24-Hour Urine Testing for Hormones: Rational Wellness Podcast 85

,

Homeopathy with Ananda More: Rational Wellness Podcast 84

Ananda More discusses Homeopathy with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

7:58  The majority of the scientific studies about homeopathy are either positive or inconclusive.  Only 5% are negative. There are over 1000 published studies and close to 200 randomized clinical trials.  On the other hand, quite a number of studies on drugs that were negative were never published and, in fact, the pharmaceutical industry had a history of doing a study over and over many times till they got three that were positive, that they would then pass on to the FDA for approval.  Ananda said that she has “heard many stories throughout my life with my friends and family who are doctors in research where they’ve been asked to change their results for specific studies, because the results didn’t quite line up with the expectations of the funders. I had a friend who was told that if she published her results, she wouldn’t be allowed to get her PhD, for example.” We also have to consider that these medical journals are being funded by advertising from big pharma.

12:47  Mainstream medical journals like the New England Journal of Medicine, rarely ever publish papers on homeopathy.  Ananda said that when the word homeopathy is in the abstract and the result is positive, the study isn’t even sent out for review. Also, there is very little funding for research on homeopathy.  Homeopathic medicines can’t be patented and they are easy to replicate.  So you don’t have the same possibility of profits that you do with other forms of medicine.

14:19  In the Magic Pills documentary there’s a section where there was an outbreak of leptospirosis in Cuba due to some severe hurricanes in 2007. They only had enough leptospirosis vaccine for 1% of the population and besides the vaccine requires two separate dosages to incur immunity. So they decided to do a homeopathic intervention, which they distributed to 2 and a half million people.  It completely stopped the epidemic and the levels of this disease dropped far below the historical averages for years afterward. But when these scientists (immunologists and epidemiologists) tried to publish their results, they were turned down by all the medical journals. They did eventually publish their results, but only in a homeopathic journal, Homeopathy. The paper is:  Large-scale application of highly-diluted bacteria for Leptospirosis epidemic control. The lead author, Dr. Bracho, started receiving death threats after publishing this paper. 

18:05  How can Homeopathy be effective when the active ingredient is is so diluted?  Homeopathy is an energy medicine and not only do you need to dilute the active ingredient, but there is this process of producing the formula that includes hitting the glass vials that the formula is in very hard against a surface, known as succussion. This creates high temperatures in the bottles and it creates nano particles of the active ingredient within the vial. It also sloughs off nano particles from the glass and silica is a conductor. 

22:38  Ananda was at a conference and Dr. Bracho from Cuba came and told this story about the homeopathic intervention that was so effective and long lasting and she wanted to get this story out there to help change people’s attitude about homeopathy, which is why she decided to make Magic Pills.

24:04  The Australian National Health and Medical Research Council released a report in 2015 that has been very influential and has led to a shift in public policy and opinion against homeopathy in a number of countries around the world, including in Australia. In both Australia and the United Kingdom homeopathy was covered by the national health system and now it is not due to the influence of this report.  This report was supposed to be a review of the research on homeopathy, but in the end they cherry picked the data and only included five studies, four of which were negative and one of which was positive, and they concluded that there is no evidence that homeopathy is effective for any condition. But this review had serious methodology problems, including using an arbitrary criteria that excluded any study with less than 150 subjects. NHMRC’s own guidelines are that a good study is over 20 subjects. Their methodology was so poor that they were refused for peer review publication. When the Australian Homeopathic Association did a freedom of information request they found out that there had been a previous study done by a well respected scientist, but they refused to release that first report. The speculation is that first report concluded that homeopathy was effective for certain conditions, so there is a global movement to release the first report, where you can sign a petition. 

28:28  Homeopathy has a long history in the United States and in fact, the senator who brought the bill that created the FDA, Royal S. Copeland, was an MD who practiced homeopathy.  There are homeopathic hospitals, which still exist today, including Hahnemann Hospital in Philadelphia, and there is a statue of Samuel Hahnemann and a memorial to homeopathy in Washington, DC, that was endorsed by President McKinley. But now the FDA has decided that they wanted to change the oversight on homeopathy and they have created a draft document that is creating some oversight over homeopathy but might be setting themselves up to make homeopathy illegal, since in order to go through a new drug application process, it requires a minimum of $300 million and homeopathy has thousands of medicines and which medicine is used is individualized for each person. The homeopathic industry isn’t big enough to be able to afford this process, so this could be setting the stage for removing homeopathy in the US.  And we know that in the US, the ability to lobby congress is what allows you to get favorable legislation, and homeopathy is a threat to the pharmaceutical industry, which spent $240 million to lobby congress in 2015 alone. 

35:16  The other problem with this draft document is that it is removing the FDA guidelines for manufacturing a homeopathic product, the CPG Sec. 400.400, which outlines proper manufacturing guidelines. By getting rid of these guidelines, it will be more difficult to assess if a homeopathic product is being properly manufactured.  Based on what has happened in other countries, this has created a worry that this document is part of a process that will limit or make homeopathy illegal in the US. 

36:24  There’s a group of mothers that depend upon homeopathy that have created this organization, Americans for Homeopathy Choice, to lobby for homeopathy and they have already delayed the passing of this draft document. You can go to Homeopathychoice.org and learn more, sign up, and write letters.  According to Ananda, “Even if you don’t believe in homeopathy, I think this is about protecting our rights to freedom of choice. It’s a basic human right to decide how you want to treat your body and how you want to medicate yourself. If you want to try other options first in a safe manner, I think that’s absolutely a human right.” 

39:48  Ananda has made this documentary about homeopathy, Magic Pills, which she if inviting people to screen with groups of people in their homes, coffee shops, churches, theaters, etc. which you can learn about by going to the website, magicpillsmovie.com or by going to the Magic Pills Movie Facebook page.

 



Ananda More is a Homeopath in Toronto, Canada at Riverdale Homeopathy, where she sees patients and teaches educational programs for homeopathy and she made an incredible documentary on homeopathy called Magic Pills that has not been released in the US yet but you can screen with groups of people in your home or in other public places.  She is dedicated to spreading the word about homeopathy. 

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 Transcripts

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 the Rational Wellness Podcast, please go to iTunes and give us a ratings and review, that way more people will find out about the Rational Wellness Podcast. Today, our topic is homeopathy, and we’ll be joined by homeopath Ananda More.

For those of you who are not familiar, what exactly is homeopathy? Well, according to Wikipedia, the source of all knowledge, skepticism, sarcasm there, homeopathy is a system of alternative medicine created in 1796 by Samuel Hahnemann based on his doctrine of like cures like, a claim that a substance that causes the symptoms of a disease in a healthy person would cure similar symptoms in a sick person.  

There are quite a number of studies that show the effectiveness of homeopathy, while quite a number of other studies show no benefit. Scientists and mainstream doctors tend to be skeptical, because some of the theories behind homeopathy don’t line up with the general accepted principals of chemistry and physics. For example, the concept that by diluting a homeopathic formulation more, it gets stronger. Goes against the principle that you need a minimum of the active ingredient to create an effect in the body, and having less than this amount will tend to be less effective or have no therapeutic effect.  This skepticism, combined with a report produced in 2015 in Australia by the National Health and Medical Research Council that declared that there are no health conditions for which there is reliable evidence that homeopathy is effective. Homeopathy, in other words, according to them, is no better than placebo. They stated that homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness.

Yet over 5 million adults and over a million children in the US and many more million around the world use homeopathy on a yearly basis. Many get positive results with very few side effects. We have asked Ananda More, a homeopathic practitioner from Toronto, Canada, and a filmmaker to help sort out the truth about homeopathy. Ananda wrote, directed, and produced an incredible documentary on homeopathy called Magic Pills that includes some amazing footage on how homeopathy is saving lives in Africa, India, South America, and Cuba, among other countries. Homeopathy can be delivered at a fraction of the cost of traditional medicine and medical care, which some of these people don’t have access to in these developing countries because of their poverty levels.  Ananda, thank you so much for joining us today.

Ananda More:                   Hi, Ben. Thanks so much for inviting me on.

Dr. Weitz:                         That’s great.

Ananda More:                   Wow, you started with a challenge there.

Dr. Weitz:                         Ananda, can you tell us how you came to become a homeopath?

Ananda More:                   Sure. So I was very, very skeptical of homeopathy. I did this course in university on witchcraft and the occult.  One of the things we studied under witchcraft and the occult was homeopathy. Were were taught that the idea is that they’re giving you highly diluted substances-

Dr. Weitz:                         Is that a broom in the back? Oh no, I’m kidding.

Ananda More:                   Probably.  So we were taught that it’s a medicine that believes that there’s these highly diluted substances, and they dilute them and dilute them and dilute them until there’s nothing there. Then we’d give this to people to treat whatever is ailing them. We’ve decided that this is medicine. To me, it just sounded preposterous. The way it was taught as well with that perspective also made it sound preposterous. I was very skeptical.  I was willing to open my mind up to traditional Chinese medicine, herbology, even Reiki, like the idea of energy medicine appealed to me, but this, I just couldn’t wrap my head around.

Then I found myself in India very sick. I was in this place called Pune, and I was traveling with a friend of mine, who’s German, which is where homeopathy originates. Her mom was a homeopath, and she had her nice little first aid homeopathic kit with her. I was, to be graphic, throwing up and everything going out both ends. It was really bad.  She comes along and goes, “Hey, want to try one of my little sugar pills?” I was delirious. I was like, “Whatever. I’ll make you happy. I’ll take your little placebo pill.”  When 15 minutes I felt absolutely fine, I was kind of floored.  In a way, there was a control, because other people in the place where we were staying had the same illness and were sick for days.  Not very scientific, but I had a nice way to compare what had happened.  I was kind of surprised.

At that point, I decided to go see a homeopath in India. That homeopath gave me some remedies. I’d been dealing with and struggling with depression most of my life. I think it’s genetic. It runs in my family. The depression that I had been dealing with, but that’s how I knew the world, that’s how my filters worked, that’s how I perceived everything around me, suddenly changed and my perception of life changed. It wasn’t sudden. It was gradual over a couple of months, but it really changed my life. At this point, I was heading to law school. I was all gung ho about doing human rights work. I realized that I thought I could help a lot of people with homeopathy, if it really did work for others the way it worked for me.  That’s when I decided to go study homeopathy, and my aspirations of being a lawyer went down the drain. Sometimes when I see what I pay my lawyers, I’m a little disappointed in my choices, but not really. It’s been an incredible journey really.

Dr. Weitz:                         That’s great. Let’s talk about homeopathy. Is there a science that proves that homeopathy is effective?

Ananda More:                   The majority of the science either shows that it’s effective or the study couldn’t tell. In a very equivalent manner to what you see in conventional medicine, you get about 40, 45% of studies have positive results for homeopathy. You get around 40% that are inconclusive, and around 5% that are negative. If you really look at the scientific literature, you’re getting more of a positive overview rather than a negative one.  We have over 1,000 clinical trials. We have almost 200 randomized controlled clinical trials that have been published. In terms of basic science, there’s thousands of studies that have been done as well. By basic, I mean working in vitro with cell lines, with plants, sometimes with animals. Many of those studies have been replicated. Again, they often more often than not show a positive result for homeopathy.  There’s something there definitely. This idea that homeopathy is unscientific I don’t think is true. Science is a way of studying things. We can set up appropriate ways of studying the effects of homeopathic medicine. Now as more and more science, particularly in physics, and our technology improves and we have more ways of looking at water molecules, at what’s going on in these solutions, we have a better understanding that what may be the basis for how homeopathy works.

Dr. Weitz:                         I’d like to point out a lot of people don’t realize this, but quite a number of studies on drugs that end up with negative results end up never getting published, whereas they tend to only cherry pick the studies that are positive and publish those.

Ananda More:                   Right. So there was this history in the pharmaceutical industry of doing a study over and over again until they were able to get enough positive studies to pass onto the FDA. I think they need three studies for the FDA. So they could do 900 studies and only three of them are positive, cherry pick those three studies and use those to defend their case. There’s more controls put in place against that now, but I know it’s still happening. But technically what’s supposed to happen is the study is supposed to register before it’s done in a way to kind of control that aspect of things.

Dr. Weitz:                         Do you think that’s actually being done?

Ananda More:                   I think it’s improving. Is it being done 100% of the time? I doubt it. I’m not one of the keepers of that process, so I can’t speak to that, quite honestly, in a good way. But the honesty is too that a lot of studies, they’re manipulating the data set. They’re finding ways to get the results they want. We see a lot of research is being funded by the pharmaceutical industry, and they have ulterior motives. I’ve heard many stories throughout my life with my friends and family who are doctors in research where they’ve been asked to change their results for specific studies, because the results didn’t quite line up with the expectations of the funders. I had a friend who was told that if she published her results, she wouldn’t be allowed to get her PhD, for example.

Dr. Weitz:                         Wow.

Ananda More:                   There’s a lot of research going on where people have created false studies and delivered them, submitted them to journals, only to have them accepted and published. This has been a matter of exposing the weaknesses of the peer review system. There’s also a lot of publishing bias, because who is it that’s actually funding these medical journals? It’s advertising dollars from the pharmaceutical industry. That really affects what we see as our evidence base. We’re talking so much about evidence based medicine, and yet how do we know we can trust that evidence base? We don’t. That’s very problematic.

Dr. Weitz:                         Yeah, that’s really important to point out. Have you found that mainstream medical journals, like the New England Journal of Medicine, you don’t see many papers on homeopathy in those journals.

Ananda More:                   I think there’s two issues going on there. One is that publishing bias that we discussed. A lot of the people I interviewed for my film, top scientists in their fields, said that as soon as the word homeopathy is in the abstract and the result is positive, the study isn’t even sent out for peer review. It’s rejected at the editorial stage. Another issue is that we don’t really have a ton of funding for homeopathic research, because there isn’t a lot of money in homeopathy. You can’t patent our medicines. They’re very easy to replicate. They’re very cheap to make. So you don’t have the same possibility of profits that you do with other forms of medicine.  Who funds most of the medical research? It’s the pharmaceutical and the medical industry. They’re not going to be funding homeopathic research. We depend on very few grants. A friend of mine, Dr. Alex Tournier, who’s a physicist in Heidelberg, he’s been struggling to raise enough money to maintain his lab, which is dedicated to homeopathic research. You’ve got both of those things, a profound publishing bias, along with a lack of funding for research.

Dr. Weitz:                         In your Magic Pills documentary, there’s a section where some doctors submitted a paper about their experience in Cuba after the hurricanes where they didn’t have enough money for medication or vaccines for leptospirosis, which commonly occurs after flooding and other types of water damage. Homeopathy was incredibly effective at reducing the rates of leptospirosis, but they were turned down for publication.

Ananda More:                   Yeah. So I just want to, just to get a few listeners up to date, what they did was there’s this disease, leptospirosis, which in North America is relatively unknown, but in tropical countries, it’s a pretty significant problem. It’s hard to diagnose, because it looks a lot like dengue and has some very generalized symptoms that are hard to specifically assign to a disease. It’s fatal up to 10% of the time, and it’s spread through water.  In Cuba in 2007, they had severe hurricanes that left the eastern coast of Cuba quite decimated. Homes were destroyed. There was no clean water, and flooding was everywhere. The Finlay Institute, which is a pharmaceutical company in Cuba that actually makes vaccines and is the only company on the planet that makes vaccines for leptospirosis, the issue wasn’t that they didn’t have the money. The issue was that they didn’t have enough vaccine on hand to take to those areas. They only had enough vaccine for 1% of the population.

The other issue is that that vaccine takes two doses and months to incur immunity. It’s not an instant fix. It takes a long time. In order to get it out there, it’s an injection. You’re dealing with cold chain, you need to be able to get to that area and maintain the vaccines cold. There’s a lot of issues with trying to get something like that to people in a fast manner.

They decided to attempt a homeopathic intervention instead, which they got out to 2 and a half million people. In the course of two weeks, they completely stopped the epidemic. Not only that, but the levels of the disease were far below their historical averages for years afterwards. Yeah, when these guys, who are immunologists, epidemiologists, they were scientists, they were not homeopaths, they have never had issues getting their work published, they got their work published all the time, and they even have their own vaccine journal that they’re the editors of. Suddenly they send it out for publication, and they were shocked, because in Cuba, they’re more isolated, they didn’t realize that there was this bias against homeopathy, and everyone refused to publish these results. They would get excuses like, “Well, we need a signature from all two and a half million people involved.” That sort of thing they’d never been asked for before. It was ridiculous.  So it was quite evident to them the level of bias that existed. They did eventually publish their results in a homeopathic journal called Homeopathy. When they did, Dr. Bracho told me he stopped reading his email because of the death threats that he was receiving.

Dr. Weitz:                         Wow.

Ananda More:                   He didn’t leave the country for over two years of fear of being attacked.

Dr. Weitz:                         Wow. Can you explain to the skeptics out there how can it be that by diluting the active ingredient that … Well, to begin with, everything we’ve learned about other forms of medicine is you need to find the right amount of the active ingredient and give that in an effective dosage. In some cases, if it’s not effective, then you give it more frequently or you give an additional dosage. That’s how we use herbs. That’s how medications are typically used. How can it be in homeopathy that by first of all diluting it so much that you’re going to have any effect at all, and then how can it be that by diluting it more, it makes it stronger?

Ananda More:                   Well, so I don’t want to say that diluting it more actually makes it stronger. We think homeopathy is an energy medicine. By diluting it more, you’re changing its signal. For one person, a higher dilution may be more effective. For another person, a lower dilution may be more effective. But in terms of this idea of dilution, what’s important isn’t just the dilution, but rather this process that we call succussion, which is we have machines or we do it by hand, and we hit these glass vials very hard against a surface. This actually causes very high temperatures to happen in those bottles for microscopic moments in time.  We believe what’s happening is it creates nano particles as it breaks down the material within the vial. It also sloughs off nano particles from the glass as well, and silica is a conductor. There’s a lot of things that are happening that isn’t just diluting a substance until it disappears.

We don’t have exact clear answers at this point, but we have several theories. We have discovered that there are nano particles of source material and very highly diluted remedies. This has been seen over and over. They’ve done this with metals like gold. They’ve done this with organic substances now too. What they do is they put the remedy under an electron microscope and look for the nano particles and see if there’s any trace. Then they have special ways using spectrography to understand what that source material is that they’re looking at.  This has been replicated dozens of times. We know for a fact now that there are nano particles in these solutions of the source material. How that relates to the mechanism, we’re not sure. How are those nano particles maintained in that solution? We don’t know, but they are there. They’re observable.

There’s ideas around now nano clusters, so actual formation of the water molecules and various … I have a cat that’s trying to get on my keyboard. He likes the keyboard. We can see these nano structures of the actual water molecules where they take on specific structures. Those have been observed. We can measure a difference in electromagnetic resonances or fields from remedies that have been actual just water to homeopathically prepared water. We have, what was it? Polar dyes. Studies have been done using polar dyes where they bring the remedies to very low temperatures. As they rise, these dyes change color and respond to usually material in the water. But what they’re doing is they’re actually responding as they should in the homeopathic remedies, if that substance was in the water, where they don’t with the plain water.  We can actually measure and see differences within those preparations. There’s still a lot to understand where it’s just at the infancy of the science, but it’s not because it’s unscientific. It’s because the technology’s just catching up that’s allowing us to look at these models. The funding is lacking.

Dr. Weitz:                            How did you come to make this documentary, Magic Pills?

Ananda More:                   So the story about Cuba that I just told, I was sitting at a conference, and Dr. Bracho from Cuba came and presented their results. I thought to myself, “Everybody needs to know about this. If this was a vaccine that had no adverse reactions, that could be prepared within minutes, or not minutes, but could be prepared within a manner of days, enough doses to reach two and a half million people, you don’t need cold chain, and it’s that effective and long lasting? Wouldn’t everybody know about it? Wouldn’t this be headline news?” But nobody heard about it.  I was racking my brain as to what do we, as a homeopathic community or scientific community need to do to get that data out there to let people know what’s going on, because in my view, this was all being suppressed. That’s where the idea of a film was born. I’d seen movies have incredible results in terms of changing how we respond to things like black fish and our responses to Sea World and how we raise animals, or rather marine mammals and how we keep them. Things like that. I was hoping that we could have a larger influence through a film and reach more people.

Dr. Weitz:                            Cool. Can you talk about the Australian National Health and Medical Research Council report that found that their conclusion was that there’s no good scientific evidence that homeopathy is effective?

Ananda More:                   Yeah. So this has been a very, very influential study. They’ve really shifted policy in Australia, according to what the study has said. They’ve done the same in the United Kingdom where homeopathy has been part of the culture there for a long time. The royal family, themselves mostly use only homeopathy, and they have these incredible homeopathic hospitals across the country. Homeopathy was covered by the national health system there and it was part of your public healthcare plan. Suddenly with the use of the study and some other commissioned reports, they decided that, “Oh, there’s no evidence that homeopathy works, so therefore we shouldn’t fund it anymore.” But the study is very problematic. From the point in time where they reached out to other scientists to say, “Can you look at our methodology and give us some feedback?” They got a lot of feedback, because their methodology was very poor, but they didn’t respond to those criticisms, and they didn’t change how they were doing the study.

When the report came out, it’s supposed to be a review of all of the literature out there, but their final data is based on five and only five studies, because they created a, in a way, very arbitrary data set that they decided was what qualified a good study versus a bad study. Part of that data set was a study that was over 150 people. That may sound reasonable, but if you look at the NHMRC’s guidelines, what they think is a good study is over 20 people. When they really cherry pick the data down to five studies, four of which were negative, one of which is one of our best studies showing that homeopathy works, which is a study on diarrhea in children, and they, based on these five studies, they didn’t even address the one study that was positive and didn’t look at it. They just said there is no evidence for any disease to say that homeopathy works. Also, yeah, just the rabbit hole just keeps going and going and going around why didn’t they look at these studies? Why didn’t they look at those studies?

When the Australian Homeopathic Association reached out and tried to get … Well, they did a freedom of information request to learn more about the study, they learned that there had been a previous study that had been done. That previous study had been done by a very well respected scientist. They’d seen the feedback on that study, which said that the methodology was of very high quality, and yet that study was buried. The lead scientist on that study was fired, and they decided to make a whole new study. They’re refusing to release that first report.

Dr. Weitz:                         Wow.

Ananda More:                   On top of that, this current report was rejected for peer review because its methodology was so poor.

Dr. Weitz:                         Wow.

Ananda More:                   So now we’re using this to uphold that homeopathy doesn’t work, and yet it couldn’t even get published, an anti-homeopathy study that couldn’t get published. I think that’s very meaningful. Now there’s a campaign, and it’s a global campaign, so I invite everyone who’s listening to this to go and sign this petition to release that first report. That could be a game-changer. People can go to releasethefirstreport.com. There’s tons of information, a real in-depth analysis of what is wrong with this study. Other people won’t say it, but I’m willing to say that I think the study is quite fraudulent and had something to prove that they couldn’t prove the first time. Yeah, I invite everyone to go there, learn more, sign, share. I think it’s really important.

Dr. Weitz:                         So how about in the United States? I understand the FDA has taken note of this report and issued some sort of a warning or something.

Ananda More:                   So homeopathy has been, in a sense, accepted by the FDA since its inception. Homeopathy was grandfathered in. The senator who brought in the bill to create the FDA was actually a homeopath himself.

Dr. Weitz:                         Really?

Ananda More:                   Yeah. So there’s a long-

Dr. Weitz:                         What was his name?

Ananda More:                   Pardon?

Dr. Weitz:                         What was the name of the senator?

Ananda More:                   I can’t remember his name. I’ll have to look it up.

Dr. Weitz:                         Wow. Interesting.

Ananda More:                   Quick Google search. But homeopathy has a long history in the US. We’ve had homeopathic hospitals, which still exist today. They’re just not homeopathic anymore, like the Hahnemann Hospital in Philadelphia. There is a memorial to homeopathy that was built by a president in Washington, DC.

Dr. Weitz:                         Really?

Ananda More:                   Yeah.

Dr. Weitz:                         Which president built it?

Ananda More:                   Again, I can’t remember his name. I’m not very helpful there, am I?

Dr. Weitz:                         You Canadians, you don’t know anything about American history.

Ananda More:                   It wasn’t a major president whose name was burning in my ears.

Dr. Weitz:                         That’s okay.

Ananda More:                   Resonate. But now the FDA has decided out of nowhere that they wanted to change how homeopathy is the oversight, how it’s overseen. They created this draft document which basically in a sense states that homeopathy is legal. It stated that we brought homeopathy in, but these remedies haven’t gone through the new drug application process. Therefore, we’re going to pursue this on a risk basis, on a high risk basis.  To the industry, they were saying, “Don’t worry. We’re only going to address remedies that are going to people that are immunocompromised and babies and things like this where there may be a risk to them using these remedies.” But in all honesty, what’s the risk if there’s no active ingredient in it? It’s not going to hurt anyone. It’s non-toxic, and in many situations, it’s the only medicines available to pregnant women and compromised individuals, people like that.

The other issue is that they’re basically setting themselves up to make homeopathy illegal with this document. In order to go through a new drug application process, it’s at minimum around $300 million. We have thousands of medicines. There’s a level of individualization to homeopathy, so you could have one remedy that could be good for 50 different ailments in 50 different individuals in different ways, and the kind of research that the FDA requires is very pathologically centered and per drug rather than homeopathy as a whole, which does not allow for individualization and using homeopathy as it’s actually used in practice.  Being able to pass those requirements are very doubtful, and our industry isn’t big enough to be able to afford that kind of money to pass every medicine for every possible indication. It really complicates things, and it’s basically setting the stage for the removal of homeopathy in the United States.

Dr. Weitz:                            Yeah. No, I can totally understand that. On the one hand, I saw a recent report where the FDA stopped the use of a particular brand of homeopathy, because they found bacteria or something in some of their products, and that sounded totally reasonable and sounded like what they were talking about. On the other hand, we have to understand in the United States especially, and I don’t know how many other countries follow this, but our government is increasingly controlled by big corporations and even the heads of the FDA and these other agencies are often lobbyists or people who work for these big corporations because of the way that the government is set up with the lobbying and everything.  For example in California, where I practice as a chiropractor, all the individual healthcare plans include no chiropractic coverage. How can that be in a liberal state like California where people use chiropractic and other alternative medicine quite readily?  It came down to lobbying, and the chiropractic profession didn’t do a good job of lobbying to make sure that chiropractic, which is relatively inexpensive, was going to be included in the new healthcare plans.  They wanted to cut something, and that was a low-hanging fruit they could cut.  It was based on lobbying. That’s I think one of the risks for homeopathy in the future is that everything seems to be based on influences based on the amount of funding.

Ananda More:                   Mm-hmm (affirmative). Yeah, and like what you’re talking about, there’s been a few situations recently where they have found bacteria in remedies. There is a story of Highland’s Teething Tablets, which garnered a lot of news because of their belladonna content, or deadly nightshade. Again, there was a freedom of information request done on that data, and it was so arbitrary. These supposed cases of death attributed to this remedy had nothing that was very hard to attribute the death to the remedy. You’d see cases like a child born without kidneys or who then had a dose of this remedy and died three months later. They were just completely … It just looked like falsified data. A lot of the data had been doubled as well. So they had to do a lot of filtering, and they claimed it was hundreds of thousands of complaints when you really looked at it, half of them you didn’t know what the complaint was about. Half of them were replicated from other things. Half of them had nothing to do … I keep saying half, but it dwindled down to almost nothing, in terms of complaints.  If you really took those teething tablets, in order to intake enough to have the minimum level for toxicity, you’re looking at taking hundreds of boxes or consuming hundreds of boxes of this medication. It really feels like there’s a witch hunt out there.

The other problem around that with this document is that if it passes, they’re actually removing the manufacturing guidelines for these remedies. There’s a document called the CPG 400.400. Within that document, it outlines proper manufacturing practices. The FDA has every right to go after these manufacturers who aren’t maintaining the purity of their remedies. What they’re doing is they’re getting rid of that. Suddenly you can’t even go after them with proper manufacturing, and we can’t even assess whether they’re selling a product that they say is what it is, because there’s no manufacturing guidelines.

Dr. Weitz:                         Wow, so you can’t go after the big pharma companies are having this stuff made in China that has all kinds of proven toxins.

Ananda More:                   But that’s very specific to homeopathy. That’s what they’re removing, the guidelines for manufacturing a homeopathy, which makes no sense.

Dr. Weitz:                         Right.

Ananda More:                   There is this fantastic group of mothers that formed in the United States headed by this very vibrant woman named Paula Brown. These were all moms who depend on homeopathy on a daily basis. It really amazed me, because we have public healthcare here. I can go to the hospital, and it doesn’t cost me anything out of pocket. But a lot of these-

Dr. Weitz:                         What a concept? You socialists.

Ananda More:                   Yeah, I highly recommend it. But these women were either didn’t have access to healthcare, couldn’t afford these hospital visits.

Dr. Weitz:                         We’ve got the greatest system in the world where a simple emergency room visit for a flu can cost you $3,000.

Ananda More:                   Yeah. I can’t wrap my head around that in any way, shape, or form, because I’ve never experienced that. But you see these women who were dependent on drugs and suddenly lost their plans and couldn’t get their thousands of dollars worth of medications anymore. They couldn’t afford to take their kid to the hospital. They saw miracles happen with homeopathy, so they really stand behind it. You hear these stories. They’re just astounding. They were so terrified of losing access to homeopathy that they formed this organization called Americans for Homeopathy Choice.  These women have been a powerhouse in the US, in terms of lobbying for homeopathy. This document that the FDA, this draft would have passed already if it wasn’t for them. They’ve put in place a petition and were asking for people to write letters to the FDA to support this petition. It’s not the kind of petition that everyone signs. It’s a petition specifically for them that’s clogged up the passing of this document. People can go to homeopathychoice.org and learn more, sign up, and write their letters. There’s all the instructions there as to what needs to be done.

Even if you don’t believe in homeopathy, I think this is about protecting our rights to freedom of choice. It’s a basic human right to decide how you want to treat your body and how you want to medicate yourself. If you want to try other options first in a safe manner, I think that’s absolutely a human right.

Dr. Weitz:                            I totally agree with you on that. There’s many cases now in the United States where those options are being taken away, where vaccines are being made mandatory to send your kids to school, and there’s a lot more things, a lot more cases where those individual choices for choosing your own healthcare, making your own healthcare decisions are being taken away.

Ananda More:                   Mm-hmm (affirmative).

Dr. Weitz:                            Well, this has been a very interesting interview, Ananda. Thank you so much for joining us.

Ananda More:                   Thanks so much for letting me talk and spread the word. I appreciate it.

Dr. Weitz:                            So how can listeners get a hold of you, if they want to talk with you or if they want to get more information about homeopathy? I’ll put links in the show notes, of course?

Ananda More:                   Brilliant. Well, we have made this … I think it’s a fantastic documentary called Magic Pills. We’re inviting people to screen it all over the US. We have a goal of 1,000 screenings. It’s actually been screening all over the world. It’s been in a bunch of film festivals. But what we want to do is bring it into people’s homes. There’s this model of you can screen the film in your own living room, invite your friends and family to come watch it. Or you can screen it in the church, a theater, all kinds of different places are being used. Coffee shops, museums. But we want to make it really accessible, and we want people to come together so there could be a really great discussion afterwards and a building of community around the issues presented.  We invite you to go to the website, magicpillsmovie.com. There’s lots of information there on how to make that happen. Through the contact us link there page, you’ll definitely reach out and you’ll hit me. Could also check us out on Facebook, which is Magic Pills Movie. We’re pretty active there as well. Those are the two excellent ways to reach us.

 

,

Men’s Health with Dr. Myles Spar: Rational Wellness Podcast 83

Dr. Myles Spar discusses Men’s Health with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

1:22  Some of the ways in which men’s health is different than women’s, is that men die younger. They have higher rates of heart disease. They may have issues with erectile dysfunction, prostate problems, and low testosterone especially as they age. Men, on average, die five years younger than women.  According to the Harvard Health Blog, the reasons why men die younger are that: 1. men tend to take bigger risks, 2. have more dangerous jobs, 3. die of heart disease more often, 4. are larger than women, 5. commit suicide more often than women, 6. are less socially connected, and 7. tend to avoid doctors.

3:45  Dr. Spar said it appears to be masculinity that results in men dying younger than women. In countries where the masculine machismo is more prevalent and they engage even less in the behaviors we know contribute to longer life and healthier living, are countries where men’s health is actually worse.  Dr. Spar said that we need to figure out how to message wellness to men so that they respond, which is what his professional mission has been about.

4:31  Dr. Spar said that the five factors that most contribute to premature death in men are 1. lack of exercise, 2. drinking too much, 3. engaging in risky behaviors, 4. smoking, and 5. being overweight.

5:29  We need to message in a way that men will tend to respond. Talking about a prevention and wellness approach means a lot to us as practitioners, but it only resonates to someone who is fairly abstract thinking, while guys tend to be more specific results oriented. Dr. Spar explained that we need to message to what matters to that person, such as performance at work, losing weight, getting cholesterol down, sexual function, etc. Men tend to respond to a more performance oriented message. but there are also lots of women who also think in this goal oriented way of thinking. 

7:11  When working with men to lose weight it is important to measure not just weight but bodyfat percentage and setting goals and holding men accountable.  Dr. Spar finds that apps like Strava are helpful in using technology that helps with accountability and tracking improvement or not. 

9:25  Dr. Spar prefers to look at genetics to see if his patients have trouble with detoxification. He uses either Pathway Genomics or PureGenomics from Pure Encapsulations that allows you to put your 23and me raw data through. But he is concerned about a report that such programs that analyse genetic data tend to have up to 20% errors when reporting on the SNPs of these genes.

12:17  To help men reduce their risk of heart disease, men need to have an advanced lipid profile, since the tests that are run with the annual physical exam are inadeguate in assessing the risk for heart disease. Dr. Spar likes to use the Cardiometabolic Profile from Spectracell, which looks at LDL particle size and number and also at inflammatory markers like CRP. We also need to look at Lp(a), which is a huge risk factor for heart disease.  Take the case of Bob Harper, the trainer from Biggest Loser who appears to be in great shape, and had no risk factors except that he had a high Lp(a) and had a near fatal heart attack.  It will also look at homocysteine, which is a risk factor for heart disease and is easy to lower with the right supplements. And homocysteine is also an indication that you don’t methylate well, if you haven’t had genetic testing. Your primary MD will usually not order such an advanced lipid profile because it’s usually not covered by insurance and they usually avoid such conversations.  Dr. Spar also likes some of his patients to get a coronary calcium score to see directly if there is any plaque in their arteries, which is another useful test that is not covered by insurance. But despite some patients’ concerns, there is very little radiation associated with such a limited scan and there is no radioactive dye.  If he has a patient who has cholesterol problems and he has them on fish oil and plant sterols and he is deciding whether to place them on a statin, the coronary calcium scan can help him and his patient make that decision. 

17:08  Men tend to have lower testosterone levels today because of 1. stress and anxiety, since our bodies shut down reproductive drive if we are under stress, 2. environmental toxicity, which especially seems to affect free testosterone, and even lowers sperm count, and 3. opioids, which have been correlated with lower testosterone levels.  Testosterone should ideally be in an optimal range betweeen 350 and 900. Too much and too low can both be risks for heart health. Men should also have an optimal range of estrogen with an ideal estradial range of 15-30. Men who are taking a lot of estrogen blockers can be causing themselves harm with respect heart and bone health if they drive their estrogen down too low.

23:50  Natural ways to raise testosterone levels include: 1. zinc and chrysin are both natural aromatase inhibitors and will block the conversion of testosterone to estrogen. When you take zinc you should also take 1/10 as much copper. 2. Chinese panax ginseng, 3. Tribulus, 4. Maca root, 5. stress management techniques, including meditation, yoga, Tai chi, journaling, prayer, some breath work, 6. 7-9 hours of sleep per night is very important 

26:45  Free testosterone levels seem to be often very low, even more so than the total testosterone.  Some of this can be due to thyroid and liver problems, but most of this is probably related to increases in SHBG (sex hormone binding globulin), which may be related to environmental toxins.  Dr. Spar noted that when tracking men whom he has placed on topical estrogen supplements, he will track them with saliva free testosterone levels, which is more sensitive for this than serum. This is part of his tack180.com program.

31:57  Dr. Spar does measure PSA levels in men, especially if he has placed them on testosterone.  We do know from the work of Dr. Abraham Morgentaler that testosterone does not cause prostate cancer, though if someone has prostate cancer, we don’t want to give them testosterone.  Dr. Spar will do a digital exam and if the prostate is enlarged he will also check a free PSA. If the PSA is elevated, will have the patient get a prostate MRI. If that is positive, only then he will recommend a biopsy.  This reduces unnecessary biopsies.

                                                                                          

 



Dr. Myles Spar is a Medical Doctor who practices in Hollywood, California and he is a leading authority on men’s health. He is a co-author and editor of a comprehensive book on men’s health, Integrative Men’s Health. Dr. Spar provides a lot of useful information on his website, MDSpar.com where he offers his Tack180 program of comprehensive men’s care.

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 Transcripts

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 iTunes and leave us a ratings and review. That way more people will find out about the Rational Wellness Podcast. Today we are going to focus our discussion on men’s health, with our special guest, Dr. Miles Spar. We’ve talked in prior episodes about prostate health, and libido, with Dr. Geo Espinoza in episodes eight and number 48. These are important issues for men. But today, we’re going to talk about these and other factors in an overall approach to improving men’s health.

Some of the ways in which men’s health is different than women’s, is that men die younger. They have higher rates of heart disease. They may have issues with erectile dysfunction, prostate problems, and low testosterone especially as they age. Men, on average, die five years younger than women. What are some of the reasons for this? According to the Harvard Health Blog, men tend to take bigger risks, have more dangerous jobs, die of heart disease more often, are larger than women, commit suicide more often than women, are less socially connected, and tend to avoid doctors. As a chiropractor, I can definitely endorse this, because my practice, like most chiropractors, is 60% women, and a lot of the men who come in are only there because their wives or girlfriends pushed them to come in.

I’m happy that Dr. Miles Spar will be joining us today. He’s a medical doctor in Hollywood, California. He practices Functional Medicine, and he also directs the integrated medicine program at the Venice Family Clinics, Simms/Mann Health and Wellness Center. Dr. Spar is a leading authority on men’s health. His comprehensive book on integrated men’s health was published in 2014. When Dr. Spar sees patients, his consultations usually include an analysis of genetics, nutrient levels, hormones, and advanced cardiovascular testing. Dr. Spar is also an iron man athlete, and he works both with Hollywood celebrities, and professional athletes, including being a medical advisor for the NBA. I’m honored that you’ll be joining our podcast Miles, to speak about men’s health.

Dr. Spar:              Thank you. Thanks Ben. It’s great to be here.

Dr. Weitz:            Absolutely. So, do you agree with those reasons the author of the Harvard Health Blog wrote about why men tend to die younger?

Dr. Spar:              Yeah I do. I think it’s definitely proven at this point, that it’s not genetic, it’s not biologic. There’s differences in life expectancy between men and women, but those differences change over time, and across cultures. If there’s really biology, it would be a fixed difference or more close to a fixed difference. It really just seems to be, it’s more like masculinity is killing us, as opposed to being male. There’s a really interesting report, just a couple of weeks ago, the World Health Organization put out on the status of men’s health in Europe saying very similar things to what you quoted from that Harvard blog, that the countries where the masculine machismo is more prevalent, are countries where men’s health is actually worse. There are countries where they are engaging even less in behaviors we know contribute to longer life and healthier living.  Absolutely, I think it’s coming upon us to really try and figure out what are we doing wrong, and messaging wellness towards men. Why aren’t they responding? What can we do differently. That’s really what my professional mission has been all about.

Dr. Weitz:            Of those factors we mentioned, which ones do you think are the most important?

Dr. Spar:              Basically I think there are five that are most important. There are five that are most likely to contribute to the decrease in mortality, the decrease in life expectancy, because they contribute most to the preventive causes of premature mortality. That’s basically lack of exercise. It’s a lot of what you mentioned, but I think … I can’t narrow it down to one. I think it’s lack of exercise. It’s drinking too much or not moderating alcohol. It’s taking risky behaviors. It’s smoking. I have a little thing here. It’s also maintaining a healthy weight. Men are more likely to be obese than women, and I think that may be the most important cause of it right there.

Dr. Weitz:            Yeah great. How do you address some of these issues in your practice?

Dr. Spar:              I think, first of all, like I kind of refer to we don’t message what we’re trying to do to men very well. We’ve been using this prevention and wellness approach, which is great, and it means a lot to us as practitioners, but it only resonates to someone who is fairly abstract thinking, able to put off things now for future benefit. By and large, guys are a little more result oriented. “What do I need to do now, and how is it going to impact me now?” It’s more about results, outcomes, specific goals, as opposed to broad ideas of wellness or prevention. I think part of what we need to is really think about messaging that’s directed at what matters to the person that you’re in front of. Is it about performance at work? Is it about losing weight? Is it about being more on mentally? Is it about getting cholesterol down? Is it about sexual function? Then making very specific recommendations that will impact that particular goal that’s of concern to that person. I call it a men’s approach, that it’s really about performance oriented, but it’s really not just for men.

I think that would help us in general, because there are a lot of people who think in this more stereotypical masculine way that’s result oriented, goal oriented that is more abstract and wellness orientated. By and large, that’s more men than women, but this is a caveat to our whole conversation today. When we talk about men, I really mean anyone who thinks in a stereotypical male way. It doesn’t have to be a person who’s a male in gender. That’s the first step, is really more goal results oriented way of talking about why it’s important to make behavior change.

Dr. Weitz:            You mentioned weight gain and obesity. How do you specifically deal with that with men, and how do you come up with more … How do you approach it in a way that’s more impactful than just making general recommendations, “You should lose some weight”?

Dr. Spar:               Yeah. Good question. I think it’s about measuring and holding patients accountable and having real milestones. As opposed to a general grid. “I have this great anti-inflammatory diet. Here’s what you eat. Here’s what you shouldn’t eat.” That doesn’t work as well as, “Okay, let’s look at specifically what you’re eating, meet with a nutritionist, and then let’s measure not just weight because with guys oftentimes they’re working out and then they don’t lose weight because they’re building muscle mass, so let’s look at waist circumference or let’s put you in a DEXA scan, which you can do now pretty inexpensively and check your body fat percentages. Whatever single measure can really be important to that guy, find that, and then check it periodically because guys like to compete even if it’s against themselves or against other people.  That’s the other part of that. I think physical activity is as important as diet. With guys especially trying to get them to engage. I love Strava, which is an app that’s like a social media/competition app or Weight Watchers even now has a great app. They’re using some kind of technology that helps have accountable measures. It’s all about having a measurement that you track and being able to show improvement or lack thereof and then figuring out where do we need to change our tactics.

Dr. Weitz:            Yeah, we use bioimpedance in our office, and that’s helpful.

Dr. Spar:              That’s great. Something that you use the same one each time, then it really is good. It’s showing changes, and then you know if you’re going the right direction or not. I think guys especially, everybody, especially guys like to feel like you’re holding yourself accountable. As a practitioner you’re going to say, “Look, I know this is going to work, and we’re going to show it’s working. If it isn’t, we’re going to change things. Then they like to see that they’re making improvements in black and white.

Dr. Weitz:            Do you ever look at toxins as a factor in having trouble losing weight or so many other health issues?

Dr. Spar:              Yeah. I like to do both looking at toxins and looking at genetics because sometimes people have genetics where they’re not detoxifying as well, so I like to do genetic testing to see if they need issues with detoxifying because it may be that they’re being exposed to the same amount as everybody else, but their hormones are getting messed up because they’re not clearing them out. Even if you do measure their testosterone, TSH and all that, it’s kind of okay, but their hormones aren’t operating as maximally because there’s so many toxins. Some of that is determined I think by how good their liver is at clearing things out. We can measure that through some of the genetic tests. They can tell us, “Oh, okay. This person really does have a propensity to not clearing stuff out, so let’s give him supplements that help boost whatever phase of detoxification they might need help with.”

Dr. Weitz:            What’s your favorite genetic panel?

Dr. Spar:              That’s a really good question. I play with all of them. Right now I’m using Pathway Genomics. It’s not really my favorite, but I like it for right now in terms of price and availability. I also like Pure Encapsulations products. It has this free if you’re one of their clients. It has this thing called PureGenomics, which is great. You can run 23andMe data for free through there. You get a great report.

Now the caveat is I’m concerned because I’m hearing that there is concern with some of these secondary data analyses from 23andMe data, that there have been found to be quite a bit of misinterpretation. I take it all as one piece of evidence. None of them is going to be a sole decision maker for me. It’s just if someone comes in with symptoms that could be relating to, let’s say, detoxification, then I look to see how are they detoxifying. How is their SOD? How is there MTHFR or some of these other genes? To see, okay, that could explain it or, “You know what? This doesn’t even make sense. I don’t really think this is significant.”  I mean I think hopefully whole genome sequencing will become more affordable, and that’s going to be a lot more reliable than any of these tests that look at individual SNPs.

Dr. Weitz:            What was that concern about the 23andMe?

Dr. Spar:              There are some just some studies that are showing that these Promethease and PureGenomics and some of these other programs that basically do secondary data analysis, they basically take the raw data from 23andMe and run it through their systems, that there’s a lot of error.  I forget the numbers now. I wish I could tell you. It was 20% or more were recording genes that were just inaccurate, that patients didn’t have those genes as it said they had.

Dr. Weitz:            Oh, wow.

Dr. Spar:              Yeah. It was really high rate of error. It definitely gave me some pause.

Dr. Weitz:            Interesting. Yeah, we’ve been utilizing that service as well. How do you deal with the heart disease risk that men have?

Dr. Spar:              Well, I think it’s important number one to look beyond just the general annual physical lipid panel. That’s a big thing. I think that just plain old cholesterol and LDL cholesterol is one part of the picture. You need to really look at these advanced VAP panels like Berkeley Heart Lab or I use SpectraCell, one of these advanced panels that looks, A, at things that go beyond the plain lipid panel. So they look at lipid particle number and particle size. Do they have a bad pattern of LDL or bad kind of cholesterol. You can have the worst pattern or the not as bad pattern.  Then especially looking at other markers because we know that heart disease number one is plaque and inflammation. Those are the two essential parts, right? We know that cholesterol can increase risk for plaque, but if their inflammation markers like CRP are really low, I’m less concerned. It’s really important to measure that. Then we know things like Lp(a), separate from cholesterol, a huge risk factor for heart disease. Bob Harper made that famous. He’s the guy that is a trainer on Biggest Loser, really in shape guy, had a heart attack or at least needed a stent placed emergently, and I think it was a heart attack.  Then there was a big article in the New York Times about the fact that his only risk was his high Lp(a) back in January or February of this year, your listeners can look that up, by this really good science writer for the New York Times. It really brought to light how important that marker is, which unfortunately isn’t always covered by insurance, but it’s a really important mostly genetically based risk.

Dr. Weitz:            I think that’s one of the big factors why when someone goes for their typical annual physical and they get this very limited number of blood tests, especially today, which when it comes to lipids is maybe going to be like LDL and HDL, total cholesterol, and triglycerides and sometimes even less because that’s what the insurance is going to pay. Unfortunately, most primary MDs are trying to stick with the insurance guidelines, and so unfortunately I think short changing the patients.

Dr. Spar:              Yeah. I mean there have been studies showing the annual physical as it’s currently done literally is a waste of time. It doesn’t provide any change in mortality or morbidity. There have been articles in the New England Journal of Medicine and JAMA and in very prestigious, very conservative journals about that. It’s because it’s all based on what insurance says as opposed to what is really optimal in terms of preventative medicine and evaluating risk, which is unfortunate because then it puts us in this position of saying, “You know, you really do need this test and this is how much it’s going to cost, and I’m not making money off of it, but you really need this.”  Patients who are low income, it’s not fair.

Dr. Weitz:            MDs rarely even offer patients that choice, though.

Dr. Spar:              Right because it’s a whole discussion that they don’t feel like to have. Either they don’t know about it because they don’t learn about it.  It kind of goes down they only learn about what’s in the annual physical or they’re like, “Okay, I know he needs this, but I got three patients waiting. Do I really want to go into ‘Well, you need this. This is why. Is it covered or not covered.'” They’re just like, “No, I’m just going to check off the lipid panel.”  It’s really unfortunate.

Dr. Weitz:            Yeah.

Dr. Spar:              Then the other marker I would say in there that I didn’t mention is homocysteine. That’s if someone can’t afford genetic testing that’s kind of a hint that they might have like an MTHFR, a gene where they don’t methylate their B vitamins well and don’t clear homocysteine.  Homocysteine is easy to lower, and it’s a very known risk factor for heart disease.  That’s part of it. And then imaging, I really think again is not covered by insurance but is not that expensive.  It’s like $200 for a coronary calcium score.

Dr. Weitz:            Right.

Dr. Spar:              To me, I love those because if somebody does have high cholesterol, but they don’t really want to go on a statin and I don’t really want to put them on a statin, we’re trying fish oil, we’re trying plant sterols. They’re watching their diet. The thing that will help me decide, “Okay, do we really need a statin or not?” is something like a phenotypic test. Is that risk translating into real disease? The way to look at that is something like a coronary calcium CT scan, which is only a few cuts, a couple inner bugs, and we can see do they have plaque or not, and if they don’t, then I know, “You know what? Don’t worry about it. You have some cholesterol, but it’s not really manifesting as plaque,” versus, “Ooo, you have a high calcium score of 100, we’re putting you on a statin.”

Dr. Weitz:            I think the reason why you mentioned that it’s just a few cuts is to point out that it’s not a lot of radiation.

Dr. Spar:              Right. Exactly. Some people get scared of having too much CAT scanning. This one, there’s no contrast dye that they’re injecting in you. It’s really limited to just looking at the arteries around your heart.

Dr. Weitz:            Right. Good. Yeah. Let’s bring up the testosterone topic.

Dr. Spar:              Yes.

Dr. Weitz:            First of all, we’re seeing lower levels of testosterone in men over the last several decades. Why is that?

Dr. Spar:              Good question. I don’t know that we know. I mean, I think the hypotheses that seem most likely are number one, anxiety and stress. There’s just more stress. There’s less time to do what we need to do. There’s less people unplugging and relaxing. We know that reproductive drive is completely directly correlated with or inversely related with stress. Women stop menstruating when they’re really stressed. Men stop making testosterone. It’s literally evolution protecting our progeny because if our bodies sense stress or crisis, and that can be emotional stress from work or from relationships just as much as being under attack from a saber tooth tiger, it’s going to say, “Whoa, we need to protect the home front. We can’t make progeny that we may not be able to protect. Let’s shut down reproductive drive and just focus on survival.”  It’s kind of hard where it ends. Stress lowers testosterone. I think that’s a lot of it.

I think some of it is environmental toxicity. We see that in to some degree this difference between total testosterone and free testosterone, which I know you were going to ask about anyway. Basically, some guys like their total testosterone is okay, but they have so much of this binding up protein called sex hormone binding globulin that their amount of testosterone available to really work is low. Some of that, I think, is due to environmental toxins that affect the liver and then the liver makes more of that protein.  I think between the stress and the toxins, those are probably the most likely. We see fertility going down. We see sperm counts going down. There’s something really affecting reproduction in general in men and women, but you can see a direct correlation in men.

Then opioids as well I guess would be the third one. We hear a lot of this opioid epidemic. Opioids are very directly correlated with lower testosterone, completely, even if you’re just appropriately taking them for a couple of weeks after having surgery or something. Your testosterone is going to go down while you’re on them.

Dr. Weitz:            Yeah. Opioids have all sorts of negative effects on the gut, every system of the body really. When it comes to testosterone levels, it’s interesting that really high levels of testosterone like professional body builders have will increase their risk of heart disease, while really low levels also increase their risk of heart disease. Then, yes, testosterone levels lower. A lot of times there’s higher estrogen levels, and it’s interesting that that’s a negative for men.  For women, higher estrogen levels are very protective for heart disease, which is one of the reasons why women have lower risk of heart disease.

Dr. Spar:              Yeah. I mean, I think there’s this whole controversy about testosterone, but it shouldn’t be a surprise that it’s not good if it’s too high or too low. I mean, we know with thyroid for example if it’s too high you can have problems. You can have palpitations and a risk of heart attack. If it’s too low, you get a wheeze and constipated, and you can even have all sorts of skin and other immune system conditions. All hormones are very finely tuned. They affect each other. It’s the same with testosterone. There’s definitely evidence too low testosterone affects increased risk for heart disease, increased risk for obviously osteoporosis and bone problems, and too high of testosterone increases it as well.  Really, it does need to be in the optimal range. I think that’s part of the issue with guys like bodybuilders that are taking too much of it. It’s not like … I don’t know if there’s any good example, but it’s not like more is better. You know? I mean, more is better if they’re low and they’re just getting it to the upper 25% of the normal range.  If they’re taking it over the normal range, it’s not good.

Dr. Weitz:            Yeah, what bodybuilders are taking though is nowhere close to the normal range, you know?

Dr. Spar:              No, no.

Dr. Weitz:            They’re taking thousands of times above what the normal range is.

Dr. Spar:              Exactly. They get results in terms of muscle mass, but they also get dangerous side effects, liver, heart disease, all sorts of issues. I think the estrogen is the same thing. You want it in that what’s normal for men. That’s the other thing bodybuilders and some guys do. They’ll read it in Men’s Health magazine or these magazines to take all these estrogen blockers, and then they take too much, and their estrogen is unmeasurable. They think that’s great, but that actually puts them at risk for osteoporosis because you want between 15 and 30, if you’re measuring your estradiol level. If it’s much higher than that, no it’s not good. You can get breast tenderness and issues if you do maybe take a blocker a couple of days a week.  These guys who are taking blockers like every day, and they feel great that their estrogen is unmeasurable, are really in trouble.

Dr. Weitz:            You think 15 to 30 is the sweet spot for estrogen for men?

Dr. Spar:              Yeah, for estradiol specifically. Yes.

Dr. Weitz:            Estradiol. Yes. What about for testosterone? When you look at these testosterone tests, let’s start with the total testosterone. The range on some of these labs is 150 to 900, which is a big range.

Dr. Spar:              Yeah. I know. I think for a total really if it’s under 350, they’re likely to have symptoms.  First of all, with testosterone I rarely just treat the number. If it’s in the 100s, I will treat the number.  Even if they don’t have symptoms, that’s dangerous for bone and heart health and even diabetes risk. If it’s in the 300s, likely they’re going to have symptoms if it’s under 350. So the symptoms that a guy can have, they may not report sexual function issues, but they could have depression. They could even be put on antidepressants because nobody checked testosterone, but really they’re depressed because their testosterone is low.  They can have low energy.  They can just have lack of muscle mass or losing muscle mass or losing weight. Sometimes guys won’t talk about having issues with sexual function, but they’ll talk about these other things.  Those all can be improved if you get the testosterone normal.  I would say probably 350 is the lower limits of normal, optimal, and up to maybe 900, probably much above that you risk the blood count getting too high. You risk acne. You risk getting that kind of road rage kind of feeling.  There’s probably no extra benefit of getting it to 1,100 versus 900.

Dr. Weitz:            What are some of the strategies for helping to normalize or elevate testosterone levels besides taking testosterone?

Dr. Spar:              A couple of things. Number one, you can take some things that naturally do block some of that conversion of testosterone to estrogen, like zinc for example or there’s a natural herb called chrysin which you can even put into a topical thing. Those help a lot.  The conversion, you know we all convert testosterone to estrogen via this enzyme aromatase.  Those are natural aromatase inhibitors, so they will naturally boost testosterone a little bit.

Whenever you take zinc, you want to take a little bit of cooper with it in a ratio of about ten to one zinc to copper because they go together, so they are supplements that will have those combined. Those are kind of natural ways.  Other than that, there are other things that help boost libido and male energy, but they don’t boost testosterone per se.  Still, I think they’re worth using if testosterone is mildly low and somebody has symptoms.  For example, in Chinese medicine the ginsengs, we all know about, right? Especially Panax ginseng. In Indian medicine there’s Tribulus, which is kind of like the Ayurvedic form of ginseng. In South America, there’s Maca root, which is what they call Peruvian ginseng. Every culture kind of has their own male energy formula.  I really like Tribulus.  Maca has been really well shown to help with mood changes. There is a good study showing men on I forget if it was Celexa, Prozac, one of those SSRIs, which are known to cause sexual side effects taking Maca I think it was about two grams a day.  This was like a very well peer reviewed study.  They had a decrease in those side effects after they started the Maca, those sexual side effects.  I think that’s a great thing to try.  Those don’t raise T per se, but they do help some of the symptoms of low T.

Dr. Weitz:            Right. Tongkat Ali, have you tried that herb?

Dr. Spar:              No, I haven’t.

Dr. Weitz:            Yeah, check that one out. Look into the research on it.

Dr. Spar:              Okay. Great. Yeah, I definitely will. Obviously the other things we talked about that are real important. We talked about how stress lowers testosterone, so one of the most important interventions to increase testosterone is to find some stress management approach, whether it’s meditation, yoga, Tai chi, journaling, prayer, some breath work. I counseled a guy to do every day to really help decrease the impact stress has on the body. That’s probably the most powerful thing.

Dr. Weitz:            I found sleep to be really impactful as well. So many of us are sleeping four, five, or six hours a day.

Dr. Spar:              Yeah. That’s true. Most people do need seven to nine on average. You can get away with one or two less than that, but over time that absolutely decreases your ability to deal with the stress of life and then that’s going to cause a cascade of events. Yeah, that’s a really good point.

Dr. Weitz:            To bring up the free testosterone thing, I’ve noticed a huge percentage of men with low free testosterone levels. Even if their total testosterone level has sort of been normal or mid-range.

Dr. Spar:              Yes. Yeah, I don’t know that we know exactly why. Like I said some of that is from this increase in this binding protein, HDGN. We don’t know why that’s raised. We know thyroid disease and liver disease affects it, but it seems like more and more guys are getting a lot of testosterone gunked up with this SHBG, and I suspect myself, and I don’t have a lot of scientific basis for it, that it is part of this environmental toxicity affecting the liver and liver manufacturing more of this.

Dr. Weitz:            A lot of these environmental toxins are estrogenic substances.

Dr. Spar:              Exactly. The program I do called Tack 180, and in the show notes I’m sure you’ll have a link to that, it’s tack180.com that does a lot of this testing like we’ve talked about. I do saliva testing in addition to the blood. The blood is good for checking total, and you can check free as well, but the saliva is really good because it only checks the free really available testosterone and especially if I’m using topical testosterone replacement for a guy. Sometimes that salivary will really help me hone it in better because you can kind of overdose pretty easily a patient on topical testosterone just checking serum levels. The saliva will help you catch if you’re using too much or not.

Dr. Weitz:            Just in conversations with some patients who have used topical, they often feel like it doesn’t do much especially that AndroGel stuff.

Dr. Spar:              Yeah, it’s funny. You know, I think it’s like 50/50. I don’t know the percentage, but some guys it absolutely works, and it’s great. Some guys it does nothing. A, they don’t feel anything, and, B, it doesn’t even raise the level much. It must have something to do with the carrier and whether it gets absorbed or not. Just so your listeners know, bioidentical testosterone, it’s all the same. It’s much less complicated than with women, right? With women you can have all these nonbioidentical estrogens and progesterones, but, man, it’s all the same testosterone compound. It’s all pretty much bioidentical.

Dr. Weitz:            Yeah, there’s no testosterone coming from horses.

Dr. Spar:              Right. That would be right. I guess if they would take like stallions maybe they could get some or something.

Dr. Weitz:            Actually, that could be a big seller.

Dr. Spar:              As opposed to the mares, yeah. Okay. Let’s delete that. It’s going to be my patented thing. I don’t know how we’re going to collect it, but we’ll figure it out. Yeah, it is all the same. That’s why sometimes I like to go with compounded because you can put it in a carrier that might work better than whatever AndroGel uses. You can put it in a cream instead of a gel so it’s a little less sticky. You can use less volume and make it more concentrated so it’s less done. I’m using more and more of clomiphene, which is a pill so it’s easier, but it is off label. It’s not FDA approved for men. It’s approved for women. It’s safe. Urologists started using it a lot a few years ago, and so those of us doing men’s health started looking at that. It’s been out for a long time, so it’s available generically. It’s not that expensive.  It especially is good because it helps get the testosterone to be made by the patient themselves, so it stimulates their own testicle production so you’re not taking over completely the testosterone by putting it in either injecting it or topically. You’re just kind of fooling the pituitary gland into telling the testicles to make more testosterone.

Dr. Weitz:            Yeah. Dr. Elkin who’s in my office on Tuesdays, he’s an integrative cardiologist, he likes to use that in combination with HCG.

Dr. Spar:              Yeah. They work in a similar way, so it’s working on the level of the pituitary and hypothalamus. The other thing people don’t talk about when you use testosterone testicles shrink because you’re really taking over production. I don’t care with doctors say. You are taking over production unless you’re adding in HCG or clomiphene. As soon as the body senses you’re taking much higher doses of testosterone than you would make on your own, they’re like, all right we’re good. You’re just going to handle it through the shot or the topical. And the testicles stop producing and do shrink. That’s a concern for a lot of guys.

Dr. Weitz:            Over a period of time if men stay on that they may lose the ability to product their own testosterone, right?

Dr. Spar:              I don’t know if that’s true. I don’t think we know that.

Dr. Weitz:            I know it’s the case with former body builders because I used to treat a lot of these guys, and that was pretty common. They would take them in crazy excessive amounts.

Dr. Spar:              Right. Yeah, definitely if you’re using high doses like that. If you’re using just kind of therapeutic doses, I don’t know because the reality is guys are guys, right? No offense. They don’t use it all the time. Even guys on it for years are missing a lot of doses that are going on. They run out. They forgot how they felt off of it, so then they stop. It really ends up not being an issue. Most guys are not on it day in and day out for years unless they’re like you said body builders or something.

Dr. Weitz:            Do you use PSA to screen for prostate problems? I just recently had a physical with my primary care doctor, and he said, “I don’t believe in PSA anymore.”

Dr. Spar:              Yeah. No, I definitely do if they’re on testosterone. You have to. I do believe in annual exams.

Dr. Weitz:            But even if they’re not?

Dr. Spar:              Yeah. I mean, it’s really important. I mean, we know testosterone treatment does not increase risk for prostate cancer. That’s been proven. Abraham Morgantelar from NYU or Columbia proved that. If somebody gets prostate cancer, you don’t want to keep giving them testosterone. Yeah, I do screen for it with PSA. You know, in the other patients it’s tough. I will have the discussion. Basically I always do a digital exam and feel the prostate. If it’s enlarged, I will check it. I usually try and also check a free PSA. I think on one hand, yes, it’s like what do you do if the PSA is elevated. Half the time it’s just causing stress and worry, and it’s nothing, but the good thing is nowadays most men have access to a prostate MRI. That can really make the need to jump from a high PSA to biopsy much less likely.  They can instead have an MRI if the PSA is a little high, and if the MRI is fine, they don’t need to have the biopsy. If the MRI is not fine, they know exactly where to go for the biopsy so they’re not just doing a ton of random punches. The MRI helps me feel better about ordering a PSA.

Dr. Weitz:            Unfortunately, once again, we have another situation where you’ve got a procedure that’s not always covered by insurance.

Dr. Spar:              Right, right. Usually if the PSA is over 4, at least in my patients who are mostly PPO kind of insured, they’ve had it covered. Sometimes you have to go through the urologists, but usually they can get it covered.

Dr. Weitz:            Right. I think the big issue with the PSA test is that men who have positive PSA who show elevated PSA levels sometimes jump to biopsy and then just jump to surgery and then have a lot of side effects when maybe it was a slow growing prostate cancer that they could’ve monitored for years without any problems.

Dr. Spar:              Exactly. It’s heartbreaking. It really is. We’re trying to figure out. We need better tests to know which ones are just there and will never cause problems and which ones are scary.

Dr. Weitz:            Yeah. I think we’re doing a disservice though to not do the PSA. We just need to make sure that when they get it that they don’t panic and rush out and get a procedure that can cause incontinence and impotency when they might not need it.

Dr. Spar:              Right. Exactly. Yep. The free PSA even if there’s not access to the MRI it’s a little bit helpful. It kind of breaks out if someone has an elevated PSA into the percentage that is what’s called free, and that correlates with the likelihood that that elevated PSA is just enlarged prostate versus cancer.

Dr. Weitz:            Right. I think those are most of the questions that I had. Is there any other issue you’d like to raise?

Dr. Spar:              No, not really. I think it’s just important for listeners to know that, number one, there are ways to help men make behavior change, and I think it’s really, really important whether you’re a practitioner or patient to do that. It’s Movember right now. I’m not sure when this is going to air, but this is men’s health month. It’s literally life and death. I mean, it sounds like a hyperbole, but men are dying because they’re not resonating with the message you are giving. I just encourage listeners to really think about one step at a time. Don’t talk about big global prevention messages. Talk about one thing you or your patient can do to decrease the risk of getting some kind of problem. Make sure they understand how it affects something they’re concerned about. Make it goal oriented.

My whole tag line is when you’re healthy you can win. When you’re not healthy, there’s that saying, I forgot who said it. Somebody who is healthy has a thousand dreams. Somebody who’s unhealthy has one. That’s really something to think about.

Dr. Weitz:            That’s great. That’s a great note to end on. How can listeners get a hold of you and find out about what you offer?

Dr. Spar:               Sure. My website and blog and everything is at drspar.com. D-R-S-P-A-R dot com, and then the program I have for optimal men’s health is called Tack180, T-A-C-K 1-8-0, so Tack180.com. Really, I encourage you to sign up for my newsletter. It’s very brief. It’s once a week, just three nuggets of information that are germane to men’s health, and you can sign onto that right on the website.

Dr. Weitz:            That’s great. I’ll put links to that in the show notes. Thank you, Miles.

Dr. Spar:               Thank you. Appreciate it. It was a pleasure.

Dr. Weitz:            Yeah, excellent.

 

,

Breathing with Emma Ferris: Rational Wellness Podcast 82

Emma Ferris discusses proper breathing with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

5:20  Most of us come out as belly breathing babies, but then either trauma or infections or stress lead to bad breathing habits that we get stuck with.  So then we need to retrain these people to use proper breathing techniques. 

6:17  Emma explains that when you feel stress, your sympathetic nervous system takes over and results in faster, shallower breathing through our mouth, rather than slower, deeper, belly breathing.  This shallow, fast breathing tends to recruit our neck muscles, like our scalenes, SCMs, and our upper trapezius muscles and can contribute to neck pain.  We should be using our diaphragm as our primary breathing muscle.  Activating our diaphragm helps to support our back. Taking a longer exhale will tend to activate the parasympathetic system, that teaches the body that it can go into the rest, digest, and recovery mode.

10:11 When you’re breathing too fast, you breath out too much carbon dioxide and your blood chemistry shifts, making your body more alkaline.  When your body becomes more alkaline, you get more anxious and you may have trouble sleeping.  This reduces blood flow to the brain and also to the fingers and toes. 

13:45  The importance of deep, belly breathing is that you use your diaphragm to breath. If you breath fast and shallow through your chest, you’ll end with tightness and trigger points in your scalene, SCM, upper trapezius and your other neck muscles. Your diaphragm on the other hand has several roles, including respiration, speech, and stability. Using your diaphragm helps to stabilize your lower back by building up the intra-abdominal pressure. Manual therapy and chiropractic manipulation can be helpful for reducing trigger points in these neck muscles, the ribcage, and the diaphragm. 

18:40  When you are in sympathetic, stress mode it tends to shut down three systems in the body: 1. Hormones, which results in more infertility, 2. Immune system, so you tend to get more colds and flus, etc., 3. Digestion, so IBS is more common. If you are running away from a lion, it is no time for digestion.  This is a result of our inability to handle stress. Breathing is a strategy that can help.

29:30  When Emma works with athletes she will often have them use a device called a PowerBreathe, which is an inspiratory muscle training device. It is like dumbbells for your diaphragm and it makes it harder to take a breath in.

 

 



Emma Ferris is a physical therapist and acupuncturist from New Zealand who created an online breathing hub called The Butterfly Effect and The Big Exhale breathing course to help patients recover from dysfunctional breathing patterns.

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 Transcripts

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, Dr. Ben Weitz here. Thank you so much for joining me again today. For those of you who are enjoying listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and reviews, so more people can find out about the Rational Wellness Podcast.

Our topic for today is breathing. How important is breathing, what proper breathing is, why breathing properly is important for our health, and how improper breathing can lead to the following health consequences: neck and back pain, the inability to recover from injuries, fatigue, depression and anxiety, stress, concentration and memory problems, reduced performance for athletes and the inability to work through emotional trauma or grief.  While there are a large number of different breathing techniques out there, especially when you start looking at all the different forms of breathing coming out of the yoga tradition, but when it comes to the more therapeutic forms of breathing, breathing through your nose and deep, slow belly breathing, rapid and shallow rapid mouth breathing seemed to be two of the more important concepts I’ve come across.

Today, our special guest is Emma Ferris. She’s an acupuncturist, a Pilates instructor, a registered physio therapist, and a public speaker, and she’s joining us all the way from New Zealand. Emma created an online breathing hub called the Butterfly Effect, and she offers the Big Exhale Breathing Course to help patients recover from dysfunctional breathing patterns. Emma, thanks so much for joining us today.

Emma Ferris:                      Thank you Ben for having me.

Dr. Weitz:                            Good. So, can you explain how you became so interested in breathing as a form of therapy?

Emma Ferris:                      Well, breathing kept coming up in my life with my experiences, both with my patients as a physical therapist, but my first exposure to learning about breathing was when I was around 12 years old. I struggled with a speech impediment and a stutter. And so for me, I started at a very early age getting some speech and drama and therapy for that. And, one of the most important things for that was learning to breathe. I particularly learned to breathe into my belly. So I learned that, but I never connected the dots as I went through my physical therapy training; we often put things in silos, which they often do in medicine and healthcare. Cardio, respiratory was over here, and neuro or the brain work was over here, and then muscular, which I was really fascinated with by fixing necks, back pain, all that sort of stuff; that was what I loved.

But, what really changed for me was the patients that I couldn’t fix, and it frustrated with me. You know, the neck pain and back pain that kept coming back. People that struggled with the multiple symptoms that when with it, the fatigue, anxiety, the poor sleep, and I guess in my training and in my life experiences, it wasn’t really explained how key that was until I began to dig a bit deeper and look at what the underlying causes and what the wires, and that’s obviously what you’re all about here too, Ben, is finding out what the why behind people getting to that place of dysfunction.

So, definitely in my patients, it began to show up for me. Then, I had my own life crisis when I was around 28 when I got pregnant with a condition called hyperthermesthesia. So, it’s extreme morning sickness. I realized that all the things I’d done before that point with my life; I had a busy physio practice, I was teaching, I was running workshops, and my body was running on empty before I even started to carry this little baby, little human being. I ate okay. I did a bit of exercise, but the reality was that’s not good enough, and my nervous system was just shot.  So, I learned then that what I’d been doing beforehand wasn’t good enough, and so I went into this process of researching and trying to formulate my own thesis, and I became a bit of a mongrel with breathing. So, I got all these different ideas from yoga and Pilates and Butyeko and Greycliff breathing, all these different versions. And, what really stuck with me for learning about breathing was it’s actually the story about why we connect with every person, why that’s important and why breathing as it makes a difference, but the reason they got here in the first place. You know, what was the stress and trauma, what was the environment that got them to learn to need to change?

And, I think that’s so important because most of us come out breathing like babies that are beautiful belly glorious breathing. So, we don’t come out sometimes when people don’t come out screaming and yelling and appraising very well, but most of the time we’re naturally belly breathers. So, things happened along that process, whether it’s trauma, illness, infections, stress, and then the habit gets stuck, and so I’m all about looking at the why, but retaining the habit and looking at the science behind it and the muscles because it, as a physical therapist, that’s what I treat a lot of, you know, motor patterns, dysfunction, and that actually has a huge trouble with breathing retraining. Yeah.

Dr. Weitz:                           So, that’s interesting. So, we start out as mouth breathers. Is that what you said?

Emma Ferris:                      No, we start as nose breathers.

Dr. Weitz:                           Oh, okay.

Emma Ferris:                      But, belly breathing. Sorry, so we start out as beautiful, slow belly breathing. Watch a baby sleep. It’s just glorious. And, they do it so naturally.

Dr. Weitz:                           Right. So, can you go into some of the details about what’s proper breathing is and, and why is it so important to breathe through your nose rather than your mouth?

Emma Ferris:                      Yep. Well, I’ll go into the nose and the mouth breathing constantly mistaken, but a lot of it’s all about the reaction to stress and how our body’s nervous system gets overridden with breathing. So, breathing is both under conscious and unconscious control. And, that’s a really powerful point because we have the power to actually override our autonomic nervous system, which more often than not gets pushed with our busy modern day lives or the stresses we have in it, and that changes us to push into what we call your sympathetic nervous system, much of which I know you’ve talked about before on the podcast, and the reaction to stress, whatever it is, whether it’s past, present or future, drives us to change our breathing. So, if you imagine that lions are chasing us, we take a big breath in, we inhale, and we use our neck and shoulder muscles.  We prepare our hip flexor muscles that like to get us out of danger, and we use those muscles to mobilize and get more air in. Now, that’s really important for that stress with danger that’s coming after us, but if that danger is a relationship issue or a problem with somebody at work or you’ve had back and neck pain for a long time, and even the thought process behind that keeps you stuck in that space of going, oh, this is dangerous. I’m sore. I’m going to get sore if I do this. In a response to a dangerous activates that fierce into our brain to trigger that reaction, and so the problem is we get stuck in that cycle, and one of the main things that changed is our breathing. So, we become faster or begin to breathe through our mouth because that’s a fast way of getting air in and getting more oxygen. which again is important for exercise, in and times of stress, to get us out of danger, but not all the time. So, as learning why we use it, people say to me, “Should we be using our nose all the time?” And, it’s like, well no, that’s not practical because when you walk up a hill, your body’s going to need to get more oxygen in, so you need to be able to go to mouth, but it’s as soon as possible going back to that nose breathing and reconnecting with it.

So, the reason why the nose is important is because it’s got two holes versus one for the mouth, and so it slows the air down. Like, it’s simple concepts, but if you can use that, it slows the air down, which is really important for your diaphragm, and the diaphragm is your main breathing muscle, and that sits between your rib cage and your stomach, so to say, and your lungs, and learning to use your diaphragm in the right way is really what for me, changes people’s perception and understanding of breathing, so it’s not about taking big breaths, and that’s the content I want people to be aware of as well.  When you say take a big breath, it’ll calm you, that doesn’t actually work always. That can actually stimulate you more. So, for me, it’s about low, slow belly breathing and long exhale, which is why my program is called the big exhale, so then you need to get out of that fight or flight inhale mode and learning to drop the chest down, and that’s really important for neck and back pain, which we can talk about it a bit more later on.

Dr. Weitz:                           Why is it more important to have a longer exhale?

Emma Ferris:                      Well, that’s one of the easiest ways to activate that parasympathetic nervous system, so activating that teaches the body that it can go into that rest, digest, and recovery mode. And, that’s why in Yoga and pranayama and all the techniques like Tai Chi work on lengthening the exhale, free diving, Pilates, meditation; naturally they’re getting your comps of your breathing, which is activating that parasympathetic nervous system.  That’s why people feel good doing those activities that you don’t always know why. So, and the other reason is that we’re not meant to be driven into that fight or flight response. And, we do, when our blood chemistry changes over time, when we’re breathing too fast. And, I know you’ve talked about this before with Rosalba Courtney, who I’m a really big fan of; she’s a wonderful breathing teacher around the world, an osteopath from Australia. Now, the blood chemistry shifts when you’re breathing too fast. What it does is your, by breathing out too much carbon dioxide, which is way more important than oxygen, you end up increasing your pH and making it more alkaline. So, over time that if your body stays in that state, it thinks that that’s normal, that new level of CO2 balance is what you’re supposed to go to and keeps you driven physiologically to breathe in that vast state.

So learning to lengthen your exhale also overrides that new level of normal or what you think is normal, and that’s really important for anxiety, patients who struggle with anxiety, with a shortness of breath and a suffocation response. And, so a lot of the techniques that are out there are great, like Butyeko, which gets you to lengthen your exhale to increase that CO2 liberal response, so that your brain goes, okay, I can now hold for longer. I don’t feel that fear and danger response of suffocation, which means I need to take a big breath in and gets you stuck on the inhale mode.

Dr. Weitz:                            Most of us think that the whole purpose of breathing is just to get oxygen. So, can you talk about why getting enough carbon dioxide is important?

Emma Ferris:                      Well, CO2 has a really big impact onto both the pH, like I say, because it actually shifts the … By breathing out too much CO2, you shift the pH, and then your body’s going to try and replace that acidic component, and it’s going to start leaking bicarbonate into the blood. So it has a bit of a knock-on effect and disseminates systems. One of the other impacts is the brain, so when you change that pH and the CO2 depletes, you actually reduce the blood flow to the brain, which is why there’s a connection with memory and concentration, brain fog, or whatever you want to call it, processing and cognition, and for learning, that’s a really important part for children and for adults. And, one of the things that I find really powerful was when people get stuck in that fastest stressed breathing and our habits contribute to that, like caffeine or alcohol that can shift our breathing. But, stimulants we don’t realize then that our body will be shifting its blood chemistry, and it takes a while to recover. And, even those habits and stimulants can actually then create a shift in the blood chemistry, which then creates more anxiety and other components of poor sleep that gets you stuck in that cycle.

So, the pH is pretty powerful. One of the other things is it actually causes, with that shift in pH, your blood is going to go from our limbs and our extremities because we don’t, we’re not worrying about feeding the blood into the limbs and the hands when you are in that stressed state, and this is important for athletes as well, so it’s going to divert blood flow to areas that need it, like our organs. And, so we can get cold fingers and toes. This is one of the signs of breathing dysfunction. I get tingling in fingers and as well. And, so there’s a change even in blood flow and our brain and our organs. We just divert things around because of that physiological push.

Dr. Weitz:                            What’s the importance of deep belly breathing as opposed to, I guess more shallow chest breathing?

Emma Ferris:                      Yeah, one thing is that as changing the right breathing muscles to work, so most of the breathing, like 70 to 80 percent of our breathing should come from our diaphragm, our big belly breathing muscle. So, what happens when you’re stressed and you start to use the inhale?  You’ll get stuck with what we call breath stacking, where you breathe in and you hold, and then you might do that a little bit, but then your brain goes, oh, I feel like I’m suffocating. I’ll take another breath in. Then, you get stuck in that mode and using our backup breathing muscles and what I call your parachute reserve.  And these are your neck muscles, your scalenes on the side of your neck, your sternocleidomastoid from the front of your neck all back up into your head and your skull down into your sternum and your upper traps, those muscles that get really sore and tight on the back of your shoulder.

Now, we’ve seen them all the time. Clinically, I know you do too, Ben, with our patients. I gave you a cue there, and this is a really important point because we’re using those muscles between, depending on your breathing, that breathing frequency between 17,000 and 210,00 times a day, the amount of breaths we take. So, if you’re using the wrong muscles in the first place, you’re going to cause more trigger points, those achy, knotty spots that can become active and referred to be trigger point index or trigger front for zero down the arms. So, that’s one of the main ones is that you’re actually using the wrong muscle all the time, and it’s like a reverse drug when you start using the top part and not the bottom part. So, teaching them how to use the diaphragm is really important, but also what I talk about is 360 degree breathing.  So that diaphragm has attachments right from the front of your stomach all the way around the ribs down the sides because it’s like a dome and all the way into your lower back into by your L1, L2, your lower vertebrate, and your hip flexor, your fight or flight stress muscle, and it has that neural connection through the ear, which is pretty powerful. So, learning to activate the diaphragm is really important for both intraabdominal pressure, and there’s a lot of research now looking at diaphragm function and dysfunction with back pain, and when someone has an episode of back pain, one of the first things we’re going to do is inhale and protect, and they actually lose that activation of the diaphragm, which actually is needed to actually stabilize. So, you get in this vicious cycle because of not breathing right, and they create more trigger points because the physiologic physiology changes, and then they also feel more stressed and anxious about being in pain. And, so when I go to bend or twist, they go, “This is how I injured my back last time; I’d better protect.”

So, from the point of view of the diaphragm, it has several roles: respiration’s king, speech is queen. And, I guess the next one is stability. So, if you’re walking up a hill, first thing that’s going to go is stability. You start to not stabilize very well. And, then you speak each, and then respiration. So, that’s always going to be the key thing. So, you start to recruit from other muscles. So, it’s really important to look at that role of diaphragm, but to understand that it actually, it’s a one way muscle, and that only works on the inhale, and then if you learn to lengthen your exhale and relax as a diaphragm recoils back up, then you can activate that parasympathetic nervous system.  But, a lot of time, when I’m looking at people that have been training yoga or training other techniques, they’re actually forcing the air out and causing that CO2 balance to actually be shifted just by the way they’re breathing, so a lot of it’s just conscious retraining and moments.  You know, I had to lie down for 20 minutes. It can be I’m going to stop right now on my drive around LA or New Zealand and just cause an exhale. You know, simple things add up.

Dr. Weitz:                            You’ve refined restrictions in the diaphragm and have to use manual techniques to free those up. Yeah.

Emma Ferris:                      Absolutely, and, all of those breathing, so scalenes, verse ribs, upper traps, and I use a lot of dry needling or I think … What do you guys call it over there? Trigger point needling, and that’s really effective for releasing the result of the poor breathing pattern, but unless you change the breathing pattern, the driver on the why it comes back. So I love the manual therapy for that.

Dr. Weitz:                            Yeah. We find chiropractic manipulation also beneficial in those cases as well.

Emma Ferris:                      And, particularly for thoracic because if you’re not getting thoracic mobility and ribcage, you’re not going to get that lower stability. So, I 100 percent agree because that also goes into that parasympathetic loop, automatic nervous system.

Dr. Weitz:                            Yeah.

Emma Ferris:                      So I love manual therapy. There’s so many ways of getting somebody into a calm state. That’s why I love acupuncture as well to go look, what is the right formula for a person in front of you?

Dr. Weitz:                            Yeah. One of the things, one of the conditions we didn’t talk about or I didn’t mention, which comes to mind when you talk about rest and digest, is IBS or CBO, and I could see how breathing be really super important for those patients because if they’re always in this sympathetic mode, they’re never going to properly digest their food, and it’s going to increase all their digestive symptoms.

Emma Ferris:                      Absolutely, and the same stress mode … If you’re stacking stress on that sympathetic thing, they usually change the bacteria in your stomach in the first place. So, one of the great things with learning to use a diaphragm and is that you’re actually going to pop through, you get the empty stomachs to actually work in the right way, get the blood flow, and when you are in a stressed state, blood flow is diverted from your bowel and your stomach because when you’re running away from that lion, you’re not worried about processing food. There are three areas that get shut down hormones, so particularly females, and we’re seeing that a lot with infertility problems these days, but that cycle and upset from that by being stuck into the sympathetic drive and immunity, so we get colds and flues, we’re rundown, or we’re stressed and particularly the digestive system.

So, there’s so many more problems these days all because of our inability to manage stress, and that comes in so many forms, and there’s a lot of pressures and by society that drives us, and I just think as the more that we can get this understanding out because people are hungry. There’s a groundswell of looking at techniques that are focused on holistic treatments like the manual therapy, like acupuncture, like yoga, because it makes you feel good in a way that is not a pill in a bottle. It’s very hard to override that nervous system.

Dr. Weitz:                            Yeah. When it comes to nose breathing, when I talked to clients there’re so many people that have problems with allergies and with you know, issues not being able to breathe properly. How do you deal with some of those issues if you’re trying to get them to breathe through their nose, and their sinus passages are partially clogged, or they have deviated septum, or they have allergies, or they have, you know, some of these chronic respiratory problems?

Emma Ferris:                      They’re huge problems, and that can be the driver in the first place for getting stuck in the habits, but then also that habit of mouth breathing gets them stuck with the sinus problems as well because they’re not actually using that nose as a filter and keeping the blood flow through there. So, it’s really problem solving for the individual. And, so one of my first steps for someone struggling, getting them back to the doctor and check for any polyps and any problems in teeth. And, then there’s simple things that you can do, like sinus rinses for instance. Have you done them, Ben, a sinus rinse?

Dr. Weitz:                            Yeah.

Emma Ferris:                      People don’t always like them, but they’re so satisfied, and that’s a really good way of cleaning out the nose and allowing it to get that filter through. And, one of them is learning to breathe through both nostrils because you actually switch nostrils through the day that you break through. Do you know that?

Dr. Weitz:                            No.

Emma Ferris:                      So, every one to four hours, you’re switching nostrils, so one side becomes the one you’re breathing through. And, the other side is the cleaning system. So, if you have one side that is actually blocked, you have a deviated septum, then even in your sleep, you’ll be switching through the mouth breathing because you’re short of air. So, getting that correct is very important, and during those steps, before you try anything like mouth taping, because that’s not for everybody. You’ve got to check people’s saturation and stuff as well, but you know, I use it myself. I use it on different patients, and it’s very successful. So again, it’s not a one size fits all model for nose breathing but learning to-

Dr. Weitz:                            How do you decide when somebody, when it’s appropriate for somebody to do mouth taping, and can you explain what mouth taping is? This is where you use special tape to shut your mouth while you’re sleeping, right? To keep it closed.

Emma Ferris:                      Yeah, absolutely, and you don’t need to have much on it because a lot of people can even open your mouth. People go, “Oh, that feels really scary. I don’t like the idea of that.” And, it’s always a bit of a jug of patients, you know, they keep them quiet, and I said, look, you can say goodnight to your partner and husband then rollover and then take your mouth up. I have to see it, but it’s actually really effective in getting that diaphragm to actually activate when you’re sleeping in the first place instead of going to that mouth breathing, but really what people got to think about is … I’ll come back to nose taping in a second, but you’re breathing at night is a consequence of what you’ve been doing with your habits in the day. So, if you have been caffeinated, if you have, which is very strong culture we have, and you’ve been pushing your body hard and driving it hard, and you’re basically running a marathon through the day with your breathing, then when you go to sleep, your body’s not going to go, oh, I’m going to go calm and relax. It’s going to go really fast, be fast, be fast. And, so you’re not going to sleep well; you’re not gonna get into that nice delta wave when you’re sleeping. You’re gonna keep that mouth breathing.

So, taping is again as dependent on to make sure that people can breathe through here. So, I do a test to check that they can put like a knife or a spatula under there, and we can say if they’re breathing through both nostrils. I can check the nozzle sides. I usually get an EMT to check or a Dr. to check to make sure there’s no polyps or anything else, and we checked saturation as well, so make sure when you do practice, that’s a practice that before you go to sleep, have a lie down and see how that feels and that I get too anxious or short of breath with that and that saturation levels don’t drop down.  So, it’s kind of a looking at the why behind that person. It’s used really commonly, but again, don’t use it for just everybody. I have a lot of athletes because they have already been breathing too much mouth breathing too much in the daytime, and what they try, and they don’t realize that that’s still contributing to the recovery at night. And, so when they start doing that, they sleep in the muscles, at least teens. They don’t need as much magnesium, which is to relax muscles and help with recovery.

Dr. Weitz:                            Interesting. Can everybody change their breathing? Or, are some people just stuck with mouth breathing?

Emma Ferris:                      Well, there’s some physiological reasons which will be driving you to breath faster. And, so there could be. It’s really important to get checked out by your doctor. What we find is that breathing dysfunction is often the last thing that gets diagnosed, and for reasons like diabetes, that can be a real reason why you’re driving faster. I have a lot of patients. I work with a lot of people with Parkinson’s as well, and the anxiety behind that also drives you to breathe faster within the breathing faster drives you to have more anxiety. And, so that has low dopamine as a big part of it. So, there are some people that need even medical support to help shift and get them into a good space. Like, I don’t say that this is going to cure everybody, like there’s not a one size fits all model, but learning to use breathing as an adjunct like with asthma, it’s a really important part. It’s like 40 percent of people that are asthmatic also breathing dysfunction in them, so you can use breathing alongside your other tools into that you can wean off or get the support and work with the respiratory physio to help get that under control.

So, there’s lots of conditions that also benefit highly from training your breathing, become a conscious of it, but anybody can do it, and in regards to how long it takes, it depends how long you’ve been stuck in that fight or flight mode. And, I have a patient that I worked with recently or the last last year really, and he’s a good example of someone that he came into his doctor with several factors, not sleeping well. He’s 40. He was going through a cardiac experience. So, he went to the emergency room thinking he was having an anxiety … Sorry, having a cardiac, a heart attack, and he was getting tingling in fingers and arms, and so many symptoms, the body, stomach problems, erection dysfunction, which is also a sexual dysfunction can be also linked to breathing function because you’ve got to be able to get arousal both sympathetic and parasympathetic with your breathing. So that’s an important area to look at all aspects.

So this guy, because Dr Stefanie was very switched on and went, “I think your breathing’s part of it,” and sent them him to see me, and over three or four sessions, that stress dropped down dramatically, and it was a huge shift for him. And, so he’d basically been, the why behind it though was he was going through a huge a court case trying to get custody of his children through a big divorce, and that had been driven him, and he was really PTSD; he was posttraumatic stress given his marriage, struggling with balancing business and life, and it wasn’t until he got those tolls he can recover, but there was a lot more behind the scenes for that too with family experiences, and so you’ve got to dig deeper and not go there’s not just a habit. There was the driver and the why behind it.

And, when he started to see that his breathing pattern was actually linked to emotions, so when he came in, I’ll be like I, “Okay, so what’s the fear today, mate?” Because, he’d be out here and holding that upper chest, breathing in, and beholding and be like, “Okay, no, this is what’s happening in my life.” And, when we actually talked about and expressed it, it dropped away and belly breathing, they need to do actually to activate the diaphragm is also linked in with your emotions with happiness and joy. So, that’s one of the powerful things I find too is that it’s not just about breathe through your nose and breathe through your belly and actually has an impact on our emotions. And, the research for me that has changed it was a few years ago now, in 2011. It was a guy called Pierre Philpot, and he did this research study. And, I love it because for me, emotions is important in life; we connect; we interact with people. Relationships are huge. So, what it showed was he had this group A, and it looked at four emotions: sadness, joy, fear, and anger. And, he asked that first group to think of those emotions and then look at their breathing patterns.  And, each emotion had a separate breathing pattern. So, I look at it clinically; we see that fear and anger is upper chest breathing. We see. Sorry, fear is upper chest breathing, anger as bracing and holding through our stomachs and obliques, which has a big impact onto a stomach and digestive system. Sadness is often that depressive, a posture that slumped down teenagers, posture that impacts, again, the way we breathe. And so, and the joy breathing is that belly breathing opening up into their stomach. So, what he found in the other group, group b, who knew nothing about group a, once he said, “Breathe in these four patterns, and then what emotion do you feel? The top summary of it.” And it was either the joy, sadness, fear, or anger. So, we have the power to change our emotions by the way we breathe, and we have the power to change our breathing by the way, our emotions, which is why coming back to the simple practices like gratitude, which, you know, hard to put the science behind that, but it’s getting there, you know, and mindset and our shifts behind that has a huge physiological impact onto our body and the way that we breathe in and breathing has a huge impact onto the way we sleep, the way we play, they way we love. That’s huge.

Dr. Weitz:                            Cool. So, you work with people in a one on one basis as well as offering group classes, right?

Emma Ferris:                      Yes, absolutely.

Dr. Weitz:                            So, when you’re working with a professional athlete, how is that different and do have them try to breathe through their nose while they’re running or doing their athletic performance?

Emma Ferris:                      Yeah, so it depends on the athlete and what their sport is. Many athletes need to train specifically for what they’re doing, like swimmers and rowers and cyclists all have different aspects, and many of the sports that actually impact diaphragm position like rowing and cycling ’cause they’re bent forward have more breathing dysfunction in the first place, so they’ve got to work harder to control that, and that one is a high link with back pain and neck pain because of that, because they’re having to switch between. So, the reality is when I look at training somebody, it goes back to breathing pattern first. So, how are they breathing? Have they got the right control? Can I activate the diaphragm? And, you might have to train them for a while to get that right in the first place. Once you’ve got pattern right, then you go to strengthening, and I use a great device called a power breathe. Have you heard of that before?

Dr. Weitz:                            No.

Emma Ferris:                      So power breathe is a … So, I’ve talked about exhaling being really important in that first phase, it really is getting that long exhale and activating because if you can’t exhale, you can’t inhale. It sounds really silly again, but if you don’t get that diaphragm to lift up and exhale, you can actually get the power into it to actually get the right inhale into the base. So, for that second stage, particularly for athletes, though I do use this to people that got anxiety, neck pain, back pain, COPD problems as well. We use a device called power breathe and that is inspiratory muscle training. So, it’s training your diaphragm to actually be strong for the activity. And, it’s pretty powerful. It’s only the science behind it, the research shows 30 breaths twice a day using this inspiration master trainer is enough to get the same results as a … So, there was one research study that showed over six weeks, I think it was, four to six weeks later the research.  And, one group was using the inspiratory trainer, and the other group was using, was running 45 minutes five times a week, and they had the same changes in the respiratory function from doing the diaphragm strengthening. So, it’s, you know, it’s a lot, a lovely adjuncts to training for people because they can actually get really good changes in physiology because the diaphragm is getting thicker, and it also shows after six weeks of using that, that your diaphragm thickens up to around 13 percent, which is quite a lot for work-

Dr. Weitz:                            Well, how does this device work? Does it wrap around you or something like that?

Emma Ferris:                      I actually brought one from the clinic I was going to show, you know, it’s in your mouth, so you put in your mouth, and you’re going a quick breath into using a diaphragm and to get in there. So, it’s a quick, breath in, fast and hard. You’ve got to work at least 50 percent resistance to get the diaphragm. So, they learned from the research as well that you can’t go at like resistance training for like 30 percent on your one rep maximum isn’t actually enough to get the changes in your diaphragm strength. I think it needs to be that 50 percent to 60 percent mark, and so I teach people in the clinic that you can work at it to sort of feel what that energy is or that level is for you when you train it. There’s a company out of UK that’s created them, and there’s a wonderful respiratory physiologists, and she is Allison Connell I want to her say name is that’s loved a lot of this research, and there’s great research now even in New Zealand, physio, and Aukland is looking has led to the break of breathing at the diaphragm, changing the strengthening and the dysfunction that occurs, people with anxiety, with back pain, and looking at that under ultrasounds, which is pretty cool seeing those changes.

Dr. Weitz:                            I’ve seen people in the gym with these things, so it’s some sort of a mouthpiece. And what does it do exactly, makes it harder to get a breath in?

Emma Ferris:                      Absolutely. I mean it’s like breathing through lots of straws. So it kind of risk for respiratory through there, so it’s like dumbbells for your diaphragm. And, so if that’s targeting that breathing muscle, you still want the pattern to be right though. Some of the research I went and saw a respiratory researcher in Canada about two years ago who was researching the respiratory training with athletes. And, what they noticed was the pattern store. If you don’t breathe in the right pattern, all your training is the upper chest breathing muscles, and what he wants to do is that diaphragm, so it might mean you turn the resistance down, and you work on the pattern, but then that diaphragm strengthens to actually help pay for working in a high level when you go and run or when you go and lift something, it’s going to naturally activate and do its job, so it doesn’t fatigue faster. And, what I loved about the research there as well, another, I think it was in the UK, they looked at the blood flow and the limbs.  So, they’re looking at when you were doing your exercise and training. So, I think this is cycling athletes; they looked at the blood flow in your veins and the legs, and what they found is after six weeks of doing the the inspiratory master training with the power breath thing, it was a device they used, they reduced the … The blood flow stayed in the limbs for longer. So, what it showed was the body’s stress response was better. So, the body didn’t go all right, I can train harder, and then when I get fatigued I had to pull the blood in, and it could actually keep the blood and the limbs for longer, which is really important for athletes, for endurance and for training. So, lots of consequences with using something like that. 

Dr. Weitz:                            How do you tell if they’re using their diaphragm? Do you put your hand on their diaphragm?

Emma Ferris:                      Yeah, I’m very manual with that. So, very much feeling that, you can see it. You can get them to put hands on their chest while I’ve got one hand here, and they don’t all use a mirror, biofeedback in any way that you’ve got. Posture’s a huge part of that, so if you slumped down and then you’d try and breathe, your diaphragm is going to start recruiting somewhere else. If you lift up too much, you’re gonna use your upper chest. So, even teaching people when your choose is like good simple habits add up, and that’s like a modeler for me is small changes make a big impact with what we’re doing.

Dr. Weitz:                           We work a lot with posture, and that’s super important, and it goes hand in hand with the breathing.

Emma Ferris:                      Yeah, absolutely. So using that posturing, raising that with your breathing is a very powerful tool, and then add some credit to it that you’re doing really well.

Dr. Weitz:                           Great. So, any other final thoughts you want to have for our audience? I think we got some good information to help folks with their breathing.

Emma Ferris:                      I think my take-home and something that I really like people just to be aware of is just take a moment and enter the day as many times you can is just to exhale, and the one thing I can say is you can do it out the mouth just once. Do it for me now, Ben. Breathe out the mouth, go uh, noticing your chest drops down, so that’s like a little valve release, then go back to nose breathing, but that little we exhale just drops you bit more into that calm part of that nervous system that needs a bit of love and attention. So, do it when you had the kids, when something’s winding you up, when you’ve got a traffic, wherever you are. I don’t have much traffic in my small town in New Zealand where I live, but you never know in LA and around the world.

Dr. Weitz:                           Oh yeah, LA traffic is brutal all the time. Yep.

Emma Ferris:                      Take moments. Take moments and use it to change that breathing. And, when you think about that, a lot of conscious drop, see what emotion you can bring up. Can you create joy? Can you shift your mindset, which will then impact your nervous system? Okay, take power back.

Dr. Weitz:                           I’ll be using it on the drive home because I’ll be hitting the 4:00 traffic. And then I’m going to go vote after that. So, I’ll need some stress reduction there too.

Emma Ferris:                      And, the next few days, good luck in New York is all I can say.

Dr. Weitz:                           God help the world.

Emma Ferris:                      And, please help us out over here.

Dr. Weitz:                           So how can listeners get a hold of you and find out about your programs?

Emma Ferris:                      Well, there’s a few ways. I have my online breathing hub called thebutterflyeffect.online. So, if you go through or search the “big exhale” or my name “Emma Ferris.” I’m not related to Tim Ferriss. I’ve got only one s at the end of my name. You can find me there, and there’s lots of ways. I have a free online Pilates video, 15 minutes that you can do, which helps work through some of the stretches that I do because what I find is if you can’t get the neck muscles and chest muscles and the hip flexor to release in the breath flow dropdown. So, that’s the place to sign up and join in and watch that. I also have my online breathing course called the big exhale, and that’s a 30 day program, but you can do it over a whole year. And, the first five days of it are free, so if you want to sign up for the big exhale, you can do that. Or join me on a workshop, come to New Zealand’s, come on my retreats, or meet me around the world in Malaysia or wherever the next one’s gonna be I have tour retreats in the states, so I can fly over and change the way that we breathe in the states post election.

Dr. Weitz:                           Sounds good.

Emma Ferris:                      Yeah.

Dr. Weitz:                           Emma, I really enjoyed this.

Emma Ferris:                      Thank you. I appreciate you having me on.

Dr. Weitz:                           Okay. I’ll talk to you soon.

 

,

Hypochlorhydria as a cause of SIBO with Angela Pifer: Rational Wellness Podcast 81

 Angela Pifer discusses how Hypochlorhydria can lead to SIBO and IBS with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

6:26  Low stomach acid or hypochlorhydria can result in Small Intestinal Bacterial Overgrowth (SIBO), which is the cause of IBS in the majority of cases.  Low stomach acid can be caused by chronic stress or hypothyroidism. There are pathogens that come into the digestive tract through your food and we need hydrochloric acid and a pH of 3 to kill such pathogens. Such acidity also signals gastric emptying, a release of digestive enzymes, and a release of bile, all of which help to reduce bacteria in the small intestine. And when it comes to treating SIBO, it is easy to just think that we have to kill the bacteria. However, to really fix the gut, we need to help reset and rebalance and reseed to cure SIBO and get someone to a negative breath test. 

12:17  There are certain symptoms that might make you suspect that your SIBO patient has low stomach acid, such as when they feel that food is just sitting there and does not move through their stomach normally of if they say that they’re not breaking down their food. You might also suspect low stomach acid if there are intact pieces of food in their stool or if they have peanut butter stool that is very sticky and requires multiple wipes. We can also look at a Spectracell Micronutrient test and look at nutritional deficiencies like iron or B12, which might be trending lower if they have low stomach acid.

13:38  Once you suspect a patient may have low stomach acid, Angela will rule out H. pylori as a cause and she recommends looking at the urea breath test for H. Pylori and she also likes to order a GI Effects stool test and include a stool H. pylori antigen test.  She finds that more sensitive than the blood antigen test for H. pylori.  Interestingly, if H. pylori grows in the antrum or lower portion of the stomach, H. pylori can cause increased hydrochoric acid production and ulcers.  But if the H. pylori grows in the fundus or upper portion of the stomach or in the body, or corpus, the areas where the parietal cells are that make the hydrochloric acid, it can lead to decreased acid production.  If there is chronic burping or you have any kind of burning or warmth in the stomach or a sense of fullness, we need to rule out H. Pylori.  If you suspect it is a chronic case of hypochlorhydria, then Angela will look at advanced markers, like anti-parietal cell or anti-intrinsic factor antibodies to see if it is a case of atrophic autoimmune gastritis. If there is no H. pylori, then we should see what can be done with diet, lifestyle, and supplements. If they are stressed and in sympathetic mode, then we need to work on stress reduction and this could include the Wim Hof breathing technique. 

18:55  When Gastroenterologists do an endoscopy and biopsy for H. Pylori they usually biopsy the antrum and the duodenum to look for celiac.  They will miss H. pylori in the fundus or the body of the stomach.

20:33  When it comes to Atrophic Gastritis, one cause is H. Pylori and the other cause is autoimmmune gastritis, in which you get antibody production against the parietal cells. We routinely check of celiac, despite the fact there is only a prevalence in the US of .5 to 1%, whereas autoimmune atrophic gastritis has a prevalence of 2 to 8% and we hardly ever screen for this and the rate is going up.  These parietal cells that produce stomach acid also produce intrinsic factor, which is required to absorb B12.  And if they are not making stomach acid, then they will not be breaking down their proteins to be able to absorb B12.  If you suspect a patient of having low stomach acid you can send them for a Heidelberg test.

27:26  When you are treating a patient who has low stomach acid because they have been on PPIs, Angela will work with their MD to slowly wean them off the PPIs.  Angela likes to add in bitters, like Bitters 9 or Bitters X from Quicksilver Scientific, to stimulate their own production of digestive enzymes and hydrochloric acid production. She has them use the Bitters X and do one or two pumps and hold it in their mouth for 90 seconds, swishing it around, before swallowing it.  She will also have them cook all their vegetables and eat smaller, more frequent meals, and chew their food three times more than they think they need to. She will also sometimes add digestive enzymes. She will have them use a little baking soda in water if they need to to take the edge off.

31:10  Angela treats autoimmune atrophic gastritis by treating both the gastritis and also by treating the underlying autoimmune condition.  We have to look for the triggers for the autoimmune condition, whether they are stress, environmental toxins, food sensitivities, etc. We need to treat the nutritional deficiencies that result, including vitamin B12 and iron.  They may initially need iron and B12 injections.  Such patients may need hydrochloric acid supplementation for life.

 

 



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 SIBO Gurushe has launched a gut prescription recipe site, Gut Rx Gurus 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 Transcripts

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 Rational Wellness Podcast on iTunes and YouTube, and sign up for my free e-book 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. And for those of you who enjoy the Rational Wellness Podcast, please go to iTunes and give us a ratings and review so more people can find out about the Rational Wellness Podcast.

So on this episode of the Rational Wellness Podcast, we are going to focus on low stomach acid as a cause of SIBO. Small Intestinal Bacterial Overgrowth, abbreviated as SIBO, is the cause of irritable bowel syndrome in the majority of cases. While the large intestine or colon is lined with trillions and trillions of bacteria, the small intestine is relatively free of bacteria. This is because this is where most of the absorption of nutrients from our food occurs, and if there were a lot of bacteria lining the small intestine, it would interfere with that important function.

There are a number of mechanisms that prevent more than a small amount of bacteria from growing in the small intestine. These include the migrating motor complex, which are the peristaltic waves that occur when you haven’t eaten for more than three or four hours, when you hear your stomach gurgling. These help to sweep out any bacteria out of the small intestine. There’s also the GALT, or GI-Associated Lymphoid Tissue, which is the immune system that surrounds the digestive tract. This tends to remove pathogens that enter our body with the food. Then there is the hydrochloric acid secretion from the stomach, and this also serves to kill unnecessary bacteria as well as help us digest our protein. Bile, which is secreted by the liver and stored in the gall bladder, which not only helps us digest fat, but has an antiseptic function, and stands to scrub away bacteria from the small intestine. You also have digestive enzymes, which besides helping us digest our food, have an antimicrobial function. And then we also have the ileocecal valve, which is a protective barrier to stop bacteria from migrating from the colon back up into the small intestine.  When any of these processes and structures fail, it can facilitate the growth of SIBO. Today, we’re going to focus on what happens when you have inadequate amounts of hydrochloric acid produced by the stomach.

Our special guest is one of the nation’s foremost functional medicine nutritionists, Angela Pifer, who practices in Seattle, Washington. Angela specializes in treating patients with functional gastrointestinal disorders like SIBO and IBS, and she’s known as the SIBO guru. She lectures around the world on such topics, and has launched a gut prescription recipe site, Gut RX Gurus, and a FODMAP free line of bone broths, Gut RX Guru Bone Broth. Angela, thank you so much for taking time out of your busy schedule to speak to me and our listeners.

Angela Pifer:                      Thank you, Ben. Thanks for having me.

Dr. Weitz:                          Great. So how did you get interested in treating patients with gastrointestinal disorders?

Angela Pifer:                      Gosh, you know, I’ve been in practice about 13 years, and it was just out of the gate, the gut has always fascinated me. There was never anything else. It wasn’t even a thought, and I loved it. To me, there’s some other things going on with the body. We can look at the brain and everything, but we start with the gut in so many cases, don’t we? Like you know, how we’re digesting, how are bowel movements moving along, is digestion working from top down? Like we have to look at all of that to see how we can then support the body and the system with almost everything else. So it’s really kind of this hub, and working with people with functional or chronic gut presentations has always just fascinated me.  And honestly, I think that population as a whole, my lovely patients and anyone out there who’s listening who has a functional gut disorder being in that chronic state, they need help. They need support. They need hand-holding, and they really need someone to sometimes step in and be that hub between all their other specialists, because everyone seems to be going off in a different direction sometimes when they’re seeing different specialists, and to have somebody pull everything together is really really helpful.

Dr. Weitz:                          Yeah, absolutely. You know, if you deal with Functional Medicine, the gut has got to be one of the starting places for almost everything. I just saw a patient this week, and her big complaint is that she’s having unexplained seizures, one after the other, and she’d been to the neurologist and nobody could figure anything out. So we did some stool tests, and she’s got all kinds of things going on in her gut. You can’t even believe the things happening there. Layers and layers. And it turns out, she’s had all these gut symptoms which she was really sort of used to and not even complaining about, and now she’s doing so much better just by fixing her gut.

Angela Pifer:                      Yeah. And I say the word complacency with so much love and respect and empathy for a person, but I think they have this known sense of norm. “This is what I deal with day in and day out, this is just how it is,” and over time, they adapt to it.  Never liking it, but adapt to it, and it isn’t until you show them what it really feels like to not have to sit with that, it’s mind-blowing sometimes what they’ve had to deal with, right?

Dr. Weitz:                          Yeah, no, absolutely.

Angela Pifer:                      Yeah.

Dr. Weitz:                          Yeah, they don’t know what it’s like not to be constipated or not to have gas.

Angela Pifer:                      Yep. Yeah yeah.

Dr. Weitz:                          So can you explain how low stomach acid can be a cause of SIBO, which is the cause of IBS in a majority of cases?

Angela Pifer:                      Yeah, absolutely. So when we look at SIBO, we really have to always consider that SIBO is a secondary condition. It’s never a primary condition. It was set up because something else has happened, some other thing or things have happened. And so we have to try to get at the root of what is setting this up for the person. You know, SIBO needs to be addressed, but we have to look at everything else as well to fix that root cause. So SIBO doesn’t continue or come right back or be reoccurring because you’re not fixing the real correct thing here.  So one of the very big contributors can be low stomach acid.  Low stomach acid can be caused by a few different things.  Low stomach acid could be caused by really really really chronic stress, it could be caused by hypothyroidism as well.  So it’s this spiderweb of connections that we have to get in and try to figure out this root cause for people.  And we’re starting to look at low stomach acid, I mean this is, you know, it’s like not chewing your food. This is like a major component and stuck within the digestive tract, and if you can’t use low stomach acid to actually break your food down properly … And really the main thing is we’re talking about SIBO is to clear up pathogens that are coming in.  You know, we need that proper really acidic pH that’s under three pH to actually clear everything off, otherwise we’re just gonna get bombarded with things that we’re taking in by mouth multiple times a day.  We want that first step, it’s a really big line of protection there.

We also have to look at, we’ve got a pH at that acidity for a reason, and it signals gastric emptying properly, it signals the proper release bile, it signals the proper release of digestive enzymes. So as you were talking about in your intro, bile being needed as well to clear out the intestinal tract. We have a lot of conjugated bile with our intestinal tract. It actually acts as a detergent. And every time we eat some fat, your gall bladder goes squish squish. It’s like a stress ball, squish squish. And it’s gonna release some bile, and with that, that will help your emulsify your fats. Then it’s also coming through as a detergent and clearing out that small intestine. And it also happens in between meals, so it doesn’t just happen that you get a bile release with your meals, you also get it in between meals, and that’s gonna piggyback the migrating motor complex and those cleansing waves that come down.

So in your intro, I’m going to disagree just a little bit here because I think it plays into the conversation we have about what the heck to do with SIBO. I think if we start to compare the trillions of organisms that are in the large intestine, there’s so many massive amounts of organisms in the large intestine that when you look at the small intestine, it seems quite minuscule. And yet if we look at the small intestine just by itself, we’re looking at millions and upwards of billions of microorganisms per milliliter, per teaspoon of fluid. So it’s not sterile by any means, there’s lots of organisms there. But we also have forward-moving matter. Everything’s moving forward, it’s not hanging out like it does in the large intestine where everything hangs out there and ferments and we get all this beautiful relationship with our microbiota in that area. Things are moving through a lot faster, so we don’t get this big buildup of organisms in the small intestine. And we’ve got bile moving through, like there’s lots of mechanisms to help keep the organism load at a specific load.

When one of those mechanisms, or multiple mechanisms, goes wrong, of course, then we get a buildup. And then we get fermentation happening in the small intestine and lots of other things that could come with SIBO that’s quite debilitating, because that small intestine is not meant to stretch, and that causes a lot of pain. And we don’t get as much gas movement of course, out or just spilling across the intestinal lining.  So why I say that is so many people think SIBO, “I gotta kill it.” And we can’t Drano that small intestine, we want to look at this as a re-balancing. Really fixing the underlying issue, getting on the mechanisms and what’s going on there, but then re-balancing and just taking the person to that level. Not “kill kill kill,” and then stepping back, because that’s not gonna work either. We’ve got to help reset and re-balance and reseed, affect change with the immune system, and there’s so much that goes into play with this even once you get somebody to a negative breath test. There’s so much healing on the other side to make all this beautiful work that you’ve just done stick.

Dr. Weitz:                          Do you sort of use the four R or five R program as kind of a backbone of your approach?

Angela Pifer:                      Yeah, you know, I don’t. Not with SIBO specifically. There’s so many other things I do. I mean as we start to look at autoimmune and others, I know we’re gonna talk about an autoimmune condition as we talk here. But in terms of SIBO, I don’t … There’s so many beautiful things that that four R program does, and there’s bits and pieces filled in along the work that is done, that really it’s more, you know, stabilize the patient and whatever that means. We’ve gotta evoke change with the diet, oftentimes. We don’t always have to go drastically low, but we wanna adjust the diet to make sure they’re nourished, adjust it to how they’re digesting and absorbing, adjust it to make sure their symptoms are somewhat calmed down so they can hang out in this period of time as we treat properly, you know. So there’s a lot of change that happens with the diet.  And in terms of kind of that whole repletion, we’ve got to get on the other side of actually treating SIBO to get to that point where we can start to work on more of that reseeding of the gut, a lot of immunoregulatory support at that point. And it’s bits and pieces, but not the perfect four R.

Dr. Weitz:                          Okay. Sounds good. So when would you suspect low stomach acid as a cause for a patient with SIBO?

Angela Pifer:                      You know, I would say that I actually assess that with every patient. It kind of comes out of the gate when you’re doing the intake with the patient, and they start to talk about different symptoms that they have, 

Dr. Weitz:                          What symptoms would make you think about low stomach acid?

Angela Pifer:                      Yeah, absolutely. Food just feels like it’s just sitting there and not moving through their stomach.  A little bit bit of food makes them feel full fast.  It could be that we start to look at, you know, they’re not breaking down their food, they see a lot of intact pieces of food in the stool, or even peanut butter stool, I call it.  So it’s really sticky stool, it takes a lot of wipes.  They’re probably not breaking their proteins down, so then we would look back upstream and figure out what’s going on there, which low stomach acid is oftentimes a culprit at that point.  I would say what I see with a lot of patients is a lot of burping.  Food just feels like it’s a heavy weight in their stomach.  They need to space their food out because they don’t feel like they’re digesting at a quick enough clip that they can eat a little bit more consistently than that. And then as we step back and look at labs, you know, Spectracell and nutritional markers, we can look at different things to see if their iron is trending lower or B12 is trending lower, and we would see that if they have low stomach acid.

Dr. Weitz:                          Okay. Once you suspect that a patient has low stomach acid, how would you figure out what is causing the low stomach acid, whether it be a H. pylori infection or autoimmune-related or something else?

Angela Pifer:                      Yeah. I think we always are gonna start with the basics, I mean unless somebody presents with a really chronic case where they’ve had just chronic low B12 over time, I’m gonna start to step into some of those advance markers, looking for anti-parietal cell or anti-intrinsic factor antibodies to see if there’s actually something going on more as an autoimmune front.  But once we start to look at this, you know, how are they digesting their food, what is their diet presenting like, can we correct this with supplements, and then what is also going on in terms of their lifestyle?  If they’re, you know, really in a sympathetic state, we work a lot on stress reduction because a sympathetic state, being more stressed chronically over time, is really gonna drive digestive chemicals away from the digestion, from top-down. So there’s a lot of lifestyle effect that we can have as we start to see people move away from that. But really, and again, I say this with great love for the patient that is sitting there feeling like this is just … ‘Cause chronic presentation, and they deal with this all the time. Most people with functional gut disorders like this feed forward cycle, stress is always gonna contribute to that, but then once it’s present, they’re having to deal with these symptoms all the time. And so stress is almost always some sort of factor that’s adding to that, and so I think there’s a lot of … You know, I introduce people to the Wim Hof breathing method, I have them make sure they’re walking an hour a day …

Dr. Weitz:                          Wim Hof is when you take a cold shower?

Angela Pifer:                      No, Wim Hof is actually … So that’s more contrast hydrotherapy. Wim Hof is actually a breathing technique. You should look him up on YouTube, he’d be interesting to have on your podcast. I don’t even know if I’ll explain it correctly. It’s this beautiful way of actually really taking in almost this hyper amount of oxygen into your blood, and huge diaphragmatic breathing technique, and then you actually ride that out a little bit. But in terms of oxygenation and capacity, people aren’t using the full lung that they have, or lungs, and moving it up. And so it’s a really interesting breathing technique to get them to use that entire space and diaphragm. Yeah, it’s very very cool.  So yeah. So I think there’s a lot that we can do in terms of just the stress piece, you know, to really help people out. So as we’re starting to look at the low stomach acid piece, you know, we’ve gotta really listen to the patient, and SIBO is going to contribute. Once SIBO is set up in terms of … And where SIBO is at the small intestine. So the further SIBO is up, and the worse SIBO is with all those contributing factors, it can start to break down digestive enzymes in that brush border, uncoupled bile. It can really interfere with a lot of nutritional absorption that we’re doing in that area. So it just depends on the patient as we’re working on, to what degree we need to come in and do any kind of intervention at that point.

Dr. Weitz:                          So how would you rule out H. pylori?  What tests do you like to use for H. pylori?

Angela Pifer:                      Yeah. I actually prefer the breath test for H. Pylori.  I really do.  The urea breath test.

Dr. Weitz:                          Okay. Why is that?

Angela Pifer:                      That’s my favorite one. Oftentimes I want to see a GI Effects so I’ll add that on, as we look at a stool antigen for that.

Dr. Weitz:                          Yeah.

Angela Pifer:                      You know, if they’ve never been diagnosed with H. Pylori, then we’ll do a blood antigen, but I really like the breath test. I know there’s a like controversy on SIBO’s presence, sometimes you’ll get a false positive. I’ve not seen that line up.  And of course we have endoscopy, right, is where rather referring over to the GI doctor. But I think the urea breath test is really pretty straightforward to me. I think the antigen test with the stool antigen actually misses it a lot more than when we see that breath test.

Dr. Weitz:                          So the notes you sent me over before we did this podcast, it was really interesting that you talked about how if H. Pylori grows in one part of the stomach, it’s associated with increased hydrochloric acid. For those of you who aren’t aware, H. Pylori is often an undiagnosed cause of ulcers because you get this bacteria that burrows into the wall of the stomach, and then the stomach produces more and more acid to try and get rid of it, and so it can often be the true cause of ulcers. On the other hand, if that H. Pylori grows in another part of the stomach where the cells that make the hydrochloric acid are, it actually destroys those parietal cells, and you end up with less hydrochloric acid from H. Pylori.

Angela Pifer:                      Yeah. So you really can’t go off of … There’s some symptoms that are present that we need to investigate if H. Pylori is present. I mean to me, if any kind of burping, if they’re chronic burping, I think H. Pylori should be ruled out. But any kind of burning, any kind of warmth in the stomach, a really early sense of fullness, we really should be ruling out H. Pylori and stepping through the sequence from there.

Dr. Weitz:                          And you also mentioned in your notes that GI docs, when they do an endoscope, they’re often looking in at that part of the GI tract where H. Pylori leads to ulcers, but not the … What’s the other part of the stomach where …?

Angela Pifer:                      Yeah, so if you think about the stomach like a kidney bean, like up on it’s end, you’ve got the fundus is up top, the body is kind of in the middle, and then the antrum is on the bottom. When we start to look at parietal cells, which produce stomach acid, they’re in the fundus and the body, so in this upper two thirds part. And then in the bottom part is the antrum, and if you look on almost every single endoscopy, they’re doing biopsies on the antrum. They’re looking for H. Pylori, and they’re gonna miss if there’s an autoimmune issue with parietal cells. And they’re also doing biopsies in the duodenum to see if there’s celiac.  So I feel like, especially as we’re gonna get into it here, we really should be assessing the whole stomach and looking a little bit beyond this. But it’s interesting that even when recommended that, it doesn’t come back as the biopsy in that area. I think they’re just on … And I say it with great respect, they do things none of us can, but that’s just where they’re looking, and they’re not looking in the fundus or the body.

Dr. Weitz:                          Yeah, interesting. Yeah, you have to try to develop a relationship. There’s not many integrative GI docs around.

Angela Pifer:                      Yeah.

Dr. Weitz:                          Fortunately we have Dr. Rhabar in LA, so …

Angela Pifer:                      Yeah. Yeah, and Dr. Mullen. Yep.

Dr. Weitz:                          Yeah. Is he in LA?

Angela Pifer:                      No, Dr. Mullen, Jerry Mullen up in …

Dr. Weitz:                          Yeah yeah yeah yeah.

Angela Pifer:                      Yeah.

Dr. Weitz:                          Yeah. So let’s talk about autoimmune atrophic gastritis. What are some of the symptoms associated with that in particular, and how do we assess for that?

Angela Pifer:                      Yeah, absolutely. Well I think when we start to look at autoimmune, there’s a lot of conversation around the CDTB toxin and autoimmunity coming from that, and that being a cause of this IBS-C or SIBO.  What we have to look at is that’s definitely a percent, that can set SIBO up, but when we’re starting to look at the population that has low stomach acid and trying to get to the root of what’s going on with SIBO, there’s going to be a small percentage there that we really do have to have, you know, a keen eye on to see if any of those people have autoimmune atrophic gastritis.  And basically what that is is you’ve got some atrophy of the stomach, and you have gastritis, which is inflammation.  So we’ve got atrophy and inflammation, and then you’ve got this autoimmune involvement.  So atrophic gastritis, there’s two types.  One is caused by H. Pylori, and the other is autoimmune atrophic gastritis.  And so basically you’ve got the autoimmune involvement and you’ve got antibody production against the parietal cells.  And so as we start to tuck deeper into low stomach acid and its implications, when we start to look at autoimmune atrophic gastritis, this is everything that we’ve just talked about tenfold because this isn’t simply more stress induced or a bit of hyperthyroid pushed in in terms of setting that metabolic rate and how much stomach acid you’re producing, or you’ve got a zinc deficiency.  All of those can be recovered fairly easily, depending on the case.  But what we’re really talking about is an autoimmune connection here with low stomach acid.

I think to discuss this, we kind of have to talk first about prevalence, because I think it seems like kind of a foreign term, and yet when we start to look at prevalence, everyone’s pretty much heard about celiac.  Almost everything is screened for celiac, especially if there’s digestive stuff going on. So even as practitioners, we’re so quick to jump on that. But when we look at celiac disease, it’s .5 to 1% prevalence in the U.S.  Very, very small percent of people, and if you have it, it’s a very big deal.  But it’s a small percent of people, and yet, as practitioners, we’re fairly quick to rule that out.  When we look at autoimmune atrophic gastritis, we’re actually looking at a 2 to 8% prevalence.  So even if we just take the 2%, it’s 2 to 4 times more likely present than celiac.  And so we really have to kind of stand up and pay attention to this.

When we look at atrophic gastritis caused by H. Pylori, that’s actually going down in America because it’s being screened for.  But when we look at autoimmune atrophic gastritis, it’s going up. It’s starting to increase as are a lot of the autoimmune conditions, right?  People are becoming more susceptible, and we can have a whole ten shows over why we think that is, right?  But when we’re starting to look at the autoimmune atrophic gastritis, basically what we’re looking at is, we’ve got inflammation of the stomach, atrophy of the stomach, we see a breakdown of the parietal cells because you’re making antibodies against those.  And when we look at the parietal cells, those make stomach acid, and they also make intrinsic factor.  And intrinsic factor is what binds to your vitamin B12, and that coupling, as it moves through the intestines, is absorbed together.  If you’re not making intrinsic factor, you’re not gonna absorb your B12, and if you’re not making stomach acid, you’re not gonna break down your proteins to get to your B12 in the first place.

So as we start to look at this patient population … This isn’t everyone that needs to be screened for this, but we have to start to look at if there’s a chronic digestive presentation here. And we really want to start to key into this is if somebody’s taking massive handfuls of HCl Betaine and they’ve been doing that for a really long time or they don’t digest their food, this is something that we should be screening them for.  When we start to look at this, you know, we kind of have this …

Dr. Weitz:                          By the way, do you ever use that HCl challenge test as a way to screen for this?

Angela Pifer:                      You know, I don’t as a way to screen for this. I refer people over for the Heidelberg test if we’re suspecting low stomach acid, especially if I see them on this level of HCl Betaine.

Dr. Weitz:                          Okay.

Angela Pifer:                      I feel for a time, that was really working for me. So setting aside autoimmune atrophic gastritis, it was working for me in terms of getting people on a certain load, and it was making a difference, and then I feel like it just didn’t work as well anymore.

Dr. Weitz:                          Right. By the way, for people that aren’t aware of what we’re talking about, this is where you give a patient one HCl tablet taken before a meal, and then you give them two or take it after a meal, and then three, and you keep increasing it until they get a burning sensation, and then you back off.

Angela Pifer:                      Yeah. Or a warming sensation, but yes.

Dr. Weitz:                          Warming, yeah.

Angela Pifer:                      Yeah. So I’ve seen that work for some people. I’ve seen other people … A lot of times when people come to me, they’ve been to quite a few practitioners, and they’ve already done that test in the past, so you know, we just kind of learn from what they’ve already been working through.

Dr. Weitz:                          Yeah.

Angela Pifer:                      Yeah. So it’s pretty interesting. So I would just go off more symptoms of what we would expect. Again, you know, total protein’s low in a lab. You’ve got B12 that’s chronically low.  Iron is low with no really good cause for it, and when you’re recovering.  You know, they’re kind of the slight, not life-long, but say for the last few years at least this has kicked in at some point, they’ve been trending more towards meat, yeah, they’re not quite getting it recovered.

Dr. Weitz:                          What tests do you like for B12 and for iron?

Angela Pifer:                      I do serum B12. And then when we’re looking at iron, it’s just the full panel.  Serum, TIBC, saturation, ferritin.  And then of course looking at all the rest of the CBC, looking up, you know… 

Dr. Weitz:                          You don’t find the need to do like methylmalonic acid or homocysteine for B12 status?

Angela Pifer:                      I actually like both of those when looking at folate and B12.

Dr. Weitz:                          Okay.

Angela Pifer:                      Yes yes. I look a little bit more at that, and of course it depends on what I see in terms of supplementation that they’ve been on, you know, for a really long time. I’m also looking at that more for folate and B12 status, and methylating. Yeah.

Dr. Weitz:                          Okay, cool. So let’s talk about treating a patient with low stomach acid.  How do you approach that?

Angela Pifer:                      Yeah, absolutely.  Well I think low stomach acid and autoimmune atrophic gastritis are gonna be really two different things in terms of approaching that.

Dr. Weitz:                          Okay, so let’s start with a few different cases.  With somebody who’s got low stomach acid because they’ve been taking proton pump inhibitors for years, how do you handle that?

Angela Pifer:                      Yes, absolutely. So with their doctors approval for coming off of medication, of course, I actually will start to add in bitters. I’ll have them cook all their vegetables.  I’ll have them eat more frequent meals just to start, and then we’re really gonna work on stress management, setting the tone for the meal, and chewing their food three times more than they think they need to.  We might need to address fat load a bit, just depending on how well their gastric emptying is going.  We might need to adjust things that way.  I work a lot with that.  I love bitters, I love them.

Dr. Weitz:                          And bitters are designed to stimulate your own digestive enzymes and acid secretion, right?

Angela Pifer:                      Yeah, absolutely. Our food, I mean it’s kind of crazy to think about, even our broccoli and brussel sprouts are bred for sweetness.  All of like the bitterness, the different species within those, they’re all bred more sweet. We’re like setting aside anything that has more bitter because the masses don’t trend towards that, right, in terms of what we’re choosing at the supermarket.  So when we give somebody bitters, it literally is bitter.  Your mouth has these beautiful taste receptors back here that just light up when you give somebody bitters, and if you even think about it if you’ve done it, it makes your mouth water. Like it’s really stimulating digestion from the top down. So I have people … I like Quicksilver Scientific, their Bitters 9.

Dr. Weitz:                          Oh, okay.

Angela Pifer:                      And their Bitters X is fantastic, and I just have them do one or two pumps 15 minutes before a meal. They hold it in their mouth for 90 seconds, swishing it around, trying to get it to the back, and then they swallow. We’ve got bitter receptors in our stomach as well, so it’s wonderful. It’s a great way to kind of help stimulate digestion there.  In terms of digestive enzymes, one of my favorites is Panplex 2-Phase by Integrative Therapeutics.  It has a low-level digestive enzyme, low-level bio-support, and just a little bit of HCl Betaine.  So I think less is more.  I wanna kind of just start with these lower levels and work up from there.  So that’s my way to approach it.  I would try to set the tone for the meal, really look at your food, smell your food, think about where it came from, what it’s gonna taste like, put that first bite in your mouth and really set your fork down and taste it.  And to me, that sets the tone for the meal and really slows people down.

Dr. Weitz:                          When you’re weaning patients off of PPIs, you have to be careful about sort of a rebound, right?

Angela Pifer:                      Yeah, you do. You know, I’ve had really great luck again with, you know, Dr’s approval on this, and really great luck in weaning people off of proton pump inhibitors. There hasn’t really been a case that I haven’t been able to do because we set everything else up first, and then depending on the medication, we might be able to halve that medication, or we just start to slowly take that every other day. And I’ll always aim that around a weekend, because if you’ve ever really watched people’s food journals over the course of a week, like year after year like I have, you realize that hunger is much more increased during the week. Like there’s just more stress going on. So I start to wean them over a weekend, and you know, have just a little bit of baking soda on hand if they need to do like a half teaspoon of baking soda and water just to take the edge off. And then they have the medication. If something comes up, nobody is asking them to sit in misery with heartburn.  It’s usually pretty good. I think most people just try to stop cold turkey, and then they realize that didn’t go well, so they feel like they’re really chained to it. So you just have to work with them to get them set up.

Dr. Weitz:                          Okay. And then how do you treat patients with atrophic gastritis, and is it the same treatment if it’s autoimmune origin or H. Pylori?

Angela Pifer:                      Yeah, so atrophic gastritis is caused by H. Pylori, and so there’s some great treatments out there for H. Pylori. What we’re talking about is the autoimmune atrophic gastritis, and that’s gonna be more from an autoimmune perspective. So you know, just as if there’s autoimmune thyroid, you’re going to treat the thyroid, but you’re also going to treat the autoimmune condition. So with autoimmune atrophic gastritis, you’re going to treat the autoimmune condition in that you’ve got to work on the whole stress cycle with everybody, getting them sleeping well, calming down the body’s reason for ramping everything up and attacking.  You want to calm down and figure out triggers, you know, where triggers are coming from, whether it’s stress, environmental, internal in terms of food and all.

And then we really want to look at treating nutritional deficiencies, making sure that they’re recovering their B12, recovering their iron. So when we look at autoimmune atrophic gastritis, the vast majority of cases aren’t even diagnosed until they’re completely at this end stage of pernicious anemia, and that pernicious anemia is basically you’ve got anemia because you can’t absorb your vitamin B12, and you need B12 along the iron pathway.  And then you’ve got this autoimmune component causing this.  So pernicious anemia is also an autoimmune condition, but it’s this end stage of autoimmune atrophic gastritis.  So most people aren’t diagnosed ’til that point, so we want to catch them before that. We want to catch them when they consistently have B12 levels of under 500, that we see indications of pancreatic insufficiency.  So they’ve got this low stomach acid and signaling of the pancreas, you know, we don’t see that and that connection. We wanna look for vitamin B12 deficiency symptoms like peripheral neuropathy.  We want to look for even restless leg syndrome, which is strongly connected to this.  That you know, again, at that beginning they’re going to have poor gastric emptying, they’re gonna feel full, they’ve got this excessive burping, sometimes they feel a little nauseous ’cause food is sitting there, and all of this has been kind of chronically presenting.  We’ve got a store of iron in our system, you know, in our body. It isn’t until we really start to see this very big shift, and same thing with B12, this really big shift with this autoimmune attack. We don’t usually start to see this rear up for a good year and a half, two years, so we wanna catch this earlier on, and it might be that chronic presentation that we get to see that with.

So again, first rule out H. Pylori. Absolutely let’s rule that out, but then let’s start to look at, you know, do we start to see B12 levels dipping down? Which is kind of hard sometimes because everyone’s taking B12. And serum B12 is a really great indication that you’re taking good supplements sometimes, so maybe we need to take people off of things for a couple of weeks to get a better read on that serum level. But we wanna look at that, we want to investigate gastroparesis if that’s there, or again, if gastritis is present, we’re going to look for H. Pylori and then start to look at iron and B12 and start to recover those.

If somebody’s gotten to the point of pernicious anemia, they might need iron shots, they might need intramuscular B12 shots, you know, the supplementation may not do it. And this population of course is interesting because they’ve got lower stomach acid and poor signaling, and oftentimes they’re gonna have slower motility. So if you’re trying to recover iron on a consistent basis, you know, you can really slow things down more because iron can be quite constipating. And iron isn’t necessarily … It can be toxic to the colonocytes as well, so you know, sometimes iron shots are gonna be a better choice depending on that patient and what’s going on there.

Dr. Weitz:                          Interesting. And of course, trying to heal the gut as well, right?

Angela Pifer:                      Mm-hmm (affirmative). Absolutely, absolutely. I think that’s going to come with it, and I think that comes with a lot of conditions after as well.

Dr. Weitz:                          And those patients are going to need HCl supplementation probably for the rest of their lives, right?

Angela Pifer:                      They probably will, and you know, I think it’s again, if somebody has an autoimmune condition, we need to be able to tell them that they have an autoimmune condition, because autoimmune comes in pairs. And also, I would say that autoimmune, you know, as we start to look at this, we need to be able to say like there is a reason that you might need ongoing supplementation, in terms of HCl Betaine, in terms of B12 support, in terms of iron support. There’s a connection to be made there with the patient, because sometimes I think, you know, patients might go from practitioner to practitioner and they’ve got these long laundry lists of supplements, and we don’t know which are necessary and which aren’t. But if we’ve got an autoimmune condition set up for this, they’re going to need to really support their system long-term because of the autoimmune condition that’s present.  And the more stressed out they get from wherever this is coming at, the worse the autoimmune cycle can get. And then you get more degradation and targeting of those parietal cells which makes everything downstream worse. So the stress management piece can’t be talked about enough with this population, but then we also have to start to look at how else are we gonna support them, and they’re gonna need supplementation lifelong. They’re going to need it, like absolutely. So they need to know that and be able to connect with that because I think people can fall in and out of favor with supplements, or you know, “I don’t know if these are even doing anything for me” kind of thing. In this case, this is really something that needs to be looked at.

Dr. Weitz:                          So can you monitor those anti-parietal cell antibodies the way you monitor like TPO antibodies with patients with Hashimoto’s to see to what extent their autoimmune component is active, or?

Angela Pifer:                      Yeah. You really can, but I think we have to be careful to say, you know, parietal cell antibodies are at 82 and they go to 72, it doesn’t mean that they’re necessarily getting better. You know, antibodies are volatile. They don’t just go up a ladder and down a ladder depending on two things. If we are in a very stressful situation, we can see a shift there. If we are fighting off a cold, we can see a shift. If we …

Dr. Weitz:                          Right, but maybe are there bigger shifts? Like with TPO, you know, antibodies for thyroid, if they have 500 and it goes up to a thousand, that’s significant, or it’s 1,200 and it goes down to 150, you still have elevated antibodies, but that’s a significant shift, whereas if it goes from 100 to 400, maybe it’s insignificant.

Angela Pifer:                      I agree. I completely agree, yeah. When there’s 

Dr. Weitz:                          Is there a similar sort of range with the anti-parietal cells?

Angela Pifer:                      You know, I think it’s going to be based on the person and what we’re looking at with both of those and where they kind of fall into. I think as we start to look at the progression and how long this has been there for people and how advanced they are, they might not be able to get those fully recovered like we’d like.  But for the anti-parietal cells, the anti-intrinsic factor antibodies, you know, we’d look at both of those, and of course if there’s a positive test, we’re gonna refer over to a GI doc to get a biopsy. But in the right place, they’ve got to biopsy the fundus or the body of the stomach to be able to actually confirm that.

Dr. Weitz:                          Cool.  Okay, that’s good.  Very interesting information.  Thank you for informing us about a condition I think most patients and even a lot of practitioners are not aware of, which is autoimmune atrophic gastritis as a cause of low stomach acid leading to SIBO.

Angela Pifer:                      Yep.

Dr. Weitz:                          So how can listeners and practitioners get a hold of you if they want to contact you, sign up for your courses, get your bone broth?

Angela Pifer:                      Yeah, absolutely. So my practice site is siboguru.com, and I’d love to have everybody visit me there.  And then GutRxGurus.com is a beautiful collection of practitioners and chefs that are in the low-FODMAP realm. And there’s a SIBO-specific category in there, and everything is low-FODMAP.  And I’ll say it really quick, I don’t as a whole put every single person that’s ever even, you know, SIBO glaring, on a low-FODMAP diet, but there’s going to have to be some adjustments, and so to be able to have a recipe set that you can go to to really fill in the gaps and give people ideas … Because we’re so used to eating what we eat, and then when we can’t eat that anymore, it’s like chicken on a plate. Like what do you do? So it’s nice to be able to have all these beautiful recipes for sauces and sweets if you need them, and the foods just really tasty. So that’s a subscription site for recipes, gutrxgurus.com.

And then GutRxBoneBroth, the first low FODMAP bone broth to hit the market, and people can order that online. It just ships directly to their door, and we actually ship beautiful high-protein, high-gelling bone broth that tastes absolutely amazing. We’ve got a big plant here in Seattle, and we sell beef and we sell chicken, and it is just absolutely delicious, so it’s just nice to have that to kind of fill in the gaps and have that as a base of a soup, because you can’t just go to a store and get a garlic-free, onion-free anything, right? Everything has it in it. So it’s nice to have a broth that people can really connect to there.

Dr. Weitz:                          Cool, great. Thank you so much for spending time with us.

Angela Pifer:                      Of course, thank you!

Dr. Weitz:                          Okay, I’ll talk to you soon, Angela.

 

,

Best Diet for IBS with Dr. Norm Robillard: Rational Wellness Podcast 80

Dr. Norm Robillard discusses what is the best diet for patients with Irritable Bowel Syndrome with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

6:47  When you look at studies on IBS, there is a wide range as to what percentage of patients are caused by Small Intestinal Bacterial Overgrowth (SIBO), in one meta-analysis from 4 up to 78%.  This has made some doctors and researchers to question what relationship SIBO has to IBS. Dr. Robillard explained that there are some issues with test methodology, including whether you use lactulose or glucose as the substrate and glucose is less sensitive since it will miss SIBO in the distal part of the small intestine, since it is absorbed in the proximal portion of the small intestine. Lactulose should be a preferred substrate, since it is not digested by humans. There are some potential issues with the 24 hour test preparation, which requires strictly following essentially an intervention diet and then an overnight fast and if these procedures are not strictly followed, it can affect the test results.  Also, this test is only one snapshot in time and there is a constantly changing situation in your gut where if you eat a lot of fermentable carbohydrates, the likelihood of SIBO will go up, while there are a number of mechanisms that work to prevent it from developing, including the Migrating Motor Complex, bile, hydrochloric acid from the stomach, digestive enzymes, and your Gastrointestinal Associated Lymphoid Tissue (GALT), the immune system clustered around your digestive tract. Dr. Robillard thinks the correct number is somewhere in the range of 45-65% of people with IBS who have SIBO. 

11:48  Dr. Robillard has coined the term LIBO for large intestinal bacterial overgrowth because he believes that some of the time the gastrointestinal symptoms are coming from an overgrowth of bacteria or archaea in the large intestine. When bacteria ferment carbohydrates they produce short-chain fatty acids, which are acidic. They did a study at John’s Hopkins that looked at 47 patients with IBS and they had them swallow a SmartPill that could detect pH changes.  They did not see any pH changes till they got to the large intestine, which they interpreted as bacteria in the large intestine, not the small intestine.  Dr. Robillard believes that when you have methane SIBO it is likely caused by archaea not in the small intestine but the large intestine, because the methane gas slows down motility, which causes constipation. This is why you get methane showing an elevated methane even in the zero time point in the breath test. He thinks that the archaea in the large intestine can overgrow and produces so much gas that if forces open the ileocecal valve leading to the gas getting into the small intestine. Evidence has shown that when researchers placed a pressure sensitive instrument in the ileocecal valve it was weaker, which could be because it is being forced open by back pressure from gas being produced in the colon.  Dr. Robillard also mentioned that he has written a book about reflux and his theory that reflux is caused by pressure from the gases being produced by the overgrown bacteria pushing up into the stomach pushing the acid up into the throat.  He found that a low carb diet made his reflux go away. 

25:37  If the archaea are really overgrown in the large intestine instead of the small intestine, this might explain why treating methane SIBO is more difficult and why Rifaximin is not as effective for the archaea, since it acts mainly in the small intestine.

27:18  The causes of SIBO can include the motility of the intestinal tract related to the migrating motor complex and the iliocecal valve. Hypochlorhydria or low stomach acid can also be a factor, since the acid helps to keep the bad bacteria out of the small intestine and from moving up to your throat, lungs and sinuses.  Low stomach acid can result from the use of Proton Pump Inhibitors (PPIs). It can also come from H. pylori infection, which is a corkscrew like spirochete bacteria that burrows through the mucosa into the lining of the stomach. If H. pylori grows in lower part of the stomach, the antrum, it can result in increased hydrochloric acid.  But if it grows in the upper part of the stomach, the fundus, where the parietal cells are, it can damage these parietal cells and results in decreased hydrochloric acid secretion. Low stomach acid both increases the risk of SIBO and also stomach cancer. Patients with liver problems like cirrhosis will produce less bile and are at increased risk for SIBO. Also patients with pancreatitis, since they may have decreased production of pancreatic enzymes. Kids with cystic fibrosis have a high instance of SIBO and GERD and have to be on digestive enzymes. Pain medications can slow motility and cause SIBO.  There’s an increased risk of SIBO with Celiac and Crohn’s disease. Diabetes can lead to nerve damage and predispose to SIBO.  Surgery and other adhesions in the intestines can lead to SIBO.  Scleroderma is also risk factor for SIBO.  Simply eating too many fermentable carbohydrates in your diet, esp. as we age since our digestion may not work quite as well as we get older.

33:18  Dr. Robillard has developed a special diet, the Fast Tract Diet, and the Fermentation Potential (FP) point system to easily keep track of how to eat less fermentable carbs. Dr. Robillard has also found that a super low carb diet like the ketogenic diet works well with GERD and SIBO. The Fast Tract diet limits lactose, fructose (and polymers of fructose), resistant starch fiber, and sugar alcohol.  The FP calculation uses the glycemic index, which measures how quickly carbohydrates are broken down and converted into blood sugar. For diabetes you want low glycemic foods, but for gut issues you want higher glycemic foods that digest more easily.  After you take the glycemic index you add in fiber and sugar alcohols to do the calculation and Dr. Robillard has developed an app for your phone that does this for you, the Fast Tract Diet Mobile App.

47:50  Wine and light beer are surprisingly low on FP points because foods that are fermented have less carbohydrate in them because the carbs are being converted into alcohol.

50:19  It is common in the Functional Medicine world that after the patient has been placed on a treatment protocol for SIBO that involves a restricted diet, such as a low FODMAP diet, along with herbal antimicrobials or other supplements for a number of months, once the patient feels better, that we try to broaden their diet as much as possible.  But Dr. Robillard does not really agree with this concept.  He does not feel it is helpful or necessary to add back in a lot of fermentable carbohydrates and fiber. He likes to see people diversify their diet by adding more low FP vegetables, fresh herbs, and small servings of fermentable foods, like pickles, kimchi, sauerkraut, and maybe a little bit of yogurt. If you have an animal-based diet with some fatty fish, plenty of green leafy vegetables, and some nuts, there is no reason to add grains and beans and other fermentable carbohydrates.  If you need some fiber, you can use psyllium or cellulose, or something like that’s not very fermentable.  Rather than supplement with prebiotics, Norm would rather have someone have an organic garden and compost pile, which will inhance your micobiota. Studies on compost piles show that they are similar to the microbes in your gut.  Dr. Robillard is also not a big fan of antibiotics for SIBO, given the harm they cause to our microbiota as well as other side effects.

 

 



Dr. Norm Robillard has a PhD in microbiology and he is the founder of the Digestive Health Institute and he is a gut health expert and author. He is the creator of the Fast Tract Diet and the Fermentation Potential (FP) System, the author of the Fast Tract Digestion book series and the publisher of the Fast Tract Diet mobile app. He also consults directly with patients.

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 Transcripts

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 expert 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. This is Dr. Ben Weitz. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and review.

For those of you who’d like to see Dr. Robillard’s face, as well as listen to him, you can always go to our YouTube page and watch the video version of the Rational Wellness Podcast. Anyway, our topic for today is Irritable Bowel Disorder, or syndrome, and small intestinal bacterial overgrowth, and then how to treat it. Irritable Bowel Syndrome is a condition marked by gas in the intestines, bloating, abdominal discomfort, constipation, diarrhea, alternating one and the other, as well as a series of other symptoms. IBS, Irritable Bowel Syndrome, is the most common gastrointestinal disorder and occurs in up to 20% of the U.S. population.

For many years, IBS was considered a stress-related condition with no known cause, and this is partially because IBS was most common in women. Traditional medical treatment has been generally composed of medications for controlling symptoms, such as medication to reduce constipation, another medication to control diarrhea, et cetera, et cetera, but in functional medicine, we don’t wanna just treat symptoms, we’re trying to get to the underlying cause of our health conditions. Dr. Mark Pimentel, from Cedars-Sinai, was really the first one to discover that small intestinal bacterial overgrowth, or SIBO, is the cause of IBS in up to 84% of cases. SIBO consists of bacteria that normally grow in the large intestine or colon that then start to grow into the small intestine, which normally has relatively small amounts of bacteria.

When you eat certain types of carbohydrate foods that contain fermentable fiber, our gut bacteria eat the carbs and they produce various types of gases, like hydrogen and methane. When this occurs in the colon, this is not a problem, since the colon’s very expandable and there’s a valve, the ileocecal valve, to keep this gas from going back up into the rest of the digestive tract, but the small intestine is a relatively narrow tube and it’s not really expandable in a way that the large intestine is. If there are bacteria there that are eating fermentable carbs, they’ll produce gas, and this gas, likely, will cause discomfort, a feeling of gas and bloating, and many of the other symptoms of IBS or SIBO. The gold standard for diagnosing SIBO is finding more than a tiny amount of bacteria upon jejunal aspirate, which means that when putting a scope down into the intestines, you scoop a small amount of the liquid in the proximal jejunum, which is the lower part of the intestine, and then analyze it via culture, or PCR.

Unfortunately, this test is very invasive and it’s not typically done on a regular basis in clinical practice. What we have is a somewhat imperfect but fairly useful test, which is known as lactulose hydrogen-methane prep test to diagnose SIBO. Dr. Pimentel also found that SIBO often results from a bout of food poisoning, where the bacteria that causes food poisoning give off an endotoxin referred to as cytolethal distending toxin. The immune system reacts to this toxin and attacks this cytolethal distending toxin, but then, because the cytolethal distending toxin is similar to some of the structural proteins in the intestinal wall, the immune system cross-reacts and ends up attacking the intestinal wall. By this understanding, SIBO is really an autoimmune condition.  This can be diagnosed via a blood test that Dr. Pimentel developed called the IBS check test, and now Cyrex Labs has Array 22, that’s a more sophisticated way of trying to measure these antibodies produced by the immune system in this attack on these toxins, as well as the antibodies to the structural proteins in the intestinal wall, in order to be able to diagnose SIBO. This is all, obviously, a very complicated and confusing condition, and that’s why I’ve asked Dr. Norm Robillard to join us today. Dr. Robillard’s an expert at IBS and SIBO. He has a PhD in microbiology from the University of Massachusets where he studied Bacillus species of bacteria, which are the spore-based bacteria.  He’s the founder of the Digestive Health Institute, and he’s also a gut health expert, author, and microbiologist. He’s the creator of the Fast Tract Diet and the Fermentation Potential system. The author of the Fast Tract Digestion book series and the publisher of the Fast Tract Diet mobile app. Thank you for joining us, Dr. Robillard.

Dr. Robillard:                      Thanks for having me on, Ben.

Dr. Weitz:                            When you look at the studies on IBS, there’s a big range as to what percentage of patients with IBS are actually positive for SIBO, and so there’s one review paper that says it ranges from as little as 4% all the way up to 78%. This has led some practitioners and doctors and researchers to even wonder if there really is a relationship with SIBO and IBS and what percentage it is. On the other hand, Dr. Pimentel did a study in which he found that 84% of patients with IBS tested positive for SIBO.  Why do you think there’s such a wide variation in these results and what percentage of patients with IBS do you think are really caused by SIBO?

Dr. Robillard:                      Yeah, that’s a good question. Of course, there’s basic test methodologies. I used to run an analytics testing laboratory, and so there’ll always be precision, accuracy, intermediate precision, which is how closely different laboratories get the same result, so it requires a lot of training and a lot of calibration to get these labs on the same page. Of course, the test for SIBO, there are different techniques used.  Some people, you mentioned lactulose sugar, which is really, I would think, the preferred method, because lactulose is not digested by humans, so it passes through the intestines until it runs into bacteria that can break it down and produce hydrogen.  When you use lactulose, you can detect bacteria all the way through the small intestine.  But a lot of labs use glucose, which is quickly absorbed, and so if the bacteria are not up in the proximal or early part of the small intestine, you may not even see them with that test, so it’s less sensitive, however, it’s more specific.

There are some test methodology issues.  Before we went live, you and I were just talking about the test preparation, which I think is also important and, potentially, a flaw or an imperfection in this testing, because before people take the breath test, there’s a 24-hour preparation period where you’re, essentially, on an intervention diet, and so you’re avoiding legumes. You can still have some fish and chicken, no fruit juice, and you mentioned they can have some rice, and some rice is worse than others, as we’ll get to in a little bit, but nevertheless, they’re on an intervention diet for 24 hours and then they fast overnight before taking the test.

You, obviously, follow Dr. Pimentel’s work, and those folks down there have really worked a lot on this migrating motor complex, so SIBO is a snapshot in time. If these bacteria move their way up into the small intestine, your body, stomach acid, a lot of these mechanisms we’ll be talking about today, motility, it’s always trying to move these bacteria out, bile, antimicrobial factors, your immune system, and so the more chance you give it to not be either fed more with carbs, things like fasting, the more of a chance you have of being negative. On the other hand, if you feed everybody a lot of fermentable material, you’re going to see the number of people with SIBO go way up. Again, it’s a snapshot in time.

The last point I wanted to make is, and I hope we get a chance to talk about this a little bit today, I had coined the term LIBO in an article I wrote a few years ago on resistant starch, it’s to stand for Large Intestinal Bacterial Overgrowth. In your introduction, you mentioned, well, as long as all this fermentation happens in the large bowel, you can accommodate that all, bacterial growth and a lot of gas, but if you have too much, that could be problematic as well. People would come in with symptoms and test negative for SIBO, and they still have excess bacterial fermentation, that’s what I believe. The second part of your number was what’s a number, right? What should it be–87% or 4%?  Again, from being analytics testing all of these years, I do know that if you test something enough, the answer gets closer and closer to the accurate value. Dr. Pimentel had put together a meta-analysis of a whole variety of studies and really validated the finding of SIBO and connecting it to IBS, and I thought that was pretty powerful. When you look at enough data, you’re going to get a better answer. Is it 45% or 65%? I don’t know, but it’s probably somewhere in there, again, fluctuates.

Dr. Weitz:                            Right. Yeah, that’s interesting, you talk about LIBO, or bacterial overgrowth in the large intestine, I wonder if you could use the SIBO breath test to diagnose that if you just look at the rise in gases after 120 minutes or beyond.

Dr. Robillard:                      Probably not, because when you go from even somebody with SIBO, they have greater than 100,000 bacteria per mill in the small intestine, which anybody that works with bacteria will tell you, that’s such a tiny, tiny amount, and then you get to the large bowel, and the large intestine contains 100 trillion bacteria, so much more, so basically, this lactulose would be just rapidly consumed and produce a lot of gas, even if somebody didn’t have “LIBO”.

Dr. Weitz:                            Oh, okay.

Dr. Robillard:                      However, there was a study done, jumping into this LIBO thing a little bit, by a group that looked at, I think they were out of John’s Hopkins, looked at 47 patients with IBS, and some controlled, so it’s pretty good end for statistical analysis, and they had them swallow a wireless motility capsule, kind of a SmartPill, and this pill could detect pH differences, so it’s going through the stomach, small intestine, and into the large intestine, and it was measuring acidity. What they found was really interesting, they didn’t see any pH change, no increased acidity in the small intestine. Just to back up for a minute, when bacteria ferment carbohydrates, they produce short-chain fatty acids, right? They’re fats and they’re acids, and that’s where the acidity comes from, but they didn’t see any increased acidity in the small bowel of people with IBS, but when the SmartPill got to the large bowel, they did see an increase in acidity, and they indicated that they interpreted that as the bacteria in the large bowel.

For IBS patients who were very active, producing more of these short-chain fatty acids and more of the acid, they were questioning SIBO. While we’re on that topic of questioning SIBO, there was another lab up in Canada that used a radioactive tracer molecule when they gave people, and again, it was a pretty good sized study, I think it was about 40 people with IBS and some controls, when they gave them the lactulose breath test, at the same time, gave them the lactulose, they gave them this radioactive tracer probe. They could literally follow this probe on somebody’s body, and they had mapped out, here’s the end of the small intestine, the ileocecal valve should be right here, and they were literally following this radioactive probe through the small intestine. What they found was that by the time people were registering as hydrogen-positive within 90 minutes indicative of SIBO, that that dye had already reached the ileocecal valve and was entering at the large bowel.  Again, they were saying that they think that people that test positive with SIBO, perhaps, have faster motility, and that’s what they’re measuring, not the actual SIBO. I thought about both of these studies and I really think the answer is that both LIBO and SIBO exist. For instance, in this radioactive probe study, yes, as people were recording a positive breath test, some of this dye, for at least 5%, had reached the large bowel, but a lot of the dye was still back in the large intestine, small intestine, and a lot of the lactulose was still back in the small intestine, so I don’t think it debunks SIBO so much as it suggests, both of these studies, that we need to look at LIBO and SIBO. While we’re on that topic, again, with the SmartPill and the acidity, they found that they had no change in acidity in the small intestine, but they did in the large bowel, but again, getting back to the numbers, even if you have 100,000 or 500,000 bacteria in the small intestine, is that enough bacteria to meaningfully change the PH, especially when the small bowel adds bicarbonate and it neutralizes the acidity from the stomach, and all of that?  I think SIBO could exist, easily exist, and that it’s not debunked by these methods, but I do think it is a good reason for us to look at it in a different way and think maybe it’s a combination.

Dr. Weitz:                            Yeah. A thought I also have about that, and then I think maybe I should ask you to explain what the SIBO breath test is for those listeners who are not familiar with it, is some of the real acid-loving bacteria, like the lactobacillus, is they’re typically not part of the SIBO equation, whereas primitive archaea are, and I wonder, if they’re not really as acid producing as some of the bacteria, so that could be a factor as well.

Dr. Robillard:                      Well, in SIBO, so we’ve been talking about breath testing, but you also mentioned the gold standard, which is taking an endoscope that can sample the small intestine, aseptically as possible, pull these bacteria out and try to culture them. Some of those studies have been done and they’re not perfect studies because, first of all, 80 or 90% of the bacteria in your gut will not grow and culture. They haven’t figured out how to grow them, and that’s why they use the 16S rRNA gene sequencing to look at these strands molecularly. They have done some culture work and they find that SIBO is comprised of an overgrowth of some bacteria that are from the small intestine, so there’s your lactobacillus and some staph and strep, but also, bacteria that are more associated with the large bowel, some Firmicutes, some clostridium species, some bacteroides, like bacteroides fragilis and several other Gram-negative and Gram-positive strains, so bacteria in the large bowel and from the small bowel are overgrowing there, so that-

Dr. Weitz:                            Also the archaea, right?

Dr. Robillard:                      Well, okay, some people may have thought that early on, because in some of these breath tests, the people have high levels of methane and they’re like, “Wow, okay, must be the archaea,” they’re not bacteria. These other micros called archaea take the hydrogen and they use it to reduce carbon dioxide to methane. That’s the little molecular food chain there, and so where are these archaea? Because wow, even in the first sample, they have high methane and they just continually have high methane, but remember, with these breath tests, they have you blowing in these tubes, right, so that if any hydrogen’s being produced by bacteria in your gut gets absorbed into your bloodstream, exhaled through your breath and you capture it in this tube.

You blow in that first tube, it’s called times zero, put the cap on, put a label on it. That’s times zero, that’s before you drink the sugar solution, then you set that aside, then you drink the lactulose sugar solution, and then every 15 minutes, 20 minutes, depends on the test, usually about every 15 minutes, you blow in a new tube and put the cap on. With hydrogen, you can see a real kind of time course there if you plot it out. Zero sample is hardly any hydrogen in it, and then all of a sudden, starts to come up, and it may be 40 minutes, and 60 minutes comes up, then it starts to, maybe, go down a little bit, and then it hits the large bowel past 90 or 120 minutes and it goes through the ceiling.  You can get a profile like that with hydrogen, but with methane, you almost always just see that it’s high in the zero time point, so that’s telling us that it has no dependence on the lactulose sugar. It’s doing its thing, taking the hydrogen and CO2 and combining that to make methane. There has been some work on it, I’m not sure I can cite any particular studies at the moment, but that shows that these archaea are in the large bowel and that they’re just churning away. Some people may not know this, people with IBS-C, or constipation-predominant IBS, almost always have these really high levels of methane because methane, there’s been good work on this, you can inject methane into the intestines of animals and it slows down the transit.  There’s just such a tight corelation with people that are high methane having slow transit and constipation. There is a strong belief that these archaea organisms are doing that in the large bowel.

Dr. Weitz:                            I thought that they had grown into the small intestine, and that was one of the theories, I talked about Dr. Pimentel’s theory about the autoimmune component, but to follow up on that, what that meant is by damaging the structural proteins in the small intestine, it caused decreased motility, and he describes it as like a stream that stops running quickly and starts backing up and that allows the bacteria from the large intestine to grow into the small intestine, so I thought that’s where the archaea-

Dr. Robillard:                      Well, right. This whole story, and it’s a great story, by the way, they worked out with Cytolethal Distending Toxin and the autoimmune reaction with Vinculin, which slows down motility, hits the nerves and so forth, causes constipation. Slowing everything down, whether that causes archaea organisms to back up all the way into the small intestine, I’m not sure. I do have my own theory about connections between the LIBO and SIBO. Something we’re not talking about today, but it’s just relevant in this discussion, is when I first got into nutrition and dieting, it was only because I had chronic acid reflux myself, and I had found that a super low carbohydrate diet caused my symptoms to just go away, and so I was so amazed by this.  I was playing around with this idea, and I started following the food groups through the digestive process and came up with this new theory that, what was happening, I believed, was that I was consuming too many carbohydrates, too many were getting malabsorbed, feeding blooms of gas-producing bacteria, right? As a microbiologist who grew these bacteria, right? You mentioned I worked in a Bacillus lab for my graduate work, but I also worked as a post-doctorate fellow on bacteroides fragilis, that’s 10% of the gut bacteria, and E. coli. I was actually the first one to be able to move genes between E. coli and this strict anaerobe bacteroides through this conjugative process.

One thing I knew about these bacteria, they produced a lot of gas. They were saccharolytic, they loved carbohydrates, they produced a lot of gas, and I came up with a theory that all this gas produced too many carbs, was pressurizing my stomach, it was translating into my stomach, and they do know people with GERD, acid reflux, have much higher pressure in their stomach, and the theory was it was pushing reflux, opening this valve instead of the original theory that stood for 60 years. We’re saying that this valve was dysfunctional or it was weaker, or it was relaxing spontaneous, and so there’s a lot more evidence for this gas-producing bacteria driving reflux, and so I’ve written a couple of books on that. Now, to this new discussion on SIBO versus LIBO, these guys with the PH SmartPill, they found all this acidity past the ileocecal valve in the early part of the large bowel.

How could that relate? Suppose you had SIBO and LIBO, how’s the SIBO getting there? I have a theory that it might work the same way as my acid reflux theory, that these bacteria are producing a lot of gas in the early part, the ascending colon, just past the ileocecal valve, a lot of growth, a lot of gas, and maybe this same gas pressure is pushing back on the ileocecal valve. It’s interesting, it ties into another study done out of John’s Hopkins as well, I think, where they found that people with SIBO, was it a SIBO population or an IBS population? I think it was SIBO, but one or the other, but probably people with SIBO, they found their ileocecal valve pressure and they measured it like a colonoscopy tube going right up to the valve.  They put a pressured, sensitive, like a manometry instrument, position it right in the ileocecal valve, and it was weaker, there was less pressure, people that had SIBO. It could be the same thing, if you have gas pressure from bacteria pushing back on that valve and pushing it open, if you have a pressure-sensitive tube in there, it’s going to look like it’s weaker, but really, it’s being forced open by back pressure. Anyway, something to think about.

Dr. Weitz:                            That’s interesting. If the archaea are really in the large intestine, that could be one of the reasons why it’s difficult to correct methane SIBO and kill or cut back the archaea if Rifaximin, which is what gastroenterologists often use when they treat this, is basically acts in the small intestine, so it might not be acting in the large intestine where, under your theory, the archaea really are.

Dr. Robillard:                      Yeah. Well, it probably explains why Rifaximin alone is not efficacious for IBS-C.

Dr. Weitz:                            Right, that’s why they usually recommend Rifaximin plus Neomycin, or another antibiotic.

Dr. Robillard:                      Yes, and both are nonabsorbable. If you’ve seen my other work, you know I’m not a big fan of antibiotics, but at least these two are nonabsorbable. You can eliminate some of the systemic problems.

Dr. Weitz:                            Right.

Dr. Robillard:                      They use both. The Rifaximin is probably, by their own estimations, not very useful in the large bowel, right?  There’s a whole story about, well, it won’t upset your microbiome because it requires bile for its most efficient inhibition, and 95% or more of the bile is reabsorbed at the end of the small intestine, so the Rifaximin is probably not a big factor. It would be, really, what’s the Neomycin doing?

Dr. Weitz:                            Interesting. We’ve talked about a couple other things that could cause SIBO, we’ve talked about the damage to the motility of the intestinal tract, and you mentioned the migrating motor complex, and you also talked about the ileocecal valve. What are some of the other causes of SIBO?

Dr. Robillard:                      Yeah. Motility is big, and Pimentel thinks it’s really probably one of the biggest. Low acid is another one, people with hypochlorhydria, achlorhydria. The acid not only is it important for digestion, but it’s important for keeping the bad bacteria out of your gut, keeping the bacteria in your gut from moving up to your throat, lungs, and sinuses, so acid’s important. By the way, on the acid, there is an autoimmune disease that will lead to atrophic gastritis and hypochlorhydria, but it’s quite rare, actually, so unless somebody has a lot of other autoimmune conditions, you might not have to look at that one, but definitely PPIs, that’s what they do, they knock down your stomach acid.

Dr. Robillard:                      The other big one is a prolonged infection with Helicobacter pylori, bacteria that infects the stomach, it’s a corkscrew shape, like a spirochete, and it burrows down through the mucus and anchors on the stomach lining and it makes these colonies. Depending on where those colonies are in your stomach, that’s where the damage happens and that’s where the gastritis and atrophic gastritis happens. For some people, it effects the hormones that regulate stomach acid and they can have too much stomach acid, and they’re very susceptible to duodenal and stomach ulcers. People that have these bacterial colonies of H. pylori near the parietal cells that produce the acid, those are the ones you have to worry about having low stomach acid, so that’s a big one, too, I think, in a subset of people. Any kind of-

Dr. Weitz:                            That’s really interesting because most people think of H. pylori as automatically associated with increased acid production, but you’re saying if the H. pylori grows in a certain part of the stomach, it can be associated with decreased hydrochloric acid secretion?

Dr. Robillard:                      Absolutely. Right. The two doctors down in Australia, one of them gave himself an H. pylori infection and got gastritis.

Dr. Weitz:                            Yeah, Marshall, right.

Dr. Robillard:                      Wow, that was a great story, but they were focused on the ulcers, with the cause of ulcers, but they can also cause the opposite.

Dr. Weitz:                            Interesting.

Dr. Robillard:                      The people that have low stomach acid, not only will it really mess with your digestion, can still have symptoms, but they also are at higher risk for stomach cancer with the low stomach acid, which caused me to wonder, if they studied PPIs, if they would see there was also a gastric cancer risk with PPIs. No one’s been reported so far, but it also really knocks down your stomach acid. Just to cover a couple more quick ones, any kind of liver issues, we talked about liver and it produces the bile and that’s antimicrobial, people with cirrhosis, any kind of liver problems, they can have SIBO, a lot of problems, anything with your pancreas, pancreatitis, the pancreas produces amylase, protease and lipase, right? If you have any kind of problem with your pancreas, you won’t be digesting food as well, especially if you’re deficient in the amylase.

Even kids with cystic fibrosis, while they don’t have a pancreas problem, per se, they do have a lot of mucus in the ducts where the enzymes are released from, so kids with CF have a very high instance of SIBO and GERD, for that matter, right? There’s another link there, and they have to be on digestive enzymes. Problems with drugs, we talked about PPIs, pain medicines, man, there’s a whole story about MSDS, it’s just unbelievable. Too many pain meds, especially narcotics on the motility front, Pimentel, in one of his interviews, was talking about anybody on morphine has SIBO. You don’t even have to ask, so they really do slow down the motility.  We talked about GI infections already, and not just bacterial. Gastroenteritis from food or water-born illnesses, bacteria, yes, but also protozoa, viruses, anything that causes gastroenteritis.

Dr. Weitz:                            You mean even fungal infections, and you can have what’s called a SIFO, or a Small Intestinal Fungal Overgrowth?

Dr. Robillard:                      Certainly, sure. We talked about the ileocecal, other genetic-based diseases, celiac and Crohn’s, it’s huge, diabetes, it might be a nerve damage issue going on, surgery and adhesion’s, I’ve heard Pimentel talk about that. I cover all of these in the Fast Tract Digestion books, by the way. I have a whole chapter on this. Speaking of scarring, scleroderma is a big problem for a lot of people with SIBO.

Here’s one that never gets any attention, and I’m not sure why, too many fermentable carbohydrates in your diet. Now, I learned that the hard way myself. When I was in my early 40s, I was having a terrible time eating all these carbs and having all these symptoms, took the carbs out of the equation and no problem, so I really think that some people, maybe as we get a little bit older, a lot of these functional GI issues start in our mid 30s and 40s, our digestion just may not work quite as well. You might not be able to put your finger on exactly what it is, but if you’re not digesting and processing carbohydrates well, digesting these things is a real finely tuned collaboration between our own digestive powers and the ability to use bacteria to help us out. If we overwhelm them and then throw in a couple of these other potential underlying causes, I mean, you’re in real trouble.  There’s a handful. I have a whole chapter on this if people want to read more.

Dr. Weitz:                            Yeah. It’s interesting, I think a lot of us in the functional medicine world, when we are putting patients on treatment protocols, I know myself, we usually use a diet that’s designed to have less fermentable carbohydrates. I typically use the Low-FODMAP Diet. Now, you’ve looked at some of these diets, like the Low-FODMAP Diet, specific carbohydrate diets, some of these other diets that are popular, and you found some problems with those diets and so you came up with your system. Maybe you could tell us about your Fast Tract Diet and your fermentation-potential figure for being able to analyze, quantitatively, which foods to include.

Dr. Robillard:                      Sure. This story goes back quite a few years, 15 years ago is when I really found that very low carbohydrate helped my GERD symptoms, started looking into this, and so that’s not on your list, right? You mentioned FODMAP and specific carb diet, but just a low carb, even a ketogenic diet, I use ketogenic diet in my own consultation practice as a troubleshooting tool. We’ll get into the Fast Tract Diet in a minute, but it allows some carbohydrates, kind of a flexible approach for people with different dietary preferences. Jasmine rice is better than basmati rice, for instance, for reasons we can talk about, but what happens if, well, even the jasmine rice I’m having IBS symptoms or heartburn symptoms”? Okay, well, there may be a problem for you even digesting the easier to digest starch.

For instance, jasmine rice has amylopectin, an easier to breakdown starch, some people have trouble even with that, so I’ll go to a ketogenic diet just as a troubleshooting method to say, well, let’s take all the starches out and see how you do. Why did I come up with this diet? Well, initially, I had just found low-carb diet works, but when I came up with this theory about the underlying cause of reflux, linking it to bacterial overgrowth, similar to what Pimentel was doing at the same time with IBS, I was doing with acid reflux, when you limit all of the carbs that seem to be okay, so I had written a book on just this mechanism. I just wanted to get out there, it’s a new theory, new way to look at acid reflux.

I was living not too far away from you at the time in Thousand Oaks California, and I was pretty close to Dr. Mike Eades who was living down in Santa Barbara, he and Mary Dan, his wife, also an M.D. who wrote Protein Power, their book was the first time I ever read about any kind of diet ever, and it was to go on this low-carb diet. I noticed, in his book, which he had written in the mid-90s, he said, “Oh, by the way, we have patients that their heartburn improves on a low-carb diet,” and I’m like, “Ah, that guy speaks my language,” so I sent him my book on the mechanism. Well, actually, I didn’t just send it to him, I was going to send it to him, but when I had him on the phone, I said, “Gee, I’m gonna be at the farmer’s market down in Santa Barbara,” we agreed to meet and I gave him a copy. We became friends, drank some wine together, and we’re talking about this stuff, and he was the one that really asked a key question, he said, “Well, low carbs is helping heartburn, we know that, and now we know there’s a mechanism for it,” and he bought in fully into my theory.

He thought it made sense, and there’s a lot of evidence for it, but he said, “You know, which types of carbohydrates are the most problematic?” That one question sent me on my way for another couple of years of research. I wasn’t really aware much of the FODMAP and the specific carb diet. I think I had, at some point, read Elaine Gotschall’s book Breaking the Vicious Cycle, I can’t remember exactly when, so I was aware of that, but I was just thinking about which of these carbs are hard to digest? I didn’t have any specific lenses on except just look at these, so I came up with lactose, fructose, and, of course, polymers of fructose, those are actually dietary fibers, resistant-starch fiber and sugar alcohol, so there’s five.

The next step was to come up with a way to quantitatively measure these in foods because you pick up a pear, how much of these five things are in that pear? Who knows. Give it to the best dietitian in the world, she might not know either, or he. I was thinking about this problem, and by the way, the specific carb diet, it limits disaccharides, it limits grains and starches but not honey. That didn’t cover these five that I was interested in, and the same with the FODMAP diet, which, right, Fermentable Oligo-, Di-, Mono-saccharides and Polyols, so some of the monosaccharides like fructose, polymers are fructose, sugar alcohols, polymers of galactose, for that matter, too, but not fiber or resistant starch.  I think the reason not all these diets cover it is because they either just don’t think some of these are very fermentable or they just think they’re so darn healthy for our gut that we need to include them. I came up with the five, I came up with the FP calculation to quantitatively measure them, but many years after I wrote the first Fast Tract Digestion book, I came across this textbook, can you see that?

Dr. Weitz:                            Yeah.

Dr. Robillard:                      Textbook of Primary and Acute Care Medicine, it’s fat.

Dr. Weitz:                            Wow.

Dr. Robillard:                      A lot of good stuff in there, but this book was published in 2004. It’s used to train doctors, but I think some doctors might have skipped the chapter on intestinal gases because when you go to page 1192 and open it up and read it, there’s those five carbohydrates that the Fast Tract Diet restricts, so it’s not that far out there. It’s aligned with this Textbook of Primary and Acute Care Medicine, that’s why I chose those five and why I developed my own diet that was low-carb keto is a great approach. The other ones, I think they’re missing a couple, and I think that can be challenging for some people if they’re having problems.  There’s so many different types of fibers and we know some of those are very fermentable, stachyose, ravinose, various other polymers of sugars. I think you need to limit all five, and then the other thing was I needed to find a way to do it quantitatively, so I could make the diet something people could use. In the books, in the mobile app, the Fast Tract Diet mobile app, there’s all these tables of all these foods with these FP values. The FP calculation, it took me a long time to figure it out because I didn’t know how I was gonna measure the five carbohydrates in a way that you could just look at any food and say is there a lot of fermentable material in this or not?

I struggled with that issue, and for a while, I started thinking about the glycemic index instead of thinking, well, that measures how quickly carbohydrates go into the bloodstream, must be some way to use that. I was just, I don’t know, kind of dense thinking about it at first, but as I thought about it more and more, eventually I realized that it wouldn’t be that hard to modify that equation, flip it around and modify it because instead of measuring carbohydrates going into the bloodstream, I wanted to measure how many carbohydrates were persisting in the small intestine and not being absorbed. I turned the equation around, but because the glycemic index equation does not measure fibers or sugar alcohols, I needed to add those back after, so I flipped the equation around. Then, after that first part of the calculation, you add dietary fiber and any added sugar-alcohols, and so all you need is the glycemic index and the nutritional facts for any food and you can do this calculation.  Of course, the app has a calculator for this, but also, it has tons of table sets. We’re releasing a new version in the next month, we’re about 10 months behind releasing this, but it’s going to have over 1,000 foods in it now. It’s got voice recognition on it, so if you just open it up, I have it opened up now, search. Whoops, I pushed on the happy face instead of the other thing.  Carrots.  You can bring up carrots raw, and you can cook them after, by the way, but it will just tell you what the fermentation points are for any given serving size.  And if the points are too high and you still like carrots, just use a few less. Use half the number of carrots, it will cut the servings, it will cut the points in half. That’s how it works, in a nutshell.

Dr. Weitz:                            Is there a quantitative amount of FP points somebody’s supposed to have in the course of a day or is that related to their total caloric intake, or how does that work?

Dr. Robillard:                      No, that’s a good question, it does matter a great deal.  In fact, we’re listening to our readers on this one.  We had initially set a flexible range between 25 and 35 points, and just to put that into perspective, 30 grams of undigested carbohydrates that are fermented by bacteria can allow bacteria to produce 10 liters of gas, so just an ounce of these carbs can drive a whole bunch of gas production, that’s why you do need to limit these.  Typical western diet may have 150 or more FP points a day, so that’s 50 liters of gas, that’s a lot. We wanna get that level down, and so we recommend somewhere between 25 and 45, depending on if you have a lot of severe symptoms, you want to go to the lower end, and as you get better and start improving, you can increase up to more than 45, but you’ll probably never really be eating 150 a day again if you’re somebody that suffers with these functional issues.

We have a Facebook group, Fast Tract Diet Official Facebook Group, people should join. There’s about 8500 members on there right now sharing recipes and talking about all this stuff. We have a lot of groups of people with these different conditions, not only IBS and SIBO, acid reflux, we have people with laryngo-pharyngeal reflux, real subtle irritation in the throat and vocal chords, it’s linked to reflux but it’s subtle, but it’s also persistent and it’s hard to get rid of. We’ve had people on the page, many of them, saying, “Well, this irritation’s persistent, subtle, but you know what?  If I really was diligent with my points, I had to go less than 20, down to 15, and I had to do it for weeks,” and some people months, and finally their throat symptoms would get better when nothing else worked.  They were driving this with us and they were saying, “You know what?  You’re not cutting the points enough, you have to cut more,” so we’re learning from them.  We’re involved in a clinical study where we’ve actually reduced the points based on what people on our Facebook group are telling us.

Dr. Weitz:                            Interesting.  I wonder if there’s an issue with pre-diabetic or diabetic patients, because your program is actually promoting consumption of foods that have a higher glycemic index, right?

Dr. Robillard:                      I never thought about it as promoting.  It is a flexible eating plan, right?

Dr. Weitz:                            Right.

Dr. Robillard:                      Yes, if you were going to have rice, rather than Uncle Ben’s or basmati white rice, because a small bowl of those is going to give you a whole lot of points, maybe 10, 20 points, depending on how big the serving size is.

Dr. Weitz:                            Partly because those foods are digested slowly, right?

Dr. Robillard:                      Yeah, yes.

Dr. Weitz:                            It makes them more preventable.

Dr. Robillard:                      So far, I’m making your point for you, yeah, versus a jasmine or sushi rice has a higher glycemic index, hence a lower FP.  They’re more easily digested, more will go into your bloodstream, less will stay behind, so you’ll have less GI symptoms.  Now, what happens, though, your blood sugar increases, and so in the book we’re cautious to warn people about prediabetes metabolic disorders and diabetes, and people have to be responsible for their own blood sugar levels.  Somebody that doesn’t have an issue, or they’re an athlete, or they’re carb loading, or they’re a construction worker, so this book, a lot of different people are going to use this book.  Other people may have to really watch their carbohydrates, so a low GI, low GI carbs is one way to do it, but it is going to feed the bacteria a lot, so that’s the downside.

If you’ve got functional GI issues, your solution, in the end, will probably be a lower carbohydrate diet. That way you’ll have less blood sugar, you’ll also feel less of the bad guys in your guts, the overgrowing bacteria. We’re not telling people to load up on sugars, even if you look at our tables and the serving sizes.  I mean, there’s different categories on this app, so let’s just go down to rices, right?  Well, here’s the one we just talked about.  I’m gonna click on jasmine rice.  Cooked jasmine rice, all right.  What’s the total serving size?  I don’t know if you can see it there, but it’s a half a cup.  People with blood sugar issues, chances are they’re wolfing down a lot more rice than that, so we purposely, even though it’s low in FP points, we purposely tell people that, really, small serving sizes are better, lower carb is better, and eat slowly and chew well, which will also help digest these starches and some of these carbs better.

Dr. Weitz:                            I was surprised to see wine and beer, or light beer, on your list because these are fermented, but I guess there’s a difference between foods that are fermented and are fermentable, is that the case?

Dr. Robillard:                      Okay. Yeah, you’re bringing up a couple of points there. Foods that are fermented, right, there’s less carbohydrate in those foods when you consume them because the fermentation happens in a vessel, in a vat or a tank or a mason jar, right? The lactic acid bacteria, in the case of pickles, the yeast in the case of beer and wine, they’re using the sugars and they’re producing alcohol, right? Well, not in the lacto-fermented, they’re producing short-chain fatty acids and so forth, but in the beer and wine, they’re producing alcohol and they’re consuming the carbohydrates, so when you consume those foods, there’s less carbohydrates than there otherwise would be in there.  However, when it comes to beer, a light beer has many fewer points. I think it’s somewhere around six or something for a bottle of light beer, four to six maybe. No, I’m sorry, maybe three or four, but when you have a heavier beer, like one of my favorites, IPA, it has a lot more points because there are a lot more carbohydrates in there. Regardless of the fermentation process, you still have to look at, anyway, it’s gonna take me too long to find the drinks and open up the beers, but-

Dr. Weitz:                            Yeah, I got it.

Dr. Robillard:                      Yeah. I purposely watch my points on days when I’m going out with my buddies because I want to have a couple of IPAs, but they have more points, and so if I’m also eating french fries, and something like that, and I have a couple of these beers, it’s kind of like death from a thousand cuts. These points add up and then they really get you, and then you need a couple of days, two or three days, to unwind it. You have to pick your poison. Distilled liquors are fine because they have no carbohydrates at all.  Dry wines, red or white, are pretty low in points, and light beer is pretty low on points. From there you just have to conserve your points and pick your poison.

Dr. Weitz:                            Now, it’s common in the Functional Medicine community to put a patient on one of these restricted diets along with using some other protocols to try to get rid of the SIBO, and yet, once we’re done with the treatment period, whether that be one month, two months, six months, whatever that period is, it’s usually recommended that we try to broaden the person’s diet as much as possible. This is to make sure that we are bringing back in some of the fibers that are necessary to have a healthy microbiome and also to make sure we’re getting all of the phytonutrients from having that diverse diet, but you have a little bit different take on using your Fast Tract Diet, don’t you?

Dr. Robillard:                      Well, I do. I’ve been doing this for 15 years myself, and my own, which was terrible, chronic acid reflux, it was horrible.  I was choking in the middle of the night, reflux entering my lungs and all-day heartburn, it was a terrible situation, so I’ve been doing this for 15 years. I don’t worry so much about encouraging people to add back fermentable material. I find that when people get better, and the more you do stay lower FP or you control these fermentable carbs or focus on identifying and addressing all of these underlying conditions, like a lot of people with H. Pylori, they will say, “Well, I’m just not gonna do anything about it. I heard it’s not that big of a deal,” maybe when you’re younger, but in time, gastritis, loss of stomach acid, and you might need some help.  We have a consultation program where we really work on this, what are these things and what are the risk factors and what are your symptoms?  How do we mostly throw things out, but the things that are remaining, the few things that are remaining, we have to confirm and address those.  Of course, I’m a microbiologist, I’m not a doctor, so I give them my notes.  I’m a consultant microbiologist to them, they take my notes to their doctor and we work through these things.  You have to identify and address potential underlying causes, that’s one thing.  

As you reduce the fermentable carbs, work on the underlying causes, you’re going to have less fermentation, less bacteria there that make proteases that damage the enzymes and the tips of your villi, toxins, you may actually damage the microvilli and villi themselves, kind of like a mini version of celiac disease where you get some blunting, does occur with SIBO. As you have less inflammation, control your diet, look at these causes, your digestion will improve.  I do like to encourage people I work with to broaden their diet, in terms of three food groups, low FP vegetables, and there’s a lot of those.  If you look at the vegetable lists and apps, there’s, I don’t know 180 vegetables, fresh herbs, but low FP, fresh herbs, low FP fresh vegetables with the idea of a diverse diet.  They do have some fiber and some fermentable material, just not as much, but diversifying it will diversify your gut microbiota.  Fresh vegetables, fresh herbs, and then also some small servings of some fermented foods, lacto-fermented pickles, kimchi, sauerkraut, that kind of thing, maybe a little bit of yogurt, just don’t go overboard.  That’s a nice mix, but this thing about immediately feeling like you have to come back with a ton of fiber, I think that’s misguided. I think I might be one of the only ones out there, at this point, arguing against too much fiber. Everybody just seems to think we’re starving our microbiota.  I just don’t believe it, especially if you have an animal-based diet with some fatty fish and you still have plenty of green leafy vegetables and you’re consuming some nuts, to me, that is an ancestral diet and a healthy one.

I feel like people, when they get better, they can be the best judge of what they can tolerate.  I feel like I don’t have to ram fiber down their throat.  On that topic, I was reading a review by, his name’s William Chad, I haven’t met him yet, a gastroenterologist up in Michigan who I hope to meet at this upcoming SIBO conference because he’s a GI guy doing work on diet, it’s just great to see.  He wrote a review, co-authored it with, I think, one of the Australian folks that works on these diets, on fiber, and they are on the same page with me.  They recognized there’s so many different types of fiber and their fermentability is so different, and so they worked, well, what’s the fermentability of all of these diets?  I have a chapter on that in the Fast Tract Digestion books where I do the same thing, and they reach the same conclusion, psyllium, cellulose, something like that’s less fermentable, and if you’re gonna play around with anything, maybe start there, that’s the less invasive of all of these other ones because some of the other ones are very fermentable. There’s papers on using these.  People that had GERD, they gave them fructooligosaccharide, right?  A polymer fructose, but it’s a mini dietary fiber, and their reflux, they were measuring it with probes.  The reflux occurred much more frequently, it was much more severe, and they had terrible symptoms, so that’s a prebiotic.  They gave people with GERD a prebiotic and they really almost killed them.  I mean, it was terrible symptoms and terrible reflux.

Dr. Weitz:                            That’s very common in the Functional Medicine world right now, is prebiotic supplements.  You even see doctors saying, rather than use probiotics, it’s much more important to use prebiotics, and it’s definitely very popular right now.

Dr. Robillard:                      Yeah, it is.  I’m not against prebiotics in very small amounts or a little bit of experimentation.  Some people are worried about taking a probiotic because some of these probiotic contain a prebiotic with the idea that it’ll help get these bacteria going once you swallow them and they get into your intestines, but if you look at the label closely on those, they typically add about 50 milligrams of one of these prebiotics, which is really a tiny amount.  It’s less than a 10th of an FP point because an FP point is a gram.  One FP is one gram of fermentable material.

Dr. Weitz:                            Yeah. I think part of this putting the prebiotics in afterwards, also, after your treatment period is part of the 4-R or 5-R program that’s been so prominent in the functional medicine world and pretty much accepted as one of the few biblical versus in the functional medicine world, which is that first you get rid of the bad bacteria and then you replace and repopulate with bacteria and prebiotics with probiotics and prebiotics.

Dr. Robillard:                      Yeah. I mean, my favorite way to repopulate is just to have an organic garden and a compost pile. That’s what I’ve been doing my entire adult life, flipping the compost and growing my own garden so I get away from the chemicals for a lot of the year. We’re harvesting some squash right now, we’ll put them in a basement, they’ll still be good next spring. If you make some pickles, those will last you another winter. There are ways to eat less chemicals.  Also, when you eat some of your vegetables raw, I mean not all of them, cooked vegetables are little bit easier to digest, but at least some of them raw, some grains. We grow a lot of dill and parsley and basil, then you are repopulating your gut with bacteria from your environment. By the way, they’ve done studies on compost piles. There’s a lot of similarities between the microbes in our gut and what’s in a compost pile. A lot of the same groupings of bacteria.  That would be my preference, yeah.  I’m not a real nut for the prebiotics unless they’re in limited amounts.

Dr. Weitz:                            Right. I’d like to ask you one more question because I know we need to wrap up soon. From reading some of your articles, you’re generally not recommending a lot of nutritional supplements. You do recommend digestive enzymes and ox bile and probiotics, but you don’t particularly like herbal antimicrobials, and I think these are a common part of many functional medicine protocols for SIBO. I know myself, we typically put the patients on one of these restricted diets and include these antimicrobials, and the thought is first we’re gonna starve the bacteria and then we’re gonna try to kill them using natural agents like berberine and oregano oil, et cetera, et cetera, but you’re not a big fan of these?

Dr. Robillard:                      Yeah. I mean, I could see why there’s a temptation to do that. I’m not totally against it. I spent 10 years working on and developing antibiotics. I worked on the development of Cipro, I’ve studied a mechanism of action of antibiotics, I’ve studied mechanisms resistance and the genetics of antibiotics, so I’ve worked on them for along time, they can be lifesavers.  I mean, they’re very important. I’m against the loose use, I guess, of antibiotics because of resistance and a lot of problems. I really want to see diets continue to be improved and refined, and a lot of people have eating disorders or preferences and it’s hard for them to change their diet, I understand that. “I’m a foody,” I hear that a lot, “I wanna eat what I wanna eat.” I get it, but I have more of an ancestral health perspective and I’ve been reading more and more about this over the years and it just makes so much sense, that the more we can eat like our ancient ancestors, that’s really the way we evolved, but of course, it’s not exactly the same today. The foods not the same.

The Western diet is just not only terrible but also the availability of all of these snack foods, it’s just too easy to eat these things, and so it’s harder to change your diet. Also, our microbiota is changing, especially since the invention of antibiotics and the clinical development of antibiotics in the 40s, that’s only been, what, 60 years, it’s having a huge impact on our gut. Also chemicals and preservatives, so our gut bacteria are not the same, they’re not nearly as diverse. If you go back and look, and Jeff Leech has done some great work living with and eating like and sampling the guts of the Hadza in South Africa. Their guts are much more diverse and much more in touch with the biosphere than we are.

We’ve got this gut microbiome that’s gotten used to eating more processed foods, more easy to digest food, and then, all of a sudden, we’re getting all this advice, well, if you wanna be like the Hadza, you better throw some of this fiber at it, but your gut microbiota and your digestive tract is not handling it well. You can keep fighting it or you can just say, “Well, I have to go with it a little bit, but I still wanna eat healthy, green-leafy veggies,” occasionally maybe a half of a sweet potato or a half a cup of rice, for some people. You also have to consider, you mentioned diabetes, but also, how about cardiovascular risk? It’s huge. I don’t know if you follow the work of Ivor Cummins and Jeffery Gerber, but they just came out with a new book that’s super, and follow their lectures.

Dr. Weitz:                            What’s the name of the book?

Dr. Robillard:                      Eat Rich, Live Long, I believe. Yeah. I just started reading it myself, but yeah, you can also google Ivor Cummins lectures, just phenomenal stuff.

Dr. Weitz:                            Okay.

Dr. Robillard:                      Really looking at things, starting out from the basics and saying, “What’s important? Is LDL really that important?” Turns out, actually, it correlates very poorly with cardiovascular risk, but you know what all correlates really well? Insulin. It’s just fascinating lectures, I can’t say enough for their work.

Dr. Weitz:                            I’m not sure if you’re distinguishing between antibiotics, which are prescription medicines, and oregano oil. I totally agree that antibiotics, especially broad spectrum antibiotics, have a negative effect on the microbiota and can have harmful effects, but generally speaking, my understanding and my reading of the research is that these herbal antimicrobials don’t have a negative effect on the microbiota.

Dr. Robillard:                      Yeah. Okay, so I didn’t cover that, let’s cover that. First of all, when you look at the history of antibiotics, most of them came from other living things, back in the day, anyway, from bacteria, from fungi, and then the Germans started to figure out how to use chemistry and sulfur drug, came up with sulfur drugs and so forth, and then it grew from there. A lot of regular commercial antibiotics come from other organisms, so do these herbal antibiotics, and while I would say you could put them, maybe, on a less invasive scale than some of these more powerful pharmaceutical antibiotics, every antibiotic is going to kill or inhibit, right? Some are cidal, some are bacteria static, are going to kill or inhibit a certain variety of bacterial types, and they’re also going to have a certain potency, right?

What is the concentration of antibiotics you need to get to to kill those particular microorganisms? With herbals, and there is that one study, is that also, I think that was John’s Hopkins as well. It’s funny, all these study’s from John’s Hopkins, talking about using berberine, some other herbals, and they were as good as Rifaximin, so I think that’s interesting and it’s good to look at. Maybe they’re not as bad, but we don’t really know that much about it.

A lot of the work for those has been done on the side, outside of the mainstream, and I do think we need to learn more. By the way, when you say something as good as Rifaximin for treating SIBO, you’re basically saying, if you look at the target studies, that’s 10% better than placebo. I think diet, behaviors, and identifying and addressing underlying issues, those three things should be front and center. If you don’t do that, I think you’re dead in the water. After that, then you can start to look at supplements, digestive enzymes, absolutely.  If there could be a stomach acidity issue, betaine, right, some vinegar, work your way down. Somewhere, herbals are in there as something to try, but for me, at least, and for people that I work with, I just don’t know enough about it to really be too gung-ho.

Dr. Weitz:                            Have you used motility agents like ginger and 5-HTP, things like that?

Dr. Robillard:                      Yeah. I think, again, there’s a whole thought that motility is slow because something’s wrong, right? That could be, and yes, with the vinculin and then the gastroenteritis, absolutely. There may also be an adaptation too, depending on what you’re consuming, right, because bacteria want to help us get all of those calories out of the food. Our bodies are collaborating with the bacteria, so depending on what you’re eating, your motility could speed up or slow down for a whole variety of reasons, it doesn’t really mean something’s absolutely wrong.  Also, you do have to look at the extremes of diet, as well. I was reading a study the other day that, in anorexics, they found that they had a spike or an increase in these archaea organisms, Methanobrevibacter smithiii, that produces the methane, so it makes me wonder, under extreme caloric deprivation, is this a mechanism to make sure you ring every last calorie out of any kind of vegetative matter you consume by these archaea going up and motility slowing down? I first try to look at everything in terms of what could the natural mechanisms be here. Am I smarter than 50 million years of evolution? No.  I just have a little more of a cautious approach. I try to really understand before I just jump to try this and try that.

Dr. Weitz:                            Awesome. Thank you Dr. Robillard. This has been an amazing podcast, gives us a lot to think about. How can listeners get a hold of you and get your books and your programs?

Dr. Robillard:                      Sure. Well, you can find us at DigestiveHealthInstitute.org, and I would also encourage people to join the Fast Tract Diet Official Facebook Group. I’m on there most days, poking in here and there and answering a few questions, but there’s a lot of people that have become real experts on the diet, and they’re very helpful as well. I think those are the two main places to find us. If you wanna specifically look at the mobile app, you can go to FastTract, T-R-A-C-T, Diet.com. You can find those on iTunes and Android store, as well.

Dr. Weitz:                            That’s great.

Dr. Robillard:                      Thanks for having me, Ben. It’s great talking.

Dr. Weitz:                            Thank you Norm. Yeah, I really enjoyed the conversation.

Dr. Robillard:                      Me too.

 

,

Toxic Mold with Dr. Jessica Tran: Rational Wellness Podcast 79

Dr. Jessica Tran discusses how to avoid and correct Mold Toxicity with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

6:05  The diagnosis of mold toxicity is difficulty to make, since the symptoms like fatigue, joint pain, skin rashes, respiratory problems, cognitive and neurological issues, fatigue, and headaches could be indicative of many other conditions.  Mold may be a diagnosis of exclusion, after other causes have been ruled out.  Patients with dementia or Alzheimer’s may have mold toxicity as a trigger.  In fact, Dr. Tran said that she has seen a handful of patients with triple negative breast cancer who have all had tremendous mold exposure.  Patients who have multiple chronic illnesses, say somebody who has hypothyroidism, Lyme infection, allergies, etc. will often have a mold allergy or mold sensitivity or a mycotoxin issue.  We can get mycotoxins from our food, which most people will eliminate on their own.  But these patients may have a compromised ability to eliminate mycotoxins.  The key is to take a good, detailed history.

14:12  Dr. Tran likes to screen patients who she suspects of having mold toxicity with a urine test through either RealTime Labs or Great Plains but she likes to have them take either liposomal oral glutathione 500 mg three times per day the day before or an IV Glutathione drip or push the day before collecting the urine.  This will increase mold excretion.  Without doing the glutathione challenge, you can have someone who has been exposed to mold and is reacting to it, but they may be a poor excreter.  It may be stored or stuck in their body and not coming out.  It’s the same concept when you test for heavy metals and do an oral chelator challenge and then test the urine. Dr. Tran talked about the Autism study when they looked at the baby’s first haircuts looking for mercury to see if mercury was related to autism. But they found the opposite–those with autism had lower levels of mercury. But what this study really showed was that the autistic kids were poor mercury excreters.

20:25  The best ways to test your home for mold is to contact a mold expert to come and impect your home or office.  If you want to test it yourself, the ERMI kit is better than the HERTSMI, since the ERMI looks at more forms of mold and is more extensive than the HERTSMI.  If your budget is very limited, you can get a petri dish from Home Depot or Amazon and just leave it in your home for a couple of days and then mail it in and they send you a report.

21:57  A Functional Medicine approach to treating mold problems should include looking at the whole person and also look at food allergies and other environmental allergies. For the mold component, treatment should start with glutathione, either liposomal or intravenous. You should also add phosphatidylcholine, which helps improve the lipid membrane. Dr. Tran says she may also use binders like psyllium, bentonite clay, and/or activated charcoal.  She finds that cholestyramine is fairly harsh, so she does not use it.  Dr. Tran will also look at the gut, esp. since mold has a relationship with candida overgrowth. 

 



Dr. Jessica Tran is a board-certified Naturopathic Doctor who is practicing Functional Medicine at the Wellness Integrative Naturopathic Center in Irvine, California, where she practices with Dr. Darin Ingels. The website is WellnessIntegrative.com and she can also be found at DrJessicaTran.com   Dr. Tran’s office phone is 949-551-8751 where she sees patients in office or remotely. 

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 Transcripts

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. Dr. Ben Weitz here. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and leave us a ratings and review. That way, more people can find out about the Rational Wellness Podcast.

Our topic for today is toxic mold, its effect on our bodies, and how to get rid of it, with Dr. Jessica Tran. Exposure to mold and mold toxins, known as mycotoxins, affects many people and often is an undiagnosed underlying trigger for many other symptoms and conditions.  Many people are unwittingly living or working in water-damaged buildings, and this exposure may be causing many negative effects on their health including skin rashes, respiratory problems, cognitive, neurological issues, fatigue, headaches, joint pain, even increased urinary frequency, and a list of other symptoms. When looking at a patient from a functional medicine perspective, we usually focus on likely underlying triggers and root causes of their health condition, and mold may be one that is sometimes overlooked.  Research indicates that mycotoxins can bind to DNA and RNA and cause damage, alter protein synthesis, increase oxidative stress, deplete antioxidants, alter cell membrane function, act as potent mitochondrial toxins, and alter apoptosis, which is important for killing off cancer and other cells that we don’t want in the body. Molds and mycotoxins can negatively affect our hormones including our sex hormones, thyroid, and adrenal function. In some cases, POTS, postural orthostatic tachycardia syndrome, fibromyalgia, chronic fatigue, and a bunch of other conditions can be caused by mold exposure.  Other conditions that may have a mycotoxin component include various cancers, diabetes, atherosclerosis, heart disease, hypertension, autism, rheumatoid arthritis, lipid problems, Crohn’s disease, Sjögren’s syndrome, MS, Alzheimer’s disease, et cetera. 

This is why we’ve asked Dr. Jessica Tran to join us today. Dr. Tran is a board-certified naturopathic doctor having completed her naturopathic degree from Bastyr University. She also completed a three-year specialty environmental medicine fellowship, and she also recently completed an MBA in health care from UC Irvine.  Dr. Tran is extremely knowledgeable about mold and mycotoxins and environmental conditions, and this is why we’ve asked her to join us to share some pearls of wisdom with us today. Dr. Tran, thank you so much for joining us.

Dr. Tran:              Thank you so much for having me. I’m excited to be here.

Dr. Weitz:            Excellent. How did you become interested in environmental medicine and studying mold and patients suffering with mold toxicity?

Dr. Tran:              It was through my fellowship program at Southwest that I became more familiar with mold. It was never on my radar. It wasn’t anything I ever learned in undergrad or even living in Seattle where it’s very moldy and damp. I rarely had encountered anyone or any patients that came in for us with symptoms that remotely resembles mold, toxicity or mold allergy. I was probably seeing them, but it wasn’t anything that was exposed to me at that time.

Dr. Tran:              In my fellowship program, because I was at the Center of Environmental Excellence there, we saw patients from around the globe, and it was there that I had patients come in, and it was through my mentor and faculty director who through our history uncovered that patients who were living in water-damaged homes or had exposure to mold had chronic illnesses that after seeing 40 or many, many different doctors, their symptoms and condition wasn’t resolved.

One of the things that really fascinated me was that you can have mold exposure and not even see it in your home because it could be behind the drywall of the home, and patients would usually have a history of, “Yeah, we had water damage. We cleaned it up,” or, “The toilet overflowed,” but we then … Part of the fellowship program, you learn about building practices and how to ask certain questions. We have our patients or a home inspector go in, take a look, and lo and behold, sometimes people would have black mold behind their shower wall or in their bathroom or even in their home or kitchen sink, roof leak, and that was really where I learned a ton about patients who were exposed to mold and having mycotoxin issues.

Dr. Weitz:            Cool. So, what would make you suspect that a patient that you’re dealing with may have an underlying mold problem that’s part of their health struggles, especially when symptoms of mold toxicity could also be caused by a number of other things?

Dr. Tran:              That’s the hardest aspect. It’s usually for most … As a general practitioner, it’s really hard to know because patients are coming with fatigue, joint pain, and all these other things that are so many different things that you can have value … they have … For me, sometimes, I’m one of the last people that patients see, and it’s a diagnosis of exclusion. If it’s something that a doctor hasn’t looked at, it’s something that I usually ask. One of the things that are strange, rare, peculiar, or that patients will come and being overlooked is patients with dementia or Alzheimer’s.  To this date, I’ve had a handful of patients who have triple negative breast cancer, and hands down, every single person has had a tremendous mold exposure. So there’s certain cancers that I believe-

Dr. Weitz:            Wow.

Dr. Tran:              Wait. We don’t know if it’s the culprit, but it’s definitely an association that we see. It’s definitely something that’s, for me, just my bias is strongly correlated that I see in my practice. We take an environmental perspective, environmental history, and part of the history, somebody who has many chronic illnesses, I would say three or four conditions, like hypothyroidism, Lyme infection or other allergies. Most of them will struggle with a mold intolerance, and that could be mold allergy or a mycotoxin issue.  The mycotoxin issue, we get mycotoxins from our food, right? So we’re all exposed to mycotoxins to some degree. Our body naturally will eliminate mycotoxins on its own. But as you know, people who struggle with metal issues, their ability to eliminate may be slowed based on their genetics. So they may have a compromised ability to eliminate. Even though, naturally, we all have the ability to eliminate it, some people eliminate slower than others, and because it’s slower there’s a buildup that occurs, and we develop this toxic burden, and it’s not just with mold, it’s with other things like metals in the environment, glyphosate, like different herbicides. You know, pesticides we’re exposed to also.  So it’s the totality of everything that we have to look at. But definitely, the mold mycotoxin issue is huge, and it’s hard to really know if it’s how big a factor it is.  I’m always asking a patient about whether they have water damage in their home, and most patients who are mold-sensitive will know because through their history, with their itchy eyes, runny nose. When they walk into a damp room, they’ll know. Others may not. So it’s a good history, is what I’d say.

Dr. Weitz:            So what percentage of patients that have symptoms of mold toxicity or that do have mold toxicity know that their home or office has mold that they’re getting exposed to?

Dr. Tran:              Surprisingly, I believe, and maybe my patients are more educated. They will say to me, “I think my home … ” Maybe I’m mold-sensitive because I’ve read about it online. But for most patients, I don’t think … They don’t suspect because it’s never anything that they’re clued into.

Dr. Weitz:            Right.

Dr. Tran:              So I actually believe it may be more diagnosed than we ever realized it to be because it’s something, but it’s not really talked about or taught in conventional medicine. Most conventional practitioners will send a patient to an allergist. The allergist will do a skin scratch test. It may not even show up because the mold, allergy is not IgE-mediated–it may be a delayed response. So we may-

Dr. Weitz:            An IgE or IgM reaction.

Dr. Tran:              Yeah, so there are patients who are immune-compromised that are more susceptible to getting certain mold infections, especially in their lungs. When patients are immune compromised, that’s recognizing how much medicine. But for people who have a low-level toxin exposure with mold accumulation, it may be overlooked.

Dr. Weitz:            You mentioned triple negative breast cancer, and we’ve had a few patients with that over the years, and that’s really a grim prognosis, very hard cancer to treat. Do you find that treating the mold increases their prognosis?

Dr. Tran:               It’s hard to say. But in my experience caring for these patients, with triple negative, their prognosis is better, and I think it’s because we’re doing everything else, right? We’re changing their diet. We’re helping them change … decrease stress. I think it’s everything together. But I say that with the triple negative breast cancer because there isn’t anything … The prognosis is terrible. Some patients go around different chemotherapy agents, which usually have no evidence, which blows my mind because it’s supposed to be a research … science-based.

Dr. Tran:               But I know they’re doing their best. They’re trying to find the best regiment for patients.  I find a lot of my patients with the triple negative breast cancer and comparing to people who decide to go conventional versus integrating Functional Medicine, alternative medicine aspect, they do better because of everything they’re doing, the diet, lifestyle, supplements and hormonal balance. Even though estrogen/progesterone isn’t playing a role, there’s cortisol, the adrenal glands, right? So that plays a role too. We have to address that.

Dr. Weitz:            Yeah, and I’m not convinced. Even though they’re estrogen-receptor negative that estrogen metabolism still isn’t important in these women.

Dr. Tran:              Oh, and it’s gut, right? Gut function?

Dr. Weitz:            Right, yep.

Dr. Tran:              Gut function’s essential, right?

Dr. Weitz:            Right.

Dr. Tran:             Our microbiome is very important. How our gut … You know, B vitamins are important. If the patient has dysbiosis, they’re most likely to have an altered level of beads. I mean, we know that there’s so many different co-factors in our body that we need for metabolism, essential detoxification. I really believe for triple negative and certain types of cancer, it’s the depletion of essential nutrients that leads to altered or uncontrolled growth of cells, right?  So that’s why when we see patients with certain cancers, we’re always looking at nutrient levels. How can we support them from that?  And food is medicine.  We start there first and look at how will they absorb.  We can see that we go through higher levels of intervention.  We may need like IV nutrient therapy.

Dr. Weitz:             Right. Do you find any tests useful for screening patients for mold toxicity? Such as, say, some of the urine tests?

Dr. Tran:              They can be useful, yes. So the caveat for that is that when you do these urine tests, it doesn’t tell you what your burden is. It tells you your level of exposure, and it tells you you’re able to excrete. Similar to toxic metals, so we … There are some people who are non-excreters. They don’t excrete well. What I do find in the patients who are poor excreters, they’re not going to have a high level of mycotoxins in their urine. It’s going to actually show a low level. It’s counterintuitive, but then what I learned, and I learned this through Dr. Tim Guilford that glutathione binds to mycotoxins.

So what I’ve done in patients where I know they’re living in a water-damaged home. I know they’re … They have every classic symptom that the urine test shows that it’s negative. I do a glutathione challenge. So the day before, I will either dose with liposomal glutathione throughout the day, with 500 milligrams three times a day. Or I’ll do an IV bolus of glutathione drip or push and then collect the next morning first urine void. Then you’ll see it.

Dr. Weitz:             Cool.

Dr. Tran:              I do have a case. I can show you with the lab results at the presentation. So whole family has exposure living in the moldy home, and there’s one … The mom has very high levels of leukotoxin, and of fragilis in the home, from air samples in the home. Her urine test shows that she’s exposed. Her friend who has developmental delays and issues, his levels showed very little, like nothing. Nothing excreted out. The interesting thing is that the son saw my colleague in the office, Dr. Ingle. I recommended the tests. He saw the results. He’s like, “Oh, okay. No exposure.”

Dr. Tran:              But when you look at … because they’re exposed. The kid has to have some excretion.  But what it tells me is that this kid is a poor excreter.  He’s probably very, very burdened but he’s not excreting well.

Dr. Weitz:            Did you do the glutathione and retest with him?

Dr. Tran:              Yeah, and so you will see when you do the glutathione and then you retest. You see a greater level of excretion, maybe not a ton. I have a handful of cases where that’s the case, where toxic mold exposure. Their practitioners will do … I see them. They will see other practitioners around town. They have a test. It’s negative, and I’m like, “Let’s try this. Let’s try a glutathione challenge test,” and then lo and behold you see a greater expression of mycotoxins, and I believe it’s because it’s stuck, stored or what not in the body, and not excreted well. We see that with metals. So it’s my experience in metal toxicology with the chelaters. I drew from that to apply in this situation.

Dr. Weitz:            Meaning when somebody comes in, you suspect might have heavy metal toxicity. Instead of just measuring their urine, you give them a oral chelater, and then you measure their urine the next day with the idea that the chelater is pulling the metals out that then will get excreted?

Dr. Tran:               Exactly. That’s the exact concept because we don’t really … When we’re doing a first morning urine challenge test either for mold or heavy metals, just first … No chelater. First morning void just shows us what the patient is exposed to and how well they’re able to eliminate. It doesn’t tell us what’s bound … For metals, we know this from metals really well, is that certain metals will bind very strong to proteins and make certain enzymes non-functional. It’s the affinity of these metals that bind it so strongly when you have a chelating agent on board, it pulls it off and then freeze it up, and then you excrete it out through the urine.

Dr. Tran:               So, same concept. I don’t know if you’re … Are you familiar with the autism study When they looked at the baby’s first haircuts and looking at mercury?

Dr. Weitz:            No.

Dr. Tran:               There’s a study looking … because we had believed that mercury was implicated in developing autism. So there’s a study that looked at babies’ first haircuts, and we expected to see a higher level of mercury excretion in kids on the spectrum. But the opposite was what the studies showed. It was in fact the neurotypical kids. The control’s had high levels of mercury versus the autistic kids, and that study demonstrates and illustrates the fact that the autistic kids are poor excreters since their genetics doesn’t allow them to excrete. That’s the takeaway from that study.

Dr. Weitz:            I see.

Dr. Tran:               We have a study similar, which I’ll talk about. Same thing with children on the spectrum do not excrete ochratoxin very well either. So you’ll see the control group will excrete really well, but the children on the autistic spectrum will not excrete ochratoxin very well. The study doesn’t take the leap to do a glutathione challenge test or anything. They hopefully one day will get there. But the research does show that there are people who just do not excrete very well.

Dr. Weitz:            Cool. So what’s the best way to test your home for a mold or mycotoxins?

Dr. Tran:               There’s different ways to test. So you can do a spore trap analysis. You have somebody come to the home, measure the spores in the home. You could do … The inexpensive way to do it is … I tell some of my patients. You can get a petri dish. You go to Home Depot or buy on Amazon online a petri dish mold, you know, test. Just put it in the home, and if you just leave it in there, in the home for a couple days, then you send it back and you get a report. It’s not very expensive.

Dr. Tran:               I usually recommend patients to get it evaluated by a mold expert or somebody who comes in the home. They can do the moisture test testing, looking at indoor mold samples and outdoor mold quality. There’s some people who will talk about the ERMI and the HERTSMI. So we’ll go over that at the presentation, the pros and cons. But in a nutshell, the ERMI is a more extensive evaluation. The HERTSMI is looking at the five molds, mycotoxins, like producing molds that Shoemaker believes are most … has the most adverse effects on our health. So those are the differences in a nutshell.

Dr. Weitz:            Okay, so let’s get into treating. So how do you treat a patient that we believe strongly or is confirmed from testing are sick from mold or mycotoxin exposure?

Dr. Tran:               For treating a patient, you also have to not only look at the molds. You look at the whole entire person. You have to look at the food allergies and there are other environmental allergies to get the best resolution. There’s some people who will just treat in isolation, like feel like we will do a disservice if you just do that. But there’s some people who just want just the mold component. If you look at just the mold component, what the evidence shows is that liposomal glutathione, IV glutathione does bind into the mycotoxins.  If we’re talking about mycotoxins alone, you know, glutathione, in conjunction with phosphatidylcholine, because it helps improve the lipid membrane, is essential because we know it impairs cellular … a lipid bilayer. So phosphatidylcholine is another oral or IV. It’s something that can be used. Looking at the gut microbiome is really important.

Dr. Weitz:            So it’s interesting. You talk about liposomal glutathione is something that binds to the mold. I’ve been hear people talking about liposomal glutathione or the forms of glutathione as a way to push the mold out and then using clay and charcoal and pectins and things like that to bind it.

Dr. Tran:              Yes.

Dr. Weitz:            One of the experts calls it the push-catch strategy.

Dr. Tran:              In my experience, if we had to pick one, glutathione’s my favorite.

Dr. Weitz:            Okay.

Dr. Tran:              The binders, yes. Some people like to use cholestyramine. I find that it’s really harsh. So there are other binders that are good like psyllium, bentonite clay, that’s good. It’s hard to find a good source of it too. It’s fairly inexpensive. Some people will take activated charcoal at nights.

Dr. Weitz:            Right.

Dr. Tran:              I think it’s essential for us to know how to schedule it so patients don’t deplete their nutrients more than they are depleting their nutrients.

Dr. Weitz:            Right, because those binders if they’re consumed at the same time with foods that have a lot of nutrients or nutritional supplements, they’ll bind with those two and take them out.

Dr. Tran:              Yes, yeah, absolutely. We’ll do a lot of gut work too when patients are exposed to mold. Some patients are like, “Why do I have to look … Why are you making me do a stool test?” I’m like, “It’s part of the evaluation,” because it’s not just … because mold has a relationship with patients with candida too.  Some people who have an overgrowth of candida will just experience symptoms of mold, allergy, and toxicity to a greater degree.  So we want to make sure we evaluate it, and we treat it appropriately.  That’s why I like the sensitivity testing, our functional comprehensive stool analysis, because we can actually treat with the correct nutraceutical.

Dr. Weitz:            Cool. Of all those binders, I’ve seen clay, charcoal, cholestyramine, chlorella, zeolite, modified citrus pectin, beta-sitosterol, glucomannan, diatomaceous earth. Can you sort those out? Or what are your two favorites? Or do you like to use some in certain cases?

Dr. Tran:              I would say my favorite would probably be the bentonite clay and activated charcoal.

Dr. Weitz:            Okay.

Dr. Tran:              And there are super soluble fiber products that I like to use too. I think fiber’s important because it also helps, and it really depends on the patient’s budget too. So, activated charcoal is relatively really expensive, and it is something that’s put on board for just to help. If they can do with different fibers, and we rotate the fibers, that’s something that I like. Some people can’t tolerate one fiber over the others. That’s why you have to understand what theIr intolerances are too.

Dr. Weitz:            Okay, interesting. Hey, have you noticed that we seem to be in this charcoal phase of consumer products? I mean, in fact, in my household, my wife had brought home a toothpaste with charcoal, a facial mask with charcoal. Occasionally, we have a treat of ice cream made from coconut, and they have a flavor that is charcoal ice cream.

Dr. Tran:             I think that’s a new trend and fad.

Dr. Weitz:           I mean, it’s … Everywhere is charcoal.

Dr. Tran:             I was with a friend this weekend, and I ordered a lemonade charcoal, and she was like, “What is this?” I’m like, “It’s lemonade charcoal. It’s a trendsetter.” We went and had an amazing bowl in Los Angeles, and it had charcoal, and she was like, “I can’t … Why is there charcoal in everything?” I’m like, “Just wait. In a couple of months, six months from now, it’s going to … support everyone there. But it’s trending here in LA. Yeah, it’s every … lemonade, yeah.

Dr. Weitz:           Yeah, I guess we haven’t had a new fruit that only grows in the Amazon that’s the new super antioxidants. So we got charcoal now.

Dr. Tran:             I could tell you about other exotic fruits that hasn’t been well talked about.

Dr. Weitz:           Oh okay. Maybe we could start a trend right here on the Rational Wellness Podcast.

Dr. Tran:             I’ll bring that to you next time, other botanicals and nutrients that aren’t trending yet that that we can tell about, yeah.

Dr. Weitz:           Okay. We’ll be the trendsetters. So when you’re treating a patient for mold or mycotoxin toxicity, do you have them avoid foods that may contain mold or … And do you have them avoid eating mushrooms, by the way, which is another trend is foods that have dried mushrooms in them, like reishi and chaga and whatever the latest trendy medicinal mushroom is-

Dr. Tran:             Cordycep.

Dr. Weitz:           … that’s put in coffee and tea and everything else?

Dr. Tran:             Yeah, so, it really depends on the patient’s tolerance, and that’s of the other thing is making sure we understand the patient’s food intolerances. In general, most providers who are treating patients with molds, they avoid all of it. Even avoid the mushrooms. Avoid cheese, everything. I find that some patients will be able to tolerate taking cordyceps or reishi for adrenal support when they’re mold sensitive, but there are other patients who cannot tolerate it. So it’s patient specific. You really have to identify their needs, yeah.

So as a blanket statement, I think, in general, sure, you can avoid. But I think mushrooms have such beneficial uses, and I also there are good uses of mold. Not all molds are bad.

Dr. Weitz:           But we could very easily say since these are common foods that have mushrooms, and they’re also very common allergen, say, avoid wheat, corn, cheese. There’s a few other common foods that also are probably irritating to the gut. You could easily take those out as part of your program and improve their overall health. Take out alcoholic beverages.

Dr. Tran:             Yes, yeah, you can.

Dr. Weitz:           Should we be using an air filter?

Dr. Tran:             Well, in Orange County, LA area, I think we should … air filter.

Dr. Weitz:           What’s the best kind of air filter to get?

Dr. Tran:             It depends on what you’re trying to eliminate. So what I tell patients-

Dr. Weitz:           Mycotoxins.

Dr. Tran:             So if you’re looking to get rid of mycotoxins and mold spores, you want to look for an air filter that has a MERV 8 rating at least. Each filter will have a different rating. I’ll show that to you in the presentation. There’s different types of air filters and qualities, and the issues of the air filter is … You can have charcoal, carbon filter, air filter, or you can have one with ozone. Then people will say that certain air filters will emit too much EMF. So you have to look at the EMF excretion. You know, the emission of EMF.

Dr. Weitz:           Yeah, I just did a podcast with Oram Miller, and he’s the EMF guy. He spoke in our last Functional Medicine meeting as well.

Dr. Tran:             One of my favorites air filter, which is the IQAir Air … You know, he and other people will say, “It emits too much EMF for certain patients.” So I like the IQAir, Blueair or the Austin Air are the three top air filters that … It was just passed down from me … I’m just regurgitating that information … and in our industry is what we recommend to patients. There are other ones like-

Dr. Weitz:           So what are those three again real quick?

Dr. Tran:             The IQAir.

Dr. Weitz:           IQAir.

Dr. Tran:            IQAir is big and bulky, but it’s beautiful. It’s quite expensive. The Blueair is nice and sleek.

Dr. Weitz:          So we can turn our home into a blue zone with the Blueair filter.

Dr. Tran:            Yeah. The Molekule, which is newer. I have one in my office. It’s-

Dr. Weitz:          Could you repeat that last one because you broke up a little bit.

Dr. Tran:            Oh, I apologize. My internet. I am hardwired, though. Is the Molekule. The Molekule is the last one that a lot of you were … or a lot of people have been talking about. I actually have three in my office. I love it.

Dr. Weitz:            Oh, wow.

Dr. Tran:               I have every single one in my office. I have the Blueair, Austin Air, just so that I can show patients the different types of air filters they can pick for their home. I think honestly, like anything at Costco is good too. If they want to go Target, most products at Target are sufficient too.

Dr. Weitz:             Yeah, but don’t buy your fish oil at Costco.

Dr. Tran:               I know. I don’t get that. But yeah, it’s interesting. But yeah, but quality of Costco fish oil is just …

Dr. Weitz:             Oh my God.

Dr. Tran:               We’ll talk about … I don’t know. Do you talk about that on your podcast because I don’t think the consumer, the public knows about the quality of their own fish oils.

Dr. Weitz:             I haven’t done a podcast just on that, but it’s definitely something I’m passionate about, but I definitely should.

Dr. Tran:               I have lab results for patients who take my supplement, and then they want to go to Costco to get it for less expensive, and their numbers change, and I’m like, “Well … ” I just don’t pay attention because my staff deals with the dispensary side. I mean, dispensing supplements, and I’m like, “Well, what supplement are you taking?” They show me this Costco bottle. I’m like I cringe.

Dr. Weitz:             Oh, I know, and it’s the size of a garbage can, and it costs $20, and you go, “What do you think?” You think you’re going to get caught?

Dr. Tran:              They’re like titanium dioxide. I mean, which is more than a lot of supplements and more patients can be safe. But there’s a lot of coloring and fillers, and I haven’t even … Yeah, you read the label, and you’re like, “Wow.”

Dr. Weitz:            I know.

Dr. Tran:              But it is something, and if it’s what they can afford, something is better than … But I don’t know. It depends on the situation.

Dr. Weitz:            Okay, Jessica. So thank you for providing us with some very interesting, useful information about mold. How can listeners and viewers get ahold of you? How can they contact you?

Dr. Tran:              At my office or through Gmail?

Dr. Weitz:            Yeah, yeah. Well, I mean, what’s your website? And you can give out your office phone number, and you do consultations in person, and do you also do them remotely?

Dr. Tran:              I do for certain situations, yes. So my website is wellnessintegrative.com. My office number is 949-551-8751, and I’m on drjessicatran.com. Instagram is Dr. Jessica Tran. I also have a Facebook page, I guess. People message me through that, my Facebook.

Dr. Weitz:            Okay, good.

Dr. Tran:              That’s Dr. Jessica Tran-Naturopathic Doctor.

 

,

Reversing Diabetes with Dr. Mona Morstein: Rational Wellness Podcast 78

Dr. Mona Morstein discusses how to overcome Diabetes with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

2:57  There are four or five main types of Diabetes:

  1. Type I is an autoimmune disease where a person’s own immune system attacks their pancreatic beta cells, and destroys it enough so that they cannot produce the insulin that the person needs to live. 
  2. Type II is the most common type and it is due to insulin resistance.
  3. Type 1.5 is Latent Autoimmune Diabetes of the Adult (LADA), which is type I that happens in people over 35, say generally 35 to 60 is where we see people getting a less intense type of type I, but can lead to the need for insulin.
  4. Gestational Diabetes, which is when a nondiabetic woman enters pregnancy, and then becomes a type II diabetic, generally due to gaining too much weight during the pregnancy
  5. MODY, mature onset diabetes of youth, which is diabetes because of gene defects, like when the beta cell produces insulin, but lacks a good gene to secrete it, or a cell doesn’t genetically have a good receptor.

5:34  Type II diabetics if poorly controlled or poorly managed, the high blood sugars cause oxidative damage that can destroy their pancreatic beta cells and these patients end up needing insulin, like type I diabetics.  And most diabetics are not properly controlled. 75% of type II diabetics do not get their HgA1c below 7 as recommended by the American Diabetic Association. And type I diabetics, if they end up injecting too much insulin in order to try to control their blood sugar–say 100 to 200 units a day–can develop insulin resistance like type II diabetics. Normally our bodies secrete between 30 and 40 units of insulin per day, so 100 units is a lot. The reason so many diabetics are poorly controlled is that we are only using a big pharma approach based around medications.  We need to use diet, exercise and lifestyle approaches to control blood sugar.  And most of the drugs do not directly affect insulin resistance, except for Metformin, which deals a little with insulin resistance. But Metformin’s main job is to decrease the liver’s production of glucose. The TZDs like Actos and Avandia were directly affecting insulin resistance, but they are not in broad usage because of all their side effects. The 2nd most common category of drugs for diabetes are the sulfonylureas, like Glyburide and Glipizide, which can cause weight gain, hypoglycemia, and they can aggravate insulin resistance. They also don’t significantly reduce the HgA1c. The DPP4s like Januvia lower the HgA1c at the highest dose say 0.5%, but a low carb diet can take someone who’s at 10 and lower them down to 6 in 3 months. There is no drug that can do what diet, exercise and lifestyle changes can do, what a Functional Medicine approach can do.

13:30  With type I Diabetes you have a gene that can turn on and give you type I Diabetes and then we have to look at what factors might turn this gene on.  These could include gluten, dairy, vaccine, environmental toxins, family stress and nutrient deficiencies.  Finland has the highest rate of type I Diabetes and they have done studies showing that giving newborns vitamin D and fish oils reduces the onset of type I.  Celiac disease can lead to type I diabetes.  Leaky gut seems to precede type I diabetes in many kids, so the gut is an important factor. 

26:16  When it comes to type II Diabetes, eating refined sugar, refined grains, junk food, and fast food and lack of exercise are important causative factors.  But Dr. Morstein also believes that saturated fat intake can play a role in worsening insulin resistance. If you are getting too much saturated fat without omega 3 fats to offset it, this will make diabetes worse. Here is a reference: Dietary fat, insulin sensitivity and the metabolic syndrome.

30:06  The lab testing that Dr. Morstein recommends for patients with diabetes include the following:  

  1. CBC
  2. Chem screen (liver, kidneys, etc.)
  3. Ferritin, which is the best early sign of fatty liver.
  4. Fasting glucose, HgA1c C-Peptide, which tells us how much insulin your pancreas can secrete, insulin (as long as they haven’t injected insulin)
  5. GlycoMark is a test that gives you a better idea of blood sugar control than HgA1c because it picks up blood glucose excursions better.
  6. HsCRP for inflammation
  7. Testosterone in guys.
  8. Red Blood Cell magnesium and zinc.
  9. Fibrinogen to see how clotty they are.
  10. Random Microalbuminurea through urine to pick up early, early liver damage

 

35:05  The best diet for Diabetes is the low carb diet and two of the most well known advocates for this are Dr. Richard Bernstein and Dr. Richard Feinman and here is a paper that they were among the authors of: Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base.   There is another approach that has evidence to show that it is also effective for diabetes, the Macrobiotic diet, which was demonstrated in the Ma-Pi2 study: The Macrobiotic Diet for Diabetes. Dr. Mornstein feels that for most patients, the low carb program will work better. She does think the low carb diet can include nuts and 30-40 grams per day of carbs, but no grains or legumes. She does not think you have to do keto, which is very, very low carb and harder to follow. Dr. Morstein thinks you can include some muffins or bread or pancakes made from almond flour. and she advocates including at least 5-10 grams of fiber powder to make up for the lack of fiber in a low carb diet.

40:34  Dr. Mornstein recommends not snacking between meals in contrast to some nutrition programs that advocate having a small meal or snack every 3 hours to maintain a stable blood sugar. The human organism easily has the capacity to not eat for 5 hours and that way you let your body rest from having to process foods. And this lets the liver and the digestive system rest.

46:00  Dr. Morstein recommends certain supplements for patients with diabetes, including a good multivitamin and mineral, like one that might require taking 6 capsules per day.  Taking a one a day multi may be a waste if the nutrients are not found in therapeutic dosages.  Dr. Morstein mentioned that she is big fan of fish oil and she is not a big fan of krill oil because each capsule contains fairly small levels of EPA and DHA, the active ingredients, such as a total of only 50 mg of EPA and DHA combined in a capsule. To get a therapeutic dosage of say 2000 mg of EPA and DHA would require taking 40 capsules per day. It’s a joke!  Dr. Morstein designed a proprietary formula made by Priority One called Diamend that includes therapeutic levels of nutrients that can benefit diabetics, including Zinc, Chromium, Berberine, R-Apha Lipoic Acid, Gymnema extract, Benfotiamine, Bilberry, NAC, Green Tea Extract, Turmeric, and Vanadium (4 capsules taken after breakfast and 3 capsules taken after dinner). With respect to Lipoic acid, if you take R Lipoic acid you get twice the amount of the active ingredient than if you take just Lipoic acid, which is a combination of the R and the S isomers, but the S form is not active in the body. An elevated HgA1c is causing oxidative damage to the body, so taking the proper anti-oxidants can prevent some of this damage, such as R Lipoic acid and NAC that can provide antioxidant protection, reduce insulin resistance, and also support the liver.  Berberine is a great herb that is comparable to Metformin and also supports the liver. Benfotiamine is the fat soluble form of thiamine (B1) which can prevent damage to the nerves, the kidneys, and the eyes, at a dosage of 450 mg per day. The Burmannii or Indonesian type of cinnamon is a helpful supplement that if taken in capsules at bedtime can help to lower their morning glucose at a dosage of 1000 mg per day. Fat cells in the stomach region can make tumor necrosis factor alpha that causes insulin resistance and curcumin can help to decrease the inflammation and help with insulin resistance. Curcumin can also help rpotect the brain and reduce the risk of developing Alzheimer’s.  Gymnema sylvestre is Dr. Morstein’s favorite botanical and it has been shown to help the pancreas produce insulin again, and it also reduces cravings for sugar. If you are going to a holiday party, bring some gymnema sylvestre and swish some around in your mouth and it will reduce your craving for sweets.

 

 



Dr. Mona Morstein is a board-certified Naturopathic Doctor who is practicing Functional Medicine at the Arizona Integrative Medical Solutions with a focus on treating patients with obesity, diabetes, thyroid, hormonal imbalances, and gastrointestinal disorders like SIBO and IBS. She is the author of the best-selling book, Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type I and Type II Diabetes. She is the founder and executive director of the Low Carb Diabetes Association. Her website is Arizona Integrative Medical Solutions and Dr. Morstein is available for telemedicine.

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 Transcripts

Dr. Weitz:                            This is Doctor 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 doctorweitz.com. Let’s get started on your road to better health.

Hello Rational Wellness podcasters thank you so much for joining me again today, Doctor Ben Weitz, here, and for those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and review, so more people can find our Rational Wellness Podcast. Our topic for today is diabetes and prediabetes, which are epidemic and increasing in the United States and around the world. 9.4% of adults in the US are diabetic, and in some states as many as 15%. This equates to about 30 million Americans with diabetes, and somewhere around 90 million with prediabetes, and these rates are climbing among children and teens.

One out of three Americans have diabetes or prediabetes, and 90% to 95% of these are type two diabetes, which are caused by diet and lifestyle. Rates are even higher among certain populations among American Indians, blacks, Hispanics, and Asians, and among whites. This paralleled by an increasing shocking rates of obesity and being overweight with about 70% of the US population being overweight or obese. Of course, these numbers are pretty much paralleled by the rest of the world especially as we spread our American lifestyle around the globe.

I’m happy to have Dr. Mona Morstein to join us today to give us some information. She’s a naturopathic doctor from Tempe, Arizona, who’s practicing functional medicine at Arizona Integrated Medical Solutions with a focus on treating patients with obesity, diabetes, hormonal imbalances, and gastrointestinal disorders like SIBO and IBS. She’s the author of the bestselling book, Master Your Diabetes: A Comprehensive Integrative Approach for Both Type I and Type II Diabetes. She’s also the founder and executive director of the Low Carb Diabetes Association. Mona, thank you so much for joining us today.

Dr. Morstein:                    Thanks very much. Ben, I really appreciate it.

Dr. Weitz:                         I’d like to begin the discussion by talking about the different types of diabetes, and the distinctions between these.

Dr. Morstein:                    Yeah. There’s kind of four or five main types, there is type II diabetes, which is the most common type is due to insulin resistance where usually early on at least for sure people can make insulin but their cells are no longer responding to the signals to take glucose in, and like you said there are a number of reasons the cells don’t respond. Obesity being one of them, but there are other factors involved, as well. Type I diabetes is an autoimmune disease where a person’s own immune system attacks their pancreatic beta cells, and destroys it enough so that they cannot produce the insulin that the person needs to live.  There’s gestational diabetes, which a nondiabetic woman enters pregnancy, and then becomes a type II diabetic, generally due to gaining too much weight during the pregnancy. There’s MODY, a mature onset diabetes of youth, which is diabetes because of gene defects, like the beta cell produces insulin, but lacks a good gene to secrete it, or a cell doesn’t genetically have a good receptor. Then the last is type 1.5, Latent Autoimmune Diabetes of the Adult (LADA), which is type I that happens in people over 35, say generally 35 to 60 is where we see people getting a less intense type of type one, but they can still for sure lead to full need of insulin.

Dr. Weitz:                         Yeah. Type 1.5, right? I never heard of that, before.

Dr. Morstein:                    Yeah. Type 1.5. Yeah.

Dr. Weitz:                         Interesting. I think there’s some confusion among the general public, I’ve heard people discuss diabetes and say that type twos become type one-

Dr. Morstein:                    Yeah. Right. Yeah. We have a couple things. One, we have a lot of patients who are adults getting type two, very commonly misdiagnosed as type two, and there’s a very simple blood test that can be done. We do have some lean type two patients. You will see lean, so we have to make sure is it really type two, or do they have LADA. Now, the type two becoming type one, so if you are under poor care and/or are not making changes you need to reverse your type II, if you have bad control of your type II, the damage that these high blood sugars can cause over the years can affect the pancreas as well as eyes, kidneys, nerves, and heart, you know the blood vessels, and so people can kind of destroy their pancreatic beta cells and this oxidative damage from poorly controlled diabetes, and then as a type II need to be on insulin, like a type I.

Dr. Weitz:                         Right. Then type Is can also have concurrent type II, if they’re poorly controlled?

Dr. Morstein:                    Yes. I’ve seen type I’s coming into my office that are injecting a 100 or 200 units a day, so for a nondiabetic, say for not a lean, but a normal weight nondiabetic, so we make maybe around 30 to 40 units of insulin a day, for whatever we eat, or drink, or whatever. If you have someone walking in the door, and they’re injecting a 100 units a day to control their blood sugar, that’s going to cause insulin resistance.  That’s way above the physiological norm of what the body is designed to have in it all the time, so you can get type Is that have insulin resistance. Now, a type I is going to develop insulin resistance when their blood sugars go over about 170 anyway, just high blood sugar can make them insulin resistant, so that is a part of it, but it’s not the core nature of their condition, which is the autoimmunity.

Dr. Weitz:                         Right. It’s amazing, though, the patients that I’ve seen how many are poorly controlled, the kids they really don’t want to prick their finger, they don’t want to test their blood sugar, it’s a pain, and the type II a lot of them are in denial, or just think everything’s okay, and they don’t want to test regularly, so I don’t know what the percentages are, but it seems like a lot are uncontrolled, or poorly controlled.

Dr. Morstein:                    I know the last statistics we really have in that regard, you know, from 2002 to 2006 where almost 75% or so of people couldn’t get below seven-

Dr. Weitz:                         Wow.

Dr. Morstein:                    Which is the ADA guide. 

Dr. Weitz:                         On the hemoglobin A1C. Yeah.

Dr. Morstein:                    There’s a significant generally 50 to 60, to sometimes 70 depending upon the study do not obtain at least what they consider the three ADA goals, which is an A1C less than seven. LDL’s less than a 100, and blood pressure less than 130 over 70, so we have very bad goal reaching in our country, and a lot of it is of course due to the obvious, that it’s a big pharma based treatment, that it’s drugs, and those with type II there’s only one drug really that was designed to deal with insulin resistance, and that was the TZD’s, which because of a lot of problems with them have essentially gone off the market. I mean, you can use them, but-

Dr. Weitz:                         What drugs would those?

Dr. Morstein:                    Those were the Actos and Avandia type drugs.

Dr. Weitz:                         Okay.

Dr. Morstein:                    Right? Now, Metformin deals a little bit with insulin resistance, but it’s not it’s main job, which is to decrease livers production of glucose, so you have a disease of insulin resistance, and essentially no medications out of the huge list of medications that they give patients that actually deals with insulin resistance, they’re all just about clear the glucose out of the bloodstream, and the way they do that can actually cause quite a number of problems in patients.

Dr. Weitz:                         Why is that? I guess they’ve just been unable to develop a drug that controls insulin resistance.

Dr. Morstein:                    Yes, or that controls insulin resistance, but again you’ve got it also might cause this or that damage. Right?

Dr. Weitz:                         Right.

Dr. Morstein:                    Drugs have side effects, many of them, we’re lucky with Metformin that it’s just some gastrointestinal distress, and doesn’t really cause anything else.  But some of these other drugs, the second most common one, the sulfonylurea’s, they cause weight gain, they can aggravate insulin resistance. They can cause hypoglycemia, significantly. They’re all just designed to clear the glucose-

Dr. Weitz:                         By the way, what drugs are included in the sulfonylurea?

Dr. Morstein:                    Sulfonyurea’s are like glyburide, which is the worst for causing hypoglycemia. Glyburide, Glipizide, so those kind of drugs, but they’re cheap. They’re going to be by conventional care, another drug to use, but they have problems. Right? Also, many of them don’t really significantly reduce the A1C’s very much, like the drugs like Januvia, the DPP fours, they may lower the blood, the A1C in three months at the highest dose of maybe 0.5% where a low carb diet could take someone who’s at 10 and lower them down to six in three months. The diet, and the lifestyle there’s no drug that equals the amount of improvement that just what we’re trying to do on this naturopathic, or functional level can do. Right?

Dr. Weitz:                         Right. But that word doesn’t seem to have gotten out.

Dr. Morstein:                    Yeah. Well, you know the ADA acknowledges there is a low carb diet, it’s not like they’re saying, everybody should be on it, and then now they’re approving bariatric surgery for people who can’t get their A1C’s under control, but they can’t just come out and say, hey, everybody, you guys, everybody, really just do the low carb diet.

Dr. Weitz:                         Right. Yeah. They’re still recommending whole grains, and a low fat diet.

Dr. Morstein:                    Well, you know, I went to the ADA site, and you know I will say there’s a lot of good things about the American Diabetes Association.  For one thing, they devote a lot of money to research, and they have also, if you’re a fireman, and you’re a diabetic, or you’re in school, and you’re a diabetic patient they’ve paved the way for the rights, the civil rights, and the working rights that people with diabetes in our country.  However, to become a sponsor in the ADA you have to drop at least a $100,000.00, that’s the lowest level.

Dr. Weitz:                         Wow.

Dr. Morstein:                    You know, who aside from drug companies can be supportive of the ADA?  That’s their funding.

Dr. Weitz:                         Yeah. Let’s talk a little bit about type I diabetes.

Dr. Morstein:                    Yeah.

Dr. Weitz:                         What are some of the most common triggers?  A lot of people have talked about milk products–dairy sensitivity–as being one of the triggers. Can you talk about that?

Dr. Morstein:                    Well, here’s the deal, obviously the number one cause of type I diabetes is you have a gene that can turn on and give you type I diabetes.

Dr. Weitz:                         Right.

Dr. Morstein:                    It starts from you just randomly got this gene. Then what might be factors turning on the gene?  Well, you know I go through things with every patient, and there’re questions on vaccinations on gluten, on dairy, on environmental chemicals, on stress in the families, on nutrient deficiencies. The Fins, Finland, had the highest per capita onset of type I diabetes, and they’ve done studies where giving new born vitamin D and fish oils reduced the onset of type I in those populations compared to the kids that didn’t get those supplements.  What is it individually that affects each child, who knows? We have a lot of kids drinking milk, and they’re not getting type I, so we can’t say, oh, my goodness. I will say this, I read a good article, a study saying that with, you know, for me, as I note in my book, if we could identify kids with celiac disease early on, right away, and we got them off of gluten their risk of developing type I would go down about to zero.

Dr. Weitz:                         Wow.

Dr. Morstein:                    We’ve got all these pediatricians giving them antibiotics of their ears, or vaccinations whatever, but we need to get them to screen every child who’s now eating gluten, because you have to be eating gluten, so toddlers, a two year old, right, test them for celiac disease before potentially it’s unknown and then we get kids developing type I diabetes since those two are so connected, but-

Dr. Weitz:                         By the way, what’s the proper test for celiac?

Dr. Morstein:                    The proper test with celiac in a child is you can do a stool sample for toddlers. Right? There’s also a blood test, a pediatric blood test, but people, you know, you have to be eating gluten every day, like equivalent of about a piece of bread for at least three to four weeks before the test, otherwise we can’t see if there’s celiac disease. 

Dr. Weitz:                         Unless you do an intestinal biopsy.

Dr. Morstein:                    Well, they’re going to do that after the blood work.

Dr. Weitz:                         Right.

Dr. Morstein:                    Yeah. We’ve got a lot of kids, I see kids, they never had a vaccine, parents, they’re a very loving family, there was no stress, like a pet dying, or grandma, God forbid, they don’t spray environmental, they don’t have an exterminator come into their house, or outside, and you’re just like, why did this happen? We just don’t know. We can’t identify it on each individual.

Dr. Weitz:                         Right. I notice in your book you mention the A1 milk being more problematic than A2 milk?

Dr. Morstein:                    Yeah. I think most people understand, or not most people, but milk in America, that A1 milk is from cows that have a different amino acid basis to the protein molecule of milk, and that is more allergic in humans versus many other countries in the world use cows that make what’s called the A2 milk that has a different amino acid, it’s very less reactive. Our milk is why we certainly see many people have at least a cows milk sensitivity, which can be a lot of mucus, and sinus, and asthma, or it’s the number one food that causes GERD, reflux, even without mucus, it just goes right to the stomach. Those are from the allergy to the milk protein.

Lactose intolerance, you just can’t you just can’t digest the lactose, that would be A1 or A2, but in terms of allergic to milk, and there are some connections if you have that allergic to milk, there are some similar proteins on the pancreatic cells, so if the immune system is kind of attacking the milk, and it could get confused and maybe attack the similar proteins on the pancreas.

I do want to mention one thing, though, when we talk about food sensitivities, or just in general we’re talking about often times leaky gut, and what’s interesting with leaky gut is that when kids have diabetic antibodies, but are not yet showing the disease they pick up an upregulated Zonulin, they show leaky gut in these kids. Another reason people might get type I is a virus getting through the gut wall, and then attacking the pancreatic beta cells, and causing damage to them, so we look at the gut quite a lot, and if you’re getting into food sensitivities, we’re going to think your gut is unhealthy, as well, since it all comes from the gut, but leaky gut seems to precede type I diabetes in many kids.

Dr. Weitz:                         That’s interesting, because we heard about the research from Alessio Fasano, who talks about this triad of autoimmune disease where you have a leaky gut, and then you have gluten, and then you create this upregulated immune system and that sets up the potential for autoimmune disease.

Dr. Morstein:                    Yeah. Although, I will differ in one regard, I know there’s a very big anti-gluten, anti-dairy, but for those of us like myself who does a lot of food sensitivity testing, you know some people are sensitive to corn, and some to soy, and some to eggs, and some to almonds, and I think before we just pull everybody, and not everybody actually reacts to gluten. I really think that we should always strive to do very individual care with the food sensitivities and really see what does this patient, what does their body reacting to?

Dr. Weitz:                         One of the problems is these food sensitivity testing is so problematic.  Sometimes you do a test, you seem to get reasonable results, and then you do a test and nothing comes up except clams, and some other bizarre food, which they’ve never eaten, and now you spent all this money for this test, and nothing comes up, or-

Dr. Morstein:                    I would say there are-

Dr. Weitz:                         Or you do a test and everything comes up.

Dr. Morstein:                    Everything coming up, obviously, is a-

Dr. Weitz:                         Leaky gut.

Dr. Morstein:                    Sign of leaky gut, but I think there’s a lot of labs doing food sensitivity, but I know the lab I use, I’ve flown out there, I visited their lab. I can verify the one I use for the last 16 years, which is Alletess Labs at foodallergy.com, they must have got that right at the beginning. I mean, I can verify their consistency with truly finding what people seem to be reactive to, and if people have a lot of foods, you know, the idea with food sensitivities you take them all out the first month, start healing their gut with the supplements, and then they come back in a month, then they should be significantly better, and then you can start adding the foods back in. Nobody has to be off all of these foods for a year, or two, or whatever. It’s an indication of something needs to be healed, but guts heal from leaky gut enormously quickly when the irritant is removed, because they’re so vascularized.

Dr. Weitz:                          Yeah.

Dr. Morstein:                     Yeah.

Dr. Weitz:                          I just want to point out, I just had a discussion with Cyrex where I had one of these tests come back where there was nothing tested, and they said, from now on we can include a total IGG with the test at no additional cost, and that way you can tell if the person’s immune system just isn’t working well, and they’re total IGG is suppressed then they can factor that in, and recalculate the results, and-

Dr. Morstein:                     I guess there’s also cheaper tests than Cyrex.

Dr. Weitz:                          You mentioned vaccines as triggers.

Dr. Morstein:                     Yeah.

Dr. Weitz:                          As possible triggers for type I diabetes

Dr. Morstein:                     Possible.

Dr. Weitz:                          And I noticed in your book you mentioned giving the kids some supplements to help with their immune system like you mentioned vitamin D, and echinacea, and milk thistle.

Dr. Morstein:                     Yeah. When I was in medical school we had a pediatrician come in and say, “Hey, when I have to give vaccinations I’m boosting their immune system a couple days before, during, a couple days after.” Then obviously it made great sense to us, because we don’t usually get exposed to viruses by injection, we breathe them in, and then it takes days for the process to happen, so it’s a little bit of a shock to the immune system. I think giving NAC, you know, there are kids that maybe can’t make glutathione, that might get, as well, they might get some nerve damage.

I do a product called Immugen from a company called Progena, because it’s glycerine, kids love it, it’s a great immune system booster, and D, and maybe some Liposomal, now, I give glutathione, because kids can’t really take, obviously, an NAC capsule, and it’s nasty flavor wise, so by giving some ways to support antioxidant status, immune status, it can really, I hope, seem to boost things in the kids, so they don’t have a really serious reaction against not only just against the vaccination, but the liver as just part of the excipients, but I have a good website where the CDC lists all the excipients in all of the vaccinations, and so-

Dr. Weitz:                          Yeah.

Dr. Morstein:                     That’s what we’re trying to have the liver clear better-

Dr. Weitz:                          Right.

Dr. Morstein:                     It’s that junk that it comes with, you know the virus that they’re injecting.

Dr. Weitz:                          Yeah. The World Health Organization actually recommends giving 200,000 IU’s of vitamin A prior to the MMR vaccine.

Dr. Morstein:                     Yeah. They came out 25 years ago saying they’re very much into 2,000 units of vitamin A, also for treatments, if someone has measles they said, “Hey, give them a 100,000 vitamin A,” as this huge immune booster. I’ve used that in many conditions in toddlers that were pretty sick. Of course, I do it maybe for three days, or four days, but vitamin A is cheap and the World Health Organization can use it in rural villages, it’s easy. It’s a huge immune booster. I would just give a clinical pearl, don’t give it all at one time, if it overwhelms the kid, they can have a really nasty headache, so you want to break it up into several doses throughout the day, and that should stave off the headache that can last for a few hours with acute elevated vitamin A.

Dr. Weitz:                          Yeah. I never liked the idea of giving one huge bolus, the same thing with the 20,000, or 50,000 injectable vitamin D, it seems to make so much more sense to give 5,000 or 10,000 a day over the course of a week than give them a 50,000 unit shot.

Dr. Morstein:                     Yeah. Shots are a little rough, anyway.

Dr. Weitz:                          Yeah.

Dr. Morstein:                     With vitamin D, it’s oily. 

Dr. Weitz:                          Moving on to type II diabetes, and-

Dr. Morstein:                     Yeah.

Dr. Weitz:                          Mechanism for type two. Most of us are aware of the fact that eating sugar, and lack of exercise are some of the main factors, because we got this rising blood sugar, and insulin resistance, but I read in your book that you also said that increased saturated fat intake can play a role.

Dr. Morstein:                     Yeah. I mean, I know there’s a lot of ketogenic, and et cetera, Paleo people out there, but the science is pretty clear that if you are getting too many saturated fats and I believe it’s too many saturated fats unopposed by a good amount of omega three fats, so omega three fats lower insulin resistance. Saturated fat, if you’re getting too many they can absolutely worsen insulin resistance.  The idea is not that you can’t eat saturated fats, but that we have got to make sure people are getting into their diet a balance of omega three oils, for sure. If you get even with meat, if you get grass fed, grass finished organic meat, half of that is essential fatty acids, but if you’re getting it, you know, you’re just lazy, or you’re going out to eat a lot, that’s feed rot meat, that has no omega threes, after 90 days of being fed grains, that meat has no omega threes left in it, so this can be throwing people off with their oil balance.

Dr. Weitz:                            Interesting. Yeah. It’s true with the Paleo movement, and the ketogenic movement there’s a big push for saying that saturated fat is perfectly fine, and a lot of people are sort of like, can it really be fine? Should we really have as much butter as you can consume? Then of course, there’s the fat with sugar problem. You know? That I think Mark Hyman calls sweet fat, which is that’s really a bad combination is when they’re eating junk food, and they’re getting the saturated fat with the high glycemic carb, sugar combination.

Dr. Morstein:                     Yeah. I mean, it’s certainly refined sugar, refined grains, junk food, fast food, but if you just want to overeat anything, gluttony, unfortunately is whatever you’re overeating to gain that abdominal fat is going to be a problem, and of course the problem with insulin resistance is once it sets in insulin is one of the hormones that tells your brain I’m full, I’m done, that’s enough, you know, that’s it, I don’t need to eat more, and you can get that insulin resistance in the brain can tell people I’m still hungry, I still want food.

It’s not lack of willpower, it’s literally our appetite is driven by chemicals and hormones, and when they’re thrown off we’re just not going to get signals that I’m done, that’s enough, walk away from the table. Once people get on a low carb diet in a week, they’re like, “Oh, my God, it’s easy. I can just eat a piece of fish, and this, I’m full,” because that can settle down in their brains very quickly through food when we get that under control. Whatever you’re overeating to become overweight, or drinking, of course, soda pop, you know, energy drinks, these sugary, sugary things they’re just really some of the worst. Right?

Dr. Weitz:                          Yeah. Even Gatorade-

Dr. Morstein:                     Yeah.

Dr. Weitz:                          And some of the things people think are healthy. When it comes to lab testing, what labs do you like to run for patients with either prediabetes, or diabetes?

Dr. Morstein:                     Obviously, people need to have their yearly with the liver, and kidney, and glucose, and the lipids, and their CBC. I always include ferritin, which is not standard on labs, not just ferritin, has three different roles in the body. One is storage of iron. Two, we store it when there’s a bacterial infection, a serious bacterial infection, and three is acute phase inflammatory marker, and if we have a type two who’s got elevated ferritin while you do maybe have to rule out a condition called, hemochromatosis, which is a genetic hyper absorption of iron from your food, mostly these people have fatty liver, and so we need to do an ultrasound of their liver, and we can pick up fatty liver. That really drives insulin resistance, and fatty liver is the number one chronic disease of the liver in our country, today, and can cause the same kind of fibrosis and cirrhosis that alcoholism does.

Dr. Weitz:                          And truly caused by sugar and high glycemic carb intake. Right?

Dr. Morstein:                     It’s just caused by too much fat, really, whatever caused the fat. It’s the abdominal fat will then go and get to the liver, and cause the liver to have now too much fat in its cells. Of course, an A1C, a C-peptide, so you can draw insulin to see how much insulin they make as long as they’ve never injected insulin. As soon as someone’s injected insulin, that you can’t measure it anymore, it’s an inaccurate reading, because as soon as you inject insulin you’ll make insulin antibodies, so C-peptide is the part of the insulin molecule that breaks away from it for it to actually form insulin, so they’re equal.  There’s one C-peptide for one insulin, but we never make antibodies to C-peptide.  That tells us what is your pancreas able to produce in terms of insulin.  There’s another test called GlycoMark, which is a 1,5-AG substance that helps us look at excursions, and sometimes interpret the A1C better, because you can have an A1C at six, because you’re having lows all the time-

Dr. Weitz:                          By the way for those who don’t hemoglobin A1C is believed to be a three month indicator of blood glucose levels.

Dr. Morstein:                     Yes.

Dr. Weitz:                            Right?

Dr. Morstein:                     A1C is our monitor, how you’re doing longterm. It could the same number of A1C can be there if you’re under good control, or if you’re just going up and down all the time, so the GlycoMark can help us interpret that. I do vitamin D, we might need to check thyroid, we might need for guys, we might want to check their testosterone levels, there’s just maybe some red blood cell magnesium, red blood cell zinc, these can be low in people with diabetes. I would want to do an HsCRP, which is a monitor of inflammation that’s related to cardiac disease, and a fibrinogen to see how clotty they are, just because people with diabetes type II, well, if it’s not well controlled have a very high increased risk of dying of cardiovascular disease, which is basically what they usually die from. These are broad base labs that we’ll want to do.

Dr. Weitz:                          Cool. Do you include adiponectin and leptin in your labs?

Dr. Morstein:                     I don’t. I don’t do either of those.

Dr. Weitz:                          Okay.

Dr. Morstein:                     For one thing, leptin, you know there is a leptin resistance, or adiponectin, those are going to be fixed when fix their weight, so to measure them we don’t really have any specific ways, I feel, that’s really effective in that, and those will readjust once the insulin resistance is settled down.

Dr. Weitz:                          Cool.

Dr. Morstein:                     One other lab, the Random Microalbuminurea that’s a good urine test to pick up early, early liver damage, before it shows up in the lab work. No, I don’t measure those hormones.

Dr. Weitz:                          Okay. Cool. Let’s talk about treatment.

Dr. Morstein:                     Yeah.

Dr. Weitz:                          What type of diet is best for diabetics, and prediabetes?

Dr. Morstein:                     Doctor Richard Feynman and Doctor Bernstein, Richard Bernstein and 25 other physicians, or researchers came out with an article that was printed in Elsevier Journal on that a low carb diet is the premiere treatment for people with type two diabetes.  https://www.sciencedirect.com/science/article/pii/S0899900714003323 Actually, other researchers just came out showing that type one diabetes pediatric patients were improved on a low carb diet, plus a thousand other studies. Now, you’ve got two, you do have the MaPi2 study, which show that people on a macrobiotic diet, that was higher carbs, but no animal fat at all, no real oils at all, actually was very significant in uncontrolled type two diabetic men at really reducing everything we wanted to have reduced. The Macrobiotic Diet for diabetes study. You get some people that are saying, you know, a plant based diet, higher carb, but for most people it’s got to be low carb.

In our society, honestly, people are going to thrive much better in our society, and be able to socialize and eat out, and on a low carb diet then they will on some macrobiotic diet. Now, the low carb can be what I call the omnivore low carb, where you eat some meat, and fish, and some organic soy, and you make things out of nut flours, and coconut, and eggs, just all around variety, you eat nuts, or there’s the keto aspect, which is very, very low carb, or there’s actually a vegan type of low carb, and then there’s an ovo-lacto vegetarian type of low carb.

Dr. Morstein:                     For my patients, in reality, most of them don’t want to do keto, and I don’t make them, and I don’t think you need to, but they do that 30 to 40 grams a day of carbs, which will work very well for almost everybody, but it gives them a little more food to eat, you know, almond muffins, or pancakes, and things that make life more enjoyable for most people eating low carb.

Dr. Weitz:                          Do you let them include any whole grains, or legumes?

Dr. Morstein:                     No. I don’t. No, the grains, you can’t, no, you can’t do any grains.

Dr. Weitz:                          What about legumes?

Dr. Morstein:                     Yeah. Legumes, no, you can’t, now, every now, and then I have a couple patients who are in really great control, and if they have a couple tablespoons of hummus, because there’s got oil in it, and it’s got the garlic in it, they say that a little hummus doesn’t bother them. Okay. No, beans and grains, and potatoes, and sweet [crosstalk 00:38:29]-

Dr. Weitz:                          Beans are so high in fiber. Right?

Dr. Morstein:                     Yeah.

Dr. Weitz:                          And their glycemic index is in the 20s.

Dr. Morstein:                     You would think with the beans it would work, but for my patients eating beans, you know, they’re going to go up now, they might come down just after an hour or two, say, but it’s tough. The beans are incredibly high in fiber, in fact that’s for a nondiabetic patient, I’m not an advocate of keto, or Paleo at all, and there are studies where these changes in the microbiome by not eating grains, or not eating beans in nondiabetic patients just as a general diet are devastating to the microbiome, because the microbiome, the beneficial bacteria eats fiber.  When we take out these great sources of fiber, we change the bacteria, we start making less short chained fatty acids, and that’s not a good thing for colon cells, or even systemically. On a low carb diet I’m very adamant that my patients have to add fiber powder back in. If you’re on low carb, you’ve got to be getting at least five to 10 grams of fiber powder in a day to make up what we’re taking out, because vegetables just really won’t do it enough.

Dr. Weitz:                          Yeah. Of course, whole grains are also high in fiber, too, which that makes it harder to get the fiber.

Dr. Morstein:                     Yeah. I mean, for people that are nondiabetic to eat whole grains, and to eat beans I am an advocate of that, as well, for sure, but once you become a patient with diabetes they just can’t do it anymore, so at least with supplements we’ve got to replace both water soluble, and water insoluble that balance of fiber at least into the diet while having to eat healthy diet, or otherwise.

Dr. Weitz:                          I notice you recommend no snacking, and for years we’ve always recommended snacking, you don’t want to go to long, or your blood sugar will dip, so every two to three hours you have to have some food in your system to keep an even blood sugar, and that theory seems to be gone.

Dr. Morstein:                     I have from day one in medicine, which is about 30 years ago, I’ve always been an anti grazer, even for hypoglycemia you have to eat many meals throughout the day, that’s called enabling the condition-

Dr. Weitz:                          Yeah, but grazing is different than snacking, like say, here I’m going to have 12 almonds as a snack, or something at 3:00.

Dr. Morstein:                     I mean, if you just want a snack, but the question is that the human organism easily has the capacity to not eat for five hours. I eat a breakfast, and I go hike 10 miles without eating, that’s what the human organism can do. Right? This idea we cannot go from breakfast to lunch, and lunch to supper, and then from supper to breakfast, we can’t do that physiologically, this as just wrong, and so we want to at least in terms of intermittent fasting, at least from dinner to breakfast, at least 12 hours. Right?

Now, you want to go 16, whatever, there’re other ways to do intermittent fasting, but we have got to teach people that have trust in your body, eat a decent meal, and then don’t eat for five or six hours, and you’re going to be fine, and not only that, now you don’t have to think about eating, and now your adrenals aren’t stressed, and your liver isn’t stressed. You know what, I tell patients, when we’re measuring your heart rate, or excuse me when we’re measuring your blood pressure, the first number is when it’s feeding and the second number is when it’s at rest, and the second number is really the number we are really interested in. Right? Because that heart needs to rest, and you know what, your gut needs to rest, as well, it does not want to be digesting food all the time.  You don’t want to be active all the time, you need your sleep, you need to rest. Think of your gut as any other part of your system that needs rest. Right?  That means it doesn’t have to digest all the time. In fact, fasting is the healthiest a human can do to get over an illness, a chronic illness, that’s not eating at all, is putting your gut totally at rest. We just have to retrain people, and especially people who are injecting insulin, snacking, well, how are you going to, that’s going to screw up your insulin totally, so yeah, I’m a very big anti grazer, for everybody.

Dr. Weitz:                            You know, when it comes to intermittent fasting I just think it’s so ironic, because I’ve been involved with healthcare, and nutrition for 30 years, and I know when we got started the biggest thing was you have to eat breakfast, you have to eat within a certain period of time, everybody skipping breakfast, and they’re running out of the house, and that’s why they’re fat, because they eat too much at dinner, because they didn’t eat breakfast, and you have to eat breakfast, because that gets your metabolism going, so that was so important, and now the big trend is if you want to be healthy you got to skip breakfast.

Dr. Morstein:                     Well, not me-

Dr. Weitz:                          Okay.

Dr. Morstein:                     But that is for some. I eat breakfast. I’m breakfast, lunch, and supper. We have to learn, everybody

Dr. Weitz:                          A lot of people do the intermittent fasting

Dr. Morstein:                     Yeah, they do. I do fast from supper to breakfast, but I like breakfast.

Dr. Weitz:                          I’m with you on that. I prefer to skip dinner if I’m going to skip a meal. Right?

Dr. Morstein:                     I know. Here’s the deal, we have unfortunately, right now on planet earth we extremism all over the place with politics, and whatever, this, and that, and it’s certainly

Dr. Weitz:                          Planet Trump, now.

Dr. Morstein:                     Yeah. You know, it certainly entered into nutrition, too, and I think what we have to realize is that there isn’t one way that everybody is going to thrive eating, and so our jobs with Functional, Naturopathic medicine is what does this person need for their health? Me, I like breakfast, and I work better with it, but other people, especially if you have weight to lose, and so forth, doing a longer fast is great, and working out, where you don’t have food in you can burn more fat.  If it works for them, and they can do it, I mean, these are good ways to consider, but we just have to not make rules that everybody has to eat this way, and unfortunately we get too many docs that say, “I eat this way, so now everybody has to eat this way,” and that’s the exact opposite of the beauty of say Functional Medicine where we’re supposed to be looking at each individual.

Dr. Weitz:                       Right. And individualizing the program 

Dr. Morstein:                  Right.

Dr. Weitz:                       To their specific physiology, and their needs, and the way their body works.

Dr. Morstein:                  Exactly.

Dr. Weitz:                       For the final section, here, I’d like to talk about supplements that can be a benefit for patients with diabetes, or prediabetes.

Dr. Morstein:                  Yeah. Now, just to get out of the way, I have a proprietary formula called Diamend-

Dr. Weitz:                       Yeah.

Dr. Morstein:                  From Priority One, which I think is a really good product. It’s in one bottle, you get everything you need at therapeutic doses, but when we’re taking supplements, yeah, I mean, people with diabetes say everybody needs to me on a good multiple vitamin, and a good one, like maybe you’re taking six a day that gets in all of the basic nutrients, so we know that you’re getting in everything you need to have your body work well, and antioxidants, and nutrients that help your organs, your liver, your adrenals work better, and help you become less insulin resistant, which is zinc, and chromium, and vanadium, and so forth, and it’s just easy to get them in one good package. 

Dr. Weitz:                       I know you mentioned therapeutic levels, and-

Dr. Morstein:                  Yeah.

Dr. Weitz:                       You talked in your book about how you can take some multi one a day vitamin-

Dr. Morstein:                  Oh, yeah.

Dr. Weitz:                       It has these ingredients that people are reading about in the latest news story, but they’re in trace levels that are going to be insignificant if you’re going to take a specific nutrient like chromium, or like cholic acid, or some of these others, it’s got to be a therapeutic level, or you’re kidding yourself.

Dr. Morstein:                  That’s an excellent point, and that’s why I think docs like us, because we can have patients bring their supplements in, we know how to read the label, see if it is a valid supplement, a good dose for what they need, or not, and like with fish oil, I’m not an advocate of krill oil. Right? Because when you see the amount of EPA and DHA 

Dr. Weitz:                       Oh, it’s a joke.

Dr. Morstein:                  It’s a joke.

Dr. Weitz:                       I know.

Dr. Morstein:                  It’s a total joke. 

Dr. Weitz:                       24 milligrams of EPA, and 30 of DHA-

Dr. Morstein:                  Exactly. People have heard that it’s krill oil, so you’re paying twice as much for a useless therapeutic EPA/DHA product, so 

Dr. Weitz:                       I know you’d have to take 20 of those capsules to get-

Dr. Morstein:                  Right.

Dr. Weitz:                       Two grams of EPA and DHA.

Dr. Morstein:                  Exactly. Thank you. Yeah. I am a big advocate of quality fish oils just like you said, and then there are supplements, you know diabetes damages oxidative damage. There’s several different pathways that happens through, but it’s oxidative damage, so we need supplements that help reduce insulin resistance, and that help protect the body, so that even if their A1C isn’t at 5.1, because an A1C over 5.5, and certainly over 6.0 is indicating by science it’s causing damage to the human body. That damage is oxidative. You’ve got some supplements like alpha lipoic acid, or NAC. they’re not just antioxidants, but they reduce insulin resistance. Right? They both help the liver, and most patients who are type two diabetic, and overweight have fatty liver. You can get some nutrients that really have a really big crossover benefit in several ways to the body. Right?

Dr. Weitz:                       By the way, in your book when you talked about lipoic acid, you mentioned something that I think most people are not aware of, which is that there’s a difference between lipoic acid, which is commonly seen on the market, and R-Alpha Lipoic acid. Can you talk about what the R four means and the difference?

Dr. Morstein:                  Right. There’s two different isomers, or chemical ways it presents Alpha Lipoic acid.

Dr. Weitz:                       We usually think of D and L forms, but-

Dr. Morstein:                  That’s with vitamin E-

Dr. Weitz:                       Oh, okay.

Dr. Morstein:                  Of course, certainly-

Dr. Weitz:                       Right.

Dr. Morstein:                  Yes, exactly D and L, and that’s with phenylalanine as well as a DL-

Dr. Weitz:                       Right.

Dr. Morstein:                  But in alpha lipoic acid there’s the R and the S isomer.  The S isomer is not active in the body.  In fact they say it may interfere a little bit with the R. Only the R isomer is active in the body, and if your bottle just says alpha lipoic acid, half of it is R, and half of it is S. About 20 years ago, companies figured out a way to make just R, and have it be stable, and so if you’ve got alpha lipoic acid, 600, only 300 of it is the R, if it says R alpha lipoic acid 600, you know, you’ve got a double effect, so we prefer just the R’s when we’re working with our patients.  Of course, Berberine, right when 

Dr. Weitz:                        By the way, what’s a therapeutic dosage for R, lipoic acid?

Dr. Morstein:                   I would say orally if you’re getting around 600 milligrams a day, there’s a very, very rare side effect I’ve only seen in two patients in 30 years, which is it can burn the stomach, but I mean for literally the hundreds, and hundreds of thousands of people that I’ve put on Alpha Lipoic acid it’s very rare. But you certainly can’t open the molecule and drink it down, it’s an acid, so it does have to be swallowed in a capsule. Little kids can’t take it until they can swallow a capsule.

Dr. Weitz:                        Okay. I’m sorry, keep going.

Dr. Morstein:                   No, I’m just saying we mentioned Berberine-

Dr. Weitz:                        Yeah.

Dr. Morstein:                   Had that great study comparing it to Metformin.

Dr. Weitz:                        Right.

Dr. Morstein:                   We like Berberine, it can upset some stomachs, but if you give a 1,000 or 1500 most people can handle that. Also, a very good liver herb as well. That’s another good product to consider.

Dr. Weitz:                         Okay.

Dr. Morstein:                    We’ve got the blueberry, bilberries for the eyes. Green tea extract was shown to help the pancreas. There’s little 

Dr. Weitz:                         You got benfotiamine which is the fat soluble form of B1

Dr. Morstein:                    Yes. Benfotiamine, very excellent, shown in studies for nerve damage, kidney damage, eye damage, and of course that, and the endothelial lining are the four areas where diabetes has its most effects, because those cells cannot prevent glucose from entering them. Insulin resistance does not affect those cells, so if your blood sugar is 300 your eyeballs are 300, and your kidney is 300, and your nerves are 300, and your endothelial lining, your blood vessels, so this is why those degenerate so commonly in people with diabetes, but benfotiamine around the max doses around 450 milligrams a day, very good safe, safe product. Ironically, we usually think fat solubles are harder to absorb than water solubles, but with benfotiamine it’s actually better absorbed than water soluble thiamine.

Dr. Weitz:                         Cool. In your book, you also talk about L-carnosine.

Dr. Morstein:                    Yeah.

Dr. Weitz:                         Which can reduce glycosylation.

Dr. Morstein:                    Yeah, I actually don’t use it too much.

Dr. Weitz:                         Okay.

Dr. Morstein:                    Yes. I learned about that from another physician years ago, and there are some studies supporting that, but to me also vitamin E might be able to do that, I just think if we’re getting the person under better control then that should lower, and it does, the glycosylation throughout their body. We think of it as the A1C, but it can also, fat and protein, it’s a fat and protein reaction, the maillard reaction, and that can happen in joints, and tendons, people with diabetes can get more into injuries of frozen shoulders when their blood sugars and A1C’s are higher, because that’s happening throughout their body, not just on their red blood cells where we can measure the A1C.

Dr. Weitz:                         How about cinnamon?

Dr. Morstein:                    Yes. Cinnamon. There’s a type of cinnamon that was shown in studies to help lower blood sugars. Some people 

Dr. Weitz:                         Which type of cinnamon is that?

Dr. Morstein:                    The Burmannii type of cinnamon. It tastes good, and it’s good in the fall when it’s getting cold. Cinnamon is another. Some patients take cinnamon, like some capsules at bedtime, and they say it can help lower their morning glucose, so it’s a pretty benign substance, it’s a 1,000 milligrams, they did studies on a 1,000, 3,000, 6,000, but even the 1,000 might be beneficial, or just using it as a spice on your food. Curcumin of course, as an anti-inflammatory, we do know that the tummy fat makes tumor necrosis factor alpha, it makes Interleukins, these can go to cells that cause insulin resistance, and so decreasing inflammation via fish oils, and curcumin can all be helpful to patients. Also, we do know the association with Alzheimer’s in people who have had poorly controlled diabetes, and curcumin has been shown to help reduce the risk of Alzheimer’s, so there was a good study in India that people eating more curcumin have less risk of developing Alzheimer’s, so again, and it’s also a good herb for the liver, so these things, again, have really good crossover for our patients.

Dr. Weitz:                            You talk about fiber and the need for fiber. What do you think about some of the resistant starch supplements on the market, and they have medical foods with resistant starches?

Dr. Morstein:                     Yeah. I mean, you know I’ve tried those and never really saw they did too much, and historically there were bars that were given to kids at night time to prevent them from having lows during the night, but kids on insulin don’t have to have lows during the night if they’re on a low carb diet. I mean it’s not like, I mean in conventional care eating whatever you want and covering it with insulin is the axium of treatment, and that’s going to cause all kind of highs and lows, but in terms of did I see real clinical benefits to resistant starch, I honestly didn’t, and if people are just eating correctly, that’s going to work for so many people. I mention it in the book as people think about it, I haven’t seen it clinically that helpful addition.

Dr. Weitz:                          You also mentioned the herb gymnema sylvestre.

Dr. Morstein:                     Yeah. I should have mentioned that earlier.

Dr. Weitz:                          Yeah.

Dr. Morstein:                     Gymnema sylvestre is my favorite botanical. There’s that and bitter melon as kind of two, but I love gymnema sylvestre, the studies have used 400 milligrams, but with some patients I’ve gone up to 2,000 or 2400. Gymnema sylvestre has been shown to help the pancreas produce insulin again, and it also reduces cravings for sugar. In a tincture form, it’s pretty amazing, that if you put a tincture of gymnema sylvestre in your mouth, and swish it around for a minute and then swallow it you can’t taste anything sweet, it’s disgusting. You can’t eat it. For some patients that are still working, you know, the holiday times, and going to parties I’ll give them a little one ounce bottle and say, “Just take this before you go to the party, then try to eat that cookie,” you’re not going to spit it out, because-

Dr. Weitz:                          Wow.

Dr. Morstein:                     It’s just going to be nothing in your mouth, and it’s really an amazing way to go, it just numbs the sweet taste for about an hour, or hour and a half.

Dr. Weitz:                            That’s great.

Dr. Morstein:                     Yeah.

Dr. Weitz:                            That’s a great hint. I know we both have patients, and we got to go, so let’s make this a wrap here. For listeners who want to get a hold of you, what’s the best way for them to contact you, and to get ahold of your book?

Dr. Morstein:                     Yeah. My book, the short name is Master Your Diabetes, it’s up on Amazon, Doctor Morstein, M-O-R-S-T-E-I-N, Master Your Diabetes, and my website is drmonamorstein, M-O-R-S-T-E-I-N, and from there I’m in Tempe, Arizona. I do telemedicine, as well. Check out my website, and give a call if you are interested.

Dr. Weitz:                            That’s great. Doctor Morstein, thank you so much for this interview.

Dr. Morstein:                     Thank you very much, Doctor Weitz …

 

 

,

Detoxification with Dr. Bryan Walsh: Rational Wellness Podcast 77

Dr. Bryan Walsh discusses proper detoxification with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

3:04  Dr. Walsh had the typical health care provider’s view that we are all toxic and we should detoxify when we can. But then he heard a detox guru talking about phase three detoxification and it didn’t accord with his understanding of it.  Secondly, he learned that there was a phase zero detoxification. Thirdly, he had read that there was a biphasic response to toxins in that certain nutrients at a low dosage increased detoxification enzyme activity, while at a higher dosage it inhibited the same enzyme for detoxification.  This meant that the amount of some of these nutrients found in food would stimulate detoxification, while the concentrated, isolated forms and the amounts found in supplements such as in detox formulas and powders might actually be inhibiting detoxification.  This led Dr. Walsh into doing a deep dive into the scientific literature and to formulate a detox program that does not include a lot of supplements.

8:24  Which toxins each person gets exposed to has to do with your socioeconomic status, your occupation, where you live, your lifestyle, what kind of cosmetics and cleaning products you use, your water, and your air.  When you look at the data from National Health and Nutrition Examination Survey data from the CDC, we’re excreting all kinds of toxins, including heavy metals like mercury and arsenic, organophosphates, organochlorines, and aflatoxins from mold.  Some toxins exert oxidative stress and others are endocrine disruptors and may disrupt the thyroid, sex hormones or adrenal function.  Toxins may also have a direct cytotoxic effect on our cells.  Some toxins affect the endocrine system, while some have more of an effect on the neurological system and the brain.

13:52  Dr. Walsh doesn’t like most of the serum or urine tests for toxins and prefers using questionaires.  Here are two of the questionaires that he finds helpful to screen for toxic exposure:  http://www.eha-ab.ca/acfp/docs/taking-an-exposure-history.pdf  and  Qeesi.org

19:22  To properly detox you have to do three things: 1. Mobilize, 2. Optimize the detoxification pathways, and 3. Promote excretion. To mobilize, you want to go on a hypocaloric diet so that you start breaking down fat stores, which will mobilize toxins stored there. You should also use a 6-8 hour time restricted eating period, which means that you should have your two or three meals within an eight hour period of time and have no food the rest of the time. To optimize the detox pathways, this is heavily nutrient dependent, requiring certain vitamins, minerals, amino acids, and other nutrients.  You need methyl groups, you need sulfur groups, you need glutathione, you need certain amino acids, like glycine. To promote excretion, you have to sweat, so Dr. Walsh recommends using a sauna.  You want to drink a lot of water, so that you urinate.  You want to consume enough fiber so that you poop and include some binding agents to insure that the toxins leave the body.

28:18  Detoxification does occur in the liver, but also in the kidneys, the enterocytes, and even in the testes.  The four phases of detoxification include phase zero, which is the entry of these environmental pollutants into the cells. Phase one makes the fat soluble compound water soluble by adding a hydroxyl group. But it also produces a toxic intermediate, so it is important that phase two be sufficiently upregulated so that these toxic intermediates go through conjugation or sulfation or methylation or glucuronidation or glutathione or acetylation.  Then phase three takes that water soluble detox product out of the cell to be excreted through stool, urine or sweat.  You need to be careful to avoid nutritional supplements like curcumin, piperine, and milk thistle, which inhibit phase three of detoxification. For excretion, it is important to include fiber and binding agents, like bentonite clay, charcoal, and chitosan.  And it’s also crucial to sweat, such as by using a sauna, though Dr. Walsh does not like steam rooms, unless you are using purified water.  But overall, Dr. Walsh is not a believer in taking a bunch of nutritional supplements for conducting a detoxification program.  For example, when you take curcumin via food, it enhances phase III detoxification, while curcumin as supplement decreases it: https://www.ncbi.nlm.nih.gov/pubmed/18439772

43:17  Dr. Walsh also recommends as part of his 10 day detox program, 4 days of a modified Fasting Mimicking diet.  He cites the work of Dr. Valter Longo from USC who has published research on the anti-aging benefits of it, though he is not worried about the issue of a low calorie diet mobilizing toxins, which Dr. Walsh is concerned with.  So Dr. Walsh uses the same macronutrient ratio recommended by Dr. Longo, which is basically a low protein, ketogenic program, though Dr. Walsh recommends including foods that facilitate detox.  While Dr. Longo recommends the same amount of low calories to everyone, Dr. Walsh recommends low calories, but with the exact amount of calories based on your weight.

 

 



Dr. Bryan Walsh is a board-certified Naturopathic Doctor who sees patients and teaches at the University of the Western States and is an expert at detoxification. Dr. Walsch’s web site is drwalsh.com and he offers a course on detox for patients https://www.metabolicfitnesspro.com/walshdetox/  and also a course on detox for other doctors and practitioners: https://www.metabolicfitnesspro.com/everything-you-wanted-to-know-about-detoxification-2/

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 Transcripts

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, Dr. Ben Weitz here. For those of you who enjoy the Rational Wellness Podcast, please go to iTunes and leave us a ratings and review. That way, more people can find out about the Rational Wellness Podcast. Today we’re here. We’re going to speak about detoxification, getting rid of toxins from our bodies. We all are probably aware of the fact that we live in an environment in which there are toxins in the air, in the food, pesticides, chemicals in products that we put on our skin, use in our house. We have tons of information that we been exposed to about all these different toxic substances that get into our bodies and, potentially, have negative health affects.

Today we have Dr. Bryan Walsh, who’s a board certified naturopathic doctor, who sees patients, teaches courses in biochemistry and physiology at the University of Western States. He’s also scientific advisor at Lifetime Fitness. He’s devoted a considerable amount of time researching and writing about the concept of detoxification to help us to get rid of some of these toxins. That’s what we’ll be discussing today, his particular approach to detox. Dr. Walsh, thank you for joining me today.

Dr. Walsh:           Thanks for having me. It’s a pleasure to be here.

Dr. Weitz:            How did you get interested in detox as a particular topic?

Dr. Walsh:           Well, that’s a great question. I’ve been steeped in the health world for a long time, well before I became a naturopathic physician. I started out as a fitness professional a long time ago, read up on nutrition as much as I could. I was a massage therapist. I was really into that world and it doesn’t take long being in that world to come across this concept that we’re all toxic and we’re going to die if we don’t detoxify. You’re introduced to all these different ways of supposedly detoxifying your body from foot baths, to colonics, to you can see people online saying, “Drink a little bit of lemon juice in the water. It’s a great way to detoxify the body,” and all these different claims.

My initial, I guess, exposure to this whole concept was that of what everybody else’s is. We’re super toxic. It’s killing us slowly and if we care about out health, we should probably detoxify. And that was it for a really long time. Then, I forget the specific time, but there was a time, recently, I’d say maybe this year or last year. I heard a particular detox guru talking about phase three detoxification. Which most people in this industry have heard of, it’s been around for a little while. I think phase three might have been discovered in the early ’90s. The way that he was describing phase three didn’t entirely jive with what my understanding was. This guy is a guru, I’m not. At least, I don’t consider myself to be. I thought, “That doesn’t really … that’s not right. I don’t think.”

I decided to go into the scientific literature and say, “What is phase three really?” I’ve heard a lot of people say a lot of things about phase three. What it is, what it’s not. I decided, I was like, “I’m not going to listen to anybody else, I’m going to do this myself.” You know how PubMed works. Where you go in and you read a paper. Then it’s cited in other papers and then you go down, the next thing you know, you have 50 tabs open in Firefox or Chrome and you’re reading all these papers. This little mini dive to just trying to figure out what phase three was three things happened.

One was I realized that this guru, who’s teaching people about phase three to sell his supplements, wasn’t entirely accurate. I have a problem with that, as we were just talking about that prior to this interview. In this space, whatever you want to call it, Functional Medicine, nutritional medicine, alternative complimentary medicine. We need to be 100% accurate with what we’re talking about, because we’re so intensely scrutinized by conventional medicine. First of all, the way he was describing phase three to practitioners wasn’t entirely correct.

The second thing that I saw was that there’s a phase zero detoxification. Which, I’ve been in this business for a long time, and I have never heard anybody ever, at any time, utter phase zero. I thought, “Wait a minute, what is this phase zero, that I’ve never heard about?” If we’re talking about detoxifying people, it should be a part of this conversation that we’re having. So, that blew my mind.

Then the third thing, and this may have been one of the things that really sealed the deal for me, was I started reading about what’s called a biphasic response when it comes to certain compounds, or nutrients, or herbs, or minerals, whatever. This biphasic response, specifically in these papers, was talking about how, at a low dose, increases certain detoxification enzyme activity, but, at a high dose, inhibits the very same enzyme for detoxification.  I thought, “Well, wait a minute.”  A low dose would be the kind that you find in food.  So if you were to eat the herb, itself, or to take turmeric, for example, for its curcumin content that, that might stimulate detoxification.  But these papers didn’t explicitly say this, but in a high dose, which I read as, isolated, concentrated, supplement form.  Trying to get as much of the herb, or nutrient, or compound in your body, as possible, might inhibit detoxification.

When those three things happened … All it was, was this guy was talking about phase three. I thought it was wrong. I decided to look it up myself. A, he was a little bit wrong about phase three. B, there was a phase zero that I never heard about. And, C, I really wondered if what we’re doing, as an industry, if we were actually detoxifying people, or not, by giving people these powders, and potions, and supplements in concentrated, isolated forms when the studies were pretty clear that many of the things that we’re using in detoxification formulas might actually be inhibiting detoxification. Then I though, “Oh my gosh, I need to completely get any bias out of my head. Everything that I though I knew about detoxification.” Wiped my brain clean. Wiped my desk clean. And I started from the very top. I said, “All right, what have I heard? That we’re toxic. All right. What does the literature really say? Are we, in fact, toxic or not?”  Two was, are these things stored inside of us? We hear that they are. Is there a synergistic effect of multiple low-dose toxin exposure all at the same time? We hear that, but what does the scientific literature say? Does the dose matter? We hear that the dose makes the poison. And, at the doses that we’re probably exposed to, that it’s not going to cause a problem, so I wanted to look into that.

 Then after answering all these, I guess, basic questions that you and I have heard about for a really long time in this industry. If those are true, if we do have exposure, if it does get stored, if it is causing damage, if there is a synergistic effect, if the dose doesn’t matter, and if a low dose can cause just as much damage as a high dose, what can we do about it? What does the scientific literature say or suggest is the most efficient and safe, I will add, safe, efficient, effective ways of actually detoxifying the body, and assessment. That was a big … How do we test this? You know the labs. There’s labs out there that are supposedly these toxin panels and will … What does the literature suggest about those, as well?  That was the dive. I ended up reading over 300 papers on this topic over the course of months.  That’s my story with this.  So I have come up, now, for air again with a brand new view of what detoxification is.  With really solid answers to those questions that I feel very confident talking about, in fact.

Dr. Weitz:            Okay, maybe we could start by just talking about what are some of the most common toxins that we get exposed to in our environment, and get stored in our bodies. What are some of the health consequences of some of these?

Dr. Walsh:           That’s actually … That’s interesting. That’s a difficult question to answer, because … Well, I just give you an example. There was one specific paper that I found that said that based on one’s socioeconomic status, we are exposed to different toxins.  For example, somebody might have a garden in their backyard, and they’re, therefore, spraying pesticides.  But somebody with a lower socioeconomic status might eat more fast food and, therefore, are more exposed to certain other toxins.  A certain class might use more, what’s it called, sunscreen on themselves, or their kids, or certain cosmetics.  They’re all common.  When you look at the NHANES data, in terms of what people are excreting. We’re excreting everything. We’re excreting everything from elements, so things like arsenic, and the heavy metals, mercury, aluminum. We are exposed to a lot of organo-phosphates and organo-chlorines that persist of organic pollutants. We’re exposed to … Some people might be exposed more to aflatoxins, because they have mold exposure, which other people don’t.

I actually think that’s a really difficult question to answer, because it depends on, well, according to studies, your socioeconomic status, the job that you have, where you live. We’re out in well-water country. I can tell you that we don’t use any pesticides in our yard garden, but I drive down the road, and these farmers around us are spraying who knows what. That’s absolutely getting into our water.

Dr. Weitz:            Absolutely.

Dr. Walsh:           But, on the other hand, and somebody that lives in an urban society and is drinking city water. They’re going to have different exposures. So it depends on your lifestyle. What kind of cosmetics and cleaning products do you use? What kind of food you eat? The water, the air, all these things. I think it’s difficult to say what are the most common ones, because that really will be specific to one’s diet, lifestyle, job, where they live, for example.

The second part of your question is the damage. That was another question I had. We hear these things are so bad. Well, why? Why do they cause problems? And it turns out that depending on the specific, I’ll call it a toxin, they’re really xenobiotics or environmental pollutants. Or the class that they’re in, they really do exert different effects. One of the most common ones, though, that across the board is oxidative stress, surprisingly. I didn’t know that, that was going to be the case, but in many individuals that have multiple chemical sensitivity, they exhibit a tremendous amount of oxidative stress. Other ones, you hear them as endocrine disruptors, but what does that really mean?

It turns out the stuff is so compelling, though, when you look at it. Depending on the environmental pollutant, let’s just talk about thyroid. Just about every single aspect of thyroid hormone physiology can be negatively impacted by an environmental pollutant. So, starting up at the top, the hypothalamus, the pituitary, TCH, thyroid’s ability to bind onto … thyroid binding globulin on the receptor, itself, and conversion on the thyroid’s production of this, every single step. We often think of the sex hormone, that these are all estrogenic. That’s not entirely true. There are some that have been shown to suppress adrenal function, and suppress cortisol, for example.

Then there’s other ones that have direct, what I call cytotoxic effects, on a cell. For example, certain ones might mess up the membrane of the mitochondria. Other ones might negatively impact some of the enzymes involved in the citric acid cycle, or the electron transport chain. Other ones have more indirect effects, like with the immune system, and then that will have system-wide effects. It’s really … There’s so many of these things out there. There’s so many classes of these and they all exert different effects. That it’s hard to say. Some of them exert more neurological symptoms, whereas other ones might impact the endocrine system more. It really depends on the environmental pollutant and what specific effects it causes. But …

Well, here’s another quick one. In the scientific literature, so many chronic conditions have been linked back to xenobiotic or environmental pollutant. Things that you don’t … I mean, of course, the neuro developmental things, like ADD, ADHD, and autism, as well as, things like Alzheimer’s and Parkinson’s. But then there’s things, like obesity, things we never think of, but the studies are really clear, cardiovascular disease, atherosclerosis, hypertension, and even diabetes. Some of these papers say the correlation is so strong that, perhaps, xenobiotic exposure is, not only associated with diabetes, but maybe a significant contributor.  Anyhow, that just speaks to the fact that it depends on what it is, but it can impact virtually any part of a cell, the mitochondria, the pliable membrane, the endoplasmic reticulum, enzymes, transporters, hormones, neurons. You name it, they can cause damage in some way.

Dr. Weitz:            What’s the best way to screen to see what kinds of toxins that we have in our body?

Dr. Walsh:           That was disappointing to me. When I looked into the literature to see what really was the … That’s the big question, of course, because … So, right now, what have we talked about?  Yes, we’re exposed. There’s absolute proof that they’re stored. They do cause damage. Then the next rational question is, all right, well, how toxic am I? When people are talking about how toxic they are, what they’re actually asking is, what’s my total toxic load or total body burden? Which is really to say, “How much do I have stored in my body?” That’s really the question. And the problem is, there’s no way to assess that. There’s no way to evaluate that. I know that people, “Well, what about the hair tissue mineral analysis test?” No. What about the urinary test to show excretion? No. I can go into some of the reasons why too.

One of the gold standards in toxicology, when evaluating this, is a fat biopsy. That’s really what we’re looking at … How much is stored in fat? Well, it turns out that for a variety of reasons, and there’s papers on this too, that suggest that you have different amounts of stored xenobiotics in subcutaneous fat, than you do visceral fat, than you do in different fat depots in different areas of the body. And these papers say that, that doesn’t correlate to serum levels, so you can’t do a blood test and say that, that reflects you and what your storage is, because it may differ.  Then there was one, and this is a rodent study, so you have to take that into consideration. Well, here’s a good example. Let’s say you and I, right now, let’s say we practice in the same area. We live the exact same lifestyle, exact same exposure. You’re following a hypocaloric diet, right now. Intermittent fasting, time restricted feeding, hypocaloric diet. I’m stuffing my face, standard American diet. I’m eating more than my basal metabolic rate. We both go to do a test. Now, because you’re in a hypocaloric state, you’re probably mobilizing more of your stored xenobiotics, and every mammal study says that. That when there’s a hypocaloric, or fasted, state, serum levels of xenobiotics go up every single time, every single mammal, including humans.

Now, I’m in an anabolic state. I’m storing things. When we go to do this toxic panel, you come out sky-high in all these toxins. And you see your practitioner and they’re like, “Oh my gosh, you are so toxic. You must do a detoxification program.” Then, me, because I’m in an anabolic stuffed fed, overfed state. That mine are probably stored. And my levels, on my test, might come back as normal or low. And the practitioner says, “Wow, you’re not toxic, at all.” When, in fact, I might be far more toxic, in terms of my storage, than you are, but you’re in a hypocaloric state. Right there, that totally negates … It’s a severe confounding variable when considering assessments.

Then the last one, that rodent study I was going to say, they showed that when these … They put these rats on a yo-yo diet, poor rats. They would go hypocaloric and their xenobiotic levels would go up in their blood. Then they’d make these rats hypercaloric and guess what happened? These xenobiotics went into different tissues. You might have a certain amount in a certain fat depot in your body that does get mobilized, but then it’s going to go somewhere else depending on your caloric state. In terms of screening, all of this is my opinion. It’s based on the scientific literature, but people can use it how they want. Is there is some pretty good questionnaires that are out there, that are in the … They’re validated questionnaires in the scientific literature that, I personally, think are amongst the best ways of screening if we have toxic exposure or not.

Dr. Weitz:            Can you mention which ones those are?

Dr. Walsh:           There’s a whole bunch of them. One of them is abbreviated and I forget the actual … It’s the Qeesi questionaire. If you do links to this in your show notes, we can-

Dr. Weitz:            Yeah, I will. Yeah, maybe you can email me.

Dr. Walsh:           That one’s the most elegant. It’s fairly long. I’ll give you a couple of them that I like for two reasons. One is this one is very comprehensive. It’s not quick, 10 questions, are you toxic or not. It looks at a variety of things from your actual physical exposures and your lifestyle, as well as symptoms across a variety of systems in the body. And I think is really very comprehensive. The benefit of some of these, though, is it forces you, when you ask these, or answer, these questions to jog your memory to see what your exposures might be that you are totally unaware of. Right now, you can say, “What are my exposures? I drink reverse osmosis filter water. I eat organic food. I use coconut oil for my lotion. Apple cider vinegar for my deodorant. I don’t have any exposures.”  But when you go through some of these questionnaires that have these questions, you say, “Oh my gosh, I work in a building that whatever.” They’re really good at helping, not only see if you might have a certain amount of toxicity, if you will, but also what the sources might be.

Dr. Weitz:            Okay. In your concept of detoxification … Actually, you were talking about the phases of detoxification. I’m not sure everybody even knows what phase one and phase two are, and you were talking about phase zero and phase three. Well, actually, your concept of detoxification, you have three basic principles, and then you list the phases in a second one. Maybe we could go through your three main important principles of detoxification that you outline in your program.

Dr. Walsh:           Yeah. And, again, I humbly will say that I think my … I’m a teacher, not by choice, I think I was born into it. When I look past throughout my entire life, everything has been teaching. I say that because when I go through what these three principles are, there’s a feeling you know that being empowered just feels amazing. That you feel like that you know enough information that nobody can pull the wool over your eyes. That you’re an informed individual. So by teaching these three things, these are just … These are principles that must be in place for anything to call itself a detoxification program. I say this so that when people are evaluating, “Well, what about this detoxification?” They can run it past this list of three things.  The first thing that for something to call itself a detoxification, that it absolutely must include is mobilization. You have to get these things out of storage.

Dr. Weitz:            I thought you were going to say it has to come in a box, just kidding.

Dr. Walsh:           No. It can, if it’s a well developed one, it absolutely can, UPS, no.

Dr. Weitz:            Okay.

Dr. Walsh:           You have to mobilize in the first place. The best ways to mobilize, that I’ve seen, and also makes physiological sense, is to go on a hypocaloric diet. Now, i think a calorie restricted diet, I also believe a time-restricted feeding in a window of about six to eight hours, is probably the best. And all that calorie restriction means is less than, essentially, your basal metabolic rate. Exercise. So the technical word is, lipolysis, which is the breakdown of the lipids, or fat cells, but that’s where the majority of these things are stored. When you are in a state, a catabolic state of lipolysis, you do get mobilization of toxics, period. This is not conjecture.

Dr. Weitz:            Right.

Dr. Walsh:           Every mammal study that I’ve looked at, including humans, when people, or mice, or monkeys go hypocaloric, their levels in the blood go up every single time.

Dr. Weitz:            You’ll have to admit that virtually every detox program out there involves some sort of modified fast or fast. They pretty much all involve eating less foods.

Dr. Walsh:           Right.

Dr. Weitz:            So this concept, I think, is incorporated in most of the commercial detoxification-

Dr. Walsh:           Whether they knew it, or not, right. It absolutely involves that.

Dr. Weitz:            Right.

Dr. Walsh:           The second thing, then is, and this speaks to those phases of detoxification. You have to optimize detoxification. Step one is to get them out swimming in your body. All these things, now, are mobilized. They’re going through your blood. You are not going to get rid of them. These are the fat soluble ones that you do not, you cannot … The normal routes of excretion are any water forms of excretion. You can sweat it out. You can urinate it out. There’s a little bit of water in stool, so you can poop it out. You can, technically, salivate it out, or if you cry a lot, you watch a lot of This is Us reruns, then you can cry it out, technically, through tears.

Those are all … I mean, in theory, you could measure any one of those as a form of toxin … Those are all measurable things. We have to take these things that are fat, they like fat, and turn them into things that like water, so we can get rid of them. Those are those four phases of detoxification; phase zero, phase one, phase two, phase three. You have to optimize those. If you’re not, then these things just go in the body and you can’t excrete them, because they’re still fat soluble. Then the third, and last one is, you have to focus on excretion. I’ll just take a step back and say, “Let’s talk about different detox programs to see if they fit those things.”

Mobilization, improved detoxification pathways, and then to really, really facilitate excretion in some ways. Let’s say that somebody were to do a juice fast, some popular juice fast where the juice comes in a box, or maybe they’re just juicing things on their own. Are they in a hypocaloric state? Probably, if all they’re doing is just drinking juices, they’re probably in a hypocaloric state. So they’re probably mobilizing, and that’s fine. Step two is, are they improving detoxification pathways? Now, it depends on what they’re consuming. There are studies that suggest that things commonly juiced, things like carrots and celery-

Dr. Weitz:            We’ve had a technical difficulty, so we’re going to continue this podcast. We’re not exactly sure where we left off, but hopefully we won’t have any lost train of thought. So, go ahead Dr. Walsh tell us more about detox.

Dr. Walsh:           Yeah, no problem. You can tell me if I’m going too far backwards. I was saying the three things that are required in order for somebody to do a detoxification program; mobilization, optimizing detoxification, and then optimizing excretion. Those three things are critical. Then what I said was if you go back, and you start evaluating things that are supposed to be detoxification programs, where they detoxify the body, they have to have those three things. So, just a juice fast, is really common. You mentioned that most juice fasts are hypocaloric, so they probably are increasing mobilization. But then, I think this is the part that we got a little bit glitchy, is depending on what somebody’s consuming, you may, or may not, be either stimulating or inhibiting detoxification pathways. The things that have been shown in the literature to stimulate detoxification pathways, people typically aren’t juicing things like, broccoli, for example, or cabbage, or possibly things like mung beans, which aren’t really juiceable.

Dr. Weitz:            But it is the case that detox is a nutrient dependent process, right?

Dr. Walsh:           Absolutely. Well, yes. I mean, if you want to really get into the biochemistry of it, there are a number of different micro-nutrients, vitamins, and minerals that are even required for these pathways to be taken place in the first place.

Dr. Weitz:            Right.

Dr. Walsh:           In phase two, which I’ll get to, but just really quickly. You need methyl groups, you need sulfur groups, you need glutathione, for example, you need certain amino acids, like glycine. It’s heavily nutrient dependent.

Dr. Weitz:            Hence, the concept of trying to put together a program that has concentrations of these nutrients has some basis in the science, right?

Dr. Walsh:           Totally. Here’s the point. Is a juice fast a detoxification program? From the mobilization standpoint, yes, it probably is. You will be mobilizing. But from optimizing detoxification, I think that, that’s highly skeptical. And it depends on what somebody’s juicing. There’s some evidence in the literature that things that people usually juice, like apples, carrots, and celery may actually inhibit certain detoxification pathways, so then, that’s questionable. Then for excretion, if somebody is just doing a juice fast, they are not doing anything to enhance excretion. In fact, if they’re only consuming juice and, therefore, not fiber, and we can go into great detail on this, or not, but they’re probably urinating, and that’s fine. If they’re not sweating, that’s a huge problem. It’s a huge problem when it comes to detoxification.  Certain things are preferentially excreted via sweat, other ones are preferentially excreted via biliary, in the bile and the gastrointestinal tract. If you’re not sweating, or your not binding things up severely in your gastrointestinal tract, and in the juice fast, you’re not, then you’re not excreting. I, myself, would say that a juice fast is not a detoxification program. Yes, it mobilizes whether, or not, it increases detoxification pathways depends on what you’re consuming. Then the third one, excretion, I’d say a big, no, to that.

Does a colonic, is that a detoxification? Well, if you’re not mobilizing, then, no, all you’re doing is your moving things through your bowels faster. Which is great, that’s excretion, that does nothing for the second step detoxification of the first step, mobilization. That’s what I really want people to do is to be able to look at a detox … something that is allegedly a detoxification program, and say, “Does this increase mobilization?” Check, yes. “Does this increase detoxification pathways?” That’s a big one. That’s questionable with a lot these nutrients that people are using in powders, and supplements, and capsules. And excretion, is just saunaing detoxification? You maybe excreting things that you had swimming around in your interstitial fluid, technically, but not out of your cells, because you might not be in that mobilized state.

Dr. Walsh:           So those three things are critical for something to be called, to truly, truly be called a detoxification.

Dr. Weitz:            Can we go through those detox pathways? People typically talk about phase one and phase two of detoxification. It’s phase zero and phase three that are the newer ones. Typically, people talk about phase one and phase two as related to the liver, correct?

Dr. Walsh:           Yeah, well, and that’s not true, at all. When people talk about these … I’ll tell you what the phases are, then we’ll talk about why it’s not just a liver. The liver happens to be a huge organ and, yes, it does this, but the kidneys do this very well. The enterocytes of the intestines do this very well. In men, it turns out the testes, actually, do this very well also. Which isn’t surprising, given the role of the testes in terms of, essentially, passing along somebody’s DNA in that xenobiotics. If one couldn’t detoxify well down there, then that could really disrupt somebody’s …

Very simply, if you’re to picture, like a box. I’m trying to look for a prop real quick, but I don’t have one. If a box is a cell or, you’re in a room there. I would say, if somebody’s in a room it’s pretty easy to picture. If this room has two separate doors, this is as simple as it is. Phase zero is quite simply the entry door into your room, which is the cell. Your cell has a nucleus and mitochondria. It has a computer. It has lights and electricity and ATP. That first door is phase zero. That’s the entry of one of these environmental pollutants inside of a cell. You can say a liver cell, but it’s not the only organ that does this. It comes in, now, it’s inside the liver cell. We’ll say it’s a person came through that door.

Then phase one is biochemically not too challenging, but I’ll say what it does biochemically and then I’ll change it back to this metaphor or analogy. Phase one makes that fat soluble compound, first of all, makes it water soluble. It does so, not exclusively, but either by adding what’s called a hydroxyl group or exposing one that was already there. Now, this has this hydroxyl group on it. It’s water soluble. The way that I use this as an analogy. If somebody walked through the door, phase zero. They’re now inside the cell and you, put a sticky note on their forehead, just right on their forehead, or you start berating them, “You suck as a human being. You’re a horrible, miserable, ugly, smelly human being.”

Now, and that’s phase one. Now, this person is really angry. Who wouldn’t be if you start to berate … and they have a sticky note?  So they start trashing your room. They throw your computer across the desk. They start knocking lights over. They start doing all these things.

Dr. Weitz:            Fake news.

Dr. Walsh:           But in a cell, after phase one, and this isn’t across the board, all the time, but it’s actually considered to be more damaging to the body than, in some cases, the original environmental pollutant was, after phase one. You just berated this person, “You’re fat, ugly and your breath stinks.” Now, they’re really, really mad, but that’s phase one. But phase two is collectively called conjugation, and conjugation means, to add something.  Now, in phase two, you’re like, “I’m so sorry. Here’s $100 bill.” Well, the person may have had hurt feelings about what you said, but now you gave them $100 and they’re not angry anymore. After phase two, it’s still water soluble, but it just got $100 bill. It’s not going to damage anything inside of your cell anymore. It’s not going to damage your room. Now it’s a happy person. You made fun of it, it was angry, it started messing things up after phase one. Phase two, you handed it something, now, he’s happy.

Dr. Walsh:           Now-

Dr. Weitz:            Now, let me just stop you for one second. So the story that’s often told about detox, especially from some of the companies that provide these detox programs is, phase one produces a toxic intermediate that’s why if you just do a juice fast you get all these toxic reactions, and headaches, and all these negative things. You have to have the right nutrients that help support phase two, so you take that toxic intermediate, put it into a water soluble form so it can get excreted. Therefore, you support phase one and phase two, and that’s the end of the story.

Dr. Walsh:           Yeah. That’s a good story, but if the intermediate metabolite, after phase one. With that hydroxyl group, it’s technically a free radical. Now, I haven’t seen too many people that get sick from free radicals, if that makes sense?

Dr. Weitz:            But doesn’t that explain when somebody does a juice fast and they have toxic reactions-

Dr. Walsh:           I think that part of it-

Dr. Weitz:            – and the amino acids and the other nutrients for phase two.

Dr. Walsh:           I don’t know. I’m not convinced that, that … It might be because of mobilization, and they’re not excreting things. I don’t know if it’s only because it goes through phase one. Technically, I mean, they’re water soluble, but technically it’s still inside the cell. It hasn’t gone out of the cell yet, so that’s a good story, and it might be true, but I don’t think there’s any proof as to that’s what’s causing this.

Phase two is the conjugation. You hand them $100 bill, or in the case of actual biochemical pathways, sulfation hands to the sulfur group, methylation hands to the methyl group, glucuronidation hands to the glucuronic acid, glutathione gets glutathione glycine, acetylation gets in the acetyl group. That’s the $100 bill. Now, it’s water soluble and happy. Now, it has to get out of the cell to go back into the interstitial fluid, which is water, to be excreted. That’s the other door and that’s phase three. Now, here’s the problem. There’s certain things that can block phase zero, like diesel exhaust has been shown to block food. It’s fairly new. It’s only been discovered in the early 2000s. But phase three, curcumin blocks phase three, piperine from black pepper, which is usually used with curcumin to make it more available, blocks phase three. Milk thistle, honestly, is a mild phase three inhibitor, as well.

And here’s the thing, so now you have this happy person that could leave that third door. Then you’re done with them. You’ll never see them again, because they get excreted. But here’s the problem, you know, beta glucuronidase, which undoes glucuronidation. There are other enzymes that can undo conjugation, which to put it back into the metaphor is, there are things that can take that $100 bill away from that person, whether it was sulfation or methylation. Can take that $100 bill and, now, they’re the intermediate metabolite again. If you block phase three, and that person, metabolite, after phase two stick around inside that cell, now, the conjugation reaction can be undone. Now, it’s back in the intermediate metabolite. That’s why making sure that … This becomes my opinion, at some point here, but I don’t know that we should be taking a lot of supplements when it comes to a detoxification program. Because the reality is, and I can go head-to-head with a lot of people on some of these things, it’s really hard to say whether something actually improves detoxification or not.

Not from enzyme activity, or MRNA expression, for these proteins. There are all these things, but if it actually … What I’ve looked at, which is biphasic response, is that food, and the doses that are found in food, will generally stimulate detox … There was one great paper, by the way, that looked at food-based curcumin and isolated curcumin. Food based stimulated detoxification pathways and isolated absolutely inhibited. In fact, conventional medicine … Think about cancer, think about chemotherapy. What they really want is to keep that chemotherapeutic agent inside of the cell, so that it can fight cancer, correct?

Based on what we’re saying is that best way to do that is to block phase three. If you close that second door, you keep inside that cell whatever is inside that cell. If it’s a chemotherapeutic agent, that’s what you want to be able to exert more of an effect on cancer. What is conventional medicine using as a potential phase three inhibitor to help augment, or improve, chemotherapy? Is curcumin, so should curcumin be in a detoxification program? If it’s truly detox, you want to open up phase zero, have phase one and phase two working very well, and keep that second set of doors wide open, phase three, so that stuff can actually get out. Then, for the third part of the detox, is to be excreted via sweat, via bile and poop, via urine, or, like I said, technically, salivate, saliva, or tears.  I don’t know if that answers the question. But that’s phase zero. Phase zero is entry into the cell. Phase one redox, oxidation, the hydroxyl group is added or exposed, intermediate metabolites, sometimes more toxic, not always. Phase two conjugation gets handed something. Phase three exits the cell and then is excreted, as long as the body is excreting.

Dr. Weitz:            Interesting.  In order to promote excretion, you talk about using particular fibers and binding agents to help get rid of some of these toxins?

Dr. Walsh:           Yeah. What I did, again … Bentonite clay, I’ve been familiar with bentonite clay, as a fitness professional, and different types of fibers, and all these things. But what I wanted to do was look to the literature and say, “Well, what actually shows an improvement in the excretion and, not necessarily, of xenobiotics, but of bile.” So like a bio-acid sequester, like cholestryramine, the old cholesterol lowering drug, bound up bile to excrete it. If we can bind up bile, because so many xenobiotics are found in bile, and is their primary form of excretion, we need to bind up bile. We need to bind up all the stuff in the gastrointestinal tract for a variety of reasons, but I tried to find things that had some scientific basis behind it, so things like charcoal, for example, fiber, soluble, insoluble fiber.  An interesting one is chitosan or ketosan, which is typically used for fat loss, not very well. But there is papers showing that it is, actually, effective at increasing xenobiotic excretion via bowel habits. The other big one is sweat. You have to sweat. In fact, I recently came across a paper that, the short version was and, again, if I come back in a future life as a lab rat doesn’t sound very good. They had two groups of mice or rats and they gave one group a pretty significant burn on their skin, which is unfortunate. They injected both sets of mice with a certain xenobiotic and, not surprisingly, the ones that had a burn had higher levels of this environmental pollutant, because skin is such a major route of excretion. And, in fact, is the preferred route of excretion of some xenobiotics, not all, but some.

So if somebody is not actively sweating, during this hypocaloric phase, then I don’t think we’re getting rid of as much as we need to. To the point then, this is a bold statement. But I have some more papers that I’ll be adding as some bonus content coming down the pike. This stuff just blows your mind, blows your mind. I would not, myself, my family, or any patients, or clients put them on a fat loss program without supporting detoxification pathways, period. If they couldn’t sweat, I would say, “You probably don’t want to do a detoxification program.” If it’s really … I’ll just give you a tip on some of these things. There’s evidence that weight loss actually increases one’s risk for dementia, cardiovascular disease, diabetes and cancer, very strong, and the author cite this as a reason. Weight loss induces mobilization of xenobiotics. They go up and if you’re not getting rid of them, cause damage to cells way down the level.

Now, you look good in sexy jeans, or skinny jeans, but in 20 years might have cancer, or dementia, because of the weight loss. And, in fact, a steady increasing BMI, as one ages, seems to be protective over some of these thing, which is counter to what we want to look like, ourselves, but it’s very compelling stuff. Yeah, this is real, man. I would not do a fat loss program without making sure I was sweating and excreting and supporting detox. I would not. I would not put a patient on one, because I think that the detriments are too strong.

Dr. Weitz:            Sounds good. I know you’re a fan of infrared saunas, or a particular type of infrared sauna, right?

Dr. Walsh:           Well, you know, no, actually. I don’t like steam rooms, because of the water that they’re potentially using. I think that you can have a lot of model organic compounds found in steam. Again, unless it was purified water. But, no, here’s the thing. Again, I try not to have much of an opinion, but base it off of what I’ve read in the literature. Interestingly, in the literature, when they collect the sweat they’ll have a cohort of people to collect their sweat to look at xenobiotic levels. But they don’t tell them how to sweat. So, whether it’s via exercise or in a sauna, it didn’t matter. That when you sweat, you excrete. There’s people out there that might split hairs about a far infrared sauna and a near infrared sauna or the old ones, which are called the radiate heat saunas.  Listen, from what I’ve read, I tend not to like to split hairs over things, just sweat, man. If all you have is an old coal one, and you pour your water on it, and that’s all you have. That’s fantastic, do it. I love near infrared, personally. I think far infrared are interesting. There’s some questions about the electromagnetic frequencies, and stuff, and some of those things. But the goal is to sweat. I don’t care how somebody … In fact, I have people contacting me about my program. They’ll say, “I don’t have access to a sauna, but what if I went up into my attic?” I’m like, “As long as it’s not filled with asbestos or all this toxic stuff up there, then fine. Listen, sweat. It doesn’t matter.”  I like how the near infrared saunas feel and the bright red lights. But, no, I think to say one’s superior is myopic, personally. I think just sweating, according to science, is the most important aspect.

Dr. Weitz:            Interesting. I got that from an interview you did with Mercola. Maybe it was Mercola who liked the near infrared.

Dr. Walsh:           Yeah, he likes near infrared more than far.

Dr. Weitz:            Okay.

Dr. Walsh:           But that’s splitting hairs. To me-

Dr. Weitz:            He didn’t like the EMF thing about it.

Dr. Walsh:           No, just to sweat is the most important aspect.

Dr. Weitz:            Let’s go-

Dr. Walsh:           I would say this … Sorry to interrupt. What’s nice about the sauna, though, is it’s controlled. You can control the temperature and the time, so that, in terms of knowing the quantity that you’re sweating. That’s why I suggest the sauna, but if someone doesn’t have access to it, just sweating is what’s important.

Dr. Weitz:            Let’s go over one more thing. This will be the final question. Is part of your program involves … I know you have a 10-day detox program and part of it includes a four-day version of the Fasting Mimicking Diet that’s been popularized by Dr. Valter Longo, who sells you this box, or his company, and people who are part of this program called, ProLon, sell you this box of pre-packaged foods that you open up and make soup and things like that. You basically have put together a program that involves using real food, but to create the same effects.

Dr. Walsh:           Yeah. The short version is, if someone’s never done a detoxification, just an average person, that maybe has never done one. I recommend doing what I put together, just my view on this, is a 10-day program. The first six days, because of what you talked about, is the very high nutrient … It’s low calorie. It’s hypocaloric, you have to mobilize, but it’s fairly high protein. It’s high protein to ensure that, whoever this average person is, that maybe wasn’t eating perfectly, isn’t particularly healthy, might be protein deficient, or I should say, amino acid deficient. That they have the sulfur groups, and they have the methyl groups, and they have the glycine and all the precursors, the glutathione, in order to really support those phase two detoxification pathways.

That’s why I recommend the 10-day program for somebody who hasn’t done it before. That’s the first six days. Then the last four days, or someone could do five, if they wanted. It is what I refer to as a modified fasting mimicking diet.  Now, I think the work that Longo did is … the papers are brilliant. I think they’re fantastic. The findings of these things are so interesting.  My concern, however, is that every paper that I’ve looked at, where any mammal goes hypocaloric, their xenobiotic levels go up, period. He’s looking at this from diabetes reversal, and autophagy, and mitophagy, and all these health promoting effects, and that’s great.  However, instead of … So the macro-nutrient ratios that he’s come up with are brilliant. The calorie levels, which I won’t get into, but I think that should be based on one’s weight, rather than just having set calorie levels.  So a very hypocaloric diet with very specific macro-nutrient ratios.

Dr. Weitz:            By the way, what are those macro-nutrient ratios?

Dr. Walsh:           It depends if it’s … According to the one paper that I use, that have the specific ratios. Honestly, it’s basically ketogenic.  It’s very low calorie, first of all, but it’s moderate carbohydrates, very, very low protein.  In fact, you can, in what I put together, you can reach your protein levels just by eating vegetables for that are required.  It’s very low protein, which there’s no additional protein that’s actually consumed.  The amount of protein found in the vegetables that I consume, you hit your mark.  Then a little bit of fat.  It’s like carbs, protein, and fat, so that somebody can be in a ketogenic state and not push themselves out. My concern with his work, however, is while really compelling stuff that he’s produced is what about this xenobiotic thing? What about these papers that I’ve seen that show that, if you lose weight, or if you mobilize, and that can cause some other chronic conditions or situations much later in life? Instead of just saying, “Here’s some soup or here’s some avocados and some tofu, or whatever it is to reach the macro-nutrient ratio level that he recommends.” I recommend specific food that, according to the literature, have been shown to support detoxification pathways.

I mean, again, what he’s put together is brilliant. I think it’s genius. I think it’s fantastic. I have no problems with it, other than, if you just eat rice and avocados to meet those macro-nutrient ratios, you’re basically doing nothing to help support detoxification pathways. And these people will have increased environmental pollute levels in their blood, period. I say, instead of eating foods to meet the macro-nutrient ratios, eat specific foods that, according to the literature, have been shown to support detoxification impact. That’s the 10-day.

Now, what I do recommend for someone, like yourself, however, if you’d really wanted to do a good detoxification program over the course of a few months, is not to do … You’re a healthy guy. You eat a healthy diet. You live a lifestyle. I think that you could do two four to five day fasting mimicking diets a month. In week one, you might do four or five of those days. Then, again, in week three do another four or five days. And the next month, do the same thing. So you don’t need to do the full 10 days, because arguably those last four or five days, where it’s really hypocaloric, that’s where you’re going to get the maximum, and it’s time restricted eating, you’re going to get the maximum mobilization. And if you’re eating the right foods … I have some evidence that this absolutely lowers xenobiotic levels.  For someone, like you, that’s already healthy, I don’t think you need to do the 10 days. I think four to five day, modified fasting mimicking diet, a couple times a month would be the most effective way.

Dr. Weitz:            Awesome. It’s been a great interview Dr. Walsh. How can we find out about your fasting programs and the other programs you offer?

Dr. Walsh:           Remember, I don’t agree just with fasting. I think we’re too sick to-

Dr. Weitz:            I’m sorry. I’m meant your detox programs.

Dr. Walsh:           I know.

Dr. Weitz:            How can listeners and viewers-

Dr. Walsh:           Yeah. If you go to drwalsh.com, D-R-W-A-L-S-H dot com, backslash detox, that’s all you have to do. Then there’s a funny little picture of me with two buttons. One says, “Practitioner,” and one, basically, says, “Non-practitioners,” because I created two programs. The practitioner version of this goes into great detail. They both go into the science. I show the studies on the screen. I walk people through the pathways on the whiteboard. Again, I don’t want to tell people what to do without having the reason why the recommendations are there. So that they’re knowledgeable and empowered and understand why they’re doing these things. Why everything is in the program that’s in there. I don’t just say, “Take these potions and detox.” I want them to know. The difference in the programs is the practitioner program is about nine hours. The non-practitioner is about four hours of video. The practitioner program goes in way more detail in the biochemical pathways of phase zero, phase one, phase two, phase three. I go heavier into the science. It’s more technically detailed, but they both have the same output, where it’s, here’s the program, here’s how to do it.

Dr. Walsh:           When I add on some of these additional, bonus, content features, both programs … And the practitioner program, if a practitioner gets the practitioner program, they also get the non-practitioner program for free.

Dr. Weitz:            Great. Any other points of contact you want to give out for people who would like to get hold of you?

Dr. Walsh:           No, that website is the hub.

Dr. Weitz:            Good. Good. Excellent. Well, thank you, Dr. Walsh.

Dr. Walsh:           It was my pleasure. Thanks so much.