your PCOS, which offers well-researched methods for the natural treatment of polycystic ovarian syndrome. Thank you Dr Fiona for joining us here today.

Dr. McCulloch:                   Thank you so much for having me on your show again Dr Weitz, it’s great to be here.

Dr. Weitz:                          Good. So why don’t we start off talking about what thyroid is, what it does and what its importance is?

Dr. McCulloch:                   Absolutely. So, a lot of my practice is dedicated to treating thyroid issues even though.

Dr. Weitz:                          Oh my.

Dr. McCulloch:                   Yeah. So even though most of my practice is women’s health, I would say about 50% of that is treating thyroid health.

Dr. Weitz:                          Okay.

Dr. McCulloch:                   So it’s a huge thing and it affects so much about our health. So, the thyroid is a gland, it’s shaped like a butterfly in the neck, as you were mentioning. And it’s actually responsible for running the metabolism in every single cell in the body. So this tiny little gland is basically running the show for a lot of different things, including how our brain works, how we expend our energy, how our immune system works, and how all the rest of our hormones work. So this is a really powerful little gland that can easily have problems. So it’s definitely one of the most common hormonal conditions that we see in the clinic.

Dr. Weitz:                          Great. So, I’ve always wondered why does the thyroid primarily produce an inactive form of thyroid hormone T4, and then it has to get converted into T3.

Dr. McCulloch:                   That is a such a great question. And as we’ve been doing more and more research into this area, what we’re learning is that the way that the thyroid hormones are converted from the inactive hormone, which is mostly what the thyroid gland makes to the active hormone, it actually happens differently in different parts of the body. So in different cells there might be different things happening with the conversion of T4 to T3, so it’s a very intelligent mechanism that our tissues know what they need and they convert as they need so that the storage hormone that’s coming out, it’s our tissues that have to know what to do with it. And sometimes that goes really well in healthy people, and then at other times not so much.

Dr. Weitz:                          So, in other words each system of the body, each organ converts T4 to T3 as needed for its particular needs?

Dr. McCulloch:                   That’s right. Yeah. So most of the conversion happens inside the cell and these conversions are independent in many ways of other things that are happening in the body, so it’s very complicated what causes that. And there are certain people that have a lot of trouble converting and I can talk later about what those reasons are, but we’re learning more and more about why this is. We know there’s been a lot of people who’ve had thyroid disease, who are on medication, who’ve just never ever felt the same since they developed the thyroid disease, despite the fact that they’ve been treated and everything’s normal.

Dr. Weitz:                          So where is most of this being converted? So you’re saying it’s in every cell in the body? I thought it was primarily in certain organs like the liver and the gut.

Dr. McCulloch:                   So it definitely happens more in certain organs. Like the liver is definitely a big one, but we see this happening in the brain immune system, so all the different cells have different needs for metabolic energy. And for example, even our fat cells. So I was reading a study the other day that was showing us if you take a fat cell and you expose it to cold, that fat cell will then start producing T3 in order to generate heat and energy. So it becomes hyperthyroid inside that fat cell.

Dr. Weitz:                          Really interesting.

Dr. McCulloch:                   Yeah, it’s pretty interesting.

Dr. Weitz:                          So that can be another mechanism for why getting exposed to cold has a beneficial effect. Normally we hear about being exposed to cold increasing brown fat production, which is metabolically active and helps us burn calories. But it sounds like it has a direct effect on thyroid?

Dr. McCulloch:                   Yeah, exactly. And that’s actually part of how that whole thing works is by using the thyroid hormone to generate what we would call a sympathetic drive, so that kind of fat burning energy producing mechanism. So it’s really the thyroid hormone that’s involved in that. And that’s why a lot of people when they are hypothermia they feel very cold all the time, and their basal body temperature gets really low. And when you correct that you’ll see that their temperature gets much better.

Dr. Weitz:                            Right, yes. And you see more commonly in women who get cold easily and tend towards a little hypothyroid. So how do we measure thyroid? What are your favorite tests, and what do you think is the most important measurements of thyroid?

Dr. McCulloch:                   Yeah. So I’m so happy you asked this because it’s definitely one of the number one problems that we have today in understanding the thyroid. So the common-

Dr. Weitz:                            I’ve heard some doctors, even a prominent functional medicine doctor say, “Just TSH, that’s it, end of story. You don’t really need to worry about anything else.”

Dr. McCulloch:                   Yes, exactly. And so this has been sort of the standard for years that we only need TSH, which is really the hormone that the pituitary gland makes. And TSH basically tells our thyroid to make mostly T4, which can then trickle down into T3. But the TSH is supposed to be the regulator and it is true. And that it often is a leader in showing you problems with the thyroid first before you’ll see that sometimes with the other hormones. But it’s not going to give you all the information.  So we know from research, for example, if a patient is hypothyroid and then you correct their TSH age within, when you correct it to one point or to 2.5, what they find is that there’s actually not a lot of difference with the person’s energy expenditure at those different levels of correcting the TSH and getting their T4 levels optimized. But what they find is that there is still a deficiency in energy expenditure compared to people that never had a thyroid problem. So there is something where the tissues can still be hyperthyroid even if the TSH is normal in someone who has a thyroid condition.

Dr. Weitz:                          Wow, interesting. So what exactly is happening there?

Dr. McCulloch:                   So, probably the vast majority of what is happening is that the T4 is really not being converted in the cells very effectively into T3. And there’s so many different reasons for that.  So some of the reasons we’ve known for some time involve things like illness.  So they’ve known for a really long time that when patients get sick in the hospital their T3 levels go down, and their levels of reverse T3 which is like an inactive kind of hormone that our body turns T4 into, those levels go up.  So when someone is sick, so they could have inflammation or an infection or be sick from surgery or something like this, so their T3 will go down. And this is just the body’s way of preserving the energy and protecting against energy loss when you’re sick. Other things can do that as well, like stress for example, or nutrient deficiencies, like iron deficiency. And there’s also interestingly some genetic polymorphisms in some of the deiodinase enzymes. So those are the enzymes that convert T4 to T3. There’s three different enzymes, D1, D2, D3. So D1 and D2, those two are the ones that convert T4 into T3. And especially D2 it does most of that. So when we’re converting, this enzyme is responsible for most of that. And then D3 turns T4 into the inactive reverse T3. So what they’ve found is that about, I believe it’s something like five to 15% of people have a genetic polymorphism in D2, meaning that they can’t convert T4 to T3 as well.  So when you’re giving T4 hormone or Synthroid for example, which is the most commonly prescribed medication, there are many people no matter what they take they’re just not going to convert it the same way. And the way that, that’s given is not exactly the same as all the complex regulations the body would to if it was healthy, because we’re actually giving a hormone. So for that reason, yeah, some people they just don’t convert that well and they still have symptoms.

Dr. Weitz:                          Interesting. Since a lot of conversion is happening in the cells, I wonder if even serum levels of T3 are necessarily even going to reflect this?

Dr. McCulloch:                   Yeah. So it is thought that the serum free T3, because it’s a free hormone, does to some degree mostly correlate to the intracellular levels.  Because we do see that people’s energy expenditure rates when they’re looking at people in a metabolic chamber where they’re controlling everything, when their T3 goes up, their free T3, their energy expenditure goes up.  So there is some kind of correlation there, but there is all kinds of other things that we are not seeing.  You are so right, and so many things that we do not even understand at this point.

Dr. Weitz:                          So are these genes, these genetic polymorphisms for D1, D2 and D3, are these part of 23andMe or an Ancestry panel?

Dr. McCulloch:                   I have not seen them on there. I would have to revisit that and look again because I haven’t looked at what they have recently, but the last time I looked at it I did not see them on there.

Dr. Weitz:                          So do you test those?

Dr. McCulloch:                   Well, in Ontario where I practice we are not allowed to do genetic testing here.

Dr. Weitz:                          Really?

Dr. McCulloch:                   Yeah. I used to do that back a while ago when that was allowed. But my background is in molecular biology, but yeah, we are not allowed to do that. But patients can do that on their own, with 23andMe for example.

Dr. Weitz:                          Oh, okay. So it’s part of the 23andMe, okay.

Dr. McCulloch:                   Yes. I’m just not sure if those are in there or not, the deiodinase polymorphisms because I just haven’t looked recently. But it would be interesting to know.

Dr. Weitz:                          Yeah, I’m going to have to check. I know in the last year or a year and a half, 23andMe is not testing as many genes as they were before.

Dr. McCulloch:                   I know. I know they took some off their panel, some of the bigger ones too.

Dr. Weitz:                          Yeah. They use the less advanced method of testing unfortunately. So apparently Ancestry might be a little better for some of our purposes.

Dr. McCulloch:                   Yeah. It’d be pretty interesting to see that. And I think also the other way that I really noticed it is that the patients are taking T4 medication. And you check everything, you get everything fixed for them, you fix their iron levels, do everything you can for their sleep, their adrenals, their stress levels, their diet, and they’re still not converting T4 to T3, so you’ve got high T4 and low T3. My guess is it’s probably one of these polymorphisms that’s involved there.

Dr. Weitz:                          And so what do you consider a high T4 and a low T3?  Is it outside the typical range or is it more nuanced than that?

Dr. McCulloch:                   The way I look at it is where are they in the range comparatively to each other. So is the T4 up at 19 and the T3 is down at the bottom of the range at 3? Then we know for sure they’re not converting. If they’re around that same level, it looks like they’re most likely converting. But there’s a large percentage of people I would say, especially the people that are on a lot of Synthroid. So they’re on a very high dose of Synthroid, many of them are not doing well on that medication because they’re raising their dose to try to improve symptoms, and they just end up accumulating a lot of T4, it’s just all trickling down into reverse T3. So those levels on the panel can really tell you a lot, just the TSH, free T3, free T4 and reverse T3. And then looking at that compared to if they’re on medication or not, you can get a lot of answers from that.

Dr. Weitz:                          Interesting. So what’s your complete thyroid panel consist of besides TSH?

Dr. McCulloch:                   So yeah. So I definitely include TSH, free T3, free T4, reverse T3. And the two thyroid antibodies that I do most commonly are anti thyroglobulin and anti-thyroid peroxidase. I also do sometimes do the TRAb, which is a thyroid stimulating antibody that you’ll see more in patients who have hyperthyroidism or Graves’. So if I see anything like that, I’ll definitely run that as well.

Dr. Weitz:                          Is that the same thing as a TSI? I think they call it in some of the labs here. Okay.

Dr. McCulloch:                   Yes, exactly.

Dr. Weitz:                          So, now when it comes to TPO enzymes, what level are you concerned about? So this is an indication of autoimmune hypothyroid. So, I’ve heard one prominent functional medicine practitioners say, “Well, basically if it’s under 500 you don’t really need to worry about it.”

Dr. McCulloch:                   So, I kind of look at it, at first I look at the patient and I’m like, “Is this person well, or are they sick? Are they experiencing fibroids symptoms, are they experiencing brain fog, fatigue, weight gain? Do they have like a low body temperature, they’re feeling depressed and they weren’t like that before?” And then I look at the panel and I see how does their function look, and then I look at the antibodies. Now, you can see some people with really high antibodies that are totally fine, which is always interesting to me.

Dr. Weitz:                          What do you mean? What level antibodies are you talking about?

Dr. McCulloch:                   I even have some patients who are doing really well, but they have maybe in the hundreds. And they have no symptoms, it’s founded incidentally, their levels look great. So, for me it really matters if they’re sick or not. And then the more sick they are and the higher the antibodies are, the more concerned I am about that. And especially if I see the antibodies jumping, especially in the order of like a hundred or a couple hundred, or going from something like 50 to 300 then I know something’s going on there. So I think I am like, if they’re in the tens, like up to like 50 or so, many people like this can have a more mild type of Hashimoto’s. But if their thyroid’s really hypothyroid, maybe there’s more going on than we’re seeing those antibodies, then they have more damage to their glands. So I find the antibodies they guide, but they don’t tell me as much as looking at those hormone levels and correlating that with the patient’s overall history and how they’re doing their health. So I kind of take it all in consideration.

Dr. Weitz:                          Yeah. I think some of the labs say under 30 they consider that normal.

Dr. McCulloch:                   Yeah, they’re. Anything under like around 30, I don’t know if you guys use the same units, but yeah, around 30 for the TPO is considered normal. And everybody has some of these antibodies, you don’t see anybody with none. So I don’t tend to see people at that level, below the reference range or really having, I don’t see that as an issue really. If it’s a mild elevation, like sometimes I’ll see that for women who’ve just had a baby and then that can go back down, and that can go away. But when you see the people in the hundreds, that’s probably not going to just disappear overnight. So usually those people have to manage it for the most part. There are the rare cases that don’t, but most of them do have to manage their Hashimoto’s ongoing.

Dr. Weitz:                            So let’s say a patient comes into and they do have some hypothyroid symptoms and they do have elevated antibodies, let’s say not super high, let’s say they’re 150 or 200 or something like that. And what is your rationale? How do you think about this? How do you try to drill down and try to find some of the underlying causes of what’s going on here besides simply putting them on thyroid?

Dr. McCulloch:                   Yeah. So the very first thing I’ll do is if they’re having those symptoms, I’ll try to see do they have low T3 or are they not converting well? And then I’ll start looking at all the reasons they might not be converting well. So I’ll take a look at their cortisol and their sleep and their stress because that’s just huge. I’ll also look at, another good example is if people lose a lot of weight, their T3 will tank at that time because of the weight loss and the body is just really trying to conserve energy. And this all happens because the leptin actually has a huge impact on pushing back on the brain and causing us to actually not burn fat basically. So that mechanism there is a huge part of why people once lose weight, they hit the plateau.

So I always look at that. Did you lose a lot of weight recently or did you do a major change to your diet? I’ll check their iron, their vitamin D, I’ll check their blood sugar to make sure they don’t have diabetes or prediabetes. I’ll check their hsCRP to see if they have inflammation. I’ll look at their CBC to see if they have any signs of an infection. So I look for all the things that might be like the brain is trying to lower the thyroid about, and try to fix those things because that’s the underlying cause of the problem. But if they have these antibodies that are high and you’re working on everything else and you’re still seeing that problem, I’m always going to look at providing the nutrients the thyroid needs because with the antibodies you’re going to need a lot more selenium.

Zinc is another important nutrient as well. So I look at making sure the person’s sufficient in those nutrients and they’re not deficient in anything really important. And also that they have what they need to protect the thyroid gland from oxidative stress and damage from these antibodies. So the selenium is really important. I also tend to minimize iodine intake if they have recently elevated antibodies or a big spike in antibodies because those can be a bit of a trigger too. So I just tend to make sure they’re not consuming kelp or anything else that might be kind of triggering up the antibodies. And then I look at their gut and make sure that there’s nothing triggering infection with their gut infection or inflammation. They’re having some kind of reactions to foods. Do they have a gut infection of some sort, dysbiosis, yeast or bacteria or something else really happening with their gut that’s aggravating their immune system. So I try to look at the autoimmune part that way, and then once I’ve taken care of all of that then I might consider looking at natural desiccated thyroid as an option for some patients.

Dr. Weitz:                            So you prefer using natural desiccated thyroid versus synthetic T4?

Dr. McCulloch:                   I think if certain people are doing very well on synthetic T4 that’s totally great. If your cells work well enough to convert it, fantastic. I think that’s a great sign of being really healthy. Unfortunately, most patients with Hashimoto’s are not in that boat and they’ve gone through a lot like just they’re not feeling well. That might have disrupted their sleep, it might’ve caused stress, they might have other hormone problems. So those patients tend to do better on the desiccated thyroid because it doesn’t require every cell to convert T3 exactly right on point. It would be great if we all could do that, but not most people who have Hashimoto’s are not feeling well. So not so much in that case.

Dr. Weitz:                            What’s your preferred desiccated thyroid product? And there seems to be some issue these days with Armor having maybe change their formulation and some of the products being difficult are on back order.

Dr. McCulloch:                   Oh yes. So we have that problem here too. So in Canada we have only one product which is pharmaceutical called… Yeah. So we don’t have Armor and we don’t have-

Dr. Weitz:                            WP and Nature-Throid no?

Dr. McCulloch:                   No. We don’t have WP or anything, but we do have Erfa. And Erfa is great. It’s actually a really good desiccated thyroid product. So I actually really liked that. And I know a lot of Americans do order that from here, but we are having the same issues with the shortages which appear to be raw material related, because it’s a problem with the manufacturer. So it’s really like a worldwide raw material shortage that seems like it will be improving soon, but it’s really come from that, that all these deficiencies. And that’s why all of the different companies have run out of stock around the same time.

Dr. Weitz:                          So the reason you liked the natural desiccated thyroid is because it’s essentially is a combination of T4 and T3? Is that the main reason why or are there other reasons as well?

Dr. McCulloch:                   That is the main reason. And I also feel that the other thing that it has the other thyroid hormones in there, like T2 for example, which we’re learning does have to play a role in cholesterol metabolism. And you’ll just see night and day changes with patients when they switch from a T4 medication to desiccated thyroid. And there’s very consistent ways that we don’t sit and tweak people’s medications. And my clinic we’re pretty experienced with doing that with the desiccated thyroid and we have really good results. So we tend to get more of the patients who aren’t feeling well on Synthroid. So I think that they’re coming to us for that reason. That tends to be my preference probably because I’m already getting the patients that are not doing well in the first place.

Dr. Weitz:                          Right. You mentioned nutrients and you mentioned iodine, and there are some docs out there recommending super high dosages of iodine. Typical amount of iodine recommended per day is typically you 100 to 200 micrograms per day in most multivitamins or somewheres in that range. And yet there are products on the market that have 12 or 25 milligrams, so that’s thousands of micrograms.  And some doctors claim they get really great results with that. I’ve tried it on some patients that weren’t doing that well and I haven’t seen good results with it.

Dr. McCulloch:                   Yeah, this is a super controversial topic and I totally agree that these higher dose iodines, they’ve been around for quite some time as well as the testing for it.  And I agree there’s probably people that do feel well on this. There’s lots of people who report that they do. I have not seen that either, I agree with you. I haven’t seen patients improve and I’ve actually had patients come in who’ve done this on their own, maybe like the really high dose milligrams of iodine, like Lugol’s for example. And ended up with really bad flare ups of their antibodies and even thyroiditis and hyperthyroidism. So, and we do know from some of the population studies that populations that increase their iodine intake, they have increased levels of antibodies.  Hashimoto’s is actually even named for an area in Japan where there is more of this iodine intake.  So it’s just something I have not seen personally to help that much. And to me it’s potentially risky. And I have seen patients who were intaking iodine in medium amounts, maybe not as high as these really high milligram amounts, but when they cut back on the iodine their antibodies have gotten better.  So I know we have a lot of information in the literature that high-dose iodine is definitely going to be aggravating too many people.  It’s difficult to predict who those people are, so I tend to go towards the treatments that I know are safe and effective and that I have more experience with prescribing.

Dr. Weitz:                          Have you looked at the other products–halides?  So these are elements in the same category as iodine, like fluoride and bromine and chlorine, and some have claimed that these can negatively affect thyroid by interfering with the iodine. Have you looked at that or do you have an opinion on that?

Dr. McCulloch:                   Yeah, I agree with that. I think that can be an element where you can see that these elements will interfere with the uptake of iodine and the utilization of iodine, so that could potentially be true.  There are some tests where you can check for urinary bromide for example, and fluoride and see if you’re being exposed to that.  You would want to make sure you’re not deficient in iodine if that’s the case.  But it’s very difficult to know that without doing this testing.  And then to give them iodine and assume that these negative reactions are a detox type of reaction.  We just don’t really have evidence that’s what’s happening because there are a lot of people that have reactions to iodine and they’re not feeling well, but people are saying this is a detox reaction.  We just don’t really know. It could be the iodine aggravating the patients because we know that this can happen too. So I do believe there is some definitely the fluoride is not great for our thyroid and bromide.

Dr. Weitz:                          Do you have mandatory fluoride added to your water up there in Canada?

Dr. McCulloch:                   Yes we do, absolutely.

Dr. Weitz:                          Yeah, I know a lot of our water has chlorine. I know in Los Angeles where I am we have chlorine and ammonia both added as antiseptics in the water.

Dr. McCulloch:                   Ammonia, that’s not good.

Dr. Weitz:                          Chloramine, yeah.

Dr. McCulloch:                   I don’t know what we have. I have a reverse osmosis in my house.

Dr. Weitz:                          I use that too. Yeah.

Dr. McCulloch:                   Yeah, because I just don’t even want to know what is going into the water supply. One day I moved into my new house and there was a lot of rain and I had my tap on, and I smelled this chlorine smell so strongly coming out. And I was like, “This is crazy. How is this coming out of my tap?” And then I was talking to someone who works in the city and they were saying, in this area because we’re on the Lake and there’s a lot of rainfall, they’ll shock the water supply with chlorine to get rid of organisms. And so that’s what that was.

Dr. Weitz:                          Yeah. There goes the organisms in your gut, right? Bye.

Dr. McCulloch:                   Yeah. I figured it’s got to be bad if your tap water smells like bleach, it’s intense.

Dr. Weitz:                          Yeah, not good. You probably could have lit it on fire, right?

Dr. McCulloch:                   Yep. So, then I called up the water filtration company and here we are.

Dr. Weitz:                          There you go. So talk a little bit about reverse T3. I saw you had an article about reverse T3 and why that’s so important.

Dr. McCulloch:                   Yeah, so reverse T3 it’s one of the hormones that is inactive. So we have the T4 that can turn into either T3 or reverse T3. So T3 is the active hormone and reverse T3 is the inactive hormone. So when people learn about this, I think something happened on the internet where people started to almost villainize reverse T3 as this terrible hormone that we must eliminate and get it down.

Dr. Weitz:                          And everybody said you have to look at the free T3 to reverse T3 ratio. And that was the true marker for thyroid health.

Dr. McCulloch:                   Yes, exactly. And then another trend that happened was if your reverse T3 is high, well what you must do is give T3 medications to force it down, and often very high amounts of this has been done. And it’s really ignoring the wisdom of the body. So the reason that the reverse T3 is high is cause your body wants that to be the case. It’s choosing to do that because it’s saying there’s something that it wants to conserve energy around. And I think before we can say that we need to lower this reverse T3, we need to figure out why is it like that and help the patient overcome that.

And reverse T3 does not compete with the T3 for the T3 receptor, that’s been proven. So it’s not a competitor, it’s just a product that your body is using to kind of get rid of extra hormone it doesn’t want or need. And we’ve also found in new research reverse T3 seems to have, it actually seems to have functions that are on the immune system that are related to times like starvation or illness. So forcing that down is in my opinion pretty risky, especially if you don’t really know what’s happening. And I’ve seen a lot of patients taking all this T3, they end up with palpitations or arrhythmias or not feeling well. Just kind of stressing out, getting yourself into that flight or fight stimulated stage. Sure you have energy, but it’s not great, it’s not good for your health to be in that kind of amped up state all the time.

Dr. Weitz:                          Yeah. You mentioned that people who have a lot of sudden weight loss will see a decrease in their thyroid function, so can people with normal thyroid just because they lost a bunch of weight all of a sudden be suffering from hypothyroid?

Dr. McCulloch:                   Yes, absolutely. And the thing with that is that the thyroid gland is totally fine. It’s more the peripheral conversion. So the fat cells they start burning the fat, the fat mass decreases. And then our fat cells are like, “Oh, I think we’re in a famine maybe because these are very primitive parts of our brain.” So the fat cells are now buckling down and conserving all the energy. And that part of how they do that is actually by deactivating the thyroid hormone. So changing T4 into reverse T3. This happens in healthy people who have no thyroid problem, but it’s not really that their thyroid is involved, it’s more that the cells are doing this to conserve energy.

Dr. Weitz:                          So what do you do about that if you’re trying to lose weight and now you hit this sticking point where your thyroid is slowed down or the conversion of T4 to T3 and the periphery is slowed down?

Dr. McCulloch:                   Yeah, it’s a really good question. So, firstly we would want to do anything we can to optimize that conversion and take away other stressors. And I always say to people the worst time to lose weight is especially I think drastic is if you have stress or a lot going on or can’t get enough sleep.

Dr. Weitz:                          Is there anybody who doesn’t have stress?

Dr. McCulloch:                   Yes. So, no. But yeah, you want to do it at a time that your life is somewhat normal. You’re not doing something really super intense like releasing a book for example. It may not be the best time. Yeah. So basically we take care of everything else that could be contributing to that first. And then there’s different methods that you can use, for example with exercise to just increase your metabolic rate. Ways that you can increase your mitochondria so they’ll burn more energy, so those I always prefer to recommend first. And then there are some patients who do benefit from a little bit of natural desiccated thyroid when they get really stuck. And so in those patients, as long as everything else is taken care of and that’s not going to be a stressor to their system, it’s something that I’ve done for patients and it’s been really helpful for them.

Dr. Weitz:                          Is that something that they’re now going to have to take the rest of their life?

Dr. McCulloch:                   Not usually, so it depends. Yeah. So it’s more when they get to the weight they want to be at, especially if they’re able to increase their muscle mass or do other types of methods to make sure that they do kind of keep their metabolism healthy, then that small amount might just be there to help them get through that plateau and improve further with their metabolism. But yeah, these would be very tiny amounts, not clinical like the higher clinical doses we would see in hyperthyroid patients.

Dr. Weitz:                          So what dosage are you talking about?

Dr. McCulloch:                   Maybe 15 milligrams. The standard starting dose is between 30 and 60 for the patients that have that real weight loss resistance, just like a little bit because their T3 sometimes can be like really, really low and they start getting really cold. And so we do that along with everything else that we can. So getting their sleep and their exercise all dialed into.

Dr. Weitz:                          And when you have a patient who needs some thyroid support, how often do you find that they also benefit from some adrenal support?

Dr. McCulloch:                   Pretty much every single time. Yeah, I don’t think there’s any. Because the other thing too is that having a thyroid condition is really stressful. It just affects so much. So it affects your brain a lot. A lot of people don’t realize how much it affects our brain chemistry. We can have depression, anxiety. People who’ve never had these issues in the past, just develop them. So this causes a lot of disruptions to sleep which really affects the adrenals, or you can have anxiety, which really affects the adrenals. So, just having a thyroid condition is a stressor. And then treating the thyroid as well it can take some time. And so giving the person that extra stress relief and helping them their adrenals to be healthier, helping their brain to perceive stress more normally and have less cortisol reactions to stress is always very helpful for thyroid patients.

Dr. Weitz:                          So what’s your favorite way to support the adrenals?

Dr. McCulloch:                   Oh, I have quite a few. I guess one of my favorites would have to be ashwagandha if we’re looking at a supplement, because it’s so multipurpose. I find many people respond really well to ashwagandha, whether they’re hyper or hypo. It’s nice and calming, so it’s not overstimulating. And then my other favorite would really be keeping blood sugar under control.  A lot of people don’t think of that as something that relates to the adrenals, but every single time your blood sugar drops your cortisol goes up.  And so when you run people’s cortisol, a lot of the time their cortisol spike in the afternoon above the range and it’s because their blood sugar dropped at that time.  So it’s just one of those little things that I’ve learned that makes a huge difference for people’s adrenals.

Dr. Weitz:                          So how do you keep their blood sugar from dropping in the afternoon?

Dr. McCulloch:                   So, I just make sure that they have a really good lunch with a lot of… serving of protein about the size of the palm, two or three cups of vegetables, a nice serving of healthy fat. So something like a half of an avocado or a closed handful of nuts or seeds. And then just keeping the carbs on the lower side. So like a half of a cup of carbs for example. And then choosing carbs that are more slower burn. And so you could look at resistance starch. So something like for example, white beans have a good amount of carbs but they’re high in resistant starch, which really stabilizes blood sugar. Or you could look at sweet potatoes as a tuber that is a very low reactivity kind of carb. So, but really making sure that it’s the proteins, the fats and the vegetables are dialed in. And then just keeping the carbs from running the show, that really stabilizes blood sugar for many, many hours.

Dr. Weitz:                          How does the thyroid interact and affect the liver?

Dr. McCulloch:                   So, the thyroid actually has a huge impact on the liver. Some of the different things that it does, one of the big ones is regulate cholesterol production. So the liver produces cholesterol and a lot of this is actually under the regulation of the thyroid. So for example, if someone’s hypothyroid, what happens is their bile actually slows down. So the bile is the stuff your liver secretes, it goes through your gall bladder and out into your intestines and out your body it goes, and there is cholesterol in the bile. And what happens in hypothyroidism is that slows down and so the cholesterol is actually reabsorbed back up through the liver again. So you’re getting more cholesterol taken back up. The other thing that it does is it reduces-

Dr. Weitz:                          That’s interesting. So if you are working up a patient for cardiovascular disease and you’re trying to control their cholesterol, maybe they have elevated LDL particle number or a small dense LDL and your strategy’s not working, think about looking at the thyroid?

Dr. McCulloch:                   Oh yes, absolutely. I see so many patients who have high cholesterol, they actually have a thyroid problem.

Dr. Weitz:                          An alternative to simply increasing the statin level.

Dr. McCulloch:                   Yes, because it’s not the cause, it’s actually in many cases it’s… I think I saw a study where they were saying that-

Dr. Weitz:                          A Lovastatin deficiency is not the cause of high cholesterol?

Dr. McCulloch:                   Yeah, whatever. It’s just that’s not addressing that the fact that their thyroid is low. But yeah, it’s super common. One of the first things I think when I see high cholesterol, I’m always like, “Lets look at the thyroid.” Because a lot of the time it’s that.

Dr. Weitz:                          By the way, with men, they hardly ever screen for thyroid.

Dr. McCulloch:                   I know. Yes, absolutely, they never do. And if they do it’s just TSH, they’re not looking at anything else.

Dr. Weitz:                          Right, absolutely.

Dr. McCulloch:                   And a lot of men they’re just tired or they’re gaining weight, but they’re not as likely to mention this to the doctor and they’re just in there getting their blood. They’re like, “What’s on my blood?” Your cholesterol is high So they don’t necessarily think to mention that they’re feeling tired or they’ve gained some weight, it’s just not something brought up to men very often is hormones unfortunately. And it really should be.

Dr. Weitz:                            Absolutely, yeah. So go ahead with thyroid and the liver. So it affects cholesterol and?

Dr. McCulloch:                   Yeah. And then the other thing is that it’s responsible for the production of the LDL receptor. So, basically when someone’s hypothyroid their LDL receptor can reduce by around 50%, which is huge. So it suppresses the uptake of LDL, and then of course you’re going to have increased LDL. So that’s another way. So it has a pretty profound effect on cholesterol. And then it also regulates the way that the liver produces glucose, and the liver is sensitive to insulin through actually the nervous system that goes from the brain down to the liver. So it has really high level effects on the liver and metabolism too.

Dr. Weitz:                            Interesting. So, what would we see on a lab test if we saw somebody with the liver enzymes are slightly higher? We typically start thinking maybe they have fatty liver. And so you’re saying this can be related to thyroid?

Dr. McCulloch:                   Yes, very much so. And they exacerbate each other. So having fatty liver can reduce thyroid hormone conversion because of the inflammation that’s there. So they actually make each other worse. So, the hypothyroid affects the liver and causes all of the fatty liver, it slows the metabolism down too. So, the burning of fat is lower. So it just accumulates more, less is going out, more is getting taken back up, the receptor is down. So it’s just a vicious cycle.

Dr. Weitz:                            So, besides lowering the carbohydrate intake of the diet, what other strategies are there for… what are your favorite strategies for combating fatty liver?

Dr. McCulloch:                   So yeah. I would say 100% diet is the number one strategy for that. But just to go even further into diet, intermittent fasting is fantastic because it really gets the insulin down and allows the liver to really release the extra energy that’s there.

Dr. Weitz:                            What do you call intermittent fasting?

Dr. McCulloch:                   So, it really could mean anything about going from one meal to another. But what I’m talking about more is at least 12 hours and maybe like a 16:8 would be the minimum that I would consider to recommend to patient. The 16:8 I find I recommend those several days a week for patients a lot. Not every single day, but a lot of patients can do that and it makes a huge difference with the liver and its function. So, that’s definitely one of the big ones that I suggest for people.

Dr. Weitz:                            Are there any nutraceuticals, nutritional supplements that can be beneficial for fatty liver?

Dr. McCulloch:                   Yes, absolutely. So, I find some of my favorites are alpha lipoic acid because it definitely helps with the insulin resistance as well as provides antioxidants to the liver. And acetylcysteine is another one of my favorites. It’s very much-

Dr. Weitz:                            Which is the precursor for glutathione, right?

Dr. McCulloch:                   Exactly, the precursor for glutathione. It’s used in liver detox pathways. It is antiinflammatory, it helps with insulin sensitivity. Making sure that there’s enough choline as well is really important, which can be taken in through something like phosphatidylcholine or you can get choline from eating liver or eggs as well. So those can be really key. And I’d find as well just making sure that there’s really good antioxidant status. So even something as basic as vitamin C, if you have low vitamin C, your liver will not be functioning at its most optimal. And when the liver is fatty, it’s already very congested and there’s so much inflammation and so much additional need for different nutrients, that vitamin C is very easily depleted.

Dr. Weitz:                            I don’t want to go down another rabbit hole because we’re just about out of time, but you mentioned choline and I’ve had several discussions on the podcast about the current controversy about TMAO being caused by consuming choline. Do you have a comment about that? TMAO is this marker that the Cleveland heart lab came up with for increased cardiovascular risk.

Dr. McCulloch:                   Interesting. I don’t know about that study, but is that a certain kind of choline or is it dietary choline or supplemental choline?

Dr. Weitz:                          Both. Absolutely. So, Stanley Hazen who developed this TMAO marker, it’s on a blood test, it’s being offered, I think Boston heart lab includes it now. And they’re saying this is an independent of cholesterol marker for heart disease risk. And intake from food or supplements of choline, L-carnitine or phosphatidylcholine are all the things that he says you need to reduce. And I have a lot of problems with this concept because those nutrients are super helpful and we found choline super beneficial for the liver, and L-carnitine another super beneficial nutrient, including for patients with congestive heart failure. So it’s really hard for me to buy into this TMAO hypothesis, but it’s a point of controversy right now in discussion.

Dr. McCulloch:                   Yeah. I’ve never heard of that.

Dr. Weitz:                          Look it up, TMAO.

Dr. McCulloch:                   Yeah, I definitely will. And I would find it, I would want to see like some kind of information that it shows because we know that the choline has been found in many other studies to be very beneficial for the liver.

Dr. Weitz:                          Absolutely. And we’ve seen eggs do not increase your risk of heart disease, which are high in choline. Yeah.

Dr. McCulloch:                   Yes. I want to see what are the elements that are related in how is this pathway, could it be related to something else and is it directly damaging? I’m just sort of interested to see more about that, but I’ll definitely look into that. That’s really interesting.

Dr. Weitz:                          Yeah. Listen to the podcast interview I did with Bob Rountree. That was one of the things we discussed, but it’s come up several times in discussions about cardiovascular risk.

Dr. McCulloch:                   So interesting because we don’t see in population studies that really consuming eggs increases cardiovascular risks.

Dr. Weitz:                          By the way, this is another tool right now for the… there’s kind of a dietary war going on right now and we have the different sides.

Dr. McCulloch:                   Yes.

Dr. Weitz:                          But the plant based side, i.e. the vegan side is, yeah, we got you with the TMAO now.

Dr. McCulloch:                   Yes. So may be there are certain things you can pluck in.

Dr. Weitz:                          Reason why you can’t eat meat, you can’t eat eggs.

Dr. McCulloch:                   Yes. I think we saw that with carnitine in the past as well.

Dr. Weitz:                          Exactly. Carnitine like this TMAO. Yeah, exactly.

Dr. McCulloch:                   Yes. So I will have a read and do some thinking on that too.

Dr. Weitz:                          Good. Okay. So how can viewers and listeners get ahold of you and contact you, and find out about your book and your program? And when is your thyroid book coming out?

Dr. McCulloch:                   I still haven’t recovered from my last book. But you can reach me at whitelotusclinic.ca. I have a practice in Toronto. We have a clinic where we serve lots and lots of patients with hormone problems. I have a book called 8 Steps To Reverse Your PCOS on polycystic ovary syndrome. I have an Instagram page @drfionand, and I have a blog also at drfionand.com with lots of information. So feel free to follow me there.

Dr. Weitz:                          Excellent. Thank you Fiona.

Dr. McCulloch:                   Thank you Dr Weitz, it’s so nice to talk to you today.

Dr. Weitz:                          Excellent, I loved it.



Detoxification with Dr. Alejandro Junger: Rational Wellness Podcast 136

Dr. Alejandro Junger discusses Detoxification 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

4:23  The term detoxification has started to be accepted by mainstream America, though not so much by mainstream medicine, who tend to think of it as quackery.  This is because the term detoxification has been hijacked and misused by so many people who have no idea what they are talking about that the Institute of Functional Medicine has changed the name to biotransformation. The body is bio-transforming these exogenous chemicals from toxic to non-toxic and from lipophilic in to water-soluble so that the body can eliminate them.  This happens more intensely in the liver, but it happens in every cell in the body, and also it happens in the intestines through your intestinal flora, which detoxify about 40% of these toxins that we are exposed to through our diet and water.  Whether you call it biotransformation or detox, which Dr. Junger still likes to use, you are not turning on any function of the body that was not turned on before, but you are creating the conditions for this to happen more effectively by supplying all the nutrients that the body needs in order to attach to the toxic molecules to convert them into non-toxic and water-soluble.

8:00  Some of the most important toxins that are impacting our health are the preservatives in food that prolong shelf life. These preservatives prevent bacteria and fungus from growing on the product, so they will kill the bacteria in our gut. Dr. Junger likes to tell people that the longer the shelf life the shorter your life. We need to avoid eating these chemicals found in processed foods because they will eventually promote chronic disease.  These toxic chemicals are everywhere and they are cumulative. Just like how the big fish eat the smaller fish and accumulate mercury and they will eventually cause chronic diseases.  The good news is that your body knows how to get rid of most of these toxins, especially if you learn how to create the conditions and you support your body nutritionally, you will be able to rid yourself of 90% of these toxins.  There are some toxins that will require some extra effort to get rid of, like heavy metals, which require doing some chelation to help your body detoxify them. 

12:57  Some of the impediments to our bodies being able to clear these toxins is that there are so many chemicals being released into our air, food, water, in our cleaning products, and in our furniture on a regular basis, but our body’s ability to detoxify is impaired for 3 main reasons.

1. One reason our ability to detoxify is that we need specific nutrients to detoxify that are not being found in our food, since much of our food is depleted of nutrients, and you will not have the raw materials that your body needs to do this work. 

2. Also, our intestinal flora has been decimated that is responsible for up to 50% of the detoxification work of the body. 

3. An additional impediment to detoxification is that we are eating constantly and digesting throughout the day, that it is taking so much of our body’s energy.  This goes against nature’s design, which for thousands of years involved periods of fasting until the next time you were able to find food.  Our bodies evolved in a way that it gave the digestive system a lot of importance with a nervous system that has the power to shut off other functions in the body so that the body could shut off everything else (including detoxification) to dedicate itself to being able to digest and absorb the food, since we never knew when the next meal was going to come.   

21:14  Dr. Junger explained that the reason his new Clean 7 program is for 7 days instead of his Clean program, which was for 21 days, is that many more people are willing to commit to a 7 day program than one for 21 days, even though the 21 day detox resulted in incredible benefits.  To help people get the same benefits as the longer program, Dr. Junger incorporated Ayurvedic medicine principles, along with Functional Medicine and intermittent fasting.

25:58  From Functional Medicine Dr. Junger uses the elimination diet, which is one of the most powerful tools in the Functional Medicine chest for helping patients, and the 5 Rs, which are remove, restore, re-inoculate, repair, and relaxRemove by avoiding all the toxins, processed foods and even foods that are considered healthy but hinder somehow the detoxification processes like grapefruits and nightshades and things like that. Then, restore all the nutrients by eating whole foods, local, and ripe, and organic, and then repair by adding glutamine and other nutrients that help the intestinal lining repair and re-inoculate by adding probiotics so that your army of helpers can get strong and help you detoxify amongst other things.  Relax, you spoke about how our stress, it takes away from the healthy processes in the body. 

28:10  From Ayurvedic medicine, Dr. Junger uses the dosha system, which places you into a specific category based upon your constitution, which further individualizes the elimination diet.  He adds to the foods to avoid from the elimination diet a list of foods to avoid according to your dosha. For example, if you are fiery dosha, which is pitta, you will avoid the foods that are also fiery like spicy foods and mango and there’s a list of foods that contain a lot of fire. The dosha categories are pitta, kapha, vata.  The other principle that Dr. Junger draws from Ayurvedic medicine is the use of Ayurvedic herbs and he uses the most powerful adaptogenic herbs from Ayurveda, including ashwagandha, shatavari, and tulsi/holy basil.

30:15  Dr. Junger also mixes in intermittent fasting so that you allow the body to give the digestive system a rest to allow some of your body’s energy to be reallocated to help you burn more fat and to intensify the biotransformation reactions involved in the detox process. Intermittent fasting really requires a 24 hour fast and Dr. Junger said having a 12 or 14 hour fast by skipping breakfast is not really an intermittent fast but intermittently stopping from eating.

40:07  An elimination diet should include eliminating dairy, sugar, coffee, alcohol, and gluten.  Dr. Junger also recommends eliminating nightshades and citruses and a few other foods like grapefruit, that blocks phase one detoxification.


Dr. Alejandro Junger is a cardiologist who has embraced a Functional Medicine approach to treating patients.  He went to medical school in Uruguay, where he was born and did his postgraduate training at NYU and Lenox Hill Hospital in New York.  He also studied Eastern medicine in India.  He is the best selling author of the books Clean, Clean Gut, Clean Eats and his new book Clean 7.  His website is CleanProgram.com.

Dr. Ben Weitz is available for Functional 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 or go to www.drweitz.com.


Podcast Transcript

Dr. Weitz:            This is Dr. Ben Weitz with the Rational Wellness Podcast bringing you the cutting-edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube and sign up for my free eBook on my website by going to drweitz.com. Let’s get started on your road to better health.   Hello Rational Wellness Podcast listeners. Thank you so much for joining me again today. For those of you who enjoy listening to Rational Wellness Podcast, please go to Apple Podcasts or wherever you get your podcast and give us a glowing rating and review. That way, more people can find out about it. Also, if you’d like to see the video version, please go to my YouTube page and if you go to my website drweitz.com, you can find a complete transcript and detailed show notes.

                                Today our topic is detoxification with Dr. Alejandro Junger. Our modern world, as many of you know, is awash in toxins. They’re in our air, our water, our food, Teflon pans, sprayed on our lawns, used to build and clean our homes, fire retardant chemicals in our furniture, and toxic chemicals and products that we use to clean ourselves and rub on our bodies. To quote from Dr. Junger’s new book Clean 7, your mattress mostly contains fire retardants and other chemicals.  As your sheets, pillowcases, and pajamas have been rubbing against skin, so is the residue of the detergent, softeners, and scents with which you wash them. You step out of bed and walk barefoot on your hardwood floors or your cozy carpets. Chances are they’re off-gassing benzene, phenylcyclohexene used to make carpet backing or the solvent perchloroethylene, all known carcinogens.  In the bathroom, you splash water onto your face or get under the shower, which I did this morning. Most city supplied water contains all kinds of unwanted and unintended toxic chemicals as well as some intended ones. Trihalomethanes such as chloroform, chlorine, and lead, and just about every medication you can imagine including antidepressants, erectile-dysfunction meds, anti-inflammatories and antibiotics.  We can go on and on about all the chemicals in our environment but it’s clear that we are awash in all sorts of toxic chemicals and we need to spend some time and energy making sure that we rid our bodies of some of these toxins if we want to have optimal health. This is why Dr. Junger developed this detoxification protocols in Clean and now in his new Clean 7 book.

Dr. Alejandro Junger is a cardiologist who has embraced the functional medicine approach to treating patients.  He went to medical school in Uruguay where he was born and did his postgraduate training at NYU and Lenox Hill Hospital in New York. He also studied Eastern medicine in India. He’s now the best-selling author of the books Clean, Clean Gut, Clean Eats, and his new book Clean 7. Dr. Junger, thank you so much for joining me today.

Dr. Junger:          Thank you for having me.

Dr. Weitz:            I noticed your books are getting shorter and shorter from Clean, which was like a 30-day program. Now, we have a seven-day program. I figure the next book could be Clean One Hour and the patient gets an IV glutathione along with colon hydrotherapy while sitting in a infrared sauna.

Dr. Junger:          Well, that definitely would help.

Dr. Weitz:            Dr. Junger, is the concept of detoxification, is it finally starting to be accepted by mainstream medicine?

Dr. Junger:          I’m not sure if it started to be accepted by mainstream medicine but it started to be accepted by mainstream, and the problem I think and I agree with the Institute for Functional Medicine stems a little bit from the name, which has been prostituted and used nilly-willy by so many people that have no idea what they’re talking about, and therefore, these days, you say detox to a mainstream doctor or nutritionist and they tell you that this is quackery, and then that your body already knows what to do and that there’s no need and all these chemicals are all approved and studied and that’s why the government lets factories put it in all our products.  Functional medicine has now changed the name to biotransformation, which I think is genius because this is really what’s happening inside the body. The body is bio-transforming these exogenous chemicals from toxic to non-toxic and from lipophilic in, meaning the only, you know 90% of these molecules dissolve only in fat, and the body doesn’t know how to get rid of things that are only dissolvable in fat, so it has to be converted to water-soluble so that the body can eliminate these things.  This happens in the liver mostly or more intensely but it happens in every cell in the body, and also it happens in the intestines through your intestinal flora, which detoxify about 40% of these toxins that we were exposed to through our diet and water. Biotransformation is the new name, even though I still use detox because I hope one day, everybody will understand the value and the importance of helping your body do what it already knows how to do.  Because there’s nothing that you do in a detox program, you’re not turning on any function of the body that wasn’t turned on two minutes before you started your detox program.  It’s just that you are creating the conditions for this to happen more effectively, more intensely, and you’re supporting this process is nutritionally. Meaning, you’re giving the body all the molecules by the way of nutrients that the body needs in order to attach to the toxic molecules to convert them into non-toxic and water-soluble.

Dr. Weitz:            Right. You’re talking about the phase one and phase two of liver detoxification, and how we take these lipid-soluble toxins, convert them into water-soluble, and then into a form that can be excreted through our poop or urine or sweating them out.

Dr. Junger:          That’s exactly what I’m talking about.

Dr. Weitz:            Right. What are some of the most important toxins that you think are impacting our health these days?

Dr. Junger:          I believe that, and listen, it depends on where you live and how you live and how you eat and what products you use but the biggest problem is in our food.

Dr. Weitz:            Okay.

Dr. Junger:          Because it’s so intimate and it’s so, the impact is so direct and it’s like a two-step punch. First, these preservatives, conservatives, coloring agents, smelling agents, texturizing agents, all these foods that, all these chemicals we put in our foods to prolong their shelf life and if you think about it, what is the shelf life of a product depending on? It’s depending on the fact that no organisms will grow on it, no fungus, no bacteria, right?  The products we use, the chemicals we use to prevent the bacteria from growing in your food in the shelves will also prevent and kill the bacteria in your gut, so the longer the shelf life the shorter your life. That’s what I tell people, and so first, it passes through your intestines, it kills your bacteria, then it’s absorbed into your blood, and they start causing havoc.  Yeah. Maybe if you eat one cookie with preservatives the impact is not going to be that bad but throughout the years of you eating and accumulating these chemicals, and then interacting in your body, you never even know how it’s going to fire somehow.  What it’s going to trigger and what kind of symptom and eventually chronic disease they’re going to promote?

Dr. Weitz:            Yeah and they’re cumulative so we just, because we’re constantly getting exposed to so many, even if we try to eat organic and use non-toxic personal care products and cleaning products, they’re just everywhere.

Dr. Junger:          That’s why many of them are called POP or persistent organic pollutants. They persist and they accumulate just like they accumulate in the fish. Why do big fish have more mercury than the smaller fish? Because big fish eat smaller fish, smaller fish have a little bit of mercury, and then big fish eat them and accumulate or bioaccumulate and end up in a different situation, which is what happens to human beings because we eat everything.

Dr. Weitz:            Right. Not only do the fish have mercury and other toxins from the oceans but now they’re having microparticles of plastics because there is so much plastic in our environment everywhere and huge floating islands of plastic in the ocean as big as countries.

Dr. Junger:          Yeah. We are so now, the healthy, aware people are so focused on avoiding plastic bottles because they would leak BPA into your water, and then your phthalates, and then you will drink them, and the fact is if you eat a piece of fish it’s like you’re eating a couple of bottles of plastic. Yeah. We are being bombarded. That’s the bad news, but the good news is that your body knows what to do.  Miraculously, your liver will be able to deal with molecules that were invented last week even though your body is ancient in its design, right? This is the good news, and then even better news is that if you learn how to create the conditions and you support your body nutritionally, you are able to rid yourself of I’d say 90 something percent of the toxins. There are some toxins that you won’t, even if you detox from here into your death, you won’t be able to get rid of them because you need an extra action to do that.  For example, heavy metals. Heavy metals, the body gets rid of very little heavy metals by its own so you have to do something extra like chelation or something extra that your body can’t really do fully in order to get rid of it.

Dr. Weitz:            Right. What are some of the impediments to our bodies not being able to clear these toxins?

Dr. Junger:          At a moment in evolution where we are so bombarded, thousands of chemicals are thrown into our environment each year, tons of chemicals in our air, in our water, in our cosmetics, in our cleaning products, in our furniture, but mostly in our food. At the time, where our body should be detoxifying the most, our detoxification ability is impaired for two main reasons.  One of them is that, well, three main reasons. One of them is that the chemicals that your liver and other cells need in order to do the work of detoxification are actually nutrients. They come in foods, and if they don’t come in the foods that you eat, then you will not have the raw materials that your body needs in order to do this work. Now, our foods are depleted of nutrients and the ones, the nutrients that do come in whatever we eat are less absorbed because our guts are destroyed. That’s one of the reasons, the depletion of nutrients.

                                The second one is the decimation of your intestinal flora, which as I said before is responsible for up to 40, 50% of the detoxification work in your body. The third one is that energetically, we are harming this processes of detoxification just like we are harming or we are stealing from mostly everything and I’ll tell you why, because we are digesting all the time.  We are a species that does not stop the process of digestion because we are eating all the time. You see this idea that we have that life, normal life is breakfast, lunch, and dinner, this is only an invention of humans in the modern world.

Dr. Weitz:            In fact, it’s breakfast, lunch, and dinner with three snacks in between.

Dr. Junger:          Three if you’re careful, if you’re watching. This idea goes against nature’s design, and this fact that we are eating all day long and therefore we are digesting all day long is killing us. One of the main reasons why it’s killing us is because, see, for thousands of years, our digestive systems developed this almost autonomy that because of the importance of that meal that you were eating, which your genes adapted in a way that they didn’t know when the next one will be because animals in the wild, and we were animals in the wild at some point, are eating when they find food and fasting until they find the next meal.  Now, there’s imposed episodes of fasting which we are not really experiencing and living. For thousands of years, life depended on the meals that you found. The body adapted and evolves in a way that it gave the intestinal system, the digestive system, it gave it a lot of importance.  It even gave it a nervous system that’s bigger than the one in your skull. Therefore, the intestinal, the intestines, the digestive system has the power to shut off other functions, right?  Because since when food was there the body had to shut everything off so that it could really dedicate itself to digest and absorb because it never knew when the next meal was going to come, and this you can prove yourself this Thanksgiving. You can go stuff your mouth with a lot of food, and then you’d see that you’re tired and you can barely move, and you fall asleep. You can explain it through the alkaline way or whatever you wanted to experience, but that’s just the-

Dr. Weitz:            The tryptophan in the turkey.

Dr. Junger:          That’s just the physiological explanation of what really nature is doing which is saying, “Well, we don’t know when the next meal is coming so we might as well really dedicate ourselves to digest and absorb as much as possible.” Therefore, shut off other things that would interfere with that like walking, thinking, and detoxifying, right? Your body doesn’t know that two hours from now or two minutes from now, you will be having some more food, right?  We are always, always digesting.  We don’t finish digesting.

Dr. Weitz:            And that digestive process is prolonged because all the stress of modern life is interrupting our digestive process and you get that sympathetic stimulation that reduces our ability to digest and absorb food so it even-

Dr. Junger:          Excellent point.

Dr. Weitz:            … longer.

Dr. Junger:          Excellent point and one thing adds to the other and we end up with an energetic deficit to dedicate to different functions, repair, healing, detoxifying, thinking. We’re a bunch of a, as a society, we are lethargic in a way. We don’t have that awakeness and awareness and like animals in the wild, they hear everything, and they’re aware of everything and they have this impetus to go and find the next meal. We lost that. We’re just walking around kind of anesthetized digesting our last three meals.


Dr. Weitz:            Now, I’d like to take a break to tell you about our sponsor for this episode which is Metagenics, which is a leading practitioner exclusive, nutritional therapy company offering physicians evidence-based formulas to improve their patients quality of life. Metagenics partners with practitioners like you to support the implementation of therapeutic lifestyle programs in your practice as you put patients on a path to greater wellness.

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Dr. Weitz:            What are the three pillars of your Clean 7 program?

Dr. Junger:          Before I answer that question-

Dr. Weitz:            Yes.

Dr. Junger:          … I’m going to address something that you mentioned at the beginning.

Dr. Weitz:            Okay.

Dr. Junger:          Which is that you said it seems like your books are getting shorter and shorter and the truth is I will use only one shorter because we went from 21 to 7, right? Maybe the next one, we can say shorter and shorter. Yeah, and there’s a very important reason why they weren’t, this program, my program went from 21 days to 7.   21 days is unbelievable in terms of the results my program gives you, right? I developed this program when I was working with Dr. Joe Francis, your friend. He actually was the one that introduced me to functional medicine. The 21-day program is amazing and it’s life-transforming and it helps people get rid of so many problems. I’m still finding out about different problems that this program improves or resolves and I get letters from all over the world and direct messages and Facebook messages and whatever, right?  But I really want to make an impact in numbers. I want to help as many people as possible, and the number of people that are ready to wrap their minds around 21 days of something that is quite strict in, if you compare it to like regular life is so little that I realized people are much more prone or much more likely to jump into a seven-day program. But then, I had the problem that during the 21-day program the first 7 days are, the first 3 days, 4 days are kind of the hardest ones.  Then, the next three, four days, you start adjusting and start feeling better. I didn’t want to just give people the first 7 days of the 21-day program because they wouldn’t have that kind of experience that will inspire them or propel them to keep on making changes and keep on improving. It took me about 10 years between the 21-day program to design this program. What I was looking for is a way to accelerate and potentiate the bio-transformation and the results, right?

                                To improve and get people to get in 7 days more than what they would get in the first 7 days of my first 21-day program. In this search, I was fortunate to meet some very interesting people. One of them was the founder of a company called Organic India that is creating the most powerful Ayurvedic and cleanest Ayurvedic herbs in the planet and through him, I ended up studying with an ayurvedic medicine master in India.  He basically taught me how to accelerate by using certain Ayurvedic medicine principles, right? Then, I was already experimenting with intermittent fasting and I saw that, I observed that intermittent fasting also accelerates these processes. By mixing the principles of functional medicine that I’ve learned and use in my first program with Ayurvedic medicine principles and intermittent fasting, I really nailed a way of potentiating the detoxification activity, and therefore, the results in seven days, it’s pretty amazing what people experienced.

                                Those are the three pillars of Functional Medicine, Ayurvedic medicine, and intermittent fasting. From Functional Medicine and you are a student of Functional Medicine and a practitioner of Functional Medicine so you would remember there’s two huge pillars. One is the elimination diet and the other one is the five Rs, right?  The elimination diet is so powerful that sometimes I say that if you put an actor in a medical office and you send them patients and this actor would just smooch the patients and at the end, we’ll just let them go on the elimination diet. Judging by the results, this probably would be considered the best doctor in that neighborhood, right? Or in that city because of the elimination diet alone improves and resolves around 60% of the problems that people come to see me for, right?   The five Rs, remove, restore, re-inoculate, repair, and relax, right? Remove by avoiding all the toxins, processed foods and even foods that are considered healthy but hinder somehow the detoxification processes like grapefruits and nightshades and things like that. Then, restore all the nutrients by eating whole foods, local, and ripe, and organic, and then repair by adding glutamine and other nutrients that help the intestinal lining repair and re-inoculation by adding probiotics so that your army of helpers can get strong and help you detoxify amongst other things.  Relax, you spoke about how our stress, it takes away from the healthy processes in the body. Well, this is something that functional medicine has been aware of for a long time. Those two are the two big principles from functional medicine that I use in the program.

                                  For Ayurvedic medicine, I also used two principles which is the distinction of your body constitution called the dosha system which further individualizes, personalizes the elimination diet.  What I do is basically, I add to the foods to avoid from the elimination diet a list of foods to avoid according to your dosha. For example, if you are fiery dosha, which is pitta, you will avoid the foods that are also fiery like spicy foods and mango and there’s a list of foods that contain a lot of fire, and therefore, if you are fiery constitution, they will be more prone to throw your fire out of balance and so on and so forth with the three different party constitutions according to ayurvedic medicine, pitta, kapha, vata.  Then, the second principle or set of principles from Ayurvedic medicine is the use of Ayurvedic herbs and mostly I use the most powerful adaptogenic herbs from Ayurveda being ashwagandha, and shatavari, and tulsi holy basil. All these herbs not only give you antioxidants, nutrients, and prebiotics, and fiber but they also help the body energetically so that distribution of energies that we’re talking about before will be benefited towards the processes that need more at the time. That’s why they help the body adapt, right?  Then, I mix in intermittent fasting so that you allow the body to give the digestive system a rest, and therefore, don’t use any energy for digesting for a little bit, giving, reallocating this energy into other things and you’ll be sharper mentally and you’ll be, you’ll go into ketosis and burn more fats and really intensify the biotransformation reactions.

Dr. Weitz:            In terms of intermittent fasting, do you think it… Typically, I hear a lot of people in the Functional Medicine space, friends of mine, and they’re basically skipping breakfast and maybe just have black coffee or something like that or Bulletproof coffee and that’s the way they do their intermittent fast so they don’t eat from dinner until maybe lunch the next day and that’s so-

Dr. Junger:          That is not really intermittent fasting.

Dr. Weitz:            Okay.

Dr. Junger:          That is intermittently stopping from eating.  But intermittent fasting really if you want to go into definitions and detail, it’s intermittently entering the fasting state, which you won’t enter just by skipping breakfast and having a Bulletproof coffee.  I’m not saying that intermittently stopping from eating is not good but let’s call it what it is. It’s not intermittent fasting.

Dr. Weitz:            Typically, people say if you go at least 12 hours and I think they came up with that because that’s the period of time when the digestive process is probably fully completed.

Dr. Junger:          In my first program, in my first book, I talk about the 12-hour window, right?  Basically, what that, which means respect 12 hours between the last meal of one day and the first meal of the second day or the next day. The reason why that is important and we should all be doing it all the time is because it takes about eight hours, depending on what you ate to end or finish or complete the digestive and absorption processes.  Then, you need at least a few hours to allow, because when energy is directed to digestion, it’s stolen from other things. When digestion ends, this energy now will be reallocated to thinking, to moving, to detoxify. You want to give it at least a few hours to do that.  I say 8 hours to complete the digestion, 4 hours to reallocate energy for the detoxification, 12 hours, right?  A 12-hour window is the minimum that you can do to maintain some kind of detoxification activity that will give you any benefits, right? But it’s not enough to catch up with the burden that we have accumulated. The fasting mode, you don’t enter in 12 hours.

Dr. Weitz:            How long does it take to enter the fasting mode?

Dr. Junger:          Well, that’s a really good question that I don’t know the answer to, right? Because different people say different things and nobody really has studied this and there’s no distinction, there’s no blood test that you can measure, you can say, “Oh, here, we enter the fasting state.” Right? But to have an experience of entering the fasting state, you, at least, need a 24-hour fast.

Dr. Weitz:            Okay.

Dr. Junger:          That’s why in the middle of my 7 day from day 4 to day 5, you fast for 24 hours by not having anything caloric between lunch in the fourth day and lunch in the fifth day. That 24 hours will not be as hard because you’re sleeping for a lot of it, right? That’s the way that I give your body a taste of true intermittent fasting. I prepare people to do that by prolonging the 12-hour window from the first day to the second day to 14 hours from the second day to the third day, to 16 hours from the third day to the fourth day, and then going to 24 hours.  He’s going to be even less intense in terms of difficulty to do it because you’ve been working yourself up to it, right?

Dr. Weitz:            In your own anti-aging program, how often do you fast?

Dr. Junger:          You mean in my own life?

Dr. Weitz:            Yes.

Dr. Junger:          Not too often. Not too often. For 24 hours not too often but I do do it. I am striving to do it more often, right?  But that the fact that I don’t do it that often doesn’t mean that it’s not super beneficial.

Dr. Weitz:            Right.

Dr. Junger:          I just don’t do a lot of the things that I know are super beneficial because I’m a little lazy, because I’m an addict to sugar and dairy. I mean, I don’t know if you noticed my sniffles this morning and this is… I’m paying the price for eating a sandwich yesterday with a lot of gluten, yeah?

Dr. Weitz:            I know in the past your detox program included the use of a medical food that adds specific nutrients, your Clean program, unlike the Clean 7 had medical food shakes that were designed specifically to have phase one, phase two…

Dr. Junger:          If you read my book, Clean, the first book.

Dr. Weitz:            Which I did.

Dr. Junger:          It shows you how to do the program without using any foods, any products.

Dr. Weitz:            Okay.

Dr. Junger:          I give you the recipes that take into consideration what nutrients will be supporting the liver so you know it’s full of recipes that are more like the results of a laboratory experiment, right? I sat together with the chef for weeks at the time and went over nutrient by nutrient what the body needs, and therefore, created the recipes, right?  But I did put together a kit with medical foods for those people that are not willing or not, don’t have the time or the commitment to go and prepare all their foods, right?  There’s a lot of those. I wanted to create a user-friendly kit that people can use in order to complete the program. It really, really works. It’s the same with this book Clean 7The only difference with this book is that to do the program completely, you will need to buy some stuff–being the Ayurvedic herbs because those don’t come, you just can’t get them in the supermarket, right?

Dr. Weitz:            Right.

Dr. Junger:          As real foods. That’s the only difference but you can even do this Clean 7 program without the Ayurvedic herbs, you’re just not going to get the full spectrum of the results.

Dr. Weitz:            Right. Now, can you get the phase one, phase two nutrients and, of course, now people are talking about phase three or phase zero of liver detoxification as well.  But can you get all those specific nutrients that are needed?

Dr. Junger:          Yeah. Of course, if you eat a balanced food. If you eat lots of colors of vegetables and fruits, you’d get mostly everything you need.

Dr. Weitz:            I looked at the recipes for some of these shakes, some of these shakes are, seem a little weird.  There are shakes in here, well, depending upon your Ayurvedic type that include mung beans, rice, even yams-

Dr. Junger:          Listen, I give people a lot of options.  Most people just do the same couple of shakes and alternate between one and another because truth is life is so busy, people don’t have time to go and buy and do and prepare.

Dr. Weitz:            Yeah.

Dr. Junger:          Yeah. I put that in there because I am fortunate that I worked with one of the best chefs I’ve ever came across, James Barrie, and he… I mean, he’s like a mad scientist.  Yeah.  There are some weird things there but that doesn’t mean they’re not delicious.  You should try them.  The reason why behind is the assurance that you’re going to get all the nutrients in.

Dr. Weitz:            Right. You talked about an elimination diet, which foods do you think are the most important to eliminate?

Dr. Junger:          The five big ones, dairy, sugar, coffee, alcohol, and gluten are the five big ones.  Then, there’s nightshades and citruses, and then there’s a few other ones there.

Dr. Weitz:            I’d say probably the most controversy about coffee, because we’ve had such a ton of studies showing that we really get a lot of benefit from coffee, especially if it’s an organic, clean cup of coffee.

Dr. Junger:          As I said, there’s a lot of things in the list that are there only considering the detoxification processes of coffee.

Dr. Weitz:            I see.

Dr. Junger:          Coffee will intensify phase one and as you know, a toxic molecule that goes through phase one, ends up as an intermediate metabolite, which is more toxic than the toxic molecule itself. Therefore, has to jump directly, immediately into phase two. Now, if there’s a lot of phase one going on and not so much phase two, you’re going to end up with a detoxification phase one, phase two imbalance, which is not a good thing.  This is the reason why even if you drink, even if you’re talking about pure organic coffee, because that’s the other reason why I take away coffee because most people don’t drink organic coffee and coffee is the most irrigated and polluted crop in the planet. The third reason is because most people don’t drink coffee in a healthy way in which these studies were done.  I used to live in New York and I used to go from my apartment to the hospital and I used to pass through two long lines. One was a methadone clinic and the other one was Starbucks. There were a line of people waiting for the doors to open and you couldn’t tell which one was which. People are addicted so giving a rest to drinking coffee is important to building up your adrenals.  When people say, “But coffee is healthy.” Yeah. It’s healthy if you’re drinking real moderation or maybe in small quantities organic and making sure that you have every other nutrient for phase two detoxification, but most people don’t so I take away coffee.

Dr. Weitz:            When they stop drinking coffee they end up having to sleep which is also-

Dr. Junger:          Yeah. Then, I take away other things like grapefruit because it does block phase one detoxification as well. Then, nightshades, which, in general, in life, they’re very, very healthy like eggplants and peppers. I take them out also because of solanine and the triggering of certain inflammatory processes and especially for people with arthritis and bone inflammation. The list of foods that I take out or the list of foods in the elimination diet is not that every food, you should avoid for the rest of your life.  It’s a list of foods that you should avoid for these 21 days in my first program or the 7 days in my Clean 7 so that you give your body the best chances of doing phase one and phase two and everything else.

Dr. Weitz:            How often should we do a detox program whether it be 7 days or 21 days?

Dr. Junger:          Well, you said you showered this morning, right?

Dr. Weitz:            Yes, sir.

Dr. Junger:          So when are you going to shower next? If you go for a run and you jump in the mud, you’re going to need to shower in the afternoon or as soon as you come back from your run, but if you just stay home and you do a few more podcasts, and then you watch TV, you may go for three, four days without showering, right? How often you do a detox program depends on what you do between detox programs, right?  Just like how often you take a shower depends on what you do between showers. Now, in general, when I look at the average American. People should do either a 21-day program once a year or a 7-day program every change of season, in general, but some people need more and some people need less.

Dr. Weitz:            Right. How about on an ongoing basis to just facilitate normal detox?

Dr. Junger:          Well, that’s the goal. That the goal is that you never need to do a detox program because you are respecting the nature and the way that nature intended things to be but that way, you’d be intermittently fasting, you wouldn’t be eating any products that are edible, just foods, real foods, local, in season, ripe and without any additives, without any chemicals. You’d be living in a wooden house with no chemical treatments and, yeah.  Definitely. There’s ways of living in which you would reduce the need of a detox program or eliminate it completely, but I don’t know anybody like that.

Dr. Weitz:            Excellent. Thank you for spending some time with us, Dr. Junger. Any final thoughts you’d like to leave our listeners, viewers?

Dr. Junger:          We talk about preventive medicine and we go to the best hospitals because they have the best machinery and the best specialists and super specialists and when we spend so much money on all this, but we are sitting, we’re begging for pennies, but we’re sitting on a treasure inside our bodies is the knowledge, and the ability to heal and really live an optimal, healthy life, right? Just as you said, if you daily do the things that the body needs, you won’t need all those specialists and machinery, so maybe it’s time for everybody to learn about biotransformation and detoxification and start using it just like you learn about how to use your washing machine and use it every day.

Dr. Weitz:            Right. How can they get a hold of your books?

Dr. Junger:          Amazon and any other online store.  Yeah. You can go to my website, cleanprogram.com where you can get the books and the products, the kits for the programs in an easy, user-friendly way. You can check my Instagram dralejandrojunger.com.

Dr. Weitz:            Your book, Clean 7, which should be coming out just about the time that this podcast-

Dr. Junger:          It’s ready for pre-order.

Dr. Weitz:            Ready for pre-order.

Dr. Junger:          That’s my dog celebrating when he heard Clean 7.

Dr. Weitz:            Thank you, Dr. Junger.

Dr. Junger:          Thank you. Thank you. Hope to meet you in person one day.



Sleep with Dr. Felice Gersh: Rational Wellness Podcast 135

Dr. Felice Gersh discusses Sleep 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

3:21  Sleep is so important for our health and for rejuvenating our brains and our bodies. And it’s also important to sleep at the right time. Our bodies are designed for us to go to sleep when the sun is down, so we should ideally go to sleep at around 10 pm and get between 7 and 8 hours of sleep.

5:35  But many of us today, esp. women with PCOS, fail to get enough, deep, quality sleep.  Watching late night television and eating late at night throw off our body’s natural rhythms. And we have all these bright lights that contain a lot of blue light in our homes.  And besides television, we sit in front of computer screens, iPhones, and iPads and all this blue light suppresses our melatonin, which under natural circumstances, would gradually rise with the sunset. And our television and computer screens stimulate our cortisol, which keeps us awake.  Higher cortisol also leads to elevated blood sugar and causes metabolic syndrome, which raises our risk of obesity, diabetes, heart disease, dementia, autoimmune disease, and even cancer. Some folks claim that they are naturally night owls and they stay up until three in the morning, but they are really ignoring their natural circadian rhythm and they are putting their health at risk.

8:48  There is a lot of talk about the dangers of blue light at night, but blue light is not necessarily inherently bad.  In fact, we’re supposed to have blue light and white light in the morning to wake us up. It’s just that it’s supposed to change as nightfall comes.  We have scientific data showing that watching the sunset with all the yellows, oranges, and reds of the sunset will actually trigger the production of melatonin and shut down our cortisol production.  A weekend of camping outside with natural light and being grounded and sleeping on the ground will help to reset our circadian clock.  It makes you want to go to sleep at the right time and wake up at the right time.  Dr. Gersh points out that we need to understand that we are part of the animal kingdom.

13:04  Dr. Gersh said that she likes to think of the human body like a heart, which basically has two phases.  The heart contracts and pumps blood out and it relaxes and refills with blood.  Even a lot of cardiologists today pay little attention to the filling or resting or diastolic phase.  But resting is just as important as running and acting out and doing things. So that’s why we’re like a heart.  Sleeping, just like for the heart when it’s resting and filling is just as important, if you’re going to have healthy longevity.

16:40  When we are born, we each get on our own individual conveyor belt. Some people have a rough ride and bounce off really fast and others have a long ride but it’s rough and goes down and down. We want to have a smooth ride that goes sideways rather than down. We want to avoid that descent into all the chronic diseases that reduces the quality of our lives.  In order to maintain the health of our brains, we need to maintain our circadian rhythm. If we get good, quality sleep, our melatonin will be peaking around 2 AM and that is when the flow of blood to the brain is also peaking.  This is when the lymphatic system of the brain drains garbage from the brain and rejuvenates it. But this requires good, quality sleep and many people aren’t getting it. If the go to sleep with the television on, then they have this blue light coming through their eyelids that lowers their ability to produce melatonin and lower their cortisol. They will stay in an insulin resistant state all night long, creating inflammation.  They won’t be producing enough melatonin in their GI tract and their guts will be messed up and they will develop an unhealthy microbiome in their gut. When we produce melatonin at night in our guts, it causes the microbes to swarm like insects and they produce different metabolites that lower our risk of colon cancer, which is an epidemic today, including in young people.

20:31  Dr. Gersh explained that a lot of older folks are sad and depressed and lonely, so they think of their television as their company.  But this interferes with their sleep.  Or they they have dogs or cats, which can be great pets, but if they sleep in their beds with them, then this can negatively affect their sleep, esp. if their dog has to go out to the bathroom at 3 AM.

23:28  Some patients will turn to alcohol to help them to sleep.  But they don’t get good sleep from alcohol and it’s a brain toxin, a gut toxin, and a liver toxin.  They often get a paradoxical reawakening in the middle of the night.  Women with PCOS have problems with their master clock due to their estrogen/androgen balance problems and they often end up with disturbances in their circadian rhythm.  If your master clock is working properly, you should be hungry in the morning but not at night.  This usually means that you have low production of the endocannabinoid called enendomide in the morning and a high production of enendomide at night.  They will also likely have high cortisol at night and low in the morning.    

27:37  We have an epidemic of sleep apnea in the US today, which is really related to a circadian rhythm disorder, which can be related to hormonal deficiencies, such as in menopausal women.  Sleep apnea is not just about having a fat tongue that blocks the airway, it’s related to your hypothalamus in your brain, which is not putting out the right signals for breathing and sleeping and appetite and blood pressure and urine production.  Your autonomic nervous system is out of whack.  Sleep apnea can disrupt the normal phases of sleep, so you don’t get the restorative functions of sleep.  Make sure to get all the devices out of the bedroom and go to bed at the right time and make sure that your bedroom is cool and dark.  You may want to take a warm or hot bath before bed to relax you and drop your cortisol levels.  We don’t want television or ipads in the bedroom because they emit blue light and this lowers their ability to produce melatonin and doesn’t allow our cortisol levels to drop. Then you will stay in an insulin resistant state all night long, creating inflammation.  This will also negatively affect our microbiome and our gut health since when we get good sleep, we also produce melatonin in our guts and this causes our microbes to swarm like insects and they produce different metabolites that keep our guts healthy and this lowers our risk of colon cancer, which is rising now in younger folks.

32:34  Melatonin and Cortisol are two of the key substances regulating our sleep and awake cycles.  Cortisol is produced by the adrenals and it starts to rise in the morning should peak around the time we wake up. Cortisol makes us feel activated and stimulates our appetite and elevates our blood sugar levels.  Dr. Gersh does not think that it is a good idea to skip breakfast, since we are designed to eat in the morning and this helps to reduce our cortisol to a moderate level.  If you skip breakfast, your cortisol will tend to stay at this higher level, which is harmful and it can cause leaky gut and hypertension.  High cortisol levels tends to lead to low T3 (thyroid) levels.  Eating in the morning is when our insulin is most effective and sensitive.  When we eat breakfast, the glucose that is produced will go readily into our muscles, into all of our tissues and our brain. Because we want to utilize glucose. Glucose is the preferred energy source for most every organ in the body.




Dr. Felice Gersh is a board certified OBGYN and she is also fellowship-trained in Integrative Medicine. Dr. Gersh is the Director of the Integrative Medical Group of Irvine and she specializes in hormonal management. Her website is IntegrativeMGI.com, and she is available to see patients at 949-753-7475, she lectures around the world, and her first book, on Polycystic Ovarian Syndrome is PCOS SOS: A Gynecologist’s Lifeline to Restoring Your Rhythms, Hormones, and Happiness, which includes a wonderful chapter of sleep. Her second book, PCOS Fertility Fast Track will be available soon.

Dr. Ben Weitz is available for Functional 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 or go to www.drweitz.com.


Podcast Transcript

Dr. Weitz:            This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field.  Please subscribe to the Rational Wellness Podcast on iTunes and YouTube and sign up for my free eBook on my website by going to drweitz.com. Let’s get started on your road to better health.   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, please go to Apple Podcasts or your favorite podcast app and give us a ratings and review, that way more people find out about the Rational Wellness Podcast. Also you can go to my YouTube page and there’s a video version and if you go to my website, drweitz.com you can find complete show notes and a detailed transcript.

Today our topic is sleep with Dr. Felice Gersh. Dr. Gersh, recently authored a wonderful book on how women can overcome PCOS, polycystic ovarian syndrome called, PCOS SOS: A Gynecologist’s Lifeline To Naturally Restore Your Rhythms, Hormones, and Happiness. This is an excellent book for women with PCOS but it’s also a treatise on how to lead a healthy lifestyle. And her chapter in the book on sleep has so many clinical pearls that I thought we would focus on this for our discussion today.  We all know that sleep is important for our health, but that doesn’t mean that most of us pay any attention to it. Many Americans today are not getting enough sleep due to working longer hours around the clock, entertainment and poor diet and lifestyle. Getting good sleep however, is crucial for the rejuvenation of our brains and our bodies. And a chronic lack of quality sleep increases our risk of heart disease, high blood pressure, diabetes, obesity, et cetera. And when we sleep we cycle through different stages. Actually four stages of sleep, multiple times per night, two periods of lighter sleep, one period of deeper sleep and one period of rapid eye movement sleep. Dr. Felice Gersh is a board certified obstetrician and gynecologist and she’s also fellowship trained in integrative medicine. Dr. Gersh is a Director of the Integrative Medical Group of Irvine where she continues to see patients. She also lectures around the world and I just mentioned her bestselling new book, PCOS SOS, that’s available from Barnes & Noble and Amazon. Dr. Gersh, thank you so much for joining me again today.

Dr. Gersh:           Well, it’s my pleasure and I just love just listening to your beautiful summary of sleep. I think we can all take a nap now. That was so good.

Dr. Weitz:            You’re such an amazing doctor that you can talk about so many different topics. I am just amazed. But let’s talk about sleep and what constitutes a good night of sleep?

Dr. Gersh:           Well, like everything we’ve learned about our human bodies, we need to not only sleep, we need to sleep at the right time. So everything is about quantity and quality and timing. So in terms of sleep, we are designed as diurnal human beings, right? We are not nocturnal. So we need to sleep at night. So our bodies are designed for us to go to sleep when the sun is down. And typically we have adapted and this is probably not the same as what ancient people did or prehistoric people did, but we have adapted to a lifestyle that would be very good for us if we went to sleep between 10:00 and 11:00 at night, even closer to 10:00 is better. And then getting somewhere between seven and eight hours of sleep every night. Hopefully it was not too much disturbance in the middle. Now, probably in the ancient times, people went to sleep even earlier, and when the sun went down, because in early times age, they maybe didn’t even have fire. They weren’t going to stay up late at night.

                                So when the sun went down, they went to sleep and they would get up with the sunrise. So that’s probably really how we evolved, but we can do quite well because we have to realize that we invest not like prehistoric people, so we have to make some concessions. I can’t expect everyone, the sun is down, jump in bed. But probably, during the times when it was cold out and the nights were longer, they didn’t necessarily want to sleep longer. They may actually have gotten up in the middle of the night and did a few things, chatted, maybe they had sex or whatever. And then they went back to sleep for another few hours. So we do have some adaptive lifestyle, but I’m perfectly happy with anyone who can get to sleep between 10:00 and 11:00 at night and then have a nice continuous sleep for seven, eight hours. And your body will have a lot of wonderful opportunity to do all that rejuvenation that you mentioned in your little introduction.

Dr. Weitz:            So why do so many of us fail to get enough deep quality sleep and especially women with PCOS?

Dr. Gersh:           Well, if we talk first about the general population, a lot of the things that you mentioned, people are just doing so many things wrong. We are enticed to watch late night television. They say, what’s the late, late show? And people get, they think of these people on TV as their friends. They really want to see their funny monologues and everything and they forget this is all now recorded and you can have it on demand, you can watch it at a different time. But they get used to getting into that pattern. And people often are eating very late at night and they just don’t really feel as tired because their body’s rhythms are so off. And then we have all this ubiquitous lights, they have bright lights.

                                Remember ancient peoples didn’t have all that artificial light maybe in less ancient times. But still long time ago they had candle light, which puts out a whole different hue, the candle light compared to the all blue lights that we have now, the fluorescent light bulbs and so on. And they’re bright light. And then we watch computer screens, iPhones, iPads. And then with television screens, with all that blue light, it’s just totally suppressing our melatonin, which should be gradually rising with the sunset. So our rhythms are so off, then people are often not feeling as tired, they’re often feeling more alert at night because they’re eating, they’re watching television and computer screens. They’re actually being so stimulated to wake up and their cortisol is going up that they don’t feel tired. And so they say, you’ve heard this a million times, I’m a night owl and I don’t feel tired. I’m fine, but they’re not really fine because their bodies are not getting what they need and then not realizing the incredible metabolic risks that they’re putting themselves into.

                                And of course, we now know that metabolic ills are the ills of everything. That’s what leads to cancer, to autoimmune disease, to dementia, to cardiovascular events. Everything is linked to metabolism and your metabolism will be off guaranteed, like you mentioned, you’re going to gain weight. Is that your goal? You don’t even have to eat really unhealthy foods if you eat at the wrong time of day. So we have a society that sort of pushes people to be up and now we know that, close to like one third of people or 3% of people, are working at night because our society demands a 24 hour worker crew.  And so those people have the worst of all worlds because no matter what they do, their circadian rhythm will never really be properly fixed because some days they’re up until three in the morning and then other days they’re working at a different time of day. ER doctors are among the worse off. But I was in that category when I did obstetrics for 25 years.

Dr. Weitz:            Sure late night…

Dr. Gersh:           I was up all night, so many nights. It’s like a wonder, still in recovery mode.

Dr. Weitz:            So you were talking about blue light. So blue light is not necessarily inherently bad. In fact, we’re supposed to have blue light and white light in the morning to wake us up. It’s just that it’s supposed to change as nightfall comes.

Dr. Gersh:           Absolutely. So it’s really wonderful how humans have adapted to live on planet earth. It’s like the … I love science fiction. My favorite show when I was a kid was Star Trek. And I love all these sciences, the science fiction, Star Wars and all of that. But we really are earthlings and we evolved with the beautiful rhythms of earth in our planetary system. It’s so amazing. We have a 24 hour rotation of earth and so we are the day creatures and there are other creatures that are night creatures. And it’s just so amazing how we have evolved. So the light of the morning, like you mentioned is our wake up lights. And it has a different spectrum of light than when you look at the sunset. And now there’s actually data that watching the sunset and the beautiful sort of yellows and oranges and reds of the sunset will actually start triggering the production of melatonin and shutting down our cortisol.

                                So living outside, and so many of us are so, we’re living in constructed man-cave. We’re in buildings where so many people they don’t even have the lighter day, people who work in basements or they work in cubicles that are interior to buildings where there are no windows. They’re just surrounded by these phony walls and things. And they really have very little natural light. They don’t get outside. And if they live in a big city, like New York City or Chicago where you have really tall buildings, it’s like blocks the sun. So they’re always in the shadows, except when the sun is right overhead, which is very brief in the course of the day. So it’s so important for us to be outside. There’s data that when people go camping and they live with the natural light of the sun, the way we evolved, where they actually have the sun, they’re sleeping outside maybe in a little tent where the light comes right in and the sunlight actually really wastes them up because that’s just what happens.

                                And then when the sun goes down, there’s no television, there’s not much to do. Hopefully, they didn’t bring in all their equipment so that they could watch free recorded stuff. Hopefully they didn’t do that with the batteries. So they’re actually camping like people should in the woods without any of that stuff. And then after the sun goes down, they’re tired. And when people are in the sun all day long, it changes how their brain works, how they produce serotonin and melatonin. So they’re really tired. Everyone has spent a day at the beach, right? Something like that where you’re outside in the bright sun and then when the sun goes down, you just can’t even keep your eyes open. It’s like, I just want to go to sleep. And that’s what nature intended. So you’re doing your own thing, you’re grounding, you’re on the ground, you’re getting all that beautiful sunlight and it makes you want to go to sleep at the right time, wake up at the right time.

                                So just a weekend of camping outside with the natural light coming and going from the sun and the moon will actually help reset your circadian clock and you will sleep so much better. And it’s just an amazing thing, how when we’re out in nature, how much better we do. And there’s so many studies about the calming effect of nature, just looking at a tree can lower your cortisol level. And so even looking at a picture of a tree can lower your cortisol level. So we need to understand that we are part of the animal kingdom.

Dr. Weitz:            It’s actually a therapy now, they call it forest bathing.

Dr. Gersh:           Oh, really. I should have discovered that one. Well, maybe we can promote it on our own word, we’ll call it and stuff. We’ll modify it, we’ll call it jungle something.  You should look like, this is so beautiful. So basically we need to rethink so much of what we have done in our lives because we cannot neglect the value of sleep. It’s like the heart. I really think about the human body like a heart. So a heart sounds so simple. It just has two things. It contracts and it relaxes, right? It pushes the blood out and then it refills with blood. And people, in fact, many cardiologists today, pay very little attention to the filling or diastolic, the resting phase. They only look at the contracting phase. And of course, when people have congestive heart failure, the standard, that’s when they don’t contract well, okay? But now we know how the heart rests. The diastolic filling phase is equally important, the diastolic phase. So we can’t think that resting is not as important as running and acting out and doing things. So that’s why we’re like a heart.

                                And during the day we’re busy and we think that that’s all that matters. But sleeping, just like for the heart when it’s resting and filling is just as important, if you’re going to have healthy longevity. What we call health span, right? Because we are very good in conventional medicine and keeping people alive, but with pretty low quality of life, right? If you’ve ever been to a nursing home, it’s pretty darn distressing and depressing. People alive who have no quality of life and that is so not what my, I want my future, my patient’s future to be like … Everyone should have a role model of someone who does things right and has good results. So my personal favorite right now is my aunt, my mother’s sister, and she’s heading into her mid 90s. She lives by herself, she goes out for outdoor walks. Every day, she gets the sun and she gets the exercise the way nature intended and so she can travel, she travels around the world. She does everything just as if you were 40 years old, and she’s in her 90s and she’s amazing.

                                So we should all find a role model because if all we know as role models are the people who are in nursing homes, who are really having poor quality of life, because I have patients and say this to me, “I don’t want to live long.” Because the only role models they have are people who are living long with no quality of life. Then it doesn’t have to be that way. It really doesn’t. But we have to be really actively going against what most in society are doing. We have to live off the beaten path because the beaten path is full of people having poor quality of life. We were talking earlier about statins, and does every person have to understand I would qualify for statins simply based on age. They made it into their protocol. It’s built into their algorithm that it doesn’t matter what the quality of your life is, your health, what your labs show, anything, nothing. All that matters is your age. So if you hit a certain age, you qualify for statins. What is that all about? We can define-

Dr. Weitz:            It’s all about accepting that there’s this inevitable decline in your health. After your 30s or 40s, it’s all downhill after that. And really anti-aging medicine, like both of us practice is not just about lifespan, it’s much more about your health span and yours can you have a long healthy functioning life. And then the decline maybe happens quickly towards the end. It’s-

Dr. Gersh:           That’s right.

Dr. Weitz:            Long, slow, gradual-

Dr. Gersh:           That’s interesting.  When we are born we each get on her own individual conveyor belt, right? And some people have a really rough ride, they bounce off really fast and others have a long ride, but it’s really rough and it goes down, down. So we want a smooth ride on our conveyor belt. It always goes in only one direction, it can never go backwards, it can’t go sideways. And then you get to the highway conveyor belt, about get to get to this and then it goes to happen. But that’s how we’re having a smooth long ride. And what has to happen. I have, in one of my talks, I have a slide, I just love this slide because it shows what happens in the 24 hours. So it has 2:00 PM, 2:00 PM and in the middle it’s 2:00 AM. So it really shows you what happens and it shows you the circadian rhythm of flow of blood to the brain. I love it. You look at that and you see that when melatonin is peaking at 2:00 AM the way it should, the flow of blood to the brain is also peaking.   Oh my gosh. It’s like if you don’t have that amazing flow of blood to the brain, that’s what nature intended so that your brain can rejuvenate. And now we’ve discovered that there’s a whole lymphatic system to drain garbage from the brain. But all of this requires quality sleep, and people aren’t getting it. The other thing is the environment of the bedroom. So I have so many patients. The first thing I ask is, “Do you have a television set in your bedroom?” And the answer is overwhelmingly yes. I have so many patients they go to sleep with the television on and you can’t come up with a worse scenario than that. So they have this blue light blasting at them along with all the noise and the sound, and then they’re so tired that they just fall asleep. But what they don’t know, what they don’t understand is that even a little bit of this light coming through their eyelids is lowering their ability to produce optimal amounts of melatonin and it’s not lowering their cortisol properly.

                                So they’re going to stay in a somewhat insulin resistant state all night long, creating inflammation instead of anti-inflammation, which is what the body designed. They’re not going to get all of that amazing antioxidants and reducing free radicals and everything by the melatonin, their guts are going to be messed up. They’re not going to produce enough melatonin in their GI tract, which is key to having a healthy gut microbiome we now know. They’d sat there are microbes, all the microbes in our gut and all the microbes everywhere, they all have clocks too. They have clock genes and they actually are sensitive to the way that we eat, when we eat and so on. And when we produce melatonin at night in our gut and also we make it from our own cells and also the microbes make melatonin as well.  When we have this surge of melatonin in our GI tract at night, the rest of the different microbes actually swarm like insects, they actually swarm and they produce different metabolites that have all these different effects, that help to keep the gut healthy, so we lower our risk of colon cancer, which is a modern disease which is at epidemic levels. Now even in young people, I’m sure you’ve seen that young people having higher and higher rates of colon cancer. It’s shocking because they too are not having proper lifestyle. They’re born with all this light at night, not getting enough melatonin in their GI tract, which is protective as well and it helps to develop the right microbiome. So the implications of having inadequate sleep or whole body white systems, white cell is every single system of the body is going to be harmed.

                                And then, as well, we just have to understand that a lot of people are tired and sad and depressed and they think of the television as their company. And they may have a sound snoring next to them but they’re still feelings lonely. There’s a lot of isolation, we don’t have the family tribes the way we used to and so people watch television for companionship. So we have to have better ways for people to relate to other people. We know, for example, that one of the biggest factors for elderly people dying is loneliness. But we can’t use a television to help put us to sleep because we’re not going to have quality sleep. We have to have other ways to have relationships and meaning in life. And there are ways, some of them, I spend my time with my patients who are elderly, exploring what they can do to have relationships with people, volunteer work, working with, even going to animal shelters, if they love animals.  I mean, there are ways that people can access other people, and if you need to, you get a few pets. But I don’t want them sleeping in bed with you. That’s the other thing I’m finding. They’re lonely, they love their animals and they’re all over them at night. They’re sleeping in the bed, like these big dogs and cats. They talked about the baby family bed, now it’s the pet bed. So you can’t get a really good night sleep when your animals are roaming all over. And then my patients who have elderly animals, like dogs that need to somehow go out at three o’clock at night, so they have poor bladder function. I mean, we have to figure this out.  We can’t destroy our health for the animals.

                                But I had one patient recently who said that her cat is very picky and likes to get wet cat food at two o’clock every morning.  Oh my gosh, your cat needs to be retrained, getting up at two o’clock in the morning to feed the cats.  No, this is not good to happen.  So we need to control cats also children.  Okay, I have young women patients who just don’t understand that kids need to sleep and they don’t know how to control their kids and they don’t help their kids to have good sleep habits.  So this is starting from very young ages and their kids are all on all these other blue light emitting devices and they can’t sleep. So the kids are roaming the house in the middle of the night-

Dr. Weitz:           They’re on their phone or on their iPad and-

Dr. Gersh:           I know.

Dr. Weitz:           Keeping the TV out of the bedroom. They got to keep their phones and their iPad and those devices out of the bedroom.

Dr. Gersh:           All of that out of the bedroom. That’s the phrase that they get all of that stuff out of the bedroom and the kids’ rooms too. So they have the kids playing on these things in bed before they go to sleep. And then the kids-

Dr. Weitz:           Not to mention EMFs that are being emitted from these devices and the blue light. 

Dr. Gersh:           Yes. And then what some of my patients do, they turn to alcohol. Oh my God, they say, well the alcohol puts me to sleep, but they don’t understand that it’s not a good sleep. Alcohol is a brain toxin, it’s a gut toxin, a liver toxin. And then they get this sort of paradoxical reawakening in the middle of the night. So you have children roaming the house, you have animals roaming the house, you have people drinking alcohol to try to sleep, you have the television on all night. We have to stop, stop in its tracks. And then you have women, like all my women with PCOS, and they have also on top of all of that that’s going on like in everybody else’s life, they have inherently a problem with estrogen.  And estrogen is very key to brain health and brain function and mastering the master clock and keeping the clock on beat.  The master clock that sits at top of the optic nerve in the brain.  So their master clock is not set properly do this. So they have often what they call phase disorder. So they wake up too late, they go to bed too late but if they have to wake up early so they can’t. They’re like shifted so that they want to go to bed later and then wake up later. Kind of like, a lot of teenagers are like that. And our society is not tuned to that, so you got to get up and go to work. So they go to bed too late, they get up earlier than their bodies want to. They’re still at that point having more melatonin, although they don’t have proper functions on their melatonin. But they have of course melatonin and so they’re feeling really groggy in the morning. And then because they don’t have the proper circadian rhythm of their cortisol, they’ll have high cortisol at night, low in the morning.

                                They have no appetite. Nature made it so our appetite has a beautiful circadian rhythm. When things are right, you’re not supposed to be healthy at night. If you’re hungry at night, that’s a sure sign you have circadian rhythm dysfunction, and now we know and we can talk about this more another time too. The whole incredible endocannabinoid system, which goes with our hormones and is incredibly circadian. And everyone knows that, whether they do it or not, hopefully not, but if they smoke marijuana, people who smoke marijuana get the munchies, right? People always talked about that. Now why is that? Well, that’s because there’s a component called THC in marijuana that can act on the receptors or one of our endogenous cannabinoids, an endoccanabinoid called enendomide. Now enendomide is part of the appetite regulation system. But if you stimulate it a lot, you will have uncontrolled appetite, you’ll have the munchies.

                                And people who have circadian rhythm dysfunction have what they shouldn’t have. You should have very low production of enendomide at nights, very low. And you should have no appetite at night and then it should rise in the morning. But people with dysregulation of this system, they have high production of enendomide at night, so they are really hungry. Remember our bodies are finely tuned for input of food to match our metabolic needs, but we are so dysregulated now that our appetites are not matching our metabolic needs and or the timing. So people who, the people out there who have this or their patients, if they are really hungry at night, that is a red flag. You have circadian rhythm dysfunction. You’re producing a lot of enendomide at night when you should have none. And people who urinate a lot at night, they’re always getting up to go to bathroom, that is another sure sign that they have circadian rhythm dysfunction. Because at night you should be making a lot of the hormone, antidiuretic hormone.  And I have on my beautiful slide that shows what happens during the day. It shows that urine is being produced at very low rates during the night when you’re doing things right. Because nature did not want people to have to get up and go to the bathroom all night long or have to go and poop in the middle of the night. That’s a sure sign. If you’re going to the bathroom for any purpose in the middle of the night, especially multiple times, you have a problem with your circadian rhythm.

And now we know this epidemic of sleep apnea, which is hugely exacerbated in women with PCOS, women after menopause have high, high rates of sleep apnea, that’s really a circadian rhythm dysfunction. And people are not putting that together. And of course elderly people who have hormonal deficiencies and so on and they also do things that are not proper for their circadian rhythm, they have a lot of sleep apnea. And obese people have a lot of sleep apnea.  It’s not just about their tongue is big and their throat is getting blocked at the top. That’s just part of it. They really are having a brain inflammation problem and their area of the hypothalamus that controls breathing and sleeping and appetite and blood pressure and urine production, all of that. The whole autonomic nervous system is out of whack, it’s off the beat. And so sleep apnea is not just about your tongue, though that’s part of it. It’s also a problem in your hypothalamus, in your brain, that your brain is not putting out the right signals for breathing, coordinating with sleeping. So it’s really a significant issue. And then people shouldn’t just do a CPAP machine and call it a day. If you have high cholesterol, even if you go on a statin that is not the solution to the problem, that may lower your cholesterol, but it’s not getting to why is your cholesterol high in the first place, right? So we need to look at that. So we do in functional medicine, right?  We look for root causes.

                                So we don’t want to just say like, Oh, it just breaks my heart, my conventional medicine. Somebody goes into the doctor and they say, I can’t sleep my insomnia. They don’t even do a study of, often if they have sleep apnea, if they do, they never talk about why they have sleep apnea. They don’t ask about their sleep hygiene, they don’t ask about what’s happening in the middle of the night with the pets, the kids, the spouse. The spouse keeps them up because the spouse is snoring all night, all kinds of things are happening. The television light all the time. They don’t take any history and then they just give them a sleeping pill. And sleeping pills do not allow the normalcy phases that you alluded to at the beginning in your wonderful introduction about, we have sleep phases. And we know that for example, women who have sleep apnea, they don’t have long pauses in their breathing. There can be a tiny fraction of a second. They often are not snoring. You can’t witness this kind of cause, it’s only seen if you do a monitor of it, but it disrupts their sleep patterns.

                                So they don’t get the proper phases of sleep, so they don’t get the restorative functions of sleep. So these are huge deals, but we have to start. Sometimes I think I’m into simplistic thinking. It’s like you just have to do certain basic things in life. And I’m not against hyperbaric oxygen and all kinds of electrical magnetic waves to the brain and all these things that people are doing, high tech stuff.  I’m so foundational.  It’s like major bedroom cool. Because you sleep better and your temperature should dip at night. So try to make your bedroom really dark and really cool and really comfortable. Get all the devices, like you mentioned, all the devices out of the room. Go to bed at the right time. Oh, another great tip. If you take a really hot bath for as much as an hour, I do this myself. This is my part of my routine. It dramatically drops your cortisol.



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.

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                                                Now, back to our discussion.



Dr. Weitz:  can we just talk about cortisol, melatonin for a minute, for some those who don’t know. So these are two hormones that are playing an important role in regulating our circadian rhythms and our sleep. And so cortisol is a hormone produced by the adrenal glands, right? And it tends, it’s supposed to spike in the morning and that helps us wake up.

Dr. Gersh:           Yeah. So it’s all beautifully, perfectly aligned for what we need to be healthy. So cortisol starts to gradually rise and then it peaks right about the time that we should be getting up. So what does cortisol do for us? It makes us feel activated, it increases appetite and it makes us a little bit insulin resistant. What does that do? It helps to elevate our blood sugar levels, right? So in the morning when you’re still fasted, you want to have higher blood sugar so that you can get going. Because if you think about ancient times they had to go out and do stuff like get the food and actually make sure that the other wild animals are now up, right? So they need to be on alert to protect themselves and their families. So cortisol makes you more on high alert.  It makes your blood sugar go up, it starts mobilizing fats so that your body really can just get going. But then if you don’t eat, what if you don’t eat? What if you’re into this problem? I call it problem, where people think that they should fast through the morning. They don’t get it. So they think I’m fasting, I’m doing time restricted eating, so I don’t eat until one or two o’clock in the afternoon, and they think they’re doing themselves a favor. They’re really harming themselves because our bodies were designed, just like we’re supposed to sleep at night, we’re supposed to eat in the morning. Now we’re adaptable, resilient creatures. That’s why we can get away with all kinds of stuff and still live, but we’re not going to be living optimally. And that’s really important because if you don’t eat in the morning, your cortisol is not going to start dropping.

                                So you’ll maintain a high cortisol and consistently high cortisol is actually harmful. Then you are going to get leaky gut, you’re going to get more stressed out, you’re going to start getting more hypertension, you’re going to have fluid retention because you’re going to get into a more chronically inflamed safe. So cortisol should not be chronically high. It’s critical. In fact, it’s the only hormone that you cannot live with. In 24 hours, if you don’t have any cortisol, you’ll be dead. You could live without thyroid hormone or estrogen or testosterone for a day, you will not die but cortisol you’ll be dead. That’s how critical cortisol is. So we should, I sometimes have to defend cortisol because people stay down with cortisol, no it’s about having the right amount at the right time. It’s essential but we don’t-

Dr. Weitz:            In fact, patients who have very low cortisol throughout the day, that’s associated with the worst prognosis in cancer and other chronic disease.

Dr. Gersh:           Terrible. That’s right. And then those people always have really high cortisol, they always have low T3 because cortisol and thyroid are so intimately related and it turns out that our insulin sensitivity is also on the clock. Just like I said, if you eat at night, you’re going to be insulin resistant, you’re going to be prone to diabetes and weight gain because we are eating on the clock. If you eat in the first half of the day, in the morning time, that is when our insulin is most effective, our insulin receptors are most sensitive and that really matters. So when you eat food in the morning, the glucose that is produced will go readily into our muscles, into all of our tissues, our borne, our brain. Because we want to utilize glucose. Glucose is the preferred energy source for most every organ in the body. We can use ketones fats as a secondary source, that’s because we we’re so resilient and food is not always available. So you have to use your backup source, your own body fat as a source of energy when you can’t eat, right?

                                But the preferred source of energy is glucose. But the problem is people are so insulin resistant, the receptors don’t chase up the glucose. And so they just set higher and higher levels of sugar in their blood, which becomes very inflammatory and damaging. And then you have high levels of insulin but it doesn’t work well. And high levels of insulin is also inflammatory and it increases IGF-1 which you need. But you don’t want it all the time because then it’s called cancer because your pro grows. So insulin promotes fat production, fat storage and IGF-1 promotes growth and proliferation, which you need but not all the time. Because chronic proliferation and when you have chronic inflammation, that’s the perfect team for DNA breakage in cancer. So we don’t want all of that. We want to have the beautiful rhythms. And if you keep fasting through breakfast and you don’t eat until the afternoon-

Dr. Weitz:            But they’ve been told that the way to reduce your IGF-1, to reduce those growth factors is by fasting. And so that’s why a lot of people are doing it.

Dr. Gersh:           That’s why I’m telling you, when you do time restricted eating, so here’s these definitions. So fasting is when you’re not eating, right? So that’s pretty obvious. But we have these words that just sort of tell what you’re doing-

Dr. Weitz:            So the other one is intermittent fasting, that’s-

Dr. Gersh:           So if you don’t eat for certain periods of time in the 24 hour day, that’s time restricted eating. If you don’t eat for a full 24 hours, that’s intermittent fasting. If you don’t eat for a few days, that’s periodic fasting. If you don’t eat for more than a week, that’s prolonged fasting. So these are just definitions so we know what we’re talking about. But so if you want to do time restricted eating, that’s doing periods of fasting during the 24 hour day, it matters which portion of the 24 hour day. Just like it matters when you sleep, it matters when you eat, it matters when you don’t eat. So I’m all for time restricted eating, but the time that you should stop and be fasting is in these later part of the day. So you should get 13 hours.   You can have more than 13 hours of fasting in the 24 hours, but the return on investment goes down so you don’t get as much bang for the buck. If you fast for 14 hours versus 15 hours versus 13, but the difference between 13 and 11 or eight is very significant. So you so plateau, that’s what I would say. But if you fast from say five o’clock in the evening or six o’clock and then you don’t eat until nine o’clock then I’d say something like that’s fabulous. But if you don’t eat from like nine o’clock at night until two o’clock in the afternoon that you got it wrong. Because, I am so sorry for those of you who are doing this to tell you this, but you’ve got it wrong. Because you’re eating too late at night, if you’re stopping eating at nine o’clock and then you’re not eating when your body is most prepared and evolutionarily designed to receive food, which is in the first half of the day.

                                They’ve done studies on prisoners because they’re our captive audience. So where they’ve taken the same food and giving it to them either in the morning or the night, the same food. So they give almost all their food in the morning and then they do a watch out for two weeks, and then they do the same thing where they give all the food at night. It would just about, and they found that you can give the exact same food, but when you give it will determine if you gain weight or lose weight. It’s not just about calories in, it’s about your metabolic state. So you’re metabolically prepared and equipped to properly handle food in the first half of the day and not once you get past about seven o’clock at night. And don’t blame the messenger. For those of you who like to eat late at night, it just is what it is. We are who we are. We’re not owls, we’re not bats, we’re humans. That is so so what it is.

                                And I used to wonder, why are all my patients going into labor at night? It’s like, are they doing this to torture me? Why do I have to have all these laboring women in the middle of the night? Because I thought that was like a white sail until now, of course, I understand circadian rhythm. Women are designed to go into labor when it gets dark, to labor through the night and deliver in the early morning hours because that’s the safest time. Because when women are in labor, they are very vulnerable. What are they going to do? Get up and run away when they’re about to have a baby? So that’s nature’s way to protect women. So women are designed to labor during the night, have their babies in the early morning hours and then they can move, they can protect themselves and their baby. So that’s why women labor during the night, that’s actually totally natural.

                                And we even have seasonal rhythms, right? Left to nature. Have you ever seen the movie Bambi? All those babies born in the spring? Because if a baby from an animal is born in the spring, then were likely to survive because there’s so much more food available right in the spring. And the summer they can set a nap so that the mum will have a fat source. So that they can continue to take care of their little offspring through the colder winter time. And so everything is based on our beautiful solar system, all the rhythms. And that’s the part that drives me crazy is that, and now we have evidence that women on birth control pills have altered it’s weak, because you do not have rhythms when you’re on birth control pills. There are no hormonals in birth control pills. They are chemicals, they’re not hormonal, they should be called anti-hormonal contraceptives.

                                And the problem is, and I feel very sorry about this because I know that I don’t have all the most amazing solutions for contraception, but we need to define the problem if we’re ever going to get better solutions. And the problem is that everything in the female body is designed to support successful reproduction. Whether we want to have babies or not. That’s how our bodies are designed. Just like if we want to work at night, I am sorry but we are not designed to work at night, it’s just so we will pay the price. If we really don’t want to conceive, we need to understand that that’s how our bodies were designed. So all the systems in the female body are designed to support the health of the woman for the purpose of successful reproduction. That’s why I talk a lot about estrogen as the hormone, the master hormone of metabolic homeostasis that links reproductive functions and metabolic functions. And birth control pills alter our rhythms.

                                You don’t have normal rhythms, either lunar rhythms or even circadian rhythms when you’re on birth control pills and there’s higher rates of depression. We know people who don’t get adequate sleep have much higher rates of mood disorders. It’s horrible. They’re depressed, anxious. And women on birth control pills have higher rates of depression, anxiety, and we need to recognize this and we need to develop contraceptive methods that don’t poison reproduction because you’re poisoning reproduction, you’re poisoning the whole body. We just need to understand that we need these beautiful rhythms. In fact, part of the aging is loss of these beautiful rhythms, right? And women after menopause, when they no longer have rhythms and they don’t have these hormones being produced by the ovaries, that’s the onset of the whole array of metabolic dysfunctions that are assigned to the aging, but they’re really about estrogen deficiency.

                                And of course, not just that, everything that goes with it. They’re beautiful rhythms. That’s why women in menopause have tremendously high rates of insomnia and gurge, acid reflux, mood disorders, increased in all the pain syndromes. They have a lot more osteoarthritis, osteoporosis, they have a lot, women have almost three times as much dementia as men. They don’t sleep as well. And that’s a big part of it. Remember we need that big blood flow to our brains at night. So it’s all late and we’re giving birth control pills to young women. I see them getting it at age 14 now, 13, 14. So what is happening to their brains and their beautiful rhythms? And what’s happening to their sleep? They’re not having the same sleep. The blood flow to the brain is not there. So nobody links things that happened 40 years later, right?

                                But what happens is it turns out that all the women that send most of their lives on birth control pills, is they have higher rates of dementia and I’m seeing muscle skeletal problems. I’m sure you are too. They’ve been on birth control pills for 20 years and they’re only in their early 30s and they want to have kids now at 36. They delay it because they’re busy going to school and having a career, and they were put on birth control pills when they’re 14 and they’re on a continuously, now they’re 34. They go out Zumba dancing and they just pick up their own videos dancing and they’re doing nothing. They’re just dancing and they rip their shoulders, things like that. And then go to the orthopedist and they say, you need to have shoulder surgery or we’re going to inject you with steroids which great the tissue more, and all these things.

                                And nobody’s saying what on earth is a young woman in her early 30s getting her shoulder ripped, just because she goes dancing and lifts her arm. And because they don’t develop proper musculoskeletal health from being on all those years, not having proper sleep, not having proper hormones, not having proper development of their muscle cell system. And you don’t know, we don’t know how to fix that. We can’t go back and do a redo. And all of this is interlinked with sleep and with nutrition and gut health because everything is one in the body. It’s like, that’s when you said, how do I talk about everything? Because unfortunately for me as a lecturer, if I don’t understand the whole body, how am I going to put it all together? So it’s kind of fun.

                                But once you realize that every system links with every system, like you have lines going everywhere, so you have the access to everything. You kind of have to learn about everything. Not necessarily everything on the cellular level, about every single, I’m trying to, it’s really complex, but at least on a more macro scale to really understand how all these systems interlink. And sort of if we’re going to create a pyramid at the top, if we put sleep at the top, because if you don’t have sleep, everything below is going to kind of crumble. It’s going to just fall apart. So we have to have sleep. It’s just part of being a healthy human. Got to have that sleep.

Dr. Weitz:            I got it. That was awesome. Let’s touch on one more topic in terms of helping us to sleep. In your book, you talk about using melatonin and it was interesting. I’d never seen anybody recommend taking two separate dosages of melatonin. And the dosages you’re recommending are very, very small which is different than what I’ve heard with other practitioners.

Dr. Gersh:           Yeah. Well, sometimes less is more so it turns out, everything I do is I try to be evidence-based physiologic. So when we see the sunset, which is so important for people who have trouble sleeping or have mood disorders, just go outside every day unless it’s pouring or snowing or something like that and see the sunset. It’s a beautiful spectacle and it just helps to do what for so many things. It starts slowing the production of cortisol and starts increasing the production of melatonin. So, but little bits, so it doesn’t make us want to go instantly to sleep. It’s just the process begins, the process of preparing us for sleep by decreasing cortisol. And the melatonin just starts to come up a little bit. And the trigger to that can be to give a half a milligram of melatonin. We don’t have to do it at the time of the sunset but we can do it like a couple of hours before we go to bed. You can even do it earlier. You can do it as early as six hours before you go to sleep.

                                So somewhere in that time frame, depending on what you’re, you can play with it. So you can do a two hours, three hours, up to six hours even before you actually will go to sleep and try that little bit of melatonin. It’s just a half of a milligram. And that can just sort of set the tone for your body transitioning because remember everything is a beautiful curve. The cortisol rhythm, it’s just, it’s not like jaggedy, it’s curves. It’s like beautiful curves. And so this will help start you on the curve to up the melatonin, down the cortisol. And then, specifically in women who are menopausal and women with PCOS because they don’t have the proper amounts of estrogen or estrogen receptor function and so on.

                                And this is all linked, if everything is linked, all these different hormones are interrelated. Giving a little bit at bedtime. So like a half hour or so before bedtime. And not a large amount, because remember melatonin is also on a curve, right? So in peace to 2:00 AM, but if we give a whole gigantic bolus of melatonin early on, right before when you’re starting sleep, you may knock people out. You may sedate them heavily, but you’re going to alter those sleep phases. And remember, so sleep is a dynamic process. Otherwise, we could do things like give everybody Ambien, right? That’s all that matters. Who’s knocking people out. But we don’t want to go from a drug to a supplement or a hormone to effectively do the same thing, knock people out. So we don’t want to knock people, we want to get them into a natural sleep rhythm.

                                So giving a smaller amount of melatonin and you can do other things like ashwagandha. I know you know that. Ashwagandha is wonderful at lowering cortisol. You can’t, I always say things like, you can’t multitask. We keep talking about multitasking, you can’t burn fat and build fat at the same time. You can’t lose weight and gain weight at the same time. It doesn’t work that way. And you just have to look at what you’re doing so you can’t lower cortisol and raise cortisol at the same time and get any of fat. So what we want to do is have our bodies naturally start to lower the cortisol and raise the melatonin but we have to do it in a gradual way so that everything will work out probably for the whole sleep phase. So this is how we’re going to do it.

Dr. Weitz:            So you talked about using a half a milligram a couple of hours before bed and then two or three milligrams 30 minutes before bed. Right?

Dr. Gersh:           Right. So what that will do will be to help start you on your sleep process and then your body will make melatonin in the natural space. So we don’t want to push the melatonin too fast so that you get disrupted, improper sleep phases. Now, there are people that sometimes can benefit from a very, very high dose of melatonin, but we’re not really using it to get a proper sleep phase. They’re using it for its antioxidant value. For like anti-cancer, like people have breast cancer. So we’re using it like a drug.

Dr. Weitz:            I know one prominent functional medicine doctor who takes 50 milligrams.

Dr. Gersh:           Well, if you’re trying to use it as a drug to deal with cancer, then that’s a whole different thing than if you’re trying to-

Dr. Weitz:            [crosstalk 00:52:14] like preventative anti-aging purposes, there’s that-

Dr. Gersh:           I think that is misguided. Okay. I think not just-

Dr. Weitz:            [crosstalk 00:52:23] anybody else who takes that much.

Dr. Gersh:           Okay. Well, I’m also open-minded. If there’s documentation, some kind of study that really proves that if you take 60 milligrams of melatonin at bedtime, you’re going to prevent all kinds of diseases of aging, I’m all for it. But right now, like I said, I’m a little bit simple minded that I just figured nature does, we evolved in such a way that nature does everything best. So I just tried to try to get people back on track with what nature intended. Now that said, I actually go against nature when it comes to menopause. And of course, if you have a medical problem, like PCOS, because nature has not really done anything wrong to you. It’s our society that really has damaged women who have a genetic predisposition to something that happens with a lot of things.  The lifestyle, the food, everything else has come to play to alter women so that they don’t function properly. But menopause is universal for women and every woman when she goes through menopause is going to have some disruption of her sleep and her metabolic state. So I don’t care that it’s natural, I don’t like it. So I go against nature. I say, I love you nature, but in this case I am going against you because nature only really supports reproductive creatures. We’re sorry that nature doesn’t like us much after we’re no longer reproductive. Most creatures on this planet are no longer alive when they stop being reproductive. Most animals die at the end of the reproductive function but humans are among the very few that continue to live. The women can still live but they don’t necessarily live long.

                                Women live longer than men because we do have more robust immune systems and we tend to survive infections better. And that’s built into our X chromosomes and it’s not just hormonal, it’s actually in our X chromosomes. So we tend to live longer, but we actually live with more chronic diseases than the men. And so I go against nature when it comes to menopause and I’m very open to bash. It’s like I love you in nature, but sorry, I’m not accepting menopausal status as what nature dishes out. Now the other thing is that in earlier times people went into menopause with, I called it like, more health in the bank. They had better musculoskeletal systems, they didn’t spend their life on birth control pills, they ate real food and so forth. And because they didn’t have all these electrical devices, they actually went to sleep at the right time.

                                So when women hit menopause, they had more reserved and more resilience to deal with it. So I look at menopause, it’s like you’re in a plane and the engines go out. Now if you have a lot of health to begin with and you have great reserves, then your plane without the engines goes into a glide and it becomes like a glider and it goes down but it’s like a slow decline and maybe a softer landing, but it will land. But if you have no reserves and then you hit menopause and the engines go off on your plane, you go into another a nose size. and that’s what’s happening to women more. Because when they hit menopause, they don’t have reserves because they haven’t had good health their whole lives. They’ve not had proper sleep, they’ve not had proper food, they’ve not had exercise, fitness, and all the things that go into making a person healthy and resilient, they don’t have it.  So they hit menopause and they lost their last support system, which is their estrogen and their progesterone so they do go into a nose size. And we now know, for example, that hot flashes are associated with increased risk. So everything bad you can think of because it’s really a sign of brain inflammation. Neuroinflammation is actually an ominous sign of [inaudible 00:56:10] and we know that. So women who go into menopause and they have no hot flashes, that’s a very good prognostic sign for their future because it shows that they have resilience and they don’t have a lot of neuroinflammation that’s happening in their bodies. That’s it.

Dr. Weitz:            Interesting. Awesome. Okay. So thank you so much Dr. Gersh. You’re still seeing patients at your office in Irvine, right?

Dr. Gersh:           I sure am. I’m a regular brick and mortar doctor. I’m in my office. This is my exam room. So yes, I definitely see patients everyday. I’ll be seeing someone in a few minutes and I would love to see anyone who is interested in integrative women’s health care. And I also, and so I’m in Irvine, California and my group is called the Integrative Medical Group of Irvine. And so I have my support team, I have a naturopath, integrated PA, nurse practitioner, fitness specialists. We have a gym in my office and we do high tech ultrasounds for vascular health and of course abdominal and pelvic ultrasounds. I have a fabulous body worker, massage services. So we try to uncover, and I have a new person who’s going to be starting a holistic naturopathic, not naturopathic, natural chef. So she’s going to help people to not only see, Oh, I do things like I say eat more vegetables.  And then I find out that people don’t even like vegetables, they don’t know how to cook them and they don’t know what half of them are. So my saying eat more vegetable is not really resonating too well. So I’m having a chef who will actually teach patients how to shop for vegetables, how to find good ones, how to cook them, find ways to enjoy them. Because just telling people eat more vegetables just doesn’t do it. So obviously I need help and so I’m getting it because it’s like one thing to tell people, but that’s the problem. You tell people do something, but then you don’t give them the real tools and they don’t like it. So we have to take it one step at a time. And we have to recognize that many people have grown up in families where they didn’t eat vegetables and they don’t know what it is, really. So we’re trying to help people to have a love affair with vegetables.

                                And I brought my book so that people can see it. You have it too. All right, we have matching books and I have my new book, which is actually out in Kindle version, but it will be officially debuting in January. And this is the PCOS SOS Fertility Fast Track. So for people who want to have a baby and has a healthy pregnancy and a nice healthy baby. But like everything, it’s all lifestyle medicine. So even if you, remember, I always say fertility and health are one. Fertility is a vital sign of female wellbeing. If you’re not fertile, then you’ve got a metabolic problem. And especially in the reproductive years, if you have a fertility problem, you have a health problem.  So even people who don’t want to get pregnant, they just want to be healthy, you can follow this because this is how to get healthy. And then of course for women who want to be pregnant, this is a key. So we call it Trimester Zero, right? Two months before you even try to get pregnant, we have to optimize women and men’s health because just getting a baby is not the answer. We want to have a healthy baby and we want to have a low complication rate during pregnancy. And these things are really astronomically increasing. Pregnancy related complications and children who already at birth are having metabolic issues. So anyway, those are my new missions is to-

Dr. Weitz:            When is your new book available?

Dr. Gersh:           What? I’m sorry.

Dr. Weitz:            When is your new book available, is it out now?

Dr. Gersh:           Kindle version, it’s available on Amazon right now, but then the physical version of it will be available January one.

Dr. Weitz:            Awesome. My pleasure. Thank you Dr. Gersh.

Dr. Gersh:           My pleasure.