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Nutritional Testing with Dr. Warren Brown of Genova Diagnostics: Rational Wellness Podcast 202

Dr. Warren Brown of Genova Diagnostics speaks about Nutritional Testing with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on March 25, 2021.

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


Podcast Highlights



Dr. Warren Brown is the 

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



Podcast Transcript


SIBO, A Personal Perspective: Rational Wellness Podcast 201

Shivan Sarna discusses a personal perspective on SIBO with Dr. Ben Weitz.

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


Podcast Highlights

2:30  Shivan recalls having food poisoning when she was five and then again when she was eight.  She spent a lot of time in the bathroom growing up due to constipation and she was called “Buddha belly” due to abdominal bloating. Then after college she found herself working in a moldy building and she was getting really sick. She went to a Gastroenterologist who told her that she had IBS and prescribed an antidepressant.  Shivan did a SIBO breath test and she was told that the results were negative, but it was actually positive but someone had written positive and then crossed it out and wrote negative.  She finally saw another doctor she calls the digestion detective, who showed her that it was clearly a positive test result.  She became an ideal patient and she sought various treatments, including seeing Dr. Allison Siebecker and going for Ayurevedic, rolfing, steroid shots for firbromyalgia, acupuncture, etc. and she took notes and became knowledgeable about SIBO and IBS.  Then Shivan started the SIBO SOS Summit One and then did SIBO SOS Summit Two and the IBS and SIBO Summit. Shivan also did the documentary Digestion SOS: Rescue and Relief for IBS, SIBO, and Leaky Gut. She also did the Microbiome Rescue Summit and then her book, Healing SIBO: Fix the Real Cause of IBS, Bloating, and Weight Issues in 21 Days, came out.

8:40  Shivan has post-infectious IBS that she learned through taking Dr. Pimentel’s IBS Smart test, which is a blood test that measure antibodies to Cytolethal Distending Toxin and to Vinculin.  The concept that Dr. Pimentel discovered is that after a bout of food poisoning, the bacteria secrete an endotoxin called Cytolethal Distending Toxin. The immune system reacts and creates antibodies to the Cytolethal Distending Toxin and then these antibodies cross react with a structural protein in the intestinal wall called Vinculin, which then damages the motility of the digestive tract. This is the autoimmune component of IBS and SIBO, aka, post-infectious IBS.

11:12  Essentially the IBS Smart Test tells us that IBS is an autoimmune disease.  There is a new breath test from Gemelli Labs called the Trio Smart test that can diagnose SIBO and the type of SIBO based on which gas is found, whether it be hydrogen, hydrogen sulfide, or methane.  Treatments include pharmaceuticals, herbals, or the elemental diet. For hydrogen and hydrogen sulfide the preferred pharmaceutical would be rifaximin, while for methane rifaximin would be combined with Neomycin.  The advantage of rifaximin is that it acts locally in the small intestine and it is not systemic, so it will not devastate your microbiome, which can happen with broad spectrum antibiotics.

13:40  Shivan took rifaximin but had to do multiple two week rounds of it.  She kept relapsing because her migrating motor complex was not working properly, so a key for her recovery was to take a prokinetic drug.  Shivan described the migrating motor complex (MMC) as the sweeping motion of the small intestine, which is like the crumb clearing that occurs when the waiter at a restaurant clears your tablecloth. If you have scleroderma or diverticulitis or endometriosis, these can all inhibit the migrating motor complex.  The collagen condition, Ehlers-Danlos, also negatively affects the MMC.  If the MMC doesn’t clear out the small intestine, then bacteria can overgrow and then the bacteria eat fermentable carbohydrates and it becomes like a microbrewery. It causes bloating, and can lead to nutritional deficiencies, anemia, rosacea, and restless leg syndrome.

16:05  SIBO breath test preparation.  This test requires a 12 hour prep diet followed by a 12 hour fast.  For the diet, there are no veggies. You can have white rice, eggs, chicken without the skin, and black coffee. You don’t want to eat anything that will take a long time to digest and that can cause fermentation. Shivan also suggests for the 12 hour fast to sleep as much of that time as possible.  She suggests to do the test at home instead of at the doctor’s office. It is best to pre-label all of the tubes ahead of time and so you don’t mess it up, it is best not to plan to do anything else during those 3 hours.  It is also helpful to have two timers, like two phones or a timer and a clock.  But this test is important to find out what your levels are and what type of gas you have.

18:43  SIBO can cause brain fog, which Shivan suffered both from doing the breath test and from SIBO.  Dr. Satish Rao has done an interesting study about brain fog and gut issues. (S. Rao, A. Rehman, S. Yu, N.M. de Andino.  Brain fogginess, gas and bloating: a link between SIBO, probiotics and metabolic acidosis. Clinical and Translational Gastroenterology: June 2018 – Volume 9 – Issue 6 – p e162.)

19:52  Does taking probiotics help with SIBO?  Do probiotics, which are bacteria, contribute to the bacterial load in bacterial overgrowth and make the condition worse?


Shivan Sarna, who was originally a patient, but Shivan has now become an expert at IBS and SIBO as a result of her experiences as a patient and due to her being the creator and the primary interviewer for the docuseries Digestion SOS: Rescue and Relief for IBS, SIBO, and Leaky Gut, as well as the SIBO SOS Summits. Shivan has now just published a book, Healing SIBO: Fix the Real Cause of IBS, Bloating, and Weight Issues in 21 Days.  

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


Podcast Transcript

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

                                Hello, Rational Wellness Podcasters. Today our topic is SIBO, small intestinal bacterial overgrowth, with Shivan Sarna. Now, we’ve certainly discussed SIBO quite a number of times. However, there’s always different perspectives, and today we’re going to get a little bit of a patient’s perspective, along with additional scientific information that she’s gleaned both from her own experiences, as well as being the primary interviewer and creator for the docuseries Digestion SOS: Rescue and Relief for IBS, SIBO, and Leaky Gut, as well as the SIBO SOS Summit.

                                And now Shivan has published a book, Healing SIBO. It’s a very readable, helpful book for anybody dealing with SIBO. And so, what is SIBO? SIBO is small intestinal bacterial overgrowth, and it is the most common cause of irritable bowel syndrome, IBS, which is the most common digestive disorder.  IBS is characterized by one or more of the following symptoms: abdominal pain, gas, bloating, diarrhea, constipation, sometimes alternating, nausea, and the urgent need to defecate, as well as a whole bunch of other symptoms. Sometimes skin issues, sometimes brain fog, et cetera. And so, Shivan Sarna, thank you so much for joining us today.

Shivan:                 Oh my gosh, thank you so much. I’m a long time listener and a huge fan. I appreciate it. I got to get the word out, man, so thank you for letting me talk about constipation, diarrhea, and bloating on your show.

Dr. Weitz:            Yeah. Hopefully, we won’t have constipation of the mouth. Maybe you can tell us about your personal journey with digestive disorders and SIBO.

Shivan:                 Before I tell my story, I always say I’m going to tell the story in a way that hopefully will help someone else. Not just like, “Ooh, what’s my story?” Because I usually … As an interviewer, I’m like, “Oh, is anyone going to listen to the story? What’s in it for you? I’m going to tell you.”  I had food poisoning when I was five. Then I had food poisoning when I was eight. Trip to India. Trip to a farm. And I was never the same afterwards. And the reason I know that, it’s not that I have these overly vivid memories of that time in my life, although I do remember the episodes. My father’s from India. My mom’s from Upstate New York.   And my dad, familiar with Ayurvedic basics, was like, “I don’t think Shivan’s going to the bathroom enough,” to my mom. And my mom made inquiries to me, the five-year-old. And that was the first time ever experienced shame. Like, “Really, am I doing something wrong? Get out of my beeswax. I’m five.”    But that was a big, like, “Is something wrong with me?” And they had a poster in the bathroom with this long quote on it and it’s the first thing I ever memorized, because I spent so much time in the bathroom. So, that’s the beginning. I grew up and we called it “Buddha belly,” with all respect to Buddha. And I’m skinny everywhere else, but I have this bloated belly, and-

Dr. Weitz:            So we’re going to talk about the spiritual aspect of SIBO.

Shivan:                 Oh, absolutely. Oh, honey. There is no doubt about it. It has taken me there. Lot of praying. Praying, expressing gratitude. It all blends together in my world.

Dr. Weitz:            There you go.

Shivan:                 So, I went to college and my girlfriends in the sorority house, they clearly didn’t have the same patterns that I had. I had been drawn into health food starting at age 15 with food combining, if you remember that. And just, I was different, which I’m used to. It’s fine, but there was something going on.  And then fast forward, I have this big career. I work in a moldy building that I didn’t know was moldy for 20 years, and I’m getting really, really sick. And people are asking me if I’m pregnant on Facebook, which I am not.  And that’s devastating for somebody who’s supposed to be an aspirational TV host. But I’m also really not feeling well. So, I finally go to a gastroenterologist, and the gastroenterologist is like, “Well, you probably have IBS. Run three miles. Here’s an antidepressant.”   And I thought, “Are you trying to tell me it’s all in my head? And I don’t have the energy to run a block, much less three miles.” So, I had this other girlfriend at work, and she was another weirdo, because we were gluten free, and we were weird. Fine. That’s fine.  And she told me … I saw her randomly and she’s like, “Oh my gosh. I’m doing this really crazy antibiotic, and I had to do this test where I breathe into this test tube. Got to go. Talk to you later. Bye.” And I was like, “What? Wait a minute.”   So, I got the information. She was not … She was wonderful, but did not know what the heck she was talking about. She was just doing what her doctor said. I did a SIBO breath test. Same thing, didn’t know what I was talking about. I was just like, “Whatever. Maybe it’ll help me. I don’t know. I’m desperate.”   And I got the wrong information, in that someone said it was negative, when actually, it was positive, and I lost 18 months. And when you’re chronically uncomfortable and you’re trying to figure out your diagnoses, you’re like, “Oh, don’t have that. Great.”   I begged for a colonoscopy on the last appointment before Christmas break. They were closing the outpatient clinic down, basically, as I was recovering. “Oh. No, I don’t have cancer.” Which is great, thank you. But, “Oh, don’t have cancer. What is it? What is it? What is it?”  So, it was difficult because I actually did have SIBO, but for 18 months of intense questing, didn’t know that was it. Finally went to a doctor who I call “the digestive detective,” and he’s like, “I want to see the results. I want to see that graph.”

Dr. Weitz:            Yeah, there’s a lot of differences in interpretation.

Shivan:                 Well, there it was. Someone had written “positive,” crossed it out, and wrote “negative.” And when you look at the graph, if you’re even mildly familiar with this, it’s so blazingly obvious that it was a positive result. So, that made me really mad and sad.   And my husband was getting his CPA as a grown-up, and so he was studying a lot. And I became, for the first time since the ’80s, someone who had a little bit of time on her hands. So I sat there in front of my computer and did Dr. Google, and took all my notes, and the typical chronic condition patient journey.  And I would go to all my doctor’s appointment. Ayurvedic, Rolfing, steroid shots for fibromyalgia, acupuncture, you name it. And every time I’d sit down, I’m like, “Here are all my notes.” I was super like, nerd patient. And they’d look at me and they’d be like, “You know, you really need to write a book.”   My spiritual teacher: “You know, you really need to write a book.” So I’m sitting there and I’m like, “Listen, God. I really need to tell the world about what I’m discovering, and if I figure it out, I will tell the world.”   What happened was, I was trying to write the book. It’s not that easy. I’m a TV person. I can definitely do an online summit. I can do video. I can do interviews. So, I started with the SIBO SOS Summit One, which Dr. Allison Siebecker was so pivotal in, because she introduced me to all of her colleagues.   And then, I did SIBO SOS Summit Two. I did the IBS and SIBO SOS Summit. I did the documentary you referred to, Digestion SOS: Rescue and Relief for IBS, SIBO, and Leaky Gut. Looks better on paper than mouthed. And then I’ve done the Microbiome Rescue Summit, and then the book came out, because I took everything I learned from these summits as well, and put it into the book.    So, that’s how I got here. I do have post-infectious IBS. I learned that from Dr. Pimentel’s blood test, which I know your listeners … Go back and listen to Dr. Mark Pimentel’s session, if you haven’t listened to it. So I know I have the antibodies, which we’ll explain, and therefore I’m very religious with the prokinetic, which we’ll also explain. And so, another message is, if you have a chronic condition that goes untreated, you can feel horrible. If you have a chronic condition that is treated, you can feel 100% better. And that’s what I do.

Dr. Weitz:            Right. So, for those listening who don’t understand about the autoimmune component, how you could take a blood test and tell you that you have SIBO, is that Dr. Pimentel discovered that one of the most common causes of SIBO is that somebody gets food poisoning, and the bacteria that causes the food poisoning causes an immune reaction.  And the immune system reacts against a toxin that that bacteria secretes, called “cytolethal distending toxin,” and then those antibodies, again, cytolethal distending toxin, then also react against a structural protein in the intestinal wall called “vinculin.”  And so, there’s a blood test that Dr. Pimentel developed, that measures antibodies to cytolethal distending toxin and vinculin. And so, when this test is positive, it shows … and then what happens as a result of the immune system, the antibodies attacking the vinculin, it affects the migrating motor complex and the motility of the small intestine, and that allows the bacteria to build up. And so, this blood test will tell you that you have these antibodies, and that’s how your SIBO developed.

Shivan:                 So, officially, if you have post-infectious IBS, like if you talk to the guys at the lab, they will not say that it’s a SIBO test, right?  Because the SIBO breath test, which Gemelli Labs, also from Dr. Pimentel, does. But it tells you have post-infectious IBS, which is SIBO, which is … but it’s not a SIBO, officially, according to all the medical people. It’s not.

Dr. Weitz:            Right. [crosstalk 00:11:07]

Shivan:                 Yeah. But I’m really glad I did it, because now I know my underlying cause.

Dr. Weitz:            Yeah. And one of the most fascinating things about that test is, it tells us that IBS, which is the most common digestive condition, is actually an autoimmune condition. So, how should patients think, who have IBS and they go to a conventional gastrointestinal doctor, and they’re told to just take some drug to treat the symptoms, like you were told to take a antidepressant?  Or maybe they have diarrhea and they’re given a drug to control the diarrhea, or maybe they even got diagnosed with SIBO and were given two weeks of an antibiotic known as rifaximin, and then they’re still not better? What should SIBO patients think about that situation?

Shivan:                 Well, first of all, there is a breath test for SIBO that you can take, that will tell you what kind of SIBO you have. Do you have hydrogen-dominant? Do you have methane-dominant? “IMO” for short. Or do you have hydrogen sulfide? And that’s called “Trio Smart” from Gemelli Labs, and also Aerodiagnostics does a beautiful job with breath testing.   So, you find out what your levels are, right? And what kind of gas you have: hydrogen, hydrogen sulfide, or methane. Then that will dictate the treatment, and there are three major treatments. One is pharmaceuticals. One is herbals, and one is the elemental diet. And that rifaximin that you were just talking about is the antibiotic that Dr. Pimentel discovered works in the small intestine, stays in the small intestine.  It’s actually the one given for traveler’s diarrhea. So, since e. Coli is the cause of much of the SIBO out there, that makes sense. And then if you have the methane-dominant, it’s combined with Neomycin, and then if you want to do … and there’s some other variations, but those are the main ones.   And you need to realize that, after you do that round, it’s not like normal antibiotics, where like, “I was sick. I took the antibiotic. I’m well.” You may have to do multiple rounds, but the studies show that to rifaximin, the resistance … I would say the clinical experience, at the very least, the resistance is not like with other antibiotics. It also stays in the small intestine, so it’s not like a nuclear bomb goes off in your microbiome, whereas Neomycin, it is bigger.

Dr. Weitz:            You took rifaximin, right?

Shivan:                 Oh, yeah. Oh, yeah. I’ve done it all.

Dr. Weitz:            What was your experience with it?

Shivan:                 Well, so to your point, I was not told that I would have to do multiple rounds. So I took it and wasn’t better, and I was like, “What the hey?” Like, “Wait a minute. This isn’t normal.” So I took it and then re-tested, and saw that it helped, so then I did a couple multiple rounds.  This whole time, though, I was not told to do a prokinetic.  So, I was relapsing because I wasn’t still moving my migrating motor complex.  So, in a prokinetic-

Dr. Weitz:            Maybe you can explain what the migrating motor complex is?

Shivan:                Yeah. Sure. You know… 

Dr. Weitz:            I know, I know.

Shivan:                 You [crosstalk 00:14:22]. The migrating motor complex is that sweeping motion of the small intestine. They call it the “crumb-clearing” … like, think of a waiter in a white tablecloth restaurant who comes around with that little crumb clearer. Fancy, fancy. That’s not my analogy, but I do love that one.  And it sweeps out the debris from the small intestine, and if you have adhesions, if you have scleroderma, if you have endometriosis, diverticulitis, those all can impact the migrating motor complex, along with the antibodies that you were just talking about.  And if it’s adhesions or endometriosis, it’s because literally, it can be pulling the small intestine out of a particular place in the body. Ehlers-Danlos, the collagen condition as well. So, your migrating motor complex actually might work from a mechanical, chemical perspective. But the physicality of the placement of the intestines could be inhibiting that motion.

                                Or if you’re like me and you have post-infectious IBS, then you have that mechanical chemical thing going on. So, when you don’t sweep the debris out, the food in the small intestine can overgrow, thus small intestinal bacterial overgrowth, because … not the food. The bacteria eats the food in the small intestine, and that is what overgrows, and become like a micro brewery.   And it ferments your food, all that bacteria overgrowing, and that’s why the bloating comes, and it can rob you of your nutrition. It can lead to imbalances of anemia, rosacea, restless leg syndrome. I’ve spoken to some of these doctors and they theorize, some of them, that it may even impact fertility, which I found fascinating.

Dr. Weitz:            Interesting. So, do you have any suggestions, you mentioned a breath test, for patients who are getting ready to take the SIBO breath test, from a patient’s perspectives?

Shivan:                 Yeah. No, I’m a vegetarian, so it’s even more intense because you have to do a 12-hour prep diet, followed by a 12-hour fast. And so, they suggest that, for the 12-hour fast, you sleep-

Dr. Weitz:            You don’t have any vegetables?

Shivan:                 Oh. Well, during the diet, it’s no veggies … Well, it’s rice. You could do white rice. You can do eggs. You can do chicken without the skin. You can do black coffee. It’s super, super limited. And the reason is, is because they’re trying to get you to not ferment your food.   And even though rice is a carbohydrate, it stays higher up in the intestine and gets digested fairly quickly, so it doesn’t really get a chance to ferment in the low intestine. So, I suggest doing the prep diet, being very strict on it.

                                Then I suggest sleeping for as long as possible the next day for that 12 hours. I’m not saying sleep for 12 hours, but if you can sleep for eight hours, then you only have a four-hour window until it’s time to take the breath test.   And you could take it in the office of a doctor who gives them, but you can also do it at home. And I prefer that, because I can … especially now, do it at home. But I tend to not do well with lactulose, which is the sugar that you drink prior to breathing into the test tubes. The body doesn’t digest it, but the bacteria love it.   And then, you breathe into these test tubes every 20 minutes for two or three hours. It depends on whichever test you’re doing, by the manufacturer and the lab. But I tend to get a lot of brain fog when I drink lactulose, so I have messed the test up, simply by going, “Did I just breathe into this test tube? Is this test tube eight or is this test tube nine?”   So, pre-label everything. Have two timers, like two phones or a timer and a clock, and try not to get too distracted, because keeping track after a while … and it looks … not nothing, but it looks like, “Oh, I can handle this.”    Now, Dr. Siebecker will run an errand, go to the grocery store and do a SIBO breath test no problem. I’m like, “Okay. I’m locked and loaded. For the next three hours, no one bother me.” So, everybody’s different. But it is a little bit of a project but it’s totally worth it to find out what your levels are and what type of gas you have.

Dr. Weitz:            Right. And so, you have some issues with brain fog from lactulose. Do you get that from your SIBO as well?

Shivan:                 I do. I did have really bad brain fog from … I do believe it was my SIBO, combined with my mold. At one point, I couldn’t … It was one day, I should say. I mean, it’s been fluctuating, but the worst brain fog I ever had was, I couldn’t speak. And that was extremely scary since I talk for a living.   And it was on a weekend, so I was able to actually recover. But I couldn’t speak. And it’s fine to lose a word every now and then, but I literally could not find a couple of words. Not to mention the mechanical, putting my lips together and breathing, speaking. It was bad. It was bad.  So, that was the worst case scenario. But brain fog is real. And Dr. Satish Rao has done a very interesting study about brain fog and these gut issues, which was not without controversy, but I think was quite compelling.

Dr. Weitz:            Are taking probiotics good or bad for SIBOs? Some practitioners say if you take any bacteria, it’ll only add to the bacteria you’re trying to eliminate. There are some practitioners, like Dr. Ruscio, who feels that probiotics, after you institute a diet, should be your first intervention, and that alone can take care of the SIBO. What do you think about probiotics and SIBO?

Shivan:                 So, I’m definitely a big fan of Dr. Ruscio’s, and I’ve heard his … I’ve interviewed him about this topic, about the rotation and the different types of probiotics. I think it’s fantastic. I mean, if you’re sitting there going, “I’ve tried everything.” First of all, Dr. Siebecker always says, “Have you really tried everything?”    But anyway, if you feel like you’ve tried everything, I would definitely read Dr. Ruscio’s book and go to his website for his blog posts about it, about the rotation of these three types of probiotics, to see if it helps. He has incredible clinical results with it.   Classically, people are very split down the middle. Why would you take a probiotic and add more bacteria when you already have an overgrowth of bacteria? But if you sit and think about it, is that bacteria making it to the small intestine from the probiotic? Is that probiotic full of a gatekeeper-style probiotic that will actually help to balance the diversity, and actually help to get rid of the bad guys in an overgrowth?  So, I think it’s very personal as the microbiome is, and I think if you feel like you’ve tried everything, it’s worth a try. But so, I don’t have an answer for you that’s clear-cut and like, “Yes, this always works,” because it doesn’t. It’s very personal. I know people that it has been like a miracle for, and I know people that it’s been really uncomfortable for.

Dr. Weitz:            You have a chapter in your book on quick symptom relief strategies, and I thought some of those were really interesting. Maybe you can talk about some of these quick symptom relief strategies for … You have ones for bloating, pain, constipation, diarrhea, acid reflux.

Shivan:                 So, remember, I’m the patient, right? And I’ve interviewed all these experts, and so this is based on Dr. Allison Siebecker’s symptomatic relief guide. And-

Dr. Weitz:            Right. Now, one of them that you talked about was applying castor oil, and you put that directly over your stomach. Tell me about that.

Shivan:                 Love it. Love it.

Dr. Weitz:            Okay, so how do you do it, exactly?

Shivan:                 Okay, so there are a couple of techniques. So, you get the organic, good castor oil that’s in a dark glass bottle, and you take a … This is an old school naturopathic technique, right? You take a piece of flannel. I know some people who only do organic flannel, whatever. I have seen people use a T-shirt before.  This is before you go to bed, right? And you put the castor oil on, and you put the flannel on. Maybe you put a piece of parchment or wax paper on, and then you put a hot water bottle. Some people put heating pads. They’re going, “Oh, the EMFs,” whatever. So you have to decide.  But then you just keep it on for as long as possible. It will stain your sheets. It will make your night clothes sticky, so I put on a … To be very personal, I take my husband’s boxer briefs. I wear them that night, and I take an old T-shirt of his, and I put it on underneath and kind of tuck it in and around, and it works great. This is not something to wear with your pretty nighties.  And basically, the castor oil, which is, in my opinion, not a great idea to consume, it’s an old school, very, very strong laxative. There are so many other options.

Dr. Weitz:            Yeah. Remember, castor beans are where the poison ricin comes from.

Shivan:                 Exactly. Let’s not go crazy here, people. There are too many other options. But it reduces inflammation. It helps with motility. It helps balance things. So I know people with diarrhea that have done really well with them. I know people with constipation. Just even the bloating. It’s very soothing.  I also … I have a Facebook group with 18,000 people in it. So when I’m talking about, “I’ve seen people do this and I’ve seen people do that,” the SIBO SOS Facebook community is what I’m referring to. Not to mention all the emails I get.   But I’ve heard people say like, “I tried it for two nights and didn’t notice it.” Give it like five nights in a row, and I mean, chances are you’re really going to notice something good. It’s pretty magic from that perspective. So, that’s very soothing. Very, very soothing. And I think we need to be soothed. I think we need to be comforted.

Dr. Weitz:            Yeah. What are some of the other relief strategies?

Shivan:                 Some of the other relief strategies include, if you have diarrhea, activated charcoal which is sold everywhere. If you feel like you ate something that was, “Did I just get food poisoning?” That’s really handy, and it does tend to constipate, so Dr. Siebecker suggests that you take it with magnesium if you’re worried about that. Although it does also absorb nutrients, so maybe wait a little bit, then take the magnesium. You don’t want to take it with food.  We see charcoal showing up as an odor remover, as a teeth whitener, which I don’t suggest. I’m doing a dental summit, so I know, don’t do that. I mean, it can be totally life-changing for people. So charcoal if you have diarrhea. I also just talked to Steve Wright, I don’t know if you know him, from SCD Lifestyles?

Dr. Weitz:            Oh, I’ve heard him. I’ve never met him. Yup.

Shivan:                 Lovely guy. Really smart guy. And he just talked to me about Tributyrin-X, basically tributyrate, for diarrhea, and that works like a champ as well, so I thought that was really interesting, that particular-

Dr. Weitz:            Tributyrate? Is that similar to butyrate?

Shivan:                 Yes. Yes, but they’re different forms of butyrate, so this is the tri. But yeah. He’s had great success with that. Some of the other things are Iberogast, which is hard to find with American English writing on the box. You can get it on Amazon, and it looks like it might be an Eastern European language. I don’t know if it’s Russian or what.  But that is a natural prokinetic, and interestingly enough, will help people if they’re nauseous, help people if you have diarrhea, constipation. It’s really interesting. It is not to be taken if you are on opioids, so that’s just a little disclaimer.  But that’s been also pretty miraculous for a lot of people, and you can play with how many drops that you take. I personally don’t like the taste of it. I’m a super taster, so I was doing our course, the SIBO Recovery Road Map with Dr. Siebecker, that we created together. And we were taping that day and I was like … I’d just come back from work. I’d just been in the mold. I didn’t really feel well.  And we had all these products out in front of us, and I’m like … She’s talking to me about Iberogast and I’m like, “You know I hate the taste.” She’s like, “Yeah, but you don’t feel well to begin with.” I’m like, “I know. It’s terrible. I feel terrible.” So, we caught me on tape taking it, and then how I reacted within an hour, and it did the trick. It really did the trick, so that’s my personal testimonial for that.

Dr. Weitz:            What about for constipation?

Shivan:                 So, that does work for constipation too, but certainly, making sure you’re drinking enough water. I’m not going to say, “Do fiber,” because if you have SIBO, the bacteria feeds on fibers. So that’s why, in my book, it’s a vegetarian set of recipes, because you can always add any kind of protein you want.  But when you are doing recipes and eating for SIBO, it’s hard if you want vegetables. Of course, we all want veggies. And so, if you are constipated, I’m not going to say, “Do fiber.” I am going to say that Dr. Siebecker talks about … Let’s see. I’m going to try to remember here.

Dr. Weitz:            Well, magnesium, of course.

Shivan:                 Oh my gosh. Magnesium, of course. Magnesium is her go-to. Most people, she says, don’t do enough. Right? So we think, “Gosh, I’m doing 600 milligrams. That seems like a lot.” And for somebody, it is. But maybe for you, it’s not. So, she likes the Vitamin Shoppe’s magnesium. I like it, but my husband has it around the house, so I usually just take that, but magnesium is like magic for a lot of people with constipation.

Dr. Weitz:            And what about any other hints for pain? You had a couple of interesting ones in there.

Shivan:                 For pain, it’s definitely something that … So, I just want to talk about pain for a second, from the perspective of people with IBS. You may have visceral hypersensitivity. And visceral hypersensitivity is pretty much what it sounds: visceral, the belly/abdominal area, and hypersensitivity. What hurts you might not hurt somebody else.  It could feel over the top for you. Like, “Oh my gosh, I feel like I’ve got a knife in my belly.” Other people could eat the same thing or have the same experience and they’re like, “Oh, I’m fine. It’s no big deal.” So, in your practice, how do you handle visceral hypersensitivity?

Dr. Weitz:            Curcumin is an interesting nutrient that’s been shown to be beneficial.

Shivan:                 Oh, we love. Love. Okay, do you do the pepper or no pepper?

Dr. Weitz:            No pepper. I don’t like the pepper.

Shivan:                 I don’t like the pepper either!

Dr. Weitz:            Patients hate it, especially if you want to do a high dosage. The pepper’ll just irritate their gut, so we use the one blended with phosphatidylcholine, the Meriva form.

Shivan:                 Oh, yeah. Nice. Nice.

Dr. Weitz:            Yeah.

Shivan:                 So just real quick, this is the section on the symptoms, like you were talking about. There’s a section on bloating. Oh, Atrantil, I have to give a shout-out to. If you have methane-dominant, methanogen overgrowth, Atrantil is worth looking at.

Dr. Weitz:            Yeah, we use that. Dr. Ken Brown, yeah.

Shivan:                 He’s awesome. Awesome. So, peppermint oil and peppermint tea is also great for pain. It helps things move, but not in a laxative way. Also, some of the pain, I think is … depends, obviously, but from gas. And Gas-X helps to break the big gas bubbles into smaller bubbles, so it doesn’t feel as much pressure.

                                And also, Pepto-Bismol is around for a reason, for a really long time. There is a brand from Target. I can’t remember the name of it right now. I think it’s in here, but it’s the in-house brand of Target. They have the safest for SIBO-

Dr. Weitz:            We just can’t do that. I just can’t … Artificial sweeteners and artificial colors, and …

Shivan:                 Yeah. Oh, the color. Oh, yeah. The nature pink. What? I’m not saying it’s natural. I’m not saying it’s natural.

Dr. Weitz:            I know, I know.

Shivan:                 I’m saying, in desperate times, sometimes, desperate measures. [inaudible 00:31:33] This is full of natural [crosstalk 00:31:35]

Dr. Weitz:            I notice in your book, you talked about, if they’re having abdominal pain, that if they use … If the pain is in the upper part of the abdominal cavity, that peppermint tea might be better, whereas if it’s lower down, enteric coated peppermint capsules might be better.

Shivan:                 Because of the enteric coating, it’s going to make it further down.

Dr. Weitz:            Right. Yup, yup.

Shivan:                 The IB Guard, I think is what it’s called. And that’s been studied, and you can get it at all your local drugstores, so that’s a Godsend too. And it’s something like … It’s not going to hurt. It might help, right? So, very low risk. Very low risk.

Dr. Weitz:            So, let’s go to diet. Which version of the SIBO … There’s multiple SIBO diets out there. The one that’s talked about today the most is the low FODMAP diet. And you mentioned the specific carbohydrate diet. There’s one diet where you actually count up the points for the amount of fermentability.

Shivan:                 Fast tract diet, Dr. Norm Robillard. Yeah.

Dr. Weitz:            Exactly, so there’s that one, and then there’s Nirala Jacobi’s got her version in phases, and …

Shivan:                 Bi-phasic diet, which is based on …

Dr. Weitz:            Bi-phasic diet.

Shivan:                 Which is based on Dr. Allison Siebecker’s SIBO specific food guide, which is kind of all of them combined.

Dr. Weitz:            Right. And Pimentel likes the Cedars-Sinai white bread, white rice diet, of low fiber diet.

Shivan:                 Diet Coke.

Dr. Weitz:            And then, Allison Siebecker has her version of it. So, what did you find best for you?

Shivan:                 For me, I did the SIBO specific food guide, and that’s in the book. Allison very graciously let me use her work in the book, and it’s based on all of those things combined, to way oversimplify it. And it’s very portion-specific, so you have to be careful not to get too focused on the portions, or I think we can go a little bit overboard.  And also, on the one hand, it’s careful. Like, “Oh, I can only have this many grams of this, or half a cup of this.” And then we get really, really uptight about it. On the other hand, this is what happened to me in the beginning. Like, “Oh my gosh, I can eat zucchini.” And I would eat five zucchinis in a day.  That’s the other end of the spectrum, so you have to be aware of those portions. But you’re trying to reduce your fermentable load, so that the bacteria doesn’t go crazy on these carbohydrates that are more easily fermented than others.    So, this is so important. The diet does not cure SIBO. The diet controls the symptoms. That’s really important. There is a lot of mythology around that the diet is going to cure SIBO, and it doesn’t. It will make you feel better. It definitely controls the symptoms.    You could feel better in a couple of days by fixing your diet, by being on the SIBO specific food guide, or some of these other carefully calibrated, low fermentation carbohydrate diets. So, that is a huge point in the book. But also, I have 40 recipes, vegetarian. Again, if you’re a vegetarian, it’s much harder if you have SIBO. And so, I wasn’t going to make it like, for the easiest common denominator. I was going to make it for the most difficult common denominator. And then you can always add whatever protein you want.

Dr. Weitz:            So, how long do you have to stay on this kind of diet? And do you still have restrictions in your diet?

Shivan:                 So, do not give me garlic. It’s not going to work. It’s not happening. I stopped liking it. It doesn’t work for me. It makes me sick. I hate it. I love the smell and I’ll put it in some garlic-infused oil. That’s fine, and it’s occasional.   So, how long should you be on the diet? So ideally, you’re on the diet while you’re trying to get your treatment under control. This is not a long-term fix, because the biodiversity of the microbiome will be impacted. It’s not going to be devastated.

                                If you’re doing it for eight weeks, you can rebuild it. Your microbiome is changing all the time. Ideally, you’re trying to do, even within these foods … In the back of the book, there’s this chart. There’s a lot of diverse foods in there. It’s not like you’re eating three foods. You can do bok choy and all kinds of fruits and vegetables and cabbage and green beans.  I mean, it’s not like you’re going hungry, and it’s not like you couldn’t even really, maybe eat some foods you didn’t usually eat to diversify your microbiome. But it shouldn’t be forever. I know people who’ve been on it for five years. That’s too long. It’s really too long. You need to diversify.

Dr. Weitz:            So, other than garlic, where are you in terms of food restriction?

Shivan:                 I’m, by choice, gluten free. I don’t do onions. Really, it’s onions and garlics. I used to not be able to do apples, which are notoriously high in FODMAPs, and something I literally said to myself, “I’ll eat an apple. It’s good for me. It’ll keep the doctor away, right?” And then was like, more bloated. This was way back. So, I can eat almost anything now. I just don’t do garlic and onions. That’s me. Everybody’s different.

Dr. Weitz:            I noticed in one of your recipes, you were talking about taking a green onion and just not eating the white part. So, it’s kind of a way of sort of getting an onion without getting an onion.

Shivan:                 Exactly. So, the green part of scallions is-

Dr. Weitz:            “How to get an onion without getting an onion.”

Shivan:                 Yeah, that’s the way to do it. That’s the way to do it.

Dr. Weitz:            So, let’s see. What else do we want to talk about? Did you do antimicrobial herbs? And which ones did you find helpful for you?

Shivan:                 So, I did the pharmaceuticals. Then I did the antimicrobial herbs. I did oil of oregano. I did the allicin, like Allimed, or Allimax. And Allimed is stronger, even though “Allimax” makes it seem like it’s stronger. And I also … This was on a rotational basis. I did CandiBactin-AR and BR, which is what was studied compared to the rifaximin, and was found to be a little bit more effective, but you have to do it for a month versus two weeks.

                                I’ve pretty much done it all. I’ve done the elemental diet as well, and that was okay for me. I didn’t last the whole time, which is supposed to be anywhere between 14 and 17 days. My lifestyle at the time … You have to really be prepared mentally, because it’s only liquid diet for that time, and-

Dr. Weitz:            Really hard.

Shivan:                 It is hard, and a lot of people say, “Oh, I wish I had this to begin with,” because it’s so effective. It is the most effective treatment, but it is hard. And I couldn’t take 17 days off to do it. And if you do the high performance job that I have, of doing live television, you can’t mess around. You have to feel good when you go out there. There is no messing around.  So, I played with it. I also have used it as a meal replacement on occasion, and it’s a great gut reset. This is a diet that is originally a liquid diet that was for feeding tubes, and it’s made up of amino acids that are quickly absorbed into your body, almost like instantly digested, and it feeds you but it doesn’t feed the bacteria, so you’re starving the bacteria instead of killing it through a killing agent like an antibiotic.  They used to taste disgusting. Disgusting. And people, speaking of desperate times, were so desperate to change the flavor that it became sort of famous that people put Crystal Lite to fix the flavor, and it still didn’t fix it.  But Dr. Ruscio and Integrative Therapeutics, they’ve made a much, much better-tasting set of elemental diets that you can pick from, like chocolate and vanilla, and they taste like really sweet milkshakes, like really sweet. But I mean, it’s so much better by comparison.

Dr. Weitz:            I think that’s Ruscio’s version, not Integrative’s. Theirs is just one flavor.

Shivan:                 Yeah, it’s vanilla. Right. He’s got more variety. I like his taste better, but maybe you’ll like the Integrative Therapeutics better. Who knows? But you have to make you’re doing enough calories so you don’t lose weight.

Dr. Weitz:            Right. Prokinetics. Do you continue to use a prokinetic? Is it a natural one or a prescription one? Have you tried the natural ones?

Shivan:                 I can’t do ginger, because I tend to have a little reflux with my lower esophageal sphincter, so I get the ginger burn. Or you get it once and you never even want to try it again. But other people love ginger. It is a natural prokinetic which is what we talked about earlier, of moving the migrating motor complex so that it sweeps the bacteria out of the small intestine so it doesn’t overgrow.  It’s what helps prevent relapse. There are prescriptions that are … like Motegrity, which was called “Resolor,” which was usually only available in Canada, and now it is available in the States. There’s MotilPro, which is also natural. It has a lot of ginger in it.  There’s one called … It used to be called “Zelnorm,” and it was taken off the market, and it’s back on the market. And I cannot remember the name of it to save my life right now.

Dr. Weitz:            I think it’s called “Prucalopride.” No?

Shivan:                 Yup. Well, Prucalopride is the Resolor, which is now Motegrity.

Dr. Weitz:            Oh, okay. Okay.

Shivan:                 Tegaserod. I think it’s called “tegaserod,” or something similar to that. That is another prokinetic. You could literally type in “Zelnorm” and you’ll find the new name for the prokinetic. These are IBS medications sometimes.

Dr. Weitz:            Right. So, do you continue to take a prokinetic?

Shivan:                 I do. Oh, yeah. I definitely do.

Dr. Weitz:            Which one do you take?

Shivan:                 I still have those antibodies, so I definitely still take it, and that’s-

Dr. Weitz:            Which one do you take?

Shivan:                 I take Motegrity, which was Resolor in Canada.

Dr. Weitz:            Okay.

Shivan:                 Love the stuff. Love it. I never thought I’d say that about a prescription medication, but I’m like, “I love it.” Does the trick. And it doesn’t necessarily cause a laxative type reaction, so prokinetics are not laxatives. You may have a laxative experience, but it’s not the goal. The goal is to keep the migrating motor complex going.

Dr. Weitz:            Right. So, you have the motility that occurs when you’re eating, that pushes the food down, and then you have these cleansing waves that happen in between eating when you haven’t eaten for three or four hours, and that’s what you’re really trying to stimulate.

Shivan:                 Yeah, and I’m glad you just said that. Meal spacing is super important. You want to not eat small meals throughout the day, unless your doctor’s advised that because of your blood sugar scenario. But to get the migrating motor complex moving, you need to not consume calories for about four to five hours, because the migrating motor complex will not work when you have that full mode of the body and calories indicate that, so you need to have, like … A lot of people take their prokinetic at night. I do, because you’re not taking calories in at night.

Dr. Weitz:            Right. You mentioned biofilms, and that being an issue with trying to get rid of the bacteria. Did you find anything that was effective in breaking up biofilms on your journey?

Shivan:                 So, I’ve had the pleasure of interviewing Dr. Paul Anderson multiple times, and his combination, he’s got a formula at Priority One, and then he has a prescription biofilm buster. That has proven to be really helpful for me, and if anybody doesn’t know what a bio-

Dr. Weitz:            Do you use the Priority One one, or the prescription one?

Shivan:                 I’ve used them both. I’ve used them both. They were both great for me. If people have long-term SIBO and they have not been able to reduce the bacterial load, I do suggest reading up on how a biofilm buster can help you, because maybe that biofilm is keeping that bacteria overgrown in a lockdown position … not to be medical, because that’s not a medical term, but in a state where it isn’t breaking up and releasing, so it’s not behaving as it normally would, if a biofilm wasn’t there.   And we have biofilms everywhere, right? The skin, the mouth, the genital area. Yeah, the intestines. So, it’s like … I call it “mucus” in my head. I just think of that as a biofilm, and it keeps pathogens trapped in it, and it’s very elaborate in the way that it likes to survive. It’s quite interesting.

Dr. Weitz:            Right. Yeah, I think we’re all aware of the fact that bacteria often have biofilms, and that could be a problem in getting rid of them. The problem is, is a lot of the strategies we try, the products on the market all seem to be somewhat disappointing, so maybe we’ll have to look into the Paul Anderson formulas a little more.

Shivan:                 Oh, yeah. I think people have a lot of success with those. A lot of success. And if you have been trying for a long time to get rid of SIBO and you just can’t beat it, and you haven’t done a biofilm buster, I would definitely suggest doing that in conjunction, very carefully timed with your treatment.

Dr. Weitz:            Right. So, how can our listeners and viewers get ahold of your book? Where is it available?

Shivan:                 Well, I’m so glad you asked, darling. Thank you. It’s on Amazon and …

Dr. Weitz:            Barnes and Noble.

Shivan:                 Barnes and Noble, and where all books are sold. We’ve just gotten it into the UK, and a couple of other overseas markets, at the very least, in Kindle. And yeah. I mean, this is what I wish I had known five years ago when I started my figuring out about SIBO. It is loaded with information.   Some of the feedback, which I so appreciate, has been like, “It’s an easy read.” It’s something that they’re highlighting. On page 111, there is a map. We call it the “SIBO recovery road map.” It is the algorithm that Dr. Pimentel originally created, that then Dr. Allison Siebecker and Dr. Steven Sandberg-Lewis added to.   And it literally takes you step by step through what to do. Like, “Test, symptom relief, diet. Then do your three-hour lactulose breath test. Choose a treatment: elemental, herbal or antibiotics. Afterwards, test again. And if you’re well, manage. If you’re not well, treat again.” And it just takes you through the whole cycle so you don’t have to keep memorizing everything I was just talking about.   So, that’s in there, and that’s also what the core SIBO recovery road map is based on as well, is that algorithm. So, sibosos.com is my website. And our SIBO SOS Facebook community, we’d love to have everybody there. And that’s how you can get ahold of me.

Dr. Weitz:            Awesome. Thank you.

Shivan:                 Thank you so much. Keep up the great work. We love your work, and getting us all educated. Appreciate you.

Dr. Weitz:            Excellent, excellent. Thank you so much.

Dr. Weitz:            Well, thank you, listeners for making it all the way through this episode of the Rational Wellness Podcast. Please take a few minutes and go to Apple Podcasts and give us a five star ratings and review. That would really help us, so more people can find us in their listing of health podcasts.

                                I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at 310-395-3111. That’s 310-395-3111. And take one of the few openings we have now for a individual consultation for nutrition with Dr. Ben Weitz. Thank you, and see you next week.



Coronary Artery Disease with Dr. Howard Elkin: Rational Wellness Podcast 200

Dr. Howard Elkin discusses Coronary Artery Disease and How to Prevent it 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. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

3:55  Myocardial Infarctions.  A myocardial infarction, aka, a heart attack, is the end result of a plaque in an artery becoming unstable and rupturing, resulting in no blood going beyond that clot.  Plaques build up in the arteries over time and we don’t know what makes a stable plaque into a stable plaque.  While it was thought that about 25% of heart attacks are silent, a recent analysis published in a Harvard Health letter found that up to 40-45% of heart attacks are silent. [The Danger of “Silent” Heart Attacks]  Such silent heart attacks are usually smaller, which means that a smaller amount of damage occurs to the heart muscle. But a small heart attack will often presage a larger heart attack. We actually don’t know why or how chest pain occurs, since there are no sensory nerve fibers in the heart. Diabetics have a larger percentage of silent heart attacks and diabetes is still on the rise in the US, which is why the number of silent heart attacks is increasing.

8:35  After taking a careful history, if you suspect coronary heart disease as a result of a constellation of symptoms, including chest pain, shoulder pain, arm pain, jaw pain, shortness of breath, fatigue, nausea, and it could present as digestive symptoms, then Dr. Elkin will employ stress testing.  Stress testing means doing either a stress echocardiogram or a nuclear stress test, which adds about 15% more sensitivity to stress testing.  A stress echo is more accurate than just doing a treadmill test.  A stress echo involves doing an echocardiogram to see how the heart functions while at rest and then how if functions after exercise.  If an area of the heart wall is not contracting well, then that indicates that there’s not enough blood flow going to the heart.  A nuclear test involves a nuclear (radioactive) pharmaceutical and it is done at rest and if there’s an area of the heart that doesn’t take up that pharmaceutical, then that’s another suggestion that there is a blockage.

10:40  Given that our body is designed (through evolution) to help us survive, why would our body form these cholesterol plaques in our arteries that can kill us?  The body is responding to inflammation in the artery walls and the cholesterol plaque is coating the arterial wall and protecting it from the inflammation. The inflammation could result from food sensitivities or toxins or chronic infections.  Dr. Elkin explained that when he was studying cardiology in school there was no knowledge of inflammation. They were taught that cholesterol was bad and that you had cholesterol plaques that would get more and more narrow until they led to choking off the blood supply, causing a heart attack. But that really isn’t the true story and most heart attacks are usually with blockages that are less than 50% of the width of the inside of the artery.

13:13  About 50% of those with heart attacks have normal results on standard lipid testing, which is why we want to do advanced lipid testing to pick up additional cardiac risk factors. A number of labs offer advanced lipid testing and Dr. Elkin prefers to use the panels from Boston Heart Diagnostics and Cleveland HeartLab. The standard lipid panel (total cholesterol, estimated LDL, HDL, and triglycerides) is very limited.  An advanced lipid profile will include the standard, plus LDL particle number, aka LDL direct, which actually counts the number of LDL particles, as compared to the standard panel that estimates the amount of LDL.  It also tells you how much of the LDL is small, dense particles, which are the ones that create the most risk, since small, dense are about 30% more likely to be oxidized.  LDL oxidation is a precursor for plaque formation and we also want to measure oxidized LDL as part of the advanced lipid panel.

17:29  HDL we used to think that the larger the particles the better, but now we know it is more complicated.  We also used to think that with HDL that the more the better, but now we want to know about HDL functionality and when we see HDL above 80, it is probably unhealthy.  When HDL functions properly, it does reverse cholesterol transport, which means that it escorts the bad cholesterol out of the arteries back to the liver. HDL functionality is also known as HDL efflux capacity. 20:29  An advanced lipid profile will also measure inflammatory factors, including C-reactive protein and it is a non-specific marker and it can fluctuate for various reasons, like infection, but if it is high on a series of panels, then it is a real concern.  We also want to look at Lp-PLA2, which stands for Lipoprotein-associated phospholipase A2, which is an enzyme that plays a role in the inflammation of blood vessels.  Another marker is MPO, myeloperoxidase, which is a white blood cell-derived inflammatory enzyme that is a marker for inflammation in the arterial wall.  A fourth inflammatory marker is fibrinogen, which is an acute phase inflammatory protein and it is involved in the clotting process, though it is nonspecific. 

21:45  It is also important to look at the metabolic profile, which means looking at fasting glucose, insulin, Hemoglobin A1C, and C-peptide, which tells how hard the pancreas is working to keep that patient a non-diabetic. Dr. Elkin said that 88% of Americans are not metabolically healthy.  Dr. Elkin also likes to look at HOMA-IR, which tells you whether the patient is insulin resistant.

23:59  Homocysteine.  Homocysteine is a breakdown product of protein, so your body wants to break it down to methionine and cysteine, but some of us can’t do that very effectively.  Those who have a genetic variance at MTHFR, which makes it more difficult methylate and degrade homocysteine.  Elevated homocysteine can add to the plaque burden in both the brain and the heart and it can be treated with a series of B vitamins.

25:02  TMAO.  TMAO is a new marker for increased risk for heart disease and stroke, which was developed by Dr. Stanley Hazen from Cleveland HeartLab.  But it is very controversial and to lower it, it is recommended to avoid dietary sources of choline and carnitine and to avoid cold water fish like salmon, which we know are very healthy.

28:00  Genetic factors. APOE is an important genetic factor, esp. if you have APOE3/4 or APOE4/4, which means that you have increased risk of coronary disease and they tend to be hyperabsorbers of cholesterol.  Cholesterol comes from your liver manufacturing it as well as from absorbing it if it is contained in your food. Dr. Elkin often measures if patients are hyper absorbers or hyperproducers, a part of the Boston Heart panel.  APOE4 is also puts you at increased risk for Alzheimer’s Disease.

There are some other important genetic variants, including the rs20455 KIF6 gene variant, which is found in 40% of the population and is associated with a 1.5 fold increased risk of cardiovascular disease and these patients tend to have a more favorable response to statins. There is also the rs10757278 and the rs1333049 variants of the 9p21 gene, found in about 40% of the population, have 1.5-2.0 fold increased risk of cardiovascular disease.  and there is also the rs2200733 and rs10033464 variants of the 4q25 gene, found in 20% of the population, that increases risk of atrial fibrillation, which the most common arrhythmia. This is especially the case in those over the age of 60.

30:23  Prevention.  Dr. Elkin does not believe that there is one best diet for everyone when it comes to heart disease.  Many facts need to be taken into consideration when choosing a diet or eating style, including your lifestyle, travel, athleticism, medical history, metabolic picture, food sensitivities, and the genetics.  Dr. Elkin has found that in general a lower carb diet is usually helpful.  Dr. Elkin personally follows a lower carb version of the Mediterranean diet. Whatever diet his patients choose, Dr. Elkin prefers to do advanced lipid and micronutrient testing to see how they are doing. It is especially the case that those following the more extreme diets, like Vegan or Carnivore, will tend to have a lot of nutritional deficiencies.  Dr. Elkin generally does not like to see patients consuming a lot of saturated fat in their diet, but he has some patients who do and are doing fine. He has one patient who recently starting using the ketogenic diet because he is a 60 year old cyclist who is very lean and he wanted the performance benefits running on fat rather carbs for fuel. His LDL has gone up, but scans have not shown any increase in coronary disease.  Saturated fat will tend to increase your HDL and it tends to increase the size of the LDL particles, which is good.

37:24  Marijuana use and the heart. While there might be some benefit to using marijuana for anxiety, insomnia, pain, and nausea from chemotherapy, we don’t really know the full impact of marijuana for the heart.  We know that smoking cigarettes is bad and there are something like 200 different chemicals with each inhalation, including nicotine, heavy metals, and other toxins, so smoking marijuana is likely to be equally potentially harmful.

39:38  Nutraceuticals.  There are a number of nutritional supplements that can be used in a targeted manner to modulate lipids, prevent or reverse coronary heart disease, and potentially modulate other heart disease risks. While Dr. Elkin does prescribe statins for patients with confirmed coronary heart disease for secondary prevention, but for primary prevention, Dr. Elkin uses pharmaceuticals like statins as a last resort and starts with diet, lifestyle, and nutraceuticals.  Dr. Elkin finds Citrus Bergamot a very interesting nutraceutical because it can both decrease cholesterol production and reduce cholesterol absorption in the gut.  Berberine acts like a natural PCSK9 inhibitor, acting both on the LDL receptors and on liver production.  Berberine also acts like a natural Metformin for improving insulin resistance.  Dr. Elkin includes berberine in his product GlucoWise Plus. Fish oil is very helpful in larger dosages, esp. in reducing triglycerides, and there has been some positive research on some EPA dominant omega 3 products called Vascepa and Lovaza.

42:32  Red yeast rice. Red yeast rice is a precursor to the first statin, Mevacor, which was approved in the 80s. Red yeast rice is statin-like but it’s more natural, has some other beneficial components, and does not have the excipients and other chemicals that are often added to pharmaceuticals. It has fewer muscle pain and muscle weakness and other side effects than statins, but it is still a good idea to add CoQ10 as you should when taking a statin to decrease the potential for muscle problems. The proper dosage is 2400 mg per day at night.  180 mg of vitamin K2 MK7 can be helpful.  And aged garlic reduces the oxidation of LDL.   

46:31  When using a pharmaceutical to control LDL, there are now other drugs besides statins, including Pembadoic acid and ezetimibe, and these can be combined.

48:48  Niacin.  You want to use a controlled release/intermediate release, not the long term/timed release.  Niacin can help both to raise HDL and lower LDL and it can also increase LDL particle size, which a statin cannot do. Niacin can also lower Lp(a), which is a significant cardiovascular risk factor found on an advanced lipid profile.




Dr. Howard Elkin is an Integrative Cardiologist and he is the director of HeartWise Fitness and Longevity Center with offices in both Whittier and Santa Monica, California. He has been in practice since 1986. While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for exercise, diet, and lifestyle changes to improve their condition. He also utilizes non-invasive procedures like External Enhanced Counter Pulsation (EECP) as an alternative to angioplasty and by-pass surgery for the treatment of heart disease.  Dr. Elkin has written a book, From Both Sides of the Table: When Doctor Becomes Patient, that will soon be published. He can be contacted at 562-945-3753 or through his website, HeartWise.com.

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


Podcast Transcript

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

                                Hello, Rational Wellness Podcasters. Our topic for today is coronary artery disease from the standpoint of an integrative cardiologist, with Dr. Howard Elkin. I just wanted to point out to everybody, in addition to listening to this podcast on Apple Podcasts or Spotify or wherever you listen to your podcasts, there’s also a video version on YouTube.  And if you go to my website, drweitz.com, there will be a complete transcript and detailed show notes all for free. And my ask for you today is, if you enjoy listening to the Rational Wellness Podcast, please go to Apple Podcasts and give us a ratings and review.

                                So, what is coronary artery disease, also known as coronary heart disease? And how does an integrative or a functional medicine approach look at that? When we’re talking about coronary artery disease, we’re talking about a process that results in the buildup or atherosclerotic plaques in the artery walls that gradually leads to a decline and choking off of the ability of the blood flow in that artery wall, leading to potentially a heart attack or a stroke or other damage to the heart over time.  Heart disease continues to be the number one cause of both morbidity, which means sickness, and mortality, which means death, in the United States. From an integrative cardiology perspective, the question is, how do we prevent this from happening? And if this atherosclerotic process has already started, to stop it from progressing and to possibly reverse it.

                                Dr. Howard Elkin is an Integrative Cardiologist with offices in both Whittier and Santa Monica, California. And he has been in practice since 1986. While Dr. Elkin does utilize medications and performs surgical procedures, including angioplasty, stent placement, and putting in pacemakers, his focus in his practice is employing natural strategies for helping patients, including recommendations for diet, lifestyle, exercise and targeted nutritional supplements to improve their condition.  Dr. Elkin also utilizes non-invasive procedures like external enhanced counterpulsation as a non-invasive alternative to angioplasty and bypass surgery for the treatment of heart disease. Dr. Elkin has written a book, From Both Sides of the Table: When Doctor Becomes Patient, that will be soon published. Dr. Elkin, thank you so much for joining me today.

Dr. Elkin:              Thank you, Dr. Weitz. It’s a pleasure being here again. We’ve done a few podcasts together, and they’ve always been so enjoyable.

Dr. Weitz:             And when is your book going to get published?

Dr. Elkin:              Well, let’s say it’s taken me eight years to write it and I’ve had four edits. I’m done with it now, actually. So now, after this … This is Heart Month, so after Heart Month, I’m going to be dedicated my time to getting the book published. I’m self-publishing, so that’s going to be my next … but I promise it’ll be in 2021. I hope.

Dr. Weitz:             Okay, sounds good. We’re going to hold you to that.

Dr. Elkin:              Please.

Dr. Weitz:             So, there’s a lot of things to talk about how an integrative cardiologist looks at heart disease, but let’s jump right into something that’s in the news to start with, which is that about 45% of people with heart attacks known as myocardial infarctions are silent, meaning they didn’t have any symptoms. They didn’t even know they had them. So, maybe you can start by explaining what a myocardial infarction is, and how can it be that this could happen without even knowing about it? And what’s the significance of this?

Dr. Elkin:              Thank you. Well, myocardial infarction is the end result of a plaque being ruptured, which happens … so there’s plaque buildup over a period of years in the arteries, and this is really many years in the making. And we don’t know what makes a stable plaque into an unstable plaque. That’s the million dollar question.  So, what happens is that, when a stable plaque becomes unstable for whatever reason it does, then it ruptures and then you have an actual heart attack, because there’s no blood going beyond that clot. So, now, we’ve heard of this crushing chest pain, radiation of the left arm.   And actually, that isn’t as common as we think it is. And I was always taught that about 25% of heart attacks are silent. However, a more recent analysis was published in a Harvard medical letter saying that really, we’ve underestimated the number of silent heart attacks. It’s more like 40, 45%, which is huge.  Silent heart attacks tend to be a little more frequent … definitely more frequent in diabetics and also in males and elderly. So, that much, we know. But I mean, that’s a huge percentage of people then, so we really have to look at how to assess risk and employ preventative strategies in these folks.

Dr. Weitz:            How could it be that patients don’t have any symptoms when they end up with a clot that damages their heart?

Dr. Elkin:             Well, most of these heart attacks that are silent are generally not really large ones. But it doesn’t matter, because a small heart attack will often presage a larger heart attack. So, a heart attack is a heart attack, but these tend to be smaller, because obviously there’d be some sequelae if it’s a really large one.

Dr. Weitz:            So, when you say the heart attack is small, essentially what you mean is that a smaller part of the heart muscle is damaged?

Dr. Elkin:             Exactly. It’s all about how much damage takes place, which is why we tell patients if they’re having chest pain, they think it may be the real thing, get to the hospital because time equals muscle. And that’s when we do employ emergency angioplasty and stent placement, which is life-saving.  But we’ve known for years that diabetics tend to have different pain thresholds. No one understands this. In fact, no one understands really why and how chest pain occurs, because there’s really no nerve fibers in the heart. Most of the pain that we experience with heart pain or angina is really through dermatomes and poorly-explained mechanisms.  So, for some reason, diabetics tend to have a higher percentage of silent heart attacks. And let’s face it, diabetes is on the rise. I mean, it’s becoming an epidemic, so that could be part of the explanation as to why the number has increased.

Dr. Weitz:           So, when taking a patient’s history, what facts would make you suspect that they’re suffering from coronary heart disease?

Dr. Elkin:             That’s a great question. This always goes back to taking a good history. So, you want to take chest pain. It could be shortness of breath and exertion. It could be just fatigue. With women, it’s very interesting. If I have a woman, I’m going to have this little dictum that, if it’s above the belly button in a woman, it’s probably heart until proven otherwise, because women have such different presentations. In fact, just nausea, sometimes just overwhelming fatigue can be a presenting complaint with women. So, this whole thing about-

Dr. Weitz:           They could think they’re having digestive symptoms, right?

Dr. Elkin:             Absolutely. And oftentimes, they’ve come for a GI workup. And if it’s a good GI doctor, they say, “You better get your heart checked out first, before we do any testing on you.” So, you look for symptoms and …

Dr. Weitz:            They could have other symptoms too, right? They could have pain in their shoulder or their back, or …

Dr. Elkin:             Yes. Yes. I’ve had people presenting with back pain, like mid-scapular pain. So, there’s a constellation of symptoms, but it’s really a gestalt that you have, like taking a good history, listening to the patient. If they’re going to explain to you that their lifestyle has changed because of these disabling symptoms, then that tells me one thing. And then, that needs to be worked up.  So that’s number one on my list is, is it really cardiac? And if they’re having symptoms, then I’d probably go to my first major thing, which is employing some type of stress testing.

Dr. Weitz:            So, what does that mean, “some form of stress testing”?

Dr. Elkin:              Okay, so stress testing, so I want to see … Stress testing is still the major way of … Is a patient ischemic? In other words, by the term “ischemic” means, are they getting adequate blood flow to the heart and muscle? So, I’d like to do it … In the old days, we just did treadmill testing, but there’s a large amount of false negatives with that and also false positives.  So I usually use some type of imaging, either an echocardiogram or nuclear stress testing. Nuclear stress testing adds about 15% more sensitive over the stress echo, but I use them both. And so, when I do a stress echo, I look at the heart muscle at rest, and then once we-

Dr. Weitz:            By the way, what is a stress echo for patients?

Dr. Elkin:              Sorry. Basically, it combines a treadmill test with an echocardiogram, which is an ultrasound of the heart. So, first we do a resting echocardiogram and see how the heart functions. Is it totally normal function? Does all the segments contract normally? And then, we exercise the patient. And then as soon as they finish exercise, we re-scan them and we see if there’s any change in wall motion.  So, let’s say you have a normal wall motion at rest, and then with exercise, you see an area of the heart that’s not contracting well. That’s a hint that there’s not enough blood flow going to the heart. So, that’s how a stress echo works.  A nuclear test is different. It’s actually a nuclear pharmaceutical, and we do it at rest to see … Usually, it’s going to be a normal uptake, and then if we see, after we stress them, that there’s an area of the heart that doesn’t take up that pharmaceutical, then that’s another huge suggestion that there’s a blockage.

Dr. Weitz:            So, one of the important parts of this heart disease process is that we get a buildup of these cholesterol plaques in the arteries. Why would our body do something that’s harmful for us? Meaning, forming these plaques that eventually could kill us?

Dr. Elkin:              Well, it’s because the body is trying to protect itself. And I think we could all relate to what happened with COVID-19, is that, why do some people go on to have this thing called a cytokine storm? In which the body’s actually … It’s not just so much the virus, it’s the offshoot of all the inflammatory cascade.  So, similar things happen to the heart. And so the heart, let’s say there’s a plaque, and there’s inflammation in the arteries that lead into the heart. And the heart wants to contain that. Your immune system is activated. It wants to contain that, and so it sets off this process that attempts to do just that. And sometimes it works, and sometimes it doesn’t. And that depends on the individual’s immune system activation.

Dr. Weitz:            Essentially, there’s inflammation in the artery walls, which could result from a whole series of things. It could relate to food sensitivities or toxins or a whole series of other reasons why there’s inflammation or chronic infection, et cetera. You mentioned viral infections. And then the body uses the cholesterol to kind of calm, coat the artery walls to reduce the inflammation, right?

Dr. Elkin:              Right. I mean, cholesterol and even LDL, which I like to think of LDL as lousy, HDL as healthy, but it’s really not that simple. It’s just an easy mnemonic. But we need cholesterol. It’s essential for life. So, it’s just what happens in this constellation of events with inflammation and so forth.  When I was a fellow several years ago, studying cardiology, we didn’t know about inflammation. That term never came up. We just figured you have a blockage called a “stenosis” and over a period of several years, it gets more narrow and more narrow and more narrow, and eventually you have a heart attack.  Well, that really isn’t the real story. In fact, most heart attacks are usually with blockages that are less than 50%. I mean, occupies less than 50% of the inside lining of the heart. And we were clueless back in the ’80s with this.

Dr. Weitz:            And another interesting fact about heart attacks is that 50% of them, when you just do normal, standard lipid testing, look perfectly normal.

Dr. Elkin:              Absolutely, absolutely. Which is why … Then we get into the whole category of advanced lipid testing or advanced cardiac testing, which is, I think as integrative cardiology, it’s essential. I mean, I would like to think that all cardiologists would do this, but they don’t. Normally, what they order is that standard lipid panel, which is total cholesterol, LDL, HDL, and triglycerides. And that’s the standard panel that everybody orders.

Dr. Weitz:            And the LDL is actually calculated. They actually don’t even measure the LDL.

Dr. Elkin:              Right. Absolutely. And-

Dr. Weitz:            And it’s very common for patients to say, “Well, I had all my lipids done. Everything’s normal. They think that every test that could be run was run. Unfortunately, that’s not the case.”

Dr. Elkin:              And even most cardiologists order that standard panel. Your traditional cardiologist doesn’t really get into the more advanced testing. It astounds me, but …

Dr. Weitz:            And really, by all the research that has come out, doing this advanced lipid testing really should be the standard, right? In 2021?

Dr. Elkin:              Absolutely. It really should be. I mean, I’ve been employing it for years. I can’t imagine any other type of workup, you know?



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

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

                                                Now, back to our discussion.



Dr. Weitz:           So, let’s go into what is involved in an advanced lipid profile.

Dr. Elkin:             Okay. Well, first of all, you will get your standard lipid profile like you do, and they’ll also do what’s called “LDL particle number.” LDL, just remember one thing: Bigger is better. I tell my patients that bigger is better. The larger the size of the LDL, the more beneficial it is.   Why? Because small dense is about 30% more likely to be oxidized. And now, we can actually measure oxidized LDL. There are a couple labs that measure that, and that’s important because if you have oxidized LDL, that is the setup for inflammation and coronary disease. I don’t care what your LDL is. I mean, I do but I don’t. But if it’s oxidized, then that’s a big concern, because then that’s the whole cascade of events. That’s what starts off.

Dr. Weitz:            So, the bottom line is, you could have an LDL, as you mentioned, say a conventional LDL number of 80, and your doctor would say, “Everything’s fine. It looks perfect.” But it turns out that if your LDL particle number is 1200, the reason why it’s 1200 is because you have the same amount of LDL, but because more of the particles are small and dense, which are more likely to be problematic, you actually have a larger number of particles, and that’s what’s significant.

Dr. Elkin:             Right, so we look at the number and we look at the size. Now, HDL is … It’s really interesting because we used to think bigger is better with that. And I’ve been around long enough to note that there were like, at least three trials that come to my mind, which we tried to increase HDL because HDL was thought to be healthy, right?

Dr. Weitz:            Yeah, people often refer to LDL as the “bad cholesterol,” and HDL as the “good cholesterol.”

Dr. Elkin:             And I think there really are some really things about HDL. We’re just learning about it now, but it’s more than just the size or the amount. We used to think, “Wow, the higher the number, the better.” Now, we think that if an HDL is much greater than 80, it probably is unhealthy.  I’ve had patients that have HDLs of 100. It’s like, “Wow, this must be really good.” And we’re finding out that it really isn’t. We’re now going into HDL functionality and this … What do you call it? Reflux capacity. And these tests aren’t really standardized, so they’re really kind of new.   They are coming out, but I think we’re going to see some new tests in the future, hopefully in the next two or three years, that are going to help us more with HDL. Now, Boston Heart and Cleveland measure the size of the HDL particle. So, again, we thought bigger is better. It’s probably more complicated than that.

Dr. Weitz:            But the bottom line is, the reason why people often refer to HDL as the good cholesterol is because one of the functions of HDL is something called “reverse cholesterol transport,” meaning that the HDL can escort the bad cholesterol out of the system. It’s like the security guard who grabs your arms and says, “You got to leave.”

Dr. Elkin:              Right. That’s exactly right. And that does take place. That actually does take place, but …

Dr. Weitz:            And so, when you talk about HDL functionality, really what we’re talking about is, “Is HDL doing its job of reverse cholesterol transport? Is it removing bad cholesterol?”

Dr. Elkin:              Right. And that’s what these new tests are going to be showing, I think. It’s called … There’s a term for it. I can’t think of it now, but it’s a reflux thing. And I think once we get better testing that’s standardized, and we don’t have it yet …

Dr. Weitz:            Right. I think Cleveland has a test for it, right?

Dr. Elkin:              They’re working on it. Yeah, they’re working on it. And I think Boston is too, so I think within the next two years, we’ll know more about HDL functionality and what’s really good, and what’s neutral and what’s maybe harmful.

Dr. Weitz:            So, what are some of the other things that you measure in an advanced lipid profile besides LDL particle number, LDL particle size and HDL particle size?

Dr. Elkin:              Well, there’s three major things that I want to gather in addition to that. Number one is inflammatory profile. Is there inflammation going on? So, there’s four major factors that we look at. One is the C-reactive protein. Everybody should know their C-reactive protein. It’s a routine test.  It astounds me that most doctors don’t order it. Cardiologists don’t even order the test. And now, we know it’s a totally non-specific test. But if I follow a patient and I continue to see serial CRPs that are high, I’m very concerned. I’m going to work it up.  But inflammation of any cause that’s chronic leads to the four major diseases of aging, so it’s heart disease, cancer, autoimmune disorders, and Alzheimer’s. They all have that in common, inflammation. So, I definitely want to know about inflammation.  So, we look at the C-reactive protein. There’s a couple of tests that are a little more specific for the heart. Something called Lp-PLA2 which is actually an enzyme. Another test is called MPO, myeloperoxidase. And they point more in the direction of inflammation in the vascular system itself.   And there’s also fibrinogen, which is an active phase reactant, which means like CRP, it’s terribly nonspecific. So, I want to look at the inflammatory profile.

Then, I want to look at the metabolic profile, and I’ve mentioned this on one of my YouTube Lives, is that only 12% of the adult American population is metabolically healthy. That means 88% are not.  And there’s definitely association between metabolic health and heart disease, diabetes and heart disease. So, we’ll learn about hemoglobin A1c. How well has the blood sugar been controlled for the previous three months? And their fasting insulin level. And that’s important.  And also something called C-peptide, which tells me how hard the pancreas is working to keep that patient a non-diabetic. So, these are really useful tests. And then, you and I talked about another one to assess insulin resistance, and there’s a few different ones, which-

Dr. Weitz:            And one of the things to look at is fasting insulin as well as fasting glucose.

Dr. Elkin:             Right, right. Exactly.

Dr. Weitz:            And the point of that is, you don’t want your blood sugar to get too high. You don’t want it to get too low either, but if you’re keeping your blood sugar in a normal level, only by producing a lot of insulin, then you’re masking this pre-diabetic condition where your pancreas is working overtime, producing more insulin to manage your blood sugar.

Dr. Elkin:             I like this test called HOMA-IR, which stands for Homeostatic Model Assessment of Insulin Resistance. It’s a calculated value, but you need to know your fasting insulin and your fasting glucose, and then there’s a calculation, an algorithm, and it lets me know whether a patient truly is … It tells me more whether the patient’s truly insulin-resistant.  It takes those things into account, and there can be a disparity between blood sugar and insulin on a given day. That’s why this is an additional test that I like to see. Okay, so we have the lipid test which shows particle size and particle number. We have the inflammatory profile. We have the metabolic profile, and then we also have a few genetic tests that are pretty useful when it comes to evaluating heart disease and coronary disease.

Dr. Weitz:            And let’s not forgot homocysteine as well.

Dr. Elkin:             Right, right. So, homocysteine, thank you. Homocysteine is a breakdown product of protein, so your body wants to break it down to methionine and cysteine, but some of us, it can’t do that very effectively. And there’s a genetic test we’ve heard of, the MTHFR?   And usually, whatever lab you’re using, they’re testing two different copies, and about 60% of us, I’m one of them, that has one or two copies. And that can affect our ability to methylate, and therefore really degrade homocysteine.   So, why do I even care? Because homocysteine in elevated numbers can affect the … can add to the plaque burden, both in the brain and in the heart, so it’s so easy to treat, a series of B vitamins, so I always check it. And I mean, I see levels of 15, 16, 20, over 20 sometimes. And it’s almost always … That genetic test is always going to be positive.

Dr. Weitz:            There’s another marker … and of course, they’re always coming up with new markers, because bottom line is, we have this 15% of people who weren’t picked out the first time. So, a new marker. We’ve discussed this before, but I think we should mention it again, is TMAO, which Stanley Hazen from Cleveland Clinic developed. And this is something found in the blood that correlates with increased risk for heart disease and stroke, but it’s very controversial. What’s your perspective on it?

Dr. Elkin:              My perspective is, I look at it and I follow it, but … because really, to lower TMAO levels, you have to decrease things like choline, and you have to make some dietary changes. I think it’s really a reflection of the gut bacteria responding. There’s so many other things that I look at first, so if I see an elevated TMAO level, but other things are looking pretty good, I’m not terribly concerned because it is controversial.

Dr. Weitz:            Yeah. Yeah, I think a couple of reasons why it’s controversial is, number one, the food that is highest in TMAO is cold water fish like salmon, and there are just unbelievable amount of studies showing that eating fish is correlated with lower risk for heart disease, as well as fish oil, EPA and DHA.  So, it’s just a complete contradiction with that. And then, the other way you get TMAO is that you consume TMA, which is found in substances like choline and L-carnitine, which we also know are super important for you. L-carnitine is super important for the heart, for the mitochondrial function. Choline’s super important for brain health, and then the foods that these are often found in. But they’re converted into TMAO in the microbiome, so perhaps this is really a marker for an unhealthy microbiome that’s converting these into TMAO.

Dr. Elkin:              Good point, and that may be a good reason to work up the gut with a stool test, to really investigate the microbiome. So, if I see it persistently … If it’s a little borderline, I mean, I will tell you, and all the testing that I do, I don’t see that much TMAO in my patients. It is prevalent, but not as much as you would think, but it’s-

Dr. Weitz:            Yeah. And of course, you’re talking about the … There’s been a lot of talk about the gut-brain connection, and the gut immune connection, and now you’re mentioning the gut-heart connection. At some point, we need to do a whole podcast about that. But you mentioned genetic factors. Let’s touch on a few of the genetic factors that you find most helpful, maybe starting with APOE?

Dr. Elkin:              Right. So, APOE is an interesting one. You get one allele from each parent, so if you have the APOE-3 is the preferred pattern, but if you have 3/4, it means you have one good gene and one that’s not so good, and you can also have 4/4, which is even worse. That means you got a bad gene from each parent.  So, what’s the significance? Well, people that have APOE can predispose to coronary disease, and they tend to be hyper absorbers of cholesterol from the gut. So, there’s two ways you can get cholesterol in your bloodstream. One is through production. I mean, your liver’s going to make cholesterol no matter what, because it’s essential for life.  And the other way is hyper absorption, meaning it absorbs more from the gut, from the food that you eat. So, people that are APOE-positive tend to be hyper absorbers, and we can measure that. Boston heart test does that quite nicely.  And then, it also is a gene for Alzheimer’s, which is important to know, and the reports that come from the lab don’t really tell you that, but I mean, any person can just look on the internet and find that out. So, I do tell the patient. I let them know if they have APOE/4 or 4/4, I let them know.

                                So, that’s one. There’s another one. A couple that I like is KIF6 and 9p21. I don’t know. These are all based on chromosomes, and they’ve been shown several years ago, by Dr. Superko … At that time, it was the Berkeley Heart Lab, and these patients tend to have increased incidence of heart disease, coronary disease.  KIF6 is interesting, because those patients have been shown to respond favorably to statins, like pravastatin. 9p21 is seen, really, about 15% of the population, which makes sense when you think about coronary disease. And there’s another one that’s new called 4q25, which actually predisposes people to atrial fibrillation, which as you know, is the most common arrhythmia in those over the age of 70. However, I’ve seen it in people of all ages.

Dr. Weitz:            So, let’s get into some of the preventative stuff. Let’s start with diet. Is there a best diet for coronary artery disease? Does it depend on the person? What’s your preference? Do you prefer a vegetarian diet for most patients, a Mediterranean diet, a paleo diet, a carnivore diet? Should we eat all vegetables, all meat?

Dr. Elkin:              The answer is, in my book, all of the above because there is not one diet for one person. In my book, I talk about why there can’t be one diet for all people, because like you say, there’s so many things to take into consideration: lifestyle, travel, athleticism, history, metabolic picture, food sensitivities.   I mean, there’s so many factors, so many variables. So, is there a heart-perfect diet? My basic diet tends to be low carbs, because whether you’re a cardiac patient or not, that’s going to be your better diet for aging. I think if a person prefers to be vegan or vegetarian, that’s great.  I think whether you’re straight vegan or straight carnivore, I think what you need to do is do, within a few weeks or months of being on that type of diet, you should get … It’d be nice to have micro-nutrient testing, because in those particular diets, it’s not unusual to have some deficiencies. We know, with vegan diets, there’s going to be a lack of B-12, of carnitine, carnosine …

Dr. Weitz:            Omega-3.

Dr. Elkin:              Omega-3, yeah. So, it’s really important to account for that. But if it works for someone, I’m okay with it. And again, I’m going to look at their … I’m going to continue to follow their advanced cardiac testing while they’re on these diets, so the bottom line … I’m not into low-fat, low-cholesterol diets anymore.   I went to a conference, Orange County. It was the preventative cardiology conference. They do it once a year, and they’re still counting the benefits of low fat. But they also say that canola oil is good to take. I beg to differ with them. So, it’s really an individual thing.

Dr. Weitz:            So, what’s the deal about fat? Does fat lead to heart disease? Does saturated fat lead to heart disease?

Dr. Elkin:              Okay, so saturated fat, I have a patient that I’m calling right now, who … very interesting. He has documented coronary disease, by coronary calcium scan. However, he’s an athlete. He’s 60. The guy does … big time cyclist. He’s in impeccable shape, lean as can be.  And he went ketogenic. I said, “Okay, if you want to do it, do it.” I mean, he didn’t have any weight to lose, but he was interested in the anti-aging effects of going ketogenic. So, we watched his LDL go up, but his scans have not shown any increase in number of coronary disease.

                                But do I care about that? Depends. And this is an unusual guy, who’s in unusual shape. The average person who has coronary disease … It’s very controversial about saturated fat. Some people say it’s not the culprit at all.  There’s a couple of good things about saturated fat. It can increase your HDL, which is supposed to be good, the healthy cholesterol. And it can also increase the size of the LDL particle, which we know is good, right? Because bigger is better when it comes to LDL.  So, there are some benefits to saturated fat. I kind of like combining things. I’m not [inaudible 00:34:08] saturated fat. I’m really neutral until we get really information that says, “This is what we should be doing.” And I don’t think it’s going to come. I think it really depends on the individual, based on all the variables we’ve discussed.

Dr. Weitz:            But you are somewhat worried about consuming too much saturated fat, right?

Dr. Elkin:              Yeah. There’s also a gene you can check. I can’t remember the … You can do it with 23andMe and Ancestry. It’s a specific gene, and I can’t remember the name of it right now, but these people that have this specific genotype actually do very poorly with saturated fat. So, that’s another thing. Do you have the genetics for it?

Dr. Weitz:            And from my experience, I know there’s controversy about this, when I’ve had patients who had the APOE-4 gene, they don’t tend to do very well with a high saturated fat diet.

Dr. Elkin:              Interesting. I don’t know that about the APOE, but you may be right. I’ll have to check that.

Dr. Weitz:            Yeah. I have a patient, a guy 40 years old, in good shape, exercises, was following a paleo type of high fat diet with the Bulletproof coffee, with the fat in his coffee. And he had a heart attack at age 40.

Dr. Elkin:              Wow. I get concerned about any kind of extremes. There’s this talk about … I’m sure you’ve read some of these people that are into the carnivore diet.

Dr. Weitz:            Yes.

Dr. Elkin:              And there may be a place for it. I mean, I think if you had a lot of gut issues and you want to put your gut at rest, I think being on a carnivore diet for a few weeks might be useful. But I have a couple of people that have been on it for a long time, and they swear they’ve never felt better from the gut. Is it the best thing on the heart? I don’t know. I worry about these extremes. I’m a middle-ground kind of guy.

Dr. Weitz:            One thing about food sensitivities, there’s a lot of controversy about these tests. But from my experience, one of the things I’ve noticed is, when people eat certain foods over and over, like the same foods day after day, meal after meal, they tend to come up positive on those food sensitivity tests.  And people always get bummed out about that, but I do think that the immune system, when it’s constantly bombarded with the same types of amino acids, and I think that it starts to develop sensitivities to that. And that’s one thing I wonder about a carnivore diet, where people are essentially eating a very limited number of foods over and over again.

Dr. Elkin:              Right. Well, these people are totally polyphenols, when there’s a plethora of material, from olive oil on down, that helps the importance or the significance of that.

Dr. Weitz:            There’s different versions of the carnivore diet. Some who follow the carnivore diet say that, to really be healthy, you actually need to eat the intestines of the animal, including what’s in the intestines, which could include plant matter, but it seems like a crazy way to get some plants.

Dr. Elkin:              Right. Yeah, you’re talking about the nose the tail?

Dr. Weitz:            Yeah.

Dr. Elkin:              Seriously, it’s …

Dr. Weitz:            So, I just wanted to mention something. Marijuana use is on the uprise in many ways. People are eating it, but they’re also smoking it, and they’re also vaping it. And we’ve known for many years that a major, major factor in increasing risk for heart disease is smoking cigarettes. What’s the story about smoking pot and/or vaping pot?

Dr. Elkin:              Well, it’s a great question. And I’ve been to a conference in which there was pros and cons. I don’t necessarily recommend it for the heart. Now, that said, there could be really utility in marijuana. It can help you with extreme anxiety, insomnia, pain, nausea from chemotherapy. There’s a definite role for certain things. I don’t know the full impact on the heart. I don’t think anyone really knows.

Dr. Weitz:            But even if there’s a benefit to taking CBD and possibly THC as well, or even a whole marijuana plant, it seems to me that smoking it is probably liable to be a problem.

Dr. Elkin:              Yeah, I think so. I mean, with cigarettes, what are there? 200 different chemicals with each inhalation? It’s something like that, ridiculous. It’s not just the nicotine, right? There’s lots of different things.

Dr. Weitz:            Right.

Dr. Elkin:              And heavy metal and all kinds of garbage. I tend to believe-

Dr. Weitz:            And by the way, you’re smoking a tobacco plant. So, for people who say, “Well, marijuana’s natural and cigarettes are not,” well, I mean, cigarettes to some extent are natural too.

Dr. Elkin:              Right. Tobacco is a plant. Right, exactly. So, we’d still need to learn more about it. But I agree with you. I don’t feel comfortable smoking, especially if you’re a cardiac patient. It can also impact your sympathetic nervous system, right? Which isn’t great if you’re a cardiac patient. Depends if you’re stable or not, but it’s not one of my go-to things.

Dr. Weitz:            So, let’s get into nutraceuticals, i.e., specific use of targeted nutritional supplements to help modulate lipids, to either prevent coronary heart disease or to stop it, or possibly reverse it. When you have somebody with unfavorable lipids, a lot of small dense LDL, high LDL particle number, what are some of your favorite go-to nutraceuticals?

Dr. Elkin:              Right. First of all, a lot of people come to me for that one reason, because they know that I’m not just a standard cardiologist who’s going to put them on statins. And again, it depends on the risk of the patient. I mean, I do use statins on patients that have confirmed coronary disease, that have had multiple procedures and there’s no question for secondary prevention.  We’ve known that since the ’90s, really. But yes, there are some go-to things that I do. I like bergamot, that can help … Bergamot’s a very interesting nutraceutical, because not only can it increase production delivery, it can also decrease absorption in the gut. So, it kind of can work two ways.  

                                Berberine’s kind of an interesting one. It kind of acts like this new class of drugs that we call PCSK9 inhibitors, which works on the LDL receptors, on the liver itself. And these are new drugs, and they’re injected twice a month subcutaneously. Very expensive, but they do an amazing job of decreasing your LDL by as much as 70%, so berberine is kind of a natural nutraceutical to use for that.

Dr. Weitz:            Also, some people regard it as a natural metformin, because it modulates blood sugar in the body.

Dr. Elkin:              Yes. I use it more, actually, for … I use it in my own product called GlucoWise Plus, because it has been shown to be, in some studies, to be as effective as metformin, and not as difficult on the GI tract. There are my two big ones. Fish oil … and I use a lot of fish oil, really, for triglycerides. But you need big doses.   Now, there’s two new drugs out. “New” meaning in the last few years. Vascepa and Lovaza. And those are pure EPA. Pretty much pure EPA, but they’ve been shown in studies to be very effective in decreasing triglycerides. So, the problem is that you need like two grams twice a day. That’s four grams a day.  It’s true, but you could also do the same with … I like using regular fish oil, because I like combinations of EPA and DHA. In fact, I often use DHA by itself to augment the … make [inaudible 00:42:28] patient because it’s good for the heart, the brain and for vision.

Dr. Weitz:            What about red yeast rice?

Dr. Elkin:              Okay, I use a lot of red yeast rice. Now, it’s very important. Boston has an interesting test called the SLCO gene test. It tells you if you are a hyper responder, which means that the statin will last in your system longer than usual. So, you have to be very careful about using a statin in these patients, especially if they have two alleles versus one.   So, how does it relate to red yeast rice? Because red yeast rice supplement actually is a plant from China, and it was a precursor to the very fast statin that was approved in the ’80s, Mevacor. So, it is statin-like, but it’s not as potent, and it’s a little more natural without so many excipients and things that you see in pharmaceuticals. So, I think that-

Dr. Weitz:            Well, the other thing is, while a statin is pulled out of red yeast rice, red yeast rice has a number of other components that can all help modulate cardiovascular risk in a positive direction.

Dr. Elkin:              Right. In fact, a lot of my patients would rather do that than statins and I’m fine with that. I’ll try it.

Dr. Weitz:            And doesn’t it have less side effects than statins, potentially?

Dr. Elkin:              Yeah. It can. I mean, some patients will still experience muscle cramps or muscle weakness. I’ve had it with a few, which is why that SLCO gene is … I would be a little more cautionary with that, but I’ve found-

Dr. Weitz:            And of course, you want to add CoQ10 with it to decrease the potential for that.

Dr. Elkin:              Absolutely, yeah. So, whether I use a statin or red yeast rice, I … First of all, all my patients are on CoQ10. It’s just one of my go-to things for people over the age of 40, but it’s essential for statins or red yeast rice supplements. And I think it’s Mark Houston, he uses really large doses, doesn’t he? Of …

Dr. Weitz:            24 to 4800 milligrams at night.

Dr. Elkin:              Yeah. I use like 2400. I haven’t gone to that large dose yet. But I may try it. But it’s well-tolerated. Let’s see. So, we’ve discussed red yeast rice, fish oil, berberine, bergamot. They’re the main ones that are helpful.

Dr. Weitz:            But what would be your go-to combination for somebody … Let’s say somebody gets a coronary artery, a calcium artery scan, and they have plaque. What’s your go-to for reversing it? What combination of things would you put them on if they want to do natural stuff?

Dr. Elkin:              I think the things you’ve just mentioned, really. And then, pending the results … So, once I see a coronary calcium scan … and the reason I do a lot of them, because it’ll tell me not only what your value is, which is nice. I mean, the perfect value is zero. You don’t want to have any calcium in your arteries, but that’ll be less lucky as we get older.  But it’ll also tell me, “Okay, if you’re 60 or 50, how do you compare with other 50-year-old females or 50-year-old males?” So it lets me know, “Oh, you’re in the 30th percentile. You’re in the 50th. You’re in the 80th or 90th.” I’ve had folks in the 80th and 90th percentile that have no symptoms.

Dr. Weitz:            Would you add vitamin K2 to the mix?

Dr. Elkin:              Yes. Yes. They all go on vitamin K2. Vitamin K2, specifically I like MK7 because it’s longer-acting, and that’s a little bit debatable, but I like vitamin K2. And people are interested-

Dr. Weitz:            And what dosage are you using these days?

Dr. Elkin:              I use 180, but you should use at least … Dr. Sinatra and I have discussed this, Stephen Sinatra, but at least 150.

Dr. Weitz:            Yeah, he’s actually recommending 360 now.

Dr. Elkin:              Oh, he’s gone up now? Okay.

Dr. Weitz:            Yeah. Aged garlic, have you used that?

Dr. Elkin:              Yes. Garlic is very good because it also cuts down on the oxidation of LDL, right? We’ve talked about that LDL, in itself, isn’t the culprit, but once it’s oxidized, okay, that’s when the whole inflammatory process begins. So, I use kale and garlic. Aged garlic is very useful in that. So, there’s so many things we really can do.

Dr. Weitz:            What about when we go to pharmaceuticals? It used to be that pretty much, if you had a problem with coronary heart disease, you would go on a statin. But now there’s a number of other alternatives, what would be your favorite drug or combination of drugs for patients who don’t want to take a statin or are intolerant to taking a statin because they get a lot of muscle cramping or other symptoms?

Dr. Elkin:              There’s a new one out, Pembadoic acid. It’s relatively new. I’m just starting to use it, so I don’t have a lot of experience with it, but it works on the liver like a statin, but it’s at a different site. It’s not an HMG-CoA reductase inhibitor. So what it does, it really is very good for those that are prone to muscle aches and pains and weakness. So, it obviates that step.  It seems to be perhaps a little less hepatotoxic, at least potentially, so it’s an interesting drug. And they have it by itself, and they have it combined with ezetimibe, which is a drug that cuts down on the absorption of cholesterol.  So, again, I’m just starting to use them now. But it’s an interesting class, and I think a little bit better-tolerated than statins. The drug companies, they kind of downplay this, but I would say there’s at least 20, 30% of people that have side effects with statins. Usually, it’s muscle myalgias, weakness, muscle weakness.  And what I do, whenever that happens, I say, “Okay, let’s stop it. Let’s see how you do. Come back in two, three weeks. I’m not worried about your cholesterol in that time.” And if the pain goes away, then basically, I’m going to believe the patient, right? I believe in patient smarts, so there’s your answer.

Dr. Weitz:            Do you ever sometimes just drop the dosage to see if that takes care of it?

Dr. Elkin:             It is somewhat dose-dependent, but at the same token, I usually use low … I don’t ever use huge doses of statins. I mean, for obvious reasons. I have very few patients that are on top-level atorvastatin or rosuvastatin which is Crestor, because I use combinations and I use supplements with it, so I don’t usually use it or need it. But yeah, that’s a concern.

Dr. Weitz:            You know what? When we were talking about natural supplements, I know there’s a natural product they use quite a bit, we didn’t mention, is Niacin.

Dr. Elkin:             Oh my God, yeah.

Dr. Weitz:            Maybe talk about Niacin, because Niacin, I would say for the last several years, is really not seen as a good thing to take by most conventional medical doctors.

Dr. Elkin:             Well, I think for a couple of reasons. First of all, it’s not really … It’s more of a supplement than an actual pharmaceutical, so there’s no real money in it. Now, there are couple of … There is a Niacin that you can get through pharmacy, I mean, pharmaceutical brand.  However, it’s the sustained release one that you take at night, and you have to take it with food. And I don’t really like people snacking at night if they don’t have to, number one. Number two, they often wake up at 2:00 am with flushing. And number three, it’s more hepatotoxic, so I haven’t used that one in years. So, I use the standard supplement ones that we all carry in our office, and I-

Dr. Weitz:            But a controlled release one. That’s important, right? Because you don’t really want-

Dr. Elkin:             Right. So, mine is not an immediate release. It’s medium. It’s kind of intermediate.

Dr. Weitz:            Yeah, intermediate release is good. Yeah.

Dr. Elkin:             It will take longer. Right. So, you take it two or three times a day, depending on the dose. It has been effective. I’ve had maybe a couple of patients that have had liver abnormalities with it, but much less so than a statin.   If you do a good prep, usually the flushing is pretty well-tolerated, and it could be very effective. It doesn’t work as well as the statin. If you’re just interested in LDL lowering, which is what most cardiologists are interested in, it’s not going to do the same thing as the statin, so that’s why they go to a statin.

Dr. Weitz:            Except that a statin is not going to increase the LDL particle size, and Niacin can do that.

Dr. Elkin:             Right, it can do that. It also can, in large doses, decrease Lp(a), which we haven’t really talked about. It’s another kind of inherited trait, that it’s sticky, inflammatory, and it’s not good. Most cardiologists don’t even order it, because there’s no pharmaceutical for it. At least, to-

Dr. Weitz:            Yeah, we left out Lp(a) in the advanced lipid profile.

Dr. Elkin:              Right. It’s very common. I check it. It’s part of my advanced cardiac testing. It’s always included in Cleveland, and also in … You should do it at least once [crosstalk 00:51:18]

Dr. Weitz:            Now, some of my patients come to me, and we do the testing. And then sometimes, they’d rather see if they can get the testing through their MD. More likely, it’s going to be covered by insurance, and so a lot of times, we get a lot of opposition when I say, “Include the Lp(a).” They say, “Oh, there’s no point in doing that. It’s hereditary. You can’t do anything about it, so what’s the point?”

Dr. Elkin:              Well, it’s nice to know if you have it, because that … Again, I always tell people, I just wrote my blog for Heart Month, and it’s like, it’s not about how low you can go. It’s about knowing your risk, so my whole thing-

Dr. Weitz:            And even though there’s no prescription drug yet on the market, they’re working on one. But things like Niacin and L-carnitine, and there’s some natural products that can help to modulate it.

Dr. Elkin:              Right. Fish oil may be helpful, and also for women, estrogen can be helpful. And they are working … There’s something in the pipeline, and I reported this about a year ago at UCSD. There’ll be another biologic similar to Repatha, those …

Dr. Weitz:            And the PCSK9 inhibitors.

Dr. Elkin:             It’s very interesting. It can decrease your Lp(a) by like 60% in like four weeks. It’s amazing. But that may be … That’s in the future. I don’t know when that’s going to happen.

Dr. Weitz:            Right, okay. I think that’s pretty much a wrap. Final thoughts for our listeners and viewers?

Dr. Elkin:             Well, I think the thing … My take-home message is, look beyond the numbers. Like I said, it’s not about how low you can go. I mean, a lot of my colleagues now will want their patients with coronary disease to have levels of like 40, 30, even 20.

Dr. Weitz:            Or like the LDL you talked about.

Dr. Elkin:             Yeah, and it really frightens me because … And then they’ve got a couple studies saying, well, we’ve got long-term studies. Long-term studies, two to three years, which hasn’t been damaged. I really worry about the effects on the brain, because I don’t know about you. I don’t want a good heart with a bad brain, and LDL is very essential for the brain.  So, it’s more about how low you can get, it’s really knowing your risk. And I would like to employ these advanced lipid testing and either coerce their doctor to order it, or find a doctor who does it, because there’s a lot of us that do this kind of testing, and it really has major benefits.

Dr. Weitz:            Yeah, I was just having a discussion with somebody about vitamin D and he said, “Well, I go out in the sun. How could I have a vitamin D of super low?” It was one of my employees, and her vitamin D is like … I think she said it was close to zero. And one of the reasons why vitamin D levels are low is that the body makes vitamin D when the sun hits the skin, and it uses cholesterol to produce the vitamin D.

Dr. Elkin:             Right. You need cholesterol.

Dr. Weitz:            Another example of reducing our cholesterol too low is, you make it very difficult for the body to make vitamin D.

Dr. Elkin:             And sex hormones, and bile acids.

Dr. Weitz:            Absolutely.

Dr. Elkin:             I’m with you, and I’ve been this way for a while. But cardiologists, mainstream cardiologists, and I’m not trying to be negative, they just … it’s like they have tunnel vision and they’ve heard about how low you can go, and it still seems to be the prevalent view. I mean, I go to conferences and I hear this all the time. Now, they want to combine PCSK9 inhibitors with statins. I generally … So, anyway.

Dr. Weitz:            Right. How can our listeners get a hold of you, find out more about your information, and how can they contact you?

Dr. Elkin:             Thank you. Well, I’m pretty active on social media. First of all, my website is heartwise.com. And then, on social media, if you want to check me on Instagram because I try to post regularly, it’s dochelkin, D-O-C-H-Elkin. And I’m also on Facebook, HeartWise Fitness and Longevity Center. So, I try to be pretty current and I’m also on YouTube Live now.  I do it every two weeks on Thursday nights at 7:00 pm, which is a lot of fun, because I pick a topic, I talk for no more than 10 minutes, and then we have the audience chat in questions. So it’s fun. You can stump the cardiologist. It’s fun.

Dr. Weitz:            Awesome. Thank you, Howard.

Dr. Elkin:             All right. Thank you, Ben. It’s a pleasure. I always enjoy doing this with you. Take care.


Dr. Weitz:            Well, thank you, listeners for making all the way through this episode of the Rational Wellness Podcast. Please take a few minutes and go to Apple Podcasts and give us a five star ratings and review. That would really help us, so more people can find us in their listing of health podcasts.  I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at 310-395-3111. That’s 310-395-3111. And take one of the few openings we have now for a individual consultation for nutrition with Dr. Ben Weitz. Thank you, and see you next week.



Nutrigenomics with Dr. Yael Joffe: Rational Wellness Podcast 199

Dr. Yael Joffe discusses Nutrigenomics with Dr. Ben Weitz.

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


Podcast Highlights

1:40  Nutrigenomics has to do with the relationship between genetics and diet and lifestyle, including exercise, stress management, meditation, trauma, and anything that impacts our health.

3:06  Weight control.  We are all 99.9% identical genetically, but we can still have millions of places in our DNA where our code sequence is different. 1. One thing to consider is what drives us to eat?  We experience hunger differently and this is driven by our genes.

8:24  Epigenetics is how the choices we make in our environment change the way our genes express. When you switch on a gene it makes a protein and proteins are often enzymes that drive our metabolism. Let’s say we find out that we have a gene that means that we are not efficient at detoxifying. We can then encourage them to eat cruciferous vegetables like broccoli sprouts and brussel sprouts, which contain sulforaphane, which can switch on your detoxification genes once it is activated by an enzyme called myrosinase, which is also in the vegetable.


Dr. Yael Joffe has a PhD in genetics and the nutrition of obesity from the University of Cape Town in South Africa. She is part of the team that created the first nutrigenomic genetic test in 2000 and she cofounded 3X4 genetic testing and she is the Chief Scientific Officer and the website is 3X4genetics.com.

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


Podcast Transcript

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

Hello Rational Wellness podcasters, today our topic is nutrigenomics with Dr. Yael Joffe. To give us some idea of what nutrient genomics is, I looked at an article in Nature Magazine and here’s the quote, nutrigenomics is a study of the effects of food and food constituents on gene expression and how genetic variations affect a nutritional environment. It focuses on understanding the interaction between nutrients and other dietary bioactives with the genome at the molecular level, to understand how specific nutrients or dietary regimens may affect human health.

Dr. Yael Joffe has a PhD in genetics and the nutrition of obesity from the University of Cape Town in South Africa. She’s part of the team that created the first nutrigenomic genetic test in 2000, and she co-founded 3×4 Genetic testing. Dr. Joffe, thank you so much for joining me.

Dr. Joffe:   Hey, Ben. Thanks for having me join, thank you.

Dr. Weitz:  Absolutely. I do think that we really need some more detail and nuance about this whole concept of genomics and nutrigenomics and epigenetics. How how do you… I gave a definition of nutrigenomics from Nature Magazine, but how do you define nutrigenomics?

Dr. Joffe:   I actually thought that was a excellent definition, but I think you could probably break it down a little bit more and maybe just make it a little easier. So it was great for me, I’m not sure it was great for everyone else. So maybe we can start by just coming down to some really basic concepts of what is this story of the relationship between genetics and nutrition. And when I say nutrition, I’m always talking about diet but I’m also talking about lifestyle, exercise, stress management, meditation, trauma, anything that impacts our health. So-

Dr. Weitz:  By the way, I would think it would be great if in this next 50 or 60 minutes we have, if we could get some help on, is can we get some idea from genetics, what type of diet different people might do well with as well as a little more detail about some of these genetic SNPs and how to handle it?

Dr. Joffe:   All right. We can focus on one topic. So if you want to do weight, we can do weight or we can do exercise because we haven’t got enough time to cover them all, but I’m going to use weight as an example which is a great example. I think everyone can relate to it. Let’s start off with the idea that we are 99.9% identical genetically. And what I mean by that is we have a code, we have a blueprint in our body. Everyone’s heard of the word sequence, that’s our DNA blueprint. But at 0.1%, we’re different from each other.   And that means that at millions of places in our DNA, our sequence code is different. We call this genetic variation. Now, why is this important? It’s because these differences determine how we respond to the world around us. So we know that we’re different in the foods we respond to and the way we respond to exercise, training, how injured we get or how well we recover from training, but we’re going to talk a little bit about weight because we chose one topic. So why is it that we respond differently in terms of weight gain and weight loss? When I studied dietetics which was my first degree, I was taught calories in calories out. If you reduce the calories and increase the expenditure of calories, you would lose weight. And I soon found out this was absolutely not the truth, that patients would come to me and they would say, “But I did what you told me to do,” and yet they didn’t lose weight?  And because it was 20, 30 years ago, I’d be like, “Well, you must be lying to me and you must be cheating.” So what has genetics taught us? Genetics has taught us that actually there is an amazing amount of variability in how all of us respond to the food we eat, the way we eat, the behavior about eating, the way we store energy in our bodies, store fat and how we burn up fat. And this is around the concept of genetic variation. So I’m just going to touch on why that is because it used to be, my mother used to say like, “Oh, she’s got such a high metabolic rate, she just looks at food and burns it up.” But the reality is it’s much, much more complex than that.

So when we think about weight, I like to think about genetics in three different ways. One is what drives us to eat? So when we see food, some of us are snacking, some of us are binge eating, some of us are hungry. So what are the drivers? Well, we experience hunger in a different way. I always used to think that everyone was the same hungry as me, but actually we experience hunger completely differently. And the same way that if we all eat a cheeseburger with fries, we experience fullness of the word satiety in a different way. So I might need two or three burgers to feel full and you might be okay on one burger. These differences in how I feel hunger and satiety are actually driven by our genes.  Now we walk into a buffet and we see this beautiful spread of food and we’re all kind of hungry and some of us will go and have a plate of food, we’ll load it up, we’ll come and we’ll eat and we’ll go, “Yeah, that was a great meal, I feel full,” but the others will just take a look at that buffet table and even if they have a sense of fullness, they’ll still go back again and again. So even our eating behavior when we see food is driven by genes, and that’s just the beginning of the story.  Because once that food is in our body, we manage those calories in different ways. Some of us are really efficient at storing and we hold on to it, it’s very evolutionary, it’s from when we were hunter gatherers from the plains of Africa, others of us are very good at burning that up. So how do we burn up energy? Two ways, through exercise and through what we call basal metabolic rate, which is sitting at our desk working, you’re burning up. And yet we are so different in our ability to burn it up.

Now suddenly I’ve just mentioned like six things that would change how you, Ben and I respond to the world of calories around us. So when a patient walks into your practice and says, “I’ve been battling my whole life, I’ve been tried every single diet, I just can’t lose weight,” what we really want to do is we want to use genetics to try and discern why. What is your story, your journey that is driving these calorie interesting conversations in a different way? That’s the first part of the story. Any questions on that part?

Dr. Weitz:  Well, I’ll wait a few minutes to let you drill down but I do want to drill down and come out with some practical ways of dealing with these things.

Dr. Joffe:   Okay. It’s like that’s where I was going. So when you did the definition from Nature, they spoke about two things. They spoke about genetic variation which is what I’ve just spoken about. It’s what gives us our insight about ourselves, it’s self knowledge. How do I react to the world about us? But there’s a second part, the other 50% of the equation, which is how do I change gene expression? And I call this the action part. So insight, I find out about myself or you find out about your patients, action, what are we going to do now? So what? So I find out all the stuff about you, now what difference does it make? I’m sure you’re all familiar with the word called epigenetics.

Dr. Weitz:  Yeah, yeah, yeah.

Dr. Joffe:   Epigenetics, that’s what we’re talking about now. Epigenetics is when choices we make in our environment change the way our genes express, or I like to say the way our genes behave or even better, think of genes as being light switches. When you switch on a gene, it makes a protein, when you switch it off, it stops making the protein. Proteins are enzymes, they drive our body. So I have found out something about myself, I have found out that… let’s talk about detoxification. Everyone understands detox, right?  We have exposure to toxins, we have exposure to internal metabolites that are made by body that we want to make sure that it’s clearing whether it’s through over-training exercise, whether through its exposure. Now I can have a genetic test done and understand how optimally my body is detoxifying toxins or hormones. Now I know that, and I’ve discovered that I am not so brilliant at detoxifying, I want to take action. And the best way to take action is to be able to switch on the genes that are responsible for detoxification in the body.  Because if I can get the genes to make enzymes that detoxify, that is way more powerful than anything I can do. So I’m not just going to take a supplement and plug a hole, I want to switch on enzymes that are going to do stuff that it’s going to heal my buddy and my body is much better at heating itself than me plugging it with another 25 supplements, right? Here’s an example. So you know the… because we want to be practical. So cruciferous vegetables, cauliflower, cabbage-

Dr. Weitz:  [crosstalk 00:10:04] Brussel sprouts, yeah.

Dr. Joffe:   Brussel sprouts, and my favorite broccoli sprouts, the little sprouts. So they contain this extraordinary compound where you spoke in again, a fantastic Nature definition, bioactives, plant practice, but actually all they are, are molecules of compounds that we find in plants. But they’re very magical, they’re very powerful. And there is one called glucoraphanin, and this really amazing compound when it is acted on by an enzyme called myrosinase which is also in your vegetable, you bite into your cauliflower, when you bite, you actually break open that enzyme, it changes accurately and you land up with this very magical plant molecule called sulforaphane. Now this is what is so magical about sulforaphane, it can switch on genes. So sulforaphane, once it’s activated in your body, switches on your detoxification genes.  So you walk into the house and everything’s dark, you switch it on and suddenly you have light, sulforaphane’s doing the same thing in your body with detoxification. And your body is now able to clear those toxins from your system. And we could talk about sulforaphane for hours, but it is probably one of the most potent ability of a plant molecule to switch on genes. So we used to think vegetables were good for us, vegetables is still good for us but we never understood why are vegetables so incredibly good for us? It’s because they are more powerful than anything at switching on genes, epigenetic mechanism. But epigenetics can work the other way as well.

Epigenetics can be environmental toxins, pesticides and herbicides and fertilizers which are getting into our body, and those toxins also switch genes on. They just switch on the genes we don’t want, which is inflammation oxidative stress. Does that make sense? So insight is I want to understand myself, I do a genetic test to understand myself, action is I use what I have, be it exercise, meditation, cold water immersion or nutrition to change the way genes get switched on or switched off.

Dr. Weitz:  Let’s drill down on the weight loss thing. What are a couple of genes that affect whether or not we feel full and whether or not we feel full, is it related to other factors?  In other words if I’m constantly eating large meals, does my stomach get stretched out?  So maybe I don’t get full as quick, maybe I eat quick, so I haven’t even gotten to the point where my body’s getting a signal that it’s full because the food hasn’t even gotten to my stomach yet and I’m still eating. Maybe there’s psychological factors on eating because I feel stressed, I’m tired of this raging pandemic and I just want to eat myself into oblivion. How much do these other factors and then talk about somebody’s genes, maybe one or two of these genetic snips, and then what can we do about these genetic snips?

Dr. Joffe:   Yes, yes and yes, absolutely. There are many factors that contribute to how we experience fullness and you’ve actually named some really well. But here’s the interesting thing, they did a lot of the research on children, little children. Now we as grownups are really complicated and messed up when it comes to food, so it’s about overeating. It’s about watching TV and eating, it’s about comfort eating, it’s about soccer social dynamic of connection and loneliness and isolation, so complicated. And then it becomes really hard to say what is genetic, what is this? But I did a lot of the research in children and in twins, which is the best genetic research. And when they did them in kids, they found that there were certain children who would be very, very hungry. And when they were given the same amount of food as the other kids, they would just have no sense of being full.

And this was before they had enough time to develop company eating or eating disorders or TV watching, this is when they were still really small. So they started looking at what are the genes in the body that are really driving them? So there’s a very famous gene called FTO, which is actually bizarrely named fat mass and obesity gene, barely you’ll find it in the media, it’s all over the place. What’s really interesting is it has been related to fullness. But what I find fascinating about FTO is that if you have the genetic variant, so the alternative version not a Deepak design mutation, it’s just a different version. You have less locus of control around food. So when I walk into that buffet and I see the food, I am likely to have less control in how many times I’m filling up my plate than if I had a different genetic variation that didn’t have the AA gene. There are other ones that drive taste. So we taste food-

Dr. Weitz:  Hang on a second. So if I have that AA variant of the FTO gene, what’s the solution?  Don’t go to buffets?  What else?

Dr. Joffe:   Don’t go to buffet. Two things I want to say, is you cannot make recommendations on a single gene. So I just did that with you, but actually I don’t believe man, you can never say, oh one gene and they’re like… and one gene, don’t ever do this. We look at all your genes that impact your weight, all of them and then we build schools around them and say, you know what? Your issue actually, because you only one gene that impacted fullness, but the other 10 genes that impacted fullness didn’t, so let’s not overreact. So I just want to say that. So we group genes together to understand that we don’t create recommendations phase one.

Now, what do we do? Where I’ve had patients who’ve come to me, I’ve said, “You know what? I’ve been dieting my whole life, and we do the genetics.” And the genetics do come back to say, “You know what? You hit the tough road. Your genes are not helping you. What are we going to do about it?” So the first thing is… And this has led to many patients crying in front of me, [inaudible 00:15:56] is saying, “I’ve been told my whole life, I’m a failure, I have no self control and no willpower. You’re the first person who’s seen me through who I am.” That’s the first thing, is we start dealing with self-acceptance. This is my inheritance, this is what I got. Once we can get positive and say, okay, now let’s think about realistic goal setting.

We’re not going to use the BMI which is based on population, let’s talk about you and your genes and say, you know what? If we can get to a BMI of 27, if we can get like… that is all, even like 20 or 30, that is not bad if we can make sure you’re healthy. So let’s focus on your health parameters. Let’s look at your insulin, your glucose, your lipids, let’s look at your apple versus pear. So we want to focus on what will make them overweight healthy, which is a real thing. You know that it’s that absolute real thing.

That we can keep people a little bit overweight or even completely overweight, but actually still have them extremely healthy by using exercise and making sure that the quality of the diet is right. The third thing I do is a lot of behavioral work. I work with psychologists and psychiatrists who do a lot of behavioral work. In the same way that they work with addiction, they work with eating. In the same way that I’m driven to drink or to gamble, how do I manage those triggers? With a buffet? Be at a bowl of pasta? Be at a party? How do I manage my triggers because my genes are pushing me to the table, but I want to use my mind and my brain to override those triggers?

Dr. Weitz:  Okay. Are there any secret sauces for influencing the FTO and the other genes?

Dr. Joffe:   Well, FTO responds really well to protein, and I don’t say like, everything was one’s protein, I’m not like everyone’s got to be on like a [crosstalk 00:17:48]-

Dr. Weitz:  We certainly heard they’re proteins, one of the foods that’s associated with society.

Dr. Joffe:   It definitely is. And that’s why FTO probably does respond well to protein, is because entirely protein works really well at driving society. So if I have a patient who’s got FTO-

Dr. Weitz:  By the way, does that drive satiety as well, or almost as well as protein?

Dr. Joffe:   It depends on the individual. So fat is much more complicated in terms of responsiveness on how people respond to fat, which is why we would see things like the ketogenic diet works extremely well in some people and really badly and others. That people’s response at part of that is that genetically, we learn about how you break down fat and which pathway fat goes on. And depending on where that pathway fat is, will determine your response to fat and that’ll determine lots of things, not just satiety, and what’s the ability to store and burn fat? Some people are super fat-burning efficient, and others are super fat-storing efficient. That’s also driven by genes.

Dr. Weitz:  Wait. I want to know that.

Dr. Joffe:   Which part?

Dr. Weitz:  How do we know if somebody doesn’t process that well? You’re talking about looking at their lipids and seeing if their LDL or… what-

Dr. Joffe:   No, no, no. We can look at your genes, so genes are going to give us some of that insight and to tell us about how efficient you are at metabolizing and storing fat. So those of us again who are really, they could have the refugee and apotheosis, that when we consume calories, particularly fat calories, we store that, we hold onto that fat, it’s actually a protection against the old evolutionary thing. We can see in your genes when we look at that, whether you’ve got more of these kind of fat storage hold onto energy genes, or whether you’re actually quite good at burning it up.

Dr. Weitz:  Can you name a couple of those?

Dr. Joffe:   The main ones would be ADRB2, the adrenergic receptor genes. We always think of ADRBs, there’s ADRB twos and threes as the burning up versus the storing. I don’t know how long we’ve got, but I’ve got a really great story I can tell you about a Japanese trial where they… Can I quickly tell it?

Dr. Weitz:  Yeah, sure.

Dr. Joffe:   So they did this amazing research study in Japan and they took 127 Japanese men who were overweight. Not obese, overweight. They were like BMI 27. And they put them on a program for two years, 24 months, where they decreased their calories to about 1,200 calories a day and they increased the energy expenditure to 20,000 steps a day, which is a lot of training because we normally base on 10,000, it’s a lot of training. And they tracked them for 24 months. They tracked them to make sure that they were staying on the program, the calories and the expenditure, and they tracked them to see how they lost weight. Now being Japanese, and not American-

Dr. Weitz:  By the way, just for clarification. I believe that somewhere’s around two hours a day of same walking, right?

Dr. Joffe:   Correct, exactly. So they did, I think it was mostly cycling. So they managed to get it in a little bit less at a higher rate, but it was roughly an hour, hour and a half of training a day.

Dr. Weitz:  Okay. [crosstalk 00:21:08]-

Dr. Joffe:   You’re 100% right. I was saying that because they were Japanese and not American or South African, they listened and they did exactly what they were told. Non drops of the study. They all decreased their calories to 1,200 for 24 months and managed to train for 24 months. And at the end of the program, what they did was they took them and they put them into weight loss groups, and they observed that there were four different ways that they lost weight. So in group A, in the first six months, they lost the weight they needed to, they went from like BMI 27 to BMI 22. And after six months, they maintained their weight loss for another 18 months. Brilliant, that’s what we call very successful weight loss.

In the second group, at the six month, they hadn’t lost much weight, very slow to weight loss. But by 24 months, they had got to almost the same place as the first group. So they lost weight but it was extraordinarily. So think of all the programs are blues, 10 kilograms and 10 days. In this group, they lost very slowly but they got there. In the third group, they called the rebound group. At six months, they lost all the way to that the first group lost but by 24 months, all of the weight came back again, plus a little bit of extra.  Remember they never changed their intake or expenditure. So it’s not like six months they lost the weight then they started eating again and it bounced back. It didn’t change their calories, it bounced back. And the fourth group never lost any weight. They decreased their calories to 1,200, they did 20,000 steps a month for two years and they never shifted any weight. Now, why I love this study more than anything is it makes us understand that when we sit in with a patient or a client in front of us, we must always remember those four different groups, that we all react differently and we cannot start off with an assumption of what our expectation is of patients.

Now what they did was they then did their genetics. And I said, “Can we try understand why this group didn’t lose weight? This group lost weight?” And some of the genes that came up as being the most insightful were these ADRB2 genes and the ADRB3 genes. ADRB2 is around how do I store energy and store fat versus burning it up? And ADRB3 is really interested in how responsive am I to exercise training? Because some people will only use exercise to lose weight not successfully, and actually they really to manage their intake to be able to lose weight.

Other people can use exercise and it’s quite efficient. So the ADRB3 is really informative about understanding that nuance between them. And they came up exactly, they could divide them into four groups and see where the genetics were in the four groups. So really, really fantastic study. There are other genes, the FTO gene, the awesome MC4R, TCN2, that also are how do we store fat? How do we… and PPAR gamma. So you put up PPAR gamma, a very, very well-researched gene has been around for 20 years and it’s very much around insulin and glucose, which of course relates a lot to how we store fat. Our insulin levels driving fat storage, and and so PPAR gamma is always a gene that we look at when we’re interested in that.

Dr. Weitz:  So what do we do with the group that wasn’t able to lose weight based on these genes?

Dr. Joffe:   We make them believe that having a BMI of 27 is what is going to be their BMI. What we really want to do with those, that fourth group is we want to make sure they’re healthy. So we’re going to check all their parameters because 27 BMI is okay. If they-

Dr. Weitz:  But you’re saying they can’t lose weight, no matter what.

Dr. Joffe:   They can’t… So we could have tried some different stuff, right? Which of course wasn’t done in this study. So we can manipulate the macronutrients, we can have a look whether we can change around into kind of a different macronutrient distribution because remember they got the same macronutrient distribution. It was not low carbohydrate, it was very moderate carbohydrate. We could try that, that could shift things. We could also change the way they exercise. So there’s a lot of research that says in some people, that kind of aerobic endurance type exercise does not drive it but if we get them into gym and we do high intensity weight training, we might be able to change it. That’s when we start playing around and we can get some of those insights because remember, genetics is not about weight. We have a whole part of our panel which is about exercise potential. How should we be training? How do we respond to training?

Dr. Weitz:  But can you take a set of genes and say based on these genes, this person should do weight training, not cardio, this person needs a low fat diet, this person needs a low carb diet? And there are programs out there that we can send our patients for and they’ll give you this detailed panel that will tell you, this person should eat in this kind of way and this person should do this kind of exercise. What do you think about that?

Dr. Joffe:   In my genetic test, I do a lot of-

Dr. Weitz:  What is your genetic test?

Dr. Joffe:   My genetic test which is 3×4 Genetics, it looks at a whole lot of different stuff from what we call action, which is detox inflammation oxidative stress. So what’s the stuff that’s most caught your body?

Dr. Weitz:  Is it using more… I’m sorry to keep interrupting you, but-

Dr. Joffe:   No, no, it’s fine. Exactly.

Dr. Weitz:  Does it have more genes than I could get from a 23andMe or Ancestry or is it just organizing those genes and give me an explanation? In other words if I did a 23andMe or an Ancestry, and got the raw data, would I have what I need, or?

Dr. Joffe:   Great answer. So I have way less. I have like 134 genes in my report and you are going to get thousands from 23andMe, thousands and thousands and thousands.

Dr. Weitz:  So all the genes in your report, are they included in 23andMe if they were just analyzed the right way?

Dr. Joffe:   Not all of them.

Dr. Weitz:  Okay.

Dr. Joffe:   That’s one that comes to 23. But here’s the thing. I actually can test 600,000 of your genes, 600,000 of your snip genes, because we only have 25,000. But actually of that 600,000 snips of test, I believe and my science team believe that only 134 of them are well-researched enough to give me as a practitioner insight in what to do with you. So one of the problems we’ve had in genetics is everyone kept on coming out of the test and going, “I’ve got 500 genes, I’ve got 1,000 genes, I’ve got 6,000 genes for 29 99.” But actually there’s no value in that because what you need to make sure is, so what?

So you can get raw data of 600,000 snips and you can know nothing about yourself. What do you need to make sure that whatever company you choose to work with genetically is what can I do with this information? Will it be useful to me with my clients and practitioners? How would it change my decision-making? Will it help me decide, should I go to the gym? Should they do endurance? How many days a week should they train? What kind of active recovery should we build in? What about collagen and bone and joints? What are the susceptibilities to ACL injuries? So you need to make sure that we’re answering very specific questions. So the problem is by-

Dr. Weitz:  So if we order your panel, we’re going to get a specific report telling us how this person should eat, how they should exercise, what they should do for bone density?

Dr. Joffe:   Yes. All of that, except a test does not come to you directly. So 23andMe, you can order get at home or send you an answer. We do not do that, we only work with practitioners. Chiropractors, nutritionists, doctors, naturopath. Here’s the reason why. Genetics does not exist in isolation. All the answers to your problems are not just in your genes. You raised this earlier on, right? So when someone comes to me, “Tell me about yourself.” Like, why did you come here? What are you trying to look for? What’s worrying you? What are you looking to get out of it? Tell me what happened when you were growing up. What has your training been? What’s your diet like? What’s your connection like? Do you have friends? How are you feeling? What’s your stress levels?

So I want to take some black tests, I want to understand who you are but I also want to know your genes because if I can know your genes, remember insights of knowledge and know who you are sitting across me and know what you want to get out of this consultation with me, now as a practitioner, I’m super powerful to be able to personalize what you need.

But if I just produce… So there are many companies that you can buy genetic tests from and it’ll say to you, “You’ll do really well on a low fat, high carb diet or a high carb, low fat diet.” I don’t believe that’s true. So for me, the science cannot determine that. We can give you many insights about fat storage and fatty acids and protein and FTO, but you as a practitioner need to take the information and the insights we give you and put it together with everything you know because you’re a practitioner and give the advice. So I, that’s why I like practitioners and that’s why we train our practitioners. We teach them, we mentor them so that they’re able to integrate genetics, but you should never only do a genetic test and believe that they know who you are.

Dr. Weitz:  Now, of course you know in the functional medicine world that there’s a tendency to have the patient get one or several gene tests and then on a result and the basis of that, claim to know the answer to why they’re having this problem that nobody else has solved because we just measured your MTHFR and in case you’re heterozygous or one of the variants, that proves that you need methylated B vitamins which you weren’t taking, or you weren’t taking the right amount and now all your problems will be solved because you have MTHFR. And by the way, you should walk around with a sign that says I have MTHFR.

Dr. Joffe:   And what your sign says, you can have a tattoo and it says MTHFR defect, which is my favorite. So thank you for raising the MTHFR-

Dr. Weitz:  I have the disease of MTHFR.

Dr. Joffe:   I’m going to join the 6,000 MTHFR forums that I can find on the web. So you’re 100% right that one of the worst things [crosstalk 00:32:16]-

Dr. Weitz:  We should not let MTHFRs cross the border. No, I’m kidding.

Dr. Joffe:   Oh, we should board the wall and [inaudible 00:32:22] MTHFR. We’ve got to stop. Stop, stop, stop.

Dr. Weitz:  Okay.

Dr. Joffe:   But MTHFR is a problem because the genetic testing, and MTHFR is one of the first genes that was ever researched and it’s beautifully researched-

Dr. Weitz:  And we couldn’t have a discussion without mentioning MTHFR.

Dr. Joffe:   Right. But here’s the thing. 15, 20 years ago, everyone got so excited at MTHFR, they stuck MTHFR’s really big pedestal and they said, “Oh my God, I can make so much money from this gene because what I can do is I can say, if you have MTHFR which is just a snip,” it’s just a single snip, it’s just one of 600,000. But if you have it, I can sell you lots and lots and lots of supplements, I can sell your diet plan, you’re going to come to my forum because if you have MTHFR, you’re going to have 6,000 diseases. Well, this MTHFR has been the absolute worst thing that happened to the genetic testing industry. It made some individuals very, very wealthy, I will not name them, but it made them very, very wealthy. But what it did was it actually undermined the true value of genetics for the individual.

And so if you study one of my courses I teach, you get a whole module on what we’re drawing with MTHFR and why it is so damaging and why it is wrong. So when you hear people say I have MTHFR mutation or defect and I’m going to take 20 supplements and I’m going to get these diseases because I have it, this should be the biggest red flag and fireworks going on. It’s like, no, no, no, these genes are not that powerful. They’re informative, they’re interesting, they give us some information about the biochemistry of our body, but by themselves and that’s what I said early on, we never make a recommendation on a single gene or a single snap, whether it’s FTO, APOE, MTHFR, I don’t care. We group genes together that are interesting to us in methylation, in cognitive, in detox, in fat storage, we group them all together and we evaluate what did you inherit altogether? And we get a sense whether we should address that issue.

And one of the things that happen in MTHFR is that the supplement industry made so much money that they took people who had MTHFR and made them more sick because they gave him so many methylated B vitamins. And I think people are starting to wake up. So you’ve got to be really careful about what genetic… Genetics is awesome, it gives us self knowledge and insight but you’ve got to be very careful. It is [crosstalk 00:34:56]-

Dr. Weitz:  I have gone down the MTHFR rabbit hole a little bit. It’s been that much time with it. And then I ran a couple of these detailed methylation panels that look at say 15 or 20 different genes and then correlate it with various factors like homocysteine and still after all that, it seemed to me almost every one of these genes said check vitamin B2 and B3, check folly, check B12. And we ended up with the same thing. So I couldn’t help but think, okay, if I just give everybody methylated B vitamins, I guess that pretty much takes care of.

Dr. Joffe:   Yeah. That is a problem. So the companies have [crosstalk 00:35:48]-

Dr. Weitz:  And maybe a slight variation like this one, [crosstalk 00:35:51] a lot of it just is around these B vitamins, right?

Dr. Joffe:   Well, not in my test.

Dr. Weitz:  Okay.

Dr. Joffe:   Not in my test. So methylation is a single pathway, right?

Dr. Weitz:  Right.

Dr. Joffe:   I have six pathways that we analyze and each pathway has 10, 15, 20 snips it. But methylation isn’t an important pathway but a single pathway. So we never say that one pathway [inaudible 00:36:17]. And so what happened to many of the companies that were testing MTHFR, when they got into trouble for only testing MTHFR, they’re like, “Well, let’s just test methylation because if MTHFR is awesome, methylation must be more awesome and we can make a million decisions just of methylation. Wrong, right? Because there are multiple biochemical processes happening in our body and they all interrelate with each other.

So we can’t understand what’s going on in methylation and not understand oxidative stress, what’s happening with our mitochondrial stuff, glucose, insulin, hormone metabolism? Methylation is important but the same way that you cannot make a recommendation based on a single gene, you should never make a recommendation based on a single pathway. Because otherwise we’ll land up where we started, which is too many methylated B vitamins, which actually, excuse me for saying, you don’t actually need because methylated B vitamins bypass MTHFR. So the amount and the dose you need is actually really low.

Dr. Weitz:  And on his methylation pathway, methylation is a way to actually get a sense for anti-aging now as we look at these methylation time clocks. However, it’s not just whether all the genes are methylated, but it’s whether some of the genes are demethylated, and you mentioned the FTO gene, and this is actually a gene that demethylates. And so you don’t necessarily want all your genes methylated, some of the genes should not be methylated with health, right?

Dr. Joffe:   Yeah. And so there’s a huge confusion here which is a great place to address it. Huge confusion about methylation. You actually spoke about methylation and there’s two different kinds of methylation, is what I’m trying to say, right?

Dr. Weitz:  Okay.

Dr. Joffe:   Two different kinds, and this is where everyone gets completely confused. There is genetic variation methylation. That means… We know that there’s the methylation pathways. And if you have a whole lot of genes, MTR, MTRR, CBS, MTHFR, and they have snips in them. So they have speeding changes in the sequence that change how efficient they are. We get a sense for how efficient or inefficient or optimal or suboptimal our methylation pathways are working. And those methylation pathways are involved in DNA repair and making new DNA. So they’re like the basic engine. Now the other methylation you spoke about is actually epigenetics, which is attaching a methyl group onto a gene which either switches it on switches it off, which is what you spoke about. Demethylated or methylated.

And this goes back to our previous conversation where we switch on genes and then we switch off. And there’s some choices we make in our life that will either switch on and switch of genes. So methylation is so complicated and [crosstalk 00:39:07]

Dr. Weitz:  So there’s two methylation processes in the body, are they related, directly related, somewhat related or totally separate?

Dr. Joffe:   They are related in the sense that those first ones I told you about, the ones that have gene variants and they’re producing methyl groups. And they need to produce enough methyl groups to be able to switch on and switch of genes. So that’s how they’re related, but they’re actually doing two different things. One is we’re looking at genetic variation and how optimal we are at producing those methyl groups. I mean, looking at epigenetic methylation, I call it epigenetic methylation, it makes more sense of how efficient are we at switching on and switching off genes without methyl groups? Now, the problem is there’s a couple of tests in the marketplace that are being sold to consumers of epigenetics. They say that they can measure how your genes are being switched on and switched off. There’s about three companies out in the marketplace at the moment.

Dr. Weitz:  Yes.

Dr. Joffe:   Here’s the thing, is I think they all, genetics was 30 years ago, where they can measure something, it doesn’t mean they’re able to understand what they’re measuring and here’s why. If you wake up in the morning and you go to the coffee shop and you have a double kotato, double shot espresso caffeinated thing, that’s not just the caffeine, but the other compounds in the coffee are going to switch on a whole lot of genes, either through methylation or demethylation. Anyway, they’re going to switch on a whole lot of genes. So if I measure your epigenetic profile, your methylation profile, after your double espresso, I’m going to get a reading. Then you’re going to go home and you’re going to do your 30 minutes meditation and then I’m going to test your epigenetic prevalence. Guess what, I switched on and I switched off a whole lot of different genes.

Dr. Joffe:   So when I test you, what actually am I testing? And that is the problem. If we just… I’m going to say one more thing and then you can bug in there. Every single decision we make, sorry, you and I be like, every decision we make every minute of the day changes the way our genes express themselves. When I wake up in the morning and I choose what coffee, if I wake up in the morning and grab my phone to look at as opposed to going to do 20 minutes of meditation, changing the way my genes behave. So health is not something that we decide of a month or year, it’s a decision we make every minute of every day.

Dr. Weitz:  So you’re saying that all this research being done by Steve Horvath at UCLA and these other folks and they described this as epigenetic methylation clocks, that it’s not an accurate way to assess our biological aging because minor things that you do switch on and switch off before you get the test.

Dr. Joffe:   I think his research is brilliant and I definitely think he’s leading the charge, but just because we can measure it in a research which came out of research doesn’t mean we understand how to translate it yet. And I think he is at the forefront and I think he will lead the forefront but personally, I don’t think we’re close to understanding how we’re measuring it, what it means because we haven’t been able to figure out what is the influence of the decision I made two minutes before I took your test even more? So I’m waiting.  I’m waiting and I’m watching, we’re definitely going to be doing in the future. We can definitely do it in clinical trials, but there’s a difference remember between insights measuring and then actually what do we do? And so I’m going to stay on the fence for a little bit longer.

Dr. Weitz:  My methylation epigenetic measurement test, it should be arriving today.

Dr. Joffe:   Well, let me know. With the true age. Did you do true age?

Dr. Weitz:  True age, yeah.

Dr. Joffe:   So let me know how that goes, I’d be fascinated to… It’s cutting edge but I’m not happy yet that the science is ready, but that’s how it works, that’s how science works. You get… When we built the first nutrigenomic test in 2000, it was three years before the human genome was developed and everyone said to me, “It’s too soon, you don’t have enough,” and they were right right?

Dr. Weitz:  Right.

Dr. Joffe:   So someone’s got to start it.

Dr. Weitz:  I know this is a huge topic in every one of the categories we’ve talked about you could spend a week with and I know I’m taking you down another topic that could take a week to discuss, but it’s on my mind and I had to ask you about the APOE gene. So maybe we can just talk about that for the last 10 minutes or so. For those of us who aren’t aware, if you have the APOE 34 or 44 snap, that increases your risk for heart disease and Alzheimer’s disease. And I know in practice, it’s not unusual to put somebody on what seems to be a healthy program or maybe get somebody who comes in the office who’s on what seems like a healthy program, and then you find out they have a 34, 44, and a lot of times they don’t respond in the same way.

But we’re still debating in the literature what that means. Do you have any insights? I know we haven’t had enough long-term large-scale prospective randomized clinical trials, but we know on patients who have APOE 34 or 44 if they’re going to do better on a ketogenic diet or a vegetarian diet, or do we have any idea?

Dr. Joffe:   I have a deep fascination with this gene, it’s an amazing gene. Do you know that it’s called the God gene?

Dr. Weitz:  Oh, is that right? I hadn’t heard that.

Dr. Joffe:   It’s referred to as the God gene. And I’ll tell you something even more interesting is that if you look at evolutionary biology, because of course genetics is evolutionary and then we got this really bad, dark messed everything up. The original version of APOE was E4.

Dr. Weitz:  I thought it was E2.

Dr. Joffe:   No, it was E4.

Dr. Weitz:  Okay.

Dr. Joffe:   So when we were hunter gatherers on the plains of Africa, E4 was the common variant, not E2.

Dr. Weitz:  That’s right, that’s right, that’s right, that’s right.

Dr. Joffe:   E2 came later. So why would we have this E4 variant to help us survive on the plains of Africa? And then suddenly we’ve got E2, E3 and everyone’s terrified of E4, right? It’s because it’s such an interesting gene, it’s an inflammatory gene. And when we were attacked by the tiger and we needed to heal quickly, you actually want to be able to get a very quick acute inflammatory response to be able to heal. But the problem is we don’t get attacked by tigers anymore and we have these very bad diets and all the various entry and everything. So suddenly the inflammatory aspect of APOE became harmful instead of helpful.

Dr. Weitz:  And the biggest risk to survival was starvation, not getting some chronic inflammatory disease. So having a lot of inflammation was beneficial, whereas now the predominant cause of disease are chronic inflammatory conditions like diabetes or heart disease and cancer.

Dr. Joffe:   [inaudible 00:46:55] Cancer, they’re all inflammatory diseases, right. So it’s fascinating how the gene itself has evolved because the problem of health is the problem of the disconnection between our genetics which is ancient and evolutionary and our diet, which is very modern and very quickly changing and very bad. And it’s this clash between the two that we’re seeing is causing so much disease. Anyway, back to APOE. APOE when you start studying is actually not this great body that actually everyone thinks, but one thing it is, is hyper responsive. So we talk about the E4, whether E 44 makes you hyper responsive, which means when I change your diet plan to a health diet plan, you are unlikely to be very responsive to those changes, which is a really good thing, it’s a really good thing.

So if I have a patient with hot stuff happening, particularly like lipids, lipid metabolism, and I see they have a three, four or a four, four, before I go in yet any start on, I’m going to do everything in my data and lifestyle, because they’re more likely to respond to a healthy data and lifestyle intervention than to resend to medication. Let’s talk about Alzheimer’s and cognitive decline. There is absolutely-

Dr. Weitz:  By the way… I’m sorry. When you say they’re more likely to respond to healthy diet, what type of healthy diet?

Dr. Joffe:   Well, that depends on what impact [crosstalk 00:48:23]-

Dr. Weitz:  It depends on the person still?

Dr. Joffe:   Yeah, it depends on the person, depends on the other genes. It depends on… there’s so many things I don’t want to say, but we know that we’re going to move them towards a healthier diet. It’s going to have less sugar and it’s going to have more plant foods and it’s going to have great diversity and it’s going to be safer and not have… et cetera, et cetera.

Dr. Weitz:  But just on APOE, there’s no way we could say better to be on a vegetarian diet or better to be on a ketogenic diet?

Dr. Joffe:   No, not just on APOE. First, I’m going to send you an article that they did about APOE and ketogenic that is absolutely fascinating. I’m going to send it to you, you’re going to find it very interesting. But there isn’t a single definitive job. Here’s what’s interesting. So I’ve got a family history [crosstalk 00:49:07]-

Dr. Weitz:  I guess one thing we could say is whatever diet they’re on, if they come to us and they have heart disease, then we know that’s not the right one.

Dr. Joffe:   Probably not the right one. You need to make some change, that’s always a good start. Most people don’t come to us with the perfect diet. So there is interesting stuff around APOE 34 and the ketogenic and I’m going to send it to you.

Dr. Weitz:  Thank you.

Dr. Joffe:   I don’t want to talk about it now because I actually contract with the detail and I’m part of making this of it.

Dr. Weitz:  Okay, sounds good.

Dr. Joffe:   But what makes… I come from family of Alzheimer’s. My father had two sisters, they both got Alzheimer’s young in life, so young Alzheimer’s [crosstalk 00:49:40] and I’ve known since I first started in genetics that I had E 34, so I’m carrying one of the E4s, right? Someone has got a family history like I do, and he’s having that E 34, I was convinced, but convinced that Alzheimer’s was going to be my burden to carry. That it was going to happen to me and it was going to be my life.  When I started learning more about genetics and became a bit more experienced in it, I started understanding again, this idea that a single gene, a single snip cannot determine a disease, not even Breca which is the breast cancer gene, not even Breca which is 10 times more powerful than APOE. And when we both, these what we call polygenic risk scores, where we look at a pathway, so the pathway is cognitive decline dementia, that’s the pathway.

We get more plugs, we lose connection, the neurotransmitters. So we looked at all the genes that would impact that. APOE is definitely one of them, it’s definitely significant but it’s one of them. And when we built these polygenic risk scores, so a score based on all my genes and cognitive decline, I actually landed up with a no risk. I was like, come on, I’ve spend my whole life believing I’m going to get Alzheimer’s, how’s that possible?   And the reason was I only had the E 34. But actually all the other genes that are driving cognitive, I was actually doing well. So I embrace APOE because it’s the one thing that gives us so much we can do. If you look at Dale Brisbane’s protocols now, there is so much we can do and that includes with APOE. It is not a sentence, it is not a disease, it is none of that. What it does do, and in fact they’ve done research to show that people who knew the APOE results, particularly if there was E4 made better and more lifestyle changes than those who didn’t know the APOE result.  So we teach our practitioners not to be fearful of APOE but rather to embrace it because the patients are responsive. If they understand how powerful their diet and lifestyle choices are, and especially because since Brisbane came into our lives and many other great scientists, we understand that there are so many ways we can reverse cognitive decline and APOE being a responsive gene, APO, really helps with that. So actually there’s some Alzheimer’s with E2 is more of a problem because it’s not a non-responsive one.

Dr. Weitz:  Interesting, interesting. I think it’s probably time to wrap.

Dr. Joffe:   Yeah, we can talk about APOE also for hours. I’m going to send you a link to a webinar I did on APOE [crosstalk 00:52:26]-

Dr. Weitz:  Peter T I just had like a two hour some researcher talking about APOE. So that was an interesting one. So how can, which scenarios practitioners find out about your genetic test? And by the way is there one version of it or multiple versions?

Dr. Joffe:   Single version, only one. So I don’t want you to have to figure out whether you want to buy energy, which is we don’t talk about weight, energy, exercise, everything is important to you. So it’s a single test, you can come to a 3x4genetics.com or email info@3x4genetics.com-

Dr. Weitz:  Saliva, [crosstalk 00:53:13]-

Dr. Joffe:   Saliva, Cheek Swab, easy peasy, [crosstalk 00:53:15].

Dr. Weitz:  Okay.

Dr. Joffe:   We’re drug shop, so we send it to your house, you send it back to us, goes to our lab, but remember we will always do it through a practitioner. So if you contact us, you tell us what you’re looking for, we’ll find you the best practitioner that suits what you’ve come looking for. And they are trained, they’re mentored, they’re nurtured, they’re looked after, they’re really what we call expert practitioners.

Dr. Weitz:  So what does that say for somebody like me? Let’s say if I want my patient to get that.

Dr. Joffe:   If you want to, you’d have to come. So we do a basic three-hour training. You’re not allowed to go near our product until you’ve done the basic training, which is… I’m sorry. And we want to make sure you know what you’re doing. I can hear you understand what you’re doing, right?

Dr. Weitz:  Right.

Dr. Joffe:   It’s going to be easy for you, you’re already deeply into genetics. But we want to make sure you understand polygenic risk scores. We want you to understand scientific and clinical utilities. A couple of things we want to make sure you understand before you represent our tests to your patients. When you do that, you get an amazing portal which has got an incredible back end clinical guide, everything you need to research is there. And then you go, you have access to a mentorship program.  So we have these amazing mentors that’ve been working with me for 10, 15 years that you can access in every way. We have webinars, we have a next level education program for practitioners. If you want to take your expertise to a higher level and become more specialists, we’ve got layers of education, layers of mentorship and we have an incredible community of practitioners in the U.S. totally multidisciplinary.  So chiropractors, dentists, psychiatrists, psychologists, nutritionists, doctors, natural paths who are working with our tests and are also teaching and learning from each other. We have amazing, I can see you’re in a very sports space, we have amazing sports dietician, sports people who… And I haven’t even touched on sports unfortunately, because one of our absolute areas of expertise is sports and genetics. And I have three scientists whose only job is sports genetics. So maybe another time you’ll invite me back.  And in fact not even me, you can invite them back. And they’re actually world-class to athletes as well and they’re geneticists. So they’re really, really great to talk to and it’s another whole fantastic conversation.

Dr. Weitz:  Cool. So what’s the website again?

Dr. Joffe:   3×4 Genetics. Three and then the little X, four genetics.com.

Dr. Weitz:  Excellent, excellent. Thank you so much, Dr. Joffe.

Well, thank you listeners for making it all the way through this episode of The Rational Wellness Podcast. Please take a few minutes and go to Apple podcasts and give us a five-star ratings and review. That would really help us so more people can find us in their listing of health podcasts.

I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at 310-395-3111. That’s 310-395-3111 and take one of the few openings we have now for a individual consultation for nutrition, with Dr. Ben Weitz. Thank you and see you next week.



SIBO with Dr. Vincent Pedre: Rational Wellness Podcast 198

Dr. Vincent Pedre discusses Small Intestinal Bacterial Overgrowth with Dr. Ben Weitz.

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


Podcast Highlights

4:37  Dr. Pedre had gut problems himself for years that he believes stemmed from taking many rounds of antibiotics–two or three courses of antibiotics per year as a child for various infections, such as a throat infection, bronchitis, or sinusitis. They would also sometimes give him a gamma globulin shot and this would make him feel better for a while.  By the time he was 17, Dr. Pedre had taken 21 courses of antibiotics, which took a toll on his microbiome.  Dr. Pedre developed dysbiosis that led to leaky gut that led to becoming reactive to foods like gluten and dairy.  When Dr. Pedre became a doctor, he wanted to figure out why he felt so sick, which is what led him to focus on gut issues.  As he treated patients with gut issues, he came to realize how many other health issues are connected to the gut.

10:30  Taking a thorough history is the most important factor in patient care.  The history can then help guide your choice of testing. Should I get a breath test to confirm a suspicion that the patient has SIBO. Should we also order a PCR based stool test because there might also be a parasite or yeast overgrowth. Or should I order an organic acids test to get a broader look at metabolites and better be able to rule out fungal overgrowth.  For stool testing, Dr. Pedre switches between both Diagnostic Solutions GI Map and Genova’s GI Effects, which both have their strengths.

23:20  Treatment protocols for SIBO.  Dr. Pedre believes in starting with diet first. He used to use the low FODMAP diet, but now he uses Dr. Siebecker’s SIBO Specific Diet, which is a little less restrictive than the strict low FODMAP diet. Intermittent fasting can also be helpful to have periods when the gut can rest. Dr. Pedre will often put SIBO patients on Rifaximin at the same time as the SIBO diet but he will also put them on Slippery elm bark as a prebiotic to make the bacteria easier to kill.  This avoids Dr. Pimentel’s concern that placing patients on a low fermentation SIBO diet will starve the bacteria and make them harder to kill. Dr. Pedre has found that patients with SIBO tend to be type A personalities, high achievers, who tend to be anxious, and this tends to affect vagal tone and decrease gut motility.  He recommends patients improve vagal tone through things like gargling, humming, and he recommends spore based probiotics.

29:44  Spore based probiotics. Dr. Pedre has found that many of his patients with SIBO do not tolerate typical probiotics, such as acidophilus, esp. at higher dosages, but they tend to do well with spore based -probiotics. One reason that spore based probiotics may help SIBO patients is that many also have fungal overgrowth (SIFO).  He believes that this may be why patients who get treated with Xifaxan get better and then a month later, their symptoms come back.  Spore based probiotics do quorum sensing to group together, and they produce other active compounds, enzymes that can break down biofilm, called bacteriocins, which are like local antibiotics that inhibit other species from growing.

32:45  Biofilms. If you have a treatment resistant SIBO patients, then you should consider biofilms and you can use things like Serrapeptase to break down the biofilm and use that on an empty stomach.

34:41  If Dr. Pedre does not use Rifaximin, he may use natural anti-microbials like Candicid Forte. But yeah, they include berberine, caprylic acid sometimes mixed in with some artemisinin and black walnut.  Kind of broad spectrum herbals, olive leaf extract, all these things.  He may also use serum derived, bovine immunoglobulins.

35:40  Prokinetics.  Dr. Pedre said he has heard Dr. Pimentel talk about Motegrity as a magic bullet for lack of intestinal motility, but he has not found it to be a magic bullet and he tends not to prescribe it. Dr. Pedre looks at the behaviors in his patients and encourages his patients to do cardiovascular exercise like running and he works on improving parasympathetic tone in his patients.



Dr. Vincent Pedre is the Medical director of Pedre Integrative Health and president of Dr. Pedre Wellness.  He is a clinical instructor in medicine at Mount Sinai School of Medicine.  He is a board certified internist, as well as the best-selling author of Happy Gut: The Cleansing Program to Help You Lose Weight, Gain Energy, and Eliminate Pain. His website is PedreMD.com.

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


Podcast Transcript


Hey, this is Dr. Ben Weitz host of the Rational Wellness Podcast. I talked to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me. And let’s jump into the podcast. Hello, Rational Wellness podcasters. Our topic for today is small intestinal bacterial overgrowth with Dr. Vincent Pedre. Many of you are probably already somewhat familiar with small intestinal bacteria overgrowth, also known as SIBO from previous conversations we’ve had with many in the functional medicine world, including Dr. Pimintel and Dr. Alison T. Becker. But for those of you who have not heard of SIBO. This is the most common cause of IBS or irritable bowel syndrome. And irritable bowel syndrome is the most common gastrointestinal condition marked by a number of symptoms including gas, bloating, abdominal pain, diarrhea, or constipation, or alternating of the two, urgency to defecate and nausea among other symptoms.

And IBS affects approximately 15, maybe as much as 20% of the population. And now we know that IBS is, in many cases, an autoimmune condition resulting from a bout of food poisoning. And we know that the reason why we have a problem with bacterial overgrowth in the small intestines is that, our small intestines are supposed to only have a relatively small amount of bacteria, especially as compared with the large intestine or the colon. Too many bacteria in the small intestine will affect the ability of the small intestines to absorb nutrients and excess bacteria can also produce gas, specifically hydrogen, methane, or hydrogen-sulfide gases. And these gases increase many of these symptoms that I just mentioned above. And so that’s really what we’re talking about with small intestinal bacterial overgrowth.


I’m very happy that today’s podcast episode is being sponsored by Lifestyle Matrix Resource Center, which is a hub of clinical resources, digital patient education materials, and marketing tools to help healthcare practitioners successfully implement lifestyle medicine in their practices. With the resources offered by Lifestyle Matrix Resource Center plus access to their knowledgeable implementation support team, practitioners can quickly become the go-to expert in their communities on a variety of functional medicine topics like GI health, immunity, and stress. Learn more on your website, lifestylematrix.com exclusively for Rational Wellness listeners. Lifestyle Matrix Resource Center is offering a free download on dysbiosis and probiotic supplementation. Head to lifestylematrix.com/rational-wellness-download to claim your copy. That’s lifestylematrix.com/rational-wellness-download and claim this free copy.


And Dr. Vincent Pedre is the medical director of Pedre Integrative Health and president of Dr. Pedre Wellness. And he’s a clinical instructor in medicine at the Mount Sinai School of Medicine. He’s a board certified internist, as well as the best-selling author of Happy Gut: The Cleansing Program to Help You Lose Weight, Gain Energy, and Eliminate Pain. Dr. Pedre, thank you so much for joining us today.

Dr. Pedre:  It’s a pleasure. Thanks for having me.

Dr. Weitz:  Good. So why don’t you tell us a little bit about your story and how you became interested in focusing your practice on digestive disorders?

Dr. Pedre:   Ooh. Yeah. I mean, I basically grew up with I guess you would call it IBS. And honestly, I can’t say whether it was due to food poisoning of any sort like Dr. Pimentel says, or if it was what I think due to being put on multiple rounds of antibiotics as a child. Probably starting around the age of 10, I was put on so many rounds of antibiotics, probably two or three courses of antibiotics per year for all infections that the child would get, a throat infection, long bronchitis, sinusitis. And sometimes back then, which is scary to think about, my immune system didn’t seem to just wasn’t functioning. And I don’t think they do this anymore, but it was custom back then that if you weren’t responding to the antibiotic, they would give you a gamma globulin shot.  So it’s basically pulled immunoglobulins from a bunch of people. And usually when I got a shot of that, I would start to feel better. But no one was really figuring out like, “Hey, why is this child having an immune system that’s not functioning properly and he keeps getting sick over and over and coming back for course after course of antibiotics?” Which by the time I was 17, I had been on probably 21 courses of antibiotics. So you can imagine what that did to my gut and my gut microbiome. And as a result, I had no clue what leaky gut was back then and nor did my family. But I can look back after my training as a doctor and then training as a functional medicine practitioner, that I developed a dysbiosis that led to leaky gut that then led to becoming reactive to foods like gluten and dairy.

And it wasn’t just fructose intolerance, it was actually a sensitivity to the proteins and dairy, and that weekend my immune system. So my selfish endeavor in becoming a doctor was to figure out, “Hey, how do I not get sick?” But as a result of that, it led me to my life’s passion, which is working with people on gut issues and then just realizing that so many things are connected to the gut. That it’s really not just about the gut, it’s your immune system, it’s your brain health, it’s auto-immunity, it’s allergies, asthma, lung health. So many other things are connected to gut health that it just became just something that I did that I really enjoyed. And before I knew it, even though I was a general internist, I had patients referring. They would come in with gut issues and they would get better and other things would get better, not just their gut.

And then they would refer a friend, friends would refer another friend, family members. And before I knew it, I was this accidental gut expert without really planning on it, which I think is the best way to find something that you’re passionate about is just to fall into it. Because a lot of times when we do our training as doctors, before you really understand what you feel passionate about, I mean, maybe some would understand that, you’re already having to decide if you want to be a pulmonologist, cardiologists and you’re just trying to survive to get through your residency. You’re working 80 to a 100 hours per week and now you have to decide what you want to do within that. And I couldn’t decide at the time, but then it just fell on my lap and I’m so happy that it did that way. Because it stemmed from my own childhood problems and even early adulthood with gut issues and then working with patients on their own gut issues.

Dr. Weitz:   So when you see a patient complaining of gastrointestinal issues like gas and abdominal pain, constipation, et cetera, how do you work them up and what type of testing do you do?

Dr. Pedre:   Oh, I mean, first and foremost, super important to take a thorough history. I think that’s a slowly dying art in our insurance driven medicine where doctors have less and less time with patients.

Dr. Weitz:   Well, actually, that’s one of the questions I was going to ask you because I went over to your website and I noticed that you actually take insurance.

Dr. Pedre:   I have a bit of a hybrid system. So I have a-

Dr. Weitz:   I’m curious how you can spend 90 minutes doing a full, detailed, functional medicine history for HMO insurance. How do you make that work?

Dr. Pedre:   For that reason, I only take PPOs and I actually have cut them down over the years. And now I only take about, I don’t know, somewhere between three and five plans. And I also have cash based programs between supplements, concierge program, functional medicine program. That then allows me to still see insurance patients and be able to balance the time and be able to give them the time that they deserve. Because you can’t take a thorough history in 15 minutes.

Dr. Weitz:   No. I know.

Dr. Pedre:   You just can’t. And the history is primo, it is the most important thing that you start with because the history is then going to guide you on which direction you choose in terms of testing. Especially sometimes and I look at it as a challenge because I do see some patients who have financial limitations, and a lot of this functional medicine tests that are out there are quite expensive. So if a patient can afford it, then you have to start deciding, “Well, which is the most important test for me to do? Should I get a breath test because I suspect that they have SIBO and maybe that’s going to point me in the right direction. At least we can get the ball rolling? Or am I going to get a PCR based stool analysis along with a breath test? Because I think maybe there’s more going on here than just SIBO. There could be a parasite, there could be yeast overgrowth, or maybe I want to do organic acids testing to get a broader look at metabolites and see what else might be going on that could be going into the picture of the patient.”

And I will tell you this, test results can either mislead or they can surprise. And I have had test results that have surprised in patients that had no GI issues and turned up with a parasite and with a yeast overgrowth. So if there is a suspicion, and the reason I did the test even though the person did not complain about any gut health issues, is because there was enough in the history and they had tested positive for multiple autoimmune markers.  And because we know there’s a connection between gut health and immune system and auto-immunity, I decided, “Okay, with this patient, even though she answered every question negative on the review of systems on GI, no constipation, no problems.” And yet she was presenting with autoimmune disorder with hives, skin rashes, with achy joints. So I knew, “Okay, got to look at the gut with this person,” even though they’re not coming in with a gut complaint, but they have gut related health issues. So I think, first of all, is the story. You have to understand the person’s story, and then from there you start to put the picture together.

Dr. Weitz:   Yeah. Absolutely. What’s your favorite stool tests these days?

Dr. Pedre:   I have been using, I switch between the two and they give you different information. But I’ve been using the GI-Map Diagnostic Solutions. But the one thing that doesn’t give you that I really like that the Genova GI Effects Profile does is that, the GI Effects will give you a view of diversity whereas the GI-Map, it doesn’t really give you that. The great thing about it is, it has a really fast turnaround. So you can get a result within three to five business days of them receiving it. But the GI-Map does a lot of similar things as the, I mean, the Genova GI Effects does a lot of similar things but it takes a little bit longer to get the results.

Dr. Weitz:   Yeah. We seem to prefer the GI-Map these days. We seem to get more clinical useful information. And when you talk about autoimmune, I liked that section where it has the potential autoimmune markers and it’s one thing to consider.

Dr. Pedre:   Yeah, definitely. I see a lot of Prevotella coming up there.

Dr. Weitz:   Yeah, yeah. And sometimes it really correlates and we’re still waiting for the research to see if reducing the Prevotella is actually going to have an effect on their autoimmune condition, right?

Dr. Pedre:   Yeah. I think it’s always difficult to… Because then we’re trying to bring it down to that one thing which is like Western medicine magic bullet approach, and it really isn’t a magic bullet. And I think even when you get these test results, it’s always really important to put the test result next to the patient. And the story that the patient and the symptoms that the patient is having, and make sure that the two sync up with each other. And if they don’t, you have to wonder like, “Am I going to do an intervention that even though the person doesn’t have symptoms or do I pay attention to the patient and leave this alone?” Because we still don’t understand it completely, and we’re still learning how to manipulate the gut microbiome. And even a test like the GI-Map is not like doing whole genome sequencing. You’re going to get a full picture of what’s in the gut.

Dr. Weitz:   And that’s the other type of stool testing which is a whole different thing. And that as much clinical focus on parasites and things like that, but a better overall picture of the whole microbiome.

Dr. Pedre:   Yeah. And the thing is, then you get a lot of information and I honestly think we’re still figuring out how to use that information.

Dr. Weitz:   Absolutely. And everybody’s focused on which bacteria are low or high. And then of course we know that even if you give supplemental bacteria probiotics, they’re only temporary visitors there, they don’t actually take up permanent residence.

Dr. Pedre:   Yeah. We do know that certain bacteria influence the growth of other bacteria. And for example, because there’s cross feeding between strains, so certain bacteria can help promote butyrate producing bacteria. But I know there’s a company out there that does whole genome sequencing and then creates a customized probiotic based on the whole genome sequence. And when I saw patients use the product, I saw that were mixed results. Which tells me that we still don’t know fully what… If you have a genome sequence and you see that something’s low, does giving them more of that, does it actually improve the outcome or is the picture much more complex than that?

Dr. Weitz:   Yeah. I think it’s early. I think we definitely do not know the answer to that.

Dr. Pedre:   I don’t think so. I mean, the one thing that I do find remarkable and I’m just going to segue just a little side note to FMTs, because I’ve been looking at the research at Memorial Sloan Kettering using autologous FMTs for patients undergoing bone marrow transplant. And so they’ll take their stool, they’ll keep it. And then they’ll give them their own stool back after the bone marrow transplant. And it helps re-institute, because they have to use high doses of chemo and antibiotics because their white blood cells drop. And what they found is that by giving them back their own stool during an autologous FMT, that it recedes the gut with the diversity of the gut microbiome. And it actually helps prevent things like graft versus host disease and improve survival.

Dr. Weitz:   Wow. And this is with cancer patients?

Dr. Pedre:   This is with bone marrow patients who are undergoing bone marrow transplant at Memorial Sloan Kettering. So I was really happy to see that they’re studying that because they’re realizing, “Okay. We do cause damage as doctors by giving patients antibiotics. And these are the most delicate patients out there, how can we improve their outcome?” And it turns out just take their stool and give it back to them after the bone marrow transplant.

Dr. Weitz:   Yeah. Interesting. So there’s actually a whole series of medications that are commonly prescribed to have negative effects on the microbiome, not just antibiotics, but all anti-inflammatories, proton-pump inhibitors.

Dr. Pedre:   Definitely. And just to connect it with SIBO, I’ve had a couple of cases of SIBO that were triggered by putting a patient on a proton-pump inhibitor. That basically it changes the environment in the gut. So if you change the environment in the stomach, then what you have to realize is that you’re going to change everything downstream from there. So once you’ve raised the pH in the stomach, you’re affecting the pH in the rest of the gut by using these proton-pump inhibitors. And I’ve seen a few cases where the person very clearly did not have any issues was put on a proton-pump inhibitor, usually for too long, because they’re really only meant to be used for two to four weeks. They’re not really meant to be used for months on end. But the practice unfortunately in medicine that I see is, doctors will place patients on PPIs and then just keep giving them refills with no end point in mind.

Dr. Weitz:   Well, the problem is you’re treating a chronic condition like reflux or GERD without any understanding, or even trying to probe what the underlying triggers and causes are, and you’re just treating it symptomatically. So if you don’t try to get to somebody’s underlying root causes, what’s the likelihood that you’ll ever be able to stop taking the drug.

Dr. Pedre:   Exactly. And the longer you’re down the trail, the much more difficult it is to wean somebody off that PPI.

Dr. Weitz:   Right. Have you started using the new breath test for hydrogen sulfide gas?

Dr. Pedre:   In New York, we’re not allowed to use that test yet.

Dr. Weitz:   Really?

Dr. Pedre:   Yeah. But I am aware of it and I know that patients can go across the bridge to New Jersey and get the tests done. But we can’t run it in New York yet. New York has really weird regulations on which tests can be run and which ones can’t be run because they basically have their own licensing board that reviews all these tests and-

Dr. Weitz:   So you can use the existing SIBO breath test but not the new one?

Dr. Pedre:   Yeah. Exactly. And I really do think that we’re missing stuff with the old SIBO breath tests that we really need to do the Trio breath test to look at sulfur as well.

Dr. Weitz:   Right. Are you presently diagnosing hydrogen sulfide by a flat line?

Dr. Pedre:   It’s a good question. That’s where I go back and say, we’ve got to not just look at the test, but look at the test and the patient. And if the test result doesn’t make sense based on what the patient is telling you, then you pay attention to the patient.

Dr. Weitz:   Right. So-

Dr. Pedre:   I can’t tell you how many times in Western medicine, patients will present with symptoms and then they go have blood work done and the doctor will tell them, “Well, your blood work is fine.” And they’re like, “There’s nothing wrong with you,” but the patient is like, “But I feel this way.” And I think it’s so disempowering to patients and I always think, “The patient is not wrong, it’s the test.” And the test that we did, wasn’t the test that showed exactly what the problem was. It doesn’t mean that there isn’t a problem.

Dr. Weitz:   And especially today, as you mentioned, our insurance based system, there’s very strict limits on what tests are going to be approved to be paid for.

Dr. Pedre:   Exactly. Yeah.

Dr. Weitz:   Lab panels have gotten skinnier and skinnier and skinnier.

Dr. Pedre:   Oh yeah. I mean, I’ve had insurance reject a cholesterol panel in a routine wellness visit. Now, this is not common, but I thought, “Well, if it’s a wellness visit, cholesterol is part of that. What’s happening here?”

Dr. Weitz:   Yeah. Well, you probably tried to order an Advanced Lipid Profile and they definitely don’t want to pay.

Dr. Pedre:   Oh, I’ve been told all sorts of things and had patients receive letters from insurance plans being told that I’m ordering experimental tests.

Dr. Weitz:   Yes. We’ve had the same thing of course. So let’s get into some treatment protocols for SIBO. So what are some of your favorite treatment protocols for patients with hydrogen SIBO, methane SIBO, now we call it IMO, and hydrogen sulfide SIBO?

Dr. Pedre:   Yeah. These are obviously complicated cases and I think diet is always first and foremost really important-

Dr. Weitz:   So you start with diet before?

Dr. Pedre:   Diet along with other interventions. If it were-

Dr. Weitz:   What’s the best diet for these patients?

Dr. Pedre:   I really… So initially I was using FODMAP diet, low-FODMAP. But what I don’t like about the FODMAP diet is that, it’s very black and white in terms of what’s in and what’s out. So I started using Dr. Siebecker SIBO Specific Diet, Because there you have green, orange, red, I think you have three categories. And I think it’s much easier for patients because the FODMAP is so limiting. But if you can eat a quarter of an avocado, but not the whole avocado, then at least you’re making the diet a little more diverse and not feeling so restrictive. So I tended to use more the SIBO Specific Diet to guide patients and intermittent fasting too. I think that’s really important when treating patients with SIBO is having at least a 12 hour overnight fast and letting the gut rest. And then depending on the type of SIBO, so if it’s-

Dr. Weitz:   So will you put the patient on recommend dietary changes first, or will you also use other protocols at the same time?

Dr. Pedre:   At the same time. Yeah. Because people want… And the thing is, I have to say that most of the time when patients are coming to my practice, they’ve already been to the gastroenterologist. They’ve already been treated with Rifaximin. They’ve at least had one or two rounds of antibiotics of different sorts. So they’re frustrated, their patience is at the very end of the line. Lucky us, we inherit these patients at this point in the treatment. And so you want to try to get results as quickly as possible. And I was trying to figure out, “Do I put them on another round of antibiotics and then really try to work on diet.” Normally when they go to a Western based doctor, they’re not even addressing the diet component. They’re just putting them on the antibiotic and saying, “This is your magic bullet. And you’re going to be better than that.”

Dr. Weitz:   Well, Dr. Pimentel actually thinks that going on a low-FODMAP diet at the same time would interfere with the antibiotics’ effectiveness at killing the bacteria, because antibiotics tend to work by breaking down the replicating cell wall of the bacteria. And if you put them on a low-FODMAP diet, you starve them. So they don’t tend to replicate as much.

Dr. Pedre:   Yeah. What I started doing is, if I say I used Rifaximin in a patient, I would give it to them with Slippery Elm Bark at the same time. And the Slippery Elm Bark as a prebiotic serving as a shuttle to help get the bacteria to gobble up the Slippery Elm and they also taken the antibiotic with it. So that was my trick. And then I really started thinking, “This is a chronic issue. This is not a quick fix issue with persons.” It’s like what Willie Moseler used to say, “Tell me the patient that has the disease.” It’s really more like the type of patient. And realizing that there’s a psychosocial component to SIBO, these patients tend to be generally very anxious type of people, type A personalities over achievers.  So their vagal tone gets effected and that can affect gut motility. So working on stress reducing tactics, working on improving vagal tone through things like gargling, humming. And then I was looking for, “How can I approach this in a way that would really help people get through the hump?” And that’s when I started using spore-based probiotics as part of the treatment protocol, because there’s so many research based benefits to these spore-based probiotics that made a whole lot of sense to me in terms of treating patients with SIBO. And when I started using them-

Dr. Weitz:   I just want to let everybody know that there’s been a big controversy, should we be using probiotics when we’re treating patients for bacterial overgrowth?  In other words, why would we want to put more bacteria in when they already have too much bacteria?

Dr. Pedre:   Exactly. And you certainly don’t want to put a patient on a traditional probiotic like lactobacillus bifidobacterium species combination. I’ve seen that just…

Dr. Weitz:   And yet you know there’s a very prominent practitioner who treats a lot of SIBO patients and he has popular podcasts. And that’s his first line of therapeutic intervention, putting patients on several different probiotics. So he uses spore-based, and a Broad Spectrum, or he calls it like Acidophilus Bifido blend and Saccharomyces. And some of the studies have shown benefit from taking probiotics.

Dr. Pedre:   Yeah. I mean, what I found in my experiences that the dose matters, and generally what I found patients with SIBO, they don’t tolerate even a 20 billion CFU probiotic. It would have to be really low potency. But when I started using the spore-based as my first line, I found that maybe sometimes they had a period of die off and then they really started to feel better and they tolerated the probiotic really well. And the other thing is that we haven’t really addressed or spoken about is that, everybody’s thinking a SIBO patient is a small intestinal bacterial overgrowth. But the truth is that a lot of the SIBO patients are SIBO and SIFO combined. And what’s confusing, and I think what happens when they go to Western doctors is they get a round of antibiotics. They get better, and then a month later, they’re slowly start to get bloated again and symptoms come back. And you’re wondering, because a lot of times what I’ve seen is, they don’t retest them. They just treat them.  And I used to think that Xifaxan could not cause a fungal overgrowth, but I found that it actually can like any other antibiotic. And sometimes what people think of as recurrent SIBO might actually be intermixed with a bit of SIFO. And I mentioned it because these spore-based probiotics, because they do a number of things, including quorum sensing to group together, and they produce other active compounds, enzymes that can break down biofilm, bacteriocins as they call them. They’re like local antibiotics that inhibit other species from growing. It’s almost like you’re giving them a targeted antibiotic that’s not going to destroy their gut, because they found that using these spore-based probiotics actually improve diversity of gut bacteria.

Dr. Weitz:   When is the best time to take probiotics? Is it better to take them apart from meals, with meals, time of day? What do you think works best?

Dr. Pedre:   It depends on what type of probiotic. So if you’re giving a regular probiotic that has lactobacillus and bifidobacterium in an acid stable capsule, I tend to prefer patients to take that on an empty stomach. So either 30 minutes before a meal or some patients I have them do it 30 minutes before bedtime, so after dinner. But if it’s a spore-based probiotic, you reverse that because the spores need to germinate. So you do it five to 10 minutes after a meal, instead of on an empty stomach.

Dr. Weitz:   Interesting. Okay. So what do you think about biofilms? The podcast we have up this week is an interview with Dr. Preet Khangura from Canada. And he finds that biofilms are a big player in SIBO as well as in a lot of other forms of gut dysbiosis infections. And he feels that until you can break up those biofilms, it’s hard to reduce or eradicate the bacteria.

Dr. Pedre:   I definitely agree. And I’ve had some really challenging cases. And what I think is important too for the clinician is to think that, if they have a treatment resistant SIBO. So a patient you’re doing everything right, and they’re just not responding in the way that you think they should respond, then the next thing you should be thinking about is biofilm. And then you should be using things like Serrapeptase to break down the biofilm and use that on an empty stomach between meals. And that could be a treatment that goes on for a while because biofilms can be pretty challenging to break down. Whether they’re in the gut or in the sinuses, I’ve had patients with a biofilm in the sinuses.

Dr. Weitz:   Dr. Khangura prefers using bismuth dial combinations. He has something compounded with with DMSA or DMPS along with bismuth and alpha-lipoic acid. I guess Dr. Paul Anderson has pioneered that kind of a biofilm disruptor.

Dr. Pedre:   Yeah. It makes sense because biofilms can also have heavy metals and other things that need to be removed in order to break up the biofilm.

Dr. Weitz:   So as far as natural anti-microbial treatments, if the patient doesn’t want to go on Rifaximin or you don’t think it’s appropriate, what is some of your favorites?

Dr. Pedre:   I will use some herbals and it depends again, what I think is going on with the patient. I really like… the name is escaping me now, but I will use sometimes-

Dr. Weitz:   Berberine, oregano.

Dr. Pedre:   Yeah. I was thinking of products like Candicid Forte. But yeah, they include berberine, caprylic acid sometimes mixed in with some artemisinin, black Walnut in there. Kind of broad spectrum herbals, olive leaf extract, all these things.

Dr. Weitz:   Okay. So what about trying to restore the motility with a prokinetic?

Dr. Pedre:   Yeah. Good question. Probably I’m going to suspect Dr. Pimentel has more experience with that than I do. I tend to try to not in terms of prescribing prokinetic drugs like Motegrity. It seemed when Motegrity came out and I heard Dr. Pimentel talk about it, that seemed like it could just turn on the migrating motor complex and it was going to be a magic bullet for that. But as all magic bullets, they’re never really a magic bullet.

Dr. Weitz:   Yeah. I thought a number of practitioners used to say how tremendous it is. And for some reason, in my practice, I seem to have seen a lot of patients who didn’t get much benefit from it.

Dr. Pedre:   Yeah. Or what I’ve found is they get benefit in the early stage, the first couple of weeks. And then the benefit starts to wane down. And you really have to treat the behaviors that lead to the symptom in the first place. A lot of my patients don’t realize how stressed they are. They just don’t realize how stressed they are. And there’s also other herbs that you can use, or roots like ginger, D-limonene to stimulate motility in a more natural way. But really even just getting patients to do cardio exercise, like going for runs, can improve motility, vagal nerve stimulation like I mentioned before. Really important. And working on… I’m going to throw in their heart rate variability, getting them to really create more of a balance between parasympathetic and sympathetics, as most people are just living imbalance. There are too high on the sympathetic and not high enough on the parasympathetic, which wouldn’t improve gut motility.

Dr. Weitz:   Yeah. We actually just started using a wearable called the Apollo that uses vibrations to help put you in more of a parasympathetic mode and it’s been shown to improve HRV. So it’s a new tool to use to help [crosstalk 00:38:03] stressed patients.

Dr. Pedre:   Interesting. I just ordered, I don’t have it yet. But I wanted to experiment on this, the quorum sensor or… what is it called? What is the name of the company?

Dr. Weitz:   I know there’s a lot of new wearable devices.

Dr. Pedre:   Sorry, the brand is called Whoop. And it’s a wearable sensor that it’s waterproof, you can wear it into the shower, tracks your sleep. But I more ordered it because I was curious about heart rate variability and the connection to gut health.

Dr. Weitz:   So when you’re treating a patient with SIBO, how long do you typically treat them for?

Dr. Pedre:   That’s the million dollar question.

Dr. Weitz:   So we normally say like if you’re going to use rifaximin, then it’s typically two weeks.

Dr. Pedre:   Yeah. Or sometimes, actually some doctors will treat for four weeks with rifaximin depending on the case.

Dr. Weitz:   Okay. Or [crosstalk 00:39:07] and repeating it. And then if you use herbals, then…

Dr. Pedre:   Then you’re looking at month long treatments, so usually at least a month. But a lot of times it could be two months then incorporating the spore-based probiotics. And I might use a serum derived, bovine immunoglobulins as well in that combination, and there’s reasons for that. And that might go on for three to six months as I’m working on the lifestyle factors of the person diet, stress management, exercise. Because working with patients, especially in New York City, people are busy and getting them to institute those lifestyle changes can actually take six months of work.

Dr. Weitz:   Yeah. Now you mentioned SIFO, which is small intestinal fungal overgrowth, and there’s no breath tests for a fungal overgrowth. So now, how do you diagnose the fungal overgrowth if you suspect it? Are particular tests you use to help confirm it, do you use the stool tests? Do you use the organic acids test? And then how do you exactly fungal overgrowth?

Dr. Pedre:   I look at a combination of tests. So if I can do the stool test, stool piece TR. It’s very hard to get a yeast culture on the stool. So those most of the time come back negative. I like using the organic acids. At least it gives you another window into whether there might be yeast overgrowth. And then of course, the story that the person tells you. If they have yeast overgrowth symptoms, like craving refined carbs, craving sugar. Just those signs that you look for mental fog, then you can suspect that there’s yeast overgrowth. And I will tend to use things like, again, berberine, oregano oil, as well as caprylic acid. If you use the right dose of caprylic acid, you can get a really strong die off in a person. It can be quite powerful. And then I use combinations supplements as well.

Dr. Weitz:   And then do you change the diet for the fungal overgrowth?

Dr. Pedre:   Definitely. I mean, but it will be usually three to four weeks where I’m really limiting refined carbs and sugars. Because that diet is very difficult for people to continue on. Before they’re asking you for a lifeline when they’re on that type of diet. Like, “When can I have a carbohydrate, please?”

Dr. Weitz:   Sometimes you get these patients who’ve been on the scene at the low-FODMAP diet for so long and you treat them and they finally feel better and now they don’t want to expand their diet. And it’s actually a little bit of a struggle to get them to start eating more diversity of foods.

Dr. Pedre:   Yeah. And I can understand that having gone through so many gut issues over the years myself. But what I tell people is, just try little bits at a time and see how that affects you. And if it doesn’t cause symptoms, then you know you can slowly start to expand the diet. The error that people make though is that, I tell them, “If you don’t know what the temperature in the pool is, you’re not going to just jump in, right? You’re going to dip your toe in first to see how cold is this pool before I jump in?” But a lot of people what they do is that they’re like, “Oh, I’m going to have pizza.” And they just jump in and then they call me the next week then telling me, “Oh, my symptoms are back. I feel horrible.” I’m like, “Well, what did you do?” Like, “Well, I eat pizza.” Like, “Well, I told you to dip your toes, not to jump in the pool.”

Dr. Weitz:   So which form of SIBO do you find the most challenging?

Dr. Pedre:   I’m going to say methane predominant.

Dr. Weitz:   So any particular strategies that you find particularly effective for methane?

Dr. Pedre:   I’m still looking for the best strategy for that one. That is a really tough one. I still will use spore-based probiotics for that one. Because I do believe that, that’s an important key part of the treatment protocol. And then I’ve tried different things including bioflavonoids seem to play a big role in helping with those patients. There is a product that includes a combination of bioflavonoids that-

Dr. Weitz:   Oh, [inaudible 00:44:00]?

Dr. Pedre:   Yeah. It can be helpful. And even just peppermint oil for treating the gas, the uncomfortableness of it. But those can be quite challenging because you need to get their bowels moving too. You really need to get their bowels moving.

Dr. Weitz:   [crosstalk 00:44:22] do that?

Dr. Pedre:   Any means you can. No, I’m just kidding. But usually things like throwing in Cape aloe, making sure that you want them to get fiber, but you don’t want them to get too much fiber. And-

Dr. Weitz:   What was the first thing you said? Aloe?

Dr. Pedre:   Cape aloe. Yeah.

Dr. Weitz:   What’s Cape aloe?

Dr. Pedre:   It’s just a different type of aloe that is really good for constipation.

Dr. Weitz:   Okay. That comes from the capsule or liquid or?

Dr. Pedre:   Capsule.

Dr. Weitz:   Okay.

Dr. Pedre:   Yeah. And it comes in different strings.

Dr. Weitz:   Okay. And use magnesium?

Dr. Pedre:   I will use magnesium, but in a patient with methane predominant SIBO, they’re most of the time going to be pretty resistant to magnesium. So I will resort to other things like Cape aloe sometimes gut motility agents as well. But again, these patients, it’s like a patient profile. You see the patients who come in and these are also tend to be very high, strong, stressed out people, and you really need to work on vagal nerve tone. You really do.

Dr. Weitz:   So you mentioned gargling and what are some of the other strategies you find helpful for vagal tone? [crosstalk 00:45:49].

Dr. Pedre:   Some really great ones. Humming, humming is really good because the vibration here through the vocal cords stimulates the vagus. Or just singing, like singing in the shower at a high voice almost like operatic, that can also stimulate the Vagus. Some people often wear-

Dr. Weitz:   Poor to me, that makes everybody around me a lot more painted

Dr. Pedre:   That might put other people into sympathetic. It’ll put you into the parasympathetic.  There are also tools that can be used, I don’t use them with patients. But there are devices that E-stim devices that can be used to stimulate the vagus nerve. And they’ve used these in studies on treatment resistant depression and found that they can be quite effective.

Dr. Weitz:  So do they actually attach wires to… How do they get to the vagus nerve?

Dr. Pedre:  I think the easiest access is here.

Dr. Weitz:  Right there?

Dr. Pedre:  Yeah. Right on the neck.

Dr. Weitz:  So they insert wires into it?

Dr. Pedre:  No, no. It would be on the surface.

Dr. Weitz:  Ooh okay. I see.

Dr. Pedre:  No. Not an invasive type of thing.

Dr. Weitz:  Yeah. I know some doctors use infrared laser to stimulate the Vagus. I don’t know if any of this stuff is really documented, but I guess if it works, it’s good.

Dr. Pedre:  Yeah. I mean, I found at least one study where it did have a significant reversal of treatment resistant depression. So it is possible to stimulate the Vagus. I think it’s easier just to sing in the shower.

Dr. Weitz:   Yeah. Do you ever find patients with difficult to treat SIBO and may turn out to have mycotoxins, for example?

Dr. Pedre:   Very possible. I think the thing is that the patient doesn’t always tell you exactly what they have. They just come in with a host of problems and you need to figure it out. And that’s why I think my functional medicine training has been really helpful. And just having a roadmap of where to think, just a questionnaire to see, where is it that you need to be thinking that there might be problems where you need to dig deeper and look at other possibilities as well. Patients are complex, right? They never come in with just one singular problem.

Dr. Weitz:   Right. Yeah. I know the methane patients, as you mentioned, that seems to be really difficult to treat. Dr. Rahbar, who is an integrative gastroenterologist in LA, I talk to him a lot and he finds a lot of these patients either have fungal overgrowth, as you mentioned. Some of them actually have Lyme disease or parasites. And he’s been doing some actually culturing, going in and doing a scope and pulling out some of the juice in the small intestine and testing it and finding some of these things.

Dr. Pedre:   Yeah. I mean, obviously not practical for every patient and it’s invasive. But that’s the gold standard for diagnosing SIBO. But I great to hear that he’s thinking about other things. Because I think that’s where we can hit our heads against the wall is, if you’re just thinking this one thing and the patient’s not getting better and you just keep doing it, that’s where you have to think, “There must be something else going on here. What else could be going?”

Dr. Weitz:   Exactly. And often layers, not just one thing but different layers.

Dr. Pedre:   Oh, I can tell you I’ve had so many patients come in to my office as, let’s say a SIBO patient, and then once we resolve that, then they realize how the process works. And then they tell me, “Well, I have this other symptom that I’ve had for a really long time,” and then we start working on that. And it’s really funny, it’s like peeling the layers of an onion, you’re finding heavy metals, mold exposure, all sorts of things.

Dr. Weitz:   And these things are cumulative. So you don’t necessarily need to have one cause or one trigger, you can have multiple triggers. And so as you peel back those different layers of root causes and triggers, you’ll see the symptoms continue to decrease.

Dr. Pedre:   Definitely. Yeah.

Dr. Weitz:   So I think that’s all the questions I have. Any final thoughts you want to leave our viewers and listeners and then how to get a hold of you and find out about seeing you and getting your book and your courses.

Dr. Pedre:   Best ways, they can check out my website, pedremd.com or really just find me on social media, Facebook, Dr. Vincent Pedre or Instagram @Dr. Padre. And I’m constantly posting gut related information on my social channels. So trying to stay active there.

Dr. Weitz:   Right. Good. And in your book, I’m assuming is available wherever books are sold?

Dr. Pedre:   Yeah. The big monster called Amazon. Yes. You can get it there.

Dr. Weitz:   I go out of my way to try to go to Barnes and Noble.

Dr. Pedre:   I don’t think we have any Barnes and Noble opened in New York City now anymore.

Dr. Weitz:   Or you can order online and find its available.

Dr. Pedre:   Exactly. You can order online. The book is called Happy Gut and yeah, you can get it from… Or you can even-

Dr. Weitz:   Oh, and it’s so sad that there’s almost no bookstores left.

Dr. Pedre:   Oh, it’s really… I miss going into a bookstore and just browsing.

Dr. Weitz:   Yeah. I know I do too. Okay. Thank you, Dr. Pedre.

Dr. Pedre:   Thanks for having me.

Dr. Weitz:   Well, thank you listeners for making it all the way through this episode of the Rational Wellness Podcast. Please take a few minutes and go to Apple Podcasts and give us a five-star ratings and review. That would really help us so more people can find us in their listing of health podcasts. I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at (310) 395-3111. That’s (310) 395-3111. And take one of the few openings we have now for individual consultation for a nutrition with Dr. Ben Weitz. Thank you and see you next week.



Nutrition To Manage Mycotoxins with Dr. Jill Carnahan: Rational Wellness Podcast 197

Dr. Jill Carnahan discusses Nutrition to Manage Mycotoxins with Dr. Ben Weitz.

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


Podcast Highlights

2:32   Dr. Carnahan was exposed to mycotoxins in 2015 after a huge flood that occurred in Boulder, Colorado and it caused mold in her office. She had a lot of respiratory symptoms, including shortness of breath, esp. when trying to run or walk upstairs. She had brain fog, including trouble recalling words and names and typing the wrong word when typing emails. She also had trouble with focus and concentration.  Mold for her also triggered a histamine/mast cell response resulting in rashes and hives and swelling of her lower extremities. She also had redness in her eyes and sinus congestion.  She had acne breakouts, including on her scalp.

Some patients exposed to mold, may have issues with their gut such as leaky gut and sensitivity to foods because the gut and mold will directly affect the integrity of the gut lining. Some people have electrostatic charge on the surface of their skin, because they’re sweating out sodium and they create a gradient or a battery on their skin.  Frequent urination may occur due to dysfunction with the secretion of antidiuretic hormone (ADH).  An enzyme called aromatase, which converts our testosterone into estrogen, is increased, so this may result in men having man boobs, weight gain around the middle, and decreased libido drive. Women will have excessively heavy periods or painful periods, or they’ll have fibroids, or endometriosis, or all kinds of things to do with estrogen dominance.

6:45  Mold can also be a contributor to Alzheimer’s Disease as Dr. Dale Bredesen has discussed, calling it inhalation Alzheimer’s from inhaling mycotoxins that enter the cribiform plate into the brain causing dementia-like symptoms. This seems to be more common in patients in their 50s, which is young for Alzheimer’s.  Here is Dr. Bredesen’s paper: Inhalational Alzheimer’s disease: an unrecognized–and treatable–epidemic.   Patients exposed to mold can also present with inflammatory bowel disease like Crohn’s or ulcerative colitis, because it causes inflammation of the gut lining.  Mold can also raise TGF beta, which is one of the drivers of autoimmunity.  Patients can present with MS, or lupus, or Hashimoto’s or Crohn’s and mold can be the underlying cause.

11:58  Some of the symptoms of mold toxins are common to many other conditions, so taking a careful history with a timeline of how and when symptoms developed can be helpful in making the diagnosis of mycotoxins.  You also have to ask the right questions, including how to discover if ther might be mold in their home or office. Questions could include:  So are there condensation on your windows? Have you ever had a washer or dryer leak? Does the washer gasket rubber smell when you open that up? Has your, you see under the sinks, the faucets, the pipes, the garbage disposal ever leaked? Do you have a tile or grout that’s discolored? Do you have leakage around the shower pan? Is it properly sealed?  You need to inspect the basement and also the attic.

17:03  Probably the best way to test your home for mold is with the ERMI test, which uses pcr analysis of the DNA of any mold in dust in your home. Dr. Carnahan recommends getting the dust sample from two feet above the floor so that you are not getting outdoor dirt trapped in the sample.  And you should wait 7-10 days after you have cleaned to allow dust accumulation. While not as accurate, you can get an idea from the inexpensive petri dishes you can get at Home Depot or Lowe’s.

19:10  There are various ways to screen and test patients for mold exposure, including a screening cluster symptom analysis and the visual contrast test (VCS). Dr. Carnahan recommends the VCS test available on Dr. Shoemaker’s website for $15, Survivingmold.com:  Online VCS screening test.  Dr. Carnahan noted that if she suspects mold is an issue until the test results comje back, she will give her patients a binder and some basic liver support, including glutathione or the precursors, like NAC, lipoic acid, vitamin C, glycine, and glutamine.  She finds it helpful to do urinary mycotoxin testing and she sees a good correlation with symptoms in her patients and she mentioned that there are three excellent labs that offer this, including RealTime Labs, Great Plains Lab, and Vibrant America.  And then there is blood work, including TGF beta, MSH, MMP9, antidiuretic hormone, and osmolality, and C3 and C4a, which can be ordered through LabCorp.  If they are not covered by insurance, these blood tests can cost thousands of dollars, so your patient can order some of these tests directly through Life Extension for about $400. These blood tests were pioneered by Dr. Shoemaker and they alert you that the patient has CIRS (chronic inflammatory response syndrome).




Dr. Jill Carnahan is a Medical Doctor who runs the Flatiron Functional Medicine clinic in Louisville, Colorado and has a specialty in treating patients with chronic diseases, including with mold related toxicity. Dr. Carnahan speaks around the world and lectures for the Institute of Functional Medicine.  Dr. Carnahan can be reached at JillCarnahan.com.  Here is a link to a free guide to mold toxicity for Rational Wellness listeners from Dr. Carnahan: https://www.jillcarnahan.com/exposed-to-mold-now-what/

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.


Podcast Transcript

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

So, our topic for today is toxic mold, its effect on our bodies, how to get rid of it, and how to get rid of it with Dr. Jill Carnahan. Exposure to mold and mycotoxins affects many people and is often an undiagnosed underlying trigger for many other symptoms and conditions.  Many people are unwittingly living or working in water damaged buildings, and this exposure can be causing many negative effects on your health. And not only can mold and mycotoxin exposure cause a host of symptoms that we will go into but it can also be an underlying trigger or root cause for many other serious health problems, including affecting our hormones, thyroid, adrenals, fibromyalgia, hypertension, heart disease, autoimmune diseases, Crohn’s disease, Alzheimer’s, and even cancer. 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 frequently overlooked.

                                                Dr. Jill Carnahan is a medical doctor who runs the Flatiron Functional Medicine Clinic in Louisville, Colorado. Dr. Carnahan is one of the first 100 doctors certified by the Institute of Functional Medicine. Dr. Jill is a survivor of breast cancer, Crohn’s disease, and mold toxicity. That’s quite a lot to be having gone through in your life, Jill. Dr. Carnahan is a sought after speaker at conferences when we used to have conferences, and often teaches other health care practitioners the functional medicine approach, and she’s one of the most recognized experts about mold and mold toxicity, which is our topic for today. Thank you, Jill, for joining me today. And for me, thank you for letting me join you on your Facebook Live.

Dr. Carnahan:                    Thank you, Dr. Weitz. I am delighted to be here. We had a little snafu because of scheduling, but I am so glad to finally be here and to talk to you about mold.

Dr. Weitz:                          Sounds good. So why don’t we start by perhaps maybe you could tell us a few things that are not commonly known about mold and mold toxins.

Dr. Carnahan:                    You got it. And I’m going to go into just a two second version or a quick version of the story because story always drives what I do. 2015 after the huge flood in Boulder in 2013, I realized that my office had mold in it, and it had been causing, which is some of the symptoms we’ll talk about for me respiratory issues. I had shortness of breath, trouble running, difficulty catching my breath when I’d walk upstairs. I had a more brain fog trouble with words and names. So finding like names and words of things. I’d say cat instead of dog or something like that. And I noticed when I was typing emails or letters, sometimes I would actually type the wrong word, too. Now, cognition problem solving wasn’t so affected, but it’s weird how mold can selectively affect portions of the brain.   The other thing I noticed was focus and concentration. So where I could maybe write a blog in an hour before it took me a little bit longer to really focus and concentrate and be productive. So all of those things and then mold can trigger a mast cell response. We’ll probably talk more about that and cause histamine issues. So for me, I had rashes and hives and I had swelling of my lower extremities. At the worst of it I had three plus pitting edema. It was really severe. I had redness in my eyes. I had congestion in my sinuses. I had more acne breakouts. I had skin lesions on my scalp. And I can go into more, but those are just a few of the things.

                                          Some of the unique things you ask about. Some people have electrostatic charge on the surface of their skin, because they’re sweating out sodium, they’re losing sodium, and so they create a gradient or a battery on their skin. So, it’s not uncommon to have electrostatic shocks when you touch metal or doorknobs or to actually break watches or computers if you’ve had mold exposure. That’s one of those really unique things. And another thing frequent urination, which is along the same lines because your body, the ADH, the antidiuretic hormone, which controls our hydration is dysfunctional. It goes very low so you don’t conserve water. So, you drink and you pee, and you drink and you pee. And a lot of these patients will get up during the night three, four, or five times to urinate at night during the day. And they’re walking around, they can be drinking loads of water, but they’re chronically dehydrated because they can’t maintain the volume in their vascular system.  Some of the other things that happen are there’s an enzyme called aromatase, which up regulates and converts all of our hormones into estrogen especially testosterone. So men will have man boobs, weight gain around the middle, decreased libido drive. Women will have excessively heavy periods or painful periods, or they’ll have fibroids, or endometriosis, or all kinds of things to do with estrogen dominance. It affects, like I said, mast cells. So, histamine reactions, more sensitivity to foods. And we didn’t even talk about the gut. But mold will directly affect the integrity of the gut lining causing leaky gut and causing more sensitivity to foods and more issues with the gut as well.

Dr. Weitz:                          So, tell us a few things that we didn’t know about mold and mold, toxins things that aren’t commonly discussed.

Dr. Carnahan:                    Yeah. So, did you know mold can cause increased risk of infertility in both men and women?

Dr. Weitz:                          Ah, interesting.

Dr. Carnahan:                    Yeah, and it’s interesting because a lot of our studies on mold come from… So, the animal livestock industry is a big one because a lot of the food can be contaminated with mold.  And so for the farmers who raised cattle, and pigs, and sheep, and all these animals that could have contamination in their food, they see a loss in the bottom line dollar when there’s mold contamination in the food because they don’t produce.  Their herds don’t reproduce as well.  So they have noticed fertility issues.  They have rashes, just like humans. They have gut issues, just like humans, and all kinds of things.  So you’ve seen these.  So in the animal studies, they’ll show these and then of course, it’s very, very similar in humans.  But there’s lots of research on mold contaminated feed in cows and pigs and all of these things, especially fertility.

Dr. Weitz:                          That’s fascinating because when working up a patient for fertility problems, I don’t think many people consider mold as one of the possibilities. We’re looking at thyroid. We’re looking at a whole lot of other things. Maybe toxins in general, but we don’t really typically think about mold.

Dr. Carnahan:                    Yeah, some of the other unique things. Alzheimer’s disease, Dr. Dale Bredesen works a lot with Alzheimer’s patients has written multiple books on the topic, and he claims that 1/3 of the patients that he sees have mold related Alzheimer’s. He wrote a paper about five years ago now called inhalation Alzheimer’s, and it was basically related to inhaling mycotoxins from mold going into the cribriform plate right into the brain and causing dementia-like symptoms, especially in someone who’s in their 50s. They’re so young for Alzheimer’s. I’ve had a case, for example, an attorney 55 years old, who all of a sudden can’t practice because of dementia-like symptoms, and it was all related to mold.   A few other unique things would be like I said, the gut issues. It can present with Crohn’s or colitis, inflammatory bowel disease, because it has a massively inflammatory effect on the gut lining. And so, some people will present with autoimmunity of other types as well. Mold can raise TGF beta, which is one of the drivers of autoimmunity. And so, if patients have that process going on, they might present with MS, or Hashimoto’s, or lupus, or Crohn’s, or colitis, and it’d actually be mold as the underlying cause.

Dr. Weitz:                          Interesting, interesting. So, a lot of the medical profession today, the conventional medical profession has traditionally been very skeptical of this concept of mold toxicity. Are they starting to come around to accepting that this is a common problem for patients?

Dr. Carnahan:                    Yes, just like mold this is a sticky situation, and it’s interesting because I’ve had even people almost angrily-

Dr. Weitz:                          I get the double entendre. They’re sticky in terms of possibly-

Dr. Carnahan:                    Exactly.

Dr. Weitz:                          … legal issues.

Dr. Carnahan:                    Yeah, exactly. And it’s interesting because I’ve even had patients on Facebook groups and things. They’re kind of angry because they’re like, “Doctors, why don’t you do something about the way that we can’t talk to our landlord, and there’s no regulations and the insurances aren’t reimbursing.” And granted, I mean, what I like to do is stay in my lane, which is I’m a physician, I take care of patients. I mean, what I do is I know the experts to deal with environmental issues like environmental air quality specialist, and I know enough to help them navigate that world. I think that’s important. But I’m not a person who can remediate your home. I’m not a person who can do the politics of talking to your insurance company.  Again, we stay in our lane, but I think we need people to have more awareness. I think it started way back. Mold is super common. Insurance companies know this. There’s about a fourth of all homes and buildings in the US that have some sort of water damage. And we could even expand it when I say water damage. What that includes is anything that’s… We used to have homes that were built of more stone or brick, and that’s very impervious to mold. Nowadays, we have these niduses that are basically like cardboard. So, our drywall or sheetrock, which is very, very commonly a source or a problem with mold.   If it gets wet, it’s the perfect growth substance for mold. And most houses now are more quickly constructed with these types of materials, then the materials that are used are more prone to mold. And then during the construction process, they can bring in wet woods that maybe have mold already starting to grow on them. Even during the construction process, depending on where it’s being constructed, it can actually rain in the house while it’s open and all of these things. And then as you build a house, you can have washers, dryers, you can have windows that leak, you can have poor construction, and more and more. There’s quick construction methods that aren’t as detailed and done well. And so, there’s more likely for problems even in new homes.

Dr. Weitz:                            Yeah, I’ve actually heard a similar problem, and this is especially the case for some reason in California. They tend to build the homes so air tight that there’s no ventilation. So, in between the walls, if there was a little bit of moisture, that venting would decrease the likelihood for mold, but they make them so airtight that any moisture in there is more likely to cause mold. So you can have poorly constructed homes. You can have homes that maybe are too tightly constructed.

Dr. Carnahan:                    Yes, that’s 100% true. In fact, I talked to a highly paid investor in New York City that was part of the LEED certification. So this is a certification that certifies the greenness of the buildings. So the kinds of processes, the building materials that are recyclable, and the air tightness, the efficiency of the building. And what’s happened in some of these buildings, not all of them, but they’re super efficient. And by nature, they are very sealed from the external environment. And so, that breathability of the building can be an issue because I’d rather be in 100 year old log cabin, and I wouldn’t in one of these super airtight, efficient buildings that has no airflow.  Some of the times when you have a patient with a mold in their environment, just opening the windows and getting a little airflow to dilute. We always hear this. I’m not the original, but dilution is the solution to pollution, which means as soon as you get some outdoor air in there are you to fan bringing some airflow in, that will automatically decrease the toxicity of your internal environment. So, that can be part of the solution.

Dr. Weitz:                            So when you are going through some of the symptoms of mold that you had, and a lot of the symptoms that other patients get, they’re they’re common to many other conditions. So when you have a patient that presents with some of these symptoms, what really alerts you to the thought that they might be dealing with mycotoxins.

Dr. Carnahan:                    Yeah, I love this question, Dr. Weitz because one of the things patients always say is, “Oh, it’s so expensive to see a functional doctor, or a functional chiropractor, or to see… to do all the testing.” I would say that just by taking a great history I am usually 95%, maybe even 99% accurate on where the direction needs to go. And if I think there’s mold involved, and that’s just a history, which granted the office visit is part of the expense, but it doesn’t take a lot of expensive testing. So usually I know before I do the test the direction I’m headed, and my office staff jokes with me because my batting average is like 100%. It’s like, so far, there’s not one person that I’ve suspected of mold that hasn’t had the lab results to back it up. But the questions are important.  So let’s go through a few of those. I’ll often ask, when did you first start feeling poorly? Because the timeline in my mind is so critical to 10 years ago, 20 years ago, five years ago.  Oh, when we moved into that new house, that’s a big one.  And if the other family members also have some symptoms, they may present differently.  The daughter may be perfectly fine.  The son may have depression.  The dad may have congestion, and the mom may have chronic fatigue and fibromyalgia.  So it could present highly differently among the individuals with some of them being less affected.  And that’s because there’s a genetic variance in our ability to get rid of these antigens, these toxins from our body.   So, say the mother is extra symptomatic, she might have more difficulty in tagging and getting rid of these toxins from her body.  But all that to say it can be variable, so history is key. And then I’ll ask them if I just ask someone, “Do you have mold in your home?” Everybody says, “No, I’m fine.” Or they might have a musty smell but it’s like mildew, and that’s just not true. So first of all musty smell is VOC, volatile organic compounds released from mold so there is an issue if there’s a musty smell somewhere.

                                                Second thing is you have to ask the right questions. So are there condensation on your windows? Have you ever had a washer or dryer leak? Does the washer gasket rubber smell when you open that up? Has your, you see under the sinks, the faucets, the pipes, the garbage disposal ever leaked? Do you have a tile or grout that’s discolored? Do you have leakage around the shower pan? Is it properly sealed? A lot of people don’t know some of these really expensive types of tiles that go in beautiful multimillion dollar homes and bathrooms are actually quite porous.  So if your contractor has not put a vapor barrier or a sheet between the tiles and your wall, you can have… I just saw a beautiful multimillion dollar home was loaded with mold in the master bath nothing visible.  And what happened is that slapped up tiles right up against drywall with no barrier and these are permeable tiles and after eight years, there was massive black mold all underneath there and there was nothing visible.  The bathroom looked beautiful.  So, all of these kinds of things, and then basements. So there’s crawl spaces. If there are earth crawl spaces where there’s damp moisture, and that is venting into the home. If you have a sump pump that’s open and then closed, and there’s water that standing anywhere in your home. If you have water that seeps in through the landing, and there’s no barrier there where you get condensation or water into your basement, there’s so many different ways this can leak in. Attics can be a big place. So if the attic isn’t sealed, and there’s lots of heat and condensation, those can be a big place, too. So, part of the is looking for the problem. And then also eventually a good remediator will seal off your wall cavity from your home environment so that you’re not getting that air from the crawlspace, from the attic, or from the in between walls to exchange into your home.

Dr. Weitz:                          Interesting. So, have you ever had a patient, for example, as a way to test if they’re dealing with mold? Have them just go out of their home for a while, take a mold vacation?

Dr. Carnahan:                    Yeah. So, often, I’ll just ask the question. Nowadays, no one’s going on vacation. But before I would ask you, have you been to vacation or gone for 10 days or seven days or a period of time, and did you ever feel better? Now, interestingly, I’ve had a couple situations. One patient of mine, I always suspected mold. She had recurrent colitis and fatigue, and she had infertility, amenorrhea. So, she stopped having menstrual cycles. She’s in her 30s. So, she’d be normally cycling, infertility, and then the colitis and fatigue. And she had a condo in Winter Park in the ski area, and then her home in Boulder. And she always said, “Well, I feel poorly at both locations.” So then you’re like, “Well, maybe no mold.” She went camping for 10 days and she said, “Dr. Jill, my colitis went away. My fatigue was amazing. I didn’t feel fatigued.” And of course, her cycles didn’t start back in that 10 days, but a lot of symptoms improved. We found out both through ski home and her home in Boulder both had mold. So, she had to leave both places.

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

Dr. Carnahan:                    Yeah, so this is also a tricky one because there’s a lot of inspectors and remediators that don’t really like ERMI testing. But what I like about that is… So, ERMI testing, what is it? You can get a dust sample of the dust in your home. If you do this, the couple rules about it are you want to get it from two feet above the floor. So you’re not getting like outdoor dirt and stuff trapped in. So maybe it’s shelving or door handles or kitchen cabinets or things like that, or shelving in your living room or like behind me here. But you wouldn’t want to get on the floor itself. And then you want to wait seven to 10 days after your cleaner so that you actually have some dust accumulation. And you can collect the sample yourself and send it in.

                                                There’s Environ, MentaBiotics, I’ll have to get the name for that for sure and post it, and then there’s Micrometrics. There’s a couple companies that do this. And then you get a read back of the PCR, the DNA of the mold that’s in your dust. And even though that’s not perfect, and I actually don’t use the ERMI score, I just look at the individual molds, I can often tell if there’s a big issue because if there’s 30 of Chaetomium or Stachybotrys on that test, that’s a big problem. Even if there’s five of some of those really toxic molds, it’s a big issue. So, I will often look at that. And then that can tell us, do we need to get an inspector in or look further. Ideally, everyone would have a complete inspection, but that can be costly. So, I’m always weighing the balances of the cost. And I do still feel like ERMI is good.

                                                And then there’s those little plates, the petri dishes you can buy at Home Depot or Lowe’s or any store. And you can put those out in your house. And here’s the cheap and easy way. You don’t even have to send them in. If you just want to get stalled, you can set them out for 24 hours, and then cover them. You can put them in different rooms, and then you let them grow. I think the kits are like seven to 10 days. You can look at the colonies. If there’s zero to four colonies growing of anything at all, that’s pretty normal. If there’s five to eight colonies, that’s a moderate problem. And if there’s nine or more, that’s a big issue. So even though that’s not perfect, these are little very inexpensive ways to test, to start the process.

Dr. Weitz:                          Cool. So how do you test the patient for mold? What’s your workup? In terms of testing?

Dr. Carnahan:                    Yeah, so like I said, I don’t want to forget history because that’s free and a good clinician can ask the right questions. And then two things that are also free in my office. I have a screening cluster symptom analysis where I have them check off boxes, and there’s a scoring system that tells me if there’s more likelihood of mold or not. And then the second thing is a visual contrast test, a VCS test. you can do these online for free, or Dr. Shoemaker’s site, survivingmold.com has another one. I think it’s five or $15. That’s the one I actually prefer but they’re both excellent. And in my office I  actually do this in-person. We have an actual visual contrast board and my staff knows how to do that.  And that will test for this visual acuity.  What happens is when we have biotoxins from mold, they affect our retina and our retina’s ability to differentiate black and white lines.  And so, you’ll actually, these are little circles of black and white lines at different angles.  And so, as you do it, you hold one eye closed, and you say, “Oh, it’s left, right, central and left, right.”  And if you miss those on on some of the smaller lines and increments, there’s a more likely chance that you have had a biotoxin exposure.

Dr. Weitz:                          Do you ever start to treat a patient as a result of history and maybe a questionnaire or the visual contrast test without doing lab testing?

Dr. Carnahan:                    Yes. So, I didn’t get to lab tests, so I’ll get there next-

Dr. Weitz:                          I know. We’re going to do that next.

Dr. Carnahan:                    So, yes, let’s say someone comes in, and they have a positive visual contrast. They’re highly symptomatic. It all started when they moved to this home, there’s a musty smell in the home. And then three people in their family are also sick. I’m like, “Okay, there’s a high likelihood.” What I know to be true is they’re going to eventually need to get away from that exposure, remediate or do something. But in the meantime, some sort of a binder, which we can talk about, and some basic liver support, things like glutathione or the precursors, like NAC, N-A-C, lipoic acid, vitamin C, glycine, glutamine, those can all be helpful, and they’re pretty safe for all of us. Especially, start low doses and workup. So I’ll often start a detox protocol no matter what, and you ask about other testing.  I do use urinary mycotoxin testing. There’s a lot of controversy about that. But I do believe after five years of doing this on many, many, many patients, thousands of cases, I see a very good clinical correlation. There’s three labs that do that right now. There’s RealTime Labs. There’s Great Plains Labs, and there’s Vibrant Labs, and they’re all excellent. There’s different variances depending on them, and I do have my favorites. But those all are good test companies to use. There’s bloodwork. So, there’s things like TGF beta, MSH, MMP9, antidiuretic hormone, and osmolality, and even C3 and C4a, and those are serum labs that can be done in any lab. Right now I use LabCorp, but you can use typical hospital labs will sometimes do them. It’s a little tricky to get some of them on Quest, but it can be done as well. But those are options. And those are the [crosstalk 00:22:13]-

Dr. Weitz:                          What do those labs actually tell us?

Dr. Carnahan:                    Yeah, so there’s a term that Dr. Shoemaker came up with called CIRS (chronic inflammatory response syndrome). And it was his way of describing this inflammatory response from a water damage building and all the inflammagens. And when I say inflammagens, I’m broadening it. There’s molds clearly and mycotoxins, but both bacteria can grow there, and other things like methyl brevi, and algae, and Candida can all be in a water damaged environment. So, it’s not always just mold. But all of those things can trigger an immunological response in the body. And it’s not just the mold attacking the body, but it’s actually the mold causing immune activation.

                                                It’s very similar to COVID and the virus with this aisle six response in this immune activation that causes collateral damage and side effects. It’s very, very similar. Both the virus and then things like lipopolysaccharide, gut toxicity. So leaky gut can cause this, and so can mold. So many, many things causes inflammatory response in the body. And when I mentioned those labs is basically looking at all these inflammatory cytokines, and saying are many of these that are common to mold active or abnormal? And if most of them are abnormal, it paints a picture for more likelihood of mold being part of the picture.

Dr. Weitz:                            So, here’s a question for say a practitioner like myself who’s a chiropractor. When I send patients out for certain labs, I’m assuming they’re not going to be covered by insurance. You might have different experience as a medical doctor, but we’re assuming most of the time it’s not going to be covered.  And let’s say I have a patient who’s a little bit cost sensitive.  If I was going to choose between the urinary mycotoxins, and these blood biomarkers, what do you think is the best bang for your buck?

Dr. Carnahan:                    Yeah, so the urine… Well, first of all urinary mycotoxins I do on almost everybody. And again, you have to know… First of all, what you have to know is, it is excretion. So number one, you could have a patient who is so toxic, they’re not excluding, and you get a false negative with nothing in the urine because they’re so toxic they’re holding on to it. And you’re like, “Oh, they’re fine, and they’re not fine.” So, that’s one thing. Number two, if you start treating a patient, you’re actually pushing that detox pathway and you want that to go into the urine and be excreted. So a lot of patients after two months will be like, “Dr. Jill, can we retest the mycotoxins?” “I guess, we can if you want, but guess what, it’s probably going to be higher, and we want it to be higher because you’re excreting.”

                                                So, as a physician or a patient, you have to know when you’re testing. I will as a rule, unless a patient absolutely begs or demands to be retested. I won’t test before six months after treatment and even then the levels might be higher. So knowing what you’re doing and then mycotoxin testing range from three or $400. So while it’s not cheap, if you have to, one thing it kind of guides. And now we have more data on the types of binders and treatments and pathways for each toxin. So that will actually say I have ochratoxin versus a T2 toxin or gliotoxin. I might use different binder and different pathways for that. So, that actually guides my treatment. So, that’s my number one test. But again, you have to know what you’re doing because it’s not perfect. You have to know you’re measuring excretion. Number two-

Dr. Weitz:                          By the way, where’s the best source for that connection between specific binders for specific mycotoxins?

Dr. Carnahan:                    Yes, so Dr. Neil Nathan has written about it a little bit. And he just posted some work on his blog. And then in his book, it’s also available, I think, in a chart with the binders. Beth O’Hara who’s an expert on mast cell has done some work as well with the pathway. So I think in her website, she has it posted as well. And I think that’s mastcell360.org. If you just search Beth O’Hara and M cast, you’ll find her website. And of course, Neil, Nathan, as well. He’s an MD. Those are some good sources of that information.

Dr. Weitz:                          Great.

Dr. Carnahan:                    What about for patients who can’t afford it?  So, first of all, I do often get it covered.  Not always, and if it’s not covered, it’s really… These are thousands of dollars.  Like the LabCorp can be so expensive, so you’re right. But there’s a trick Life Extension has navigated a discount with LabCorp.  It’s called the mold biotoxin panel.  You can go on it as a patient, order it yourself. It’s usually three or $400 depending on if it’s on sale or not. So, still rather… I mean, there’s hundreds of dollars, but way better than thousands of dollars. And a patient can actually order this themselves. So that’s a way that I’ll do it if I want… And it’s only five of the markers, but it’s pretty helpful if that’s all I can get. It’s a way cheaper price for the patient to get it directly from Life Extension.

Dr. Weitz:                          And that’s basically not measuring the mold, but it’s measuring whether you’re reacting to the mold, right?

Dr. Carnahan:                    Yeah. And again, it’s kind of this… If I had a million dollars for every question that I had was what’s the one test for mold? We get that all the time. What’s the one treatment or the one test? There’s there’s no one test. But kind of again, so I look at the-

Dr. Weitz:                          Or the one pill.

Dr. Carnahan:                    Yeah, the one pill, the one test, I wish we could give it to you.

Dr. Weitz:                          Well, actually, there was just another study about the polypill. The medical profession has been wanting this one pill that everybody could take that would promote your long term health.

Dr. Carnahan:                    Gosh, if we only had that, but you and I practice individualized medicine. There’s no one size fits all.

Dr. Weitz:                          Of course.

Dr. Carnahan:                    I have a lot of colleagues who have protocols, and I have no disrespect for them. But I have resisted so hard. I really truly don’t have a protocol. I do some of the same things depending on the situation, but every patient is individual, and I like to treat them that way. So, we talked about testing and cost. And then your last question. Let’s see, you’d asked about the direction to go depending on… Oh, if there was one test? Yeah, there really isn’t.

Dr. Weitz:                          I know. Okay. So, what was I going to say? So, let’s get into treatment. So, obviously, the first thing they have to do if they’re getting presently exposed to mold is that they somehow get out of that environment.

Dr. Carnahan:                    Yeah, and let’s talk a little bit about this. Because the confusing thing is if you have a remediator that is not aware of the sensitivity of the types of patients that we see.

Dr. Weitz:                          So, a remediator is somebody that you pay who comes to remove the mold, and they have a specialty in that?

Dr. Carnahan:                    Yes, yes. And they’re often called… So, there’s a bunch of nuances in the industry. IEPs are indoor air professionals, and for example, I’m on the board of iseai.org. But there’s no… This has nothing paid. But it’s a great resource. It’s all free. It’s internationalsocietyforenvironmentallyacquiredillness.org. So, I-S-E-A-I.O-R-G, free resources, free professionals that have been trained in mold. If you’re looking for some resources, that’s a great place to start. And there’s blogs and things on there. It’s a nonprofit. They teach physicians, and I just love mold and I love teaching, so I’m part of them just for that sake. But that’s a good resource to start with. And same with survivingmold.com, which was Dr. Shoemaker’s website. He has a lot of free resources and literature there if you’re wanting to start on the journey, but back to remediators.  So remediators, indoor air quality professionals might be someone that either virtually or in person looks at your quality of air, and they’re beyond the scope of just mold. They might look at radon, they may look at EMFs, they may look at a broader spectrum of air quality. Remediators in the mold industry can be a varied batch. I like to joke it’s like used car salesman. There’s some wonderful ones and there’s some not so wonderful ones. And so, you got to know who you’re dealing with because you might get five different answers from five different mediators.  The main thing is number one, they have to have containment and negative air pressure so that the rest of your home doesn’t get contaminated while they break down that wall and take out the mold. Number two, if they’re not wearing personal protective gear, that’s a problem. They don’t know what they’re doing because mold is super toxic, even to someone who doesn’t feel it over the time, over years.

Dr. Weitz:                          And by the way, protective gear doesn’t mean one of those really inexpensive masks that they get from Home Depot. It really should be… Yeah, a high intensity… What’s it called? A ventilator, or?

Dr. Carnahan:                    Yeah, and nowadays we know because of COVID, the N95, that’s a minimum. And I’m talking N95s with the charcoal filters like the painter would use.

Dr. Weitz:                          Exactly.

Dr. Carnahan:                    And ideally, they have a complete suit. And sometimes in the severe cases, they’ll have complete, their own air supply. That’s a little less common, but I have known situations where they’re so bad that they are completely, almost like an astronaut type of get up with their own oxygen and own air supply. And then, the basic thing behind remediation is, if you have… You might look at my study here, and there’s no visible mold. There isn’t mold in my condo, but there’s no visible mold, there’s no issue, but I might not smell it or see it. And so, patients are confused because they’re like, “There’s no mold in my house. I don’t see anything.” Most of the time, it’s not visible.   So, it might be behind this wall because there’s a pipe that burst, and it leaked into my home or in my basement and caused damage behind the wall that’s not visible. So you might not see it, you might not smell it. But those toxins released from the mold could still go into your air supply. So say that’s the issue, the remediator would have to come in, put off plastic Visqueen, put up negative air pressure common, and take out that piece of the wall, replace it. And that’s not the end of the story because number one, they have to do that appropriately. And then after that, you need to clean your vents and clean your house because that mold has been spewing toxins into your environment. And that dust left in your house, that’s what we checked with an ERMI test can still cause illness in someone even after the main mold source is gone.

                                                So typically, what I recommend is get a remediator, get the source out, get the crawlspace fixed, get the attic fixed, get the sump pump fixed, seal the windows, do the work.  Then number two, clean your HVAC system if you have one because that’s been circulating toxins and dust, and you clean that first. And then number three, a small particulate cleaner or somewhere where you have someone completely… There are instructions for this. You can get it from your IEP. You can do it yourself or hire someone, and they literally wipe down every surface of your place. And then you want to get rid of porous materials if you’ve been really affected. That would be like the books behind me.  I don’t really love to tell people to get rid of everything in their home. I don’t think that’s the right way to do it. But a lot of times those porous materials like paper, or things that you can’t clean easily will continue to make you sick. So if in question like say these books behind me, you could store them in a plastic bin while you get well and then go back later and open it up and see. And then after the small particular clean, some people will do a fogging, or they might do the fogging with an enzyme and then a small particulate clean in that order.

Dr. Weitz:                            Before we get into the rest of the treatment, I wanted to bring up a point of confusion that sometimes comes up when I discuss this topic with patients. So there are some related conditions that are different. So you can have exposure to mycotoxins just like you were talking about. You can also have fungus growing inside your body. It can be growing on your lungs, it could be on your skin, it could be under your fingernails, it could be in your vagina and other organs. And then you can have fungal overgrowth in the GI tract like Candida. How related are these? How should we think about these?

Dr. Carnahan:                    Oh, I love this because this is one of those kind of secrets where I’ll see people who have been to five, 10, 20 other doctors, and they’re still not well, and understanding that you can be colonized or infected with molds, or with fungus is really part of the puzzle. There are some doctors that teach that that doesn’t exist. Well, there’s tons of literature to support the fact that you can have Aspergillus, and the sinuses in the lungs, in the gut. I mean, it is very well documented. This is not anything new. In fact, some diseases like multiple sclerosis, they’re using antifungals and having great success because it’s so common to have fungal colonization.

                                                So, let’s talk about the difference. [crosstalk 00:34:10]. Yeah, it is and there’s a lot of articles. A neurologist friend and I sometimes talk about this, how big the fungal burden. So the first thing I want to talk about is just the mycotoxin exposure. So you can have exposure to mycotoxins where they don’t grow in your body, and they can cause the immune damage and the cytokine storm and you can be very, very sick, but not be colonized. And some of the ways to differentiate would be you can do urinary organic acids, and there’s something called furans that come in the urine that show Aspergillus or some other types of species. You can do the urinary mycotoxins, and if they’re coming out in your urine, you’ve probably had an exposure and have been partially colonized as well. So, there’s these things.

                                                And again, then you have to figure out is it sinuses, is it gut? Systemic antifungals can treat both sinus and gut, but topical you might use Nystatin which treats locally in the gut, it’s very effective. Or you might use something like grapefruit seed extract in the sinuses. And again, you’re treating locally. So you can do everything from sinus sprays. You can do nebulized antifungals, which goes to the lungs. Or you can do oral herbs and medications for the gut, or for the whole entire system. And things like Aizawl drugs, fluconazole, voriconazole, ketoconazole, atroconazole. Those are all systemic antifungals. They can be toxic to the liver. So you absolutely want to work with a doctor who knows what they’re doing. But in some cases, they can be life saving because if someone’s colonized with fungus in the gut, that’s an issue.

                                                Now, the other thing you mentioned is SIFO or small intestinal fungal overgrowth super common, hard to detect, often it won’t show up in the stool, but it will show up in the urine. Or it might show up with serum Candida antibodies or saccharomyces antibodies. And this is a big deal because both the mold toxins and the yeast metabolites like acetyl aldehyde, they will further weaken the immune system. So part of this balance is the mold tends to weaken immune system. And yeast in general is opportunistic. So what that means is it takes advantage of a weakened system. If you have a really strong robust immune system, you’re probably not going to have a fungal colonization issue. Nowadays with EMFs, with poor diet, with stress, with isolation, all these things, many of us have a weaker immune system. So, it’s very common to see colonization with Candida and other things because of our weakened systems.

Dr. Weitz:                            Cool. So what if a patient does have say fungus under their nails? Is that at all related to systemic fungus or mycotoxins?

Dr. Carnahan:                    Yeah, so this is interesting on two fronts. The technical name is called onchomycosis, which is [inaudible 00:36:46] fungus. If you’re looking at the real discolored toenails, or thickening, or the sloughing that is often that fungus. Two things, often the periphery, the extremities, if they’re a little cooler due to either dysfunctional thyroid or adrenal, then you can have more growth there because just that slight degree change in temperature in the periphery will enhance the ability of fungus to grow. So there might be a thyroid or adrenal issue contributing.

                                                And then the second thing is systemically that can be a sign of systemic fungal overgrowth as well. So I’ve seen actually Nystatin is supposed to be a drug that treats just the gut locally, not systemically. But in certain cases I’ve seen because of reservoirs in the gut, if we treat with Nystatin sometimes the nails will actually improve, which isn’t supposed to happen.

Dr. Weitz:                            Interesting. What about if you use your mold mycotoxin removal strategies, which we’re going to talk about it in a minute. Do those also help with fungus under the nails?

Dr. Carnahan:                    They can. Again, the gut is a lot of times the reservoir. So if your gut is full of yeast and fungus and you remove that, sometimes you’ll see the nails improve. Again, the nails are not… There’s not a lot of blood flow there and it’s on the periphery so it’s cooler, so they’re hard to treat. And typically docs who treat them are going to treat them with three months of a heavy hitter antifungal, and even then it might not clear it. So I always want to look at the terrain because of the terrain, if it’s a weakened immune system, poor thyroid function, poor adrenal function, you want to fix those first or at least in conjunction with the nail fungus because to me, that’s just a symptom of something bigger.   The other thing that can correlate with it is blood sugar issues. So, if you’re diabetic, uncontrolled, those blood sugars will make fungus more happy and growing because they love sugar. So, that’s another piece of the puzzle. If your blood sugar is not controlled, you want to work on that, in addition to working on the nail fungus.

Dr. Weitz:                            Yeah, I know that you recommend a low mold diet as part of the treatment plan. Maybe we should talk about that.

Dr. Carnahan:                    Yeah. So, this is, again, there’s some controversy among other doctors, do you really need a low mold diet? I find the less exposure to mold even in your diet while you’re getting well will help. And maybe the bigger thing is histamine. So there’s also a low histamine diet. And a lot of patients who have had mold exposure, they have mast cell activation and more sensitivity to histamine. And if that’s the case, they’re going to be very reactive to things like fermented foods, bone broth, aged meats and cheeses, leftovers. Those are all high histamine, so that can be an issue for patients as well.

Dr. Weitz:                            Interesting. So what constitutes a low mold diet?

Dr. Carnahan:                    Yeah, so this would be like, berries can have mold on them. Like I said, blue cheese, anything with visible mold or growth. Similar way leftovers or things that have left out, and then nuts and seeds and grains can be contaminated. I have a suspicion that one of the reasons that paleo and grain free diets are so popular is because grains are one of the most highly contaminated food sources of mold. And in fact, a lot of our data on the gut is from African children where their grain supply have been contaminated with mold, and they got inadvertently fed moldy grains and they developed a leaky gut and even sometimes villous atrophy, which is the same thing you see with celiac disease.

Dr. Weitz:                            And is that because the grains are stored in these silos for periods of time?

Dr. Carnahan:                    Yes, I grew up on a farm in Illinois. So, I know a little bit about grains and storage.

Dr. Weitz:                            Yeah, I’m a city boy. So, I have no idea what really goes on, on farms.

Dr. Carnahan:                    You’re right. And so I grew up… And it’s funny because I had horrible allergies as a child to corn and soybeans, which was the main crops. Now looking back, I feel like I understand this so much more. I might still have been sensitive to the corn and soy, but what I believe Dr. Weitz is it wasn’t just the corn and soy, it was the molds and fungus that were growing on the corn and soy. I mean, I would literally have my eyes almost swell shot from allergies. I think I was really sensitive. And then you store them a little bit damp. Part of the purpose of the grain bins is to dry the greens out because they have to have a certain moisture content to be sold. So this is kind of wet and damp grain sitting in huge bin and there is massive mold growth.  Again, there’s levels… What’s sad about the United States is our levels of tolerability for mold toxins on grains is actually quite high compared to Europe. So, for example, coffee and chocolate are things that often contain mold as well. And there’s a European standard of coffee and if it’s above a certain level, they won’t accept it into the country. Guess who gets those leftovers that aren’t accepted? We accept them in the US, so our coffee, our typical Starbucks coffee I hate to say for all those of you love Starbucks it’s got mold in it. I know now. I drink a really clean brand called Purity, and I’m so cleaning my diet that if I get a cup of Starbucks, I don’t feel well. I can tell immediately that sense of headache or not wellness/

Dr. Weitz:                          And a lot of processed foods. Things like jellies all have mold in them, and there’s so many foods that contain small amounts of mold that we’re not aware of.

Dr. Carnahan:                    Yeah, children’s apple juice. You’ve seen those videos.

Dr. Weitz:                          Oh, yeah, horrible. Basically, anything that comes in a squeezable, plastic kind of container, don’t eat it.

Dr. Carnahan:                    Yeah.

Dr. Weitz:                          So let’s talk about the rescue mold protocol. I know Richie Shoemaker talks about using some of these prescription bile binders like Cholestyramine. Do you use those?

Dr. Carnahan:                    Yeah. So, I’ll talk real quickly about treatment protocols and the gamut. And I also want to mention I have on my website, again, I’ll link it here, and then for your podcasts, we’ll give you a link. The low mold diet is there. You can search my website, jillcarnahan.com. If you want to know exactly what’s on it, it’s there. I also have a free mold guide. I’ll make sure your listeners as well as mine have linked to that. Most of my listeners already have it. It’s all free. But lots of the stuff if you don’t remember the details or want more to read, it’s all on my website. So, you can go find it there as well.

                                                So, treatment, so basically, you’re thinking about first of all out of a source of exposure, which we just talked about, and then you’re working on getting your body rid of these toxic levels of mold and detoxification. So you’re focusing on liver support. We mentioned glutathione. Not everybody tolerates glutathione, and glutathione has to be recycled by NAD, so I’m a big fan of NAD as part of the protocol. Sometimes not the initial part. And if you can’t tolerate glutathione you can use precursors, and acetylcysteine, vitamin C, glycine, glutamine, lots of different things. I almost always put people on milk thistle or some other liver support, sometimes bitters, those will help the liver, gallbladder.

                                                And then binders, binders are key. There’s many, many types of binders. Dr. Shoemaker is real heavy on the prescription drugs and binders. I actually don’t use those as much because I find some of the natural binders work well and are a little more gentle. I will say with Ochratoxin, cholestyramine tends to be very effective. So that’s the kind of toxin that if they have a very high level of Ochratoxin, I might consider cholestyramine. But in general, I like clay and charcoal and chlorella. There’s also glyco maintenance, there’s zeolite, there’s silica-based binders, which are also great for heavy metals. But I get really good results with clay and charcoal, pretty simple stuff. So, supporting liver, clay and charcoal. Now, while you’re doing this, you’re doing a complete functional medicine approach. So, if they need probiotics or gut support or brain support or adrenal or thyroid support I’m doing all that as well.

Dr. Weitz:                          I know some docs say before you even go into a detox protocol. If they have leaky gut, and a lot of patients do, you should work on fixing that first because otherwise they’ll reabsorb the toxins.

Dr. Carnahan:                    Yes, yes. And there is a point too, if someone has really bad mast cell activation and permeability issues. Sometimes I found I agree with you and I’ve done 20 years and started with the gut and love the gut. But once in a while if you don’t get that mold level down, the gut won’t heal and you get stuck. So if you’re getting stuck with gut protocols, I would go to the mold and make sure you’re addressing that at the same time.

Dr. Weitz:                          Yeah, it’s always a question of this is a root cause, and that’s the root cause of that, and what’s the root cause of that?

Dr. Carnahan:                    Yes.

Dr. Weitz:                          So, let’s see what else? I think we’ve pretty much covered most of the things. What about air purifiers that remove mold? Is there a best one on the market?

Dr. Carnahan:                    Yeah, so there are some that are out there. And there is a specific name that is eluding me at the moment. But I’ll give you some examples, Airwise and Molekule. And what they do is they actually can neutralize the toxins in the air. And they can actually, they’ve shown to improve air quality, so it’s almost like it’s an air modifying the air quality. However, there’s a caveat with that because when mixing that type of device that can produce some ozone when it reacts with the molecules in the air. So someone like me with a history of the lung sensitivity, those kinds of air filters actually would irritate my lungs. That’s not common with everybody, and those are really great air filters. So I’m not saying those are bad or wrong, but if you have any sensitivity with the lungs you might be hypersensitive to the little bits of ozone they actually produce when they combine with the air molecules.   I tend to use the ones that are just filtration and they have a HIPAA filtration and a BOC filter. Those would be like Austin Air and IQAir. So, and Airwise and Molekule are the other types. They’re all good, and they’re all different. I have Austin Air 2 here in the condo, and 5 at the office, and I’ve just loved them.

Dr. Weitz:                            On the average, how long a protocol does it take to remove mold? Is it reasonable to think that patients are going to get significant benefit from a month? Do they need three months? Does it takes six months? Does it take a year?

Dr. Carnahan:                    Yeah, so great question. Because people can be frustrated with the timeline. I usually say six to 18 months is kind of this average. I have [crosstalk 00:46:53]-

Dr. Weitz:                            Of through treatment that whole time.

Dr. Carnahan:                    Yeah, yeah. And again, not that you can start to feel better in two months, but it’d be really unusual for someone to just turn around in a month or two, it takes some time. Especially, if you’ve been significantly impacted, and depending on the amount of time, and I’ve seen sometimes it’s two years, but not that you’re not making progress. It’s interesting. One of the things that I developed with Quicksilver is the Mold Detox Box. So yeah, you can go molddetoxbox.com to find out.  Now, this is not for everybody, and it’s a fairly… I mean, it’s an aggressive, great treatment. So if you’re on the super, super sensitive side, you either want to go really slow products one by one because it will detox but it’s a 30 day kit. And I didn’t do that because I thought the 30 days would cure everybody. But what we wanted to do is put everything you might need for the detox all in one package for 30 days. And so, I think about it that way, but I’ve had to clarify a lot because people are like, “Can I get well in 30 days?” And it’s like, “No.” I mean, you might be able to get a significant handle on it, but it’s usually six months minimum, and then sometimes a lot longer.

Dr. Weitz:                            And so, a lot of times when we’re using herbal protocols, we’ll rotate the herbs. On a detox protocol for mold, if you have something after the first month that seems like it’s helping do you just stay on the same protocol, how do you decide when to change things?

Dr. Carnahan:                    Yeah, so again, history is so good because I’m always checking in, and I will tell them to start things individually. So start things one by one and see if there’s a reaction or a problem. And sometimes it’s dose. So binders can be something that… Basically with binders, you’re grabbing from the bile these toxins that are stored after they’re thrown from phase one, phase two into the bile from the liver, and you’re pulling them out through the stool, that’s a great way to detoxify. So if a patient is having trouble tolerating it, often we’ll have to go to a quarter teaspoon or an eighth of a teaspoon or a pinch to get them to tolerate. And what’s happening is on the way out as they’re pulling those toxins out of the body, they can get re-exposed. So you have to factor that in to how you dose since sometimes you’re doing very small increments. So, it doesn’t mean that the detox failed, it just means go slower.

                                                I am not a big fan… There’s herxheimer reactions or things that happen when you try to treat an infection, you have massive die off of an organism. You can also have a herx reaction when you’re trying to detoxify. And I’m not a huge fan of pushing through those kinds of reactions. To me that’s like, there’s always this concept of mobilization of toxins and excretion. So you’re mobilizing metals or toxins from mold or toxins from infection, and then you’re trying to get them out of the body through the urine, through the breath or lungs, through the sweat, through the stool, all these ways that we get them out of the body. And if you have a reaction, you’re probably mobilizing faster than you’re excreting. So, my job then is to slow down the mobilization and increase the excretion. And that can be done with things like infrared sauna. Just increased hydration or electrolytes, alkaline water or mineral water, things like Epsom salt bath at night, dry brushing, castor oil packs, even coffee enemas, those can all be helpful for excretion.

Dr. Weitz:                            So, if a patient has a reaction, and they say, “Oh, I can’t take that.” The answer is, A, it’s not necessarily that you can’t tolerate, it’s just the dosage. So, we need to dial way back on the dosage, go with a very small amount, and slowly bring it up.

Dr. Carnahan:                    Yeah, there’s three things. You could be allergic to something and not tolerate it, period. That usually will get worse over time instead of better. And some people just know, no matter how low of curcumin I take, I don’t tolerate it. Number two, it could be dosage dependent. So as you go very slow and very small, and you’re mobilizing not too much for excretion you’re tolerating, and then over time you tolerate more. And number three, you could actually have a deficiency of NAD, so you’re not recycling glutathione, so every time you take it, it becomes oxidized, and causes more toxicity. Or you could have a limit of B12, and you’re trying to take methylfolate and not working. So there’s really is an order of operations, and I find even for myself years ago there was a lot of things I didn’t tolerate that I can tolerate now. That’s a sign that that toxic load is decreasing.

Dr. Weitz:                          Cool. I think that, I think we really covered it. Do you have any final thoughts?

Dr. Carnahan:                    No, but thank you for coming on. Thank you for doing the interview. It’s really fun to talk about mold. And I think we did really cover a lot of the areas that people might have questions about with mold. If you have any questions, I’m going to be sure and link Dr. Weitz’s site so you can know more about him. And all the things I mentioned with the Mold Detox Box, and my free blogs, and all that we’ll make sure and link those as well, so you can stay tuned.

Dr. Weitz:                          But by the way, what is your website?

Dr. Carnahan:                    My website is just jillcarnahan.com. And then drjillhealth.com is where you can find products and the Mold Detox Box, and that kind of thing.

Dr. Weitz:                          Awesome. Thank you, Jill.

Dr. Carnahan:                    You’re so welcome. Thank you so much.



Estrogen Dominance with Magdalena Wszelaki: Rational Wellness Podcast 196

Magdalena Wszelaki discusses Estrogen Dominance 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. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

2:10  Magdalena’s personal health journey was highlighted by being diagnosed with both hyperthyroidism and hypothyroidism at the same time along with estrogen dominance.  She was first diagnosed with hyperthyroidism when she started having a rapid heartbeat, anxiety, and hair loss and she was placed on a thyroid blocker.  But seven years later when she was living in Shanghai, it came back with a vengeance. She noted that she had a lot of food sensitivities when she was growing up and she had eczema and cystic acne.    Magdalena also pointed out that she was not breast fed and she ended up being hospitalized during her first month of life with pneumonia and she was prescribed a broad range of antibiotics.  She also grew up with a narcissistic and nervous mother.

6:00  Magdalena was diagnosed with hyperthyroidism and was put on thyroid blockers and six months later she was declared cured.  But nobody looked for the root cause and a few years later it came back with a vengeance. Magdalena learned that gluten can cause acne, so she eliminated gluten. She discovered that she had other food sensitivities, including diary and eggs, which she also eliminated, which put her on the path to starting to feel better.  She also had terrible PMS and swollen lymph glands and water retention related to estrogen dominance.  Her PMS was so bad that she would have to take a few days off work or school and be in a fetal position with multiple pain killers. Her lymph would be so swollen that if she took a flight and took her shoes off, she could not get her shoes back on.  She also had a lot of thyroid nodules, which she said is a sign of estrogen dominance.

10:25  When a woman experiences one hormonal imbalance, like estrogen dominance, they are much more likely to have another hormonal imbalance, like thyroid problems. Your hormonal system is like a symphony orchestra and all the instruments must play together for it sound good.  When you have too much estrogen, your sex hormone binding globulin, which tends to increased your thyroid binding globulin, which binds your thyroid hormone and makes it inactive.  This is why you want to measure your free T3 and not just your total T3, because the free T3 is the one not bound by the thyroid binding globulin, thus it is the one that is bioavailable. 

13:10  Magdalena breaks down estrogen dominance into 3 categories or types:  1. Excess estrogen to progesterone.  2. Unhealthy estrogen metabolism.   3. Estriol (E3), the weaker form of estrogen, is low compared to Estrone (E1), and Estradiol (E2), the stronger forms of estrogen.  One of the reasons for estrogen levels being high compared to progesterone is that we get exposed to many forms of environmental estrogens, such as from skin care products with parabens, phthalates, air fresheners, pesticides, flame retardant chemicals sprayed on our mattresses, our furniture, and our car seats.

18:50  The second form of estrogen dominance is unhealthy estrogen dominance, which means that you break down your estrogen in an unhealthy way, into either clean or dirty estrogens. The best way to analyze estrogen metabolism is with DUTCH testing (dried urine testing) that will report on the 2, 4 and 16 hydroxyestrogens, and you cannot see these metabolites on blood tests. This estrogen metabolism takes place in the liver and as we get older, our liver tends to get more taxed. We need to do proper detox on our liver with foods and supplements on a regular basis to maintain our liver health.  If there is constipation, then your estrogen is not being excreted and it will be recirculated.

24:19  The third form of estrogen dominance has to do with the ratio of E1, E2, and E3 and E3 being low compared to E1 and E2, which are the stronger forms of estrogen, with estradiol being the most aggressive.

25:10  Strategies to reverse estrogen dominance. One of the most important things is to support the liver and not by doing a severe, deep detox by taking a large amount of detox powder that contains a lot of sugar, and then going back to eating unhealthy once the detox is over.  It is better to support the liver on a daily basis, including by eating bitter foods like radishes, arugula, kale, etc. or by taking herbal bitter supplements.  We also want to support liver detoxification by supporting the sulphation, glucuronidation, and methylation pathways. Ground flax seeds can help with estrogen detoxification due to the lignans.



Magdalena Wszelaki is a nutrition coach, certified herbalist, a bestselling author, speaker, and educator. Magdalena is the founder of Hormones and Balance, a thriving online community dedicated to helping women balance hormones naturally.  Magdalena offers several programs, including Estrogen Reset.

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.


Podcast Transcript

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

                            Our topic for today is estrogen dominance with Magdalena Wszelaki. Estrogen dominance, which is typically described as having too much estrogen in relationship to progesterone, can lead to many symptoms, including mood swings, anxiety, decreased sex drive, worsening PMS symptoms, heavy periods, irregular periods, infertility, bloating, weight gain, hair loss, insomnia, brain fog, hot flashes, and night sweats. It can also lead to various health conditions including ovarian cysts, fibroids, endometriosis, and fibrocystic breasts among others. Magdalena Wszelaki is the founder of Hormones Balance, a thriving online community dedicated to helping women balance hormones naturally.

                                Magdalena is a nutrition coach, certified herbalist, a best selling author, speaker, and educator. She has a long history of hormonal challenges. Her health crisis was a direct result of a highly stressful life in advertising. Starting from Graves’ and Hashimoto’s Disease, autoimmune conditions causing thyroid failure, to total burnout in estrogen dominance. Today, she is in full remission and lives a symptom-free life and teaches women how to find their hormonal balance with her books and programs. Magdalena, thank you so much for joining me today.

Magdalena:        Thank you so much for having me and for spreading the word about estrogen dominance.

Dr. Weitz:           Absolutely. Can you tell us about your personal health journey and how you ended up having both hyperthyroidism and hypothyroidism at the same time along with estrogen dominance?

Magdalena:        Yeah. So I think the pivotal moment for me was in 2008 when I was diagnosed with Hashimoto’s Disease and I was living in Shanghai in China at that point. We didn’t have as many resources as we do now. Today, you google Hashimoto’s and you have so many websites coming out, you don’t know where to get started. Back in the day, there was absolutely nothing. So that put me on a journey of trying to figure out why am I having a autoimmune disease and what’s going on. I suspect I did have Graves’ Disease seven years before that and so that wasn’t really diagnosed as such, but it was diagnosed as-

Dr. Weitz:           What were the symptoms that made you suspect that?

Magdalena:        Of hyperthyroidism?

Dr. Weitz:           Yeah.

Magdalena:        Yeah, I was actually diagnosed properly with hyperthyroidism and put on thyroid blockers. The symptoms were waking up in the middle of the night with an anxiety attack, your heart pounding so much so you can see your shirt actually bouncing off your chest, sweaty palms all of the time, losing it with the people you love the most. So going to a restaurant where the server screwed up your order and you yell at the person, and you think, “That’s not really me.” Then beginning to have a lot of hair loss at that point with… Even though people think it’s hypothyroidism or low thyroid that causes hair loss, it doesn’t have to be. You can also lose a lot of hair with hyperthyroidism. But with a lot of allopathic medicine, I wasn’t treated from the root cause perspective. I was just put on a thyroid blocker and six months later declared cured. Of course, it all came back with a vengeance a few years later, seven years later, when I was living in Shanghai.  I was really lucky to be diagnosed really quickly. I did tell my doctor that I have a history of thyroid problems. She happened to measure my antibodies and that’s where things proved… Proof was in the pudding, if you will, with those antibodies. But I think more importantly, we always talk about our stories from the onset of the symptom or from the time of diagnosis. But when I think about it, it really starts much earlier in your life, right? So not being a breast-fed child, I ended up in the hospital the first month already with pneumonia and a broad range of antibiotics. Grew up with a very narcissistic and nervous mother, so that could be a contributing factor.

                                Had a lot of food sensitivities right from the beginning. I remember being covered with eczema. My mom was… I think she had enough foresight to realize that eggs were causing my issues, but like with a lot of food sensitivities, that it turned into cystic acne. So in my 20s until I was about 28, 29, I was covered in cystic acne, not just the face, but also my chest, my back. I used to have it behind my ears. On my butt even. When you’re in your 20s, this is your prime time of dating and having romantic relationships. It really takes a toll on your self-confidence.   The pivotal moment was when my girlfriend was getting married and she designed these beautiful dresses for us, but fully open everywhere. I’m like, “I can’t wear this.” She’d be like, “You just put makeup on.” I’m like, “I can’t cover up these volcanoes on my back. It’s going to show.” That’s when I started searching. Mind you, 25 years ago, or 20 years ago, this was revolutionary. I remember this article popped out and said, “Gluten causes acne.” I was like, “Wow.” So this is really where my journey started. As I eliminated gluten, it turned out not only did my acne started clearing out, but my headaches were gone, my bloating was gone, and then I discovered that I had a lot of other food sensitivities, including dairy and eggs were my problem. So that put me on that path, but I’m pretty sure it all started much earlier.

                                I have these photographs. I grew up in a tropical country called Malaysia. I just found the other day photos of being in a schoolyard. I’m wearing this really, this kind of sweater-like top. Like a sweat top, sweatshirt, but it’s thick. I’m thinking, “What am I doing with a sweatshirt in a tropical country right after exercising?” But I was cold all the time. That’s already telling you it was a low thyroid. It was just brewing right from the beginning.  Then the estrogen dominance part, which we appear here to talk about, I’ve always had swollen lymphs where I couldn’t take off my rings. I’ll go on a flight. I couldn’t put my shoes back on because my lymphs were so swollen. My PMS was so terrible that I had to take one or two days off from school or later work and be in a fetal position with multiple painkillers to just get me through the day.

Dr. Weitz:            Wow.

Magdalena:        Always lumpy breasts. A lot of issues with thyroid nodules, which is also another symptom of estrogen dominance. So interestingly, on both sides of my family, I have aunts who passed away from estrogenic cancers. So when I had my genetics done and went to see my functional doctor here in Boulder, Colorado where I live, I printed out a whole stack of my results. She’s flipping through it as we chat and she says, “Have you had breast cancer?” I said, “No. Why would you say that?” She said, “Well, patients with your kind of genetics would have had breast cancer by now.” I was 45 at that point, so this was a few years ago.  So genetically, a perfect candidate for estrogenic cancer. As you mentioned in your introduction, estrogen receptor positive breast cancer, but also uterine cancer, ovarian cancer, thyroid cancer, and lung cancer. Nonsmokers, most of the time, are fueled by estrogen or the excess estrogen or the dirty estrogen.

Dr. Weitz:           Interesting. I just was reading an article in the news about the increase in nonsmokers getting lung cancer.

Magdalena:        Yeah, yeah. People go, “I never smoked,” right?

Dr. Weitz:           Right.

Magdalena:        In men, mind you, I know probably your audience is majority women, but I will say almost every woman has some kind of a male partner or a brother or a father, and let me say prostate in men, both prostate cancer and prostate problems, inflammation of the prostate as well as man boobs and man boob cancer, all estrogenic too. So a lot of times when women embark on this diet that I advocate, which is nothing crazy, I mean, it’s just a way to metabolize your estrogen, to support your body through that, and they ask me, “Can my husband eat this?” I’m like, “Actually, it’s going to probably help his boobs too. Yeah. So that’s the story.

Dr. Weitz:           Yeah, no, it’s definitely the case that we’re awash in toxic estrogens in this society and we’ve talked about that quite a bit.

Magdalena:        Yeah. Absolutely. Just to wrap up my part of the story is that I think that in some ways, I dodged a bullet with estrogen dominance and not going the path of developing estrogenic cancer, and I hope not to. But I think it’s because of the work that I do and it’s just the amount of effort that I put in. The genetic testing also created a lot of forgiveness and kindness to myself, just to understand that I’m much more prone to developing these symptoms versus somebody who doesn’t have these genetic SNPs. So let’s always remember genes are not your destination. It’s just you’re just inheriting a loaded gun. But something needs to pull the trigger, right? There’s a lot of things that we can do to prevent that trigger being pulled.

Dr. Weitz:           Yeah, certainly heard that analogy quite a bit. What is the mechanistic connection between estrogen issues and thyroid?

Magdalena:        Yeah, so that’s really interesting that a lot of… Let’s just say, first of all, most of the time, when a woman experiences one hormonal imbalance such as, for example, a low thyroid issue, she also would experience, or most likely experience, these other hormonal imbalances. So it hardly ever is just one. So it’s good to think of our whole endocrine system as this really beautiful orchestra that plays really nicely. If you’ve been to a high school concert where the guy with the trumpet screws up at the back, everybody is just like a domino effect. Everybody gets completely dysregulated, right? So with hormones, it’s a little bit like that. But specifically since you’re talking about thyroid and estrogen dominance, it’s really interesting how many women who have Hashimoto’s or low thyroid function also happen to have estrogen dominance with also coupling up the symptoms where you talked about earlier.

                                The mechanism that happens is the biggest thing is that when you have excess estrogen that you referenced earlier, what happens is your thyroid binding globulin is also gets higher. So estrogen bumps up your thyroid binding globulin. It’s the form of a protein. As the name applies, binding globulin, thyroid binding. So when you have too much of that protein, it basically, whatever thyroid hormone your thyroid produces, that protein binds out that thyroid, making it unavailable for your body to utilize effectively. This includes even women who are on synthetic thyroid… It’s not really medications. It’s thyroid hormone replacement.  Like Synthroid as an example. So it’s a lot of times, when you go and see your endocrinologist and you say, “Doc, the Synthroid isn’t working anymore,” and what do they do? Just increase your dose. A lot of times, that dose increase doesn’t really do anything. A lot of times actually kind of flips them the other way when they become hyperthyroid, but they’re still tired and they’re still losing hair. They’re still putting on weight and all these other… They still have depression, anxiety. All those typical low thyroid function. That’s because estrogen could be the cause of binding.

Dr. Weitz:           So you got to look at the thyroid binding globulin and you need to look at free T3?

Magdalena:        Absolutely. Absolutely. So free T3 is your working horse, right? That’s where you can have the-

Dr. Weitz:           That’s the active form of thyroid-

Magdalena:        That’s the active hormone. I mean, that’s what gives you beautiful hair, beautiful skin, healthy nails-

Dr. Weitz:           And the free one is the one that’s not bound up by the globulins.

Magdalena:        Correct.

Dr. Weitz:           Okay. So you break down estrogen dominance into three types or categories. I mentioned one of them which is this estrogen-progesterone ratio. Maybe you can talk about these three categories and explain them for us.

Magdalena:        Yeah, so let me start of with… Because it can get a little bit complex, I’m going to try to make it really simple for folks to understand. Let’s talk about maybe… I’ll mention all three, but I think the first two are really good to remember. So the first one, as you said, is excess estrogen to progesterone. Now, one thing I would like for our listeners just to realize is that we are not here to demonize estrogen in any way, okay? As women, we need estrogen to function properly. If you’re still in your pre-menopausal, you’re still cycling, you wouldn’t cycle without estrogen. You wouldn’t get pregnant without it. We wouldn’t sleep. We wouldn’t have healthy bones, good cognitive function, beautiful skin. It’s like we need it in order to function, right?

Dr. Weitz:            Yes.

Magdalena:        So let’s not demonize it. The problem is in the detail, right? So it’s very nuanced in some way. So the nuance here is that, like you said, is specifically the estrogen that we are looking at is estradiol. It’s the most aggressive form of estrogen and you need it-

Dr. Weitz:           So let me just clarify for some who don’t know. Our bodies, men and women, contain three different forms of estrogen and you have E1, which is estrone, and you have E2, which is estradiol, and you have E3, which is estriol. Now, you’re specifically talking about the E2, estradiol.

Magdalena:        That’s right. For example, part of the reason why estradiol has become a real problem is because it’s not only that your body is producing it on its own, but you’re also coupling it up with, for example, if you are using conventional skincare products that are full of parabens, phthalates, all these nice smelling things, all these various chemical, many of them are estrogenic-

Dr. Weitz:           I just went to the bathroom and they had one of these air fresheners, which is filled with phthalates and-

Magdalena:        Please, if you have that in your house, throw it away right away. I assume that it is your landlord who provides that-

Dr. Weitz:           Yeah, of course. Actually, I couldn’t tell what smelled worse, that or the pesticides that they just sprayed to kill bugs. It was just the whole bathroom was awash in toxic chemicals.

Magdalena:        So that’s-

Dr. Weitz:           That’s with somebody who’s trying to do everything right and there’s all these things you can’t control.

Magdalena:        Right. I mean, what you can control is just don’t use it at home, don’t use it in your car, right?

Dr. Weitz:           Of course not, of course not.

Magdalena:        You get into Uber, Lyft, ask the guy to take it off. I always tell them I’m allergic and I get a headache from these smells. I’m like, “I’m so sorry you have to take this down. It makes me sick.” So we are invaded by estradiol externally as well. So the body doesn’t really recognize the difference between those two, so that’s why many women are so excessive in that form of estrogen and progesterone. So effectively, there is not enough progesterone to oppose it. Think of estradiol and progesterone like two dancing partners. Have you ever seen a dancing competition? If the woman is overly beautiful and exuberant and the guy is timid and lacks presence, they don’t look good as a couple. They’ll never win an award. So we’re looking for a balance here.   A lot of women ask us, when they do a quiz on my site, they ask us, they say, “Your quiz sucks. You have all these errors on your website because I’m in menopause and your quiz tells me I’m low estrogen, which is correct, but you’re also telling me, according to your quiz, I’m also estrogen dominant. How is that possible?” It’s a plausible comment although it can be hurtful to hear sometimes. We do explain in the result of it, most people don’t read them in full, is that you can have both estrogen-progesterone dropping, but the percentage of how much of estrogen to progesterone you have can be unbeneficiary. The problem is the progesterone drops a lot quicker, especially for women after 45, as compared to estrogen. So this is the reason why, if you think about it, this is a reason why who develops breast cancer. The biggest demographic are women from 55 to 75. These women are very low on estrogen, but guess what? They are even low on progesterone. This is where the imbalance can play a role. Second-

Dr. Weitz:           Hang on one second.

Magdalena:        Sure.

Dr. Weitz:           I’ll get you right back on track, but I want to take us down a detour for a second. I know that you mostly treat women, but when it comes to men, do you ever consider adding progesterone for men? I treat a number of men as well as women and I very frequently see the progesterone levels extremely low.

Magdalena:        Yeah. So I don’t treat men and I’m not in private practice anymore, but whenever I attend conferences where there are practitioners who do recommend and there are case studies presented, yes, I have seen multiple times, same as you, practitioners prescribing very small doses of progesterone to men. That actually helps them balance estrogen dominance, which we said, when men can also experience.

Dr. Weitz:           Okay, good. So let’s go back to the three categories of estrogen dominance.

Magdalena:        Yeah, so the second kind of estrogen dominance is what I call a ugly breakup. An ugly breakup basically means is that your estrogens get broken down to metabolites. Guess what? The most important organ that this happens at is your liver. The liver breaks down, a lot of people know, is all the alcohol. Some people know about coffee. But there’s actually a lot more. It breaks down a lot more, including hormones. You mentioned thyroid at the beginning. Thyroid also, like your Synthroid, also gets converted from T4 to T3. The liver’s important. So the liver, in the context of estrogen, is so fascinating that it breaks it down to these metabolites. Just for simplicity, I call them clean or dirty estrogens. Some of those dirty estrogens are those metabolites that are causing the problem.  So as you can see, that goes back to the first type of estrogen. You can be low on estrogen, but even in spite of being low, you’re still breaking down those estrogens in an unfavorable way. I suspect part of the reason is because, as we get older, our liver gets more and more taxed. If we don’t do proper maintenance on a regular basis and don’t do foods and supplements that really help us gently detox on a regular basis, then we are not as effectively breaking down those estrogens. What makes it even worse is women and constipation. I looked around your website and I suspect you do work with a lot of women with hyperthyroidism and Hashimoto’s, right?

Dr. Weitz:           Yeah.

Magdalena:        Constipation is one of the biggest issues women experience due to a low thyroid problem. This where, again, the estrogen comes in, because you’re not pooping out your estrogens on a regular basis. Those metabolites I’m talking about aren’t getting popped out, and when they don’t, they reenter your blood stream making estrogen dominance worse. So that’s the-

Dr. Weitz:           So I just wanted to ask you. I know in one of your articles in your book, you mentioned the 2:16 hydroxy-estrone ratio. There’s some controversy now over whether that really holds up or not. There have been some review articles saying while it’s not really a good predictor for breast cancer, where do you think we are in terms of understanding those estrogen metabolism pathways?

Magdalena:        Yeah, so that’s a really good question. The 2:16 is a little bit of a old-school of doing it by testing. You have a lot more accurate testing these days. One of my favorites is definitely DUTCH. Do you use that in your practice?

Dr. Weitz:           Yes, I do. The Dried Urine Testing, yeah.

Magdalena:        Right. So it’s a wonderful test. Then you’re looking at not just 2 and 16, but the 2, 4, and the 16. I mean, the biggest functional medicine practitioners in our industry use that. I certainly have seen women correlating their symptoms with the results, with the diagnosis they got, and find it very accurate. Far more accurate than blood testing, which is completely useless for steroid hormones such as these.

Dr. Weitz:           I mean, it can be helpful for getting levels, but it doesn’t tell you about metabolism at all.

Magdalena:        Right. Exactly. So yeah. I mean, I still find it very effective. I think, like any good practitioner, you always want to overlay the results of lab testing like that with the symptoms and the health history and the family history of a person. If your mom has had a history of fibroids and you are suddenly having really heavy periods and sex is really painful, very likely might be a fibroid. You don’t want to get it tested and you get it tested, let’s just say that your results don’t show, just for the sake of argument, show that you are not really estrogenic as such. You don’t have estrogen dominance, but your symptoms are screaming that you are. I mean, are you not going to do something about it?   The other interesting thing about testing I find is that every woman needs a different range in order to feel really good. My levels of progesterone might be needing to be on a much higher side for me to feel good as compared to someone else, but the range tends to be very broad.

Dr. Weitz:           What range in particular for yourself do you find to be effective?

Magdalena:        Well, I mean, depends what you’re using for measurement, right? I don’t remember the ranges right now and I typically, for progesterone, I wouldn’t use DUTCH. I would use saliva testing because, yeah, DUTCH only predicts progesterone. It’s a prediction, not an actual number. So I use saliva. If I remember correctly, it was like 600 to 1,200, was the range. It’s a broad range. If you think about it, it’s 400 to 1,200. That’s three times more.

Dr. Weitz:            They did the same thing with testosterone. They say the range is 150 to 900, which is ridiculous.

Magdalena:        Right, exactly. But if I’m bleeding in the middle of my cycle, that’s a classical low progesterone symptom. If I’m suddenly waking up in the middle of the night, I can’t go back to sleep when I used to be a really good sleeper before, then you’re going to, yeah, it looks like I might need more progesterone supporting nutrients or do bioidentical progesterone. Just because it shows me that I’m okay on a lab test, that’s a little incomplete view, if you will.

Dr. Weitz:           Yeah. Okay. Then let’s go over the third form.

Magdalena:        The third form is there’s three different types of estrogens as you alluded. E1, E2, E3, so estrone, estradiol, and estriol. Every one of them has a little different function. So estradiol, like I mentioned, is the most aggressive one. There is an equation that’s used for looking at the number and determining the relationship of those three. That’s typically done through saliva. So I don’t typically talk too much about this kind of estrogen dominance because I have found that if you do DUTCH and you combine it with your symptoms, it’s very telling. I think those first two that I mentioned, the estrogen to progesterone ratio and the metabolites, the clean and dirty estrogens, I think that paints a pretty good picture of then what do you need to do in order to help yourself.

Dr. Weitz:           Okay. Sounds good. Let’s talk about some of the approaches for each one of these. So why don’t we start with the dirty estrogen, the estrogen metabolism. What types of strategies can we use to promote healthy estrogen metabolism?

Magdalena:        Yeah, so I mentioned liver, right? As a nutrition person, I’m a chef also and a herbalist. Obviously I love to support the liver in the first place through a lot of nutritional changes. One thing I will say is that, especially I find that it’s very true in America, and as you know, as you can probably hear, I’m not American. One of the interesting things that I found when I moved here is how people go very intensely into something, like doing, for example, a very severe, deep detox. Some of them are great and some of them are terrible because of just the amount of product that are put in there and how much sugar is in them. Then they come out of the detox and they go back to the old way of doing things because they deserve it. I find that kind of… It’s like as if you were deciding to do a cleanup of your house on your unboxing day and maybe on spring day again, on the first day of spring, and otherwise, you never clean your house. I think that’s the best analogy I can give.

                                So there’s a lot of things you can do on the daily basis to really support your liver. One of the big things is incorporating bitter foods into your diet. So things like turnips, radishes. Throw away the lettuce that you’re making your salads with. Switch to something like arugula or baby kale. They have a lot of bitter qualities. Every time you eat something bitter, what happens? You produce a lot of saliva. Well, guess what? That creates a big cascade of enzymatic production in the body. Not only are you going to extract a lot more nutrients from your food, but the liver loves bitter. The liver gets stimulated. All those detoxification pathways that are responsible for evacuating estrogen. So the sulphation pathway, the glucuronidation pathway, methylation pathway. All those pathways work really hard and they love bitters in order to… Also, you can stimulate that. Another one that I-

Dr. Weitz:           Bitters also stimulate bile production. A lot of these toxins are put into the bile and that’s how they’re excreted.

Magdalena:        Thank you so much for mentioning that. Absolutely. I did something a few months ago where I posted on our Facebook page saying, “Who here had a gallbladder removed? Did you notice any correlation with symptoms of estrogen dominance later on?” It was a very emotional post. A lot of women came on and said, “Now that you say it, I realize that ever since I had my gallbladder removed, my estrogen dominance symptoms, whatever that might be, I suddenly developing fibroids, my breasts are so lumpy.” A few women came on, said that they were convinced that breast cancer… I mean, I’ve never found a study. I did search when I was working on my book to find a correlation between gallbladder removed and breast cancer. I haven’t found that. But I think it’s very plausible. To your point about gallbladder source bile, the bile also binds out those dirty estrogens we talked about. It’s tragic because doctors don’t tell you the consequences of removing your gallbladder and they are and hormones could be one of them.   So back to supporting the liver, and there’s a lot of things also you can… So yeah, so bitters also stimulate your bile production, which is awesome, and release of bile. So that’s a really wonderful thing to do.

Dr. Weitz:           You can take herbal bitters in a concentrated form, like in a supplement?

Magdalena:        Absolutely. Not everybody loves those, but they are super beneficial. They’ve been around for centuries. Like if you think about it, if you go to France or if you go to… You have pastis, which is a very bitter drink, anise seed. It’s derived from anise seed.

Dr. Weitz:           It’s actually common in restaurants here a number of years ago to have them at the front.

Magdalena:        Oh, really?

Dr. Weitz:           Yeah.

Magdalena:        Huh. Okay. There you go. You go to North Italy, you have Campari, right? You go to Denmark, you have… I grew up in Denmark too, so they have those digestive called Gammel Dansk. Old Danish, it’s called. You have that before and after a meal, so it’s there for a reason. It’s not to get drunk or high. It is just to get those bitters in. They just happen to be extracted best in alcohol, so that’s why a lot of times in alcoholic form.

                                Another great way of really moving your liver is flax seed. I thought I’d mention that as well because I think it’s an interesting food because it’s naturally high in estrogens. So this is another source of a lot of controversy in our community, especially for people who first joined. We get this email saying, “You are crazy. You don’t know what you’re talking about. You are suggesting flax seed is estrogenic. I’m already very estrogenic. Why would I do that?” So I think again, it’s a plausible question. But I just refer back to what I was saying earlier is that how you break down those estrogens is the issue.  Here’s the beautiful about flax seed. I think hemp is the magical food, and I know you believe in nutrition and food as well and the biochemistry of it. So one of the beautiful things about flax seed is that, yes, it is a phytoestrogen. So actually, if you’re low on estrogen, like you’re having severe hot flashes, flax seed can actually really help you. But at the same time, guess what? The lignans, which is in the fiber of the flax seed, they block those receptors from those dirty estrogens from coming through. So again, so it’s like a dirty estrogen blocker. How amazing is that, right?

Dr. Weitz:            Yeah, well, actually, it’s common for these phytoestrogens… This has been a debate in years we’ve been having now in the functional medicine community. The food people often talk about is soy, which is high in these phytoestrogens. Do these phytoestrogens increase your risk of breast cancer? Are they, in a sense, estrogenic? It’s kind of similar to when you were talking about the estriol, estradiol. So I think, at least, my understanding so far of the literature is that these phytoestrogens for the most part are weaker estrogens, so they glom onto these estrogen receptor sites and they can potentially block the toxic estrogens like the estradiol or the toxic estrogens from pesticides, et cetera?

Magdalena:        Absolutely. You’re right about soy. You have research showing both sides. Again, it’s very nuanced. One of the things that studies do not show, do not state, and I’ve contacted a couple of them and I never heard back, is that what kind of soy were they using? I think that’s a very big difference if you’re using organic soy versus nonorganic GMO kind of soy on testing someone or giving them that over prolonged period of time. So that is never disclosed in any of the studies. I think it’s a lot more nuanced. I tend to stay away from soy just because of the variety of having both kind of results. All my meal plans and just generally diet is free of soy for that reason. But one more think-

Dr. Weitz:            I think another thing has to do with if you grow up eating soy as a regular part of your diet and if it’s part of the natural area where you live, it’s part of the natural diet there because there’s something to eating in accordance with where you’re from, I think the body handles it a lot differently than, say, maybe an American woman who has never eaten soy and all of a sudden, at age 50, she starts pounding down all the soy milk and her body’s really not used to dealing with it.

Magdalena:        Yeah, I think that’s a very plausible argument and a lot of people argue that. That’s based on your genetics, what you should be eating. Yeah. I think it’s a very interesting point. To build on top what you’re saying, it’s also most of the soy products in the United States are highly processed. So tofu’s highly processed. Soy milk is highly processed. So it’s not as natural as what you find, for example, living in China or Japan. Mind you, when they make, for example, soy tofu in China, they sell it from a big pot and it’s hot and you’ve got to eat it within a couple of hours because then it goes bad. So it gives you an idea, like how much preservatives they need to put in in order to preserve that soy, that tofu. Going back to flax seed, I just want to say one more thing.

Dr. Weitz:            Yeah, sorry.

Magdalena:        Because that’s one of my favorite foods to add. One of the also amazing things is it’s full of fiber. So you both have the soluble and insoluble fiber in flax seed. So insoluble fiber is superb for really helping your gut, but the insoluble fiber, there’s a roughage, if you will. It’s like a broom that sweeps through your colon and it really helps a lot with constipation. It specifically has an affinity towards removing estrogens from the colon. So it’s just a really wonderful food to add on when you’re supporting your liver, on top of all the things that-

Dr. Weitz:            So where do you get the flax seeds and how much per day for the average woman?

Magdalena:        Yeah, so don’t buy flax meal because that stuff is already pre-ground and it gets oxidized really quickly. If you notice, for example, in a supermarket, flax seed oil is always sold in a fridge. That’s because it gets oxidized really quickly in dark bottles. I’m not advocating oil. The lignans are found in the fibers, so you’ve got to have the actual flax seed. So buy it in full seeds. Whether it’s yellow or brown, it doesn’t really matter. So grind it yourself at home. Just use your, not a coffee grinder, but a dedicated coffee grinder so it doesn’t smell of coffee, and just grind it up for a few days and keep it in a fridge in an airtight container. Two tablespoons a day is what seems to produce really great results for women.

Dr. Weitz:            Great. So can you talk about some of the supplements like DIM and calcium-d-glucarate that promote detoxification of estrogens?

Magdalena:        Absolutely. I will mention, let me lead to this just by saying one thing that… One of the super foods for estrogen dominance, and there’s actually studies that were done using broccoli sprouts for women with breast cancer, for example, and the incredible work that sulforaphane does. Sulforaphane is super high in broccoli sprouts. It’s also high in all the cruciferous vegetables, so all your Brassicaceae family. So the cabbage family. So cabbage is kale, collared greens, all part of that. However, it depends on the variety, but it’s between a 20 to 100 times more sulforaphane is found in broccoli sprouts than in actual broccoli head. The problem-

Dr. Weitz:            So DIM also comes from those cruciferous vegetables too, right?

Magdalena:        It absolutely does. Yes. So if you are incorporating… That’s why I said earlier throw away the zucchini and the lettuce and bring in all those cruciferous because they really can help you. This is the way I’m talking about that long-term every day detox that you do instead of those severe detoxes that people do and then they go back to eating trash. So yeah. So the interesting thing was we were working with our formulator on producing sulforaphane because of its efficacy in helping with estrogen dominance. I’ll explain in a second where does that fit in the picture with DIM because it does have a very different role than DIM does.  So what happened was we realized, and we came across this study and then we realized that broccoli sprouts can have sulforaphane from negligible to all the way being super high. So it was very disappointing to see because I would just love to get all my sulforaphane from broccoli sprouts instead of having to rely on a supplement. But the thing was whether you bought it from Trader Joe or Whole Foods or you went to a farmer’s market, the content sulforaphane was all over the map. So there was no concentration that you were guaranteed on that. So I still think-

Dr. Weitz:            I just want to stop you right there. I think that’s a really important point. Of course, we want to eat as many of these natural foods, these cruciferous vegetables and these other health promoting fruits, vegetables, et cetera. Those were all super beneficial. However, if you want to know that you’re getting a concentrated therapeutic dosage of some of these nutrients, the only way you can know for sure is to add some nutritional supplements to your overall health regimen. Does that mean you can have a terrible diet and just take a few supplements? No. But, on the other hand, if you think you’re getting a specific amount because, say, you look in some book and it says that a carrot on the average has so many milligrams of beta-Carotene, that’s an average. If you looked at 20 different carrots, some have way less, some have way more. So if you really want to be accurate and scientific and make sure you’re getting a minimal necessary amount to have a therapeutic effect, this is one of the reasons why supplementation on top of healthy diet is really the only way to do it.

Magdalena:        Yeah, thank you for mentioning that. One of the things I have in my book is this pyramid that shows food at the bottom. It’s food is first and always. Then herbs the second. Then third is supplements because it really is there to supplement our diet. Unfortunately, it has become unnecessary these days. So back to sulforaphane. I still want to encourage everybody to eat their broccoli sprouts. Whether that’s through your salads, your soups, and such. But if you want it standardized, let’s say, 7%, 8% of sulforaphane in the supplement, you do have to rely most likely on a supplement.  So you mentioned calcium-d-glucarate, sulforaphane, and DIM. So I just want to contextualize it a little bit because one of the things I think DIM manufacturers have done a great job in terms of marketing is to develop the perception that DIM is the estrogen buster. So it’s like take DIM and all your estrogen dominance symptoms go away. It can initially. Most of the women will feel like it either works initially and then it stops, works initially and then makes them sicker, or just makes them sicker right upfront. So the question is why?

                                The interesting thing is that your liver has got two parts of the detoxification process, phase one and phase two. What DIM does is upregulates your phase one liver detoxification, which is actually quite dangerous because you are just upregulated that part of the liver that’s actually just released a lot of the toxins. Phase two of detoxification is going to be now coupling them up, marrying them, with different compounds, whether it’s sulfur, whether it’s methyl groups, et cetera. So DIM upregulates that. If you don’t have something to support your phase two liver detoxification in the form of foods and supplements, that’s the reason why women start feeling so bad and their symptoms actually get worse with estrogen dominance.

                                So the way to provide a full estrogen detoxification protocol, this is the way you can start looking into sulforaphane and calcium-d-glucarate. Sulforaphane, both of them work on phase two liver detoxification. Some practitioners, I also know, who like to also work with things like NAC, Resveratrol. All play a very big role in a phase two liver detoxification. So I think you can play around with all these supplements. I personally love using… I’ve had the best results with sulforaphane and calcium-d-glucarate just because they work on different pathways. Sulforaphane tends to work a little bit more on the sulphation pathway. That’s one of the pathways that is used to neutralize estrogen and get rid of it. Then the second one is the glucuronidation pathway where calcium-d-glucarate plays a role.

Dr. Weitz:           Cool.

Magdalena:        Yeah.

Dr. Weitz:           We were talking about progesterone. Do you ever use chasteberry or Vitex to stimulate progesterone production?

Magdalena:        I love your questions, I will say.

Dr. Weitz:           Thank you.

Magdalena:        It’s so great that you’re asking that question because in Germany where, by the way, herbal medicine is covered by the insurance and so is homeopathy, which is… I hope the United States comes to that point one day.

Dr. Weitz:           Let’s hope not. Because that means you’ll get three cents reimbursed and [crosstalk 00:42:05]-

Magdalena:        Right. Well, I was talking more from a patient’s perspective. But I hear you, yeah.

Dr. Weitz:           Yeah. Let’s just [crosstalk 00:42:12] and homeopathy, like they have in Australia.

Magdalena:        Right. So the interesting thing is when you have a woman who walks into, say, a OB-GYN in Germany and says, “I can’t get pregnant,” or, “My periods are super irregular,” or, “I’m having lumpy breasts,” so whatever and it’s a clear progesterone deficiency, the first thing that a German doctor will prescribe is guess what? Vitex. So absolutely, Vitex is phenomenal at just helping boost progesterone. So that’s definitely one of my absolutely favorite herbs. Coupling that up with a couple of vitamins and minerals. So zinc, vitamin E and vitamin C can be just also, just give a really beautiful boost to the corpus luteum to produce its own native progesterone. So I like combining them together and I find that just works really well.   Just a little thing just to share with you. Because of COVID, I upped my vitamin C levels. So I’m 48, so I’m certainly headed for perimenopause. My luteal phase, so from ovulation to period, now it’s suddenly become five days instead of being two weeks. So classical symptoms. I’m slowly getting into it. Nothing dramatic, nothing crazy. It’s just there. It’s coming. So when I upped my vitamin C levels because of COVID, guess what? My luteal phase just suddenly became two weeks again. I’m like, “Ooh, do I really want this?” I actually, “Go away.”

Dr. Weitz:            Interesting. I wanted to go back to the seed thing because you mentioned flax seeds and pumpkin seeds as both helping with estrogen and, what was it? Sesame seeds and-

Magdalena:        Sunflower.

Dr. Weitz:            … and sunflower seeds as helping with progesterone. Can you talk about that for a minute?

Magdalena:        Yeah. Seed rotation is something that I discovered many years ago. I had a very difficult patient. This was back in the day when I was in private practice. I had a very difficult patient and her hormones were all over the place. Super estrogenic. I remember doing a consult with the lab where we got the results from and there was a naturopath who was consulting me on this case. She said, “Have you tried seed rotation?” I was like, “No.” So she explained it, which I’ll tell you in a second, and I’m thinking to myself, “How?”

                                This woman, her hormones were all over the place. I’m thinking, “How are these little seeds going to help this poor woman?” But she was game. She was down. She didn’t want to take supplements. That was one of those challenges. But she was willing to do the seed rotation. So the results were amazing. One of the things that really changed for her was that her fibroids shrank. So this woman had these huge fibroids, very heavy periods, severe anemia because of all of that. So her fibroids shrank just significantly within two months. So that was my aha moment to seed rotation.

                                So seed rotation can be used for both women who are still cycling as well as women who are perimenopausal and menopausal. We view our cycling… You’re basically studying the first part, which is you want to boost your estrogen levels as you said, and you can do that by using flax seed and pumpkin seeds. You do that for two weeks and it’s basically one tablespoon of each, freshly ground. Then you switch over around your ovulation. So if your cycle is, let’s say 28 days, then after 14 days, you switch over to the second combo, which is now going to be helping more with… So it’s vitamin A and vitamin E rich, so you’re switching to sesame seeds and sunflower seeds. Then again, you’re doing one tablespoon ground each until you get your period. Look, it’s not a magic bullet. Some women try it and swear by it, including women who have hot flashes.

                                So if you’re menopausal, your period has stopped, basically you can pick two weeks anytime you want. You can do it with the moon, so doing the seed rotation with the moon. Meaning when it’s full moon, it’s like as if you were having ovulation. So that’s when you start your progesterone boosting seeds, your sesames and sunflower seeds, and do that for two weeks. Some women report amazing results. But I feel like with everything else, is homeopathy a answer to everything? No. Is nutrition alone the answer to everything? No. Is chiropractic care, like getting adjusted, an answer to every single pain in your body? No. So I feel like it’s just one tool in a toolbox that we have.  Look, let’s be honest. If somebody’s super inflamed, you’re still eating gluten, you’re living on coffee your whole day, you don’t sleep properly, you’re having three glasses of wine at night, but you do seed rotation and you expect to have great results, well, I’m so sorry to say ain’t going to work, right?

Dr. Weitz:            Yeah, you-

Magdalena:        So combine it with anti-inflammatory diet. Make it a Point to go back to sleep. Do all the things that helps you sleep better, et cetera, et cetera. Incorporate magnesium. I’m a fanatic for magnesium and women’s hormones. What a change it can make. Your breast health, your PMSs, your sleep quality. Then adding seed rotation, I think, can generate some really nice results.

Dr. Weitz:            Right, you mentioned alcohol and I saw in your book, you’re pretty outspoken that the evening glass of wine is not a good thing for women for breast cancer risk.

Magdalena:        Absolutely. I mean, there is hard, solid studies that show connection between women who drink more than three glasses of alcohol a week and a connection to breast cancer. But I think there’s more to it. I mean, do we have to look at drastic things like breast cancer? Just look at the quality of your life. One thing I will say is that I have a big chapter on sleep as well. One of the things I do wear, and I took it off right now because it’s charging, but I use the Oura Ring. With the Oura Ring, I’ve been experimenting a lot on my own sleep because my sleep has been… Now I’m 48. I certainly feel like my sleep is not as deep and I don’t get it as easily as I did in my 20s. You can have like five tequilas at night, go and party, look a screen all day long, and go to sleep and wake up, and you’re resting and ready to conquer the world. Ain’t going to happen now, right? So when I use my Oura Ring, it just shows me… And I’ve been experimenting a lot.

                                So I would encourage everyone to… Everyone has got a little different tolerance since we’re talking about alcohol. Let me say, if I have… That’s probably also, I think, I also have a problem with histamine a little bit, so I don’t degrade histamine as quickly as probably… Also, it’s partly genetic. Partly, it’s probably just because stress and things like that. But alcohol is a source of histamine as well, which can mess up your sleep. So that glass of alcohol could just mean that from sleeping deeply and beautifully and not waking up in the middle of the night, now you were just waking up at 1:00 and you can’t sleep until 3:00, and then you wake up and you’re not rested. I mean, it can make a huge difference in that way. So for that reason, I am very cautious of alcohol. Same as with caffeine too. I’m a bit of a caffeine Nazi too.

Dr. Weitz:            Oh, okay.

Magdalena:        Coffee, rather. Not caffeine overall, but coffee.

Dr. Weitz:            Okay. So let’s talk about hormones, all right? Hormone replacement therapy.

Magdalena:        Yeah. I will say that’s not really my primary jam because as a herbalist and as a nutrition person and a chef, I’m just like, “Hey, here’s a great recipe. Here are some beautiful herbs you can incorporate.” But the way I look at it is if you decide to go the hormone path, make sure it’s bioidentical hormones that you’re working with. You don’t want to be working with your OB-GYN and taking progestins in any way or form.

                                I’m interesting to hear your perspective on this, but again, because I’m not in private practice anymore and I’m not licensed to prescribe hormones to women, but one of the things that I think is a something to be cautious is a lot of women are told that bioidentical estrogen, for example, is super safe. I have come across a few women who really bought into this belief, but they never did any regular testing, like with DUTCH for example, to see how they could breaking down those estrogens. A number of them have developed breast cancer. So have the developed breast cancer because they were taking that bioidentical estrogen? I don’t think so. I think the problem was that their liver just wasn’t breaking it down properly. They were not eliminating these estrogens properly. But I’m curious to know what you think.

Dr. Weitz:            Well, obviously there’s lots of controversies and as a chiropractor, we don’t prescribe hormones either. But it does look like bioidentical hormones are quite a bit safer. Theoretically, there is every reason to think they should be safe because if they’re basically virtually identical to your natural hormones, why should your natural hormones cause cancer or heart disease? On the other hand, the long-term studies that were done, they show that synthetic hormones look like they increase the risk of breast cancer and heart disease in women who take them, especially starting 10 years after menopause. So that’s another whole factor with the Women’s Health Initiative, are problematic. We don’t really have the large long-term studies with bioidentical, but we have every reason to think that they are safer. But I would still say I don’t know if we really 100% know.  On the other hand, there are plenty of women who get breast cancer who never took hormones. So your point about how they metabolize their estrogen, how their body handles it, toxic estrogens from the environment, are probably more important factors. And-

Magdalena:        Yeah, I will say, if I come to a point in my own health journey that I feel like my estrogen is dropping so much so that through nutrition I can’t support it anymore, my cognitive function is declining, my bones aren’t as strong, et cetera, et cetera, and I decide to go that path, I will certainly every six months be doing DUTCH to see how I’m breaking down those estrogens because I think that’s really, really important as part of the equation for sure.

Dr. Weitz:            Yeah, yeah. One of my friends is Dr. Felice Gersh and she’s come on the podcast a number of times. She is such a huge advocate for estrogen. When she talks about all the benefits for cardiovascular and brain health and all these other things, I was ready to start taking some estradiol myself. One last thing, I just wanted to ask you about using topical progesterone versus oral progesterone. Bioidentical, of course. Most of the functional medicine practitioners who prescribe hormones in my circle feel that oral is the only way to go. That when you use the topical, you just don’t get the levels in the system that you really need.

Magdalena:        Yeah. So that’s an interesting debate. Again, I speak purely through the experience of my colleagues and through conferences, endocrine conferences, functional endocrine conferences, that we used to go to before ‘rona took over the world. So another way of looking at this is that the oral progesterone tends to work on the GABA receptors in the brain, so it’s got a really nice, calming effect and helps tremendously with sleep and anxiety. A lot of my colleagues maintain that if you don’t apply it topically, you don’t get the same benefits of what progesterone can give you beyond just feeling calm and sleep. Those benefits can go anywhere from opposing estrogen to helping you with HDL cholesterol, helping with cardiovascular health, helping with sex drive. It’s a much longer list of these two.   Again, I really wish I could show you studies that prove that. I don’t think there are any of those. But it’s just more of anecdotal. But I don’t want to dismiss anecdotal because if you have thousands of doctors who are in practice with hundreds of patients who come back and report that this is your oral versus this is a topical effect that I’m getting, then that’s something to be, I think, reckoned with.   So I personally, whenever I travel and I’m going through a stressful time, progesterone tends to… We burn through progesterone a lot more. We get depleted because cortisol steals progesterone. I mean, a lot of women relate to this when I say when you go through a really stressful time, suddenly your period becomes really terrible or you just can’t sleep. Progesterone can be due to that, due to the progesterone steal, if you will, that happens. So whenever I do experience that, I definitely do my topical and I do feel way, way better. So yeah.

Dr. Weitz:            Awesome. So this has been a great podcast, Magdalena. How can our viewers find out more information about you and access your programs and your book?

Magdalena:        So my book is called Overcoming Estrogen Dominance. It’s available on Amazon right now. Yeah. If estrogen is something that folks are struggling with or if somebody you know who’s struggling with the symptoms that we talked about here, there’s so many things you can do nutritionally through supplements. A lot of women are opposed to bioidentical hormones, so I just touch on them in the book. But really the meat of the book is herb supplements and nutrition. Yeah.

Dr. Weitz:            Great. Then your website is what?

Magdalena:        My website is hormonesbalance, hormones with an S, hormonesbalance.com.

Dr. Weitz:            Excellent. Thank you so much.

Magdalena:        Thank you so much for having me.



Manage Stress with the Apollo Wearable with Dr. David Rabin: Rational Wellness Podcast 195

Dr. David Rabin speaks about How to Manage Stress using the Apollo wearable 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. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

3:27  The Apollo is a wearable device that was first conceived of while Dr. Rabin was studying psychiatry at the University of Pittsburgh and he was inspired by the ancient practices of meditation and breathing that change the way we handle stress. So many people today have stress related chronic problems, including anxiety, depression, PTSD, insomnia, and many others. When we are experiencing real or perceived threat, our nervous systems will be in our fight or flight, sympathetic mode much of the time, instead of being in the rest and digest and recovery response, parasympathetic mode of our nervous system. This also translates into low heart rate variability, negative effects on our digestive system, reduced ability to absorb nutrients, negative effects on our reproductive system, our creativity, and our sleep.  This also translates into various physical ailments as well, including chronic pain.  Safety makes our heart rate variability go up, which is a good thing. Safety and the perception of safety turns on our immune system, our metabolism, our digestive system, our ability to absorb nutrients, our reproductive system, our creativity, and our sleeping system. All of this good stuff that makes our lives really lovely.  But this can’t happen if we under real or perceived threat and in modern life many of us feel that stress much of the day, which means that we are in flight or fight sympathetic mode much of the time, instead of being in parasympthetic mode most of the time.

7:48  All mammals, including humans have developed this system where as soon as there’s a perceived survival threat of something coming to eat us or kill us or the lack of shelter, food, water, or air, our survival system kicks in, as you said, to divert all available resource to our muscles, to our heart, to our lungs, and to the motor cortex of our brain to fight, flight, or freeze, get out of that situation to safety.  If we are accidentally diverting resources to our reproductive system at a time or digestion when we’re supposed to be running from a bear or a lion, we will not likely make it out of that situation. So that system is tightly evolved to save us.  But we no longer have bears and lions around, but that sympathetic nervous system gets turned on by too many emails or cell phone notifications or our work responsibilities, etc.  Gentle touch applied to our skin can help to create balance by sending a signal to our amygdala, which is the fear center in our brain, that we are safe.  If you are safe enough to take the time to feel like you could pay attention to the feeling of gentle touch on your body, you can’t possibly be running from a lion right now.  This happens on a subconscious level. 

11:32  Dr. Rabin chose touch as the type of stimuli because touch can stimulate the release of a number of hormones, from our brain, including dopamine, serotonin, oxytocin, endorphins, natural endogenous opioids.  The other thing about touch is that you can be touched while you’re doing other things, including performing surgery, giving a talk, seeing a patient, running a meeting, driving, etc..  You can be touched gently, and it’s not distracting, and it can improve your performance and your presentness and focus.

13:54  Different vibrations have different effects on the body.  Different types of music, different rhythms, tempos, and styles have different effects on our body. The Apollo is based on how music affects us in waking us up, stimulating us, relaxing us, or making us fall asleep. The frequency patterns of touch in the Apollo is based on what music makes us feel good and these patterns are predictable for 90 to 95% of people.

22:00  The Apollo can help manage stress and reduce anxiety and depression.  A significant percentage of people with depression, anxiety, and PTSD do not respond that well to treatment, so it’s great to have another alternative approach to helping patients. 50% of patients with PTSD and 30% of patients with depression do not respond well to treatment.  And this is a very safe, natural approach that does not involve invasive procedures or pharmaceutical drugs.  A number of people who have been using the Apollo have reported that they voluntarily were able to taper off their medications, including opioid narcotics, benzodiazepines, and methamphetamine.

27:50  Heart Rate Variability.  Heart rate variability (HRV) is a marker for anti-aging, for various diseases, and for athletic performance. We want to have a high heart rate variability, which means that when stress occurs, our heart rate jumps up quickly to respond to the situation.  This means we will more likely recover from our workout or from illness.  If we have a consistently lower HRV, we are more likely to develop mental and physical health problems, our immune system isn’t going to work as well, and we will probably not sleep as well on a regular basis and not feel as good on a regular basis.  If we, on the other hand, use techniques like deep breathing, getting at least 30 minutes of exercise most days of the week, eating healthy, doing meditation, yoga, mindfulness, or soothing touch, listen to soothing music, and getting good sleep, then we can reverse that process and train our nervous system to be more in balance more of the time, which is reflected as high heart rate variability and more likelihood of recovering from illness, better likelihood of performing consistently at a high level and a better likelihood of just feeling good more of the time.  While the most accurate way to measure heart rate variability is with an EKG, outside of a clinical setting, the Apple Watch, the Oura Ring, and the WHOOP do a decent job of measuring HRV.





Dr. David Rabin is a board-certified psychiatrist and neuroscientist, is the co-founder & chief innovation officer at Apollo Neuroscience, the first scientifically-validated wearable system to improve heart rate variability, focus, relaxation, and access to meditative states by delivering gentle layered vibrations to the skin. Here is more information about the Apollo wearable: https://apollo-neuro-fact-sheet.carrd.co/  The following affiliate link will give you a 10% discount if you would like to order one:  Get 10% off Apollo, the wearable wellness device for stress relief | Apollo Neuroscience, Inc

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.


Podcast Transcript

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

Today we will be speaking about stress, the science of the part of our nervous system that regulates stress and about a new wearable device, the Apollo that uses gentle vibrations to help us to activate our parasympathetic nervous system known as our rest and digest nervous system so we can have a better balance with our sympathetic flight or fight nervous system.  In today’s fast-paced world made even more stressed by worrying about getting COVID-19 and dying, many people are in sympathetic mode too much of the time. This can lead to a number of symptoms and health problems. In fact, it’s a very long list, but it can include anxiety, depression, insomnia, hypertension, adrenal dysfunction, other hormonal imbalances, and a weakened immune system. Given that we’re still dealing with COVID-19, having a weakened immune system is not exactly a good thing right now.

                                The Apollo wearable device, which is the wearable device that we’re speaking about also improves heart rate variability, which also translates to better athletic performance. Today we’ll be speaking with the inventor of the Apollo, Dr. David Rabin, MD, PhD, a board-certified psychiatrist, a neuroscientist. He’s the co-founder and chief innovation officer at Apollo Neuroscience, which is the first scientifically validated wearable system to improve heart rate variability, focus, relaxation, and access to meditative states by delivering gentle, layered vibrations to the skin.  In addition to his clinical psychiatry practice, Dr. Rabin is the co-founder and executive director of the Board of Medicine and a psychedelic clinical researcher currently evaluating the mechanism of psychedelic assisted psychotherapy in treatment-resistant mental illness. Dr. Rabin, thank you so much for joining us today.

Dr. Rabin:            Thank you so much for having me. It’s a pleasure.

Dr. Weitz:            So tell us how you developed the Apollo wearable device and about some of the research that went into it.

Dr. Rabin:            Sure. Happy to. So Apollo was a technology that originally wasn’t called Apollo, was just an idea starting in 2014 at the University of Pittsburgh-

Dr. Weitz:            Was there an original name?

Dr. Rabin:            There were a couple names actually. So the first name was Emoto, which was named after the famous Japanese scientist, who discovered that water can store vibrations and frequency patterns.

Dr. Weitz:            Interesting.

Dr. Rabin:            So the idea that applying a vibration pattern to water creates what’s called structured water, which actually changes the way that the water molecules interact with each other, and that can be a visualized in what people call cymatics, which is like patterns of vibration in water or some kind of liquid. You could just google cymatics with a C, C-Y-M-A-T-I-C-S, and you’ll see a lot of this stuff. But there was a lot of inspiration that goes back thousands of years to the ancient practices of breathing and meditation that change the way that we interact with different parts of our bodies and how we become aware of our bodies that led to a lot of this work.  I think you kind of summed it up in the introduction with the balance of the stress response, sympathetic nervous system, and the parasympathetic rest and digest and recovery response nervous system, which we can get into in more detail. But the main gist of it is that people who have chronic stress-related illnesses, and I’m just going to talk about mental illnesses, for the time being, but this does apply to physical illnesses like chronic pain as well, and nerve pain and things of that nature. People who have these illnesses tend to have higher. The illnesses that you mentioned earlier, depression, PTSD, anxiety, insomnia, these kinds of illnesses get worse with stress almost all the time. Invariably, the symptoms get worse with stress.

                                So we can measure this by looking at heart rate variability, as you mentioned earlier, which is a measure. It’s one of our most accurate measures of the way that our heartbeat changes in response to stress in the environment or safety from the environment. Safety makes our heart rate variability go up. Safety makes us feel recovered and helps us feel like it’s safe enough for us to allow our recovery nervous system to turn on, which means recovery means turning on the immune system, turning on metabolism, turning on our digestive system, our ability to absorb nutrients effectively, our reproductive system, and our creativity system, and our sleeping system. All of this good stuff that makes our lives really lovely.

                                But we can’t be under threat, or we can’t perceive that we are under threat or believe that we are under threat for that system to turn on. So many of us who have experienced any kind of trauma or negative experiences, and this is the population that I worked with at the University of Pittsburgh that kind of spurred this idea, a lot of veterans and people who have treatment-resistant PTSD, and we saw that they all have low heart rate variability. This was actually seen in the literature for many other scientists and doctors who were looking at these folks and that they’re meaning low heart rate variability, meaning their stress response system is always up here, always on and very active, and their parasympathetic recovery nervous system is always underactive. They’re always perceiving themselves to be unsafe or in a survival threat situation and-

Dr. Weitz:            Just to interrupt for a second.

Dr. Rabin:            Yeah, sure.

Dr. Weitz:            That’s where the whole concept of the sympathetic and parasympathetic nervous system, it’s often explained by thinking about the zebra on the Savannah, and it sees a lion. So we’re designed for our sympathetic nervous system to put us in this state of stress and have all the blood go to the muscles, which means there’s no time to deal with digestion or all the other things that the parasympathetic nervous system is associated with, because right now, the zebra has to run for its life to avoid being eaten by the lion. Under normal circumstances, maybe that occurs once or twice during the day and the rest of the time, the zebra is calm, and-

Dr. Rabin:            Exactly.

Dr. Weitz:            … our body’s designed to go into this sympathetic nervous system, but only for short periods of time.

Dr. Rabin:            Right, and only-

Dr. Weitz:            In modern life, we-

Dr. Rabin:            Yeah. And only to get us out of danger in the moment.

Dr. Weitz:            Exactly. In modern life, we’re constantly feeling like we’re in this state of stress, real or perceived, that we constantly have to be in this revved up state.

Dr. Rabin:            Right. Part of the reason for that is evolutionary, right? We purposely evolve the system, which is not unique to us. All mammals, almost all animals on the known earth that have brains have this system in place, even going back to very ancient sea snails that only have like 12,000 neurons. Just give you an idea, we have like a hundred billion neurons. So all of these animals have the system where as soon as there’s a perceived survival threat, lack of something coming to eat us or kill us, lack of shelter, food, water, or air, our survival system kicks in, as you said, to divert all available resource to our muscles, to our heart, to our lungs, and to the motor cortex of our brain to fight, flight, or freeze, get out of that situation to safety. Right?   If we are accidentally diverting resources to our reproductive system at a time or digestion when we’re supposed to be running from a bear or a lion, we will not likely make it out of that situation. So that system is tightly evolved to save us. But we don’t have bears and lions around us most of the time anymore. So that system unfortunately starts to get turned on by other things, like too many emails or too many cell phone buzzes and pings or our kids screaming or work responsibilities or you name it, pandemic thoughts and the election and whatever else is going on in the world, right? Every little thing starts to trigger this system because we don’t have the context to say, “Oh wait, this isn’t a survival threat. This is just something that’s annoying me.” All right.

                                So that is critically important to understand, because what is important, because that helps us to know that we are in control of the outcome. So if we recognized that our emails are not actually a survival threat, even just for a moment or our kids or our work responsibilities, whatever it is, is not actually a survival threat that’s triggering us, and we can recognize that by taking a deep breath, taking a walk, pressing on our chest, doing some basic self-touch exercises, doing a brief meditation. This is not necessarily easy. It can be tricky to do in the moment.  But all of these activities naturally bring us very quickly back into balance because they send a signal to our brains, our amygdala, which is that fear center in our brains that governs the balance of this stress response and recovery response system that says, “Hey, bud. If you’re safe enough to take the time to feel like you could pay attention to your breathing right now or pay attention to the feeling of a gentle touch on your body or the feeling of Apollo vibrating on your body, you can’t possibly be running from a lion right now.” Right?

Dr. Weitz:            Right.

Dr. Rabin:            That’s mostly subconscious. It’s beneath our awareness, and that creates an instant loop. That’s a positive loop that says, “I am safe enough to be able to think about myself right now. I’m safe enough to feel my breath right now. I can’t be in a survival situation.” That gradually brings the amygdala activity down, and that helps us to cope with stress more effectively. So Apollo, we designed at the university to tap into this network and activate the safety response system to help people who are struggling with treatment-resistant mental illnesses recover and be able to have more of their cognitive resources available at any time when they would normally feel unsafe by helping them remember that, “Hey, you’re actually safe.”   If you can feel Apollo right now, you’re safe enough to take your time to make a good decision rather than a decision that’s impulsive and based on a past pattern that isn’t serving you.

Dr. Weitz:            So the various types of stimuli, why did you choose touch?

Dr. Rabin:            So we chose touch because, number one, touch is the most evolutionarily tight pathway that connects to safety. So if you look back at ancient animals, like we were talking about, we don’t even have to go back into sea snails, but we can go into old mammals, right, like monkeys, and earlier than monkeys, all of these mammals, which are millions of years older evolutionarily than we are, they all use touch to convey safety to each other. A mother holds their young, right? That comforting of touch in and of itself allows the body to reregulate itself through the secretion of natural hormones that many of us, unfortunately, self-medicate to get those hormones released, but they actually could be secreted by our brains naturally, and those hormones are the best ones that come from touch.  They’re dopamine, serotonin, oxytocin, endorphins, natural endogenous opioids from our own brain that makes opioids that are natural that reduce pain, and even endocannabinoids that reduce inflammation and help balance our nervous system through the endocannabinoid receptors in our body. There’s others too, but those pathways get activated by touch. They get activated by touch, not just in us and all of these other animals, and then those pathways help to reduce inflammation in the body very, very quickly and help to remind us very quickly that we’re safe.   The best part about touch is you can be touched while you’re doing other things, right? So if you’re performing surgery, giving a talk, seeing a patient, running a meeting, whatever it is, driving, you can be touched gently, and it’s not distracting, and it can improve your performance and your presentness and focus.  Music is harder to do that with.  Music’s great, but it’s harder to take with you everywhere you go. So based on convenience and the evolutionary psychology and the biology, that is how we ended up settling on touch.

Dr. Weitz:            Interesting. How do certain vibrations and the Apollo wearable device work to create this balance? Explain why certain vibrations have a different effect.

Dr. Rabin:            Sure. So I think this is one of the most interesting things about neuroscience in the body, because we’re actually experiencing this phenomenon that you described in every day of our lives. When we turn on a song in our house, right, or in our headphones or wherever we are, that song has a certain tempo, a certain rhythm, a certain energy level to it, and we don’t listen to the same kind of music when we’re working out or dancing or hanging out with our friends that we listen to when we’re meditating or relaxing or going to bed. Right?   We would almost never switch those musical types, because they are very different energy levels and different mood states. So that pathway of frequency rhythm, that impacting our energy level and our mood is well described and characterized in music for thousands of years. It’s not new by any stretch. Actually, our whole founding research team all had musical backgrounds. We all either played instruments growing up or still played instruments or were just heavily influenced and lovers of music, and we were always fascinated by the way that music affects our bodies.  So when I started doing this work in 2014, a lot of my strategy was, what can I take from our understanding of the neuroscience of music, the understanding of the neuroscience of touch and use what we know to compose songs for the skin instead of the ears. Right?

Dr. Weitz:            Right.

Dr. Rabin:            That’s really what Apollo is. Apollo is music that is composed for our touch receptors on our skin instead of our ears that you can wear with you and take with you at any time. So the frequency patterns are in large part derived from what music makes us feel good, what music rhythms make us feel good, and also what breathing rhythms make us feel good, and we kind of mash the two together based on the scientific literature that had been done before us, and we ended up coming to these really incredibly powerful patterns that are not just powerful. They’re predictable for 90% to 95% of people where we can send this to you, and as long as your goal is aligned with the energy of the frequency vibration, you’re very likely to get the outcome that you desire, which is really interesting, which is very similar to what happens with music.

Dr. Weitz:            Interesting. I think you just answered my next question, which is going to be, do all people respond in the same way to the same types of vibrations? Is there a range of response?

Dr. Rabin:            Yeah, there is a range. Not everyone is the same. The reason for that is because we have different associations with the stimuli, right? We have different associations with vibration, just like not everybody likes the same kind of music, not everybody’s going to like the same kind of vibration. So we did a lot of testing before we put this out onto the market. Apollo was released in January of 2020. We had been working on it in the lab for about five to six years before that, and then we had done I think three clinical trials and about 2000 case studies in the real world with prototypes before we released the commercial device to figure out how to get the best results.   We tried to remove as much of the subjective experience as possible in terms of, from music where somebody could say, “Oh, I like the song. I don’t like the song.” We didn’t want that. Right?

Dr. Weitz:            Right.

Dr. Rabin:            It shouldn’t be personal. It should just be the bare minimum that activates the nervous system in a soothing way. So after a lot of refinement and an enormous amount of experimentation in the lab and the real world, we figured out that there are specific rhythms that work in, as I said earlier, roughly 90% to 95% of people based on a goal-directed behavior. So you say, “I want to wake up.” If I want to wake up, you set up the wake-up frequency, 90%, 95% of people will wake up. Same for clear and focus, same for socializing and creativity, same for recovering after exercise.  But if you say, I want to wake up and you put it on a sleepy mode, it probably won’t wake you up. Right. It’s going to do the opposite. So the whole goal is to align your outcome with what your action is and for anything we do. So the way that we’ve designed the app sort of helps with that alignment. It’s going to get better over time, and that helps increase the outcomes, because people are goal directed in their behavior.  There are about 5% to 10% of people who interestingly we call paradoxical responders, and there’s a lot of reasons why people respond differently. But again, this is a wellness product that is not… No product works 100% of the time for everyone. Right?

Dr. Weitz:            Right.

Dr. Rabin:            So what we always tell people is if you’re one of those people who this doesn’t work the way you expected, play around with the different modes, because sometimes the modes that energize you might actually be the modes that calm other people down, and the modes that calm you down might be the modes that energize other people.

Dr. Weitz:            Yeah. I have patients, the same thing. They’ll say that any drug or nutritional product that is designed to stimulate me makes me tired and the opposite.

Dr. Rabin:            That’s exactly right. A lot of that has to do with, I think, two things, one of which is just our body’s makeup, that we’re mostly the same, but we’re a little bit different between each of us. I think the other part of it is just our past experience and the association we have with that feeling. So for example, if you have a negative association with touch and that you’ve never been touched in a loving way, or it was always associated with pain or discomfort, then it may take a little longer for you to get comfortable using the Apollo if you associate it with touch in that way.   Again, that’s a cognitive association that’s associated with trauma. So that’s just one example, but there are lots of other situations that are fairly uncommon, but people do have these kinds of experiences where there’s a little bit of variability. In the future, looking into 2021, 2022, we’re really excited to increase customization of the Apollo. So the software will grow and learn about each user to deliver a more personalized experience for each person starting with timing and then gradually customizing the patterns as well.



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

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

                                                Now, back to our discussion.



Dr. Weitz:            How can Apollo improve anxiety and stress and depression, and can it be an alternative for people who maybe don’t do well on antidepressants or want to get off them, and they’re phenomenally difficult to get off of?

Dr. Rabin:            Right. Yeah. So that’s a great question. That was actually the focus of when we first developed Apollo. The whole goal was, how do we help these people who have treatment-resistant depression, treatment-resistant PTSD, anxiety disorders, substance use disorders, people who have tried everything under the sun nearly and never had good results and outcomes. How do we help those people feel better?  The reason why we focused on that group, because in PTSD populations, that’s like 50% of the population, maybe more. In populations of depression, that’s 30% or more of people. These are two of the most common mental illnesses worldwide. So it’s a real problem. It’s-

Dr. Weitz:            Anxiety is really growing, especially among younger people.

Dr. Rabin:            Right. So it’s a real problem if 30% to 50% of people are not getting better with what is considered to be the gold standard of treatment or several gold standards of treatment. So when we originally developed a technology, this population was a huge focus for us, and veterans were a big part of that and still are. So we have found that these people in our preliminary findings from people just telling us about their experiences in the real world, but also from our early clinical trials actually respond really, really well to the Apollo. It’s hard to say exactly why, but we do know that certain stress response, stress recovery techniques actually work better when people are more stressed out.   When the body is more activated on the stress response side, there’s a bigger shift and for longer. There’s a bigger shift noticeable when people experience an intervention that makes them feel safe because all of a sudden, they’re like, “Oh, wow. I haven’t felt this feeling in a really long time.” So that in and of itself is therapeutic because it helps them recognize that, “Hey, I didn’t really have to do that much to achieve this, but it didn’t require a medicine. It didn’t require a pill, and I can just press these buttons and activate the state as often as I need to and kind of deep breathing it over time actually trains the body or trains us to remember and learn how to enter these states more effectively without the device.”

                                So oftentimes people who use it start using it a lot from the beginning. They use it every day for a month or three months, and then after several months of using it, they actually start to decrease their usage naturally because they’re getting more benefit with less frequent use, and they start to use it more intentionally for specific goals. But yes. So the goal was to develop the technology down the medical path, which we are going in addition to the consumer path to help these people with these illnesses. From the report so far, which again, are not published yet. They’re still in progress, but from the report so far, we are seeing really incredible results for these illnesses, and it’s incredible.  Again, I will say as a caveat, this is not yet a FDA approved or clear treatment tool. It is a consumer wellness product, and we are working down that path. But right now, it’s a consumer wellness product, and we’re not making any treatment claims about it. But it does help with- It does help a lot.

Dr. Weitz:            Yeah. It’d be great if you included in that if you could do study with people who are on SSRI and similar medications

Dr. Rabin:            Oh, I forgot to mention that.

Dr. Weitz:            … who are trying to get off those medications and use this as part of the program of weaning them off those medications as well as maybe other lifestyle factors.

Dr. Rabin:            Yeah, that’s a great point. I forgot to mention that. So that is one of the most interesting things that we found is we do see that people who use Apollo are voluntarily able to taper off of some of these medicines, everything from… SSRIs, we haven’t done a study yet with those, but-

Dr. Weitz:            Those are really, really hard to get off of.

Dr. Rabin:            They are really hard to get off of. But the medicines that we’ve been seeing people come off of are, I would say, harder to get off of, they’re opioid narcotics, benzodiazepines, and methamphetamine. So I would say they’re in the same category of tough to taper. We’ve seen people who have chronic illnesses who are using Apollo, people in the real world, They’re just writing us, and people from our trials are writing us and telling us that they are using Apollo, and they’re finding that they don’t need their Xanax anymore. They don’t need their benzodiazepines for sleep. You’re able to use less or none of their pain medicine. We just had a person write in today that on our reviews, they decrease their pain medicine dosing from every day to once a week within a month of use. I mean, yeah.

Dr. Weitz:            That’s amazing.

Dr. Rabin:            So this is why this is so exciting, because it starts to show us how much of our suffering might actually be caused by our stress and how we address stress and how we approach it, which is completely 150% within our control most of the time.

Dr. Weitz:            Absolutely. I treat a lot of patients with the functional medicine approach for gut health challenges, like IBS, reflux, and I could see where this device could be really helpful. Have you tested for digestive disorders?

Dr. Rabin:            We have not tested it for that yet. We have a lot of interest from folks in the microbiome community. So we will be looking at that, but we don’t have any of those studies ongoing currently.

Dr. Weitz:            Yeah. Cool. So you mentioned heart rate variability. Maybe you can explain more about exactly what this is and how heart rate variability can be improved with the Apollo and then also how heart rate variability is associated both with various types of diseases. I was looking at some of the data. It’s associated with increased risk of coronary heart disease, risk of death from heart disease, and it’s also associated with improved athletic performance. It seems to me HRV should really be a good anti-aging marker as well.

Dr. Rabin:            Yeah. I mean, I think that’s really where this is going, because we haven’t for many years, I mean, forever. We haven’t had good biomarkers in science for tracking the effects of aging or stress and how quickly we are aging. HRV, heart rate variability is a really interesting biomarker because what it is is it’s a measurement of the rate of change, how quickly our heart rate goes up or down with the environment. So as you were saying, if we have a low heart rate variability, meaning our heart rate takes longer to go up in response to stress and longer to come down when the stress is gone and we’re in a safe environment, then we are more likely to perform inconsistently. We are more likely to be injured in intense performance, to demanding performance, especially in the elite athletics literature, more likely to become sick and more likely to have to suffer from a metabolic disorder, heart disease and to die if we get sick. Right?   So what this is saying… The complete contrary is true. If we have high heart rate variability, which means that when stress comes, our heart rate jumps up really quick to adapt to the situation, and then when stress has gone, our heart rate comes down very quickly to adapt to the situation of safety and enter a recovery mode. So what this is really saying is that if we’re in a chronically stressed state more of the time, then we can measure this as low heart rate variability. That is a biomarker that shows that if we stay in that situation without doing anything about it, we are more likely to develop mental and physical health problems, and our immune system isn’t going to work as well, and we’re going to probably not sleep as well on a regular basis and not feel as good on a regular basis.

                                If we, on the other hand, train ourselves using the techniques like deep breathing, getting at least 30 minutes of exercise most days of the week, eating healthy, doing meditation practices, yoga, mindfulness, or soothing touch, listen to soothing music, and getting good sleep, and all of these kinds of things are a combination of some of these things, then we can reverse that process and train our nervous system to be more in balance more of the time, which is reflected as high heart rate variability and more likelihood of recovering from illness, better likelihood of performing consistently at a high level and a better likelihood of just feeling good more of the time.

Dr. Weitz:            What’s the preferred way to measure heart rate variability. What do you use?

Dr. Rabin:            So that’s a tough question, because the preferred way as a scientist or a doctor is an EKG machine, and you have to do… Traditionally, to measure heart rate variability accurately, you actually have to do an EKG of a person at rest for three minutes, and that is not easy to do outside of a laboratory or outside of a clinical setting. So now there’s wearables that can measure heart rate variability, because a lot of companies have realized, “Hey, this is really cool, and we’re already tracking heart rate. So why don’t we just try to measure HRV from the heart rate data that’s coming in.” Because it’s just taking a fancy… It’s just taking the heart rate data and doing a fancy mathematical calculation.

Dr. Weitz:            Are there devices that do a better job of this?

Dr. Rabin:            Yeah. So the Apple Watch is fairly decent and the Oura Ring. This guy is fairly decent. I would say those are two of the best. However, the caveat is that the quality of the measurement has a lot to do with when you’re taking the measurement. Right? So if you’re taking the measurement when you’re moving in any respect or you’re in a an environment that has lots of noise or physical, electrical noise, sound noise, lots of ambient vibration, like you’re in a car or a plane or something like that, you will get consistently inaccurate unreliable results from these measurements. Even with an EKG, you would get unreliable results in a noisy environment.  So it’s really critical for people to understand that the wearables they use at home to track their biometrics, like HRV are notoriously unreliable, and they have to be looked at in an over time kind of fashion, not in a short-term fashion. The short-term data is sometimes useful, but most of the time it’s not, and it’s hard to tell when it is and when it’s not. So the trends over time are way more interesting, and what we want to aim for is trending our resting heart rate, coming down, our HRV, heart rate variability going up, and our deep sleep and REM sleep going up, and our total sleep efficiency going up, which is a… These are all the common measures these devices use.

Dr. Weitz:            So right now, there’s no really good device for just regular every day clinical usage if you’re not going to be doing an EKG for three minutes.

Dr. Rabin:            There’s no great devices for HRV specifically for the average person to use at home right now. For heart rate, there is good stuff, like the ones I mentioned. WHOOP is also good, and resting heart rate is a pretty good measure that could be very useful. We’re getting there on the HRV front. Devices are getting better. The technology is rapidly getting better, getting smaller, getting more precise. But I think we’re just at a point where we’re not quite there yet. Even if you are using these other wearables, you really have to be in a quiet setting to get accurate measures that you trend over time. But we will get there eventually.

Dr. Weitz:            Right. What about arrhythmia. I, not long ago, interviewed Dr. Aseem Desai who has a book about arrhythmia, and he talked a lot about training, emphasized the parasympathetic state and how nervous system stress plays a big role in arrhythmia. That’s a really common problem for people these days. (See episode 181: https://www.drweitz.com/2020/11/atrial-fibrillation-with-dr-aseem-desai-rational-wellness-podcast-181/)

Dr. Rabin:            It is.

Dr. Weitz:            I could see where this would be beneficial.

Dr. Rabin:            Yeah. We don’t have any studies on arrhythmia yet, but we do have a number of people, and I work with a cardiologist in Pittsburgh, an interventional cardiologist who’s a really wonderful help to us.

Dr. Weitz:            Is that Joseph Maroon?

Dr. Rabin:            No, Dr. Brian Donahue. Joseph Maroon is a neurosurgeon who we also work with.

Dr. Weitz:            Oh, okay.

Dr. Rabin:            But we all work together, and it’s been really interesting to see how many people have used Apollo for atrial fibrillation or for arrhythmias, as you said on their own. We don’t instruct anybody to do it, but people will use it, and they have told us that they feel like they have less frequent arrhythmias because they’re calmer on a regular basis. I think that it just shows again how much stress actually impacts us without us knowing it. When we haven’t been taught to recognize what’s going on because it’s just of the normal day-to-day, being stressed all the time, we sometimes forget that stress really does play a major role in our health.

Dr. Weitz:            Absolutely. So yeah. You mentioned that there’s different modes that the Apollo device has. So I know there’s one mode to help improve concentration and work performance. Maybe you can explain how that works differently, and it’s fascinating that the same device that can improve sleep can also improve alertness and performance.

Dr. Rabin:            Yeah. So again, going back to the music analogy, right, our speakers can do this too. As long as you choose the right song and the right volume, we can do the same thing with music. I think that with Apollo, what we did was we were in the lab at the University of Pittsburgh, and we wanted originally because people with PTSD and people who are chronically stressed out have notoriously struggled with intense cognitive performance tasks and they require a lot of attention, and especially boring tasks.   So we ended up giving 38 healthy subjects one of these very boring and taxing tasks that NASA gives to astronauts before they go into space to test their ability to do very tedious work under frustrating conditions. So what was really fascinating was when we put people through this task, our goal was, and this was the first study that we did, which was a double-blind, randomized, placebo-controlled, crossover study in healthy folks at the University of Pittsburgh.  We found that there was a specific increase in heart rate variability in these folks with Apollo frequencies only and not with placebo and with no vibration conditions, and every subject had every condition and had no idea what condition they were getting. Nobody knew what was what this was supposed to do. To clear and focus mode was the mode that put people into the best of what we would call a peak performance or flow state, where people felt like zoned in.  So people on this mode, some of them had up to 25% increase in performance in three minutes. So if you could imagine what that is, that’s like the amount of difference on this kind of task that people see with amphetamines, with just a vibration on.

Dr. Weitz:            [crosstalk 00:38:36] stimulate the sympathetic nervous system in some way, like amphetamines do?

Dr. Rabin:            So it’s both. So I think what’s really interesting about flow or peak performance is that it’s not… The sympathetic and parasympathetic systems, they coexist all the time. They are never just one or just the other. They coexist all the time, just at least a little bit, and because we need both systems to function. So what’s interesting is if you can boost parasympathetic and sympathetic together, which is what many scientists have classified as the state necessary to access flow or peak performance, then you can bring the body into a state where there’s increased energy, sympathetic, right, increased awareness, sympathetic, but also increased attention control and increased emotion regulation, and the combination of those things directly increases performance. Right?

So that was what we aimed for in that trial, and we hit it right on the money, which was really exciting. So then we started looking at, what other states can we induce, right? That was also initially a part of that study as well, where we gave people like 20 different frequency patterns that we came up with in the lab, and we just said, “Feel this for 30 seconds and rate on the scale how it makes you feel.” Is it possible for people to tell in 30 seconds that a brief vibration changes the way they feel?   We actually saw there was pretty reliable reporting. People generally said close to the same answers for the same vibration pattern. So that started to give us the beginnings of an algorithm that was not just one pattern or two patterns that can induce one or two states, but really a mathematical understanding of how you can change the frequencies reliably a little bit in different directions to reliably and do certain states because our states of energy are actually on a spectrum from sleep to running from a bear, right?   So all the performance and recovery states actually when we’re awake, lie in between running from a bear and sleeping. So everything exists between those two, and those are the two that form the top end and the bottom end of the Apollo modes.

Dr. Weitz:            So what are the modes that the Apollo has?

Dr. Rabin:            So the most energizing mode, which is not… I would not say this is calming at all, personally, but it’s very energizing. It’s like having a shot of espresso for most people, but it lasts a shorter time, and that’s the energy and wake-up. Then there’s the social and open, which is like a social creative flow state that’s a calm… Most people use it when they’re working in groups or socializing when they’re tired. Clear and focused is the next one down, and these go in order from most energizing to least energizing.  So energy and wake-up, social and open, clear and focused is that deep focus flow that’s kind of like amphetamines, and then the one lower than clear and focused is rebuild and recover, which is basically the most balanced, even sympathetic and parasympathetic, which is with the goal of just rapidly calming the body down after a physical or mental or emotional stress of any kind. I really use that after travel or after exercise in particular, and we’ve shown that brings heart rate down much faster after exercise, which is really interesting.   Then we go into the much more calming parasympathetic frequency. So that’s meditation and mindfulness, which is great for meditating. It’s also great for what we call calm flow. So this is just like being like a Buddha master, just going throughout your day, just feeling in the zone and calm, but not worry, not anxious, not like you have to do anything.

Dr. Weitz:            You can use this while you meditate to reach a deeper meditation state, right?

Dr. Rabin:            Yes. We showed that in a study at the University of Pittsburgh as well that’s in the works and then-

Dr. Weitz:            It’s really fascinating, because people say you have to spend enormous numbers of hours meditating before you can finally reach this state. People say you have to spend 12 hours a day for weeks on end to reach a deeper state if that’s something that could be achieved.

Dr. Rabin:            Yup. Yeah. Sometimes hundreds of thousands of hours of breath work and meditation to learn how to enter deeper states, which is really interesting. So we’ve shown that Apollo within 12 minutes can start to make a non-meditator’s brainwave patterns look like an experienced meditator’s brainwave patterns.

Dr. Weitz:            Wow, fascinating.

Dr. Rabin:            So that’s something that is really exciting because transitioning into a meditative state, it’s also like a safety situation, right? When we’re meditating or sleeping, and for us to really recover deeply, which is doing things like meditation, yoga, sleep, that kind of stuff, we have to feel safe, right? When you’re meditating and your eyes are closed and where you’re sleeping, “That’s the time that we are more physically vulnerable than any other time.” So if there’s any part of our reptilian old brain, the amygdala that thinks that we are not safe in those situations, we won’t be able to meditate, and we will not be able to sleep, and we will not be able to access these higher states of consciousness that facilitate very powerful healing for ourselves.   Which is what I teach people in my clinical practice. So Apollo helps people state change, and whether that’s going from stress to calm, calm to work, calm to focus, focus to meditation, meditation to socializing, whatever the state change is, automatically, all state change for human beings or any animal creates a stressor. So what Apollo does is it just smooths out the transitions. By calming the body, it reminds us that this change of state is not threatening to us.

Dr. Weitz:            Wow.

Dr. Rabin:            In and of itself. Then that smooths out the transition from one state to another.

Dr. Weitz:            This is really fascinating, right? I just can’t believe how fascinating the applications of this device can be.

Dr. Rabin:            I mean, we couldn’t either at first, and then it was really exciting when these results came back, because I’ve been doing research for a long time. My colleagues that I worked with on this have been doing research for a long time, and I can tell you that it’s like once in a lifetime that you actually come up with something that works this well.

Dr. Weitz:            Now, where do you wear the device? You wear it on your wrist, or you wear it-

Dr. Rabin:            I actually wear it on my ankle? The device comes with an ankle strap and a wrist strap. Most people I think prefer to wear it on the ankle, and the main reason for that is because the primary use case of Apollo that most people use it for is relaxation and sleep. Then the second one is focus. So for sleeping, most people prefer to have the wearable on the ankle, where it will never be near anyone’s head when they’re sleeping and-

Dr. Weitz:            Are there EMFs produced by this?

Dr. Rabin:            Only what is produced by any Bluetooth device. It’s been tested for all of that radio frequency signaling. So it’s under all the legal limits and all that. That being said, there are people who are still sensitive to EMF below the legal limits, and we have included an airplane mode from the beginning to turn off all signaling for people. So the device actually works and can be completely untethered from the phone, and you could turn off the radios entirely so there’s zero EMF in airplane mode, and we have-

Dr. Weitz:            [crosstalk 00:46:36].

Dr. Rabin:            Yeah. The device doesn’t use EMF as a therapy. It uses sound waves. So the sound waves are very safe. They’re one of the safest things that we know of to deliver to the body. So the sound waves can be still delivered and activated with the device on the buttons on the device, and you can adjust the intensity with the buttons on the device even when it’s not connected to the phone, which is really nice because personally, I get it. I don’t want to have my phone on me all the time or have to have my phone on me all the time to feel good. I want to be able to set my phone down and be able to still have my tools with me that work without requiring the phone. Then if I want to go back to the phone, I can go back to the phone. But it’s more intentional with that.

Dr. Weitz:            Will it hold a charge for a long time?

Dr. Rabin:            So it holds a charge if you don’t… In standby mode, I think it’s something like 12 days, 15 days.

Dr. Weitz:            Oh, wow.

Dr. Rabin:            If you use it, it will last… If you use it as we recommend, which is roughly two, two and a half hours a day or two to three hours a day, then you get about two days out of it. If you use it more than that, then you have to charge it more frequently. That’s not a big deal. You just find a time to charge it, and it charges within one to two hours, and then you have another full battery capacity out of that. We are constantly working to make the battery life better, but it just takes time and-

Dr. Weitz:            Yeah. As long as it goes through your whole night sleep or most of your day, that should be fine, I would think.

Dr. Rabin:            Yeah. Yeah. It does. I think the people who do use it more often, that use it all, all the time when they first get it, they actually schedule in time during their day and usually during a meal to plug it in, which is funny. But it’s good because that structure of having a schedule is also very helpful to us in terms of recovering, because it sets boundaries that says, “Hey, it’s time for recovery now, not time for work.” Right? Then you kind of have these from self-imposed, but still from boundaries that allow us to disengage from one state of mind or activity and then enter into another.

Dr. Weitz:            Interestingly, I talked to a lot of people are working from home right now, and that’s become increasingly difficult when they’re working at home, and they just end up, can keep working.

Dr. Rabin:            Yup. Yeah, I did that too. I am a complete perpetrator of that. It is very difficult, and it’s something that I’ve really struggled with in the last year, in particular with COVID. But now, it’s really just a matter. What I started do now is I made a schedule, and I just really hold myself to it, and I just got it because I know that if I do it, I just feel so much better. That’s all there is to it. I want to feel good.

Dr. Weitz:            Oh, I feel the same thing. Besides my full-time practice, I do the podcast, and I’m always working on show notes or working on notes for the next interview or et cetera. So it’s hard to shut off. That’s one of the reasons why we need a device like this.

Dr. Rabin:            Oh, yeah. I mean, yeah, the struggle is real, for sure. I think that’s why, especially with doctors. I used to work in the psychiatric ER when we first had this prototype, a prototype of the Apollo. I was working in the psychiatric ER a lot. I was seeing a lot of very, very high risks mental health patients. Having the Apollo was just a game changer, to be able to have something that allowed me or helped me figure out again how to call myself down quickly without taking a supplement to help me sleep or without having a glass of wine or… Not that having a glass of wine is a bad thing. It’s not, but we shouldn’t be dependent on it for rest because it doesn’t actually help us sleep. It actually just makes us feel like we sleep better, but we actually sleep a lot worse and are actually less rested at more of a sleep deficit down the road.  So I think ultimately, what working on Apollo really taught me that was so incredible was that we have the ability in ourselves to heal ourselves. We through learning how to use the tools that we have access to in ourselves, we have the ability to heal ourselves and to really make ourselves so much better than we are. Life is like a constant game of growth, and how fast can we grow out as well as we can grow in the direction we want to grow. Right? We think we want to grow.

Dr. Weitz:            Absolutely.

Dr. Rabin:            Working on Apollo really taught me and using Apollo over time taught me that there’s a hell of a lot more going on in here than I thought there was.

Dr. Weitz:            Cool.

Dr. Rabin:            Because the anxiety and the fear is what… Kathryn, my wife is the CEO of Apollo, we came up with this funny term, which I think is really true, which is the fear that we are either taught to feel or feel for whatever reason about uncertainty or newness or unfamiliarity or anxiety or whatever, it’s really fear of the unknown. It’s fear of uncertainty and fear of losing control of our lives, our situation, and that creates a box around us that we eloquently entitled the fear box, that literally creates the reality that we live in.  In every moment of our day, we have the opportunity to pay attention to love or fear. There’s love and fear and every moment coexisting together in every moment of our day, and if we direct our attention to fear, we will live in that fear box, and if we direct our attention to love, we will climb out of the fear box, and we will find our actual path.

Dr. Weitz:            Right. Awesome. Great way to end this interview. It’s been very fascinating. How can people find out… How can they order the Apollo and find out more information about you-

Dr. Rabin:            Well-

Dr. Weitz:            … and the device?

Dr. Rabin:            Sure. Yeah. So, for Apollo, you can go to apolloneuroscience.com or apolloneuro.com, A-P-O-L-L-O-N-E-U-R-O, dot com. I believe we have some sales that are either going on or coming up. So stay tuned there. You can also sign up for our newsletter on the website where we send out a lot of very helpful tips that I have helped to write myself based on things that I’ve done and that I do with my clients, which is basically free information to help people feel good at a time where things are really crazy in our world and to feel frankly just more in control of our own lives. That’s what this is about.

                                If we spend more time paying attention to things we can control, we will feel more in control. Breath is the start of that, and movement, and these things, everything we’ve been talking about. If you’d like to find me or get in touch, you can check out my website. It’s drdave.io. That’s my clinical practice website. I also can be reached through social media at Twitter @DaveRabin and on Instagram @drdavidrabin.

Dr. Weitz:            Awesome. Awesome. Thank you so much, and I’ll send you links after we post this in about six weeks.

Dr. Rabin:            Sounds good. Thank you so much for having me. I really appreciate it, Ben.



Hydrogen Sulfide SIBO and SIFO with Dr. Preet Khangura: Rational Wellness Podcast 194

Dr. Preet Khangura discusses Hydrogen Sulfide SIBO (Small Intestinal Bacterial Overgrowth) and SIFO (Small Intestinal Fungal Overgrowth) 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. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]


Podcast Highlights

1:34  Dr. Khangura learned about naturopathic medicine when his wife had some significant gastrointestinal issues and after multiple visits to the ER and to her family MD, who prescribed Proton Pump Inhibitors, she saw a Naturopathic doctor who really turned her health around. Dr. Khangura switched his career path from medical physics to naturopathic medicine with a focus on gut health.  Dr. Preet started exploring SIBO (Small Intestinal Bacterial Overgrowth) in Naturopathic college, even though it was not taught very well in Naturopathic school.  SIBO became one of the focus points of his practice from day one.

5:08  IBS (Irritable Bowel Syndrome) is a lazy diagnosis because it is really more of a label and it does not indicate the cause of the symptoms.  Conventional MDs will often say, “You just have IBS.” “You’re just going to have to deal with it.” “You’re just going to have to take a laxative.” “You’re just going to have to take a PPI.” 

7:04  While SIBO is the most common cause of IBS, another cause is pancreatic insufficiency, which involves a lack of sufficient digestive enzymes being produced like lipase, proteases and amylase.  One way to diagnose pancreatic insufficiency is to run a stool elastase test, and while 200 is the lab designated cutoff point, anything less than 500 is potentially indicative of the need for enzymes.

9:43  Some of the cases of patients with constipation, esp. if there is methane, can be some of the most difficult cases to treat till resolution.  While some constipation patients have methane overgrowth on the SIBO breath test, others may have a low level of methane that may not show positive on a breath test, but may still induce constipation.  For example, while on the SIBO breath test, the cutoff for methane is 10, perhaps it should be 3. You may have to get rid of virtually all of the methanogens to resolve the constipation.  One natural product that Dr. Khangura will use is an herbal tincture called the Tincture of Death, which contains a very concentrated combination of the three herbs: golden seal, myrrh and thyme.  Allicin extract can also be very effective.  Oregano can work and he likes the emulsified oregano formula from Biotics, ADP.  He also finds the combination of Candibactin BR and Candibactin AR from Metagenics very effective.  If he uses pharmaceuticals for methane SIBO, Dr. Khangura will use Rifaximin and neomycin or Rifaximin and metronidizole.  He may also use Amoxicillin/clavulanate or trimethoprin/sulfamethoxazole.

17:25  Biofilms. Bacteria biofilm is one of the reasons why we can’t eradicate the bacteria in stubborn SIBO cases. We need to pick a good biofilm disruptor and the best biofilm disrupting complex would be what’s called the Bismuth thiol complex.  It is typically bismuth subnitrate mixed with either DMPA or DMSA along with alpha lipoic acid and this is usually compounded by a pharmacy.  There are phase one and phase two biofilms. Phase two is a very mature biofilm that is much more difficult to disrupt.  There are metalloid lengths within the biofilm, which is what the Bismuth Thiol complex acts on by forming a wedge to open the biofilm.  NAC can be very effective and Dr. Khangura recommends a dosage of 1000 mg of NAC twice per day on an empty stomach.  A lot of practitioners will use enzyme formulas, like Interphase Plus, but these are pretty weak at opening biofilms and are probably better for prevention to prevent relapse.  If you are a practitioner that can’t prescribe DMPS or DMSA, Dr. Paul Anderson developed a bismuth thiol product without DMPS or DMSA that combines bismuth subnitrate with alpha lipoic acid and black cumin seed.  Dr. Khangura will often have patients continue with biofilm disruptors until they get a flareup of symptoms, which indicates that the biofilm is being broken up.  Dr. Anderson teaches that when the biofilm is broken, the bacterial colonies will become more active and they start fermenting more, leading to more symptoms.  It can be difficult to kill the bacteria until the biofilm is broken up.  Once the biofilm is broken, the immune system will more likely now activate to reduce the overgrowth. 

26:29  Erradication period.  To erradicate the bacterial overgrowth, Dr. Khangura will either use Rifaximin or herbals for 2 to four weeks and he expects to see some significant improvement in two weeks or he will not continue.

28:35  Dr. Khangura does not recommend patients to follow a strict anti-SIBO diet at the same time as the erradication process, since the bacteria may go dormant and produce even more biofilm.  It can help to use guar gum with rifaximin, since guar gum will feed the bacteria and make it easier to kill them.  The other reason is that if you have them follow a low FODMAP diet and put them on rifaximin and they feel 50% better, you don’t know which intervention worked.

31:36  Dr. Khangura recommends not giving broad spectrum probiotics to SIBO patients and he finds that most SIBO patients feel worse if they eat fermented foods like sauerkraut or drink kombucha.  The probiotics contain bacteria that can take up residence in the small intestine and studies have found that lactabacillus are hydrogen producers and have been found in 25% of cases of SIBO.  Dr. Khangura sees less issues with using bifido species and with spore based probiotics. 

35:15  Hydrogen sulfide SIBO.  While the flat line on a SIBO breath test might be an indication of hydrogen sulfide SIBO, Dr. Khangura finds that medical history and symptoms can often alert him to this condition. Patients may report a very pungent, rotten egg smelling gas that occurs on a regular basis or they may have an unexplained halitosis.  The new Trio Smart Breath Test, which also measures hydrogen sulfide gas, is not yet available in Canada, so Dr. Khangura has not been able to use it yet. 

The bacteria that produce hydrogen sulfide typically don’t feed on fermentable fiber or sugar, but they feed on foods rich in sulfur compounds, like garlic and onions.  Chronic or reoccurring UTIs occur from hydrogen sulfide producing bacteria.  Drinking well water is an easy way to pickup hydrogen sulfide bacteria if they’re not using UV light to kill the bacteria.  Some of the most common hydrogen sulfide producing bacteria are klebsiella, proteus, citrobacter, E. coli, and morganella.

For treatment of hydrogen sulfide SIBO, Dr. Khangura usually uses Rifaximin or Amoxicillin/clavulanate or trimethoprin/sulfamethoxazole.  Natural treatments for hydrogen sulfide SIBO include Uva Ursi, which is often used for UTIs.  He will have a good herb dispenser in Canada make a one to one or a one to two tincture of Uva Ursi, whereas most health food stores carry a one to four or a one to five, which is less potent. This herb does contain a hydroquinone, which some people worry might affect the liver, but using it for a few weeks he has never seen it cause a problem. Silver can also be very effective against hydrogen sulfide producers either as colloidal silver or silver hydrosol.  He may use a combination of Uva Ursi plus Silver Hydrosol.

47:30  SIFO (Small Intestinal Fungal Overgrowth).  Candida or other fungal overgrowth can occur in the small intestine or the colon or in other parts of the digestive tract. There is no breath test for SIFO for fungal dysbiosis. Stool tests might show yeast/fungus like candida in the colon and this might indicate fungal overgrowth in the small intestines as well.  While Rifaximin only works in the small intestine and does not affect the microbiome, other antibiotics like neomycin, metronidazole, Amoxicillin/clavulanate, and trimethoprin/sulfamethoxazole could make the fungal growth worse. If they have a chronic gastrointestinal fungal issue it may present systemically as oral thrush or fungal scalp problems or recurrent skin fungal infections or athlete’s foot, or recurrent vaginal yeast infections.  You can ask the patient how they feel after eating a candy bar or having a drink?  Fungal overgrowth can lead to the production of acetaldehyde, which can cause brain fog, a hung over feeling, nausea, tachycardia, increased heart rate.



Dr. Preet Khangura is a Naturopathic Doctor with an integrative and functional medicine practice at Juniper Family Health in Victoria, British Columbia, Canada. Dr. Khangura has a practice focus on treating gastrointestinal conditions, including SIBO – the #1 cause of IBS.  Dr. Khangura has also been educating doctors about SIBO at in person and now at online conferences. To learn more, here is a course that Dr. Khangura offers: Beyond Superseding SIBO.

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.


Podcast Transcript

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

                                                Hello Rational Wellness podcasters. Our topic for today is hydrogen sulfide SIBO and SIFO, and difficult SIBO cases with Dr. Preet Khangura. Dr. Preet Khangura is a naturopathic physician with an integrative and functional medicine practice at Juniper Family Health in Victoria, British Columbia in Canada. Dr. Khangura has a practiced focused on treating gastrointestinal issues including SIBO which is the main cause if IBS. Dr. Khangura has also been educating doctors about SIBO in person and now with COVID at online conferences. My goal for this interview with Dr. Khangura is to gain some insights into treating some of the more difficult SIBO cases. We would like to highlight the diagnosis and treatment of hydrogen sulfide SIBO and small intestinal fungal overgrowth in particular. Thank you so much for joining me, Dr. Khangura.

Dr. Khangura:                    My pleasure, thank you for having me.

Dr. Weitz:                          That’s great. Perhaps you can explain to our listeners how you came to become so interested in SIBO and in functional gut disorders?

Dr. Khangura:                    It’s kind of an interesting story. My wife always takes credit for it, of course. There’s some truth to that. Years ago-

Dr. Weitz:                          You’re not going to win by denying that.

Dr. Khangura:                    Exactly, that’s true. Years ago, before I even went to naturopathic medical school, my wife and I have been married for close to 14 years but we’ve been dating for 20 plus. In our early 20s she came down with some very significant gastrointestinal issues. It kind of came out of nowhere at such a young age and her hair started falling out, she started getting arthritic joint pains but it all started with very significant gastrointestinal issues. I had to take her to the ER a few times, of course they couldn’t find anything. Her family doctor was just prescribing her antacids even though she never had GERD. I was talking to my friend’s mother-

Dr. Weitz:                          That’s the classic treatment for everything.

Dr. Khangura:                    Yeah. Throw a PPI at it.  I was talking to one of my friend’s mothers over Christmas break one time and she said, “Oh that sounds like what our daughter dealt with last year. We saw this great naturopathic doctor that focused on gut health.” That sparked my interest. She saw a naturopathic doctor here in B.C. all those years ago, within three months completely turned her health around. That really sparked my interest in not just naturopathic medicine, functional medicine but gut health. At that time I was doing my degree in physics. I was going to go into medical physics but I totally switched gears. Went to naturopathic medical school and always had a sight on gastrointestinal disorders. When I started practice I started really diving into SIBO even in naturopathic medical school, even today, especially back then. SIBO’s not really taught very well even in naturopathic medical schools. I had to do a lot of it myself. I dove right into it and really focused on it since day one of practice. As you know, whatever we practice more of, that’s why it’s called practice, we get better at.

Dr. Weitz:                            Right. Of course, SIBO is one of those conditions that on the one hand seems like a really simple condition. We do have our cases where everything fits, they have the symptoms, you get the breath test back, you do your normal treatment, whether it be antimicrobials from the natural world or rifaximin or whatever. Then they resolve, end of story. Then we have our 50% or so of cases that don’t seem to come along so easily.

Dr. Khangura:                    Yeah, exactly, that’s exactly it. I see a ton of that in my practice because I do have expertise in SIBO and other GI disorders, dysbiosis disorder especially. I get a lot of these very stubborn cases referred to me. I’d say in my practice, more than 50% are the stubborn cases but that’s where you really learn as a practitioner and that’s why I try to get across in my courses and seminars for other doctors. Keep your fingers crossed that you get a really easy case because it’s good for you and the patient, of course. But where you’re really going to learn, especially the individualistic treatments for patients as opposed to protocols or blueprints are those patients where they’ve already tried this, they’ve tried this. The SIBO is not resolving or it’s coming back quickly or whatever it may be.

Dr. Weitz:                           Right. I heard you say that IBS is the lazy diagnosis, what did you mean by this?

Dr. Khangura:                    Yes. That ruffles a lot of feathers, especially more M.D. colleagues-

Dr. Weitz:                           Conventional GI docs.

Dr. Khangura:                    Conventional GI docs, yeah. Really what I mean by that is kind of tongue in cheek. Obviously it is a diagnosis however it’s more of a label than a diagnosis, kind of like fibromyalgia is a label, chronic fatigue syndrome is a label. There’s obviously always root causes to these conditions and digger deeper to find out that root cause, then you can actually treat that as your therapeutic target and actually not just mask signs and symptoms but actually resolve the case, hopefully, for these patients. The problem is, I’m sure you know this yourself, when the patients get that label of IBS, so many times that’s where the doctor stops. They just the word “just” quite often. They’ll say, “You just have IBS.” “You’re just going to have to deal with it.” “You’re just going to have to take a laxative.” “You’re just going to have to take a PPI.”

Dr. Weitz:                           Partially it’s a diagnosis of exclusion, they’ve excluded IBD, their scope is negative, there’s no parasites. It’s a functional gut disorder.

Dr. Khangura:                    Exactly. It’s becoming a lazy diagnosis because those doctors will stop at that point and give maybe some dietary recommendations. Now a lot of doctors are recommending the low-FODMAP diet and other things. But that’s really the extent they get other things to slow down the diarrhea or slow down the cramping or whatever it might be. That’s basically why I call it a lazy diagnosis. By no means is SIBO always the root cause of someone’s IBS. It’s definitely near the top of the list for a lot of the patients but of course there are cases of “IBS” that SIBO is not the root cause. But definitely SIBO should be there on a practitioner’s DB-

Dr. Weitz:                          What are some of the other causes of IBS besides SIBO?

Dr. Khangura:                    One that mimics SIBO extremely well, definitely a lot more rare than SIBO would be something like pancreatic insufficiency. This would be a condition where the patient’s pancreas is not producing enough of the digestive enzymes like lipase, proteases and amylase.

Dr. Weitz:                          How often do you think that happens?

Dr. Khangura:                    I couldn’t really give you a number but I have seen it a decent amount in my practice whether I suspected it and I prescribed actual prescription strength enzymes to see if it made a significant difference or we ran a stool elastase test which is very diagnostic of pancreatic insufficiency if the number comes back lower than usually a threshold of 200. It depends on what units they’re using. But-

Dr. Weitz:                          Actually I recently spoke to Dr. Stephen Sandberg Lewis. Even though the labs usually give 200 as a cutoff point, he feels that really a normal elastase should be over 500.

Dr. Khangura:                    Yeah, exactly. In that kind of gray zone, if a patient comes back with 300 I’ll still usually prescribe the enzymes just in case because the reason why it’s a perfect mimicker of SIBO is when you boil down SIBO, you get into all the patho-physiology, you can get into all the nitty gritty details of why we develop it, what happens, what bacteria is there. But really what it comes down to is over fermentation from an over pooling of bacteria in the small intestine. Now, pancreatic insufficiency, even if a patient does not have SIBO, they have a regular amount of small, tiny amount of bacteria in the small intestine but if they now don’t produce enough enzymes to break their proteins, carbs and fats down properly, the meals they’re eating are just sitting there in their small intestines much longer than they should be. Even that small, regular amount of bacteria can now over ferment the fibers and sugars that came in that meal because it’s just sitting there. They can produce SIBO-like levels of gas even though the actual community count isn’t at an overgrowth level.   That’s one that I’d say is almost a perfect mimicker of SIBO.  You’ll sometimes hear that, okay sometimes pancreatic insufficiency, they definitely are going to have diarrhea because of the fact that the food isn’t breaking down well, fats aren’t breaking down well.  The gut will send things out. We do see that very often, IBS-D caused by pancreatic insufficiency but I’ve had many constipation cases where pancreatic insufficiency was the big root cause.  Those are things also to watch out for.  It doesn’t always have diarrhea.

Dr. Weitz:                            I’ve found some of the constipation cases are some of the most challenging of cases. They often don’t fit the classic, they don’t have elevated methane and a lot of times getting rid of that constipation seems to be really, really tough.

Dr. Khangura:                    They can be, they probably are the most stubborn cases to crack. I find when we talk about methane, there is that big connection between methane production in the small intestines and slowing of the colon motility leading to constipation. I think the reason why they can be the toughest cases to crack is that if you do not resolve the constipation aspect, it can be very difficult to have the patient feel better even as you’re getting rid of, say, their hydrogen sulfide SIBO because if the colon motility is not very good and they’re not evacuating their bowels very well, they are going to have higher levels of discomfort, gas, bloating, just not feeling well, low appetite. Until you can resolve that constipation, if that means eradicating enough methane bacteria to do that, okay, great. But the problem is, as you probably know and your listeners may know is that there is methane producing SIBO and then there’s something called methane induced constipation. These can be two separate things. Obviously if someone has methane SIBO, they have an overgrowth of methane bacteria that can very easily lead to constipation, not always. It just depends on what else is going on.   But there’s some patients that have what’s called methane induced constipation where they don’t actually need a full overgrowth of the methane bacteria colony. They’re just the unfortunate subset of patients where they need a small amount of methane production to cause their constipation. You as a practitioner and any other practitioners out there may see this in SIBO breath tests where they say, “Okay, the cutoff for methane producing SIBO is between 10 to 12 parts per million of methane.” But then as soon as you see this fine print saying, “But some practitioners see 3 parts per million as a positive diagnosis.” But they don’t tell you positive diagnosis for what. Really, what they’re trying to say is some patients if they have constipation and they have at least 3 parts per million of methane, there can be a big correlation. Those patients can be really tough.

Dr. Weitz:                            When we see those recommendations for how these tests should be interpreted, like the North American Consensus, that’s a consensus of different doctors that had to all agree. I’ve spoken to Dr. Pimentel before, he had recommended a cutoff of three but the consensus was ten.

Dr. Khangura:                    Yeah. That’s exactly it. That’s something I brought up in a lecture I did the past summer I did on breath analysis. Really what the real data shows and how this consensus was just decided by a group of docs based on some research but the research is quite flawed in some ways. I do agree with Dr. Pimentel with the whole three parts per million aspect because I’ve had many patients where we have to eradicate virtually all of the methane bacteria in that small intestinal tract before that constipation resolved. Until we can do that, the patient was getting some benefit in a lot of these cases because we were getting rid of maybe some other problems, hydrogenic SIBO, whatever else. But because they were not able to move their bowels properly until we were able to eradicate enough of the methane bacteria, archaea technically, then these sometimes can be the tougher cases.    What I also will mention to practitioners is that if you have a patient that has methane induced constipation where you need to get their methane levels down to below three parts per million, these are also cases that their constipation will very likely relapse very easily because it won’t, even if you have them on a good pro-kinetic and you’re doing all these good things. The reason being is that it won’t take much over pooling or re-pooling of methane archaea again to get back to three parts per million and all of a sudden they get constipated again. Even if you’re able to resolve one of those cases, you’ve got to be on top of even prophylactic treatments and good prevention- [crosstalk 00:13:51]

Dr. Weitz:                          What are your favorite prophylactic or what are your favorite treatments for breaking the constipation cycle until you eradicate the methane?

Dr. Khangura:                    The way I look at it is, if I do suspect that the methane growth and methane production is the cause of the constipation, eradicating that growth is the treatment that I go with. Of course, you could do things like some pro-kinetics that can help colon motility, like prucalopride for example. You can get their bowels moving in a sense artificially because you’re inducing the contractions or even other over the counter laxatives or high dose magnesium or senna, whatever it might be. That’s not getting to the root cause. The way I look at it is, if a patient needs to be on something as we begin treatment just to get their bowels moving otherwise, only going twice a week or something like that, I’m fine with them remaining on something like that at the beginning but my goal is to eradicate the methane archaea to a point where they don’t have to be on those laxatives anymore, they don’t need the actual pro-kinetic to have a bowel movement. That’s where there’s a lot of confusion on what a pro-kinetic is for. It’s really for retraining the migrating motor complex contractions as opposed to making sure patients have bowel movements. That’s the way I look at it. If that means using pharmaceutical antibiotics, if that means using specific herbal extracts to kill the methane archaea, elemental diet, picking the right agents in that scenario.

Dr. Weitz:                          What are your favorite herbal agents for killing the methane?

Dr. Khangura:                    For the methane? I have this one tincture, I just call it my SIBO tincture.  A lot of docs here in Canada, they know it by the name Tincture of Death.  It goes back to a story of one of the first patients I gave it to, I asked them, because the tincture has a really strong taste. I go, “How did you handle the tincture?” He goes, “Oh, you mean the tincture of death?” and I go, “What do you mean by that?” He goes, “Well, it obviously worked at killing the bacteria because I’m feeling better but it also tasted like death.” I’m like, “Okay.” Basically I just call it my SIBO tincture, calling it the Tincture of Death is a great marketing ploy. Basically this is personally what I use and a lot of docs I taught use it but it’s a very concentrated combination of the three herbs golden seal, myrrh and thyme. Some docs do equal parts, I do a little bit more of the golden seal and myrrh than the thyme in the tincture. But that tincture I’ve seen work over and over for methane overgrowth. Also it can help with hydrogenic overgrowth. Probably not the best choice for hydrogen sulfide overgrowth, which we can get into in a little bit. But that tincture I use quite often.  Allicin extract can be good, I specifically use a product called Allimax.  A lot of docs know about that one.

Dr. Weitz:                          We use the same one.

Dr. Khangura:                   That one can work well in some cases. You’ll hear that oregano is better for hydrogenic SIBO.  It’s definitely not black and white. I’ve seen oregano work well for methane overgrowth. There’s a very specific emulsified oregano that I use called ADP emulsified oregano from Biotics Research. That’s a good one. I’ve seen that one work well. Of course there’s other good formulas that can work, Candibactin AR, Candibactin BR products when used in combo they can work. There’s a lot of options. Definitely the methane archaea will be tougher than the hydrogenic bacteria. But if you use the right agents, then you can hit them pretty good.

Now, the caveat to all of this is whether it’s hydrogenic, hydrogen sulfide or methane producing SIBO. I talk a lot about this when I do my courses is biofilm production. Bacteria biofilm is, in my opinion, the number one reason why we see a lot of those very stubborn SIBO cases out there where you can’t even start an eradication. You either give them rifaximin or neomycin. Rifaximin and metronidizole, you give them all these herbs but the SIBO is just not budging. You retest, the numbers aren’t getting better. They even may be getting worse. Bacterial biofilm is definitely a big problem in a lot of these cases. A good, good biofilm disruptor, no matter what you pick to kill the bacteria, a good biofilm disrupting agent is key for a lot of these cases.

Dr. Weitz:                          What are the best biofilm disruptors?

Dr. Khangura:                    There’s some very simple single ingredient things you can use. But by far, the best biofilm disrupting complex would be what’s called the bismuth thiol complex. Bismuth like the bismuth that’s in Pepto Bismol. But it’s a little bit different version of it. It’s bismuth sub-nitrate as opposed bismuth salycilate. But the Bismuth vial complex is bismuth sub-nitrate mixed together with either DMPS or DMSA. One or the other and also alpha lipoic acid. ALA- 

Dr. Weitz:                          Is this something that’s compounded?

Dr. Khangura:                    This is something that has to be compounded. Here in Canada there’s a couple of pharmacies that do compound it for clinicians. I know in the states there’s some pharmacies that do a lot of this product as well. This product has had some good research on it showing that … There’s two different forms of biofilms.  There’s phase one biofilm, there’s phase two biofilm. There’s a lot of agents that can work on phase one biofilm, especially a lot of natural agents.  But once the biofilm gets to phase two, essentially what that means is, it’s very much matured biofilm. It’s been getting produced for many, many years, at least many, many months. There’s significant amounts of metalloid lengths within the biofilm, you need something better than what can open up the phase one biofilm. That’s where the bismuth vial complex comes in.

                                                When the compounding pharmacy mixes the three ingredients together in the right ratio, the ALA and the DMPS will bind tightly to the bismuth sub-nitrate and this will form one whole new agent. It’s not like taking three separate, really awesome biofilm disruptors, they’re actually all really mediocre at opening up biofilm but when they combine they form this one whole new agent. In an analogy sense, it forms a wedge that opens up the metalloid lengths and it’s been shown to open up phase two biofilm, at least at this point, probably the best compared to anything else. But if you weren’t going to use that or you couldn’t use it, then something as simple as NAC can work very, very well. Very good research on that with inhibiting biofilm protection and also opening up biofilm. There will be cases where it fails, if it’s significant phase two biofilm

Dr. Weitz:                          What dosage do you like for the NAC?

Dr. Khangura:                    I typically will do a little bit higher dose than we normally do for NAC. 1,000 milligrams twice a day empty stomach. Empty stomach for any disruptors is important to get to the gut biofilm including the bismuth vial complex you want to do empty stomach. A lot of people will talk about enzymes. They’ll do enzyme formulas to open up biofilm. They’re pretty weak at actually opening up biofilm. They’re more so for prevention so they can inhibit biofilm production by the microorganisms. In a lot of cases, especially my cases that have been pretty tough to crack or I do see we can solve it but there is a relapse rate that happens, a lot of times we’ll put patients on these enzyme formulas or lower dose NAC long term after we actually resolve the case just to inhibit more biofilm production as time goes on.

Dr. Weitz:                          Which is your favorite enzyme formula?

Dr. Khangura:                    If I was going to use an enzyme formula, I don’t use it often because I’ll typically prescribe the bismuth vial complex but there is, I’m forgetting the actual name of the product now but it’s made by the company Klaire Labs.

Dr. Weitz:                          Yeah, yeah. Interphase Plus.

Dr. Khangura:                    Interphase Plus, yeah. That would probably be one of the better ones and then here in Canada there’s one called BioFilm X by Vita Aid, which is a fairly similar formula to that one. But like I said, if I had to choose and I wasn’t using the bismuth vial complex, I would still pick high dose NAC over the enzyme formulas.

Dr. Weitz:                          I think Paul Anderson developed a bismuth thiol product that just doesn’t have the DMP-S or DMS-A.

Dr. Khangura:                    That’s exactly … Thanks for bringing that up because I was going to say that an alternative if you’re a practitioner that can’t, let’s say, prescribe the DMPS or DMSA, Paul did formulate for the comfortable Priority One and it’s a product called Phase Two Biofilm which has the bismuth sub-nitrate which is just over the counter and then alpha lipoic acid and then black cumin seed. The black cumin seed will bind to the bismuth in a similar way as the DMP-S but just not as tightly and as strong but it’s a very good alternative formula.

Dr. Weitz:                          Okay. You use that for which forms of SIBO? Or all of them?

Dr. Khangura:                    Pretty much all of them because virtually all microorganisms produce biofilm directly including fungal species, candida species. They produce a lot of biofilm when they co-colonize with certain bacterial species. I’ll use a biofilm disruptor pretty much with every SIBO case. Now, not all SIBO cases need it but I like to hedge my bets because if I do a very well rounded treatment on a patient and two or three weeks later they tell me they’ve had zero resolution of any symptoms, zero improvement at all, then the next step would be, “Well, we probably should have done that with a biofilm disruptor. Let’s try again.” I’d rather not do that. I’ll do the biofilm disruption along with the eradication agents. In some cases what I’ll do is, especially if it’s a case that comes to me and I see in their history they’ve already tried everything under the sun for their SIBO and their SIBO is very much there still, I’ll do very good biofilm disruption like bismuth vial complex all by itself for a set period of time before we even go back to eradication. There’s going to be some cases out there that are going to need extensive biofilm disruption before anything is going to work. I have cases where three, four months of biofilm disruption and then we go back to something they’ve already tried. All of a sudden they get full resolution. 

Dr. Weitz:                            How did you decide that three or four months is the right amount of time?

Dr. Khangura:                    Yeah. For some of these cases I’ll have them stay on the biofilm disruptor until they get a flareup of symptoms. Paul teaches a lot about this as well. Basically what happens is when biofilm is produced and these colonies are living within it, it actually can inhibit how bad that patient’s SIBO symptoms are because what happens is the colonies are living within the biofilm and then when that patient eats, only some of the SIBO comes out of the biofilm to feed. The rest stays behind, dormant and protected in the biofilm. It actually limits how bad the fermentation can be. When you put a patient on just biofilm disruption, a lot of times I’ll tell them, “You’re going to stay on this until you get an unexplained flareup of your symptoms.” A lot of these patients, they don’t believe me because their symptoms are already quite significant. How could it get worse? It does. When this biofilm opens up, all of a sudden there’s two things that happen. One is the actual colonies, the overgrowth actually become more active. They’re going to ferment more. They’re going to give you more symptoms.

                                                But the other thing that happens is that the gut’s immune system can now activate against the overgrowth, because that’s one major reason why bacteria produce biofilm isn’t just to adhere to a surface, it’s to protect themselves from your immune system, from the environment, whatever else is out there. For two reasons the patient might get a flareup. Gut’s immune system activates, the actual overgrowth gets more active and I tell them, “We’re looking for an unexplained flareup so it’s not because you change your diet, it’s not because you’re getting sick. You’re doing your every day old thing and all of a sudden for the last two or three days you thought your bloating was a 10 out of 10, it’s a 12 out of 10 now. Diarrhea has increased, constipation has gotten worse, whatever it might be. That’s when I’ll add in the eradication agent. When I talk about those cases that took three or four months, those are cases where the patient had enough patience to stick with that protocol until they got that flareup. It can be tough, I don’t lie about that because the patient is like, “Okay I’ve been doing this for a very long time, I haven’t got that flareup you told me is coming.”   Sometimes practitioners will start the eradication before that flareup. Sometimes it still works because the flareup isn’t always distinct but it can be very distinct. It’s a good hallmark so you know it’s time to start the actual eradication.

Dr. Weitz:                            For eradication agents, rifaximin we know is 10 days or 2 weeks, but what about when you use herbal agents? What length of time do you usually prescribe them for?

Dr. Khangura:                    Regardless if I prescribe pharmaceuticals or herbal agents, I’ll prescribe about two weeks’ worth at a time. Some cases I’ll do up to four weeks because we already have a history, you already had an idea that this body will take more than two weeks. I know that the patient is okay with these agents, there’s no side effects I’m worried about or anything like that. But in general I’ll break down treatments into two week chunks because the way I look at it is, if a SIBO treatment is working, actually working at a significant level, even if it doesn’t completely resolve someone’s SIBO case in two weeks, which is very common that it doesn’t, you want to still see at least moderate to good improvement with that treatment protocol you have set. I know a lot of practitioners will give a patient six weeks of the same combo of herbs and then say, “We’ll chat in six weeks.” Then they find out in six weeks that did nothing in those six weeks. It was a waste of time, also a waste of the patient’s money because if that combo was going to work, they should see some improvements within the first couple weeks. It may only be 20, 30% or it might be 80, 90% or anything in between. You want to see some improvements. I’ll still prescribe in that manner. Then go from there. But there are cases where I do prescribe for longer.

                                                When it comes to pharmaceuticals, typically it is a maximum two weeks at once. Herbs, sometimes I’ll go longer than two weeks. Rifaximin is very, very safe in general when it comes to antibiotics. If you were going to do an antibiotic for more than two weeks at a time, that would be the one that I wouldn’t be too worried about at all. It doesn’t absorb. It’s pretty much inactive in the large intestine. It doesn’t eradicate where you want to keep bacteria. But those other antibiotics, neomycin, metronidazole, amoxi/clav, trimethoprin/sulfa, all those other ones, definitely I wouldn’t prescribe more than two weeks at once. You just want to make sure you’re doing more good than harm, of course.

Dr. Weitz:                           Do you recommend specific dietary changes at the same time as the eradication process?

Dr. Khangura:                    My recommendation is not to do a strict anti-SIBO diet, not to do a strict low-FODMAP diet, biphasic diet, whatever anti-SIBO diet that the practitioner uses. Dr. Pimentel talks about this a good amount as well. It actually has to do with biofilm. If you do a very strict anti-SIBO diet, however you classify it, what can happen is the bacteria can produce potentially more biofilm because you’re not feeding them as much. They start to produce more biofilm, they start to go more dormant. There’s that research that a lot of people cite and quote about rifaximin with guar gum showing that rifaximin works better if you give guar gum with it. Essentially what the research was showing- 

Dr. Weitz:                           I think in the U.S. they call it guar gum. 

Dr. Khangura:                    Guar gum? Tomato, tomato. Basically what the research is really showing is that if you bring the bacteria out to feed by giving that gum, the rifaximin will hit the bacteria better.

Dr. Weitz:                            I think that’s the main reason why Dr. Pimentel actually recommends not restricting the diet-

Dr. Khangura:                    Exactly.

Dr. Weitz:                            … because antibiotics work by acting on the cell walls during replication. If the bacteria happily fed, they’re going to be reproducing so it will be more effective.

Dr. Khangura:                    Exactly, yep.

Dr. Weitz:                            But we don’t know that herbs are going to work the same way. In fact, we don’t think that they do.

Dr. Khangura:                    They might not but the way I look at it is there’s another reason why I don’t have patients do one of those strict anti-SIBO diets, especially if the patient has never done it before. If they come to me saying, “I’ve been doing a low-FOBMAP diet for three months straight. It helps reduce my symptoms by 50%.” Okay, we have that benchmark, we know what that diet is doing. We then know if they only get better with the antimicrobials that they are actually doing something. Whereas if a patient has never done that diet before and I’m starting them on eradication and I say, “You know what? You’re also going to do a low-FODMAP diet.” Then in two weeks they tell me they’re 50% better, at that point I don’t know how much is because they’re not feeding the bacteria or how much is because the eradication is working. Then you just have to figure that out. I’d rather not do that. The thing is, it’s not like I tell patients or Dr. Pimentel tells patients to do the opposite of the low-FODMAP diet. Just go nuts on high FODMAPs. Patients aren’t going to feel well if you do.

                                                It’s really about just having some fermentable fibers or sugars in those meals, especially the ones they take the antibiotics with or even the herbal microbials just to cover your bases, just enough that this can potentially help. If they only get better with antimicrobials and you’ve done nothing to the diet, then you know the antimicrobials are very likely the reason for that. There’s actual eradication occurring. That’s the other reason why. There’s certain things I still tell them not to do. For example, there’s that controversy over probiotics and SIBO. What I will say is it’s not black and white but what I do see is that most patients with SIBO will do worse with broad spectrum probiotics. Not always the case but-

Dr. Weitz:                          Dr. Ruscio is a huge fan of using probiotics.

Dr. Khangura:                    I know.

Dr. Weitz:                          His first line for SIBO.

Dr. Khangura:                    That’s one place I think we disagree on. Really what it comes down to is we can all have theories on it but it also is patient experience. A lot of my patients, when I ask about do probiotics make you feel better, no different, worse? This is before I even mention the word SIBO to patients, the patient might not even know what SIBO is. So many patients that have SIBO will say, “That’s interesting you say that because I’m told to take probiotics and I get worse when I take them.” Or this is the dietary thing I tell them not to do, “I’ll drink kombucha and I’ll feel horrible.” Or, “I started eating sauerkraut every day and I just felt worse, worse and worse.” They’re just probiotic foods. Those type of foods I will tell SIBO patients to actually if they are eating to limit them or completely eliminate because if taking a probiotic is actually making their SIBO worse, we’ve got to eliminate those probiotic foods at least while you’re trying to deal with the SIBO. It doesn’t mean they have to eliminate them forever but at least at that point because it’s counterproductive otherwise.

                                                Now, the reason why probiotics may make SIBO worse, it all comes down to the root cause of developing SIBO. It’s not the same for everybody but the majority of SIBO patients is because their migrating motor complex or their phase three contractions of their migrating motor complex have become weakened. Aka the sweeping action of the small intestines. If they’re putting a bunch of bacteria in through the oral route and they’re not being forced into the large intestine where they’re supposed to go and they’re just pooling in the small intestines, they’re still fermenters. They’re still gas producers. They’ve done separate studies on SIBO patients and one study quite a few years ago found that 25% of the SIBO patients had lactobacillus overgrowing. They’re still hydrogen producers. That’s the side I’m on when it comes to probiotics and SIBO.

                                                Bifido species I’m not so worried about because bifido species, they never really have been implicated in causing SIBO, like in separate studies. They don’t seem to be the species that over pools. The one theory on why that is, is that they don’t really survive well in the small intestines whereas lactobacillus species do. Of that 1% of bacteria that’s supposed to live in the small intestines, it’s supposed to mainly be lactobacillus. If they are not forced out, they can survive there. A bifido-only probiotic, which there’s now more on the market as “SIBO okay probiotics.” I don’t see as much trouble with them but with lactobacillus, with probiotic foods I do see quite a few patients have issues with them-

Dr. Weitz:                           We’ve had good luck recommending spore-based probiotics with SIBO patients.

Dr. Khangura:                    Yes, that’s another one I think I’ve seen less issues with. I don’t use a lot of the spore based probiotics with the practice but not for any real reason like that. I haven’t really included it in my practice too much but that is something I’ve seen with patients that, once again, when they mention spore-based probiotics aren’t so bad but this other probiotic is.

Dr. Weitz:                           Yeah, particular the mega spore products we’ve found to be really helpful.

Dr. Khangura:                    Mm-hmm (affirmative).

Dr. Weitz:                           Let’s get into hydrogen sulfide.

Dr. Khangura:                    Sure.

Dr. Weitz:                           So far we’ve been diagnosing hydrogen sulfide SIBO by patients who have IBS SIBO symptoms. We do the breath test and they have essentially a flat line. We see no significant increase in hydrogen or methane. Of course, now Dr. Pimentel has finally come out with the new breath test, the trio, that also includes not only methane and hydrogen but also hydrogen sulfide, which I haven’t used yet but I just got a couple kits.

Dr. Khangura:                    The flat line test results on the hydrogen methane breath test can indicate hydrogen sulfide SIBO. Not always but it can. The other thing I think that really needs to be known is something I really focused on in that lecture I gave in the summer when it came to the SIBO breath test is that, I see it’s been practiced all the time is that when someone has hydrogen sulfide SIBO, they can still have regular looking SIBO test results. Spikes of hydrogen or elevated methane and hydrogen or elevated methane causing hydrogen flat line. All these are still in the realm of possibility. If a patient has hydrogen sulfide SIBO, don’t only look for the flat lines. I think that’s where we’re going to get a lot of value out of the new trio smart test is that now a lot of practitioners are going to see, “Oh wow this patient actually does have a hydrogen spike and they have hydrogen sulfide SIBO.” If I was only looking for the flat line I would have missed the hydrogen sulfide SIBO aspect. That’s why I always teach about don’t just go based on flat lines, go based on medical history and hallmark symptoms of hydrogen sulfide SIBO.

                                                A lot of us know a couple of those hallmark symptoms. One can be chronic, very pungent, rotten egg smelling gas. Not just once in a while but it’s always there. Obviously that smell is produced by hydrogen sulfide gas. Another symptom that can happen is unexplained halitosis. Unexplained bad breath. If their hydrogen sulfide overgrowth is high enough in the small intestines, hydrogen sulfide gas will come up into the stomach, up the esophagus and cause unexplained bad breath. We know that these can be hallmarks of hydrogen sulfide SIBO because when you treat the hydrogen sulfide SIBO very specifically with specific agents, which we can get to in a few minutes, all of a sudden that bad breath starts to go away. The pungent smell goes away. You can also use that as an indicator of your treatment, even if you aren’t using the trio smart breath test.

                                                For example, here in Canada, the trio smart still is not available in Canada just yet. They’re hoping to get it available here hopefully by early mid next year. But up until that point, if you’re not using the trio smart test, looking for those couple hallmark symptoms but there are other things to look for. For example, a lot of us know that high FODMAPs or fermentable fiber foods and fermentable sugars will trigger a lot of classic SIBO symptoms. But hydrogen sulfide bacteria, I call them hypo-fermenters because they don’t just feed on fibers, they don’t just feed on sugars, they also are sulfate reducing bacteria. Foods rich in sulfur compounds will also trigger a lot of the symptoms. Of course, garlic and onions, they’re sulfur containing foods but anyone with SIBO, garlic and onions could cause symptoms. What I ask a lot of patients when I’m trying to figure out if it’s hydrogen sulfide SIBO is I’ll ask them have they ever noticed just eating eggs causes the same bloating or the same gas smell or cramping, diarrhea? Does eating just red meat do the same thing? If they haven’t tested just eating red meat, go ahead and just have a steak and tell me what happens.  It’s because the sulfur compounds in those foods may still be enough to trigger the hydrogen sulfide symptoms. Things such as that, of course the medical history stuff as well. Chronic or reoccurring UTIs, a lot of times, can stem from hydrogen sulfide dysbiosis. Most UTIs are hydrogen sulfide producing bacteria. Well water use, that definitely is an easy way to pickup hydrogen sulfide bacteria if they’re not using the UV light.

Dr. Weitz:                         Okay. What are some of the favorite treatments for hydrogen sulfide SIBO?

Dr. Khangura:                   Naturally there’s less options than we have against hydrogenic and methanogenic SIBO cases. A big reason why … Same thing with pharmaceutically although there’s some really good options in both realms. Hydrogen sulfide bacteria are notoriously resistant to a lot of different antimicrobials and antibiotics. This is why a lot of the hydrogen sulfide bacteria that live in the human gut and propagate in human gut are actually very dysbiotic bacteria. With hydrogen sulfide-

Dr. Weitz:                          Do we know what some of the most common bacteria are that produce hydrogen sulfide?

Dr. Khangura:                    Yeah. The most common ones and the ones that are most common overgrowing, unfortunately in the human gut would be dysbiotic species such as klebsiella species, klebsiella with a K, especially klebsiella pneumonia, proteus species with a P, citrobacter species with a C. Those three are ones I focus a lot on in my seminars because they don’t just cause hydrogen sulfide SIBO, these guys just overgrowing in the colon terrain where we’re supposed to have a lot of bacteria, they are very enterotoxic bacteria. They’re very much correlated with developing autoimmune conditions including Crohn’s and ulcerative colitis and even things like rheumatoid arthritis, proteus and rheumatoid arthritis go hand and hand. Ankylosing spondylitis and klebsiella go hand in hand. They can be bad for us throughout the gut. Now there are some regular bacteria that produce hydrogen sulfide. E. Coli is one. Not the food poisoning E. Coli but the regular E. Coli is a hydrogen sulfide producer. The majority of the hydrogen sulfide producers in the human gut, especially in these gut cases, are the dysbiotic species. Morganella morganii is another species, that’s a big time histamine producer as well. A lot of these histamine cases that doctors see, for some of them it’s actually stemming from the gastrointestinal tract. Obviously Morganella is not the only histamine producer but it’s a big one. That’s another dysbiotic hydrogen sulfide species.

                                                When you diagnose someone with hydrogen sulfide SIBO, just like if you diagnose them with hydrogenic SIBO and you just do it based on a breath test or just based on symptoms, obviously you don’t know exactly what species are overgrowing. Some docs will talk about running a stool test and trying to determine that but the problem with the stool test is it only tells you what’s going on in the colon terrain. It doesn’t tell you what’s going on higher up. You can maybe use the stool test to say, “Look at that. There’s heavy growth of klebsiella, heavy growths of let’s say proteus, maybe they’re overgrowing higher up as well.” But you can’t guarantee that. To treat them, to go back to that question, is that because these guys are notoriously resistant, that’s why they hang around a lot after heavy antibiotic use. That’s another history thing for practitioners to ask their patients is their antibiotic history. Did things get much worse after that?

                                                What I found that works the best when it comes to pharmaceutical antibiotics, if it’s primarily hydrogen sulfide SIBO, you only need to get rid of them in the small intestines and they’re not overgrowing in the colon, rifaximin is a pretty good option. Rifaximin does have proven activity against most of these species but what I’ve seen work even better than rifaximin from the pharmaceutical side would be amoxicillin clavulanic acid or sulfatrim, the sulfur-based antibiotic. When one of these works, it works extremely quickly. I only typically prescribe a five to seven day course of the amoxiclav or the sulfatrim because when it’s working, the patient should see significant changes in those five to seven days. If they haven’t seen much change in five to seven days, I don’t typically continue the same antibiotic. I’ll switch to something else.

                                                Now, of course, these antibiotics do come with some side effect risk and things such as that. If you want to go natural or you can’t prescribe the antibiotics, what I find works best for hydrogen sulfide SIBO naturally, I do this combination quite a bit but it’s the herb uva ursi which a lot of us know or use for UTIs. The biggest reason why it’s used for UTIs is most UTIs are caused by hydrogen sulfide producing bacteria. Uva ursi is very specific at killing hydrogen sulfide bacteria. If they’re overgrowing in the gut, it will hit them there first. I do use a very concentrated version of uva ursi. I’ll use a one to one or one to two tincture which can be tough to get. Some good herbal pharmacies do carry it but most of the times in health food stores you’ll find a one to four or one to five. 

Dr. Weitz:                            Are there products on the market that are available to practitioners that you could recommend?

Dr. Khangura:                    We typically just get the tincture from a good herbal dispenser here in Canada. There will be some good herbal tincture dispensaries and pharmacies in the States, I’m sure, that make a one to one uva ursi or a one to two. It’s easy to get a one to four, one to five like at a health food store but the patient would have to take boatloads of it to really work for hydrogen sulfide SIBO case. With a one to two, which is the one I typically use, I’ll do about three and a half to four milliliters twice a day with food. About seven to eight milliliters a day. It does contain hydroquinone, which some people worry that will affect the liver and cause liver damage. There’s always a theory that hydroquinone in uva ursi might but it’s never really been solidified. The hydroquinone in uva ursi is called arbutin and yes, I don’t prescribe an extensive amount of it. I’ll prescribe about two weeks at a time but in my opinion it’s not a big thing to worry about. But if you do the three and a half to four mils of a one to two for two weeks, unless the patient has a history of liver issues and liver disease, I don’t think there’s much of a problem.

                                                That’s one agent I use that can work very specifically for those guys. If you give someone that uva ursi and the patient is getting better, you know you’re specifically treating hydrogen sulfide bacteria. That’s really all that goes after. It doesn’t go after hydrogen or methane bacteria. Now, another product that can be used with uva ursi that can work in a lot of cases is silver agent. Old school colloidal silver is out there but the newer version of silver called silver hydrosol, which instead of the silver bound to the water molecule, the silver is part of the water molecule. The hydrosol version, about 99% is eliminated in 24 hours and about 100% is eliminated in 48 hours. It doesn’t actually pose the risk of giving the patient Blue Man syndrome like standard colloidal silver does because that one, the silver can disassociate from the water molecule in the colloidal silver version. Silver hydrosol it can’t do that. But silver is very antibacterial, as I’m sure you know. Hydrogen sulfide bacter is something it can target. A lot of times I’ll do a silver hydrosol product with uva ursi as a combo, kind of natural therapy or sometimes I’ll do one of those with other herbs because the patient has hydrogenic SIBO as well or they have methane producing SIBO as well.

                                                This is another tangent but the thing is, as well, if someone has one form of SIBO, they usually have … Let’s put it this way. A patient usually has more than one form of SIBO. Sometimes they might just have hydrogenic SIBO and very low methane and no hydrogen sulfide overgrowth. That does happen. But usually if someone’s migratory motor complex isn’t working very well, they are going to have an over pooling of bacteria across the board. Not always all three but usually two of the three. Doing a well rounded treatment, even if the patient has hydrogen sulfide SIBO, is recommended. Sometimes I’ll do a very specific hydrogen sulfide treatment first just to see what gets better first and then move on from there.

Dr. Weitz:                            Okay. Small intestinal fungal overgrowth. This is something that comes up when we have a patient with IBS SIBO type symptoms and the breath test is negative. Then we ask ourselves, “Could this person have SIFO.” How do we diagnose that? How often does that happen? What do we do about it?

Dr. Khangura:                    That’s always the million dollar question is how to diagnose SIFO or just fungal dysbiosis in general. SIFO, obviously, is just a good, obvious buzz term that’s been created because of SIBO. But it’s always been, whatever you want to call it, yeast overgrowth, candida overgrowth, fungal overgrowth. Sometimes it is isolated to the small intestines or that’s where the big problems are happening and sometimes it’s in the colon. But diagnosing it, no matter where it is, can be tough because there is no breath test to determine if someone has SIFO because the only gas those fungal species produce is carbon dioxide. We, as humans, obviously breathe out carbon dioxide. We can’t distinguish what’s from what. There are stool tests that will do yeast cultures and microscopic counts of yeast. If there is an overgrowth of the yeast, at least in the colon, that might be a decent test to diagnose at least colon yeast growth. That might mean they do have too much yeast high up in the small intestines as well. For diagnosis, put it this way, I don’t test for fungal growth as much as I test for SIBO but you can definitely look for hallmarks, again.

                                                Prevalence, I would say SIBO at least being the root cause behind someone’s “IBS” case is higher than a fungal dysbiosis being the root cause. A lot of times they happen together. Sometimes, depending on what SIBO treatment you give, it actually might make the fungal dysbiosis worse as well. You’ve got to keep in mind should I do a fungal treatment along with the SIBO treatment or just wait and see. Some hallmarks for fungal overgrowth, of course-

Dr. Weitz:                            For example, if you use the elemental diet, that tends to promote the growth of fungal because there’s sugar in it.

Dr. Khangura:                    Yeah, exactly. Another thing could be even the pharmaceutical antibiotics. Rifaximin I’m not really worried about it causing a problem because it’s not eradicating good bacteria in the large intestine where fungal growth can start to take hold is in the colon. But those other antibiotics, neomycin, potentially Metronidazole, amoxi/clav, sulfa/trim, they all could make the fungal growth worse as well. But elemental diet, yeah, you’re right. That can be a problem as well. There are some keto versions of the elemental diet out there now, without the glucose, which tastes even worse than the standard elemental diet. Most patients don’t go for it anyway. Basically looking for certain hallmarks as well. What I see in practice at least, maybe you see the same thing, is that when someone has a chronic gastrointestinal fungal issue is that it will present systemically in a lot of ways as well. Maybe it’s oral thrush but maybe a fungal scalp problems or recurrent fungal infections on the skin elsewhere. It doesn’t always have to be scalp or it doesn’t always have to be athlete’s foot. If it’s a female patient and they get recurrent vaginal yeast infections. A lot of these things can stem from a fungal dysbiosis as the root to all these systemic issues.

                                                If you have a patient with a lot of that history, consider that they might be stemming from the gut. Then asking patients specific reactions to things as well. The classic would be the sugar in alcohol because that would be the primary fuel source for the fungal species. What I’ll ask patient about sugar is not just does it cause gastrointestinal symptoms but I’ll ask questions such as, I usually just ask first, “If you eat a candy bar, does anything strange happen?” Just let them answer without me leading them. Then if I need more details I’ll ask, “Okay, if you ate that candy bar, would you feel like you almost had a drink or two an hour later? Almost like that buzzed feeling? Or maybe not the buzzed feeling but you feel like you’re getting a little bit of a hungover feeling a few hours later or even the next morning?” Same thing with alcohol. I would ask, “Are you very sensitive to alcohol? Do you have one drink and feel like you had two or three? Or is it that you only have one drink but the next day you feel like you had two or three? Or even more?”

                                                The big reason for those questions isn’t just that they use it as a fuel source, is that especially candida species, they’re probably most harmful metabolite is acetaldehyde. Acetaldehyde is caused by a neurotoxic and it’s also a carcinogenic. Heavy production of it over years is not very good for us. But that metabolite from fungal species definitely can cause things like brain fog, that hung over feeling, nausea, tachycardia, increased heart rate. If patients are getting those kind of strange reactions when they have high amounts of sugar or alcohol, I’ll definitely start to suspect fungal growth and possibly include a fungal treatment.

Dr. Weitz:                            What’s your favorite fungal treatments?

Dr. Khangura:                    Once again, break it down to pharmaceutical and natural because there’s obviously pros and cons. One of the pharmaceutical agents that I do use is high dose nystatin. I’ll get it, at least here in Canada, we can’t get it in capsules anymore, it only comes in liquid with things like parabens in it and all that. I don’t prescribe that version of it. I get a compound into capsules. I do about three million units a day. One million units three times a day. You can go up to five million units a day but the higher you go, the higher chance of gastrointestinal symptoms. That’s one reason why I go with it is that it’s not really a dangerous medication by any means. It’s nonabsorbable. If it’s going to give side effects it’s usually gastrointestinal side effects. At three million units a day, most patients tolerate it just fine. Because it’s nonabsorbable, it can target the fungal species throughout the GI tract, small intestines and large intestine. You don’t have to worry about it being absorbed before it hits, let’s say colon growths. It’s very effective. Nystatin, it’s old school it’s been around for years but it is still very effective at killing most candida species by disrupting their cell membranes. I do use that one quite often.

                                                I don’t prescribe Fluconazole or other azole antifungals that often. In some cases they are the magic bullet but they do come with a higher list of potential side effects, some more contraindications with other medications which could be dangerous depending which medication the patient is on. Short term use, they’re not that bad but I know of docs that will do two, three, four, five, six weeks of it. It’s still a pretty moderate dose but then you’re running into potential problems. I do find good success with nystatin pharmaceutically. I’ll typically start with that. But naturally there’s some very good options as well. They’re all pretty much fatty acids. A lot of them coconut oil derived but not all of them. Obviously a lot of people know about caprylic acid. Caprylic acid and capric acid from coconut oil are definitely very good antifungals. Those acids don’t only disrupt the cell membrane of the yeast, they also inhibit the hi-fi formation of the yeast. Candida species are polymorphic. They can go from a dormant, uni-cellular form to a multi-cellular form. It’s the multi-cellular form that’s the problem. They can even produce hi-fi, these little legs that come off the cell body to be more invasive. Caprylic acid and capric acid can actually inhibit that. It can also arrest the cell cycle of candida when they replicate. It doesn’t just kill the candida, it can actually inhibit the replication efficacy.

                                                Getting that from pure MCT oil is an option. You can get higher doses much easier. The benefit of doing a caprylic acid supplement like a magnesium caprylate or a calcium caprylate is that when they combine it with the mineral, it will get further down the GI tract. If you are worried about that, just the pure MCT oil version of it, which is easy to get the high dose, it may absorb too quick. That’s the one issue. Then there’s another fatty acid from coconut oil which gets not as much attention-

Dr. Weitz:                           By the way, what’s the dosage you use for caprylic acid?

Dr. Khangura:                    If I was doing … Ideally if you’re doing an MCT oil, I’d go up to three grams two to three times a day, up to.

Dr. Weitz:                           Okay.

Dr. Khangura:                    One to three grams, two to three times a day of pure MCT oil. Some patients don’t do well with high amounts of fat for various reasons. You’ve got to be careful with that. But when it comes to the caprylic acid supplements, the ones that can get a little bit further down, I typically don’t do up to three grams three times a day. I’ll do maybe a gram, 1,000 milligrams three times a day. If that’s a pure caprylic acid supplement or it’s one that has other ingredients in it, they might be taking a bunch of pills compared to eating the oil. But up to tolerance, too. If they can go a little bit higher in the fatty acids not causing any sort of strateria or nausea or anything like that, I’ll push it a little bit, especially if they’re getting better.

                                           The other fatty acid from coconut oil, lauric acid, monolaurin is the supplement version of it. I’m a huge fan of monolaurin. There’s a product at least here in Canada that’s available called Lauricidin. It’s monolaurin in a little tub. Monolaurin comes in this little soft, white pellets and it comes with a scoop. You put a scoop of it in your mouth, you swallow it with water. You don’t chew them or anything like that. It will taste like soap. Make sure to tell your patients not to do that. But monolaurin is very, very antifungal, well proven like caprylic acid. It also inhibits the actual replication efficacy of candida species. The bonus of monolaurin, which caprylic acid doesn’t have, is that monolaurin has also been shown to be very effective against gram positive bacteria. It’s not very effective against gram negative. The problem with SIBO is most SIBO cases have gram negative bacteria overgrowing. In some SIBO cases, if it is gram positive bacteria, monolaurin might actually help. It might cross that threshold and an antiviral as well. Monolaurin, for viruses that have a lipid membrane, monolaurin does have antiviral capabilities against that as well.

Dr. Weitz:                           A number of the antimicrobial herbs like [inaudible 00:58:13] and oregano are known to have antifungal properties as well.

Dr. Khangura:                    Yes, that’s exactly it. There are some herbs, too, that can cross over from the SIBO side of things to fungal. A lot of times when you’re prescribing a patient high dose herbs for their SIBO, you’re actually treating maybe a fungal growth that’s there as well and you don’t even know it. But the patient is getting better. That is true. Allicin extract, [inaudible 00:58:36] is a really good antifungal herb and can work in some SIBO cases as well. When you’re talking specific for fungal, these fatty acids are really where it’s at. There’s another fatty acid from castor oil called 10-undecylenic acid. This has been around for decades. It was one of the original over the counter creams back in the 70s has 10-undecylenic in it. It’s still, to this day, extremely antifungal. It’s just gone to the wayside of popularity. You can still get it in supplement form. Thorn still makes it. They have a funny name for the product but it’s called Formula SF722. That’s their 10-undecylenic formula. It comes in little soft gels. You’ve got to take a high dose of it, four soft gels three times a day is what I would dose it at. But 10-undecylenic acid, it can directly kill the yeast but what it’s really, really good at is inhibiting the yeast from replicating, inhibiting the yeast from wanting to multiply. When you treat fungal species with-

Dr. Weitz:                          Castor oil is pretty toxic, right?

Dr. Khangura:                    Yeah, no don’t drink castor oil. Let’s make it clear on that. This is a fatty acid from castor oil. This is totally safe to take internally. Don’t drink castor oil, everyone.

Dr. Weitz:                          Isn’t that where they get ricin from, I think?

Dr. Khangura:                    Yeah. Is it from castor beans? I don’t know. [crosstalk 01:00:05] I think so. Something like that. Don’t drink castor oil but the supplement 10-undecylenic acid, that’s okay to take. It is very, very effective at inhibiting yeast from being opportunistic. That is a big difference between treating fungal overgrowth and SIBO is that yes, some of the bacteria overgrowth in SIBO could be opportunistic, especially some of those hydrogen sulfide dysbiotic bacteria but the majority of bacteria overgrowing in a SIBO case are not opportunistic. Fungal species are totally different. These candida species are very opportunistic. They wait for a chance to replicate and take over. One thing they can do, when you come at them with artillery and I see this mistake in a lot of practitioners is they’ll just throw a bunch of nystatin at it or a bunch of whatever, caprylic acid at it. The problem is, the candida, when you do that, if they’re already in a stronghold, they can start to multiply faster in the presence of you trying to him them with artillery.

                                          What I like to do with a lot of these yeast cases, I’ll put them on things like a 10-undecylenic or the one reason why I use the monolaurin as well or even caprylic acid is a lot of these natural agents don’t just kill the yeast, they inhibit their ability to be opportunistic. They inhibit their ability to replicate quickly. If you come at them with that aspect, you’re probably going to have more success. Even though I do prescribe nystatin very often, I’ll typically still give 10-undecylenic acid with it or monolaurin with it so we can hit it from multiple viewpoints.

Dr. Weitz:                          Cool. This has been a great discussion Dr. Khangura. Any final thoughts? How can practitioners and listeners and viewers get ahold of you? You have a great course for practitioners available.

Dr. Khangura:                   Like you mentioned at the beginning of the chat, I’m up in Victoria, B.C., Canada. Because I’m doing a lot more stuff in the States I’ve been having a lot of U.S. patients wanting to book. Unfortunately I can’t take any U.S. patients. I still have to keep that to Canadian patients but for any U.S. practitioners that are looking for either the comprehensive course in SIBO and dysbiosis in general, my latest course is called Beyond Superseding SIBO. I’ve had a series of them over the years and my latest one is still up for registration. The website is SupersedingSIBO.CA. Seding is S-E-D-I-N-G, not two E’s. It’s about a six hour course, very comprehensive on SIBO and other dysbiosis including some fungal. Next year I’m hoping by spring 2021 I will have an updated version of this course with more specifics on certain areas. Obviously as time goes by there’s more to learn about and more to teach about. This will be my most comprehensive course at this point.

                                          Otherwise, any closing comments, the one thing I like to mention is that I understand where a lot of practitioners are coming from, is that SIBO seems almost like a fad diagnosis in the last few years. A lot of practitioners are starting to scoff at it because of that saying that it’s the new thing, it’s the new flavor for diagnosis of IBS and all that. The one thing I will tell practitioners that maybe think that’s true is that give it a chance with your patients because if you have not gone down the road with SIBO with most of your “IBS” patients and your looking at your practice and wondering why just cutting out wheat hasn’t helped them, just cutting out dairy hasn’t helped them. Giving them a healthier, more fibrous diet has made them worse but you don’t have any answers for it. Definitely start looking into SIBO specifically as the diagnosis. It’s not an end all, be all by any means for a lot of patients, it’s just part of the problem. I talked to Dr. Ruscio about practitioners really need to be careful not getting into SIBO tunnel vision, once you get that SIBO diagnosis a lot of us just look at that and be like, “We’ve got to tackle this, we’ve got to tackle this.” You’re missing something else.

                                                But for the practitioners out there that don’t even consider SIBO, I really do recommend starting to look into it more because for a lot of patients it really is the very, very specific root cause. We talked about the stubborn cases but some cases will resolve in two to four weeks. We’re talking 10, 20 years of IBS, gone in two to four weeks of treatment. If that’s what the patient needs, that’s what they need. Really, just putting it all together. That’s the way I look at it. That’s what all of us, integrative and functional, whether naturopathic doctors or medical doctors need to do is put it all together from all angles.

Dr. Weitz:                           Excellent, excellent. Thank you.

Dr. Khangura:                    No problem at all.



Integrative Dermatology with Dr. Julie Greenberg: Rational Wellness Podcast 193

Dr. Julie Greenberg discusses an Integrative Approach to Dermatology with Dr. Ben Weitz.

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Podcast Highlights

1:26  Conventional Dermatology approaches skin problems as if they totally separate from the rest of the body, but the functional medicine or naturopathic or integrative approach looks at the whole person. This is why the conventional dermatology world is having so much trouble with chronic dermatological conditions like acne, eczema, psoriasis, and rosacea.  Many patients with eczema will be prescribed a steroid, which reduces the symptoms, but once they stop the steroid, the condition tends to come back and then they go back and get more steroid like hamster on a wheel.  We treat the skin condition from the outside in and merely suppress the symptoms. We need to understand that the skin is a reflection of what’s going on inside the rest of the body.  The source of many skin conditions is coming from the gut and what’s going on inside the body.  If we take a Functional Medicine/Integrative approach, we search for the root causes and treat your skin condition from the inside out. Of course, we can also do some topical treatments to help with the symptoms, while we are treating the underlying causes of the inflammation.

4:43  Eczema.  There is much discussion about the microbiome in the digestive tract, but the skin has its own microbiome. Let’s take eczema, we often see the pathogen, staph aureus present on the skin in large amounts. When it is present in the skin, it is usually also overgrown in the GI tract and it often colonizes the nose, so we have to treat the staph not just on the skin, but also in the GI tract, and in the nose.

6:09  Leaky gut is when the intestinal mucosal layer is damaged and allows large molecules and toxins to enter the body, resulting in immune problems. But leaky gut often results in leaky skin, such as in eczema when we see that early skin barrier disruptions can lead to food allergies and asthma. Babies with skin barrier disruptions are six times more likely to develop food allergies.

9:05  Leaky skin is also a reason why you want to treat the skin topically as well as treating the gut and the other underlying, root causes of skin conditions.  With eczema, we want to keep the skin moisturized to help that skin barrier. Skin pH is very important and the skin needs to be acidic to function properly, which is from 4 to 5.5. In nearly every dermatological disease, the skin barrier has become more alkaline.  Staph aureus thrives at a pH of 7.5. This is similar for other common skin pathogens, like strep bacteria, herpes virus, malassezia, or candida, which all want a more alkaline skin pH.  There are certain supplements like L-histidine that can help with this.

11:10  Coconut oil is often touted as being good for your skin, but while it has potentially beneficial antimicrobial properties and can be beneficial to use it to spot treat skin conditions and can be blended with essential oils to kill off things like staph aureus on the skin or malassezia, coconut oil should not be used as your main moisturizer since it can dry out your skin. It is often said that coconut oil has an alkaline pH, but technically oils do not have a pH because pH is based on water. If you want to make your skin more acidic, the water-based products like aloe vera gel, apple cider vinegar, and hydrosols would be the best to use.

14:10  There is a strong gut skin connection and there is a lot of research that correlates an abnormal, dysbiotic microbiome with specific dermatological conditions, such as eczema, psoriasis, and rosacea. With most patients with skin conditions, they have something wrong with their gut, whether it be overgrowth of certain bacteria or protozoans or candida overgrowth. Rosacea is often associated with SIBO and H. pylori.  Psoriasis is often associated with pseudomonas and with streptococcus overgrowth. Acne is often associated with H. pylori. So is alopecia areata.  With eczema there is often a staph aureus component.  Dr. Greenberg likes to run the GI Map stool test and the Organic Acids Test from Great Plains Lab for patients who can afford them, since they are not covered by insurance.  The OAT test will tell if there is a candida overgrowth, that doesn’t always show up on the stool test and the OAT test can also test for fusarium and aspergillus, which would indicate a bigger mold problem. 

19:56  H. pylori. If H. pylori is found on a stool test, it is controversial whether or not it is considered a normal part of the gut (commensal) or is it pathological and should be treated?  There is also controversy about whether H. pylori is associated with hyper or hypochlorhydria.  We know that H. pylori can be present and cause problems or it can be present and not cause problems.  If you see elevated H. pylori and a bunch of virulence factors, this indicates that it is pathological. If H. pylori is present with no virulence factors but all of the dysbiotic and autoimmune trigger bacteria are high and they are low on elastase and the steatocrit is high, then H. pylori is a problem and needs to be treated.  Dr. Greenberg usually sees hypochlorhydria when she sees H. pylori and low stomach acid tends to foster the growth of staph and strep and prevotella and fusobacteria that are often associated with skin conditions.  So reducing the H. pylori is often helpful, which Dr. Greenberg likes to use Pyloricil by Orthomolecular.  She will use mastic gum and DGL and GlutaShield.

25:23  Eczema.  Eczema is also known as atopic dermatitis, which is extremely common in children.  And eczema is probably more common in adults than often recognized, though not every rash is eczema.  Eczema in children is a Th2 driven pathway, though Th1, Th17, and Th22 are immune pathways that may also be involved in eczema. Eczema is often associated with staph infection and such infants are usually deficient in filaggrin, which is a protein in the skin that is a master regulator of the skin barrier, a natural moisturizer, and it controls the pH of the skin. Filaggrin is composed of several amino acids, including L-glutamine and L-histidine.  If you give 4 gms of L-histidine per day to adults for one to three months, this improves the skin barrier and reduces staph bacteria equal to the effectiveness of a topical steroid.  For Children she will use Clark’s rule for dosing and then only for 2-3 months and then ramp down.  Here is a study showing effectiveness of L-histidine in eczema:  Feeding filaggrin: effects of l-histidine supplementation in atopic dermatitis. 

29:47  Topically, it is important to reacidify the skin, since staph bacteria love an alkaline pH.  Apple cider vinegar diluted 50/50 with warm water applied to the skin is a way to make the skin more acidic. Hydrosols, which are the water based product that results from making essential oils, can also be helpful in acidifying when applied to the skin.  Making sure your skin is kept acidic will not only help with reducing eczema, but our skin will age slower and you will have less wrinkles and dark spots.  Dr. Greenberg recommends using aloe vera gel, rosemary hydrosol, and a serum blend that she makes every day to try to keep the wrinkles away. 

There are a number of foods that can be triggers to eczema, including dairy. If you see an infant with bad eczema and cradle cap, then you most likely have an overgrowth of candida in their gut, because cradle cap is a yeast on the scalp called malassezia.  The malassezia eats our sebum and overgrows. As they produce antibodies against the candida, then there is often cross reactivity with the malassezia yeast.  Drinking milk (cow, goat or any mammalian milk) seems to make these infants worse.  They would do better with plant based formulas, according to Dr. Greenberg.

35:40  Low vitamin D is a risk factor for eczema and Dr. Greenberg said that she will add vitamin D for nearly every patient, except for those with rosacea, who have an antimicrobial peptide on their skin called cathelicidin, which gets exacerbated by vitamin D.

36:32  There is a topical vitamin B12 pink cream that you can get compounded in the pharmacy that helps a bit with inflammation that is fairly popular, but this is really a symptomatic treatment and Dr. Greenberg doesn’t use it that much.

37:26  Psoriasis.  We used to think of psoriasis as mostly a Th1 mediated inflammatory disease, but then we discovered Th17 and Th22 as other pathways tied in with mucosal inflammation.  There’s an herb scutellaria baicalensis, which is Chinese skullcap. Research study after research study, it has been shown to decrease Th17 and IL-17 and increase Treg and IL-10.  Psoriasis is an inflammatory system condition that is a response to a massive overgrowth of bacteria, like strep. Pseudomonas can also be a driver for psoriasis. When the psoriatic plaques are tested, we find DNA of gut microbial origin. There is often a compromised skin barrier. On top of the primary infection, such as of strep, there is often also a secondary infection with staph or malassezia or candida yeast. With psoriasis we have to treat the strep in the tonsils and the gut as well as the skin.  For older kids and adults she will use nasal sprays, including colloidal silver, propolis, a saline spray with an essential oil blend. Dr. Greenberg’s go to product is an ACS nasal spray with colloidal silver with echinacea and some herbs. For the strep she likes the Biocidin throat spray.  Bile can also be helpful, so Dr. Greenberg will often use a digestive enzyme formula that included hydrochloric acid and ox bile, like DuoZyme by Karuna or Panplex 2 by Integrative Therapeutics. Herbal bitters can also be used, esp. in kids, who can’t swallow capsules.  There is a topical vitamin D that some practitioners use for psoriasis, but Dr. Greenberg feels that it is not addressing the root cause.  Psoriatic skin pH is alkaline, so using topicals to acidify the skin is beneficial, so she will recommend topical emollients made with indigo naturalis, which is an herb that has been studied with psoriasis and it has been shown to decrease IL-17.  However, this product will have a blue color, so it can stain clothes and sheets.

49:34  Dr. Greenberg does not like skin creams that combine oils with water based products mixed together, since they require a chemical called an emulsifier such as parabens or other endocrine disruptors and a preservative. Plus, a lot of oils in lotions are mineral-based or petroleum-based, which are not good for the skin either.  It is much healthier to have the oil and the water based products in separate bottles and apply these products on the skin separately without emulsifiers and preservatives. 



Dr. Julie Greenberg is a Naturopathic Doctor who specializes in Integrative Dermatology. She is the founder of the Center for Integrative Dermatology in Santa Monica, California, a holistic clinic that approaches skin problems by finding and treating the root cause. Dr. Greenberg holds degrees from Northwestern University, Stanford University, and Bastyr University. She lectures at naturopathic medical schools and speaks at conferences across the US on dermatology. Her website is IntegrativeDermatologyCenter.com.

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


Podcast Transcript

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

Today, we have a fascinating topic, which is integrative dermatology with Dr. Julie Greenberg. We’ll look at a general approach for a naturopathic or integrative approach to dermatology, and we’ll also dial down a little bit on two of the more common and troubling conditions, which are eczema and psoriasis. Dr. Julie Greenberg is a licensed naturopathic doctor who specializes in integrative dermatology.   She’s the founder for the Center for Integrative Dermatology, a holistic clinic that approaches skin problems by finding and treating the root cause. Dr. Greenberg holds degrees from Northwestern University, Stanford, and Bastyr University. Dr. Greenberg, thank you so much for joining us today.

Dr. Greenberg:                 Thanks, Ben. I’m happy to be here.

Dr. Weitz:                         Absolutely. Conventional dermatology approaches skin problems as if they are totally separate from the rest of the body, but the functional medicine or naturopathic or integrative approach looks at the whole person. Can you talk about how your integrative naturopathic approach is different?

Dr. Greenberg:                 Yeah. I think it’s the main point of why we’re having so much trouble in the conventional dermatological world with these chronic dermatological conditions. If you have something acute, if you have a staph infection, you can go to a dermatologist, get a prescription for antibiotics, and the staph infection like an impetigo will be cleaned up right away. But if you have something like eczema or psoriasis or acne, these long-term, rosacea, chronic skin diseases, I think patients and practitioners know that a lot of people experience kind of a hamster wheel where they go in, they get maybe like a steroid for eczema.   The eczema goes down. Then they stop the steroid. The eczema comes back. They have to go back, get more steroid, and you kind of get on this hamster wheel where you have to use more and more topical things and then they’re not working. The reason is because a lot of what we’ve done conventionally is to approach the skin like, oh, it’s happening on the skin, so we’re going to do it from the outside in, and we’re just going to suppress symptoms.

                                                But in the functional medicine and the naturopathic medicine world, we know the patient sitting in front of you is one human, one body, all systems are connected, mind, body, and spirit, and everything affects the other. When it comes to these chronic dermatological conditions, there are so much evidence now that the inflammation that’s happening that’s causing the things to appear on the skin, they’re not happening topically at the skin. I mean, we see them, that’s where the end game is, but the source is actually coming from inside, much of it from the gut.   Therefore, we are not going to successful treat patients and get to the root cause just by coming at it from the outside in and trying to suppress symptoms. We have to take this functional medicine, naturopathic medicine, whole person approach and connect the systems and address it at every level.

Dr. Weitz:                         The skin is really a reflection of what’s going on inside the rest of the body.

Dr. Greenberg:                 Absolutely, and that’s what I tell patients. I think a lot of patients feel that their body has turned on them, like, why is this happening? Why do I have acne or rosacea? Why is my body doing this to me? I try to reframe it for them like, look, your body is always on your side. It’s always trying to do the best for you that it can. And when we see these kinds of skin presentations, whether it’s in an infant having just terrible eczema, I’ve seen 90% of babies covered in crusting bloody lesions or adults who have this chronic nodulous cystic acne, it’s not because your body has turned on you, it’s that it is telling you that it has a problem inside it cannot resolve, and it needs help.  And we’re going to get in there and help it. And that’s all it is, it’s just a signal to your body, to yourself like, we got big problems inside, and we can’t handle it. And that’s why this is happening.

Dr. Weitz:                         Right. And interestingly, most people don’t realize this. They know about the microbiome inside the digestive tract, but the skin has its own microbiome and that’s so important to the health of the skin. We might even consider the skin a part of the digestive system.

Dr. Greenberg:                 Yeah. I mean, for me, again, taking this everything is connected, depending on the disease, like let’s take eczema, I’m thinking about the pathogen staph aureus. It’s always basically present in eczema on the skin in too large of amounts. It’s not an infection like we would see in like an abscess or impetigo, but it’s an over colonization. It’s causing problems on the skin. It also colonizes the nose. And usually when we got tested, it’s overgrown in the GI tract. Again, there’s this concept that we can’t just pay attention to one thing.  The skin microbiome is critical, of course, to what’s happening on the skin, but we have to treat the nasal colonization or the staph will keep coming back, and we have to treat the gut colonization because if you have leaky gut, then leeching staph aureus into the bloodstream as well. It’s critical. The skin microbiome, the oral microbiome, and the gut microbiome are distinctly different. They look very different, but they are all absolutely interrelated and absolutely when it comes to dermatological disease.

Dr. Weitz:                         You mentioned leaky gut. Most of us who deal with patients with gut problems and people who do have chronic gut problems I’m sure have heard this term a lot is that leaky gut is often common at the intestinal mucosal barrier is broken down, allowing toxins and large proteins to get in, which cause immune problems, et cetera. But often people who have leaky gut often have damage to the barrier in the skin. Leaky gut often results in leaky skin.

Dr. Greenberg:                 Yeah, we see both. Anytime the skin barrier gets compromised, you’re going to get leaky skin. There’s an interesting aspect of leaky skin as it pertains to eczema, because we know that for infants and babies that early skin barrier disruptions can lead to food allergies and asthma. The same idea that we have like… I think most of your listeners know what leaky gut and that things are leaking through the intestinal lining, getting into the bloodstream and causing an immune response. The same thing can happen topically with leaky skin.  And it’s actually quite dangerous in infants because their immune system is learning what in the environment is okay and what is not. And if their first introduction to like a pollen or a food protein comes through the skin, that’s an inappropriate presentation to their immune system and they can get primed in a way that’s not good, and it can lead to food allergies and asthma. We know this not just statistically, like because babies with skin barrier disruptions are six times more likely to develop food allergies. I do mean allergies, IgE, not just IgG, IgA.

                                                But they’ve done studies in mice where they’ve actually first created eczema on the backs of mice. These mice had no problem with eggs before, no antibodies. They then taped gauze filled with ovalbumin or egg white protein in cycles to their backs, and they created IgE and IgG antibodies and full blown egg allergies in these mice where they never had them before. We know what happens because of the numbers, but they can actually be created in the lab. You give the mouse eczema and then you can induce a full blown food allergy.  The leaky skin is a huge issue. And it’s something, particularly in my eczema babies, I talk to parents about we really want to try to clean up the skin barrier as quickly as possible. Because for them, it’s a whole different issue than somebody who’s an adult who has skin barrier disruptions.

Dr. Weitz:                         Of course, it’s also a reason why you want to use some topical treatment to treat the skin, as well as treating the inside underlying root causes of the skin condition.

Dr. Greenberg:                 Yeah, absolutely. I mean, we know with eczema, we want to keep the skin moisturized. We want to try to help that barrier. I focus a lot on skin pH.  I think we know the stomach is supposed to be very acidic. The blood is very tightly regulated at 7.4. If the blood pH gets much off of 7.4, we can die. But people don’t realize that the skin has its own pH that’s absolutely critical.  I ask every patient… Now that I’m doing telemedicine, we do a screen share and there’s a slide on pH.   We go through the scale, what’s acidic, what’s alkaline, and I have them just guess, where do you think the skin pH to be? And I think just to feel safe, most of my patients guess seven, like neutral, water, blood, which is a reasonable guess. But the truth is, it’s acidic. The skin needs to be acidic to function properly, which is about anywhere from 4 to 5, 5.5. I definitely do things to help bring that skin pH back down again to protect it. Because we know that in basically every dermatological disease, the skin barrier has become more alkaline.   It’s not at four to five. It’s up higher at six or seven. And that leads you susceptible to pathogens. Staph aureus, for example, it wants 7.5. But if you name any pathogen, whether it’s like a herpes virus, malassezia, or candida yeast or bacteria, all of those pathogens want a more alkaline skin environment so that it can thrive and so that our natural defenses can’t attack it.  If we can do things topically to pull that skin pH back down and internally, there are supplements I use like L-histidine to do that, we can definitely improve the skin barrier and start to see improvements on whatever the skin disease is.

Dr. Weitz:                            Yeah, I find that interesting. Same thing for the importance of hydrochloric acid to help keep the bacteria from overgrowing in the small intestine. I think there’s been this over emphasis in health enthusiasts about having an alkaline system, about being acidic is bad, being acidic causes disease, causes cancer, causes all this stuff, so the answer is to drink alkaline water and to eat this alkaline diet. There’s a lot of problems with that, and especially when it comes to the skin, trying to alkalinize your skin. I talked to Jennifer Fugo about… She’s a big opponent to using coconut oil on the skin, which a lot of people feel is good, but it’s very alkalinizing, and so it ruins the acidic pH of the skin.

Dr. Greenberg:                 Jen and I have had discussions about coconut oil. I know she’s not a fan. I’m not a fan of people using stripped coconut oil day after day as their moisturizer, because it can dry out the skin. I mean, the things that I do to make the skin more acidic, they’re more of the water-based products, things like aloe vera gel, apple cider vinegar, hydrosols. All the water-based products have this acidic pH. Technically an oil doesn’t have a pH, because the pH scale is based on water and stripped oils don’t have it.  It gets a little more complicated when we’re talking about something like coconut oil. I use coconut oil to spot treat topical skin problems, but I only use it to spot treat, and I only use it when we do essential oil blends to kill off things like staph aureus on the skin or malassezia or something like that. I do think it gets overused, and I don’t like people to use it as a general moisturizer.

Dr. Weitz:                         But for therapeutic purposes, coconut oil has this antimicrobial benefit, right?

Dr. Greenberg:                 It does, and there’s plenty of studies that show that use of coconut oil versus let’s say mineral oil or even olive oil in eczema patients, it’s a lot more effective at lowering staph. I do think there is a time and a place for coconut oil, but it’s not kind of the panacea that sometimes… If you look at YouTube, it’s like you can use coconut oil for everything. You can use it for a lot, but I wouldn’t it as your main moisturizer.

Dr. Weitz:                         It’s funny how Google was kind of the bane of our existence for a while. Everybody is saying, “Oh, I just Googled it.” And now everybody is coming in saying, “Oh, I just watched the YouTube video.” We’re having that with chiropractic. “Aren’t you going to do that adjustment? What about the one where you pull the towel and pull on my head? I saw that on YouTube. That fixed everything.” It’s kind of interesting.  In terms of dermatological conditions, we were talking a little bit about the gut bacteria, and I know that you find it super important to look at the gut as a way to analyze what’s going on underneath. Why is gut health so important?  And then what test do you like to do to analyze gut health for patients with skin conditions?

Dr. Greenberg:                 For me, it really is critical to look at the gut so that I can get to the root cause of what’s driving the skin disease. There is a lot of research out there. It’s not pulled together into a cohesive body. But once you start going looking for it, you can do research for each different type of dermatological disease like eczema, psoriasis, rosacea, on and on. And you will find studies and research that show that the gut of patients with chronic dermatological disease is not the same as normal healthy controls. They have too little good gut bacteria, too much bad bacteria.  Often they have candida overgrowth or other problems like protozoa. I think as integrative practitioners, it actually makes sense. 80% of our immune system is coming from the gut. And obviously when it’s disrupted, we get all sorts of problems. It can lead to diabetes. It can lead to heart problems. Just the inflammation through the system is going to cause problems. Now, specifically why certain people are going to get psoriasis versus rosacea, we haven’t really untangled that. We know that there are some element of genetic components to that.   But the important thing is I know when my patient is sitting in front of me, something is wrong with their gut, even with acne. It doesn’t matter what they’re presenting with. Something is wrong with the gut. I need to get in there and try to figure out what it is. For different conditions, I kind of have different suspects at the top of mind. For rosacea, for example, there’s a lot of research that shoes SIBO and H. pylori are at play. Now, that’s now 100%, so I still have to go test them and figure out what exactly is going wrong.

                                                I have two tests that I like to run on every patient who can afford it, because of course, unfortunately, they usually aren’t covered by insurance. One is the stool test. I want to look at what is in the colon, what are the strains of good bacteria, what are the strains of bad bacteria, how many of each, where is the problem. Is it an enormous pseudomonas overgrowth? I see a lot of psoriasis and psoriatic related diseases, there’s a lot of pseudomonas overgrowth that tends to trigger it. It’s high in LPS or endotoxins. With acne, there’s a lot of correlation to H. pylori.  With eczema, of course, there’s a big staph aureus component. With psoriasis, there’s a big strep component. Strep is the number one environmental trigger that we know that can cause psoriasis. I use the stool test and also for their digestive health. To your point, the stool test I use has H. pylori. I have to know what’s the H. pylori situation in their stomach and is their stomach acidic enough.   Because if it’s not acidic enough, then I’m going to see overgrowth of all the commensals, overgrowth of all the dysbiotic and autoimmune ones, and I have to treat the H. pylori since it’s at the top of the stream. If I just go in and treat the overgrowth, but I haven’t corrected the H. pylori and stomach acid problem, we’re going to have this problem and this discussion in a month, and we’re going to keep having it. That’s really critical. And then the other test that I like is an OAT or an organic acids test, which is a urine test.  That one I use because the stool test don’t always pick up candida, because candida tends to overgrow in the small intestine. There’s plenty of times when it won’t come out in the stool test, but it does come out on the OAT. And also the OAT that I use test for fusarium and aspergillus. I need to know not only is there a yeast or a candida problem, is there a bigger mold problem, and then that might lead us to look at mycotoxins.

Dr. Weitz:                         Which OAT test do you like?

Dr. Greenberg:                 I personally like Great Plains OAT and I use the GI-MAP, which I know you’ve had them on. I work with them. That’s the stool test that I prefer. It’s the one that I just find most actionable. Together, I love both of those tests. Once I get those labs back, it’s like suddenly this curtain opens and everything is revealed and I see why exactly what’s happening on their skin is happening. We just go in and we start to address the things one by one, because it’s usually multiple things happening.  Certain diseases like once we get to alopecia areata and we’re attacking hair follicles and it’s full blown autoimmune, I usually see that there is a huge amount of gut dysbiosis that needs to be addressed and usually also a toxic element that needs to be addressed. But I can always start with those two gut tests and start to see great improvement usually within the first month. We come back for our visit and it’s like, yeah, things are definitely getting better. Much better. Baby is sleeping through the night. The rash is gone X percent.  Sometimes it’s just gone, but I have to tell them, we still have to treat all the stuff or it’s going to come back. Patients are usually just thrilled with it. They finally have answers. They finally are getting solutions, and they’re off of this kind of hamster wheel of convention medicine where it’s like, well, I didn’t know what else to use on my baby besides steroids, so that’s what we were using. But I knew it wasn’t right and that’s why I was looking for something else. It’s really fulfilling.

Dr. Weitz:                         You mentioned H. pylori. I know I probably should stay on topic and not jump down a rabbit hole, but I love rabbit holes. Recently I’ve had a number of discussions with different practitioners and there’s a lot of controversy about H. pylori. Should we even treat H. pylori? H. pylori is a commensal. I know Dr. Steven Sandberg-Lewis said for the most part, you usually don’t want to treat H. pylori. It’s a commensal. Other gut experts have said absolutely, it’s crucial. Some people feel that only if there’s certain virulence factor should the H. pylori really be treated.  There’s controversy about whether H. pylori is associated with hyper or hypochlorhydria.  I don’t want to spend too much time on it, but maybe you could just give your take on H. pylori.

Dr. Greenberg:                 Yeah, no, it’s a good point, and I have that issue with H. pylori and then with some of the protozoa, right?

Dr. Weitz:                         Yes. Yes. Right. That whole discussion.

Dr. Greenberg:                 I know. It’s kind of a similar issue, but I’ll stick with the H. pylori for now. Yeah, for me, it definitely depends. I don’t think we fully unraveled the H. pylori story. We know that it can be present and not cause problems and it can cause problems. For me, that’s part of why I’m looking at the stool test in whole. I want to see how much H. pylori is present. I want to see if there’s virulence factors. And then as I start to look down the stool test, that’s where I start to see, is there overgrowth of the normal bacteria? Is there overgrowth of the dysbiotic and potential autoimmune bacteria?

                                                Let’s say I see H. pylori in moderate amounts with no virulence factors, but then the stool test just starts lighting up. All of the normal bacteria are high. All of the dysbiotic and autoimmune are high. Then when I get to the intestinal health section, they’re maybe low on elastase and the steatocrit is high. I know they’re not digesting their food property. Then absolutely for me H. pylori is a problem and I need to treat it.   If the H. pylori is moderately low, the normal is not overgrown, and there’s not a lot of huge overgrowth of the other dysbiotic bacteria and the elastase is good, and they’re digesting their fat, then I probably won’t choose to go after H. Pylori, or I’ll kind of put it in the back of… If I think H. pylori is a problem, it’s one of the first things I go after, because, as we talked about, it’s upstream. But if it’s on the fence and I’m like, well, I’m not entirely sure, I might start with other things. And if I’m not getting the response that I need, then I might add like digestive enzymes.   See did that make a difference? Did adding a little hydrochloric acid help things? And then maybe I will go back and go after the H. pylori. But it is definitely on my radar and I don’t think it’s an innocent bystander. In older patients, we know that already the stomach acid is not as acidic. Is it a 74 year old patient with alopecia areata with H. pylori? Now I’m getting more concerned about that H. pylori than I would in a 21 year old.

Dr. Weitz:                         Because you’re thinking one of the issue is H. pylori tends to be associated with hypo, low hydrochloric acid secretion.

Dr. Greenberg:                 Yes.

Dr. Weitz:                         Even though we first learned about H. pylori as a cause of ulcer from hyperchlorhydria.

Dr. Greenberg:                 Yeah, but I have to say that for me, for the derm stuff that I deal with, really almost 100% of the time the H. pylori is causing hypochlorhydria. The stomach acid is too low. I look for specific strains of oral bacteria that are high. Staph and strep, prevotella and fusobacteria are usually coming from skin and oral. And if those are overgrown, I know they’re not dying in the stomach acid. So yeah, for me, it is so rare that I’m concerned with hyperchlorhydria. It’s almost always hypochlorhydria.

Dr. Weitz:                         What’s your favorite strategy for reducing H. pylori?

Dr. Greenberg:                 I like Pyloricil by Ortho Molecular. I’ll use mastic gum and DGL and GlutaShield and stuff like that. That’s how I tend to go after it. I’m licensed in California, Oregon, and Washington. And with our fun naturopathic licensing by state, I have different scope of practice. In Oregon and Washington, I can prescribe just about anything because it’s physician level. But in California, we’re doctor level. I mostly turn to herbals first unless there’s a skin infection and you need an antibiotic or something, but I tend to mostly use herbs to treat the gut dysbiosis in all states.

Dr. Weitz:                         Have you prescribed mastic gum for kids?

Dr. Greenberg:                 Yeah, mastic gum and DGL. Just kind of using Clark’s rule. They’re pretty safe. It’s helpful. Usually they taste pretty good, and so they’ll take it.

Dr. Weitz:                         Oh really? The mastic gum?

Dr. Greenberg:                 The DGL. Not the mastic gum, but the DGL.

Dr. Weitz:                         Oh okay. The mastic gum has a nasty smell too.

Dr. Greenberg:                 Yeah. I mean, there’s other stuff I use. I use butyric acid on kids, which smells kind of poopy too. A lot of the stuff I feel like you have to hide in other things.

Dr. Weitz:                         Right. Okay. Let’s drill down a little bit on eczema, which we’ve just been talking about kids. And eczema is also known as atopic dermatitis. This is extremely common in children. I have a feeling it maybe more common in adults than commonly recognized.

Dr. Greenberg:                 It’s a little hard in adults. I think a rash is like… Whenever we see a rash, we call it eczema, right? In my mind, there’s like the infant eczema that’s true eczema, that’s this Th2 driven pathway. There’s other immune pathways in eczema that we know like Th1, Th17, Th22, but it’s a heavy Th2 driven pathway. When an adult comes to me and they’re now having rashes for the first time, for me, that’s not eczema. Usually that’s being driven by something else. It can be yeast overgrowth or bacterial overgrowth, but it’s not classic eczema as I think about it.   It’s more of a dermatitis. But in the kids and the babies who come to me, that’s eczema.

Dr. Weitz:                         You mentioned that it’s often associated with staph infection.

Dr. Greenberg:                 Yeah. And I think infection confuses people. It is an infection, but it’s easier for people to understand if we say colonization. The staph will get on the skin. What happens in a lot of these babies is they’re deficient in something called filaggrin. Now, I feel like most of us as doctors haven’t heard of filaggrin, but it’s really important. It’s a protein in the skin and we call it the master regulator of the skin barrier. Filaggrin is something that we use then to create a natural moisturizing factor. We breakdown the filaggrin into its amino acids.  It’s very high in L-glutamine and L-histidine, and then we create acids out of it, and we build natural moisturizing factor. That natural moisturizing factor controls the pH of our skin, which we talked about is so critical. It really is the critical thing to whether or not you have healthy skin, because it keeps the moisture in. If you dry out the stratum corneum, like 20 to 30% of it should be natural moisturizing factor. This is a big deal in the skin.

                                                And a lot of kids have filaggrin gene mutations where they’re not just producing enough filaggrin, and therefore not producing enough natural moisturizing factor. That’s something that needs to be addressed, especially in kind of the early days for them, to try to help them with the skin barrier. The interesting thing is I think we think of skin barrier, well, let’s put something on it, which is true. We know that putting emollients and moisturizers on babies with eczema is helpful.   But there is a very interesting amino acid called L-histidine, which filaggrin used to be called histidine-rich protein, because it was so abundant in it. There’s good evidence, there’s this good study on humans that show that dosing four grams a day in adults for one to three months really improved their skin barrier. They had reductions in their eczema about 30%. The effect was the same as about a mid-potency topical steroid, but with no negative side effects. I use L-histidine widely in everybody from my infant to my adult patients.   Because the nasty thing about staph is there’s 11 different ways that we know of that it attacks the skin and creates just a horrible situation for the person, but a great situation for staph. It is able to more easily kill filaggrin-deficient cells. We need to build up that filaggrin in anybody who’s got staph colonization on their skin and that protects them from the inside out. And then, of course, we’re also doing things topically to address the staph overgrowth. And nasally, as I said. We have to address the colonization in the nose or it just keeps coming back.

Dr. Weitz:                         Give us some specific treatments for staph.

Dr. Greenberg:                 For adults, I use the four grams a day of L-histidine. And then for infants or smaller people, I use Clark’s dosing. I usually keep them on a full dose for like two to three months and then I start to ramp down. Because we don’t have any long-term studies of L-histidine, so I don’t keep them on long-term. Topically, I use lots of things to get that acidic pH. Staph aureus hates acidic pH. It wants 7.5. If the skin can tolerate it, apple cider vinegar diluted 50/50 with water or hydrosol is great. Now, at the beginning, that might be very stingy to really compromised skin.  Hydrosols are wonderful. Hydrosols are gentle, yet powerful, and they’re acidic.

Dr. Weitz:                         What is a hydrosol?

Dr. Greenberg:                 I feel like everyone knows what an essential oil, and they’ve taken over. It worries me that people create their own essential oil stuff at home, which is actually quite dangerous because essential oils are very potent things. Hydrosol is a part of the process of making an essential oil. Let’s say we wanted to make rosemary essential oil. You’re going to take hundreds of pounds of plant material of the rosemary. You’re going to put it in like a copper distiller with water. You heat it up and boil that plant material with the water, and then it’s going to evaporate and cool in a secondary receptacle.   Water evaporates and the volatile oils evaporate. What we collect in the second unit on the top, “the floating top” oily layer, is the essential oil and underneath it is water. And that is the hydrosol. They siphon this top floating layer, and they put it into essential oil bottles. But that water that gets left behind is really a beautiful substance. It’s infused with a lot of the plant properties, so the microbial aspects. I love rosemary hydrosol. It’s got good antibacterial and antifungal action, but it’s very gentle, so you can use it on infants.  You can use it on pets. Essential oils are toxic to cats, so you can kill your cat using essential oils. I don’t like using them on infants, because they’re just too concentrated and we absorb them into our skin. It’s a lot for a baby, but hydrosols are totally safe.

Dr. Weitz:                         That would be a great name for the podcast, how not to kill your cat.

Dr. Greenberg:                 Right. People don’t know. It’s like, oh, essential oils, we’re going to diffuse them day and night and close the windows and the doors. Honestly, if your cat is in there, they can’t detoxify it, and it’s toxic to them. Essential oils is a whole different podcast on how to use them responsibly, but I don’t like to use them on infants and babies if I can help it. And I use hydrosols every day as part of a beauty regimen. Because not only is acidic skin healthy skin in terms of not having eczema, but our skin will age slower. You will have less wrinkles and dark spots if you keep your skin acidic.  I use aloe vera gel, rosemary hydrosol, and then a serum blend that I make every day to try to keep the wrinkles away.

Dr. Weitz:                         Cool. I noticed from reading some of your literature that eating dairy is often a trigger for eczema.

Dr. Greenberg:                 Yeah, there’s lots of different foods that tend to make eczema flare. The problem a lot comes from infants who maybe can’t be breastfed, or they’re being supplemented with cow and goat’s milk. In infants who have bad eczema and cradle cap, once I see cradle cap, then I know that they’ve pretty much got an overgrowth of candida in their gut, because cradle cap is a yeast on the scalp called malassezia. We all have malassezia. It’s a commensal again. But what happens with cradle cap or even dandruff in adults is we have this malassezia on our scalp.  It’s eating our sebum. We think in some level it probably starts to overgrow. But what really goes wrong is instead of looking at it as a commensal, which the body should be doing, suddenly the body is producing an inflammatory response to it. I see clinically and in my test they always have candida overgrowth. I think that internally they’re starting to produce antibodies against the candida, which is a yeast, and then the body I think misfires and sees the malassezia yeast and thinks, oh, well, wait, we’ve got this problem with candida yeast in the gut, and we’re producing antibodies to that.  And this malassezia yeast looks a lot like it, so let’s attack it too, and you get that inflammatory cradle cap. Every time when these babies are on cow or goat’s milk, there’s something about it with the candida overgrowth. Usually we take the cow and goat’s milk away and their skin gets dramatically improved. Sometimes, I don’t know why the parents fight me on it, we have to find other plant-based formulas. It’s hard, but they’re out there.

                                         These kids don’t do well with cow and goat milk, and I just have to talk to the parents and say, “Your baby is not a baby cow. It’s not a baby goat. I know you want to give them milk from a mammal, but it’s just not working.” Every time we pull that other mammalian milk source, usually the skin gets better. Not for human milk, but the other milk sources. And then you get the negotiation, “How about camel’s milk? How about donkey milk?” No. All mammalian milk is out. Unless it’s you, unless it’s human, we have to cut it out. Every time it gets better.

Dr. Weitz:                         You ever do testing for milk allergies or milk sensitivities?

Dr. Greenberg:                 I don’t, because I don’t want to stick an infant. The easiest thing is just to pull it and see if it gets better. There’s plenty of supplements for formulas that we can use to get them through that stage where they still need milk. Yeah, I just don’t like sticking babies, so generally not.

Dr. Weitz:                         I understand low vitamin D is a risk factor for eczema, as it is for almost everything.

Dr. Greenberg:                 I think D is one of those things where we see the test and the D is low, is associated to be low with the conditions, but then we can’t always show that supplementing improves the conditions. But I still think giving D is like giving probiotics. I think it’s one of those things that can’t hurt. I will say, the only condition where I don’t supplement with D is rosacea, because rosacea, there’s something happening with an antimicrobial peptide on the skin called cathelicidin, and we know that it actually gets exacerbated by vitamin D.   That’s the one condition where I don’t supplement with D, but everybody else, I feel pretty good supplementing with D because we’re all deficient. It might help and it’s not going to hurt.

Dr. Weitz:                         I understand there’s a number of topicals for eczema as there is for many of these conditions, and one of them topical B12.

Dr. Greenberg:                 Dr. Peter Leo is an integrative dermatologist and he talks a lot about pink cream. The B12 is kind of antiinflammatory. It comes in as a red or pink powder. If you’re using that ointment, it is going to pink. You can get compounded in the pharmacy. It helps a little bit with inflammation. It’s not one that I tend to use just because again… It’s more symptomatic. It’s not that the person is deficient in B12 on the skin, but it certainly can help with the eczema.   So I’m going at things from a different perspective, but it is popular and it does help improve the skin topically. It seems to be antiinflammatory.

Dr. Weitz:                         Let’s touch on psoriasis a little bit. How has thinking on psoriasis changed, as well as treatments? I know we think of psoriasis as a systemic autoimmune condition.

Dr. Greenberg:                 That’s one of the changes. I mean, we really used to think of psoriasis as, oh, look at what’s happening on the skin. That’s a dermatological disease. This person has a skin disease. And then over the past few decades, it’s really evolved into understanding… And we used to think it was mostly a Th1 mediated inflammatory disease. Then we discovered Th17 and Th22 as another pathway that’s highly tied in with mucosal inflammation. So now we know that psoriasis is a heavily Th17 mediated disease with a dash of Th22 and Th1. There’s a lot going on.

Dr. Weitz:                            What does that really mean though? How that does help us?

Dr. Greenberg:                 It helps the pharmaceutical industry because they’re going for suppressive effects, right? Everything now in the psoriatic is an anti, an anti-IL-17, an anti-IL-23. Those are functions of Th17. For us as functional medicine docs…

Dr. Weitz:                            Blocking agents.

Dr. Greenberg:                 Right, although I will say that I do do research and use certain herbs. There’s an herb scutellaria baicalensis, which is Chinese skullcap. Research study after research study, it has been shown to decrease Th17 and IL-17 and increase Treg and IL-10. There is away that we can use that information herbally.

Dr. Weitz:                            Also, something helpful to reduce cytokine storm.

Dr. Greenberg:                 Right, exactly. Psoriasis, as we know, it is an inflammatory systemic problem. We call it an autoimmune disease, but the interesting thing is we haven’t found what that piece is. The more research I do on it, the more I actually am not sure that it is autoimmune. Not in the same way of like Hashimoto thyroiditis where we can test for antibodies against thyroid. We have never found that for psoriasis. And the more research I do and the more I treat psoriasis, I really think it’s just a response to massive overgrowth of a lot bacteria.   Earlier I talked about strep. Strep is a huge, huge trigger for psoriasis. I see other kind of similarities, like pseudomonas seems to be a big driver of it. But it’s just massive gut dysbiosis, massive leaky gut. It gets into the bloodstream. It gets into the skin plaques. When we test the plaques, we find DNA of gut microbial origin. We find all of these connections to what is happening in the gut. It gets into the bloodstream, and it lodges in the skin. There is a genetic component to psoriasis.

                                                And again, why somebody is getting psoriasis as opposed to another disease, we don’t fully have the answer for that, but it’s massive gut dysbiosis. And once we start to clean that up, then it really starts to resolve. With psoriasis, again, we talk about compromised skin barrier. I’m always thinking about secondary skin infection, so a lot of times there is a secondary staph aureus infection on top of psoriasis, and there can also be malassezia or candida yeast infections on the psoriasis.   We definitely want to treat those as well if that’s a factor, because the psoriasis is only going to get so much better while it’s still got a colonization and an overgrowth of pathogens on the skin.

Dr. Weitz:                            I think I read in one of those courses that strep is often associated with psoriasis as well.

Dr. Greenberg:                 Yeah. It’s the number one most associated environmental trigger. We know that people who have a case of strep throat, that can trigger an outbreak of particularly a guttate psoriasis.

Dr. Weitz:                            What is guttate psoriasis?

Dr. Greenberg:                 There’s different types of psoriasis. The most common and the one that’s most well-known is plaque psoriasis, and those are the big pouches that you would see typically on the outside of the elbows or the knees. Guttate psoriasis are kind of spots or teardrop psoriasis that happen all over. There’s inverse psoriasis that happens in the intratendinous zones or the folds, so women will get it below the breasts, in the armpits, in the groin. There’s different types of psoriasis. Strep is associated with all of them. When I do gut testing, I often see strep overgrowth in the gut.

                                                When they do antibody testing, pretty much everyone with psoriasis has titers or some sort of response to strep, whether they knew that they had it or not. Sometimes in my psoriasis patients, I’ll treat their throat with antimicrobial throat sprays because strep tends to hide and colonize the tonsils. It can form biofilms that it can be hard to get to. This is another instance of… With eczema, we have to treat the staph on the skin, in the nose, and in the gut. With psoriasis, we have to treat the strep in this case in the tonsils and in the gut as well.

Dr. Weitz:                         How do you treat the strep in the tonsils? And then going back to the last discussion, how do you treat the staph in the nose?

Dr. Greenberg:                 The staph in the nose, I use various nasal sprays. There’s a lot of different options. I don’t do this in infants or children because it’s just torture. For this, I just have the parents try to wipe stuff into the nose. But for older kids and adults, it’s nasal spray. I like colloidal silver spray. There’s colloidal silver sprays with herbs in it. There’s propolis sprays. You can take a saline spray and make an essential oil blend and shake it vigorously and spray. There’s a lot of different options for the nasal treatment, but my go-to is like a colloidal silver with herbs.

Dr. Weitz:                         Is there a particular product?

Dr. Greenberg:                 Yeah, there’s an ACS nasal spray that is colloidal silver with echinacea and some herbs, and I like that one. That’s kind of one of my standards. And then for the strep, there aren’t studies and we don’t know for sure if it’s helping, but I like Biocidin throat spray. It’s interesting. They do all these studies with psoriasis patients where they remove their tonsils and they get dramatically better. It is because they’re basically removing the staph. That’s pretty dramatic to remove somebody’s tonsils, right?   But time and time again, you have these small studies, like 15 people, and they removed all their tonsils, and like 13 of them the psoriasis improved. There are significant numbers that we know that this strep colonization is causing problems, but a lower intervention seems to be using a throat spray.

Dr. Weitz:                         Well, in this society, we remove tonsils all the time. It’s not that big a deal. You know?

Dr. Greenberg:                 I know. We remove tonsils. We remove uteruses, appendixes. It’s like, well, we don’t need it. Cut it out.

Dr. Weitz:                         It’s just extra bar. Who really need them?

Dr. Greenberg:                 Exactly. I feel like let’s try to a throat spray before we remove the tonsils and see if that helps.

Dr. Weitz:                         Oh my god, that’s so dramatic. You’re going to take some herbs.

Dr. Greenberg:                 Yeah, exactly.

Dr. Weitz:                         Let’s use surgery. What’s the connection with bile acids in psoriasis?

Dr. Greenberg:                 Bile is really interesting. I think most of us in the functional medicine think of bile as like, okay, we need bile to emulsify fats and digest the food. If we saw high steatocrit…

Dr. Weitz:                         Bile solidify liver and stored in the gallbladder and the intestines.

Dr. Greenberg:                 Exactly. It’s like, okay, yeah, that’s the function of bile is to emulsify fats. And if we see high steatocrit…

Dr. Weitz:                         Except that half the people have had their gallbladder removed too.

Dr. Greenberg:                 Right. Exactly.

Dr. Weitz:                         Get rid of it.

Dr. Greenberg:                 Yup. That’s one of those, like chop it off. Bile is interesting in that it’s actually hugely antibacterial and antimicrobial. There are definitely case studies that have been done trying to treat psoriasis just by using bile acids, just by trying to make sure that when someone is eating, that there’s enough bile to kill the bacteria that’s part of the leaky gut.

Dr. Weitz:                         When you say bile acids, do you mean things like ox bile or drugs like cholestyramine?

Dr. Greenberg:                 Again, I tend to use more herbal protocol, so I use ox bile. Either ox bile by itself or what I usually like are… I like enzymes that have hydrochloric acid, pancreatic enzymes, and bile salts. I tend to use…

Dr. Weitz:                         Is there a particular product that you like?

Dr. Greenberg:                 Yeah, I really like DuoZyme by Karuna. That’s kind of a go-to.

Dr. Weitz:                         I’m not familiar with that one. We usually use Digestzymes from Designs.

Dr. Greenberg:                 But that one I don’t… I don’t know if it has hydrochloric acid and bile salts.

Dr. Weitz:                         It does.

Dr. Greenberg:                 It’s hard to find that.

Dr. Weitz:                         It has a little bit of both.

Dr. Greenberg:                 Oh okay. Panplex 2 by Integrative Therapeutics also has all three. A lot of them will have just the pancreatic or just HCL and pancreatic, but I look for the trio. I’m usually just giving all three together. Bile does an amazing job at killing bacteria. As you’re eating and as there’s a leaky gut, we definitely want to kill off that bacteria.

Dr. Weitz:                         What about herbal bitters to stimulate bile?

Dr. Greenberg:                 Yeah, you can use that too. It’s obviously a higher intervention to give the ox bile. For kids, I have to use more of the herbal bitters, because anybody who can’t swallow a pill, they can’t take ox bile. I have tried. As a naturopathic doctor, I feel like I’m pretty immune smells and taste of things. Andrographis isn’t even that bitter to me. It is possible to ask a patient to take the ox bile and open up the cap? It was so vile, I literally almost vomited. I was like, this is going to be… There’s no way to hide this.  Of all the things I ask patients to do, there’s no possible way to ask them to do this. And somebody who can’t swallow a capsule, it’s going to have to be bitters. If any of your listeners have found a way to get ox bile in somebody not in a capsule, please contact me because it is appalling. It’s just horrific.

Dr. Weitz:                         I know there’s a topical vitamin D that is sometimes used for psoriasis.

Dr. Greenberg:                 Yup. Again, it is used. It can be somewhat helpful. For me, again, it’s not a root cause. I’m not addressing a pathogen overgrowth with it, and I’m not addressing kind of other things. I tend not…

Dr. Weitz:                         Are there any topicals that you like to use for psoriasis?

Dr. Greenberg:                 For me, it’s somewhat similar in terms of addressing the skin pH. Psoriatic skin pH is definitely alkaline. I’m going to pull it back down to acidity and try to improve the barrier. There is a particular herb that is very well researched for psoriasis called indigo naturalis. There are topical emollients like body butters and stuff that are made with indigo naturalis that can be helpful. Indigo naturalis has been shown to decrease IL-17. Again, knowing the cytokine pathways can be helpful for our herbs. It is blue as the name indigo would indicate.  Depending on if they’re making their own, it can stain things, so you should warn them. There are a couple products out there with the indigo that aren’t quite as stainy, but that’s a well-known Chinese herb that’s used topically with pretty good success in psoriasis because we think it’s decreasing the IL-17 in the skin.

Dr. Weitz:                         I noticed in one of your articles you mentioned that when applying things to the skin, that you don’t like… I’m not really familiar with skin creams and stuff. I personally don’t put anything on my skin, but my wife certainly does. One of the products contains oils along with water-based stuff sort of mixed together and you don’t like that. You like doing them separately.

Dr. Greenberg:                 Yeah. I get on my little soap box rant about lotion. I really hate lotion, and I don’t know why it’s so prevalent in our society. But here’s the problem with lotion.

Dr. Weitz:                         You mix it all together and just do one thing.

Dr. Greenberg:                 I know. Yeah, I mean, I guess it’s the convenience. But the problem with mixing it up is this, fundamentally, a lotion is oil and water together. Well, we know from fifth grade science class, when you pour oil and water together, they don’t mix. They float on top of each other. Well, that would make for a horrible product, right? So what the product company needs to do is add a chemical called an emulsifier. An emulsifier will smash together at the molecular level the oil and water and keep it together. Well, now that we have water in this product, we must have a preservative.

                                                You have to or it’s not going to shelf stable and it’s going to be overrun with bacteria and fungus very quickly. Anytime you buy a lotion, what you’re buying is oil, water, emulsifier, and preservative. Those are the bulk of what’s in there. A lot of the oils that are used in classic lotions are mineral-based or petroleum-based, which are not good for the skin either. And a lot of the things like parabens or endocrine disruptors, those are in there as emulsifiers and preservatives. A lot of the products that now we know cause huge problems for people fall into the emulsifier and preservative camp.   For me, it’s like, well, why would we do that? Let’s just keep our water-based products separate from our oil-based products. We don’t need emulsifier. We don’t need preservative. And now we can put 100% good things on the skin just by keeping them in separate bottles. Like how hard is that really?

Dr. Weitz:                         What does that mean?

Dr. Greenberg:                 That means that using things… My water-based products are the things like the aloe and the hydrosol. Those stay in separate bottles. And those you spray on the hydrosol, you let it dry for 30 to 60 seconds. Then you apply the aloe vera gel. You let that dry for 30 to 60 seconds. And then you’re going to apply your body butter or your facial serum separately. We’ve kept all the products separate. We have not mixed the oil and the water. And just literally by keeping them on separate bottles and applying them one after the other, we have avoided emulsifiers, preservatives, and a lot of those chemicals.

Dr. Weitz:                         Forgetting about the skin conditions, what’s the best oil for the skin?

Dr. Greenberg:                 It depends. For the face, I really love pomegranate seed oil. It’s wonderful for antiaging, for helping to prevent wrinkles. It’s got ellagic acid and some special punicic acids. Some special things that we only get from pomegranate seeds. The pomegranate plant is just so wonderful all around. I love that for the face. It’s pretty pricey, so it’s hard to imagine using that as like a full body moisturizer.

Dr. Weitz:                         Besides that, are there other oils for the face?

Dr. Greenberg:                 Mm-hmm (affirmative). Yeah. For acne, I like grapeseed oil because it tends not to cause breakouts. For the body, I mean, I like blends for everything. You can us straight oil. The cheapest thing to do is probably go to like your local market and buy a high quality organic cold pressed avocado oil. You can just keep that in your bathroom and use that as a body moisturizer, and it’s cheap. I don’t like olive oil. It’s high in oleic acid and a lot of people have problems with oleic acid. I don’t actually like products heavy in olive oil.

Dr. Weitz:                         It’s hard to find organic avocado oil.

Dr. Greenberg:                 It’s not. It’s not. If you go to Whole Foods or here in LA, we’ve got fancy places like Erewhon, you can find it. But I also like blends, so I like body butters, which is oils mixed with a shea butter or cocoa butter, and that makes it a little bit thicker. That’s good in the winter, let’s say, where we might need a little more hydration to sit on the skin. But really just all the oils and butters. They’re great for your skin. Just be careful with what you put on the face. I don’t put coconut oil on the face. It’s comedogenic and can pretty easily cause breakouts.  But if you stick with grapeseed or pomegranate on the face, it usually doesn’t cause any breakouts or anything. Yeah, just anything. Grab your avocado oil and lather up.

Dr. Weitz:                         One more obscure comment. I noticed in your webinar you discussed the negative effects of polyamines. I just recently went down a wormhole. I guess there’s a number of articles. One of the polyamines is called spermidine, and I guess there’s some interesting antiaging benefits to spermidine.

Dr. Greenberg:                 I’ve seen those new things out. I mean, I think the problem with polyamines… Polyamines are naturally occurring substances. They do contribute to growth. We tightly regulate them. But what can happen particularly in psoriatic patients is when we eat meat and we don’t digest the meat properly, it goes into the large intestine and it gets fermented by more pathogenic bacteria there that create these polyamines like putrescine and cadaverine, which as the names indicate, oh, it’s putrid, it’s a cadaver. Yes, these are the things that create a stench in rotting meat and corpses.   I think we already know that having high amounts of those is probably not something we want in a living body. There are other polyamines like spermidine and spermidine, which we’re learning about, but these high levels of putrescine and cadaverine and the polyamines are found in the plaques of psoriatic patients and in their blood and urine. When we reduce the levels of these polyamines in psoriatic patients, we see improvement. I personally would not take a spermidine supplement. I don’t want high levels of those. I will wait and see what the research says about it.   So far for the research I’ve done, we really don’t want to be pushing high levels of polyamines. I wouldn’t personally do it.

Dr. Weitz:                         Interesting. Okay, great. Thank you, Dr. Greenberg. This has been a fascinating discussion. How can listeners and viewers get a hold of you, find out about your programs?

Dr. Greenberg:                 My clinic is the Center for Integrative Dermatology. I practice and see patients in California, Washington, and Oregon. My website is integrativedermatologycenter.com. I also do consults for healthcare practitioners nationwide. If you need help on a touch patient, I can help you out. I’ve also got a series. For your healthcare practitioner listeners, they might be interested in a series of 20 CE courses, and they’re AMA… They’re CE accredited for both MDs and NDs. I’m not sure what other ones, but there’s 20 courses.   They’re all free. You can earn up to 10 CE credits, and it’s at learnskin.com. It’s the Naturopathic and Integrative Dermatology Series. I’ve written some of the courses, and I’ve worked with thought leaders on many of the other courses. It’s all the things I’m talking about here. You can find a course on gut health and skin health. You can find a course on skin pH and skin disease. We have specific courses on diseases, so there’s a naturopathic approach to acne or a naturopathic approach to psoriasis.  We’ve really tried to pull together all this information, because there’s so much information out there, but the dots have not been connected well. Either in functional medicine or naturopathic medicine, we don’t have a lot of continuing ed or modules on dermatology. But when you do the research, it’s all there. You pull it together. Clinically you will get results. If anybody’s interested in learning more, it’s free. Head on over to LearnSkin and look for the Naturopathic and Integrative Dermatology Series.

Dr. Weitz:                         Awesome. Thank you, Dr. Greenberg.

Dr. Greenberg:                 Thanks so much for having me, Ben.