Brain Body Diet with Dr. Sara Gottfried: Rational Wellness Podcast 113
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Dr. Sara Gottfried discusses the Brain Body Diet with Dr. Ben Weitz.
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5:16 Dr. Gottfried decided to stop practicing McMedicine when she felt she had hit the wall. She was practicing in a conventional medical model and she was seeing 40 patients a day and she was trying to incorporate some Functional Medicine concepts that she learned from listening to the audiotapes from Dr. Jeffry Bland. She had a couple of kids in her 30s and she had PMS and depression and had gained weight and was on the path to burnout. And she wasn’t able to practice the quality of medicine that she was trained to deliver. She had to step away from this insurance-based system, since it had driven up the number of patients doctors have to see each day. Reimbursement has come down to the point where it is abusive to doctors and it has led to burnout and triple the rate of suicide among US physicians that’s even higher than war veterans!
10:32 Dr. Gottfried was a practicing gynecologist and her focus was mostly on using bio-identical hormone balancing and she had come to realize that this was just one node in the Functional Medicine matrix, which led her to write this Brain Body Diet book. She realized that so much of hormonal balance is mediated by the gut and she needed to pay more attention to the microbiome in her patients. Often they may not have any gut symptoms, but they may have increased intestinal permeability (leaky gut) or dysbiosis and decreased microbial diversity. Dr. Gottfried does a careful history and asks about exposure to toxins, such as glyphosate. And she may test for glyphosate with the Great Plains urine test. Dr. Gottfried likes to look at serum markers of hormones, thyroid, CBC, and glucose metabolism. She also likes to look at the microbiome by running Rob Knight’s American Gut stool test. Dr. Gottfried used to use uBiome, but the FBI just raided them. She may also do a basic comprehensive stool analysis like with Genova or Doctor’s Data. Dr. Gottfried also likes to look at functional tests like calprotectin, lactoferrin, and sigA.
17:15 Dr. Gottfried talks about toxins in her book that affect brain health, including glyphosate, heavy metals like lead (which is a dementogen), cadmium, and arsenic, and EMFs. We know that EMFs are associated with brain cancer and increased oxidative stress. There is also Bisphenol A, which is an endocrine disruptor, a disruptor of insulin, and an obesogen. Other toxins include household cleaners with phthalates, flouride in toothpaste, flame retardants in furniture, sunscreens with PABA, and mosquito repellants with DEET. Also that new car smell that comes from pthalates is a toxin. Pesticides, herbicides, and fungicides in food. Toxins in our air and our water.
20:20 In order to help detoxify heavy metals and other toxins, Dr. Gottfried likes to use glutathione to mobilize the toxins and then binders like activated charcoal to bind to the toxins and take them out of the body in the stool. Modified citrus pectin and chlorella can both also be helpful. Leeks can help the body with glutathione production and N-Acetyl Cysteine is the precursor for glutathione and is very helpful, including the Metagenics product GlutaClear.
24:28 If a patient comes in complaining of brain fog and memory problems and there are no gut symptoms or other obvious causes, besides gathering a detailed history, what would be some of the lab panels Dr. Gottfried might order? She said that she always looks at hormones and she will often order a serum panel, but she is now a big fan of the DUTCH (dried urine) panel, which tells you about estrogen metabolism, metabolized cortisol, and the total cortisol load. She also likes to use the Genova NutraEval, which is a really comprehensive Functional Medicine panel that looks at vitamin and mineral status, antioxidants, fatty acids, amino acids, and heavy metals. Dr. Gottfried believes that carefully monitoring glucose is very important since so many patients have disrupted glucose metabolism. But just doing a morning fasting glucose does not tell you the whole picture. She wears a continuous glucose monitor as a way of measuring abnormal glucose signaling, since she may have good fasting glucose but she may eat a sweet potato and her glucose spikes up to diabetic range, so it gives such a more accurate picture. She may also order stool testing to map the microbiome and look for dysbiosis. If she wants to focus more on heavy metals, she used to do provocative urine testing for heavy metals [give the patient an oral chelator like DMSA and then measure a 6 hour urine] but now she tends to use Chris Shade’s Quicksilver heavy metals serum panel.
30:54 Sleep is super important for brain health. Dr. Gottfried cited sleep researcher Matthew Walker, who found that it is the deep sleep that’s associated with clearing amyloid beta and other toxins from the brain through the glymphatic system. Dr. Gottfried describes the gymphatic system as like a shampoo for the brain and she noted that it works best when you sleep on your side, esp. your right side. Deep sleep is also where neurogenesis and memory consolidation occurs. REM sleep is very important for emotional regulation and for prevention of depression and anxiety. She likes to track sleep using an Oura ring.
35:97 Food sensitivities and intolerances can play a role in brain health and gluten and diary are two of the most common sensitivities, though not everybody needs to avoid them. Dr. Gottfried has used Cyrex food sensitivity testing. For many patients, food sensitivities are caused by leaky gut, so she usually focuses on improving intestinal permeability, but that is a fairly difficult project. If you do an elimination diet, one of the difficult parts is when you start phasing foods back in and it is difficult to get patients to do it slow and gradually. If they add all the foods back in at once that they took out, they are more likely to relapse.
40:05 Hormone deficiencies in menopause increase the risk for dementia and Alzheimer’s in women. Dr. Gottfried explained that if she is seeing a woman in her 40s with brain fog. She will do a careful history and do some testing to look for nutritional deficiencies and probably put her on an elimination diet. If that doesn’t resolve symptoms, then she will usually look at hormone balance. In the first phase of perimenopause, where progesterone tends to drop first. She will often find that chasteberry is a really good solution. Dr. Gottfried also likes to do some genetic testing and look at the risk of clotting and of cardiovascular disease. And then she finds that having women start taking bioidentical hormones in their later 40s and early 50s, since cerebral hypometabolism starts in women at this age, and it is more effective and safer than giving hormones later. The Women’s Health Intitiative showed us that giving hormones to women in their 60s, esp. synthetic hormones, increases the risk of dementia and Alzheimer’s Disease. Dr. Goffried tends to prescribe estradiol in the Vivelle patch together with Prometrium, which is most proven.
Dr. Sara Gottfried is an MIT and Harvard trained Medical doctor, a board certified gynecologist, and she is also board certified in Preventative and Anti-Aging Medicine. Dr. Gottfried is also now the Chief Medical Officer of Metagenics. She has just written her 4th NY Times best selling book, the Brain Body Diet, and the book is available here. Her other best sellers are The Hormone Cure, The Hormone Reset Diet, and Younger.
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 or go to www.drweitz.com.
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 again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to Apple Podcasts, which replaced iTunes, and give us a ratings and review. That way, more people can find out about the Rational Wellness Podcast. Also, if you want to see the video version, you can go to my YouTube page, Weitz Chiro, or put in Rational Wellness Podcast into YouTube. And if you go to my website, drweitz.com, you can find show notes and a complete transcript.
Our topic for today is the brain-body connection, which is discussed in The Brain Body Diet, Dr. Sara Gottfried’s latest bestselling book, about how to understand and improve your brain health by improving the brain-body connection. Brain health tends to deteriorate for women as they age. And this can be related to toxins, gut problems, diet, lack of exercise, sleep deficits, blood sugar imbalances, stress, hormones, nutritional deficiencies, and other factors. One fact that Dr. Gottfried discusses that I found particularly interesting is that the enzyme that removes beta amyloid from the brain, and beta amyloid, as it accumulates, increases your risk of Alzheimer’s, is the same enzyme that clears out insulin, insulin-degrading enzyme. So, if you have higher insulin levels due to a lot of blood sugar spikes, your insulin-degrading enzymes won’t be available to break amyloid beta. Dr. Gottfried mentions in her book that a study from Harvard shows that only 13% of women can be classified as healthy agers, which means that they have no impairment of memory, physical fitness, or mental health, and are relatively free of major chronic diseases. She then lays out a series of steps that women can take to promote healthy aging of their brains and their bodies.
Dr. Sara Gottfried is an MIT and Harvard-trained medical doctor, a board-certified gynecologist, and also board-certified in preventative and anti-aging medicine. Dr. Gottfried is also now the Chief Medical Officer of Metagenics. She has written her fourth New York Times bestselling book, The Brain Body Diet, to go along with The Hormone Cure, The Hormone Reset Diet, and Younger, her three prior bestselling books. Dr. Gottfried, thank you so much for joining me today.
Dr. Gottfried: Oh, I’m so happy to be here. That was the most thorough bio I’ve ever heard in my life. And I love that you took maybe the most important takeaways that I have in my book. It just warms my heart that you noticed the insulin-degrading enzyme, and this fact that so few women are healthy agers. I think that’s alarming.
Dr. Weitz: It is.
Dr. Gottfried: So, thank you. Thank you for your careful intro.
Dr. Weitz: Oh, absolutely. I’d actually like to start this interview with a comment. I was preparing for this interview on Sunday afternoon, by reading your Brain Body Diet book, and I was sitting on my deck in my backyard, and I was sipping some organic red wine. And I came to your section on memory, and you wrote, “Alcohol impairs memory, erodes mental function, reduces brain size, and causes brain cell dysfunction. Makes you want to put down that glass of wine, doesn’t it?” So, if I have any trouble remembering what I want to say today, I have an excuse.
Dr. Gottfried: That’s so funny. Well, yeah, I don’t like to start with my feeling about wine, because it’s maybe the least popular message that I have. But let me say this. I think that, based on the epidemiology that we have, on especially red wine, in places like Italy, and Europe, Framingham study, we know that men probably do better with alcohol than women do. I think there’s certain reasons for that. Women have different sex hormones, we’ve got a different process in the liver. And I think part of the issue for women is that alcohol raises the bad estrogens, and leads to a greater risk of breast cancer, as well as other things. As little as three glasses of red wine per week. I think men can often get away with one to two glasses a day, without any adverse outcome. I just want to reassure you that I think you were okay in the backyard. It sounds like you were getting a little nature, maybe some vitamin D. All those things are good.
Dr. Weitz: Thank you. Dr. Gottfried, why did you decide to stop practicing McMedicine medicine, in your words, and switch to Functional Medicine, or integrative approach?
Dr. Gottfried: Well, I wish it were as simple as just deciding to stop, because, in some ways, I think I was forced to stop. My body forced me to stop. And I think a lot of clinicians come up against this. I imagine you have some listeners, a listener in particular, who’s got one foot in the allopathic medicine world, and one foot in the functional medicine, holistic medicine world. Trying to figure out how to reconcile those two worlds can be very tricky. For me, I was practicing some of the concepts that we have from functional medicine. I was listening to the Jeff Bland tapes in the ’90s, and I-
Dr. Weitz: I listened to every one of those.
Dr. Gottfried: You listened to them too? Yeah, you’re one of the-
Dr. Weitz: I had the little cassettes I used to listen to.
Dr. Gottfried: Right. I mean, there are people listening to this right now who don’t even know what a cassette is. I’m with you on that. But what happened for me is that I hit a wall. I hit a wall physiologically. I had so much stress, I had a couple of kids in my 30s, I was seeing 40 patients a day, and it just got to a point where I couldn’t practice the quality of medicine that I was trained to deliver. And I felt like I was failing my patients. I had patients who were coming to see me, and saying, “This antidepressant isn’t working. I have PMS. It doesn’t make sense to me that I would take Prozac every day.” Or, “I’m trying to deal with stress, and I’m not just going to go sit in a corner and meditate on a cushion. That’s not going to solve it. What else do you have for me?”
What I did is … I had my own health crisis. I went to my primary care provider, realized that what he was offering was totally wrong. Antidepressant birth control pills, because supposedly that helps with every hormonal imbalance. And I was overweight. I had issues probably with insulin-degrading enzyme. And so I decided, at that moment, that I couldn’t continue in McMedicine. That I was on this path towards burnout. And so I built a bridge, an 18-month bridge, to get out of there, and to build my own practice, the kind that would really serve patients the way that I felt like they needed to be served.
Dr. Weitz: Great. What did that bridge look like, if you don’t mind maybe just taking a minute. Because there probably are practitioners listening to this who are trying to figure that out.
Dr. Gottfried: Sure. Well, the cool thing is, you can start the education while you’re still in that allopathic realm.
Dr. Weitz: Of course.
Dr. Gottfried: I was listening to Jeff Bland, I was starting to do some of the things he talked about. I was starting to do really basic things, even in a seven to 15-minute appointment, I could talk about the elimination diet. I could order a fasting glucose and a fasting insulin. I could order a hemoglobin A1C. And so I could have conversations about those things, and we all know that something simple, like an elimination diet, which we’ve been using for almost 100 years, that can reduce symptoms, based on the MSQ, by 50%. It’s a pretty strong tool. So I started to practice in that way with education first, and then I built, with a coach, how to step away from the security of this insurance-based system, to opening-
Dr. Weitz: That’s the hard part, is when you’re taking insurance for your medical practice, how do you start building that functional practice, which is not insurance-based?
Dr. Gottfried: Well, it’s hard, and in some ways it’s very liberating, because the reality is that taking insurance has become increasingly difficult. It’s driven up the number of patients we have to see each day. Reimbursement has come down. And so it’s not a sustainable model. In fact, I would even say it’s abusive.
Dr. Weitz: Yes.
Dr. Gottfried: And it’s serious. It’s led to burnout, to the level that we have something like triple the rate of the baseline suicide rate among US physicians right now.
Dr. Weitz: Wow.
Dr. Gottfried: It’s higher than war veterans.
Dr. Weitz: Wow.
Dr. Gottfried: We have post-traumatic stress disorder. So we have a real crisis on our hands, and I think that the kind of medicine that we practice, Ben, lifestyle medicine, precision medicine, functional medicine, integrative medicine, whatever you want to call it, this is a solution to the burnout. And it’s also a solution that serves our patients better. It took me about 18 months to figure this out, to figure out, okay, where’s the location? What’s the minimum, the MVP, the minimal viable product? What’s the pared down number of staff that I would hire? Malpractice insurance, all those kind of pieces, it took a while. It took 18 months to get those together.
Dr. Weitz: Okay, cool. Thanks for some of those insights. I’m sure that could be a long conversation at another time. Why did you decide to write this new book, the Brain Body Diet?
Dr. Gottfried: I wrote it for a couple of reasons. I’m a board-certified gynecologist, from my allopathic days. And so the way that I tend to take care of patients is starting with hormones. The way that … my focus has been, for 20 years, bioidentical hormone balancing. But what I realize is that it’s only really part of the story, especially when you consider the matrix of the Functional Medicine model, and you realize that hormones are just … it’s one node in the matrix. I realized, based on my own health issues, which always feels like a message from the universe about what I need to pay attention next, I realized that so much of hormonal balance is mediated by the gut. And I needed to pay more attention to it. And maybe most importantly, I realized that my patients who had no gut symptoms, so they didn’t have gas or bloating or constipation, or diarrhea, or irritable bowel syndrome, they had gut issues. They had increased intestinal permeability, they had reduced microbial diversity. And they had dysbiosis, even in the absence of GI symptoms. This is what got me to pay attention to this. And as I started to dig deeper, I realized, oh my gosh, the way that we’re treating anxiety, the way that we’re treating depression, the way that we think about cognitive decline, really needs to be reset. We have to change the paradigm. And we really have to put the gut, microbiome brain access, at the center of this.
Dr. Weitz: Yes. That’s great. How do you try to analyze the gut to see what might be going on that might be affecting brain health?
Dr. Gottfried: Well, I still think it’s helpful to ask, to do a thorough history and physical. I think you can get a lot from that. I use the MSQ for all of my patients. Do you use it too?
Dr. Weitz: Yes, absolutely. It’s incorporated into the initial paperwork, yeah.
Dr. Gottfried: I find that so helpful. But when I go back and I look at my patients, so few of them have gut symptoms. So the way that I assess it, in the history, I’m thinking, in particular, about the gut disruptors. I’m thinking about antibiotics, how many courses have you had? Because we know, even a single course of antibiotics is associated with a greater risk of anxiety, depression, insulin resistance, obesity, diabetes, learning and memory problems. And multiple courses, the rate goes up. I ask about that on history. I ask about food, of course. I’ve got a food-first philosophy. I imagine you do, too.
Dr. Weitz: Sure.
Dr. Gottfried: And then I also ask about other toxins. Things like glyphosate. Things that disrupt the integrity-
Dr. Weitz: Glyphosate’s contained in Roundup, which is an herbicide, a pesticide, that’s often sprayed on foods, and especially in genetically modified crops.
Dr. Gottfried: That’s right. And when I started to test my patients for glyphosate, I was really surprised at how many of them had a toxic load of glyphosate, even though they were eating primarily organic food.
Dr. Weitz: You use that Great Plains urine test?
Dr. Gottfried: I use Great Plains. You asked about assessment. I start first with some of the blood biomarkers that I think are helpful. I want to know about stress, and cortisol, and the hypothalamic-pituitary-adrenal-thyroid-gonadal axis, of course, that’s my focus. And we know that, if you are someone who’s chronically stressed, the high cortisol can poke holes in your gut lining, can disrupt the integrity of your gut lining. And then I look at other things too. I want to measure inflammation. I want to look at white blood cell count, I want to look at leukocytes and neutrophils. I want to look at glucose metabolism, because the gut is so intricately involved in insulin resistance. I do look at the microbiome. I think this is somewhat controversial, and a lot of people would say it’s not quite ready for prime time. But what I tend to use is Rob Knight’s test (American Gut), which also is one of the most affordable. I previously used uBiome, but the FBI just raided them, so I don’t use them anymore.
Dr. Weitz: Really? I didn’t hear about that.
Dr. Gottfried: Yes. I do some of the basic, comprehensive stool analyses, like with Genova, or Doctor’s Data. I try to mention at least a couple of labs here, so that I’m not associated with just one. And I like to look at functional tests, things like Calprotectin, as well as lactoferrin, sigA. I’ve done a lot of testing of intestinal permeability. I wish we actually had better tests of intestinal permeability. I end up with a mix, and I want you to answer this question, too. I end up with lactulose-mannitol as the gold standard, although I wouldn’t really say it’s gold, I think it’s more aluminum or tin. And then I look at things like zonulin, Cyrex array. But tell me what you do. What kind of testing do you do?
Dr. Weitz: A lot of times we’ll do a stool test that includes zonulin. But a lot of times it’s not positive, even when we’re pretty sure that they have leaky gut. In most of the patients who have any kind of dysbiosis, I’m just assuming that they have leaky gut, because it’s so common.
Dr. Gottfried: Sure.
Dr. Weitz: We used to do the lactulose-mannitol test, but it’s not my priority right now. So I’d rather know what’s going on in the gut that we can try to rebalance things first.
Dr. Gottfried: Absolutely.
Dr. Weitz: I’m more interested in doing a good stool test.
Dr. Gottfried: I agree with that. I think about the lactulose-mannitol test, and I’ve been using it for maybe 15, 20 years, whenever I first started doing this, and I think about sitting on your back porch, drinking a glass of organic red wine. And I know, if I do the lactulose-mannitol test on you before you have that glass of wine, versus after you have the glass of wine, it’s probably going to be different. Because we know that alcohol is what we feed animals to test for leaky gut-
Dr. Weitz: But I sprinkled some probiotics in my wine.
Dr. Gottfried: Oh, good. Okay. You’re well-covered. A little bone-broth chaser.
Dr. Weitz: Exactly. You talk about various toxins in your book that can affect brain health. What are some of the most common toxins that affect brain health that Americans come into contact with? I know you just mentioned glyphosate. What are some of the others?
Dr. Gottfried: Well, unfortunately, the list is very long. I think heavy metals are at the top of the list. We all know about mercury toxicity, that’s something that I’ve talked about a lot in my books. But I was amazed to find, in myself as well as in my patients, higher lead levels, higher cadmium levels, higher arsenic levels. And I think, increasingly, our food and water is exposing us to some of these toxins. We know that EMFs, for instance, have some modest data. It’s not as strong as I would like it to be, but it’s a little tricky with EMFs.
Dr. Weitz: Right. So you’re talking about the radiation from cellphones, and laptop computers, and wifi in our home, et cetera.
Dr. Gottfried: That’s right. That’s associated with a couple of different brain cancers. We know that it increases oxidative stress, especially if you’re holding the phone next to your head. We think that probably increases risk. Bisphenol A is another one. BPA is brought up anytime we talk about endocrine disruptors. But it’s much deeper than just a xenoestrogen or a disruptor of insulin, which it is, it’s an obesogen that makes you fat, and insulin resistant. It’s also, it does other things to the brain. In terms of disrupting the hypothalamic–pituitary–adrenal axis. It’s one of the bad players. I’ve got a list. You made me think of the table that I have in my book, where I go through a list of these toxins. The other thing I think about with lead is that it’s a dementogen. It’s one of those toxins that robs you of IQ points. And we don’t want to be exposed to this, but we know, from the example in Flint, Michigan, that many-
Dr. Weitz: Yeah, horrible.
Dr. Gottfried: … of us are exposed in our food supply. I found it in my lipstick. So, for those of you who are listening, and you are a woman, or maybe gender non-binary, and you wear lipstick, take a look at your lipstick. Because if it’s not organic, there’s a good chance it contains lead.
Dr. Weitz: Absolutely.
Dr. Gottfried: I have a few others listed here. Household cleaners that contain phthalates. Fluoride in toothpaste. Flame retardants that are in furniture. Sunscreen that contains PABA. Mosquito repellent with DEET. That new car smell, that’s a toxin for the brain. It disrupts thyroid function, too, which can affect your brain’s ability to focus. And then there’s a long list of food. But I think water and air are some of the exposures that I think we really need to be thinking about, not in a doom and gloom way, but how do we reduce exposure on the one hand, and then how do we detoxify?
Dr. Weitz: How do we detoxify? What’s the best way to get rid of heavy metals, and some of these other chemicals?
Dr. Gottfried: Well, this is a great question. This is fun to riff with you, because I imagine you’ve been dealing with this for a few decades.
Dr. Weitz: Of course.
Dr. Gottfried: And when I first started dealing with it-
Dr. Weitz: I’ve been in practice for 30 years, yeah.
Dr. Gottfried: You’ve been in practice for 30 years, so longer than me. And I was taught, when I went through my training, to use chelators. And so I had a whole system for how to do that. And what I’ve learned, especially from Chris Shade over the years, is that it maybe be better to focus on glutathione, and to support the detoxification pathways in the liver. I’ve shifted. There’s still some … there’s a time and a place for chelators, but I have shifted toward really focusing on glutathione as the master detoxifier and antioxidant. But I’m curious what you would say in response to this.
Dr. Weitz: Well, no, I totally agree. After finding out about so many patients that we referred for a chelation, who got worse, or had all sorts of adverse symptoms, and even after long courses, that the glutathione, and then binders to capture it, seems a much better strategy.
Dr. Gottfried: Yes. I’ve been using his PushCatch quite a bit recently. And I like his binder. I looked at the data on binders, and I wish we had more robust data on the binders. I use them. I think activated charcoal is probably the most proven, but I like his PushCatch system. I can’t think of an alternative that’s similar to that. There’s lots of companies that make activated charcoal and other binders. Do you have any other supplements that you use for binding?
Dr. Weitz: We’ve used modified citrus pectin, I got into a whole discussion with Chris about this. He doesn’t think that’s a very good binder. But Isaac Elias, he has some data showing that it binds lead and certain other heavy metals pretty effectively, so that’s one we’ll throw in there.
Dr. Gottfried: Yeah.
Dr. Weitz: Chlorella.
Dr. Gottfried: Right. Yeah. There’s hope that that makes a difference. There’s certain foods that I think can really help you with glutathione. I don’t think, for some of us, that it’s quite enough. I’m someone, I don’t have glutathione S-transferase, and so I just need to take liposomal glutathione. And I have a fair number of patients … the ones, the canaries in the coalmine, the ones who really have the symptoms from toxic overload, tend to have trouble producing glutathione. So, yes, you can get it from your food. Always a good idea to start there first, but I think a lot of people who have to detoxify, need something more.
Dr. Weitz: Right. A lot of people talk about onion, garlic …
Dr. Gottfried: Leeks.
Dr. Weitz: Leeks, yeah, as being beneficial for stimulating glutathione production.
Dr. Gottfried: Right.
Dr. Weitz: And of course NAC, which we’ve used for years, which is an amazing compound for so many things.
Dr. Gottfried: I love N-acetylcysteine, because it’s got such a great safety profile, and yet it’s so well-proven. This is one of the few supplements that I would say mainstream medicine has actually embraced, because we use it in the emergency room, when someone comes in with Tylenol poisoning, as an example. So, I think it’s one of the … I’m always looking to, how do we build bridges between the allopathic world, and this more integrative, functional world. And I think, with proven supplements that have randomized trials, like N-acetylcysteine, that’s where we start.
Dr. Weitz: Yeah. Well, good luck.
Dr. Gottfried: Exactly.
Dr. Weitz: I’m sure there’ll be-
Dr. Gottfried: How much energy do you have?
Dr. Weitz: I’m sure there’ll be a negative study on NAC next week, and then …
Dr. Gottfried: Exactly.
Dr. Weitz: In the American Journal, in the AMA Journal.
Dr. Gottfried: That’s right.
Dr. Weitz: If you have a … what would be a set of tests that you might do? Let’s say you have a patient who comes in, they’re complaining of brain fog and memory problems. And you go through their history. What might be a set … we’ve talked a little bit about panels, but I’m wondering, what would be some of your go-to panels?
Dr. Gottfried: Sure. Let me just apologize, because I have no air-conditioning, and it’s 100 degrees outside. Because my power just went out, so I’m going to strip here.
Dr. Weitz: Oh, okay.
Dr. Gottfried: It might make more people go to the video, we’ll see.
Dr. Weitz: Exactly.
Dr. Gottfried: Maybe not. This is such a good question. Again, I’m a hormone doctor, so the way that I think about this, especially in a woman over the age of 40, is I’m thinking first about estradiol. Because estradiol is the master regulator in the female body. We know that when it comes to perimenopause, even the most subtle, early changes that begin at 40, that there’s a central effect with cerebral hypometabolism, as a result of the loss of estradiol. And you may not measure it peripherally. You could do a serum test, a blood test, measuring estradiol, and you may not see a change. But there are brain effects that have been documented very well by Lisa Mosconi at Cornell, showing that 80% of women have cerebral hypometabolism, so they start to have the symptoms that you’re describing. Brain fog, they walk into a room, and they can’t remember why. They start to have vasomotor symptoms, maybe sleep becomes disrupted, and it becomes this snowball, that I think leads to much greater health risk as they get older.
What kind of panels do I do? I start with serum panels, because again, that’s part of building this bridge. I think we’ve got good evidence with serum estradiol levels, as well as other hormones, like cortisol, and DHEAS, and testosterone, free and bioavailable, in total. I look at progesterone, and then I’m a big fan of the Dutch test. I wonder if you do this too? I think it gives you so much more information in terms of-
Dr. Weitz: Yeah.
Dr. Gottfried: … estrogen metabolism, how much metabolized cortisol, the total cortisol load. How do you use that?
Dr. Weitz: We just started using it. I was doing the 24-hour urine test, because I like to look at the metabolites, because I think that’s super important for breast cancer risk and everything else. So we just started using the Dutch test more. And I think it’s great, and it’s so convenient, easy for patients to use.
Dr. Gottfried: It’s easier than saliva testing. I actually think, at least what I’m seeing in my patients, I think the data is more reliable. And it’s … I’ve just found that it’s been a real game-changer in the way that I take care of patients. That’s one of the panels. The other basic functional medicine panels that I do, I tend to use a Genova NutrEval. Other people use the ION. Other people are religious about organic acid testing. I do that as well. But I tend to start with a combination of serum testing of sex hormones, as well as a larger panel. I always think about glucose metabolism, because we know it’s disrupted in at least half of our patients, if not more. In fact, I wear a continuous glucose monitor, because-
Dr. Weitz: Oh, cool.
Dr. Gottfried: Because I think glucotype is so important. Our ways of measuring abnormal glucose signaling, I think are 30 years ago. They’re so 30 years ago. Fasting glucose, fasting insulin, hemoglobin A1c, we miss a lot of patients who are like me, who have a sweet potato, and my glucose goes up to the diabetes range. And that’s … I can talk about the reasons for that, but I think understanding how this might map onto symptoms like brain fog, and this gut-brain axis issue, is really essential. So those are some of the tests that I tend to start with. What about you?
Dr. Weitz: That’s great. Yeah, no, I love the NutrEval. I love the fact that it includes organic acids, amino acids, fatty acids, it’s got some heavy metals, it’s got some oxidative stress markers. It’s a really neat, general screening tool. I love that test-
Dr. Gottfried: It’s kind of one-stop shopping.
Dr. Weitz: Yeah. Yeah, yeah, yeah.
Dr. Gottfried: And I like to keep this as simple as possible, and it also, I think, for the most part, for patients who have insurance, it’s well-reimbursed. So they have a good pay assured price. I like to do that to start with. Often you end up dissecting after a NutrEval. I tend not to do serial NutrEvals. I use that as a screening test. And then, from there, I’ll order organic acid testing, from Great Plains, and then I’ll do some additional stool testing, and I’ll look more at heavy metals. I tend to use Chris Shade’s quicksilver testing to look at heavy metals.
Dr. Weitz: Oh, okay. Have you done provocative urine testing?
Dr. Gottfried: Well, I’ve done a lot of provocative urine testing over the years. I do less of it now. I still think there’s a time and a place for it, because I believe in Chris Shade’s science, for the most part. And I think his way of measuring heavy metals makes a lot of sense to me. There’s mixed data on provoked testing. Here’s where I think it’s helpful. We know, especially for women who reach their peak bone mass at somewhere around 30 to 35, that they tend to store a lot of heavy metals in their bones. And so I think provocative testing, especially in a woman before age 50, can be very helpful to try to unroof some of that heavy metals that are hiding behind the bone matrix. How about you?
Dr. Weitz: Yeah, I think that’s actually one of the keys for detox, is if you’ve got a woman who’s losing bone, and she’s liberating more heavy metals, you’re never going to get rid of the heavy metals until you stabilize her bone metabolism.
Dr. Gottfried: That’s right. Totally agree.
Dr. Weitz: Let’s see, we talked about that. You write about the importance of sleep for brain health. And you write in your book, “Lack of sleep affects neurogenesis, particularly in the hippocampus. You can even develop false memories if you lose sleep.” So, if you were to stay up half the night tweeting, you might think that thousands people who are protesting you were actually cheering you. Just kidding.
Dr. Gottfried: Oh, that’s very funny. I didn’t realize we’re going to be-
Dr. Weitz: No, no, but-
Dr. Gottfried: … talking about politics, too. This is going to be funny.
Dr. Weitz: No, no, I’m kidding. But can you talk about the importance of sleep?
Dr. Gottfried: Sure, sure. Absolutely. I’m also happy to talk about politics.
Dr. Weitz: No, no, no, no. I don’t talk about politics.
Dr. Gottfried: The power just came back on. So I’m taking over here. I was just listening to a podcast with Matthew Walker, where I felt like he got into the details of sleep in a way that I found really captivating. What he talks about, he’s a sleep researcher, a PhD, so he doesn’t have clinical experience, but what he believes is that it’s your Deep sleep that’s associated with clearing amyloid beta and other toxins. So we know that the glymphatic system becomes its most effective when you sleep at night, and you have to have that full conversation with the glymphatic system.
Dr. Weitz: Can you explain what the glymphatic system is?
Dr. Gottfried: Yeah, so the glymphatic system is kind of like a shampoo for the brain, that’s how I describe it to my patients. It’s where the spaces, the interstitial spaces in your brain open up, and this cleansing process happens through your brain. It’s not the lymphatic system, it’s got a G in front of it. The glymphatic system. And it was only discovered, I think, 10 years ago. It’s a relatively new thing that we’ve found. The glymphatic system seems to work the best when you sleep on your side, especially the right side, and deep sleep is really essential for this. I use an Oura Ring to track my sleep.
Dr. Weitz: Cool.
Dr. Gottfried: And it’s not quite the same as a sleep lab, but I think a sleep lab is often very artificial. And I don’t know that it gives you the best data, other than to tell you whether you have sleep apnea or some other clinical diagnosis. But for the average person who’s trying to improve their sleep, like their deep sleep and the REM sleep, I think sleep tracking can be very helpful. You don’t have to do it every night. I think just getting a sense of what your issues are, and then working on them, designing an N of 1 experiment, can be very helpful.
And then REM sleep, we know, is really important for emotional regulation, and for prevention of things like anxiety and depression, as well as other what are called mental health issues, and I think are basically health issues. I think of deep sleep also as that place, as you mentioned, it’s where neurogenesis occurs, and it makes sense to me that not only are you clearing amyloid beta, but you’re also doing memory consolidation, and you’re working on emotional regulation. Those are some of the things that happen with deep sleep. Do you track your sleep?
Dr. Weitz: I have in the past, I haven’t recently, but I definitely … of all the things I do to promote long-term health, it’s the one I’m least good with.
Dr. Gottfried: Well, I think it’s close to a panacea as we have. And it’s interesting to me, because I feel like there’s certain topics, Ben, that people’s eyes glaze over when we talk about them. And I would say sleep is one, stress is another, sometimes food. People are just like, “Oh, yeah, yeah, I got that.” And yet, we know that common sense is not common practice, and so I feel like it’s on us to talk about sleep in a way that really magnetizes people to understand how it’s going to help their health, and what concrete steps they can take to make a change.
Dr. Weitz: Right. You mentioned food. What role do food sensitivities play in our risk for diminished brain health? Should we all avoid gluten and dairy?
Dr. Gottfried: Well, certainly, gluten and dairy are the most common food intolerances. And I see that all the time in my patients. I don’t know that all of us need to avoid them. I can tell you that I’ve got two daughters, and they both do fine with gluten and dairy, especially the gluten in Europe. They do especially fine with the gluten in Europe. They don’t have food sensitivities, and I think it’s remarkable, given how stressed teenagers are right now, with social media, and iPhones, and other pressures that they experience. I find that food sensitivities are incredibly common. The way I think about it is that it tells me that someone has increased intestinal permeability. And so I want to always be thinking of, okay, what’s the root cause? How do I help them with their symptoms? But how do I also address the root cause? How do I improve the integrity of their gut lining? I’m curious what you would say about this, because I’ve found, over the years, that it’s kind of a big project to improve intestinal permeability. It’s not the kind of thing where you just give them a jar of glutamine, and say, “See you in six weeks,” and they’re done. It’s not like one and done. It’s a much bigger project than that.
Dr. Weitz: Yeah, multi phases. You’ve got to try to see what’s out of balance in their gut, and you got to try to reduce the pathogens, and dysbiotic bacteria, and fungal overgrowth, and get the inflammation down, and strengthen the immune system of the gut, and do all those things. And then you’ve got to try to repair the gut, and then sometimes food sensitivities become a problem, so you’ve got to sort through those. How do you like to sort through food sensitivities?
Dr. Gottfried: This is another one of those moving targets, I think.
Dr. Weitz: You use Cyrex food sensitivity testing?
Dr. Gottfried: I use Cyrex. I sort of, honestly, I somewhat reluctantly use Cyrex. I think it can give me some helpful information, but often, what I find is, it just tells me what I know already, which is that I have to work on a 5-R protocol for the gut, and we have to focus especially on intestinal permeability. I used to use Alcat. I used to do …
Dr. Weitz: There’s many food sensitivity tests out there.
Dr. Gottfried: There’s many different food sensitivity tests, and so I used some that were more convenient than others. There’s some that allow you to do home testing. And I’ve found, over time, that they’re less useful than understanding that the patient in front of you has increased intestinal permeability. In pretty much anything they’re eating, they’re going to become somewhat intolerant to. To me, I think the name of the game is to understand what someone’s triggers are, and to help them, as close to the root cause as you can. But I also am careful not to do what I think of as root causeism, where all we’re doing is addressing the root cause, and we’re not helping the patient feel better as fast as they want to. Because they have to see results to continue to buy in.
Dr. Weitz: Yes.
Dr. Gottfried: So I think we do have to treat symptoms, along with addressing the root cause.
Dr. Weitz: Absolutely. Yup, yup, yup. And then, of course, we always have the elimination diet, which is the true-
Dr. Gottfried: And I actually … I’m a huge fan of the elimination diet. I was just looking at some data from so long ago, on rheumatoid arthritis, and the use of the elimination diet. Really strong data showing this is so beneficial. And I read that, and I think, “Oh my gosh, why doesn’t every rheumatologist know this?” I’m a huge fan of elimination provocation. I think that’s, in many ways, more useful information than an expensive Cyrex array, or some other food sensitivity testing. The problem is, a lot of patients, by the time they do three weeks, or three months of a food elimination diet, when they’re adding food back in, what I find, time and again, is they are not patient. They don’t do that one dose a day, watch for three days to see the response. They lose their minds, and they have a piece of pizza, and they have gluten and dairy, and tomatoes, and nightshades, and it’s-
Dr. Weitz: And they get symptomatic all over again.
Dr. Gottfried: And they get symptomatic, and you just lost all that time. So I’m a huge fan of a carefully constructed elimination provocation, where the patient really understands, okay, you have a clean canvas now, at the end of your three weeks or three months. And we need to take our time, and really understand your response to these test foods.
Dr. Weitz: Yeah. Let’s talk about hormones, and their relationship to brain health.
Dr. Gottfried: Yes, what would you like to know? I can talk about this all day long.
Dr. Weitz: I know, that’s your favorite topic.
Dr. Gottfried: Yes, it is.
Dr. Weitz: Perimenopausal, menopausal women, you’re having symptoms related to hormone deficiencies, estrogen, progesterone. Should we substitute bioidentical hormones? How much is that going to benefit their brain health? Which women should have that done? Should we try other alternatives first?
Dr. Gottfried: That’s a great question. The way that I think about this is a pretty simple network medicine, functional medicine, precision medicine formula, which is, I start first with what symptoms she’s having. Maybe it’s a 40-year-old with brain fog. I’m going to start first with doing testing, and understand what the root cause is, as well as addressing the symptom. I’ll probably put her on an elimination diet. For me, step one is to fill any nutrient gaps. We may find that she’s a little low on B12, or B6, or folate, and so we may top off some of those nutrients that she’s missing. Maybe she’s low in vitamin C, and so she’s not making enough progesterone. That’s often a low-hanging fruit for someone who’s 35 to 50.
Dr. Weitz: That’s a great clinical pearl.
Dr. Gottfried: Yeah, and then step two, if that doesn’t resolve symptoms, I’ll start to look a little deeper at what’s going on with hormone balance. And what I find, in the first phase of perimenopause, which is where progesterone drops, but estradiol can be fluctuating wildly, what often find is that chasteberry is a really good solution, because it modulates progesterone levels, it’s been shown to raise serum progesterone in randomized trials, and it’s one of the most proven herbs that we have in perimenopause. It doesn’t work once you stop ovulating, but there’s a window of time where I find it works really well. And then, if that doesn’t resolve symptoms, then I move on to bioidentical hormones. And I’m someone who’s pretty careful about it. I would say I’m not … on the spectrum of the people who are really heavy-handed with bioidenticals, and use … well, we can get into that topic, versus people who are scared to death of prescribing hormones, I would say I’m in the middle. Where I like to do genomic testing, I want to understand what’s your risk of clotting, what’s your risk of cardiovascular disease? How do we make a risk balance alternative balance sheet for you, and have a sense of here’s what your individualized risk is, and here’s why I am coming out in favor of or against using hormone therapy. But at the same time, I would say it’s not a yes/no question. I think it often is what type, what dose? What’s most proven?
You asked specifically about the brain, and I know you asked that for a specific question, because we know that … the emerging data is that there’s a window of opportunity for taking exogenous estradiol. And the window is much smaller, I believe, for brain health, than it is for, say, cardiovascular disease. We know from the Women’s Health Initiative, as well as some other trials, that the window’s about 10 years for cardiovascular disease, and it’s potentially dangerous and provocative to give it beyond that 10 years for menopause, so after age 60, although I have patients who consent to that, they understand the risk. But I think, when it comes to the brain, there are these subtle changes, the cerebral hypometabolism that I mentioned, that starts in 80% of women over the age of 40, and I think that’s the window for getting estradiol. I think we have to consider this as more a problem of middle age, a problem of women in their 40s and 50s, and really consider the benefits and the risks of prescribing bioidentical estradiol in that population much earlier. And we have data on this from women who go through surgical menopause, that earlier treatment makes a big difference in terms of brain health. The problem is, we have the wrong study, which is giving Premarin and Provera to older women over the age of 60, and it increased the risk of dementia.
Dr. Weitz: You’re referring to the Women’s Health Initiative, which used these synthetic forms of estrogen and progesterone, and give a lot of them to women who were in their 60s, or 10 years or so past menopause.
Dr. Gottfried: That’s right. And what we found is that it actually increases dementia, it may increase Alzheimer’s disease. But I would say the problem is, it’s too late. And we know that when you put estradiol together with neurons, there’s a point, almost like a switch point, where the neurons respond well to the estradiol. We don’t know what that age is. It might be sometime in your late 40s, maybe early 50s. And then, when you give it after that, it can actually accelerate the decline of those neurons. So there’s this window of opportunity that we have to define better. And as we wait for better data, I can tell you that I prescribe estradiol to my patients. I usually give a three-quarters dose, like a estradiol patch, Vivelle patch, .0375 milligrams is one of my favorites, together with Prometrium, is what I think is most proven. That’s a standard prescription that I give for my patients who are in their 40s.
Dr. Weitz: Okay, great. We talked a little bit about nutritional deficiencies. I think that’s pretty much all the questions I had prepared for today.
Dr. Gottfried: All right. Well, it was a fantastic list of questions, I really appreciate it.
Dr. Weitz: Thank you, thank you. Any final thoughts, or insights for our listeners, about the brain body connection?
Dr. Gottfried: Yeah. I’ll finish with a quick story, because I love how Brené Brown talks about how stories are data with soul. In 2017, I took a month of antibiotics. I’d never had antibiotics before. And I turned this into an NF1 experiment, where I measured my microbiome before and after. But after that month of antibiotics, I had anxiety for the first time in my life, and I gained about 15 pounds. I had insulin resistance, and a lot of trouble with my fasting glucose and fasting insulin. And so that’s what got me to go to the literature, and that’s where I found this association between a course of antibiotics and the increased risk of anxiety, depression, learning and memory problems, obesity, insulin resistance. And I can tell you, when I went through my medical training, I was never told to give this kind of informed consent. I feel like this is a real game-changer. And I’ll give you one teeny little piece of data from my N of 1 experiment. When I measured my microbiome before and afterwards, I had an 87% reduction in the diversity of my microbiota. That’s pretty huge. And that’s anecdotal information, it’s only one subject, but it’s a subject who was studied over time in a scientifically valid manner.
And in many ways, what I was taught at Harvard is that randomized trials are really important. But the N of 1 study is even higher in terms of evidential hierarchy, because it allows you to personalize, it allows you to really know the individual, and not base your decisions on a population. I feel like that’s where we’re heading. That was part of what motivated me writing this book, and really diving into the literature. But I feel like that’s where we’re heading, with the way that we practice medicine, is to understand … we’ve got to think about how to address … the reason why I took these antibiotics after my surgery, there might be a better way to do this that isn’t a nuclear bomb for my gut microbes, and for those of our patients. It’s not me that’s so interesting, it’s that so many of our patients go through this. I’ve been prescribing antibiotics for 25 years, right? This is news to me, and it really changes clinical practice. I pay attention to those things that have really changed since we went through our medical training.
Dr. Weitz: Right. Are you still in clinical practice?
Dr. Gottfried: I am. I went on sabbatical, but I have to tell you, I have 10 patients that just would not let me go, so I still have these 10 patients. And then I’m planning to open my practice again next year. We have a clinic that’s opening in Aliso Viejo, kind of a clinic of the future. So I’m planning to see patients again, starting next year.
Dr. Weitz: Okay, great. So how can listeners find out about your book? And find out more information about you, through your website?
Dr. Gottfried: Yeah, the best place to go is BrainBodyDiet.com. That’s where we have a lot of information. We’ve got an anxiety documentary coming up. And that’s where they can learn more about the book.
Dr. Weitz: An anxiety documentary? Cool.
Dr. Gottfried: Yes. Which is basically functional and integrative medicine, to address anxiety, instead of just throwing benzodiazepines at it.
Dr. Weitz: Awesome. Thank you so much, Dr. Gottfried.
Dr. Gottfried: Thank you. Such a pleasure to be with you, Dr. Weitz.
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