Vertigo and Tinnitus with Dr. Benjamin Asher: Rational Wellness Podcast 206

Dr. Benjamin Asher discusses Vertigo and Tinnitus with an Integrative Approach with Dr. Ben Weitz.

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Podcast Highlights


Dr. Benjamin Asher is a board certified Otolaryngologist and a Head and Neck Surgeon and he has been at the forefront of applying an Integrative approach to ENT (ear, nose, and throat) disorders.  He has a specialty in the area of Lyme and tick borne illnesses.  Dr. Asher has served as the house physician for the New York City Opera and the New York City Ballet and has pioneered the use of IV glutathione for vocal cord polyps instead of steroids or surgery. His website is BenjaminAsherMD.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 and also athletic performance, 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, we’re going to delve in to a different topic that then we’ve covered in the past. As you know, our podcast is devoted to covering the full breadth of different topics in functional medicine, and that really means covering all the different conditions and health issues that people deal with. Today, for the first time, we’re going to cover an integrative approach to ear, nose, and throat specialties, and in particular today, we’re going to highlight a couple of conditions that are fairly common and are difficult to treat, vertigo and tinnitus or least I think they’re difficult to treat or they have been for a lot of people.   Vertigo is the sensation that you or the environment around you is moving or spinning. Tinnitus is a ringing or a buzzing noise in one or both ears and maybe constant or come and go. Both of these are fairly common conditions. With tinnitus or tinnitus, I’m not really sure how to pronounce it, affecting about 15% to 20% of people, and it’s especially common in older adults.   Here to give us some information about these topics is Dr. Benjamin Asher, who’s a board certified otolaryngolist.

Dr. Asher:            Otolaryngologist.

Dr. Weitz:            Thank you, a head and neck surgeon, and he’s been at the forefront of apply an integrative approach to ear, nose, and throat disorders. Prior to attending medical school, Dr. Asher worked as a full-time meditation teacher. Dr. Asher is focused on identifying the root cause of symptoms and has a specialty in the area of Lyme and tick-borne illnesses. Dr. Asher served as the house physician for the New York City Opera and the New York City Ballet, and he’s pioneered the use of IV glutathione for vocal cord polyps as an alternative to steroids or surgery. Dr. Asher, thank you so much for joining us today.

Dr. Asher:            Thanks a lot, Dr. Weitz. I really appreciate you having me.

Dr. Weitz:            Excellent. So, perhaps you can start by telling us a little bit about yourself and how you found your way to an integrative, functional approach to care.

Dr. Asher:            Well, before I went to medical school, I was a meditation teacher. Really, the truth is is that I went to medical school because I thought if I became a doctor, people would listen to me and I would get more people to meditate.

Dr. Weitz:            Were people meditating?

Dr. Asher:            Not because of me, necessarily, but … So, everybody has their reasons, and when you’re young and naïve about how life goes. So, when I was in medical school, I actually never felt that Western medicine was particularly good at treating chronic illnesses. It was basically good if you had an acute problem or an immediate life-threatening issue. So, I was trying to decide actually between choosing going to a surgical specialty like ENT or going to psychiatry. My dad who was a psychiatrist at the time said, “Don’t go into psychiatry.” So, I listened to him.  I chose ENT because it struck me as something that you could fix things. If something was broken, you could fix it. I didn’t realize at the time how many of the chronic ENT issues really have much deeper underlying things going on, and surgery is not the answer for many of them.

                                So, in any case, I over the years have studied and worked with all kinds of alternative healing modalities. Actually, when I was in medical school, there were some chiropractic students that were living right by me, and we used to get together and work on each other and do stuff, and they would teach me some of their chiropractic manipulation, although I don’t do that. I was very interested, and then later on in my career, I started working with an osteopath and learned cranial osteopathy, and that is a very big part of my practice for the last 26 years.

Dr. Weitz:            Oh, interesting. So, there’s a lot of topics we could talk in the ENT area, but when we had a brief conversation, you mentioned vertigo and tinnitus, and I think these are two conditions that are fairly common. I know I had certainly seen a lot of patients in practice with these, and I think these would be good topics to highlight, though I’m okay with the discussion on any topic in ENT.

Dr. Asher:            Sure.

Dr. Weitz:            So, let’s start with vertigo. What is vertigo?

Dr. Asher:            Okay. So, vertigo is the experience of motion when you’re not moving, basically. It can either be you spinning or it can be the room spinning, but there’s some-

Dr. Weitz:            Do those two different distinctions can be-

Dr. Asher:            Well, people will report it different ways. So, when a person comes to see me and they say, “I’m dizzy,” then I’m trying to determine whether it’s a problem with the inner ear, whether it’s some other reason. So, I always ask people the question, “Without using the word dizzy, what’s your experience?” Then the people will either say, “I’m moving.”   If somebody says, “I feel like I’m going to faint or blackout,” then that’s not an inner ear issue, but there are many flavors of … You can disequilibrium or feeling like you don’t have balance, and it’s not vertigo, but that can be an inner ear symptom. One symptom is called mal de debarquement, where you feel like you’re on a boat all the time. So, vertigo can happen for … There are many causes of it.

Dr. Weitz:            By the way, what percentage of cases of vertigo do you think are related to inner ear issues?

Dr. Asher:            True vertigo, I’d say the largest percentage of them are an inner ear issue.

Dr. Weitz:            70%? 80%?

Dr. Asher:            Yeah, something, at least that amount, some inner ear issue. So, basically, the way our balance organ works is the balance is related to the inner ear, and there are two functions of the inner ear. One is hearing, and one is balance. So, there is an organ called the vestibular system, and that is the balance part of the inner ear. If you imagine what’s going on is is that the inner ear is giving the brain like a Morse code signal. When we’re sitting still both sides, the Morse code signal is the same. When you turn one way or the other, the fluid shift, and then one Morse code on one side speeds up and the other one slows down. The brain reads that difference and it says, “Oh, I must be moving.” So, the brain gives you the experience of motion when you are moving.   Now, it can also happen, let’s say there’s an injury to the inner ear, and then one side shuts down and isn’t giving any signal or speeds up, then the brain reads that and it says, “Oh, I must be moving,” and it gives you the sensation of motion and you’re not. That’s vertigo. Okay?

                                Now, there’s another part of the inner ear, which is involved in perception or gravity, too. In any case, the most common cause of vertigo is something called benign paroxysmal positional vertigo, and that’s where the understanding is, once again, nobody really knows because the inner ear is the hardest bone in the body, and it’s bone encased in bone. So, it’s the cochlea, vestibular system, the semicircular canals are encased in the temporal bone. The only way to look at it is person for them to be dead, and it’s a really big deal to get to it, anyhow. So, a lot of these things, people don’t really, there’s no way to know when on a live person exactly what’s going on.

                                So, what happens in the benign paroxysmal positional vertigo, and this is the most common, the most common form of vertigo in adults is benign paroxysmal positional vertigo, is there’s thought to be a loose crystal in the inner ear. A loose crystal then when you move in a certain position, you lay down with your right ear down or your left ear down, all of a sudden, there’s a little period of latency, and then, boom, you’re hit with vertigo and it lasts for a few minutes, but it can be horrible. It freaks a lot of people out. It happens a lot to elderly people, but it can happen to anybody.

                                So, the solution to that problem is not to take a medicine, right? That’s not what you want to do. The solution to the problem is, actually, you can either do what’s called an Epley maneuver, which you can actually look this up online. You can watching a video, but you can see a physical therapist or a-

Dr. Weitz:            Yeah. I’ve performed that procedure on patients before.

Dr. Asher:            Right. So, an Epley maneuver is a type of manipulation where you just basically get the crystal to go back to where it belongs and then the vertigo goes away. So, that’s the solution there. There’s another maneuver called the Semont maneuver, which is if the crystal is in a different canal and you can do both of them, and you can do it at home. You don’t have to go see somebody. The reason to go see somebody is that most people are so freaked out about the vertigo they think they’re having a stroke or they think that something terrible is happening. It’s not. That will often solve the problem.

Dr. Weitz:            When you do that Epley’s maneuver on average, how many times have you … Do you see patients having to do it before it actually resolves?

Dr. Asher:            Oh, that’s a good question.

Dr. Weitz:            Personally, I haven’t seen it to be the magic cure.

Dr. Asher:            Right. So, it depends. Usually, when I do it on somebody, I probably have to do it two or three times when I do it. Sometimes, I don’t know, maybe 50% or 60% of the time, the person is better. Then sometimes I’ll tell the person, “Look, you can do this at home, too.”  The key thing is to get the positioning right, and then that makes a big difference, having the head extended to a proper degree. So, there’s a good animated video online that goes over it very carefully.

Dr. Weitz:            Perhaps you can send me the link to that and I can put that in the show notes.

Dr. Asher:            Okay. I’ll do that.

Dr. Weitz:            Thank you.

Dr. Asher:            So, another solution to BPPV is just get in that position to make you dizzy 10 times twice a day because what happens is the brain after a period of time figures out that you’re really not moving, and then it figures it out, and it shuts the experience down, and tells you you’re not moving and you realize you’re not and then it doesn’t give you the experience of vertigo.   So, that’s not a functional medicine thing, but it is actually not taking a medication. If you take medication in this situation, you will actually prolong your symptoms because if you take Antivert or Dramamine or whatever, a medicine that suppresses the vestibular system, if you do that, you will stay dizzy longer. So, the best thing is to be dizzy to get over the dizziness.

Dr. Weitz:            Okay, and then we have Meniere’s disease.

Dr. Asher:            Right. So, let’s go into that because that’s actually, and once again, there was a homeopathic medicine and it was called Vertigoheel, and that company, Heel, can’t sell in the United States, and they … I’m trying to remember the name of what they converted it to. It’s Cocculus Compositum. It is a homeopathic remedy. Actually, if you have a lot of imbalance, it does actually help support equilibrium. So, that is a natural remedy that’s helpful.

                                So, regarding Meniere’s syndrome, the Meniere’s syndrome, the pathological term for that is something called idiopathic endolymphatic hydrops, and what it means is that there’s a mixture of inner ear fluids going on between two chambers of the inner ear, and it’s this rupture of a membrane, and it results in three main symptoms, true vertigo and it’s horrible vertigo, and it lasts anywhere from 20 minutes to 18 hours. So, if it’s two minutes, it’s probably not Meniere’s disease. If it lasts for seven days, it’s not Meniere’s disease. You have a fullness and roaring in the ear, hearing loss, and loud tinnitus. So, that’s the triad of Meniere’s.

                                Nobody really knows what causes Meniere’s, except the treatment is to put people on a low salt diet and a diuretic is what conventionally is done. One of the things in my practice that I do in the area that I live is I test everybody for Lyme disease because late stage Lyme disease, Lyme is caused by a spirochete. Another organism that is a spirochete is syphilis and tertiary syphilis, late stage syphilis will give you endolymphatic hydrops. So, being in the New York area or New England where Lyme is so endemic, and you have the issue in Los Angeles, too-

Dr. Weitz:            Yeah. I think Lyme is pretty much across the country now.

Dr. Asher:            Right. So, people that are having these symptoms, I test everybody for Lyme disease.

Dr. Weitz:            Now, testing for Lyme disease is somewhat problematic.

Dr. Asher:            It is.

Dr. Weitz:            So, which particular test do you find most effective?

Dr. Asher:            So, I always order a Western blot for Lyme, and I order a coinfection panel. So, when the ticks bite people, the ticks are carrying more than one organism often. So, they carry borrelia. They also carry babesia, bartonella, ehrlichia, human granulocytic anaplasma. So, I test people with the Lyme Western blot, and then I do a coinfection panel.

Dr. Weitz:            Is that enough because most of the companies that specialize in Lyme tend to include the Western blot and a series of other tests as well.

Dr. Asher:            They do. So, one of the restrictions I have when I’m practicing in New York is a lot of tests aren’t available for New York State doctors, so we’re limited by what we can order.

Dr. Weitz:            I see.

Dr. Asher:            I also am cognizant of people’s pocketbooks, and some of the Lyme testing gets incredibly expensive. So, even though the commercial labs are not as good as the Lyme labs, if I can establish a diagnosis with a commercial lab where it’s covered under a person’s insurance, great, and if I still think they have Lyme disease, then I use one of the specialty labs because they do better. Some of the specialty labs do better PCR or other kinds of tests.

Dr. Weitz:            Is there a specialty lab you like best?

Dr. Asher:            I wouldn’t say that. There are several that I like. I mean, I like the IGeneX Lab in California. I like MDL. That’s the Medical Diagnostic Lab in New York State. I like the Stony Brook Lab in New York State. I like ArminLabs in Germany. They’re all good labs for Lyme, but I’d say the largest percent of the time I can use a commercial lab and figure out what I need to do.

                                I got into the Lyme thing through the backdoor, like why would an ENT be doing Lyme, but I had a patient who had non-serviceable hearing and one ear is deaf. Basically, deaf in one ear. He had Meniere’s spells. He had Lyme disease, which had been inadequately treated. So, he came to see me. It had been 10 years down the line. He was so dizzy. Actually, he was having spells all the time. He couldn’t even find his way home from work.   He told me he had this history of Lyme. So, I said, “Why don’t we just try treating the Lyme disease? Maybe it’s this persistent Lyme.” I treated him, and his deaf ear basically came back.

Dr. Weitz:            Cool.

Dr. Asher:            That’s really unheard of. That’s a miracle medicine.

Dr. Weitz:            What kind of treatment did you use?

Dr. Asher:            Actually, I just treated him with doxycycline. I mean, I do-

Dr. Weitz:            For a short period of time or a long period of time?

Dr. Asher:            I treated him for probably two, three months, but after about … It was about three or four weeks in his hearing just came back. His dizziness went away and that was it. I’ve had several people like that. So, if I have a patient who has typical Meniere’s spells, and if my index of suspicion is that they could have Lyme, whether they have a positive Lyme test or not, I will treat them for Lyme disease. Now, I may use herbs. I may use antibiotics. It just depends on what the person is interested in doing, but it can be a big game-changer. I think I’m the only ENT that does that, but-



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Dr. Weitz:            I saw a few articles that link abnormal abnormal glucose and insulin metabolism with Meniere’s disease.

Dr. Asher:            Oh, yeah, yeah. That’s Ken Brookler. Right. That’s Ken Brookler’s work.

Dr. Weitz:            Apparently, the inner ear is rich in insulin receptors.

Dr. Asher:            Right. Yes. So, Ken Brookler, who’s retired now, he’s just a really brilliant guy. Once again, he was a lone warrior out there treating people for insulin resistance. For some people, he was using bisphosphonates, actually, because he found a lot of people who had vertigo and tinnitus had what he called inner ear otosclerosis, which-

Dr. Weitz:            A loss of bone in the inner ear?

Dr. Asher:            Right, right, a bony overgrowth sort of. It’s a complicated condition, but in any case, he had a lot of success, but nobody has actually taken up that mantle. So, there’s not anybody out there doing that work anymore in my specialty.

Dr. Weitz:            What about some of the natural treatments for vertigo and Meniere’s? I understand that glutathione may be effective.

Dr. Asher:            That’s a good question. I mean, I used a lot of glutathione both orally and intravenously. When I first started using glutathione, I started using it in patients that had what’s called sudden sensorineural hearing loss, which can be Meniere’s or hydrops. You can just have the hearing loss portion of it, but not the vertigo portion of it. It’s complicated, but I started using intravenous glutathione on those people. Personally, I didn’t find people had much of a benefit from it. The one thing that you can do for the sudden hearing loss aspect is hyperbaric oxygen.

Dr. Weitz:            Okay. You find that to be effective. I saw a few articles about vitamin D, CoQ10 and ginkgo.

Dr. Asher:            Mostly, that’s for tinnitus. I’ve not seen that for … Well, there is this product called lipo-flavonoids that people use. You can get it at the regular pharmacy.

Dr. Weitz:            Right. Yes. I’ve had patients get prescribed that.

Dr. Asher:            People will use that for Meniere’s. They’ll use it for tinnitus. The research on it is not that great, but people try it and it does help some people. So, you take what you can get.

Dr. Weitz:            Now, how often have you seen cervical manipulation be a benefit?

Dr. Asher:            For vertigo?

Dr. Weitz:            Yeah.

Dr. Asher:            It can be. There is a condition called cervical vertigo, and the spells can be very similar to BPPV-like spells. So, why can the neck cause vertigo? There are three legs to the balance stool that keep it upright, okay? One of them is your inner ear, one of them is your eyes, and the other is your proprioceptor fibers. They are your proprioceptor fibers and your muscles. For people that aren’t familiar with that term, proprioceptor fibers are these small fibers that are in all of your muscles that inform the brain where it is in space.  If you have inflammation in muscles, particularly in your neck, that are getting the proprioceptor fibers to mistrigger, once again, they will misfire and give the brain misinformation, and that can cause vertigo.  So, whether it’s directly a subluxation in the neck that’s causing the vertigo or whether it’s the fact that the nerve impulse to the muscle groups is what the issue is, it’s then developing these trigger points. I’m not sure, but it definitely can help. I’m sure in your experience you found it to be helpful.

Dr. Weitz:            Yes, we have. When I was looking at some of the possible triggers would cause us a vertigo, I also saw that heavy metal toxicity can play a role, and it can also be a side effect of a whole series of prescribed medications.

Dr. Asher:            Oh, yeah. I mean, yeah, many, many medications have some kind of toxicity to the inner ear, absolutely. Heavy metals are neurotoxic, and certainly if you have heavy metal issues, people can have balance disturbance. I will sometimes look for heavy metal issues in patients that are chronically dizzy.

Dr. Weitz:            Which of the medications do you find are most at fault? I noticed antibiotics.

Dr. Asher:            Right, minocycline, particularly. Of the tetracycline, doxycycline family, minocycline is the one that I find the most problematic for vertigo.

Dr. Weitz:            I also saw blood pressure meds, statins, NSAIDs.

Dr. Asher:            I mean, it’s everywhere. Listen, if you look at the side effects of every medication, vertigo is almost one of them.

Dr. Weitz:            Right. Okay. So, let’s move on to tinnitus or tinnitus. Which is the correct pronunciation?

Dr. Asher:            Both are correct, actually.

Dr. Weitz:            Okay. So, what’s your definition of it?

Dr. Asher:            It’s the perception of a sound that isn’t an internal sound in the head or from the ear.

Dr. Weitz:            So, what do you think are some of the most common root causes, triggers for tinnitus?

Dr. Asher:            It’s a very common problem, first of all. So, it’s actually sometimes hard to ascribe a cause because it is so common, and people have it for no apparent reason. One of the common causes tinnitus, of course, is hearing loss. So, if a person comes complaining of tinnitus or it’s new onset, I get a hearing test. It’s important to do that. Sometimes if it’s a hearing loss in one ear, then you should evaluate that in a certain kind of a way. So, a hearing test is always a good thing to get if tinnitus is bad or is concerning to somebody.

                                In the field of chronic issues, it’s one of the toughest nuts to crack quite frankly. Medications can cause tinnitus. Herbs and supplements can cause tinnitus, particularly many, many herbs have salicylates in them, like willow, feverfew. They have salicylates, and then if you’re taking them in higher dose, salicylates is a base of what? Aspirin. Aspirin can cause tinnitus. So, it’s important to note that even if you’re taking herbs, they can have side effects and you should be aware of that.

Dr. Weitz:            Herbs other than ones that contain salicylates or base of-

Dr. Asher:            No. Mostly, the ones that I know of are the salicylate family, and I don’t know all of them, but a lot of herbs who have salicylates in them.

Dr. Weitz:            What are some of the other common triggers?

Dr. Asher:            Well, noise. So, if you go to a loud rock concert or expose to loud noise, you can be left with tinnitus for a period of time. Usually, it’s a short period of time. So, tinnitus can happen in various ways. Sometimes you’ll just get a loud piercing sound in your ear. It happens for 10 seconds and it goes away, and that’s the end of it, right? That’s tinnitus, but it’s not the kind of tinnitus that people go see the doctor for. People go see the doctor because the sound is loud and it’s bothering them or they’re worried about something serious going on.

                                I would say it is possible that any systemic inflammation in the body can support tinnitus happening, but I wouldn’t say that if you eliminate all the inflammation by going on all kinds of dietary restrictions, et cetera, et cetera, you will necessarily help the problem.

Dr. Weitz:            Can food sensitivities, can they be triggers?

Dr. Asher:            Like I said, anything could potentially be, but I would never … From my perspective, I see people who have come in to see me have tried a million things and their tinnitus doesn’t go away. So, the problem is is that tinnitus, and let’s say you have tinnitus today, it came on, and it can go away in two days. It can go away in one day. So, the natural history of tinnitus in many people is that it’s short-lived.

Dr. Weitz:            What percentage of people who get tinnitus have short-lived?

Dr. Asher:            I can’t answer because the people that have that probably I had never see, right?

Dr. Weitz:            Okay. You think it’s 20%, 50%?

Dr. Asher:            I think it’s a lot of people. Many, many, many, many people will have tinnitus and they may have it for a week and it goes away, and then they forget about it. They forgot they even had it.

Dr. Weitz:            So, would you say if you ended up having tinnitus and you give it a couple of weeks and it’s not gone-

Dr. Asher:            Yeah, and then I probably would look into it a little bit more, but even at two weeks, I wouldn’t rush into freaking out.

Dr. Weitz:            Right. So, if you have a patient in your office with tinnitus, how would you work them up? Are there certain tests you would do or would you just try certain treatments?

Dr. Asher:            I get a hearing test. Another thing that will cause tinnitus is TMD, by the way, temporomandibular joint disorder, people who grind.

Dr. Weitz:            Interesting.

Dr. Asher:            So, there is a small percentage. I’d say 10% to 10% of people have something called somatic tinnitus.

Dr. Weitz:            Okay. What is that?

Dr. Asher:            Somatic tinnitus is there is something going on once again in the proprioceptor fibers or some fibers in the neck, and there is this paper from Japan from many years ago, which actually explains the whole neural pathways of how it happens, but there is this path where muscles in the neck can generate tinnitus.

                                So, I’d do some manual therapy releasing trigger points, and particularly paying very close attention to the suboccipital area. So, releasing, opening up the suboccipital, so many people because we’re in front of the computer all day long because of how we live-

Dr. Weitz:            [inaudible 00:33:03] posture.

Dr. Asher:            Right. The junction between the occiput and the cervical spine is compressed, and freeing that up can actually really make a big difference in some people with tinnitus. If you want to get blood work, you can and you can look for B12 levels, CoQ10 levels, vitamin D3 levels or you can just supplement with B12 and D3 and CoQ10.

Dr. Weitz:            I saw several papers on the use of pine bark extract, also known pycnogenol, which was shown to increase cochlear blood flow and eliminate tinnitus in a percentage of patients.

Dr. Asher:            I’m not familiar with that, actually. Maybe I was at one point, but I don’t use that on a regular basis. So, I don’t have any experience with it.

Dr. Weitz:            What about other supplements?

Dr. Asher:            So, one of the things that I’ve been using, there is a compound, a natural product called synapsin. It was developed by this pharmacist named Jim LaValle, who’s always-

Dr. Weitz:            Oh, yeah. I had him on the podcast a month ago.

Dr. Asher:            Right. So, he’s quite a brilliant guy.

Dr. Weitz:            He is, yeah.

Dr. Asher:            He came up with this product called synapsin, which is RG3 from ginseng, which is the most potent part of the ginseng plant, which reduces brain inflammation. Nicotinamide riboside and methylcobalamin. Now, nicotinamide riboside is a supplement. It has been shown to protect the inner ear from noise channel-

Dr. Weitz:            Oh, interesting.

Dr. Asher:            … and as has N-acetylcysteine, NAC. Both of those supplements will protect the ear from noise channel.

Dr. Weitz:            Interesting.

Dr. Asher:            So, I have in a number of tinnitus patients prescribed the synapsin nasal spray. It’s expensive. You have to prescribe it. It’s compounded from a compounding pharmacy, but it reduces brain inflammation. I’ve had some people where it helps, not everybody. Once again, not everybody is helped by any one thing in tinnitus, but you take what you can get. If it helps, great, and if it doesn’t, no harm, no foul.

Dr. Weitz:            So, it’s a nasal spray?

Dr. Asher:            It’s a nasal spray, right.

Dr. Weitz:            So, is this something that would only be available through an MD prescription?

Dr. Asher:            I’m not sure whether … It depends on what the prescribing laws are in the states that you’re in, but I know that there are a lot of integrative doctors and Lyme doctors that use synapsin all the time. It improve mental clarity. It’s great for brain fog. I use it in some people for anosmia. So, it’s a great product.

                                So, I will prescribe the other supplements, too. People ask me often about acupuncture, and acupuncture, there has never been a paper out there that show that acupuncture has done anything for tinnitus. So, I don’t generally recommend it, but I have a colleague who’s a neuro-otologist and he does a lot of complex inner ear surgery and middle ear surgery. He says that he believes that acupuncture helps 50% of his patients. So, if somebody wants to do it, I would never tell you not to, but I wouldn’t go with the expectation it would.

Dr. Weitz:            I also saw at least one paper using zinc.

Dr. Asher:            I’ve seen that. I’ve not seen that it’s been particularly helpful in my experience. Zinc has the side effect of nausea. A lot of people don’t tolerate it very well.

Dr. Weitz:            Then ginkgo.

Dr. Asher:            I’ve used ginkgo. There is this product called Arches Tinnitus Relief Formula, which is available online. It’s high-dosed ginkgo, and they say that it’s very, very helpful. For people that are really having a lot of problems, I will prescribe it. It’s not a prescription. You just go online and you order it. They have the Arches Tinnitus Relief Formula, then they have a zinc product, and they have something else. I just tell people to get the basic one with ginkgo in it.

Dr. Weitz:            You know what would be interesting is since so many people, I don’t know what the number is, but I know all my patients, and I think quite a number of people are taking additional supplemental zinc as part of their immune-strengthening protocols in the last year. I wonder if that has affected rates of-

Dr. Asher:            Tinnitus?

Dr. Weitz:            … tinnitus.

Dr. Asher:            Good question. Good question. So, I will recommend Arches Tinnitus Relief Formula for people. The people that are most struggling with tinnitus are people that have depression, actually. The natural course of tinnitus is that most people habituate to it. So, if you develop tinnitus and you have it for a little bit of time, over time, you will not notice it. When you’ve habituated to it and you’re not noticing it, the question is, do you even have it if you’re not even-

Dr. Weitz:            [inaudible 00:39:02]

Dr. Asher:            Right. Exactly. So, I mean, I have tinnitus, and it’s been surprisingly not annoying for a long time. Actually, of late, I’ve just been tuning in, and it’s hardly there. So, the question is, for the person that’s really struggling, what are the strategies to work with? Antidepressant medication does not really particularly work. So, I treat tinnitus like a pain syndrome. So, what do you do with somebody who’s got chronic pain? How can you manage that non-pharmacologically because, obviously, pain medications don’t do anything for tinnitus?

                                You can’t run away from it. The issue with tinnitus is that you’re living, it’s in you, and you can’t get it to go away, and you can’t run away from it. So, how can you embrace it? If you can embrace it and not run away from it, the strategy is to hold it with loving kindness and not push it out. That can actually make a really big difference in tolerability because the key for the person that’s really suffering with tinnitus is they’re experiencing something absolutely intolerable in their life. So, it’s how to hold space for what’s intolerable.

                                There is a really great book that I recommend to people. It’s called The Path is Everywhere by Matt Licata. It’s all about holding space for intolerable feelings, and tinnitus in that regard can be in that realm of feeling because it’s all the stuff that it brings up. What it brings up in people is idea of, “What if this never goes away? I’m never going to have quiet again in my life,” blah, blah, blah. You have all these stories that you tell yourself, and those are the things that make it more and more intolerable.

Dr. Weitz:            Okay. Great. I think that’s a wrap, doc. You’ve provided us with some interesting useful information in the realm of ear, nose, and throat disorders, specifically vertigo and tinnitus. How can our listeners and viewers get a hold of you and-

Dr. Asher:            They can call my office. My office number is 212-223-4225. I have a website. My website is asherent.com. I do do telemedicine, so if people want to get a consult from not in the New York, I do that all the time.

Dr. Weitz:            That would be great. Thank you so much, doc.

Dr. Asher:            Okay. Dr. Weitz, nice to meet you on virtually and thanks for your great questions.

Dr. Weitz:            Excellent. Excellent. Thank you.



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 an individual consultation for nutrition with Dr. Ben Weitz. Thank you and see you next week.



Integrative Approach to Eczema with Dr. Julie Greenberg: Rational Wellness Podcast 205

Dr. Julie Greenberg speaks about an Integrative Approach to Eczema with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on April 22, 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 my WeitzChiro YouTube page.] 


Podcast Highlights

2:03  Like Hippocrates said, all disease begins in the gut.

2:22  The goal of Naturopathic and Functional Medicine is to look beyond the symptoms and the triggers to treat the root cause(s).  For dermatological conditions we can use topical steroids to treat their rash, but that’s not the goal of Functional Medicine.  We also don’t want to get stuck on triggers.  A trigger is something that can make the skin condition worse, like diet.  There are too many practitioners, esp. in the Functional Medicine world, get stuck on diet to treat dermatological disease.  While there may be a few conditions where diet is the root cause, like pediatric eczema, but for most derm conditions, such as adults with rashes, the root cause is very unlikely to be food.  Food is more likely to be a trigger and just eliminating those foods will be unlikely to clear up the condition.  Dr. Greenberg believes that Functional Medicine testing, esp. stool testing, organic acid tests (OAT), and urinary mycotoxin testing can be helpful in discovering some of the root causes of many derm conditions. 

4:54  Stool testing, like the GI Map, helps us to see both commensal (normal), opportunistic, and pathogenic bacteria in our microbiome. It also tests for fungi and yeast.  But it is not that reliable for candida, which is why Dr. Greenberg likes the OAT, which is better for identifying candida overgrowth.  A stool test will also look for parasites, like worms and protozoa, and for viruses. It will also give information about digestive markers, short chain fatty acids, inflammation, and intestinal permeability.

5:57  The organic acid test (OAT) is more complicated than the stool test and the one Dr. Greenberg orders from Great Plains Lab includes 74 metabolites from urine.  It includes yeast and fungal markers, and markers for bacteria, clostridia, and oxalates. It also looks at mitochondrial function and neurotransmitter metabolites. It takes more work and training to learn how to use the OAT test.

6:35  Mycotoxin testing.  Mycotoxins are toxic secondary metabolites of mold and can be found in urine.  The mycotoxins found most frequently are aspergillus, penicillium, fusarium, stachybotrys (the black mold), and chaetomium.

8:38  Up to 80% of our immune system comes from our gut.  If the gut isn’t healthy, the skin is not going to be healthy.  When you see someone with a skin problem, you should be thinking that’s somebody with a gut problem.

9:07  Immunology.  Eczema is a Th2 mediated pathway. Th22 is also involved in skin inflammation. Also, Th17 primes out immune system and it is also involved.

10:09  The gut affects the immune system.  Gram negative bacteria often produce endotoxins like lipopolysaccharides (LPS), which trigger an acute inflammatory response.  LPS also inhibits the liver’s ability to do its job and detoxify.  It can even cross the blood-brain barrier and promote neuroinflammation.  Gram positive bacteria can also stir up the immune system and create inflammation.  They contain a peptidoglycan layer and teichoic acid and lipoteichoic acid in their outer cell walls.  Staph aureus, which is a gram positive bacteria, is a major player in eczema.  Candida is also present in so many derm patients and it produces extracellular proteinase that breaks down collagen and keratin in the skin.  It can also break down the IgA complement and decreases IgA production.  Candida also increases vascular permeability and leaky gut.  Candida also weakens our immune system and makes it more difficult for our immune system to kill staph aureus and E. coli.

13:33  Leaky gut.  The bloodstream is right below this one layer of intestinal epithelial cells, which should have tight junctions that prevent large food molecules from getting into the blood.  There is a thick mucosal layer that helps protect the epithelial layer and secretory IgA is in this mucosal layer and it provides immune protection and it grabs onto pathogens and endotoxins like LPS.  When this mucosal layer is eroded, we will have a loss of the tight junctions and leaky gut.  There are two keystone species of bacteria that help protect against leaky gut and these are faecalibacterium prausnitzii and akkermansia muciniphila.  Akkermansia is mucin loving and while it eats a bit of this mucus layer it stimulates the goblet cells in our gut to produce more mucus.  Faecalibacterium is a butyrate producer, which is the main food for our intestinal epithelial cells, which turn over every 24 hours.  Butyrate also calms our immune system and enforces the tight junctionsl of the epithelial cells and helps to prevent leaky gut. We need to feed the Faecalibacterium with prebiotics or fiber.  Unfortunately, antibiotics can kill off good bacteria like faecalibacterium and akkermansia while it’s killing off the bad bacteria. Alcohol, NSAIDs, and a lack of fiber can also kill these two keystone species of good bacteria.

21:22  Eczema, aka, atopic dermatitis, is a disease of skin barrier dysfunction and inflammation.  While we see the inflammation in the skin, there is inflammation in the gut and the system.  We think of eczema as a Th2 mediated disease with its related cytokines, IL-4, 5, and 13.  But there is also a chronic phase of eczema where there’s increased levels of Th1, Th17, Th22, and related cytokines.  By treating the gut, we can treat all these types of inflammation.  Patients with eczema tend to have lower levels of beneficial gut bacteria like bifido and bacteroidetes and higher levels of pathogenic bacteria like C. diff, E. coli, and staph aureus.  Staph is often found in patients with eczema, including in the skin, the gut, and the nasal passages.  The staph suppresses IgA and IgG production in peripheral blood lymphocytes and increases IgE and histamine synthesis.  IgE is the Th2 pathway.  Many eczema patients also have candida overgrowth and when you treat the candida, the eczema will improve.

27:07  It can be helpful to use butyrate supplements, for adults one capsule three times per day with meals and for infants, one scoop mixed into milk or apple sauce once per day.

28:44  The first case study is Sam, who is an 11-month-old male with eczema.  His eczema started 2 months prior and 2 months after receiving pasteurized donor milk.  His mom has been using triple therapy cream on him, which contains triamcinolone, which is a steroid, nystatin, which is an antifungal, and mupirocin, which is an antibiotic. The triple cream worked at first and then it stopped working. This is typically what happens when they go to a conventional dermatologist. Then they will need a stronger and stronger steroid. Dr. Greenberg then ran a stool and an OAT test on him. When you look at the stool test, you might see C. Diff, which might be alarming in an adult, but is fairly common in infants.  Sam was low in certain healthy bacteria, including lactobacillus and two keystone species, akkermansia and faecalibacterium prausnitzii.  Akkermansia helps the goblet cells in our gut produce the mucus layer, and faecalibacterium is the main butyrate producer.  He has high enterococcus, which in adults causes a lot of UTIs.  He is high pseudomonas, which is a gram negative bacteria and a huge LPS producer.  Both staph and strep are also overgrown.  Eczema patients often have candida, but it often is present in the upper GI tract rather than the colon, so it may not show up on the stool test, which is why the OAT test is better for picking up candida.  Both citrobacter and klebsiella are present and these are bad actors, so we want to clear them out. Also, his secretory IgA is very low, so we want to support this.  When we look at the OAT we need to look at 7. Arabinose, which is the marker for candida, we see that Sam’s is very high.  So he has high candida, high staph, and high strep, which is often seen in eczema. But he also has high aspergillus, which is mold. He also has high oxalates, which you don’t need to treat, since it will come down if you treat the candida and the mold. When there is candida and mold you want to look at B2 riboflavin, which they will also often need, and she will give in drops for infants.  Dr. Greenberg will treat the bacterial overgrowth with antibacterial herbs and antifungal herbs that are safe for infants and a lactobacillus-bifido blend probiotic. She does not like using spore based probiotics for infants, since she has found that spore-based probiotics don’t play well in the guts of infants.  She also uses a new akkermansia probiotic that is available from Pendulum Probiotics and a prebiotic, Mega Pre from Microbiome Labs that helps to bring up levels of faecalibacterium prausnitzii and akkermansia.  She will also give butyrate supplements.  To bring up the IgA, Dr. Greenberg will use Mega IgG2000 or SBI Protect. 

Dr. Greenberg may use a botanical topical on the skin of patients with eczema, but this works best if it is acidic rather than alkaline.  The skin pH is supposed to be acidic but it is often alkaline in patients with eczema. If the skin becomes more alkaline, staph will really proliferate, so using things that are both antibacterial and acidic will be the most effective.  She may use things like colloidal silver spray or a mix of apple cider vinegar and water, but if the skin is really compromised, then apple cider vinegar will likely burn too much.  Rosemary hydrosol works well and is both antifungal and antibacterial.  She likes to use a neem oil that has a bit of peppermint and lavender essential oils. Sometimes she will make a salve with essential oils.

50:37  Sam’s parents agreed to run the mycotoxin test and it showed a lot of mycotoxins, including ochratoxin A from aspergillus and sterigmatocystin that’s specific to penicillium. Dr. Greenberg treated the mycotoxins with binders and glutathione and she adds fish oil, because mycotoxins are lipophilic. Then we have to have the family investigate the home to find out the source of the mold and remove it.

53:10  The second case study: Alice, a 39 year old with eczema.  She had eczema as a child and on and off as an adult, but the eczema on her neck got severe during her pregnancy nine months ago and she cannot sleep at night. A dermatologist prescribed tacrolimus, which is a topical calcineurin inhibitor, and crisaborole, aka, Eucrisa, which is a topical PDE4 inhibitor. These drugs are like steroids trying to suppress inflammation, but they are not working now. The fact that the skin is oozing indicates that there’s a staph infection. You should either refer them to a dermatologist or swab it and send it out for testing.  Dr. Greenberg ordered a stool test, which showed high H. pylori, which indicates that there is low stomach acid. Not only should we treat the H. pylori, but we also need to give HCL.  Low HCL can lead to overgrowth of dysbiotic bacteria like enterococcus and prevotella, and even SIBO.  Akkermansia is not found, which means no mucosal lining, which means leaky gut.  She also has overgrowth of methanobacteriaceae, which can cause constipation and methane SIBO.  There are two large groups of bacteria, the bacteroidetes and the firmicutes, and most of the inflammatory bacteria are in the firmicutes, which in this patient is overgrown.  Her pancreatic elastase is low and in Functional Medicine we want to see this level above 500, which means that she needs enzymes, so she will recommend digestive enzymes that also contain HCL and bile.  The stool test did not show candida, but we need to also look at the OAT test for this. She did show another type of fungus, geotrichum. When you have this much dysbiosis, it allows yeast and fungus to get a foothold.

1:00:25  Dr. Greenberg will not usually use enzymes with infants, but she may use the chewable enzymes with kids. There is no way to get bile into them, since you have to swallow a capsule and if you open the capsule, the taste is really bad.

1:02:11  Beta-glucuronidase.  This is an enzyme that is part of how the liver removes estrogens and certain toxins, in this case by attaching glucuronic acid onto the estrogen, so then it will be excreted through the stool.  Beta-glucuronidase is the enzyme that will cleave the glucuronic acid from the estrogen and this can lead to reabsorption of the estrogen back into the body, so this is a bad thing.  It can make women more estrogen dominant, so you might want to supplement with calcium d-glucorate, though since this patient is breast feeding, Dr. Greenberg will not give it.  Also she had a really low secretory IgA. 



                                                On her OAT test, we see that her aspergillus is not an issue. This is all nice and low, but she has candida overgrowth as I would expect with eczema. So, we have to treat the candida. The fusarium is undeterminate. It’s elevated, but it’s not frank high. So, I’ll think about whether or not she needs a mycotoxin test.  We talked about candida and oxalates. So, hers are elevated. She’s not high yet, but she’s going that direction. Again, this is due to the candida throwing off oxalates. Her vitamin B2 actually was not deficient because she’s still on prenatal vitamins. So, she’s getting a whole pop of B2 and it’s helping her, but I think if she wasn’t on the prenatal vitamins, she would be deficient in this vitamin B2 as we talked about.

                                                So, for her, I have to treat the staph infection on her skin. She’s bleeding and oozing. She cannot sleep at night. I am okay with topical antibiotics. Mupirocin ointment for a few days is a really good way to quickly get a staph infection down, and it’s a topical. It’s not an oral, but then I created an antibacterial essential oil salve for her to use. So, we just used the mupirocin for a few days, but it does a pretty good job of whacking it down, and then we’re going to work on all the underlying factors.    For her H. pylori, I have to give her altered protocol because she’s breastfeeding. So, she didn’t get my normal H. pylori, but there’s a different protocol, of course, safer for baby. It’s mastic gum and all this stuff that I think most of us treat H. pylori with. Her low elastase, this is where I give her that and the H. Pylori, the digestive enzymes, the hydrochloric acid, and the bile supplement.

Dr. Weitz:                         Which is your favorite digestive enzymes?

Dr. Greenberg:                 I really like DuoZyme by Karuna. They have all three of these. Integrative Therapeutics actually has a very good one, too, Panplex Phase 2, and I use that one a lot as well. So, those are my two favorites because it’s hard to find the digestive enzymes, the hydrochloric acid, and the bile together. So, one of those two.   For the bacterial overgrowth, again, I’m going to treat with herbs, but a modified protocol, safe for breastfeeding mom knowing her infant is going to get exposure to these herbs, and same with the candida. She doesn’t have akkermansia, so I’m going to give her the probiotics with akkermansia, the Pendulum, and give her the IgA supplement while I’m treating all these dysbiosis.

                                                Again, I would have given her calcium D-glucarate for this high normal beta-glucuronidase, but she’s breastfeeding and this has not been proven safe for breastfeeding, so she did not get it. Then, of course, addressing the skin barrier disruption with topical protocols to support.

                                                This was Alice on her first visit. Three weeks later, we can see it’s actually in a better state. This is really common for staph infections. They start off really concentrated, and thick like that, and oozing, and crusting, and bleeding, and creating all sorts of havoc, and as we start to treat it, it does spread out, and I think this is just partially as they’re putting the topicals. It’s spreading it around a bit, but it’s okay. You can see that. It’s a much better state actually than where it was and she’s not being tortured at this point.   Then a few weeks later, it’s gone. You can see that the skin is still not completely normal because it’s been traumatized like this for nine months. It’s going to take some time for the skin to repair itself, but there’s no more eczema. There’s no more staph infection. She’s completely normal. Then, actually, the baby had eczema. So, once we cleaned her up. I started treating the baby for eczema.

Dr. Weitz:                         What are your favorite candida formulas for adults and infants?

Dr. Greenberg:                 Well, so for infants, it’s different. For infants, I really like Biocidin Liquid. It’s broad spectrum, and it addresses a lot of things, clostridia, candida, bacteria, and it’s safe for most infants. It just have walnut hull and leaf, so make sure that there’s not a walnut problem in any patient. There’s also formulas by another … Obviously, infants cannot swallow capsules. Infants, we’re not going to give alcohol. So, I give them glycerides, and Biocidin is a glyceride.  There’s also a company, Beyond Balance, that makes glyceride formulas. So, I use some of their formulas in infants as well to treat the dysbiosis because, again, it’s not alcohol-based, and it’s proven safe for infants, and we can get it down easily.    For adults, I use a lot of different things. I actually like Candida Support now. I like grapefruit seed extract, caprylic acid, neem. It just depends. I do different protocols for different people, and it depends on the full spectrum of what I see as well, but those are some of my favorite internal candida protocols.


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 and athletic performance, 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 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.

                                                I’d like to introduce our speaker for tonight, Dr. Julie Greenberg. Dr. Greenberg is a licensed naturopathic doctor, who specializes in integrative dermatology. She’s the founder of the Center of Integrative Dermatology in Santa Monica, a holistic clinic that approaches skin problems by finding and treating the root cause, but Dr. Greenberg sees patients now mostly virtually in various parts of the United States. Dr. Greenberg holds degrees from Western University, Stanford University, and Bastyr University. Dr. Greenberg, you have the floor.

Dr. Greenberg:                 All right. I’m going to screen share with you guys. Can you enable screen sharing for me?

Dr. Weitz:                         Oh, yes. There you go.

Dr. Greenberg:                 Okay. There we go. Okay. All right. So, thank you guys for joining today. I appreciate your time and I’m going to try to make the most of it. I know all of our time is very precious. So, this is functional medicine test for treating dermatology, and we’re going to focus on stool test and OATs or organic acid urine tests. You just heard a little bit about me, but I’m licensed naturopathic physician in California, Oregon, and Washington. I’m also a registered herbalist, and, yeah, my clinic, the Center for Integrative Dermatology is on Wilshire. I’m still there. Just right now for COVID practicing mostly virtually.   So, this guy may look familiar. He’s our old friend Hippocrates, and he said, “All disease begins in the gut.” If we were old school and still at the Santa Monica Library, I’d ask everyone who agrees with this statement raise your hand, and I’m sure all of our hands would shoot up because this is the functional medicine group and we know how important the gut is.  So, the goal of naturopathic or functional medicine, as we know, is we want to treat the root cause. There are triggers and symptoms. So, symptoms, we know especially in derm, somebody walks in, they got a rash, that’s their symptom, and we can do things like put topical steroids on it, but that’s not the goal of functional medicine.    At the same time, we want to treat root causes. We don’t want to get stuck on triggers. What a trigger is is something that can make it worse, but even if you eliminate it, it’s not going to fix the problem. I bring up triggers versus root causes because when we get to dermatology, particularly in the functional medicine and naturopathic world, people focus a lot on diet, and I have too many people who are really exclusive focused on diet to try to treat their derm disease.

                                                So, I’m going to pose a question, is diet the root cause of dermatological disease or a trigger?  Really, it’s usually a trigger.  There are some exceptions to this, pediatric, infant eczema that’s moderate to severe. There really can be food root causes, but in adults who breaks out on a rash, it is very unlikely to be food and people get stuck on it.  Can changes in diet affect dermatological disease? Absolutely 100%. I’m not saying diet doesn’t matter, but I’m saying it’s a trigger, and even if you eliminate those flares, if the skin condition doesn’t clear up, it was a trigger and not a root cause.

                                                So, why are we talking about functional medicine testing?  Why aren’t we just using conventional testing?  Again, I think everyone here knows the answer. We can run CBCs and CMPs, but we’re just not always going to get the answer.  A lot of times, they’re going to come back normal.  Your patient’s hair is falling out, there’s rashes all over the place.  That’s not normal.  So, these aren’t particularly helpful most of the time.  We definitely want to get to the root cause, so we aren’t just suppressing symptoms.  So, really, we have to run these tests to get there.

                                                I know there’s differing levels of knowledge of functional medicine, so I’ll just really briefly review it so that we’re all at a baseline. What are functional medicine tests?  There are so many and we can use all sorts of substances, urine, stool, blood, saliva, breath, DNA. Here’s just a sampling list of different types of functional medicine tests.  Again, there are just so many.  I know many of us here use a variety of these.  Today, we’re going to focus on stool testing and OAT or organic acid testing, and then we’re going to do a dash on mycotoxin testing.

                                                So, stool testing, again, in case you’ve never run one and you’re wondering what you get out of it, it’s testing for both pathogens and commensals. Three to five pounds of our gut bacteria lives in the colon. It makes it really convenient. We test the stool. That’s where it’s coming from. We see the bacteria. So, I like to see H. pylori. We want the normal, the opportunistic, and the pathogenic bacteria. It also tests for fungi and yeast. I have found it is not super reliable for testing for candida, which is very important in dermatological disease. That’s one of the reasons why I run the OAT is I find it a lot more reliable for testing candida and then other types of molds.  Stool tests will look for parasites, protozoa, and worms, viruses, and then a host of other things, digestive markers, short-chain fatty acids, which we are going to be talking about butyrate quite a bit, inflammatory markers, and intestinal permeability. You can test for zonulin. It is one marker of leaky gut.

                                                The OAT, organic acid test, is a little more complicated. There’s about, I think, 74 metabolites of the urine testing in the OAT that I use. It does do the yeast and fungal elements, some bacterial and particularly pathogenic clostridia, which we’ll look at, and then lots of other information that you can get.  In terms of being a practitioner using these tests, I think it’s much harder to learn how to analyze and use the OAT, but it is a very useful test. The stool test is much more straightforward because you’re looking at strains of bacteria or lists of protozoa, but this requires more training.

                                                So, mycotoxins, I mentioned that we’re going to touch on mycotoxin testing. Some of you may be wondering what’s a mycotoxin. Other of you may be mold and mycotoxin certified. Again, just to make sure we’re on the same page, mycotoxins are defined as toxic secondary metabolites produced by organisms of the fungus kingdom. In simple terms, what that means is that when certain molds feel threatened, that other mold or bacteria is encroaching on its face and it’s going to come and kill it. It has to fight back and it produces chemical warfare, and it creates these things called mycotoxins and shoots them into the air.   They are quite toxic and they can cause disease in both humans and animals. So, this is a big deal in livestock. They eat moldy grain and the whole herd can die, but it’s an issue for humans as well. Some of the molds that we look at in terms of mycotoxin production are aspergillus, penicillium, fusarium, stachybotrys or the black mold, and chaetomium. So, we’re going to look at little bit at some mycotoxin tests.

                                                Just to make sure, again, I know everyone knows a lot of gastro, but just to make sure we’re on the same page and so that the significance when we go do the case studies because we’re going to look at a pediatric and an adult eczema case, we’re going to look at their labs, before and after pictures, and how they were treated, I want you guys to understand what I’m assessing.  So, why are we doing a gastro review for a derm talk?  Well, we know that gut dysbiosis leads to systemic inflammation. No doubt about that. Systemic inflammation leads to chronic disease, and chronic dermatological disease.  For some reason, derm has been left out of the functional medicine world and even the naturopathic world. I’m one of the only specialists I know in the naturopathic world who specializes in derm, and it is so important and so tied to the gut.  So, I hope to prove that point out to you guys so that you think about derm problems in a different way after this talk.  So, we’re going to test and treat the gut to treat derm.  I won’t go into all the ways that our gut basically primes our immune system and all the crosstalk that goes. I think you guys know this, and we’ll be touching on some of these points, but there’s estimates saying 80% of our immune system comes from our gut, and it’s very real.  If the gut isn’t healthy, the skin is not going to be healthy.  Basically, when you see someone with a skin problem, I want you to be thinking that’s somebody with a gut problem.

                                                So, a little bit of a microbiome, actually, I guess this is an immunology review. So, we have T cells and cytokines that influence the immune system. When we look at T cells, when we first develop them, they’re called naïve because they don’t know what they’re going to be when they grow up. The body has to tell them, “Here’s the problem and this is what you need to become.”    So, I talk to patients and I say it’s like Army, Navy, Air Force, Marines. Where is the threat coming from and what kind of T cells do we need to attack that invader? So, when we look at different T cells, we typically think of eczema as a Th2 mediated pathway, and that is true, but we’re going to see that it is much more than that. Th22 is involved in tissue inflammation. So, any derm disease, any skin inflammation is going to be Th22. Basically, this is what’s priming our immune system, and Th17 is often involved. That’s mucocutaneous sites. That’s the gut. So, we’ll look at some of these pathways.

                                                So, I think we know that there’s some of the major influencers of our immune system from the gut would be bacteria, gram negative and positive, candida and molds, whether we have leaky gut, and even short-chain fatty acids. So, here’s a microbiome review. Just real fast, I think we focus a lot on gram negative bacteria and endotoxins. So, there are similarities, right? We have a peptidoglycan outer layer wall in gram positive bacteria, things like staph, strep, and clostridia.  We do have a peptidoglycan layer in gram negative bacteria, but what we really see is this outer cell wall of lipopolysaccharides, LPS. We refer to them as endotoxins. We focus a lot on these LPS endotoxins in this world, but I want to give a little screen time to the gram positives because they can get the immune system flared up, too.  In addition to the peptidoglycans, there’s teichoic acid and lipoteichoic acid in their outer cell walls. Staph aureus is a big player in eczema. So, I called this out particularly for today’s talk because if you have a patient with eczema, you do have a patient with staph problems and it’s a gram positive problem.

                                                So, all of these things fire up our immune system, great, and that ultimately leads to an uptick in complement and cytokines, AKA inflammation. So, if we dive a little bit deeper, we’d look at the LPS, lipopolysaccharides or endotoxins. We know that they trigger an acute inflammatory response in the body. It increases leaky gut. It inhibits the liver’s ability to do its job and detoxify. It can even cross the blood-brain barrier and promote neuroinflammation.  The gram positives cause problems as well. This teichoic and lipoteichoic acid in the cell walls, they cause a lot of issues in our immune system. They trigger neutrophils and macrophages and, basically, that leads to a cascade of inflammation as well.  The peptidoglycan layer fires up the innate immune system. We know that there’s relation to various autoimmune diseases, and it can even produce toxins. Usually, that’s a toxic shock syndrome. That happens less frequently, but the gram positives are not good players in our immune system just as much as the gram negative, even though I think we focus on LPS a lot more.

                                                Candida, we can’t forget about candida. It’s present in so many of my derm patients. It produces extracellular proteinase that breaks down collagen and keratin in skin. It also breaks down IgA complement, and we’re going to talk about secretory IgA in the gut. We’re going to see how deficient it is in some of my patients, and candida can be a cause of that. It erodes the mucosal layer in the stomach and, therefore, decreases the IgA production.  It also increases vascular permeability. Think leaky gut. We know that it compromises the immune system. So, there are studies that show a reduced ability of the body, of our leukocytes to kill staph aureus and E. coli in the presence of candida. So, I know that any of patient who has candida overgrowth, their immune system has been compromised and that’s part of why I’m going to be seeing all this other overgrowth and dysbiosis.

                                                Again, I know this crew talks about leaky gut and knows leaky gut, but just to make sure we’re on the same page, again, when we go to the case studies, I’ll take just a few seconds to talk about this. I think the easiest way of talking about a leaky gut is looking at a healthy gut. So, what we’re looking at here is a cross-section of the gut. These, of course, are the intestinal epithelial cells, and they’re stuck together with tight junctions so things don’t get through. Our bloodstream is right below our entire digestive tract because the whole point from mouth to anus of this GI tract is to digest food, break it down into very small pieces like amino acids, vitamins, minerals, get that into the bloodstream and send those nutrients out to every cell in the body.   So, of course, the entire GI tract has the bloodstream underneath it, and we have an immune system just at the ready in case something goes wrong. What’s happening up top here, it’s the hole. So, if you swallowed a plastic ball, we’re like a pinball machine. It’s just going to go through and you’re going to poop it out the other side. We have a hole, and three to five pounds of gut bacteria live up in this zone. Undigested food is up here. Then the critical part, of course, is this blue zone or strong mucosal barrier, whose job it is to separate the contents of our gut from these intestinal cells. These really need protection. They’re not too robust, and they can’t be in contact with all this.

                                                Secretory IgA, we’ll talk about a lot. I call it the Y guys to my patients. We see it grabbing on to LPS or endotoxin. It’s secreted by the mucosal barrier of the gut, and it helps us deal with the pathogens in the gut. So, we do want a good amount of secretory IgA.

                                                Well, leaky gut is what happens when the mucosal barrier is eroded, of course. Two specific bacteria we’re going to be talking about when we get to stool test are faecalibacterium prausnitzii and akkermansia muciniphila. Akkermansia, it’s in his name, mucin-loving. So, he actually eats a little bit of that mucus layer, but he stimulates these special cells in our gut, goblet cells, to produce more mucous. So, we want good levels of akkermansia to not have a leaky gut. We’ll talk about faecalibacterium in a minute, but he’s a butyrate producer. He does a lot of good for us. So, these are two keystone species I look for on every stool test.  So, over here when we get the leaky gut situation, how do we get in this situation? Antibiotics, it’s going to kill off good bacteria like faecalibacterium and akkermansia while it’s killing off the bad guys of the UTI or mastitis or whatever you’re taking the antibiotic. Also, we can get candida blooms when we take antibiotics and candida will erode that mucosal layer. Alcohol will do it, pathogenic bacteria-producing toxins, NSAIDs like Advil, and just a general lack of fiber, where we’re not feeding the good guys and they’re not there in the right amounts.

Dr. Weitz:                            How do we know if our patients have leaky gut? Is zonulin a good test for leaky gut or should we almost assume that most of our patients with dysbiosis probably have leaky gut?

Dr. Greenberg:                 That’s a great question. I used to run the zonulin test, but I’ve found that it’s just one marker of intestinal permeability. If it came up as not high, then my patients will be lulled into this false sense of security like, “Oh, I don’t have leaky gut,” which is not true.   So, I do assume that almost all my patients have leaky gut, but I’ll show you when I look at the stool test, I’m looking for that akkermansia muciniphila. Is it present in good numbers? Faecalibacterium prausnitzii, is it present in good numbers, and the secretory IgA.  When those three things are off, you can pretty much assume that your patient has leaky gut, whether or not it’s zonulin. So, I don’t even test the zonulin anymore, unless a patient specifically asks for it.

Dr. Weitz:                         Are there any other tests for leaky gut that are valid?

Dr. Greenberg:                 There are other gut permeability tests that-

Dr. Weitz:                         We used to do the lactulose mannitol permeability test.

Dr. Greenberg:                 Exactly, but, for me, I can get what I need out of the stool test and so I don’t have patients go do that.  Sometimes I’ll do a SIBO breath test in particular patients, but a lot of times I don’t have to.  Sometimes if it’s really bad, I need to determine is it hydrogen or methane or both, but I can also usually tell from the stool test whether or not they SIBO and potentially SIFO.

Dr. Weitz:                         Okay.

Dr. Greenberg:                 So, we were looking at a cartoon of the gut and, of course, that’s really easy to draw. This is a stain of an actual gut. We can see the importance of the mucosal layer. So, this is the three to five pounds of bacteria. These are those intestinal epithelial cells stuck together with tight junctions. This is the mucosal barrier separating the two, creating a calm immune system.  If we start erasing the mucosa, and this bacteria floods the cells, that’s basically leaky gut, and now our immune system has to deal with this stuff. So, I really love the stain. Just to drive the point home, this is a rat gut, but it was a study that showed this very thick mucosal layer from the stomach all the way to the backend. We have a very robust mucosal layer in all mammals, and it serves a real function and without it, we’re in trouble.

                                                I mentioned faecalibacterium prausnitzii. He’s such a keystone species and so important to intestinal health because he produces butyrate. Butyrate is the main food source of our intestinal epithelial cells, and they turn over every 24 hours. We have so many cells that need food.   So, what we see here is that process of we feed the faecalibacterium prausnitzii with prebiotics or fiber. Faecalibacterium is the probiotic and it produces postbiotics for us or beneficial things like butyrate. Butyrate has benefits all over the body, but we do focus on it in the gut. So, it’s that preferred fuel of enterocytes. It calms the immune system, and it creates a calming effect. It enforces tight junctions and also helps to prevent leaky gut. So, this is a keystone species I look for.

                                                Then when I’m assessing GI function of my patients, I think about it in two buckets. One bucket is their digestive function. How is their stomach acid? Are they producing enough bile? Are there enough digestive enzymes? We can get this a lot from the stool test.   Then, of course, what is the microbiome? Is there H. pylori in the stomach that’s affecting the stomach acid? The stool test I use has H. pylori on every test because I need to see it particularly for derm. I’m assessing if there’s SIBO and just what kind of growth and dysbiosis is in there.   Of course, as a functional medicine and naturopathic provider, we treat the whole person. So, I’m really thinking about the microbial distribution on the whole body. We certainly talked about the GI tract, how important that is, but I’m also looking at, I’m checking their oral mucosa. Do they have root canals? Do they have bleeding gums? We swallow a liter and a half of saliva a day. That’s going into our gut. That’s going to impact our GI health.  Of course, the skin microbiome. We’re talking about eczema today, and I don’t really have time to go into it, but staph aureus is a huge player. It’s on the skin. It’s overgrown in the gut, and it’s in the airways. It colonizes the nasal passages. Even urogenital, so many of my female patients with candida overgrowth in the gut get vaginal yeast infections. So, we always are treating the whole person and thinking about the microbiome everywhere.

                                                So, let’s talk a little bit about eczema, and then we’ll get into the good stuff and dive in to case studies.   So, what is eczema or atopic dermatitis? Fundamentally, it’s a disease of skin barrier dysfunction and inflammation. We can see the skin barrier dysfunction and we see the inflammation on the skin, but it really is inflammation in the gut and in the bloodstream and the system as well.  When we think of eczema, we think of it as a Th2 mediated disease with these Th2 cells that we looked at and related cytokines, IL-4, 5, and 13, but we now know that there’s a chronic phase of eczema where there’s actually increased levels of Th1, Th17, Th22, and all those related cytokines, and anytime you get any sort of skin barrier disruption, you’re going to get additional cytokines that are released. So, you can see that when it comes to eczema, there’s just a whole world of inflammation going on.

                                                There’s a fascinating study that was done because eczema tends to be this catch all bucket. If you have a rash, they call it eczema, and everybody’s in the same group, but dermatologists and people who specialize in derm, we know that they’re actually different, and there are actually subtypes of eczema.   This brilliant study done in 2019 divided up groups of people eczema. There was three adult groups, a pediatric, and then they were comparing it to psoriasis as showing. Psoriasis is a completely different disease. Too often, I have people come in, “I don’t know if I have eczema or psoriasis.” It matters which you have. They are two totally different diseases with totally different pathophysiologies. Even in eczema, we need to know who our patient is.   So, we can see that they took European-Americans, Asian-Americans, African-Americans, and then pediatric groups. What we see is quite fascinating. When we look at these immune pathways, they’re all Th2 for eczema, right? We know that. That’s the classic pathway we associate with eczema. In contrast, we can see psoriasis not a Th2 mediated pathway, none whatsoever.   There’s really interesting part and Th22 we said is in barrier disruption. So, any derm disease count Th22, and you can check that box. When it comes to Th17 and Th1, psoriasis is a very heavy Th17 mediated disease, but the interesting thing is it’s really present in pediatric eczema and it’s present in Asian-American eczema, but it seems to be absent in African-American eczema. So, it really does matter who you’re treating, and there are endotypes.

                                                Now, the good news is by treating the gut, we’re going to treat all of these types of inflammation, but we do want to keep in mind underlying pathophysiology. When we look at published research, so I gut test all of my patients and I can attest to this, but you don’t have to take my word for it. There’s lots of published research that shows that when you have a patient with eczema, they tend to have lower levels of the beneficial gut bacteria, bifida bacteria, bacteroidetes, bacteroidetes and higher levels of pathogenic bacteria, C. diff, E. coli, staph aureus. We’re going to keep saying staph aureus in eczema, and they have GI diseases in higher amounts than normal healthy controls.  I briefly touched on this, but staph is going to be all over your eczema patients. It’s going to be in the nose, on the skin, and in the gut. It colonizes the nasal passages, and so you have to treat them. We talked a little about this teichoic acid from the gram positive bacteria. It’s sticking out of that peptidoglycan layer. It suppresses staph. It’s gram positive, and this teichoic acid suppress IgA and IgG production in peripheral blood lymphocyte from eczema patients. Exposure to the staph aureus cell wall containing the teichoic acid or peptidoglycans led to increased IgE and histamine synthesis, two very big problems in eczema, IgE is elevated, that’s the Th2 pathway and histamine. So, again, I never want to ignore my gram positive bacteria because they can wreak havoc even in addition to the gram negative LPS ones.

                                                Candida is definitely a huge problem in eczema patients. They have statistically significant higher levels of antibodies to candida albicans. They’re pretty much colonized with it. When you treat the candida in your eczema patients, the skin will improve.

                                                Leaky gut, again, you don’t have to just take my word for it. It’s in the published literature that patients with eczema appear to have increased intestinal permeability, and there is an association between the level of increased permeability and the severity of the eczema. The worse your gut, the worse your eczema is going to be. This is absolutely true.

                                                We mentioned short-chain fatty acids like butyrate. Do they matter? They do. This whole study is called severity of atopic disease inversely correlates with intestinal microbiota diversity and butyrate-producing bacteria. So, we talked about faecalibacterium prausnitzii is one of the main butyrate producers. The study found infants who are healthy or have mild eczema have higher levels of this butyrate-producing bacteria compared to those with severe eczema. Remember, butyrate, these are intestinal cells, enhances tight junctions, and decreases inflammation. It decreases leaky gut.

Dr. Weitz:                            So, since there’s no supplements of prausnitzii faecalibacterium, I butchered that name, sorry, but is it best to try to increase butyrate production by using the appropriate prebiotics or is it more helpful to use butyrate supplements?

Dr. Greenberg:                 Yeah, and we’ll get to this once we get to my treatment plans. I do start off supplementing with butyrate because I want to come in and make a big impact immediately, and I find that it really, really helps my derm patients, their gut, and the skin issues. So, I give them the butyrate, but definitely, obviously-

Dr. Weitz:                         What’s an appropriate dosage for butyrate?

Dr. Greenberg:                 Well, so the products I use I do one cap. For adults, I do one cap three times a day with meals, and for infants, there’s a little scoop of powder that they’ll put in to milk or mix it into apple sauce, depending on the age of the kid. So, actually, I don’t know the micrograms or the actual numbers. I just know what I dose.

Dr. Weitz:                         Okay. Thanks.

Dr. Greenberg:                 Yeah, but then to your point, we don’t want to keep somebody on a butyrate supplement forever. That’s not treating the root cause. So, we treat the gut dysbiosis, and I do then go use the prebiotics that are going to try to increase the akkermansia and faecalibacterium, and we’ll talk about akkermansia because there is a probiotic on the market now for akkermansia, but, yeah, I’m not aware of the faecalibacterium prausnitzii probiotic at this time.

                                                So, okay. So, let’s hop in to the interesting stuff, the cases, now that we’re all on the same page. So, our first case study is Sam. Sam is an 11-month-old male with eczema who came to see me. I think you can see the eczema. It was on other parts of the body as well, but the face was the worst. His eczema started two months ago when he was nine months old. He’s always had dry skin.  It was interesting. It started a few months after receiving pasteurized donor milk. I do hear this story not infrequently, and it begs the question, was it really pasteurized? What happened? Is it other things in the milk? We don’t know the answers, but this is not an infrequent story that I hear.  Mom has been using triple cream on him. This is a prescription given by a dermatologist including triamcinolone, which is a steroid, nystatin, which is an antifungal, and mupirocin, which is an antibiotic.  It’s not working anymore.  If any of you guys see eczema patients, you will hear this story over and over again.  If they go to a dermatologist first, they’re going to get a steroid or a triple cream. It is going to work at first, and then they’re going to need more and more and more and stronger steroid, and stronger steroid, and it’s going to stop working eventually, and then people will often try to come to people like us in functional medicine to offer them something that’s not just a tube of steroid cream.   So, my next steps are going to be I got to test his stool and his urine.  I’m going to run a stool test and an OAT.  So, we’re going to go through some of Sam’s results.  So, we see, first of all-

Dr. Weitz:                         Let me just ask you real quick. Somebody asked, “What’s the minimum age that you could do a stool test?”

Dr. Greenberg:                 I don’t know that there is a minimum age. I treat infants as young as four months with eczema and we do test them, but I am going to discuss here that the microbiome of infants is different than the microbiome of adults. You have to assess them in different ways. So, if I got this on an adult, this would be a lot more alarming than on a kid because we see it’s C. diff, C. diff that’s capable of producing toxin A and B. This doesn’t mean that it is producing that. If it was, your patient would be having bloody diarrhea. So, this would be a lot more alarming in adults.  We often see, for example, C. diff in infant microbiomes. We’re not sure how it gets there or why it’s there, if the microbiome is just trying to sample everything. So, this isn’t super alarming. I mean, I’m still going to treat the C. diff, but it’s not like, “Oh, my God! This baby has C. diff. How did it happen?” A lot of the infant stool test will come up with C. diff. So, you do need to get used to assessing infant microbiome and understand that it’s different than the adult microbiome, but I’ll do it on the four-month olds.   Okay. So, we just talked a little bit about C. diff. Yeah, I’m going to treat it, but it’s not as alarming as it would be as if Sam was an adult because it’s just often there.

                                                So, when we look at the normal flora, there’s a couple of things. First of all, this stool test puts clostridia in the normal flora. We already know there’s clostridium difficile. That’s a pathogen. So, we take these normal flora with a grain of salt, right? There’s good and bad within a lot of these different groups. So, that’s the first thing. It came out here that there’s C. diff, but the OAT test for pathogenic clostridia. So, I always look at the OAT to see what levels of pathogenic clostridia are part of this number.

                                                What we can see here is a mix of things. So, Sam is overgrown on certain types of bacteria. He’s low on lactobacillus, which is not rare for eczema patients. We can see when I go those keystone species for akkermansia and faecalibacterium, a lot of times I will see none for either. This symbol means below detectable limits. They didn’t find it. That’s good for the pathogens like campylobacter. It’s not good for faecalibacterium or akkermansia. We want to see good levels. How we read these values are this is 1.28 times 10 to the second power. So, we read this as 128, and the range of akkermansia is one times 10 to the first power or 10 ranging to five times 10 to the fourth power or 50,000.  So, he’s got 128, but the range goes up to 50,000. This is way too low akkermansia. We need akkermansia to be higher and we certainly need faecalibacterium prausnitzii to be higher. Again, akkermansia helps our gut, our goblet cells produce the mucus layer, and faecalibacterium is that main butyrate producer.

                                                Then when I get to the section for his dysbiotic bacteria, we can see a lot of stuff, enterococcus faecalis and faecium. So, in adult females, this causes a lot of UTIs. Pseudomonas is a gram negative. This is a huge LPS or endotoxin producer. So, when we are talking about endotoxins flooding the system with a leaky gut, pseudomonas is not one that we want to see.

                                                I will tell you that for my different types of dermatological disease, I see different patterns of these results. So, when it comes to my eczema patients, there’s three things that I expect to see. I expect to see staph aureus is high, and we’ve talked about staph aureus a lot. You saw it in the published literature that staph aureus is overgrown in the gut. You see it on this patient. I know it’s on his skin, and I know it’s in his nose, and strep. So, staph and strep are usually overgrown and candida is usually overgrown.

                                                Sam’s stool test did not show high candida, and this is as I talked about part of the reason why I used the OAT. Candida often will grow up in the small intestine. It doesn’t always show up on the stool test because, again, the stool test is from the backend, the colon. So, just because the stool test doesn’t have a high candida reading, that’s meaningless to me. I have to go look at the OAT.   So, right now, he’s two for three. He’s high on staph and high on strep, and that’s typical of my eczema patients, but they’ve also got other stuff, which is why I need to test them, and we can see he’s got a lot of pseudomonas and other overgrowth that needs to be addressed.  He’s got growth of citrobacter freundii and klebsiella pneumoniae. These are not good guys. These are in the potential autoimmune triggers. This does not mean that Sam has or will develop autoimmune disease, but these bacteria are associated with certain autoimmune diseases like klebsiella is associated with ankylosing spondylitis, for example. So, we don’t want them around. We want them to be less than detectable limits, and I want to clean all of this stuff up in him.

                                                His secretory IgA is low. If you remember, I said that was the Y guy on that picture. The Y guy was grabbing onto the LPS. So, you see we got tons of pseudomonas. That’s LPS and other ones. We need a good level of secretory IgA to help him cope with this, and he’s low. This is one of those markers. So, the three things I said I’m looking for leaky gut, two little akkermansia, two little faecalibacterium, and low secretory IgA. I can absolutely, even though I was suspicious that Sam had leaky gut, he absolutely has leaky gut now and there’s no doubt about it. So, his secretory IgA is 54. That’s a 10th of the lower limit of the scale. We want 500 to 2,000, really, to be healthy.

                                                So, now, I got to his OAT test. Now, we see a whole other world, which is the fungal world. If you just pay attention to the bacteria, you’re really doing your patients a disservice. I think this is what happens in SIBO a lot is that they’re testing and treating for bacteria and not paying attention to the fungal world. It’s huge.  So, what we see on his OAT test, the first marker I go to is seven arabinose. That’s the marker for candida. We can see his absolutely high. He has three times over the upper limit of what we want to see in candida. So, he’s just fulfilled the trifecta in my eczema patients, high candida, high staph, high strep, and other things.   What’s concerning on this OAT is these aspergillus because this is mold. Candida is yeast. It’s a single-cell fungal organism. Aspergillus is a mold. We don’t want to see mold overgrowing in him. The question is where is this coming from because candida is actually commensal. We all have candida. We just don’t want it overgrown, but we shouldn’t have aspergillus. So, there’s exposure coming from somewhere. So, we’re going to have to detangle that. Now, my hackles go up for mycotoxins. Am I worried about mycotoxins in this infant? We’ll see how I assess that and what we do with it.

Dr. Weitz:                            I just wanted to comment that I’ve seen a lot of times with patients who end up having mycotoxins and they also are dealing with fungal overgrowth.  What exactly is the relationship between those and how do they interact?

Dr. Greenberg:                 Yeah. It’s intimately connected. So, at the beginning, when I talked about those mycotoxins, mycotoxins are produced by mold. So, you’re not going to have mycotoxins without mold. Mold is two problems. One, is the mold growing in the system? This test is showing yes. He has actual aspergillus, fuzzy mold growing in his system. Then the second question is, is that mold producing mycotoxins? We can be affected by mycotoxins either by mold growing in our gut or mold growing in the environment.   So, I think people look around their house and say, “Well, I don’t see mold. I don’t live in a moldy environment.” You don’t actually really know that unless you come in and have full inspectors or rip up the walls because you’re doing construction. Mold hides behind the wall. It eats paper. It eats wood. That is what we build our homes out of, and all it needs is just a little bit of water, and it’s off to the races, and there can easily be tons of mold growing behind walls. If that mold is feeling threatened, it’s going to start pumping out mycotoxins. So, they are intimately related. You don’t have mycotoxins without mold.

Dr. Weitz:                         Thank you.

Dr. Greenberg:                 Then when we look down here, we see the bacteria markers from the OAT. They’re all overgrown, but we already knew this from the stool test and from the stool test, we know the specific strains of overgrowth that are driving these numbers, but these are two different labs. One is urine, one is stool, and they usually do back each other up, which is nice to us providers to feel like the labs are valid.

                                                So, I want to point out that there are patterns that you learn to recognize on the OAT. So, for candida, once I see that there’s candida overgrowth, I’m specifically looking at two other markers, the oxalates and the vitamin B12. So, let’s look at his. Sam’s oxalates are high. This is because candida and mold kicks off oxalic acid or oxalates. So, when I have patients who have candida overgrowth and high oxalic acid, I don’t do anything to treat the high oxalates. I treat the candida and the oxalic acid will come down.   I mean, there are foods that are high in oxalates, but they’re healthy. It’s spinach and Swiss chard. So, unless someone is really going crazy like eating massive amounts of spinach, I never take away the high oxalate foods. I just treat the candida and mold, and this will come down naturally, but expect to see it and know where it’s coming from.

                                                Then the second is vitamin B2 or riboflavin. Candida and mold create acetaldehyde. If you have ever had too much alcohol one night and the next morning you woke up and had a hangover and felt terrible, you know what acetaldehyde is because that’s what pretty much poisoned you the next morning. So, candida and mold produce this and we use up our vitamin B2 trying to deal with it. So, I do supplement patients with additional B2 while I’m treating the candida and mold because I want to help them out. Again, they don’t need to be on B2 forever. We’re going to clean up the candida and mold and then they’re not going to need vitamin B2 supplementation. So, look for those two when you see candida.

                                                Then I need to look at the indicators of detoxification. I know he has mold growing in his gut, and now I need to try to figure out, do I think mycotoxins are a problem for this kid? Two of the ones that I look at are glutathione and this methylation toxic exposure.   So, his glutathione needs are not elevated yet, but he’s 11 months old. So, we may not have just depleted it yet, but if we keep going with all this overgrowth, he is going to be deficient in glutathione, but this toxic exposure methylation, this 2-hydroxybutyric marker is elevated, and that really worries me when it comes to somebody who’s got aspergillus overgrowth because my number one suspect for the toxic exposure is mycotoxins. So, in this case, I would recommend to the parents that they do a separate mycotoxin urine test to make sure either this is a problem or it’s not a problem, and we need to fix it or we don’t have to worry about it.

                                                So, we look at all of these issues for Sam, and we’re going to have to deal with all of them. Again, this is to treat the eczema. So, he’s got massive bacterial overgrowth of both commensals and dysbiotic bacteria. So, I need to treat with antibacterial herbs that are safe for infants. So, we’ll talk about it or if you’re an MD and you want to prescribe pharmaceuticals, then that’s your path. I really rely on herbs much more. There are occasions where I’ll prescribe antibiotics, but 95%-99% of the time I’m using herbs.

                                                I do give probiotics. I’m a huge fan of spore-based probiotics, but not in infants or breastfeeding moms. So, this infant would be getting a lactobacillus-bifida bacteria blend. I just find the spore-based, they just don’t play well in the guts of infants and even through the breast milk. I just get complaints from mom that the poop is this and it’s that. It just doesn’t happen with the lactobacillus and bifida probiotic. So, those are the type of probiotics I give infants.

                                                Then he had massive fungal overgrowth. He’s got candida and aspergillus and elevated markers of detoxification. So, we have to start investigating the source of the mold. Where did he get this aspergillus overgrowth in his gut? Is it coming from his home? I had one parent, not this infant, but another one who opened up the bottles and there was hidden pockets in the bottles and she found this black disgusting mold in there, and the infant was overloaded with molds. So, we have to figure out where it’s coming from.  This is related to testing the environment. So, you can do mold plates, which are agar plates, ERMIs, which are dust collections or call in mold inspectors, which are the best, but certainly the most expensive.  Then we need to treat with antifungal herbs safe for infants. So, a different protocol, and I don’t have an eczema protocol because I’m treating on the dysbiosis that I see in the gut.  Then I recommended the mycotoxin testing, and we’ll take a look in a minute, and an anti-candida diet. Now, he’s 11 months old. He’s not eating that much stuff, but we’re going to limit fruit and sugars and things like that because we don’t want to be feeding the candida while we’re trying to address it with herbal protocols.

                                                So, there’s no faecalibacterium prausnitzii, we discussed it, I am going to give a butyrate supplement. There’s a powder for infants and capsules for adults, and then eventually work on feeding prebiotics that will help the faecalibacterium come back. The akkermansia, there are probiotics that are available that now contain akkermansia. They came out last year. So, the good news is akkermansia is available. The bad news, it’s $200 a bottle, and they’ve been back ordered, so it takes a few months to come.  I called the company and asked if it works for infants or children to open the capsules if the akkermansia will survive, they’ve never tested it. They don’t know for sure. So, I do tell the parents that because it is $200 a bottle, but the company feels like it’s worth a shot as long as they eat it right away. So, I will give the infants this akkermansia.

Dr. Weitz:                         What’s the name of the company that sells this?

Dr. Greenberg:                 It’s called Pendulum Probiotics. It’s marketed as a diabetic, a glucose control one because as it turns out, diabetics have no akkermansia muciniphila, and leaky gut, and chronic inflammation. I think that’s why they priced it at $200 a bottle, but, yeah, it’s a glucose control, but it’s akkermansia and beneficial clostridia.

Dr. Weitz:                         Are there certain prebiotics that would stimulate the growth of akkermansia?

Dr. Greenberg:                 Yeah. I mean, I know MegaSpore has been on here and people use it. They have a Mega Prebiotic that they claim helps enhance the growth of faecalibacterium prausnitzii and akkermansia muciniphila. So, I haven’t looked at their studies, but I do use the Mega Prebiotic because they made those claims and I do find it’s a nice prebiotic.

Dr. Weitz:                         Okay.

Dr. Greenberg:                 So, for the low secretory IgA, of course, this is due to the leaky gut, but, again, while we’re waiting, I’m going to give a supplement that has IgG, IgA, and IgM because we’re not going to fix the gut overnight, and there’s so much dysbiosis, and especially as we start to kill off this dysbiosis, we need that secretory IgA to be there to capture the LPS and gram positive and all of this stuff. So, I just give it as a supplement when I start.  We talked about his need for-

Dr. Weitz:                         Is there a particular product for IgA, IgG, IgM that you like?

Dr. Greenberg:                 So, again, I do use Mega IgG2000 in adults, and in infants, we just open up the cap. That’s the one I tend to use, but there’s others. There’s SBI Protect and some other ones as well.

Dr. Weitz:                         Okay.

Dr. Greenberg:                 Then we talked about this need for vitamin B2 or riboflavin. He is deficient in it because of the candida and mold. So, I’m going to go ahead and give him, for infants I do drops of vitamin B2. For adults, I just do one cap a day of a vitamin B2 supplement while we’re treating the overgrowth.  Then, again, we don’t have time to get into it in this lecture, but I’m obviously addressing the skin barrier disruption, the staph aureus on the skin. I use natural botanical topicals, no steroids, no antibiotics, nothing like that.

                                         Okay. So, let’s look at what happens. So, this was baby Sam when he first came to see me and three weeks later. We can see. So, he’s not totally cured of his eczema, but it’s a lot better even three weeks later. He’s not itching as much. Your eczema parents are suffering as well the children. They’re watching their children suffer, and they’re kept up all night because the child is up all night scratching and itching.   So, he’s gone from a situation where he wasn’t able to sleep. The kids will scratch themselves until they bleed, and then they risk infection because the pain of scratching themselves until they bleed feels better than the itch. They’re this tortured by the itch of eczema. So, already, I mean, he’s not looking perfect, but he’s no longer awake and itching and on all of that stuff.

Dr. Weitz:                         Can you name a topical botanical cream that you like?

Dr. Greenberg:                 Yeah. It’s not like one thing, unfortunately. With naturopathic medicine, there’s no tube of magic cream like the steroid. It’s a whole thing, and I lecture on this at conferences and other situations, but you have to address the staph aureus on the skin. The staph is high pretty because the skin pH is off. The skin pH is supposed to be acidic, and when it raises and it becomes more alkaline or neutral, staph aureus will grow out of control. So, I’m doing things that are naturally antibacterial, and also will create an acidic pH on the skin. So, things like colloidal silver spray, antibacterial, a mix of apple cider vinegar and water, it is so acidic. Staph hates it. The problem is when the skin is really compromised, you’re not going to be able to use the apple cider vinegar because it’s going to be too stingy, but as the skin starts to heal up, then you can get in there with the apple cider vinegar and whack the staph down.

                                                I use hydrosols, which are water-based plant extracts. I love rosemary hydrosol. It’s antifungal and antibacterial. Depending on what’s going on, we’ll use different topicals. There’s a neem oil I like that has a little bit of peppermint and lavender essential oil. Peppermint essential oil is good for soothing the itch. So, we get a two for one, but there’s lot of things. Sometimes I’ll make a salve with essential oils or instruct the parents how to do it. So, it really depends, but a combination of topicals that are going to be antimicrobial, and pull that skin pH back down again to acidic.

Dr. Weitz:                         Is there a benefit to use some phototherapy for eczema?

Dr. Greenberg:                 I mean, people do find some benefit from red light therapy. At a certain place when people are suffering, anything you can do to ease the suffering, but I don’t find that I need it. They’re expensive machines. It’s time-consuming. It’s hard to get an infant to sit still in front of a red light machine. I find that I don’t need it most of the time. So, again, it is controlling symptoms, but it’s not actually getting to the root cause. So, I’m much more focused on let’s just clean this thing up.

Dr. Weitz:                         Okay.

Dr. Greenberg:                 Okay. So, the parents agreed to run the mycotoxin test on Sam, and what we see is he’s got a lot of mycotoxins. So, there’s two things going on here. We already knew that he had aspergillus overgrowth in his gut, and ochratoxin A is going to be your most common mycotoxin that you see on any test because aspergillus is the most common mold. He’s got a massive amount of ochratoxin A. It’s seven, eight times the limit. So, there’s a green zone because we live on the planet, we eat food, food can have mold and mycotoxins. The only totally clean mycotoxins I see are the infants. So, just having a little bit in the green zone is not concerning, but these are concerning levels. His aspergillus is producing mycotoxins, and we need to get rid of the aspergillus in his gut at the source and deal with the mycotoxins.   There’s something else. So, penicillium is another kind of mold that produces mycotoxins. The OAT, unfortunately, only tests for aspergillus and fusarium molds. It doesn’t test for penicillium. So, we didn’t know that he had penicillium overgrowth or was being exposed to penicillium in the home, but, indeed, he has mycotoxin sterigmatocystin that’s specific to penicillium. So, there’s two molds, two mycotoxins, and this is absolutely creating immune suppression and exacerbating his condition.

                                                So, we have to treat the mycotoxins. We treat with binders. I add glutathione. I add fish oil because mycotoxins are lipophilic. So, the skin and the organs are lipophilic, but we want to give some fish oil like those mycotoxins find in the fish oil. Then we definitely have to do that home investigation and figure out where is the aspergillus and penicillium that he got exposed to because this is an 11-month-old infant. It narrows it down. It’s COVID, he’s not going to daycare. He doesn’t get up and go to work every day. He’s not sitting in a car for hours in traffic. It’s a home environment, and that’s what we need to figure out.  So, I think it’s important for people to get mold and mycotoxin training to become mold and mycotoxin literate before you try to treat patients. We’ll talk a little bit about that, but these are some foundations of treating mycotoxins.  So, at the initial visit, we see Sam. Three weeks later, much better, and then two months after that, the eczema has basically cleared up and everyone was happy. Okay.

                                                So, now, we’re going to look at the second case study. This is an adult with eczema. So, we looked at our pediatric eczema. We going to now look at adult eczema. This is Alice. Alice is 39 years old. She had eczema as a child. She’s had occasional eczema on and off as an adult, but her neck went really crazy during her pregnancy about nine months ago. She cannot sleep at night. This thing is itching and oozing. It’s just torturing her all day and all night.  Her baby is now four months old. She’s a breastfeeding mom. A dermatologist prescribed tacrolimus and crisaborole. Tacrolimus is a calcineurin inhibitor. It’s a topical cream. Crisaborole is also known as Eucrisa. It’s also a topical cream, a PDE4 inhibitor. So, both of these things are like steroids trying to suppress the inflammation, just shove it back down into the skin, which is clearly not working.

                                                So, my next steps are I’m going to give her a stool test and an OAT test, but I want you to note, this eczema has a secondary staph infection, and this happens a lot in eczema patients. You’re not just treating eczema. They’re staph way overcolonized and actually infecting. The keyword here that should clue you in that there’s a staph infection that needs to be addressed is the oozing. Once you get to the point when something is oozing, you could pretty much figure you got an infection.   You can send them to a dermatologist or if you can, swab it yourself. You need a wet sample. I don’t even do it. I just assume it’s staph and it needs to be treated stronger like a staph infection instead of just the colonization that we see in typical eczema.   So, let’s look at Alice’s stool test. So, she actually has high H. pylori, and once I see H. pylori, now my red light is flashing. Is this impacting the stomach acid? Is she having hypochlorhydria or too low stomach acid.  Is she not digesting her food properly?  Is this leading to overgrowth of commensal and dysbiotic bacteria and potentially SIBO? So, we have to go on.  When we look at her normal bacteria, we do see overgrowth of enterobacter, which in high amounts can be inflammatory. That akkermansia, not found.  No akkermansia, no mucosal lining.  I’m already basically diagnosing her with leaky gut. Her faecalibacterium prausnitzii was actually in the range, so not too bad. So, the bacteroidetes and the firmicutes are the big groups of bacteria. Together, they’re about 80% of the gut bacteria, and she’s high on this whole group firmicutes. So, there’s a lot of overgrowth of normal bacteria in there.  Usually, this is the more inflammatory class.  So, if one of them is going to be overgrown, usually it’s going to be the firmicutes like hers is.  When we look at her dysbiotic bacteria, we also see a lot of overgrowth. Again, we see strep is overgrown and staph is present in her. She’s also got this enterococcus, and prevotella, and methanobrevibacter, which can cause constipation. We definitely don’t want constipation in these patients. We want them moving out all the stuff on a daily basis, but these produce methane and it paralyzes the gut.

                                                Then, again, her candida stool test did not show that she had a candida problem, but I got to wait and look at the OAT. There was this other type of fungi or yeast, the geotrichum. I will see this on the stool test. There’s another one, rhodotorula, that can show up. Basically, when you’ve got this onslaught of dysbiosis, it allows these yeasts and fungi which we should normally be able to clear to get a little foothold. So, it’s not unusual to see other little yeasts pop up as well like this and the rhodotorula.   Then when we look at her digestive health, so her elastase is low. In functional medicine, we actually want to see this over 500. She’s definitely low. One of my number one reasons why I see elastase low is that there’s high H. pylori. The stomach acid is now hypochlorhydric, and the pancreas is not getting the strong enough signal to produce the pancreatic enzymes. So, this tells me that she is hypochlorhydric, and I need to be worried about not just treating the H. pylori but also dealing with the enzymes.   Her beta-glucuronidase is high normal.

Dr. Weitz:                         By the way, how do you deal with the enzymes?

Dr. Greenberg:                 I will talk about it, but there’s an enzyme that contains HCL because I want to raise that stomach acid, and that’s hydrochloric acid, enzymes, and ox bile. I like the ox bile. Even though her steatocrit was not elevated, so she is digesting her fats. Bile is antibacterial and antimicrobial. So, it’s actually really beneficial to give that extra bile when they’re eating because that’s when they’re going to get the flood of LPS and endotoxins is when we eat, and those tight junctions have to open up so we absorb food. So, I like an enzyme that has HCL, enzymes, and bile.

Dr. Weitz:                         You just showed on previous test how the methane producer was high, and that’s one way that you could potentially diagnose SIBO. What are the other ways you can potentially diagnose SIBO through a stool test?

Dr. Greenberg:                 So, obviously, we want symptoms in SIBO, right? So, we’re going to start with, is there the gas and bloating? Are they having the GI symptoms? Because I think, and it will be interesting to see if Mark Pimentel talks about this when you have him back on. There was another talk I listened to where basically, now, whatever the SIBO breath test show, if they don’t have symptoms, it seems like now we don’t diagnose them with SIBO, that they have to be symptomatic.

                                                So, I take that to heart. Are they having any any GI symptoms? If they’re not, I’m not going to diagnose them with SIBO, but if they have the gas and bloating and all the rest of it, then the H. pylori is going to be your first clue because we know H. pylori is related to SIBO because of this hypochlorhydria and we swallow a liter and a half of bacteria a day, we eat food with bacteria and mold, and if the stomach acid is not acidic enough to kill off most of those bacteria and fungal elements, first stop is the small intestine. What a great place to set up shop, right? There’s no competition. You’re already here. So, we know that H. pylori and SIBO are related.

                                                So, if I see H. pylori, and then I see, is there overgrowth of commensals, especially down here in the phyla group, and is there a lot of overgrowth of dysbiotic bacteria, and particularly, is there constipation? Is the methanobrevibacter high? There has to be symptoms for me. They have to be constipated. They’d had to have all of the SIBO-type presentations, but that’s how I use it.

Dr. Weitz:                         Good. Thank you. Somebody asked, “Can you use pancreatic enzymes in infants?”

Dr. Greenberg:                 I tend not to do it because a lot of times they’re on milk and other things, and I feel like it will work itself out. So, I tend not to give them. I mean, in kids, there’s the chewable enzymes, so depending on the age. I tend not to give it in the really tiny infants, but in the ones that can chew, I might give them the chewable enzymes. There’s no way to get the bile into kids because you have to swallow a capsule. I’ve tried opening up capsules and tasting bile to see, is there anything we could hide the bile in? It is so revolting. I almost vomited.

                                                As a naturopath, we’re pretty immune to most of these tastes. I can take almost anything. The ox bile was too much for me. No one is going to be able to take ox bile if it’s not in a capsule that they’re swallowing. So, there’s no opportunity for that, but I will give chewable enzymes to kids, but in infants, they’re usually doing a lot of milk. I mean, we might need to talk about their supplement if they’re not on breast milk and get them off of the dairy supplement. I tend not to give enzymes until they start getting to the chewable phase.

Dr. Weitz:                         Can you use bitters to stimulate enzymes?

Dr. Greenberg:                 Absolutely. So, a lot of times, I’ll start off with the stronger HCL, enzymes, and bile, and then as the gut is improving, switch to bitters because the bitters are a lower forced intervention. It stimulates the system to get going instead of just giving it to them. So, yeah, we love bitters in naturopathic medicine.

Dr. Weitz:                         Cool.

Dr. Greenberg:                 So, I was talking about the beta-glucuronidase. Just in case you guys do stool tests and wonder what this is, beta-glucuronidase, it tells us ASE. It’s an enzyme, and just a little biochem lesson, it has to do with the liver. So, the liver in phase two detoxification, phase one is how do we change the molecule into something and then phase two is how do we get it out of the body. So, one way that the liver can make a substance water-soluble is to do something called glucuronidation. It takes the glucuronic acid and sticks it on the molecule.   Estrogens are taken out of the body this way through glucuronidation as are some toxins.  So, the liver puts this glucuronic acid on, and now it can be put into the poop, and you poop it out, and we get rid of that excess estrogen and the excess toxins.  Well, this enzymes, beta-glucuronidase, can be produced in high amounts by a bacteria and it does something not good.  So, now we’ve got the substance the body was trying to get rid of, estrogen or toxins, the liver has put a glucuronic acid on it.  Well, at the last minute, beta-glucuronidase comes in and goes, “Hiya!”  It releases that glucuronic acid.  Now, this substance is like, “I’m free,” and it goes back into circulation in the body.  So, if you have estrogen-dominant females and they have high beta-glucuronidase, this might be why they’re estrogen-dominant. They’re not getting the estrogen out, but it can also impact other toxins and things the body is trying to get out.  Normally, you treat down the overgrowth and it will rectify this, but there is a supplement called calcium D-glucarate that you can give to block the beta-glucuronidase. She’s breastfeeding, so she’s not going to get the calcium D-glucarate, but if she wasn’t, I might give it to her, and that’s a pretty classic supplement that we give in naturopathic medicine. It’s a symptomatic treatment, but to deal with the high beta-glucuronidase while we treat down the gut.  Then her last thing, her secretory IgA is really, really low. Again, leaky gut, no akkermansia, low secretory IgA. She’s got leaky gut, and so we’ll have to deal with that.

                                                On her OAT test, we see that her aspergillus is not an issue. This is all nice and low, but she has candida overgrowth as I would expect with eczema. So, we have to treat the candida. The fusarium is undeterminate. It’s elevated, but it’s not frank high. So, I’ll think about whether or not she needs a mycotoxin test.  We talked about candida and oxalates. So, hers are elevated. She’s not high yet, but she’s going that direction. Again, this is due to the candida throwing off oxalates. Her vitamin B2 actually was not deficient because she’s still on prenatal vitamins. So, she’s getting a whole pop of B2 and it’s helping her, but I think if she wasn’t on the prenatal vitamins, she would be deficient in this vitamin B2 as we talked about.

                                                So, for her, I have to treat the staph infection on her skin. She’s bleeding and oozing. She cannot sleep at night. I am okay with topical antibiotics. Mupirocin ointment for a few days is a really good way to quickly get a staph infection down, and it’s a topical. It’s not an oral, but then I created an antibacterial essential oil salve for her to use. So, we just used the mupirocin for a few days, but it does a pretty good job of whacking it down, and then we’re going to work on all the underlying factors.    For her H. pylori, I have to give her altered protocol because she’s breastfeeding. So, she didn’t get my normal H. pylori, but there’s a different protocol, of course, safer for baby. It’s mastic gum and all this stuff that I think most of us treat H. pylori with. Her low elastase, this is where I give her that and the H. Pylori, the digestive enzymes, the hydrochloric acid, and the bile supplement.

Dr. Weitz:                         Which is your favorite digestive enzymes?

Dr. Greenberg:                 I really like DuoZyme by Karuna. They have all three of these. Integrative Therapeutics actually has a very good one, too, Panplex Phase 2, and I use that one a lot as well. So, those are my two favorites because it’s hard to find the digestive enzymes, the hydrochloric acid, and the bile together. So, one of those two.   For the bacterial overgrowth, again, I’m going to treat with herbs, but a modified protocol, safe for breastfeeding mom knowing her infant is going to get exposure to these herbs, and same with the candida. She doesn’t have akkermansia, so I’m going to give her the probiotics with akkermansia, the Pendulum, and give her the IgA supplement while I’m treating all these dysbiosis.

                                                Again, I would have given her calcium D-glucarate for this high normal beta-glucuronidase, but she’s breastfeeding and this has not been proven safe for breastfeeding, so she did not get it. Then, of course, addressing the skin barrier disruption with topical protocols to support.

                                                This was Alice on her first visit. Three weeks later, we can see it’s actually in a better state. This is really common for staph infections. They start off really concentrated, and thick like that, and oozing, and crusting, and bleeding, and creating all sorts of havoc, and as we start to treat it, it does spread out, and I think this is just partially as they’re putting the topicals. It’s spreading it around a bit, but it’s okay. You can see that. It’s a much better state actually than where it was and she’s not being tortured at this point.   Then a few weeks later, it’s gone. You can see that the skin is still not completely normal because it’s been traumatized like this for nine months. It’s going to take some time for the skin to repair itself, but there’s no more eczema. There’s no more staph infection. She’s completely normal. Then, actually, the baby had eczema. So, once we cleaned her up. I started treating the baby for eczema.

Dr. Weitz:                         What are your favorite candida formulas for adults and infants?

Dr. Greenberg:                 Well, so for infants, it’s different. For infants, I really like Biocidin Liquid. It’s broad spectrum, and it addresses a lot of things, clostridia, candida, bacteria, and it’s safe for most infants. It just have walnut hull and leaf, so make sure that there’s not a walnut problem in any patient. There’s also formulas by another … Obviously, infants cannot swallow capsules. Infants, we’re not going to give alcohol. So, I give them glycerides, and Biocidin is a glyceride.  There’s also a company, Beyond Balance, that makes glyceride formulas. So, I use some of their formulas in infants as well to treat the dysbiosis because, again, it’s not alcohol-based, and it’s proven safe for infants, and we can get it down easily.    For adults, I use a lot of different things. I actually like Candida Support now. I like grapefruit seed extract, caprylic acid, neem. It just depends. I do different protocols for different people, and it depends on the full spectrum of what I see as well, but those are some of my favorite internal candida protocols.

Dr. Weitz:                            Somebody asked about Saccharomyces boulardii to increase sigA.

Dr. Greenberg:                 Yeah. I know a lot of people use sac boulardii. The problem is it’s a yeast, and I would say most of my patients have candida overgrowth, and I just don’t like to give more yeast when yeast is a problem. So, I know a lot of people do sac B. I just don’t really use it because almost all of my patients have candida overgrowth, and I just don’t want to be plowing them with more yeasts. So, I think it works for some practitioners. I just personally don’t use it.

                                                So, you guys just saw two case examples on eczema, and you may be thinking, “Well, that’s great, but does it work for other dermatological disease?” I’ll just show you some quick before and after photos. So, this was an acne patient, 20-year-old, complaining of back and chest acne. Test, treat the gut. One month later, pretty significant improvement in the acne, and this was the chest. Same patient.

                                                This is a patient with actually fungal acne. So, we see those little white spots. That’s malassezia yeast in there. It’s different than acne vulgaris, which is bacterial. This is in the first visit, and in three months, we can see clear skin.

                                                This was another patient with classic acne vulgaris on the cheeks, another teenage female. Two months later, we see it’s clear and the other cheek.

                                                This is a patient who’s an adult who came to me with a full body rash. A lot of her body looked like this. It was pretty brutal. She thought it was, again, she was really focused on food, and it’s a food reaction and a food allergy and I had to be like, “We’re leaving this food discussion behind. It’s not food. It’s pathogens.” Test and treat the gut. Two months later, gone, done, cleared up. That was her arm. This was her stomach.

Dr. Weitz:                            What kind of rash is this?

Dr. Greenberg:                 This, she had a lot of candida. I mean, again, it was a lot of different types of dysbiosis, but there was a big fungal element to this one. Candida will just wreak havoc on your gut and havoc on the skin. Clean up the gut, you’re going to clean up the skin. Of course, I had a whole topical protocol for her as well, but it was pretty uncomfortable.

                                                This is a rare condition called palmoplantar pustulosis. It’s in the family of what we call papulosquamous disorders, so psoriasis. It’s also called pustular psoriasis. Although the interesting thing about it is these pustules are sterile. So, if you sample them, there’s not going to be anything in there, and it’s really considered a mysterious disease. We don’t know why it’s happening. This patient, her dermatologist was trying to put her on Otezla. She’s a medical professional, needs to use her hands. It was a huge problem. So, at the first visit, five months later, she’s got a big improvement. She’s able to use her hands for her job.    Two months after that, we’re starting to see some good clearance, and then one and a half months later. So, these kind of autoimmune diseases take much longer to treat than a simple eczema, but this is considered an untreatable disease, and you can see from the first visit to now huge, huge difference, almost normal, and the dermatologist say it’s untreatable mostly. You have to go on biologics for it.

                                                This is another patient with a psoriatic type disorder. If you look down at his ankles, you’ll see red, oozing, crusting, bleeding. I said oozing, I hope you all are already thinking that’s a staph infection or an infection. You’d be right. We get these staph infections on top of other skin diseases, even psoriasis. So, he’s been living like this for two years. You can see it’s going up his legs. He’s not able to wear shoes and socks. Total disaster for him. He’s not able to participate in his family.   Seven months after treating him, he’s totally cleared up from this and also, he’d seen many dermatologists over the two years and nobody could help him. This was the front at month zero and seven months later. His feet are also clear. He just took it in the shoes.

                                                This is an infant with alopecia areata. You lose hair. It’s not just from the scalp. You can lose your eyebrows, your eyelashes or full body hair. This infant actually lost all his eyelashes and we were able to treat the gut and have them come back. This is a progression of it. It was also on his head, but I just got the eyelash pictures in here.  So, does this method work for other dermatological disease? It does. It really does.

                                                Some things that you may want to consider as a practitioner using these methods. You’re going to have to analyze all of the problems that you’ll need to address on both labs. So, I look at everything as these are all my problems, and then I have to decide what order I want to treat them in. You can’t treat everything all at once. There’s going to be probably too many issues to address.

                                                I pretty much start with mold and candida and/or H. pylori because the H. pylori is upstream in the stomach, but it does depend on what I’m seeing and what the symptoms are.

                                                You want to learn the best protocols to treat each issue, both topical and internal. Then, of course, you’re going to adjust your protocols based on your patient, infant, toddler, breastfeeding mom, what allergies do they have. I move through different protocols every one to three months depending on the patient and how things are going.   So, there is no one protocol. Everyone’s like, “What’s the eczema protocol?” I don’t have an eczema protocol. It changes and it’s different for every patient. This really is individualized medicine, and that’s how you get good results for people.

Dr. Weitz:                            Have you ever treated lichen sclerosus?

Dr. Greenberg:                 I haven’t. I have a new patient who I think I’m going to be seeing soon. I’m planning on treating it the same way. It’s an autoimmune attack. Depending on how far the scarring is, it’s very hard to bring back skin that is already sclerosed. I think the goal would be to reduce the further sclerosus. I haven’t treated it, but I certainly plan on applying the same methods to it.

                                                So, if you’re wondering like, “Well, how can I learn how to analyze stool test and OATs and mycotoxin test?” The labs who you can run these with, they usually have a lot of free educational videos available, and you’re going to need to invest a significant time doing it. Some of the labs has been on weekend training courses. I think it’s vital for the OAT. It’s so complicated. When you first look at it, it’s like, “What is happening on this test? I don’t understand this. How could I ever understand it?” Do the weekend training course if you want to understand OATs.  There’s paid courses offered by a lot of functional medicine and naturopathic doctors and professionals. I think they’re a couple of thousand dollars. I’ve never taken them, so I can’t say whether or not they’re worth it, but I think you can do it on your own if you can put in the time.

                                                The labs offer free consults on each lab that you run. I would suggest that you take those free consults at least on the first 20 tests that you run that’s a new test for you. You’d schedule a half hour visit, and that professional at the lab is going to take you through it and help you understand what are you looking at, how do you put these pieces together. It’s really useful.   I always say start by running the test on yourself first. Be your own guinea pig. Schedule a consult and see what’s going on in your own gut and try to treat yourself. Then you can start using it on patients.

                                                How do you learn to use herbs? I really think people need formal education and training. I know it’s not like pharmaceuticals where you need to be licensed. Anyone can prescribe herbs, but I think you really need, in order to be responsible, to get formal training, and not just an online course.      There are a lot of courses and ways to become trained as a registered herbalist or a lot of professional degrees with herbs built in like naturopathic doctor. We have four years of herbal training and it’s part of our board exams to pass an herbal medicine section. Otherwise, you won’t be a licensed naturopath. Same for traditional Chinese medicine in Ayurvedic doctors. The herbs are built in and they’re tested and formally trained on it.

                                                In terms of getting mold and mycotoxin literate, I also think you should get some formal education and training. This one can be online. There’s a lot of doctors who offer courses on it. Like there’s SIBO training courses, there’s mold and mycotoxin training courses as well, but they’re going to assume that you either have formal herbal or pharmaceutical training because, again, this is mold. So, you’re going to be treating it with prescription antifungals or herbal antifungals, and you need to know what you’re doing and have proper licensing.

                                                If you guys like skin and find it interesting, I am the Program Chair of the Naturopathic and Integrative Dermatology Series on LearnSkin. This is free. There are 20 courses. They’re CE accredited. So, you can earn up to 10 free credits, either AMA PRA Category 1 if you’re an MD. There’s naturopathic credits if you’re an ND and CBRN for nursing. It’s a lot of the stuff that I talked about. So, there’s naturopathic approach to atopic dermatitis, gut dysbiosis and its role on skin disease. So, you can check out. There’s SIBO testing for dermatological disease conditions. You can head on over the LearnSkin and take any of these courses. Again, they’re totally free.  This is my contact information. I’m at the Center for Integrative Dermatology. If you want to contact me, it’s drgreenberg@integrativedermatologycenter.com. Yeah. That’s it. Well, we’re at 8:00, but I can stay and take questions if people are interested.

Dr. Weitz:                         A couple more questions. Somebody asked about seborrheic keratoses.

Dr. Greenberg:                 Seborrheic keratoses and not dermatitis? So, seb keratoses is, yeah, it’s a disease of keratinocytes, and it can look pretty fungi on the skin. They can be removed. They are never going to turn into anything carcinogenic as opposed to actinic keratoses. AK, actinic keratoses can and will turn into basal cell carcinoma or squamous cell carcinoma. Those are the non-melanoma skin cancers, but seborrheic keratoses is never going to turn into a malignancy. It’s just unsightly, and a lot of people, it can be genetic, it can be due to sun exposure, but it’s nothing to be concerned about medically, but you can have them removed. They’ll burn them off or cut them off. Yeah, but they can never turn into something carcinogenic.

Dr. Weitz:                         Somebody asked, “Which mycotoxin course do you recommend?”

Dr. Greenberg:                 So, Dr. Shoemaker is probably the most famous protocol. I, personally, Dr. Jill Crista is a naturopathic doctor. So, I did Jill Crista’s course for mold and mycotoxin certification. I really enjoyed her course, and find it very usable. I also just signed up. I think it’s AAEM, just had a mold and mycotoxin course that I’m still working through, but I found it helpful. I like both of them because … So, Dr. Jill Crista is a naturopathic doctor, so she does talk about some prescription pharmaceuticals, but she’s a lot heavier on the supplement and herbal treatments.   The AAEM course that I’m doing right now is MDs. So, they’re pretty heavy on the pharmaceutical stuff, but I like learning about both and getting both perspectives. So, even do more than one, but I can personally recommend Dr. Jill Crista, C-R-I-S-T-A.

Dr. Weitz:                         Somebody asked, “What stool test do you recommend?” I know you like to use the GI map, right?

Dr. Greenberg:                 Yup, and I know that they’ve been on here. I really love the GI map. I find it price-wise is great for patients. I love that it includes H. pylori. I find it really easy to read, very usable and actionable. When I treat on the basis of my results, I usually get very good results for my patients. I’m doing, if any of you guys are members of IFM, the Institute for Functional Medicine, they have an upcoming conference. There’ll be an international conference in June, and I was selected to present a poster, and I’m presenting the OAT and stool test for about 35 acne patients showing what dysbiosis I see in acne patients. So, if any of you guys are at that conference, you could check it out, but it’s based on 35 GI maps and 35 great plain OATs. Those are the two tests that I used.

Dr. Weitz:                         Let’s do one more question. Can you answer, how do you treat hair loss, in 30 seconds or less?

Dr. Greenberg:                 Well, it depends. There’s two types of hair loss. There’s alopecia areata, which is an autoimmune problem, where you’re attacking the hair follicle and there’s androgenic alopecia. It is very complicated. If any of you guys are interested, through the CNDA or California Naturopathic Doctors Association, I’m going to be doing a two and a half hour presentation webinar on hair loss through the CNDA in August. So, there’s no 30-second description for hair loss. It’s pretty complicated, but if you want to attend the two and a half hour webinar, go over to the CDNA and the California Naturopathic Association, and I’ll be giving that webinar in August.

Dr. Weitz:                         That’s great. If you could post that on the Facebook page also, that would probably be helpful. Thank you so much, Dr. Greenberg. So many of the practitioners said it was an amazing presentation, which it was. So, thank you so much.

Dr. Greenberg:                 Thank you all for your time. I really appreciate you spending Thursday evening with me.

Dr. Weitz:                         Thank you. Bye, everybody. See you next time.


                                                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 Podcast 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.



Diet For Great Sex with Christine DeLozier, LAc: Rational Wellness Podcast 204

Christine DeLozier, LAc, discusses Diet For Great Sex 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 my WeitzChiro YouTube page.] 


Podcast Highlights

1:06  Hormones, including both testosterone and estrogen, are important for sexual health.  In men, not only is testosterone important, but so are small amounts of estrogen and progesterone important for sexual health.  Testosterone is also important for sexual health in women.

6:41  Eating the right diet by avoiding junk food and avoiding sugar, consisting of lots of fresh fruits and vegetables and leafy greens can help some women to not have to go on hormone replacement therapy after menopause.  Both a diet high in refined carbohydrates and sugar and a diet very high in fat can disrupt your hormones.

13:07  Leafy greens are very high in both potassium and antioxidants, like vitamin C, which protect not only our hormones but our neurological health and reduces oxidative damage to our nerves.

18:19  Omega 3 fats are super important for brain health and neurological health. Dopamine is a neurotransmitter that is a huge component of pleasure and the circuitry for dopamine requires omega-3 fats, which you can attain from consuming wild salmon or from taking fish oil capsules. 


Christine DeLozier, LAc, is an acupuncturist and herbalist at Needle and Herb Acupuncture and Traditional Chinese Medicine in Rochester, New York, and author of the new book, Diet for Great Sex: Food for male and female sexual health. Her website is ChristineDelozier.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. Today, our topic is diet for great sex with Christine Delozier, LAc. Christine Delozier is an acupuncturist, herbalist, and author of the new book Diet for Great Sex: Food for Male and Female Sexual Health. Christine, thank you so much for joining us.

Christine:            Thank you so much for having me on your show.

Dr. Weitz:            So my first question is how much does it facilitate sex to wear an N95 mask?

Christine:            Well, it can be a barrier to oral for sure.

Dr. Weitz:            So for the first real question, Christine, in your book Diet for Great Sex, you focus on the three systems of our body that affects sexual health, and you break it down into hormones, neurological and vascular. So let’s start with hormones and let’s talk about which are the most important hormones for sexual health.

Christine:            Well, the short answer to that is all of them. Our hormonal balance is like a symphony. And when one of them gets out of whack, many of them tend to fall out of whack. It’s very rarely that one hormone is out of balance in isolation. Of course, testosterone is really important. Estrogen is really important, and both of those are important for both male and female sexual health. So men need estrogen just as much as they need testosterone, but of course, in different proportions. So for sexual health, males do better with higher levels of testosterone, lower levels of estrogen and for females is just the opposite.

Dr. Weitz:                 So when it comes to testosterone for men, I was surprised to see that you wrote that testosterone improves mathematical reasoning and cognitive ability, because we usually think that when testosterone levels rise, those things go out the window.

Christine:            Yeah, it’s amazing. How many bodily functions, testosterone affects. I mean, the short answer is everything. Testosterone affects cognition. It affects overall health, it affects our energy levels, it affects everything. So when testosterone is low, that can affect so many aspects of health, the brain, it affects sexual function, it affects cardiovascular disease, everything.

Dr. Weitz:           So in the section where you’re talking about men, you also mentioned estrogen and even small amounts of progesterone, enhance sexual function in men. Maybe you could talk about that.

Christine:            Sure. Again, it’s in the right ratios. So progesterone, it’s not good when it’s too much, it’s not good when it’s not enough and the right ratio ratios, it facilitates an optimal sexual function, optimal blood flow, optimal hormonal balance.

Dr. Weitz:            I mean, we measure a lot of hormones in men and I often find that progesterone is low. And I often wonder if men would ever benefit from taking a small amount of progesterone.

Christine:            That’s interesting because the problem with that is that progesterone has actually been used to reduce libido in men like sex offenders and things like that. So when you don’t get the ratio right, you might have just the opposite effect, if that makes sense.

Dr. Weitz:           And so when it comes to estrogen, let’s take estradiol. On a serum test, what would you consider a good level of estradiol for a man?

Christine:           I don’t know. The most of my research focused on the evidence for how foods effect these different things.  So the specific numbers, I wouldn’t say that’s really my specialty, but what I looked at was the research on foods that help to balance hormones.  So it’s hard.  The thing about it is it’s just like minerals hormones are kind of like minerals in the sense that as soon as we try to kind of play God with them, we can sometimes throw things out of whack and you need somebody who really knows what they’re doing to attempt that game. And it’s the same with minerals. We take a calcium supplement and we can sabotage our iron, we take a magnesium supplement, we can sabotage our calcium, we take a zinc supplement and we can inadvertently, make magnesium levels low. So all of these-

Dr. Weitz:            Or you could just measure all of them.

Christine:            We could. Yeah, but there’s so many minerals that come into play that your best bet is to try to get as much as you can from food. Obviously, a lot of times that’s not possible. And then maybe take kind of a broader mineral supplement, for example.

Dr. Weitz:            So on the testosterone theme with respect to women, testosterone is also very important for the libido, but too much testosterone leads to PCOS. So what about testosterone? And what is a good level and especially what about for post-menopausal women?

Christine:            So some women for example, have improved libido by taking testosterone, but again, taking one hormone in isolation can be risky like you mentioned with PCOS. So the answer to that is enough for that individual. There’s no one right answer for every person, but when it’s low women definitely experience low libido, they experience a decline in sexual function. So there are a lot of ways to help normalize those levels though, and help normalize that whole kind of symphony of hormones.

Dr. Weitz:            Should women take hormone replacement after menopause, if they want to have good sexual function?

Christine:            That’s a conversation I would say, would be best left to their doctor. What I can say is this. Food can help you to not have to go on hormone replacement therapy. A proper diet can help balance your hormones without needing to do that. But again, some women will still need to do that, talk to your doctor about it, but eating well can only help. The way our lifestyles are. It definitely puts a strain on our hormones. The high sugar intake will sabotage hormones. There’s tons of evidence that shows that eating a high refined sugar in our diets, it disrupts our sex hormones. It makes for worse sex. So that’s just one simple thing that you can do to help move your body in the right direction post-menopause or at any time in your life.

                            And other things also are very high, fat diets can also disrupt our sex hormones. Certain foods can help restore balance to our sex hormones. So when we eat a lot of leafy greens, which is kind of how nature intended it, when we look at other primates, we see that they sit around eating leaves a good portion of their days. We don’t eat a whole lot of leaves. We eat a lot of junk food and leaves, for example, reduce cortisol levels. And cortisol is a stress hormone that can interfere with testosterone in males and females. So that’s one way to help normalize that balance.

Dr. Weitz:           I just wanted to mention as far as the hormones that you mentioned for sexual health, one that I often have heard other people talk about that seems to be important for sexual health is oxytocin.

Christine:           Yep. I found that in my research as well, that it was important. Again, it’s this symphony of hormones, even things that you don’t think of as being related to sexual health, like ghrelin and leptin. We know that these are hormones that tell us when we’re full and when we’re hungry, but they actually just can interfere with sex hormones when they’re out of whack. So when people have what we call leptin resistance, which is when we eat so much refined sugar, well, in some cases, it’s because we eat so much refined sugar, our body has become desensitized to leptin, which then affects our sex hormones.

Dr. Weitz:           So what are some of the principles of the best diet to promote healthy hormones? And should men and women eat differently?

Christine:           All the research that I came across was that men and women should eat the same pretty much. The specific hormone ratios are different, but eating in a way that’s in accordance with the natural biological design of humans promotes that balance. So if we were going to say a general overarching theme would be lots of fresh fruits and vegetables, we have tons of research to show that helps with hormonal balance and optimal sexual function related to sex hormones. So lots of fresh fruits and vegetables, lots of leafy greens, that sort of thing.

Dr. Weitz:            Some would say if we’re going to go in balance with nature, we’d want to follow a paleolithic diet because that’s similar to what say the caveman ate for hundreds of thousands of years.

Christine:            Sure. There’s so much debate about that. And everybody has an opinion. It’s interesting to note that when we look at other animals, whether it’s squirrels or chipmunks or any other animal, they seem to know what to eat, what is the healthiest, but humans have kind of lost their way. If we look at other primates though, they are biologically kind of our cousins. And if we look at how much, for example, meat, that’s a big issue with diet. If we look at how much meat other primates eat, there’s a big range.  It’s anywhere from 0% of their calories to 90% of their calories comes from animal product, whether it’s bugs, whether it’s mammals, that sort of thing, where humans fall in that range is a big matter of debate. But what we can agree on is that we know that they eat tons of leaves. We know that they eat lots of fruit and vegetation and that they take in many times the amount of certain minerals like calcium, magnesium, zinc, certainly potassium for sure. And so that’s one thing that we can strive to do, whether we’re following like a keto type diet or whether we’re following a more plant-based diet.

Dr. Weitz:           A keto diet is fairly popular these days. And that basically involves a very low carb diet. And a lot of people have found this type of diet to be beneficial for cardiovascular health and neurological health. What about the ketogenic diet?

Christine:           The problem with the keto diet is this, it falls short in terms of vitamin C and also things like potassium. Potassium is one of those things that we don’t get enough of. There’s lots of evidence to support that. And it’s lacking in a keto diet. All of the things that contain a lot of potassium almost all of them are high in carbs. So your best sources are potatoes with the skins on. Yams with the skins on. Squash, bananas, oranges, all the things that have carbs in them. There’s one though, if you are following a keto diet, what I would say is really make sure that you’re getting lots of leaves in, because leaves are one of the few non carby sources of potassium. So humans, we used to take in about 10 times as much potassium as sodium in our diets. And now it’s kind of the opposite. We take in about 10 times as much sodium as potassium, and it’s wreaking havoc on our blood vessels and also hormonally as well. So get those leafy greens in if you’re going to do keto.

Dr. Weitz:           So talk about some of these aspects of diet that you feel are important for promoting hormone levels.

Christine:            So again, eating leafy greens, eating-

Dr. Weitz:           And how does eating leafy greens help with the hormone levels?

Christine:           Well, like we talked about, for example, we know that it lowers cortisol levels for example. Also even things like antioxidants, leafy greens are very high in antioxidants, even antioxidants can have an effect on hormone levels. So one study I was reading, for example, there was an effect of certain antioxidants on estrogen levels, for example, in the female menstrual cycle. So antioxidants definitely something that you want to focus on, but hormones, aren’t the only piece in this trifecta of great sex. We consider nerve conduction and we consider vascular health and they all kind of mutually influence each other. So when we talk about hormones, every hormone that’s produced by the body, every neuro-transmitter, every substance produced by the body is ultimately controlled by the nervous system.   And so in strengthening the nervous system, we also affect hormonal health. And one of the best ways to strengthen the nervous system is through antioxidants, which they help repair damage to nerves just caused by our lifestyles, our environments. And they also protect from oxidative stress because most of that damage comes from oxidative stress. It comes from eating processed food. It comes from not exercising. It comes from being exposed to the environmental toxins that we’re exposed to every day, all of those sort of things.

Dr. Weitz:           So what are the most important antioxidants? Because we have a broad range of antioxidants. We have vitamin C, we have the vitamin E family. We have tocopherols, tocotrienols, we have selenium, we have whole bunches of many, many phytonutrients, polyphenols, which are some of the most important antioxidants for sexual health.

Christine:           All of them. Yeah. All of them can play their role. Vitamin C is a huge one. Absolutely. It’s important for many different processes, including balancing our body chemistry, also serving to protect our nerves and our blood vessels help repair damage, that sort of thing. So vitamin C is a huge one. Everything that you mentioned is a huge one. Polyphenols are a huge one. Polyphenols were shown to improve vascular health excuse me, arterial function. So they helped blood flow within a couple hours of eating them. They were actually measurably functioning better in their measurably more elastic within a couple hours of eating things like berries, which are high in polyphenols. So those are really high, our mineral balance is really high like selenium you mentioned. So they’re all really important. If you’re getting a broad variety of fruits and vegetables, you’re going to be getting a broad variety of antioxidants.

Dr. Weitz:           In your chapter on neurological health, you mentioned mushrooms as a key category of food that helps with neurological health. Maybe you could explain that.

Christine:          Sure. Yeah. Mushrooms are so exciting and they’re especially exciting in modern nutritional research with so much emerging research showing how important the microbiome is to our health. It’s important not only to weight, it’s important to cardiovascular health. It’s important to pretty much every system in the body. We’re finding that things we didn’t even think were related to this delicate balance of microbes in our digestive tract affect so many things. They even, for example, we’re able to transfer cardiovascular disease risk from one group of subjects to another simply by trans giving them these fecal transplants where they took feces from the group of high risk of cardiovascular disease and transferred it to those who did not have high risk of cardiovascular disease repopulating their microbiome. And they then developed high risk of cardiovascular disease.

                           So it affects everything. So the cool thing about mushrooms was that there’s a lot of emerging research showing that one of the actions of mushrooms is on the microbiome. One of the ways that it exerts all of its contribution to health is by actually improving the diversity of microbes in the gut. So improving populations of beneficial microbes and reducing populations of non beneficial microbes, which is really cool. Also, they’re loaded with antioxidants, which again, speed nerves, repair damage. One of the superstars, as far as nerve repair was lion’s mane, but all of them had offered benefit to this aspect of sexual health in terms of their contribution where they had say accidents.

Dr. Weitz:           And of course, Omega-3 fats are super important for brain health and neurological health as well, given that most of the nervous system is made of fat.

Christine:           Yeah, absolutely. Absolutely. And dopamine is a huge component of pleasure, so the circuitry for dopamine requires abundant omega-3 fats and everybody can’t make it. We have to take it in from our diets. So it just shows us again how omega threes can equate to pleasure. When our dopamine pathways are operating functionally, we experience pleasure when our partner touches us.

Dr. Weitz:           Do you advocate taking omega-3 supplements?

Christine:           I’m always a little bit more conservative with supplements than I am with whole foods. I’d rather see people having some wild salmon. There’s mercury in fish, a wild salmon is one of the ones that does have mercury, but it’s a little bit more balanced than some of the other ones. It offers a lot of omega-3s and it offers relatively less mercury.

Dr. Weitz:           For me that’s one of the advantages of taking omega-3 fats besides consuming salmon. I know I can get a high dosage in a molecularly distilled product that is going to be free of mercury and other contaminants.

Christine:           Yeah. And that works for people. So my personal philosophy on supplements is just to be cautious and then when possible get them from the diet, but our lifestyles makes it very difficult to do that. So there’s definitely a reason why that would be an attractive option.

Dr. Weitz:          Yeah. So let’s talk about blood flow and sexual health. What is some of the nutritional approaches to improving blood flow?

Christine:           Sure. So we all know that males need blood flow for sexual health and for sexual function, but most people don’t realize how important it is for female pleasure, female sexual arousal, lubrication, blood flow is responsible for lubrication. It’s very much involved in the arousal response. It’s very much even involved in how sensitive the female clitoris is to stimulation. So blood flow is important for everybody. And our diets tend to compromise that blood flow in a lot of different ways. One of which is we were talking about our potassium intake. Potassium is something that softens the delicate lining of blood vessels, improving the elasticity and improving blood flow. So getting more potassium in our diets is something that we really want to do. The vast majority of Americans do not get enough potassium in their diets and should increase it.

                                                Not only that, the processed foods that we eat actually sabotages our potassium because in order to deal with all that extra sodium, we have to flush potassium with it. And then your body is forced to conserve potassium in other ways just to have basic bodily function. So getting more potassium will definitely help increase blood flow. Again, leafy greens. Leafy greens are kind of important in this whole trifecta of great sex. So leafy greens, what they bring to the table is they bring a lot of antioxidants for sure which help blood vessels. They also are high in dietary nitrates, which first of all, it promotes vascular health. And secondly, it dilates blood vessels, even in the short run. So dietary nitrates basically convert to nitric oxide, which is a vasodilator. And so in one study that I read, for example, the subjects ate one serving of spinach and within a couple hours, their salivary nitric oxide levels were eight times what they were at baseline. So it can definitely have a very immediate effect on blood vessels, as well as promoting vascular health in the long run.

Dr. Weitz:            And of course, drugs that stimulate nitric oxide production are among the most popular to promote libido.

Christine:            Yeah. Right. Exactly. Exactly. So if you’re looking for maybe a more natural approach, you might try food. There are three to four categories of food that actually have been shown in research to improve blood flow within a couple hours of eating them. So you can choose certain foods for date night that will do that. As well as kind of avoiding foods that might tank your testosterone. So for example, in research, a very sugary meal that really bumped up glucose a lot sharply reduced testosterone, which is definitely not what you want in the short term.

Dr. Weitz:            And of course, beet root juice is something that some athletes take to stimulate nitric oxide production.

Christine:            Yeah. And that’s another good choice for a date night sex menu too. Beet juices is a real good one, celery juice, beet juice.

Dr. Weitz:            And of course we have supplements on the market with the beet root and L-Citruline and certain other nutrients stimulate nitric oxide production. Are you a fan of those at all?

Christine:            I have not used the beet root. My daughter has, my daughter uses a lot of those supplements for her pre-workout, but I haven’t used them myself. Some of the nitrate supplements have not had really great results clinically and have had some adverse risks to them. But that doesn’t necessarily include the B root powder and things like that. But these are just more like strictly, nitrate supplements.

Dr. Weitz:            So you mentioned potassium, what are some of the other minerals that are super important for sexual health?

Christine:            Yeah. So again, all of them are really important, but zinc is a huge one. Zinc is a huge mineral for sexual health. It’s one of those things that when it’s low, it can affect so many aspects of it can affect hormones. It can affect the vascular system, it can affect nerve function, it can affect everything. So that’s a really big one. And it’s one of those ones that is focused on even in fertility. So it’s good for sexual health, good for fertility. And it’s something that Americans get way too little of. I read a few studies that were saying that 97% of Americans have an inadequate dietary intake of zinc. So really important. It’s antiviral of course as well. And it also promotes-

Dr. Weitz:             I certainly have all my patients take an extra zinc because of their antiviral properties.

Christine:             Yeah. Yep. Yeah. So that’s a really big one.

Dr. Weitz:             Zinc with quercitin because that increases zinc absorption.

Christine:             Okay, cool. Cool. Yeah.

Dr. Weitz:            So which is some of the best herbs to stimulate libido?

Christine:            So we’ve got our culinary herbs, then we’ve got our more medicinal herbs, things that have been used in traditional Chinese medicine, like horny goat weed was one that had a few studies to show its efficacy. So that was a big one. Anybody though, if you’re going to go the medicinal herbs route, I would suggest consulting a practitioner who has been trained in it. Most acupuncturists have a master’s degree in herbal medicine as well, Chinese herbal medicine. So that’s one choice.

Dr. Weitz:            Let’s say if you were speaking to practitioners, because we have a percentage of practitioners that listen into our podcasts. Which ones do you find can be most efficacious for female and now sexual health?

Christine:            Yeah. So horny goat weed is one. The research on something like [inaudible 00:26:38] is one that was shown to be effective though it also had its risks as well for toxicity.

Dr. Weitz:                 [inaudible 00:26:48]?

Christine:            Yeah. [inaudible 00:26:50] was definitely one that had a few studies to support its use. Then there’s some culinary herbs that also actually had some studies like saffron. Saffron actually had several studies to support its efficacy, to promote sexual health, both animal studies and human studies. It showed that those taking saffron had more sex, higher libido and more blood flow.

Dr. Weitz:            Interesting.

Christine:            Yeah.

Dr. Weitz:            You mentioned viruses. Are more people having sex now that they’re home because of COVID?

Christine:            If they can stand their spouse there. Yeah.

Dr. Weitz:            So heavy metal toxicity. How can this be a impact on sexual health?

Christine:            So I would say most people think of heavy metal toxicity as some sort of freak exposure that happened because they lived near a landfill or something like that. But actually the research shows that all of us are exposed to a growing number of toxins in our environment, from our water, our air, our food, we’ve got ketamine in our food, we know we have ketamine in our food. It goes into the air from smelting and then it comes down into agriculture. And then we see it in our food sources in our food chain.

Dr. Weitz:            We know a lot of the soil that fruits and vegetables are groaning contains lead. We have arsenic, we have arsenic in the chicken. We have arsenic in the rice. We have warnings about arsenic all the time. We know we have mercury spewed into the atmosphere from coal fired power plants and we have mercury in the fish.

Christine:           Yeah, exactly. So all should be concerned about this, not just somebody who’s living next to a power plant or night or next to someplace that we know has more risk. So one of the things I found in research where there were a lot of studies again with antioxidants, that was a big one in terms of protecting yourself from the damage of these toxic heavy metals. So things like vitamin C, vitamin E, vitamin A were all important. And then there were certain foods too, like cilantro, like onions and tomato were shown to either deal with the effects of that or reduce absorption of those. But as far as reducing-

Dr. Weitz:            Do you ever measure heavy metals and use specific protocols to try to reduce them?

Christine:            No, I don’t have any experience at all with that. I don’t. But I am familiar with research that has measured specific levels and then measured them following things like cilantro and found that it actually had a stronger ability to reduce. I forgot which one study I’m thinking of. I forgot. I think it was arsenic that it had a stronger ability to actually remove that from brain and liver tissue than some of the pharmaceutical drugs, but minerals were actually really important in reducing absorption. So the fact that we are exposed to all these heavy metals, improving our mineral profile can help us to not absorb as many of those heavy metals, because zinc was a big one actually, zinc is a big one. Calcium’s a big one. And magnesium is a big one in terms of helping our bodies to flush that out before it’s absorbed by our tissues.

Dr. Weitz:            How about an EMS? Are those an issue for sexual health?

Christine:            Absolutely. And it’s again-

Dr. Weitz:            Basically with 5G coming.

Christine:            Yeah. I wasn’t sure what kind of research I was going to find on that because it’s such a big controversy with 5G that it’s these extremists or conspiracy theorists that are concerned about the electromagnetic fields or wifi. So I really didn’t know what I was going to think. And everybody thinks of these people with these tinfoil hats and things to protect them from the rays and stuff. So when I looked at the research, I was really flabbergasted because the research is so strong that I found study after study, after study. In fact, I found very few studies that failed to find negative effects of EMFs on our health and the most prominent effects are neurological and hormonal. They definitely disrupted hormones and they definitely caused oxidative stress to the point that it caused neurological damage.

Dr. Weitz:           So what are some of the best tips for dealing with that?

Christine:           Again, what I found were antioxidants helped deal with that. Helped, it doesn’t eradicate it. We still need to make a conscious effort to reduce our exposure to EMS and including cell phones, things like that, turning off our wifi at night and trying to use a hands-free piece so that our heads aren’t right next to our phones, that sort of thing. All are important in reducing our exposure. Because the studies that I found were that normal exposure, I’m talking about the amount of exposure that the average person has to wifi through their cell phones, for example, was enough to cause damage.

Dr. Weitz:            Right. And of course, now people using headsets that are wireless, everything’s wireless. And so we’ve got more of these EMS flying around going through our heads and the rest of our bodies.

Christine:            Yeah. Yeah, absolutely.

Dr. Weitz:            So what about natural aphrodisiacs?

Christine:            Yes. So again, the culinary aphrodisiacs that are really fun at least from my opinion, to play with being a foodie. And I like the aesthetic of food. I like playing with different kinds of concoctions and stuff. So some of them that I really like are things like cloves. Cloves, we’re one of the few culinary aphrodisiacs that were shown to actually have an immediate effect. So within a couple hours of, I think it was within one hour after participants ate the cloves, they had improved sexual function. So that’s a fun one to play with because you can make so many things with it. I like making rice dishes and then throwing in some of those aromatic spices, like cloves, nutmeg was also one that had some research to support it.

                                                And those are two spices that have a really rich history, world history as well. They’ve been highly coveted and wars have been fought over them to control the rights of them, but they kind of are worth it and how they have this wonderful fragrant aroma. And they did have some studies to show that they improve sex. In that case it’s not going to be like a Viagra, it’s going to be more subtle. It’s a more subtle enhancement. So even garlic and let’s see saffron of course, you can kind of combine all those, even onions, things like that have some aphrodisiac properties. So when I say aphrodisiac, I don’t necessarily just mean that it may improves libido. An aphrodisiac can either improve blood flow, it can improve libido or it can improve pleasure. So any of those.

Dr. Weitz:                 What are the best natural products for lubricants? Because there’s a lot of controversy over what types of lubricants are good. Some people like coconut oil, but coconut oil is very alkaline and the vagina is very acidic.

Christine:           Oh, that’s a really good question, but I’ll answer-

Dr. Weitz:          I mean, I know it’s not a part of the diet for sex.

Christine:           Well, that’s why I’m going to answer you in a cheeky way and tell you that that the best lubricant is exercise, going for a run 20 minutes prior to sex it, it’s going to offer the best lubrication and also eating some of these foods, which improve blood flow because lubrication is subsequent to blood flow. So basically blood flows to the vagina and clitoris. And from that blood flow, it basically diffuses through and becomes a vaginal lubrication, if that makes sense.

Dr. Weitz:          Okay.

Christine:           So a specific product, I really don’t know. I haven’t even thought about that question quite honestly. So I don’t know which one I would recommend, but I guess if I were to choose, I’d say maybe coconut oil would be a good thing, but as you mentioned, it’s alkaline. So you certainly wouldn’t want to disrupt the pH balance of those tissues. So I would say whatever works for that person that doesn’t irritate them, or irritate their skin.

Dr. Weitz:          So maybe a couple of foods that are most damaging to sexual health.

Christine:           There’s three. There are three big, huge culprits, and that is… The wrong kind of fats. I mean, high fat in general, but particularly the wrong kind of fats, which is not just trans fats, but if you’re loading everything with oil and frying it, that’s not good either a lot of the processed fats and high sugar, definitely a big one and then high salt. So those three, that’s the worst combination that you can get. And that’s something that should all kind of focus on.

Dr. Weitz:          So fat, sugar and salt.

Christine:           Yep.

Dr. Weitz:          Are there some fats that are really good for us that we want to load up on?

Christine:           Yeah. Omega-3 fats. So for example-

Dr. Weitz:          What about olive oil?

Christine:           Well, even if it’s olive oil, I wouldn’t want to be deep frying things. I wouldn’t want to be using tons of oil in your dishes in general, because it definitely can contribute to plaque accumulation, even when it’s olive oil. So most a high fat meal, even just one fatty meal will increase arterial stiffness within a couple hours of eating it. However, omega-3 fats actually had the opposite effect on arteries within the short term, so they improved vascular function in the short term. So making the blood vessels more elastic for example.

Dr. Weitz:                  Okay, great. So I think that pretty much completes the questions that I had prepared. Any final thoughts, information you wanted to provide our listeners and viewers?

Christine:            No. Just try to eat as close to nature as possible. And that’ll usually steer you in the right direction.

Dr. Weitz:                 Okay. How can viewers and listeners get ahold of you and find out about your book and what you have to offer?

Christine:           My website is dietforgreatsex.com and you can purchase my book Diet for Great Sex on Amazon.

Dr. Weitz:                 That’s great. Thank you so much, Christine.

Christine:           Thank you so much for having me.

Dr. Weitz:                  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.



HDL Cholesterol with Dr. Mark Houston: Rational Wellness Podcast 203

Dr. Mark Houston discusses HDL Cholesterol 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 my WeitzChiro YouTube page.] 


Podcast Highlights

4:28  What are LDL and HDL?  These are apolipoproteins that transport fats through the body and serve many functions, including immunological function. They help protect us against infections and parasites and they are part of our metabolic system for making steroids and vitamin D and sex hormones.  Today, the biggest threats to us are no longer infections, but more from environmental toxins, nutritional imbalances, obesity, and other risk factors that result in chronic diseases like heart disease and diabetes that kill us.  In order to protect us from environmental insults the LDL particle number may become elevated, which is the driving risk for heart disease and myocardial infarction.  LDL is considered the bad cholesterol and HDL is considered the good cholesterol.

7:24  The main job of HDL is to produce Reverse Cholesterol Transport (RCT), also termed Cholesterol Efflux Capacity (CEC), which are the primary functions of HDL that go into the cell and the artery walls and pick up the LDL like a garbage truck and take it back to the liver where it will be excreted with bile. HDL if it is functional can reduce atherosclerotic plaques and reduce rupture and it can improve plaque stability.  There is soft plaque that is composed of a very aggressive core of lipids and smooth muscle cells and inflammatory cells, and it’s surrounded by a sort of a firm top that is very thin. This protective top can rupture, resulting in the contents of the plaque spewing out into the artery and this can cause thrombosis and an acute myocardial infarction.  Such patients may present with an acute MI while doing intense training, such as interval training or a marathon, though they may not have much obstructive disease.  The other type is calcified plaque, which is more stable and less likely to rupture, but this type of plaque tends to become obstructive.  It may not result in any symptoms until you get to 95% stenosis.  Calcified plaques can be picked up by coronary calcium scans or by an exercise echo or by nuclear medicine scans, while soft plaques will often not be seen by such scans or tests. But soft plaques can often be seen on MRI imaging with contrast or by a PET scan or a CT angiogram.

12:36  HDL has a number of positive functions, including RCT, anti-inflammatory, antioxidant, and it reduces vascular immunologic damage in the arteries.  HDL is composed of over 100 different molecules, proteins, lipids, and other components and there are at least 25 different beneficial effects of HDL on atherosclerosis prevention.  We used to think that the HDL level and the HDL size determined the true risk, but the only thing that really gives you the true risk is the functionality of the HDL.

15:37  There are two labs that can measure HDL functionality, including Cleveland Heart Lab, which is owned by Quest Diagnostics, which offers the HDL Function Test.

18:35  There are some who feel that APOA is a better marker for assessing heart disease risk than HDL.  APOA, which is the carrier for HDL, may be a little better marker than HDL, but it still does not correlate as well with cardiovascular disease risk as HDL function does.  One study found that in a male if the HDL is over 50 or 55, and in a female if it is over 75 or 80, most of it is likely to be dysfunctional. 

20:28  Oxidized LDL and Myeloperoxidase (MPO). LDL is not atherogenic (will not cause vascular damage and create arterial plaque) until its oxidized or otherwise modified. MPO is a compound that is made by white blood cells and while it is antibacterial, it is a bad actor.  MPO increases coronary calcium and it can cause high blood pressure, coronary heart disease, atherosclerosis, and even plaque rupture. When you have high levels of oxidative stress and high MPO, it damages the HDL and makes it dysfunctional.

22:15  Dr. Houston has developed a nutraceutical that improves HDL functionality called CardioLux with Metagenics that contains quercetin, pomegranate, lycopene, and vitamin E.  These components reduce oxidative stress and inflammation, making the HDL more functional.

25:31  A lot of HDL functionality is related to the proteins in HDL. Essentially the reason why we have LDL and HDL particles is that fats don’t move readily through the bloodstream, which is water soluble, so they are surrounded with various proteins that coat the lipids.  One of the important proteins in HDL is PON1, peroxidase, which is very important for HDL function.  These nutritional compounds (quercetin, pomegranate, lycopene) protect and raise PON1 levels.

27:30  CoQ10 is a very important nutrient for heart health, but there is an issue with getting CoQ10 not only into the cell but into the mitochondria. There is a new form of CoQ10 that’s a thousand times more effective than regular CoQ10 at penetrating the mitochondrial membrane, called MitoQ.  Dr. Houston has a series of 10 patients who were on the cardiac transplant list who had end stage coronary heart disease. They couldn’t put stents in and they couldn’t do bypass surgery. He put them all on MitoQ and every one is now asymptomatic with no chest pain and their ejection fractions have gone up significantly and they’re off the transplant list.  Dr. Houston noted that he still uses the metabolic cardiology program, so he uses regular CoQ10 for the vasculature, MitoQ for the heart, and he also uses d-ribose, taurine, L-carnitine, magnesium and a few other supplements that improve the myocardial contractility and mitochondrial function.

29:44  The best diet for improving HDL functionality is a low refined carbohydrate intake and sugar intake should be less than 25 gms per day.  You should have at least 8 servings of organic multi-colored vegetables per day, which are rich in phytonutrients.  Wild game, a variety of berries, and pomegranates should be part of that diet.  Pomegranate raises HDL functionality through raising PON and it has been shown to reverse carotid atherosclerosis in one year.

31:07  Dr. Houston has developed the Coronary Heart Disease Plaque Regression and Coronary Artery Calcium Regression Program, which includes about 15 different nutritional products, including Neo40 (a nitric oxide booster), Arterosil (which protects the glycocalyx), vitamin K2 MK-7 (a dosage of at least 360 mcg per day and K2 does not promote blood clotting or interfere with the blood thinner coumadin), omega 3 fatty acids (EFA-Sirt Supreme), VasculoSirt, curcumin, and quercetin.  Quercetin has anti-inflammatory, antioxidant, and anti-immune effects and it’s the only compound that reduces SASPs, which are senescent proteins.

35:30  Exercise.  Both resistance and aerobic exercise improve HDL functionality.  In Dr. Houston’s book, What Your Doctor May Not Tell You About Heart Disease, there’s 2 chapters on the best form of exercise that Dr. Houston wrote with Charles Poliquin, a great trainer who undortunately died about a year ago with a heart attack.  Dr. Houston and Charles also wrote an exercise program that combines aerobics and resistance training with interval training to get the best cardiovascular benefits, which is published in a book titled, ABCT, Aerobics, Build, Contour, and Tone.

38:03  Most of the medications that have been developed to raise HDL levels have not been effective.  The exception is niacin, which actually improves total HDL, HDL particle number, HDL size, and HDL functionality.  There was an older lipid drug used in the VA-HIT trial, which raised HDL, but we don’t know if it improved functionality.


Dr. Mark Houston is an internal Medical Doctor and a hypertension and cardiovascular specialist. He is the director of the Hypertension Institute in Nashville, Tennessee. Dr. Houston is triple board certified in hypertension as an American Society of Hypertension specialist and Fellow of the American Society of Hypertension, Internal Medicine, and Anti-aging Medicine.  Dr. Houston teaches at the Institute of Functional Medicine and the A4M programs. He is a prolific writer and has written What Your Doctor May Not Tell You About Hypertension, What Your Doctor May Not Tell You About Heart Disease, Nutritional and Integrative Strategies in Cardiovascular Medicine, Nutritional and Integrative Strategies in Cardiovascular Medicine, and his two latest books, Vascular Biology for the Clinician, and Precision and Personalized Integrative Cardiovascular Medicine. You can contact Dr. Houston through The Hypertension Institute web site HypertensionInstitute.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 and also athletic performance, 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, 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 HDL cholesterol, and we’ll be speaking with Dr. Mark Houston. The focus of HDL cholesterol which has been called the so-called good cholesterol is that this molecule could potentially help to prevent and reverse cardiovascular disease. Much of the research about heart disease has really been focused on the so-called bad cholesterol, the LDL, which is now generally seen as a significant player in the formation of atherosclerotic plaques in the artery walls that can lead to heart attacks, strokes, and heart failure over time.  of the cardiovascular medications are designed to lower LDL levels including statins, niacin, Zetia, bempedoic acid and the new PCSK9 inhibitors. And there are a number of nutraceuticals that are also effective at lowering LDL particles, including red yeast rice, fish oil, plant sterols, niacin, berberine among others.  We also know that the proper diet and exercise can also be very effective in reducing LDL cholesterol in our bodies especially the more atherogenic small dense LDL particles. But today, we’re going to be focused on the so-called good cholesterol, HDL. We’re going to go into how to understand it, how it works, and how we can improve HDL to improve our cardiovascular health.

                                                We first learned about the potential benefits of HDL cholesterol about 70 years ago. And in 1977, we learned through the Framingham Heart Study that low levels of HDL are generally associated with increased risk of coronary artery disease. And we thought at one time that simply the more HDL, the higher the levels, the better off we are.   But our thinking about this has changed as we have learned that the HDL story is much more complex than we thought it was. And drugs that were developed to raise HDL have really failed to be effective in reducing heart attacks or death. In fact, some people with very high levels of HDL may actually be more at risk for heart disease. And so, this is why we’ve asked the expert, Dr. Mark Houston, to join us to explain what current knowledge about HDL cholesterol is and how we can use this to prevent a reverse heart disease.

                                                Dr. Mark Houston is a internal medical doctor and hypertension and cardiovascular specialist. He’s a go-to expert on cardiovascular disease in the functional medicine world. He’s the director of the Hypertension Institute in Nashville, Tennessee Dr. Houston is triple board certified in hypertension as an American Society of Hypertension Specialist and fellow of the American Society of Hypertension, Internal Medicine and Anti-Aging Medicine.  He also has a master’s degree in human nutrition and a master’s of science degree in functional and metabolic medicine from the University of South Florida. Dr. Houston teaches doctors around the world about cardiovascular medicine as part of the A4m programs. Dr. Houston is also a very prolific author, having written what your doctor may not tell you about hypertension, what your doctor may not tell you about heart disease, nutritional and integrative strategies, and cardiovascular medicine, nutritional and integrative strategies in cardiovascular medicine.  And his two latest books which are Vascular Biology for the Clinician And Precision and Personalized Integrative Cardiovascular Medicine. Dr. Houston, thank you so much for joining me.

Dr. Houston:                      Thank you, Ben. It’s a pleasure to be with you as always.

Dr. Weitz:                           So, maybe you can give us a little bit of a explanation in general what is HDL. In fact, what is LDL? Why do these molecules exist at all?

Dr. Houston:                      Well, let’s start with the LDL story first because I think people are most familiar with that one, explain why it exists and then we’ll merge into the HDL story a bit. These molecules are termed apolipoproteins in the medical world. And apolipoproteins exist for good reasons we have to have them for a lot of health benefits.   For example, one of the major benefits of all the types of cholesterol whether the LDL or HDL is immunological function. It actually protects you from any type of infection, whether it’s viral, bacterial, parasitic, fungal, or TB, and it’s also part of our metabolic system for making steroids and vitamin D and sex hormones. So, there’s a teleological explanation for why these lipids were important in the early time to protect people from getting serious infections and dying from them.   And so, over time, what has happened is the functionality, the levels of HDL and LDL, have changed because in our modern society, people don’t die so much of infections anymore. But they’re dying from other types of environmental toxins, nutritional problems, obesity, and a myriad of other risk factors like diabetes. And so, what has happened to our cholesterol levels, particularly LDL, and to a lesser extent HDL, they’re going in the wrong direction in an attempt perhaps to protect us from these various types of environmental insults.  So, LDL for example, if it’s protecting us from something, it tends to go to very high levels. The LDL level’s elevated. And then, what’s called LDL particle number becomes elevated which is the driving risk recording heart disease and MI. There’s also genetic forms of dyslipidemia. But most people who have dyslipidemia in this country, it’s environmental. It’s not genetic.  So, LDL has been considered, as you said, the bad cholesterol. And HDL is considered the good cholesterol. But it’s much more complicated obviously than that, and that’s what we’ll get into today. So, that’s sort of an introduction, and we can kind of banter back and forth with questions as you wish.

Dr. Weitz:                           So, we generally think of HDL, its main function is to produce reverse cholesterol transport, right?

Dr. Houston:                      Right.

Dr. Weitz:                           And so, what exactly happens during that process?

Dr. Houston:                      So, reverse cholesterol transport or RCT, also termed cholesterol efflux capacity or CEC, are the primary functions of HDL that go into the cell, attach to the cell wall through various receptors that pick up the LDL just like a garbage truck and then take it to the liver where it dumps the LDL and is excreted into the bile. That’s the normal process. However, if HDL, RCT and CEC are not working, our HDL becomes we say less functional, then that process does not occur.  LDL accumulates in the cell. And then, that starts the LDL process of particle size going up, LDL levels going up, LDL size being smaller. And then, you get atherosclerosis, coronary heart disease.

Dr. Weitz:                           And so, HDL can actually take the cholesterol from the artery walls, right?  And so, it can reduce plaques potentially.

Dr. Houston:                      That’s right. It can literally take them out of the cell. But also take them from the cholesterol wall itself, and it’s very important in reducing plaque rupture, and improving plaque stability in coronary heart disease.

Dr. Weitz:                           And what’s the significance of plaque stability?

Dr. Houston:                      So, there’s at least two, maybe three, major forms of plaque. There’s the vulnerable plaque which has a very aggressive core in the middle composed of lipids and smooth muscle cells and inflammatory cells, and it’s surrounded by a sort of a firm top that is very thin, and that protective top can rupture.  So, what happens is all this activity inside the plaque can eat through this protective coating or cap and rupture into the arterial wall once that spews out into the artery.  It causes acute thrombosis which is an acute myocardial infarction.  That’s the really bad type of plaque. It’s considered soft plaque. It’s usually not calcified as vulnerable.   The other plaque is one that has a much thicker cap and has less of a activity in the center with less lipids and inflammatory cells.  And because it’s more stable, it’s not as likely to rupture. But over time, it can become very obstructive and impede the blood flow through the artery.  The problem we have is those people who have stable plaque may not have any symptoms whatsoever until they get to a 95%-plus stenosis.  But the ones who have unstable plaque, the ones that have the really thin cap, those can be only a 50% blockage, but they tend to rupture.  And those are the ones that typically present with intense training, like they run a marathon, interval training, whatever, and the plaque ruptures, and they have an acute MI even without much obstructive disease.

Dr. Weitz:                           And those soft plaques wouldn’t be picked up, for example, by a coronary artery scan.

Dr. Houston:                      Those can be completely missed because they’re not necessarily calcified, and they can be missed by exercise echo and nuclear medicine scans and other non-invasive ways of looking at plaque because it’s only maybe 50%. So, it doesn’t obstruct the flow.

Dr. Weitz:                           So, what’s the best way to get a clue as to whether those exist or not?

Dr. Houston:                      You can do other testing. For example, the MRI imaging with contrast of the heart, which can pick up any kind of plaque, soft or hard. And there’s other types of metabolic testing called a PET scan which picks up activity of plaque in the arteries. You can do a CTA, CT angiogram, looking at plaque. And, of course, the gold standard is a coronary arteriogram where you actually inject dye into the coronary arteries.

Dr. Weitz:                           Is the MRI being used regularly?  I haven’t heard of it being used that often.

Dr. Houston:                      We use it routinely in the institute.  We have an MRI scanner, and it’s incredibly accurate for plaque but also for valve function, cardiac contractility, diastolic dysfunction.  It’s expensive.  But if you have a patient that needs it and get it pre-approved by the insurance, it’s extremely valuable when you don’t want to do an arteriogram.  But also, there’s no radiation exposure, usually not much and with a contrast or some.  But you can’t do it in people who have metal.  So, pacemakers and artificial joints, you can’t put them in an MRI.

Dr. Weitz:                           Right. So, we have a number of positive functions of HDL making plaques more stable, helping to reverse cholesterol transport. And in recent years, we’ve learned about the antioxidant and anti-inflammatory properties as well.

Dr. Houston:                      Right. HDL is composed of probably over 100 different molecules, proteins, lipids, and other components. And with that degree of composition being so complex, it has a very complex anti-atherosclerotic effect. You mentioned a few, anti-inflammatory, antioxidant, anti-immunologic which means it reduces vascular immunologic damage in the arteries, reverse cholesterol transport. I mean there’s probably 25 or 30 different beneficial effects of HDL on atherosclerosis prevention.   But the key point here is that no matter what your HDL level is and no matter what the size of HDL is, those used to be thought to be protective or good things.  But now, it turns out that those don’t actually tell you the true risk in an individual. The only thing that really gives you the true risk is the functionality of the HDL.   Now, in a population, if you look at statistically, is your HDL level this or is your HDL size this, there’s a correlation in a population.  But if you take an individual, and you measure their HDL total, you measure their HDL size, whether it’s big or small, and you measure the HDL map, and there’s five forms of HDL from pre-beta all the way up, those may look great on paper.  But that patient may still be at risk for coronary heart disease because you didn’t measure the true value and true risk which is functionality of the HDL.  Does it do all the things it’s supposed to do to protect you?

Dr. Weitz:                           Now, why is it that drugs that have been developed to raise HDL have all failed so far?

Dr. Houston:                      There’s a lot of reasons. Some of the studies were just bad studies. They didn’t have the right population. Another is they had other adverse effects, like one of the drugs raised blood pressure, and that counter balanced the effects of HDL. But what happened is all of the studies were done prior to the understanding really of what HDL function was all about. So, they may have raised HDL. But it wasn’t functional HDL. So, the HDL maybe went up 30 to 50%. But it didn’t work. So, there was no reduction, as you said, in MI or total mortality with it.

Dr. Weitz:                           Right. So, what is the best way to measure HDL and HDL functionality?

Dr. Houston:                      There are two labs that are presently available clinically to measure functionality of HDL, and that’s really the key to getting at the risk for a patient in their coronary heart disease and MI risk.  As I mentioned to you earlier, Ben, we’re in the process of completing a large clinical trial on HDL functionality looking at a nutraceutical compound that not only improves HDL function, but also can improve HDL size and also HDL particle number which is another thing I neglected to mention earlier.   And let me just maybe comment on that while we’re talking about it. HDL function is the most important thing to measure. So, we can do that now clinically. HDL particle number, how many particles of HDL do you have, is also very high correlated with HDL functionality. And you can measure this in traditional labs to do advanced lipid testing. So, when you look at those two, there’s a 90% correlation between HDL particle number and HDL functionality.  But what we’re trying to do is see which of those has the best overall predictability in a population and see if we can actually improve both of those numbers.

Dr. Weitz:                           And then, when it comes to particle size, you want larger HDL particles.

Dr. Houston:                      That’s what we used to think. But that now has not turned out to be correct either because there’s labs that do HDL mapping, and there’s five HDLs: pre-beta and alpha one, alpha two, and others that range from very small to the large ones. For example, the pre-beta which is a really small one is the one that actually picks up the HDL, excuse me, that picks up the LDL out of the cell.   So, if your pre-beta is not working well, you can’t do good transport out of the cell. But then as the HDL matures, it goes to different sizes, and that progress across there involves a lot of different enzymes, a lot of different complexities, but eventually gets to the form of HDL which takes it and dumps it into the liver through what’s called scavenger receptor SR1 receptor in the liver. So, you’ve got to have all five of these.   And we used to think, “Well, the big one’s like a big dump truck, and it can carry more LDL with it.” It turns out, the size turns out to be not a great predictor nor does the actual total HDL level for heart disease.

Dr. Weitz:                           Now, I’ve heard one prominent functional medicine doctor talk about measuring apoA, and that being maybe a better marker than HDL. What’s the relationship between apoA and HDL? And is there a value in measuring the apoA?

Dr. Houston:                      There’s apoA1 and apoA2, and those are the carriers for HDL. So, that’s the apolipoprotein we mentioned earlier, and they are probably a little bit better than HDL total. But even those do not correlate well with risk because neither of those are functional tests. You’re again just measuring apolipoprotein as a carrier for HDL, and it can be again dysfunctional. So, for example, if you measured total HDL in a population, you could say, “Well, if it’s between…we’ll just throw out some numbers here, 30 to 100.  If you’re below 30, you’re probably in trouble, and if you’re over 100, you’re probably in trouble because those tend to be people who have more dysfunctional HDL. There’s actually a study that was done in men and women, and it suggested that if a male was over around 50 or 55 of their total HDL, most of it was likely to be dysfunctional.  And a female, if it was over 75 to 80, was more likely to be dysfunctional, and that’s because these tend to build up in the blood because they’re trying to cancel the bad effects of the LDL. So, you make more and more of it. But as you make more of it, it’s more dysfunctional. So, the levels keep going up. But less of it’s actually working.

Dr. Weitz:                           And what is the relationship between oxidized LDL and myeloperoxidase and HDL functionality?

Dr. Houston:                      So, all of those are inflammatory and oxidative stress measurements. Oxidized LDL is the form that is atherogenic. So, LDL and its circulating in the regular serum is not at atherogenic until it’s modified into a oxidized or some other form. There’s different forms of LDL that are called modified LDL, and that’s the one that go across the vascular endothelium and actually cause damage or plaque formation.  Myeloperoxidase or MPO is a compound that’s actually made by the white blood cell, and MPO causes all kinds of havoc. Well, it’s good that it kills bacteria. But if you keep making MPO due to other reasons, it causes high blood pressure, coronary heart disease, atherosclerosis, and even plaque rupture. It’s a bad actor and increases coronary calcium.  So, MPO has both inflammatory and oxidative stress implications. Now, once you develop those, they are the cause for atherosclerosis and myocardial infarction. So, your HDL has to be around to clean that up. What happens when you have a high oxidative stress and MPO level, it damages HDL, and it makes it dysfunctional. So, when your MPO is high, you can say, “Well, chances are, my HDL is not functioning well.”

Dr. Weitz:                           So, what’s the best way to improve HDL functionality?

Dr. Houston:                      What we’ve developed is a nutraceutical product that underwent initial study with 10 patients just to see if we could demonstrate effects, and that’s actually published as a white paper through… Can I mention the name of the company? Is that okay?

Dr. Weitz:                           Sure. Yeah.

Dr. Houston:                      Okay. So, the initial study with 10 patients with Metagenics. And then, they asked us to do a double blind placebo control trial which is really the way to get the true data. The initial trial showed that the nutraceutical proprietary compound that we’ve developed is called CardioLux, CardioLux, and it’s got pomegranate. It’s got quercetin, curcumin, vitamin E and few other things in it, looked positive in the initial pilot trial of 10 patients.    So, we’re in the process of finishing the double blind control trial now. We’ll be then done April 15th. I don’t know the results because I’m blinded, and we’ll do the statistical analysis. We will then publish the trial in a journal, and we’ll know the true efficacy of CardioLux in these patients.

Dr. Weitz:                           Now, why did you pick those particular nutritional compounds?

Dr. Houston:                      It’s based on all the scientific trials that are in the literature. Plus, what we’ve done in patients over the years trying to figure out which works the best. And when you take each one of those, it improves HDL function. Each one of those also has other good effects on reducing oxidative stress, inflammation, and immune dysfunction and although they actually had an effect on raising total HDL and improving the HDL mapping and the HDL particle number.  So, the only missing piece was can we put all this together into one product and take the best of each and make the entire picture better but specifically concentrating HDL functionality.

Dr. Weitz:                           Yeah. The interesting thing is those particular compounds, we generally think of a lot of them more as antioxidants than as cardiovascular-related compounds.

Dr. Houston:                      Yeah. And that’s exactly correct because it may be that what we’re doing when we reduce oxidative stress and inflammation is we’re making the HDL compound which has all these proteins and lipids in it work better. So, the functionality actually gets improvement. And the other thing we’ve seen then is when HDL becomes dysfunctional, it’s not all or none.  And so, think of it… We’ll just pick a number. Let’s say you’ve got 100 different components in HDL, and let’s say 20 of them become damaged, but the other 80 work well. So, that HDL still functions but just not at 100% whereas you can go all the way down to zero, everything gets wiped out. And you have no function whatsoever.   So, the two tests that we use actually give you the ability to measure the functionality of HDL with a number. So, you can see where you are on the scale from that 100% great to zero which is terrible.

Dr. Weitz:                          So, a lot of this functionality has to do with the proteins, and it’s my understanding that basically the reason why you have these LDL HDL particles is because fats don’t move readily through the bloodstream because that’s more water soluble. So, we surround them with these protein structures. So, you have all these various proteins that are coating the lipids and the HDL. And one of these proteins is PON1, I understand, which is an important one.

Dr. Houston:                      Yeah. What you said is exactly right, Ben. You have to package the lipids into a water-soluble form which is apolipoprotein. And so, one of the proteins you mentioned is called PON, peroxidase, and peroxidase is incredibly important to make HDL function. And if it’s damaged, HDL does not work well. And what we found in all the different compounds we were looking at, most of these raised PON, which helps to improve the functionality.

Dr. Weitz:                           It’s kind of interesting how in the body, if you want to get something into the bloodstream that’s a fat, you have to make it water soluble. And then in a lot of other areas, we’re taking things that are water soluble and surrounding them with lipids, so we can get them into the cell membranes.

Dr. Houston:                      Right. Yeah. It’s a conundrum of how to get it into the blood. But also get sure into the cell.

Dr. Weitz:                          Right. Even a couple of the new vaccines for COVI actually take the RNA instructions and surround them with a lipophilic surrounding to get them into the cells.

Dr. Houston:                      Yeah. Exactly.

Dr. Weitz:                          And we do the same thing with glutathione and other ingredients that we’re trying to get incorporated into our cells.

Dr. Houston:                      Yeah. And actually, another compound that we use that everybody is familiar with is Coenzyme Q10. Well, the problem is it’s got to get into the mitochondria. So, it’s not only got to get into the cell, it’s got to get into the mitochondria to be affected. And a lot of the CoQ10s, they get in the serum fine. But they don’t even get into the cell. But if they get to the cell, they don’t penetrate the mitochondrial membrane.  So, there’s new forms of CoQ10 developed now, that get into the mitochondria in a concentration that’s like a thousand times greater than regular CoQ10. So we’ve able been able to reduce congestive heart failure, improve ejection fractions, reduce diastolic dysfunction using a very highly potent CoQ10 that gets into the mitochondria.

Dr. Weitz:                          Is that like the ubiquinol versus a ubiquinone?

Dr. Houston:                      No. It’s actually called MitoQ. MitoQ.

Dr. Weitz:                          Right, right, right.

Dr. Houston:                      It’s from New Zealand.

Dr. Weitz:                          I heard about that. I saw a study where it reversed… What was it? Like aortic stenosis or something like that.

Dr. Houston:                      Yeah. It’s amazing. Actually, I’ve got a series now of about 10 patients who were on the transplant list, a cardiac transplant list, and also a couple that were at end stage coronary heart disease. They couldn’t put stents in. They couldn’t do bypass. Every one of them that we put on CoQ10, has become asymptomatic with no chest pain for their coronary heart disease or their ejection fractions gone up significantly, and they’re off the transplant list. This stuff is a breakthrough, I think, in cardiology.

Dr. Weitz:                          Oh, interesting. Are you still using the combination of the CoQ10 and the ribose and the L-carnitine for the-

Dr. Houston:                      Yes, we still use the metabolic cardiology program. So, we use regular CoQ10 for the vasculature, CoQ10 MitoQ for the heart, and we use d-ribose, taurine, carnitine, magnesium and all these other wonderful supplements that improve the myocardial contractility and mitochondrial function.

Dr. Weitz:                          Interesting. So, what diet and lifestyle factors outside of these specific supplements?  What type of diet is beneficial for improving HDL functionality?

Dr. Houston:                      Well, you want to use a low refined carbohydrate intake. Sugar intake should be less than 25… excuse me 25 grams a day which is pretty strict, a lot of vegetables, at least probably eight servings of multi-colored vegetables per day. That’s got all your phytonutrients, high-quality protein that has no pesticides, organicized hormones in it.  So, you got to kind of go to wild game for that, and then a wide variety of berries particularly that are low glycemic index, blueberries, blackberry, strawberries, and always pomegranates.   So, pomegranate seeds, if you’re not prone to dysglycemia. You can use the juice. But any pomegranate whether it’s the seeds, the plant, or the juice has benefit in atherosclerosis and raising HDL in raising PON.

Dr. Weitz:                          Interesting. A pomegranate’s kind of an amazing compound seems to have a lot of efficacy and prostate issues as well.

Dr. Houston:                      Yeah, and it’s been shown to actually reverse carotid atherosclerosis in one year.

Dr. Weitz:                          Really?

Dr. Houston:                      Yeah.

Dr. Weitz:                          Wow. What’s your current protocol for patients who come in who have plaque who want to reverse it?

Dr. Houston:                      We have a very specific protocol. It’s called the Coronary Heart Disease Plaque Regression and Coronary Artery Calcium Regression Program. We’ve actually been able not only to stabilize plaque but actually to reverse it in patients. So, we use a whole host of things. It’s probably about 15 things we use. I’ll give you the name of some of them. We use Neo40 which is a nitric oxide booster. We use Arterosil which protects the glycocalyx, vitamins-

Dr. Weitz:                          Like a seaweed moss or something like that, sea moss.

Dr. Houston:                      Well, yeah. Sort of like that. It’s a glycocalyx with all kinds of glycoproteins in it. And you can get that from a company called Calroy. So, Arterosil. We use a vitamin K2 MK-7, omega-3 fatty acids.

Dr. Weitz:                          What’s the dosage of MK-7?

Dr. Houston:                      K2 MK-7 is a minimum of 360 micrograms minimum per day.

Dr. Weitz:                          So, how high might you go?

Dr. Houston:                      K2 MK-7 probably is very safe even up to 1000, 2000 micrograms. It’s really good for reducing coronary calcification and plaque formation.

Dr. Weitz:                          And unlike K1, there’s not a significant effect on blood thinning.

Dr. Houston:                      We’ve never seen any issues with Coumadin or warfarin with K2 MK-7. Now, if you got really high doses, it might. But at 360, there’s no issues like there is with K1 because that can interfere with the clotting. But it has no issues with the new antithrombotics, the factor X inhibitors like Eliquis. Those are not affected whatsoever by any form of vitamin K. So, they’re okay.   The other things we use are omega-3 fatty acids in high dose. We use one from biotics research called EFA-Sirt Supreme. Then, we have a compound called VasculoSirt which I developed about five years ago with Biotics, and it’s really good. It’s got 25 or 30 different compounds in it that improve endothelial function, reduce inflammation oxidative stress and so forth.   And then, we’ve got curcumin, use a very highly absorbable curcumin, quercetin, and then there’s a few other things you’re throwing. That’s the primary things that we use for plaque regression.

Dr. Weitz:                          Right. How does quercetin have activity in this regard?

Dr. Houston:                      Quercetin is an amazing nutraceutical. It has anti-inflammatory effects, antioxidant effects, anti-immune effects, and it’s the only compound I know that actually reduces SASPS. SASPS were like the garbage in the cells. If a cell gets sick, for example, it starts to die, and it makes saps. So, it’s senescence proteins.

Dr. Weitz:                          Oh okay.

Dr. Houston:                      Senescence proteins. And so, these senescent proteins leak out, and they kill all the cells around it. So, you start to get a fast aging process in the blood vessel or you get a fast aging process in general. So, quercetin reduces SASP formation. So, it actually can slow down vascular aging and aging in general.

Dr. Weitz:                          Interesting. interesting. So, you’re talking about cleaning out the garbage from cells.  Do you think intermittent fasting or fasting can play a role as well?

Dr. Houston:                      Absolutely.  Intermittent fasting of any type, we’ve used the prolonged trial.  We published it.  It’s going to be published pretty soon, we hope. But the initial data with fasting, in general, is you can slow down aging.  You can actually reduce some of the SASPS.  You can improve stem cell production, increase nitric oxide, and actually maybe even stabilize reverse type 2 diabetics.

Dr. Weitz:                            Really? Wow. Cool. And what about the benefits of exercise? Can exercise play a role in HDL functionality and then reversing cardiovascular disease?

Dr. Houston:                      Absolutely. HDL is generally improved in all the parameters we’ve talked about with resistance and aerobic exercise. In one of the books you mentioned, what your doctor may not tell you about heart disease, there’s two chapters in there on the best form of exercise that we developed with one of the great strength trainers, Charles Poliquin, who unfortunately died about a year ago with a heart attack. But Charles and I did some clinical trials.   And then, we wrote together an exercise program which is published in this book called ABCT, Aerobics, Build, Contour and Tone. And it’s combining aerobics and resistance training with interval training to get the best cardiovascular benefits, protection for coronary heart disease but also improve your lipid profile and your blood pressure.

Dr. Weitz:                          Interesting. What about hormones? I know some of the men that I’ve seen who had the lowest HDL levels were guys who were taking testosterone.

Dr. Houston:                      Yeah. That’s a really tricky topic. In my practice, I have really not done hormones. I’m not trained in hormones, and I’m really probably not qualified to even prescribe them and really talk intelligently about them, and then source in. So, I would just say this. When I review the data hormones and heart disease and hormones and lipids, it’s very confusing. It’s very controversial and you can kind of find whatever you want to out there to support your opinion. So, I’ll leave it at that and let the hormone specialist get into the intricacies of that topic.

Dr. Weitz:                          Yeah. Did you see that paper, that Felish Gersh published recently on the benefits of estrogen for reversing cardiovascular disease?

Dr. Houston:                      Yeah.  There’s a lot of good articles out there that you can read.  Absolutely.

Dr. Weitz:                          Yeah.  I mean you know it makes some sense since we know women have much lower rates of heart disease than men until menopause. So, it makes sense that estrogen has somewhat of a protective role.

Dr. Houston:                      Right.  Exactly.

Dr. Weitz:                          Cool.  And what about any of the medications for HDL?

Dr. Houston:                      None of them work. There’s a whole list of things out there. Probably niacin’s been sort of the primary nutraceutical that’s been looked at. And niacin actually does work. But it’s not really a medication per se. I mean, obviously, you can get it as a prescription. You consider it that way. But we don’t think [crosstalk 00:38:29]. Niacin improves total HDL, HDL particle number, HDL size, and HDL functionality. They’re one of the few supplement/drugs that does that.   Most of the other drugs that have been attempted really don’t work well. There was an older lipid drug that was used in the VA-HIT trial, and it raised HDL. But they didn’t even measure the functionality in that study. So, we don’t really know whether that change in HDL had anything to do with the outcomes.

Dr. Weitz:                          I mean when you look at all the benefits of niacin, it’s pretty amazing. It’s one of the few compounds that will increase LDL particle size. It’s one of the few compounds that can have measurable effect on Lp(a). It’s one of the few things that can improve HDL, and yet it’s not generally considered something that should be recommended by most cardiologists today.

Dr. Houston:                      Yeah, and that’s a shame, Ben, because it’s based on three clinical trials that came out that said that niacin didn’t work to reduce coronary heart disease and all these other things. But if you go back and look at all those studies as you’ve read them as I have. They’re flawed. They have an incredibly bad methodology. I mean you can take them apart literally, just massacre those trials if you really know about what they looked at.   And I’ve written several editorials with a lot of folks that that tear up the studies and say, “Look. Niacin is still a good supplement. It’s a good drug, [inaudible 00:40:13] you want to classify it.” You should use it. But you have to know how to use it. You’ve got to know what dose to give. You got to know what side effects it has, and what to monitor.   If you know how to do that, you can be a very wise clinician and use niacin to improve your lipidology and your coronary heart disease risk and a lot of other factors.

Dr. Weitz:                          Yeah. I think if you use niacin as part of the package rather than just rely on a super high dosage of niacin, you can avoid some of the blood sugar, liver stress that can occur.

Dr. Houston:                      Yeah. And you’re exactly. If you keep it in kind of a low dose and you use it as a combination agent, I mean I don’t usually go much over 500 milligrams of niacin in one day with one exception in Lp(a), that’s about the only time, and that’s about the only thing that really works. You’ve got to go to higher doses to get Lp(a)down. But for the other things we’ve talked about, 500 milligrams used with other compounds is very effective, and you don’t get the hyperhomocysteinemia, the hyperglycemia, the liver dysfunction, the itching, the pruritus, all that stuff is not very, very bad.

Dr. Weitz:                          Yeah. Lp(a) is a tough one. Anything new on the horizon for that?

Dr. Houston:                      Well, it’s interesting you should ask me that because our next clinical trial product development will be with Lp(a), and we’ll be working again with Metagenics on that one. [crosstalk 00:41:40] the HDL trial. I hope that we’ll be starting the Lp(a) study.

Dr. Weitz:                          Let me guess.

Dr. Houston:                      There is a drug being developed in fast track as you know that could be out within one to two years if everything goes well.

Dr. Weitz:                          Right. Then, all of a sudden, all the conventional MDs will want to measure Lp(a). But right now, you try to get it measured [inaudible 00:42:06] What are you doing that for? It’s a [crosstalk 00:42:07].

Dr. Houston:                      Once you get the drug for, people will start measuring kind of backwards thinking.

Dr. Weitz:                          Well, let me guess. Niacin, L-carnitine, let’s see, vitamin C, lysine.

Dr. Houston:                      But what we’ve got right now, we’ve got niacin [inaudible 00:42:29] aronia berry which is chokeberry. Yeah.  It doesn’t work all the time. It works pretty good. And you mentioned the others. There’s a Linus Pauling Protocol, vitamin C, lysine, proline, carnitine, CoQ… I mean there’s a lot of things that may work. The number consistent is the problem.

Dr. Weitz:                          All right. Okay. Cool. Okay. I think that’s the things I really wanted to talk about here. Any final thoughts you want to leave our listeners and viewers?

Dr. Houston:                      I think you’ve covered the topic incredibly well, Ben. You’ve asked all the pertinent questions, and I think that’s kind of the state of the art right now. Now, you and I both know it could change in a month. But at least after today, we’re up to date.

Dr. Weitz:                          So, are there any conferences that are going to occur this year or is that going to be-

Dr. Houston:                      Yeah. We’re getting back online. We’re going to probably have A4M in Las Vegas in December.

Dr. Weitz:                          Oh really?

Dr. Houston:                      I think that’s going to happen. They actually have something even in the fall if this pandemic ends. But I think the virtual meetings are going to phase out, and we’re finally get back to live ones pretty soon.

Dr. Weitz:                          By the way, I don’t say we’re going to wrap this up. But have you had any long COVID patients with cardiovascular issues, and do you have any insights on that?

Dr. Houston:                      I will give you my insight. I have had not very many patients in Tennessee. I live in Nashville. So, at least in my practice. I haven’t had a lot of patients who’ve had COVID. I’ve had a few. But just give me just a second. I think the reason I haven’t had a lot of people in my practice with it is because we had a lot of patients on high dose vitamin D plus a lot of nutraceuticals. They were healthy people in that respect.   And so, that was a protective thing. But the ones who did get COVID, none of them got very stick with it. Very few of them even ended up having more than like a seven-day period. They quarantined, but they stayed at home. Almost none of them ended up in the hospital. But I’ve had a few that have ended up in the hospital.

Dr. Weitz:                          Have you had any that had the long-term-

Dr. Houston:                      We’ve had a few people had had, I would say, more short-term stuff with shorts of breath. But I haven’t really seen any long-term in my practice like long-term effects with cardiac dysfunction or pulmonary dysfunction.

Dr. Weitz:                          Okay. Cool. What’s the best way to get a hold of you?

Dr. Houston:                      Oh, probably go to my website. We’ve got everything on there. It’s hypertensioninstitute.com. Our website’s very user-friendly. You can find our emails, phone numbers, all our protocols, books and so forth thrown there.

Dr. Weitz:                          And once again, the product from Metagenics for HDL is-

Dr. Houston:                      CardioLux, C-A-R-D-I-O-L-U-X, CardioLux.

Dr. Weitz:                          And that’s currently available.

Dr. Houston:                      Available through Metagenics presently.

Dr. Weitz:                          And the dosage that you recommend for that.

Dr. Houston:                      It’s two twice a day with food.

Dr. Weitz:                          Okay. Excellent thank you so much, Mark.

Dr. Houston:                      My pleasure, Ben.

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 Podcast 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 Podcast.  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.


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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 my WeitzChiro YouTube page.] 


Podcast Highlights

This podcast episode is essentially a Tutorial on the NutraEval test from Genova Diagnostics, which is a very detailed test to assess the functional need for various nutrients in patients.  For reference, here is a link to a sample report for the NutraEval.

4:55  Some of the common reasons for ordering the NutraEval test include conditions like Fatigue, Chronic stress, Chronic inflammation, Mitochondrial dysfunction, Digestive disorders, Hormone imbalances, and Mood disorders.  The NutrEval is a great way to assess nutrient status in someone with a poor diet, for athletes looking for peak performance, for those looking to optimize their health as part of their anti-aging protocols, when patients are on a restricted diet, have had GI surgery or are on medications that can lead to nutritional deficiencies.

6:15  The NutraEval includes organic acids, oxidative stress markers and antioxidants, amino acids, essential fatty acids, nutrient and toxic elements and you have the opportunity to add on vitamin D and genomic SNPs.  There’s about 125 biomarkers in the test and it really casts a wide net looking at what’s going on in the patient’s biochemistry.

10:27  The NutraEval measures organic acids and amino acids, which gives us a perspective on the metabolome, which are the various metabolites that provide a functional readout of the activity within the cells and this is based on medical biochemistry.  The NutraEval measures both nutrients directly, like DHA, which is one of the omega 3 fats, and it measures the functional need for various nutrients. This is based on the concept that if we’re looking at a given metabolic pathway and A converts to B, which converts to C, and we know that that pathway is driven by enzyme one and two and if enzyme two has a nutrient co-factor that is not being met due to a nutrient deficiency, we can see an accumulation of metabolite B that is measurable in the urine or the blood. Methylmalonic acid is a good example, which is a nutrient that accumulates if we lack B12. The NutraEval is measuring things both intracellular, like red blood cell magnesium, and extracellular, like plasma amino acids, plasma copper and zinc, and serum CoQ10.

16:24  The first page of the NutraEval now has Functional Imbalance categories with scores from 0 to 10, so you can zoom in on which are the most significant areas to focus on to help the patients feel better. These categories include oxidative stress, mitochondrial dysfunction, omega imbalance, toxic exposure and methylation imbalance.  A score of 0 to 4 is a minimal need, 5 to 7 is a moderate need for support and 8 to 10 would be a high need for support.  This helps clinicians take a systems approach with patients.

19:08  The second page of the report lists the nutrient needs with a score from 0 to 10 and there is room on the right for the practitioner to list specific recommendations or write in a product name for that particular patient.  Page 3 through 6 are the interpretations at a glance pages and these list the nutrients, the causes of the deficiency, and some food sources of each nutrient. Each nutrient recommendation is supported by between 5 and 14 biomarkers.

23:20  If conventional MDs are skeptical of the NutraEval, you can point out that it includes many markers that are very well represented in the published literature, including methylmalonic acid, the omega-3 index, RBC magnesium, CoQ10, and glutathione.   

25:08  Organic acids are on pages 7-9 and these are byproducts in a number of different body systems. There are end products in these pathways that help us to biopsy the metabolome. And they are indications of vitamin and mineral co-factor needs because of the enzymes involved in those pathways. The enzymes that drive these pathways are nutrient dependent. And there are heavy metals and toxins that can inhibit these metabolic pathways, like the Kreb’s Citric Acid Cycle, and some of these toxins are measured on the NutrEval.  This includes the fatty acid pathway, the beta oxidation pathway, which is how we move long chain fatty acids into the micochondria and if that pathway is inhibited, then we might see high levels of adipic and suberic acid and this often indicates an unmet need for magnesium or B2 or L-carnitine.  Dysfunction here contributes to a higher score on mitochondrial dysfunction on page 1. Page 8 shows markers for malabsorption, dysbiosis (bacterial and fungal), cellular energy and mitochondrial metabolites, B vitamin markers, toxin and detoxification markers, and oxalate markers, which those will be listed on the following page.

26:57  If we look at the section for malabsorption and dysbiosis markers, the first 2 markers are indoleacetic and phenylacetic, which can be elevated if there’s bacterial fermentation of tryptophan or phenylalamine, which could be an indication of poor protein digestion.  This would help us make a recommendation for digestive enzymes. A more direct measure of the need for digestive enzymes would be the pancreatic elastace that is measured on the GI Effects stool profile.  The dysbiosis markers are metabolites of gut bacteria, and there are 5 markers including Dihydroxyphenylpropionic acid (DHPPA) and benzoic acid.  If these dysbiosis markers, you should consider ordering stool testing or you might want to recommend probiotics. The next section are markers of fungal overgrowth, including D-arabinitol, which is a marker that was recently added, replacing arabinose, and D-arabinitol is a direct metabolite of candida albicans.  If D-arabinitol is elevated, you might think about supplementing with Saccharomyces boulardii or limiting simple carbohydrates in the diet to reduce candida overgrowth.

39:33  There are a number of markers for the need for B vitamins and for alpha lipoic acid, including Fomiminoglutamic acid (FIGLU), which indicates the need for folic acid, and Methylmalonic acid, which indicates the need for vitamin B12.  There are also markers for B1, B2, B3, and Biotin.

41:07  Neurotransmitter metabolites.  These are metabolites of things likes tryptophan (Kynurenic acid and Quinolinic acid), dopamine (Homovanillic acid), tyrosine (Vanilmandelic acid), norepinephrine (3-Methyl-4-OH-Phenylglycol), and serotonin (5-Hydroxyindolacetic acid). 




Dr. Warren Brown is a Naturopathic Doctor who graduated from Bastyr University and he practices in Scottsdale, Arizona.  Dr. Brown has spoken at functional and integrative medicine conferences across the United States on the topic of laboratory testing.  In his work with Genova’s Medical Affairs department, Dr. Brown enjoys consulting with practitioners from all medical disciplines and providing the support needed to help improve clinical outcomes. In his private practice, Dr. Brown helps athletes and active individuals to reach their highest levels of health and performance through his advanced clinical approach.  Here is a link to the NutraEval Test from Genova Diagnostics: NutraEval.  Here is a link to Dr. Brown’s website: Clinical Advances for Sport.


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

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 everybody, I’m Dr. Ben Weitz, in case you don’t know, and welcome to our Functional Medicine Discussion meeting this evening. And tonight, we’re going to take a deep dive into learning about how to interpret and apply clinically, the newly designed NutrEval test from Genova Diagnostics with Dr. Warren Brown. I want to thank Genova for sponsoring this evening. I encourage all of you to participate and ask questions by typing in your question in the chat box, and then I will either call on you, or simply ask Dr. Brown your question when it’s appropriate.

Please consider joining some of our upcoming functional medicine discussion group meetings. April 22nd will be on integrative dermatology with Dr. Julie Greenberg. May 27th is with Dr. Dale Bredesen on prevention of Alzheimer’s disease. June 24th, we have Dr. Felice Gersh and she’ll be speaking about hormone replacement in post-menopausal women, and she’s actually just published a paper on post-menopausal hormone therapy for cardiovascular health in a journal called Heart, which is in the British medical journal family. And then, July 22nd, Dr. Mark Pimentel will be joining us again to give us another update on IBS and SIBO.

And if you’re not aware, we have a closed Facebook page, The Functional Medicine Discussion Group of Santa Monica that you should join, so we can continue the conversation when this evening is over. I’m recording this event and I’ll include it in my weekly Rational Wellness podcast, which you can subscribe to on Apple Podcast, Spotify and there’s also a video version on YouTube, so please check out the Rational Wellness podcast and if you enjoy it, please give me a five star rating and review on Apple Podcast.

So now, I’d like to introduce our speaker for tonight, Dr. Warren Brown from Genova Diagnostics. Dr. Brown earned his doctorate degree from the School of Naturopathic Medicine at Bastyr University. He’s spoken at functional medicine and integrative conferences across the United States on the topic of laboratory testing. In his work with Genova’s Medical Affairs department, Dr. Brown enjoys consulting with practitioners from all medical disciplines in providing the support needed to help improve clinical outcomes. In his private practice, Dr. Brown helps athletes and active individuals to reach their highest levels of performance through his advanced clinical approach. Dr. Brown, you have the floor.

Dr. Brown:

All right, thank you, Dr. Weitz. Let’s see if I can share my screen here. Okay, are you seeing that first slide?

Dr. Weitz:


Dr. Brown:

Okay, great. All right, so Biopsy the Metabolome with the new NutrEval profile. And here I am, I’m the clinical science liaison for Genova Diagnostics. Been with the company about six years. Been in practice since 2012 and so, I’ve relied pretty heavily on specialty diagnostic testing to help make decisions about my patients and the NutrEval is one of my favorite tests to talk about and to utilize as well.

Here are the objectives for this presentation. I just want to have on the agenda this evening, please feel free to use the chat box for any questions, I’ll try to address those as they come in. I’m planning on 45 minutes here and some time at the end for questions as well, if needed. So we’ll take an overview of the NutrEval, we’ll talk about some of the most common clinically applicable questions that I get from clinicians in talking to them about the test as well, and we’ll try to handle the questions along the way as well.  

So, here are some common reasons why clinicians might order a NutrEval profile. It’s not a complete list of reasons, but as Functional Medicine clinicians, I’m sure you’re all aware that nutrient deficiencies are commonly found in these conditions here. Things like fatigue, chronic stress, chronic inflammation, mitochondrial dysfunction. We also see them with digestive problems, hormone imbalances and mood disorders. And you might also consider a NutrEval if you’re looking to evaluate the patients and the quality of the nutrients that’s coming in through diet.  It’s often used for sports fitness and for people interested in optimal health and it’s also a good tool if you have a patient on a gluten-free diet or a special diet. Those diets do have a place and they’re really important, but anytime there’s a narrowing of the diet, there’s a narrowing of the opportunity to get all the nutrients that we need and the NutrEval can help to cover some of those nutrient deficiencies. GI surgeries, medications, those can also lead to or contribute to nutrient deficiencies as well.  

These are the tests and the biomarkers included within the NutrEval profile. So the organic acids, the oxidative stress markers and the antioxidants, amino acids, essential fatty acids, nutrient and toxic elements and you have the opportunity to add on vitamin D and for genomic SNPs as well. So this is the big picture, and we’ll cover all of these in more detail as we work our way through the test, but just wanted to lay it all out here. There’s about 125 biomarkers in the test and really cast a wide net looking at what’s going on in the patient’s biochemistry.  If you were to lay out all of the pages on the test, there would be 13 pages. The first few pages would consist of the overview and the interpretation at a glance. That’s followed by three pages of organic acids, one page of amino acids, fatty acids that would cover the biomarkers and their layout and their metabolic pathway, as well as nutrient toxic elements. And, of course, the genomics which are optional, they’re issued as a separate report, but it is an optional add on for the NutrEval.

I included this slide here, just in case some of you were more familiar with the ION or with the Metabolomix. This is a quick comparison between the NutrEval and those tests. They all do answer many of the same clinical questions, but we can come back to this a little bit later if needed, but I just wanted to illustrate here that these tests are looking at a lot of the same things, so organic acids, amino acids, oxidative stress markers.

And the other interesting thing that I was talking with Dr. Weitz about a moment ago, was telemedicine. And of course, the NutrEval requires both a blood draw and a urine collection and the Metabolomix would be an alternative to that, because that is a test that patients can collect entirely at home, so it’s a first morning urine and a finger stick for the blood spot. So the tests are very similar, but if you’re looking for a test, if you do a lot of telemedicine, you’re looking for a test that patients can collect entirely at home, the Metabolomix would be a really attractive option for that.

Dr. Weitz:

By the way, since you just mentioned the urine part, how crucial is it if the patient, let’s say, we’ve had a number of occasions where the patient came in for a blood draw in the morning. We usually have a mobile phlebotomist come in and do the blood draws in the office and they didn’t collect their urine ahead of time, right?  You’re supposed to collect the urine ahead of time, freeze it for a period of time and then bring it in before it’s sent in. And let’s say they didn’t do that and we just collected then, how much would that change your results?

Dr. Brown:

It could be a problem if the creatinine is low. That’s probably the most common thing that we see in patients who don’t collect their first morning void. Maybe they run it from a second morning void. If the creatinine is too low, because their organic acids are reported as a ratio to creatinine, you could potentially see very high organic acid markers. Wouldn’t affect the blood markers in the test, but it could potentially affect the organic acids. And the creatinine is reported in the test, so you’ll be able to see if it’s too low. That would be something to look out for, if you know it’s not a first morning void.

Dr. Weitz:

Right, okay.

Dr. Brown:

All right, moving into this. So, the title of this presentation, Biopsy of the Metabolome. The metabolome is basically metabolites that provide a functional readout of the activity within the cells and this is based on medical biochemistry and this is a picture of a poster I used to have on my wall that looked at an amino acid metabolism and organic acid metabolism and the Krebs cycle and all of that and how those related to each other.  And so, by looking at organic acids and amino acids, we really get a glimpse of the metabolites and the precursors. This is the virtual biopsy that I’m referring to, and the NutrEval report, and even the Metabolomix report as well, do a really nice job of taking into account those organic acids and the amino acids and fatty acids and trying to acknowledge the nutrient co-factors that drive those pathways and that is the functional readout, in my opinion, so this is sort of the groundwork that I’m trying to lay for our discussion here in a moment about the new report.

Two more little issues I think will be helpful and will answer a lot of questions, is the conceptual framework behind the NutrEval. So, we have a combination of direct indicators of nutrient deficiency, like DHA, for instance. This is one of the omega-3’s. We measure this, if we see it low, it’s something we can intervene directly, to address, so very important, omega-3.  A functional indicator of nutrient deficiency would be looking at metabolites, looking at organic acids and amino acids and, for instance, if we’re looking at a given metabolic pathway here, A converting to B converting to C, we know that pathway is driven by enzymes, enzyme one and enzyme two. And if enzyme two has a nutrient co-factor that is not being met due to a nutrient deficiency, we can see an accumulation of metabolite B, and that will be measurable in the urine or in the blood. Methylmalonic acid is a really good example of that, it’s something that accumulates if we lack B12, which helps to convert it into its next step.

So, the NutrEval, you’re getting both, you’re getting some things measured directly, some things from more of a functional assessment. And speaking of methylmalonic acid, which is, we make a case that’s a functional metabolite, we also have direct, or let’s say, intracellular and extracellular measures of nutrient deficiency. So, I’ve included some examples here of what we might consider intracellular, things like red blood cell magnesium, the essential fatty acids which are reported in the red blood cell, citric acid cycle [inaudible 00:13:38] which happen inside the mitochondria and methylmalonic acid is one of those reactions that happens in the cell as well.   However, because there is a strong body of literature behind plasma amino acids, plasma copper and zinc, serum CoQ10 for instance, those kinds of things are also included in the report and they also help us to make recommendations for those things. So, in the NutrEval, you’re really getting the best of both of those intracellular and extracellular.

Dr. Weitz:

It’s interesting, there’s another popular nutrient evaluation test that looks at white blood cells kind of through a complicated process and they’re always describing theirs as intracellular evaluation.

Dr. Brown:

Right. Right. Yeah, and citric acid cycle intermediates, this is something that happens inside the mitochondria, so it’s a direct readout of that.  So, now we get into our page by page analysis, and I know that you all like literature citations, I do as well. I’ve linked the NutrEval support link in the chat box. Should be the first comment in the chat box. But it has over a thousand literature citations in it and more than I could include in the slide, so I highly recommend you check that out. It’s a great resource to have. It lists all the literature citations here.  So, this is the first page of the new report and you can see, it has two main components here of results overview, which has these colorful icons here. Patients seem to like that. It’s been a very nice addition to our GI Effects profile, so we’ve carried over some of that.

Dr. Weitz:

Hang on a second, Doc. One of the participants ask, “Can you link it again, please? I think I joined after you posted it.”

Dr. Brown:

Sure, certainly.

Dr. Weitz:

I didn’t know it worked that way.

Dr. Brown:

Give me just one second. This should be it here. You’re seeing it now? All right.

Dr. Weitz:

Yes, she said thank you.

Dr. Brown:

Okay, excellent. All right, so this is just the overview of the first page. So we have a scoring system now. That’s also similar to the GI Effects, that was a change that really helped a lot of clinicians and patients in making sense of the GI Effects, so we’ve added some of that here. And if we zoom in on those functional imbalance scores here, we can see they’re ranked zero to 10 in terms of the significance of the score. So, zero to four is a minimal need, five to seven is a moderate need for support and eight to 10 would be a high need for support. And these areas include oxidative stress, mitochondrial dysfunction, omega imbalance, toxic exposure and methylation imbalance.

And this is one of my favorite changes about the report, because the previous version of the test, we just listed the nutrient needs on the first page and I think this is a better way to do it, because we want to talk about a systems approach and a functional approach to health and wellness and these are areas where a lot of patients need support. So this is really framing it more in terms of function and in terms of a systems approach, rather than just looking at nutrient needs. Those scores are based on the biomarkers listed below each score and we’ll talk about a lot of those as we go through the test, but this gives you a little bit of insight into how we calculate the scores as well, which is based on the severity of the abnormal biomarker and the strength of evidence behind that biomarker, so it is a weighted algorithm in terms of how we generate the score.

Dr. Weitz:

I noticed you have FIGLU under mitochondrial support, and I think FIGLU is an indicator of the need for B vitamins, right? Folic acid?

Dr. Brown:


Dr. Weitz:

But you don’t think about that for mitochondrial support so much?

Dr. Brown:

Yeah, it is, because of its strong association with the need for folate that it’s also listed under the methylation imbalance heading, so some of these biomarkers are connected in more than one of these functional pillars here. FIGLU is a good example of that. Carries a little bit more weight in terms of methylation imbalance, but because folate is important to so many of aspects of cellular health, it also carries a little bit of importance in terms of mitochondrial function.

Dr. Brown:

This is now the second page of the report, so we used to have in the first page and the second page, there was a lot of overlap between that. We’ve sort of condensed that into one page and tightened that up a little bit. And we have recommendations here for antioxidants, B vitamins, minerals, essential fatty acids, digestive support, so you’ll see a probiotic and an enzyme recommendation in some tests. And of course, amino acid recommendations are at the bottom of this page, just like last time as well. There’s also space provided on the right side of the page for you to make any adjustments, since you know more about your patients than just looking at the biomarkers alone. You can make some adjustments, write in a product name, however you would like to use that column on the right. We always encourage you to customize further if you deem that necessary with your patients.

This is the interpretation at a glance page. So page three through six of the report are laid out like this, pretty similar to last time. We list the nutrients need there. This is also ranked one to 10 scale. We’re looking at a high need for alpha lipoic acid here. The nice thing about these pages is that this can help to explain the test results to the patient and you also have the function of the nutrient provided, the causes of deficiency, the complications of deficiency and some food sources, which is a really nice tool if you don’t want to prescribe a supplement for everything for your patients, you can circle a few of the foods listed like spinach and broccoli and Brussels sprouts. Those could be good sources of alpha-lipoic acid and it might be good enough to meet a moderate need.

Dr. Weitz:

So, can you explain where, say, this eight for lipoic acid comes from? What exactly are you looking at that you’ve come up with this recommendation?

Dr. Brown:

Things that trigger alpha-lipoic recommendations are things like pyroglutamic acid and oxidative stress markers, because it’s an antioxidant, so if we see evidence of an up regulated glutathione recycling pathway, like pyroglutamic, or if we see oxidative stress markers, those kinds of things are used to help make the decision about how important alpha-lipoic acid would be, but it’s not-

Dr. Weitz:

So, how many markers are you looking at that go into this recommendation on average?

Dr. Brown:

For alpha-lipoic acid?

Dr. Weitz:


Dr. Brown:

These vary, depending on the analyte, but anywhere from five to 14 markers, depending on the nutrient need.

Dr. Weitz:

And that explains why sometimes you’ll get one of these tests and it’ll say, for example, over here that they need magnesium and then you go in the back and you’ll see that their red blood cell magnesium is fine.

Dr. Brown:

Yes, that’s a good point and I’ve got a good example of that on the Krebs cycle page for this test, where we see magnesium as a co-factor in one pathway that. Does have an influence on our recommendation for magnesium, but red blood cell magnesium also helps us make the decision. So we ultimately have to look across different body systems to try and make that recommendation and it’s based on the balance of the information and whether or not we see it as a pattern. That’s a good point.

Dr. Weitz:

I think that’s one of the really unique things about the NutrEval as compared to just measuring serum levels of some nutrient.

Dr. Brown:

That’s right. That’s right. If we see needs for a nutrient across different pathways, it tends to make a more reliable recommendation and so, that’s why there are so many biomarkers in this test.

Dr. Weitz:

Now, how well has this test been standardized and proven for people who are, let’s say, we talk to a primary care doctor, conventional doctor, who’s very skeptical of this test.

Dr. Brown:

Yeah, I’ve talked to quite a few of those about this test and I always try to focus on the markers that they might have seen before, or might have heard at some point in their training, like methylmalonic acid. There are even some pretty mainstream organizations that acknowledge that methylmalonic acid is a stronger marker for tissue level of B12 status, than serum B12. And a lot of those same clinicians that are very conventionally focused are still measuring serum B12, unfortunately.  So, I always try to point to those markers where they might have heard of, or come across in their training at some point just to sort of remind them that yes, there’s a lot of this that is very well validated and very well represented in the published literature, so I think you could point to the omega-3 index as one of the markers that has a wealth of data behind it. You could point to red blood cell magnesium, you could point to CoQ10, glutathione. There’s quite a bit in the test that should be at least familiar to some degree for conventional providers, but it kind of depends on how open-minded they are and there’s a lot of nuances that goes into-There’s a lot of nuances that goes into that from what I’ve seen.

Well, the organic acids would be page seven through nine in the report, and these are byproducts in a number of different body systems. There are end products or byproducts in these pathways that help us to biopsy the metabolome. And they are indications of vitamin and mineral co-factor needs because of the enzymes involved in those pathways. The enzymes that drive these pathways are nutrient dependent.  And these are grouped into sections. So what you will see on the Krebs Cycle page is fats, carbohydrates, and proteins metabolizing into acetylcholine and that entering the citric acid cycle. Ultimately the end goal of that is to support the electron transport chain and make ATP. And this, we lay things out here in pathway format to help visualize some of the backups or blockages in these pathways. So there are nutrient co-factors that drive the pathways, of course, but there are, in some cases, metals, heavy metals or toxins that can inhibit the pathway.

So we do measure some toxic elements in the report. And if I see a report here where we’re sending a lot of activity, citric acid cycle, a lot of things that are color-coded red indicating highs or lows, and I usually flip to the back of the report look and see if there’s elevated mercury or elevated lead. That can help me know if it’s a toxic reason for an elevation or a nutrient reason for an elevation, or maybe even both. So that kind of information is laid out here in pathway format and a useful tool for trying to understand these energy metabolism pathways.

Here’s the example I was mentioning just a moment ago. So I’m going to zoom in on the fatty acid metabolism pathway, the beta oxidation pathway, which would be how we move long chain fatty acids into the mitochondria ultimately. And if that pathway is having trouble, if there’s inhibition in that pathway, we could see high levels of adipic and suberic acid.  And it’s often that inhibition is related to an unmet need for magnesium and or B2. So this is the carnitine shuttle here. And if that’s not working very well secondary to some nutrient co-factor deficiencies, you might see high levels of adipic acid, high levels of suberic acid.

A patient who is having difficulty losing that last five to 10 pounds of weight, they’re doing everything right, hormone-wise, lifestyle-wise, diet-wise, but they just can’t quite get that last little bit of weight off. Sometimes it’s because their beta oxidation pathway is struggling and it could be related to an unmet need for magnesium or B2. And this does factor into our recommendations for magnesium and B2. But, of course, it’s not the only thing that we look at to make those recommendations.  Moving on. So this is kind of how I look at this pathway page. I sort of chunk that top part of the page together and just sort of remind myself that this is an indication of some mitochondrial dysfunction. It contributes to that mitochondrial dysfunction score.

And the bottom of that page, we can see some antioxidants like coenzyme Q10 and glutathione. And we can also see if there’s oxidative damage with lipid peroxides or 8-OHdG, which we’ll talk about those in a little bit more detail in a moment. But that’s kind of the overview here of this Krebs Cycle page.

The page right behind that would be page eight, which is the organic acids. And this would include malabsorption and dysbiosis markers, some cellular energy and mitochondrial metabolites, which are shown in pathway format on the previous page, vitamin markers, which help us to make recommendations for B vitamins, and toxin and detoxification markers, as well as oxalate markers, which those will be listed on the following page.  We’re going to zoom in on that section by section here, starting with the malabsorption and dysbiosis markers. And the first two markers in that section would be indoleacetic and phenylacetic. These can happen if there’s bacterial fermentation of tryptophan or phenylalamine, which could be an indication of poor protein digestion. And that helps us to make the recommendation for enzymes that we saw on the second page of the test. We also have some dysbiosis markers here for bacteria and yeast, and these are metabolites of bacteria and yeast in nature.

Dr. Weitz:

Can you just explain those malabsorption markers a little more? And how much does that really tell us if we’re dealing with a patient with functional gut disorders?

Dr. Brown:

Yeah. These are metabolites. When bacteria come into contact with amino acids, we’re assuming that protein hasn’t been fully digested and absorbed in the small intestine, and it’s made its way to the large intestine. That’s where huge amounts of bacteria can come into contact with it and metabolize it.  Ultimately, those metabolites are absorbed by the body and excreted in the urine. So it is an indirect way of looking at how well somebody might be digesting or absorbing protein. I would put more confidence in pancreatic elastase in something like the GI effects profile. That’s a more direct way to look at the exocrine function of the pancreas.  But if I see those elevated and my patient’s telling me that they’re bloated, they have fullness after meals, they notice undigested food in their stool, then I’m more inclined to say, let’s try some enzymes with your larger meals and see if that gets better. If it doesn’t, we’ll look at a stool test, but it’s a good way to-

Dr. Weitz:

So is this something that would occur at the same time or as a result of SIBO, or this is a possible alternate explanation for bloating to SIBO?

Dr. Brown:

That’s a great question, because if there is overgrowth of bacteria in the small intestine, there are more bacteria coming into contact with those amino acids as they’re trying to be digested and absorbed in the small intestine. So that is a possible scenario where you could see high levels of indoleacetic or phenylacetic.  So that’s another thing where if your patient says, well, I’m worse when I have a lot of fiber or fermented foods, those make me bloated. My bloating is progressively worse through the day. Those things that clinically make you think about SIBO, that could be a possibility.

Dr. Weitz:

That’s interesting because a lot of times with SIBO patients, we’re taking them off of a lot of the carbohydrates on a low FODMAP or similar diet, and they may be eating more protein. And this could possibly explain why some of those patients are not getting better or getting flares.

Dr. Brown:

That’s a good point, a really good point. The dysbiosis markers, similar in the sense that these are metabolites of gut bacteria, things like DH, PPA, and benzoic acid. That if you see those elevated, you might think about stool testing as a potential follow up. Or maybe probiotics, because those will, if there is some mild dysbiosis, probiotics might be enough to help correct that. Maybe increasing fiber intake, things like that.  But if I have a patient who has a lot of gut symptoms, usually I’m ordering a GI effects comprehensive at the same time or shortly after, or maybe sometimes before this test. I think it’s just a more direct way to look at gut function.  The use of metabolites. We did make a change there, which this is another thing I’m excited about in the report. So zooming in a little bit on the use of metabolites here, we’ve added D-arabinitol. We’ve replaced the arabinose marker that was in that section. And the reason why is because D-arabinitol is a direct metabolite of candida albicans, and it has a stronger association with intestinal yeast. So this is a marker that we feel provides a greater degree of detail around intestinal yeast.  So if you’re seeing a high level of that we could be looking at a patient with some intestinal yeast, if that’s elevated. And you might think about Saccharomyces boulardii or limiting simple carbohydrates in the diet, or however you prefer to deal with these for your patients. This marker could help you make that decision.

Dr. Weitz:

Now, let’s say we see some of these yeast markers high, but it doesn’t show up on the stool tests. They still could have fungal overgrowth, and this could be an indication of that, right?

Dr. Brown:

That’s true. Probably from a published literature perspective, I think mycology culture in stool is the best tool we have. But I wouldn’t say it’s a perfect tool. So anytime I’m interpreting the yeast markers, I’m always trying to make the clinical history part of that interpretation, because I think that’s really important. And I think if I’ve ruled out other things like bacterial dysbiosis, SIBO, other GI issues, inflammation in the gut, if I’ve ruled out all of that, and I’m looking at high D-arabinitol or maybe I see yeast in the mycology culture and the GI effects, then that’s usually my next step.  Brings us to these markers. I didn’t mention this, but this was a new addition to this section of the NutrEval. We added alpha-hydroxybutyrate acid. We list it here, on this page, as a carbohydrate metabolism marker. Really this marker is one that you might see elevated if the patient has some early insulin resistance.  Or you might see it elevated if they just have very poor lifestyle habits, too much alcohol, smoking, maybe too sedentary, those kinds of things. You might see alpha-hydroxybutyrate acid elevated in those scenarios. So that was a new addition to the report as well. And there’s a lot more detail about that in our support work guide.

These are the vitamin markers and these help us make decisions about B vitamins and also has a little bit of impact in our alpha lipoic recommendation-

Dr. Weitz:

Doc, could you just go back to cellular energy mitochondrial for a second?  What do we really get out of some of these markers?  What is carbohydrate metabolism?  What is that really telling us?

Dr. Brown:

It gives you some insight into how efficient the glycolytic pathway is, how effectively they can take carbohydrates and move it into acetylcholine. And so, if you’re seeing accumulations of pyruvic or lactic acid, if those are building up, it could be an indication that maybe there are some nutrient co-factor requirements that aren’t being met for B1, B2, B3, even lipoic acid, alpha lipoic acid, to some degree.

Dr. Weitz:

Or could this indicate somebody who just has an intolerance to a lot of carbohydrates?.

Dr. Brown:

This would be after carbohydrates are already absorbed. And after that you really wouldn’t necessarily be able to tell us much about their digestion or absorption of carbs, but after that step.  And one thing that I’m seeing more and more of these days is, patients who are doing more low carb diets or paleo diets, is the pyruvic or lactic acid low, on the low side of the range. And that could be an indication that the patient’s not consuming many carbohydrates. So you can also use the pyruvic and the lactic in that way to help you gauge carbohydrate intake. Did I answer your question, Dr. Weitz?

Dr. Weitz:

Yeah, sure. Yeah. Thank you.

Dr. Brown:

Sure. That would bring us to these vitamin markers here. And these are helping us make decisions about the need for B vitamins and alpha lipoic acid. And these are things like branch chain amino acid metabolites and formiminoglutamic acid and methylmalonic acid. And these are all informing those nutrient recommendations that we saw earlier on in the report.  And they’re listed, there are some headings here that will sort of provide clues about those nutrient needs. So, for instance, this first part of the section mentions that B1, B2, B3, and lipoic acid are something to think about when these are elevated.  The next subsection there is formiminoglutamic and methylmalonic acid into heading, also to folate and B12, or something to think about if those elevated. FIGLU is the one that’s more specific for folate.  And, of course, we have a couple of biotin markers as well. They help us make the recommendation for biotin. So those are just classic. They participate in a pathway that’s B-vitamin dependent, and that’s how they’re interpreted. Functional indicators, in other words.

That brings us to the neurotransmitter metabolites. And these are metabolites of things like tryptophan and tyrosine. We look at them in the context of nutrient co-factor needs. So if we’re seeing elevations in these, they also help us make decisions about nutrient needs.  And there are some things like chronic inflammation, chronic infections, high stress levels that could influence those results. And I think that’s helpful to keep in mind when you’re interpreting. You might see a patient who’s carrying a lot of stress. They may have higher levels of kynurenic acid. There’s some data to support that.  If it’s acute stress and it’s earlier on, maybe in the earlier stages of adrenal dysfunction, then it’s more of an acute stress. You might see some of the catecholamine metabolites elevated. Regardless, if those are elevated, or if a patient has genomic snips that could impact those pathways, the answer is often B vitamin support. So that is also factored into our algorithm. And there’s a lot more detail and a lot more pathways to look at in our support guide for those.

Dr. Weitz:

And these give us an indication of brain health, neurotransmitter, psychological health?

Dr. Brown:

It’s a good question. And these are measured in the urine. So we’re not measuring these in the central nervous system between the neurons where it really counts. There’s some debate on if you can interpret them that way, or if they are a reflection of what’s going on between the neurons. Some clinicians feel pretty strongly that is the case. Others are not completely convinced.  So there is some, I would say, I have some hesitancy in determining them as a direct reflection of what’s going on between the neurons. But clinically, and just speaking from my own clinical experience, that does seem to make sense, typically, if I often see high kynurenic acid in patients who are carrying a lot of stress. And if they’ve been doing it for a long time and if they’ve been chronically stressed for a long time, you might start to see lower catecholamine metabolites over time.  So there’s a lot of factors that factor into this. But I would say it gives us some insight, but I don’t know if we can say there’s a one-to-one relationship between what we see in an epi- and norepimetabolite, and what’s going on in the brain.

Dr. Weitz:

Could the serotonin marker help us with the management of patients with depression and/or is serotonin an important factor in the gut in terms of motility?

Dr. Brown:

Yeah, that’s a great question. I think it’s just, in my own experience, I think it does seem to line up really well. I think it also depends on what the upstream amino acid metabolite is.  So if tyrosine levels are low, which we’ll see on the amino acids page, if somebody is across the board low in their amino acids, it does become harder to see elevations. And you might see more low levels in the neurotransmitter metabolites because of that.  However, when I see a low 5-hydroxyindoleacetic acid, knowing that is a direct metabolite of serotonin and ultimately of tryptophan further upstream, I do think about supplementation with tryptophan or 5-HTP, especially if the patient’s telling me that they’re having trouble sleeping or their mood is not very good. I do think it’s definitely worth considering. I’ve often seen that be helpful.

The toxin and detoxification markers, in the bottom right of this page here. The first one is pyroglutamic acid, which is part of that glutathione recycling pathway. It’s one of the ways that we can recycle glutathione more specifically through the gamma-glutamyl cycle.  But pyroglutamic acid, if we’re seeing that elevated, it could be because the glucose levels are low, there’s not enough glutaphan around in the body. It’s working harder to try to recycle it. You might also see that elevated if a patient has a current toxic exposure and their glutathione is being oxidized and reduced more quickly. You might see pyroglutamic acid borderline high or high.  And then, of course, you’ll also be able to see the glutathione level towards the end of the report. And you can put those pieces of information together to help make some useful recommendations.  

There is a styrene metabolite here, and a metabolite of MTBE, which those are pretty common environmental toxins. Styrene could be from food packaging or paints or carpeting, things like that can off gas styrene. And the MTBE metabolite is a pretty common water contaminant.  So if you see the MTBE metabolite elevated, you could think about encouraging water filtration, that’s often helpful. However, I have often seen the MTBE marker elevated in patients who do have a good quality water filter, or what they tell me is a good quality water filter. And my next thought, when that happens, is do they have enough B vitamins to help support detoxification of it?  And I often see the MTBE metabolite elevated in patients who are deficient in B2, and folate, and B12. And to me, that makes sense that if they’re lacking those nutrient co-factors that are really important in liver detoxification, you might be more likely to see an elevation of a toxin.

Dr. Weitz:

I have to say, when I see this section, there’s so many toxins that we’re always talking about and thinking about and worried about that, the toxins that you have included here seem somewhat random, like why would you pick MTBE?

Dr. Brown:

These are common toxins. Of course, there are thousands, you’re absolutely right. And we have to draw the line somewhere. We do have some toxic metals later on in the report. But this gives us a little glimpse into what they might be exposed to in terms of some common toxins. And that does give us a little bit of insight. Of course, you could run a more specific toxic panel, but this is just sort of scratching the surface here. Not meant to be an exhaustive work.

Dr. Weitz:

I know. I guess, just from my perspective, if you have like BPA… And, I mean, I can think of some really common ones that everybody’s concerned about that-

Dr. Brown:

I can appreciate that perspective. Yeah, I certainly can. I believe that you raise a good point. It’s something that we’re always looking to evolve the test and just because it’s not there now, you might see that make it into the next version of the test. But it’s a good point. Well, any other questions on that page?  So more of the organic acids show up on page nine, including the new oxalate markers. And these are things like glyceric, glycolic, and oxalic acid. And oxalic acid is the one that, in my opinion-and oxalic acid is the one that, in my opinion, carries maybe the most significance out of the three. That is the one that has the association with kidney stones. And when we think about why we might see high levels of oxalic acid, it could be from oxidative damage. So if there’s not enough antioxidants around or there’s too many pro-oxidants in the body, you might see more oxalic acid or some of these other oxalates show up.  You could also see that say if somebody is breaking down their collagen, so if they’re more catabolic, if there are your high cortisol levels and they’re breaking down lean mass and body tissues, that they’re more catabolic, you could potentially see more of these metabolites as well. So a useful tool to have, if you’re seeing patients with family history of kidney disease, or a nice tool to help protect them against that.

Dr. Weitz:

And then can this be helpful if we’re treating patients with gut problems and we’re suspecting that maybe they have problems with oxalates and needs to be on a low oxalate diet?

Dr. Brown:

That’s a great question. If I see high oxalates or oxalic acid high, I do think about that as an option. I also think about, do they have enough beneficial bacteria in their gut to help metabolize those oxalates.  Lactobacillus, Bifidobacteria and Oxalobacter can degrade oxalates.  And that can be really helpful if you’re putting together a treatment plan to help try to lower the oxalates.  Oxalate-rich foods or avoidance of oxalate-rich foods, that I think is a valuable tool for some patients. I try to think of that as a last resort, because a lot of those are [inaudible 00:52:14] for other reasons, but it something to consider if you’re seeing high oxalic acid in particular.  Let’s see here. There’s a lot more about this glycosylate pathway in our support guide, it goes into these in a lot more detail. But if I had to pick one of those oxalate markers that I put the most confidence in, it’d probably be oxalic acid.

So speaking of oxidative damage, that could be a reason for elevated oxalate, but you also have this assessment for oxidative damage with things like lipid peroxides and 8-OHdG. And they’re on the right side of this slide, but lipid peroxides is telling us about oxidative damage to cell membranes and 8-OHdG is telling us about oxidative damage to DNA, and really useful to be able to measure those. And there’s quite a bit of published literature on those, looking at signs of oxidative damage.  Of course, on the other side of it [inaudible 00:53:36] here is a measurement glutathione and the [inaudible 00:53:40] and measurement of enzyme Q10 and the serum. And so you can see some pretty potent antioxidants for through a direct measure of those. So we’re always trying to balance the pro-oxidants that the patient has in their body with amount of antioxidants need to protect themselves. And this is one place in the report where you can really get into those side by side. Of course, you also have that assessment on the first page, which even broadens the approach even further. But some things measured directly here.

The amino acids… We were talking about that earlier Dr. Weitz, this sec at the bottom of this slide talks about the difference between the NutrEval Plasma and the NutrEval FMV. So no matter what kind of NutrEval is ordered, it will require blood and urine. The difference is in what part of the specimen we look to report the amino acids. And the plasma amino acids, as you would get in the NutrEval Plasma, will tell you more of a steady state of amino acids and protein intake. And this would be about anywhere from several days to three weeks of status. So if you have a patient who’s got an inconsistent diet in terms of the amount of protein they get from day to day, it might be more valuable to look at a NutrEval Plasma.  However, if your patient’s pretty consistent in terms of their protein intake from day to day, you could do just fine with the NutrEval FMV, which would give you about 48 hours status for their amino acids. So that is the difference.

Now, as far as what we’re measuring, we’re measuring all of the essential amino acids and the non essential amino acids. And they’re listed here on the left side of the page. And the importance of these is that they are building blocks for tissues, hormones, enzymes, and even precursors to neurotransmitters as well. But they’re essential, they have to come from the diet or from supplementation, and you can see the levels measured here directly. So a useful tool to have. If I’m seeing signs that the patient has detoxification needs and things like taurine are low, or maybe they’ve got some hypertension and their arginine is low, these are things that by correcting these amino acid levels, we might be able to make some headway in those areas.

Dr. Weitz:

Should there really be an upper range for these? Is it really bad if they’re higher?

Dr. Brown:

It’s a great question. I think it can only be a bad sign if they’re high. And the reason why is, we do need B vitamins and minerals like magnesium and zinc in order to utilize the amino acids. And there may be situations where you have a patient who is not utilizing their amino acids and they’re building up and they’re circulating, but they’re not making their way into tissues or neurotransmitters or enzymes, or what have you. And it can be due to a nutrient co-factor need. So that is a scenario where I think high levels could be a bad sign, but it could be easily corrected with some nutrient co-factor support.

Dr. Weitz:

Now, what if some of these on a high protein diet, like a keto diet?

Dr. Brown:

High protein diet, I would expect to see them at the upper end of the normal range. If they’re really high, I do have some concerns about kidney health, but I rarely see them really high. I think most patients, if they’re… Unless they’re just at the extreme in terms of protein intake, I think are going to be okay on a keto diet a higher protein diet. But it’s a good question. I think one thing that would also concern me potentially is if you see the essential amino acids very high or robust, and you see the non-essential amino acids kind of at the lower end of the range, that could be an indication that they’re not converting some of the essentials into some of the non-essentials, which could also be an indication of a need for B6 and a few other B vitamins. So there are some circumstances, but you’re right. I mean, therapeutically, those diets can be really helpful for some patients. So I don’t think they’re all bad.

On the right side of the page, we have some intermediary metabolites, these are amino acid metabolites, and they sit in various pathways that are nutrient co-factor dependent. And B vitamin markers, these, of course, aren’t the only B-vitamin markers in the tests we look for multiple other ones as well. But one of those I always look at in the reports and it’s cystathionine, which is the fourth marker from the right. And here in this example, it’s kind of hard to see, but the cystathionine level is really high in this patient and cystathionine sits right in between homocysteine and cysteine in the conversion of methylation to transsulfuration. And you might see that elevated in somebody who has a CBS snip. And it might prompt you to think about a methylation panel to look at the methylation and transsulfuration cycle in a little more detail, but that’s something that I found helpful to look at in patients where I’m suspecting CBS network problems with methylation or transsulfuration.

Dr. Weitz:

And you guys offer a methylation panel?

Dr. Brown:

We do, we have a methylation panel and it’s in addition to some amino acids and metabolites of amino acids that make up the methylation cycle and transsulfuration cycle, there is also the opportunity to add on some genomic snips to that profile as well.

Dr. Weitz:

I guess the only issue I have with every time we get into a discussion about methylation and looking at the snips, it gets very complicated, but then the answer to everything is just, “Take more B vitamins.” So I wonder sometimes how helpful it is.

Dr. Brown:

Yeah, I find that methylation panel helpful for ruling out methylation issues, if I’m highly suspicious of it. With the help of the genomics snips and the biomarkers included in our profile, I can see if the patient’s hitting the target in terms of how well they’re methylating and if that looks good, then I tend to move on towards other things. Cause that methylation cycle touches on so many different areas of our biochemistry. I think the panel has a lot of use in ruling out methylation issues as well, but it does focus the lens a little bit more on methylation.  And one of the things that I’ve found helpful about that profile too, is that B3 and B2 are often forgotten about in the methylation discussion. And there’s been a pretty heavy focus on folate and B12 and B6, but B2 and B3 are also supportive. And if you see backups at steps that are B2 and B3 dependent in that test or this test, that can be helpful for supporting methylation without giving higher doses of folate or B12. So it could potentially help you make a clinical decision about some of the lesser known B vitamin co-factors in that cycle.

Dr. Weitz:

Somebody asked if the CBS snip is one of the snips that you can add on?

Dr. Brown:

Unfortunately not for this test, but it is included in the methylation panel if you add on the genomics to that test.

Dr. Weitz:

We have a question about how do we choose first morning void or plasma tests for a particular patient?

Dr. Brown:

I favor the NutrEval Plasma, and the reason why is because my patients don’t always get the same amount of protein from day to day. So for me, I always go with NutrEval Plasma. Usually after I have that conversation with clinicians about what you’re getting with the NutrEval FMV versus what you’re getting with the NutrEval Plasma, they’ve often sort of lean that way towards plasma as well. There’s nothing wrong with the NutrEval FMV test, but it is just a shorter snapshot of the amino acids, which for some patients, I think if they’re just not consistent with their protein intake, I think it becomes more important to look at a NutrEval Plasma.  So I would say make that your default and you’ll probably be okay, but that’s sort of just my own perspective on it. We still have a lot of clinicians that order the NutrEval FMV

Dr. Weitz:

Somebody asked, “Is the FMV a shorter window for all the markers or just the proteins?” And the answer is, it’s only for the amino acids, everything else-

Dr. Brown:

Correct. And that’s about 20% tests. So it doesn’t make a huge difference in the grand scheme of things, but it could make a difference in how you interpret the amino acids.

Dr. Weitz:


Dr. Brown:

Good questions. Peptide markers. This is also worth looking at on this page because if you see these peptide-related markers elevated, and you’re seeing low amino acids at the same time, it could be somebody who’s not digesting or absorbing their protein very well. And it’s because the peptide-related markers here at the bottom right of this page, they sit right in between the crude protein that comes in through the diet and the amino acids that we ultimately need to break it down to. So if you’re seeing a lot of these dietary peptide related markers or seeing those elevated rather, then that might prompt you to think about the pancreatic enzyme recommendation on page two a little more seriously, especially if you’re seeing amino acids low cause that could be a patient who’s just not digesting or absorbing their protein very well. So that is the amino acids page.

Dr. Weitz:

What do you think about recommendations for specific amino acid supplements based on this panel?

Dr. Brown:

I sometimes do that, if I see taurine low, that’s one that I like to replete, especially if the patient’s feeling fatigued or they’re having detoxification issues. If I see arginine low and somebody who has vasoconstrictive headaches, or maybe some hypertension, I might think of that as part of the strategy. Methionine, you know those kinds of things-

Dr. Weitz:

I know there are labs that will put together like a multiple amino acid profile based on this test that is higher levels of the ones that are lower.

Dr. Brown:

Right, right. And some compounding pharmacies will do that as well. I think those are great options. Those can make a big difference for people. So I do think those are valuable tools. You could take another approach though. You could say, “Well, if the peptide related markers are elevated, if the patient’s telling me they’re feeling fullness after meals,” or something that makes you think that they might not be making enough enzymes, you could go that route and they may be able to get more amino acids out of the protein that they’re already consuming.

Dr. Weitz:

So you’ve seen giving digestive enzymes and/or hydrochloric acid?

Dr. Brown:

Yeah. I mean, that could be an option. Mm-hmm (affirmative). Absolutely. And I think also too, if you’re saying low amino acids and low peptide markers, then you might have to think about telling that patient to increase their protein intake a little bit or add in a protein snack or a protein powder.

Dr. Weitz:


Dr. Brown:

Yeah. You have a lot of options in terms of how you want to support amino acids, but I think digestion should also factor into it, I think how much protein is coming into the diet should also factor into it.

Dr. Weitz:

Somebody asked, “Is this issue common with diabetics?”

Dr. Brown:

Well, it’s a good question. It kind of depends on their diet, cause I haven’t always seen low results for amino acids or high results for amino acids with diabetic patients. So it may depend on the diet. Also, there is at least a couple of studies that mentioned that the branch chain amino acids might be a little higher in diabetic patients or patients with metabolic syndrome and it might be due to utilization of those amino acids. It’s a good question, but it they’re probably a lot of other factors that weigh into that.

Dr. Brown:

I see another question here, “I have a patient who seems to have fullness after meals, even when meal is not large. He is diabetic.” Okay. Yeah. Fullness after meals, if it’s because of bloating, then you might consider a SIBO test or you might do a therapeutic trial of some digestive support. Those could be some things to look at.

Dr. Weitz:

By the way, when is Genova going to be getting the additional marker on the SIBO test?

Dr. Brown:

Yeah, it’s something we’re looking into. I haven’t heard a timeline for that, but it’s an interesting point. We measure hydrogen and methane.

Dr. Weitz:

Okay. And now the new test also measures hydrogen sulfide that Dr. Pimentel developed.

Dr. Brown:

Yeah. Any other questions on this page? (silence) All right. So a central and metabolic fatty acids here, we’re looking at omega-3s, 6s and 9s, really important for neurological function, cardiovascular function, skin health, brain health, so many different things depend on omega-3s and managing chronic inflammation, which we’re often trying to fight in our patients with chronic illness. Just sort of a quick way to get a sense of these 3, 6s and 9s is to look at the bottom of each category. The omega-3 percentage is listed right there, the omega-6 percentage is listed right here. And we can see the 3s are kind of at the bottom of the range and the 6s are borderline high here, the omega-9s look fine. So this is a patient who’s not getting enough omega-3s here and has more of a pro-inflammatory pattern based on that. Of course, you can-

Dr. Weitz:

Why is there a top range for omega-9? Is it the more olive oil, the better?

Dr. Brown:

Some say that, but what I’ve seen with omega-9s is that if patients are getting a lot of omega-9s are often not getting enough omega-3s, and that would be something to consider if you’re seeing omega-9 is high.

Dr. Weitz:

And olive oil is the main source of omega-9s, right?

Dr. Brown:

Right. Exactly. And it has health benefits, no doubt about that, but if they’re overemphasizing olive oil or olives themselves, then they might be forgetting about the omega-3s. So, that could be important.  Saturated fats are listed at the lower left. You can really kind of get an overall sense of saturated fat intake by looking at that percentage at the bottom of the saturated fat category. In this particular example, it was fine. But if you’re seeing saturated fats high and you know the patient has an APOE issue, or if you’re seeing the saturated fats high and the omega-3 is low, then that could help you make some valuable recommendations in terms of healthy fats for the patient. So that’s a nice tool to have.

There’s also a trans fat marker in this test. On the right side, there’s a trans fat marker called elaidic. If you’re seeing now in borderline high or high, that could tell you something about a patient’s diet in terms of trans fat exposures, so that’s a nice one to have. And the cardiovascular risk markers are at the bottom right of the page. The omega-3 index has a lot of published literature behind it. And if we’re below four for the omega-3 index, that puts us that increased cardiovascular risk. If we’re between four and eight, it’s intermediate risk and if we’re above eight, it’s lower risk.

Dr. Weitz:

Now some people argue that human beings at one time consumed a diet that was close to the 1:1 omega-3 to 6, and that getting below 4:1 is optimal.

Dr. Brown:

Yeah. Yeah, it’s a good point. I think for some patients that might be where they need to be. And we are currently in the standard American diet, we’re getting far more 6s than 3s.

Dr. Weitz:


Dr. Brown:

Yeah. It’s a good point. So this provides you a sense of what their omega-3 intake like, their omega-6 intake, their omega-9s and saturated fats as well. Any questions about saturated fats, the low fat, non-fat diet? It’s a good question. Sometimes you do… Every now and then I get these patients that are avoiding fat. They’re like, “Oh, I’m just doing protein and avoiding saturated fat. I don’t want to have any saturated fat.” But saturated fat comes along in the diet with cholesterol and cholesterol is the backbone for the sex hormones. So I’ve seen a few times where patients have had what looks like hypogonadism because they’re so depleted in saturated fats. I think that’s a good reason why you would have a low end or a high end for the saturated fat percentage there. But it’s a good question.

Dr. Weitz:

Unfortunately, when it comes to diet there’s still huge disagreement. I’ve interviewed vegans, vegetarians on my podcast who are promoting dairy, low fat, high carbohydrate diet. And I interviewed a couple of guys who are type 1 diabetics and find that the super low fat, high carb-

PART 3 OF 4 ENDS [01:15:04]

Dr. Weitz:

And that the super low fat high carb diet is the best diet for diabetics. And they claim that getting the fats low improves insulin resistance.

Dr. Brown:

That’s a good point. I think there’s some individuality to that and my own set point, my own belief on that is that, the more extreme the diet is the more concern I have for the patient in terms of other nutrient needs and there may be patients, based on their genetics, where they do much better on a low fat diet. There may be other patients who would perform terribly on that. So I think there’s a lot of individuality that we’re still trying to sort out. And I think it might have a lot to do with genomics, but it’s a good point.  But this at least gives you something that you could compare your patients to and track the effectiveness or their compliance to those particular types of diets.

Dr. Weitz:

So would you say the go-to thing to look at on this page, if there was one thing you’re really going to honing in on, would it be the Omega-3 index? Would it be the 3:6 ratio? What would be you think the best measure? [inaudible 01:16:27]

Dr. Brown:

I would say the Omega-3 index in my personal opinion. I think that one has the most literature support behind it.

Dr. Weitz:

And optimal levels should be above 10, right?

Dr. Brown:

Above eight, according to the published literature on it.

Dr. Weitz:

Do you think it should be above 10 for optimal?

Dr. Brown:

It’s not a bad idea if the patient has a chronic inflammatory condition or a significant cardiovascular family history.

Dr. Weitz:

Or it doesn’t want to have one?

Dr. Brown:

Well that’s true too. I’m okay with seeing it above eight but you could make an argument to see it higher than that. Yeah.

Dr. Weitz:


Dr. Brown:

The fatty acids are also reported in pathway format here and the color coding would apply here as well. So green indicating a normal level, yellow indicating a high or a low level and red indicating, or I’m sorry, yellow indicating a borderline finding and red indicating a high or low level.  I do find this page helpful to look at because if we see that linoleic acid is normal, which is one of the Omega six, with the very first Omega six at the top right. That has to convert into gamma-linolenic acid and then ultimately into dihomo-gamma-linolenic acid. This is driven by enzymes with nutrient co-factor needs. Sorry, let me go back to that slide. And if we’re low in dihomo-gamma-linolenic acid, as we’re saying in this example, the patient loses out a little bit on the anti-inflammatory benefit of dihomo. And it’s not because they didn’t have enough linoleic acid it’s because they’re not converting it very well into gamma and then ultimately into Dihomo. So just to the left of those arrows, which is showing up here in the middle of the page, you can send nutrient co-factor requirements and the enzymes make those conversions for us.

I see a question in the comments, which ratio? I think that from the previous page omega-6:3 ratio. The omega-3 index is probably the one I’d put the most emphasis on. No, they’re all good markers.

That brings us to the final page here of the elemental markers. And we’re looking at nutrient elements and toxic elements on this page. And the magnesium that you’re saying here is measured in red blood cell. But as Dr. Weitz said, sometimes you can see a normal level in red blood cell, but still see a nutrient mutation for magnesium on page two of the report. And that would tell you that there were some other pathways involved that were acquire magnesium, where the patient might need to be a little higher up on the reference range. So based on a functional analysis. So it’s ultimately, would really try to bring all of the patient’s biochemistry into this to make that nutrient recommendation for my magnesium. Serum plasma, I’m sorry, serum copper and plasma, copper and zinc, sorry, are reported here directly to, so you can calculate a copper to zinc ratio here by dividing the copper by the Zen care if you so choose.

Dr. Weitz:

You might want to add that to the report. That would be something that would probably be helpful.

Dr. Brown:

Yeah. It’s something I’ve been pushing for a while, but hopefully the next version of the test, but that’s a nice tool to have. That’s what most of the published literature is looked at for copper and zinc ratios.

Dr. Weitz:

But by the way, that’s an important marker for helping patients to reduce cancer risk. And it would be really neat to put a bunch of those markers, that functional medicine practitioners who are trying to improve the milieu for reducing risks for cancer and have a panel that had a bunch of those markers in it like CRP and there’s all bunch of them that… It would be neat to have a panel like that.

Dr. Brown:

That would be.

Dr. Weitz:

Answer the lube panelists.

Dr. Brown:

Good points.

Dr. Weitz:

So I am going to asks what do you use the zinc-copper ratio for?

Dr. Brown:

Well. I believe it’s been looked at in terms of neurological function, immune function, various different health issues. But if you were to plug the copper into the calculator, hit the divide sign, plug the zinc into the calculator, you’d be looking for a ratio between 0.7 and 1.7 typically.

Dr. Weitz:

I think one of the issues is, if you’re taking a lot of zinc, you could end up being low on copper, and that could be an issue. And copper is important for a number of functions. On the other hand, a lot of people get exposed to copper. Maybe they have copper pipes, maybe they have other reasons for getting copper and having higher copper levels is generally considered to be a potential negative for health. And I had mentioned the cancer issue and higher copper levels are generally thought to increase the likelihood for new blood vessel formation, which could make it easier for cancer metastasis or for cancer tumors to grow. So that’s another thing to think about when it comes to copper.

Dr. Brown:

A great point, Dr. Weitz, and I know copper, if it’s too high, can be pro-inflammatory.

Dr. Weitz:

Yes. Like all the metals really?

Dr. Brown:

Yeah. That’s a good point on the right side of the page, you can see the toxic elements they’re measured in whole blood, and that would give us estimated exposure of maybe a few months leading up to the blood draw. So it’s a nice tool to have, because most of the enhanced data looked at whole blood measures of those toxic elements. So there’s a lot of good, useful data we could compare that to, and that helped us to establish our reference ranges there for those. So it’s a good snapshot of exposure, not the full story there, but it does list lead, mercury, arsenic and cadmium.

Dr. Weitz:

Is there really an acceptable level of mercury?

Dr. Brown:

Yeah, that’s a good question. 4.35 is our tolerance. And I think that was somewhere between the maybe 80th or 95th percentile of the [inaudible 01:24:06] NHANES data for that. But I generally like to see it as low as possible.  There is a link to the support guide embedded in the report now. That’s new, so when you get to page 13 of the report, if you order this on your patients, you can just click on the link there in the commentary and it will take you right to that support guide that I shared earlier in the comments there.  Then of course, if you added on vitamin D for this test, the result will be right here on page 13, it’s 25 hydroxy vitamin D, which we like to see somewhere between 50 and 80. That is the profile. And I know we’re running up on time here. I wasn’t going to go into some of the genomic add-ons, but Dr. Weitz, it’s up to you. Do we need to wrap up now?

Dr. Weitz:

No, no. As long as people want to stay, I’m okay with saying a little bit.

Dr. Brown:

Okay. Well, we can go through these fairly quickly and I’m sure some of you are probably familiar with these already, but I will give you the brief overview and feel free to chime in with questions. You have the option to add on four different genomic snips to the NutrEval, the first one you’ll see is APO E and here the patient’s genotype is a two for genome type. APO E is an Apo lipoprotein. It helps to remove cholesterol from the bloodstream. So you’ll see the patient’s results here. Generally. I think if patients have an APO E2 genotype, they tend to have a higher triglyceride response from carbohydrates in the diet and folks who are [inaudible 01:26:11] forging no type. They tend to have a harder time removing cholesterol from the bloodstream and have a harder time with saturated fats, metabolizing, saturated fats. So this could potentially help you make some decisions there about coaching them on their macronutrients.

Dr. Weitz:

So what you’re saying is from your reading of literature, patients who have one or two of the APO E four variants, will tend not to do as well on a higher fat diets, such as the ketogenic diet.

Dr. Brown:

Yeah. I have some concerns about folks doing an acute agenetic diet who are APO E44.

Dr. Weitz:

Or a 3-4.

Dr. Brown:

Yeah. Exactly. That’s a good point too. In a 3-4 or a 4-4, I am a little more hesitant in terms of recommending a higher fat diet. Of course not all keto diets are the same, so I don’t want to vilify all of that, I also don’t want to say across the board, it’s not a good idea, but I am a little more cautious about saturated fat intake if somebody has an APO 4, for either or both copies. I don’t know. How do you feel about that? Dr. Weitz?

Dr. Weitz:

Yeah, in general, I had a patient a couple of weeks ago, a 40 year old guy and he had a 4-4 and he was, doing a kind of a paleo diet, bulletproof coffee, and he had a heart attack. The guy was in great shape. Everything seemed healthy. And that was a significant factor for him.

Dr. Brown:

Yeah. Wow.

Dr. Weitz:

Somebody just asked about blood draws, unfortunately on the West side of LA, there’s no labs in the Santa Monica West side area that will draw for a NutraEval for Genova labs or actually functional medicine labs in general. So I think the nearest lab is in Beverly Hills, which, once traffic gets back can be a pretty long drive. Do you of any labs or we’ll draw for Genova on the West side of LA?

Dr. Brown:

I don’t, let’s see here…

Dr. Weitz:

There is a Beverley lab. I forgot what they’re called. What, by the way, what I do, [inaudible 01:28:50] Jessica, is we use a mobile phlebotomist. I use Rosemary Mata. So what I usually do is, when I have patients for blood draws, we group them together and then she’ll come in the office maybe every two weeks or so. And then she charges each patient, a $50 for the draw, or she can go to their homes, if they rather do that. So that’s another option and of course, there’s other mobile phlebotomists around.

Dr. Brown:

A good recommendation, and I can reach out to the Genova lab in the area and see if she has some other suggestions, but she would be a good resource.

Dr. Weitz:

It’s been an issue with not having… There was one lab that was withdrawn for all the functional medicine labs. And they got bought out about four years ago. And since then we don’t have a single lab in the whole Santa Monica West side area that will draw for any of the functional medicine testing.

Dr. Brown:


Dr. Weitz:

Yeah. Unfortunately conventional labs like Quest and Lab Core only want to draw up their labs.

Dr. Brown:

Yeah. The metabolum X plus would be worth considering as an alternative [inaudible 01:30:22] test can be collected entirely at home and you’ll get a lot of the same markers.

Dr. Weitz:

One more time. The name of that test, cause you broke up. I think when you were saying it.

Dr. Brown:

The metabolum plus and I’ll see if I can just flip back to that slide so you can see the name here, but it’s this one here, this one in the middle metabolomics plus, this one does not require phlebotomy. And you can see that it does have quite a bit of overlap between this and the nutri[inaudible 00:15:58].

Dr. Weitz:

Can you add on a blood spot, vitamin D with that test?

Dr. Brown:

You can’t get vitamin D unfortunately, but you can get the fatty acids in blood spot. That’s what’s run from the blood in that test.

Dr. Weitz:

You guys should consider adding on a blood spot, vitamin D.

Dr. Brown:

Yeah, It’s a great suggestion. I’ll definitely move that up the ladder at Genova. See if we can make that happen, but is the…

Dr. Weitz:

Maybe as a follow-up to this, somebody’s asking about a phlebotomist service in Orange County. Maybe if Genova has a list of phlebotomists that work with the genomic testing and or labs that will draw for Genova in Southern California, maybe if you could compile a list and then we could email it out to everybody.

Dr. Brown:

Yeah. It looks like Jamie mentions [inaudible 01:32:00].

Dr. Weitz:

Yeah. [inaudible 01:32:02] Kimberly Jones we’ve used her as well.

Dr. Brown:

Okay, great. I’ll reach out to Jamie. Jamie’s listening it looks like, so I’m sure she’ll have some other suggestions.  All right. The next SNP that you can add on to the NutrEval or the metabolomics would be the MTHFR SNP. And I won’t go into a whole lot of detail about this one, but this is one where if a patient has a snip peer, it could potentially mean higher homocysteine levels. This is the enzyme that helps us convert full late into the active form, which helps to convert homocysteine into methionine ultimately as a really important part of the methylation cycle. We looked at two different locations on the gene, the 677 and the 1298 location. And of course at each location, looking at both copies of the gene, one from the mother, one from the father, and it’s a nice tool to help add more context to the evaluation for methergine.

COMT, another methylator, another SNP that tells us about methylation or the propensity towards methylation. And I think of this more of a detoxification type of methylation helps us to remove catacholamines like benefrine or epinephrine dopamine helps us to eliminate estrogens and environmental toxins as well. So in a lot of ways, it’s helping us to detoxify those substances. And as part of the second phase of liver detoxification and has associations with a lot of different clinical conditions in the published literature, which we tried to summarize in the right side of the slide there, but this is one where if you see a snip here, you might see higher recommendations for a full aid B12 and the rest of the B-vitamins when patients have this snip.

But an important thing to remember though, that the genomic snips don’t factor into our nutrient recommendations in the NutrEval, they’re typically consistent with what we would expect to [inaudible 01:34:41] see in terms of need, but they are not interpreted as part of the NutrEval recommendations. They’re completely independent, but I don’t often see you when patients have COMT snips that we’ve recommended some B vitamins.

TNF alpha is a pro-inflammatory cytokine. And this is one that’s used by macrophages. Snips for TNF alpha would mean an up regulation of production of pro-inflammatory cytokines, and would mean that the patient might be making or more, I should say more susceptible to chronic inflammation. And you might see higher needs for antioxidants in the neutra realm, because if there’s chronic inflammation that can deplete antioxidant status more quickly potentially, and you could see, you’d think about antioxidant support to help protect the body against some of the damage that might be produced from the up regulation of these cytokines. It also has associations with auto-immunity. That’s also something you would see mentioned in the commentary there.

Dr. Weitz:

So what would this SNP tell us?

Dr. Brown:

And that snip might help you determine how important antioxidants are going to be in terms of a long-term strategy for the patient. So if you’re seeing some of the oxidative damage markers elevated, and you’re seeing a TNF alpha snip, where they’re homozygous, they’ve got mutation on both copies, then you might think about antioxidant support with another supplement or, or through the diet as part of a long-term strategy for that patient, not just something, do this for the next six months and you’ll be good, but not that we’re doing that anyway, but it might mean that the patient is fighting this battle against chronic inflammation. There’s going to be more of a long-term strategy in terms of supporting them in that battle. And antioxidants can be helpful for that.

Dr. Weitz:

Probably not a good idea to be prone to a cytokine storm at this time.

Dr. Brown:

Yeah. That’s a good point. Good point. Well, the educational resources that Genova offers are numerous, and that includes the NutrEval and metabolomic support guide that just got updated and earlier this month. We’re really happy about that. That is hot off the press. So to speak, let’s see here, we’ve of course have video modules on our websites and webinars. We call them live GDX webinars, and we have the lab report podcasts as well.  Patty and Michael are just really entertaining and lots of great information about Genova testing and a really nice resource to have. And of course we have medical education consults as well. And that’s if you have a Genova account and you want to talk about a patient test result with us, you can let 800 number and set up a phone consult. You can request to speak to me if you’d like on that consult, but there are a great team of doctors here at Genova that can offer assistance with picking the right test or answering questions about the test. Those kinds of things.

Dr. Weitz:

Okay, great. Thank you so much, Dr. Brown. It doesn’t look like we have any additional questions. So I thank everybody and we’ll see you next month. The discussion of dermatology is going to be really good. Julie Greenberg has some great clinically useful information to help us with our patients.

Dr. Brown:

Yeah, she’s great. I’ll be tuning in for that one as well.

Dr. Weitz:

Oh, okay.

Dr. Brown:

Thank you for having me, Dr. Weitz.

Dr. Weitz:

Thanks much everyone in attendance. I appreciate that. Thanks for your time. Take care.




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 my WeitzChiro YouTube page.]


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?  Some practitioners find that prescribing probiotics can be very helpful for patients with gut problems like SIBO/IBS, while other practitioner find that they often cause their patient’s symptoms to flare and get worse.

21:50   Quick Symptom Relief Strategies, which includes strategies for relieving bloating, pain, constipation, diarrhea, acid reflux, etc., including applying castor oil packs by getting good, organic castor oil and apply it to a piece of flannel or an old T-shirt and then place it over your stomach with a piece of parchment paper and a hot water bottle on top. It will stain your sheets and make your night clothes sticky, but it really helps with pain, inflammation, and motility.  It works best if you do it consistently for a while, like five nights in a row.  Activated charcoal can help with diarrhea, but you should take it apart from food and supplements.  There is a form of butyrate–tributyrate–that helps with diarrhea.  Iberogast is a good natural prokinetic, though it is hard to find.  For constipation, you want to drink a lot of water and magnesium can be really helpful.  Abdominal pain can be related to visceral hypersensitivity and curcumin can be helpful.  For abdominal bloating, Atrantil can be helpful, and it helps irradicate SIBO, esp. the methane form.  Peppermint oil and peppermint tea are helpful for pain. Gas-X and Pepto-Bismol can also help with pain.  Also IB Gard is a form of peppermint oil capsules that is sold in drugstores.

32:16  SIBO diet.  Shivan used the SIBO specific food guide developed by Dr. Allison Siebecker, which is her version of the low FODMAP diet. You want to eat in a manner that will reduce your fermentable load.  You have to understand that while diet can help to avoid feeding the bacteria and this can make you feel better, diet alone cannot cure SIBO.  To this day, even though she feels much better with her SIBO, she still cannot tolerate garlic or onions and she eats gluten free.  You can get green onions and just eat the green part, so it is like eating an onion without eating an onion.

37:30  Shivan used antimicrobial herbs, including oil of oregano, allicin in the form of Allimax or Allimed. She used CandiBactin-AR and BR from Metagenics. She also tried the Elemental diet and she tried both Integrative’s and Dr. Ruscio’s version of it. Shivan continues to take a prokinetic and she cannot really tolerate most of the natural ones because most of them contain ginger and she gets reflux from eating ginger. She takes Motegrity, which used to be called Resolor.  You also have to make sure to space your meals out so you have 4 or 5 hours between meals to stimulate your migrating motor complex to work.  Shivan also found it helpful to use the biofilm busting agent that was developed by Dr. Paul Anderson at Priority One.


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.  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 Gard, 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 Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.]


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?



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                                                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 my WeitzChiro YouTube page.]


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:  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 my WeitzChiro YouTube page.]


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.