Gut Health and Autoimmune Diseases with Dr. Marvin Singh: Rational Wellness Podcast 189

Dr. Marvin Singh speaks about Gut Health and Autoimmune Diseases with Dr. Ben Weitz.

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Podcast Highlights

5:38   Dr.  Singh has both an integrative and a conventional Gastroenterological practice and in his conventional practice he still offers lifestyle modifications and natural treatments if patients prefer that approach.

7:28  The gut and the immune system are intimately connected and 70% of our immune system is located in our gut, which is how gut health plays an important role in autoimmunity.  The gut immune connection centers on the microbiome, which is this ecosystem of micro-organisms that live inside of our digestive tract. The microbiome runs our metabolism, makes vitamins for us, releases chemical metabolites and hormones and neurotransmitters, which is how these microbes regulate our immune system.

9:05  Leaky gut or increased intestinal permeability means that the tight junctions in our one layer thick lining of our digestive tract is damaged in some way that allows bacteria or food particles or toxins to get into our bloodstream, where the immune cells may launch an attack on them.  Once you have this immune reaction to what gets into our system through the leaky gut, either it will resolve or it won’t resolve and cause a chronic problem and there may be chronic inflammation.

14:34  Dysbiosis is a medical term for an imbalance in our microbiome. Unfortunately, there is still a lot that we don’t know about what the ideal microbiome looks like, but there has been a tremendous amount of research on this in the last few years. And we are getting a lot closer to understanding what creates such imbalances in our guts and how to fix it.



Dr. Marvin Singh is an Integrative Gastroenterologist in San Diego, California, and a Diplomate of the American Board of Integrative Medicine. He is also board certified in Internal Medicine and Gastroenterology/Hepatology. Dr. Singh is currently the Director of Integrative Gastroenterology at the Susan Samueli Integrative Health Institute at UC Irvine. He is also an Assistant Clinical Professor at UCSD in the Department of Family Medicine and Public Health. Dr. Singh is one of the editors of the Textbook of Integrative Gastroenterology, 2nd edition and he has written several book chapters and articles. 

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

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 a 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 gut health and autoimmune diseases with integrative gastroenterologist Dr. Marvin Singh. Autoimmune diseases are becomingly increasingly common causes of sickness and death in the U.S. Autoimmune diseases have been on the rise for at least the last four decades. Our immune system is designed to protect us from bacteria and viruses and parasites, and to repair our tissues from damage. Autoimmune diseases are diseases where the immune system attacks our own cells and organs instead of fighting these outside pathogens. Our immune system, therefore, is out of balance.   And there are over a hundred different autoimmune diseases, and at least 40 others diseases are suspected as having an autoimmune basis. Autoimmune diseases are one of the leading causes of death in the United States, and to just name a few of the more common autoimmune diseases, we have Alzheimer’s disease, Parkinson’s, rheumatoid arthritis, psoriasis, alopecia, which is hair loss, Crohn’s disease, Hashimoto’s, hyperthyroid, M.S., type-1 diabetes.

                                One of the first researchers to explain one of the mechanisms by which the gut is related to the autoimmune disease was Harvard researcher Dr. Alessio Fasano, who, in his 2009 Scientific American article, laid out how leaky gut is an important contributor to autoimmune disease in combination with certain generic tendencies, along with gluten sensitivity. Dr. Aristo Vojdani, Dr. David Brady are two of the more prominent functional medicine practitioners who’ve explained how, I should say, functional medicine researchers and doctors who’ve explained how immune reactions to various infections, including gut infections, food sensitivities, and toxins can lead to an autoimmune disease through the mechanism of cross-reactivity. And 75% of our immune system is centered around our digestive tract, so it certainly makes sense that our gut would play an essential role in regulating that immune system.

                                Dr. Marvin Singh is an integrative gastroenterologist in San Diego, California, and a diplomat of the American Board of the Integrative Medicine. He’s also board-certified in internal medicine and gastroenterology-slash-hepatology. Dr. Singh is currently the director of integrative gastroenterology at the Susan Samueli Integrative Health Institute at UC Irvine, he’s also currently a voluntary assistant clinical professor at UCSD in the department of family medicine and public health. And Dr. Singh is one of the editors of the Textbook of the Integrative Gastroenterology.  Dr. Singh, thank you so much for joining me today.

Dr. Singh:            Thanks for having me, appreciate it.

Dr. Weitz:            Good, good, good. So I’ve been looking forward to this discussion, there are precious few integrative gastroenterologists in the entire country, actually. In fact, Dr. Rahbar in L.A. is the only one I know in the L.A. area, and so you are a rare breed, Marvin.

Dr. Singh:            I am, thank you.

Dr. Weitz:            Not everybody is aware … actually, why don’t we touch on that for a second? It’s actually quite challenging to be a integrative gastroenterologist, because to embrace all the conventional gastroenterology strategies and thinking and also combine it with an integrative functional medicine approach is quite challenging. How did you come to meld those two?

Dr. Singh:             Well, it is definitely challenging. As you were reading my bio, you can kind of see all the different things that I’m doing. I guess it just ended up that I ended up doing a lot of different things, I have three jobs, basically. I still like doing endoscopy and colonoscopy and taking care of sick people in the hospital and things like that, so I have a conventional GI practice where I do all that stuff. I have my integrative GI practice, specifically it’s a university one at the UC Irvine, where I’m the director of integrative GI over there.  And then within this whole field, I really became passionate about precision medicine, and so I created another practice called Precisione Clinic, which is where I have a lot of fun doing these very deep, integrative and functional medicine evaluations and developing personalized protocols for people. So I guess I work all the time, that’s how I figured it out.

Dr. Weitz:            You know, I wonder how, when you’re doing your conventional gastroenterology and you’re doing these scopes, and maybe you’re seeing in the patients who have limited income on insurance, how do you … it must be difficult sometimes to just give them, when it comes to treatment, the cookbook, conventional medical strategies when you have all this integrative stuff in your head, but you know that to really go into would require a lot of time delving into a deep history and everything else that you don’t really have time for in a conventional office visit that’s covered by health insurance.

Dr. Singh:             Mm-hmm (affirmative), yeah. So that’s the thing, I can’t necessarily shut my head off whether the practice is different or not. So sometimes, oftentimes I’ll feel the person out, I’ll talk about, let’s just pick heartburn as a general topic, because it’s pretty common. And we’ll talk about heartburn, we’ll talk about lifestyle things, which is most people would do, lifestyle modifications, and then I’ll say, “Well, you know, I can give you some treatments that are more natural that are not prescription medications, they’re more like herbs or supplements, would you prefer that or would you just prefer to take a medication?”   I don’t force it on anybody if they’re not really into it or tuned into it, but I offer it. I would say nine times out of 10, they’ll just say, oh, I want the natural treatment, because most people don’t want to take medication.

Dr. Weitz:            Right.

Dr. Singh:             And then that opens up the discussion, because I always will offer integrative approach to a common GI problem. Even in my general GI practice, I am handing out a lot of herbs and stuff instead of medications.

Dr. Weitz:            Cool. So let’s get into the topic here: not everybody’s aware why the gut plays an important role in the immune system. Can you explain some of this important connection?

Dr. Singh:             Yeah, well, it comes down to the microbiome. So the microbiome is really this ecosystem of microbes, there are micro-organisms that live inside of our digestive tract, or that’s what we call the gut. And these are predominantly bacteria, but we also want to remember and acknowledge that there are other members of the community, like viruses and fungi. So there are more than just bacteria there-

Dr. Weitz:            Protozoans and sometimes worms and primitive archaea.

Dr. Singh:            Hopefully not too many worms, I think. So 70% or so of our immune system is located in the gut, and it’s not just the digestive tract itself, the elementary digestive tract, it’s the microbiome and its role that it plays in the gut. So oftentimes, when we say gut health, we’re really referring to the microbiome and its interactions with everything else in the digestive tract, which is the gut.  This digestive tract runs our metabolism, makes vitamins for us, they release chemicals called metabolites and hormones and neurotransmitters and all kinds of stuff that communicates with all the other cells in our body, so this is why the gut or the digestive tract is so important. It’s because of the functions that these microbes play in regulating our immune system.

Dr. Weitz:            Now, what is leaky gut and why is it important?

Dr. Singh:             So leaky gut, otherwise known as intestinal permeability, is basically exactly what it sounds like. To explain to people, our gut or our digestive tract is not, like, 10 cell layers thick. It’s not like a big fortress that you have to penetrate in order to create an injury. It’s only one cell layer thick. So if you imagine just a bunch of rectangles kind of standing up next to each other, boom-boom-boom across the straight line, and then in between these rectangles there’s a little drawbridge or a little connection. These connections are called tight junctions, and they kind of regulate what can pass through that gut barrier and into the bloodstream.   Leaky gut means when there’s an injury or a problem with this tight junction, which are just protein complexes. So it’s nothing too crazy, they’re just complexes of protein. And when there’s an injury to this tight junction, then stuff that shouldn’t be coming through the digestive tract into bloodstream can get into the bloodstream. These could be particles of bacteria, they could be food particles, they could be toxins. So then when that happens, these things get into the bloodstream, and now the immune system, the immune cells in the blood are like, what is all this stuff going on? So they launch an immune response.   And when they launch an immune response, you know inflammatory chemicals are released, macrophages, neutrophils, all these immune cells are kind of being called into play because they think there’s an enemy in your system and they want to clean it up. And they go through this whole process of clearing out the problem or reacting to the problem, and depending on what the actual problem is, it’ll either resolve or it won’t resolve. If it’s food, for example, like a carrot or something, your immune system now may be cued in to reacting to carrots because it saw it in that manner.  The problem with leaky gut is that chronically, we do things that we may not know are creating this leakiness of the gut, and then chronically the immune system is revved up against it. And then we have chronic inflammation as a result of that.

Dr. Weitz:            Now, leaky gut is a concept, or increased intestinal permeability is a concept that’s been around in the functional medicine world for quite a while, and I know for a significant period of time it wasn’t really accepted as a real thing by the conventional medical world. Where are we in terms of that?

Dr. Singh:            You know what’s funny, though, if you look back in the literature, the scientists who are doing the research, they’ve been talking about intestinal permeability for a long time.

Dr. Weitz:            Right.

Dr. Singh:            So I don’t really [crosstalk 00:12:14]-

Dr. Weitz:            But you know on the average it takes 17 years for a new concept that’s actually been proven in the literature to get into conventional practice.

Dr. Singh:            Yeah, and even … actually, it was a few years ago, I was reading Dr. Bland’s book, and he was talking about the stethoscope. I think he said in his book that it took 50 years for the stethoscope to be accepted as an actual tool that a physician could use in examining a patient.

Dr. Weitz:            Wow.

Dr. Singh:            Now what happens?  If a doctor walks in the room without his stethoscope around his neck, you think, what is this guy?  Doesn’t even have a stethoscope.  So I still think the conventional group of docs are still a little slow coming around to this intestinal permeability concept. There are some that are seemingly trying to be more tuned in and, I think, as different studies come out suggesting this kind of concept, that they’re more accepting. But I wouldn’t say it’s widespread still at this point; even some of my GI colleagues will still just kind of poo-poo it, no pun intended, and just blow it off.

Dr. Weitz:            Right. Plus, there’s no drug on the market to cure your leaky gut.


Dr. Weitz:            This podcast episode is sponsored by Quicksilver Scientific. Quicksilver Scientific is a leading manufacturer of nutritional supplements, featuring enhanced nanoparticle delivery systems, specializing in detoxification protocols, fast acting immune formulas, and next generation longevity products. To learn more or to sign up for a professional account, visit quicksilverscientific.com. Listeners of this podcast can receive 15% off their order by using the promo code Weitz, WEITZ2020 at checkout. And I definitely utilize Quicksilver products in our office and some of their products are just absolutely amazing and there’s nothing like it on the market, so thank you to Quicksilver.




Dr. Weitz:             So let’s talk about the gut microbiome and autoimmune disease. What is dysbiosis?

Dr. Singh:             Great question. Dysbiosis is just really a medical term for imbalance, so you can just kind of think of it as an imbalance of the microbes in the gut. And some of the key concepts, now there’s a lot of stuff about the microbiome we don’t yet know. This is a very, very active part of science and research. Actually, interestingly enough, if you got to Pub Med and you type in just gut microbiome, I think I did this recently, I think it’s like, 25,000-some hits you get, just by typing in that.  But they default to a 20-year time span. If you narrow that down to three years, 2018 to 2020, it’s 15 or 16,000. So you can see that a majority of the research has been done in the last few years, actually. So this is very growing area of science and research. And so we’re learning more and more about what happens when the gut gets imbalanced or when there’s this dysbiosis. We know some common things that can actually cause the imbalances, and I’m sure we’ll talk about some of that.  And we know that there are a lot of diseases associated with it. Exactly what mechanisms or what actually happens or what the reasons are and how to get the therapeutics to intervene in that manner, this is an ever-growing field of medicine and science. I’m super-excited about this kind of stuff, so this is going to be cool when we figure out that, oh, you have too much of this bacteria and too little of this bacteria, so in order to fix this problem, we’re going to have to do this. And voila, your Parkinson’s tremor is better now, you know? That’s going to be cool. I’m sure we’re going to get there, but we’re not there yet.

Dr. Weitz:            Have you run the GI-MAP stool test and you see that section, that list of potential autoimmune triggers? There has been a certain amount of literature showing that various bacteria are related to specific autoimmune disease, for example, Klebsiella. I recently had a patient I’m treating who has ankylosing spondylitis, we did a GI stool test, bam, he’s got all this Klebsiella. And that can be a potential trigger for ankylosing spondylitis. But then the question is, if we treat that Klebsiella, how does that impact the ankylosing spondylitis?

Dr. Singh:             There you go, yeah. So I am a big believer, and this is my philosophy, in that we don’t necessarily need to respond to one microbe or the other, because there are trillions of microbes in there, and everybody is so different. So it’s not like a blueprint, you’re not going to be able to open up the textbook of the gut microbiome and see exactly what to do for a Klebsiella, and it’s going to be the same for everybody. Because for all you know, there could be 10 excellent microbes in there who are beating up the Klebsiella every day, and the Klebsiella’s actually not doing a whole lot. Or the Klebsiella, in proportion, relative proportions to the other microbes, is very small, it may be there.

                                I mean, another classic example is C. diff, Clostridioides difficile. Oh man, I see that in so many people’s microbiome tests these days, but they don’t have an infection, they don’t need Flagyl or Vancomycin or any kind of treatment for it. It’s a commensal. Another way of looking at it is that we have criminals, right? We have jails, we have prisons, and those criminals are in jail. Just because there are present doesn’t mean we have to go around trying to figure out a way to kill them. I mean, they’re fine. They’re being rehabilitated. Just because the bad guys are there doesn’t mean that it’s actually something bad is happening.

                                So what we’re going to see happening, as the years go by, is perhaps shifting our view from just looking at the microbiome itself and trying to focus on the metabolites, because the metabolites are the things that the microbes make or produce or release. And these are the things that really make the things happen, so if you have Klebsiella in there producing a lot of bad metabolites and that’s driving inflammation and inflammatory processes, and it’s calling other bad microbes to the table so they can do their bad stuff as well, then we have a problem.  So yes, the Klebsiella may be where the problem came from, but the real problem is what the Klebsiella is doing, what it’s making, and how that’s impacting you.

Dr. Weitz:            Well, then, how do you address that?  Let’s say you see somebody with C. diff infection, and the levels of C. diff are elevated over whatever is supposedly the normal, which is a very small amount, right?

Dr. Singh:             Mm-hmm (affirmative). We can use C. diff as the example, since we’re talking about it. So you do-

Dr. Weitz:            Let’s say you have one case where it seems to directly correlate with their symptoms, and this can be a very serious, even life-threatening condition where they have severe diarrhea. I had a patient in the office a couple of days ago who I’m working with, and she’s got severe constipation and it doesn’t really seem to relate to her symptoms.

Dr. Singh:             Mm-hmm (affirmative). So we want to know whether somebody clinically has signs of infection, and then we want to usually confirm, if we have a suspicion, that oh, there was a GI-MAP or some other test that C. diff is showing up on, and this person has diarrhea. I mean, if they have diarrhea and a fever, then I think you pretty much have your answer there. But if they just have chronic diarrhea, you don’t know, is this really C. diff, or is this just IBS? Because they could have that, or is this SIBO and they just happen to have C. diff as a commensal?  I would always confirm by doing a test of toxin PCR, see whether or not there is detection of C. diff toxin in the stool. And if you do see that, then I would go ahead and treat, because it is a contagious infection that can really make people sick, especially immune-compromised people. People could even lose their colon if the infection gets out of control.  But interestingly, if you look at, you’re starting from the conventional standpoint, looking at this kind of infection, it’s like, okay, I give the antibiotic. Okay, give the antibiotic. And then if the antibiotics don’t work, then what’s the solution? Fecal transplant, which is not an antibiotic, it’s basically a ginormous probiotic enema.

Dr. Weitz:            Right.

Dr. Singh:             So what you’re doing is reconstituting the microbiome, and if you use my example before, what we may be doing is just basically hiring a bunch more police officers and throwing them into the mix so we can regulate it, and this fecal transplant stuff works really well. I mean, within a day.

Dr. Weitz:            So what you’re saying is that the good bacteria are keeping the bad bacteria in check.

Dr. Singh:             Exactly, and we see that people … so let’s just make up a scenario, person comes in, severe diarrhea, fever, classic symptoms. You do a C. diff test, C. diff is positive. They get Vancomycin or Flagyl, symptoms go away and they’re fine. And then a year later, they do a GI-MAP because they want to look at their gut health, and C. diff is sitting there. Then what? What does that mean? That means that you didn’t kill the C. diff in that it’s, like, executed and entirely gone from your system, you just shut it down.

                                So I don’t think we really talk about this in the literature much, and I would love for us, some of these scientists to do studies about this particular topic, because it definitely has implications for the general public health, but what are we doing when we treat C. diff? Are we just shutting down the genetic mechanisms that make the toxin, is that what we’re doing? Are we just impacting the functions of the organism?

                                Perhaps we’re doing that by dramatically decreasing the population of that organism in your gut. That’s why we say, oh, well, you have C. diff as a commensal, you should be cautious about using excessive or unnecessary antibiotics, because then what happens? Well, maybe we’re killing the good guys that are controlling the C. diff and some of the other bad guys, and when those populations of the good ones go down, then C. diff has the opportunity to grow. And when it has the opportunity to grow, they like making toxin. That’s why we call them a bad guy. Then you get sick again.

                                So really looking at, what are we actually talking about? What is actually happening? That’s really the important part. We’re not really fully around there in having every discussion over every medication and every situation around that, but I think, in the future, that’s where we need to go, because that’s the real deal there. That’s what we’re talking about.

Dr. Weitz:            Right. And from an integrative or functional medicine perspective, if we treat that patient for C. diff, in addition to trying to reduce the levels of C. diff bacteria, if we, at the same time … let’s say, assuming they’re not getting a fecal microbial transplant, with a functional approach, we’re not just giving the antibiotic and that’s it, we’re also trying to restore the gut with probiotics-

Dr. Singh:             Exactly.

Dr. Weitz:            -and nutrients that can help to restore gut health and a proper diet and exercise and lifestyle factors that are going to improve the overall balance [crosstalk 00:24:35]-

Dr. Singh:             That’s the difference between us and conventional doctors, because it’s not so simple as, oh, take these antibiotics for two weeks, you’ll be fine, see you later, follow up with my never type of thing. Okay, we’re going to treat this thing, now we have to rebuild the gut. We’re going to talk about probiotics, we may talk about a serum-derived bovine immunoglobulin, colostrum, other things are good for gut health.

Dr. Weitz:            L-glutamine.

Dr. Singh:             L-glutamine. So we know that this happened, we want to try to not only fix the causative agent, but we also want to repair the underlying things that that causative agent could do, because then, if you look further and we focus on IBD, which I know is one of the things we want to talk about anyways today, how does IBD happen sometimes? I could get C. diff and be treated and be fine. You could get C. diff and get treated and be fine, and then six months later you start have rectal bleeding, and then it doesn’t go away.

                                And now you have pain and diarrhea, and then they think, well, maybe you got, C. diff came back again, you got C. diff colitis. And they check C. diff and it’s negative. And then time passes, time passes, and then you eventually get a colonoscopy and they say, oh, Ben, you have ulcerative colitis. So how does that happen? This is a classic scenario, actually. It’s not just a make-believe scenario, there’s a classic scenario where somebody gets an infection, it doesn’t have to be C. diff, it could be salmonella, it could be E. coli, it could be anything like that.

                                And what happens is that your immune system may clear it out, or your immune system may not really, fully shut down after this infection is gone. And that may have to do with various different things, whether it’s genetic factors get triggered or environmental factors start coming into play when there’s leakiness of the gut, meaning that something wasn’t causing you a problem, but now you had a flood in your basement and other things are causing a problem where they being controlled before.

                                And then your immune system just says, oh my God, this is some bad stuff going on, we got to keep knocking it out, even though that C. diff or salmonella is gone. And now your colon gets inflamed. This is the basis of kind of this discussion of autoimmunity, where we started this conversation in the first place.

Dr. Weitz:            Yeah. I’m going to get a little off-topic, I tend to do that, but you just mentioned colostrum and serum-derived immunoglobulins. The thought came up recently in a discussion: when you have a patient with autoimmune, there’s generally this thought that the immune system is overactive, so is it really a good idea to recommend things like colostrum or immunoglobulins that help to strengthen the immune system?

Dr. Singh:             Well, I think you got to look at each thing on a case-by-case basis. These things I’m less worried about compared to various different kind of herbs. The concern is that if your body is revved up and you give something to further rev up the immune system and that you want to make the immune system work to your advantage, that you might actual, paradoxically, do the wrong thing and actually exacerbate the underlying process.  I think you got to kind of look at what’s realistic for that person. I was just actually looking up for somebody else, a patient a couple days ago, ashwagandha. Ashwagandha is a great adaptogenic herb, and it’s good for stress reduction, it actually has immune modulating effects. But sometimes we talk about, oh, well, if somebody has Hashimoto’s, you really shouldn’t give them ashwagandha because it might make their thyroid worse, because it’s autoimmune. And I was looking up, I mean, one of the things that’s cited is a case report of somebody who got thyrotoxicosis.

                                This is not like we got thousands of cases that say that ashwagandha equals thyroid disfunction. In that person, on that case report, or maybe in people that are similar to that, there could be a problem. But as we go back to our discussion on metabolites and things like that, that’s where the mystery really lies. We don’t really know who is going to be a problem with ashwagandha and who is not if they have Hashimoto’s. You maybe want to look at what are some of the other factors: they have a lot of autoimmune issues, are there thyroid antibodies just a little bit or is it a lot? Because it may be kind of a case-by-case, and then be aware, if you see that the numbers are going in the wrong direction, then pull back.

                                I’m cautious in these types of situations, I think things like colostrum and serum-derived bovine immunoglobulin, I think they operate a little bit differently in that they’re really kind of working at the microbiome level in the gut. They’re primarily not systemic agents, like if you take an herb, you may get some of the stuff systemically. They’re really, majority of the stuff stays in the gut, and it’s towards that end that they work. And there’s literature on C. diff in bovine immunoglobulin, in H. pylori, in all kinds of different kinds of bacterial infections and situations. There are even case report studies in inflammatory bowel disease where there are patients who were not responsive to much else, and then they got high doses of serum-derived bovine immunoglobulin and voila, the inflammation receded.

Dr. Weitz:            Yeah, and I really also think it’s probably a mis-thinking to characterize somebody with autoimmune disease as an immune system that’s on overdrive. I don’t think that’s really what’s happening. It’s not like, instead of going 60 miles an hour, now they’re going 90. What it really means is they went down the wrong road, their system’s out of balance, really.

Dr. Singh:             We want to try to find that balance back, it’s that dysbiosis concept. We want to trying to bring balance back to the system, because … I started this thought, but I don’t think I finished it. Some of the things that we universally agree on, knowing that everybody’s microbiome is different and different things are happening in different people, what we universally agree on is that diversity in the microbiome is a sign of strength or resiliency. And that’s one of the main goals that we’re looking for. And the concept is simple if you kind of think of it … I’m a king of analogies, so I often give analogies to make people understand.

                                It’s like if you’re starting a business, you’re a CEO and you got to hire 100 people, and you need 100 different employees. When you’re looking at them, you could say, okay, well, I want everybody to be from NYU with an MBA and this background, and they should all have been born in Virginia and have parents who are together for 50 years and be of this age group. They may all be smart people, but they may all have the same skillset and background, philosophies and beliefs. So if you’re thinking that you want to be entrepreneurial and do something good and new and different, it would make sense to get smart people, get people with a good background, get people that have different beliefs, ideas, philosophies, who can come to the table with new ideas and concepts so that you can actually innovate and create and do good things.

                                So you want a diverse workforce, that’s a very kep concept to being successful. You don’t want a bunch of robots in your business, you want a diverse workforce, because that’s a sign of resiliency within your workforce itself. And it’s the same thing. That microbiome is your workforce. So we want a diverse, resilient microbiome, and in order to do there, there are a lot of things we have to do: we want to try to … we can get into the conversation over lifestyle measures, but diet, a varied diet, a lot of plant foods and different kinds of things on an ongoing basis are part of that whole process as well so that we can grow that diversity and resiliency.

Dr. Weitz:            What role can gluten or glyphosate play in the development of autoimmune diseases?

Dr. Singh:             Yeah, Dr. Tom O’Bryan is the king of gluten; he often talks about the study by Harvard, which I often refer to as well, scientists at Harvard where they suggested that everybody, it was a big study, it was thousands of patients, I think, everybody develops some leakiness or some permeability of the gut when they’re exposed to gluten.

Dr. Weitz:            Right.

Dr. Singh:             Now, if you don’t usually eat a lot of gluten and you go to Paris and you want to have a baguette because you’re in Paris and that’s the cool thing to do, that’s fine, right? As long as you don’t have an allergy to gluten or whatever. But if you’re eating bread all the time, every day, then you may develop this leakiness of the gut on a chronic basis. Remember, the whole key concept is chronicity. And when that happens, it itself may not be the actual problem per se, but it may open the door; those tight junctions are now open so that problems can occur.   So it’s just like, if you get pneumonia, I’m not going to say, no, Ben, antibiotics are bad, you’re just going to have to suck it up, and you might die. Nobody’s going to say that. They’re going to say, take the antibiotics. We’re in 2020, we’re a civilized group of people, we have science and technology behind us. Medications are not all bad, they can save your life. But if you say, every time I get a runny nose I take a Z-Pak, I’m going to say, no, Ben, that is not the right thing to do. You are messing up your gut. You’re creating leakiness of your gut barrier by doing that.

                                So it’s the same kind of concept. These things, our body is not so weak that you’re exposed to a non-organic apple one day and you get a little glyphosate, oh my God, I’m going to die. That’s not what’s going to happen. Your body is stronger than that. But if you’re doing this on an ongoing basis, you’re literally just giving small punches to your gut every day all day, and then you have a problem. And it’s not just glyphosate, it’s not just gluten. Stress can do this too. Not sleeping well can do this too, not exercising and being sedentary can also do this too.   This is actually how I got really excited about lifestyle modifications and how that can influence the microbiome, because believe or not, there is literature on all of these topics as well, that you get imbalances in the microbiome when proper lifestyle choices are not followed.

Dr. Weitz:            By the way, for those who don’t know, glyphosate is the main active ingredient in Round-Up, which is a herbicide that’s commonly sprayed on wheat and corn and other crops, especially to ones that are genetically modified to be resistant to Round-Up.

Dr. Singh:             Yeah, and we’re directly ingesting it, we may be exposed to it inhalationally. Traces are found in common things like sugar, corn, soy, wheat. These stuff disrupts our detoxification capacity, it may directly disrupt the microbiome and its ability to have various different kinds of functions. It’s almost like the reason why I think I went to antibiotics is like, it’s not an antibiotic, but it’s kind of like the same concept of an antibiotic, because it’s supposed to kill stuff, basically.

                                So that’s what it’s doing. Maybe the purpose is to kill the bugs so it doesn’t ruin the plants, but when you eat that stuff, it’s killing what the bugs that are inside your gut do, and you don’t want that. That’s not the point. And there are some associates that they have felt to be from glyphosate related to diabetes, obesity, depression, Alzheimer’s, cancer. Even in the news probably a year or two ago now, there was a big lawsuit against the company that makes this stuff, because what was he … a groundskeeper at a school and he was spraying Round-Up everywhere, [crosstalk 00:37:19] and he got cancer as a result.

Dr. Weitz:            Yeah. There had been a series of others after that.

Dr. Singh:             Yeah.

Dr. Weitz:            So when you have a patient who sees you for some gut health issues and also has some autoimmune disease, setting aside IBD right now, do you place them on a gluten-free diet, do you put them on a gluten-free, dairy-free, do you take them off of corn, soy, peanuts? Do you have a certain protocol you use?

Dr. Singh:             I often do, especially if we’re going to do an empiric kind of food elimination and we’re thinking about how we can modify the diet. People are often resistant to eliminating too many things, so the conversation that I have is, we can do some tests to see if we can kind of direct it a little bit, but-

Dr. Weitz:            What kind of food sensitivity testing do you like to do?

Dr. Singh:             Well, I guess the caveat to this is I always tell people that these are not like you’re getting the commandments from Heaven, coming down and telling you that if this is a positive test, that 100% certainty, that carrots are bad for you, you’re going to go sick. So they can be very helpful. In some cases, we hit the home run. And in some cases, they’re not so helpful. So everything has a risk and benefit, so the risk in this is that you gave some blood or you did a finger prick and you paid some money for it. It’s not like we’re talking about experimental chemo or anything, it’s just food we’re talking about here. As far as that, the risk is low. I use a lot of Cyrex for the food stuff.

Dr. Weitz:            Okay. [crosstalk 00:38:59]

Dr. Singh:             Huh?

Dr. Weitz:            Yeah, I think they’re among the most accurate.

Dr. Singh:             Yeah. Dr. Vojdani is a friend of mine, both of them, father and son [crosstalk 00:39:09], and I talk to them often, and I think the methodology and the way that they make the test is pretty sound and they’re very well-intentioned, so I use a lot of Cyrex for the food stuff.  But even in the conventional literature, if you look at food elimination, what are they talking about? The top things, it’s like the big six things is gluten, soy, dairy, shellfish, tree nuts … I missed one.

Dr. Weitz:            Eggs.

Dr. Singh:             Eggs. [crosstalk 00:39:39] And then I throw in the number seven as corn. And so when people are like, I don’t want to do any tests, I just want to kind of … what can I do? Then you tell them all those things, they’re like, whoa-whoa-whoa, that’s a lot of stuff. So what am I supposed to eat, then? So I say, well, let’s just do this for a set period of time. If it was four weeks, six weeks, something like that, we want to do it for a reasonable amount of time so that if something is actually causing an immune reaction, that we have a chance for that reaction to calm down.  And then, one by one, we can try to reintroduce them in two-week intervals, so we can see if you notice anything symptomatically in your body and health as far as something happening as a result of that reintroduction. The problem is that often, at the microbiome level, you may not really feel like, it may be something that you see and you feel it in a different. So you have to kind of be astute to that, maybe follow other things like your microbiome evaluation and things like that over time, and I always try to hit home the idea of non-GMO organic, because if you’re going to reintroduce something, at least try to make it a clean product so that we’re not being confused by contaminants as driving the problem.

Dr. Weitz:            I wanted to talk a little bit about the TMAO concept. I saw it in your slide presentation that you sent me. TMAO, as maybe not a lot of people know, is a marker that was developed by Cleveland Labs that is a marker for increased risk of heart attack, stroke and … it’s very controversial. One of the reasons why it’s controversial is that TMAO is found in high amounts in fish, and there’s just tons of research showing that eating fish lowers your risk of heart disease. It’s also stimulated by eating choline or L-carnitine, and L-carnitine is found in meat and a whole lot of other foods that are often considered part of the healthy diet as well.   And in choline, of course, is found in a whole series of different things that we eat, and we’ve always found choline actually be super-beneficial for brain health. So I’ve always had a tough time believing that we should really stop eating all these things because some test shows an elevated TMAO level.

Dr. Singh:             Yeah. I presented this, these slides that you’re referring to, at a conference to specifically point out the controversial viewpoint on TMAO.

Dr. Weitz:            Right.

Dr. Singh:             Because this is what we like to do in science: we find something, we find association, and then we just go gangbusters in a kind of tunnel vision about it. TMAO bad, equals heart disease. TMAO bad, equals heart disease. Well, I mean, fish are made up of a lot of TMAO. When you do a test and you’re checking for TMAO, you’re actually supposed to stop your fish oil and don’t eat fish for 24 hours before because it can falsely create an elevation. And I actually had a specific patient whose TMAO came back at, like, 120. This guy was like, what in the world is going on? I’m a healthy guy, I’m exercising all the time, I’m eating majority plant foods, the only meat I eat is fish.

                                And I said, “Well, did you eat fish right before you did this test?” He said, “Uh, well, I think I might have.” So we repeated it, and it was normal. So fish need TMAO, it’s what helps make them float. I don’t think fish are croaking over with heart attacks in the ocean every five minutes. So we have to really look at what’s the big picture, what is TMAO, what are we actually talking about? TMAO is a metabolite that’s produced by microbes.

                                Actually, TMA is the metabolite that’s produced by microbes, so TMA is called trimethylamine, and trimethylamine is produced by, there’s a hole host of microbes, I could tell you the names of some of them, but it probably wouldn’t make sense to anybody just listening to these names, you know? But there’s maybe eight or so of these microbes that make TMA. And when TMA is produced, it goes to the liver. The liver converts TMA to TMAO, trimethylamine-N-oxide, and the Cleveland Clinic discovered this, and that’s why it’s available through Cleveland Labs, because they’re associated with each other.

                                It was felt that high levels of TMAO were associated directly with risk of heart disease. And then when they looked back at, well, where does TMAO come from, what are the kinds of foods? Like you mentioned, eggs, dairy, red meat and things like that. So therefore, the inference was that red meat equals TMAO, which equals heart attack. And maybe there is some truth to some of that, but I don’t know that that’s really the full picture. I think there’s really, again, it’s in individualized type of situation, because I guarantee you, you get a couple carnivores on your show, they’re going to have a problem with that statement.

Dr. Weitz:            Absolutely. [crosstalk 00:45:18]

Dr. Singh:             Not that I promote the carnivore diet at all-

Dr. Weitz:            When the TMAO stuff came out, right away that became a new weapon for vegans to tell everybody why they shouldn’t eat meat.

Dr. Singh:             I have seen people that don’t really eat a lot of meat that have elevated of TMAO, too. I don’t deny that their elevated TMAO is related to increased risk of cardiovascular events, MI, stroke, cardiovascular death. I mean, they have literature suggesting that. But going one step behind that one step behind that, is where is this risk coming from? TMAO directly, or other factors and they happen to have high levels of TMAO? I don’t know that we know all that stuff, you know? This is a bacterial metabolite-generated issue, then looking at the microbiome level is where probably better answers are going to come from.

Dr. Weitz:            Right, so what you’re saying is somebody with a certain microbiome with certain microbes could eat some of these foods and they would not produce a lot of TMAO-

Dr. Singh:             Maybe.

Dr. Weitz:            Somebody else with a different microbiome might, or is more likely to, and so therefore the thing to focus on is somebody with a dysbiotic microbiome and fix that, and you don’t have to worry about the TMAO.

Dr. Singh:             Yeah. So one of the slides I had in this presentation is actually, there’s literature on this stuff, but people don’t talk about it as much because I guess it’s not as beneficial for whatever argument you’re making. It’s not like you eat red meat, you have a high TMAO level, now you’re going to have a heart attack. It doesn’t work like that. TMAO levels are determined by other factors also: your host genetics. TMA and TMAO are distributed throughout the body; it can accumulate, so that may depend on what you’re eating regularly on an ongoing basis and what other factors are going in your body.

                                Half of the TMAO is excreted unchanged in the urine, through sweat, your breath and urine. So you may be excreting half of this, if you want to call it a toxin or bad substance, out of your body anyways, as it is. Then the other half may be turned into TMA, back to the original metabolite, by a bacterial TMAO reductase in the gut. So then it may become nothing again. That’s not going to be harmful. So what makes it harmful in somebody versus not? Well, maybe it has to do with TMAO reductase in the gut, how much of that is being produced? Maybe that has to do with dysbiosis, maybe that has to do with all the gluten you’re eating, not the red meat. I don’t know.

                                So these things need to really be teased out, so understanding this on a case-by-case basis, because TMAO is an osmolyte, it stabilizes protein structures against destabilizing forces, that sounds like a good thing to me, right? Maintains the volume of interstitial cells under osmotic and hydrostatic stresses. So these are some of the other things that I’ve talked about as well, and they sound like good effects. So really, this whole discussion on metabolites, which TMAO is, is really going to become a very personalized thing.

                                It’s the same concept, you know, not that I’m promoting meat here, because I actually promote a very plant-heavy, focused diet, but I’m not afraid of meat, I’m not an anti-meat person, because I think diet is such a personalized thing. When they do these studies about red meat, they’ll often say red meat and processed meat, and they lump it together in the same phrase. Well, red meat and processed meat are different things, you know? I mean, lunch meat is not the same thing as an organic, grass-fed four-ounce filet mignon.

Dr. Weitz:            And the average person’s [crosstalk 00:49:15] not getting a grass-fed organic filet mignon, they’re getting a less-quality meat that’s sort of produced at a factory farm.

Dr. Singh:             Exactly. So I just encourage people, when you’re looking at these things, these stories and these literature articles that come out or people talk about these things, dial it back and see what are they actually talking about and what are they citing? I think a lot of people notice, they’re eating lunch meat all day long and it’s not … lunch meat comes in different varieties, too, you know? If they’re eating the lowest-level salami all day long, okay, I could see how you’re going to have a problem. That’s not healthy for you.

Dr. Weitz:            Right.

Dr. Singh:             But if you’re eating clean foods that are free of toxins and that were taken care of throughout the life of that animal, the nutrient profile and what happens when you ingest it is going to be different than when you’re eating something that’s not. It’s a good idea to have a varied diet, remember, because the microbes want resiliency and diversity in their system. So it’s good to have a lot of plants, because plants do that in your diet as well, they help diversify the microbiome.

                                So it’s important not to just be uni-focused in how you’re eating as well. We want to have a varied diet, and I’m not allergic to the concept of people having meat, but I do suggest that you kind of look at what you’re doing, make a personal choice for who you are, what works for you, and if your numbers are good and your microbiome is happy, do what you like, because that’s you. That’s the whole concept of Precisione Clinic that I started, because you can’t just say everybody should eat this and that’s what’s going to make you healthy. That’s not how it works.   So in Precisione Clinic, we look at everybody on a very personalized level and we say, this is what I think you should eat, based on da-da-da-da, all these things that we kind of determined.

Dr. Weitz:            Yeah, absolutely. I’m with you on that. I know we started talking about autoimmune diseases and we thought that we would go into it later, but I’m pretty much out of time. So …

Dr. Singh:             We could talk for hours, probably.

Dr. Weitz:            We definitely could. Unfortunately, today’s patient day in my office, so let’s wrap this discussion and then hopefully we can have one in the future about some of the other topics.

Dr. Singh:             Sounds good.

Dr. Weitz:            So how can our listeners and viewers get a hold of you, Marvin?

Dr. Singh:             I’m pretty active on social media, it’s @DrMarvinSingh, my website is PrecisioneClinic.com, Precisione with an E, so P-R-E-C-I-S-O-N-E Clinic.com. Email address is there, the contact information is there, so I’m pretty readily accessible.

Dr. Weitz:            Any final thought you want to leave with everybody?

Dr. Singh:             I guess the final thoughts is just to summarize the key concept of when you’re talking about gut health and microbiome, it’s not necessarily one microbe and that’s your solution or your problem. We want to look at what’s happening in the entire ecosystem. Look at it from a global perspective, because when we’re talking about even environmental pollution and things like that in politics, it’s not just necessarily one thing that we have to go after that’s going to really solve global warming or something.

                                There’s a lot of different things. We want to attack all of these things, just like if I say, well, your diet needs to be healthy, and you say, okay, I eat a perfect diet, but I sleep two hours a day, I don’t exercise at all, I’m stressed out and I yell at everybody all the time. You’re not going to be healthy, man. It doesn’t matter what you’re eating. So you got to look at, just as we look at our lifestyle factors in that perspective, we have to look at the microbiome in that perspective, too. It matters what’s happening in the ecosystem, what’s the ecosystem generating? What’s it doing and how healthy is it, how balanced is it? Because therein is where the inflammation and chronic problems are going to come out of.

Dr. Weitz:            Great, awesome. Thank you, Marvin, and thank you for spending this time with us.

Dr. Singh:             No problem, it was my pleasure.


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Surgical Care to Remote Regions with Dr. Glenn Geelhoed: Rational Wellness Podcast 188

Dr. Glenn Geelhoed speaks about Providing Surgical Care to Remote Regions of the World 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



Dr. Glenn Geelhoed is a professor of surgery at George Washington University in Washington, D.C.. He has also completed masters degrees in international affairs, epidemiology, health promotion and disease prevention, anthropology, and a philosophy degree.  He has dedicated part of his life to providing surgical care to people living in some of the most remote regions in the world, who ordinarily have no access to medical care.  He has written several books, including Furthest Peoples First.

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

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. To learn more, check out my website drweitz.com. Thanks for joining me and let’s jump into the podcast.

                                                Hello, Rational Wellness Podcasters, Dr. Ben Weitz here. Today, our topic is something completely different from what we usually talk about. The Rational Wellness Podcast, as you know if you’re a regular listener, is usually focused on functional medicine and the ways in which diet and lifestyle changes can play a role in health and especially in chronic diseases and how we can modify diet, lifestyle, nutritional supplementation to prevent and reverse such chronic diseases and promote longevity. We typically talk about topics like gut health, bioidentical hormones, nutritional deficiencies, cardiovascular disease, how to promote longevity, how to engage in detoxifying heavy metals from the body, etc.

                                                Today, we’ll be talking about serving humanity in a different way. To providing badly needed surgical care to people in the remote regions of the planet such as in parts of Africa, we’ll be speaking with Dr. Glenn Geelhoed who has dedicated his life to this. Dr. Geelhoed has a medical degree from the University of Michigan and he complete his surgical residency with Harvard University. To assist in developing further volunteer surgical services in underserved areas of the developing world, Dr. Geelhoed completed Master’s Degrees in international affairs, epidemiology, health promotion, and disease prevention, anthropology and a philosophy degree in human sciences. There we have something in common, I also have a philosophy degree. He works as a Professor of Surgery at George Washington University Medical Center in Washington, DC and he’s a member of numerous medical surgical and academic societies. He’s an avid runner and has completed more than 135 marathons across the globe. He is a widely published author, accredited with several books including his latest book, Furthest Peoples First which is going to serve as sort of the basis for our discussion today. Dr. Geelhoed, thank you so much for joining me.

Dr. Geelhoed:                   Thank you, Ben. Appreciate your invitation.

Dr. Weitz:                         Why have you chosen to devote yourself to bringing surgical care to the remotest places on the planet?

Dr. Geelhoed:                   Oh, that’s a good question and a large one but I really appreciate your asking it because it’s the sort of thing that may be counterintuitive. Why in the first world environment with all the high technology we have is perhaps something that your guests have already been discussing for some time. That is, how is it that this is a unique period in history when we can do so much to so few who are so little satisfied with this healthcare? How is it that we kind of expect some other professional to take care of us when, in fact, we have lived irresponsibly? I think refocusing on that brings us to that developing world. An active verb, developing. When you suggested to me this is a matter of service to humanity for those who are underserved, I certainly agree with that. Remember, I go constantly as an educational experience and it’s both ways on that street. What can I learn from them?  I mean, you’re on the West Coast there and you go to the nearest hospital and you walk into that ward and you take a look about and you find out that the beds are filled with diseases that they haven’t yet learned how to develop.  I’d say, what are they doing right?  Why is it that we talk always about what weird and wonderful conditions they have out there in the tropics. These people in the middle of nowhere that’s inaccessible, how is it that we can get to them and where these strange diseases are?   Well, let me take that little notepad that I carry all around the globe and write down a few of those notes about what I see that I wouldn’t see here.  More importantly, flip it over and write down those things that are so common everyday events here that they don’t have.  Varicose veins, irritable bowel syndrome, sigmoid colon cancer, coronary artery disease, thrombophlebitis, hiatal hernia.  Tell me why don’t they and if they have none of that, what can we learn from them?  My goal is always to learn as much as I teach and when I’m out there, I find that they have a skill that we need.

Dr. Weitz:                            Let me stop you for a second because that’s an interesting insight. We often get into discussions in Functional Medicine and there’s a percentage of practitioners who talk about looking at what ancient cultures did because they didn’t have these chronic diseases and therefore if we go back to a paleolithic template for how to eat and how to live our lives, then that’s a way to avoid these chronic diseases.  Given your experience, is it the case that these people in these remote regions don’t have atherosclerosis and some of these chronic diseases or is it that they have more pressing problems that they’re dying from like infectious diseases and from trauma and things like that before those chronic diseases would actually pop up?

Dr. Geelhoed:                   Well, the answer to that if I don’t want to equivocate, is yes and yes. There are a couple of reasons for this.  One of them is if you look at the population pyramid, there are a lot of youth and there are fewer older people. However, let’s look at those youths and we find out that the under fives are very susceptible to contagious communicable diseases such as malaria, dengue, …

Dr. Weitz:                         Well, what is the average lifespan in some of these places where you go?

Dr. Geelhoed:                   When you look at one of the populations in which I’m serving, you can look at it and ask what the median age is.

Dr. Weitz:                         Okay.

Dr. Geelhoed:                   It turns out in a place such as Uganda it is 11.

Dr. Weitz:                         Wow.

Dr. Geelhoed:                   What that means is that there’s an enormous base to this pyramid and there are fewer elders. However, what it means is there’s a fairly high loss rate. Now, if you medicalize the social conditions and get a higher salvage of the youth, what then happens is you get a broader middle age and middle we’ll talk about the reproductive years, the 20s and the 30s and up to the 40s. Now, look at those people. When we look at those young people, they are susceptible. They haven’t yet acquired the immunity to several things such as chronic malaria, develops a somewhat relative resistance to the really tragic forms of the disease. However, if they get to the age of survival there, they are very healthy adults. I say that when you look at the nutrition and you look at the individuals, I will give you three-fourths of a [inaudible 00:08:11] equation. You figure out the fourth. They have young children that are in nutritional peril because they don’t usually have enough in a balanced diet of some sort.

                                                American kids, they run straight for the french fries. They’re chubby and they are running around using up energy. Now, you look at their diet and ours and you ask about their adults and ours. They have healthy, very functional adults. Muscular women that are out there gathering roots and berries and they’re out there foraging. Now, look at that same population in our group and you would ask, is their diet and their exercise and their lifestyle contributing to the health of the elders that we may find in the reverse here. Yes, you are correct in both instances.

                                                Number one, to develop heart, cancer, stroke is the number one, two, and three problems in this part of the world, you have to survive long enough to develop them. That’s the disease of 60, 80-year-olds. Now, if you’re talking about the number one through five killers on planet Earth, I say it’s a dammm shame, D-A-M-M-M. Diarrhea, acute respiratory disease that is pneumonia, malaria, malnutrition, and measles. Number one through five on planet Earth are all diseases that are typically of the under five children and it’s a high children loss rate.

Dr. Weitz:                         Measles is one of the top five killers.

Dr. Geelhoed:                   It still is and the reason for that is one of our millennium development goals has been the Expanded Program in Immunization, EPI. It is a very effective one. You can prevent it. You can prevent all five of those number one through five. You don’t need a nickel’s worth of research to find out what causes them. We know and there are relatively effective and cheap methods of solving them. For example, diarrhea we’ve taken on the oral rehydration salt program. That’s saved more lives than every antibiotic developed. The area of the acute respiratory right now is one in which we’re working very diligently. One of those having to do with antibiotic resistance in some instances particularly with some of the short-term courses of treatment for tuberculosis that are discontinued and then you get the development of resistant tuberculosis organisms. Nonetheless, each one of these has treatments and each one of these are relatively effective. Our millennium development goals have targeted them and has been quite effective.

Dr. Weitz:                            Interesting. There’s probably when I was reading your book and talking about parts of Africa and South America, I couldn’t help but think there’s probably places in America that could probably badly need your care as well given that healthcare is not often widely available in rural parts of America. I was just listening to a discussion, they were talking to potential voters in some rural part of West Virginia and they haven’t voted for years. They say, “We don’t even have the Internet. We don’t have running water. We don’t care about who’s the President.”

Dr. Geelhoed:                   You’re right. Developing worlds are two terms that I use regardless of political boundaries or geography. Right next to me here in the city of Washington, DC, there are big chunks of a third world within sight of the gleaming first world medical towers. In Karachi, Pakistan, there are the [Kachiabodies 00:12:07] and they’re sitting right next to the women and high quality restaurants that are talking about their children in the Serbonnes. There are people all over the globe, the first and third worlds are very close together sometimes in the same geographic area. The barriers are not simply economic, although that’s a major one. It can also be political. It can be religious. It can be language. It can be a number of these things that are barriers at our hospitals to be bridged. Some of which are very, very difficult.

                                                I don’t have to tell you that in the Middle East, there are barriers to people who live on either side of the same street that might not have anything different in the place they shop, the food they eat, even the language they speak. In fact, I talk about the holes of inaccessibility. It’s a geographic term. In the middle of each continent, there’s a spot you can’t get to easily. You can’t get to at all in some instances because there’s no access by river, by road, by air, by mountain or otherwise.

                                                The one that I’ve worked in fairly often is the subject of another book. That is a mission to heal book which comes from a place in Obo now called the Central African Republic used to be the eternal empire of Central Africa. Eternity only lasts two and a half years in that instance under Jean-Bedel Bokassa but that is inaccessible. Now, those people are the kinds of folks you would say, “You have a problem? Just go to the local medical center.” That local medical center is five time zones away and there is no road between them. When they get there, they don’t have the same language. Furthermore, there are three wars going on between them that are tribal and also international proxy wars. As a consequence, they are totally isolated there. Similarly, there’s a spot in Kazakhstan which is the Asian pole of inaccessibility.

                                                If you were, for example, in a, if I use the term, ghetto environment in the middle of a good city somewhere and weren’t able to access the healthcare, once again because of perhaps citizenship, Medicaid availability, language accessibility. All of these reasons are the barriers that we artificially erect to isolate humans from each other. Those are so easily bridged if only we can overcome the most fundamental prejudices and see what we can do. My goal is not to say, “Look, I’m going to build a road. Now, you can go from remote Uganda down to Kampala where they have first world medical centers.” I was a participant in developing a couple of those. Well, in fact, when they get there, they speak there a Bantu language. The people from northern Uganda speak a Cushitic language that’s from the Kingdom of Kush. There’s not one word in common there so who’s to say and how are they going to be … Furthermore, there’s a civil war between those two groups only recently resolved. They still have skirmishes.

                                                As a consequence, they had a very not so much just by geography but by a lot of artificial constraints that are political and economic and a whole lot that we could overcome if what we recognize is the commonness of humanity. Physiology is made very much the same way. The anatomy doesn’t look a lot different to me when I’m inside there looking around. As a consequence, if we can recognize how much we have in common, how little those differences make, how trivial some of them can be. I mean, for example, if we think of the enormous complexity of one human to another and all the fascinating differences in culture, something as trivial as skin color is a remarkable barrier to having been invented as an inhibition to healthcare. Our goal is inability that they have to get to healthcare, let us bring it to them and to capitalize on the assets they have and learn from them in the process.

Dr. Weitz:                            Yeah, I think it’s interesting. This is not really a medical point, this is more of a historical point. I think those of us who are sort of paying attention have learned from reading about the situation that occurred in Iraq since our country got involved there. How you have these three different tribes and how they were all put together in one country. Basically, that happened because the Europeans came in and said, “Okay. This is the country of Iraq.” Not respecting that there were these different tribes with different religions and different languages and just throw them together. That sort of issue occurred all around the globe where we just went in and said, “Okay. This is West Africa. This is the Congo. This is this country.” We drew lines irrespective of different tribes with different languages and different cultures. What you’re talking about partially is that the inability to different tribes in the same country that speak different languages and the different issues that occur with accessing healthcare with people who don’t speak the same and etc.

Dr. Geelhoed:                   You’re right, Ben. In 1850, a group of Europeans sat down in Berlin and curved up Africa never having been there. What they did is they would write a red line down the middle of the river. Now, isn’t it reasonable to think that perhaps my cousin lives on that side of the river and I’m on this bank and how did it suddenly happen that he belongs to the different nation state and that I’m at war with that nation state because although he’s my cousin, he now has a different flag. They would not know from that. They identify with their cultural groups, their language and their people that are responsible. One of the things that Africans have to make up for lack of stuff is very strong relationships so that if I speak your language and have some blood kinship to you, you are obligated to come and help me in my time of need. You have eaten today, I have not. We share the same things, language and religion and I believe you probably ought to do something to help me. That’s true for all humanity. The original-

Dr. Weitz:                            Now, you know that whole concept of, I have eaten today and you haven’t, is something that we have forgotten about a long time ago in the United States. It’s important to remember that. For most of the history of humanity, the biggest threat to survival was starvation. Now, a lot of our physiology is designed to help us overcome that starvation and that explains some of the issues around understanding insulin resistance and fat storage. There’s a whole series of physiological concepts. They’re all really built around that. We often forget that because in America we’re so far from ever facing starvation for most of us anyway.

Dr. Geelhoed:                   You’re right on there, Ben. I understand the paleolithic prescription and the stingy gene hypothesis hanging on desperately to the salt and the sugar which gives us greater problems of both the diabetes and the hypertension. Yes, in fact, that origin and the pressures that were put to bear on the early genetic population that became ours, is a number of things that we can learn from. Remember, they there have to do something which is a skill we must learn from them. They cope. They are resilient with both imagination and resourcefulness and some sort workarounds, they are able to take on what I consider bigger problems and larger numbers with far fewer resources. That’s a lesson we have to learn from them.

                                                When I go out there, I don’t come and say, “You poor [inaudible 00:20:46] savages, I’m here to tell you about the wonders of the first world.” No. I go out there and I ask, “How is it that you’ve done so well with problems that we find insurmountable? How is it we might be able to assist you who have the obligation to care for the Indigenous folk with an enhanced method for caring for them?” Mine is an educational mission and that education is two ways. It is never coming over there and saying, “We’re going to tell you what it is that you should do.” Only politicians say that. The most arrogant statement made to anyone, “I know what’s best for you.” Well hey, you don’t even know me. How can you possibly come up with that statement because, in fact, I am adapted? By definition, I exist. I’ve come through all these stresses that you couldn’t tolerate. I am a pretty good outdoorsman. I’m a pretty reasonable athlete and I could survive in the Ituri Forest for perhaps three to four weeks, I’m good. They live there. Come on now. Not a word from you.

Dr. Weitz:                            We often have discussions in a functional manner so we’re all about what the paleolithic diet or what the Indigenous people’s diet actually is. Is it a lot of meat? Is it consist of this? We often extrapolate and say we should not eat this because this was not eaten. Maybe you could provide us with some insights since you’ve had so much experience and exposure to various Indigenous cultures. Some of the insights into what Indigenous people around the globe eat.

Dr. Geelhoed:                   Well, I think that is a correct question but there’s always a balance. The intake of those calories and nutrients has to be balanced against the output of them. I would say exercise and lifestyle balance against that intake.

Dr. Weitz:                            Of course. Yeah.

Dr. Geelhoed:                   Remember that for the majority. The majority of the world’s population foraging with an occasional hunter gatherer trophy. Not often successful but obtained with a great deal of effort. Here is a cultural agronomy-

Dr. Weitz:                            Let me just stop you for a second. You’re pointing out something which is that you just said most of the world’s Indigenous population … By the way, most of the world is in this … Most of the people in the world are in the developing world, right?

Dr. Geelhoed:                   We all are, I hope.

Dr. Weitz:                            Okay. I meant in some of these poorer countries we have the larger part of our population. You’re saying that most of them are gatherers rather than hunter … What term, foragers rather than hunter gatherers.

Dr. Geelhoed:                   Right. That has changed a little bit with settled agronomy. Remember that hunter gatherers are those who have to move and they don’t stir up stuff. What they have is an occasional bonanza especially of protein and some scattered lipid whereas, in fact, the settled agronomist can come up with a fairly successful largely grain-based or tuber-based diet. What happens, they store up food. Hunter gatherers store up favors. Remember back four weeks ago when I got the antelope? Obviously, I can’t eat it all. I have no refrigeration so what I’m doing is I have a feast and I supplied all of you. Now, I’ve been hunting for three weeks and I haven’t scored. I surely could use some of that grain from your granary. Remember me, remember where I speak your language? You were my third cousin. You’re related to my second wife’s cousin. That sort of kinship pattern is one I can trust.

                                                Now, who was elected, that’s kind of arbitrary and who is that came through from a city, an urban center and said, “I’m your leader.” Well, what have you done for me? Most of the people in those developing parts of the world fear their own army. After all, they’re not worried about an invasion. They’re worried about their own army that travels without a supply line. Without a supply chain, they live off that population that already is rather timid about having any of these people that come from fancy environments such as urban ones. Yes, I appreciate those folks and how they live. How they live is by having care for each other. Remember, if you can say that about this rather unique epoch, it’s an epic of an epoch [inaudible 00:25:42] for us.

                                                We’ve just come through seven or eight months of something that none of us have experienced. That wasn’t true for your grandfather because he came through the 1918 flu. That wasn’t true for people 500 years ago because they came through the Black Death. It wasn’t true for the ions of lepers and small pox. They all lived through this. You are not designed to survive COVID-19. You should thrive under its pressure. This is not [inaudible 00:26:18], I’m taking 2020 off because according to my … I mean, the destiny that I have is [inaudible 00:26:26] circumstances around me. I must do something to overcome perhaps mitigate and more specifically modify me in order that I might do more. One of the ways we do that is by going out seeking to help others because remember if there’s some degree we can administer them, there’s a whole lot that we learned about ourselves in that process that may helpful in developing our own humanity. Therefore, this began an unusual era.

Dr. Weitz:                         What do most Indigenous cultures … What are some of the food patterns you see in these Indigenous cultures?

Dr. Geelhoed:                   Well, the food patterns are largely those right now carbs whereas before they were very high in protein and high in protein not very often meaning that [crosstalk 00:27:20].

Dr. Weitz:                         Are you saying that before we were mostly hunter gatherers or were there always foragers and hunter gatherers?

Dr. Geelhoed:                   Yes, they were always … In fact, the most fascinating story there comes from experience in the Ituri Forest. You’ve known the term [inaudible 00:27:36] for a while. They don’t use that term. They would use the Efe and the others. Now, the Efe, the female and the hunter gatherer could marry. In fact, they’d produce a fairly stable society because she was an agronomist, he was the hunter. There was never a situation of the reverse. You didn’t marry one of the female hunter gatherers from the other … What happened is that they developed an integrated status and a role society. They actually settled on that basis because you couldn’t pick up a fire or the garden. In that case, they killed the [shamas 00:28:18]. You had to do that. Now, slashing and burning occurred often the [inaudible 00:28:24] agronomy meaning that there’s very little soil in the tropics. Much of that is eluded half the year from inundation. That’s the key to the other half of the year because on the Equator there’s only two seasons, dry and wet. I know beautiful falls shooting out [inaudible 00:28:40].

                                         What happens is that they would move from point a to b but there was say relationship. Slashing and burning they would get some agronomy going while the hunter had to go further and further out. Going further and further out he did a lot of exploring but always recognized his base because there’d be long dry spells for him in which he wasn’t able to capture. As a consequence, then they said, “Look, we can’t find the animals or this has been an off year or some plague has come through the animals. Maybe we should domestic a few of those, grab what we can and see what we might do.”

                                                Then, the whole of the Great Rift Valley where I’ve been working a lot in the last several years, is a cattle culture. They live with their cattle and, in fact, some of them it’s become a real problem for them. The cattle are not only a source of some devastation to the environment. In a desert environment, they overgraze and decertify it. Second, those cattle also spread a layer, a veneer of coliform bacteria all around every place in the water supplies for the children which is why the diarrhea’s such a high problem. Third, they become a source of considerable enmity. If you think the Wild West wasn’t full of rustlers, cattle raiding is their favorite sport. It used to be that you would go out with a spear and you would grab four cattle from over the other side of the village and bring them back. Now, they would get two cousins and an uncle and they would come with a spear and try to reclaim not the four cattle, they’d try to take eight back.

                                                Well now, with the introduction of automatic weaponry that had nothing to do with the fight they didn’t even know. They had no dog in that fight at all. It was a first world environment that suddenly spilled AK-47s into their environment. Now, the lethality in the conflict is considerably greater. Now, when you rustle four cattle and I’ll ask you the question why do you need those four cattle? Then now, your cousins and uncles can’t protect against the RPGs and AK-47s that are coming. That are so redundant in that society because the conflicts for which they were imparted actually forced on the population have either been resolved or moved on to something else. There’s nothing so indestructible as an AK-47 tried to Crazy Glue and the [crosstalk 00:31:14].

Dr. Weitz:                            Benefiting for [crosstalk 00:31:15] for American culture with weapons being our greatest export.

Dr. Geelhoed:                   What happened there is some put Crazy Glue in the [inaudible 00:31:22]. What they did is put it in the fire and they burned the Crazy Glue out and they put it on full automatic [inaudible 00:31:28]. I mean, there is nothing that is indestructible and that isn’t. What happens is I need the cattle. Why is essentially because everyone can see in the distance what my wealth [inaudible 00:31:43]. My bank account is all around me. In fact, why do I need the cattle? First, for my status and second is, it takes 25 cows to get a bride. If I would show you my fertility and my fecundity is standing out there chewing its cud.

                                                The irony is about threefold. If you have a lot of cattle, number one is surviving children you have are going to be fewer because of the diarrhea, another thing we talked about. Number two, they have a placental disease named after the fellow in the United Kingdom [inaudible 00:32:20] that was Bruce, Brucellosis. Number three, cattle are a source of great enmity and an easy exchange for rustling. What I considered that first of all, they are an economic drone because, after all, you don’t eat the cattle very often because that’s pretty high. You would only do that for a marriage ceremony and the chief or something. Second is that they devastate the environment so you have to move on after the grazing and water’s exhausted. Third, it’s going to bring upon you a whole lot of armed resistance that’s going to try to scramble. I think cattle right now are not only … I call them an economic drone. No, they are more than that. They are a hazard.

                                                They are an inhibition to fertility more than its access. If you have one sheep plus 500 cattle, he can purchase eight or nine brides. Well, Ben, this is just between you and me and I’m sure no listeners are ever going to repeat this, one of the fundamental things that I learned in obstetrics is that maternity is a matter of fact. Paternity a matter of opinion. As a consequence, the number of brides that an old chief and a lot of cattle can purchase, they seem to be having children rather regularly even if he’s perhaps not what he used to be. As a consequence, society absorbs this impact [inaudible 00:33:53]. Then, the main feature a cattle culture is simply one of worship. You worship the cattle there. I point that out that we can say, “Look at these people. They are so primitive that they have this animus tradition in worshiping their cattle.”

                                                What’s in your garage? Do you need a Ferrari to get to the 7-Eleven? Do you perhaps use that Ferrari to attract nubile age mates that could possibly give you more children? I am telling you that one of the wonders of my travels is getting a close look at myself. All true exploration is an exploration of self. I have become a lot … I lean less lightly on the planet. I do a bit of grains and berries and things like that in our nutrition. I haven’t stopped running. I, in fact, am going to … Oh here, I didn’t even think about it but my running log right here will tell you that I just crossed because of the COVID pandemic and I live in the woods, it’s isolated, I’m socially distanced, I just crossed 2,400 miles for the year. I am going to say on search of the land, live as though you’re responsible for your neighbor even if you don’t know that neighbor even if you can’t talk to him in his language.

                                                I used to say, people asked me, “Why are you going there? Do you know anybody there?” “Yeah,” I would say. I mean, they have the courtesy to speak English to me. Now, when we look at people, we have a lot to learn from them because they’re at the cutting edge. We don’t have that close of a scrape with survival until recently I suspect. That’s why we are now wearing masks. We are socially distant and that’s why we are asking ourselves, “Are all these other people threats to us?” I mean, every one of those potential vectors, they could carry something nasty too. Well, maybe that’s your hope coming toward you. [crosstalk 00:36:13]-

Dr. Weitz:                            Your mission is to go out into these remote regions and you bring a mobile surgical unit to these parts of the world where they have virtually no hospitals or very limited medical facilities. Then, you perform surgeries and teach … You bring medical students with you. Then, you also help to teach some of the local doctors. Is that right?

Dr. Geelhoed:                   Yes. That is correct, Ben. As you just mentioned, in the book it shows the brand new mobile surgical units that are going there. Very, very sturdy units that can go anywhere without any need for bridges and all of that we could discuss. They’re six-wheel drive, solar powered, consistently make their own electricity, purify their own water. Add salt and sugar and you have IV fluids. It’s an amazing device. However, it’s not that purpose of going out and delivering aid. You don’t come and say, “I’m coming to help you. Step aside because I know how to do this and you don’t.” It is to say, “What do you really do to handle this problem? How can we help enhance the skill that you must carry on?” Because we don’t want to go there and do something and then vanish leaving a vacuum behind us. That parachuting is not going to be a success. It’s just going to lead to more frustration.

                                                This is an unusual era. I don’t have to tell anyone here that it is, of course, unusual year 2020. There’s another reason and here’s a reason not too many people recognize. For the first time in human history, despite the pandemic going on now, plagues and pestilences which have been the great limiting step for development for a lot of people have come under control to a degree. Remember, we’re talking about the current pandemic. It’s seven months old and we’re already talking about a vaccine to eliminate it. I mean, before this you have to go generations until there’s a susceptible population and it’s all gone. For the first time in human history, the majority of mortality is related to surgically fixable conditions. Meaning strangling the hernia, a uterus that ruptures in labor, a fall from a tree collecting mangoes. The perpetual problems of automobile and trauma and other things that come from hostility and the development of things such as the cancers and other things that come along at a later age.

                                         In addition, there are these congenital things they don’t even know can be fixed, cleft palates or [inaudible 00:39:08] defects or burn scar [inaudible 00:39:10] is a very big one because they have open cooking fires and children are falling into them. What happens is that all of these things can [inaudible 00:39:18] fixable. The mark of modernity in healthcare is a surgical operation. What do we do? Do we tell them again, “Come to the capitol? Come to Washington DC.” That’s 17,500 mile in a supply chain. What we do is we go out and we teach how to do that locally and I will take Indigenous practitioners whether they’ve been to medical school, whether they have more degrees than a cerometer which they consider kind of silly if you can’t use them. [crosstalk 00:39:48].

Dr. Weitz:                         They actually learn to do surgery? Can they actually learn to do surgery with such limited education?

Dr. Geelhoed:                   Absolutely. How did surgery evolve? Who did the first caesarian section? Where did that come from? Was that a tertiary medical center? Are you asking me we can only start where we are now in a tertiary hospital because, in fact, obstructed hernias don’t usually happen in a parking lot of a tertiary hospital. They happen in Sub-Saharan Africa. I’ll just say, “Go to the [inaudible 00:40:33].” The majority of those folks don’t have a healthcare practitioner. One in 20 see a health practitioner. I didn’t say doctor. I didn’t say nurse. Someone who was health capable. If I said to somebody … I’ll give you an example. A beautiful village named Gatab sitting on the mountain in a [inaudible 00:41:00] of the Great Rift Valley. Someone comes there and needs a caesarian section. They’ve been in labor for three days.

                                                I don’t know if you can imagine someone in California undergoing labor for three days and not having something move. There being some action in the … What do you do? Tell her to put her knees together and hold on because we’re going to refer her … Gatab is 47 hours from pavement. If you have a Toyota Land Rover four-wheel drive vehicle, and you have the diesel fuel and you know someone who can drive it, all of those are rather big blocks. Then, bouncing up and down on the roadless terrain over those mountains, you get to the Great Rift Valley, you will come to Marsabit, you will actually come to Laisamis which has a hospital but there’s no doctor. I stood in there and I tried to make an operating room out of it and talked to one of the local nurses into doing it. We actually got her capable into doing C-sections. There they would transfer you to Marsabit. Marsabit was the first place where you would see a doctor who is capable and who understood what a C-section was.

                                                I don’t know after three days of labor, 47 hours on roadlessness, then getting to a paved road and going another 90 minutes to [inaudible 00:42:30] to a Californian. Now, why should it be different for some [inaudible 00:42:36]. Remember who is worthy of medical care. I mean, how could that statement even arise? These people considered modernity reflected as an operation is one of the things that they are finally recognizing they are worthy of such attention. That means their own self-esteem says, “Well, this man, he fell from another planet like an [inaudible 00:43:07]. However, he didn’t do that operation. He came out and told everybody, “Look what Rose did. Rose is one of my wonderful midwives. She is such a wonderful person who said, ‘I am so happy that you have taught us something rather than coming in and taking over because now I feel I can not only do the things that you’ve taught but I might even be able to approach some things that we didn’t have when you were here using some of the same ideas and principles.'” Rose did this, I didn’t.

                                                [inaudible 00:43:44] back and get on your podcast and say, “Everyone send money because I’ve done some good things. I did 128 operations.” No, no, no. I’m going to tell you right now, I just came from a mission in which 128 operations done. I did none of them. I assisted each one of them and the last two dozen I assisted without putting on gloves. I’m over here because our operating room is a two table unit. It’s a teaching unit. I say to them, “Now remember, this is just like the last ones we did. I’m over here. I’ll start this one. I’ll watch you do that one. If you have a problem, go through it the way we did before.” Our two table operating theater is continuously a teaching device and it enhances the care that they will give when we’re gone. I don’t say, “Okay, we’re coming here, we’ve done our operations and are miracle machines. Now, we’ve driven off.”

                                                Now, we’ll come back in five years and we’ll do it again. Well, I don’t know how many pregnancies would still be going after five years. I don’t know how many people would be tolerating their life-threatening conditions. They have to be cared for by the people there. In addition, if they know that I’m coming back, well we don’t have to do anything, it’s just like America now. Health is the responsibility of the practitioner not mine. I’m not going to do anything to prevent my cancer. I’m not going to do anything to keep me from having heart disease because don’t you know, we have coronary bypass. We have minimally invasive techniques where you can do it with a scope. This is now. I don’t need to live responsibly. As a consequence, the people are taking the responsibility for their own healthcare and their own health.

                                                I go there to learn how it is that we could become healthier and perhaps while I’m there they learn a few things that they can adapt. Innovation and substitution and improvisation is what we teach. They don’t all have to graduate from the same schools I did because it’s impossible. They don’t all have to say, “I’m going to be just like you in having gone through how many different” … I can’t tell. Who is it that is the go-to person here? How can we get to them and help them and enhance the care that they’re already obliged to give to make it better than witchcraft, more than … I’m not telling you that witchcraft is practiced in Africa. There’s a fair amount of it going on in California. I don’t have to tell you that I’m in Washington DC and there might be a little bit of it around in a couple of the large buildings here who’s ownership is subject to change only at intervals. One of those a week away from today.

                                                The question is, how is it that we can assist others and by looking at their problems and how we might be able to give a new mindset to them, change that mindset of our own. That’s the single thing we do best. In fact, it was the subject of the other book that I had which is called Gifts From the Poor and is the subject of transformational learning. How did I encounter the other and thereby become changed by it? How is it that every single one of the medicals that I think someone else kept score, I’m not the bean counter of 2,300 people that have gone with me over this extended period of time. I’m half a century in practice in the developing world. Not one of them says, “I learned a lot.” That’s so obvious, they don’t need saying it. They say, “I will never be the same. My whole life has changed.” You don’t get that from a biochemistry course. You don’t do that from gathering six more facts, that’s transactional.

                                                Now, we have a new mindset that we can understand a little bit better how it is we might help them and thereby perhaps even us. The problems we have seem to be stuck. The stuck problem isn’t, “Let’s find several different new ways of treating lung cancer.” Well, what’s the probability of coming out of that once you have it? Why don’t we put all the marbles where we know it’s effective? Why don’t we change that mindset? Why don’t we say, “Hmm, these are problems that we seem to be stuck on. We can change a couple of them transactionally.” If I worked all day long for the rest of my life in Washington DC, I might be able to improve the healthcare there by a fraction of a percent. The freshman medical student gets 100% yield on his first day. You can’t fall off the floor. Let’s start.

                                                Can I answer everyone’s question and can I solve everyone’s problem? No. Is there a reason we shouldn’t start on the basis of the fact that we can’t complete it? We can start it because we should never complete it. It’s a continuing process and not just for us, for them. They must continue that in our absence and so must we. We must step aside to look at ourselves in the same way that we are doing in the developing world because I should hope while alive we are developing as well.

Dr. Weitz:                            That’s great. On that note, I think we’re coming to the end of our time. What final thoughts would you like to … You’ve already given us some great things, important things to think about. Is there maybe one final thought you’d like to leave our listeners and viewers?

Dr. Geelhoed:                   Oh thank you, Ben, for that because I agree. I put a few of those into the book that you just started with. That’s a publication date this week. You are number one, by the way, in its promotion. You were the first to hear about it. I would say this transformation, how is it we are able to learn the lessons that we are attempting or said to be teaching others and find out, oh my goodness, we are actually learning something that might transform our own lives. Thank you for time. Appreciate it, Ben.

Dr. Weitz:                         You’re welcome. Your book is available, I’m assuming, from Barnes & Noble and Amazon and all the other popular booksellers.

Dr. Geelhoed:                   All of the above.

Dr. Weitz:                         Great. Thank you so much, Dr. Geelhoed.



Inflammaging with James LaValle: Rational Wellness Podcast 187

James LaValle speaks about Inflammaging 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

5:10  Inflammaging is related to metaflammation or metabolic inflammation. To understand metaflammation we have to look at various systems in our body ask if our nervous and immune systems are in balance?  Is that in balance with our hormonal system?  We do this by taking a systems or network biology approach to understanding our health.  Are we absorbing things correctly?  What’s going on with our detoxification system?  Is our stress load too high?  Are we sleeping well?  Are we well hydrated?  And we need to consider all the toxins we get exposed to, such as atrazine, which is the most used pesticide in the United States and extremely prevalent in California.  Many things can put us into a state of chronic inflammation.  We are supposed to have short spurts of inflammation but the problem is when inflammation is not turned off.  This can happen just by overtraining. 

9:29  One of the things that may start to happen is that ferritin, the storage form of iron, becomes low, even though their serum iron is normal, and we lose our ability to make EPO and new red blood cells.  Patients with low ferritin are more prone to anxiety and arrhythmias and fatigue and headaches.  And their thyroid receptors can’t function right because you need ferritin to allow your thyroid hormone to penetrate the cell.  But these patients don’t need more iron.  We need to figure our why they are metabolically inflammed and correct that. On the other hand, elevated ferritin can be a sign of inflammation as well.  If we stay chronically inflammed, we will be more likely to develop plaque in our arteries, lose bone, lose muscle, become insulin resistant, and lose the neuroplasticity in your brain. If you are insulin resistant you tend to make too much ferritin.

12:25   The other factor are your lipids and when you are metabolically inflammed, you end up making more bad actor lipids, like apolipoprotein B and Lp(a).  By the way, did you know that when you are diabetic, have Lp(a) that’s too low, that is associated with more progressive damage.  Also, if there is elevated oxidized LDL, this also indicates increased inflammation.

17:27  People eat too much, they eat too often, and they eat too late. They pick the wrong foods. They don’t get enough sleep, which triggers inflammasomes in their body. When we eat too much, eat too late and eat too often we turn off autophagy. Autophagy is when you bring out the vacuum cleaner to clean out the waste products of your metabolism.  Without it they get lymphatically stagnant and they don’t clean out waste proteins.  A virus can trigger the NLRP3 inflammasome and if this is uncontrolled–if it is not balanced by NLRP6, it can lead to a cytokine storm.  This is because we are so unhealthy. 80% of our population is overweight, 42% is obese, and 50% is pre-diabetic or diabetic.

24:28  James pointed to his I watch and said that this tells me that I have to breathe, which ridiculous that we need a device to remind us to breathe.  He pointed that it is important that his clients breathe deeply, so he teaches them box breathing, so they can breathe deeply for 2 to 3 minutes.  This helps put them into parasympathetic mode. If your resting heart rate is above 62, you are sympathetic dominant.




James LaValle is an internationally recognized clinical pharmacist, board certified clinical nutritionist and the author of more than 20 books including, “Cracking the Metabolic Code.”  He lectures around the world, when we did have meetings before COVID-19, including for the American Academy of Anti-Aging Medicine and for the George Washington University Masters of Integrative Medicine program.   

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

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

Dr. Ben Weitz here and we’re here today with James LaValle and we’ll be talking about a topic called inflammaging. James LaValle will explain how chronic inflammation contributes to chronic disease and accelerated biological aging. And of course, all of us want to slow down our biological aging so that we can have a low biological age in a old chronological age.  And so this topic is inflammaging. So what happens is that excess inflammation plays a role in many of the most common chronic diseases, including heart disease, diabetes, neurodegenerative diseases, chronic kidney disease, and even cancer. And among the causes for inflammation, of which there are many, include stress, blood sugar imbalances, obesity, gut dysbiosis, chronic infections, periodontal disease, diet, poor sleep, toxins, and many of the topics we regularly talk about in the functional medicine world.

                                                James LaValle is an internationally recognized clinical pharmacist, board-certified clinical nutritionist and the author of more than 20 books. How do you write so many books, James? Including Cracking the Metabolic Code. He lectures around the world, or at least he did when we used to have meetings, including for the American Academy of Anti-Aging Medicine and for the George Washington University Master’s of Integrative Medicine program. Thank you so much for joining me today, Jim.

James LaValle:                    Oh, it’s great to be here, and I got two more books coming this year, man.

Dr. Weitz:                            Is that right?

James LaValle:                    I’m churning and burning, buddy.

Dr. Weitz:                            Wow!

James LaValle:                    It’s….

Dr. Weitz:                            What two books do you have coming out?

James LaValle:                    I’ve got Metabolic Code 2.0, which is kind of the updated version of Metabolic Code, which kind of goes through metaflammation, how do we get there, how do we look at it? And then I did a book on biomarkers in sports performance to really … I work a lot with athletes and I think there’s still just such this ignorance of where the biomechanics and biochemistry need to intersect in order to really have a healthy person who’s training. And it doesn’t matter whether you’re an amateur athlete or a pro athlete. You can start an inflammation cascade with an injury or you can get injured because you got inflammation chemistry in your body.

Dr. Weitz:                            Right.

James LaValle:                    I don’t think people have quite got that yet. So I’m really excited about that book.

Dr. Weitz:                            I think that’s great. That’s a book that’s definitely sorely needed because I’ve done some work with some professional sprinters and some other athletes and trying to put together which things are best to track is a bit of a challenge right now, so giving us some guidance on that would be helpful.

James LaValle:                    Yeah. No, it’s exciting and the world’s changed. I think we’ve got some really good awareness now of what chronic inflammation is and I don’t want to get into too heavy of a discussion but I do want people to understand that we’re all moving towards inflammation as we age. That’s what happens. Our immune system kind of starts to decompensate. As we age, things don’t work as well. Just like you said, we want our chronologic age really up there and our biologic age really back here. And when we don’t really take care of ourselves the way we need to or become aware of what’s going on with our chemistry, things slip away, people start developing chronic illnesses. 

Dr. Weitz:                            Yeah. Actually, I think the last week of political-flammation and obsessive screen-watching and-

James LaValle:                    Oh my God.

Dr. Weitz:                            … lack of sleep is probably contributing to the–we’ll add that–political-flammation.

James LaValle:                    Yeah, and you know what? I think that may be number one. I don’t want people coming in here that are just … they’re beside themselves. Just try and tell them, “Take a deep breath.” I turned 60 this year, right? And so I’ve seen a lot in my 60 years. Politics never ceases to amaze me. I’ll just put it that. It’s something else.

Dr. Weitz:                            So outside of politics, what are the biggest contributors to inflammaging and what is inflammaging?

James LaValle:                    Yeah, it’s a great question so we can set up what we’re going to talk about. There’s a process called metaflammation. Metabolic inflammation. We used to hear a term “metabolic” and you’d think, “Oh, I burn calories or I don’t.” And this is what I wrote about when I wrote the Metabolic Code book and obviously, what I teach about is systems biology or network biology thinking, which is, you have to look at the relationships in your body and understand, is my nervous system and immune system in balance? Is that in balance with my hormonal system? Am I absorbing things correctly? What’s going on with my detoxification pathways? What’s my stress load like?  Am I sleeping?  What’s my hydration like?  All of these facets. What I get exposed to. I mean, if you’re living in California, atrazine, a major pesticide.  We spray more atrazine in the state of California than I think the next three states combined. It’s crazy.

Dr. Weitz:                            And it’s interesting. Everybody talks about glyphosate, but atrazine doesn’t seem to come up as much.

James LaValle:                    Yeah, I know and atrazine’s number one. It’s the big one. It’s making all those tadpoles deformed. And humans, by the way. So there’s issues with it. So my point is that everything that’s going on with you right now. If you’re listening, where you are right now with your metabolism is really the sum total of everything that’s gone on since the time you’re in your mother’s womb to today. Exposures, emotional stress, physical stress, impact of diet, all of these things. Environmental burden. All of these things are flying at this high level in our body and they’re all trying to keep us sound. You know, just able to age gracefully.  But the problem is that as we start to get into … I get an infection, I’m on a lot of antibiotics, maybe I start to develop dysbiosis from candida. Maybe my diet’s skewed. Maybe I’m a big ketogenic dieter and I don’t take in any fiber and maybe I’m starting to make more endotoxin. What happens is, we start to push our body towards triggering a neuroinflammatory response, meaning we get sympathetic dominant, so as your blood sugars go up, you make more adrenaline. And at the same time, you start to release more inflammatory cytokines.  Inflammatory cytokines are basically the signals that tell your body, “Hey, we got to fight a good fight.” Your body’s supposed to turn those off, right? You know. You treat patients every day. An appropriate inflammation response should stop and a person resets back to normal, and the problem that we have is that when people stay in a chronically inflamed state … Now, that can happen just by over-training.  You can be perfectly healthy and train too much and put yourself in a chronically inflamed state.

Dr. Weitz:                            Right, and we need to make clear here, I think that there’s a tendency for us to say, “Inflammation’s bad.” And we need to understand that inflammation is how the body heals. When you have damaged tissue, the body sends-

James LaValle:                    Exactly.

Dr. Weitz:                            … the inflammatory cells, and that’s part of the healing process. Inflammation is how we fight infections. So short-term fluctuations of inflammation are super-important for our health. It’s just that when those short-term inflammatory states become chronic that it really becomes a problem, right?

James LaValle:                    And that’s the issue, is that when you don’t turn the inflammation off, when your body doesn’t have the reserve … I like to use terms like “metabolic reserve” and “resiliency” and “durability.” When your body’s losing its durability, when it’s losing its capacity to turn the inflammation off and say, “Okay, back to normal, back to homeostasis” there’s a bunch of things that start to happen.  And so one of the things that starts to happen, and I’m seeing this a lot and I bet you are too, is we see disturbances in iron absorption and metabolism. So people have really low ferritin. They don’t store their iron any more so their reserve for iron is low. But yet their iron store itself is okay. And that’s a sign that you’re metabolically inflamed. Inflammatory compounds turn off your ability to store ferritin and make EPO, erythropoietin, so you can make new red blood cells. A lot of people don’t look at it that way but I see it in lab tests. Every day, I see it in lab tests.

Dr. Weitz:                            I see that too and that’s kind of interesting, especially because we also think of ferritin as an inflammatory factor.

James LaValle:                    Right.

Dr. Weitz:                            Elevated ferritin being an indication of inflammation.

James LaValle:                    Yeah, and it is, right? So once again, if your ferritin’s really low, you’re more prone for anxiety and arrhythmias and fatigue and headaches. And your thyroid receptor can’t function right because you need ferritin to allow your thyroid hormone to penetrate the cell. But when it’s high, it’s toxic. So that happens a lot in insulin resistance. People that are insulin resistant, they make a ton of ferritin. Or if you’ve got hemochromatosis, but metabolically, when I’m insulin resistant, I make too much ferritin. When I’m chronically inflamed, I can have high iron and low ferritin and therefore have the signs or the feeling of being anemic.

Dr. Weitz:                            And when you see that adding more iron’s not helpful, the key is trying to conquer the inflammation.

James LaValle:                    That’s exactly right. So it’s understanding what’s going on. Now, the next thing that happens is that you lose bone. So when people are under metaflammation … because remember, inflammaging is … Well, what’s inflammaging? Okay, I develop heart disease, plaque in my arteries triggered by inflammation. I lose bone. You get osteopenia. I lose muscle. Sarcopenia. So the “inflammaging” term, it’s really accurate because all this inflammation that’s being driven by your metabolism is what’s driving those chronic illnesses.  So we have bone loss and then the insulin receptors don’t function appropriately any more. So all of a sudden, you have a disorder in your iron metabolism. You start to lose bone. You start to become insulin resistant, which is one of the worst things that can happen to your aging process, is if you’re insulin resistant. You start to lose your neuroplasticity in your brain. Your neurons don’t communicate under chronically inflamed states.

                                                And the other one that’s really easy to see action steps … everybody says, “Oh, your lipids don’t matter. Your lipids don’t matter.” Turns out that when you’re metabolically inflamed, you end up making more bad-actor lipids. So if you look at Sinatra and Bowden’s new book, they’re talking about apolipoprotein B and oxidized LDL and all these kind of hidden markers. Well, yeah, those hidden markers? Those are the things that are showing you that you’re chronically inflamed, so if you’re oxidizing your LDL cholesterol, you got a problem with inflammation.

Dr. Weitz:                            And that’s oxidation as well.

James LaValle:                    Absolutely, you’re getting your redox potential is destroyed, right?

Dr. Weitz:                            Yeah.

James LaValle:                    And so the point being is, people, they look at their lipid panel. Lipid panel, LDL, HDL, trigylcerides and most of the time, even that’s messed up. Their trigylcerides are too high, their HDLs are too low. Their LDLs are really high. But even if they’re not, you really have to look at-

Dr. Weitz:                            Doesn’t it drive you crazy when the patients come in and say, “Look, I had all my labs done.” And it’s like, “No, you had five done because that’s all your insurance company wanted to pay for.”

James LaValle:                    Exactly, exactly, and so what we run … advanced lipid panels on everybody. I want to know if they’re making those little bad-actor lipids, like apolipoprotein B. Interesting. Everybody hears about lipoprotein little A, and Lp(a) in a non-diabetic population, when it’s high, it shows excessive inflammation. Once again, it’s what’s interesting about labs. In a diabetic population, the lower the Lp(a), the more progressive the damage.

Dr. Weitz:                            The Lp little A?

James LaValle:                    Yes.

Dr. Weitz:                            You’re saying if that goes lower-

James LaValle:                    In a diabetic.

Dr. Weitz:                            Interesting.

James LaValle:                    That’s a big, big study that just came out. Literally, that rocked me too because I was-

Dr. Weitz:                            Really?

James LaValle:                    … all about the high Lp(a), high Lp(a).

Dr. Weitz:                            Yeah, can you send me a copy of that? Because I had a pretty detailed discussion with Dr. James Khan about Lp little A. He wrote a book about it and that’s a new concept.

James LaValle:                    Oh, I can send you that. It’s on over 10,000 diabetics’ tracked.

Dr. Weitz:                            Really?

James LaValle:                    Yeah. It’s pretty compelling data. I’m in a lab [crosstalk 00:14:51].

Dr. Weitz:                            So how low does the Lp little A go? Normal is under 40 or 30 or something.

James LaValle:                    Yeah, so the lower it goes, like in the 20s, the more you see problems with a diabetic.

Dr. Weitz:                            Interesting.

James LaValle:                    In their vascular network. Yeah. And I’m a lifelong student of biomarker trends. That’s why I wrote the book Blood Never Lies, was because we need to look at trends. And so it never ceases to amaze me how we see these issues like, “Really low ferritin, bad, really high ferritin, bad.” Lp(a) in populations that are non-diabetic, when it’s high, it’s bad and then when it’s low, it’s bad in diabetic populations. So I think it’s important because when you look at metabolic inflammation. The end game, when we cut right to the chase, you get mitochondrial destruction and then you get dedifferentiation of cells.  So what does that mean? It means that you’re going to be in a degenerative process and whether that’s a degenerative process that leads you towards heart disease, an autoimmune disorder or cancer, as soon as you start to uncouple mitochondrial capacity in your cell, that’s where the trouble hits, and that’s what happens when your metabolically inflamed. And I’m sure we’re going to talk about, well, what do you do about it? But that’s the essence of it, is, we’re on this path as we’re aging. You got to rage against the night, man. You got to rage against that inflammation.

                                                You got to really work it. Every day, I’m learning something different about what I can do to help people turn back that inflammatory signaling. And here’s the bottom line: why’s it important? I can hear metaflammation, inflammaging, mitochondrial, neurogenesis, big words. Bottom line is, when you turn inflammation back, people feel better. Your hips don’t hurt. They don’t have colitis any more. Their brain’s clearer. Their fatigue lifts.   These are big things. For me, when I’m working with people, I’m wanting to know how, do I change their life?  I can change their Lp(a). I can change their Lp little A and they’d probably look at me and go, “Oh, wow, that’s really cool.” A little more than me. But if I get them to poop better and they feel less stressed and they sleep better and their hips don’t ache any more, they’re going, “Yeah, man, you are the man.” And that’s why I try to always buffer highly complex metabolic discussions …

                                                Look, we haven’t even talked about the fact that people eat too much, they eat too often, they eat too late. They pick the wrong foods. They don’t get enough sleep, which triggers inflammasomes in their body. They’re going to have inflammasomes that, once again, some inflammasomes are good, some inflammasomes, when they’re being released too frequently, are not so good. But when we do that, by default, just the fact that we eat too much, we eat too often, we eat too late, we’re turning off autophagy.   So autophagy, I’m bringing the vacuum cleaner out and cleaning up the waste products of my metabolism. Now my lymph is congested. Why do I have this lymphadenopathy? Why is my lymph congested? Why am I a puffy sponge? Because I ask people that all the time. “Do you feel like a sponge? Do you feel puffy?” “Uh, how’d you know?” You know what I mean? And it’s because they’re lymphatically stagnant. They’re never giving their body an opportunity to clean out waste proteins, nor do a metabolic reset on their inflammatory activity that’s dictated by what’s called inflammasomes.

Dr. Weitz:                            So why don’t you explain? What’s an inflammasome?

James LaValle:                    So inflammasomes are basically another immune defense. Say you get a bug. I just got a flu bug. You will have inflammasomes release, which is good. They release to say, “Uh oh, there is foreign body in you and we need to attack that thing.” And so they tag it. So the inflammasome’s sitting there going like a paintball gun. Boom! Attack. The problem is when they start to attack our normal tissues and we trigger inflammation. So their paintballing everybody, right?

Dr. Weitz:                            Right.  Or when a virus triggers the NLRP3 inflammasome, right?

James LaValle:                    Right, and if you don’t have enough … and here’s the interesting thing.  When you do NLRP3, there’s … when it’s unrestricted, it creates a cytokine storm.  So you make all these cytokines, just like what happened with COVID and even in other viruses.  We’ve seen it in other things.

Dr. Weitz:                            Exactly. Right, right, right.

James LaValle:                    But you’re supposed to have NLRP6, which is a countermeasure to that that says, “Hey, you know what? It’s not that bad.” But what happens is that if our liver’s congested, if our gut has dysbiosis, we down regulate our counter-regulation of inflammasomes that are helping to kind of balance out that response to a vector. And that’s why we got into trouble … Everybody’s talking about COVID, but it’s just a perfect example of people that have fatty liver, people that have … or diabetic or pre-diabetic, so they’re not efficient at detoxification. People with heart disease. It’s one of the reasons why this inflammatory storm took place, is they didn’t have all their soldiers in line.  What I’ve been really trying to do is get out there and talk to people about, “Hey, you’ve got to start take care of your immune system. You’ve got to take care of your nervous system because they’re driving the bus. They’re sending all the signals that tell you, ‘Are you going to defend appropriately?'” Not just for COVID. Let’s face it; it’s everything.

Dr. Weitz:                            You know what?  I know everybody’s been talking about COVID, but really, the message you still don’t hear very much is the message you just expressed, and the best thing that could come out of this COVID crisis is if we understand that the fact that our society is so obese, has such high rates of blood sugar disregulation, diabetes, all these chronic diseases, from out of balance immune system, et cetera, et cetera from eating a horrible standard American diet, not exercising, et cetera, et cetera. And realize that if we turned around our health, we would be much more resilient and able to deal with viruses like COVID-19 or coronavirus.

James LaValle:                    And just live a healthier life, right?

Dr. Weitz:                            Right.

James LaValle:                    Enjoy your life, because I think one of the biggest issues we see is, look, 80% of our population’s overweight. We got 42% of our population’s obese, 50% of the US population is pre-diabetic or diabetic.

Dr. Weitz:                            Seventy percent are overweight, I think.

James LaValle:                    It’s up now. It’s up to 80.

Dr. Weitz:                            Eighty? Wow.

James LaValle:                    It went up.

Dr. Weitz:                            Eighty percent are overweight? Wow.

James LaValle:                    Yeah, yeah, it’s 80%.

Dr. Weitz:                            Wow.

James LaValle:                    Yeah, I wish it was better, but it’s not. We are the statistic breakers. We better go get some chicken wings, some nachos, some chili cheese fries and a thing of sour gummies right now. We got to get caught up. It’s a problem. Look, my brother was a-

Dr. Weitz:                            Yeah, and take your gummy vitamin with it because that’ll balance the whole thing out.

James LaValle:                    Oh yeah, those are so good. They’re really good for you, those gummies.  My brother was a 476-pound man.

Dr. Weitz:                            Wow.  And you say “he was.”

James LaValle:                    He was obese. He was obese. He was big. He was big. He was just a big mountain of a man, but he was obese. And God rest his soul, he passed away at the age of 62 and didn’t want to listen to younger brother too much.  He tried.  He tried hard but it was just difficult.  He had a lot of things that were in his way. And I think for a lot of people, they don’t realize that there’s a way out, but the way out involves work. There isn’t going to be a pill that gets invented that fixes the situation we’re in.  Yes, you can manage symptoms.  Obviously, I’m a clinical pharmacist.  I understand drug therapy really well and that’s why I try to avoid it with people as much as possible.  Use it when you need it but when you don’t need it, try to change your lifestyle, try to take some nutrients, try to manage your stress.  In general, I find that these are the big things that people miss out on, is … On the standpoint of getting people to walk, I’d love people to walk an hour a day. I start them on 10 minutes. Can you walk? Okay, cool. Can you get in a pool? Okay, cool. Can you do something for 10 minutes? Can you just stand up?  It’s pretty sad, honestly. 

Dr. Weitz:                            Yeah, before I started my chiropractic career, I worked at a health club and we used to do sales and we always had the magic pill close that we would occasionally use and that was, “Wouldn’t it be great if there was a magic pill that you could lose weight and get in great shape?  Well, there’s not, so sign here.”

James LaValle:                    Exactly!  It’s kind of crazy when you think about it.  Once again, I kind of grew up in that space a little bit too and this has to tell me to breathe.  I’m like, “What’s up with that? Really?”  I can’t tell you how many times, when I talk to people, I teach them box breathing, just simple, because they’re not going to meditate for 30 minutes.  Everybody’s in a rush, but if I could get them to breathe deeply two three minutes.  So you wanted to know.  Let’s get some usable stuff here.    Number one, you got to breathe deep. When you don’t breathe deep, you shut your parasympathetic nervous system down, you don’t oxygenate your tissues, you make more lactate in your blood and that means you’re going to be more prone for anxiety, you’re not going to oxygenate all your tissues. And then you’re going to end up staying pretty anxious. When your diaphragm gets stuck and you don’t breathe deep, it’s not good.  So box breathing.  Box breathing a couple times.   Look, you could take … Who is it? Ben … It’s another Ben.  He’s got a great breathing course.  I’ll have to think about who that is.  But he just posted it.  I’m not a big advocate of the Wim Hof stuff, where you breathe till you pass out, to be honest.  I just think that you might hit your head or something. I don’t know.  But for the average, everyday … and I’m kind of tongue and cheek. I’m kidding, but-

Dr. Weitz:                            Yeah. No, I know what you’re saying.

James LaValle:                    But not. But the point is, for the everyday person, they don’t even have a normal respiratory quotient, and that-

Dr. Weitz:                            No, and they’re breathing through their mouth, not their nose and they’re not breathing deep and they’re …

James LaValle:                    Right. So that’s big. That can help your immune system, and it helps you to restore balance in your nervous system because the number one thing that will take you to metaflammation … My opinion. Not an external toxin. It’s obvious that mercury and lead and cadmium and atrazine and glyphosate and any kind of number of things you get exposed to is going to pump you towards inflammation because it’s shutting down enzyme systems in your body that then cause a countermeasure of inflammatory saline. That’s one thing. But to me … Uh oh, what did I do? There we go. See that? You see how I kind of zapped out there? I went and did my deep breathing.  

Dr. Weitz:                            There you go.

James LaValle:                    I kind of zapped out. I was was actually on a break. You didn’t even realize it. So the biggest thing, it’s stress response, man. I look at blood pressures and heart rates on everybody. So point number two … Breathe deep is one. Point number two, look at your resting heart rate. If your resting heart rate is above 62, you are sympathetic dominant, period. It’s that simple.

Dr. Weitz:                            Yeah, unfortunately, that’s a lot of patients I see in my office.

James LaValle:                    It’s so many people. They don’t understand it. Like, wait a second. I’m going to see if I’m a good citizen. Let me see. Where am I at? It’s going to be scary. Uh oh. Fifty-five beats per minute, baby. And that’s when I’m excited right now, you know?

Dr. Weitz:                            Yeah. No, my resting heart rate is about 50 and I had surgery in August and every time my heart rate went below 50, it started beeping and they were freaking out because that’s considered so rare.

James LaValle:                    You’re an athlete! You’re an athlete! But my point is, for everybody out there, if you are measuring your heart rate and say you got a heart rate of 70 and a blood pressure of 132 over 88, those are very early signs that you’re pumping out too much adrenaline, too much noradrenaline, so epinephrine, norepinephrine, your blood vessels are compressing. You’re going to end up with … typically, the number one type of hypertension is renal hypertension. You lose blood flow to your kidneys, which is going to cause damage to your kidneys and lead to chronic kidney disease, of course, and that’s why people with diabetes end up with chronic kidney disease, because they pump out so much adrenaline and noradrenaline in their blood vessels.   So watch your heart rate, watch your blood pressure. And then, okay, I’m breathing shallow, my blood pressure’s up, my heart rate’s up. What am I going to do about that? Before we take a single pill, I got all kinds of supplements I can talk to you about. All kinds of ingredients, man, but you got to get this stuff down. I need you to walk a little bit. You don’t have to tear it up. You don’t have to carry your crossfit dumbbell while you’re walking on down the street. It’s okay. You can just walk. It’s okay.

                                                Everybody has this all-or-nothing thing these days where it’s like, “Hey, if I’m not doing HIIT training, I’m not really doing a good job.” And I’ll tell you what, I’ve been pulling people back from their intense exercise, because remember, I got a lot of population of non-athletes. Not athletes. They should be doing undulating periodicity, meaning alternating their tension, their intensity, their duration, their type of training. All that stuff should be being done for them anyway.   But for us everyday people out there, you know what? Just start with walking briskly. If you can walk, if you’re not in pain, you can’t walk, then we got to figure something else out for you. Because I have a lot of people that are just flat-out over-trained and they can’t figure out why they’re not losing weight and they can’t figure out why they’re not sleeping. And they’re keeping their nervous system completely jacked up because they’re training hard every day, which is silly, right?

Dr. Weitz:                            Yeah. You need that rest. You need that recuperation. So you were talking about stress. What about the whole cortisol adrenal situation?

James LaValle:                    Well, I spent a lot of time talking about cortisol in my life and I’m a big proponent that people need to get it measured because there’s a couple aspects to cortisol that are a problem. So first of all, you hear this term “allostasis.” This is really important to understand things. Allostasis, for people listening, it’s the balance of your stress response from your brain, called the HPA axis. Your brain takes in stress appropriately-

Dr. Weitz:                            Hypothalamus-pituitary-adrenal axis. Yeah.

James LaValle:                    Adrenal. Yeah. And it takes in that stress and it kind of dictates what to do appropriately. When you get under sustained stress, and that could be due to infection, it could be due to stress, it could be due to any number of things that we’ve already discussed. Sustained stress creates something called allostatic load. And the reason I use these terms are these are the terms that are in the literature. They’re not like terms like “adrenal fatigue,” which is a good marketing term but it’s not a real term. It’s a marketing term.  Allostatic load is when your brain changes the way it responds to the rest of your body due to sustained stress. So it either turns off your stress response. Uh oh, my cortisol curve just flattened and now I don’t make enough cortisol and I’m chronically fatigued. Or, it puts you in a hyperperseverated state where you’re like, “Oh my God, I got a white tiger chasing me all the time. I’m anxious, I’m nervous, I’m panicked,” which leads to being tired and wired versus tired and flat. And the big point of it all is that you’re supposed to have a diurnal rhythm to your cortisol. Up in the morning, down at noon, down more into the evening. Turn on your melatonin so that we balance this circadian nature of our body.

Dr. Weitz:                            And that you measure with a salivary cortisol test.

James LaValle:                    You have to do a four-point salivary cortisol or a five-point urinary cortisol.

Dr. Weitz:                            Or six, yeah.

James LaValle:                    Yeah, you can do the [crosstalk 00:31:53]-

Dr. Weitz:                            Cortisol awakening response.

James LaValle:                    Exactly. Which is pretty important. But the big thing is when you flatten your cortisol curve. It doesn’t matter whether you’re low and flat or high or flat, but when you lose this up, down and down, when it flattens, more risk for heart disease, more risk for diabetes, more risk for cancer, more risk for dementia. So when I lose my body’s capacity to go up and down, that’s a problem. And a lot of people don’t realize that your ability to go into deep sleep is basically regulated by the dip in your cortisol. When you lower your corticotropin releasing hormone enough at night, you release growth hormone, you release melatonin and now, all of a sudden, I can sleep deep and repair my body.  And when you don’t do that, when you’re having trouble sleeping, when you’re stressed out, when you’re making too much cortisol, when you’ve flattened the cortisol curve, you do not go into that repair cycle that we talked about at the start of our discussion. You go into repair to turn off that inflammation and now I don’t have a metabolically inflamed state; I have a recovered state because of my sleep pattern. And there’s a lot of folks that don’t realize that when your melatonin, it goes down, it actually controls all of your insulin signaling for the next 24 hours. That’s crazy, right?

Dr. Weitz:                            That is crazy, yup. And that’s a big issue with diabetics who either see their blood sugar drop too low while they sleep or they get up in the morning and their blood sugar’s 150 or 180 and they think they’re doing right and sometimes that stress is an underlying factor.

James LaValle:                    Yeah, it’s a big culprit. Look, a lot of this is why I ended up developing the Metabolic Code platform, why I did the cloud-based informatics platform, was to take all this data. Because here’s what happens. We see a study on vitamin D. Then we see a study on astragalus. Then we see a study on metformin because metformin’s the new anti-aging drug. It’s the darling of the new world. Other than the fact that it can raise methylmalonic acid in your body if you’re not careful, which leads to … contributing [crosstalk 00:34:10].

Dr. Weitz:                            B12 deficiency, yeah.

James LaValle:                    Yeah, it’s a B12 deficiency. And you lose CoQ10 too. And B6. But the thing is, nobody measures all of it together. And that’s kind of what we embarked on, was putting an informatics system together that said, “What’s your symptoms? What’s your labs? What are you taking? How are you eating? How are you exercising?” So that you can start to see how all of that comes together, because look, doctors always say to me … traditional medical doctors will say, “Well, you have no evidence of dietary supplements. There’s no evidence.”

                                                And I go, “Well, okay. So give me the evidence of when you give somebody ibuprofen, Luvox, metformin, a statin and their Propecia for their hair loss. Those five drugs.” Oh, wait, there’s no studies that show those five drugs together in your body. Oops. We’re all living in this fish bowl. And we’re trying to figure out what are the things that move that person.

                                                For stress, I got to tell you, I got three big things I use for stress. So once again, you made it clear. You’re like, “Hey, make sure you’re telling people something they can get and do. I already told them how to breathe. I told them the importance of sleep. Told them about measuring their pulse and their blood pressure.” Just reviewing it, Dr. Ben. Just reviewing it, buddy. I got to make sure you’re not going to invite me back sometime. I don’t want to be caught in this trap [inaudible 00:35:39] esoteric.

Dr. Weitz:                            Thank you, Jim. Brother Jim! Tell it, brother Jim!

James LaValle:                    That’s it. That’s right, man. We’re brothers from another mother, man. Look, I think there’s three big ones. Theanine is fantastic for people who are perseverators. So if you’re somebody who I just can’t stop making that list, man. I’m going to bed at night. My head is rolling. I’m anxious. I’m even on the verge of panic but sometimes you got to add kava to theanine in order to really get somebody out of a panic-panic.

Dr. Weitz:                            How much do you need, do you like?

James LaValle:                    I’m going to tell you right now. I’m a big hitter on this stuff because theanine has no adverse event limit. I start people … if they’re significantly anxious, like they’re saying, “Oh yeah, I’m really anxious. I’m nervous. I don’t sleep at night.” I start them at 400 milligrams three times a day.

Dr. Weitz:                            Wow.

James LaValle:                    So I give them a very healthy dose.

Dr. Weitz:                            Do you use GABA as well, or just theanine?

James LaValle:                    I’ll just start with theanine. I love GABA. GABA’s great. You could do it. You could add it to it if you wanted, but theanine does such a good job that if you get it at the right dosing threshold, [crosstalk 00:37:01].

Dr. Weitz:                            Okay, 400 milligrams three times a day. Okay.

James LaValle:                    It nails it. As they feel better. I teach people as they’re learning to breathe deep and understand their stress response, get themselves thinking right about the issues they have in their life, now they start to bring that theanine back and I start to get them to say, “Hey, use it when you need it.” If you’re managing your everyday life, don’t feel like, “Oh, I got to take my theanine or I don’t have my act together.” Use it as you need it because you’re going into a heavier week. I had a really heavy week this week. And fortunately, I was taught how to give stress and not take stress on, so I don’t need to take anything. But everybody around me, I give a bottle [inaudible 00:37:42].

Dr. Weitz:                            I think my staff would tell the same story.

James LaValle:                    Exactly, man. I know. I can tell already. So the next one is Relora. Relora, I did a lot of the human research on initially, when it first came to market-

Dr. Weitz:                            [crosstalk 00:38:00].

James LaValle:                    … and actually did some good human research on it. And the reason you go for Relora is if you’re stressed and eating. So if you’re like, “Hey, man, I get home at 4:00 and I hug the potato chip bag. I just love my potato chips. I love it. I eat the potato chip bag and I lick my finger to get the last crumbs out of it.” Or it’s that person that eats that cookie and they go, “Oh wow, that’s a good cookie. I’m going to have just one more cookie.” They eat a second cookie and they go, “You know what? I don’t like even numbers. I think I’m going to just go to three because I don’t like two. Three is a better number for me. I won a lottery with it once. So I’m going to have a third cookie.”

                                                So we rationalize our need for that food and literally, what’s happening is you’re taking that food and it’s almost like you’re rubbing it on your head. And I know almost everybody’s experienced this because I’ve been asking this question for a long time. People eat past the gastric sensation of being full in order to turn off the reward cascade due to stress in their brain. Relora is without a doubt, hands down, the best herb to shut down hedonic eating urge and reduce stress induced weight gain, which occurs when people start to have that kind of behavior of eating for stress response.

                                                The third one, holy basil for stress, and that’s mainly … I’ll do that more if people are having more GI symptoms, like irritable bowel. I’ll use it. And then I’ll combine them. “Hey, I got irritable bowel and I eat out of control.” “All right, Relora plus holy basil.” So those are the three biggies. Dosing-wise on Relora, it’s 250 milligrams three times a day. The dosing on holy basil, typically, if it’s a standardized ursolic acid, it’s 200 to 400 milligrams unless it’s a super-critical extraction, then it gets a lot smaller. But the typical holy basil out there, 200 to 400 milligrams three times a day.  So that’s a biggie. And then the other one is, don’t be afraid to dose your melatonin high to send that signal to turn that body’s circadian rhythm around. I’ve taken melatonin up to pretty high doses on some people in order to-

Dr. Weitz:                            What’s a high dosage? Twenty, or …

James LaValle:                    I’ve done up to 30, but I’ll do 20 pretty regularly, but once again, it’s all about-

Dr. Weitz:                            Sometimes patients get nightmares with that?

James LaValle:                    Usually, they get nightmares or they’ll get vivid dreams when they haven’t had enough, so they usually get nightmares and dreams at six milligrams and then I give them 10 or 20 and they go, “Bam! I was out.” So that’s a transition state and it could also be low B vitamins when that happens. What the interesting thing is, is I don’t want them to stay … although there’s a lot of evidence that staying on higher levels of melatonin for viral support, kidney support, intestinal support, helping with neural regeneration. It’s kind of coming out now that melatonin’s not a bad thing to take, but I still end up encouraging people, as you sleep better and manage your stress better during your day, that really helps you to cut back on your melatonin. See how little you need. Do you need it at all? Are you sleeping restfully without it?   The purpose of all this is to really get people back to homeostasis. You turn on inflammation, you’re supposed to turn it off. When I have too much stress coursing through me, when my insulin is high because of my eating practices, eating too much, eating too often, eating too late, drinking fruit juice, eating too much fruit. Holy cow, there’s so many things. But the point is, you’re trying to get that lifestyle corrected and yeah, what else can I do? Look, black ginger. Man, black ginger, one of the best things. Five times more potent at turning on the SIRT1 pathway for your mitochondria of [inaudible 00:42:05]. Black ginger. And one of the hallmark traits of being metabolically inflamed is the downregulation of that.

Dr. Weitz:                            Black ginger is different than the typical ginger root that people buy in the store?

James LaValle:                    Yes, it is. Yeah, it is. So it’s Thai ginseng is the other name for it.

Dr. Weitz:                            Oh, okay.

James LaValle:                    Yeah, it’s different. Yeah, so it’s different. So there’s some I think really cool compounds that are coming out that I think if we start to look at this metabolic model and go, “All right, where is the inflammation hanging out? What are the levers that I need to pull in order to help that patient.” Or if you’re trying to help yourself, “Where am I falling short? Am I feeling stressed? Do I feel edgy? Am I having trouble sleeping? What’s my diet like?” And we got a lot of pundits out there on diet. Everybody gets on and if they’re good at Facebook, they can be the next big diet, and it may have only been that it worked on them. There’s no science behind it.

Dr. Weitz:                            [crosstalk 00:43:07].

James LaValle:                    Do you remember the cabbage soup diet?

Dr. Weitz:                            Oh yeah, what about the celery [crosstalk 00:43:12].

James LaValle:                    Oh, the celery juice [crosstalk 00:43:14].

Dr. Weitz:                            Celery juice, yeah.

James LaValle:                    Did you know celery juice fixes everything? We should really go find some [inaudible 00:43:18].

Dr. Weitz:                            Seriously.

James LaValle:                    Right? [crosstalk 00:43:22].

Dr. Weitz:                            Absolutely.

James LaValle:                    … everything. Yeah and then the ice cream and tuna fish diet. That was the funniest one.

Dr. Weitz:                            That one, I don’t remember.

James LaValle:                    It was like, eat all the ice cream you want, eat all the tuna fish you want. Three days later, you throw up. You’re not hungry. You lose weight. I can’t imagine it. It’s crazy but honestly, I’ve become really passionate about trying to get people to understand that controlling your HPA axis, regulating cortisol, and here’s the thing: cortisol’s pretty interesting. You know pesticides, like atrazine has had studies that show that it raises your cortisol and resets your HPA axis.

Dr. Weitz:                            Is that right? Interesting.

James LaValle:                    Yeah. Yeah, I think we really have to start to step back and go, “You know what?” The guys that I learned this stuff from 45 years ago … Dr. Wood just recently passed away. Super-bright guy and he made it pretty simple. It’s like, do the inventory. Have you been exposed? What have you been exposed to? What is your stress like? What is your sleep like? What is your absorption? Is your gut broken down? A lot of people don’t realize, you get a TBI or you get under a lot of stress, your gut gets leaky automatically.  So if you hit your head, your gut’s leaky within 10 minutes. If you’re under stress, sustained stress, those inflammatory cytokines go up and it sends a signal to the tight junctions … you got those tight junctions in between our mucosal cells. And it breaks them.

Dr. Weitz:                            And when you get leaky gut, you often get leaky brain as well, so those psyllium chemicals end up affecting your brain function.

James LaValle:                    Exactly. Leaky gut, leaky brain, leaky arteries, right?

Dr. Weitz:                            Yup.

James LaValle:                    And I think it’s incredible when you think about it, because one cell layer thick, one cell of the enterocyte of the intestine, the endothelial lining of your artery, the blood-brain barrier, it’s only one cell layer thick and they are incredibly vulnerable to inflammation and immune attack. And when you compromise those one cell layer thick borders, that’s when we start to really get into trouble.  And I’ll tell you one of the big things I do for people today, I’m always doing food allergy panels where I’m looking at not just IGE and IGG, but I’m looking at IgG4 and I’m looking at the C3bd complements because what I’m finding is that people’s immune systems are loading up significantly. They’re reacting to peanuts but because their IgG4 is protecting against that reaction, you don’t have anaphylaxis but you have a lot of immune disregulation going on and if you look at the immune complement pattern against IgG, if you’ve got a C3 complement activation, you have 10,000 times higher immune response to trigger inflammation than if you don’t create that complement yet. So working on people’s guts and understanding their [crosstalk 00:46:41]-

Dr. Weitz:                            So which food sensitivity panel do you like to use?

James LaValle:                    Well, the only one that does that’s Infinite Allergy Labs.

Dr. Weitz:                            I’m not familiar with that one.

James LaValle:                    Yeah, they’re out of Georgia. They really just started testing … I don’t know, the last six months. I do some education for them because I really like the data that they’re putting out on that C3 complement, because it shows a high affinity towards the development of autoimmune disorders. So you have a complement immune response to your food and then you have an allergic response. So you’ve got an inflammatory process going on and an allergic process going on. And when you characterize the two of those together in people, man, it’s gold. It really makes a difference for people.

Dr. Weitz:                            I wanted to touch briefly on some of the labs that you mentioned in … I looked at your slide presentation on metaflammation and one of them I thought was really interesting was this MPV. Mean platelet volume is not something I normally pay a lot of attention to.

James LaValle:                    Nobody does. That’s why I’m a blood geek. You know? It’s interesting. Mean platelet volume, it goes up. It is a marker for metabolic inflammation. So we’re changing the volume size of our platelet, that is happening because of inflammatory signaling and so you can look at MPV on your regular … I think it’s funny. I know because we’ve talked previously. You look at labs and so many people, they look at a CMP and a CBC and they go, “You don’t get anything from that. You got to do an organic acid urine. You got to do [crosstalk 00:48:39].” I’m okay with that. I’m not criticizing that. I think that people have not learned how to read labs that are actually very well validated, easy to get and cheap and have big science behind them that proves the metabolic model. So MPV, that one … in getting a differential with your white blood cells and looking at your monocytes, eosinophils and basophil percents, you can tell if somebody’s metabolically inflamed.

Dr. Weitz:                            So an elevated MPV, you’re saying, is an indication of meta-inflammation.

James LaValle:                    That’s correct.

Dr. Weitz:                            Okay.

James LaValle:                    That’s right.

Dr. Weitz:                            And then, when it comes to the white blood cells, I know there’s different ratios, lymphocyte-to-monocyte ratio. Which one or ones of those ratios do you think are most significant?

James LaValle:                    My big driver’s two things. Where are your neutrophils at? Are they below the second quartile? If you’re under the second quartile, your immune system is being chronically loaded and you’re basically overstimulating your immune system all the time. So that neutrophil dropping’s not good. I go by percent monocytes, eosinophils and basophils because I know once there’s an inflammatory process going on, I add the three of those up, MEBs, and if the MEBs are greater than … I used to try to get people to get down to seven. Now, I’m happy if I can get them under 10 because so many people have chronic eosinophilia, which is a hallmark trait of metaflammation. Their eosinophils are trending high but they’re not full-blown enlarging.  And then their monocytes are activated because of their gut food response. And then you look at their basophils because when that gets high, you even have a deeper immunomologic shift, so you add the three of those up. If it’s over nine, you got metabolic inflammation going on and it’s really a simple thing that you can do.

Dr. Weitz:                            I always screw up these ratios, but is it the lymphocyte-to-neutrophil ratio that’s a bad prognostic marker for heart disease and for cancer and certain other conditions?

James LaValle:                    Yeah, that’s correct. That’s right.

Dr. Weitz:                            I think it’s also a marker for immune [crosstalk 00:51:12].

James LaValle:                    It’s autoimmune [crosstalk 00:51:13]. Yeah. Exactly.

Dr. Weitz:                            Yeah, because that’s one of the things that happens with aging, is our thymus gland tends to shrink. We get a decrease in our immune function, which is why older people tend to be more vulnerable to infections.

James LaValle:                    And that’s why everybody’s jumping on that bandwagon and taking peptides, right? Because everybody’s injecting thymus and alpha-1. They’re looking at thymus and beta-4, which I think are great. I think peptides are kind of the new, undiscovered frontier. Who knows how the regulation’s going to go, but what you could do? You can take thymus extract, freeze-dried, lyophilised thymus extract from New Zealand. I’ve been doing that for patients and giving that out for cold and flu season for years. Never failed me. You got to strengthen that thymus. You’re 100% right.

Dr. Weitz:                            Is there a particular brand that you trust for that?

James LaValle:                    I use Professional Health Products for that because they’ve been importing New Zealand’s glands, freeze-dried, lyophilised glands and they’re medical grade over there, so they’re veterinary extracted. If any of the animal is diseased, all of it gets destroyed, so the glands go, the meat goes, it all goes. There’s none of that risk that I see. “Oh, the glands over here are fine. It’s just they’re ate up with cancer in the rest of their body. But the gland’s good!” Yeah, you don’t want that. And the lyophilisation and freeze drying is important because it keeps the signal substances that are within the gland intact and I think that’s really where the value of the gland is at, is that you get-

Dr. Weitz:                            So this freeze dried thymus gland is a way to get some of these intact peptides without-

James LaValle:                    Yeah.

Dr. Weitz:                            … actually getting a prescription.

James LaValle:                    Having to do the injection. Yeah, without getting a prescription and having to do the injection. I teach peptides at A4M, at the American Academy of Anti-Aging, and obviously, they’re under scrutiny. California right now, you can’t even send peptides in here right now, so patients can’t get peptides in the state of California.

Dr. Weitz:                            What?

James LaValle:                    Yeah. Yeah, we got shut down.

Dr. Weitz:                            Oh, really?

James LaValle:                    They shut us down.

Dr. Weitz:                            You can’t get the BPC-157 either?

James LaValle:                    Orally.

Dr. Weitz:                            Orally, yeah.

James LaValle:                    But not injectibly. And I’m a big guy following pharmaceutical laws. You know what? There’s plenty of things to use that you can get that are safe, especially if you’re a practitioner that you help with people. It’s a transition experience right now as I see with peptides because you got a lot of them on the market with big pharma. A hundred and fifty applications for new drugs are all peptides right now. And so obviously, there’s some finagling going on around the, “How are we going to apply this? How are we going to use them?” But they’re interesting compounds, I have to say.

Dr. Weitz:                            And BPC-157 seems to be one of the most popular or probably the most popular peptide.

James LaValle:                    It’s very popular and it’s interesting. It’s incredibly popular I think for good reason. When my son got injured, he had a Lisfranc injury. I got him back in five months.

Dr. Weitz:                            Wow.

James LaValle:                    And he was spinning on the foot that was injured and he won the state discus championship in the state of California, five months out from a Lisfranc. And you know, that’s pretty impressive, right?

Dr. Weitz:                            Yes.

James LaValle:                    And I wish I could say it was me. He had a great orthopedic surgeon, but he was using BPC-157 and it worked really good to help restore tissue and help him in terms of his inflammation on his ligaments and tendons. So he did great there. It’s great for healing the gut. But once again, BPC-157, not a lot of human data on it yet and that’s the criticism for it.

Dr. Weitz:                            Yup, yup, yup.

James LaValle:                    That’s a fact. It’s like, “Let’s give it to a couple hundred people and let’s see what they do. Let’s just bubble something.” They take a lot of heat off that. Now, I do understand that several of those are being nominated right now in the compounding world and I think that’s going to help with availability for it.

Dr. Weitz:                            Right. Okay, cool. I think that’s a wrap, Jim. Any final thoughts you want to leave our listeners/viewers?

James LaValle:                    Well, I think the biggest thing is taking care of your body, it’s work, but it’s worth it. You got to take care of yourself. Yes, it’s work. If you got a nice car, you go out and you wash it every day. If you take five months to decide what your next refrigerator you’re going to buy is, take a little time each day, apply it to your health and it’ll be the best thing. It’ll pay off for you is when you feel good, you’re in less pain, you feel more clear, you lose some weight and you’re less vulnerable to a lot of the things that take us down as we’re aging.

Dr. Weitz:                            That’s great, and how can folks get a hold of you?

James LaValle:                    Obviously, JimLaValle.com is very easy. And then if they’re interested in our cloud-based information and what we’ve done, metaboliccode.com. So those are the two easy ones that they can get a hold of me.

Dr. Weitz:                            And then your books are available from Barnes and Noble, Amazon, et cetera.

James LaValle:                    Yeah, Amazon, all of that good stuff. And got new ones coming out. Just repurposed 16 eBooks that I’m bringing out this … launched the first seven so we’re rolling.

Dr. Weitz:                            Looking forward to seeing those. Thanks, Jim.

James LaValle:                    All right. All right, Ben.



GastroEsophageal Reflux Disease with Dr. Steven Sandberg-Lewis: Rational Wellness Podcast 186

Dr. Steven Sandberg-Lewis discusses GastroEsophageal Reflux Disease with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on November 19, 2020.

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


Podcast Highlights

3:00  Dr. SSL pointed out that reflux and heartburn and regurgitation are not well understood even by physicians.  According to the GI physiology books, reflux is a normal occurrence.  There can be up to three minimal reflux events from the stomach into the lower esophagus that are considered physiologic after meals.  But if there is adequate saliva and normal motility that help to move the refluxed material back into the stomach, there will not be any symptoms.  If it becomes more severe and lasts longer and the protective mechanisms are not there, it can cause GERD. The term gastroesophageal reflux disease means that you have reflux that either leads to symptoms, injury to the mucosa, such as erosive esophagitis, or both.

5:14  Diagnosis of GERD.  You can have reflux without there being any esophageal lesions or ulcerations or Barrett’s esophagus in order to diagnose GERD.  There is something called NERD, which is non-erosive reflux disease, and these patients do not show any visible abnormalities on upper endoscopy.  The way to diagnose GERD is to do a combination of the 4 following tests:

1. Upper endoscopy looking at the esophagus, the stomach and at least the first two portions of the duodenum.

2. Esophageal manometry.

3. 24 hour pH impedance, aka the Bravo test. 

4. Gastric emptying study.

The upper endoscopy is a good way to differentiate whether there’s any gross or microscopic changes that might be intestinal metaplasia or Barrett’s esophagus. Barrett’s is a way for the esophagus to protect itself from this chronic inflammation and irritation resulting from reflux.  If you see dysplasia, esp. severe dysplasia, that is a stage before esophageal cancer. Fortunately, even with Barrett’s, the risk of cancer is relatively low–about 1%.  Esophageal manometry measures the contractions of the esophagus to see the motility.  The 24 hour pH impedance is an indwelling pH meter that shows how often the person is having reflux and whether the reflux is acidic, neutral or even alkaline.  The patient pushes a button when they have symptoms of heartburn to see if there is a correlation.

12:00  Not everybody who has heartburn has regurgitation.  Regurgitation involves a rise of the gastric contents into the throat or mouth, which some people call vomiting into their mouth and then swallowing it again.  Heartburn, on the other hand, is more of an angina-like substernal experience that doesn’t necessarily rise into the throat.

12:55  You can have regurgitation without GERD, which is called rumination syndrome.  Some people can actually control this and use it to take drugs across the border.  But for most people it’s unpleasant and it results from a problem with motility and the treatment is to learn diaphragmatic breathing because the diaphragm is the outer sleeve of the lower esophageal sphincter.  There are manual therapy techniques that can help to pull the stomach down through the diaphragm to its proper position below the diaphragm.  Reflux can lead to hoarseness, a chronic cough, and chronic sore throats.  It can even erode the enamel of their teeth.  Reflux can be a cause of chronic ear infections in kids.

20:05  There’s a condition called Laryngeal Reflux or LPR, which is a form of reflux where patients have no heartburn but they will have some of those extra-esophageal symptoms like chronic throat clearing, chronic cough, chronic sore throat, wake up with a sore throat in the morning, and even chronic pneumonia.  These patients may be having acid, pepsin, bile, and even digestive enzymes from the small intestine getting into their lungs, which can be very irritating.  You can get tonsilar hypertrophy and you can get airway obstruction from laryngospasm.

21:52  The underlying pathophysiological causes of GERD include: 1. Hiatal Hernia, 2. Decreased defenses, 3. Impaired esophageal motility, 4. Increased intra-abdominal pressure like SIBO, 5. Reduced LES pressure, 6. Visceral hypersensitivity.

1. Hiatal hernia, which can also cause arrhythmia, including atrial fibrillation.

2. Anything that decreases the defenses of the mucus membrane, like saliva that is acidic instead of being alkaline. The average person swallows up to one and a half livers of saliva, which contains defensins and lactoferrin, which helps prevents infection and inflammation. One thing that can cause acidic saliva is overgrowth of P. gingivalis or strep mutans that creates an imbalance in the oral biome.  When you have an increase in acid producing flora, this predisposes towards cavities and gingivitis and reduces the buffering effect of normal saliva.  In order to improve this, you can do oil pulling with coconut oil or sesame oil or ozonated olive oil or ozonated coconut oil.  You suck the oil back and forth between the teeth for 15-20 minutes after brushing your teeth.  After you spit it out, let the coating that it puts on your teeth stay there.  This reduces the acid producing bacteria and helps normalize the biome in the mouth. You can also use Edgar Cayce’s Glyco-thymoline oral rinse.

29:00  3. Impaired esophageal motility. We do not know if any of the drugs or natural products for improving gut motility will help with esophageal motility, but it is worth trying them out.  Esophageal motility is related to vagal activity but it is different than gut motility, since it is not related to the migrating motor complex.

31:14  4. Increased intra-abdominal pressure. Small Intestinal Bacterial Overgrowth (SIBO) is the overgrowth of bacteria or archea in the small intestine that can result in gas that increases intra-abdominal pressure.  Pregnancy is also a problem since you have upward pressure and you also have the hormone relaxin that relaxes all the ligaments including the tone of the lower esophageal sphincter, which can lead to more reflux.  Also, abdominal obesity can result in increased intra-abdominal pressure. Also breath holding can be a factor, so you should teach your patients to do proper diaphragmatic breathing.  Hiatal hernia can make proper breathing difficult with part of the stomach contents both below and above the diaphragm.

36:42  5. Reduced LES pressure or tone.  This is affected by many things, including tobacco use, and sometimes it’s hypermobility syndrome, such as patients with Ehlers-Danlos syndrome.  Such patients are also more prone to hiatal hernia as well as to loss of ileocecal valve tone.  They are also prone to visceroptosis, which is a tendency for the stomach, small intestine, and colon to prolapse and hang down.  There are some doctors who do neurotherapy injections into the lower esophageal sphincter to help restore tone, including Dr. Ilana Gurevich.  These patients tend not to do as well with high velocity/low amplitude adjustments and can benefit from PRP and stem cell injections, strength training, and Barral therapy.

41:57  6. Visceral hypersensitivity. These patients perceive peristalsis as painful. Neurofeedback and pulsed electromagnetic field techniques can be helpful.  Low dose naltrexone is sometimes helpful and certain strains of probiotics can help. 

45:01  7. Gastroparesis or delayed gastric emptying.  If the stomach is full for long periods of time and doesn’t empty, you’re much more likely to get reflux up into the top of the esophagus.  This is especially common in type I and type II diabetes, so getting a gastric emptying study can be really helpful.

46:08  Is there too much acid with reflux?  Sometimes reflux symptoms are due to excess acid and sometimes they are not.  Acid reflux can cause erosive esophagitis, including LA grade A, B, C, D erosive esophagitis.  But there can be neutral reflux or weakly acid reflux, abbreviated WAR, or even alkaline reflux, which often results from bile refluxing through the pyloric sphincter into the stomach.  There may also be bicarbonate from the pancreas and the Brunner’s glands of the small intestine.  There can also be functional heartburn where patients have heartburn symptoms but they don’t have any reflux of stomach contents. There are several theories why this may happen, including symptoms that occur that has nothing to do with being full but more to do with something called dilated intercellular spaces, DIS, which are also present in every patient with reflux and it may make the nerves in the esophagus closer to the surface and more likely to be irritated by any secretions in the esophagus. It is essentially leaky esophagus, though it doesn’t get reported on an upper esophageal biopsy because you need an electron microscope to see it.  This is one reason why a patient can take a proton-pump inhibitor and see no improvement with their heartburn.  One thing to check for these patients is the pancreatic elastase on the stool test and while the lab cutoff is usually 200, if elastase is less than 500, say 227, then this can still be a problem and you should try them on enzymes.  You should try plant enzymes, plant enzymes with brush border enzymes, brush border enzymes, porcine pancreatic enzymes and try several different potencies.  Different enzymes work in different pH ranges.  Dr. SSL likes SIBB-Zymes from Klaire Labs.  Apex Energetics has a good product and there is Similase from Integrative Therapeutics, which has some sucrase, lactase and a few other starch digestive enzymes.  The pancreatic enzymes start the process and then the brush border enzymes finish the digestion of oligosaccharides, esp. the disaccharides. If you don’t fully digest your dissacharides because you have brush border enzyme deficiency, you can end up with massive bacterial overgrowth because you are feeding the bacteria all that sugar because you are not absorbing it.

57:12  You may need to evaluate hormones, esp. adrenal steroids and melatonin. Dr. SSL likes to use the DUTCH test for hormones. You also want to rule out hydrogen SIBO and methane IMO. We used to refer to methane SIBO, but since it is caused by archaea rather than bacteria, we now call it Intestinal Methanogen Overgrowth.  There are also food sensitivities including, gluten or lactose intolerance, that can be major causes of heartburn.  Gastric pH levels can be evaluated with the Heidelberg test.  If you suspect hypochlorhydria, you can do a trial with apple cider vinegar or bitters or betaine hydrochloride in a careful way and see if that dramatically improves their reflux, then you know that they’re probably hypochlorhydric.

1:01:16  Herbal bitters can help to stimulate digestive enzymes, hydrochloric acid, bile, and can even help with tonifying some of the valves in the GI tract.

1:03:06 You should evaluate the GI flora, including for H. pylori, and treating it may be an important thing to do. On the other hand, H. pylori can also be commensal and sometimes should not be treated. If your patient has H. pylori and CagA or VacA virulence factors, then the H. pylori is more likely to be pathological.  If the patient has gastric lymphoma, or MALToma, then you should definitely treat the H. pylori, because such tumors have an 84% success rate with treating H. pylori. There are some patients who have chronic iron deficiency anemia that doesn’t respond and if they have positive H. pylori and you treat it, the iron deficiency goes away. The H. pylori was taking the iron from the patient. You can test for H. pylori with a stool test, a breath test, or a blood antibody test.  Dr. SSL noted that he usually does not treat H. pylori very often, but if he were going to, he would use triple therapy, consisting of two antibiotics such as clarithromycin with either metronidazole or amoxicillin plus a proton pump inhibitor for 14 days. He would add lactoferrin at least 300 mg three times per day. He would also add a biofilm disruptor like NAC and also add a probiotic.





Dr. Steven Sandberg-Lewis is a practicing Naturopathic physician for nearly 40 years and he teaches at the National University of Natural Medicine and he wrote a medical textbook, Functional Gastroenterology, now in its 2nd edition. Dr. SSL (as he is often called) practices at 8 Hearts Health and Wellness in Portland, Oregon.

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

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 today, our topic is gastroesophogeal reflux disorder or disease with Dr. Steven Sandberg-Lewis. And, this condition occurs in up to 20% of Americans. GERD also known as acid reflux is a condition where the contents from the stomach come back up into the throat, resulting in a burning or acidic taste in the mouth, burning pain in the chest, vomiting, breathing problems, chronic cough, chronically bad breath, chronic laryngitis and erosion of the teeth. This can eventually lead to chronic inflammation of the esophagus, esophageal strictures or narrowing of the esophagus, Barrett’s esophagus, which is a precancerous condition.  And, it can even lead to esophageal cancer. I mean, I’m very excited that we have one of the top functional medicine doctors to join us for a discussion on this important topic, Dr. Steven Sandberg-Lewis or Dr. SSL as his patients often call him.  Dr. Sandberg Lewis has been a practicing naturopathic physician for nearly 40 years, specializing in gastrointestinal disorders. He teaches gastroenterology at the National College of Natural Medicine. He lectures around the world, or at least used to when we used to have in-person meetings, and hopefully we will soon. And, he wrote an awesome medical textbook, Functional Gastroenterology, which is now in its second edition. And, everybody should pick that up. So Dr. SSL, you have the floor.

Dr. SSL:                 All right. Thanks. Nice to join you on your discussion here. And, I’ll share my screen. I just made a little short PowerPoint to give us a kind of a place to start. All right.  So, I find that reflux and heartburn and regurgitation are things that aren’t always very well understood even by well-versed physicians. So, I have a few basic things here to just point out. According to the GI physiology books, reflux is a normal occurrence, apparently up to three minimal reflux events from the stomach into the lower esophagus are considered physiologic after meals. Now, that doesn’t mean that everybody has significant reflux, because if it’s only a small amount, if there’s adequate saliva to buffer it, if there is normal motility in the esophagus, which these contractions that can occur, that don’t require a swallow called secondary contractions, that help to move the refluxed material back down into the stomach.   And, a number of other protective mechanisms that keep it from causing any real symptoms. So, just to know that it can be physiological to have some reflux, although if it becomes a more severe, larger volumes and lasting longer, and the protective factors aren’t there, it can start to cause GERD. And, the term gastroesophageal reflux disease really means reflux that leads to either symptoms, injury to the mucosa, such as erosive esophagitis or both. So, there’s normal reflux that doesn’t lead to disease.

Dr. Weitz:            Now, are there specific criteria for diagnosing GERD or can it be diagnosed simply by symptoms?

Dr. SSL:                 Yeah, I’m going to talk about that in the next slide. It’s a great question. I’ll come back to that. So, there don’t need to be esophageal lesions, erosions, ulcerations or Barrett’s esophagus, or any changes like that in order to diagnose reflux. Because, there’s something called NERD, non-erosive reflux disease, where people have significant reflux, but they don’t have any biopsy based changes or even gross visible changes on upper endoscopy. So, we’ll talk more about that. And, it is true that the majority of people with even true reflux, true GERD don’t show any visible abnormalities on upper endoscopy and that’s the NERD.  So, if someone has significant symptoms of heartburn, and they’re going to get worked up because it’s not getting better, or there’s a concern that they may be developing complications, the way to really find out if someone has reflux is to do some combination of the following four tests. The first one would be upper endoscopy looking at the esophagus, the stomach and at least the first two portions of the duodenum, EGD, based for short. And, that’s a great way to differentiate whether there’s any reflux esophagitis or not, whether it’s NERD or GERD. It’s a way to check for gross or microscopic changes that might be intestinal metaplasia, or Barrett’s esophagus. And really, that’s Barrett’s esophagus is pretty much related to the esophagus trying to protect itself from this chronic inflammation and irritation, from reflux that’s occurring on a regular basis.  And of course, the biopsy would also show if Barrett’s is moving more toward cancer. If you start to see dysplasia, and especially advanced or severe dysplasia, which is a stage right before cancer of the esophagus, and then, esophageal adenocarcinoma. The good news is that even with Barrett’s, especially in women, if they have Barrett’s, the risk of getting cancer of the esophagus is something like 1%. So, it’s a low risk, but much higher risk, then of course, if they didn’t have chronic reflux. And, there are things we can do to help prevent that and reverse it. So, that’s a lot of what I do with patients. Then there’s esophageal manometry, which measures to see if the contractions of the esophagus are normal, whether they have a esophageal motility disorder, which could cause similar symptoms, even if there isn’t reflux.

                                And then, there’s the 24 hour pH impedance, some times it’s called a Bravo test. And, it’s an indwelling pH meter that shows how often, in a 24 hour period, the person is having reflux and whether the reflux is acidic, neutral or even alkaline, which is all really good information. And then, it also allows the patient to push a button, just like a halter monitor for cardiac issues. It allows them to push a button whenever they have symptoms of heartburn. And then, we can see if there’s a correlation between their symptoms and the reflux. And, all those things are helpful for actually truly knowing if the person’s problem is related to reflux. And then, there’s a gastric emptying study that measures to see how much food remains in the stomach at each hour, over a four hour period. Take an x-ray each hour and see how much of the test meal is left in the stomach.  And of course, delayed gastric emptying or gastro-paresis is a major cause of severe reflux, and nausea, and, or vomiting and pain. So, this is the workup that at least the manometry, the upper endoscopy and the 24 hour pH impedance would be done for any patient that is considering getting a Nissen fundoplication or other surgery for reflux. Because, the last thing a surgeon wants to do is do a surgery for somebody who really doesn’t have reflux. So, you’ve got to prove they have it in order to do a surgery, that’s only going to work for reflux. And so, these are things to consider. You may have patients that have had heartburn for decades, and they’ve been on proton pump inhibitors for decades, and they want to get off. And, that’s a reasonable thing to do to help them wean, if you know what they have, if you know exactly. Do they have reflux and what kind of reflux?

                                So, we’ll talk about different kinds. Just a quick slide to show the LA classification of erosive esophagitis or reflux esophagitis. And, grade A is just these little breaks in the tissue that, they talk about the percentage of the circumference that’s affected and how long the fissures are or erosions are. And, you can see with grade C and D you’re getting much more erosion occurring. And, it becomes more of a circumferential issue. And, these are things that show up on upper endoscopy. The clinical manifestations, Ben gave us a nice overview. I just want to differentiate between heartburn and regurgitation. Not everybody has regurgitation, even if they have reflux into the lower esophagus. Regurgitation, I define as the rising of the gastric contents into the throat or mouth, which is a unpleasant experience. Some people call it, vomiting into their mouth and then swallowing it again.  And, that’s regurgitation. Whereas a heartburn often is more of a angina like precordial experience, substernal experience that doesn’t necessarily rise into the throat.

Dr. Weitz:            Can you have regurgitation without having GERD?

Dr. SSL:                 Well, yes. I didn’t put a slide in about that, but it’s a good question. And, there is a condition that I really like you all to know that is not reflux, but it does cause regurgitation. It’s called rumination syndrome. Please don’t mix this up with vomiting or reflux. There is some reflux involved in it, but it’s, it’s a whole different thing. And you don’t see it very often, but I’ve had at least five or 10 patients over the years that have rumination syndrome. And, if you think of a ruminant animal, like a cow, they chew their cud. They’ve got a stomach that has four chambers.  They swallow the grass and it stays in the stomach, goes through different chambers of the stomach, it’s ground up. Then they regurgitate it back into the mouth and they chew it again for a while, and then they swallow it again. So, this rumination is the ability to have food come back up from the stomach into the mouth. And, this happens in some people. And, when it’s involuntary, some people actually have control over it and they use it, I guess, to make money taking drugs across the border. Because, they can swallow them and then bring them back up again. I think they’re called mules, those people. But most people, it’s an unpleasant thing that they can’t control. And so, they’re eating a meal and they’ll say, “All of a sudden 10 minutes after a meal or hour after a meal, my food starts coming back up into my mouth and it’s really embarrassing.” And, “I’m in the middle of doing a lecture and it’s terrible.”   So, rumination syndrome is a whole separate thing from this. And usually, with rumination syndrome, what comes up doesn’t feel like acid, doesn’t feel like it’s burning, it’s just their foods coming back up. And, I won’t go into any more detail about it, but sometimes I’ve seen patients like this, and the diagnosis they’ve got from previous physicians is persistent vomiting. It’s not vomiting, there’s no nausea and there’s no retching. There’s no muscular traction that’s felt, and there is no nausea.

Dr. Weitz:            So, what causes that condition?

Dr. SSL:               Well, it’s considered to be just a variety of motility, that’s a variant of motility. And, the good news is you can read about this in the Rome criteria book that talks about all the functional gastroenterology conditions. But, the treatment is to learn diaphragmatic breathing, and to practice it daily until they’re really understand how to control their diaphragm. They say, “At least a 100 days in a row, they have to practice this diaphragmatic breathing.” And, it can really change this pattern, because the diaphragm really is the outer… I should have put this picture in. The diaphragm really is the outer sleeve of the lower esophageal sphincter.  When the stomach is in the proper position, if they don’t have a hiatal hernia, the two crura or legs of the diaphragm wrap around the gastroesophageal junction, and create an outer muscular coat around the lower esophageal sphincter, making it much more functional. That’s why, if someone develops a hiatal hernia and their stomach moves up two or three centimeters, now the lower esophageal sphincter is up here and the diaphragm’s down here, and they’re not working together, they’re discoordinated. So, the better the functioning of the diaphragm, the better people will be at being able to keep their food in their stomach and not have it rise. It seems to be quite a efficacious treatment.

Dr. Weitz:            And of course, when you have that hiatal hernia, that’s where manual therapy techniques, which you’re an expert at and teach to help pull the stomach down through the diaphragm, right?

Dr. SSL:               To its proper position below the diaphragm. Yeah. Now, Ben also mentioned some extra esophageal symptoms and signs like hoarseness, chronic nonproductive cough, asthma that seems to get aggravated by reflux, symptoms in the throat, chronic sore throats. Even like you said, “Erosion of dental enamel.” I’ve had some patients whose dentists put coating, like a plastic coating on their teeth just to protect it from all the acid. So, they wouldn’t lose their enamel until we actually treated them. And then, they didn’t need that anymore. Chronic sinusitis, even chronic otitis. A fascinating thing is that there’s research that was done quite a while ago, showing that kids with recurrent otitis media, if they checked the middle ear fluid, they found pepsin in it. So, they’re laying down at night, and they get reflux, and the stomach contents go up, they actually end up with pepsin going through the station tube into the middle ear.

Dr. Weitz:            Wow.

Dr. SSL:               And, that’s part of the irritation. In some cases, not every kid. Pulmonary fibrosis, a really feared complication of often not knowing what the cause is, but chronic reflux can really aggravate this and make it progress. Tonsillar hypertrophy, so your patients who have huge tonsils, there’s a study that found that reflux can cause the lingual… Not the lingual tonsil, the regular tonsil, pharyngeal tonsil to increase its mass by three and a half times.

Dr. Weitz:            Wow.

Dr. SSL:               Just that chronic irritation. Other things can do it too, but that’s one of the things that can cause tonsillar hypertrophy. I mentioned the recurrent of otitis media, and then sleep disturbances, sleep apnea, just due to irritation in the throat and swelling. So, if you’re not aware of LPR, laryngopharyngeal reflux is a form of reflex that is unique. And often, these people have no heartburn. They have no symptoms of heartburn, but instead their symptoms are in their pharynx or larynx.   And so, they have some of those extra esophageal symptoms that we talked about, like the chronic throat clearing, chronic cough, chronic sore throat, wake up with a sore throat in the morning, every morning, bad breath, globus phenomenon, feeling that there’s a ball or something in throat. Of course, recurrent aspiration pneumonia, because if you’re aspirating some of those stomach contents, which can include everything from acid, pepsin, partially digested food, pancreatic enzymes and bile from the small intestine, because some people have reflux through the pyloric valve as well. Yeah, that’s a pretty irritating thing to breathe into your lungs. And so, if you have patients that have recurrent pneumonia, you really have to consider this.  If they develop webs or strictures, they can have trouble swallowing, things getting stuck. I mentioned the hoarseness and changes in voice. And even, airway obstruction where they get laryngospasm, and they have symptoms like asthma.  But really, it’s more that their larynx is spasming rather than their bronchioles.

                            So, let’s talk about some of these underlying physiological causes, or pathophysiological causes. These are the factors that can really lead to reflux. And, you can have combinations of them, its not just one. People can have two or three of them, and it makes it more complicated when they do. So we mentioned, “Hiatal hernia.” And, in standard medicine, hiatal hernia is considered something that can cause reflux and nothing else.  But, we know that hiatal hernia can actually cause arrhythmia, including atrial fibrillation, can be a trigger for it. It can cause a lot of the symptoms that we talked about that are extra esophageal and…

Dr. Weitz:            We got the vagal nerve to heart connection.

Dr. SSL:               Yeah. There are different theories about what it is about having a portion of your stomach pushing against maybe the vagus or pushing against the atria that may trigger this atrial fibrillation. But in any case, hiatal hernia can cause all kinds of symptoms, and fatigue and anxiety are two of them. So it’s a good idea to check for hiatal hernia with at least a functional test in any patient who has persistent anxiety that’s not responding, is my feeling. So another thing that can cause symptoms of reflux, heartburn and other reflux symptoms is anything that decreases the defenses of the mucus membrane. So if they have abnormal saliva. Some people have acidic saliva instead of alkaline saliva. And saliva think about it, we think about saliva as like it’s this thing in your mouth, but really up to one and a half liters of saliva being produced every day by the salivary glands and being swallowed throughout the day periodically. That’s a lot of functional material, one and a half liters of saliva.

                                And it’s got defensins in it, it’s got lactoferrin, it helps prevent infection, it helps prevent inflammation. It’s got the alkalinity that helps neutralize any physiologically refluxed, if it’s not excessive, amount of reflux. And the acids from the stomach, assuming the patient has acid in their stomach and just many, many important functions that it has. So saliva is an important thing. If your patient has Sjogren’s syndrome or some other cause of sicca syndrome, they have a dry mouth, that’s a risk factor for esophagitis. And of course, having a normal esophageal mucosa, if they already have erosions, they’re not going to have very good defenses against any reflux material.

Dr. Weitz:            And why would you have acidic saliva? Is that due to diet?

Dr. SSL:               I actually did a talk on the oral biome just last month at a conference, a virtual conference. And the main reason that we think people have acidic saliva is overgrowth of either Porphyromonas or strep mutans in the mouth. So it’s an imbalance in the oral flora.

Dr. Weitz:            So Porphyromonas, you’re talking about P. gingivalis?

Dr. SSL:               Yeah, P. Gingivalis, thank you, yeah. So yeah, it’s thought to be an increase in acid producing variant flora, which predispose toward cavities and gingivitis and reduce the buffering effect of normal saliva for stomach acid.

Dr. Weitz:            Not to take you too off topic, but are there clinical strategies for improving that, changing that?

Dr. SSL:               Yeah. Have me back. I did a whole hour on that and there are lots of great therapies that can help that. I’ll tell you the simplest one right off would be to use oil pulling, and you can use either coconut oil or Sesame oil typically, occasionally ozonated olive oil is used as well or ozonated coconut oil. And that’s kind of sucking the oil back and forth between the teeth for 15 to 20 minutes each night after you’ve brushed your teeth. It’s the last thing you do. And you just let it stay in there, after you spit it out, just let the coating that it puts on your teeth and gums stay there. And that can really help to reduce the acid producing bacteria and help normalize the biofilms in the mouth.

Dr. Weitz:            Wow. That’s a great clinical pearl right there.

Dr. SSL:               Yeah. And there are lots of other great treatments too, like Glyco-Thymoline. If you know the Edgar Cayce’s product in Virginia Beach. Is that Virginia? Edgar Cayce products. They’ve been making this Glyco-Thymoline product for probably 50 to 75 years. And it’s one of the three American Dental Association approved products for an oral rinse to treat gingivitis. So really, if you’re not checking your patients for gingivitis, looking for swollen or edematous or red gums or people who are having their gums are receding, that’s a really important thing to do if you’re treating any GI disorders, because people are swallowing a liter and a half of infected saliva every day, which is inoculating their digestive track. So it’s a really good thing to look for.

Dr. Weitz:            Somebody asked, is it safe to do oil pulling with coconut oil plus adding essential oils like clove or frankincense?

Dr. SSL:               I don’t know. I didn’t research that, I just researched Sesame or coconut oil or ozonated olive oil. So I don’t see any problem with it, but I don’t have any experience with it. Another one would be impaired esophageal clearance. So I talked about that manometry, esophageal manometry test. That would show if someone had a motility disorder. So for instance, if you have a patient with scleroderma, or CREST syndrome, which is sort of a milder form of scleroderma, they’re going to have problems with this because the worst case scenario is called rubber-hose esophagus. And that’s part of the CREST syndrome, right? CREST, E is for esophageal motility problems. And yeah, people with scleroderma have a lot of digestive disorders, especially reflux and reflux esophagitis, motility disorders of the esophagus, so things tend to get stuck, dysphasia. And almost all of them have bacterial overgrowth of the stomach and the small bowel because of the motility disorder of the thickening of the tissue.

Dr. Weitz:            Do any of the supplements that we use for motility of the gut help with motility of the esophagus?

Dr. SSL:               It’s a great question. I have not seen studies on prokinetics to help with esophageal motility. I try them out, but I don’t know that, there’s no esophagus-specific prokinetic agent because it has a different system of motility than the stomach and the small bowel, which is based on motilin as a hormone and the migrating motor complex. The migrating motor complex doesn’t seem to have a connection to the esophagus. That’s that’s another part of vagal function and central functioning. So it’s a great question. I don’t have a perfect answer for it.

                            Next, we have increased intra-abdominal pressure. And as I just mentioned, bacterial overgrowth would be one of those things because gas gets produced by excessive bacteria or archaea making methane or desulfovibrio bacteria, and others that make hydrogen sulfide. And all of that can increase the intra-abdominal pressure. And if it’s greater than the intrathoracic pressure, things are going to tend to move up much more easily, and reflex becomes common. So gas is a problem. Pregnancy could be a problem. Luckily, it only lasts a certain amount of time. And we know that, of course, in pregnancy, you also have the hormone relaxin being produced by the placenta, which relaxes all the ligaments in the body and can also relax the tone of the lower esophageal sphincter and lead to more reflux. And the pressure of the enlarging gravid uterus, as it comes up and pushes up against the stomach and pushes it sometimes up through the diaphragm, is a perfect way to get a hiatal hernia during pregnancy, especially when you’ve got that relaxin flowing through your body, making all of your tissues more flexible, or less elastic and more stretchy.

                                Also obesity, abdominal obesity, especially apple fat can increase the pressure. And we know that abdominal obesity is a risk factor for reflux. And then breath holding. So really important to teach your patients how to do proper diaphragmatic breathing and learn how to feel that as a normal way of breathing, because people that are doing the shallow thoracic chest breathing tend to have issues with changes in pressure between intrathoracic and intraabdominal and more likely to have reflux. Remember too, everything heads back to hiatal hernia. I hate to sound like a broken record, but breath holding, this is a good thing to check when you’re actually with your patient or you’re watching them on telemedicine. When they talk, listen to the sound of their voice. If they talk like this, that means their diaphragm’s locked up.

                                And sometimes that’s because their stomach is partially above and partially below the diaphragm, it’s like an hourglass kind of stomach. And think about it. Are you going to feel comfortable with diaphragmatic excursion if you’ve got this space occupying lesion above and below your diaphragm? It’s really going to impede, for a lot of people, it will impede their functioning of their diaphragm. And they have shortness of breath. They feel like they can’t take a full breath. You’re not going to teach that person how to do diaphragmatic breathing until you resolve their hiatal hernia. It’s just too hard to do. So remember, diaphragm and hiatal hernia, they’re just intimately related.

Dr. Weitz:            By the way, you have a course available where you teach your manual therapy techniques, don’t you?

Dr. SSL:               Yeah. And not just hernia reduction, but also the diaphragmatic technique to help take the spasms out of the diaphragm. Yeah, there was a course that was done. I actually had a wonderful experience going to the Gold Coast of Australia.

Dr. Weitz:            Oh, Nirala Jacobi.

Dr. SSL:               Nirala Jacobi set it up. We had 82 people. It was way too many people to do a manual training, but it was fantastic. And there were these bank of windows looking out at the beach. It was crazy. It was so good.

Dr. Weitz:            You can go to Nirala Jacobi’s website and you can purchase that course.

Dr. SSL:               Yeah. And Nirala is so good at organizing things. It was incredible.

Dr. Weitz:            Somebody just asked a question, have you tried Biocidin oral rinse for improving new oral microbiome?

Dr. SSL:               That is another good option. I haven’t used Biocidin for that, but I know that they they have a toothpaste and they have a similar approach to Glyco-Thymoline, which is volatile oils. So I think that that’s another option.

Dr. Weitz:            Okay.

Dr. SSL:               Next one is reduced LES pressure, tone, and many things can affect that. And sometimes it’s tobacco use, sometimes it’s hypermobility syndrome. So it’s really good to check all your patients for Ehlers-Danlos hypermobility syndrome, because by the way, they’re much more prone to hiatal hernia. They’re much more prone to LES reduced tone. They’re more prone to ileocecal valve loss of tone, open ileocecal valve. And they’re prone to visceroptosis, a tendency for the stomach, small intestine and colon to prolapse and hang down. And that can really affect function of the digestive tract.

Dr. Weitz:            If you have a patient and you find out they have Ehlers-Danlos syndrome, how does that change your clinical approach?

Dr. SSL:                 Well, the good news is full blown Ehlers-Danlos hypermobility syndrome, and there are seven different forms of Ehlers-Danlos. The other six are much more serious and life-threatening. But the hypermobility type is the most common. It’s reported to be about 1% in the United States. In some countries, in some areas of Africa, there are some tribes that have up to a 48% hypermobility syndrome, it’s a genetic finding. But about 1%. So you’re not going to find it that often, but if you do a lot of work with reflux and ileocecal valve and LES, like I do, you’ll find variants of it in a lot of your patients. And I think that knowing that your patients has hypermobility syndrome, I can’t say we have many, many excellent treatments for it, but I can tell you some of them.

                                So by the way, if you want to learn more about this, either have me come back and I’ll talk about it and we can do that or go to the Ehlers-Danlos, I think it’s just called Ehlers-Danlos Society website, and they have a physician or healthcare practitioners section of their website. And it tells you how to do a Beighton score and how to check for category two, criterion two factors as well. There’s just a number of different tests. I do this on every new patient on my telemedicine visits because you can do it with telemedicine. It’s just a really important thing to know about people.  There are doctors that do neurotherapy injections that can do injections into the LES. It sounds crazy and scary, but yeah, one of my good friends here in Portland, Dr. Ilana Gurevich.

Dr. Weitz:            Yeah, I just interviewed her a few weeks ago on my podcast.

Dr. SSL:                 Yeah. She does injections into the LES for patients whose LES tone is poor and aren’t responding to other things. You could talk to her about that. But I think even more important is to know what not to do. So I tend to tell these people use non-force manipulation techniques. Don’t become more and more hyper-mobile by getting high velocity, low amplitude frequent therapy. And I tell them that.

Dr. Weitz:            And don’t go to yoga.

Dr. SSL:               Well, no, yoga’s okay. If it says that the person’s a yoga teacher on their new patient form, you better test them for this because they probably have it because they can do the things that you see in the books that other people can’t do because-

Dr. Weitz:            No, I’m sure they could do it safely. But on the other hand, they probably are not going to benefit from yoga. They would probably benefit from strength training more.

Dr. SSL:               Yeah, well, they could benefit from strengthening so that they have more support and stability in their joints and doing a balanced approach, not just stretching. And if they need it, injections, whether it’s PRP or prolotherapy or stem cell injections, can be lifesaving for these people. As well as, like I say, sort of non-force, more of those types of manipulation. And Barral therapy can be lifesaving as well. Barral is so gentle, but it can really improve the positioning and the mobility of the organs with respect to one another in the abdomen.

Dr. Weitz:            Okay.

Dr. SSL:               And then last two here, we have visceral hypersensitivity, and these are people that perceive peristalsis as pain. Boy, that’s a tough one. There are some treatments for it, specifically biofeedback techniques like neurofeedback can be really helpful. There are some pulsed electromagnetic field techniques that can be helpful. And there are some drugs like low dose naltrexone is sometimes really helpful as well as some probiotics. There are some specific strains of probiotics that have been shown to help with this sensitivity.

Dr. Weitz:            And there’s at least one study that shows that curcumin is beneficial as well. Somebody asked, what was this Barral therapy you mentioned?

Dr. SSL:                 Yeah. So Barral, Barral. Barral was a French osteopath, I believe, who came up with this non-force visceral manipulation technique, which is very elegant. And boy, we have some Barral practitioners in Portland that do amazing things. This is just an aside, but I have a patient who has severe hypermobility syndrome and she was moving into kidney failure. She’s been at about 60 or 58 on her glomerular filtration rate for many years. And we just kind of watch it and try to prevent any problems. And suddenly, she had dropped, her GFR dropped down into the 30s, low 30s, and she was scheduled to meet with an nephrologist. And we gave her some herbs that we use that are protective for the kidneys, but the main thing was she went and had this Barral treatment and they found that her renal arteries were being compressed by surrounding organs. And they just did this gentle manipulation and her GFR went back up. It went up to 58.

Dr. Weitz:            Wow.

Dr. SSL:                 So it’s almost back to 62, like it was. So we’re watching that now. And yeah, it was just incredible.

Dr. Weitz:            Which strain of probiotics helps with gut hypersensitivity?

Dr. SSL:                 The one that was studied, I believe. You can look on Probiotic Advisor for more of this. But I think it’s Align, that regular store brand, was found to be helpful.

Dr. Weitz:            Okay.

Dr. SSL:                 And the last one is gastroparesis or delayed gastric emptying because if you think about it, if the bag is full for long periods of time and doesn’t empty through the bottom, through the pylorus into the small intestine, you’re much more likely to get reflux up the top into the esophagus. And this is especially common in both type one and type two diabetes. If your patient has type one diabetes and their blood sugar is not super well controlled, they have up to a 40, depends on the study you look at, but 40 even 50% risk of getting gastroparesis. So getting a gastric emptying study can be really helpful.

Dr. Weitz:            Hey doc, can you tip your camera a little bit because on video, your top of your head’s getting cut off. There you go. That’s good.

Dr. SSL:                 You don’t need to look at me anyway, but yeah, I’ll do that. Yeah. So this is all the things that can cause reflux symptoms and they’re probably more, but these are some of the big ones. So, the question about acid, is it always too much acid?   Well, sometimes it is, but sometimes it ain’t. So, not all reflux symptoms are due to excess acid, and I just want to point out here that these same reflux symptoms and even true GERD or NERD can be due to acid reflux. Acid reflux can cause erosive esophagitis, or sometimes, not. It may cause some LA grade A, B, C, D erosive esophagitis, or it may not.  And if it doesn’t, we call it NERD, right? Non-erosive reflux disease, but it’s not always acid. Sometimes people have neutral reflux, and there’s a lot of research on this, or what’s called weakly acid reflux, or for short, WAR, W-A-R. I think gastroenterology has some of the best three-letter abbreviations of any form of medicine, any specialty.  So, we’ve got WAR going on here with weakly acidic reflux, and that can cause reflux symptoms as well, or even neutral pH of seven. There’s even alkaline reflux, which is often related to bile reflux through the pyloric sphincter into the stomach.  So you got bicarbonate from the pancreas and the Brunner’s glands of the small intestine membrane coming back up into the stomach together with bile, which may be alkaline. And then you’re refluxing that into the esophagus as well. So that can be alkaline reflux; I didn’t mention that there.  And then there’s functional heartburn, which are people that have heartburn symptoms, identical symptoms, but they actually don’t have any reflux of stomach contents. And it’s a different mechanism.

Dr. Weitz:            What is that mechanism?

Dr. SSL:                 Well, there are a number of theories. One is that any pressure in the esophagus, food moving down or secretions, anything that causes fullness in the esophagus, or a swallowing disorder where food doesn’t make it all the way to the stomach the first time, all of those things can cause symptoms either that feel like burning or symptoms that feel like pain, like angina or chest pain.  So there’s functional chest pain and functional heartburn. And it’s just thought that there’s also something called dilated intercellular spaces, DIS, dilated intercellular spaces. And this is present in virtually every patient with reflux.  It doesn’t get reported on an upper esophageal biopsy because you need an electron microscope to see it. And they don’t typically do that on biopsies, they just use light microscopy. But it’s this spacing out of the epithelial cells that make up the esophagus that which are squamous cells. So, it’s basically, leaky gut of the esophagus.  And the research says it’s almost a hundred percent of patients that have any type of heartburn or reflux of any cause tend to have these dilated intercellular spaces. So that may sort of make the nerves in the esophagus closer to the surface, or more likely to be irritated by any secretions in the esophagus. So different theories as to why that occurs.  But it’s not reflux, and it’s not going to respond usually to standard treatments, which are aimed at getting rid of acid. So one reason why heartburn can persist when someone takes a proton-pump inhibitor, well, of course, one reason would be they already had alpha and reflux or non-acid reflux.  But if they did have acid reflux taking a proton-pump inhibitor, if it works well will lead to weakly acidic reflux. And weakly acidic reflux, according to the research, can still cause the same heartburn symptoms, especially if you have dilated intercellular spaces, which almost everybody with reflux has. And I just mentioned here that it could also be due to the fact that they didn’t have acid reflux in the first place, and it was more neutral reflux.  So, about 40% of people don’t respond to PPIs. And this is my put it all together kind of slide, which we can use as a jumping-off point for discussing different mechanisms. But patients with heartburn or pyrosis, kind of a way to think about it, if you think it’s been going on a long time, and they might have something like Barrett’s or precancerous condition or reflux esophagitis that’s getting severe, you may want to refer for some of these tests.

                                You may want to evaluate for pancreatic function by doing a stool chymotrypsin or stool elastase, fecal elastase, and if it’s low by treating pancreatic insufficiency, sometimes you get a beautiful reduction in reflux. And so it’s always a good thing to check.  By the way, I have a chapter in my book on the pancreas, and in my second edition, I decided the cutoff point is less than 200 for elastase. If the stool elastase is under 200, then they have pancreatic insufficiency, and you can use that as a diagnostic code if you want to, if you’re a diagnostician.  But most patients that you test that have normal elastase, it’s greater than 500, and they won’t even measure usually. I think GI-MAP is the only lab that will tell you it’s 733. Most labs just say greater than 500, because who cares? It’s perfect.    So my recommendation, if you see a patient who has… Like just this week, I had a patient whose fecal elastase was 227, that’s only 27 points away from pancreatic insufficiency, and it’s 250 points away from ideal level, 275 points away from ideal levels. So, I’m probably going to do a trial with pancreatic enzymes with that patient.  And I’m going to try plant enzymes, plant enzymes plus brush border enzymes, pork-based, porcine, pancreatin. I’m going to try several different ones before I give up and say, “This isn’t helping.” Because they’re all very different.  And I wrote a blog, if you go to Hive Mind Medicine, I put my website on the first slide, hmmpdx.com, Hive Mind Medicine Portland, PDX. There’s a blog that I wrote explaining about the different types of pancreatic enzymes and brush border enzymes, and my theories on why that’s important, and how you have to try different ones because they work in different pH ranges.  So, don’t give up if your patient has a, definitely, if they have below 200, or if they’re approaching 200, give it a good try with a number of different enzymes in different potencies before you give up.

Dr. Weitz:            What brush border enzyme product do you like?

Dr. SSL:               Oh, this is a place where we can talk about that?

Dr. Weitz:            Yep.

Dr. SSL:               Okay. [crosstalk 00:09:04]… where I can’t do that. So, Klaire Labs makes a product called SIBB-Zymes, S-I-B-B stands for Small Intestine Brush Border, SIBB-Zymes. And I’ve had very nice results with that.   There is a product by Apex Energetics that is also… I don’t remember the name of it because I don’t use it that much. But occasionally, I have patients that are already taking it. And it’s a combination of a bunch of different brush border enzymes. And I’ve had people do really well with that too. So those are a few.

Dr. Weitz:            Okay, good.

Dr. SSL:               And then products like, many of the plant enzyme products will have brush border enzymes in addition to pancreatic enzymes, they just kind of throw some in. Like [crosstalk 00:09:55].

Dr. Weitz:            What is some of the names that we should be looking for?

Dr. SSL:               Well, for instance, Similase from Integrative Therapeutics. It has some sucrase and some lactase, and a few other starch digestive enzymes. So sometimes they’ll just kind of pepper it with some of those.  And remember, the brush border enzymes are the second phase because the pancreatic enzymes start the process, and then the brush border enzymes finish the digestion of oligosaccharides, especially disaccharides.  And if you don’t fully digest the disaccharides because you have a brush border enzyme deficiency, you’re going to end up with massive bacterial overgrowth because you’re feeding the bacteria all that sugar because you’re not absorbing it.

Dr. Weitz:            Roxanne Yana informed us that the Apex product is known as GlutenFlam.

Dr. SSL:               GlutenFlam might be one of them. They have another one that isn’t so much for the inflammation, but it’s more of a digestive enzyme. They may have several of them, but that would be one of them.

Dr. Weitz:            Okay.

Dr. SSL:               So, that’s pancreas. And then, you may need to evaluate hormones, especially adrenal steroids and melatonin. I use the DUTCH test often, and it measures melatonin levels, but DiagnosTechs lab also does a melatonin along with their adrenal steroids. That could be a whole other discussion right there about how important that is.  You want to rule out hydrogen SIBO and methane IMO, which is Intestinal Methanogen Overgrowth. For many years, we used to call methane a type of SIBO, but because methane isn’t made by bacteria, it’s made by Archaea, we always felt funny about saying small intestine bacterial overgrowth methane type because it’s not made by bacteria. So, now we call it Intestinal Methanogen Overgrowth when it’s elevated methane.

                                And then, of course, food sensitivities including, gluten or lactose intolerance, can be major causes of heartburn. And a lot of patients will tell you, “Oh yeah, I got diagnosed with celiac disease, I stopped eating gluten, and my terrible heartburn went away. I don’t have to take any medicine anymore.”

                                Of course, you can evaluate gastric pH directly with the Heidelberg test. We do that in my office, and we were talking earlier about Sam Rahbar down in L.A. uses that in his office as well. You can do a trial with apple cider vinegar or bitters or betaine hydrochloride in a careful way and see if that dramatically improves their reflux, then you know that they’re probably hypochlorhydric.  The cool thing about the Heidelberg test is if you find that the patient directly measures the pH of the stomach through a capsule, a radio-telemetry capsule, and sends that message out to the computer, and it gives you a graph and near real-time And if you find the patient is hypochlorhydric, you can give them bitters and see what happens to the pH. And we’ve found that a lot of patients, it’ll drop their pH by as much as two pH points when you put the bitters in there.  So you can see if it works for them or not. And if it doesn’t, after 20 minutes or so, you can do a trial with a hydrochloric acid capsule or two, have them swallow that, and see what it does for the pH.

                                So, we just got a Heidelberg test back two weeks ago; it was fascinating because the patient had this sawtooth pattern, their pH was bobbing up and down throughout the entire test. And it was bobbing up quite a bit, so we knew they had hypochlorhydria, but that sawtooth pattern usually indicates that the pyloric valve isn’t functioning properly and are getting reflux of bile and alkalinity into the stomach. So you see the acidity and alkalinity, it just goes up and down like that.  They gave that patient, I think it was the Wise Woman liquid bitters as a trial during the test. And for 15 to 20 minutes, perfectly calm, there was no up and down at all. It such a great response. You could tell that woman really needs bitters.  It didn’t acidify though, she still had a pH of four, and anything above three is hypochlorhydria. So, she’s going to need something more to get some acidity in there, but it was remarkable what it did for that sawtooth pyloric valve reflux.

Dr. Weitz:            By the way, are herbal bitters best effective at stimulating bile flow, hydrochloric acid, digestive enzymes, or all of the above?

Dr. SSL:               I would say all of the above, and from what I saw last week or two helping with pyloric valve tone as well, it’s just kind of a general tonification for the whole upper GI tract.  And remember, there are bitter taste receptors throughout the entire digestive tract, even in the colon. And you might think, well, that’s ridiculous, why do you need to taste bitter things down there? Well, it turns out they do so much more than just taste bitter, but that’s the first thing that was discovered, so they called them bitter taste receptors, but they do so many important things.  And they’re also found in any tissue, I believe most tissues that change shape, like I think blood vessels have them, and the lungs might have them; bitter taste receptors are present in lots of tissues. So I would say, bitters they might do almost anything, they just help normalize function if they work for the patient.

                            So, they might have hypochlorhydria or achlorhydria, they might have normal acid, they might have excessive acid, and you can check for that if you want to do that. And it’s a great thing to do if your patient has pretty persistent reflux.  Because you want to know if it’s weakly acid or acidic or even neutral or alkaline reflux. And then, you may need to evaluate for the GI flora, especially to check for overgrowth. And you could, I list over some of the tests that can be used over on the side.

                                And I don’t do a lot of testing for H. pylori, but if they have ulcer-like symptoms, severe epigastric pain or a lot of nausea and vomiting, or if they’ve been shown to have ulcers or recurrent gastritis, checking for H. pylori and treating it may be an important thing to do. A lot of H. pylori is just commensal, so I really discourage practitioners from checking for H. pylori unless the patient has ulcer-like symptoms.  Now there are a few other well-proven H. pylori-related diseases, but H. pylori is mostly a commensal organism. It is the most important gastro biome; it’s like the center of the gastro biome. And it’s very important for maturing the immune system in the newborn in the first few years of life.  It’s unfortunate that less than 5% of kids have H. pylori in their stomach nowadays. And that’s why… research shows that there’s increased risk of Crohn’s disease, increase risk of reflux and Barrett’s esophagus. If you don’t have H. pylori in your stomach when you’re a kid, increased risk of food sensitivities, increased risk of the allergic triad, asthma, hay fever, and eczema, and even laryngeal cancer.  The list is kind of crazy how protective H. pylori is, especially for kids in the first five or 10 years of life. It tends to be more problematic in people as they get older, and we’re not exactly sure why, but there’s some virulence factors CagA and CagB and certain others.  By the way, the only lab that checks for those is the GI-MAP stool test. Otherwise, it’s just considered, those virulence factors are considered to be research only.  And I’m not so sure it’s that helpful because knowing which virulence factors they have may not really tell you much, except that if they have significant virulence factors, I think it’s less likely to be commensal and more likely to be pathologic.

Dr. Weitz:            So your recommendation, if we see overgrowth of H. pylori on a GI-MAP stool test, even if there’s virulent factors, unless there’s symptoms indicative of an ulcer, you would tend not to treat.

Dr. SSL:               Yeah, with a caveat. So definitely, I mean, if you find several virulence factors, discuss it with the patient and/or their gastroenterologist and decide if you want to treat it. But-

Dr. Weitz:            How about no virulence factors, but maybe it’s the only thing that’s significantly positive on their stool test, and it’s out of range?

Dr. SSL:               Well, okay. So, if this is a patient… Here’s the thing, I would say always treat H. pylori if you find it, if you know the patient has gastric lymphoma. It’s also called MALToma because mucosa-associated lymphoid tissue is the lymph tissue that has the lymphoma.  Lymphoma of the stomach or MALToma has an incredible response rate to treating H. pylori if the patient has both H. pylori-positive and gastric MALToma.  The tumor literally melts away when you treat the H. pylori. It’s like an 84% success rate. So I would always suggest treating that. [crosstalk 00:21:28]. But If you want to-

Dr. Weitz:            … extremely rare case.

Dr. SSL:                 Yeah. If they don’t have, yeah. And I taught pathology for 17 years, so I’m a who’s who of rare diseases if you want to talk about zebras. But anyway, that’s not what we’re going to talk about.  There are some patients that have chronic iron deficiency, anemia that responds to nothing. And they get treated with IV iron, and well, they feel terrific, and they feel better for about three or four months, and then it all goes away, it drains out, and their ferritin is at eight again, rock bottom.  If they have a positive H. pylori, and you treat that, there was several research studies that showed that within nine months is something like 75% are no longer iron deficient and no longer anemic, and by 12 months after treatment, and they don’t have to take iron, they just treat the H. pylori.  Because the H. pylori steals iron for its own metabolism, and that’s where this comes from. H. pylori can also cause hyperchlorhydria, one form of it. There’s some forms that, well, I don’t want to get into it. But if the H. pylori gastritis is specifically in the antral dominant, then…

PART 3 OF 4 ENDS [01:09:04]

Dr. SSL:                 … antrum, antral-dominant, then that tends to cause hyperchlorhydria. But if it’s pangastritis and it’s affecting the entire stomach lining, it tends to cause hypochlorhydria. So, that hypochlorhydria certainly is a cause of iron deficiency. So, that might be part of the mechanism too.

Dr. Weitz:            One more question on H. pylori, if we see antibodies to H. pylori, doesn’t that mean that we should treat it?

Dr. SSL:                 Well, so there are at least three ways to check for H. pylori, right? There’s the blood antibodies, IgG. There’s stool antigen and there’s the breath test. There’s a H. pylori breath test. The H. pylori breath test and the stool test tell you H. pylori is currently present in the gut. But if you check the blood and you find an elevated antibody, that tells you they’ve had H. pylori at some point in their life, and that’s becoming less and less common, like we said, because of antibiotics and other treatments slowly eroding the levels of H. pylori, and people being treated for H. pylori so they don’t have it. Moms don’t have it to give to their kids.

                                So the question is if you have antibodies, you should treat it. Well, that’s the standard approach. It’s called test and treat, meaning if you find it, you treat it. And that’s why I’m telling you, don’t test everybody for it. Don’t do a stool test that… Like the GI-MAP, it checks everybody for H. pylori, stool antigen. I think it’s actually stool DNA is what they test, which is a unique test. It’s not a standard test. So I would verify it. If you get a positive there, I would verify it with a stool antigen or H. pylori breath test, or even a blood antibody test.  The thing about the blood antibody test is it doesn’t necessarily normalize if you’ve treated H. pylori effectively. It’s not a good follow-up test to see if things have normalized. The stool test and the breath test will normalize if the H. pylori was eradicated, but the antibody may persist. It’s IgG, so it can persist for a long time. So unless you know that they’ve never been treated for H. pylori and there’s some other risk factor, like iron deficiency anemia that’s not responding to anything or ulcers that keep recurring or chronic gastritis. I just say think about it before you treat it. [Crosstalk 01:12:03] But the standard approach is test and treat. So if you test, you’re expected to treat. So don’t test everybody.

Dr. Weitz:            And your favorite treatment, do you use the triple antibiotic therapy or do you use a mastic gum? Do you use…

Dr. SSL:                 I never treat it anymore-

Dr. Weitz:            Oh, okay.

Dr. SSL:                 … because ever since 1995, every MD and osteopath, everybody treats it whenever they find it on a test. So it’s very rare. The only cases I usually see now are people who have… Most of the patients I see have already been to at least one, if not two or three gastroenterologists already. So, that’s been picked off. But I’ll tell you, if I were going to treat a patient for H. pylori, I would use triple therapy, and I would for 10 to 14 days nowadays, it used to be seven. And I would add lactoferrin, at least 300 milligrams, three times a day during the treatment because that increases the effectiveness.

                                I would add a biofilm disruptor. The simplest one, of course, being NAC. And there’ve been several studies showing that antibiotic-resistant H. pylori, when you add NAC to break down the biofilm, you get a much higher response rate. So I do those things and I add a probiotic because probiotics together with triple therapy have been found to increase the success rate. So if you’re going to give them two antibiotics plus a proton-pump inhibitor, give them these three extra things which can really improve the effectiveness.

                                I think I made one more slide because I wanted to make sure everybody knows about Cut Out the Crap. This is a handout. I have a GERD handout that I give to all my patients that have reflux to remind them the things that are commonly triggers and causes. So these are the things I want them to do trials with if they’re using these things, or these are things that are going on in their life. So C stands for coffee, caffeine in general, so you could include energy drinks and things, cigarettes and chocolate. So methylxanthines in general, but especially chocolate and caffeine and smoking.

                                Then, we say a number of mechanisms by which tobacco smoking can affect reflux, and perhaps even a patch or chewing tobacco as well. Chewing tobacco, of course, is horrible for cancer of the mouth. And so they can do trials removing these things. And if it turns out coffee, without coffee they don’t have any reflux, you can have them do a trial with low acid coffee. There are several brands. One is called Tylers brand that are sold in some stores. They reduced the amount of acid in it, and that can really help people with reflux be able to drink some coffee if they really like coffee.

Dr. Weitz:            What was that about chewing gum causing cancer in the mouth?

Dr. SSL:               Not chewing gum, chewing tobacco.

Dr. Weitz:            Oh, chewing tobacco. Okay.

Dr. SSL:               As a cause of leukoplakia and erythroplakia.

Dr. Weitz:            Oh, okay. Yep. Yep.

Dr. SSL:               R stands for refined carbohydrates. This comes from Sherry Rogers’ book, No More Heartburn, but I added some things. I reworked it a little bit. So refined carbohydrates, but also any carbohydrates. So we find that low fermentation diets, like Fast Tract Diet and SIBO type diets and Cedar-Sinai diet and FODMAPs diet sometimes are remarkably effective at treating reflux just by themselves, just by reducing the total amount of carbohydrate, fermentable carbohydrate per meal. I put Rx in there for drugs because there’s a whole… I have a slide when I do my full lecture on reflux, that all the drugs on the left that can irritate the esophagus and cause erosive esophagitis, and all the drugs on the right that can trigger more reflux in a patient who already has reflux, often things that are anti-spasmodic and relaxed the lower esophageal sphincter or delayed gastric emptying.

                            And then R is for rapid eating, Fletcherizing, chewing food until it’s liquid, taking your time in a relaxed manner, that can totally cure your patient’s reflux, a lot of your patients. It also tends to promote parasympathetic tone. So you’re going to have more vagal tone. You’re going to have more improved digestion on many, many levels. So please don’t forget that if your patient is a shoveler, if they eat their meals in five minutes, if they eat at their desk while they’re doing work on their computer and they don’t even know that they’re finished because they ate so fast, you got to work with that. That’s really important.

Dr. Weitz:            By the way, do you have any tricks to helping patients improve at that?

Dr. SSL:               Well, I got to put in a plug. My wife is a neurofeedback practitioner, biofeedback practitioner and a stress coach, stress management coach. She recently wrote a series of six blog articles that I would highly recommend everybody read on our website, hmmpdx.com, which is on there, Hive Mind Medicine website. You go to our blog page and she wrote six blogs. One of them is specifically on chewing and why that’s so important. I didn’t even know about this until I read her article that the trigeminal nerve, which controls mastication in large part, actually when the brain perceives through the trigeminal nerve that you’re chewing your food and taking your time and thoroughly chewing, it sends a message to the brainstem that calms the autonomic nervous system and turns on the parasympathetics. So, yeah, it’s so great the stuff that she writes, so I just highly recommend. It’s free and it’s on our website. You can recommend it to your patients to read them. Just really cool.

Dr. Weitz:            Thanks.

Dr. SSL:               And A in crap, A is for acidic foods because some people if they cut out tomatoes and nightshades especially, especially tomatoes. Personally, it’s white potatoes for me. It’s that nightshade. That’s the only food that gives me reflux. I don’t ever have reflux now because I just don’t eat white potatoes. So you know what, food allergies can be a thing. That’s why I have allergenic foods there. If someone’s sensitive or allergic to a food, that could be a big trigger for reflux.

Dr. Weitz:            By the way, do you have a favorite food sensitivity test?

Dr. SSL:               I hardly ever do food sensitivity testing. I used to do a lot of it. I actually worked at a lab that did cytotoxic leukocyte testing, and I would see those patients and go over their lab results. But because so many of my patients have bacterial overgrowth now and I’m putting them on specific carbohydrate diet or Dr. Siebecker’s SIBO Specific Food Guide, which is related to the specific carbohydrate diet, I use that as an elimination diet initially and see how much better they get. A lot of times their reflux goes away just when they’re on that diet, and it’s part of our treatment for bacterial overgrowth, a low fermentation diet. So I don’t do a lot of that food sensitivity testing, but a lot of my patients come having already had those tests so I don’t have to do it because they already had one recently and that’s really helpful.

                            And I mentioned apple fat pregnancy or apple fat increasing intra-abdominal pressure, not that it’s easy to get rid of that. Apple fat is a major cause of insulin sensitivity, and that’s where the adrenals come in with treating someone’s either bacterial overgrowth or reflux because I find that adrenal maladaption with especially high cortisol and low DHEA, that ratio being off really can promote insulin resistance and cause people to accumulate fat, visceral fat around the waist, which triggers more reflux.

                                P is for pop or soda pop because soda seems to be a big one for some people. Peppermint, oops, sorry, peppermint, because it’s a smooth muscle relaxant probably, really strong peppermint. After-dinner mints can be just murder for some people with reflux. Altoids, curiously strong menthol. Even though it’s great for people with cramps, abdominal cramps, sometimes enteric-coated peppermint can be a terrific, smooth muscle relaxant and it’s the only smooth muscle relaxant that doesn’t promote bacterial overgrowth. It actually can treat, be part of the treatment for hydrogen SIBO, but it can relax the lower esophageal sphincter for some people. So, it’s something to consider. This is one I added in also, packing in food at bedtime, right? So you really want them to finish eating at least three hours and don’t have a huge meal at dinner time. Eat breakfast like a king, lunch like a prince, and dinner like a pauper, or a queen and a princess and a pauper or they, depending on your approach.

Dr. Weitz:            It’s interesting that one of the current trends in functional medicine is intermittent fasting. And the way that most people do it is they skip breakfast, so they end up eating a bigger dinner because of it.

Dr. SSL:               Yeah. I mean, that can work for a lot of people, certainly having a light dinner at least three hours before you go to bed. And then if you want to eat breakfast later, that’s probably a better way for some people. You’re right. And then the last one is progesterone. Most women don’t produce too much progesterone, but they might be taking a higher doses of progesterone, like 200 milligrams or higher. We know progesterone is a smooth muscle relaxant. So that could at least theoretically be a problem for some women. I don’t see it very often, but it’s certainly a problem in pregnancy because progesterone levels go sky high in pregnancy, that’s a normal pregnancy, women that aren’t prone to miscarriage. So, that’s the Cut Out the Crap. You will become a reflux treating genius to your patients. So if you just really pay attention to this and have them go through whatever they’re doing and do a trial without it, this could really… If I said nothing else tonight, this is gold. It’s crap, but it’s gold.

Dr. Weitz:            If you have a patient with high acid and they have reflux, are there specific products that you like to use? Besides working for the underlying causes, like SIBO and food sensitivities and these other things, are there certain nutritional products that you like to use as part of the treatment that could at least help symptomatically on a short term?

Dr. SSL:               Well, certainly all the demulcents can be helpful and worth trying, whether it’s slippery elm or marshmallow root or DGL. Slippery elm gruel is a really nice one. Just mixing the powder with enough water to make a paste and taking up to four tablespoons of that, it can just be remarkably relieving within minutes. I would also say if you’re not a homeopath, consider the remedy nux vomica if it fits a few other things for your patient besides their severe reflux, especially in people who have tended to overdo it, like people who drink too much alcohol, take too many drugs, overeat, overdo everything, and people that overwork, workaholics. If they have severe reflux, nux vomica as a homeopathic remedy can really be the end of their reflux. So, that’s another one to consider besides the demulcents.  I have to say that if your patient has LPR that we talked about, a lot of patients with laryngopharyngeal reflux that reflux up here, they will wake up. You’ll think they have PTSD because they’ll wake out of sleep gasping for breath, or you think they have asthma or something. And it turns out it’s just that their vocal cords and their pharynx are swollen and edematous from the reflux. Especially when they’re lying down at night, they’re more likely to have reflux up into their throat.

                                Some of those patients, I’ll pick the lowest dose of famotidine, which is over the counter. Before proton-pump inhibitors, there was Tagamet and other drugs that are called H2 receptor antagonists. I mean, if you’re waking up feeling like you’re dying and you can’t sleep because you’re scared if you go to sleep, you will stop breathing, I mean, these people end up in terrible shape. So if you know they have LPR, if you need to, you may want to have them on famotidine, at least until you figure out something else to deal with the cause of their reflux.

Dr. Weitz:            Yeah. I sometimes will use a product from Gaia Herbs called Reflux Relief, and I have to chew two of those. Really, really nice product to help [crosstalk 00:19:12].

Dr. SSL:               For LPR or just for reflux in general?

Dr. Weitz:            Just for the reflux. Yeah.

Dr. SSL:               There’s a newer product called Heartburn… Oh, I always forget the names of these things. Heartburn Advantage. It’s made by Integrative Therapeutics, and it’s a combination of herbal prokinetics, so especially if your patient has delayed gastric emptying, if they have type two or type one diabetes, or even pre-diabetes or some other cause of delayed gastric emptying. So it has herbal prokinetics and it has some demulcents. I think, DGL in there as well. And so that may be really helpful as well. Some promotility and some demulcent activity.

Dr. Weitz:            Have you ever used Pepto-Bismol?

Dr. SSL:                 Yeah, I use almost everything when I have to. Yeah. Bismuth, that’s over-the-counter Bismuth. Except for the flavor and the artificial sugar that might be in there, you can just have people get, if they’re going to take it for any length of time, bismuth subsalicylate or bismuth subnitrate. And especially if they’re salicylate sensitive, if they have nasal polyps or asthma and they’re aspirin sensitive, then you’d want to use the bismuth subnitrate. But that can sometimes be really healing for ulcers and erosions and reflux. So, it’s just another demulcent.

Dr. Weitz:            Cool. Well, this was an incredible discussion, Dr. SSL. Lots of clinical pearls.

Dr. SSL:               Yeah, it’s dangerous to start asking me questions about things that I love to talk about. By the way, I’m writing. I’m taking two weeks off the end of the year to finally finish my book on reflux.

Dr. Weitz:            Oh, cool.

Dr. SSL:               We’ll make an announcement on our website about it, but it’s called Getting Real About Reflux, and it’ll cover all these things and more details. I’m trying to make it a book that laypeople can read, your patients can read, as well as doctors can learn a ton from. I’ve never written a book like that before so it’s taken me a little longer than just writing for doctors. But yeah, I’m going to take some time off and really try to get it done. I hope we’ll have it done going through the editing phase by summer. So, that’s coming up.

Dr. Weitz:            Okay. Awesome. Awesome. Thank you so much. Thank you everybody for joining us, and happy holidays. We’ll see you in 2021.




Forest Bathing with Dr. Suzanne Bartlett Hackenmiller: Rational Wellness Podcast 185

Dr. Suzanne Bartlett Hackenmiller speaks about Forest Bathing 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

7:29  The difference between just spending some time in nature and forest bathing is that forest bathing is a mindful practice that involves spending time in nature in a more organized way. It’s similar to something like yoga or meditation where you have somebody guide you at first. The guide can increase and help to heighten the experience by guiding you through the various senses in a very prescribed, sequential way.  Participants are invited to stand with eyes closed and they are guided to become more aware of their surroundings through by focusing on the sounds, what they feel, as well as what they see. The goal is to be able to really notice your surroundings and to have a heightened experience, instead of just passing through.

10:36  The benefits of forest bathing or shinrin yoku, as it is called in Japan, includes helping to manage mental health problems like depression and anxiety.  Even getting our of the city and spending an hour in a forest has been shown to reduce anxiety and depression and improve self esteem.  Forest bathing lowers blood pressure and heart rate and it improves heart rate variability.  It has been shown to lower salivary cortisol and amylase levels, since it lowers the stress response.

15:05  Forest bathing improves metabolic and cardiovascular health. It also helps athletes to improve their performance.

19:45  There are chemicals called phytoncides that are naturally secreted by trees and plants and contained within essential oils to protect the plants from bacteria, viruses, and fungal infections.  These can potentially have benefits for humans. These phytoncides are the inborn immune system of plants. We often refer to them as essential oils.  When we come into contact with these phytoncides and breathe them in, they increase our natural killer cell number and activity.  This can potentially help us in fighting viruses or cancer.

24:32  Myocbacterium Vaccae is a bacteria found in soil and researchers have found that when we’re outdoors we ingest little particles of soil and we consume some of this bacteria that is helpful for our memory, attention span, and our cognitive faculties in general.




Dr. Suzanne Bartlett Hackenmiller is a board certified medical doctor in both obstetrics and gynecology and integrative medicine and is board certified in herbal medicine with Dr. Tieraona Low Dog.   Dr. Hackenmiller sees patients at the Van Diest Medical Center in Webster City, Iowa and she is an expert at forest bathing and wrote a book, The Outdoor Adventurers’s Guide to Forest Bathing.  She is also a certified forest therapy guide and the medical director of the international Association of Nature and Forest Therapy. Her web site is IntegrativeInitiative.com.  

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

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 like 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 forest bathing and we’re here with Dr. Suzanne Bartlett Hackenmiller. Forest bathing is a concept developed by the Japanese, who call it shinrin yoku. It’s a guided, mindful experience in nature where participants are invited to explore their natural surroundings via sensory experiences. Research shows that such focused time spent in nature offers various health benefits, including reducing stress and cortisol levels, reducing anxiety and depression, improve natural killer cell activity and better immune system function, memory and cognitive function are improved. Blood pressure, heart rate, and even blood glucose levels are reduced, as are other indicators of heart health.

                                                Dr. Suzanne Bartlett Hackenmiller is a board certified medical doctor in both obstetrics and gynecology and integrative medicine, and she’s board certified in herbal medicine with Dr. Tieraona Low Dog. Dr. Hackenmiller sees patients at the Van Diest Medical Center in Webster City, Iowa, and she’s an expert at forest bathing and she wrote a book, The Outdoor Adventures Guide to Forest Bathing. She is also a certified forest therapy guide and the medical director of the International Association of Nature & Forest Therapy. Dr. Hackenmiller, thank you so much for joining me.

Dr. Hackenmiller:           Thank you for having me.

Dr. Weitz:                       Good. So, a little bit different than a typical topic we talk about.

Dr. Hackenmiller:           I was going to say. This will be quite the experience for your listeners who are going, “What happened to him?”

Dr. Weitz:                       Right. Where is all the science about gut health and cardiovascular health?

Dr. Hackenmiller:           Right. Yep, and it’s interesting because I talk with my patients about the science of gut health and all those things, too. So yeah, this seems a little tangential, but I promise we’ll bring it all back.

Dr. Weitz:                       There you go. So, before we get into this discussion of what is forest bathing, what some of the benefits are, how did you become interested in it and how do you integrate it into your medical practice?

Dr. Hackenmiller:           Yeah, thanks. Well, it’s kind of a circuitous story, honestly, but it just sort of happened. Largely, back in 2012, I had a husband who passed away from cancer. And so, I was dealing with life, and a practice of medicine, and dealing with some burnout and going through all of those kinds of things trying to raise two children, one of whom has special needs and dealing with my three stepchildren and their grief and going through all of those things. And I found that I started spending more and more time outdoors in nature. I was drawn to do that, which I think probably a number of people can relate to right now with the pandemic, because we’re hearing that park attendance is like 400 times what it used to be. So, that was what I ended up doing, and I found myself drawn to the more adventurous types of pursuits. I started mountain biking more and trail running, and started training to do adventure triathlons and things like that.   And that was all really good, but I also recognized that I needed the balance of more of the mind-body type of thing, too. I’ve been a yoga practitioner for a number of years and had been prior to that, too, and so recognized that you can’t just have all the go, go, go, the adrenaline. That, of course, contributes to burnout just like it was in my practice of OB-GYN. So, I happened upon an article about forest bathing in 2014, and I, probably like many of your listeners, thought, “What’s forest bathing? What in the world is that?”

Dr. Weitz:                       Is that taking a shower in the forest?

Dr. Hackenmiller:           Yeah, exactly. And of course, when I started offering forest bathing here in about 2015, and that’s exactly what people were asking. “What? Now, is this clothing optional?” Or, “What are you doing in the forest?” I mean, believe me, people thought I was completely off my rocker, and they maybe still do, but that’s another story. So, I was really intrigued by this idea of forest bathing or shinrin-yoku, as you mentioned in the introduction. And so, I requested a little booklet on what forest bathing was from the Association of Nature & Forest Therapy, and from that booklet, I thought, “I’m going to experiment with this a little bit.” I was doing a weekly workshop series with a local retreat center and so I thought, “I’m just going to work this in.” And one of our weeks was on nature and health. We had spirituality and health, and community and health, and whole medical systems, traditional Chinese medicine, Ayurveda, all of those kinds of things. And so I thought, “Nature and health, let’s try that.”

                                                And so, I experimented with the participants in this group and they loved it, and they came back the following week and many of them were reporting that they had this great experience. They went back out with their family or their friends or by themselves to forest bathe in the intervening week. And I thought, “Wow, there’s really something healing and medicinal and real about this.” And again, I was just kind of winging it and experimenting on these people. So after that, I started taking it a little bit more seriously, and as you mentioned in the intro, became certified as a forest therapy guide and ever since have been guiding my patients and general public on these forest therapy or forest bathing walks.  It really has been something, I really have found that it is, in many cases, more healing than many of the other things that I offer, and I have a pretty large toolbox. I can offer my patients pharmaceutical drugs and surgery. I do a lot of herbal medicine, as you mentioned. I have all of these things that I can offer my patients. And yet, there’s something that really magical happens when you take people out into nature for a couple of hours.

Dr. Weitz:                       Are you practicing mainly as an OB-GYN or an internist or?

Dr. Hackenmiller:           I do kind of a little bit of both, gynecology and integrative medicine, and that has waxed and waned over the course of the last several years. But yes, doing some of both and doing a lot more teaching and consulting and speaking and things like that about this topic of nature, also. So yeah, my practice has kind of expanded and contracted and changed over the years.

Dr. Weitz:                       So, what is the difference between forest bathing and just taking a hike or spending some time in nature? There’s something… there’s some structure attached to that.

Dr. Hackenmiller:           There is, yeah. Well so, we know that any time spent in nature has health benefits, whether it’s sitting outside in nature or going for a walk in nature, and even the definition of nature depends on where you are. Nature could be a walk in a forest or a national park, but there’s also this concept of nearby nature where nature in your backyard or gazing at a tree from your balcony, or even maybe a potted plant, or maybe an indoor potted plant. We are nature and nature is everywhere, and it doesn’t have to be this far away grandiose thing. But that being said, so the difference really between just going out and doing your own thing in nature versus forest bathing is that forest bathing is actually a mindful practice. It’s similar to something like yoga or meditation where ideally you would have somebody guide you at first.

                                                Most people wouldn’t just decide to teach themselves yoga and just start trying to figure it out. And so, we kind of liken forest bathing to that, where having a guide can certainly increase, heighten the experience that you have. And so forest bathing, the way it’s taught through the Association of Nature & Forest Therapy, and a number of other organizations now that have kind of followed suit, is the idea that you would go out with a guide and the guide would take you, typically a group but it can also be individually, and guide the participants to take nature in through the various senses in a very prescribed, sequential way. We talk about following this standard sequence, where we start with a certain, something we call the pleasure of presence, where we invite the participants, maybe even to stand with eyes closed, and we guide them through kind of a noticing of their surroundings going through the senses.

                                                Noticing what they hear, noticing the way the air moves on their clothing, perhaps noticing with eyes closed the way something like a rock feels, or a leaf or a tree or water or something like that. And so, then we kind of go through what we refer to as a series of invitations, where the participants are invited to try these different ways to notice nature. A typical forest bathing walk will take place over the course of two or three hours, which seems like a really, really long time, but it typically goes pretty quickly, and we move very slowly. So, it’s not a hoofing it hike for exercise, it’s not a nature identification walk, it’s really just a way to slowly kind of sink in and notice the surroundings.

Dr. Weitz:                       Okay. So, let’s go into some of the benefits. So, in what ways does forest bathing reduce our stress and have benefits for our mental health?

Dr. Hackenmiller:           Yeah. Well, the doctors who coined the term shinrin-yoku in Japan, doctors Li and Miyazaki started the practice in the early 1980s. Just thinking that perhaps getting people out of the city and the chaos of Tokyo where mental health problems were skyrocketing, suicide incidents were high-

Dr. Weitz:                       It’s interesting when you think about Japan, because we all think of Japan as just being so many people crowded in together and even living quarters being so tiny that people are living in cubicles. So, it’s interesting that there actually is a fair amount of natural areas there.

Dr. Hackenmiller:           Right. Yeah, so these doctors then took their patients out of the city, about an hour outside the city to a forest, just wondering if getting them out of the chaos and the noise and the lights and the stress of the city would be helpful for their mental health. And so, they started doing some questionnaires on their participants before and after these excursions to see how things like anxiety and depression and self-esteem, and all of those things changed, or whether they did, and they found that consistently they did improve after time spent in this kind of contemplative, quiet, mindful way in nature. So then, these doctors continued to study their participants, both in terms of their mental health and also physical health and found that things like blood pressure would improve and heart rate variability and that type of thing. Now fast forward to today, studies are being done on things like salivary cortisol and salivary alpha amylase. These are hormones that they can measure in the saliva of their participants and they’ve found that those things improve after forest bathing.

Dr. Weitz:                       What did they see on the cortisol?

Dr. Hackenmiller:           Yeah. A recent study, I believe it was 2019, found that 20 minutes of walking in nature, now this particular study was not specific to forest bathing, but they compared walking in nature versus walking in an urban setting for 20 minutes, and they found that there was statistically significant improvement in salivary amylase and salivary cortisol after 20 minutes of walking in nature versus walking in an urban area.

Dr. Weitz:                       So, what did they see in terms of the cortisol? Did they see it go up, go down, normalize, or?

Dr. Hackenmiller:           Oh, I’m sorry, they found that it went down. So, they found that it improved. People were showing less of a stress response in just 20 minutes of being in nature.

Dr. Weitz:                       Okay. So, these were people who were seeing some excessive rise in cortisol at some point during the day other than in the morning?

Dr. Hackenmiller:           Right, right, yep. Yeah, and if your listeners are interested, I can certainly forward you any of these studies and you can pass those.

Dr. Weitz:                       By the way, salivary amylase levels, that’s not something I’ve heard talked about very much.

Dr. Hackenmiller:           Yeah, right. It’s not something that you hear about much, but it’s something that has been associated with the stress response, and it’s something that’s fairly simple and fairly inexpensive, as far as I understand, that people can measure just from a swab of the saliva in the mouth.

Dr. Weitz:                       So, now amylase is a digestive enzyme, right?

Dr. Hackenmiller:           Right, yeah.

Dr. Weitz:                       That correlates with stress?

Dr. Hackenmiller:           Yeah, isn’t that interesting? And especially if you do a lot of GI talk, yeah. I would be interested to hear from an endocrinologist more about that, because it’s not something that there’s a lot, to my knowledge, written about. But yeah, so that can be your next guest. I can even connect you with one.

Dr. Weitz:                       Oh, really? Because most endocrinologists I know pretty much dismiss salivary cortisol measurements.

Dr. Hackenmiller:           Yeah, I can connect you with an integrative endocrinologist, Low Dog.

Dr. Weitz:                       Good, good, good. So, talk about how forest bathing improves cardiovascular and even metabolic health?

Dr. Hackenmiller:           Yeah. Well, they have found that blood pressure and pulse improve and heart rate variability. I don’t know if you’re familiar with things like heart math, I’m guessing you probably have some experience with that and your listeners maybe do too, so this idea that when we’re under stress we have less variability between each individual heartbeat, and that that is a marker of stress and can correlate with all kinds of different parameters of our health. And so, they’ve found that spending time in nature improves that heart rate variability, again the blood pressure and pulse, and all of those kinds of things have been found to be improved.

Dr. Weitz:                       Interesting. We use heart rate variability among other reasons to monitor recovery from exercise sessions. So, for professional athletes, if they could get improvements in heart rate variability they could potentially improve their performance. Has there been any looking at forest bathing for helping athletes?

Dr. Hackenmiller:           I don’t believe there are specific studies for that, but it’s something I’m really interested in. And in fact, in my book, that was one of the things that I wanted to look at so I reached out to a number of elite athletes in different areas of people who their particular sport is an outdoor nature based thing, whether it was trail runners or kayakers or mountain bikers and people like that, who aren’t just road cyclists or people who run marathons on pavement. People who for some reason are drawn to outdoor pursuits. And so, I asked all these athletes if there was something about being a nature that they felt contributed to their success in their sport. And they all did. And so, it was fun to hear the responses of these different elite athletes, as far as they maybe couldn’t put their finger on it, but there was something about being in nature that heightens their performance as opposed to, like I said, some kind of pavement type of sport.

                                                This is something that I’ve explored a lot, the idea of kind of forest bathing while you are doing your outdoor sport. And again, that was kind of the tenant of my book, The Outdoor Adventurer’s Guide to Forest Bathing, how can we combine these two things that I love? Because I do still love the adrenaline rush of the outdoor adventure, but was there some way that we could kind of marry the two and derive the benefits of both simultaneously? So, I personally find that when I’m trail running or mountain biking or hating my life going up a hill or something, climbing on a mountain bike is not my favorite, but you have to pay to play as we always say. And so, there are those times where you’re hating life going up a hill. And so, I do find myself trying to incorporate some of these ideas of forest bathing while I’m doing that. I might tell myself, “Okay, while you’re climbing this hill, just start noticing the sounds around you.”    And so, I’ll tune into the sounds of birds or the sounds of the wind or something like that, or I’ll pay attention to what I’m smelling, the fragrances, the pine or whatever, or I’ll decide some little visual game. I’ll tell myself to look for a certain color or I’ll pay attention just to the dark hues. And I find that when I kind of play these mental mindful games, it does help me. And when I was interviewing these different athletes for my book, they all reported similar kinds of things that they do. So, I found that really interesting. It hasn’t maybe been studied yet, but I think it’s a great area for study.

Dr. Weitz:                       Yeah, it’s interesting. I could see how maybe attaching a basketball hoop to a tree and playing one-on-one against a grizzly bear would really increase your quickness.

Dr. Hackenmiller:           I think you’re absolutely right. That would be slightly off topic of improving heart rate variability and all, but-

Dr. Weitz:                       I’ve been known to get slightly off topic. Can you talk about the chemicals that are naturally secreted by trees and plants called phytoncides, that means protect the plants from bacteria, viruses, fungal infections, and potentially have some benefits for humans?

Dr. Hackenmiller:           Definitely. I think this is something that is so, so fascinating. So, plants and trees emit these chemicals, as you just said, called phytoncides, and they’re chemicals that are contained within the essential oils of plants. We know that evergreen plants especially have higher concentrations of these phytoncides. And for the plant, for the tree, these phytoncides offer protective benefits. They help the tree, the plant, whatever, fight against fungi, bacteria, viruses, and help them against inflammation. So, they’re kind of their own inborn immune system. And so, what they have found is that when we, as humans, spend time in nature, and when we are inhaling the aromas of the essential oils, so if you’re smelling that fragrance of pine or juniper or something like that, you’re inhaling the essential oils and you’re also inhaling the phytoncides. And they’ve discovered that we as humans benefit from inhaling the phytoncides in the same way that the plant benefits from them. And they’ve found that phytoncides help humans in fighting these various microbes, cell viruses, bacteria, fungus, and also have anti-inflammatory effects for us. So, isn’t that amazing?

Dr. Weitz:                       That is amazing. So, would oregano oil, would that be somehow included in this?

Dr. Hackenmiller:           It very well could be. I’m not an expert in essential oils or aroma therapy. I’ve actually tried to reach out to some various experts to try to kind of hone in more on this idea of, so what exactly are the phytoncides? And believe me, I’ve asked, including Dr. Lee in Japan, this question. I have tried to grill him about it because some of his work is what I’ll refer to next, but this idea of what is the phytoncide? Is it the essential oil or is it the constituents of the essential oil, the terpenes and all of those different constituents? So yes, we know that oregano has a lot of anti-inflammatory properties as do a number of other things, turmeric and ginger and definitely oregano. And so, is it phytoncides? Is that part of what it is?

                                                These are all these questions that keep me up at night asking. So, I assume that’s what Dr. Lee’s studies have found though on the phytoncides also, and there’s evidence that by coming into contact and breathing in these phytoncides that they increase our natural killer or NK cells in number and level of activity in the body. And so, NK cells sweep around our bloodstream finding abnormal things like viruses and bacteria and gobbling them up. And they also locate tumor cells in the body and destroy them before they can replicate and divide and become a cancer.

                                                And so, just to think that possibly inhaling the fragrances of trees allow us to breathe in these phytoncides. They found that when people forest bathed in Japan, and this was a study that looked at a two night three day forest bathing excursion, so that’s longer than your typical one, but that might be similar to a weekend camping trip, they found that when people did that, that their NK cell levels rose both in number and level of activity a day later. And then, when they rechecked seven days later, they remained elevated in both number of natural killer cells and how active they were and they found that that benefit was maintained for 30 days out.

Dr. Weitz:                       Cool.

Dr. Hackenmiller:           Yeah, I mean to me, that’s amazing. So, just to think that spending a weekend out in nature gives you health benefits in terms of fighting cancer and fighting viruses for up to 30 days out.

Dr. Weitz:                       Amazing.

Dr. Hackenmiller:           That’s remarkable I think, yeah.

Dr. Weitz:                       Absolutely. What is mycobacterium vaccae and how does this help with brain health?

Dr. Hackenmiller:           Yeah, it’s a bacteria that is found in soil and researchers have found that when we’re outdoors we ingest little particles of soil, so we’re swallowing little particles and we’re also inhaling them. And they found that when-

Dr. Weitz:                       And by the way, soil contains lots of bacteria, there’s huge fungal networks, and so there’s a lot of reasons why soil and being in nature has a stimulus for the immune system and going all the way back to just having your kids play in dirt as opposed to-

Dr. Hackenmiller:           Absolutely. Oh, so true. So, they found that when they exposed mice to this bacteria that they were able to navigate a maze two times faster than the ones that were not exposed to that bacteria. So yeah, they’re finding increasingly that it is helpful for our memory and our attention span and just cognition in general. So, being out in nature and being exposed to dirt and plants and all that good stuff is good for our mental health and our memory and all kinds of things.

Dr. Weitz:                            Now, you also talked in your book about how forest bathing is typically concluded with the tea ceremony, which is a good time to reflect and to pay respect to nature and the ancestral humans who might have tended to the land before us. So, can you talk about that?

Dr. Hackenmiller:           Yeah. Well, so since this practice stems from a Japanese concept, it, we do that when we add the tea ceremony as part of what we consider the standard sequence. And so, it is really nice to do that and exactly what you just said, a time of reflection for the people who are in the group. If we can, if it’s safe and legal to do so, we like to use a plant that is in the area and create a tea from that. If not, we’ll bring loose leaf tea and make our tea that way. I find that participants really, really love the tea ceremony as much as anything. I think it’s just this idea of getting back to kind of a deep ancestral knowing that the plants in our midst are, they’re not poisonous, obviously there are some that are and you absolutely must a hundred percent know what you’re doing if you’re foraging and consuming any plants out in nature.

                                                So, that’s my caveat there, but this notion that… You could make a tea from dandelion, something that probably most people are able to easily identify and that doing so is safe and has a number of different health benefits and is not gross. When people actually try these little teas that we make they’re astonished that, “Oh, that’s actually really good.” It seems pretty woo-woo when you think about it, but I’ve gotten all kinds of people to try the tea ceremony and to try forest bathing, and pretty much consistently people are amazed at the experience. I do like to bring in some of that herbal medicine to our tea ceremonies and talk about the properties of whatever it is. And again, people are just astonished that there would be health benefits from something as simple as dandelion tea.

Dr. Weitz:                            Now, how can people access somebody to help them with a forest bathing experience and are there apps or other ways to do it if they can’t find a guide?

Dr. Hackenmiller:           That’s great, yeah. Well, my book has a number of invitations that a person could just go out and try on their own. It’s also available on audio book, which I really wanted to have happen so that somebody could be out there and listen, kind of like listening to a guided meditation. So, that would be one way. There are guides all over the world now who are trained by the Association of Nature and Forest Therapy, and so there’s an interactive map where a person could find a guide and that’s at natureandforesttherapy.org. And there are other organizations of forest bathing and forest therapy guides in addition to that organization.

                                                And yeah, I think there are some people who are working on apps and things like that. I think, especially during this pandemic, we’ve been forced to try to figure out kind of virtual ways to do forest bathing without congregating, as with everybody trying to figure that out. So, I’ve offered some virtual walks and there is a whole list on that website of virtual walks. So, you could be at your own local woods or in your backyard even. I did one one time and the lady was in her backyard. It was like, great, why not? So, there are ways of accessing it.

Dr. Weitz:                       Great. That’s good that they can use the audio version of your book to guide them through and they could be walking in nature, they could be bicycling, they could be on a boat rowing. Right? What is some of the different ones?

Dr. Hackenmiller:           Yeah. So, my husband and I guide workshops that incorporate all these different things. Sometimes in the morning we’ll do a hike and incorporate forest bathing. And then in the afternoon, we’ll have lunch then we’ll do a kayaking forest bathing. So literally, we’ll each be in our kayaks and I’ll give an invitation, people will paddle out and kind of do their own thing. And then, we’ll circle back up and kind of discuss what we noticed and go back out. I mean, I’ve really enjoyed kind of adapting, taking the concept of forest bathing and adapting them to some of these other activities. In my book, I talked about hiking and trail running and mountain biking, cross country skiing, climbing, I think I’m forgetting something but, there must be one other that I’m blanking on. Anyway, there are six different ones in the book, just ways that you can incorporate a little forest therapy into all of those activities.

Dr. Weitz:                       That’s great. How can listeners and viewers… So, we’re going to be wrapping up here, any final thoughts you want to leave with the viewers and listeners?

Dr. Hackenmiller:           Well, I’m always happy to interact with listeners and if they’re interested, they’re certainly welcome to find me on my little website, which is integrativeinitiative.com. I always love to hear feedback on the book and different ways people have used it. So, that’s very fun. I will also share that through the organization, Parker RX America, some other physicians and researchers and I just completed creating a webinar that incorporates all kinds of the most up-to-date studies on nature and health. This one hour webinar is free for anybody to watch. Physicians and healthcare professionals are able to get continuing medical education if that interests them from it. But that’s all available on the parkrxamerica.org website.

Dr. Weitz:                       So, what is that? Parker X?

Dr. Hackenmiller:           Park RX, as in park prescription.

Dr. Weitz:                       Oh, okay.

Dr. Hackenmiller:           Yeah. And that’s another whole conversation, but if people are really interested in some of these studies that we just briefly alluded to, they’re all included in that webinar.

Dr. Weitz:                       That’s great. Good, okay. So, thank you Dr. Hackenmiller.

Dr. Hackenmiller:           Thank you so much for having me. It’s been a pleasure.

Dr. Weitz:                       And your book is available through Amazon?

Dr. Hackenmiller:           It is. So, it’s The Outdoor Adventurer’s Guide to Forest Bathing and it’s available on Amazon and Barnes and Noble and in a number of brick and mortar stores, and available through the publisher, which is Falcon Guides.

Dr. Weitz:                       Awesome.

Dr. Hackenmiller:           Yeah.

Dr. Weitz:                       Great, thank you.

Dr. Hackenmiller:           Thank you so much.




Healthy Biological Aging with Dr. Daniel Stickler: Rational Wellness Podcast 184

Dr. Daniel Stickler speaks about Healthy Biological Aging with Dr. Ben Weitz.

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


Podcast Highlights

4:10  The difference between biological age and chronological age is that biological age or epigenetic age reflects the overall health of the system.  We are talking about health span as compared with life span. One way to think about biological age is that lower biological age is associated with greater levels of function–physiological, physical, and cognitive. 

9:50  We know that as we age, we tend to accumulate damage to our DNA. The telomere test is one way to measure damage to our DNA as a measure of biological age.  Telomeres are the ends of our chromosomes that tend to shorten with age, though we are not sure if telomere length is a result of aging or a cause of aging. Another marker of aging is GlycanAge, which measures glycans that build up in your bloodstream. 

12:25  Dr. Stickler said that when he is looking at markers of aging he will do DEXA scans of patients to look at lean body mass and bone density testing.  EEG studies can be helpful, since certain brain wave patterns are indicative of aging. He will perform skin glycation scanning with immunofluoresence. He will also measure senescent T-cell levels to look at naive (young) vs aged T cells in the blood.

13:05  Dr. Stickler looks at functional mobility and balance. He will look at a bunch of blood metrics like albumin and uric acid levels.  He also looks at hormone levels. They are trying to figure out a way to test intracellular NAD levels.

15:02  The methylation clock was first developed by Dr. Steve Horvath of UCLA and it looks at specific methylation patterns on our DNA.  The Horvath Clock was developed in 2013 by looking at a constellation of epigenetic marks on the DNA that correspond to chronological or physiological age.  Dr. Horvath now has the GrimAge Clock, which is an updated version, which looks at a couple of hundred methylation points on the DNA.  Last September we saw the first study published that showed an epigenetic age reversal, the TRIIM Trial by Fahy, et al, which stands for the Thymus Regeneration, Immunorestoration, and Insulin Mitigation trial.  [Reversal of epigenetic aging and immunosenescent trends in Humans]  Gregory Fahy, Steve Horvath and the other authors showed that their intervention resulted in a reversal of aging of 2.5 years, the first time this has ever been proven. The intervention used a combination of growth hormone, DHEA, metformin, 50 milligrams of zinc, and 3000 milligrams of vitamin D.

24:32  There are a lot of products on the market now that have anti-aging benefits, including Rejuvant, which was developed by Stanford’s Buck Institute on Aging that contains calcium AKG.  Also, there is NMN (nicotinamide mononucleotide), an NAD precursor, and there are also senolytics like quercetin and fisetin.  Disatinib is a prescription medication that induces apoptosis in senescent cells. 

45:03  Dr. Stickler does recommend resveratrol for anti-aging, though it is probably not a powerful stimulator of NAD. He recommends a multivitamin, 5000 IU vitamin D, 2 gm of fish oil, and sublingual or injections of B12.



Dr. Daniel Stickler is the co-founder and Chief Medical Officer at Apeiron ZOH, Inc.  He is a physician for high-performing executives, entrepreneurs, and elite athletes. He consults with Google for wearable technology, epigenetics, and AI in healthcare. He is on the faculty of the Age Management Medical Group and is also a guest lecturer for Stanford University on Epigenetics in Clinical Practice. He is on the board of TruDiagnostic, who he is representing on this podcast today. TruDiagnostic offers the TruAge, which measures your rate of biological aging based on measuring 900,000 CpG sites on our DNA to see if they are methylated or not. Their website is TruDiagnostic.com.

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

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

Today our topic is methylation, epigenetic methylation time clocks. So this is a way to measure biological aging and so we’re going to discuss that and then some of the things that we can do to try to reverse aging. We want to know why in hell we age and what we can do about it and there have been a number of attempts to develop a method to measure biological aging as distinct from chronological aging. In other words, does our health correspond to someone younger or older than our chronological age and what can we do to slow down or even reverse aging and how can we know that our methods are working if we’re engaged in an anti-aging program?   We do know that as we lead our lives, our DNA tends to get damaged and develops various types of defects and perhaps we can measure this in some way. One of the methods that has been around for awhile is measuring the length of the ends of our chromosomes, known as telomere length. Shorter telomeres corresponds to increased biological aging. Recently there’s been a lot of research devoted to developing epigenetic DNA methylation clocks, which measure the extent to which parts of our genes are methylated. Meaning are they over-methylated, under-methylated, et cetera.

                                                We know that methylation can turn on or turn off genes and there are some genes you want turned on and there are some genes you don’t want turned on. So these clocks measure whether specific locations on the DNA, known as CPG sites are methylated or not and Dr. Steve Horvath and Dr. Gregory Hannum are two of the most important researchers in this area who have each developed a different version of the methylation clock.  Now, the practical application of these clocks is starting to become available for use by clinicians and for patients to measure this biological aging and True Diagnostics is a company that’s offering the True Age test, which measures your rate of biological aging based on measuring 900,000 CPG sites on our DNA to see the extent of their methylation.

                                                Today we have Dr. Daniel Stickler joining us today and he’s the co-founder and chief medical officer at Apeiron ZOH Incorporated. He’s a physician for high performing executives, entrepreneurs, elite athletes. He’s also a consultant to Google for wearable technology, epigenetics and in healthcare. He speaks regularly and is on the faculty of the Age Management Medical Group. He’s also a guest lecturer for Stanford on epigenetics. He sits on multiple advisor boards, including the board of True Diagnostics, who I just mentioned, who he’s representing on this podcast today.  So Dr. Stickler, thank you so much for joining me today.

Dr. Stickler:                         Thanks, Doc. A pleasure to be here and look forward to the conversation.

Dr. Weitz:                            Sure. So let’s start with what is the difference between chronological age and biological age?

Dr. Stickler:                         Well, that’s a good question, because we don’t even have a consensus that aging is a true condition. I mean, we see it and we recognize that aging occurs, but some of the more recent literature coming out from the Aging Researchers is that we really don’t have a definition of age. It’s just a … It’s a constellation of markers that we allocate to it, meaning there’s no question, we gradually deteriorate and die and there’s a question is that a programmed response? Is it a gradual breakdown of the physiologic machinery or is it a combination of the two? So it’s a vague area right now, but essentially, chronologic age is just a core marker of anything.

                                                You see 70 year olds that function like a healthy 50-year-old and you can’t say that they’re 70 years old relative to a comparison of the average of that age group, so people have shifted more towards this biologic age. But again, that’s not something … I don’t like the actual metric of age as a metric, whether biologic or chronologic, because it’s really the health of the human system that we’re looking at. What we are gathering right now is all these biomarkers that indicate the health of the human system. I mean, it’s not pleasant to be necessarily told if you’re 70 years old, that you look good for your age. Well, what does that actually mean?   You’re compared to the average of people of that age. So I tend to really kind of shift away from aging as a general statement and like to look at it as more of these are markers of the youthfulness in the system or health in the system.

Dr. Weitz:                            I’ve always liked to think of it in terms of function and I think the goal for myself and a lot of us is how can we have a high level of function ’til close to the end? Instead of expecting that once you hit your 40s or 50s, you just get this gradual decline in your ability to function, in your mental capacity, in your physical capacity, so that as you go through your 60s and 70s and if you’re lucky enough to get into your 80s, you can barely move. You barely have any level of function and the idea of simply living a long time doesn’t sound all that attractive if you don’t have a high level of function.  In the past, we’ve talked about taking that curve where you gradually go downhill once you reach a certain point and trying to rectangularize it so you have a relatively high level of function until you get to the end. I think of biological aging as corresponding to having a higher level of function.

Dr. Stickler:                         Yeah and we’re seeing that. I mean, the markers that we’re gathering together, although none of them are perfect, the constellation of those markers really indicate what you’re talking about is what we refer to as health span. We want to extend health span, not only life span. People don’t have quality of life if their level of functioning is more of an invalid type of aspect or I always look at it as when I get to the point where my body can’t respond to what my brain is asking me to do. That’s a pretty broad spectrum, but it’s when it’s just basic functional aspects that get deteriorated.

Dr. Weitz:                            Right and in terms of function … Over the years, there have been a number of markers of physical function that seem to have a correspondence with healthier aging and there’s been grip strength. I saw a study where just being able to get up from the floor without using your hands and so it appears as though having a certain level of strength and mobility is important for healthy aging.

Dr. Stickler:                         Yeah, I mean, everybody’s looking for the perfect marker right now and, like I said, I think it’s going to be a constellation. I mean, in our longevity program, we call it the Rejuvenation Program, we’re looking at a bunch of metrics right now and we get varying degrees of somebody who’s really good in one area and weak in another, what does that mean? We don’t know. That’s why the more data we gather on that, and we get probably 20 or 30 markers that we use right now and we’re hoping to create kind of a health grade. Not necessarily a biologic age, but a health grade according to how you score in all these areas and it’s going to take some time and some data before we really establish what are the best markers and what grouping of markers is going to be the most telling.

Dr. Weitz:                            So we’re going to get into the epigenetic clock in a few minutes, but what are some of the other methods that can be used to calculate biological age right now?

Dr. Stickler:                         Well, like you said, the telomere testing is one.

Dr. Weitz:                            And what is the status of telomere testing?

Dr. Stickler:                         That’s a good question, because even the people in the aging industry are torn on this, because question is, is telomere shortening a result of aging such as getting gray hair or is it a cause of aging? And that question has come up recently without a good, solid answer. So telomere testing, because of such high variability in the outcomes related to other markers, it’s kind of been pushed aside a little bit. It’s an expensive test. We get it and we get it about every five years. Not frequently. And it’s not the best guide, because it takes so long to change something on that and generally you’re looking at diminishing the rate of loss on those as opposed to trying to extend them, although some of the research now is really focused on doing a genetic insertion or a plasmid that can actually add length to the telomeres versus supplements or peptides that can stimulate the telomerase themselves to add more length to it.   We use another one called GlycanAge. So glycans are substances that build up in the blood over a lifetime and we’re testing this. They have pretty good data based on some preliminary studies they did.

Dr. Weitz:                            Is that like glycation? Like glycosylated hemoglobin?

Dr. Stickler:                         Not exactly. I mean, glycation is a component, but these are glycan products that are found in the blood and they do accumulate over time. It’s a fairly new area. We’ve just started testing with it in the last year and we see huge differences in the epigenetic age and the glycan age, but they have some pretty good data from the…

Dr. Weitz:                            What’s an example of a glycan product?

Dr. Stickler:                         I don’t know the specifics on those.

Dr. Weitz:                            Okay.

Dr. Stickler:                         I mean, there’s several hundred of them that they’re measuring.

Dr. Weitz:                            Okay.

Dr. Stickler:                         We do DEXA scans, so we look at lean body mass. We look at bone density. We do EEG studies, because there’s certain brainwave patterns that are indicative of the aging process. We do skin glycation scanning with immunofluorescence. We do senescent T-cell levels from UCLA to look at the naïve versus aged T-cells in the blood.

Dr. Weitz:                            So these are young versus old T-cells?

Dr. Stickler:                         Correct and we look at functional mobility. We look at balance. We look at stress response in the system. We look at a bunch of blood metrics, so like albumin, we look at uric acid levels. We look at hormone levels and right now, like I said, it’s just a matter of collecting as much of these as we possibly can. NAD levels, if we can figure out a good way to test intracellular NAD levels is a hot topic right now as well.

Dr. Weitz:                            Right. So as a step to get into the biological clocks, what is epigenetics as different from genetics for, especially for the layperson who happens to be listening in?

Dr. Stickler:                         The best way I can put that is that genetics is the hardware whereas epigenetics is the software. What I mean by that is that the hardware doesn’t change. It is … You only need your genetic stem one time, but epigenetics is something that controls the expressions of the genes that you have. That’s why you can have one cell that creates a neuron and another stem cell that creates a lung. This is using the exact same code, so every cell has the exact same genetic code, but the expression of that code is controlled to create the outcome. We have kind of trans-generational and generational epigenetics, which are usually the epigenetics that are written in pen on our DNA so that they’re there and it’s really tough to make any changes in that and then you have the epigenetics that are written in pencil.   Those include not only the DNA methylation, but also histone methylation, which is one of the ways that we know that lifestyle, that supplementation, that medications, all of those things can actually impact and change the expression of genes and this is the area that really people focus on when it comes to the epigenetics.

Dr. Weitz:                            Okay. So what is the methylation clock? This epigenetic methylation clock?

Dr. Stickler:                         So Steve Horvath developed this methylation clock where he started looking at specific methylation patterns. So he took groupings of aged people and looked at a constellation of epigenetic marks on the DNA and what he noted is there were a bunch of these that accumulated over time that corresponded to their chronologic or physiologic age. He developed the Horvath Clock, I think back in 2013. He now has the GrimAge Clock, which is a more updated edition of it. But again, they’re only looking at a couple hundred methylation points on the DNA, so it’s rough right now, although we had the pleasure of seeing the study that came out in September of last year that showed an epigenetic age reversal.  So the prevailing theory at the time, and you even hear David Sinclair had stated it prior, was that epigenetic aging is a one way linear process where you gradually accumulate these over time and it’s not a process that we have any control over, because mostly it was thought that these were the marks that were written in pen that were accumulating.

Dr. Weitz:                            So let me just stop you for a second. So the study you’re referring to is the TRIIM Trial by Fahy and it was published in September of 2019 and TRIM stands for Thymus Regeneration, Immunorestoration, and Insulin Mitigation trial.

Dr. Stickler:                         Yes and they showed a 2.5 year gain or loss of age after a one year period on this trial and they only had nine participants, but still, it was the first time that something showed that age reversal, in a sense, if we’re using this as a marker, is theoretically possible and it excited people. So a lot of the kind of world view of aging began to shift, which was dramatic. In the same month, Sinclair releases his book, so we had the perfect storm of shifting mindset, which was great. And what they used in the trial, I mean, for those of us that do age rejuvenation medicine in practice, what they did in the trial was baby steps. I mean, we have such in depth treatments right now, not only over the counter treatments, but research chemicals, peptides and prescription medications that can be used that are amazing. Even technology. I mean, we use brain stimulation technology and we’re seeing rejuvenation of aging patterns on the brain waves with that.


Dr. Weitz:            This podcast episode is sponsored by Quicksilver Scientific. Quicksilver Scientific is a leading manufacturer of nutritional supplements, featuring enhanced nanoparticle delivery systems, specializing in detoxification protocols, fast acting immune formulas, and next generation longevity products. To learn more or to sign up for a professional account, visit quicksilverscientific.com. Listeners of this podcast can receive 15% off their order by using the promo code Weitz, WEITZ2020 at checkout. And I definitely utilize Quicksilver products in our office and some of their products are just absolutely amazing and there’s nothing like it on the market, so thank you to Quicksilver.



Dr. Weitz:                            Interestingly, as I have sort of been watching the anti-aging research, the predominant, as I see it, in my limited understanding of it, is a predominant theory maybe 15, 20 years ago is our cells die. They don’t get replaced. We lose muscle cells. Our bones degenerate. Our brain cells don’t get replaced. So a lot of the focus was on trying to stimulate growth. So things like growth hormone and testosterone and DHEA and these are really common strategies.  Recently, in the last five or 10 years, the focus seems to be, at least from what I’ve seen, not some of the stuff you’re talking about necessarily, but the stuff that gets out more in the popular literature seems to be all about caloric restriction and fasting and fasting mimicking diet and things that limit damage, but don’t necessarily stimulate growth.  So it’s interesting that they chose growth hormone as one of the strategies.

Dr. Stickler:                         One of the things they look at with hormones is you look at when the body functions optimally. What are the parameters that meet that?  And growth hormone, testosterone, these are two parameters that deteriorate with age.  Is this a natural process?  Sure.  Is it a healthy process? And most of us feel that it is not. We do note that function improves dramatically and markers of aging improve dramatically when hormones are put into healthy, youthful levels. I’m not talking about super physiologic doses in this, but in dosage levels that maintain the health. I mean, growth hormone in itself is a double edged sword. Too little is unhealthy and too much is also unhealthy. So you’ve got to keep in that Goldilocks zone of that.

                                            When it comes to calorie restriction, recent analysis has kind of pushed back a little bit on that too.  I mean, calorie restriction definitely has an impact, but calorie restriction to the point that’s required to match what they see in animal studies is pretty unpleasant state to be in.  I mean, there’s no question that total calorie restriction is beneficial, but to achieve really substantial outcomes, I mean, the hunger that you would experience wouldn’t make life worth living, I don’t think, which is a big impact and now they’re actually leaning towards the chronic calorie restriction is not the best way to do it, but that you do spurts of it.  So intermittent periods of it that allow the body to adjust.  I mean, stress is a good thing for the body. It makes the body adapt and severe calorie restriction is a stressful event on the body.

Dr. Weitz:                            So for those of us who haven’t seen this study, they used the combination of growth hormone, DHEA, metformin, which is a popular drug for diabetes, because it reduces insulin resistance, but they also used 50 milligrams of zinc and 3000 milligrams of vitamin D. One of the things they showed was that there was increased stimulation of the thymus gland, which tends to degenerate with time, and that’s what they mean by immunorestoration. As your immune system weakens, you become more vulnerable to bacteria and viruses, just like older folks are dying at a higher rate from COVID-19. So keeping your immune system robust is important.   We know zinc and vitamin D are crucial factors in immune function, but I haven’t heard too much talk about the potential benefits of zinc and vitamin D from this intervention study.

Dr. Stickler:                         Yeah and I mean, zinc and vitamin D are one of the first line interventions for COVID right now.

Dr. Weitz:                            Yes.

Dr. Stickler:                         From the consensus in the medical community.

Dr. Weitz:                            Yes.

Dr. Stickler:                         And since vitamin D is generally deficient in about 60 to 80% of a given population, it is important to supplement that and the zinc is also a double edged sword, because you can get some zinc toxicity with that.

Dr. Weitz:                            Sure.

Dr. Stickler:                         One of the things we look at is the genetics that relate to cautions with zinc and base our recommendations on that personalized approach with them. But there’s, I mean, when it comes to aging, there’s a lot of available stuff on the market right now. I mean, Rejuvant, which is calcium AKG, which was developed at Stanford’s Buck Institute on Aging, was developed by Brian Kennedy and it’s got really amazing aspects to it.

Dr. Weitz:                            Can you repeat that? That’s not something I’m familiar with.

Dr. Stickler:                         Rejuvant is the brand name of it.

Dr. Weitz:                            Okay.

Dr. Stickler:                         But calcium AKG, alpha-ketoglutarate.

Dr. Weitz:                            Right.

Dr. Stickler:                         We know deteriorates over time with aging and replacing that has, I mean, it impacts about five of the nine hallmarks of aging that need to be targeted. You have NMN, which is over the counter, and you have vitamin D, of course. You have senolytics now. I mean, supplemental senolytics. I mean, we have prescription senolytics, which take out those zombie cells that accumulate over time that the body can’t get rid of and they secrete toxins. They take up metabolic aspects of the body and when we can reduce them, we dramatically change the outcome. We use the senolytic formula that has quercetin and fisetin in it, which are two different over the counter senolytic compounds that have shown really impressive benefits. I mean, quercetin has been around forever and…

Dr. Weitz:                            It’s also a zinc ionophore and so we’re using that in our immune protocols these days.

Dr. Stickler:                         Absolutely and they found quercetin because they ran a study through a bioinformatics platform and they said, “These are the pathways we want to hit, what’s available that works on this?” And it kicked back to quercetin and dasatinib. I mean, dasatinib is a prescription, but these are two senolytic compounds that have a profound impact on aging. The key is really knowing how to take these in combinations that can create the outcome that you’re looking for.

Dr. Weitz:                            I looked at a PowerPoint presentation that Dr. Horvath had and one of his first slides shows a 71-year-old guy who’s an amateur body builder and he looks very good for his age, but it says on the slide that if you use clinical markers of aging such as body mass index, grip strength, blood pressure, he will probably be considered young for his age, though he is probably old according to molecular biomarkers such as the epigenetic clock. Dr. Horvath says that the message is that … This is what he says on the slide. That the message is that molecular markers will not be misled. What did he mean by that?

Dr. Stickler:                         Well, again, this is an area that what we’ve found, and you know, it’s funny because I found it in several of my clients, because I work with some professional athletes and their epigenetic age markers were, some of them 10 years older than their chronologic age and these were very fit, healthy people. There was a follow up study that was recently published looking at athletes and epigenetic age and they tend to be older. I know I was … I did a podcast not too long ago with Ben Greenfield and he got tested and he came out older than his chronologic…

Dr. Weitz:                            I saw it. I think his age is 38 and he was 43 or something.

Dr. Stickler:                         Yeah and so the study though that came out, some of the markers that they’re using to establish epigenetic age were methylated, which means the genes were turned down or turned off and it was interesting, because they picked out like three or four of these in particular that actually code for better health in the sense that it reduces cancer rates and heart disease. So even though the accumulation is over time, there’s benefits there. So are we truly measuring that? And that’s the issue right now, and this is what I love about True Diagnostics is they’re looking at 900,000 methylation points. How many of those do we know about? Well, maybe 5% of those that we actually have information on.   So what they’re doing is not only storing this or keeping this report together, but as data accumulates, it will update that report for you so that you can contribute to it too. You provide feedback on other aspects of like lab work and your social behaviors and suddenly we can start narrowing this down. I mean, this is the age of bioinformatics and the more data we have, the more accurate we can get with what we’re doing. This epigenetic age for these athletes and these really significant exercisers, I don’t think is a reflection of their true physiologic age. So it has to be taken with an understanding of what you’re actually measuring there.

Dr. Weitz:                            So how does the test determine if a gene is methylated, if it’s methylated too much to a point where that J shape curve now is going the opposite direction or not methylated enough, does it take into account all that? Can it?

Dr. Stickler:                         You’re asking me a technical question that’s more for the biochemist, but I don’t believe it goes into specifics of the degree of methylation. Just the specific markers they’re looking at, is there a methyl group added to that marker on the DNA is the primary focus.

Dr. Weitz:                            Right, so interesting, in the Functional Medicine world, one of the things that we’ve been looking at for a number of years is potential for methylation based on doing genetic testing and then seeing if somebody has certain genetic markers like the methenyltetrahydrofolate reductase gene and if they’re heterozygous or homozygous for two defects, they may not be able to methylate and then we may use specific methylated, activated B vitamins to try to stimulate that methylation.  But then we’re also cautious to try to make sure we don’t over-methylate, which certain genes that are over-methylated can lead to increased breast cancer risk, et cetera.  So I’m wondering if there’s a way that this methylation testing could be used for feedback, say, I have a patient, they are homozygous for MTHFR and we give them methylated B vitamins. Is there a way that we can then tell are we properly methylating their genes? Are we under or over methylating them? Can we titrate the dosage?  I’m wondering if there’s something like that, that is or might be available.

Dr. Stickler:                         Another great question, because again, we don’t have the answer to that. How does the body’s ability to methylate affect the aging methylation of the DNA? And there isn’t an answer. I mean, again, using genetics, and I run a genetics company and we test MTHFR 677 and 1298, and I have seen clients that had homozygous on both of them, which means that they have less than 25% function of the MTHFR, yet they have normal homocysteine levels and most of the time it’s because they’re consuming adequate methyl folate in the diet.  And looking at these polymorphisms, which is what we’re testing in, in genetic testing right now when we’re talking about 23 and Me, when we’re talking about the Apeiron test, Ancestry, they’re looking at polymorphisms and these are not mutations.  I think this has been taken to the point where it’s very misunderstood by the general public.   These are variations that have inherited through your ancestry that are designed to optimize your system for the environment that you’re in.  The problem is now we move around all over the world and we’re not in that ancestral environment that our genes are optimized for, so we have to make adjustments to our environment to match our genetics. This is nutrigenetics. It is basically eating for your genes as opposed to nutrigenomics, which is eating to change expressions of your genes.  I really want to see this whole idea of these polymorphisms as mutations to kind of go away, because it really is … It’s putting a lot of fear into people that essentially are unnecessary. So really understanding not only the genetics, but the markers that occur with that and the lifestyle of the person that has them. I mean, I have plenty of homozygous MTHFRs that I’m just like, “You don’t need any exogenous treatments on that. You’re doing well with what you’re eating, apparently, because you don’t have the expression that is showing.”

Dr. Weitz:                            Right. Yeah, good. Yeah, we gauge a lot of the recommendations based on things like homocysteine levels, et cetera.

Dr. Stickler:                         Yeah.

Dr. Weitz:                            So what is the difference between the True Diagnostics True Age test and the Horvath clock? It’s using the Horvath clock or it’s…

Dr. Stickler:                         There are aspects of it in there. Also, Dr. Hannum’s and the Duke clocks that are being used. So it’s a combination of them and it’s really designed to be the largest database of epigenetic marks on the market. I mean, honestly, we can’t give you a great deal of knowledge with these reports yet. We can give you an overview of the knowledge that we’ve accumulated, but over time, as more and more people do this, we’ll be able to dive deeper and give you insights into what’s happening. The great thing is we have all these markers now and so now that we know that we’re looking at these markers, we can run it through the AI that we have that will mine this stuff and say, “Here’s all the people that are smokers. What do you see in common with them that’s not in non-smokers?” And so we can start diving into the bioinformatics, which is going to be huge for people. I mean, this is truly the next three years, we’re going to see such advances in epigenetics and I think a lot of the genetics stuff is going to fall by the wayside from that point.  It’s not that we won’t need genetics, but we have to look at it as just another biomarker and the epigenetics is going to be really the top piece that we’re going to be focused on.

Dr. Weitz:                            So as I understand it, the Hannum clock used blood and measures methylation on white blood cell DNA, right?

Dr. Stickler:                         Right.

Dr. Weitz:                            But the Horvath clock or the newer version of the Horvath clock, uses DNA not just from white blood cells, but from other tissues.

Dr. Stickler:                         Mm-hmm (affirmative).

Dr. Weitz:                            Is that improvement? Your test basically is using the white blood cells, right?

Dr. Stickler:                         Right, and that’s always a question, because like I said at the beginning, every cell has different methylation. Every cell type in the body has a different methylation pattern to it, but what we’re looking at are these common denominator methylation patterns and generally you’re going to get correlation with the epigenetic markers that have been selected with like a buccal swab where we’re looking at epithelial cells from the skin or we’re looking at the blood or we’re looking at salivary accumulation. Whatever we’re looking at, the idea is that there is tissue specific methylation patterns, but then you’re also going to get universal methylation patterns that can be derived from any cell type that you get and that’s the focus of the epigenetic testing right now.

Dr. Weitz:                            So how can clinicians use this True Age test?

Dr. Stickler:                         Well, the way I use it in practice is that I will get the epigenetic age. We’ll do an intervention for a year or a series of interventions, and then we will retest. I have to say, right now, and this is being reported by several of the epigenetic companies, is that this year in particular, relative to people who got tested last year at this time, we’re seeing an acceleration of aging and what we are assuming this is relating to is the stress of this whole COVID-19 issue.

Dr. Weitz:                            Sure.

Dr. Stickler:                         It’s impacting people in ways that they don’t fully understand. I mean, the stress of anything that changes your habits in any way is a stressor on the body. We see these elevations in cortisol levels, despite the fact that we’re working with people to mitigate these, so I think that…

Dr. Weitz:                            People are eating worse. They’re exercising less.

Dr. Stickler:                         Yeah.

Dr. Weitz:                            I saw the CEO of Kellogg’s on TV bragging about the fact that more people are having breakfast cereal for dinner. They’re afraid to have time with other people, so they have less social connections. There’s a whole series of things along with the stress.

Dr. Stickler:                         Absolutely. Yep.

Dr. Weitz:                            So what are some of the things that negatively affect our aging? I noticed on the True Age test they mention exposure to heavy metals, pesticides and other toxins.

Dr. Stickler:                         Right, there’s eustressors and then there’s mal stressors. The ones that … A eustressor is good, because we have a certain kind of bandwidth that we function in and within that bandwidth, our gene expressions are set to really optimize the human body’s function within that realm. Little excursions outside that realm create stressors. Just like if you haven’t exercised in six months and you go back to exercise, suddenly you’re exceeding the body’s baseline of that comfort zone and creating a stress response. Is that a bad thing? No, that’s actually a good thing. It’s a hormetic response that the body responds and says, “Hey, this is an unfamiliar environment. I have to make adjustments to create a healthier, more resilient, anti-fragile human,” and so you get beneficial effects in that way, but there are some stressors that will take you too far out of that zone.  Those can be things like heavy metals. Those can be things like smoking. Those are parameters that don’t have really an established eustress type of benefit that the body will respond in a positive way and make you more anti-fragile. It actually drops you down outside of that familiar zone and makes the system weaker.

Dr. Weitz:                            I notice you also mentioned adrenal cortisol dysregulation as pointing a role in biological aging.  Is it in general, can you say, is it more of a lower, flattened cortisol curve or increases in cortisol that tends to correspond to worse aging?

Dr. Stickler:                         I mean, it’s not a … It’s that double edged sword again. Too little is not good and too much is not good. So you want to kind of keep within certain parameters with slight excursions outside of your familiar zone to create the positive response.

Dr. Weitz:                            Right.

Dr. Stickler:                         But most of the time … We do a lot of work with adrenals and we look at diurnal variations in the cortisol secretions and what we’ve found generally is we tend to blame the adrenal gland for it and the adrenal gland is nothing but the messenger. We find that when we work with stress response as far as what the perception of stress is and how the brain responds to it and how it stimulates the adrenal gland, that’s the win for the mitigation of this where we train through bio feedback mechanisms to do that.   Now, using adrenal adaptogens and that, they’re nice bridging pieces for it, but really you’ve got to get to the real central aspect of what’s creating the stimulation or lack of stimulation to the adrenal itself.

Dr. Weitz:                            Bringing up nutritional supplements, you mentioned a few already. We talked about zinc and vitamin D. You mentioned quercetin or quercetin, I’m not sure how it’s supposed to be pronounced, and that calcium supplement you mentioned. What other nutritional supplements … I think you mentioned nicotinamide riboside or…

Dr. Stickler:                         NMN.

Dr. Weitz:                            NMN, okay. You think that’s a preferred version over NR?

Dr. Stickler:                         Again, that’s something that we don’t have good data on.

Dr. Weitz:                            Okay. Okay.

Dr. Stickler:                         I mean, one of the biggest problems is people report doubling or tripling of NAD levels and when you see that, always question the study, because what we care about is absolute levels, not change from baseline, because somebody that’s got a 1% of where they should be and they triple that, they’re at 3%. What kind of boost is that? That’s not.

Dr. Weitz:                            Right. Yeah, yeah.

Dr. Stickler:                         So looking at the ideal way to do this, and really, I’m not a big fan of the NIDIVs. I mean, they give you a short burst, but the body gets rid of that in the next 24 hours. I think a lot of what people experience as a stress response that creates a euphoric feeling and they perceive that they’re getting benefit from it. So what most people are looking at is how do we chronically supply new NAD to the cells and so the debate is do we do intramuscular injections daily? Do we do IVs? Do we do supplementation? Should we do NR or NMN? There’s going to be some data coming out from James Clemons’ lab that I think is going to probably shift us more towards using NMN iontophoresis where we actually put a patch on, an electrical patch, that we put the NMN in to that will absorb based on electrical charges and we can do that even twice a day or a couple times a week and create the higher levels of NAD in the cells, which is really the ultimate goal in that.

Dr. Weitz:                            Interesting. What about resveratrol?

Dr. Stickler:                         Resveratrol is … I wouldn’t look at it from a standpoint of what they were initially looking at it. I mean, they were looking at it as a SIRT receptor stimulant and creating more NAD, but I think resveratrol actually has antiaging benefits.  Are they from what we think we are saying?  I’m not sure.  I think resveratrol for somebody who is interested in age rejuvenation, and we add that to our senolytic formulation.  I think that there is some benefit, we just don’t know what it is right now and I think it’s kind of minor, but we’re still looking at what’s the complete complement that can create the system?  One thing that people tend to neglect is a daily multivitamin.

Dr. Weitz:                            Right.

Dr. Stickler:                         We have so many micronutrients that are deficient when we look at our nutritional intake and our nutritional needs and so I have a core that I put everybody on. It’s a foundational multivitamin, and not an excessive one. If some people are taking like six or seven multivitamins a day. I’m just like if you’re taking more than two, you’re probably taking too much. Just eat healthy, take a small dose of it. The vitamin D, and we use a 5000 IU or D3 plus K2 fish oil, so we do use fish oil and this is because of epigenetics. I mean, there’s always debates about is fish oil good for you?  Is it bad for you?  Different outcomes in the same week from the research.  But what we do know from epigenetics and nutrigenomics is the chronic intake of fish oil really up-regulates metabolic gene activation and down-regulates pro inflammatory gene expression.  So we do use fish oil, usually just two gram a day, and we also recommend B12 supplementation and either through injections or through a sublingual.  Those are essentially our core, what we call foundational supplementation and then from that point on, we go into more bio-specific or more longevity focused or performance focused lines of vitamins, but we just have that foundation of we pretty much recommend for everybody as a core.

Dr. Weitz:                            Okay. What about specific diet? Has there been any work on … I noticed on the True Diagnostic website, Mediterranean diet was mentioned. What about Mediterranean diet versus vegan versus paleo or et cetera? Do we have a sort of…

Dr. Stickler:                         It again comes from [crosstalk 00:47:57].

Dr. Weitz:                            Depending on the person? You know?

Dr. Stickler:                         Yeah. I mean, it’s genetics again. When we look at gene expressions based on dietary patterns, there is no perfect human diet. I mean, if you take somebody that’s got an ancestry with [inaudible 00:48:17].

Dr. Weitz:                            We’re getting a weird echo.

Dr. Stickler:                         Yeah, there’s actually a lawnmower outside.

Dr. Weitz:                            Oh my gosh.

Dr. Stickler:                         Sorry. Yeah, didn’t expect that.

Dr. Weitz:                            Okay, not much you can do about that.

Dr. Stickler:                         Yeah. But if you have somebody with ancestry of Inuit Eskimo, their genetic polymorphisms that they’ve inherited are optimized for that environment, so a high fat diet is going to work very well for them. If you have somebody who is southeast Asian and more of a starchy diet works for them. Most of us in the United States have some kind of a core background of a Mediterranean heritage and around that, so European, Mediterranean, you’re going to find that the genes respond best to the components of the Mediterranean diet. A fish-based, high vegetable and significant intake of olive oils, we’re finding that the markers that we look at in aging, we are personally, from an anecdotal experience, finding that seems to correlate best with the outcomes.

Dr. Weitz:                            Yeah. So essentially as we’ve been talking about in functional medicine for a long time, you’ve got to match the right diet to the right person. What medications have been shown to slow down or reverse epigenetic aging?

Dr. Stickler:                         Well, the first one I talked about earlier was the dasatinib. That is a senolytic that’s really powerful and what we typically do is we’ll do…

Dr. Weitz:                            Is there another name for that? For those of us who are not familiar with it?

Dr. Stickler:                         Not that I’m aware of.

Dr. Weitz:                            Okay. Okay.

Dr. Stickler:                         [crosstalk 00:50:06] is, but I can’t think of it right now.

Dr. Weitz:                            Okay.

Dr. Stickler:                         That’s the generic name. D-a-s-a-t-i-n-i-b.

Dr. Weitz:                            Okay and what was that drug originally developed for?

Dr. Stickler:                         It was used as a … I can’t remember exactly, but it’s been around for many years. This was the one that they found in the bioinformatics platform that found that it limited that, but the way you use that is you typically take it for two days, like a Monday and a Tuesday for two to three weeks in a row and then you stop and then six months later you may take it again.  The thing with senolytics is they tend to target specific organ types. So the skin, the liver, the fat. You will target different areas that it will reduce the senescent cells, so you want to use combinations of those. We also have rapamycin. Rapamycin is wonderful. This was developed as an adjunct for people that have had kidney transplants to suppress the immune system.

Dr. Weitz:                            Right.

Dr. Stickler:                         But we use it in lower doses and dasatinib is a [M4 00:51:25] inhibitor, which is one of the aspects that we know creates more youthful expression in the body as inhibiting M4 over time. But the other thing they found is that, when we talk about senescent cells, and I think this is the most important thing that rapamycin does, is it mitigates what are called SASPs that are secreted by senescent cells and those are the toxic elements that are secreted by these cells. So the rapamycin seems to mitigate that and you don’t do a lot of this. I mean, it’s like a once a week dose of two to three milligrams that is effective in that and you have to watch for side effects with it.

                                                The other one is metformin. I mean, classic. Metformin is one of those ones that anybody focused on longevity, we typically work with on the metformin. It is a true M4 inhibitor. It’s one of the most potent ones that we have available to us and a lot of people will say, “Well, doesn’t inhibiting M4 limit the ability to grow muscle?” Which frailty is a hallmark of aging, but all the studies that have been done have been using metformin as an individual piece. Now, with our clients, we will use things, other things like testosterone or growth hormone, releasing hormone, and we monitor DEXA scans to see what their lean body mass is doing over time. We’re finding that the metformin is not indicative of muscle growth in that way, so we like the metformin in that regard.

                                                You’ve also got some peptides, which don’t have a great deal of research behind them, but they’re finding that they do have significant impacts on aspects of aging. I mean, we look at things like mitochondrial rejuvenation and mitochondrial biogenesis and we have things like GW501516, which is not a peptide, but a research chemical. We have things like SS31, which is a fairly new one. We have things like MOTSC, which are peptides that have the substantial impact on mitochondria. Those are also ones called [inaudible 00:53:53] which we don’t have a great deal of data on and there’s things like [Hepatilon 00:53:57] which from the Russian researchers, they have a six and a 12 year study using Hepatilon. We have things that can rejuvenate the thymus like Thymoline or Thymosin alpha, which boosts the immune system.

Dr. Weitz:                            What about BPC157?

Dr. Stickler:                         BPC157 I really like. I love the oral form for the gut. I mean, you talk about something that heals the gut almost 100% of the time, [inaudible 00:54:27] oral BPC. Talking about working on really neuro-protection or soft tissue recoveries, BPC is wonderful for that. It accelerates the recovery for that. I don’t find that it happens very well with the oral, but the oral is awesome for the gut, for sure.

Dr. Weitz:                            Cool. Good. So I think that pretty much concludes my questions. Any final thoughts you want to leave us with? And then give us information about how to find out about this test as well as anybody who would like to get ahold of you?

Dr. Stickler:                         Yeah. The one thing I always like to emphasize is that everything starts with lifestyle, first and foremost. I mean, and that’s what I tell people, 90% of what I do in my program is lifestyle orientation and you can’t focus on the standards of just nutrition and exercise. I mean, if you’re not addressing stress, if you’re not addressing brain health, if you’re not addressing even mindset. I mean, mindset is a huge piece. Love and relationships, a huge piece. So all of these lifestyle components play together and trying to isolate them into silos and thinking you’re going to have an impact is naïve. So really working with all aspects of the way you function is really important.

                                                Now, to get the epigenetic test and really to be part of something that’s pretty exciting, go to truediagnostics.com and you can find out how to order the test. You can order it direct, even. You don’t have to have a physician, but I recommend having a physician that can help you interpret it or a health coach that can help you interpret it. I mean, there’s probably more non-physicians that understand epigenetics better than the majority of physicians. I mean, I think physicians are moving into a world where it’s going to be sick care only and because 90% of our health is lifestyle, I think you’re going to see the functional practitioners, the coaches, all of this are going to be the go-to’s for really optimizing health and maintaining your baseline. So for anybody who wants to look into us, we have … Our website is apeironzoh.com, so it’s a-p-e-i-r-o-n-z-o-h.com. Apeiron Zoh is great for limitless life and that’s really our mission is to help create that limitless aspect of what’s possible.

Dr. Weitz:                            Great. Thank you, Dr. Stickler.



Supercharge Your Metabolism with Steph Lowe: Rational Wellness Podcast 183

Steph Lowe discusses How to Supercharge Your Metabolism with Dr. Ben Weitz.

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Podcast Highlights

4:30  The Low Carb Healthy Fat (LCHF) diet.  The high carb, whole grain diet promoted in western countries leads to blood sugar issues, inflammation, and weight gain. We should focus on eating foods that come out of the ground, off a tree or from an animal–foods that have the least amount of human interference and the highest nutrient density.

5:56  Healthy fats include olive oil, olives, oily fish, nuts, seeds and avocado.  We should avoid pro-inflammatory seed oils like canola, corn, and soybean oil.

9:04  Saturated fats have been demonized for five decades, but the idea that saturated fats cause heart disease has been disproven in the literature.  Steph supports the use of foods like coconut oil, grass fed butter, and ghee, as well as grass fed animal fats found in meats.  Our brain is 25% saturated fat and saturated fats are important components of our cell membranes and are the building block for hormones.   She also does not think that we should be eating a huge plate of steak with a slab of butter on top.  Her version of LCHF is actually largely plant based has a lot of fiber and she recommends eating six or more cups of vegetables per day. If we look at the Blue Zones, the areas in the world where people live the longest, people think they’re vegan, but while they don’t eat a lot of meat, they do eat eggs and seafood in small amounts and the common denominator is plants.

12:07  You get better blood sugar control and better long term energy when you rely more on fats than on carbs.  When you eat a lot of carbs, esp. high refined carbs, you are on a blood sugar roller coaster.  When you reduce the carbs and eat more healthy fats, you get fewer cravings for carbs.

20:11  After high intensity exercise Steph believes in ingesting some extra carbs, such as fruit in a smoothie. She finds that eating carbs prior to working out may cause digestive issues, since digestion is impeded by exercise.  The carbs after exercise do not need to be within 30 minutes but can be somewhat after that.

32:10  Some of the negatives of following a low carb diet are that people may have emotional attachments to foods like bread and therefore have trouble following it, so she recommends an 80:20 rule where they can follow it 80% of the time and deviate 20%.  There are also negative health consequences of following an imbalanced low car/high fat diet where you are eating a number of coffees with cream and eating a big steak with butter and cheese and very few vegetables. You will be missing out on essential vitamins, minerals, and important phytonutrients. Steph believes in eating some fruit like berries and some sweet potatoes and lots of vegetables. Having some sweet potato can make it easier to sleep.  It is also not healthy to get too extreme about following a ketogenic or low carb diet and being obsessed with your macros, your online diary, your finger pricking or your breath ketones.  It is better not to be too extreme.



Steph Lowe is a sports nutritionist and yogi from Melbourne, Victoria and she is the founder of The Natural Nutritionist and author of Low Carb Healthy Fat Nutrition.  Her website is TheNaturalNutritionist.com.auHer podcast is Health, Happiness, and Human Kind.  On Instagram Steph is @thenaturalnutritionist.

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

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

                                Hello Rational Wellness podcasters, thank you so much for joining me again today. Today our interview is with Steph Lowe, who’s a sports nutritionist and Yogi, all the way from Melbourne Victoria in Australia, and she’s the founder of The Natural Nutritionist and the author of the Low Carb Healthy Fat Nutrition book. And, so we’re going to talk about the low carb high fat diet and especially as it relates to metabolism, so thank you so much for joining me today Steph.

Steph Lowe:       Awesome to be here, thank you.

Dr. Weitz:            Good, so maybe you could start by telling us your own personal journey, how you came to become a nutritionist, and how you found now the low carb high fat diet?

Steph Lowe:       Yeah, for sure. So, I mean, like a lot of people in the industry I do have my own personal journey with food, which started back as a teenager when I decided I wanted to lose weight to achieve this happiness that I thought that being thin would create.

Dr. Weitz:           Did you achieve happiness?

Steph Lowe:       I did not. I cut all fat from my diet, I became very disordered, and my poor mother was so worried that she took me to see a dietitian. And I still remember sitting in the dietician clinic thinking how amazing this woman’s job was, that she gets to sit here and talk about food, so I definitely know that the seed was planted then. Not surprising, when you cut all the fat from your diet you start to have mental health issues because your brain is predominantly fat.  So I then experienced what was never diagnosed but certainly felt like depression, and I met someone who convinced me to cut gluten from my diet. This is over 15 years ago, I wasn’t a nutritionist, really no one knew what gluten was and how to maintain a gluten free approach, but I was pretty desperate to feel better that I was willing to try anything.  And for me personally, the difference was night and day.  So, I started to have a lot more clarity of focus, a lot less issues with regulating my mood that I was really inspired to learn more.  So, it started as gluten free but it quickly became understanding more about the healing power of food, and when you learn that for the first time it’s pretty mind blowing that we haven’t been taught that from a young age.  So, I was inspired to go back to uni and study my post grad in nutrition, so I had what we call- 

Dr. Weitz:           We learned about the food pyramid, right?  12 servings of bread and pasta every day.

Steph Lowe:       Yeah, exactly. And in Australia, and it’s obviously the same way you are, that’s what we define as healthy, and we certainly over the last five or more years have really understood how wrong we had it. So, I set myself a mission to unpack a lot of the myths in the nutrition space, especially the food pyramid and how fats have been demonized for five decades, so I got my qualifications as a nutritionist and started The Natural Nutritionist in 2011. So, that was a while ago now if we think about how rapidly the real food space has evolved in that time, but I was a triathlete doing long course distances like 70.3s or half Ironman, and naturally that will is really high carb.  I remember going for long bike rides and being told to take multiple gels that just make you feel sick, and when you read the ingredients the logical mind would definitely tell you that it doesn’t make sense to be fueling with all this sugar.  So, I was determined to find another way.  So, I do work with a lot of long course athletes to this day, but my niche is different as my journey has evolved because, as you would know, real food movement and certainly the low carb movement is pretty big now which is amazing, because we need to be having this conversation and moving away from the food pyramid.

Dr. Weitz:            So, tell us about the low carb high fat diet and why should someone follow it?

Steph Lowe:       Yeah, so there’s a lot to discuss there because my version of LCHF, it stands for lower carbohydrate healthy fat, so lower as in context to the food pyramid. So, you said before 12 serves or sometimes we see six to eight serves of whole grains per day, but regardless, that’s 400 or more grams of carbohydrates per day. And what that creates is what we see in western countries, we see not only blood sugar issues and cravings, and the weight gain that occurs with excess carbohydrates, we’re now seeing chronic diseases that are all inflammatory in nature, that have origins in excess refined carbohydrates and sugar. So, it’s a disaster. Versus lower carbohydrate healthy fat, we’re actually talking about real food. So, food that comes out of the ground, off a tree, or from an animal, and the latter is an option of course, you don’t have to eat animal products, but we’re looking for food with the lowest degree of human interference, because we know it all have the highest degree of nutrient density, the opposite is true to right, so if we see food or we look at food that has a high degree of human interference it’s nearly always going to be really nutrient poor, and that’s not what our body needs.

Dr. Weitz:            So, what are healthy fats?

Steph Lowe:       Healthy fats should be predominantly Omega-3s. So, our anti inflammatory fats that come in whole food forms like olive oil, olives, oily fish, nuts, seeds, avocado, for example.

Dr. Weitz:            Olive oil and avocado aren’t necessarily high in Omega-3s.

Steph Lowe:       Well, they certainly contain Omega-3s and they are these beautiful whole food forms. Avocado, for example, naturally contain some omega six, but we don’t want to be eating too many omega sixes, but the real issue are the pro-inflammatory seed oils like that we used through the 80s and 90s.

Dr. Weitz:           Which are those?

Steph Lowe:       Well canola is a big one that still really popularized to this day, but it’s really any- 

Dr. Weitz:           Now, some people like canola because they say it’s higher in Omega-3s.

Steph Lowe:       Yeah, look and certainly the vegan movement really celebrates canola oil. I personally disagree with that, because we know that the optimal ratio for health is a one to one ratio between our Omega-3s and omega sixes. So, we’re not saying don’t eat any omega six, but using it as your predominant oil can’t makes sense because you would be creating a pro-inflammatory environment, and there’s incredible studies in the literature around the role of that one to one ratio.

Dr. Weitz:            Well, that one to one ratio is kind of extreme, I mean, that’s not I don’t think generally accepted.  I’ve certainly heard people say the one to one ratio is maybe what our paleolithic ancestors ate, but if you look at most of the normative values for, say, Omega-3 to six ratio, they typically say under four to one is considered normal, is considered optimal.

Steph Lowe:       Depends on your health goal, it’s like our blood test reference ranges. You can certainly set yourself a goal of “normal”, or we can look at what optimal is, and everyone has their own goals around what they want their health and their longevity to look like.

Dr. Weitz:           One to One is tough to achieve though.

Steph Lowe:       Do you think so?

Dr. Weitz:           Oh yeah, I need-

Steph Lowe:       On a whole food diet?

Dr. Weitz:           I think so. I think so, because most of the fats are still not going to be Omega-3s, olive oil is basically omega nine, and there aren’t that many foods that are really high in Omega-3 other than fish oil, flax seeds, so it’s hard to get one to one in Omega-3. I know I measure mine regularly and I try to keep it at two to one, but to do that I have to consume about eight grams of fish oil a day. So, it’s not easy to get to one to one, there aren’t that many foods that are super high in Omega-3, even if you have grass fed beef it’s still not predominantly Omega-3, it’s higher in Omega-3, but… Anyways, but so what are other healthy fats besides olive oil, avocado,…

Steph Lowe:       So, then we need to look at saturated fats, which naturally have been demonized for five decades. Now, it’s been disproven in the literature, but unfortunately it’s a myth that is hanging around quite strongly. And, again, I think it’s perpetuated by specific food trends, but if we, again, think about what food has the lowest degree of interference, I support the use of things like coconut oil, grass fed butter, and ghee. And then there are additional grass fed animal fats for those that are inclined. We only need to be having about 20% saturated fat from that component of healthy fats, but we do need to acknowledge that when we look at what saturated fat is, by weight 25% of it is in our brain, it’s a really important component of all cell membrane, and is a foundation building block for hormones.  So, we need to stop demonizing saturated fat but, at the same time, we don’t need to be eating just a huge plate of steak with a slab of butter on top. I think there’s lots of extremes in the health space, whereas my version of LCHF is actually largely plant based, where eating about six, if not more, cups of vegetables per day on a good day. And that’s what everyone can agree on, almost everyone, I’m not talking about the carnivore here, but almost everyone can agree on the role of a fiber rich diet with plants predominant. If we look at the Blue Zones, for example, people think they’re vegan, they’re not really, they don’t eat a lot of meat but they do eat eggs and seafood in small amounts, but what the common denominator is, is plants. And I think that’s an important conversation, because if you look at the food pyramid it doesn’t really celebrate vegetables; it celebrates bread and cereals, and almost everyone I meet is probably eating between one to two cups of vegetables per day. And so, it’s well under our goal of that six cups.

Dr. Weitz:            Yeah, it’s hard to get a lot of vegetables in, most people are not used to eating vegetables and they’re not super tasty or super rich, so you have to get used to eating a lot more vegetables to get yourself off that rich, super palatable, standard American, standard Australian diet.

Steph Lowe:       Well, yeah. The addictive food, you’re right, when you’ve got poor blood sugar control and you’re addicted to carbs, you’re not going to crave broccoli, it’s going to taste quite bitter and you’ll find it more of a chore to eat, versus one of the major immediate benefits of LCHF is blood sugar control. So, you can do way more than a 12 hour fast without being hungry, you can eat every four or five hours, you don’t have cravings, you don’t crash at 3:30, or 4:00 o’clock, and your taste buds change. So, food that once you thought was delicious will taste ridiculously sweet or unpalatable, and then vegetables will start to taste really nice, and pumpkin will taste sweet, and you’ll actually really enjoy that food, it just takes time to adjust, like anything.

Dr. Weitz:            And, so you get better long term energy because you’re relying on fats rather than getting carbs.

Steph Lowe:       That’s the thing, carbohydrates, especially refined carbohydrates, cause that blood sugar rollercoaster. So, it’s a disaster during the day for energy and productivity, but by the afternoon it becomes pretty impossible to deal with when we’re having cravings and really struggling to stay awake, for a lot of people were relying on more caffeine, perhaps, whereas LCHF you have just beautiful stable energy, stable blood sugar, great satiety, and my clients they will definitely notice that shift in their cravings, which is, that’s proof in the pudding. We don’t need these carbs and high sugar foods to prop us up anymore we’re burning fat that energy.

Dr. Weitz:            Are there certain specific patients or categories of patients who maybe don’t do as well with a higher fat diet? I’m thinking of perhaps people with unfavorable lipid profiles and a history of heart disease, or maybe people who have one or two copies of the apoE4 gene.

Steph Lowe:       Yeah, so there are definitely some more detail that we need, and that’s why I think testing is really important. So, if you’re going to embark on a low carb diet there’s lots of different tests that you would do, and certainly your blood lipid profile and some genetics could be fascinating. Now, the thing is about how we have interpreted a blood lipid profile over the last five decades is, we’ve done that very incorrectly, we’ve just basically look at total cholesterol, and if it was high we’ve assumed heart disease risk, which we know is hugely incorrect.  So, the first thing that we actually want to look at is what the inflammation is, or is not. So, we look at triglycerides less than one, which would pretty much almost always rule out any heart disease risk, but we do want to dig deeper than that.  So, we look at the total cholesterol to HDL ratio- 

Dr. Weitz:           Triglycerides less than one, maybe in the United States that would be under 100, I think.

Steph Lowe:       Yes.

Dr. Weitz:           Yeah, okay.

Steph Lowe:       The units are always going to catch us up, but the ratios are fine. So, when you look at a total cholesterol to HDL ratio we want at 3.5, and that tells us that even if we have LDLs, or high LDLs, that they were large and fluffy, so they protect the heart. Whereas the higher that total cholesterol to HDL ratio is, and certainly five and above, will tell us that there’s small dense particles that carry plaque and that’s problematic for cardiovascular health. So, we definitely need to be interpreting our blood lipid panel differently, and then it will-

Dr. Weitz:           And even better would be to get advanced lipid profile that includes lipid particle size.

Steph Lowe:       Yeah, you can do testing now, can’t you, so rather than just interpreting and using correlated information, you can do advanced profiles and look at your lipids.  Anyone that’s, say, older who might have more risk factors like family history or carrying extra weight around the middle, you can do Lp(a), a coronary calcium score, there’s many more diagnostics that are far more indicative of cardiovascular disease health, than just looking at total cholesterol.

Dr. Weitz:           Yes, for sure. So, how is your low carb high fat diet different than, say, paleo or ketogenic?

Steph Lowe:       Yeah, there are some obvious similarities in that with focusing on real food, so that’s very much the Paleo model. But, the thing is with keto is, by definition it’s- 

Dr. Weitz:            By the way, real as opposed to refined, or processed?

Steph Lowe:       Yeah, exactly. Food that comes in a packet or a box.  So, keto is quite low carb, so it’s somewhere between 25 and 50 grams of carbs a day usually, and more typically the lower end of that, especially if someone’s got Type two diabetes or metabolic syndrome, but that is quite low and should be prescribed when someone has a metabolic condition, and we would know that by diagnostics, again, so glycated hemoglobin or HbA1c, the higher it is, the more say on the other side of 5.3 it is, the more you’re insulin resistant.  And so then the obvious solution to that is to address the insulin resistance by lowering the carbohydrate, but if you have a HbA1c of 5.3 or lower, like a five, you don’t need to be only eating 25 to 50 grams of carbs per day.  If you’re a male athlete who does some intensity, you could be eating up to 150 grams of carbs a day, so that’s more than three times a keto diet, but for some people, not everyone, but they’re still experiencing all the benefits from a clarity of mind, a concentration, a performance, a recovery, and a longevity benefit, and it’s a lot more food and a lot more sustainable. So, I think it’s important that it’s really individualized.

Dr. Weitz:            Does it matter the time of day people eat their carbs?

Steph Lowe:       There’s a lot of different theories on that, as you would know, so what we want to understand is a lot more about the exercise program or schedule, because certainly high-intensity exercise is naturally going to be utilizing muscle glycogen as the fuel. And so, many people feel like they recovered better if they eat whole food carbs like fruit in a smoothie the hour after a high-intensity workout, the same doesn’t apply for anything aerobic in nature because that’s naturally a more fat burning session.

Dr. Weitz:            What about carbs before the exercise to fuel the exercise?

Steph Lowe:       There are some people that feel much better if they do pre-load with carbohydrates before high-intensity exercise, but the thing about high-intensity exercise is that it’s really- 

Dr. Weitz:            By the way, what do we mean by high-intensity exercise?

Steph Lowe:       Well, there’s lots of formulas, but as a general rule we use the MAF formula, so it’s Phil Maffetone formula, and so 180 minus your age would tell you where essentially that crossover point is. So, higher than that would be considered high-intensity, whereas lower than that would be aerobic or low intensity. So, it’s a formula that you use, 180 minus your age.

Dr. Weitz:            So, if I were doing a traditional heavy weight training session where I’m doing sets of, say, maybe eight to 10 reps with as much weight as I can, and maybe taking a minute or two rest in between. Is that a high-intensity or are we talking about doing maybe a circuit training where you’re going from one exercise, or one set to the other with very little or no rest, and maybe lighter weight. So, are those both high-intensity, what’s high-intensity?

Steph Lowe:       It all depends on the heart rate response, so everyone is going to be really different.

Dr. Weitz:           So, it all depends on the heart rate?

Steph Lowe:       Yeah, they both sound like they’re potentially high-intensity to me, because of the volume of weight in the first example, and then of course the circuit nature is nearly always high-intensity. But, then it becomes really individual, which is why we tend to use heart rate, so it’s not so subjective. Some people use RPE which is that rate of perceived exertion, but it’s very vague, we need to know how to interpret that.  And so it’s not a clear definition, whereas, if you get to the end of a session you know what your average heart rate is, you can call it, so you know what you really need to refuel with.

Dr. Weitz:            And you’re saying for high-intensity you don’t necessarily need carbs before, but you should have carbs afterwards to refuel your glycogen?

Steph Lowe:       Yeah, the thing is about that, if you have it prior, a lot of people find I start to get digestive issues, because when you start exercising naturally your blood flow goes outwards, so to heart, lungs, legs, extremities, et cetera. So, you don’t have the blood flow coming into the gut, so we tend to find our digestion it’s compromised, and we see many examples of that certainly in Ironman races where people experience a lot of unnecessary gastrointestinal distress, and it can happen in much more mild versions of that when people eat before exercise.  If it’s later in the day and we’ve been up for many hours and we’re training in the evening, and lunch has been hours ago, and dinner is not for another couple of hours, then usually we’re going to feel better if we’ve eaten, but the same wouldn’t apply to the morning, because if we wake up we haven’t depleted any muscle glycogen, we’ve only depleted a little bit of liver glycogen overnight, and that’s irrelevant for training. And so, we don’t have anything to replenish, and we feel more often much better without having anything prior.

Dr. Weitz:            And so, is it important to get a certain amount of carbohydrates within a certain period of time after the exercise, do you believe in that glycogen replenishment window concept?

Steph Lowe:       I do, but it doesn’t need to be 30 minutes or anything ridiculous, because that’s the other thing, the same applies to our digestion on the other side of high-intensity. Almost everyone will say to you, they don’t feel like eating straightaway, and that’s because their body is diverting the blood flow outwards again it’s not coming into the gut. So, we tend to want to wait until we’ve actually cooled down, maybe do your stretches have a shower and get yourself organized, and then think about eating, rather than running to the kitchen for fear of not recovering, which is a myth that’s been perpetuated by the protein powder industry.  So, I think it’s going to be quite individual, but I’d say roughly an hour.  And it’s only between 30 to 50 grams of carbs usually for a female up to–it’s not bowls of pasta or anything like, again, we might have been told.

Dr. Weitz:            What about endurance athletes who maybe are going to go on a two hour bike ride?

Steph Lowe:       Yeah, so it depends on how fat adapted you are or are not. If you’re just starting out and you’ve been following a high carb diet, then naturally you’re not going to be able to do two hours without fueling because your body is very sugar burning in nature, so that’s why we see people needing to have gels or Gatorade or different versions of that. But, when you’re fat adapted, and in fact, a good barometer of how fat adapted you are, is when you can do two hours fasted, when you have the ability to do that on water, lemon, and salt, our natural electrolytes.

Dr. Weitz:            Should fat burning athletes maybe have a packet of peanut butter or almond butter, in other words, should they have the fat version of the carb load in the middle of their training session?

Steph Lowe:       So, it depends on the goal of the session. So, certainly if the session continues to be aerobic in nature, so under that 180 minus your age, and you want calories, you can definitely be doing that from fat sources. It’s just going to depend on whether that’s practical for the type of exercise you’re doing, there’s nothing wrong with having some carbohydrates after that two hours, but what we don’t want to choose is gels or Gatorade which play with our blood sugar and spike and crash us. So, that’s why we tend to look for more natural carbs or products like Generation UCAN, or SFuels, because they’re designed to support that fat burning metabolism, but give us a small amount of carbohydrate to help us extend those long-

Dr. Weitz:            What are those products you just mentioned?

Steph Lowe:       So, Generation UCAN is made from a modified corn starch, so it’s been heat treated in such a way that it has a slower release, so it’s a slower release in terms of that carbohydrate, a bit like how you do low GI.  We want it to be slower release, and so we can fuel off those carbs rather than spiking and crashing and needing more. And SFuels has a similar concept, they use some MCT oil in there, as well, which we know increases fatty acid oxidation, and they’ve got their own proprietary blend but the concept is quite similar in terms of it being a fuel to help us for that longer session, without impacting our metabolic goals and our fat burning capacity.

Dr. Weitz:            Is this high fat training program catching on among athletes, if we were to say survey athletes in the Olympics, what percentage of them you think are using a high fat fueling program?

Steph Lowe:       I don’t know if the Olympics is the right example because that a lot of high-intensity exercise there, so-

Dr. Weitz:            Okay, so what’s a right example?

Steph Lowe:       I think that’s why we see it happening in sports like Ironman Triathlon, because it is a really perfect example of where you need to be fat adapted, because some people are out there for 17 hours. So, it’s not possible to consume that many grams of carbohydrates every hour upon hour when you’re out there for seven to 17 hours, and so it really does suit the more aerobic athletes, ultra runners, triathletes. Now, I’m not saying that people in the live Olympics can’t do it because they’re all going to do aerobic sessions as part of their training, but I just don’t think it is as popular as they are yet. It should be because it is the best approach for longevity and managing inflammation, which naturally helps recovery and longevity, but we just need to acknowledge that it would need to be applied, very specifically for someone who’s doing a lot of high-intensity exercise.

Dr. Weitz:            Yeah, how does low carb/high fat benefit metabolism?

Steph Lowe:       So, if you’re eating a food pyramid and you’re eating those 400 grams of carbohydrates per day, your body relies on sugar so you’re in that constant sugar burning state, when we burn sugar we also produce those reactive oxygen species and they are pro-inflammatory, so that’s why we see issues with recovery, issues with our inflammatory markers, and then unfortunately those chronic lifestyle diseases that happen after time. Whereas fats burn clean, there’s only byproducts of carbon dioxide and water, so there are no inflammatory species, reactive oxygen species, and we, again, create this fat burning metabolism which means that we have fat to burn as our fuel, so as our Diesel, versus sugar which acts more like petrol.

                                And then we have those benefits that I was talking to you about before, like the blood sugar control and the satiety, but it really is the inflammation that’s the most important piece because, again, we know that there’s so many lifestyle diseases that have that inflammatory nature, and most of them could be avoided, like type two diabetes doesn’t need to exist. It is a lifestyle disease that comes from a high carbohydrate diet in someone that’s genetically inclined to become insulin resistant, and I meet people who still think that type two diabetes is a life sentence. And to me that’s tragic that no one’s told them that there’s a dietary fix to put that disease into remission, they think it’s a life sentence of taking medication and running the risk of lots of side effects which come from the medication, and the increase in medication required when the weight continues to go up, and their diabetes continues to get worse. That’s a real tragedy of this century.

Dr. Weitz:            Oh, absolutely. Yeah, I’m a chiropractor and I also do the Functional Medicine, and so when patients come in for chiropractic, and we had a patient a couple of weeks ago, and I was helping him with his back and then I noticed that he had some blood sugar issues and was pre-diabetic, and I asked him what he was going to do about his pre-diabetes and he said, “Oh, my doctor said, just wait until the blood sugar gets higher and then we’ll put you on medication.”

Steph Lowe:       And so we have, unfortunately, a reactive health care system, whereas you and I are very proactive. So, a blood sugar issue can be addressed with a lower carb diet, so you don’t need to wait until you’ve been diagnosed with diabetes to fix it, and I think-

Dr. Weitz:            Oh, it’s absolutely insane but our system which is controlled by insurance companies actually doesn’t recognize that concept, so his doctor probably can’t even bill for pre-diabetes, so we can’t really under the insurance system do anything until the patient can get a diagnosis of diabetes.

Steph Lowe:       I know, and so that’s why you go to a doctor when you’re quite sick, and perhaps a chiropractor or a nutritionist when you’re looking to improve your health, right?

Dr. Weitz:            Exactly.

Steph Lowe:       Because we would obviously be able to be much more proactive than that.

Dr. Weitz:            And it’s insane to just get put on medication and not change your diet and lifestyle for a diseases caused by diet and lifestyle.

Steph Lowe:       And there are many examples of that. I think it’s the same with, unfortunately, what we’re seeing with the Alzheimer’s and Dementia epidemic. That has come partly from the low fat era, it’s a metabolic disease, and we’ve depleted our brain of its primary building block, we shouldn’t be surprised that we’re seeing this but it’s absolutely heartbreaking that people are going through this, when they’ve been on statin drugs totally stopping their cholesterol production for years, if not decades, and no one’s really talking about this until the year 2020, and that’s another tragedy that we could have avoided.

Dr. Weitz:            Oh, absolutely. Another factor there is the incredible amount of toxins that get into us from our environment, from the food, from the air, from all the chemicals being dumped into our environment. And so, those toxins-

Steph Lowe:       Again, lifestyle.

Dr. Weitz:           Yeah, absolutely.

Steph Lowe:       For sure.

Dr. Weitz:           Yeah.

Steph Lowe:       I agree, and I think there’s so many lessons. I’ve got a little one, she’s 18 months, and I think to myself, “I don’t know what the world is going to look like when she’s my age, but I hope that we won’t have as many regrets as we do now.” Like when we look at, say, my parents who are in their 60s and 70s, unfortunately I think that generation have been the unluckiest so far in terms of health, because they’ve live through the low fat era, they’ve lived through the polypharmacy era, they’re the ones that have been taking proton pump inhibitors, statin drugs, blood pressure medication, et cetera, et cetera, 16 pills when they get up in the morning. And no one has taught them about the power of food and what you can do to actually come off many of those medications, whereas with my knowledge my children won’t be taking medications, and hopefully that will continue. And it’s important because Big Pharma unfortunately are not interested in our health, they’re really just interested in profit, largely.

Dr. Weitz:            Oh absolutely. Unfortunately I’m in the same generation with your parents, but not following the same path.

Steph Lowe:       Yes, exactly, of course there are many exceptions to the role, but you probably see it in your friends. Do you have friends or people, friends of friends that are taking lots of medication, and I think that’s something that-

Dr. Weitz:            Yeah, it’s tragic.

Steph Lowe:       … could be… Yeah, again, avoided.

Dr. Weitz:            A polypharmacy route, and then the medications counter the side effects of the other medications.

Steph Lowe:       I know, and it continues, that’s how someone could possibly end up on 16 meds.

Dr. Weitz:            Oh, absolutely. So, what are some of the drawbacks, what are the negative aspects of following a low carb high fat diet?

Steph Lowe:       Yeah, so I said to you off air that I think because people like bread, and I’m joking but I’m not because people have these real attachments to certain foods. Now, the way I approach things is 80, 20. So, when I work with a client one on one, I’d never tell them I could never eat bread again, if that was their thing, of course we talk about quality and maybe looking at homemade examples, or how to do it better, what to eat with that bread, et cetera, for blood sugar control. But, ultimately I think if we take an approach to low carb that’s balanced, there aren’t going to be many drawbacks because in that 20% of your week you could technically eat whatever you want.   Now in my 20% I’m still not going to drink heaps of wine and eat rubbish food, but that’s each to their own right, I’ve just learned over the years that sort of food and those choices would make me feel horrible, and I’m just not willing to pay the price, but I don’t make that decision for anyone else. It needs to be sustainable and that’s the main goal.

Dr. Weitz:            Right, so I think one of the important things to emphasize is, there are versions of following a low carb high fat diet whereas, when we were talking off air, the person’s having a big steak with butter and cheese and very few vegetables, and so they have a very unbalanced high fat low carb diet. And that’s where I think you’re going to get into problems with missing out on important phytonutrients, and others essential vitamins and minerals that you would get from having a high plant rich low Carb high fat diet.

Steph Lowe:       Yeah, I agree with you, and that’s why I think keto has gone a bit wrong. I meet a lot of people doing keto, and the amount of dairy that they’re eating and the number of coffees with cream and drinking, it’s really misguided that we need to be even consuming dairy at all, there’s no nutrient that we’re going to miss out on if we don’t eat dairy. Now, if you like it any preference quality and you treat it as an occasional food, then go for your life, but I’m talking about people that have cheese with everything for their fat, and cream and every coffee, and so on and so forth. But, really, vegetables are an afterthought or, as I said earlier, we want this to be plant based, you can eat fruit, you should be eating berries, and you can eat sweet potato.  And you asked me before about what time we can eat carbs, there’s a lot of people that feel like if they do have some sweet potato at night they sleep a lot better because of that serotonin and melatonin relationship, and that’s something that is good to trial and error, as well, because you don’t want to do keto or low carb and then not be sleeping, because the impact of poor quality sleep is horrific, that’s going to take 10 years of your life.

Dr. Weitz:            Right, so there are potentially some negative hormonal consequences of having too few carbs.

Steph Lowe:       There’s negative hormonal consequences of being extreme, honestly, people, I think it’s the diet industry, we’re so used to being 1200 calories, eat less, move more, or starve yourself to be skinny, or only chicken and broccoli to put on muscle, and there’s all these things that we’ve seen over the last 20 or 30 years. And then when you jump into keto or low carb, you become so obsessed about your macros, your online diary, your finger pricking, or your breath ketones, or whatever it might be, that you lose that capacity to see the forest for the trees, because you want to take an approach that’s sustainable. And I just don’t think being extreme is the answer ever.

Dr. Weitz:            So, you’re advocating on your high fat program that people are essentially running on ketones, but you don’t advocate measuring ketones through urine or blood or breath.

Steph Lowe:       You can, so I’m not not advocating, I’m just not… I just think, for many people, it’s not going to suit them, and those that want to do it can do it, and that’s awesome, but we just need to realize that certainly initially we can get some good numbers and understand when we hit that 1.5 to three millimoles of that therapeutic ketosis. But after that, if we’re really efficient at using ketones we’re burning them, so they’re not in the bloodstream, so we might get low ketone readings, but we fast for 16 hours, we only eat, every five we can do two hours aerobic training fasted and there are all these incredible barometers, no inflammation in the blood markers, et cetera. So, there’s so many other barometers that I think give us much more powerful information beyond trying to get so obsessed about every day being in this goal, or in this range, when perhaps we’re actually burning those ketones for fuel.

Dr. Weitz:           So, if people want to measure ketones, should they measure them in blood or should they do the breath testing that’s now available?

Steph Lowe:       I think both can really be good, I many years ago I bought one of the breath ketone meters, and I found that quite easy to use and quite practical, it’s certainly more affordable than doing it via blood, like people that are finger pricking all day will start to really chew through those sticks obviously, so there’s a few variables that one would consider. I don’t mind either, do you have a preference?

Dr. Weitz:           No, not necessarily, I think the blood is probably more accurate, but less convenient.

Steph Lowe:       Yeah, I’d agree.

Dr. Weitz:           Yeah, so you also advocate intermittent fasting, a 16 hour fast as part of your program.

Steph Lowe:       It depends on the individual, so if it’s a female who’s got some hormonal issues going on we wouldn’t be jumping into 16, eight. We know that the sweet spot for women is 12, 12 or 14, 10. We have to acknowledge that most of the- 

Dr. Weitz:            So, you’re talking about 16 hours of fasting, eight hours window of eating, or 10 hours of fasting and 14 hours-

Steph Lowe:       So, If I said 14, 10, it would be a 14 hour fast with a 10 hour eating window, and we find that’s the sweet spot for women usually. Most of the research that’s done around intermittent fasting is in college aged male athletes, so we don’t want to take that data and apply it to women. Now, there are some women that have been doing low carb for many years that are either postmenopausal, so they can jump into 16:8, or those that are really well versed and have a good hormonal balance as referenced by what is a healthy menstrual cycle, and they might do 16:8 twice a week, but I don’t prescribe more than that for a female.

                                But, men tend to have more free rein here, due to that lack of hormonal fluctuation across the month, so they can do 16:8, but like anything you want to qualify it. So, you don’t go into the gym and start swinging 80 kilo kettlebells, so you want to start where you’re at and then build on from there. So, it’s the same with fasting, you want a minimum of 12 hours, so don’t eat from 8 until 8, and then you might add on from there and just make sure you’ve got good blood sugar control, craving control, and that the day doesn’t unravel because you fasted too long, you don’t have your head in the pantry by four or 5:00 PM.

Dr. Weitz:            And what are the advantages of adding this intermittent fasting?

Steph Lowe:       It’s just the perfect opportunity to accelerate that fat burning, because when you’re not eating your body moves into that fat burning state, so you’re really accelerating your ability to be fat adapted, and then 16 hours is incredible because we start to promote autophagy which is that cleaning out of dead and disease-like cells. So, it’s like PAC-MAN goes in, mops up all the potential issues that could be occurring, we know that’s great for managing inflammation, resting the gut, for anyone that’s got digestive issues it’s magic, and then there’s some really powerful longevity benefits that we see with fasting when it’s done appropriately.

Dr. Weitz:            Great, and of course exercise is a great way to promote [inaudible 00:40:47], often not mentioned.

Steph Lowe:       Yeah, very true. What’s the three eat introduced strategies that are about longevity? I think we’re still waiting for a magic pill, but so far there isn’t one. It’s real food, it’s sleep, it’s movement, it’s fasting, it’s nature- [crosstalk 00:41:07]

Dr. Weitz:            Actually, the latest anti-aging compound I’m hearing about is Spermidine.

Steph Lowe:       Oh, really?

Dr. Weitz:            Yeah, there’s always a new one, so…

Steph Lowe:       There is, there is. When we will probably continue to be magic pill orientated, but I think when we go back to the proven answers, they’re right in front of us so far, which is good to know.

Dr. Weitz:            Yeah, which is sleep, rest, healthy diet, exercise…

Steph Lowe:       Time in nature, time with loved ones.

Dr. Weitz:            Time in nature, yeah. Okay, thank you so much for joining us Steph, how can listeners and viewers get a hold of you?

Steph Lowe:       Yeah, my online home is thejnaturalnutritionist.com.au, and I hang out mostly on Instagram @thenaturalnutritionist.

Dr. Weitz:            Okay, that’s great. Thank you so much.

Steph Lowe:       Thanks, Ben.



GI Map Tutorial with Dr. Tom Fabian: Rational Wellness Podcast 182

Tom Fabian, PhD discusses How to Interpret the GI Map Stool Test with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on October 22, 2020.

[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

2:01  Quantitative PCR vs Whole Genome Sequencing.  The GI Map stool test uses quantitative PCR, which is the best way to detect specific, clinically relevant bacteria or other microorganisms. It also tells you specific quantities, which is important to detect overgrowth and to allow you to see if levels are increasing or decreasing over time.  It can also allow you to detect microorganisms, like H. pylori, that are in pretty low concentrations.  Whole genome sequencing technology is better for getting an overall picture of the microbiome, but it is not good for clinical diagnosis and does not include any physiological markers, like calprotectin.  While quantitative PCR is highly accurate, the ability to detect something comes down to the choice and the design of the primers. Primers are designed for specific, individual strains or organisms.

12:50  The team at Diagnostic Solutions has designed the GI Map stool test with a focus on both research and clinical experience and it helps clinicians to understand the relationship between physiology and the gut.  You can see three common dysbiosis patterns: 1. Insufficiency dysbiosis, 2. Inflammatory dysbiosis, and 3. Digestive dysfunction.  Insufficiency dysbiosis is a lack of beneficial bacteria. And there can be a combination of these three.

15:56  There is some confusion that stool tests do not provide information about the upper gut but only about the lower gut/colon.  But this is not true.  There are a number of bacteria on the GI Map stool test that are more common in the upper gut, including H. pylori, which grows predominantly in the stomach, and the bacilli class of the Firmicutes phylum that includes species like streptococcus, lactobacillus, enterococcus and staphlococcus, which grow predominantly in the small intestine.  These species thrive in higher oxygen environments like the small intestine, whereas the colon is more anaerobic. Bile is present in the small intestine and the species mentioned above are also bile tolerant.  The Proteobacteria phylum, which we tend to think of as inflammatory microbes, are also much more prevalent in the small intestine than the large. Pseudomonas is linked to inflammation in the duodenum and it is also linked to issues with gluten and other food sensitivities.  Also, pseudomonas thrives on simple sugars and amino acids, which are prevalent in the small intestine.  They are also very bile tolerant and you can find these in the bile ducts and in the gall bladder.  Some of the data as to which species thrive in the small intestine comes from Dr. Mark Pimentel’s group, which mapped the microbiome of the small intestine, the Reemagine Study, which was published earlier this year.  [Mapping the Segmental Microbiomes in the Human Small Bowel in Comparison with Stool: A REIMAGINE Study]  

In the colon, the Clostridium class of the Firmicutes phylum tends to dominate and one of the key species is Faecalibacterium Prausnitzii, which is a major butyrate producer.  The Bacteroides group of the Firmicutes phylum is a major group in the colon. Akkermansia is a well known species in the Verrucomicrobia phylum, which is also one of the key groups in the colon. They thrive in an anaerobic environment and tend to thrive on complex fibers, as well as the mucus ecosystem, and the mucus layer in the colon is much thicker than in the small intestine.

22:17  Here are a list of organisms seen on the GI Map that are predominantly in the upper GI Tract: 1. Enterotoxigenic E. coli, 2. Vibrio Cholerae, 3. Yersinia enterocolitica, 4. Cryptosporidium, 5. Giardia, 6. Norovirus, 7. H. pylori, 8. Lactobacillus, 9. Bacillus, 10. Pseudomonas, 11. Staph, 12. Strep, 13. Citrobacter, 14. Klebsiella, 15. Fusobacterium, 16. Candida. 

Here are a list of microorganisms on the GI Map that are predominantly in the lower GI tract/large intestine:  1. C. difficile, 2. Enterohemorrhagic E. coli, 3. E. coli 0157, 4. Enteroinvasive E. coli/Shigella, 5. Entamoeba histolytica, 6. Bacteroides fragilis, 7. Clostridia, 8. Akkermansia mucinophila, 9. Faecalibacterium, 10. Methanobrevibacteriacea, 11. Microsporidium, 12. Blastocystis hominis, 13. Dientamoeba Fragilis.

25:47  H. pylori’s presence can be clinically relevant, esp. if it’s high, even without any virulence factors present.  Tom said that the presence of H. pylori is often associated with reduced stomach acid.  If the virulence factors are present, the two that stand out as most significant with the most research are cagA and vacA.  Virulence factors tend to work together, so the more that are positive, the more likely they will be significant.

33:26  Dr. Sam Rahbar, Integrative Gastroenterologist in Los Angeles, asked if bacteria like Klebsiella and Citrobacter fruendii are found in the stool, should these be seen as markers of dysbiosis or are they potential pathogens that should be targeted for treatment? Dr. Fabian explained that they are opportunistic pathogens that can exist in the gut without any effects or can potentially be part of a pathogenic process. For example, Klebsiella can be associated with certain autoimmune conditions, including inflammatory bowel disease, psoriatic arthritis, and ankylosing spondylitis.  [Here is one article discussing the connection between Klebsiella and Crohn’s and Ankylosing spondylitis:  The Link between Ankylosing Spondylitis, Crohn’s Disease, Klebsiella, and Starch Consumption.]  While a pathogen in the gut may be a trigger for autoimmune disease, it’s not yet clear whether eliminating this bug will improve the autoimmune condition. 

38:58  If a potential pathogen like H. pylori is present as either high in red or a number above the <DL that is black color on the report, whether it creates a problem for a patient depends upon the overall health of the gut and the microbiome.

43:00  If Pseudomonas is high on the stool test, that does not imply that it has colonized the large intestine. This bacteria mostly colonizes the small intestine and the stomach. 

43:57  If the secretory IgA level on the GI Map is low, that is an indicator that the bacteria in the microbiome that produce butyrate, like Faecalibacterium, are at low levels.  While it is a good idea to build up these beneficial butyrate producers in the microbiome with probiotics or prebiotics and more fiber in the diet, that can take some time. In the short term, some clinicians will recommend supplements like colostrum, Saccharomyces boulardii, L-glutamine, and even vitamin A to increase secretory IgA levels.

46:06  Calprotectin is a marker of inflammation in the colon.  If calprotectin is low and the patient appears to have a lot of gut inflammation, the inflammation is probably in the upper GI tract.  For example, Pseudomonas has been shown in research to cause inflammation in the upper GI tract. Candida is inflammatory and if often colonizes anywhere in the upper GI tract, even the oral cavity.  If you have H. pylori, which can cause inflammation in the stomach, you will not see an increase in calprotectin.

52:14  Inflammatory Dysbiosis.  There are particularly inflammatory bacteria in the Protebacteria phylum and some are in the subclass called Gamma Proteobacteria.  These include: E. coli, Salmonella, Shigella, Vibrio cholera, Yersinia enterocolitica, Enterobacter, Morganella, Pseudomonas, Citrobacter, Klebsiella, and Proteus. A lot of them have been shown to secrete the inflammatory type of Lipopolysccharides.  Dysbiosis in the mouth, like with periodontitis, leads to the increase of pathobionts like Klebsiella and Enterobacteria, which can then translocate to the gut.  If bacteria like Klebsiella are able to colonize the gut, this can activate the inflammasome.  If there is a lack of beneficial bacteria in the gut, then bacteria like Klebsiella will be more likely to colonize.  When you see Klebsiella, you should look at the patient’s oral health. You also want to look at indicators of low stomach acid, such as H. pylori or are they taking proton pump inhibitors.

55:48  Digestive Dysfunction Dysbiosis.  Elastase is a marker for pancreatic insufficiency.  If we see H. pylori, then often stomach acid is low. Also if we see overgrowth of Pseudomonas, Enterococcus, or Staph or Strep or if we see Faecalibacterium low, these indicate that stomach acid is low.  Research suggests that if Kebsiella is overgrown, this is a bacteria that often comes from the oral cavity or the respiratory tract, esp. if there is low stomach acid.

1:16:33  Are Blastocystis Hominis and Dientamoeba Fragilis pathogenic organisms (parasites) that should be treated or normal parts of the gut that should not be treated?  I recently interviewed Dr. Jason Hawrelak, well respected Australian Functional Medicine Doctor and expert on gastrointestinal disorders and the microbiome, and he said that these protozoans are extremely common and are generally irrelevant to that person’s symptoms. [Rational Wellness podcast episode 169 on Gut Parasites with Dr. Jason Hawrelak.] Dr. Fabian explained that Blasto and D. Fragilis are not commensal, since they are not present in the majority of patients tested. When we see them present, they are often part of a digestive dysfunction pattern. These protozoans are often seen in the context of things like H. pylori, candida, and general overgrowth. 



Tom Fabian, PhD is an educator and medical consultant with Diagnostic Solutions Laboratory to help clinicians learn to better interpret the GI Map Stool test. Clinicians can sign up for a professional account to order the GI Map stool test by going to DiagnosticSolutionsLab.com

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

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. Our topic for tonight is we’re taking a deep dive into the GI MAP stool test.  Tonight, we have Tom Fabian, PhD of Diagnostic Solutions and so I’m sorry for everybody who’s missing the [Biden vs Trump] debate.  And I’m sure there’s going to be a lot of poop discussed, but we’re going to have a much higher level discussion of poop tonight. So Tom, thank you for joining us tonight and I’m sure we all have a lot of questions about our favorite functional medicine stool test, and so we hope to develop some clinical skills to be able to better help our patients.

Tom Fabian:       Absolutely. Well, thanks so much Dr. Ben for inviting me to join your discussion group. And I look forward to interacting with everyone here, and hopefully giving everyone a better understanding of GI MAP and how to better apply it in clinical practice. All right.  So I’m going to go ahead and fire up the PowerPoint here.  So first I’ll just share my screen.  So tonight we’re going to be focusing on a deep dive into GI MAP. So this presentation is meant to be flexible since this is a very interactive group.  So Dr. Ben, if you have any questions in the meantime, definitely feel free to interrupt, or if anyone has anything that I’ve found over, they don’t really understand. I’m happy to stop and we can just cover whatever we can cover in the amount of time.

Dr. Weitz:            Maybe I’ll ask just one quick question since there’s a lot of different types of stool tests that are out there. Can you talk about the difference between the technology used for the GI MAP stool test, which is quantitative PCR, and how this is different than say whole genome sequencing, stool testing?

Tom Fabian:       Sure. Yeah, so they are different technologies for different purposes and you get different types of information. So starting with meta genome sequencing–that’s a DNA based method as is qPCR, at least the type that GI MAP is using. So we’re looking at detecting the DNA, for specific organisms or for genes, specific genes. So for example, in the instance of toxin genes, you can basically detect any aspect of DNA either way with either type of test but that’s kind of one of the areas where the similarity stops. So metogenomic is used, especially if you look at research for kind of a broad overview, a survey of the microbiome and the genes of the microbiome encodes to get a sense of the overall community. So there’s a lot of ongoing research in that area to figure out of the hundreds of species that you can potentially detect with that method. What does that actually mean? So that’s a lot of ongoing research and there’s really not a whole lot of conclusions we can make definitively about most of the species.  A lot of them just have not been well studied yet, of course we’re learning more every day.  So that’s one of the advantages of sequencing as you can potentially get kind of a more high level, bigger picture of the ecosystem.  But the challenge is if you want to measure specific clinically relevant organisms particularly quantitatively, so you can see what their levels are, whether they’re increasing or decreasing over time and with treatment, you really need a more quantitative method.  And especially when you look at sort of the composition overall of the microbiome, so you have very abundant species all the way down to species that are barely detectable. So there’s a really wide range of abundance levels for different species. Some of the species, in fact, quite a few of them on the low end of that range are clinically significant classic example would be H. pylori. H. pylori is mostly in the stomach by the time it’s in a stool sample, it’s usually pretty low concentration if it’s present.

                                So that’s difficult to pick up these low abundance species in typical kind of commercial based sequencing, because the ability to detect these low abundance organisms and to detect them in a way that’s at least reasonably quantitative depends a lot on the number of sequencing reads. So you may have heard the terms, sequencing depth, sequencing reads and that’s expensive to do that. So most of the commercial type testing doesn’t really go that deep. So you get a picture of the more abundant ones at the top, and that may include some of the ones in the middle, but oftentimes cannot identify the ones that are on the low abundance and of things very accurately. So that’s really where qPCR shines. In fact, it’s kind of like a technology that you want to use to find those needles in the haystack. And I’m actually going to go through a few examples here in this presentation. And I do have a couple of slides about qPCR as well, I can elaborate on that just a little bit, but that’s one of the main differences. Also a lot of the metagenome sequencing companies. In fact, I’m not aware of any right now that also include physiological markers. So to really get some insights clinically into what’s going on in the gut, you need to know both sides of the equation, microbiome, as well as what’s going on with digestion inflammation and things like that.  So you get a more complete picture, even though you have fewer markers because these types of tests focus on organisms that have been established to be clinically relevant and also these physiological markers. And then with that careful quantitation, then you can start to really see patterns and trends and things like that. And I kind of like it to say, you’re just looking at blood glucose levels on our standard lab test or a hemoglobin test. If all you got was plus or minus, higher or low, or sort of high, medium, low, that gives you a kind of a rough idea of what the levels are, but hemoglobin A1C of 5.6 is very different clinically from say 7.5. Although, in some measures, both of those might be considered kind of on the high end. So quantitation really is important in that’s part of a really a big part of what makes a marker more clinically relevant. So that’s kind of, sort of at a high level tip of the iceberg. What’s some of the key differences are.

Dr. Weitz:            Okay.

Tom Fabian:       Technologies.

Dr. Weitz:            Good.

Tom Fabian:       Okay.  You can tell from the title here. So we’re going to really focus on clinical insights, how to get some clinical insights out of GI MAP, particularly by connecting the dots.  So that’s really where the more advanced users get the most clinically relevant information out of GI MAP has learning how to connect those dots on the test with what’s going on clinically as well. And then of course, that’s all the point of all that is so you can get better clinical outcomes by really understanding what’s going on in the gut. So really in terms of connecting the dots, you have to know something about the dots, and which ones are most important and then how to connect them. And that really has to do with the microbial ecosystem as well as GI physiology and those two interact heavily. I’m going to go through a couple of examples in this presentation as well for basically illustrating how those dots are connected and can really yield some great clinical insights.

                                So in terms of qPCR which is also known as quantitative PCR or real-time PCR, so sometimes we’ll see ages RT-PCR on the purpose of that, the reason it was developed in research and is also used a lot clinically now is it’s really good for highly accurate identification and quantitation of microbes. I have heard some sort of… When you look at social media and you look at some of the comments that are out there, there’s a lot of misunderstanding of methods. So I’ve heard some sort of competing companies and other prominent folks that are out there in the community say that GI MAP uses 16 sequencing, which is pretty far from what we actually use. So we actually again use qPCR, quantitative PCR, but that it’s ability to identify something accurately comes down to the choice and the design of the primers. You can design primers that are highly specific for an individual strain, for example, you can detect right down to the strain level, for example, that’s how we detect pathogenic strains of H. pylori, C. diff, some of the other pathogens, is based on detecting them at the strain level.  So again, it’s especially good for low abundance microbes, there’s also the issue of absolute versus relative quantitation and it’s a little bit technical. I don’t want to get into that right now, unless anyone has questions, but absolute you’re looking at how much of that organism is present per say, gram of stool versus sequencing, which is all relative to what else is there. That could be a problem because if something goes up, that can make it look like something else is going down, when in fact it may be the same level, it’s just that it’s all relative. So it treats every sample as if it’s the same amount.  I do have one quick figure here to kind of illustrate that. And that’s actually in this figure from this particular article, which is quantitative microbiome profiling links gut community variation to microbial load. So it was published in a prominent journal, Nature, a couple of years ago where they compared relative versus quantitative approaches and they actually found that the absolute quantitation, especially when they looked at a Crohn’s disease patient was extremely important because without looking at absolute quantitation, you miss the whole picture of general decrease in microbes in the gut. And that’s a key feature of for example, Crohn’s disease. So I’ll look at… Show that data here in the next slide. So this is a pretty complicated diagram, but the main point here is on the left is a different samples that basically where the data is expressed in a relative sense. So every sample is treated as if it’s the same amount, starting amount, and all the different taxa indicated by different colors. So all the different types of microbes make up percentage of that pie, but you don’t really know if in person A, that the overall levels have gone down say F after antibiotics or after an infection unless you look at it from an absolute standpoint, and that’s what you see here. This is the breakdown, also expressed in terms of total amount per gram. You can see here on the side, it says per 10, they live in cells per gram.

                                So essentially you can see that they’re some individuals that have quite a bit less overall sort of total microbiome in their gut. And they found that to be very clinically significant. That’s one of the big difference between sequencing and qPCR. A qPCR is basically looking at things from an absolute standpoint. So the big question there is really why is that important? And again, I kind of alluded to some of those important clinical relevance type aspects, but it really allows you to differentiate low, normal and high levels at a much more detailed level.  So you can identify trends and patterns and that’s a big part of the connecting the dots with GI MAP. And that’s also critical for assessing the clinical relevance and your treatment approach, because you want to see if you do a retest, that organism may still be there, but it may be responding well, you may have gone down a couple of orders of magnitude in quantity showing that your approach is working. That’s really where quantitation is important.

The other thing that we bring to the table in terms of kind of a differentiator for GI MAP is, how we present our interpretive and educational information. So our staff has a really wide range of expertise, industry experience in Functional Medicine, clinical testing, several PhDs, et cetera.  And so we bring all that kind of cross disciplinary expertise to the table, particularly with clinical experience mixed with research and we really focus a lot on the latest research so that we can focus on these interactions, and GI MAP is really all about the second part of the equation helping clinicians understand the potential interactions between the microbiome and gut physiology.  So a key thing to understand here is there’s a lot of different aspects of physiology and the gut that really come into play once we understand them at a certain level that can help us understand how to interpret a stool test and what it may mean as far as these underlying issues. So we may, for example, see that, you’ll see here on the list pH is one of the major factors throughout the gut that affects the microbiome and vice versa, same with oxygen, the first nutrients from the diet as well, flow rate digestion, especially stomach acid and enzymes, immune factors, et cetera.

                                So a lot of factors can affect the interaction between the microbiome and our health. And that’s really reflected in GI MAP through three common dysbiosis patterns that we’ve identified over time, just in our overall experience with GI MAP, so those really boil down to 1. Insufficiency dysbiosis, which is a lack of beneficial bacteria, so that’s important to understand how to identify that on GI MAP, 2. Inflammatory dysbiosis, again, very important for a wide variety of diseases, autoimmune inflammatory diseases, and it’s also important to understand how to identify that. And then lastly, 3. Digestive dysfunction dysbiosis, which is kind of a generic term that we use because various aspects of digestion may be compromised or reduced and have an effect on the microbiome and the microbiome in some cases can actually have an effect on digestion. So once again, I’ll go through examples of this and in many patients, they can have a combination of these types of dysbiosis that reflect that interaction between physiological imbalances and the microbiome.

                                So just to note, we do have a resource on our website, a downloadable PDF that lists what markers constitute these different patterns. We will be updating that sometime shortly within the next couple of weeks or so, and then we will make that available on our website. But we do have that as a current resource that was created a couple of years ago, so it’s just a little bit out of date at this point. The other thing that we really kind of weave into this based on research, and how that applies clinically beyond sort of this holistic high-level integrative perspective of looking at the whole gut, a big part of that is recognizing upper versus lower GI MAP microbes. That’s something that you may have heard.

                                Some clinicians claim that with stool testing, you can’t get any insights at all, except into what’s going on in the colon that you basically don’t really understand from a stool sample what’s going on in the small intestine for example, it turns out there’s a lot that you can gain from that. You don’t get necessarily a completely accurate picture of the composition in compartments that are sort of higher up in the GI tract, but sort of the classic example is H. pylori.        We didn’t know that that is detectable in stool, and that certainly yields important clinical information with regards to what may be going on in the stomach, so think of this as kind of a domino effect that you want to get a bit of an understanding of what’s going on higher up in the GI tract, even as high up as the oral cavity.  And one of the examples I’ll go through that’s features one of the markers on GI MAP, for a lot of patients that may actually come from dysbiosis originally in the mouth. And then you want to understand how these physiological imbalances result in its presence in the gut and what it may be doing there.  So to really get into this a little bit more, it’s important to understand a little bit about the composition of the upper GI MAP microbiome.  It’s not as well studied as the lower GI, the colon microbiome, but we’re learning much more about it especially in the last few years.  Mostly what’s dominant in the upper GI from the mouth down to small intestine are a large class in the Firmicutes phylum called the Bacilli.  So that species and groups like streptococcus, lactobacillus, enterococcus and staph. We do have these groups on GI MAP when you see them overgrown, it’s likely that they may reflect imbalances in the upper GI tract. And there’s some just basic information about the physiological conditions that they thrive in, they like higher oxygen environments.  So they don’t like the anaerobic environment in the colon, unless the colon environment’s been disrupted.  They like simple nutrients that are highly available in the small intestine.  Bile is in the small intestine, so they’re bile tolerant, et cetera,.  Also, organisms from the Proteobacteria phylum, which we tend to think of more of the inflammatory microbes, the dysbiotic microbes, they’re much more prevalent as a percentage in a small intestine. So typically they constitute say 20% of the microbiome in the small intestine and only 2 to 5% in the large intestine. So proportionally they’re much smaller in the large intestine.

                                A lot of the research has come out on Pseudomonas, which you do have on our tests, actually going to go back to that, linking Pseudomonas to inflammation in the duodenum, for example, and linking that to issues with gluten and kind of the broader picture of food sensitivities. They also thrive in a higher oxygen environment, also thrive on simple nutrients like sugars and amino acids, highly bile tolerant, you can actually find many of these in the bile ducts and in the gallbladder.  So they’re very bio tolerant, so really important group in the upper small intestine.  Composition of lower GI microbiome at a high level, the most abundant groups in some ways fairly simple, the Clostridium class really dominates and that’s the..in the colon, the largest class or largest group in the Firmicutes phylum, and one of the key species is Faecalibacterium Prausnitzii which we do have on GI MAP as well. That’s a major butyrate producer, again, it’s in the Clostridium class, which is the dominant group in the Firmicutes phylum. And then there’s a Bacteroides group, which is the major group, typically in most people in the bacteria Firmicutes phylum, Akkermansia is a well known species in the Verrucomicrobia phylum, which is also one of the key groups in the colon. They thrive in an anaerobic environment, generally that whole ecosystem, at least in a healthy individual thrives on complex fibers, as well as the mucus ecosystem.  So the mucus layer in the colon is much thicker than in the small intestine. So that’s one of the reasons why there’s a more significant you can see ecosystem in the colon. So this is data from Dr. Mark Pimentel’s lab that was published just earlier this year. This is just basically showing… You can see at the bottom here on the X axis duodenum, jejunum, FD, which is their term for the furthest distance the scope could go in the ileum. So it essentially means ileum for the most part compared to a stool sample. So the take home point here is the different colors represent the different major groups in the different compartments here, but it’s fairly consistent across the small intestine and then suddenly you have this huge change in the large intestine, which is reflected by the fecal sample. So that’s really reflecting that big change in physiological parameters from the small intestine, which again has a higher oxygen content, et cetera, usually lower acid levels, higher pH, then the colon very different environments particularly because of the fact that it’s anaerobic.  So that’s why anaerobic species thrive there that ferment carbohydrates. So a big difference and that’s really key to understanding this sort of localization aspects to interpreting stool tests. And this is the Tyler study mapping, the segmental microbiomes in the human small bowel in comparison with stool, the Reimagine study. And again, this is a study that was just published earlier this year by Mark Pimentel’s lab. [Mapping the Segmental Microbiomes in the Human Small Bowel in Comparison with Stool: A REIMAGINE Study]

Dr. Weitz:           Yeah. We were lucky enough for Dr. Pimentel to join us several months ago.

Tom Fabian:       Oh, you did? Okay, great. I have to go back and make sure I check that out.

Dr. Weitz:           Yeah.

Tom Fabian:       So this is a summary of markers on GI MAP based on research that indicates where they’re predominant in the GI tract. We just sort of broke it down between upper GI and lower GI, with the upper GI being on the left and then the lower GI being on the right. So not all species or groups are known in terms of research that’s available in terms of where their predominance is, and then in other cases, they may be prevalent in both but both of these groups here research supports the predominant primarily either in the upper or the lower GI tract. So once again, there’s quite a few markers on GI MAP that are likely reflecting what’s going on in the upper GI. Again, the classic one being H. pylori, GRD is another, well-known microbe that basically thrives in the upper small intestine. The two that I’m going to focus on here just briefly in this presentation are Klebsiella and C. diff. So one example of an organism that’s present more commonly in the upper GI and also the oral cavity and then less prevalent in the lower GI except in cases of potential inflammation.

                                So as far as stool composition, just to kind of summarize it primarily reflects the colon composition. So that’s sort of intuitive, but also that’s what research shows as well. And of course within the column, there’s a mix of luminol and mucus associated microbes, with the composition primarily dominated and fecal samples with luminol microbes. But definitely you get a sense of the mucus associated microbes such as Akkermansia. It’s also dominated by anaerobic Fermenter bacteria in particular, the Clostridium class in the Firmicutes phylum and then the Bacteroidetes genus in the Bacteroidetes phylum. Those are far and away, the two most dominant groups in the microbiome in most individuals, at least in Western countries. Microbes from the upper GI tract can be present in stool, but usually in really low numbers.

                                So that’s of course where qPCR comes in, because we can still get some good insights based on the presence of some of those low abundance type organisms. So once again, this is just sort of back to the figure from the Pimentel study showing the breakdown of these major groups across the small intestine and stool. Of course, the question is why we’ll get into some of that a bit more as well. So that guy somehow made a mark there. So really, I think it’s important to consider since we can detect potentially some of these upper GI microbes. Some of them are better established as being pretty exclusive to the upper GI tract. Again like H. pylori and Giardia. Pseudomonas, mostly research does indicate that it’s likely thriving in the stomach and the upper small intestine and so far, most studies indicate that it’s not present and are not active, usually not active in the large intestine.

Dr. Weitz:            Are you going to have time to go into H. pylori? And if not, can I ask a couple of questions now about H. pylori?

Tom Fabian:       I’m sure. Yeah. I’m happy to answer questions right now, but it’s H.pylori.

Dr. Weitz:            Okay. So if we see H. pylori present, but there aren’t any virulence factors essentially it’s my understanding that that’s not super important. Correct?

Tom Fabian:       So as far as H. pylori its presence without virulence factors, it is important apparently, we certainly see a potential clinical impact quite often when it’s present and especially if it’s high.

Dr. Weitz:            O.K., so when we look at the numbers, like the normal says 1.0 e3, now what’s considered high?

Tom Fabian:       High is generally that’s what that cutoff level is indicating. So above that number is considered high, below that number is considered detected.

Dr. Weitz:            Like if it’s 5.0 e3, is that a little high or a lot high? Is it a lot high if its e4, e5 that makes it a lot high, right?

Tom Fabian:       Right. Yeah. I mean, because those are orders of magnitude, but definitely clinically in the E three range is high and it’s of course you have to take everything into the context of the patient and how that patient’s presenting symptoms that may be related to that, but also we can see a pattern on GI MAP. And so there’s a lot of research showing, for example, the H. pylori, regardless of virulence factors likely reduces stomach acid in majority of people that have a chronic infection, and so we have an overall digestive dysfunction pattern that I mentioned briefly earlier that is often associated with H. pylori, and it’s one of the ways that we can gauge based on just the test markers and connecting the dots, doesn’t look like this is having an impact in the ecosystem and then of course the clinician has to decide, is that relevant to the patient’s symptoms and how the patient is presenting?

Dr. Weitz:           So you’re saying if we have a patient with elevated H. pylori and it seems like it might correspond with the symptoms, it might be worth treating, even if there’s no virulence factors?

Tom Fabian:       It would be worth considering, a lot of clinicians do, but I think the… When it comes to functional integrative type clinicians, a lot of clinicians will often focus more on antimicrobial approaches versus going straight to antibiotics. So it’s not a scenario that would be kind of in conventional medicine it’s the more looking at the potential virulence in relation to things like potential for stomach cancer ulcers also things like that. Some of the more serious outcomes that are tied, the risk for those types of outcomes are tied to the virulence factors. But the more mild sort of to moderate effects based on just depression of stomach acid still can be clinically relevant for patients, but it may not warrant sort of complete eradication for example.

Dr. Weitz:           And in some of the virulence factors more important than others?

Tom Fabian:       Based on research so far, the answer is yes. The two that stand out the most, partly because they’ve been well-researched, but seem to be especially required for the more significant inflammatory outcomes and that would cagA and vacA.  That’s important to point out though that virulence factors tend to work together and so generally the more you see on the test, so the more that are positive, the more likely than that could be a more significant scenario.

Dr. Weitz:           One more quick question, just in general, in terms of any bacteria or pathogen or potential overgrowth when we see the number there, but it’s less than the normal that could still be significant?

Tom Fabian:       Right. Now, again that’s really where clinical judgment comes into place, so-

Dr. Weitz:           Because it’s really well, it’s has <dL> right? Like super low.

Tom Fabian:       Exactly. Yeah. That either means it’s just not there at all or it’s presence at a low level.

Dr. Weitz:           Okay.

Tom Fabian:       We often do see that based on interacting with clinicians that their judgment is, and also based on what we see on the pattern on the test that [inaudible00:30:31] can be clinically significant for some patients, again, mostly in that context of potential for contributing to dysbiosis and reduce digestion.

Dr. Weitz:           Okay, great. Go ahead.

Tom Fabian:       So that’s really kind of… It was actually a great time to talk about H. pylori because that is kind of the classic example when you hear certain folks out there saying you can’t really get any information about the upper GI from a stool test, that’s simply not true because H. pylori is sort of the case in point. We can certainly get some great insights into what may be going on in the stomach in that case.

Dr. Weitz:            And of course, zonulin gives us some information about the upper bowel as well. Right?

Tom Fabian:       Right, exactly. So qPCR, again, just kind of that analogy that it’s great at finding these needles in the haystack. H. pylori is a good example. There are a lot of the metogenomic type tests, metagenome sequencing that generally aren’t as good at detecting H. pylori let alone quantitating it. So when you really want to know about a clinically relevant organism, qPCR is a very effective way to assess that. So let’s talk a little bit about the insufficiency type of dysbiosis. So this is something that probably a lot of clinicians who worked a lot with GI MAP have seen, you may see a really broad insufficiency like we see here for this patient where there are a lot of markers in the normal bacteria section that are deficient, at the phylum level that’s certainly one of the most important levels to look at because those two groups together make up the bulk of the microbiome, particularly in the colon.  So when they’re both deficient, that’s telling you the microbiome overall is probably deficient and then all those beneficial functions that they serve are probably also deficient. It’s also a great to focus, particularly on Akkermansia and the E. coli bacteria, and those are two Keystone species. So once again, when one or both of those are low that can be pretty significant in terms of indicating that the colon ecosystem is not so healthy. The other thing I want to note about kind of connecting the dots on GI MAP is we do lots of research.

Dr. Weitz:            Let me just see if I could throw a question in Dr. Rahbar who’s joining us tonight is a integrative gastroenterologist. Let Dr. Rahbar ask a question. Let see, I’m going to unmute you Sam, why don’t you go ahead and ask your question. Did I unmute you?

Dr. Rahbar:          Can you hear me?

Dr. Weitz:            Oh yeah. Now we can hear you.

Dr. Rahbar:          Okay.

Tom Fabian:        Yes, I can hear you.

Dr. Rahbar:         Yeah. I have several questions since we use this lab quite frequently, and I kind of use my common sense approach to it.  For example, I see sometimes practitioners wanting to treat Klebsiella and Citrobacter fruendii in the stool. And I always question, are these specific pathogens, or are these markers of dysbiosis?  It means that, do you need to look at it as dysbiotic flora or like if I got Shigella or something in the stool I would say, okay, you’re going to have some specific bug that I have to treat it.  Or campylobacter.  At least from the literature that I see, I don’t recognize these as specific pathogens of the gut, indications of disease.  So I usually respond that maybe you treat SIBO some other dysbiotic scenarios, but I wouldn’t target a specific one, but Dr. Fabian, I wanted to get your opinion on this one without just saying something. 

Tom Fabian:       Absolutely. Yeah. I mean-

Dr. Weitz:           And these are two markers that are listed in the section potential autoimmune triggers.

Tom Fabian:       Right. And that actually is one of the examples I’ll be covering here in this a little bit, so that’s really why it’s considered an opportunistic pathogen. So opportunistic pathogens can exist in the gut without any effects at all or they can potentially be part of a pathogenic process. So they’re not generally recognized at least in the gut as being outright pathogens. That picture is probably going to change a little bit with some of the organisms like Klebsiella, where we do see that it’s more frequently now associated with things like inflammatory bowel disease, et cetera.  So it’s beginning to square where it’s not thought of as sort of an outright infection, a specific infection like salmonella, but it is part of the pathogenic process in some cases. So it’s kind of in that gray area, and that’s a perfect example of where clinical judgment really to come into play in combination with really understanding how to connect the dots with a test like GI MAP.  So you can really get a sense for, does look like this is a problem, or does it look like it’s for this patient probably not much of a problem.  And that’s, well-documented research some people can have relatively high levels of Klebsiella and no evidence of inflammation.  Other people can have high levels and have inflammation, but the big difference often is the ecosystem.  If they don’t have as many of the beneficial bacteria, they may be more likely to have inflammation.

Dr. Rahbar:        Right and if I may say something, obviously we need to evolve into this to understand if we correct that, whether it reverses the immunological abnormality or not.  We can say that this is part of the autoimmune trigger but if you fix it, does it fix your autoimmune problem?  And that answer obviously is not clear.  And so far, I don’t think if you just change that bug, you’re going to see it, but we have to see how that answer is going to evolve.  I wanted to ask you a question regarding the H. pylori.

Dr. Weitz:            So actually, let me just ask that same question again. Tom, is there any data showing that if we have a stool test that shows potential autoimmune triggers and we reduce that particular bacteria, that we may have a positive effect on their autoimmune disease?

Tom Fabian:       That’s a good question. So I’d have to go back and kind of dig through some of the research that I have to see what specific studies there are, mostly to date what I’m aware of is, those are associations and a few cases, there may be some kind of mechanistic insights suggesting there might be a causal link. But mostly to date, a lot of those are based on associations. I’d have to go back and again, dig through the research to see if I do have some studies that specifically talk about whether or not if they’re addressed, does the disease reverse or do some of the symptoms improve?  Not entirely sure.

Dr. Weitz:            Yeah. I just had a patient today who has Ankylosing Spondylitis and he has high levels of Prevotella [I meant Klebsiella] and there’s data showing that that can be directly related to how the Ankylosing Spondylitis is created in the body.

Tom Fabian:       Right. Yeah, definitely for some of them, at least it’s suspected, and some evidence that there might be some kind of molecular mimicry, for example where the immune system reacts to protein on the pathogen or the opportunist that then looks very similar to a protein in the body and then the body develops an immune reaction to those proteins as well. So that’s kind of an ongoing thing. I think it’s mostly well established for one of the oral microbes, which is Porphyromonas gingivalis, but there’s probably a growing list of examples there.

Dr. Rahbar:         Dr. Fabian, may I ask a question regarding H. pylori, we occasionally find this in duodenal aspirate as interesting that even in the stool test sometimes the marker comes up as red and sometimes it’s black. I agree that the best value is below <DL, below the detectable levels. So if any amount is showing would it be abnormal whether it’s in the black or red zone?

Tom Fabian:       That’s a good question. So certainly below detection limit, if you’re aiming for eradication or greatly reducing its levels from a therapeutic goal, then certainly that’s what you’d be looking at. Now there’s with any sort of microbe, I mean, except for outright pathogens and H. pylori is kind of more on the opportunistic pathogen category versus something like enterohemorrhagic E coli, which is not really pathogen. Those you generally don’t want to see those in the gut at all of course.  When there’s H.pylori there’s some debate as to whether or not complete elimination is always desirable. It really depends on kind of looking at all the risk factors, but some data indicates that there may be some increased risk for other conditions by completely eliminating H. pylori. So what we know mostly from research is that most of these types of opportunists in the gut like Klebsiella, H. pylori, as long as they’re kept in check by healthy gut and healthy microbiome, they may not be a problem.   So that’s kind of where that gray area, low levels for some people may be fine, because maybe they have an overall healthy stomach, they have a lot of Lactobacillus, for example, in the stomach, which is definitely one of the known healthy groups in the stomach and a healthy ecosystem. Then they may be fine and there may be no reason to target H. pylori, but if people are having symptoms that could be ascribed to it, plus we see a signature on the test and there may be other considerations as well.  Some clinicians may decide that they want to at least try to reduce that and see if that helps symptoms for that patient.

Dr. Weitz:           Does it make sense to also do a H. pylori breath test or antibody test to confirm it?

Tom Fabian:       Some clinicians feel that because it really depends again, on the scenario and the risks, say if you have lots of virulence factors and there’s a history, family history of stomach cancer or anything like that, there may be scenarios where you really do want to make absolutely sure that it’s eradicated, if you’re trying to eradicate it or even just verifying the levels over time. So there are some clinicians that prefer to do multiple tests. Just to really get a better handle on it. PCR is very sensitive. So it is often a scenario where we’ll see a low level detected where a breath test or a stool antigen tests may be negative.

Dr. Weitz:           By the way, is PCR ever too sensitive?  Is it ever the case that it’s picking up things that maybe are no longer there?

Tom Fabian:       That’s a highly unlikely scenario as far as past infection. So it’s a very different scenario than say antibodies, which can linger for a long time. DNA from organisms, especially in the gut is highly unlikely to linger, partly just from the simple fact that materials moving through within a certain period of time.  So if the microbe isn’t attached and to be attached to it has to be alive, because it has to actively produce those proteins that allow it to attach.  So it’s not likely, that it would be detectable past a certain relatively short period of time on the order of days.

Dr. Weitz:            Okay. And Dr. Greenberg asked if the Pseudomonas is high, does that imply that it’s overgrown in the small intestine or that it has also colonized the large intestine?

Tom Fabian:       So far there is no research supporting that it can colonize or at least colonizes on any sort of frequent basis in the colon. All the research to date supports that it’s mostly in the upper GI and stomach.

Dr. Weitz:            Okay.

Tom Fabian:       Really it’s niche where it thrives. I haven’t yet come across a single study. It can be detected, of course that’s how we pick it up. It really doesn’t seem to thrive in the colon. In fact, specific studies have looked at that based on transcription gene expression, and Pseudomonas is one of those that when you look at gene expression methods is not detected in the gut, meaning it’s not active.

Dr. Weitz:            Okay. Yeah, go ahead.

Tom Fabian:       Okay. So coming back to this section where were talking a little bit about the beneficial bacteria and what to look for when there’s a lack of beneficial bacteria. In addition, of course, to the normal bacteria section you really want to make sure you pay attention to secretory IgA. So we do know that, the main stimulus for normal physiological ranges of secretory IgA is the normal commensal microbiome, through secretion of Butyrate and other products that stimulates the production of secretory IgA. So we see a really strong correlation there.  Typically when there’s a lack of at least, one of the key groups of beneficial bacteria, we often see low secretory IgA.  Clinically it appears that the lower, the number like we see here, the more likely that is to reflect lack of Butyrate producers.  So you’ll often see, for example, really low secretory IgA below 100 when Faecalibacterium, for example, is also very low.  So it’s kind of a great overall marker for lack of beneficial bacteria.

Dr. Weitz:            So, if we see this on a test with a patient who maybe has some other infection or parasite at the same time, would we best be trying to improve their microbiome with probiotics or prebiotics, or would be better to directly try to stimulate their immune system with colostrum or some products like that have an immunostimulatory effect?

Tom Fabian:       A lot of clinicians will focus on both building up, the microbiome can take time depending on what’s going on. So if you need a more immediate effects then those types of supplements, Saccharomyces Boulardii, L-glutamine even Vitamin A, has been shown to be necessary for normal secretory IgA levels. So supplement approaches certainly can help bridge that gap until the beneficial bacteria are recovering. So again, that’s a really important marker to pay attention to that has a very strong correlation with lack of beneficial bacteria.

Dr. Weitz:            I just want to ask about the fecal calprotectin, which is a marker of inflammation. I’ve had a number of tasks where that was normal, and not particularly high, but the patient has a lot of gut symptoms and it just seems like their gut is really inflamed. So, why would that number be low if their gut’s really appears to be inflamed?

Tom Fabian:       That’s a good question. So it’s a good marker for inflammation particularly in the lower GI. So if you look at studies on Calprotectin, for example in relation to H. pylori, so Calprotectin in stool, there’s not much of a correlation, so we know the H. pylori can cause inflammation in the stomach but that doesn’t reflect so much, in ability to detect it in stool. So one possibility is that you may have upper GI inflammation, if they’re inflamed and that’s likely in a lot of cases. So for example, Pseudomonas, lots of new research shows, that when that’s overgrown that’s likely causing inflammation, doesn’t always mean it is. So again, you want to take into account the big picture but if it’s significantly overgrown that’s a significant possibility that could be causing inflammation the upper GI. Candida is known to be inflammatory often colonizes pretty much anywhere in the upper GI tract, even the oral cavity. So that’s one of the major reasons if they seem to be inflamed and Calprotectin looks fine, maybe more on the upper GI.

Dr. Weitz:            One of the patients [I meant practitioners] asked that, she had a patient with Ulcerative colitis. Calprotectin was 660 on the GI MAP a week later, the calprotectin was 150 on a standard lab.

Tom Fabian:       So, it’s difficult to kind of compare among labs due to, we know what our lab does. Our lab certainly does everything that’s required of a CLIA lab and then some, so we know that our markets are internally validates very well, but we can’t speak to other labs in terms of how they perform the test and also do their validation, but also be aware that Calprotectin is a marker that can change over time.

Dr. Weitz:           So if you change, can it change quickly in a week?

Tom Fabian:       But actually, yeah.

Dr. Weitz:           Okay.

Tom Fabian:       Yeah. Because, it’s really responding to what’s going on in the gut. Now, if you have chronic inflammation, that’s not necessarily changing, you shouldn’t expect to see that changed. Generally though, if you’re doing a retest say after treatment and you want to see what’s happening with the levels, it’s always recommended to use the same lab that you started with. So you have that consistency and baseline because otherwise, you’re factoring in possible methodological differences.

Dr. Weitz:           Yeah. I have to say sometimes this sort of question comes up when I’m managing a patient as a Functional Medicine practitioner/Chiropractor, and then the patient goes to see a standard GI doctor and they send them to LabCorp or Quest and get a different result and then they scoff at this test.

Tom Fabian:       Right. Yeah. I mean, that’s always going to be an issue when you’re comparing tests. We see that, like I mentioned with H. pylori where a patient may be negative with a stool antigen test, they do a PCR test and because of the sensitivity level, we pick it up and the other lab with the other method, didn’t pick it up. So, it’s ideally you’re doing the same if you’re kind of comparing time points with the same test.

Dr. Weitz:           Okay, good. Go ahead.

Tom Fabian:       Okay. So on the next slide, it’s just kind of a visual reminder of what we’re looking at. So, we’re so used to looking at tests, the numbers and kind of thinking about things a bit more in the abstract when it comes to the gut, because we can’t see the ecosystem.  It’s important to really kind of come back to sort of the visual understanding that we’re talking about the bugs, and this is the lumen side towards the top, and you can see the bugs here. And if these are largely representing beneficial bacteria, there’s secreting, creating factors, particularly short chain fatty acids that are absorbed into the mucosa. That then basically elicit effects, particularly from the immune cells and the Epithelial cells, certain Epithelial cells, the Goblet cells, respond by producing mucus and then certain immune cells, the Plasma cells respond by producing secretory IgA, and the secretory IgA is secreted in the mucus layer. So just kind of another quick little clinical Pearl is you’ll often see low secretory IgA along with low Akkermansia. And that’s indicating that likely this mucus layer that includes mucus and secretory IgA could be deficient. You can see here, it’s representing that this mucus layer is keeping the microbes away from the mucosa, which is important to keep the reactivity of the immune interactivity down. So that’s part of the whole immune tolerance type, a phenomenon is preventing overreaction of the immune system to harmless microbes.

And so just a little bit more about the Firmicutive bacteria to these phylum, just to reiterate they’re anaerobic and they’re dominant in the colon and the main source of short chain, fatty acids, and those short chain, fatty acids have many important effects. One of which public have a little bit of time to go through here and a little bit when I go through one of the studies, but there are definitely overall key for colon health particularly in terms of protection from pathogens and opportunists. So it’s not common to see some of these opportunists, particularly under Autoimmune triggers, for example. And when we do see them, that suggests possibly the overall beneficial bacteria may be deficient.

So the other information you’ve already talked about, so we’ll move on.  I just want to touch briefly on inflammatory Dysbiosis. So this is a subset of the inflammatory kind of the main inflammatory types of organisms on GI MAP.  So there are particularly inflammatory bacteria in the Proteobacteria phylum. Most of them tend to be in a subclass or subgroup called Gamma Proteobacteria. So they’re all fairly related. A lot of them have been shown to have the more inflammatory type of LPS, for example. But quickly I want to focus on Klebsiella.  So that’s something we’ve talked about a little bit so far here, as an example, there’s this really interesting study that just came out a little while ago.  Actually just this past summer.  So the title is Intermucosal connection between the mouth and the gut and commensal pathobiont-driven colitis.   So this is basically showing that the connection between Dysbiosis in the mouth and Dysbiosis in the gut, and then what can happen in between. So they say here real quick, Periodontitis leads to expansion of oral pathobionts, including Klebsiella and Enterobacteria species, which were both on our tests and the oral cavity amassed oral pathobionts are ingested, then translocate to the gut.

                                So basically swallow pass through the stomach and then end up in the lower GI tract, particularly if there’s not enough stomach acid, where they activate the inflammasome in Colonic mononuclear, Phagocytes triggering inflammation. And I want to go on to a little bit more information here. So they say in the article, this evidence suggests that at least two conditions must be met for oral pathobionts to topically colonize the gut.  First, the colonization resistance of the gut resident microbiota must be disrupted often, meaning that you have a lack of beneficial bacteria enabling the oral microbes to invade the gut.  Hence intestinal inflammation favors the growth of Enterobacteriaceae, that’s kind of a subgroup that includes E-coli, Salmonella, Klebsiella, et cetera in cleaning bacteria transmitted from the oral mark, because one more thing I want to highlight from this article is alternatively neutralization of gastric acid or inhibition of acid secretion could promote ectopic colonization of oral bacteria in the gut.  For example, it has been reported that the use of Proton pump inhibitors, which reduce production of gastric acid leads to increased colonization of mouth resident bacteria in the gut, consistent with his observations been reported that gastric acid inhibitors worsen clinical outcomes in IBD. So definitely this is an important article that kind of follows up on earlier research showing this integrative approach. You’ve got to take the whole GI tract into account.

                                When you see Klebsiella come up on a test, the questions you want to ask are, is there evidence it’s causing inflammation? You may even want to check with the patient, ask the patient about their oral health. You may want to look at indicators of stomach acid because it may be telling you this patient might have insufficient stomach acid. So lots of, kind of connecting the dots there when you see these various organisms. So that’s talked a little bit about the insufficiency Dysbiosis, inflammatory Dysbiosis. Those two are really linked. As you can imagine, when you have a lack of beneficial bacteria, that’s one of the key factors that allows these inflammatory microbes to grow in the lower gut. I just want to touch on the Digestive Dysfunction Dysbiosis. When we think of digestive dysfunctions, most clinicians go straight to this digestion section and look at the markers.  Steatocrit is looking at fat malabsorption in this case, it’s high.  Elastase is a marker for pancreatic enzyme deficiency or our production in this case it’s low. But if you see those normal, does that mean digestion is fine?  And often times the answer is no. Fortunately we can get some additional insights by looking at the patterns of the microbes and what we know about certain microbes, such as H. pylori.

                                So it’s just kind of coming back to what I talked about that this review article basically came to the conclusion that most patients chronically infected with H. pylori have Gastritis and also Hypochlorhydria, not necessarily all.  It’s important to know that not everybody that has H. pylori has low stomach acid but a pretty large proportion of them do seem to have low stomach acid and that low stomach acid for various reasons on this case, they’re looking at Proton pump inhibitors leads to certain types of Dysbiosis that’s really reproducible. So they mentioned here in the highlighted area that Streptococcaceae and Enteroccaceae species are among the most common that you see elevated. Also PPIs are risk proceeded infection. So I’ll get to that. Hopefully we have a little bit time later on here too. Sometimes decrease with E coli bacterium as well. So these are the patterns that we can see, for example, in relation to low stomach acid, there’s a lot of research backing this up, particularly with the Fermicutes phylum. Many studies have replicated that, finding that you see elevated levels of those in stool when patients have been shown to have low stomach acid. And so this is just an example of a patient that had high H. pylori, so suspected low stomach acid, again, not diagnostic for low stomach acid, but something to think about. You’re looking for an overgrowth pattern. We’d see the overgrowth pattern typically in the normal bacteria section.

                                This would be pretty significant. We don’t always see it, this prevalent with so many markers elevated. But we often do see this overgrowth pattern, particularly with the Firmicutes phylum. And then in this case, we also saw Faecalibacterium was low, which really follows that particular study that was found to be low as well. With low stomach acid, your opportunistic bacteria is really where you’re going to see the most common evidence of overgrowth. That’s where the Enterococcus species are and Streptococcus. So if those are high, then suspect that stomach low stomach acid may be an issue. And then some of these others too, like Pseudomonas can also be overgrown and stomach acid is too low, or there’s other.

Dr. Weitz:            Can I ask about Methanobrevibacter?  So we know that methane SIBO is now IMO according to Dr. Pimentel. And so therefore it’s an overgrowth of methanogens, like methanobrevibacter, Methanobrevibacter smithii, and so if the patient has a positive SIBO breath test for methane SIBO, would we necessarily see elevated levels of Methanobrevibacter and, what if they don’t correlate?

Tom Fabian:       That’s a good question. So they generally do seem to correlate as far as we can tell but not always. So that is an important factor to consider that sometimes you can have an increase in bacteria or in this case, microbials because Methano bacteria is they actually are archea, not bacteria kind of closely related, but and so you can have an increase in function, of microbes in some cases without necessarily a significant increase in their numbers. Now that said, on our test and based on looking at literally thousands of tests over the last couple of years then the methanobacteria family on our test tracks very closely with overall evidence of overgrowth on our test. And you’ll see here in a moment, if I get a chance to get to the one of the slides here that talks about that more, it’s, it’s really a direct reflection of the level of fermentation, particularly in the colon.  So when you see methanobacteriaceae in our experience it seems to be clinically relevant anytime it’s in the E nine range, not even above the cutoffs.  It’s highly correlated with this. So generally, yes. I would say when, when patients have also had a breath test, they will have some level of methane detected. But it’s not necessarily a hundred percent correlation for example.

Dr. Weitz:            And somebody asked a question about H. pylori, which is can it also increase stomach acid production, depending upon where the H. pylori is?

Tom Fabian:       Yeah, that’s true. So there is some evidence that in some cases that can be the case during more than acute sort of early infection. And it really does depend, apparently there’s some conflicting research on it. So it’s not really all that well studied, but it does depend on where in the stomach it’s infecting and the extent of the infection. Now, there is some evidence based on a couple of studies I came across that typically the infection can migrate in the stomach over time. And I forget which direction if it’s antrum to corpus or corpus to antrum, but the overall conclusion was that it tends to long-term be more consistent with hypo or Hyper. But some patients may have an increase in acid depending on where the infection is.

Dr. Weitz:           Okay.

Tom Fabian:       So this is just kind of showing you in this example that Klebsiella was elevated which again is something we often see when there’s other evidence suggesting low stomach acid. And that goes along with that research that suggests Klebsiella may often come from the oral cavity or possibly the respiratory tract, which is also another common location for Klebsiella. And then it may get into the GI tract to those routes when stomach acid is insufficient. I’m going to go ahead and skip this here other than, of course, whenever you see an overgrowth of inflammatory species and we had that list higher up on one of the other slides oftentimes, but not always, you’ll see Calprotectin elevated. So there is a correlation there. We see it most commonly in, for example, patients that have already been diagnosed with inflammatory bowel disease we often will see that connection between higher Calprotectin and higher levels of inflammatory species.

Dr. Weitz:           By the way, if pancreatic elastase is low, is the best recommendation is to recommend that they supplement with pancreatic enzymes or are there other recommendations?

Tom Fabian:       That’s a good question. So a lot of clinicians do take that route to help compensate. But of course you want to also ask the question what may be contributing to that.

Dr. Weitz:           Right.

Tom Fabian:       So there may be issues with the pancreas itself. Of course, Pancreatitis, things like that may play a role for some patients, but even low stomach acid can lead to lower release of digestive enzymes. That might be another factor for a lot of patients that can be gut-brain axis issues.

Dr. Weitz:           Interesting. Low acid leads to low pancreatic enzymes?

Tom Fabian:       It’s a contributor. Yeah.

Dr. Weitz:           Okay.

Tom Fabian:       It wouldn’t be considered, if you say you have really low elastase are rate sufficiency. That’s, well below that 200 cutoff it would probably be unlikely that that’s the sole contributor unless for example stomach acid is exceptionally low. You may be wanting to look into some other contributing factors at that point.

Dr. Weitz:           And if steatocrit is high, that’s fat in the stool, is the best recommendation to give them a lipase, fat breaking, fat digestive enzymes, or is bile going to be more beneficial or both?

Tom Fabian:       Good question. So just based on the presence of the excess fat in the stoool you can’t tell directly just from that which upstream process is affected.  Now, if you do see that our last days is really low, particularly if there’s outright insufficiency, meaning well below 200, then it’s more likely that, the highest steatocrit would be caused by lack of lipases from the pancreas as well. But you can also have a scenario where there’s insufficient bile but it’s probably less appreciated is issues in the small intestine, which is where fats are primarily absorbed, where they’re supposed to be absorbed in a healthy gut. So if you have an inflamed, small intestine, and you’re not able to really absorb fats as efficiently.

Dr. Weitz:           Such as if you have SIBO.

Tom Fabian:       Exactly.

Dr. Weitz:           Okay.

Tom Fabian:       Right. Just have a few more things to go through and then based on time, do you want me to stop here or take more questions or do you want me to continue on for a couple more slides?

Dr. Weitz:           Go a couple more quiet slides.

Tom Fabian:       Okay. so again, these are the three main Dysbiosis patterns that learning to recognize them can give you a lot of insights into what’s going on in the overall gut, in terms of physiology and the microbiome, and even some insights into say lower versus upper GI issues, I’ll skip this, but we all know that of course pH is one of the key factors along the GI tract. We mostly think of stomach being the key kind of checkpoint. So when you may unfortunately ingest pathogens, for example, food poisoning if you have good stomach acid, then they’re less likely to survive the transit, but what’s less appreciated is that slightly acidic levels in a healthy colon, especially the ascending colon, are almost as important and helping to keep pathogens and other opportunists from colonizing your colon. So I’m just going to go through a quick example of that here. This is a really interesting paper that was published recently, so the title is Inhibiting antibiotic-resistant Enterobacteriaceae by microbiota-mediated intracellular acidification. So that’s in the Proteobacteria phylum, that’s a particularly inflammatory group.  So inhibiting that group by microbiota mediated, intracellular acidification. So just to kind of cut to the chase, they mentioned Klebsiella and E coli as kind of the examples they’re looking at here. And then the highlighted in orange part towards the bottom says Klebsiella pneumonia, Escherichia coli, Proteus mirabilis by acidifying the proximal colon and triggering short chain, fatty acid mediating intracellular acidification. So essentially what they showed in this study is that normal levels of beneficial microbes that are producing adequate levels of short chain, fatty acids literally inhibit the growth of these pathogens by basically producing the short chain fatty acids that then are taken up by those cells and that satisfies the cells and basically prevents them from growing.  So that’s one of the ways in which these beneficial bacteria, like Clostridia, Bacteroidites can help to keep those pathogens in check. So once again, when you see those at high level particularly Klebsiella or Proteus that’s one of the things we’ll be looking at is evidence for low beneficial bacteria. And they actually showed in this study that just restoring the beneficial bacteria and the short chain fatty acids can be enough to address those pathogens. So that’s kind of an example where you don’t always have to resort to antimicrobials.  Restoring gut balance may be sufficient.

Dr. Weitz:           Can I just ask a question about anti-microbials?  I interviewed Dr. Jason Hawrelak a few months ago, and he mentioned that he thinks that taking anti-microbials like Berberine can significantly damage the microbiome.  Do you think that that is something that is liable to happen?  Do we see evidence of that?  In other words, can natural anti-microbials produce damage in the microbiome?…   The way antibiotics can say, for example.

Tom Fabian:       Generally, no, we have not seen that. Not even close.

Dr. Weitz:           Okay, good.

Tom Fabian:       Mostly when we see a really broad deficiency pattern, it’s related to antibiotics or other pathology like IBD or something like that.

Dr. Weitz:           Good.

Tom Fabian:       Real quick though, I think he was referring to at least the research I’m aware of on Berberine in one study a few years ago, showed that it can long-term or high doses can reduce diversity. But it was in an animal model in mice. So that suggests maybe not taking super high doses for a long time would be-

Dr. Weitz:           By the way what’s a high dosage? Because for example I’m using Berberine not only for gut patients, but we use it to help manage metabolic factors and I also use it as a sort of a substitute for Metformin in anti-aging programs.

Tom Fabian:       Right. Good question.

Dr. Weitz:           It works synergistically with Metformin to manage blood sugars, so.

Tom Fabian:       Right. So that was really just one study and I have not come across any additional studies on that and again it was a mouse study. It was a very high dose though. Something maybe equivalent to a least more than five grams per day for humans. Again, you have to take those kinds of things into account that if it was just an animal study and it was super high dose, maybe it doesn’t apply to real world settings. Right?

Dr. Weitz:           Okay.

Tom Fabian:       But that’s not been our experience. The patient is on strong antimicrobial botanicals. Don’t seem to develop a deficiency pattern based on what we see on GI MAP so far.

Dr. Weitz:           Right. Good then that’s been my experience as well.

Tom Fabian:       Okay. So this actually, it’s kind of interesting that we talked about that, because I won’t go through this full case. It’s not really a full clinical case, but just a quick example of an older female history of bladder cancer was on long-term Amoxicillin antibiotic for five or more years. Main complaint was just Chronic diarrhea. So of course there was a suspicion of antibiotic associated diarrhea in this case.  You can see here very broad deficiency, which would be pretty much expected from such a long-term exposure to an antibiotic.  But just based on what we’ve talked about before with the insufficiency, you would expect that this would potentially lead to overgrowth of opportunists or pathogens.  And sure enough, you see Pseudomonas and Klebsiella overgrown and it turns out that those two are the ones that are known to be resistant typically to Amoxicillin.  So, we’re seeing exactly the pattern you would expect based on that patient being on that antibiotic.  This kind of scenario to me is very important. You’re thinking about, which gut tests you want to go with and how good is a gut test? And you can kind of debate validation approaches and all these things and sequencing versus PCR. But in the end of the day, it really comes down to “Does this clinically validate?” And as you know a patient for example, is on an antibiotic long-term, you would expect to see patterns of this. If you don’t see patterns like this, there may be some individual variation, but when you… So that’s just something to keep in mind as you’re going through some people may try different gut tests. You want to make sure that the test you’re using clinically validates and that it makes sense based on the patterns that you’re seeing.

Dr. Weitz:            Can I just comment your test looks at, if there’s a pathogen what antibiotics might be effective for those pathogens, some of the stool tests, in which in the past, I know used to use natural anti-microbials, how come you don’t include that?

Tom Fabian:       That’s a good question. So I’m not sure of all the reasons why I know part of it is we wanted to kind of keep our test to molecular that’s what our lab does, that other sort of approach to look at potential sensitivity involves culturing. So that’s part of the picture, but also how realistic is it from a couple of different standpoints that what you’re measuring on a Petri plate with one organism really translates to how effective that’s going to be in an actual, vast, complicated ecosystem. You don’t really know that plus most clinicians tend to use common formulations.  Some do use single ingredient approaches.  A lot of clinicians use formulations that they found to be generally effective.  So it’s not necessarily going to affect what they use clinically either.  So it’s not always clinically useful information.

Dr. Weitz:           Okay.

Tom Fabian:       I think I’ll skip all of this here just real quick. And one more thing about Klebsiella and also Morganella they have been linked to excess Histamine production.  So again, be thinking of these things, when you see Klebsiella overgrown you want to kind of look at the context are beneficial bacteria lacking. Does the patient also potentially have Histamine intolerance symptoms, et cetera. So the more you know about these microbes, the more you can potentially clinically connect those dots. This is the only thing I was going to show and I’ll stop at this one. This is a little bit of a complicated diagram, but it’s representing the colon on the left side is the proximal colon and moving on across horizontally to the right towards the distal colon. There’s a lot of research showing basically the dynamics in the colon so that you understand better, why a patient may have say a high Firmicutes, low Bacteroidetes why they might have Sulfur-reducing bacteria and methanogens.

                                So the main point I wanted to make here is generally in the first part of the colon is where most of the Fiber fermentation, Carbohydrate fermentation is going to happen, that can release hydrogen and then basically that part has to kind of start happening first before that hydrogen is available for the methanogens.  And then basically further down the line would be the Sulfur-reducing bacteria, which tend to be more in that latter part of the colon.  Where also bacteroidetes tend to dominate and that’s going to be affected by transit time and other factors too.  But there’s a lot of, sort of modeling that’s being done to understand the ecosystem.  And I think this is a great visual and understand why do we see high methanogens on our test when there’s high Firmicutes that are showing you that there’s a general overgrowth pattern, probably because they’re fermenting, generating H2 and then promoting methanogen growth.  All right.  So that’s in a few additional slides, a lot of material that we could always cover.  Maybe we’ll have an opportunity a part two at some point.

Dr. Weitz:            Okay.

Tom Fabian:       Yeah, so I bring that in, so really it’s all about connecting the dots and just learning. We have a lot of educational information because we offer the consultation. So I encourage everyone to take advantage of those resources because the more you can connect the dots, the more you can get out of the stool tests in terms of good clinical insights that can really help you be more effective in helping your patients and clients.

Dr. Weitz:            I have one more question I’d like to ask and then, I’ll see if anybody else has some additional questions. I’ve interviewed several clinicians. One of whom is very prominent and feels that some protozoa like Blastocystis hominis and D. fragilis are commensal and not something that we should be concerned with. And he’s been talking about that quite a bit.  And I think it’s common for a number of Functional Medicine practitioners to see that on a GI MAP stool tests and say here is likely the cause of your problem and are used to treating it and getting results.  And then I also talked to, in another recent Podcasts another practitioner Ilana Gurevitch and she felt that in patients where correlated with their symptoms, very important to treat blasto and D fragilis. What do you think are these pathogens, commensals or does it depend?

Tom Fabian:       Good question. So they’re not likely to be commensals based on our experience because we don’t see them in the majority of patients. It’s commensals tend to be present in the majority of individuals. I think the real answer is probably somewhere in between. So if you look at the research, most of the research suggests that Blastocystis in particular and possibly Dientamoeba their conclusion and in most of the research is that for the majority of people that have them, they’re not a problem because most of those people are asymptomatic, but I think they’re thinking of them asymptomatic in a conventional sense, not a functional sense. So they may be ignoring SIBO and these other things, mild GI symptoms, et cetera, and not taking those into account. With GI MAP, we only see, I would say probably more than 95% of the time when we see blastocystis and, or Dientamoeba Fragilis, it’s a long with that digestive dysfunction pattern. I don’t think I’ve ever seen blastocyst is just sort of by itself with no other patterns where it’s kind of like the obvious cause of things.   It’s almost always in the context of things like H. pylori, maybe candida, general overgrowth. So the question is what’s causing the symptoms?  Now trying to pin it on an individual organism, some may be more important than others.  H. pylori often is because of its effects on stomach acid.  Candida often is because we know it has, it can cause inflammation like you got Pseudomonas. Blastocystis I think is somewhere in between probably for some patients, if they have a certain subtype and it’s a really high level that may be more significant than if it’s there at a low level.

Dr. Weitz:            Okay. So one question that came in is what causes Insufficiency Dysbiosis? Is it low stomach acid?

Tom Fabian:       That’s a good question. So recent research indicates the antibiotics are often a major cause even long-term because what can happen is antibiotics can actually effect the mitochondria in the cells that line the colon, in a way that makes the gut environment less favorable to those beneficial bacteria. So, that’s at least one example of pharmaceuticals that may have that effect. Certainly lack of fiber in the diet. That’s been correlated with lower levels of these beneficial species, any source of inflammation.  So inflammation is highly detrimental to many of those beneficial bacteria. So whatever gets inflammation going that can really turn the tide.  One of the other contributing factors and it’s related to low digestion is too much protein in the colon.  That could be from just high protein diet or not digesting well.  But this process of sort of breaking down amino acids, which is called protein fermentation, and then breaking down carbs which is carb permutation. So primarily fibers they’re antagonistic.  So the less fiber you have, and the more protein you have in the colon, that can really also be detrimental to those beneficial bacteria.

Dr. Weitz:            So another question is how does the Ketogenic diet, and I would even throw in there, how about the carnivore diet impact the microbiome?

Tom Fabian:       I’ve actually only seen two cases so far and they were all almost identical and they were probably one of the… There were both among the worst cases I’ve seen as far as Dysbiosis. That’s a perfect example of this sort of… The sayings of tests don’t guess, or the opposite of that is treat the patient, not the test, right? Two different philosophies or ends of the spectrum. When you see that, so in both cases, the patient improved in symptoms, they had typical GI symptoms, gas bloating, apparently issues with carbohydrates. So they went full carnival symptoms improved. And yet you look at the gut microbiome and it looks terrible, lots of inflammation in both cases just massive Dysbiosis. So the question is, well, is short-term improvement in symptoms, are you setting the stage for long-term problems? And is there another way to address those symptoms without kind of ruining the microbiome? So good question. I mean, I guess time will tell, from everything we know about the microbiome, those results look terrible. They really would be considered by almost everybody is really bad [inaudible00:40:45]

Dr. Weitz:           Okay. And one more question, is it necessary to stop digestive enzymes before collecting the stool sample? In fact, are there any other recommendations that should be taken before collecting the stool sample?

Tom Fabian:       Not really a lot of us can depend on the clinician goals in terms of what you want to see. Do you want to see how your patient is doing on the treatments or do you want to see them of course, before treatment, et cetera?

Dr. Weitz:           Well, I guess if they’re taking enzymes, would that affect the pancreatic elastase levels?

Tom Fabian:       There’s not much evidence that does now.

Dr. Weitz:           Okay.

Tom Fabian:       Certainly, with acid, that’s typically not in the enzyme formulation, so, you wouldn’t literally affect it from just coming from the antibiotics or the main one, if you do take antibiotics we recommend waiting at least 30 days post antibiotic treatments, maybe 60 days to allow the microbiome to recover somewhat.

Dr. Weitz:           Okay. Excellent. Thank you so much, Thomas.

Tom Fabian:       It was my pleasure. Thank you.

Dr. Weitz:           Great. And thanks everybody. And we’ll see you next month.



Atrial Fibrillation with Dr. Aseem Desai: Rational Wellness Podcast 181

Dr. Aseem Desai speaks about Atrial Fibrillation 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

9:58   Arrhythmia is an abnormality of the heart’s electrical system that can result in bradycardia, where the heart rate goes too low and often presents with fainting or extreme fatigue. It can result in tachycardia, which is when the heart rate becomes fast and in some cases can go above 200 beats per minute.  And then there are irregular heartbeats, which are broken down into two categories: 1. Benign, which include premature beats that can occur from the top chamber of the heart, the atria, or the bottom chambers of the heart, the ventricles. 2. Conditions like Atrial Fibrillation (AFIB), which are quite dangerous and can cause stroke, congestive heart failure, as well as reduced quality of life.

11:09  How dangerous AFib is depends upon your stroke risk factor, which is determined by the CHA2DS2-VASc scoring system. C is for congestive heart failure. H is for hypertension. A is for age. D is for diabetes. 2 is for prior strokes or blood clots. A higher score is correlated with a higher risk of stroke.  Even though age increases the risk of AFib, there are significant numbers of young people with AFib, esp. athletes. For example, NFL players have 6 times higher risk of AFib. This may be because athletes tend to have a lower heart rate and people who have a very low resting heart rate have an increased risk of having premature beats and these can be a trigger for atrial fibrillation.

14:07  Dr. Desai does not think it makes sense for those with a low heart rate, like athletes, to attempt to raise their heart rate with increased sodium consumption or by taking licorice.  Arrhythmia does not occur simply because you have a low heart rate. A resting heart rate of 40 or 50 is only one factor along with drinking a lot  of alcohol, sleep apnea, or goes on to gain weight after retirement goes on to develop high blood pressure or diabetes.  It is the over activation of the parasympathetic nervous system that can trigger arrhythmias like AFib. This is not to say that being stressed out, in flight or fight mode too much of the time and having overstimulation of your sympathetic nervous system is not also a problem and a risk factor for AFib.

18:01  Some of the most common risk factors for AFib include: 1. age over 65, diabetes, 2. high blood pressure, 3. thyroid disease, 4. heavy alcohol use, 5. sleep apnea, and 6. obesity. Even one glass of alcohol is associated with an 8% increased risk of an AFib episode.  Chronic high blood pressure increases the stretch in the left atrium, the the top left chamber of the heart, which is the trigger for AFib. There is an inflammatory component with AFib, which is why diet and supplements can be beneficial.  Environmental toxins can be triggers for AFib. And there is a close connection between the gut and the heart and gut issues can trigger heart problems.  Acid reflux can be a trigger for AFib, since the esophagus sits right behind the heart.  Even just eating really large, fatty meal can activate the vagus nerve and trigger an AFib episode.

27:37   Diet can play a role in preventing and controlling AFib, though this should be individualized to each person.  The Mediterranean diet is probably best for most patients, though some do better on vegetarian or a lower carb diet like Paleo.  Some patients are able to take care of their AFib purely with diet and lifestyle modification, though some need medication and some need a catheter ablation procedure. AFib is a progressive disease and AFib begets AFib.  It is an electrical cancer.  Early detection is important and in order to detect AFib, there are some great biometric tools out there, including the Apple watch and KardiaMobile, which you can buy on Amazon for $90.




Dr. Aseem Desai is a cardiac electrophysiologist (EP), a physician specializing in heart rhythm disorders.  He has been caring for people with atrial fibrillation (AFib) for over seventeen years and currently practices in Orange County, California.  He has published a number of scientific papers and he just published his first book, Restart Your Heart: The playbook for thriving with AFIB. His website is DrAseemDesai.com

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

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

                                Hello Rational Wellness Podcasters. Thank you for joining me again today. Our topic is atrial fibrillation with Dr. Aseem Desai. This is actually the most common form of arrhythmia diagnosed in clinical practice. It’s estimated that between 2.7 and 6.1 million Americans are living with AFib. I got that from Dr. Desai’s book. Interestingly there’s such a broad range I guess it’s not clear necessarily whether people know they have this or not, but that’ll definitely be something we want to understand.  But as our population ages AFib incidence is increasing. So I just mentioned arrhythmia, so what is arrhythmia? Well this is basically a problem with the rhythm of the heart which occurs when your heart beats too fast, too slow, or irregularly. Some forms of arrhythmia are harmless while others can cause serious damage and even death. Your heart has four chambers. There are two upper chambers known as the atria and two lower chambers known as ventricles. Your heart also has a built in electrical system that controls the coordinated contraction of the muscles of these chambers resulting in your heart beating between 60 and 100 beats per minute while at rest.  If the heart beats too fast this is a type of arrhythmia known as tachycardia. Well with slow heart rate is known as bradycardia. Atrial fibrillation is a type of tachycardia that originates in the atria and it can be a serious condition that can lead to stroke if it’s not controlled or managed properly.

Now we’ve had a number of discussions about the cardiovascular system on this podcast, but we essentially have focused on conditions like how to prevent and reverse atherosclerosis and hypertension.  So essentially we focused on, to use a analogy from construction, we’ve focused on the plumbing, and then the engine that helps drive the blood through the body which is the heart. But now we’re going to talk about the electrical system of the heart. Our interview today is with Dr. Aseem Desai who’s a cardiac electrophysiologist which means that he’s a physician specializing in heart rhythm disorders. And he’s been caring for people with atrial fibrillation for over 17 years and currently practices in Orange County, California. He’s published a number of scientific papers and he just published his first book Restart Your Heart: The Playbook for Thriving With AFib. Dr. Desai thank your for joining me today.

Dr. Desai:             Thank you very much Dr. Weitz. Thank you for having me.

Dr. Weitz:            So before we get into the specific questions about the cardiovascular system, I noticed that you and I have something in common which is that we both have an undergraduate degree in philosophy. How did you come to study philosophy with an interest in cardiology?

Dr. Desai:             I love it. I love that I’m meeting a fellow philosopher. We could talk about Aristotle the whole episode here. Yeah no so I was part of the seven year medical program at Northwestern so as a high school senior you gain admission to college and med school at the same time, and the idea was to foster an interest in liberal arts. And so we did have a double course load. Pre med as well as liberal arts major, but it really kind of opened my mind. I think I tend to look for challenges and I don’t know about you Ben but this was probably one of the biggest challenges was reading philosophy and writing the papers. And what’s interesting is to this day I still use a lot of the logical reasoning, the deductive reasoning even when I’m doing, when I’m taking care of heart patients and making diagnoses.

Dr. Weitz:            Right. I know for myself one of the things that I got out of philosophy is when you study philosophy you learn that there’s not a lot of concrete answers, but you want to get closer to those answers. And the way you do that is by being critical and asking good questions.  And so I think that’s also important in medicine to be critical when people make statements and challenge them and try to get closer to the best answer we’ll have at that point in time.  So I think that’s helpful–how philosophy has helped me.

Dr. Desai:             Absolutely Ben and to your point I also think it keeps you with an open mind, a beginners mind. 

Dr. Weitz:            Yes.

Dr. Desai:             I think that as physicians we do have a tendency to not have that and especially…

Dr. Weitz:            We think we know everything yeah.

Dr. Desai:             Yeah. Right. Exactly. And so I think that, I mean I look forward to learning as much from you as you will from me perhaps during the podcast and as well as your viewers. I always welcome feedback, your listeners. So I do think that these two philosophers on this podcast today will have a lot to say to each other.

Dr. Weitz:             So how did you come to specialize in heart rhythm disorders?

Dr. Desai:             Well it’s very personal. So when I was about three, my dad had a heart attack. He was 37 at the time and although I don’t have much memory of that, I think many things for kids, they get ingrained in your brain even if you may not be able to process what’s going on. And he was an oncologist so I actually saw him not only as a physician but I saw him becoming a patient and I saw how this heart disease really robbed him of enjoying his life and he was fearful that he was going to have another heart attack.  And so as I went through college, high school and then college, I had an interest in science and unfortunately in the middle of medical school, me second year of medical school he actually suffered a cardiac arrest.  And he was in India at the time and in most cases the cardiac arrest is actually due to abnormal rhythms from the ventricle, from the bottom chamber.  It’s called ventricular tachycardia and ventricular fibrillation.  And in many cases as you mentioned with regards to the plumbing of the heart, a heart attack or a blocked artery, the clot that forms in a plaque can actually induce the ventricular tachycardia and ventricular fibrillation and cause sudden death.  So I think that really got me focused on the electrical system of the heart. And as I went through training and residency and then in fellowship I just found the electrical system quite a challenge. To be honest I was terrified of cardiac arrhythmias when I was a medical resident.  I mean they were really hard to understand and interpret electrocardiograms which are the recordings that we do for the heart’s electrical system and I don’t know about you Ben but mentors kind of come across your paths in different ways.  When I was a medical intern at Stanford and I was sitting reading EKG’s as part of the cardiology rotation. And it happened to be right near the electrophysiology office and electrophysiology is the branch of cardiology where we do study and treat these rhythms.  And one of the attending physicians saw me reading EKG’S and came up to me and said, “Hey you want to write a paper with me on IV Amiodarone?”, which is a drug that we use for cardiac arrhythmias.  And the next thing I knew I was writing a paper. Had no idea what I was doing, but I did publish it and I think the story goes on from there.

Dr. Weitz:            Yeah I had sort of a recent experience with arrhythmia.  I had a EKG done and after the EKG was done my doctor left the room, came back, and repeated it. And then decided to leave the room and repeat it again, and he brought another doctor in. So in between I got up and looked at the sheet of paper that read out, and the paper read that this patient is having an acute MI and I was feeling completely fine. And he came back in the room and I said, “Hey doc. Whatever’s going on, I could have something wrong with my heart, but I am not having an acute MI.”  And so it turns out I have a early repolarization variant.

Dr. Desai:             Mm-hmm (affirmative).

Dr. Weitz:            And which is something that happens in people who are athletic and so then I also had to have hernia surgery recently and I had to make sure everybody was on board with this. That they suddenly weren’t going to freak out when I was under anesthesia and somewhere or anywhere along the line that somebody saw my EKG.

Dr. Desai:             Well I think you make a great point Ben that you actually should carry a photocopy of an EKG.  If you have an abnormal EKG and it’s truly normal just a variant of normal which is what early repolarization is it’s always a good idea to actually carry a copy of it.

Dr. Weitz:            I do I have it in my phone.

Dr. Desai:             Yeah. Yeah. Yeah because like a radiologist with chest x-rays, as cardiologists we often will look at an old EKG to really get a sense of is there a new change and it really illustrates the room that we have to move on our artificial intelligence algorithms and these EKG machines.

Dr. Weitz:            Certainly the readout from that machine was not correct. Maybe you could explain a little more about exactly what is arrhythmia?

Dr. Desai:             So arrhythmia is a generic term used to describe any abnormality of the heart’s electrical system and that can result in something called bradycardia where the heart rate goes too low and often presents with fainting or extreme fatigue. It can result in tachycardia which is where the heart rate goes too fast. A common symptom there would be a sense of a racing heartbeat, and sometimes if the heart rate goes fast enough, and in many cases it can go over 180, 200 beats a minute, people can faint with that as well.  And then you have irregular heartbeats and so irregular heartbeats are really broken down into two categories benign which include what we call premature beats that can occur from either the top chambers of the atria or the bottom chambers of the heart, the ventricles. Or conditions such as atrial fibrillation which are quite dangerous and can cause stroke, congestive heart failure, as well as reduced quality of life. So it really is a generic term, arrhythmia. And it encompasses bradycardia, tachycardia, and irregular heartbeats, AFib being the most common. But it’s important to mention that not every irregular heartbeat is AFib.

Dr. Weitz:            How dangerous is AFib?

Dr. Desai:             It’s actually very dangerous. It depends on your stroke risk factor score first off. So we use a scoring system called CHADSVASC. It’s an acronym and you calculate the number of points that include some such as congestive heart failure, high blood pressure, age, diabetes. And as you add up these points there’s a lot of large databases that have shown that once you hit a score of 2 or higher your stroke risk is actually quite high with AFib and it continues to go up as the points get added up and so we, just like many areas of medicine and I’m sure in your case as well, you look at a person’s health and you do a risk stratification, priority stratification and it’s no different with AFib. So you can have young patients actually that get AFib, especially athletes.  We’re seeing a larger population. Those patients tend not to be as high risk for stroke but certainly impacts their quality of life though.  NFL players have a six times higher risk of AFib compared to their counterparts. Most people don’t realize this.

Dr. Weitz:            Really? Why do you think that is?

Dr. Desai:             That’s a good question. So we’ve now learned that the nervous system is a big component of heart rhythm problems. So the nervous system, just like inflammation is a big part of many different illnesses including coronary disease and GI issues. The nervous system, the autonomic nervous system which includes the Fight or Flight which is the sympathetic and the Rest and Relax–the parasympathetic, actually is heavily involved in the genesis of cardiac arrhythmias. So for example, athletes have often a low resting heart rate and that has to do with the vagus nerve. The vagus nerve, being that part of the nervous system that helps to preserve your energy really. There’s no point in your heart rate being 90 beats a minute when you’re sleeping. So a good conditioned athlete often has a low resting heart rate.  But just like anything in life, extremes may not be a good thing and people who have a very low resting heart rate have an easier ability to have what are called these premature beats that I referenced earlier.  Why I said that premature beats are benign, that’s not exactly true.  If you have enough premature beats, especially from the atria and under the right perfect storm so to speak it can be a trigger for atrial fibrillation so one thought with the football players and other athletes including triathletes for example is that this low resting heart rate predisposes to these premature beats.  Because there’s a longer time interval between beats with a low resting heart rate so it’s easier for these extra beats to be a trigger and if you think of AFib as a fire, you have the matches and you have the wood.  And the matches would include something such as these premature beats, would include things such as alcohol, variety of other factors.  And then the wood are the risk factors for AFib which would include things such as age over 65, diabetes, sleep apnea, a whole host of things that we can get into.

Dr. Weitz:            So would it make sense for an athlete who has a lower resting heart rate, for example myself, actually when I was on when I was in the pre op, they, my heart rate was right around 50 and down to 48 and up to 55 and they kept going, “Oh. You’re an athlete. You’re an athlete.” And they were freaking out a little bit. Does it make sense for somebody with a low resting heart rate to try to raise their resting heart rate?

Dr. Desai:             Well it’s a good question and the problem with this is you can’t really do that from the standpoint of, I mean other than taking in stimulants such as amphetamines.

Dr. Weitz:            Well could you for example take in more sodium? Could you eat licorice? We just heard about somebody who ate so much licorice that they died actually.

Dr. Desai:             Right. Yeah the problem with licorice consumption is that it more predisposes to dangerous heart rhythms rather than purely increasing your heart rate.  And it’s not that low heart rate in and of itself.  It’s, with arrhythmias like AFib it’s the perfect storm.  So we’re now learning there’s quite a bit of complex genetics with AFib. So not every athlete with a heart rate of 40 or 50 is going to get AFib by all means, but if that athlete consumes a lot of alcohol, if that athlete has unrecognized sleep apnea, if that athlete puts on weight after they retire and goes on to develop high blood pressure or diabetes, that’s really, it’s that adding up of risk factors.  It’s just that when you have a low resting heart rate that kind of puts you at a little bit of a higher risk.  But we’re still working it out. We’re still trying to determine what’s going on. But you ask a good question which is, is it the heart rate itself? And I would say no it’s more, it’s that over activation of the parasympathetic nervous system.  And it’s not just the heart rate.  The actual vagus nerve, when you stimulate it either in laboratory models or even when we’re doing a procedure called catheter ablation, and you stimulate the vagus nerve which you can do, it’ll actually trigger AFib and it has nothing to do with low heart rate. It’s literally stimulating that nerve and the release of the acetylcholine and other components that can be a trigger for arrhythmias.

Dr. Weitz:            Now is it the overstimulation of the parasympathetic or the sympathetic?

Dr. Desai:             That’s a great question. So now we believe in most cases it’s actually the parasympathetic that’s the problem.

Dr. Weitz:            Well that’s interesting because and when we have patients who have anxiety or they have adrenal problems or they have fatigue, we’re always working with them to increase parasympathetic stimulation because the thought is everybody’s stressed, everybody’s in sympathetic mode all day long and that’s why they’re drinking caffeine because they want to be in this sympathetic mode because they’re not sleeping enough and they’re trying to get more work done, etc.

Dr. Desai:             Well you’re absolutely right. For emotional and mental stress and even physical stress, I mean the parasympathetic nervous system’s a very important part.  You I’m sure are aware of heart rate variability and using heart rate variability in certain breathing techniques activates your parasympathetic nervous system. 

Dr. Weitz:            Exactly.

Dr. Desai:             So it’s not so much as you mentioned about calming down your fight or flight.  It’s about enhancing your rest and relax.  It’s about enhancing your parasympathetic nervous system.  The only reason why I’m commenting on this from the standpoint of arrhythmias is that the parasympathetic has been implicated honestly both parts of the nervous system have been.  So we clearly see sympathetic triggers if someone’s under a lot of stress and their heart rate goes up, they can end up having more premature beats.  So it’s not, I would just say anything out of balance in the body, right, is not a good thing. And so when you come to AFib we love using this term the perfect storm.  You have a few risk factors, you have a few of these matches, you have a little bit of that wood, and then it creates the fire and that’s why on a given day there’s something or a combination of things that could lead to a patients first AFib episode.

Dr. Weitz:            Well it’s interesting when we’re talking about these risk factors because it seems like this comes up all the time. At this point we’re still going through this COVID-19 pandemic, and what comes up all the time is that people are likely to have a worse prognosis if they have any of these chronic diseases like being overweight, having hypertension, having diabetes, having sleep apnea, having lung disease. These are the same chronic conditions that are so prevalent in our society that they make it more likely that you’re going to have AFib.

Dr. Desai:             That’s absolutely right and if you look at obesity for example that it one of the number one risk factors for AFib and there’s a lot of different mechanisms that are thought of with regards to that. But obesity itself leads to many of the other conditions you mentioned. The diabetes, the high blood pressure. Chronic high blood pressure increases the stretch in the left atrium which is the top left chamber of the heart. That’s the trigger for AFib. There are so many different types of mechanisms, but as you mentioned with COVID this inflammatory component is critical right?  I mean that’s why people get this multi organ system failure. That’s why people get this myocarditis that you’re seeing in cardiac cases.  And so many cases, or many people believe I should say, that AFib is along the same lines. It’s an inflammatory disease. It’s, so you do see elevated biomarkers in the setting of AFib.  We just don’t know what to do with those biomarkers, but we do know that there is an inflammatory component like many things. I think that’s also why probably treating your body with food as medicine, that certain foods definitely and supplements definitely do help cardiac arrhythmias, but the other, I think what distinguishes it a little bit, AFib from some of these other things we’re talking about is this interplay with the nervous system so I think the gut, as you know the enteric nervous system and the gut there’s that secondary nervous system. The heart has it’s own nervous system, and so it’s interesting to see this sort of two way street between the brain and the heart and the brain and the gut, and I think when those things are out of balance and it’s usually nature and nurture, there are some genetics probably and then there’s environmental triggers.  So many things we’re not aware of right? We don’t even, there may be multiple toxins in the environment that are big components of causing AFib that’s to why one person gets it and one person doesn’t. So there are well defined risk factors: age over 65, diabetes, high blood pressure, thyroid disease, heavy alcohol use, sleep apnea, obesity is the big one. And then there’s one that we really haven’t determined yet. But I would say that you see this I call it the electrical epidemic, AFib. It’s an epidemic because as we get older we’re living longer, and so it’s arthritis of the electrical system. So when you get AFib when you get older, you could be a totally healthy person. Lived a totally healthy life, and still get AFib. And it has to do with scar tissue that builds up in your electrical system just like it would in your knee. So that is, that’s the age related factor of AFib. And then you have that obesity component that our society as you mentioned Ben, I mean we’re getting unhealthier and unhealthier and the obesity epidemic is probably a big reason why we’re seeing AFib.  We’re seeing a lot of AFib in our practice right now so our patients who have AFib are getting more AFib right now during COVID. Two reasons we think.  One is increased alcohol consumption.  One glass of alcohol is associated with an 8% risk of an AFib episode. It’s not a small thing. And then the lack of physical activity and weight gain.

Dr. Weitz:            Yeah and the stress as well.

Dr. Desai:             The stress is huge absolutely. We see, it’s interesting you mentioned the stress. Just in observation there’s a lot of people who, they’ll be in AFib, they’ll go into this AFib episode at home. Their heart’s racing, it’s going irregular, they’re feeling terrible because the heart’s an engine so when you go into AFib you lose about 30% of the pump efficiency of your heart. It’s almost like losing a few pistons in your engine. That’s what the atria do for you and when you go into AFib the part of the heart muscle beats very poorly, very chaotically. So people are feeling terrible and they go into the hospital and they’ve been sitting in AFib even sometimes for a few days and they go into the hospital and the doctor is getting ready to shock the heart back into rhythm called the cardioversion which is often something that’s done for AFib. And literally you’re getting ready to press the button and the person converts to a normal rhythm. And the hypothesis here is that people feel safe when they get into a hospital in this context. Not always. But in this context they feel safe.  And so we see it over and over again where people, that’s why I’m a big believer in mindfulness. I do a daily mindfulness practice. I have a lot of interest in that, and we definitely see through activation of the parasympathetic and calming down that fight or flight response. I mean I mentioned all of these things about parasympathetic and arrhythmias, but don’t get me wrong. It’s not that the parasympathetic is bad and it causes arrhythmias.  It’s just that we’re learning specifically in athletes, but what’s also interesting is GI triggers for AFib. So people who have acid reflux, the esophagus sits right behind the heart, or people who eat a really large, fatty meal activates the vagus nerve. So again it’s these, it’s over activation.

Dr. Weitz:            Yeah I mean, be honest with you in my practice we see a lot of patients with GI disorders, especially irritable bowel syndrome and reflux. These functional disorders, and they’re extremely common.  When you combine those with obesity, and 70% of the patients in this country are overweight, you add in the rates of diabetes and hypertension and some of these other conditions, it’s surprising that we don’t have more people with AFib.

Dr. Desai:             Oh absolutely and I’ve been on different kinds of shows and I’ve talked about these things and one of the things I started realizing and gotten humbled about is patients are saying to me, they’re like, “This is great. You’re telling me all these bad things. How do I change my life?” And I don’t know if you’ve heard of Thrive Global. It’s a organization funded by Arianna Huffington and it’s an amazing…

Dr. Weitz:            Oh I know who she is, but I haven’t heard of the organization.

Dr. Desai:             So yeah. So Arianna and I had a chance to connect as I wrote this book, partly because of my interest in mindfulness and I reached out to her to get her thoughts on the book, and she invited me to be a contributor for this website.  So for your listeners out there I would definitely encourage you to check out this website thriveglobal.com because they’re addressing so many issues of COVID right now.  Parents who are working from home, schooling people at home. I mean everything really under the sun. But what I like, their theme is microsteps.  So to make a behavior change, it’s a micro step.  It’s not what we used to think which is, 21 day challenge.  Give up this.  It’s really making those small changes every day and then, and building on that and having that accountability.  So I just wanted to mention that because you and I are having this great discussion about all these risk factors, but I don’t want people to be demoralized into thinking that there, it’s, there are ways to change, and I know that you do that you do that on a regular basis with your patients.

Dr. Weitz:            Absolutely and the greatest thing that could come out of this COVID crisis is if there’s more awareness about doing something about these chronic diseases that result from poor diet and lifestyle like we’ve just been talking about like obesity and hypertension and diabetes and etc. etc. We, America needs to wake up and get healthy and exercise and eat healthy and get control of their stress and all of these chronic, all of these conditions like AFib are, we’re going to see less of.

Dr. Desai:             Yeah I totally agree. I mean it’s interesting, a virus that is decimating part of humanity is also connecting part of humanity and waking up part of humanity that all of these thing’s we’re talking about, these are huge risk factors for massive COVID infection and poor outcomes.

Dr. Weitz:            Yeah.

Dr. Desai:             So I think you’re right. People are sort of saying well this is this end goal that we all have of not wanting to get infected and certainly not wanting to have a bad infection.



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

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

                                                Now, back to our discussion.



Dr. Weitz:            Are there certain diets that are associated with less risk of AFib or that can be beneficial for patients that have AFib?

Dr. Desai:             Yeah I think that the… 

Dr. Weitz:            And keep in mind the background is that there’s a lot of confusion today as far as what the best diet is and it’s almost like partisan politics.  We’ve got the vegans on one side and the people who only eat meat, the carnivores on the other side.

Dr. Desai:             Right.

Dr. Weitz:            And then we’ve got the Paleo and the Mediterranean [crosstalk 00:28:12] and everybody’s claiming that their diet is the best.

Dr. Desai:             Yeah and I think it raises the point. This is for AFib, this is for diet. You have to individualize to your case. You may have a certain blood type if you believe that, where a certain diet is better or you may have a lot of chronic inflammatory disorders whether it’s fibromyalgia or lupus or even cancer and a vegan diet with all the data we know about reducing inflammation on that. So as cardiologists we typically recommend the Mediterranean diet. There’s a fair amount of data with regards to that. Lean proteins, good fats, but I think that it really comes down to balance. But you also have to look at your individual situation because whatever food plan you adopt, you want to adopt something that you can stay with the long term.  Yeah you can have your cheat day once a week or what have you, but you want something that’s really going to sustain you long term which is why I’m not a big fan of things like Atkins and really high fat diets. I agree sugar is not good, but I think you really have to individualize and AFib is the exact same way. No two patients with AFib are treated the same or are the same. So some people, they may be able to take care of their AFib purely with diet and lifestyle modification. Losing weight, not drinking alcohol, etc. etc. Treating sleep apnea which is very unrecognized as trigger for AFib.

Some people, they need a medication in some cases. Some people need a catheter ablation procedure and there’s other kinds of things that we can do, but AFib is a progressive disease.  AFib begets AFib. This is an electrical cancer. People need to know about this disease. They need to know how to screen themselves for it. They need to know how to help their loved ones with it because you don’t want to wait until someone has stroke to figure out that they have AFib.  And nowadays with all these great biometric tools, Apple has their EKG function on several of their watches. KardiaMobile has a device you can buy $90 on Amazon. These are devices that actually allow you to record an EKG and tell you with a reasonable amount of accuracy, not perfect that you may be having AFib.  So we are big proponents now of early detection, early intervention.  So if someone gets diagnosed with AFib for example you don’t want to just say, “Lifestyle and diet and let’s regroup in four weeks.” Every episode of AFib even if it’s five minutes and this is really important changes the cellular and electrical architecture of the heart to want to have more AFib. It’s a muscle memory thing.   So we’ve had cases of patients where they think they’re only having one or two episodes a year, where in fact they were having a lot more silent episodes, but that’s common actually while people are sleeping. Silent episodes of AFib they don’t feel anything and their AFib is progressed by the time they go to treatment. So early detection, learn how to take your pulse after you brush your teeth. It should be like a metronome. It shouldn’t be fast and irregular.  Many patients have very subtle symptoms. This is really common. 

Dr. Weitz:            Yeah what are the symptoms of AFib?

Dr. Desai:             Yeah I’m glad you asked. So the, it depends on your age, so younger people and we’ve seen people as young as 18 by the way, tend to get that rapid, irregular heart rate. The palpitations that we described. But it’s more than just skipping beats. It’s a tremendous amount of fatigue or shortness of breath because again the engine analogy, you lose pistons when you go into AFib. That’s different. If you’re having these skipping beats, these premature beats, you don’t lose pistons in your engine. You, they may be bothersome but you don’t feel terrible and with AFib that’s the big thing is this general sense of lack of energy, fatigue, shortness of breath. But what’s interesting is that as people get older, and especially people who aren’t that healthy who aren’t that active, they may not be aware at all they’re in AFib.

                                They’ll show up for gallbladder surgery as pre op and they’re in AFib. We that so commonly. And then you ask them, “Well over the last six months or year, have you noticed a change in your endurance or activity level?” “Yeah I have I just thought it was I was getting older.” We hear that so commonly. Well it’s not until you restore someone’s rhythm back to normal which is what we often do in those cases at least once. At least as a trial. When someone says they don’t have symptoms with their AFib, we believe as electrophysiologists that unless there’s a strong reason not to, everyone, or most people I should say not everyone, most people should have some kind of attempt at restoring the rhythm. Because you don’t know how much you’re actually having symptoms of something until you restore the rhythm. It’s like having a bad knee and doing less.   You don’t really, and decide to have a knee replacement and realize that you could do more. So that, it’s the same thing with AFib. It’s the great masquerader. It’s electrical cancer. There’s so many different presentations and that’s why the early detection and these devices that I mentioned are so important.

Dr. Weitz:            So the most common symptoms, list four or five of the most common symptoms.

Dr. Desai:             Yeah so most common symptoms, fast irregular heartbeat called palpitations, shortness of breath, sometimes chest discomfort, tremendous fatigue, and that would probably be, and then unfortunately stroke is an often common presentation of AFib where there’s no symptoms. But I would probably say the fatigue part and what’s, the key thing with any of these arrhythmias in the beginning, they’re episodic so what’s different with the heart, the coronary arteries, the three coronaries, they’re, it’s plumbing as you mentioned. So if you have a blockage, it’s going to show up on a stress test. It’s going to show up on a variety of testing. AFib, it can come and go. It’s like the electrical system in your car or your house. It’ll act up sometimes, and then it won’t be there. So you show up to a doctor’s office for an EKG and then you come back in six months and you’re in normal rhythm, you could be having AFib that night and you don’t know it and it’s not until you go from this in and out AFib which is called paroxysmal to continuous AFib which is called persistent that people really then get diagnosed.

                                And the problem is by the time you get to persistent, the treatments are much less effective. We have lots of ways of treating people with persistent AFib, that’s an important point. One of the reasons I wrote this book is people are, there’s so much misinformation out there. People are told they have to live in AFib. It’s too far gone, there’s nothing that can be done, and in the introduction of the book I talk about a man who was told that for five years continuous AFib and we got him to rhythm because of current technology. It’s also lifestyle changes. So those will probably be the most common symptoms. I wanted to circle back to your question which I really didn’t answer about diet. Magnesium is really important with regards to, and I think the important thing about magnesium is you can’t go based on a blood level. 90 something percent of magnesium is stored in your tissues, not in your blood [inaudible 00:34:59][crosstalk 00:34:59]

Dr. Weitz:            Right.

Dr. Desai:             And that’s the same with potassium as you know. So we have a low threshold to recommend a magnesium supplement to someone with heart rhythm issues unless they have advanced kidney failure that’s really the only time where you want to be careful about the magnesium. As far as a specific diet I wouldn’t say, I’d be curious to see if you’ve come across anything in your research. I haven’t come across anything that says this diet is really good for AFib, but I would definitely argue that anything that results in reduced inflammation in your body is likely going to be a good thing for AFib. If nothing else it’s going to help your risk factor’s right? It’s going to reduce your obesity and all these other things which then help your AFib so it’s really about trying to prevent the AFib. Now its [crosstalk 00:35:39]

Dr. Weitz:            There are now a number of forms of magnesium [crosstalk 00:35:44] we use frequently in our office and so there’s magnesium citrate, magnesium glycinate is known to be better absorbed and have less issues with bowel laxity. We’ll [crosstalk 00:35:59] use magnesium citrate if someone is constipated. We use magnesium threonate which has been known to affect the brain and central nervous system a little better. Is there a form of magnesium that you think is more effective for AFib?

Dr. Desai:             I’m so glad you asked that because a lot of people just go to Costco or what have you and pick up whatever magnesium is on the shelf and this is nothing against Costco by the way, it’s more [crosstalk 00:36:26]

Dr. Weitz:            I’m with you.

Dr. Desai:             Yeah magnesium oxide is one of the [crosstalk 00:36:29]

Dr. Weitz:            I got this big giant bottle of fish oil for five dollars.

Dr. Desai:             Exactly. Well there’s a reason why it’s five dollars. So, but magnesium oxide is probably one of the worst absorbed forms of magnesium. And it’s one of the most common sold ones in stores. So yeah the ones you mentioned are great. Magnesium citrate, it actually comes, I love Natural Calm. Natural Calm is a product that you find online, you find in stores. [crosstalk 00:36:54]

Dr. Weitz:            It’s a powdered form of magnesium. [crosstalk 00:36:57]

Dr. Desai:             Yeah it actually comes as a gummy. Now the gummy has some sugar in it, so you’ve got [crosstalk 00:37:01] to be careful about that one.

Dr. Weitz:            Forget the gummies.

Dr. Desai:             Forget the gummies. So but magnesium citrate is a good one, magnesium glycinate as you mentioned, Doctors Best is a really good brand for magnesium glycinate for example. Magnesium malate. Malate is a really good one. And taurate, magnesium taurate. So taurate has kind of more of a specific cardiovascular effect. Sort of derivative or related to taurine amino acid and there is data with regards to taurine and heart health and even rhythm. So there’s a company Cardiovascular Research Lab makes magnesium taurate that we will often prescribe to people. So it’s really about just getting people to take it. And I always tell people go based on the serving size of the bottle. People always ask what dose you should take. It’s really, it’s very manufacturer specific, company specific, but I would say those would be the main ones to consider.

Dr. Weitz:            Yeah I would like to say when it comes to magnesium, manufacturers are often very careful and often will recommend one tablet or something line that. But they have no idea your particular circumstances.

Dr. Desai:             Right.

Dr. Weitz:            And for the most part the only side effect of taking more magnesium is that you’ll get diarrhea and you’ll [crosstalk 00:38:12] know that pretty quickly. So- [crosstalk 00:38:15]

Dr. Desai:             Right.

Dr. Weitz:            You very well may need 400, 600, even 1000 milligrams would not be at all excessive for our magnesium need so a lot of time just what says on the bottle may not be [crosstalk 00:38:29] what you need.

Dr. Desai:             I’m glad you raised that point, Ben. A few things. One is we’ve seen cases where if we give someone magnesium glycinate. Hey go based on the serving size on the bottle, continue to have rhythm issues whatever the rhythm issue is and then we add in another magnesium. So the combination of magnesiums. Know that I’ve had one patient who said, “Well the glycinate didn’t work but when I added in the taurate and lowered the glycinate.” You know so you really have to titrate based on if you’re taking it for palpitations for example, or AFib you want to titrate it based on your episodes. Is your heart calming down? That’s the point of the magnesium is there’s what’s called phase two of the action potential in the heart and the electrical system is part of your heartbeat, and magnesium and calcium have this exchange pump in the heart cell and that’s the theory behind why magnesium helps so much as a stabilizer of the electrical system. And the point you made about the GI distress, so we do have a fair number of patients that just can’t tolerate any form of magnesium orally.

                                So you have magnesium foil. You have bath flakes. There are other ways of taking magnesium that you can absorb some. [crosstalk 00:39:34]

Dr. Weitz:            And the glycinate has less effect on the bowel. But [crosstalk 00:39:39] taurine is another supplement just used [crosstalk 00:39:41] individually. Have you had experience with using that?

Dr. Desai:             Yeah I have one gentleman actually who, and of course I’m telling you stories about different people. We don’t have [crosstalk 00:39:50] these large randomized crowds, but I have this one gentleman who, he struggled with premature atrial beat. So these are benign things but it just debilitated him because if you’ve ever had one it feels like your hearts going through this rollercoaster. And so he tried initially the Natural Calm. That didn’t really work for him, he switched to the glcinate that didn’t really work for him. So then we had him on magnesium malate, and then we added a little bit of taurine in. And that, not the full dose of taurine that’s often recommended. And that really calmed him down so I do think that there’s a role certainly for taurine. My go to if someone’s having rhythm issues or heart issues is to say start with magnesium. Start with glycinate as you mentioned is well absorbed. If it doesn’t work maybe consider magnesium taurate or Natural Calm. And then if you continue to have issues that’s where you start to think about these other things.

                                And it’s also important to mention just for your listeners, there are a lot of drugs that deplete your body of magnesium and you have to be aware of that. Proton pump inhibitors for example that block acid secretion for ulcer disease notice deplete the body of magnesium. The diuretics [inaudible 00:40:59] deplete your body of magnesium and potassium so to your point Ben, those are people who probably need to have a super dose of magnesium because they’re losing so much of it. And the last point about magnesium I’ll make is intravenous magnesium has a powerful anti arrhythmic effect and what that means is we have people who have come into the hospital with AFib or with what’s called ventricular tachycardia dangerous heart rhythm and you just give the magnesium even with a normal level and it has this amazing immediate calming effect and I mentioned with the magnesium that the serum level is not very helpful. You can ask your doctor to order what’s called a RBC magnesium level within the blood [inaudible 00:41:36] and that tends to be a little bit more accurate.

Dr. Weitz:            Yeah we use that regularly. A few other supplements. Have you had any experience with coenzyme Q10 which is frequently recommended for heart health?

Dr. Desai:             Yeah I obviously recommend it to my patients generally for heart disease [crosstalk 00:41:55] treatment or prevention. [crosstalk 00:41:55]

Dr. Weitz:            By the way CoQ10 since we’re talking about nutrients that are often depleted, cholesterol lowering drugs like statins deplete [crosstalk 00:42:01] the body of CoQ10.

Dr. Desai:             Yeah it’s so interesting how we have people and so many treatments that fight each other. I mean it’s just they’re in the ring together and they’re fighting each other and it’s sort of like you’re not really sure what that outcome you’re having.

Dr. Weitz:            Oh yeah. We, statins increase your risk of diabetes and some of the most common diabetes drugs increase your risk of heart disease so.

Dr. Desai:             Right. Exactly. So I’ll be honest with you. I don’t really have a lot experience or knowledge of specifically Coenzyme Q10 and it’s impact on the heart’s electrical system or AFib. Have you come across anything in that regard? [crosstalk 00:42:34] With Coenzyme Q10 [inaudible 00:42:34]?

Dr. Weitz:            I’ve, yeah I’d seen some studies on it and CoQ10 seems to have a lot of benefits for congestive heart failure for a series of issues with the heart, so it’s probably one worth experimenting with and another one is hawthorn berry which is often [crosstalk 00:42:52] included in supplements for hypertension and heart health.

Dr. Desai:             Yeah my feeling on supplements is as you know there’s a lot of criticism from western medicine on these I think having functional medicine is such an amazing step forward. That you have physicians and practitioners from all different disciplines really focused on maintaining function not so much on giving a pill or doing a procedure. But I think that people just need to be careful that the supplement alone isn’t going to necessarily fix the problem. And you really, there is definitely a role and we do a lot of catheter ablation so I’m a very integrative electrophysiologist, but I’ll be honest catheter ablation if you look at all the different treatment options for AFib, I’m talking about people now who have the disease that is not being managed by just diet and lifestyle. It is a highly effective form of treatment and there’s a lot of misinformation including from healthcare providers about the efficacy of catheter ablation that nowadays with early AFib, the early onset of AFib peroxisomal we have some trust rates of almost 85 to 90% with a [crosstalk 00:44:03] risk of around 1%.

Dr. Weitz:            What do you hear healthcare providers saying that’s incorrect about ablation? What’s [crosstalk 00:44:12] the common misconceptions?

Dr. Desai:             It’s too risky and it doesn’t work. And then number two is it’s not going to work for you, patient, because your AFib is too far gone. And so, and then the third is well it doesn’t make sense to treat your AFib or try to get you into rhythm because you’re not having any symptoms. So those are the three. And this book that I wrote is not just for patients or family members. This book is for healthcare providers. Not just for education, but It’s hard to, nowadays in a 20 minute patient visit how are you going to talk about such a complex disease and we just have these kind of five page pamphlets that really don’t tell you much. So the idea is really to provide people with a little bit more detailed information. But catheter ablation for the listeners who haven’t heard the term, it’s simply a way of destroying abnormal tissue and preserving normal tissue. So destroying cells that aren’t supposed to be there. So if you think of the sources of AFib which are called the pulmonary veins as capsules of AFib sending out sparks, then we, well with kind of the fire analogy that we used.

                                We’re essentially creating some insulation around the fire. We’re creating insulation around a broken wire. Drug therapy, there’s a role for it, but anti arrhythmic drugs, which is what we use, they have such a high side effect in toxicity rate and at best the most effective one which is amiodarone has only about a 40 to 50% long term success rate. So again our first step always with heart disease or any kind of disease including AFib is diet and lifestyle. Lose weight. That can make a huge, I’ve had patients that have had ablations and they were overweight and then, and their AFib kept coming back. And then when they lost the weight, their AFib didn’t come back. And that’s something that shame on us as electrophysiologist in our field that we’re now learning you have to optimize those risk factors before and after any intervention to have the best outcome. And there is this mentality unfortunately in our society about sort of quick fix. Do an ablation, there’s a lot of sort of altered expectations. People come in and think that the ablation is going to reduce their risk of stroke or fix their AFib.

                                And it’s a big [inaudible 00:46:26] this is what you do. It’s a big picture functional medicine holistic standpoint. You’ve got to manage everything. Everything’s got to get in balance.

Dr. Weitz:            Yeah. I guess when I think about AFib the idea of doing a procedure that could potentially cure it instead of having to take some of these drugs for the rest of your life that have all these side effects. To me that sounds much more appealing. On the other hand, when I watched one of your videos describing how you do the ablation, boy it is a really complicated procedure that involves threading this little wire into the vein, going through one side of the heart into the other side of the heart and it makes me realize you really want an expert who’s going to do that because it is, at first watch you think oh well just go into this part of the heart and just burn this little thing and everything’s fine. It’s like I just fix this electrical socket and it’s a really complicated procedure.

Dr. Desai:             I’m so glad you mentioned that. That’s important feedback for me. Because actually that’s how, electrophysiologists consider AFib ablation to be one of the easiest procedures we do. Because the femoral vein is a vessel in your groin, we put an IV in there, we thread the catheter through the IV so there is no cutting, and there’s a, it’s a straight shot into the heart. That’s our mindset because we deal with it everyday right? But we don’t think about the other side of it, and I should really think about redoing that video because if that video sent a message to you that this is a really complicated procedure, it’s actually changed a lot over the decades and so it’s actually become quite a simple procedure. There’s, for example we use something called the cryoballoon.  It’s a balloon. We go to these four different structures in the heart. We freeze each for basically 210 seconds and we’re done. The actual ablationt takes only 20 minutes. A lot of it’s set up, a lot of it’s technology and things like that, so.

Dr. Weitz:            Okay.

Dr. Desai:             I’m glad you mentioned that because I have to really rethink what I’m putting out there now because it can look a lot more complicated that it is, you know?

Dr. Weitz:            Yeah. Yeah. You were talking about some and the risk is you go through one [crosstalk 00:48:37] side of the heart to the other and you know.

Dr. Desai:             And I’m not discounting that. I mean [crosstalk 00:48:43] to your point, you don’t just want to go to, you know whenever you’re having a procedure done or any treatment you want to go to someone who has high volume, done a lot with a low complication rate. And that’s the case with anything that you do on your body.

Dr. Weitz:            Absolutely. Absolutely. Including getting chiropractic adjustments or- [crosstalk 00:48:59]

Dr. Desai:             Including getting chiropractic adjustment absolutely. Yeah I mean for sure.

Dr. Weitz:            So what are some of the most common medications that are used?

Dr. Desai:             So oftentimes beta blockers include drugs such as metoprolol, atenolol, these are drugs to what we were talking about earlier about the fight or flight sympathetic nervous system. Those are drugs that block the effect of that on the electrical system of the heart so naturally they lower the heart rate, they lower the blood pressure. And so they can be effective if someone especially has a rapid heart rate. There’s a drug called propranolol which often has an anti anxiety effect as well which can be helpful for premature beats. But the problem is that those drugs aren’t easily titratable and so especially for young people often don’t like being on them because it really blunts your heart rate response to exercise, so people feel tremendous fatigue. It can exacerbate depression. It can exacerbate insomnia. For men it can exacerbate ED. So there’s definitely trade outs.

                                But what’s nice about beta blockers is they typically don’t harm you compared to other drugs that we use. Calcium channel blockers such as one called diltiazem and one called verapamil, these lower adrenaline in a different way and what’s nice about them compared to the beta blocker is not as much fatigue but they do, they can cause constipation and some ankle swelling. Those two classes of drugs have about a 40% efficacy rate for AFib long term. So not the highest. And then you have the next tier of drugs called anti arrhythmic drugs and there’s about five or six that we choose from. And these drugs, if you think about the heart’s electrical system as a bunch of doors opening and closing those are what we call ion channels and this is what these different electrolytes like we’re talking about, magnesium and sodium and potassium and calcium, these move in and out of the heart cells and the electrical system and it generates current. Just like you think of any electrical thing it generates a current. And so the drugs actually block these different doors, these doorways called ion channels and so as a result the drug can manipulate the current.

                                Well sometimes that works well in treating AFib and other issues, but sometimes it manipulates the current too well and it slows the heart rate down too much or it creates a dangerous rhythm called ventricular tachycardia and so the problem with drug development with AFib is that there’s been no improvement in decades. And one of the reasons why is that we still don’t have a good handle on the genetics, and we still don’t have a good handle on how do you create a drug that’s just specific for the top chambers of the heart, but do not affect the bottom chambers of the heart? Cancer for example, oncology, wonderful drugs now targeting the immune system. Same thing for many other conditions like rheumatoid arthritis, psoriasis. We don’t have that quite yet for the electrical system, so those are the two, and so the anti arrhythmic drugs would include drugs such as amiodarone, sotalol, propafenone, flecainide, multaq, tikoson, in case your listeners if they’ve ever heard of those drugs they have an efficacy of about 50% long term with very high side effect profile.

                                And again I, my job here is not to push ablation. Obviously I am biased. I do a lot of ablation. Of course I am biased and I believe in it, but I have been humbled in many cases where we ablate, AFib keeps coming back, and one day a spouse comes to the office and mentions the husband snores and we have this aha moment, “Oh I should’ve done a sleep study.” And then I do a sleep study and the AFib disappears and it’s that much of a connection between sleep apnea and AFib.

Dr. Weitz:            Yeah. There’s a huge connection between sleep apnea and a whole series of [crosstalk 00:52:34] chronic conditions and it’s definitely underdiagnosed and I think part of it just because people don’t want to be put on a CPAP machine and they don’t [crosstalk 00:52:44] want to get diagnosed.

Dr. Desai:             Yeah I’m glad you mentioned that. Not that I’m a sleep specialist, but what I, I refer a lot of patients for either home apnea link studies which is where you can screen it at home, or a sleep study and the top number one reason why people don’t show up to the appointment or don’t want to have it done is they don’t want to get a CPAP machine. And my experience has been in many cases it’s because they didn’t have the right mask, they didn’t have the right pressure setting, they didn’t have the right education. They were just given a machine, it was ordered, they dropped it off one day and they suffered with it and then there was no follow up. So I think it’s important for people to know and then there’s a lot of other treatments. There’s dental appliances as you know. There’s stimulators now. Medtronic makes one for example for treatment of sleep apnea for different, for like the tongue for example the glossopharyngeal nerve. So, but it important to treat. And the number one way to treat is to lose weight and [crosstalk 00:53:37] that’s such a big trigger.

Dr. Weitz:            Yeah there’s also a correlation between low vitamin D levels and sleep [crosstalk 00:53:43] apnea.

Dr. Desai:             Yeah. I didn’t know that actually is that true? I didn’t know [crosstalk 00:53:47] that.

Dr. Weitz:            Yeah there’s a few studies on it. I interviewed a dentist who was described how he saw a number of his patients turn around with getting the right amount of vitamin D.

Dr. Desai:             I’m going to have to keep that in mind because so many of our patients have sleep apnea. [crosstalk 00:54:02]

Dr. Weitz:            Now in his case he felt it was important to get the vitamin D to the optimal level not the [crosstalk 00:54:07] normal level. So not [crosstalk 00:54:10] just over 30 but say in that 50 to 70 range.

Dr. Desai:             Okay. All right.

Dr. Weitz:            Nanograms per milliliter.

Dr. Desai:             Okay.

Dr. Weitz:            And then I guess blood thinners are recommended sometimes too to prevent stroke which is one of the side effects.

Dr. Desai:             Yeah I think it’s important you touch on that. So stroke is the most catastrophic and so the mechanism of a stroke is a blood clot forms in the heart through a substance called thrombin and the anti platelet drug such as asprin for example don’t work that well on thrombin. They work well on clots that form in the coronary arteries or in the brain but in the heart with AFib the atrium doesn’t beat properly, you have this sort of lifeless bag of contractions so the blood clot can form stagnant blood. And so we traditionally have had blood thinners such as Coumadine or Warfarin which has a lot of challenges. Efficacious but a lot of challenges. And then there are a whole host of neuro drugs that aren’t so new anymore. Eliquis, Xarelto for example, Pradaxa. And It’s nice these drugs actually have been studied in very large trials now showing relatively low bleeding risks. We use, it’s all about the risk assessment. So you have the CHADSVASC acronym I mentioned earlier, you add up the points to determine who’s at high risk for stroke and AFib.

                                And then you have what’s called HASBLED, H-A-S-B-L-E-D, and that is another acronym and that actually tells us who’s at risk for bleeding on a blood thinner. And we can compare the two to then say, well this 80 year old person who has a high risk for stroke also has a high risk for falls because they fell three times in the last year. So that is someone we may refer for there’s a set of procedures called left atrial appendage occlusion procedures. A device called Watchman for example that you see a lot on commercials now. [crosstalk 00:55:58] [inaudible 00:55:58] scientific. But these are devices that help isolate the part of the heart that is the source to the clot from traveling elsewhere. So the Watchman is like a little basket that get implanted in the heart, and it’s typically done, I mean these are invasive procedures, but they’re not cutting open the chest, you’re doing it still through the femoral vein for example. So there’s definitely options for people, but one thing I would definitely say to people is if you can’t take a blood thinner because you’ve had a side effect or for whatever reason, get evaluated by a cardiologist or I think especially and electrophysiologist because you may be a candidate for one of these other procedures and you don’t want to have a stroke. [crosstalk 00:56:36]

Dr. Weitz:            Right.

Dr. Desai:             That’s the most catastrophic thing.

Dr. Weitz:            Yeah. One more question. This is just kind of a personal case from one of my patients. I have a longstanding patient and he kept getting AFib from, he felt like it was coming from drinking something cold. Does that make any [crosstalk 00:56:54] sense?

Dr. Desai:             Yeah it’s that vagus nerve again. [crosstalk 00:56:57] [inaudible 00:56:57]

Dr. Weitz:            Oh okay.

Dr. Desai:             [inaudible 00:56:58] nervous system. Yeah [inaudible 00:56:59] a triathlete. Every time he drank Gatorade at the end of the race he went into AFib. How much of a reward is that? You just finished a race and you go into AFib because of the Gatorade. So yeah you get esophagal stimulation. Really hot, really cold beverages can stimulate the vagus nerve. And then the esophagus is right next to the vagus nerve so there’s actually a direct sort of mechanical type stimulation. So yeah there is actually reason for that [crosstalk 00:57:24]

Dr. Weitz:            Well interesting you know we talk about the vagus nerve all the time when [crosstalk 00:57:27] we talk about gastrointestinal conditions so.

Dr. Desai:             Yeah. Yeah. I  kind of feel like the vagus nerve is getting a bad rap now. It really is important. It [crosstalk 00:57:35]

Dr. Weitz:            Well absolutely it’s a pathway for communication through the body [crosstalk 00:57:41] between the brain and the gut, and the gut and the brain, and the gut and the heart, and the heart and [crosstalk 00:57:45] the gut.

Dr. Desai:             And it’s so important. When we mentioned earlier, and maybe this is a good parting note is stress is pervasive and there are so many great ways for creating toolboxes to deal with stress. The classic stuff like exercise and being in nature and things like that. But mindfulness and breathing techniques and even simple things a few minutes a day, it activates that parasympathetic nervous system that helps to counterbalance that fight or flight response. We were built to run away from dinosaurs the problem with this is that we think that a conflict at work is a dinosaur. And sometimes it actually may be [crosstalk 00:58:18] a person may look like a dinosaur. But sometimes not and so but our brain, our limbic system and our fight or flight response and everything interprets the threats that way so its important for us to always be mindful of how we are interacting with people. We can just, that way we can kind of show up as the best version of ourselves and not be so reactive that we have choices on how to act.

Dr. Weitz:            Yeah. Big scary arm chair dinosaurs. Doc.

Dr. Desai:             Yeah. That was a great way of saying it without saying it. I love that. I love that.

Dr. Weitz:            What’s the best way for listeners and viewers to get ahold of you and contact you and?

Dr. Desai:             Yeah. Yeah. So the book is called Restart Your Heart: The Playbook for Thriving with AFib. It’s on anywhere books are sold including Amazon, Barnes & Noble. If you go to my website which is draseemdesai.com D-R-A-S-E-E-M-D-E-S-A-I .com I have a ton of information about the book and where to purchase, but also I have a blog, lots of complimentary advice there. We have a variety of different videos and things like that. And then I am very active on social media so especially on Instagram and Facebook we even have AFib groups and things like that, so it’s @draseemdesai. That goes for Twitter, LinkedIn, Facebook, Instagram, and then I have a YouTube channel as well @D-R-A-S-E-E-M-D-E-S-A-I and you can direct message me or reach out to me or follow me.

                                I definitely, I thrive on feedback. So that’s the only way that any of us, I mean your feedback about my video, I’m going to go look at that video now because your feedback about my video is important because I may be scaring a lot of other people and I need to change the way that video looks, so yeah. That’s important feedback.

Dr. Weitz:            Okay good, doc. I enjoyed the conversation and then when I put it up in about five, six weeks I’ll send you links and hopefully you can share it with your followers.

Dr. Desai:             Yeah I’d love to and love to give you a roo. Thanks to Dr. Weitz for this conversation today. I appreciate you having me.

Dr. Weitz:            Great. Thank you. Thank you.



Facts and Myths with Adrenal Fatigue with Reed Davis: Rational Wellness Podcast 180

Reed Davis discusses the Facts and Myths with Adrenal Fatigue with Dr. Ben Weitz.

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Podcast Highlights

0:30  This discussion is about a condition that exists in patients who have been suffering with fatigue and other symptoms related to dealing with chronic levels of stress.  This condition has been called Adrenal Fatigue and the concept is that over time, after dealing with high levels of stress and having to respond repeatedly by producing higher levels of adrenaline and cortisol, the adrenal glands become unable to produce optimal levels of cortisol, much like the pancreas becomes unable to produce adequate levels of insulin in diabetics.  But this condition was never sufficiently proven in scientific studies and most of the conventional endocrinological medical establishment never accepted this concept and it has become increasingly accepted by the Functional Medicine world that adrenal fatigue, per se, does not exist as we have thought about it. However, we also know that a large number of patients have been successfully treated by Functional Medicine practitioners for fatigue and other conditions believed to be related to adrenal problems with herbs and other very safe nutritional supplements, so something positive must be going on.  Check out Ari Whitten’s detailed analysis on adrenal fatigue from his Energy Blueprint podcast: Is Adrenal Fatigue Real? 

6:23  The construct of adrenal fatigue has been useful, even though the science has come to show that it may not be exactly what is happening. When we are under stress, out flight or fight sympathetic nervous system takes over and that kicks off an endocrine response from the adrenals and some other organs.  Both adrenaline and cortisol are released, both of which are produced by the adrenal glands.  Such patients are often stressed out, have extra weight gain, low energy, poor sleep, don’t like to exercise, they might get dizzy when standing, they may have sensitivity to light, irritability, etc.  These patients may be self-medicating. They may rely on coffee in the morning and alcohol at night to sleep. We still see the same patients with the same symptoms and they still have low cortisol, it’s just that we can’t place all the blame on the adrenals.  The adrenals never lose their ability to produce cortisol, so it is the signalling coming from the brain and the sensitivity of the receptors that are more to blame than the ability of the adrenal glands.




Reed Davis is the Founder of the Functional Diagnostic Nutrition (FDN) Certification Course and the D.R.E.S.S. for Health Success Protocol.  He is an Environmental Paralegal, a Certified Nutritional Therapist and Fitness Coach and he served as the Health Director and Case Manager at the Better Health & Wellness Center in Poway, California for over 10 years.  One of his specialities, beside training Functional Medicine practitioners, is teaching how to interpret lab tests.  Reed teaches a certification course for Functional Medicine practitioners, Functional Diagnostic Nutrition, which you can access by going to FDN.today/drweitz.   

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

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 facts and myths with adrenal fatigue with Reed Davis. Our topic is about a condition known as adrenal fatigue or as some people refer to it as adrenal dysfunction. And it’s been discussed in functional medicine circles for decades. The concept is that due to too much and chronic levels of stress, at first, your body adapts by your adrenal glands, which react to stress by producing more adrenaline and cortisol.  So therefore initially, you may have excess levels of cortisol, and this can result in difficulty sleeping and anxiety and other symptoms related to being in a state of excess stress. After a period of chronically over producing adrenaline and cortisol and these other adrenal hormones, in order to help your body cope with the stress, your adrenal glands become exhausted, much the way your pancreas becomes exhausted in type 2 diabetes after having to produce so much excess insulin in response to sugar surges and at some point is no long able to produce adequate insulin or perhaps any insulin at all, requiring the patient to have to take insulin injections in order to control their blood sugar.  So in this stage of exhaustion, which we often refer to as adrenal fatigue, your adrenal glands are unable to produce adequate levels of cortisol for what your body needs.  And cortisol levels are often measured in the Functional Medicine world through salivary levels and typically we do a four-part cortisol test, measuring salivary cortisol levels in the morning, midday, afternoon, and evening. On the basis of these measurements, Functional Medicine practitioners often recommend adaptogenic herbs, glandulars and other nutritional supplements.  And then medical practitioners may put patients on hydrocortisone.  There’s some controversy over whether these salivary cortisol levels are accurate, since salivary cortisol levels measure free, unbound cortisol, and only 3 to 5% of total cortisol is free. So this may not be representative of cortisol levels in the body.

Now, the conventional medical establishment never got on board with this concept of adrenal fatigue.  So here’s a typical quote from an endocrinologist from Cedar Sinai, Dr. Anat Ben-Shlomo, quote unquote, “Adrenal fatigue is the notion that our adrenal glands get overworked by stress and stop producing the hormones we need, including cortisol. It’s a medical myth.”  This view has also been put forth by the Endocrine Society and other medical groups. And there’ve been a ton of papers published on this concept that adrenal fatigue does not exist.  Now, the Functional Medicine world continued to promote this concept about adrenal fatigue, since we do these salivary cortisol levels, we see significant improvement with our patients using our nutritional protocols and adaptogenic herbs, et cetera. However, in the last five to 10 years, it’s become increasingly understood by some, many, certainly not all in the Functional Medicine world that the adrenal glands actually never lose their ability to produce hormones like cortisol.  And this view has recently been expressed by a number of prominent functional medicine doctors, including Chris Kresser and Ari Whitten. In fact, Ari did perhaps the most exhaustive detailed analysis of many of the studies and what should be concluded is that while some studies showed a decrease of cortisol levels, some studies showed an increase in cortisol levels, but most patients with symptoms of adrenal burnout or fatigue actually had normal total cortisol levels and Ari reported this incredibly detailed analysis in one of his Energy Blueprint Podcast.  So he did a great job with that.  On the other hand, we have all these Functional Medicine patients who’ve been successfully treated with adrenal fatigue, so there must be something going on.

                                So I’ve asked Reed Davis, the founder of the Functional Diagnostic Nutrition Certification Course and D.R.E.S.S. for Health Success Protocol to come on to perhaps give us some information about exactly what’s going on with this so-called adrenal fatigue with these patients who are fatigued and have these other symptoms. Reed Davis is an environmental paralegal, a certified nutritional therapist and fitness coach and he’s also served as the Health Director and Case Manager at the Better Health and Wellness Center in Poway, California for over 10 years. And one of his specialities besides training functional medicine practitioners and health coaches is teaching how to interpret lab tests. Reed, thank you so much for joining me.

Reed Davis:         Hey, thank you, Dr. Ben, it’s good to be here and hopefully answer some questions.

Dr. Weitz:            Absolutely. So unfortunately, there’s a little bit of delay because Reed’s up there in the mountains without the best internet connection. So Reed, perhaps you can start by explaining, what are the adrenal glands and what are their functions?

Reed Davis:         Well, that’s a good place to start, I guess, but I wanted to just back up a bit and say that the construct of adrenal fatigue was very, very useful before the science let us know that it wasn’t ever written in stone that you have adrenal fatigue, but it was never written in stone. It’s just a useful construct because they are considered the stress organ. And you’re absolutely right, when you’re under stress, you go into a fight flight mode, and that has to do with both the nervous system, you basically are going to go into the autonomic, the anxiety mode, the fight flight, that’s basically your sympathetic nervous system. So you get sympathetic dominant, and that actually kicks off an endocrine response.  So when you get scared, run off the road, get chased by a bear or whatever the heck, yelled at by your boss or something upsets you, the first thing that happens to your nervous system, you go into that fight flight, the sympathetic kicks in, and it’s so that you can fight or you can run away, it’s a survival mechanism. The adrenals are involved along with some other organs, because they can produce adrenaline, number one, adrenaline is an amazing hormone. It makes you feel good, makes you able to run fast and these kinds of things, or fight hard, whatever it might be. And along with that comes cortisol. They’re both made in the adrenal glands, but they’re made in different parts of the adrenal glands.

                                So that’s why they’re considered the stress organs. And they’re just some little triangular shaped organs sitting up your kidneys, the kidneys are known as the renal gland and add means above or on top of, basically. So they’re on top of the real or kidneys, very useful little organs. And they’re basically told what to do by the hypothalamus pituitary, and again, the sympathetic nervous system. And again, I thought it was a very useful construct back in the day, 20 years ago, someone would come in feeling stressed out, did some weight gain, maybe some low energy, poor sleep, don’t like to exercise, they might even get dizzy on standing, eyes are very sensitive to light, kind of irritable, things that.   The same people often are self-medicating, they need some coffee in the morning, might even need some alcohol to get to bed at night. Another common thing was crashing in the middle of the day and these kinds of things.  So since the adrenals are involved in fight flight and they would take a lot of the blame for those types of symptoms.  You can go through all the anatomy, physiology, biochemistry, I’m happy to go as deep as you want on this, on the adrenals, but it turns out that they were getting the blame somewhat erroneously.  They’re still really involved, but if they’re not producing cortisol mostly and that’s what we used to call adrenal fatigue when you had very low cortisol, there’s other reasons for it.  It’s just the signaling, the cell receptorship and interplay and so there’s a lot of moving parts there, so we just can’t call it adrenal fatigue anymore.  It doesn’t mean you don’t have the same symptoms, they’re just coming from multiple places and now we know we need to do two things and then I’ll let you chime in here. Now we know we need to do two things. One is to resolve the stressors that got you there in the first place. And frankly, I always took that approach even 20 years ago, the adrenals, well, we don’t want to just treat the paper, there’s supplements you can take to raise cortisol or what have you, we used to do licorice root and all kinds of things and people would feel a little bit better, but the real answer is to reduce the stressors and that could be quite a job, figuring out what they are and those are the real cause of those symptoms.

Dr. Weitz:            Okay. So why don’t we talk about what some of the causes of this fatigue that our patients are feeling aren’t?

Reed Davis:         Well, when you’re stressed and I don’t mean just getting cut off in traffic or yelled at or some of these mental, emotional things. If it was just that, and it was occasional, you’d be fine. Your cortisol would go up, the adrenals would kick in, you would get some adrenaline and then momentarily later you’d get some cortisol, cortisol sticks around longer. It actually just enhances the fight flight mode, but it doesn’t last more than say an hour, then you’d go back to normal, quote unquote, normal. Well, I picture zebras getting chased by lions and as soon as the lion catches one and starts eating it, the rest of them go back to normal. You see on discovery channel, they’re eating grass in the background because they’re not under stress anymore, not as long as they’re not being looked at as something to eat.   So now with us, it’s actually built in, we have this stress response and it’s the adrenaline and the cortisol and some other things, but it’s constant. We’re not under ordinary stress anymore, we’re under daily assault. There are tens of thousands of chemicals in the environment that can invoke the same kind of adaptive response. So your body just knows, it’s really smart. There’s an innate intelligence in every cell tissue, organ and system that says we’re under attack. And so you couple that with watching TV and all the relationships and your relationships with people and with money and with driving through traffic, whatever it might be, and then add on top of that injury and trauma and weakness and imbalances in the body.  So I’ve studied stress since about 2001, when I found out it was the reason for 80% of all doctor visits was based on stress and even up to 50% of all diseases were stress related. And so I started studying stress and I just categorized it, all that mental, emotional stuff, your life, things like that and a lot of times we’ll get used to it, we think it’s normal. And the same thing with the chemical salts, a lot of which we don’t even know they’re there, it’s in your food, it’s in your beverages, it’s in your clothing, it’s in your furniture and your draperies and your carpeting, it’s in your household cleaning products, it’s in your personal care products, things that are stressful, things that the body reacts in a similar way to.

Dr. Weitz:            You’re talking about environmental toxins?

Reed Davis:         Exactly, yeah. So all of that adds up to where it’s just a constant assault and your body, it can get tired of that crap and dysfunctions occur and you end up with all kinds of things upstream from the symptoms, but the symptoms remain the same, that stressed out, crashing in the day, needing coffee, immune system problems, the energy, brain fog, poor memory, all these different things come from assaults from stress, the adrenal glands are one organ involved. And they were getting the blame, all the blame for a long time.

Dr. Weitz:            So what other organs are helping us deal with stress?

Reed Davis:         Well, the sensory organs in the brain are really important. You have what’s called the limbic system, which is mostly considered the emotional center, also, olfactory–sound comes in through there and it can be loud noises scare you, that’s because the limbic system sends signals almost directly to the adrenals to make adrenaline and you get that feeling. And then again, cortisol would kick in and you have the messages going through the hypothalamus pituitary, so they are another couple of little organs up in the brain and they send the chemical messengers, the stimulating hormones to the adrenals.  So that complicates it a bit, well, what’s stimulating the hypothalamus and the pituitary? That again could be in the environment, it could be the circadian rhythm, it could be other hormones, it could be toxins, chemicals, drugs, there’s so many things that can stimulate the sensory organisms or organs in the brain, they’re very sensitive. They’re little tiny things, they can only take so much and they will send out what you might call bad signals. Oh, by the way, it makes it very interesting if you like anatomy or physiology, you’ve got the adrenals aren’t one organ, you have the medulla in the middle that basically stores and releases the adrenaline upon signals from the autonomic nervous system, your sympathetic branch.  And then you have signals coming from the hypothalamus/pituitary to three separate layers. If they want to know the names of them, that’s zona fasciculata, zona glomerulosa and zona reticularis, they make different hormones. The cortisol is only made in one. Another one makes your DHEA, which is the parent of sex hormones that is supposed to counter regulate cortisol. And then you have the aldosterone and mineral corticoids that regulate sodium/potassium levels and so on, your blood pressure, blood volume, and hydration…

Dr. Weitz:            Hang on one second, Reed. And these three zones are different areas in the adrenal glands, correct?

Reed Davis:         Yes.

Dr. Weitz:            Okay. What do they call it again? One more time?

Reed Davis:         Well, there’s the zona glomerulosa, that is the outer layer of the adrenals, and that makes your aldosterone, it’s the electrolyte and fluid balance in the body, blood pressure, sodium potassium levels. The point was that there are different things affecting the signaling organs in the brain, and then it could send good or bad signals or mixed signals and you have four different areas within the cortex, within the adrenals. There’s the cortex has the zona glomerulosa, it makes the aldosterone, the zona fasciculata makes the cortisol and the zona reticularis makes the DHEA, dehydroepiandrosterone was counter regulates the cortisol. These things by the way, are not just made in the adrenals, so if you want to get even more interesting, some people might say complicated or complex, it is very complex.

                                Your skin makes cortisol. If you get a little nick or a tiny insect bite, your skin makes its own cortisol, your skin has the same kind of axes as the HPA to adrenals. That’s why… What is cortisol? It’s an anti-inflammatory and it’s a pain killer. So you’d want some extra cortisol if you get a bite in the skin, or if you get punched in the face, same thing. So you’re going to make these things that regulate blood pressure and fluid balance in the body, why? Survival, you’re going to get from the fasciculata, the cortisol, which raises blood sugar, enhances the action of adrenaline, it is very anti-inflammatory and it’s the main signal by the way of catabolism.

                                Catabolism is what breaks your body down, which you might need to do to maintain the blood sugar levels. And finally, there’s the zona reticularis, it makes the DHEA, that counter regulates the cortisol and it’s the precursor to all your sex hormones, including estrogen and testosterone. So you can start to see why someone under a lot of stress, and you’re messing with the signaling organs, you’re messing with the organs that receive the signals, and you can have quite a lot going on there, that’s why I have one diagnosis for everybody, it’s called metabolic chaos. And that’s a term I use to just describe what’s really going on. I just find it the most interesting, fascinating area, stress and how the body reacts to it.

Dr. Weitz:            So you’re giving some complex information about cortisol and it’s interesting because there’s a tendency to see some of these hormones and other substances as good or bad and some people see cortisol as bad, high cortisol is bad. So cortisol has all these important functions and it’s neither bad nor good, in fact, it’s good and bad, depending upon the levels and whether it’s being appropriately secreted at the right times. Now, how is DHEA counterbalancing cortisol?

Reed Davis:         Well, DHEA has its own direct benefits on the body, it’s very anabolic. And so when you talk about the adrenals and testing for the adrenals, you’re talking about, maybe not the condition of the adrenals themselves, but just the levels of production, which again, we know we have mixed signals coming to these different layers and these different layers, they don’t swap the substrates. There’s no such thing as the pregnenolone on steal. The cells inside the zona fasciculata cannot steal pregnenolone, the parent hormone, from the other zones. And so that was another big myth that was shattered. And what would I look at because I was trained in a chiropractic office over 20 years ago, to think about balance and resilience.  Now, what really defines health could be considered to be balanced, everything’s balanced and cortisol DHEA would be two things you really want balanced in your body. You don’t want cortisone dominance. Remember cortisol dominance over time leads to a catabolic state and the body’s breaking down. Catabolism is the breaking down. You’ve seen people who are completely stressed out like runners who purposefully stress themselves out. They do a very unnatural thing by running 20 or so miles and their bodies are broken down. The cortisol has just pretty much even broken down their meat. Why? To maintain blood sugar levels.

Dr. Weitz:            Occasionally, I’ll have a patient who’s maybe been on cortisone for some months and even years for some chronic condition like asthma or some auto immune condition and often they have lost almost all their muscle, you can see that severe catabolism.

Reed Davis:         Yeah, exactly. And so you want the cortisol and DHEA to be balanced. They’re both coming from the adrenals for the most part. I said the skin makes cortisol and the brain makes some DHEA, but probably 80% is all coming from the adrenals. And so that would give you balance in a couple of ways. If it’s all about balance, what do we want to balance? We want to balance cortisol and DHEA, and you’re balancing the catabolic with the anabolic, your body breaks down and builds up, breaks down and builds up. You’re also balancing, cortisol is your stress hormone and DHEA could be considered your sex hormone, a main hormone responsible for the sex hormone.  So you want stress and sex to be balanced up, that’s for sure. And you want catabolism and anabolism to be balanced out, and that’s for sure. And you can tell, people, doc, you know this, when you explain this to your patient, to your client, and no one else has ever explained it to them, why they feel so crappy? Look, you’re out of balance and this is why, you got all this stress and your body is breaking down and it’s not building up in a way that’s working for you. And so what do you need to do? Reduce the stress, there’s modalities and things. If it’s physical, see a chiropractor.  If it’s energetic, you can see an acupuncturist and get some things moving, that we have seen that be helpful. If it’s mental, emotional, there’s lots of help in that area. And if it’s chemical, biochemical, well, you can eat better, get rid of all the toxins and things that are in your food and beverages, as we mentioned, the environment is so full of it, all the other stressors. And I think supplements are very helpful too, to support these systems.


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Dr. Weitz:             So what’s the best way to measure adrenal levels and cortisol levels?

Reed Davis:         It depends who you’re talking to. When I started, it was just us doing saliva testing only, way back in the days of John Lee, you mentioned [inaudible 00:25:14] he’s been around a long, long time. A lot of other good docs, but they were considered out of the box, kind of like you mentioned, conventional or standard medicine didn’t address this at all, but nowadays, science has grown, it’s expanded. I still think saliva testing is very good, but there’s not much hormone in the saliva. So you’re measuring very small amounts. You have to be very careful. I like the ease of collection, people can take the kits home, you can take it morning and noon and afternoon and nighttime cortisol, you can wake up in the middle of night and take cortisol. You could never do that with blood. Who’s going to go get four or five blood draws in one day? That’s never going to happen.

Dr. Weitz:            Right.

Reed Davis:         So blood’s not very good for this although there’s other ways to skin the cat and I know people who do a good job with blood work, they just don’t get the circadian rhythm the same way. So then there’s also urine, and there’s a 24 hour collection, which is useless. Total cortisol doesn’t mean much. You really need to look at that circadian rhythm, but now there’s dried urine. So dried urine can be done. It’s still not exactly in the moment as bioavailable saliva, but there’s a lot more hormone in urine and it can be measured that way too.

Dr. Weitz:            Do you like the cortisol awakening response. Do you think that’s a significant improvement?

Reed Davis:         Yeah, I like that. Lots of saliva testing catches that now. We’ve learned that some people, again, it’s all dependent on whose test results you’re looking at and why would you want cortisol awakening response? Well, some people stay in that sympathetic state all morning. They get up and they’re panicking and they can’t calm down and you can see it in their cortisol levels. Basically, you would take a first waking cortisol, remember it’s rising as you wake up, it’s what helps you wake up and cortisol rising at nighttime with a drop in low blood sugar, whatever it might be, cortisol kicks in to raise blood sugar and it happens in the morning. So when you first wake up, you call it a baseline.

                                Now, about half an hour to 40 minutes later, it’s going to reach its peak for the day. And then it should come back down in the next half hour or so to within 25, 30% of where it started, you don’t want it staying up that high. What’s very interesting about some people who tend to lean towards high perceived levels of stress, they have, wherever it is when they wake up, baseline, then a half hour, 40 minutes later, it’s quite high. And then the next one, instead of coming down, it stays high or it doesn’t come down very much. So you talk to that person and they perceive life as shitty and it matches perfectly with their test results, it’s so interesting to see that. So you can then coach those people up on lifestyle changes they can make to bring it down. You don’t want to stay in that state generally.

Dr. Weitz:            So what kind of lifestyle changes would you recommend to help bring somebody who is in a state of higher cortisol levels?

Reed Davis:         There’s so many different stressors and stress reduction is a huge part of our program and it could be coming from mental, emotional, as we said, it could be coming from the environment, including what you eat. So we have people tell us, if you talk to people, you can find out a lot about them and where they think it is and you just begin to get good at making impressions, forming impressions about people. You might say, “Well, this is a mental, emotional thing and you could do some deep breathing, meditation, you could do some pausing to be thankful and say, well, it’s going to be a better day than yesterday.” And lots of positive psychology things are very useful. And again, I think point of view is huge and these people are worried and what have you, so there’s other people who specialize, that’s what they do. They do that type of counseling.

                                I’ve used emotional freedom technique. And again, I think prayer and gratitude and point of view are more my style and it comes naturally to me, but other people need other modalities or therapies. Other people, we think about, because the same spikes in cortisol could happen throughout the day. You could see it at lunchtime. Wow, why is it so high above range at lunch? Well, it could be that you’re sensitive to something you’re eating, or something else is going on, but you can actually see that stuff. If you have a food sensitivity, that can spike your cortisol because it’s inflammatory and what is cortisol again? It’s an anti-inflammatory. And then if you see spikes in the afternoon or spikes at night before bed, so you can get to know the person and they can get to know themselves.      When you have good interpretations and you have good impressions, if you’re good at impression, forming and assessing, you can walk a person through a lot of this, just showing them the facts on paper itself lets them know, you’re not crazy, there really is something going on, let’s take a look at it and you have some objective criteria there plus how they feel and it can work out to be a real good relationship. So there’s other stressors obviously, but [crosstalk 00:31:05].

Dr. Weitz:            So you’re saying that anything that creates inflammation in the body is liable to lead to higher cortisol levels. And you mentioned food sensitivities is one, I’m assuming high blood sugar spikes is another?

Reed Davis:         Well, low blood sugar would be why your cortisol would go up, so if you don’t eat right, you have to eat in order to maintain steady blood sugar levels and energy and satiation and sense of well being and things. So if you’re eating right, you should also be able to maintain what we call stable cortisol levels or within range, normal circadian rhythm. And there’s no question about it, humans are diurnal, they’re not nocturnal. So we find people with highly disrupted circadian rhythms and they’re not sleeping at night, they’re sleeping in the day, all kinds of things going on.  So that matters too then. Sleep becomes important and exercise becomes important and reducing other stressors known, those are the easier ones. The unknown ones are even harder because you’ve got electromagnetic frequencies and you’ve got radiation and you’ve got parasites and bacterias and funguses and viruses and biofilms and Lord knows what else is in there, especially these days, right? So there is a system is the main thing, there’s step-by-step, you can sort out metabolic chaos and that’s what we’ve been known for 20 years, right Doc? Helping people sort it out.

Dr. Weitz:            Absolutely. So let’s say you get a patient in your office and they’re complaining about fatigue, you’re going to take their history and then what’s the next thing you’re going to do?

Reed Davis:         I would run labs on every person just because I don’t like guessing. And a lot of other people run labs too, but they guess about which labs to run and I really don’t. And it’s because over 20 years, I started recognizing patterns. So the typical practitioner clinician listens to the complaints of the patient and says, “Well, it sounds like this.” They’re forming an impression based on how that person looks and your vital signs and different intake and largely, their complaints and history and say, “Well, it sounds like it could be thyroid.” And then they’ll run a test on thyroid. So they’re guessing about what tests to run, because it sounds like [inaudible 00:33:47]. For other people, it sounds like the adrenals, or it sounds like parasites, or sounds like [inaudible 00:33:53].

Dr. Weitz:            Of course, one of the reasons we’re doing that is to try to be efficient and cost effective.

Reed Davis:         True, true. Well, it’s also just the heuristic being used. It’s go after the symptoms. The most immediate cause of the symptoms, but that heuristic leaves a lot on the table because it could be any damn thing really far upstream or a combination of things, which is more likely the case. So with me, I just run five labs in every person because I have no clue. I try to avoid it sounding like… I might do it like, “Well, it sounds like [inaudible 00:34:29], but I have no clue if it is. So why don’t we just run… I really run six assessments on every person and there is an investment for that person.

Dr. Weitz:            What are those six assessments that you do?

Reed Davis:         I look at the hormones, including the adrenal and sex hormones. I look at the immune system, I look at digestion-

Dr. Weitz:            Hang on a second. The hormones you measure through urine, saliva or a serum?

Reed Davis:         I still like the kits, the saliva kits, because people can take them home and do it. They can also do that with dried urine and they’re both good tests. It just depends on your practice and what your intention is for that person. I’m looking to develop the most holistic protocols possible. Other people are looking more to treat maybe the imbalances in estrogen and progesterone, even cortisol, DHEA, they use a lot of products.  So they’re taking the shortest distance between the labs and what products to recommend and I take a more holistic approach with what lifestyle to recommend, which I said could include some supplements. So when I look at the… It’s H-I-D-D-E-N, Doc, if you want to know the magic assessment formula, H-I-D-D-E-N, it spells hidden and [inaudible 00:35:56] things are hidden, but it’s the hormones, immune, digestion, detoxification, energy production, and nervous system balance. It’s really autonomic looking at balance between sympathetic and parasympathetic. We just call it in nervous system or nerve… So it’s hormone, immune, digestion, detoxification, energy-

Dr. Weitz:            So how do you measure immune function?

Reed Davis:         Well, there are measurable things that have to do with the immune system. For one, the gut, which is about, according to Mark Hyman, it’s 80% of your immune system, but I think we knew that 20 years ago, it was huge. And so you have something called secretory IgA, you have other immunoglobulins, now we have zonulin, that’s some little markers. We can also look at the go to bed flora, if there’s not enough good flora, that would also affect digestion. So some of it is hard with the visuals and the teaching, which could take a while. 

Dr. Weitz:            So to measure immune and digestive functions, you’re going to do a comprehensive stool test? What’s your favorite stool test?

Reed Davis:         Well, I ran one this morning. I haven’t emailed you. I’m always experimenting with new tests, but I like the GI map. I like the Bio-Flora 1, but they went out of business. So I like looking at microscopy and antigen testing and the other test, the culturing. Hardly anyone is doing culturing in these ways where humans are involved in the lab work. Nowadays, it’s all electronic, it’s all high tech and it’s just DNA, PCR type stuff. So there’s a lot of ways to skin that cat. The fact is though, we’re not looking for the disease so much or what’s the bug, “Oh, how do I kill it?” We’re looking at, “Why do you have it again?”  It’s the environment. So if you ran those labs, and I would look at an IP, an intestinal permeability test, there’s different ways to do that. There’s the old fashioned challenge, there’s blood, there’s antibody tests you can use, there’s lots of ways to do that, but it’s a preponderance of the evidence, it’s up to the practitioner. You want to be trained in forming these impressions and because you want to give that person things to do, not just things to take, that’s my opinion. And so-

Dr. Weitz:            Okay. So you’re going to do a stool test, and so for the intestinal permeability is adding on zonulin, is that sufficient or do you use the lactulose mannitol intestinal permeability?

Reed Davis:         I love that test. I like the old fashioned lactulose mannitol. That’s a great test because you’re actually getting a view of the topography inside the gut. If your lactulose is high, you have a leaky gut, you’re letting too much of this large molecule sugar get through and be recovered in urine. So it’s not supposed to be able to pass through very much. If a large amount is passing through, it’s all in a gradient and these things, by the way, are all moving targets, just changing on a regular basis, but you can detect a high recovery of lactulose tells you, you probably will see high zonulin in most of those cases.  Leaky gut’s more of an immune problem, but the lactulose mannitol doesn’t look at it that way though, through the immune system, it looks at it through physical topography, it’s a map. It’s almost like a camera when you know how to interpret it right. Now, with the mannitol, that’s a very small molecule. There should be a reasonable amount of that gets through the villi, but villi can be blunted, the brush border can be gone, you can see that on other certain markers. And if they’re blunted, you’d have low mannitol recovery when you should actually be seeing a fair amount. Now, there’s two red zones for the mannitol, because if it’s too high, then you could have extra porous villi, so they’re also beat up, it’s a dysfunctional gut, if you will.

Dr. Weitz:            Yeah, it’s interesting, I would say. I would say the lactulose mannitol test is something a lot of us used to do, and we gave up on it because we can almost assume most of our patients have leaky gut.

Reed Davis:         Yeah. But here’s the other things, these things are all in a gradient, like I said, and they tend to be moving targets. So it’s nice to know how are they doing now and what direction can we get them to move in? So you can see it’s not real blatant, by the way, the literature says, if the lactulose to mannitol ratio is in a certain range, then they’re fine, I highly dispute that. I’ve looked at thousands of these tests and correlated them with patients. And so I know that you can feel the standard interpretation, and yet there’s a healing opportunity there. Now, that’s the phrase you want to burn in your brain, is healing opportunity. Can this be improved upon? Yeah, I guarantee it can be. And you’ve got to look at the rest of the environment in that gut though, why is it looking beat up here?

Dr. Weitz:            Okay. So you’re-

Reed Davis:         That’s where the food sensitivities and [inaudible 00:41:42].

Dr. Weitz:            So your initial testing, so far you said that you would do hormones, you would do stool tests, intestinal permeability, what are the other components of your testing?

Reed Davis:         I like very, very much to look at things like oxidative stress, that’s a healing opportunity. Also, the food sensitivities [crosstalk 00:42:13].

Dr. Weitz:            So for oxidative stress, what would you look at? Would you look an 8-deoxyguanosine?

Reed Davis:         Yeah, that’s one. There’s also lipid peroxides. The hydroxy-guanosine looks at DNA damage from oxidation, but it might not be that bad yet. You’ll see cellular membrane damage, and you can detect that through lipid peroxides. Genova has oxidative stress 2.0, it measures both. Things like that give you healing opportunities, it’s how can I direct this person’s lifestyle medicine and then of course, it always leads you to another layer, where’s this oxidative stress coming from? I mean, if the person smokes, that’s one reason, but if they don’t, where do you go from there? Overexercise? Probably not.  And on and on and on. There’s some other markers that I really missed that have gone off the market. Urinary bile acid sulfates was one, it showed liver congestion, because remember, detoxification is also very critical. So I look for these clues or these healing opportunities, and by a preponderance of those things, can form an impression about a person, how much work they have to do. That’s why that IP test, even if it isn’t so clear, it tells you, “You’ve got all this stuff to improve.” Any adrenals will come back, right? You get rid of all this other crap, that’s the only way to fix those adrenals.

Dr. Weitz:            So is-

Reed Davis:         So the food sensitivities is large. Some of the bugs are worth treating, but some are just part of a bad environment. And then you can add [inaudible 00:44:08] on that.

Dr. Weitz:            Which bugs are worth treating and which bugs are just part of the normal environment?

Reed Davis:         Well, if a person’s symptomatic, you’re going to throw some anti-microbials down the pipes for anything listed as a parasite, a pathogenic bacteria, anything from salmonella to blastocystis hominis. You’ve got bugs and you have bigger bugs, but again, I’ve always looked at it-

Dr. Weitz:            Hey, you’ve just mentioned blasto, there’s some controversy over blasto and there are some practitioners who feel that it’s not worth treating and it’s actually just a normal part of that.

Reed Davis:         I think that it’s definitely a pathogenic species and it’s not unique to humans, you can find it in other animals and when they have it, it can get quite virulent. Humans, maybe it’s not as virulent as some other pathogens, but it contributes to chaos in the gut, it exudes their exudates from it and it doesn’t belong there. So the real question is, is it commensal, can your body get along with it? But to say it’s normal, it’s supposed to be there, I don’t know of any benefit it has. I mean, there’s a lot of verbiage around that thought that they say we need a balance of good to bad flora in the gut. So there’s all this microbiome in there, is it all friendly?   No. Well, why would unfriendly stuff be there? Well, it’s to keep your immune system in shape. If you had no bugs, you wouldn’t need an immune system. If there was nothing dangerous around. And then when something did come along, it would kick your ass. And so we have these things hovering to keep us active and ready for the worst, the worstest stuff. And so I don’t think in some people that I would… I wouldn’t treat everyone just because I saw some blasto, it depends how they’re doing. It depends how much is that contributing to all the chaos in their body? And if it’s a particularly bad case, I mean, we call it blastocystis hominis because it’s in humans. In a rat, it’s called blastocystis rati. In a beaver, it’s called blastocystis beaver, whatever those are, you get me? So it’s a parasite. It just may not be real virulent and parasitic, but it’s a bug that don’t belong there using my proper medical phrasiology.

Dr. Weitz:            Okay. So is that pretty much all your testing? Are there other tests that go into your initial testing panel?

Reed Davis:         The E and the N, so H-I-D-D is real simple, a matter of fact, those I figured out in fairly short order that everyone coming in the office, they’d already seen five or 10 practitioners, they weren’t better yet and I knew there had to be a better way. And I wanted to be the last person they have to see. Now, that was pretty much dreaming at the time, but I did figure out a few things. And if you can find healing opportunities within hormone, immune, digestion, detoxification, help that person to restore a balance and what have you, get those things working better, increases their resilience and last but not least, the EN, the [inaudible 00:48:21] I added on later when I started learning the importance of food with regard to the oxidative rate.

                                So we burned fuel basically, we all know how energy is produced and it’s produced by eating, it’s made from food, and we process it and we metabolize it the way that produces energy. So that cell is produced on a cellular level so that that cell can do its job. Do you have to teach that cell what it’s job is? No, that’s built in, that’s the intelligence. So you just have to fuel it right and keep interferences out of the way. And so energy production becomes a huge consideration because people are eating the wrong fuel mixture. If you’re a fast oxidizer and that’s inherent, that’s a genetic inborn quality.

                                And if you are a fast oxidizer, you better eat more slow burning fuel, the proteins and the fats, they burn slower. So if you’re a fast oxidizer, you have just been in a bonfire, you don’t want to put paper on it, you won’t get any energy out of that, it’ll just be gone. So you take a typically and traditionally really fast oxidizer. When they eat carbs, they don’t get energy, they don’t get any satiation, they don’t get a sense of wellbeing, either. They pretty much feel like crap all the time and they end up overeating and that shows a blood sugar off and on and on.

Dr. Weitz:            What do you mean by a fast oxidizer?

Reed Davis:         So it’s just the rate at which you burn fuel. Some people are genetically faster oxidizers, they burn their fuel faster on a cellular level. We don’t want to go into the Krebs cycle and citric acid cycle.

Dr. Weitz:            How do you determine if somebody is a fast oxidizer?

Reed Davis:         I use a very simple test. Some people say they can tell through other means more like chemistry. I haven’t learned that and I’m not sure about it, but I use a test called the metabolic typing test. And I discovered this when I met Bill Woolcott, who wrote The Metabolic Typing Diet, about this. Now, he didn’t invent it either, people smarter than all of us figured this stuff up, but there’s definitely the production of energy. Yeah, it’s online, but it’s got a lot of subjective questions, it’s not just objective. There’s questions about psychological traits, there’s questions about dietary habits and physical characteristics as well.

                                So psychology, physical and dietary habits things, and you can land on a certain place and then you have to dial it in through actually eating that way and dial it in and do a little bit of checking, but once you know what the things are to check, it’s fairly simple. To dial in the oxidative rate, dial in at least your proper ratio approaching fat and carbs. Real quickly, I’ll tell you this quick, my cousin’s a priest up in Canada and he had two Cree Indian villages for his parishes. And I was asking him one day, how’s things going and what do they do for a medicine man? And since he’s a priest, he said, “Well, I’m the medicine man.” And I said, “No, no, I meant when they’re sick, if they get… Then he says, “Oh, Christ, they’re all sick.” He goes, “They all have diabetes. It’s the worst health on the planet, these villages.” Why?

                                Because they don’t fish anymore, they don’t hunt anymore, they don’t eat wild natural grains in the summertime anywhere, they eat a bunch of crap that’s Tim Horton donuts and fried chicken or something. And so, here you have these extreme, fast oxidizers, and they’re just eating carbs and they don’t get energy and they feel lousy, the biggest cause of death up there is suicide. I think as a priest, he makes his living on weddings, christenings, and death, but anyway, they’re all sick and they just go to the government clinics and get their insulin, it’s a sad thing. But why are they all sick? Genetically, they’re not eating right. Yeah, it’s so obvious. It’s just so obvious.

Dr. Weitz:            Okay. So I think we’re probably ready to wrap. So how can folks find out about your functional training programs?

Reed Davis:         Yeah. Well, thanks for that. We set up a URL that everyone could go to and you could put it in your show notes, it’s FDN, that stands for Functional Diagnostic Nutrition, that’s the course and program I teach, Functional Diagnostic Nutrition. So it’s FDN.today/drweitz.

Dr. Weitz:            Okay.

Reed Davis:         Fdn.today/drweitz. It’s D-R-W-E-I-T-Z. And that way we could see [inaudible 00:53:44].

Dr. Weitz:            And who takes this course? Is this for doctors, is it for any functional medicine practitioner, is it somebody who’s new to functional medicine?

Reed Davis:         Well, all the above. We have a lot of allied practitioners and we teach health coaches and again, any kind of allied practitioner. I’ve had people take the course just for their own edification and that alone is worth the price of admission. It’s a very reasonably priced program for what we deliver, which is a ton, a heck to of training.

Dr. Weitz:            How long a course is it?

Reed Davis:         It’s going to take the average person who has a life, six to eight months. I’ve had people do it in three months, but I know they just plow through it. Again, I would call this the perfect compliment to a functional medicine practice and the practitioner, him or herself, should actually take the course, and maybe have some staff go through it with you. And we also have people for hire who practice this, who are otherwise not physicians, health coaches, the sort of the upper echelon elite health coaches. Again, I started this back in the 90s, myself training and my pursuit of trying to be the last person someone needs to see, I ran thousands and thousands of labs on thousands of people.  I was told by the labs, “How many doctors have you got working there? I said, it’s just me. And there was doctors working there, but I was the only one running labs and was told some very complimentary things, especially by the clients and patients coming in. I mean, I got miracle stories just from, forget the diagnosis and treatment of the paper, it’s the person, it’s what are the healing opportunities? It’s staying true to those and giving the person things to do at home. From your own practice, I’ll finish up Doc, from your own practice, coming in your office is great, but what they do in between visits is what makes it all come together.

Dr. Weitz:            Thank you, Reed for spending some time with us and giving us some information. Check out his Functional Diagnostic Nutrition Certification Course.