Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Medicinal Mushrooms with Jeff Chilton: Rational Wellness Podcast 103
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Jeff Chilton discusses Medicinal Mushrooms with Dr. Ben Weitz.

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Podcast Highlights

3:32  The health benefits of mushrooms include the immune strengthening properties. This is due to the beta glucan compounds found in the cell walls of mushrooms. Each mushroom has a different architecture of that beta glucan and that determines how immunologically active it is.  There are specific receptor sites in our intestines for beta glucans.

5:27  To get the immunomodulatory effects of mushrooms, to get a therapeutic benefit, you need to eat about 100 gms, which is about 4 ounces. And it is better to cook them to get the full therapeutic benefit or to consume them in powder form, such as in capsules. It’s not harmful to eat raw mushrooms, but they have chitin, which tends to bind up some of the compounds in mushrooms and cooking helps to break that down. or if you take them as supplements

11:20  The mushrooms that tend to have the strongest immune strengthening properties, such as part of an integrative cancer protocol, are Maitake, Reishi, Shitake, and Turkey Tail. In Japan they have developed drugs from mushrooms, including PSK from Turkey Tail and Lentinan from Shitake.

17:20  Mushrooms have both antibacterial and antifungal properties, which means that if you have mycotoxins (mold toxins) you probably don’t want to restrict consuming them. Some practitioners when treating patients for mold toxins tend to place them on a diet that restricts eating mushrooms to avoid getting exposed to more fungal/mold compounds is the wrong thing to do.

21:32  Mushrooms can have beneficial effects on cholesterol and red yeast rice is where statins (HMG-CoA-reductase inhibitors) come from. Oyster mushrooms have a good amount of a natural HMG-CoA-reductase inhibitor in them.

22:42  Reishi mushrooms in particular and mushrooms in general seem to be beneficial for blood sugar regulation and diabetes because they contain a lot of fiber, are 20-30% protein, and the primary carbohydrate is mannitol, which does not raise the blood sugar. and because of the fiber content, mushrooms are good to feed your microbiome.

24:14  Lions mane mushrooms help with brain function by stimulating BDNF production.  The therapeutic dosage would be 3 gms, which is 1-2 teaspoons. Jeff said that often too small a dosage of herbs is recommended than is optimal and that’s often because they often put 30 or 60 capsules in a bottle and then want to make sure that a bottle is a month’s supply. Typically the same dosage is recommended for all patients regardless of how big or small they are.

30:07  Mushrooms can be helpful for sleep, esp. Reishi mushrooms. Reishi helps with stress and insomnia at a dosage of 2-5 gms per day and they should take it for 2-4 weeks before expecting results.  Jeff explained that you need to make sure that the product that you are taking a quality product that actually contains the mushroom and not just the mycellium. The mycellium is the vegetative body of the mushroom–sort of like the roots–and it is often grown on grains and it does not contain the active ingredients, which are only found in the actual fruiting body of the mushroom.  There are no good mushroom products made in the United States, according to Jeff.

39:02  Jeff explained that mushrooms are one of the most overlooked foods and we should start eating mushrooms, because they are so rich in nutrients like B vitamins and other nutrients. Just make sure that you cook the mushrooms properly to unlock the value. Mushrooms are also high in potassium and phosphorus.  Jeff’s company that sells wholesale is Nammex and he also has a retail outlet called Realmushrooms.com that sells mushroom extracts.

 

 



Jeff Chilton studied Ethno-mycology at the University of Washington in the late 1960s. He has worked in mushroom production at a mushroom farm, organized educational conferences on mushrooms, wrote a highly acclaimed book, The Mushroom Cultivator, and started Nammex, a medicinal mushroom company that sells wholesale organic mushroom extracts.  He also has a retail outlet called Realmushrooms.com that sells mushroom extracts.

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



 

Podcast Transcripts

Dr. Weitz:            This is Dr. Ben Weitz, with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition, from the latest scientific research, and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and signup for my free eBook on my website, by going to doctorweitz.com. Let’s get started on your road to better health.  Hello Rational Wellness Podcasters. Thank you so much for joining me again today. For those of you who are enjoying listening to the rational wellness podcast, please, please go to iTunes and give us a ratings and review. That way more people can find out about the Rational Wellness Podcast.

Our topic for today is the health benefits of medicinal mushrooms, with Jeff Chilton. Jeff studied Ethnomycology at the University of Washington in the late 1960s. He’s worked in the mushroom business since then. He worked in mushroom production at a mushroom farm. He’s organized educational conferences on mushrooms. He wrote a highly acclaimed book, The Mushroom Cultivator, and he started Nammex, a Medicinal Mushroom Company that sells mushrooms, wholesale and also retail. Jeff, thank you so much for joining me today.

Jeff:                     Otherwise, thank you so much for having me. It’s great to be here.

Dr. Weitz:            So why don’t you tell us how you got interested in mushrooms and in their benefits?

Jeff:                     Well, you know what, I grew up in the Pacific Northwest, Seattle area, and it’s an area that is wet. We get a lot of rain up here. We’ve got beautiful forests and because of our climate, which is a mild maritime climate, that’s especially wet in the fall, we get an abundance of wild mushrooms coming up. And that was fascinating to me. I got out when I was younger and did some wild mushroom hunting and later at the university, my major actually was anthropology, but I studied some mycology, and really what I did was, I kind of blended the two together, and I did a lot of work on the use of mushrooms worldwide in cultures, whether it would be for food, for medicine, or also the use of mushrooms in shamanism. And as you know, in the 60s, we practiced a lot of shamanism.

Dr. Weitz:            I assume by shamanism you mean, the psychedelic properties?

Jeff:                     Yeah, that’s right. We didn’t have a set of rules to go by unfortunately. So we were flying a little bit blind. But you know what, we were discovering a lot of things and we were sort of in a sense, creating a new culture and, Dr. Weitz, a part of that culture too, was looking at the food we were eating and deciding, hey, there’s something wrong about the diet that we’re being fed. So there were a lot of things going on back then that we were essentially rejecting and trying to find out more information about.

Dr. Weitz:            Great. So let’s talk about some of the health benefits of mushrooms. I know one of the first things that comes to mind, from what I know is the immune strengthening properties. Maybe you can talk about that.

Jeff:                     Oh, yeah, absolutely. The interesting thing about mushrooms is that, in the cell wall of a mushroom, they have compounds called beta glucans. And, that makes up almost 50% of the cell wall of all mushrooms and what’s interesting is that, these beta glucans have… the… each mushroom has a little bit different architecture of that beta glucan. And the structure or the architecture of that beta glucan determines how immunologically active it is. So just eating mushrooms, no matter which mushroom we eat, we’re going to get those beta glucans. But certain mushrooms have medicinal properties where the beta glucan has a structure that will actually activate immune cells.  And what’s really interesting is that we have receptor sites in our small intestine that are very specific to these beta glucans, these fungal beta glucans. So when those beta glucans go down there, they hit those receptor sites and then that will activate different, the production of different immune cells. What I would say is, that is the really, the key underlying benefit to almost all of what we would call a medicinal mushroom. And you can get those benefits either through eating mushrooms or supplementing mushrooms. Of course when you supplement with mushrooms you’re not going to have to take quite as much because it might be a little more concentrated form. But still…

Dr. Weitz:            If we’re going to eat mushrooms, how much mushrooms do we have to eat to get, say a therapeutic benefit? Let’s say somebody is taking mushrooms to help with some health condition or, some people use it as part of their cancer protocol. How large you are serving a mushrooms and how many times a day would you have to eat them to get a therapeutic amount?

Jeff:                       Well, in terms of eating mushrooms, what I would say is probably to get a therapeutic amount you’d want to eat about a hundred grams. And, a hundred grams, I think that would be about a four ounces. And look, you think, oh, four ounces or a hundred grams, that seems like a lot. Not a lot. The other day I weighed up a common button mushroom that you see in all the supermarkets, and I weighed up a medium sized button mushroom and it weighed 40 grams! Well that basically is an ounce and half or something.  So really in terms of fresh mushrooms, you don’t have to eat that much. But what I would say is, what’s important is cooking them properly for one. You know what happens is that, and I’ve heard it for 40 years, ever since I was the guy in the mushroom business was, oh yeah, mushrooms, man, they are slimy. They are … One thing I got, people just have this conception of mushrooms. No, you have to cook them in a hot pan. You have to cook them where … I like to slice them about a quarter inch thick, throw them into your favorite oil, whatever you want to cook them in, a hot pan.  Brown both sides of them. Cook them a little bit longer than shorter. So that when they come out of that pan, they’re not wet and soggy. Actually they’re dry. Because … Or if anything, they’ve maybe got a little bit of oil, but if you brown them up and then, to me, if I’m just going to eat the mushrooms alone or even like I did a couple of nights ago with a steak, and I’m a meat eater, I just put a little bit of salt, a little bit of pepper. Oh man, they were delicious.  And, the thing about it is they go with about anything. So you can put them into stir fries, you can put them into your eggs, but again, cook them properly. Otherwise you’re going to go out and man, the texture’s not so good. These were dry and almost a little bit crunchy. They’re really tasty.

Dr. Weitz:            Can you get the medicinal value? Eating them raw?

Jeff:                     You know what, I would not recommend eating mushrooms raw. I think, generally speaking-

Dr. Weitz:            You see them at salad bars sometimes.

Jeff:                     You know what, it’s not like it’s going to harm you in any way. It won’t harm you in any way. And if you like to eat them raw, go right ahead.

Dr. Weitz:            But you might not get the full therapeutic benefit.

Jeff:                     True. Because, the other thing about mushrooms is that, in that so all, they also have a compound called Chitin. And for those people who are unfamiliar with Chitin, normally we think about Chitin, it’s what makes up the shell of a crab or other crustacean. But, that particular Chitin actually, they use calcium carbonate to build up their shell. Mushrooms don’t. But there is some Chitin in there. It does bind up some of the compounds in mushrooms. So cooking helps to break that down a little bit. The other issue really is that, one of the things about when you go to supplementation for example is that, you have a dry, it’s a dry product. It’s been ground to a fine powder. So you have a tremendous amount of surface area.  And when you’re consuming anything, I mean, let’s face it, just like if you make a soup. Well, you’ve got those compounds in whatever you got in your soup. Now they’re in a form where they’re readily available, you can take them in and they will go right to work almost immediately.

Dr. Weitz:            When you speak about beta glucans, I’ve always heard of the mucopolysaccharides as a component of the mushrooms that have the immune strengthening properties. Is that the same thing?

Jeff:                       You know what, I’m not really that familiar with a mucopolysaccharide, because that’s not really very, what they talk about very often.  But what I would say is that, beta glucans are polysaccharides. They are a … let’s just say they’re a subset in the sense that polysaccharides can be a lot of things.  Like for example, starches are polysaccharides.  And that’s a huge issue because, one of the great things about mushrooms is that, mushrooms have storage carbohydrates, much the same as we do. They have glycogen, plants produce starches that are storage carbohydrate.  So two very different types of carbohydrates there.  In fact, the other thing about mushrooms and eating mushrooms is that, one of the major components of the carbohydrate in mushrooms is mannitol.  Now mannitol is a low glycemic index carbohydrate that will slowly work in your system.  They’ve actually shown that mushrooms can be very good for people who are diabetics. They have a lot of fiber. They will fill you up, but they have a low glycemic index carbohydrate in there in this mannitol.  So even people who are in fact, diabetic or prediabetic or something like that, mushrooms are a good food for you.

Dr. Weitz:            So since we’re on the immune strengthening properties, I know several practitioners who use mushrooms as part of a integrative cancer protocol. Which particular strains of mushrooms do you think are most effective as having some sort of an anti cancer effect?

Jeff:                     Well, you know what? I would say the species that you should look for in that sense would be Maitake, Reishi, Turkey Tail. Those three are, would probably be my top three. They’re not now, Shiitake is also been shown to have those properties. And the wonderful thing about Shiitake or Maitake, is both of them, especially where you are in Southern California. I mean you could probably go into any market in Southern California and find fresh Shiitake and fresh Maitake, I mean Reishi is not really something you’re going to eat because it is hard and woody. So traditionally it’s made into a tea. But Shiitake and Maitake.  So those four I would say really would be the top ones that I would recommend for people in that sense. And, that is really the interesting part about these medicinal mushrooms, is that in Asia, they’ve actually produced some drugs based on these specific mushrooms. Like for example, Turkey Tail, there’s a drug in Japan called PSK, that’s been developed from Turkey Tail and a drug in Japan called Lentinan, which has been developed from Shiitake mushroom. So these mushrooms, there are that beta glucan as that’s part of what they have produced from these mushrooms.  That is really the key here. And what they do is they use it as what we could call an adjuvant to a cancer therapy, which is, you take it along with your therapy to help keep your immune system operating in a little bit higher level. Because it’s being torn down by those, whether it be the chemotherapy or the radiation.

Dr. Weitz:            Are you familiar with AHCC?

Jeff:                     I am, yes. And, to tell you the truth, I don’t know too much about that, other than it is a proprietary type of product that is … they use different mushrooms to break down certain organic products into this final AHCC. Again, my company doesn’t deal pretty much with those kind of products. I call that product and others like it, a process driven product, where rather than being what we considered a natural or herbal type of supplement, it goes through multiple steps to reach its final state. And so it’s quite different than most standard of your mushroom products, mushroom extracts.

Dr. Weitz:            I see. I did a little reading, prior to this podcast and I read that a couple of popular chemo drugs, paclitaxel and vinblastine are actually synthesized from mushrooms.

Jeff:                     Well, you know what, and here’s … This is interesting because. And what I want to tell your listeners right now is, what you have to remember is the mushroom is what we would call one plant part of an organism that has a couple of different plant parts. Mushrooms don’t have seeds, they have spores. And those spores will be out in nature, whether in the soil or in wood. They will germinate into fine filaments. And when multiple filaments come together into … they will form a fuse, they’ll form a network. And that network is called mycelium. That’s the actual what we would term a vegetative body of this organism. And that’s what’s out there. That’s one of the primary decomposers we have in nature. It’s breaking down organic matter out there and turning it into humus.  Without it, we’d be buried in all sorts of woody tissue and leaves and all sorts of organic matter. So we’ve got a spore. We’ve got this mycelium, which is the vegetative body when conditions are right, like I was talking about earlier, here in the Pacific Northwest, where it’s fall, the temperature goes down a little bit, it rains, humidity goes up, up pops a mushroom. So when you were talking about those particular drugs coming from a mushroom, actually, there are two divisions in this fungal kingdom and one is what we would call perfect fungi. And those are the mushrooms, the other called imperfect fungi, which are what you might consider a mold.  And the differences is that, mold does not produce a mushroom. And that, mold is where penicillin came from. So fungi have produced all sorts of really interesting compounds and a lot of them come from these compounds or these types called imperfect fungi or what we would just call molds. And normally when we see a mold, it’s like on our bread or it’s on like a piece of fruit. And we go, “oh my God! It’s a mold! Throw that out.” Right? Well, that again, that funguses, has attacked that piece of fruit or that bread because it’s getting older. The spores are there. They germinate. It’s just doing its thing of, okay, I’m going to decompose this. Right.

Dr. Weitz:            Right. So, I was reading about how mushrooms can have antibacterial and antifungal effects. Which is kind of interesting because sometimes I deal with patients that have mycotoxins, mold toxicity. And, I usually tell them not to eat mushrooms because they’re already having a problem with mold. But it looks like from some of the reading I did, that mushrooms actually can help you to fight off toxic mold.

Jeff:                     Yeah, that’s absolutely right. They can. And remember, you know that a mycotoxin, that’s actually from a, again, an imperfect fungus. And what happens is it’s an aflatoxin, it comes from a specific mold. And it will invade moist grain. And so a lot of the aflatoxins that people get are from eating grain products. Because of this mold, I mean. So people growing all those grains, they’re constantly checking their grains for these aflatoxins and the toxins. Once this mold gets into the grain, it can produce these toxins, and aflatoxins are very toxic.  I mean, you definitely, it’s very important that you never end up consuming them. You can get very sick from them. But, I don’t know whether you’d heard too? There used to be a meme going around and it was there for a long time, especially back in the ’90s where it was like, if you’ve got candida, don’t eat mushrooms. And it’s like, I know herbalists that treat candida with mushrooms, you know what I’m saying? There’s this whole idea of somehow, like produces like. And, it’s an ancient idea that’s more mythological than it is real. It’s like, okay, I’ve got a fungal infection, but that means I shouldn’t eat mushrooms.

Dr. Weitz:            Well, I think it comes from the concept that, the first step to clearing out some toxin, is stop getting exposed to it. So if you’re in a moldy house, leave the house or, remedy it. And, so avoiding foods that might have mold or mushrooms seems like that would be part of the same concept.

Jeff:                       Yeah. And here’s the thing too, because, when people are susceptible to molds, what we’re talking about here is we’re talking about molds growing in their house, on the walls or somewhere. And what they are allergic to, are the mold spores. Because those molds, when you see, like for example, a black mold, well normally most molds start out and they’re kind of whitish, but when they reach a certain point, they will mature. They will produce spores. And it’s those spores which people are breathing in. They’re not eating those spores, they’re breathing them in. And that’s causing this allergic reaction. And that’s when people have this mold issue. And it’s due to environmental factors. It is because they’re actually breathing in the mold spores and, there’s actually a thing called mushroom worker’s lung. And what it is, is that, some mushrooms, because a lot of mushrooms are grown indoors, in large houses or warehouses.  And if that cap of the mushroom is allowed to mature, the spores will come out and be in that environment. And if you’re in there, harvesting, you’re in there for hours. And you’re breathing in all of these spores. It is a very bad environment to be in. And that’s where, really, people that are harvesting mushrooms should always wear a respirator. And one of the reasons why, the button mushroom that you see in the market, it is harvested before, it actually matures and produces spores.

Dr. Weitz:            Interesting. I know mushrooms can have beneficial effects on cholesterol. And I know red yeast rice is where statins come from, right?

Jeff:                     That’s right. Yeah. That’s really, really interesting because the oyster mushroom, pretty, it was a lot of these statins. And what also is interesting is how, the company that produced the drug had the FDA keep these red yeast rice products out of the markets, and were suing people that were putting them out there. Because they said, no, you can’t do that because, we sell statins and we’ve got patents and all of this. And, isn’t that crazy? Here it is. It’s a natural product that has the statins in it and yet they’re going, you can’t sell those.  What! Oh God, are you kidding me? No. Oyster mushrooms. Oyster mushrooms have the … and they’ve got a good amount of them. I mean, people who have those issues could be putting oyster mushrooms into their diet and getting those benefits.

Dr. Weitz:            Cool. What about mushrooms that are beneficial for blood sugar regulation and diabetes?

Jeff:                     Well, that’s again, Maitake is the primary one for that. Although I think that’s something, again, that gets back to the fact of, mushrooms having this mannitol as one of their primary carbohydrates. Because mushrooms are mostly carbohydrates. They’ve got a 20 to 30% protein. So it, and it’s good quality protein, but that’s not really why you’re eating mushrooms. But they have this carbohydrate. And again, it gets back to the fact of the mushrooms being very, very high in fiber. So if you want something to feed your microbiome, man, mushrooms are perfect for that and they’re very good for your microbiome.

Dr. Weitz:            Really. What form of mushrooms would you want to eat to promote your microbiome?

Jeff:                     Well, any of them. Because they’re all very high in fiber. And that’s one of the reasons too. Foods that are high in fiber, they’re basically not super digestible. So what’s happening is a lot of that food is just going right through and right down in the colon, and that would be your nondigestible fiber that goes to your microbiome. And if it’s a good food, it will be essentially worked on there and a lot of the benefits will come right out of the food at that point.

Dr. Weitz:            So I understand lion’s mane has been touted as helping brain function. And, I did some reading apparently, it stimulates nerve growth factor.

Jeff:                     Lion’s mane. I tell you, we can’t keep lion’s mane in stock right now. I think in the US right now, everybody must be losing their memory.

Dr. Weitz:            We are seeing a rapid increase in neurodegenerative diseases like Alzheimer’s and Parkinson’s.

Jeff:                     I know, I know, I know. And, that reminds me, I better start taking more of it every day because I’m at that age. No, it’s really interesting because, it’s what, I don’t know. You’ve probably heard of this whole category now called nootropics.

Dr. Weitz:            Yes.

Jeff:                     And that’s becoming a huge category. Anything that helps us to function at a higher level. Now the nootropic that I love the most is called coffee. And that’s what I use in the morning to get me going. And it has a real effect on me. But right now lots of people want the lion’s mane because of the whole memory benefits. And I think we all could use that. We’re all, I mean, it doesn’t matter what age you are. We all think we don’t, our memory’s not quite sharp enough. Right? And so lion’s mane stimulates nerve growth factor.  Nerve growth factor is something that we produce that then will actually stimulate the growth of neurites and neurons, which are nerve cells. And those nerve cells are constantly being destroyed and regenerated all the time. And unfortunately as we get older, the destruction increases while the construction of new cells doesn’t keep up. And that’s where all of a sudden … “What did you say your name was again? I forget.” It’s like those types of issues come up and it’s not really comfortable when you start to lose your memory and it becomes a little more difficult. And so right now, certainly, lion’s mane, it’s our top selling mushroom right now.

Dr. Weitz:            Is there only one type of lion’s mane? That’s number one. And then number two is, what is the best form in dosage? Is capsules better than T versus powdered form versus … What is the best form?

Jeff:                     Well, you know what, I personally think that when something is in a powder form, you just have that much more surface area. The thing with eating mushrooms, like eating any food, how long are you prepared to chew it? Now if we all chewed our food up as much as we should, we would be probably getting a lot more nutrients out of that food. So having that food in a powder form I think in supplement, in that sense is probably very good. So that’s what I would say about the form.

The other thing too is, there are clinical trials out there with lion’s mane, which was really interesting because we don’t get many clinical trials when it comes to actually any kind of herbal products. Right? In Japan, they gave a group of people, elderly people in their seventies, three grams of lion’s mane. They had a control group. They all took a test, a bunch of battery of tests. They continued to take the lion’s mane, powder, three grams, just three grams, that’s not a lot for 90 days. At the end of the 90 days, they tested them again. The people taking the lion’s mane scored higher than the control group. And then as they did in the beginning.  What was interesting about that was that the, after they stopped taking lion’s mane, they tested everybody 30 days later. People who had taken the lion’s mane dropped back down to where they were previously.

Dr. Weitz:            I guess you’re relying on natural light; you’re starting to get washed out…

Jeff:                     Yeah. It’s interesting. That will probably in all of this, turn this over here because I’m facing south. So I’ve got the sun in my eyes right now, but I’ll get back over here a little bit.

Dr. Weitz:            There you go. So how much is, would you say three grams, how much is three grams? How much is that in terms of say tablespoons?

Jeff:                     Three grams would probably be two or maybe a one heaping tablespoon of Lion’s mane powder.

Dr. Weitz:            That’ll be the appropriate dosage to take one or more times a day.

Jeff:                     Yes. Absolutely. If you took that once a … And, look-

Dr. Weitz:            What if you are using it therapeutically for patients in early stage dementia?

Jeff:                     Well, you know what, I personally think that all of the herbal products and supplements out there, including mushrooms, that nobody ever takes enough. I mean, in traditional Chinese medicine, they would give people pretty significant doses of herbs because they wanted to see some activity. They wanted to see something happen. And you know what, the way all of the supplements are, it’s like, okay, here’s your 60 capsules, take two a day and you end up like, “okay, one gram a day of this product.” And that’s just because they want you to have a month’s supply. And also they say, “okay, take two capsules.” Well, what have you weigh 120 pounds or 200 pounds? Doesn’t make sense. Right. So I mean, if you’re a large man, you’re definitely going to take a lot more than a normal size woman.

Dr. Weitz:            Yeah, so what about mushrooms for sleep?

Jeff:                     Reishi, absolutely Reishi. Reishi’s been a mushroom that’s been used for a long time for insomnia, stress, to relax some. And, one of the things that I think everybody has to remember is that, don’t expect mushrooms to work immediately. That’s not how they work. You have to be taking them for a while.

Dr. Weitz:            So let’s say you have somebody who’s dealing with insomnia and they’d been trying some other things and now they’re going to start using Reishi mushrooms. How much should they take and how long trial do you think they should give it before they expect to see some results?

Jeff:                     I’d say probably two to four weeks before you see any results. I’d say take two to five grams. And, two to five grams. That would be … Two grams would be, in a lot of cases twice what they might tell you to take, because maybe they say two, 500 milligram capsules. Well, that’s only one gram.  So, don’t under dose so to speak, be sure you’re taking enough of this so that you know that in fact, you’re going to get sufficient to have some kind of activities.

Dr. Weitz:            It might be saying anywhere from maybe four to 12 capsules at night before bed.

Jeff:                     Well I would take it in the early evening. And also, this gets back into, what you’re actually taking and making sure that you’re taking the real thing and not some something else because there’s so many products out there that are not the real deal and would end up being nothing more than a placebo.

Dr. Weitz:            Right. How do we know if we’re getting the real deal?

Jeff:                     Yeah, that’s a really good question. I mean, my God, you go into one of the stores out there and you wanted to shop. Have you done that in a whole foods or something? How does anybody ever know what to buy? It’s like how many choices do you need of everything? What I would say with mushroom products, and this is something that I address a lot, because there’s a lot of mushroom products that are not actual mushrooms. And that’s so important because, we talked a little bit before about mycelium and mushroom to very different things. There are companies in the United States that grow that mycelium on grains, sterile grain in elaborate.

Dr. Weitz:            What is the Mycelium?

Jeff:                     The mycelium is this vegetative body and, one way to really picture this is, are you familiar with the food called Tempeh?

Dr. Weitz:            Yeah, but I’m not sure what it looks like.

Jeff:                     Well Tempeh, if you’ve never eaten it before, tempeh is cooked soy beans with like a paste. Well, it’s kind of black, but it’s a cooked soy beans and they grow a fungus on it. And, if you open it up, it’s white. And that white part of the tempeh, which is growing all around the soybeans is actually mycelium. Tempeh is actually a mycelium product. So people will grow a, let’s just say a Reishi tempeh, but instead of giving it to you as food, they will actually then dry it, grind it to a powder, grain and all. And then when you go to test it, it turns out that that product is mostly starch. But what they say on the label and what these companies claim, is, they’ll sell it as mushroom.  And it’s not mushroom. It’s mostly starch from all the grain in there. And so if that mushroom product says, “made in the USA,” it is going to be that grain based. Myciliated product.

Dr. Weitz:            So there is no good mushroom products made in the USA?

Jeff:                     If it’s made in the USA. No, there’s not.

Dr. Weitz:            Because we’re trained. We’re trained to want to avoid China because you hear about all the-

Jeff:                     Absolutely, I know,

Dr. Weitz:           …poor manufacturing in but China and all the toxins found in products.

Jeff:                     Dr. Weitz. Look, do you want to go out to Long Beach and deep into the water out there and the port and have a nice swim? Do you want to go out in front of the river down there, the Tijuana river down in San Diego and have a nice swim in the water down there?

Dr. Weitz:            No.

Jeff:                     It doesn’t matter where you are. What really matters is whether the products that you’re getting have been tested sufficiently. We grow and process all our products in China back far away from the large cities, from the industry and all of that, and then we have to test them and we test them before it leaves China. We test them again once it arrives over here. In 1997 I went to China with OCIA, the largest organic certifier in the United States, and we did the first organic certification for mushrooms in China, 1997!  I totally believe in organic products. When I buy my fruits and vegetables, I’m going to a store that has organic fruits and vegetables. Where the most people buy. What do they sell in most supermarkets? Well, most people buy the products that have been grown with pesticides and chemicals and so on and so forth.

Dr. Weitz:            Medically modified and sprayed with RoundUp.

Jeff:                     Yeah exactly, and where are they produced? Well, a lot of them are producing the United States and mean. So for me it’s, yeah, I’ve heard that a lot from people. And look, don’t get me wrong. I mean there are products and things from China and then no, you don’t want to consume them. Absolutely. But I’m just saying, there’s a lot of products in the US that you don’t want to be consuming either, because they’re just as contaminated.

Dr. Weitz:            So what do we look for on the label? Is there some sort of certification, certified by something?  How do we know if a mushroom product is good.

Jeff:                     You know what? That’s what’s so crazy about it. Because you can buy this myciliated grain product and it’ll say Vegan, kosher, organic, everything. It’ll have all the merit badges

Dr. Weitz:            organic. Really?

Jeff:                     Yes. Because they’re using an organic grain to grow it, but they’re growing in a lab with, and it’s just mycelium and they don’t take the grain out. So it’s mostly starch. What you need to look for is this, a product that you won’t see. All of these products will say the same on the front panel. They’ll say mushroom. And some of them will even say made with 100% organic mushrooms, even though they’re not. If you turn around the supplements facts panel and if it says mycelium, stay away. If it says mycelium in the other, you know the fine print, down at the bottom. If it says myceliated rice, myceliated oats, that’s what you are getting. You’re getting myceliated rice, you’re getting this tempeh product.  What you really want to look for in the product it says no mycelium, no grain, no starch. And a lot of products are starting to say that now because it’s like, yeah, they know and they know that people want the real thing.  So that’s really the issue. It’s not … these myceliated grain products. That’s not what they’ve used in China for thousands of years. They’ve used actual real mushrooms, and that’s where all these compounds are really made.

Dr. Weitz:            The mushroom products should come from the fruiting body of the mushroom, not my mycelium, which is like the sort of root structure.

Jeff:                     That’s exactly right. And, you put it right in the mycelium for a lot of people, if you were ever to see it, it would look like a root structure. And it’s functions like a root structure, because it’s … they’re supplying nutrients up to this mushroom. When you harvest the mushrooms, the mycelium stays in the ground. Now, it’s like, okay, I’m going to just harvest this plant that I’ve been growing, and not only am I going to harvest the plant, I’m going to harvest the roots and all the dirt around it.  It’s like, no, that’s not what you want. Right? You want the actual plant itself without what was in the ground.

Dr. Weitz:            Cool. So I think those are the questions I have. Any other things that you’d like to talk about today?

Jeff:                     Well, you know what, what I’d like to do is just to, mushrooms are kind of like one of those overlooked foods. It’s something that we’re just catching up to right now in the United States and North America. In Asia, they’ve eaten dozens of mushrooms for thousands of years. When I go in the marketplace in China, there are at least 12 different mushroom species there that you can buy. And so that’s something I think that we’re missing in our diet in a sense, I consider that the dietary missing link. So what I tell people is look, before you supplement and look, maybe you want, you’re having insomnia issues and you want Reishi, fine.  That’s different. Get your Reishi product. But before you supplement, buy mushrooms and start putting them into your diet. Cook them properly. But eat mushrooms. Mushrooms are a great food. They’re high in B vitamins. The mushrooms are for a hundred grams or four ounces of mushrooms, you’re going to get 25% of your RDA of a riboflavin and Niacin. Out of a hundred grams of fresh mushrooms.

Dr. Weitz:            What other nutrients do you get-

Jeff:                     They are also very high in potassium and phosphorous. Those are the two major minerals in mushrooms in. You know what’s really cool about mushrooms is that, they actually have a compound in there called gastrol which of you take a mushroom and slice it up and put it into the sun. The UV from the Sun will turn a gastrol into vitamin D too. It’s like. So if you want to like a slice up your mushrooms, stick them out there for 15 minutes, you’re going to get probably a hundred IUs of vitamin D2 from that. They’re just a great food. And that’s what I really like to tell people is, put them into your diet.

If you want to go a little deeper, you have some issues, especially immunological issues, try to supplement with them, and be very careful when you buy that mushroom product out there. Make sure it has no mycelium and it doesn’t say on the other, is kind of … a lot of people don’t eat grains anymore. They buy these products, they tell me about how much they love mushrooms, and then I asked them the brand and I say, you know what, you’re getting mostly grains. They’re shocked. Absolutely shocked. So, definitely, think about that. And maybe even in a year I … because I know you’re really a nutritional expert, and I’ll send you some papers on mushrooms and nutritional values and stuff like that, that you can access, but maybe that’s something you’d look at for some of your nutritional counseling.

Dr. Weitz:            That sounds good. So, do you want to give any links to contacts for you or your companies?

Jeff:                     Sure. Yeah. You know what? My company’s Nammex N-A-M-M-E-X, go to Nammex.com, we have a lot of information there about mushrooms. The benefits of medicinal mushrooms. Come to nammex. I’ve got slide shows on how our mushrooms are grown, and then, we have a retail outlet called Realmushrooms.com. You can go there and you can access our mushroom products right there at realmushrooms.com. You’ll actually get real mushrooms.

Dr. Weitz:            Awesome. Thank you, Jeff.

Jeff:                     Thank you very much. I really appreciate it.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
SIBO and IBS with Dr. Mark Pimentel: Rational Wellness Podcast 102
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Dr. Mark Pimentel discusses SIBO and IBS with Dr. Ben Weitz.

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

 

Podcast Highlights

4:29  Dr. Pimentel stated we now know that 60-70% of patients with IBS have SIBO, based on culture of the juices from the small intestine, not based on breath testing. There has been some controversy with breath testing, primarily because it had not yet been validated against a gold standard because we did not have good techniques for culture. He said that he’ll be presenting some data at DDW (Digestive Disease Week) with respect to better validating breath testing.

6:17  Re-Imagine Study.  Dr. Pimentel talked about the Re-imagine study who’s goal is to attain juice from the small intestine from 10,000 human samples in order to map out the small bowel microbiome. Some of the results will be presented at the DDW conference in San Diego in May. 

7:47  Autoimmune SIBO.  Dr. Pimentel explained his concept of the autoimmune origin of SIBO.  It starts with a bout of good poisoning from bacteria like Campylobacter, which release an endotoxin called Cytolethal Distending Toxin B (CTDB). The immune system reacts to this CDTB and then cross-reacts and creates antibodies against a structural protein in the intestinal wall called vinculin, which damages the nerves that control the motility of the small intestines. And there is a new blood test that measures these anti-CTDB and anti-vinculin antibodies–IBS-Smart that can help to identify this autoimmune type of IBS.  Dr. Pimentel explained that this blood test is not a substitute for the breath test, which identifies more patients with IBS and also tells the clinician which variant of SIBO is present–hydrogen or methane and these each require a different treatment protocol.  Dr. Pimentel also mentioned that while it hasn’t been published yet, the higher the level of antibodies, the more difficult the condition is to treat. 

13:19  Motility. Of the factors that have been described to potentially play a role in keeping the small intestine clear from bacterial overgrowth: 1. Hydrochloric acid, 2. Digestive enzymes, 3. Bile, 4. Motility, 5. The Ileocecal valve, 6. The GALT, the immune system surrounding the gut, Dr. Pimentel said the motility is the most important factor. Dr. Pimentel said that low acid from taking a proton pump inhibitor doesn’t give all these people IBS, so he doesn’t think low HCL is a big factor.  He also said that having low pancreatic enzymes or low bile are quite rare.  He said he’s seen a weak immune system in patients with HIV, but we don’t see it that often now, given how effective the HIV drugs are now.  As far as ileocecal valve function, Dr. Pimentel mentioned that we see a lot of patients with ileocecal resections in patients with Inflammatory Bowel Disease and they don’t all get overgrowth.  But if you have someone with an ileocecal resection and you have a little motility issue, then you can get overgrowth.

20:20  While it is easy to understand how there is a motility problem when the patient has constipation, but it is difficult to understand how there can be a motility problem when the patient has diarrhea. Dr. Pimentel explained that motility is not a passive process and motility involves the holding and moving backwards and moving forwards.  If you get amyloidosis, which is a type of scarring of the lining of the intestine, you actually get diarrhea because the tube is like a drainpipe, and water just blows right through it. So it’s motility that prevents it from being just a drainpipe.  Methane gas doesn’t paralyze the gut.  It actually causes the gut to tighten, which resists the flow of material, leading to constipation.

25:04  METHANE SIBO. Methane SIBO is particularly difficult to treat. Dr. Pimentel typically uses Rifaximin plus Neomycin. Neomycin is an aminoglycoside. There is another aminoglycoside, a Neomycin derivative drug, Genamycin that is given intravenously that can cause ringing in your ears and some patients are concerned that Neomycin can cause ringing in the ears, even though Dr. Pimentel has not seen it in clinical practice, so he will use Flagyl aka, metronidazole, which is equally effective as Neomycin, though he hasn’t published that yet.  Methane SIBO is caused by archaea, which are primitive organisms but are not, properly speaking, bacteria.  The archaea also tend to live very close to the mucosal surface and antibiotics may not penetrate the mucus layer, so Dr. Pimentel is looking at new drug proposals.  I mentioned to Dr. Pimentel that Dr. Rahbar has spoken about finding patients with methane SIBO often also having co-infections including with Lyme Disease, which could help explain why they are so difficult to treat. Dr. Pimentel said that he hasn’t seen that but he also hasn’t studied that association very much.  Here is a link to a presentation that Dr. Rahbar gave on IBS last year at our Functional Medicine meeting https://youtu.be/fd3fR97ilUA.

29:44  Methane SIBO contributes to weight gain through two mechanisms: 1. Hydrogen producers eat the fiber that we can’t digest and when they derive calories from fiber, we get the calories. If they produce too much hydrogen, they start to pickle themselves and inhibit themselves from continuing. But if there are also methane producers, they eat the hydrogen and allow the hydrogen producers to keep working. 2. Methane slows gastric transit and the more time the food comes into contact with your intestines, the more calories are absorbed from the food.

31:32  Hydrogen Sulfide.  The new SIBO breath test that measures hydrogen sulfide gas, as well as hydrogen and methane will be out soon.  The more hydrogen sulfide the more diarrhea, while the more methane the more constipation.  The hydrogen is the fuel for the methane or the hydrogen sulfide.

33:47  SIBO Recurrence.  In order to reduce recurrence of SIBO, Dr. Pimentel emphasized the importance of using a prokinetic such as low dose erythromycin or prucalopride and Zelnorm (tegaserod) which were both recently approved. In the Functional Medicine world we have a number of nutritional prokinetics, including Motility Activator, MotilPro, and others.  Dr. Pimentel referred to the Reimagine study where they are looking at aspirates from the small intestines and mentioned that they are looking at histamine in the juice. Some of the bugs produce histamine, which can explain some of the food intolerances we see.

37:09  Small Intestinal Fungal Overgrowth. We don’t know how often fungal overgrowth is playing a role in SIBO. Dr. Pimentel did say that there are cases where nothing seems to work and antifungals do work.  We don’t have a validated process for identifying fungal overgrowth of the small intestine, but he hopes that this may come out of the Reimagine study.  Dr. Pimentel said that this study will help to validate the proper way to collect juice sample from the small intestine and the right way to look for bacteria and fungus in this juice using proper extraction techniques.

42:12  Probiotics.  I brought up the topic of probiotics with Dr. Pimentel and I said that I had heard him say previously that he does not believe in probiotics.  I also mentioned that many Functional Medicine doctors use probiotics when treating SIBO, including some who will use Saccharomyces boulardii, which is not known to grow in the small intestine, or they’ll use a spore-based probiotic, which is believed to get all the way into the colon before it opens up.  Dr. Pimentel made it clear that he’s not anti-probiotic, but he does not feel that the data is strong enough to support their use at this time.  Most of the studies on probiotics are not that strong and they all use many different strains, so it is hard to even compare them in a meta-analysis. He said that once they can map out the organisms in the small intestine, which he will do in the ReImagine study, he does believe that there will be a probiotic way of manipulating the flora for the better, such as by putting some organisms that can crowd out the hydrogen producers. He just wants to make sure that we use the right probiotic, or probiotics, for the right thing.

46:06  Diet for IBS and SIBO.  Dr. Pimentel said that a low FODMAP diet has a lot of good data that it will reduce gas and bloating in patients with SIBO.  But long term it will lead to measurable nutritional deficiences and it will reduce microbial diversity in the microbiome. Thus, it is important to broaden out the diet for patients after 2-3 months.  Dr. Pimentel recommends a low fermentation diet that he developed at Cedars Sinai in 2001 that’s a little more lenient than the low FODMAP diet.  Here is the paper that Dr. Pimentel published in The American Journal of Gastroenterology in 2019 on Influence of Dietary Restriction on Irritable Bowel Syndrome.

 

 



Dr. Mark Pimentel is a Gastroenterologist who is head of the Pimentel Laboratory and Executive Director of the Medically Associated Science and Technology (MAST) program at Cedars-Sinai, which is focused on the development of drugs, diagnostic tests, and devices related to condition of the microbiome, with a focus on IBS. Dr. Pimentel has published over 100 scientific papers and speaks around the world at conferences, esp. about SIBO and IBS. Here is a list of some of Dr. Pimentel’s key publications: https://www.cedars-sinai.edu/Research/Research-Labs/Pimentel-Lab/Publications.aspx

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



 

Podcast Transcripts

Dr. Weitz:                            This is Dr. Ben Weitz with the Rational Wellness Podcast bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Resubscribe to Rational Wellness Podcast on iTunes and YouTube and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello Rational Wellness Podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and give us ratings and review. That way more people can find out about the Rational Wellness Podcast.

Our topic for today is Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome and our special guest is Dr. Mark Pimentel. Irritable Bowel Syndrome is the most common gastrointestinal condition with an estimated prevalence of between 10 and 15% in the United States. IBS is a condition marked by abdominal pain, gas, bloating, diarrhea or constipation or both, sometimes urgency, sometimes nausea, et cetera. When patients with IBS undergo a colonoscopy, there’s no visual pathology, unlike patients with inflammatory valve disease, like Crohn’s. For many years, IBS was seen as a condition arising primarily from psychological stress until Dr. Pimentel discovered that an overgrowth of bacteria from the colon into the small intestine was the causative agent in a majority of cases of IBS.  However, this has not been easily accepted by the medical profession and, from my perspective, for the most part it still looks like it’s not fully accepted. For example, the website for the American Society for Colon and Rectal Surgeons states, “No clear answer exists as to what causes IBS. It’s believed that the symptoms occur due to abnormal functioning or communication between the nervous system and bowel muscles.” Even Cedars-Sinai’s website, where Dr. Pimentel works, states that “Health experts have not been able to find an exact physical cause for IBS. It’s often thought that stress is one cause.” Quote, unquote. Most gastroenterologists continue to treat IBS with an array of drugs that control the symptoms that the diarrhea or constipation pain or one way or another modulate the symptoms without even trying to address what the underlying causes might be.

Dr. Pimentel is the head of the Pimentel Lab and executive director of the Medically Associated Science and Technology Program at Cedars-Sinai, which is focused on the development of drugs, diagnostic testing, and devices related to conditions of the microbiome with focus on IBS. Dr. Pimentel has published over 100 scientific papers and among his many accomplishments are the following. He’s pioneered the use of the Lactose Breath Tests for SIBO and has published studies correlating with IBS and he’s been development a new version of the breath test that will include a third gas besides hydrogen and methane, which is hydrogen sulfite. He’s discovered the use of rifaximin as a treatment for IBS. He’s developed an autoimmune model of IBS. He’s developed a blood test looking at antibodies to be able to diagnosis this autoimmune cause of IBS. He’s discovered that the methane-producing organism, methanobrevibacter smithii causes the constipation. And Dr. Pimentel has really spurred the development of a SIBO community, complete with SIBO testing, SIBO drugs, SIBO supplements, the SIBO doctor podcast, SIBO conferences like the one in Seattle that I’ll be attending later this week. But most importantly, he’s given hope to millions of patients with IBS that they might be able to feel better and stay better. Dr. Pimentel, thank you so much for joining me today.

Dr. Pimentel:                     Thanks Ben. That’s quite an introduction. I appreciate it.

Dr. Weitz:                          So what is your best estimate of the percentage of patients with IBS that’s caused by SIBO?

Dr. Pimentel:                     So the data are quite clear on this. It’s about 60 to 70% of IBS is SIBO and this is not based, not just on breath testing, but actually on culture.

Dr. Weitz:                          Okay. Because there still seems to be some controversy. People continue from time to time to cite different studies that show these big ranges for what’s positive and question whether breath testing is really effective or not.

Dr. Pimentel:                     Yeah, I think the problem we had was with breath testing. So breath testing is a really good technology. However, it had never been validated against a gold standard because culture, at the time that breath testing emerged in the 19 late ’70s, early ’80s, we didn’t have good techniques for culture, so it really wasn’t ever properly assembled in the way that would make people confident. And yet, despite all of that, all these doctors across the US were using breath testing. So they didn’t like it, but they still used it and they were able to diagnose SIBO and make that affirmative. It’s only when we said that IBS could be SIBO that people started to sort of say, “Well, breath testing isn’t accurate” and all of this. But all that’s sort of disappearing because we’re now showing with culture, and there’ll be some data at DDW [Digestive Disease Week] that I can’t talk about yet. I think we’ll be able to say that breath testing is accurate to a certain level and that what we were saying all along just with breath testing alone was relevant. And we can talk more about that, during your Q and A.

Dr. Weitz:                          Right. Well, what do you think about when we start using PCR testing instead of culture? We’ll probably have even more accurate results.

Dr. Pimentel:                     Yeah, that’s what we’re doing here. We have a study, which, I’m sort of jumping the gun, but is called the Reimagine study. And we’re … Our goal is to attain 10,000 human samples, juice from the small bowel to try and figure out who’s who, what’s what, and what bacteria belong there, what don’t, and what is SIBO. And the first slice of the pie of that data is going to be at the D.E.W. meeting in about six weeks. And the one on … One particular is getting a plenary session and I think your viewers may be very interested in the results from that because it’s very compelling.

Dr. Weitz:                          Right. And yet, we’re still only able to get the juice from the proximal part of the small intestine, right?

Dr. Pimentel:                     Right, but what we’re doing with this study is that anybody who gets what’s called a double balloon enteroscopy, meaning they’re going the full length of the small bowel.

Dr. Weitz:                          Oh, okay.

Dr. Pimentel:                     Also getting juice. So we have 20 or 30 patients already in the trial who’ve gone all through the bowel. So for the first time, some … Another way of saying what the Reimagine study is, it’s really the first study in the world looking and mapping the small bowel microbiome. Because everybody’s focused on stool and we’re really redirecting to the small intestine.

Dr. Weitz:                          Cool. Can you explain your concept of the autoimmune origin of SIBO?

Dr. Pimentel:                     To me, this is probably the most exciting thing because it’s one thing to say you have SIBO. It’s another thing to treat it with antibiotics or even natural products. The problem is it just keeps coming back, so we’ve really been determined to find out why the heck is this happening? And can we get in there and stop it before it starts? Or intervene once it’s there to really … maybe we don’t need antibodies, but that’s a long way away. The point is, we started to show … And this predates us, that food poisoning could be a trigger for IBS. We then took it to the next level and said, “Well, we need to develop an animal model where a food poisoning we know causes IBS in humans,” and the biggest culprit is campylobacter. Could we create a model in rats where we infect them with campylobacter and they develop IBS? And we did. And it’s that model that we’ve been able to dissect every step of the process of how this happens. And so we now know most of the steps.

So there’s a particular toxin of food poisoning called CDTB, Cytolethal Distending Toxin B. And most of the bugs that cause IBS have that toxin. So we actually proved that if you just inject that toxin in the skin of a rat like a vaccine, they get IBS. But that toxin is a marker for the food poisoning, so that’s important, but it triggers an auto antibody call to a protein that’s you called vinculin. And then you get these anti-vinculin antibodies, which are really important for the nerves of the gut. And so we think it’s the anti-vinculin that damages and keeps the nerves damaged because the nerves that are damaged recover very quickly if the antibody’s gone, but it’s there and it’s keeping the situation tenuous. So the nerves are effected. The flow of the gut is effected and then the bacteria are allowed to accumulate. And so that’s the new philosophy and there’s a new blood test that sort of measures those antibodies and we can actually diagnose IBS. But people think, “Oh, you’re diagnosing IBS.” We’re not. We’re work … Yes, we’re identifying you as IBS, but we’re also identifying you as IBS having come from food poisoning. So the test is actually much more specific than it even suggests.

Dr. Weitz:                          So it can’t be a substitute for a breath test.

Dr. Pimentel:                     No, in fact, it works synergistically. So think of it like you have a heart problem and you go to the doctor and the doctor does an EKG and they do an echocardiogram to see the function of the heart. It’s the same sort of thing. If you do the blood test, which I think for my patients now is really important because I can tell them how it all started, number one. Number two, I can tell them “This is a real disease. Not in your head. You don’t have antibodies like this because it’s in your head or it’s psychological. This is an organic disease.” So that, I can tell you a lot of stories from patients who are in tears. They say that finally somebody found something in my blood that tells me I have something because all the doctors have been saying I’m crazy and everything is normal.  So that’s important because it’s not just about the doctor. It’s about the patient. The patient wants some comfort and knowing that they have something real, but the second part of that is, if you have a positive antibodies, then you know you need to be careful with food poisoning. You can’t just be eating off food trucks or being a little more risky with your eating behavior because if you get another food poisoning, those antibodies go higher. And I know from clinical experience, this hasn’t been published yet, higher the antibodies, the tougher you are to treat with antibiotics or any other remedy for this SIBO that develop.

Dr. Weitz:                          Interesting.

Dr. Pimentel:                     The SIBO tells you what type of treatment to use, what antibiotic and so methane versus non-methane and so forth.

 




 

Dr. Weitz:                          I’ve really been enjoying this discussion, but I’d like to pause for a minute to tell you about our sponsor for this podcast. I’m proud that this episode of the Rational Wellness Podcast is sponsored by Integrative Therapeutics, which is one of the few lines of professional products that I use in my office. Integrative Therapeutics is a top-tier manufacturer of clinician-designed, cutting edge nutritional products with therapeutic dosages of scientifically proven ingredients to help our patients prevent chronic diseases and feel better naturally. Integrative Therapeutics is also the founding sponsor of Tap Integrative. This is a great resource for education for practitioners. I’m a subscriber to Tap Integrative. There’s videos. There’s lots of great information constantly being updated and improved upon by Doctor Lise Alschuler who runs it. One of the things I really enjoy about Tap Integrative is that it includes a service that provides you with full copies of journal articles and it’s included in the yearly annual fee. And if you use a discount code, Weitz, W-E-I-T-Z, you’ll be able to subscribe for only $99 for the year. And now, back to our discussion. Here is the link to TAP Integrative.

 



 

Dr. Weitz:                          So of the factors that result in increased risk of bacterial overgrowth, we have hydrochloric acid production that helps to keep the small bowel clear, digestive enzymes, bile has been shown to do that. We have the motility, the migrating motor complex. We have the integrity of the ileocecal valve. We have the GALT, the immune system around the intestines. What do you think is the most important factor that help to keep the small bowel from being overgrown with bacteria?

Dr. Pimentel:                     So if I were to rank it based on my experience, 50,000 patients in the last 10 years running through our clinic doing breath tests and so forth, hands down motility is the highest rank. So I’m ranking them based on the likelihood they’re causing overgrowth and the commonness combined because the most common cause, I think, is motility and the most provocative cause is a poor motility. Of course if you have an adhesion of the small bowel, like scar tissue from surgery, almost universally you have overgrowth. Fortunately, that’s not as common. But again, the functional part, low acid … We make people low acid all the time and they don’t suddenly develop IBS. So the link between having low acid, using a proton pump inhibitor, something like Nexium or … it’s not so well defined. Yes, you do get some bacterial buildup, but I think the other mechanisms can compensate to some degree. That’s why not everybody who goes on a PPI suddenly blows up and gets distended and then gets diarrhea. Some do, but it’s not so clear cut. Pancreatic enzymes, fortunately most people produce pancreatic enzymes and the juices that digest bile and so forth, so yes, if those are deficient, you can get overgrowth, but that’s quite uncommon to have pancreatic atrophy or something to that nature.

And then the GALT, the immune system of the gut, we do see … We used to see people more commonly with HIV who progressed in their illness would get some form of overgrowth, but fortunately, we don’t see that these days. The therapies are quite good.

Dr. Weitz:                          And what do you think about the ileocecal valve? Do you think that plays a role?

Dr. Pimentel:                     So we see a lot of people with ileocecal resections here at Cedars because it’s a large IBD program as well.

Dr. Weitz:                          So these are patients with Crohn’s who have part of their colon removed, right?

Dr. Pimentel:                     Yeah, exactly. And so they don’t have a valve anymore, and yet they don’t all get overgrowth either. I guess if they motility is really, really good, you’re able to clear it out. Nobody’s really studied the ilium motility very well because it’s really hard to access that area for motility studies, but I think about it like the esophagus. So when you have reflux or food or liquid from the stomach going into the esophagus, the esophagus immediately starts contracting. It doesn’t like the acid. It detects the acid and squeezes it back up out into the stomach. That’s normal and that’s why most people don’t get heartburn because they just … A little bit of acid comes in every day and we know how to squeeze it out automatically. I think the ilium probably has some similar things that go on. Yes, the ileocecal valve, if it’s not there, you’re at risk, but as long as the motility is good.

So and there are … I know this gets complicated, but there are people, for example, that have overgrowth and you treat them once. Then you don’t see them for two years. So they probably don’t have that bad a motility. The motility’s just a little off, but not deeply damaged. Maybe the antibodies aren’t high enough. So I think if you combine an ileocecal resection, you’ve lost the ileocecal valve, and you have a little motility issue, it doesn’t have to be strong, then you can suddenly have overgrowth and it becomes an issue. So it may be a combination of factors. 

Dr. Weitz:                          What about people who don’t have a colon at all? Do you want there to be overgrowth then in the small intestine?

Dr. Pimentel:                     Yeah, I know-

Dr. Weitz:                          I know that’s a little bit off the topic, but …

Dr. Pimentel:                     So people live forever … Not forever, but they live a pretty similar length of life without a colon. So your lifespan is not reduced simply you have part or all of your colon removed because the small bowel’s where all the action is, in terms of absorption. I sort of make a joke with the … It’s not really a joke, but I joke with the fellows and the residents. When I train them, I said, “The greatest gift for us is a colon and an anus” and it’s really the anus, but we can get into that because birds don’t have that. They can let go of their excrement all day because they’re flying and nobody’s going to trace them back to their nest. If you’re dragging this stuff along all the way to your cave, the lions, they’re going to find you and they’re going to eat you. So our survival depended on creating packages and delivering the packages at a time that is most safe or convenient, when the lions aren’t around or whatever, so that you’re not tracked back. And so another way of looking at the colon is really your trash bin and you’re basically preparing the trash for pickup. And it doesn’t have as much of a role in your health as we used to think.

Dr. Weitz:                          On the serum test for antibodies, one quick question is, isn’t it the case that the primary immune factor in the gut is IgA versus IgG? And why not test for IgA reactions?

Dr. Pimentel:                     Yeah, so we tested it early on and the problem with IgA is that it’s mainly in the gut. So how do we get our IGA? We could test it in the blood, but maybe it’s not there. Maybe it’s just in the gut. You’d have to get the right kind of sample. There’s that problem first of all. But second of all, for autoimmune disease, we don’t know a lot about IgA-driven autoimmune disease. I don’t even know of an example of one. Since IgA is mostly secretory, it goes into the gut, I don’t know how that would get to the nerves of the gut. So we followed the breadcrumbs and found that the breadcrumbs led to more of a really systemic autoimmune response and then kept going in that direction. Haven’t gone back to the IgA, but it’s a good question. 

Dr. Weitz:                          When it comes to motility, and I know addressing motility is a factor I’m sure we’ll get into in a few. When trying to keep SIBO from recurring, one of the questions a lot of people have is, when they have constipation, it makes sense that they have a motility problem. But when they have diarrhea, they don’t understand how they could have a motility problem.

Dr. Pimentel:                     Yeah. So for the viewers, this is sort of a thing even a lot of doctors don’t quite get and I try to explain it to them. So motility is not a passive process. So if you paralyze the small bowel, completely paralyze it, like it’s rigid. Let’s say it’s thickened with tumor or amyloidosis, which is a type of scarring in the lining of the intestine, you actually get diarrhea because the tube is like a drainpipe, and if water just blows right through it. So it’s motility that prevents it from being just a drainpipe. So your gut is not moving things through in one direction. It’s actually holding and moving backwards and moving forwards. There’s a complicated process that goes so that you aren’t just a drainpipe. Otherwise, you’d put food in and about 10 minutes later food would come out if it was just a drainpipe. So that’s what confuses people. For example, when you talk about methane and constipation, methane isn’t paralyzing the colon or the gut. It’s actually causing the gut to tighten, and by tightening, it resists the movement or flow of the material and so then you get constipated because it isn’t allowing things. Things can’t go because it’s holding it up. And so it’s a little difficult sometimes to explain to patients how that all works, but that’s some of the nuts and bolts.

Dr. Weitz:                          Yeah, the whole constipation thing is way more complicated than we realize. A lot of times I’ll be a conversation with a patient about constipation and there’s a bunch of things that are all called constipation. There are patients who don’t go to the bathroom for days on end. There are patients who go to the bathroom multiple times a day, but nothing comes out. There are patients who can go to the bathroom, but they have to strain like crazy and it’s hard. So there seems to be multiple variations of what’s called constipation.

Dr. Pimentel:                     Yeah, you should be teaching my residents and fellows because you almost said it exactly the same as I do. So constipation is what the patient feels, not the textbook. The old textbook definition of constipation is less than three bowel movements a week is constipation, but as you very accurately point out, I have patients coming to my office say, “I’m constipated,” and then I say, “Do you go every day?” “I do, but it’s like two hours on the toilet every day before I can get anything out.” So of course they’re constipated. It’s obvious, but they don’t meet the definition that 30 years ago, doctors set in textbooks as the definition. So constipation’s complicated and you need to take a proper history, as you described.

Dr. Weitz:                          And is one of those forms of constipation more related to methane?

Dr. Pimentel:                     Yeah, so what we’ve seen … So there’s … I sort of bucket in three ways. There are the patients where it’s more of an anal-rectal problem. They feel the stool there and they just can’t get it out or they have trouble getting it out. And those patients, we need to do some physiological testing. Sometimes, more commonly in women, because they don’t have a prostate gland, the anterior front of the rectum can bulge and the stool gets trapped there and that’s called a rectal seal. And there are other little structural things that can happen that can make that particular type of constipation. That history’s pretty clear. I usually can pin it down with history and then do a couple of tests and we’re on our way to figure it out.  The middle group are the patients where they’re constipated. Every week’s a little different, but they have some bloating with it. And those tend to be more the methane patients, where they’re probably going two or three times a week completely, and then they have a smattering of other things.  And then there’s the third group where they’re not going for two or three weeks at a time. Like literally not a drop. And those are called colonic inertia and that’s a different animal all together. That is not methane, at least we haven’t seen it that way.

Dr. Weitz:                          Okay. So why is methane SIBO so difficult to treat?  Not that either form is easy to treat, but the methane seems to be particularly problematic.

Dr. Pimentel:                     Yes, this is why we’re working on this Centene project because we know even from our double-blind study using rifaximin and neomycin versus neomycin, yes, rifaximin and neomycin was superior, but a month later, things start coming back. So we know on the diarrhea side, people can go a month, six months, two years and not have recurrence. On the methane side, that’s not the case. They’re more troublesome. So-

Dr. Weitz:                          By the way, just to stop you for a second. I read something online, it was an interview with you or somebody talking about the fact that you prefer now flagyl, rather than neomycin. Have you changed your protocol on methane SIBO?

Dr. Pimentel:                     Happy to talk about the neomycin versus flagyl topic. So neomycin is a drug that’s been around for a long time. It’s a categorical drug called aminoglycoside. Now, back in the ’70s and ’80s and even further back, aminoglycosides were used intravenously because, in general, they’re not absorbed. They don’t get into your body. When you use gentamycin, which is a neomycin derivative intravenously, if you use it for an infection of a heart valve you got to be on it for three months back then. And so you’re on it for three months and then you started to get ringing in your ears and so they realized that that category, when it gets in your blood, can eventually cause ringing in the ears and those kinds of neurological changes.  So the FDA basically brush stroked neomycin with the same potential side effects, but neomycin’s taken by mouth, not absorbed. 95% stays in the gut, so it’s not like gentamycin where you would give it intravenously. And so people have said, “Well, what about this ringing in the ear business?” And I have never seen ringing in the ears after neomycin and we’ve treated thousands of people. Not even one case. There was one case in a trial. The neomycin and rifaximin trial. The first patient in the trial complained of ringing in the ears and they were getting the neomycin. And we had done, because of the FDA, ear testing before and then we did ear testing after. Turns out the day after he described the ringing in the ears, he developed a sinus infection and cold and all this stuff. So it as an impending flu that he was developing that was causing. And then we did ear testing two weeks later and his testing after neomycin was better than before neomycin. So I’m not saying neomycin makes your hearing better, but there was no damage even in that one instance that I’m describing to you. So for people who are uncomfortable about neomycin because of what I just described, we have used metronidazole in the clinic and it seems to have the same sort of efficacy as neomycin with rifaximin and so we’ve suggested that as an alternative, but haven’t published it.

Dr. Weitz:                          Okay, so let’s get back to just in general, why methane is so hard to treat.

Dr. Pimentel:                     Yep. Again, we don’t know. I’ve spoken to a lot of archaea experts and methanogens or methane-producing organisms are in the category archaea. And they seem to think, in the veterinary world, because they study methane production more, that these organisms are very close to the mucosal surface and maybe the antibiotics penetrating the mucus layer, maybe that’s a challenge. We don’t know the answer to that, but we’re working towards trying to find better and better treatments. And that leads us to the Centene proposed drug because we’re using a different mechanism.

Dr. Weitz:                          I spoke to Dr. Rhabar, an integrative gastroenterologist in LA, and he said that often when he has patients with methane, he often finds other infections, like Lyme, et cetera. And then so you have a complicated factor and that’s what he deals is one of the reasons why it’s so difficult to treat methane.

Dr. Pimentel:                     There can be complicating factors with methane. We haven’t seen that association with Lyme so much, but I should admit that I haven’t studied it as much as he has, perhaps, and so I’m not … I don’t know. I don’t know.

Dr. Weitz:                          How is methane SIBO related to increased risk of obesity?

Dr. Pimentel:                     Yeah, that’s a very interesting story. There’s sort of two perspectives on that and probably two mechanisms. The first mechanism is, you need hydrogen to make methane. So you need hydrogen bugs sitting beside methane bugs to give the fuel. Hydrogen is the fuel for methane production. So it’s like you have a car, but you have no gasoline. Nothing happens. So, but the fumes from the gasoline, all that hydrogen intoxicates the hydrogen producers. Now, the hydrogen producers, let’s talk about them for a second. They’re eating all the junk that you can’t eat, the lettuce, the fiber. They’re chewing on everything to get calories. And when they do that, they give the calories to you, but if they produce too much hydrogen, they start to pickle themselves and inhibit themselves from continuing. So they can’t fire through as much material when their hydrogen is intoxicating them, but when there’s methane bugs around, the methane’s sinking the hydrogen away and allowing the hydrogen producer to keep firing through and they get actually creating more calories for you by burning through all that lettuce and material that humans generally can’t digest. So that’s one mechanism.

The second mechanism is methane slows your transit. Slower transit, more time to absorb food. So I tell patients this if they’re methane. If you look at the calories on the back of a box that you’re buying at the grocery story, that’s not the calories that you’re going to get from this material. It’s going to be something different, something higher, because of the mechanisms I just described.

Dr. Weitz:                          Can you talk about the new breath test? And when is that going to be available?

Dr. Pimentel:                     Yeah, so it’s coming out shortly. It’s weeks or months. It should be weeks, but it’s basically measuring three gases, hydrogen, methane, and hydrogen sulfite. And just to explain, methane is causing constipation. We know the higher the methane, the more constipated. We put methane into animals, they get constipated or slowed transit. So we know methane’s the culprit and hydrogen is the fuel for methane. The higher the methane, the more constipated you are. We were never able to correlate hydrogen with diarrhea. So you could have a hydrogen of 200 or a hydrogen of 50. Your diarrhea could be the same, the bloating could be the same. It was not statistically different, even thousands of breath tests analyzed, we couldn’t see that signal.  So we knew there was another gas. We knew hydrogen sulfide was there because that’s been known for decades, but nobody’s measured it on the breath. So we did and we presented that last year and the more hydrogen sulfide you produce, the more diarrhea you have. So basically what we now understand is hydrogen is a marker for SIBO, but it’s a fuel marker. So it’s providing the fuel for either methane or for hydrogen sulfide and depending on who’s winning the battle for hydrogen in that game of thrones, so to speak, you either have diarrhea or constipation.

Dr. Weitz:                            Interesting. So would that mean in the future you’re going to focus on just treating the methane or the hydrogen sulfite and not treat the hydrogen?

Dr. Pimentel:                     Well, the funny thing is, it just goes back to what I said earlier. If you get rid of the methane, the hydrogen goes up and pickles the hydrogen bucks. So you could, in fact, by getting rid of methane, impact the amount of hydrogen produced by hydrogen organisms. So as in medicine, the story is always more complicated than when you first start and we’re getting more complicated, which is why we’re doing podcasts so people can be educated and as up to date as possible.

Dr. Weitz:                            So what do we do about SIBO recurrences? In the functional medicine world where we usually don’t use antibiotics, we’ll use antimicrobial herbal combinations. And when we treat once and then it recurs, we of course think about using motility agents. And a lot of times we’ll use a motility agent like things … 5HTP and ginger and things like that. And there’s a number of products on the market. And then if they don’t resolve in two or three months or they recur, then we think about changing the antimicrobials. We sometimes think about getting a biofilm busing agent or we wonder, could this be a case of fungal overgrowth or could there be another infection? Could it be histamine intolerance? That’s another common concept now in the functional medicine world that some of these patients with these functional gut disorders who have SIBO but they don’t get better, one of the reasons could be histamine intolerance.

Dr. Pimentel:                     Yeah. Well, so you asked a very compound question with a lot of facets.

Dr. Weitz:                          I threw a bunch of stuff out there.

Dr. Pimentel:                     Yeah, you did, but it’s all important and so one of the mainstays of preventing SIBO is we use a prokinetic of some kind. You mentioned some of the natural prokinetics, so we use a low dose of erythromycin, which is a prokinetic and not an antibiotic at that dose. Prucalopride just got FDA approved and so that’s available now. Zelnorm (tegaserod), which is another product which hadn’t initially got approved in December now got approved. So we’ve got, at least on the allopathic side, we’ve got a plethora of prescribable preventative or maintenance therapies that we think are very effective. We’ve been using resolor or prucalopride, it’s called motegrity here in the US, extremely successfully with some patients lasting a year or two years with no recurrence. But the histamine story is very interesting and again, I go back to what we first said at the beginning of this interview is the Reimagine study that we’re doing. We’re not just taking aspirates and looking at bugs. We’re looking at the juice, what the bugs produce. We’re looking at histamine in the juice, histamine in the blood, serotonin in the juice, in the blood, genetics. We’re looking at immune markers in the blood, in the biopsies.  The collection of data that we’re getting around … because bugs produce histamine. There are many organisms in the gastrointestinal tract that are histamine-producing and can explain maybe some of these food allergies or food intolerances, especially if you’re feeding that one organism that happens to be producing histamine, that’s not a good thing. And so there’s … We don’t have all the data yet, but I am greater than 90% certain we’re going to see some really interesting signals because bacterial can also produce serotonin, as you probably know. And if we happen to be feeding the wrong types of bacteria in there, we’re going to overproduce those chemicals that can make people unwell.

Dr. Weitz:                          And when is fungal overgrowth or what we could call SIFO, how often is that seen?

Dr. Pimentel:                     So we’ve treated a lot of people with antibiotics and we would imagine that they would get worse if it was fungal, or at least that’s the old teaching, but we do see some patients where nothing works and antifungals do work. We don’t … Dr. Cynthia [Shroun 00:37:33] in Georgia has a process by which she identifies SIFO. We haven’t validated a process like that here at Cedars, so I think we should. I think as we’re doing this Reimagine study we’re actually looking for fungus as well, and as we identify who would be the target, I think we’ll have some better … So again, not continuously going back to this Reimagine study, but part of the Reimagine study was people were doing cultures from the small bowel wrong. People were getting juice from the small bowel wrong. People were handling the juice wrong.  We’ve been validating every step of what … because at the end of this next year, we’re going to educate on how to get those samples, how to process those samples in papers that we’re publishing. How to look for fungus the right way. How to look for bacteria the right way, because we get 10 times more bacteria after we pretreat our samples. And so if we’re getting 10 times more bacteria, we’re getting a better perspective on what all is there because some bacteria are locked in certain compartments of the juice and if you don’t unlock them, you don’t even know they exist. Same with fungus. So the problem with just taking the juice and looking for fungus is none of this has been bedded through proper validation and extraction techniques. So we’re going to educate around all of this over the coming years. Maybe we’ll do more podcasts.

Dr. Weitz:                          Have you considered urinary organic acids as a way to screen for fungal?

Dr. Pimentel:                     Absolutely, I think there’s something to be said about that. So we are not collecting urine as part of this. We’re looking at blood as a hopeful area. So let me paint a picture for you so that you can see where we’re going. So let’s say we find a bug. Maybe it’s candida, maybe it’s klebsiella or something in the gut that’s the culprit for that patient. Is there are a marker in the blood that tells us it’s there? Because we’re collecting blood and so we’re able to find some chemical that that organism produces that happens to be spilling over into the blood. We can measure it and then a doctor can diagnose that patient with that bug in their gut as a cause of that disease and then be able to get it. We haven’t turned towards urine, only because urine is important right now, but urine tends to be a filtrate of blood. So it only detects some of the things in blood. Blood has everything in it, so we think we’re going to have a better capture rate by doing blood rather than urine as we refine our searching. But you’re right, maybe we have to do some urine in this as well eventually.

Dr. Weitz:                          Now, when it comes to treatment, we have all these complicated protocols, but can we just drink celery juice? I read on the internet that it cures SIBO. I’m kidding.

Dr. Pimentel:                     There’s a lot of things on the internet report to cure many things. I never bash anything because the way I look at … There are doctors who will say, “Oh, that’s just rubbish.” And this. We don’t know what we don’t know and until we study it, we don’t know. There were many people in the 1980s and ’90s who said that H pylori is a joke. It doesn’t cause ulcers. There are people who said that the herbs are not antidepressants and then we learned about studies from St. John’s Wort and other products and they are antidepressants. So I don’t say no til I see a study that says no, a good study. And so I’m sort of giving you a vague answer. I’m sorry.

Dr. Weitz:                          That’s okay. So-It wasn’t a serious question anyway.

Dr. Pimentel:                     I know, but I really don’t … I don’t really like criticizing until I know that … What I don’t … Here’s what I don’t like. I don’t like when there are companies making a lot of money on the backs of patients suffering and not putting the money where their mouth is and do a couple of trials and give us some good information about it. That’s what I like. And I’m happy to talk all day, all night about good trials and good products.  Whatever it is, I don’t care.  If there’s good trials and good information around it, let’s help some patients.  Let’s get them the black, white, or gray answers, but let’s get the answers.

Dr. Weitz:                          I’d like to talk about probiotics. I know I’ve heard you say in the past that you didn’t think there was any benefit, but in the Functional Medicine world, we tend to use probiotics for patients with SIBO. And I did see a meta analysis in 2017 from Zhong, and others in the Journal of Clinical Gastroenterology, who did find that even though probiotics didn’t prevent SIBO, they were effective at decontaminating SIBO and reducing hydrogen gas levels. And I know one prominent Functional Medicine doctor is very big on using probiotics and I know other Functional Medicine who want to use a probiotic to see. They want to make sure we maintain the integrity or improve the microbiota and so they’ll use Saccharomyces boulardii, which is not known to grow in the small intestine or they’ll use a spore-based probiotic, which is believed to get all the way into the colon before it opens up. What’s your thought about probiotics and SIBO?

Dr. Pimentel:                     So I’m not, again, anti probiotic. I think people get that perception that I’m anti probiotic. I’m not. Again, I’m pro data. And so yes, this meta analysis came out and kind of affects us in a way because you’ve got a whole bunch of tiny trials that … and mostly small trials that if you pool them all together, you get some power. So I’ve heard the probiotic companies say, I’ll quote a trial that says, “Look, this probiotic didn’t work.” And they say, “Yeah, but that’s not our strain. Our strain is different,” right? And I said, “Okay, so we need a study with your strain.” But then the probiotics will come and they’ll quote this meta analysis, which is 10 different probiotics that are totally unrelated and say, “Look, probiotics work for SIBO.” So that seems dichotomous to me. On the one hand, when a study’s negative you’re quoting that’s not our strain. On the other hand, when there’s a meta analysis of 10 different strains, you’re saying, “Look, probiotics work.”

It’s a little mysterious to answer in that way. My answer is, once we understand the organisms better, I do believe there’s a probiotic way of manipulating the flora. I do believe if you put more of one organism in, you’ll overcrowd some of the hydrogen producers and maybe that will reduce hydrogen and so forth, but I also know that no matter what bug you put in there, it’s producing gas because that’s what they do. So the question is, are you just shifting it from one phenotype of overgrowth to another type, because the motility’s still bad. So you’re shifting it to another type of overgrowth that may have a different phenotype, so maybe you’ll say, “Oh yeah, my bloating’s better, but now my diarrhea’s worse” or my … What are we really, really doing? And again, this speaks to the Reimagine trial because the Reimagine trial is going to say, “Okay, this is what the normal small bowel bacteria look like.” Never had that answer. So until we have that answer, we don’t know how to make it look normal because we don’t know what bugs to put in there.  So we’re going to educate around probiotics eventually, but I know it’s a long answer to a tough question. I’m not against probiotics. I just want to make sure that what we end up doing in the end is the right probiotic for the right thing. And it may be five different probiotics with five different scenarios, or maybe even more. It may be much more complicated.

Dr. Weitz:                          On diet, I read your paper on diet and IBS and you talked about the low FODMAP diet. Which type of diet do you use with your patients?

Dr. Pimentel:                     So everybody is pretty convinced with the research that’s been published on the low FODMAP diet. So it’s sort of like I put the things on a spectrum.

Dr. Weitz:                          It certainly is the most common diet used in the Functional Medicine world for SIBO.

Dr. Pimentel:                     Well, absolutely. And for good reason. There’s good data. But I look at diet on a spectrum. If you don’t eat anything, you won’t be bloated. So that’s the ultimate extreme. If you go on a low FODMAP diet, which is fairly extreme, you will reduce gas and bloating. I’m convinced of that, because you’re not eating anything that produces much gas. We tend to lean more towards the low fermentation diet because it’s more tolerable. The problems we’ve encountered and seen in the science on low FODMAP is, after three months, there are measurable nutritional deficiencies on the low FODMAP diet.

Secondly, and functional medicine people know this almost better than anybody else. Low diversity of bacteria is a bad thing. That’s why you’re administering probiotics and other things, trying to expand the diversity. Low FODMAP equals low diversity over time, so it’s … You could say in the 2019 way of thinking of the microbiome, it’s damaging the microbiome and we don’t know … And a lot of times when we damage the microbiome, it doesn’t bounce back after stopping. We see that sometimes with antibiotics as well. So in essence, it’s acting like an antibiotic because it’s destroying a part of the microbiome in some way. So we try to be a little more liberal with the diet and that’s why we favor the low fermentation diet, something that we started in 2001. Never really published a lot about it because we’ve been focused on the other stuff that you and I’ve been discussing today, but we like it because it’s more lenient and a little bit more tolerable for patients.

Dr. Weitz:                          Yeah, we usually just use the low FODMAP diet for no more than two to three months and then we try to expand the diet as much as possible.

Dr. Pimentel:                     And that’s the right way to use it. So it is effective, but you have to start reintroducing for the sake of the things we talked about.

Dr. Weitz:                          In that review article, you mentioned Curcumin, which I thought was really interesting because it’s one of my favorite herbs and I use it regularly with patients with inflammatory bowel disorder. And you mentioned that it reverses gut hypersensitivity, which can be beneficial for IBS. So I thought that was really interesting.

Dr. Pimentel:                     Yeah, Curcumin is a fascinating chemical. You think about all the stuff that has been done over the millennia, pickling, anything to preserve food. You didn’t have a refrigerator back then. You couldn’t even get ice. So how do you keep food from spoiling? So herbs were one of the mechanisms and my wife said, so it’s an interesting story. We were watching a movie and there’s a scene that … There was a battle and the new person in charge said, “We’re going to move the capital of India to Delhi.” And they said, “No, you can’t do that because the river is contaminated.” And the king says, “We’ll figure it out.” And the way they figured it out, and actually, I think it’s a docuseries to be honest. The way they figured it out was they added spices, which were able to ward off some of the poisonings and things and kill the bacteria that was in there, and tumeric was one of the roots. Think about it, roots growing in a dirt of bacteria and it manages to survive. So roots are interesting and so I guess they figured out that tumeric doesn’t have a lot of flavor, just preserves. So it’s an interesting compound and interesting root.

Dr. Weitz:                          Yeah, I followed up with your references, the paper from Dilbecco, and he was particularly talking about the Curcumin phytosome form, which seemed to be particularly beneficial. So I think that might be something for us to consider in the functional medicine world for adding to our SIBO protocol.

Dr. Pimentel:                     Yeah.

Dr. Weitz:                          So your clinic at Cedars, are you guys still looking to see more patients or are you not accepting new patients there?

Dr. Pimentel:                     So I’m, as you can imagine, full to the gills.

Dr. Weitz:                          With research, yeah.

Dr. Pimentel:                     Not just research. I’m trying to do the research. So there’s two problems for me. If I don’t have time to do the research, we don’t get the new things that are really good for patients because I’m too busy with clinic. But I still see patients in clinic. It’s just … The number of calls we get a week to see me is more than my capacity, so I’ve sort of shut things down because what happens, and I’ll be very transparent here, is that they wait six months to see me and then when I see them, I find something catastrophic that should have been diagnosed six months ago. It’s not fair for people to wait six months. Better not to accept a patient than to have them linger on the hope of finding something for six months with an illness that’s more tragic than they expected. So there’s a lot of things that I’ve encountered over the years that have made me stop seeing news until I have room again and then I open up and then I close down again. But we have other motility doctors who work with me who have the same sort of skill and experience I do and they’re still accepting patients and we’ve just hired a new doctor who’s starting in September and I trained her way back and she’s coming back and she’s incredible. So we’re trying to find the space for all the patients.

Dr. Weitz:                          Great. Do you want to leave a way for patients who are listening to this to contact your clinic?

Dr. Pimentel:                     Our clinic … No. If you look on the website at Cedars-Sinai, you can definitely find the telephone number, but I don’t want to have a … Our call center is already overwhelmed. And if I leave that …

Dr. Weitz:                          Right.

Dr. Pimentel:                     But I do want to say one last thing if I can. I think the biggest thing I experience with some of our discoveries, like the blood test for example, is that patients are frustrated. It’s, “Well, my doctor doesn’t know about it and I really want it and I can’t get it and my doctor is … ” We had the same problem with rifaximin back in the day. The doctors weren’t believing. Now everybody believes. Everybody’s onboard with the SIBO IBS concept. It’s not a mystery anymore and so that’s really good, but all this stuff takes time and I … If your viewers are patients, I’m sorry for the frustration that your doctor doesn’t know about this stuff yet. This stuff takes months or years to filter to them. And we’re doing our best, like this, to try and get as far out there as possible and educate. And I appreciate you taking the time to do this podcast with me now.

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

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Non-Alcoholic Fatty Liver Disease with Dr. Bob Rountree: Rational Wellness Podcast 101
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Dr. Bob Rountree discusses Non-Alcoholic Fatty Liver Disease (NAFLD) with Dr. Ben Weitz.

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

 

Podcast Highlights

0:53  Non-alcoholic Fatty Liver Disease is the leading cause of liver disease in the US, even though many people have not heard of this condition.  75% of patients who are overweight have this condition, which consists of an accumulation of fat in the liver. Nonalcoholic fatty liver disease, NAFLD, is an asymptomatic condition, but it can progress to non-alcoholic steatohepatitis which can lead to fibrosis, cirrhosis, liver cancer and liver transplantation. Dr. Rountree described it as a tsunami that no one’s paying attention to.  Technically, the definition is when 5% of your liver tissue is replaced with fat.  What is usually seen first is that one of the liver enzymes (AST, ALT, or GGT) is mildly elevated on a blood test.

8:25  It’s not just that the liver stores fat, but it produces new fat.  We know how to create fatty liver, which is when we produce fois gras.  We do this by force feeding the goose or duck grains, which is turned into fat by the liver. It’s eating sugar and carbs and esp. high fructose corn syrup, that turn on genes in the liver that cause fatty liver and not eating fat that causes this. Big Pharma is investing billions of dollars trying to develop drugs to reverse the progressive form of fatty liver, known as Non-Alcoholic Steatic Hepatitis (NASH). Technically speaking, fatty liver doesn’t hurt you, but a percentage of people with fatty liver will develop fibrosis because the inflammatory pathways have been turned on–an auto-inflammatory process. If you lay down enough scar tissue, eventually you end up with cirrhosis or possibly liver cancer.  It is expected that within the next 5-10 years, NASH will be the number one cause for liver transplants.

13:20  Studies show that when you track patients with fatty liver, they have much a higher incidence of mortality from other diseases. [Here is a good review paper on this topic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5397356/?fbclid=IwAR19ujpU2qfD7mFaV-bAM96oN_SNZRoHiXb1BU3AbRM7xE4BLUmPUl-RW0g] The number one marker for this is C-reactive protein (HsCRP) and you start to worry especially when it is above 3. We also know that gum disease, like the existence of a bacteria known as Porphyromonas gingivalis in the gums, increases this risk.  Also dysbiosis of the gut increases inflammation and leads to fatty liver. 

15:56  We diagnose fatty liver first by measuring liver enzymes on a blood test, esp. ALT, AST, and GGT.  ALT and AST are called transaminases because they move amino acids around–they’re part of the digestion process.  Dr. Rountree feels that GGT, (Gamma-glutamyl transpeptidase), is a more sensitive test, though it is often not tested. GGT is an enzyme involved with glutathione metabolism.  But when you discover that these enzymes are elevated, you must first make sure that they don’t have a virus, that they haven’t taken too much Tylenol, or have some other toxic exposure.  After ruling these out, if you are suspecting Fatty Liver, then you should order an ultrasound.  A biopsy would be more definitive, but nobody wants to have this procedure done.

19:37  Elevated triglycerides indicate a condition we call Metabolic Syndrome, which Dr. Rountree believes is an intersection between several different biochemical pathways that have gone awry, and at the core is a person who’s over-producing triglycerides. This means that you have insulin resistance, that your body is not responding well to insulin, which is why high triglycerides can be a tip-off that the person has fatty liver. High triglycerides and low HDL is a really big deal.

22:57  To reverse Fatty Liver the conventional medical approach is to put you on a statin or Metformin, which is a drug for diabetes. From a Functional Medicine perspective, the first thing to do is to get them to change their diet and stop drinking sweetened beverages and get rid of processed food and high fructose corn syrup and start eating fresh foods. Eliminate refined carbohydrates and sugar and go on a Mediterranean diet. You don’t need to go on a Ketogenic diet. And you have to get active and do some exercise every day and lose some weight.  Exercise improves your sensitivity to insulin. High intensity interval training is the most effective form of exercise.

29:03  Dr. Rountree recommends the following nutritional supplements for reversing fatty liver: 

1. Curcumin phytosome–500 mg twice per day. This is a form of curcumin that’s better absorbed because its blended with lecithin.  There are at least three published studies showing that this resulted in dramatic improvements in fatty liver. Here is one study that I found using Curcumin phytosome for NAFLD:  Efficacy and Safety of Phytosomal Curcumin in Non-Alcoholic Fatty Liver Disease: A Randomized Controlled Trial

2.  800 IU of vitamin E in the mixed tocopherol form

3.  Fish oil is sold as a drug that lowers triglycerides, so it shouldn’t be a surprise that it improves fatty liver. Dr. Rountree recommends 2-3,000 mg of EPA and DHA per day. 

4.  Milk Thistle phytosome

5.  Berberine at a dosage of 1500 mg/day helps to reverse fatty liver. Berberine can also help with blood sugar and compares with Metformin, so it can also be thought of as a anti-aging compound. Dr. Roundtree notes that berberine can cause upset stomach, so if that happens you can start with just 500 mg and take it with food and work your way up to 1500. If you take berberine long term, you should take it with probiotics so that you don’t have an adverse effect on the microbiota.

41:02  One of the reasons that Dr. Rountree likes the curcumin and milk thistle phytosome/phosphatidylcholine supplements is because they are also good sources of choline. Many people don’t get enough choline, which can result in fatty liver.  I asked Dr. Rountree about Dr. Stanley Hazen from Cleveland Clinic who has developed a test for measuring TMAO levels and he has found that elevated TMAO levels contribute to heart disease.  Dr. Hazen tells patients that they shouldn’t consume choline or L carnitine because it’s going to increase their TMAO.  But Dr. Rountree thinks that TMAO is actually a marker for choline deficiency.  When TMAO is up that means that bacteria in the colon are consuming dietary choline and turning it into TMAO.  The problem is not the TMAO but the reduction in choline. Therefore you need to take more choline, not less.  Choline is a great source of methyl groups and undermethylation is a major cause of fatty liver.

 



Dr. Bob Rountree is an MD with certifications in Family Medicine, Nutrition, Herbology, and Mind-Body Medicine and he is in private practice in Boulder, Colorado and he is the Chief Medical Officer of Thorne Research, a nutritional supplement company. He has written three books on Integrative Medicine, Immunotics: A Revolutionary Way to Fight Infection, Beat Chronic Illness, and Stay Well (Putnam, 2000); Smart Medicine for a Healthier Child (Avery Publishing, 1994); and A Parent’s Guide to Medical Emergencies (Avery, 1997). He also teaches regularly for the Institute of Functional Medicine.   

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



 

Podcast Transcripts

Dr. Weitz:                     This is Dr. Ben Weitz with the Rational Wellness podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field.  Please subscribe to the Rational Wellness podcast at iTunes and YouTube and sign up for my free ebook on my website by going to drweitz.com.  Let’s get started on your road to better health.  Hello, Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness podcast, please give us a ratings and review on iTunes. That way more people can find out about the Rational Wellness podcast.

Our topic for today is Nonalcoholic Fatty Liver Disease with Dr. Bob Rountree. While many people have never heard of it, nonalcoholic fatty liver disease is actually the leading cause of liver disease in the United States, and as obesity rates continue to rise, so does this condition. It’s estimated that 75% of patients who are overweight and 90% of patients who are morbidly obese are afflicted with nonalcoholic fatty liver disease.  Nonalcoholic fatty liver disease, NAFLD, is an asymptomatic condition meaning, you have no idea that you have it and it’s marked by an accumulation of fat in the liver. And while it’s traditionally been considered a benign condition, it can progress to nonalcoholic steatohepatitis which can lead to fibrosis, cirrhosis, liver cancer and liver transplantation.

 Dr. Bob Rountree is an MD who’s one of the founding members of Functional Medicine along with Dr. Jeffrey Bland and Sidney Baker, et cetera. In today’s parlance, he would be referred to as an OG. Dr. Rountree has certifications in family medicine, nutrition, herbology and mind-body therapy. He’s written three books in integrative medicine, Immunotics, Smart Medicine for a Healthier Child, and A Parent’s Guide to Medical Emergencies. He also teaches regularly for the Institute of Functional Medicine.  Dr. Rountree, thank you so much for joining me today. I’m very excited to get an opportunity to speak to you.

Dr. Rountree:                    You bet. It’s a real thrill to be on.

Dr. Weitz:                          Good. So, maybe you can tell us how you first got involved with Functional Medicine.

Dr. Rountree:                    Oh, my God, that’s a long story. When I was in training in my residency, one of my fellow residents went to a conference put on on Integrative Medicine, and Dr. Jeffrey Bland was one of the speakers, and this resident came back and said, “You will not believe this guy. He talks about nutrition from a highly educated standpoint where he cites all of the research and connects the dots in a way that no one has ever done.” So I got intrigued and I ended up tracking Jeffrey down and went to hear him lecture, and then when I finished residency I spent a week at a place called the Omega Institute in upstate New York, and I studied with Jeffrey Bland and Leo Galland, Sid Baker, and a guy named Neil Ornstein, who are the founding fathers of Functional Medicine. That was about 38, 39 years ago.

Dr. Weitz:                          Cool.

Dr. Rountree:                    So there was no Functional Medicine at the time, but this is this group of forward thinking people, were putting these ideas together and eventually I continued to follow their work and go to Jeffrey’s seminar year after year after year, and eventually it became what we call Functional Medicine.  I actually taught in the very first Functional Medicine training, which was out at the Orchid Hotel in the Big Island in Hawaii. It was a lovely experience.

Dr. Weitz:                          Cool. Yeah. I used to listen to Dr. Bland’s audio tapes every month. I think it was originally called preventative medicine update, and …

Dr. Rountree:                    Yeah. PMU.

Dr. Weitz:                          Used to get those little cassette tapes, pop them in the car …

Dr. Rountree:                    Yeah. Yeah. I still got a stack of them in my closet. Yeah. Yeah. Well, Jeffrey still had it. I just heard him on a conference last weekend, and he’s still cranking away and he’s in his mid-70s now, and quite robust and healthy and alert and his brain is just going 100 miles an hour as always.

Dr. Weitz:                           That’s great. Yeah, I know, he’s got his preventative, PLMI Institute. Right?

Dr. Rountree:                      Preventative Lifestyle Medicine Institute.

Dr. Weitz:                           Right. Cool.

Dr. Rountree:                     Yeah.

Dr. Weitz:                           So tell us about nonalcoholic fatty liver disease and what causes it.

Dr. Rountree:                     Oh, my God. This is one of these huge problems that nobody’s ever heard of. Right? They call it the tsunami because this is such a huge problem that doctors aren’t paying attention to. In the past, if you read a typical mainstream medical article on metabolic syndrome or prediabetes, they would always say, “Oh, and you can have this complication of fatty liver.” And they just described it as, “Oh, it’s not that big a deal. You’ve a little bit of fat in your liver and it could cause some problems,” and now we’re realizing that fatty liver may be the problem.  It may be one of the main causes of diabetes, not the other way around.  So, what is it exactly? It’s an accumulation of fat in the liver, just like the name says.  It’s not caused by drinking alcohol or a toxin.  I mean we know there’s toxins out there like acetaminophen or Tylenol.

Dr. Weitz:                           Yeah. The number one cause of acute liver failure, right?

Dr. Rountree:                     Absolutely. I just saw a patient a couple of weeks ago that had a routine blood test and her liver enzymes were both elevated and I said, “Well, this is either fatty liver,” she was a bit overweight, so I said, “This is either fatty liver or it’s Tylenol.” It turned out she was taking 1,500 milligrams of Tylenol every day. She stopped and her liver enzymes came back to normal, so she got off the hook for the fatty liver. But that raises the point of the fatty liver, is when you got something going on with the liver, it’s not because of another proveable condition like a toxin or alcohol, which is a toxin.  So they call it nonalcoholic fatty liver. Technically, the definition is that when 5% of your liver tissue is replaced with fat, you have fatty liver. 5%. So, in order to get that you’ve got to have some kind of scan of the liver. You can’t tell that based on blood tests alone. Typically what would happen is a person’s getting a routine screen, like the patient I mentioned, and she’ll get told, “Okay, your hepatic transaminases, the ALT and the AST, one or both of these are increased.” And again, the first thing you think is, “Well, is there a toxin, or is there … does she have a virus or something like that?”  But when you’ve ruled those things out, you go, “Why will the liver show an increase in these enzymes?” It’s because there’s a very mild level of inflammation that’s going on there. In the past, they would have said that fatty liver doesn’t really cause a problem. It’s a consequence of other problems, and as I said, the newer thinking is, no, this may actually be at the core of the problem.

Dr. Weitz:                          Why does the body store fat in the liver?

Dr. Rountree:                    Well, everything’s being processed through the liver, if you think about it. When you’re ingesting foods, right, the extract of the food goes into the lymphatic system and that drains into the liver. The liver is like a big sponge.

Dr. Weitz:                          Right.

Dr. Rountree:                    But it’s not just that the liver is storing fat, it’s actually making new fat.

Dr. Weitz:                          Okay.

Dr. Rountree:                    This is a really important point. So, how do you create fatty liver? Well, we’ve been doing it for centuries. It’s called fois gras. Right? That’s fatty liver. And how do you produce fatty liver in a goose or in a duck? You force feed them grains. Right? It’s not fat. So the logical thing would be to think, “Okay, you eat too much fat and so the liver just stores it.”  Instead, what happens is, you eat too much sugar and the sugar actually turns on genes in the liver that tell the liver to convert that sugar into fat, into what’s called triglyceride, the triglyceride form of fat. So it’s a partially genetic thing. So, yeah, if you eat, you know, gobs and gobs of fat in your diet, some of that will end up in your liver and get stored there, but a big proportion of the fat in the fatty liver scenario is from high fructose corn syrup. That’s a big wow, right?

Dr. Weitz:                          Yeah. Yeah.

Dr. Rountree:                    Wait, wait a minute. I get fat from eating sugar. Yes.

Dr. Weitz:                          Right. Sure. We know that most of the cholesterol in the body is produced by the liver. That and drugs don’t work by blocking the cholesterol that we eat. It stops the liver, reduces the liver from producing cholesterol.

Dr. Rountree:                    Well, there’s this old notion. Somebody’s got high cholesterol, so maybe it’s just ending up in the blood stream. They’re eating too much high cholesterol food therefore they have high blood cholesterol. Well, now we know that even going on a low cholesterol diet doesn’t change blood cholesterol levels that much.

Dr. Weitz:                          Right.

Dr. Rountree:                    Even restricting cholesterol and fat from the diet doesn’t change blood cholesterol.

Dr. Weitz:                          Right.

Dr. Rountree:                    Right? It’s because the liver’s making that cholesterol and the odd thing is that even, as the same scenario with fatty liver, eating too much sugar can actually stimulate the liver to make more blood fats.

Dr. Weitz:                          Yeah. It’s interesting when you talk about fois gras. I guess the aliens are fattening us up for a big meal.

Dr. Rountree:                    They’re getting ready for a big meal. Yeah. They’re preparing us for the yummy feast. Yeah. Either that or if it’s not the aliens, it’s the big agricultural companies. They’re really … they’re having a field day with us.

Dr. Weitz:                          Oh, yeah, absolutely. And Big Pharma, right?

Dr. Rountree:                    Big Pharma. You know, so Big Pharma knows that this fatty liver problem is an epidemic, right. They’re not denying it at all. And they are investing billions of dollars in drugs, because they figure, if we find the drug that will reverse … It’s not so much reversing fatty liver, but reversing, as you mentioned, the progressed form of it, which is called NASH. Now NASH is the concern here.  So, technically speaking, fatty liver doesn’t hurt you, but it does increase your risk of other diseases. But the problem is a certain percentage of people with fatty liver will develop fibrosis, and you get the fibrosis because you turn on inflammatory pathways. The immune system gets involved. You don’t want that. Once the immune system is involved, you’re in trouble. When the immune system gets involved, you start laying down scar tissue, and if you lay down enough scar tissue, then eventually you end up with cirrhosis or possibly liver cancer.  So, for that reason, they’re expecting that within probably the next five to ten years that fatty liver NASH, the progressed form of it, is going to be the number one cause for liver transplants in this country.

Dr. Weitz:                          Wow.

Dr. Rountree:                    And that’s what they mean by the tsunami. We don’t have enough livers for all these people.

Dr. Weitz:                          Right. Wow. So, essentially when you say the immune system gets involved, we’re creating autoimmune liver disease.

Dr. Rountree:                    I guess you could call it an autoimmune thing because the body is attacking itself.

Dr. Weitz:                          Exactly.

Dr. Rountree:                    Technically, we call it autoinflammatory. So it’s not quite … autoimmune be like very specific attack on the joints. Right? Autoinflammation is like autoimmunity but it’s more like there’s inflammation in a certain area, like hardening of the arteries, arthrosclerosis, that’s autoimmunity.

Dr. Weitz:                          Right.

Dr. Rountree:                    That’s autoinflammation.

Dr. Weitz:                          Okay.

Dr. Rountree:                    So, autoinflammation. They overlap. They’re very similar. So, this is an autoinflammatory disease, it’s inflammation that’s somewhat confined to the liver. Now here’s a little interesting tidbit about it. Well, I don’t know if you’d call it interesting if you have the problem, but, people with fatty liver, again, were not thought to have any consequences of it, but what they’ve done is they’ve tracked people with fatty liver, know their diagnoses for years, and they found their incidence of mortality from other diseases goes way up. And probably the number one marker for that is something called the C-reactive protein which I’m sure you’re aware of.

Dr. Weitz:                          Sure. Absolutely.

Dr. Rountree:                    Yeah. If your CRP, if you’ve got fatty liver and your C-reactive protein is up, which is a marker for inflammation, then that’s a very bad sign, right? That tells us that your risk of dying or getting ill from a number of different diseases goes way up.

Dr. Weitz:                          And when you say the CRP is up, do you mean anything over 1, or anything over 3, or …

Dr. Rountree:                    Oh, over 3 is when you start to get worried. When you get up to 4 or 5, then it’s a real concern.

Dr. Weitz:                          Okay.

Dr. Rountree:                    But hopefully not over 1 or a lot of us would be in trouble.

Dr. Weitz:                          But I guess a lot of us Functional Medicine practitioners now are using 1 as the optimal range.

Dr. Rountree:                    Right. So we’re talking about optimal, but when you get into the danger ranges, more like your 3, 4, 5 et cetera. I find a lot of people, if they got a C-reactive protein of say 2, they can get it down just by flossing their teeth. Because bad gums can definitely cause inflammation in the body.

Dr. Weitz:                          Yeah, it’s amazing what bad gums can be involved in. They can increase your risk of heart disease, as we know, that’s why a lot of people get dental work and they get prescribed antibiotics to decrease the possibility of a heart infection, and recently we’ve seen research correlating it with Alzheimer’s disease.

Dr. Rountree:                    Yup. Yeah. Absolutely. There’s actually a bacteria that gets under the gums called Porphyromonas gingivalis. You probably heard of it.

Dr. Weitz:                          Yes.

Dr. Rountree:                    That’s one of the bad guys, and I bring this up in the context of the discussion on fatty liver, because now there’s a lot of research coming out showing that dysbiosis, which is unhealthy bacteria in the intestines, can actually lead to fatty liver.

Dr. Weitz:                          Right. Which-

Dr. Rountree:                    You know, powerful.

Dr. Weitz:                          From a Functional Medicine perspective, not surprising at all, because essentially dysbiosis seems to be a factor in everything.

Dr. Rountree:                    Every chronic disease.

Dr. Weitz:                          Yes. So, how do we diagnose fatty liver?

Dr. Rountree:                    Well, it’s mostly diagnosed in people as part of a routine screening. What’s called a chemistry profile or a liver function test. I would say a large percentage of patients in my practice came to see me because they’d been to a health fair and had a routine screen, and said, “Gee, I thought I was healthy. I’m just a little overweight. I got a little paunch going on, but otherwise I thought I was pretty healthy, then I went to a health fair, and lo and behold, my liver enzymes were elevated and they told me, go see a doctor.”  Those liver enzymes, as I mentioned earlier, can be a tip-off that something’s wrong but you’ve got to first make sure it’s not a virus, make sure they’re not overdosing them on Tylenol which isn’t hard to do, make sure they don’t have any toxic exposures, and when all that’s left, you get, “Okay, let’s get an ultrasound.” The ultrasound is really the best test, I think, to determine it, because it will tell you whether there’s a lot of fat in the liver.  Unfortunately, ultrasound doesn’t specifically say, you have 8% fat or 10% fat or 15. It just says, you’ve got enough fat that you qualify for having at least 5% of your tissue replaced with fat. So, again, starts with abnormal liver enzymes and then it’s confirmed with an ultrasound.  Now, if you want to be technical about it, you probably should get a biopsy, but nobody wants to do that. Right? If you don’t have any symptoms and your doctor says, “I think you’ve got this bad condition that could lead to something even worse,” and then you say, “And I want to stick this huge needle into your liver and get a piece of your liver and see what it looks like there,” that’s not going to go over very well. So, no one gets a biopsy for fatty liver.

Dr. Weitz:                          So, which of the liver enzymes are most important?  And how much do they need to be elevated to indicate this?

Dr. Rountree:                    They don’t need to be very elevated. So the two that we look at, there’s three actually, ALT, AST and GGT. Those ALT and AST are called transaminases and they’re called that because they move amino acids around. They’re part of the digestion process. And when the liver has this fat built up and for some reason it will leak these enzymes into the blood stream. But an even more sensitive test that a lot of doctors don’t do is called the GGT, Gamma-glutamyl transpeptidase, that’s involved in our old friend, glutathione.  And you know that if an enzyme that’s involved in glutathione metabolism is elevated, that’s not good news.

Dr. Weitz:                          Right.

Dr. Rountree:                    Because you’re only increasing your glutathione processing enzymes if you’ve got some kind of toxin to be processing. Right?

Dr. Weitz:                          Right.

Dr. Rountree:                   The liver’s saying, “I’m under stress and I need more glutathione.” That’s actually … It’s a better enzyme but for some reason doctors don’t do it that much, so I always add it on. If I get a chemistry profile, I always add on the GGT.

Dr. Weitz:                          What about alkaline phosphatase and, or elevated triglycerides?  Are those potential indicators as well?

Dr. Rountree:                    Though alkaline phosphatase can be, it’s generally not the first one that goes up.  It’s a little bit later in the process, but, yeah, alkaline phosphatase can definitely be increased.  I just saw it in a patient the other day.

Dr. Weitz:                          Okay.

Dr. Rountree:                    And your other question was about triglycerides, and there, again, there’s this condition that we call metabolic syndrome, right?  And metabolic syndrome is either its own deal or it’s prediabetes depending on whether you’re a diabetologist or not. Diabetologists say you either have diabetes or prediabetes.

Dr. Weitz:                          Right.

Dr. Rountree:                    The endocrinologists, who are not diabetologists, and the cardiologists, they say there’s a whole other syndrome called metabolic syndrome that it’s own deal that can lead to diabetes. And the reason that’s important is because I’m in that camp. I think metabolic syndrome is a phenomenon, it’s an intersection between several different biochemical pathways that have gone awry, but at the core of it is the person who’s over-producing triglycerides.

Dr. Weitz:                          Okay.

Dr. Rountree:                    Why is this a big deal? Because, in the old days when we did a cholesterol panel, we looked at their LDL cholesterol and HDL cholesterol, and that’s all that mattered. Well, occasionally, you’d see a person whose high triglycerides were part of the deal, and we would tell them, “Oh, that’s no big deal.” No big deal. Now we know … I mean, high triglycerides and low HDL is a really big deal. What it means is that the body is not responding well to insulin. It means you have insulin resistance. And insulin resistance, it’s not the only cause of fatty liver, but it’s clearly one of the major causes, so the same thing that causes metabolic syndrome causes fatty liver.  And so, that’s why, high triglycerides could be a tip-off that the person has fatty liver. We generally think, if a person is a Type 2 diabetic, if they’re at the point where they have to take drugs to keep their hemoglobin A1C down, chances are 70% that they’ve got some degree of fatty liver. If they’ve got metabolic syndrome, it’s not quite as high but it’s definitely moving in that direction.

Dr. Weitz:                          Right. And when the ALT is elevated, it could be like, say, 45 instead of below 40, right? It doesn’t have-

Dr. Rountree:                    It doesn’t … it’s only a slight increase.  In fact, when you have these super high increases, you actually don’t think of fatty liver, you think of virus or a toxin.

Dr. Weitz:                          Right.

Dr. Rountree:                    Right?  You think there’s been some kind of damage and there’s certainly viruses like Epstein-Barr virus that people can get.  Even a younger person who gets Kissing disease, mono, you know, their liver enzymes can go through the roof.

Dr. Weitz:                          In the thousands, even.

Dr. Rountree:                    Yeah, in the thousands. So when I see that, I don’t think fatty liver. I only think fatty liver when, if the normal range is up to 40 and they’re 45 or 50. So, it can stay that way for months or years, and that’s your tip-off as you go … You know, the first thing is if you see these enzymes and they’re 3 points up, the first thing I think is, “Okay, I’m going to repeat this in a month and see if it’s real.”

Dr. Weitz:                          Right. So, when we have patients with this condition, how do we reverse it?

Dr. Rountree:                    Well, that’s the million dollar question.  As I said, you know, the drug companies-

Dr. Weitz:                          Is that going to be revealed in the next Dr. Rountree book on fatty liver?

Dr. Rountree:                    Well you know, my wife was saying, “Why don’t you write a book about it?”  I’m like, “Who’s going to buy a book called Your Liver May Have Fat In It.”  It’s not exactly what you’d call a sexy topic for the public in general, but I tell you, so many people have it and the doctors are not recognizing it, and then they go on from fatty liver to NASH and they go, “Why didn’t anyone tell me? Why hasn’t anyone said anything about it?”  Well, so that gets us back to, how do we treat it? You know, the drug companies are saying, “Let’s run-

Dr. Weitz:                          You don’t call the book that. You call the book This Is Going to Rejuvenate Your Sexuality, Make You-

Dr. Rountree:                    Yeah, you’re right.  Right.  Win Free Something. Win and free has got to be in the title if you want it to sell.

Dr. Weitz:                          Sex is somewhere in there too.

Dr. Rountree:                    You know what the drug companies think? They’re expecting that there’s about a 35 billion dollar market in drugs for NASH.

Dr. Weitz:                          Wow.

Dr. Rountree:                    35 billion dollar market. But the first drug they came up with was a total failure.

Dr. Weitz:                          Not surprising. Right?

Dr. Rountree:                    And I think it’s because they’re going at the wrong thing. I mean the first thing you do, really, is look at it from a Functional Medicine perspective. I think Functional Medicine has got the solution.

Dr. Weitz:                          They never do that.

Dr. Rountree:                    They never did that 

Dr. Weitz:                          They went on one pathway, the one drug that blocks out one pathway …

Dr. Rountree:                    Yup. And so, let me put you on statin.

Dr. Weitz:                          Yeah.

Dr. Rountree:                    Or let me put you on Metformin, which is a drug for diabetes. Well, those drugs, they’re somewhat helpful, but they don’t make that big a difference. Now if you look at it from the Functional Medicine perspective, the first thing you ask is, “What are your lifestyle factors that are … What’s contributing to this condition?” Right?  And a lot of times it’s got to be the person drinking a lot of pop or eating a lot of foods that are processed and have the high fructose corn syrup. Now people say, “Wait, it’s corn syrup. How could it be a problem?” Well, it is a problem. There’s no question. There’s many published papers on it, so the first thing is to get rid of the sweetened beverages, and to get rid of processed food. Almost all processed food has got high fructose corn syrup in it.  So, look for that on the label, or better yet, just stop eating things with packages. You know, go to fresh, all the time.  It doesn’t even have to be organic. Just fresh.

Dr. Weitz:                          Right.

Dr. Rountree:                    That’s going to make a huge difference. So, that’s the first step. The second thing is to cut back on any kind of refined carbohydrate, any kind of sugar or sweets, candy, things like that. Do you have to go to a ketogenic diet, extreme low carb? It doesn’t have to be. It’s just carbohydrate restricted. In fact, studies have shown that the single best diet for people with fatty liver is the Mediterranean diet. That’s not a super carb restricted diet, but it’s minimal carb, there’s minimal sweets, there’s a nice mix of fruits and vegetables, there’s a lot of olive oil, not a ton of meat but some meat, a fair amount of fish. So, that doesn’t even have to be a really kind of crazy, elaborate diet, just a basic Mediterranean diet.  But then you got to have people working out. That’s a stumbling block for a lot of people. If they’re not working out, if they’re not exercising, you’re never going to burn that fat.

Dr. Weitz:                          Right.

Dr. Rountree:                    And I’ve certainly, I’ve seen it in patients where their liver enzymes will go up and down depending on how much they’re exercising. And the standard complaint I hear is, “I don’t have to time to exercise. I can’t fit it in. I got too many things going on.” It’s like, you know, “Would you rather …” So, the whole joke is, “Would you rather exercise for 30 minutes a day or be dead 24 hours a day?”

Dr. Weitz:                          Exactly. Yeah, that’s no excuse. I just tell patients, “What time do you wake up? Whatever time it is, wake up an hour earlier, and that’s when you get your exercise in.”

Dr. Rountree:                    You’ve got to do it, and studies have shown that exercise lowers fat in the liver regardless of weight loss. So, it’s not that you’re exercising to lose weight. Probably what’s happening when you exercise is you get more sensitivity to insulin. So, again, at the core of this problem is resistance to insulin.

Dr. Weitz:                          Right.

Dr. Rountree:                    When you have resistance to insulin, then for the same level of blood sugar your body makes more insulin because it’s harder to get that blood sugar down, but when you make more insulin, insulin turns on the genes that generate fat in the liver. So, you exercise, you decrease the insulin resistance, you increase the sensitivity to insulin. And how much do you need? Probably about 150 minutes a week. That’s 30 minutes, five days of the week. Not a huge amount, and it doesn’t have to be super-duper intense, although it’s better if it is. So high intensity interval training works better than anything.

Dr. Weitz:                          Cool.

Dr. Rountree:                    And you know what that’s about. That’s telling the person to get on the treadmill, go all out for 20 to 30 seconds. Just as hard as they can until they can’t stand it anymore, doesn’t have to be a long time, then you rest, then a few minutes later you do it again. If you do that, you can get as much benefit from 15 minutes of exercise as you do from two hours of slow walking.

Dr. Weitz:                          Right. And weight training is high intensity exercise also.

Dr. Rountree:                    Absolutely. Yeah. When you’re doing these really intense reps, you know, that’s definitely working your muscles.

Dr. Weitz:                          I was at the gym this morning.

Dr. Rountree:                    At the gym doing that, getting your insulin sensitivity up.

Dr. Weitz:                          Absolutely. So besides losing weight, what else can we do about this condition? What nutritional supplements can be of benefit?

Dr. Rountree:                    Oh, I’m glad you asked that question. As it turns out, there’s a lot-

Dr. Weitz:                          I never ask that question.

Dr. Rountree:                    Okay. Well, you know, what would surprise you is that if you look at the mainstream text books where articles that have been written on fatty liver, they say there’s no proof drawn, and you go, “Wait a minute. So that means there’s nothing you can do but lose weight and exercise?”  No, actually, if you do what I did, which is you start talking to my friend Mr. Google, or I should say, Dr. Google. And just started messing around looking at articles that people have written, what do you find? You actually find that there’s a huge number of dietary supplements that have been studied, and really good studies, for fatty liver, and you think, “Why doesn’t the mainstream doctor know about this?” It’s because there’s no financial incentive, there’s no drug rep that’s going to come in and say, “Hey, you should take curcumin, which is an extract of turmeric. You should take milk thistle, you should take berberine.” So I’ve already listed a couple of my favorites-

Dr. Weitz:                          Right.

Dr. Rountree:                    Probably the top of the list is curcumin phytosome. Curcumin is the active ingredient in the herb turmeric, curcuma longa. Turmeric is fine for general health purposes, but it’s not well absorbed, so there’s a version of it called curcumin phytosome where it is mixed with lecithin, which is a substance that you find in soy and sunflower, you can find lecithin in eggs, and when you combine the curcumin with the phytosome, it dramatically enhances absorption.  Well, I mention that form of it because there’s at least three, and maybe four published studies where they took people that had significant fatty liver based on ultrasound and they gave them curcumin phytosome, 500 milligrams twice a day. That’s the dietary supplement that you can get, it’s pretty widely available if you ask for that specific form. They found dramatic improvements with the dropping of liver fat, people lost weight, their liver enzymes came down on every single study they’ve done on.  So here’s something that is inexpensive, it’s easy to take, it’s non-toxic, and it’s been proven in three to four studies, that are all published in medical journals. So that’s my first choice. I put everybody on that.

The second one would be vitamin E. Now vitamin E is actually something that the mainstream liver specialists agree on. The American Association for the study of liver diseases, you know that’s kind of the mainstream organization that is an advocate for doing something about fatty liver, they actually say, “Everybody with fatty liver should get vitamin E.”

Dr. Weitz:                          And you prefer the high Gamma-tocopherols?

Dr. Rountree:                    Yeah. Well, it’s mixed tocopherols that are high in the Gamma-tocopherol. So, that’s the way … I don’t … So a lot of Vitamin Es that you buy or d-alpha-tocopherol 

Dr. Weitz:                          Yeah, the synthetic form. Yeah.

Dr. Rountree:                    I’m not a big fan of straight d-alpha-tocopherol because the active form of vitamin E is actually Gamma-tocopherol.

Dr. Weitz:                          Correct.

Dr. Rountree:                    But I don’t think you have to isolate the Gamma-tocopherol, I think you just get the mixed tocopherols. And a typical dose of that is 800 international units, or IUs a day. So, everybody with fatty liver should be on that.  The third thing would be fish oil, right? The Omega-3 fatty acids. There are very good studies showing that fish oil can improve fatty liver. Well, that shouldn’t be a surprise because fish oil is actually approved by the FDA as a drug. Fish oil is a drug to lower triglycerides. Well, it’s going after the same thing.  Again, if a person didn’t understand this, they might say, “Wait a minute, you’re recommending a fat, which is fish oil, to treat fatty liver. That doesn’t make any sense.”

Dr. Weitz:                          Right.

Dr. Rountree:                    Except that what the fish oil does is it decreases inflammation and it actually improves the genetic activity in the liver so it stops making all that fat. How much do you need? About 2 to 3,000 milligrams of the active ingredient, which is EPA plus DHA. And that ends up being somewhere between 2 to 4 caps a day, or about a tablespoon of cod liver oil. So everybody can do that.

Dr. Weitz:                          Yeah.

Dr. Rountree:                    The next supplement that I recommend a lot that’s actually got good research on it, is milk thistle. We know that milk thistle has been around for a long time, for a wide range of liver conditions. Now, similar to the curcumin, the milk thistle extract called silymarin is not well absorbed, and there are a number of studies using the phytosome which complex with lecithin showing that the phytosome is much better absorbed and actually works really well in the liver.  I believe that that’s actually a trademark name and I would say this, I’m not plugging a specific company’s product, but this is what’s in the medical research, it’s called Siliphos. That’s made by a company in Italy. A lot of companies will sell the Siliphos, so it’s sold under different brand names, but that’s the one you want to look for and there’s two or three published studies showing that that improves fatty liver.

Dr. Weitz:                          Cool.

Dr. Rountree:                    So that’s a good one. Another one I love is called berberine. I’m sure you’re familiar with berberine.

Dr. Weitz:                          Use it all the time. Yup.

Dr. Rountree:                    Berberine, you know, why mainstream doctors don’t know about it just completely beats me.

Dr. Weitz:                          There’s been studies where it’s gone head-to-head with metformin and this is useful.

Dr. Rountree:                    It works just as well as metformin for diabetes. Sometimes I actually combine the two for a person that’s got bad diabetes, and when I do that it keeps me from having to go to insulin or more powerful drugs. So, berberine is a yellowish chemical that’s found in a lot of medicinal plants. Plants are found basically all over the world. In China, it’s in a plant called coptis chinensis. A European plant that’s used a lot is Berberis vulgaris. Here in the United States we have a plant called Oregon-grape root, and all of them have berberine.

Dr. Weitz:                          Do you think it matters where it comes from, because some of the products on the market have it from four different sources, some don’t.

Dr. Rountree:                    Berberine is berberine.

Dr. Weitz:                          Okay.

Dr. Rountree:                    In my opinion, and there are studies using different sources of it, but berberine is the active ingredient. Now, berberine for years is mostly used to treat infections in the gut.

Dr. Weitz:                          Absolutely. SIBO, dysbiosis.

Dr. Rountree:                    Yeah. Dysbiosis. Candida. We used it for years for that. And the way I understand it is that some astute doctor in China said, “Wait a minute, my patients are taking berberine to treat dysbiosis or treat infectious diarrhea, that kind of thing, but gee, their blood sugar is getting better.”

Dr. Weitz:                          Right.

Dr. Rountree:                    So it was some chance discovery. The berberine had been around for a long time, but nobody thought of using it for diabetes, but the Chinese jumped on that, started doing some studies and found out that it lowers blood sugar. And it’s fabulous for that.

Dr. Weitz:                          What dosage do you like for the berberine?

Dr. Rountree:                    If a person’s got full-on fatty liver, they need about 1,500 milligrams a day.

Dr. Weitz:                          Okay.

Dr. Rountree:                    And that’s of berberine, that’s not of Oregon-grape root, or Berberis vulgaris, right? So you’ve got to say, how much of the active ingredient, 500 milligrams up to three times a day. Now there’s some caveats with that. Berberine is a very powerful substance. It can’t interact with certain prescription drugs. For example, it can interact with statins and when you take the two together, it can make the blood level of the statins go higher, so if somebody is on a statin and they take berberine, then they may need to reduce the dose of the statin. So not a problem if they’re not on prescription drugs, but if they’re on prescription drugs and they want to do berberine, they should probably either talk to a pharmacist or a doctor about it.

Okay? So that’s number one thing that they should be concerned about, but the other thing to be aware of with berberine is that it can cause upset stomach, and the way you get around that is you start with one a day. 500 milligrams, take it with food, and generally take it for one to two weeks, make sure the stomach is settled down, and then you bump it up to two a day, and then eventually three a day.  Is it worth it? I mean, what? Why, that sounds like a hassle. It could upset your stomach, could interact with drugs. Well, I mean, the amazing thing about berberine is that, again, it works as well as metformin for lowering blood sugar. That’s a powerful effect.

Dr. Weitz:                          Anti-aging.

Dr. Rountree:                    It has the anti … Well, I just gave a lecture on longevity pathways at a conference and I was looking at some of the drugs that are being touted. There’s a drug called rapamycin-

Dr. Weitz:                          Yes.

Dr. Rountree:                    … being touted as an antiaging product.

Dr. Weitz:                          mTOR, yeah.

Dr. Rountree:                    It’s an mTOR inhibitor. I was looking at metformin. There’s actually a study that the FDA approved looking at metformin as an antiaging drug. But then I started diving through my friend Dr. Google’s research, and I found a paper saying, “Could berberine be acting as an antiaging drug the same way that metformin is.”

Dr. Weitz:                          Absolutely.

Dr. Rountree:                    And the doctors were saying, “Yeah, actually it’s doing the same thing as metformin, but it’s cheaper and easier. It’s not prescription. It’s safer.” So, yeah, berberine may be something you would take, maybe a lower dose. I wouldn’t take the 1,500 just for anti-aging, but 500 to 1,000 a day, seems plenty safe. People can use it for a long period of time, but they should take probiotics with it, regularly.

Dr. Weitz:                          Right. To make sure. You don’t want to kill off too much of your microbiota.

Dr. Rountree:                    Yeah. You don’t want to mess with your microbiota. Now, I haven’t actually seen it be a problem with the microbiota, but it’s so this is a theoretical concern.

Dr. Weitz:                          Right.

Dr. Rountree:                    But it’s the real deal. Now, what about fatty liver? There’s several published studies showing that berberine can decrease fatty liver. There are animal studies showing it and human studies showing it. So it’s not hypothetical, it’s not theoretical, it really does work, so it’s well worth it.  But berberine, I don’t put it in my first level, right, because it’s stronger, it’s more potent, and some people do get the upset stomach. So, again, I start with the curcumin phytosome, the vitamin E, the fish oil, the milk thistle phytosome, the Siliphos. I try those things first and if I need something stronger, I go to berberine.

Dr. Weitz:                          And one of the reasons why you like the phosphatidylcholine supplements it’s because of their benefits of choline, right?

Dr. Rountree:                    Well, okay. I’m glad you asked that question. Again, for a long time, we thought that fatty liver was only a result of being overweight, having insulin resistance and eating too much sugar or high fructose corn syrup. But now we know that there are people that can have a genetic abnormality in the ability to process folic acid. It’s called the MTHFR. I’m sure you know all about it and probably talk to your listeners. Right?

Dr. Weitz:                          Yes.

Dr. Rountree:                    Well, the fact that methyl compounds can help fatty liver has kind of opened up this whole new realm of research, right? A lot of people aren’t aware that choline in the diet, which you can find in eggs and meat and dairy products, that choline is actually a great source of methyl groups, and it turns out that undermethylation is a major cause of fatty liver. Why is this a big deal? Because we think fatty liver affects somewhere around 20 to 25% of the population.  Nutritional surveys that have looked at choline intake and what percentage of the population you think gets enough choline?

Dr. Weitz:                          Probably most don’t.

Dr. Rountree:                    Yeah. Most don’t, and up to 20, 25% are actually deficient in choline. So that is totally parallel to the people that get fatty liver.

Dr. Weitz:                          And yet you have a doctor from Cleveland Clinic measuring TMAO levels and telling patients that they shouldn’t consume choline or L carnitine because it’s going to increase their TMAO.

Dr. Rountree:                    Yeah, that’s doctor Stanley Hazen’s hypothesis. I think TMAO is a marker for choline deficiency.

Dr. Weitz:                          Interesting.

Dr. Rountree:                    It’s the other way round. So I think when TMAO is up, that means bacteria in the gut are consuming dietary choline and turning it into this toxic compound. Well, I think, the problems you see associated with the TMAO are a result of the choline deficiency.

Dr. Weitz:                          Ah. I see.

Dr. Rountree:                    Now, what’s the evidence for this? If you take people that are, for some reason they can’t eat and they get all their feeding intravenously, called total parenteral nutrition. So, you put it in an IV and you give them all their food intravenously. If you leave choline out of that formula so that they have a totally controlled formula, you know everything that’s going into their body. If you don’t put choline in there, 100% of those people will get fatty liver, 100%. And if you add the choline back in, then the fatty liver goes away within a couple of weeks.

Dr. Weitz:                          Wow.

Dr. Rountree:                    Very clear, very elegant. So, again, these phytosomes are a source of phosphatidylcholine and I think they’re quite beneficial. So not only am I not concerned that they’re contributing to the TMAO, I think the high TMAO is an indicator that they need more choline.

Dr. Weitz:                          Wow, we should take two groups of patients that have elevated TMAO levels and give one group choline and then measure their liver and their …

Dr. Rountree:                    Do their ultrasound. Look at their ultrasound and see … Yeah, they’ve done similar kind of tests, again with these people getting total parenteral nutrition, with the ultrasounds before and after where they add the choline. That’s a similar kind of experiment to what you’re talking about. They just need to add in the TMAO and see which direction that’s going.

Dr. Weitz:                          Interesting.

Dr. Rountree:                    Yeah. So, choline is a good thing. You know, you can actually take choline as a separate supplement and a typical dose is about 500 milligrams twice a day. Who needs choline the most is pregnant women.

Dr. Weitz:                          Oh, yeah?

Dr. Rountree:                    Yeah, for the baby’s brain.

Dr. Weitz:                          Absolutely. And it’s added to some of the newer supplements in the Functional Medicine world. [crosstalk 00:45:08] back in the day taking choline and inositol to help clean out your liver.

Dr. Rountree:                    It’s an all kind of naturopathic formula which they called lipotropics.

Dr. Weitz:                          Yup.

Dr. Rountree:                    I thought it was interesting because I, for years, I kind of used them but didn’t know why.

Dr. Weitz:                          Right.

Dr. Rountree:                    My naturopathic friend said, “This is good for your liver.” “Well, why?” “Well, because they’re lipotropics.” “Well, why are they lipotropics?” “Because they’re good for your liver.” Right? They’re just kind of a natural observation. And one of the things that in this lipotropics is called trimethylglycine, TMG. TMG is great for the liver, so that’s another source of methyl groups.  Well, where does TMG come from? It’s made from choline.

Dr. Weitz:                          Ah, interesting. What about inositol? That probably would be beneficial too.

Dr. Rountree:                    I’m not … Maybe. I’ve not seen any research on inositol for fatty liver.

Dr. Weitz:                          Yeah, we use it for PCOS right now.

Dr. Rountree:                    I use it for mood disorders.

Dr. Weitz:                          Oh, okay. Yeah.

Dr. Rountree:                    You know, in high doses, like 10 to 20 grams a day.

Dr. Weitz:                          Right.

Dr. Rountree:                    Really good for mood. For panic, anxiety, things like that.

Dr. Weitz:                          Yeah. Cool.  So, this has been a great discussion, Dr. Rountree.

Dr. Rountree:                    Cool.

Dr. Weitz:                          How can our listeners get hold of you and find out more about your programs and your books, et cetera, or be able to contact … Are you available for consultations? You do-

Dr. Rountree:                    Well, my practice is pretty full right now because I’m mostly on the road traveling, but I do have a LinkedIn website so that’s probably the best place to find out more about my practice, is just go to LinkedIn.

Dr. Weitz:                          Okay.

Dr. Rountree:                    Type in my name and Boulder Wellcare, or I highly recommend that people go to the Institute for Functional Medicine website. So they don’t … I do have people occasionally fly in to see me, but if there is Functional Medicine doc near you, like, what about you?

Dr. Weitz:                          All right. Absolutely. What about me?

Dr. Rountree:                    Yeah. What about you?  So that, Institute for Functional Medicine has got a great referral network.

Dr. Weitz:                          Yes. Absolutely. Awesome. Thank you so much for spending some time with us, Dr. Rountree. This was a great podcast!

Dr. Rountree:                    You bet. It’s been a pleasure.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Predictive Biomarkers with Dr. Russell Jaffe: Rational Wellness Podcast 100
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Dr. Russell Jaffe discusses Predictive Biomarkers with Dr. Ben Weitz.

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

 

Podcast Highlights

5:25  Dr. Jaffe is an advocate for looking at eight biomarkers that he believes are the best measures of the quality of our health and predictors of longevity. He notes that life in the 21st century results in more internal and external toxic load, which requires more nutrients than it used to to maximize your epigenetics.  Epigenetics is the expression of your genetic code.

10:25  The Telomere length test has been shown to be a valid test to help predict long term. It measures the end of the chromosomes and it’s length does correlated with survivability.

12:11  Dr. Jaffe believes that the most important eight biomarkers are: 1. Hemoglobin A1C, 2. High Sensitivity C-reactive protein, 3. Plasma Homocysteine, 4. Lymphocyte Response Assay, 5. First morning urine test for pH, 6. Vitamin D, 7. Omega 3 index, 8. 8-Deoxyguanosine.

14:33  According to Dr. Jaffe, Hemoglobin A1C should be less than 5 percent.

17:37  The second predictive biomarker test is High Sensitivity C-Reactive Protein (HsCRP), which is a marker for inflammation and repair deficit and the optimal range is below .5.  Dr. Jaffe discussed the benefit of doing a vitamin C cleanse by taking vitamin C to bowel tolerance levels. He also mentioned that it is a good idea to check your bowel transit time by using charcoal capsules. He mentioned that these are both written up on his website, Perque.com.  Dr. Jaffe mentioned that he has a company betterlabtestsnow.com that offers these biomarker lab tests.

21:38  With regard to the Lymphocyte Response Test for food sensitivities, the goal is to be tolerant and not to have any delayed sensitivity reactions. Lymphocyte Response Testing measures three types of delayed sensitivity reactions through lymphocyte activation, which includes reactive antibodies (IgA, IgM, and IgG), immune complexes, and T cell direct activation. 

21:56  The first morning urine pH test, which is a way of measuring the risk of magnesium deficit in the cells. Magnesium and potassium are the minerals that help to alkalinity in our cells. According to Dr. Jaffe, when we get into a slightly acidic state our cells become depleted energetically. You need one molecule of magnesium for every molecule of ATP and when magnesium is depleted, the cells shift from an active elective-protective mode to survival mode. Our morning urine pH should be between 6.5-7.5 and below that means metabolic, cellular acidosis.

24:06  Optimal vitamin D levels should be between 50 and 80 ng/mL.  Vitamin D is really a neurohormone and it communicates with cells and has an anti-cancer function and a pain-relieving function.

27:07 The omega 3 index should be more than 8 percent. This can be accomplished by reducing or eliminating edible oils, which are sources of omega 6. Dr. Jaffe recommends not cooking with oils and instead use wine, broth, or freshly made juice to cook with. He points out that the oil in nuts and seeds is protected from oxidation, but after expressing such oils, oxygen tends to create rancidity.  He avoids such oils including extra virgin olive oil.  He recommends eating fish and taking fish oil capsules to raise your omega 3 levels and he explains that we need both EPA and DHA, so we should take the fish oil that contains both and not just one.

31:28  The final biomarker is the 8-oxo-guanine, (aka, 8-hydroxy-2-deoxyguanosine), it’s the measure of oxidative damage in your DNA, in the nucleus of your cell, including the DNA in the mitochondria and this test has been validated. If you have too much 8-oxo-guanine it means you need to take in more antioxidants.

32:58  Dr. Jaffe believes in order to be healthy you should avoid added sugar and cut out almost all packaged and processed foods. You should eat whole foods and if you eat processed or packaged foods, you should know every ingredient on the label. Processed foods have a long shelf life, but they are not real food. They have too much sodium and too little potassium. They have too much calcium and too little magnesium. They tend to feed diabetes and fluffiness. Dr. Jaffe said that he does recommend complex carbs and fiber. In fact, he recommends eating 40-100 grams of prebiotic fiber and 40-100 billion probiotic organisms per day.

Dr. Jaffe recommends taking the Perque Endura/PAK Guard supplement, which recycles glutamine. This product contains glutamine to feed the cells that line the intestines, but this glutamine will get turned into glutamate, which is an excitatory endotoxin.  The PAK in this product then recycles the glutamate back into glutamine up to 10 times. This makes it safer to take glutamine. Dr. Jaffee said to have lifelong good health you should eat what you can digest, assimilate, and eliminate without any burden.

39:18  In order to lower HsCRP Dr. Jaffe recommends to take more of the good stuff and less of the bad stuff. He said that you can do the urine pH test and then take enough magnesium and choline citrate to get your pH in the optimal range. He explained that only choline citrate uniquely enhances the uptake and chaperones the delivery of magnesium to the cell, correcting the metabolic acidosis and the metabolic syndrome, recharging the cell’s ATP, protecting essential fats in transit where magnesium functions as an antioxidant. And allowing the battery of the cell to recharge. And other things as well, including hundreds of enzyme catalysts that require magnesium to work, and if magnesium runs down, they’re pro-enzymes. They’re potential enzymes. While Dr. Stanley Hazen from the Cleveland Clinic is recommending that people avoid consuming choline to lower their TMAO levels, which is a marker for heart disease risk, Dr. Jaffe says not to worry. You will only make TMAO if you have a long transit time, which you won’t if you do a quarterly C-cleanse and have enough prebiotic fiber and probiotic good bugs.  And he also recommends choline citrate over choline bitartrate. And with respect to vitamin C, Dr. Jaffe explained that you want to take the fully buffered L-ascorbate and not the D-ascorbate, which much of the vitamin C on the market is. And ascorbate will also raise you glutathione levels.

42:10  Your homocysteine level should ideally be below 6 and in order to lower it we take methylfolate, methyl B12, and vitamin B6. We should also eat garlic, ginger, onions, broccoli sprouts, and eggs.

45:15 When it comes to urine pH, you want between six and seven and a half. To facilitate this, you want to take 2 dosages of Perque Mag Plus Guard and Perque Choline Citrate, which enhances the uptake of the vitamin C to get into the cells.  Dr. Jaffe does not think that taking baking soda to alkalinize your system is a good idea because it may reduce the acid of the stomach, which reduces stomach acid and impairs digestion and reduces the uptake of minerals and B vitamins.

 



Dr. Russell Jaffe has an MD and PhD from the Boston University School of Medicine and he is also board certified in Clinical Pathology. He worked at the National Institute of Health and he has published over 80 scientific papers.  Dr. Jaffe is a pioneer in Functional Medicine and he developed the first lymphocyte response assay for food sensitivities and is the lab director and owner of ELISA/ACT Biotechnologies (betterlabtestsnow.com) and the founder and chairman of Perque Integrative Health supplement company Perque.com.  Here are the phone numbers for the Dr. Jaffe’s lab and for Perque Integrative Health: 1-800-525-7372 or 1-800-553-5472.

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



 

Podcast Transcripts

This is Dr. Ben Weitz with the Rational Wellness podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness podcast on iTunes and YouTube, and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness podcast, please go to iTunes and give us a ratings and a review. That way more people can find out about the Rational Wellness podcast.

Our topic for today is predictive biomarkers with Dr. Russell Jaffee. Predictive biomarkers are things that can be measured objectively that will be the best predictors of our long term health.  These are typically measured through blood or urine or saliva tests, and from the hundreds of thousands of lab tests available Dr. Jaffee has selected approximately eight tests that he feels the evidence shows are the best predictors that we’ll still be alive in 10 years.

Dr. Russell Jaffee has an MD and a PhD from the Boston University School of Medicine. He’s board certified in clinical pathology, he’s worked at the National Institute of Health, has done research and has published over 80 scientific papers and was originally quite skeptical of functional medicine. He developed the first lymphocyte response assay for food sensitivities and continues to be the lab director of ELISA/ACT Biotechnologies, as well as the founder and chairman of a nutritional supplement company Perk Integrative Health. Dr. Jaffee, thank you so much for joining us today.

Dr. Jaffe:           Thanks for inviting me.

Dr. Weitz:            So, Dr. Jaffe you’ve worked at The National Institute of Health and you were fully immersed in the conventional medical model of care and somehow you made your way over to the progressive side of things, to the Functional Medicine side of things.  Can you tell our listeners what changed your thinking in how you’ve come over to this different way of understanding the body?

Dr. Jaffe:           Well, thanks for asking. In the early ’70s I arrived as a public health service officer at the Clinical Center at The National Institutes of Health, that’s my full-time job, but I heard that there was a man named Quing Loo, an acupuncturist who would needle people and get results that we couldn’t get at NIH and as a skeptic I went and then I did a seven year apprenticeship with him, and then taught a program called Oriental Medical Strategies in Western Medical Practice, which was a part of the foundation of continuing medical education to licensed medical acupuncture in New York and California.

Then I heard about Dr. Ramamurti Mishra and the Yoga Society of New York and the Textbook of Yoga Psychology. An MD PhD cross trained in Banaras and I went to debunk him and I had five years as his student, and then I met a Cambodian Buddhist monk named Bhante Dharmawara. I met him at his birthday on Sunday. On Tuesday he moved in because he had decoded a non-invasive color healing system that the Buddha taught that was practiced for 500 years, lost for 2000 years, and he, from his study of the ancient text deduced what it was and brought it forth and I’m one of his students.

So I did come as a skeptic. My experience taught me that my skepticism came out of my ignorance not out of wisdom, and that yes the analytic skill, whatever I have as a methodologist, as a clinician, as a diagnostician, as somebody who’s made up … Every year at NIH we introduced what became a gold standard of laboratory testing because there was a lot of need at that time. A lot of support for the kind of work that I was doing. So I did, indeed come as a skeptic. I did apprenticeships that taught me to respect wisdom traditions, observational science, as well as double-blind placebo controlled studies, and our super-multi, the Perque Lifeguard tabsule, an all active novel delivery system.  It’s a super B complex with a super mineral complex and 40 active ingredients, not 20, in meaningful amounts because we don’t have any binders, fillers, excipients, filling agents and shmootsy stuff or need it because as a biochemist and a physical chemist I know how nature brings foods together and there’s no glue involved, and we do the same thing with all of the Perque products.  And we did this double-blind placebo-controlled trial at the military medical school in Bethesda, Maryland because someone was going to say to me, “Did you do a double-blind study,” and I was going to say to them, “Yes,” and it came out and it was published by my colleague back at Patricia Deuster and it was done at the military medical school, which means it was done properly with proper controls.

 So, yes, I’m an advocate for these predictive biomarkers that cover lifestyle, they cover choice, habits of daily living and most of us don’t have perfect habits as reflected in the value, the test value, being above the ideal.  Now, I want to make a very clear point that labs produce ranges and you compare results to ranges making people into statistics. Now, that’s fine for population studies. It tells you almost nothing and may actually be confusing with regard to the healthy value for that test. So my suggestion is, instead of even looking at the range, just fold it under so you don’t have to look at it, look at the value of these eight biomarker tests and yes, we did a funnel analysis starting with over 100,000 tests and we wanted to cover all of epigenetics, all of lifestyle, all of the things that your habits control which is 92% of your lifetime health, and each of these eight tests is an all-cause morbidity mortality marker and when you put them together you cover the 92% of lifetime quality of life and health that is determined by epigenetics.  Now, the simplest I can explain epigenetics is–it’s not genetics. It’s not the DNA. It’s not the RNA. It’s the products. It’s the functional quality of your cells. It’s the acid/alkaline balance. It’s whether the essential, and by essential we mean the nutrients you must take in because your body can’t make them, and yes, the 21st century is more intoxicating and intoxicated over five different categories so therefore you have to increase the anti-toxic nutrients that get consumed, and chewed up, and spit out by the toxins of every day, the stresses of every day living. Technically it’s called the allostatic and homeostatic load for those of you who are into Greek and Latin, but that means the internal and external total toxic burden which requires more nutrients than it used to because the 21st century is, spoiler alert, more toxic than the 20th, and the 20th was more toxic than the 19th.

Dr. Weitz:            Cool. So can you explain which predicted biomarkers you think are most important, and I just wanted to point out for the listeners who are still a little confused about epigenetics. Your genes are the things that are laid it down in your DNA and the epigenetics basically has to do with how you lead your life and whether or not those genes get expressed. Whether or not they get turned off or turned on.

Dr. Jaffe:           Right. That’s right. The environment, your attitude, your nutritional status, your toxic load all modulate the expression of your genetic code.

Dr. Weitz:            Right.

Dr. Jaffe:           And that’s what epigenetics is and it turns out it’s much more important than even we thought a few decades ago. In fact, it’s probably where the opportunity to feel and function better because not only are we looking at the 10 year horizon and your probability of living 10 or more years, but we’re also talking about the functional age, the functional age, at which you operate and perform.  As an example, I can tell you that by the measures that we do, and I get to do a lot of measurements on myself, I am functioning mostly as a 35-40 year old which means half my biological age. I get restorative sleep, I can preach the value of restorative sleep, I eat moderately. I’m a reformed fluffy person. I used to weigh 65 pounds more and, I think it was Mark Hyman who taught me this, if you look at yourself in a full length mirror and you wiggle your tummy and it jiggles your fat pads are too fat. So, it was not a simple resolution one day and resolved the next day. It took me time to lose the weight. I don’t plan to find it again, but I can tell you that after I got down to the weight I choose, which is more or less what you see, it took another year before the leptin hormone, the hormone that causes raging appetite, to come back to normal.  So because of having had that humbling experience I can advocate for it. I can explain to people what happened to me as an example and how much better I feel and function and how much more able I am to get at least 8000 steps in a day, as my current goal, because when I wake up in the morning first I stretch in bed, then I get up and I stretch in the shower, and then I’m ready for the day.

Dr. Weitz:            Hey, before we get into the specific biomarkers, have you heard of the telomere length test?  This is a test that people have come up with to measure the end of the chromosome and this one test is designed to be a predictor of long term health.  What do you think about that test?

Dr. Jaffe:           I can tell you that my telomeres were shorter when I was fluffy.  My telomeres have gotten much longer, which is better now that I’m more moderate in my habits.  So yes, I think the telomere test, in general I do not recommend genetic tests.  I can explain why Eric Lender and I agree. He’s a geneticist, I’m an an epigeneticist. However, I do think that telomere length is validated on every ethnic group, on every socioeconomic group. That’s what you need. You need a test that’s been around long enough that people who have skepticism about split sample precision, measuring telomeres is not easy.  It has a variance.  It has to be done right.  So if someone is selling you a telomere test on the street corner, be skeptical.  But it is the one test, ’cause I wanna get onto the eight that cover for epigenetics.

Dr. Weitz:            Yes. I know.

Dr. Jaffe:           It is the one test that I think you’re absolutely right. Telomere length correlates with your survivability.  And it’s not that expensive. It won’t break the bank. But if it’s okay, let me list the eight predictive biomarkers.

Dr. Weitz:            Yep, let’s do that.

Dr. Jaffe:           And then we’ll come back and talk about what the best outcome value is. What is the goal value and what does it mean, in terms of ten year survival but also short-term quality of life.

Dr. Weitz:            Sure. Sounds good.

Dr. Jaffe:           The first is a very familiar test. Hemoglobin A1C. The second is a pretty familiar test. High-sensitivity C-reactive protein. HSCRP. The third test, familiar but you have to follow the rules on how to do it correctly. It is a plasma homocysteine. That’s not a political statement, that’s an amino acid. And there’s the ratio of methionine to homocysteine that predicts cardiovascular events and other potential catastrophes. The fourth test is the lymphocyte response assay. This is the cell culture to measure T and D cell function. Not the physical chemistry of an antibody because you can’t tell if it’s good or bad, but lending white cells called lymphocytes react ex-EVO  just as they do in the body to tell us where you’re tolerant. Foods, chemicals, environmental substances. And where you’re intolerant, where you’ve broken tolerance. Where you have the body attacking itself, inducing repair deficit called inflammation. Inducing self-attack called autoimmune. The fifth test is a self-test. This is a urine test. After six hours of rest, and you can go to the bathroom, you just can’t go to the kitchen or the gym, but after six hours of rest, the fluid in the bladder has equilibrated with the lining cells, and it’s the one time of day when you get a meaningful pH that correlates with your magnesium at the cellular level. We’ll come back to that, so it’s first morning your own pH. And we’ll come back when I go through what the goal values are.  That’s the fifth. The sixth is a vitamin D level. The country is low in vitamin D. That’s quote statistically normal. But it increases your risk of everything from pain to cancer, so we recommend having a healthier vitamin D level. And how much vitamin D should you take, well enough to get into the health to your range which I’m gonna give in just a minute after we get through the eight.  Number seven is the Omega 3 index, this is Bill Harris’s test looking at the Omega 3 to 6 ratio.  And the last is an unfamiliar one to most people but it’s the test of DNA oxidative damage, which by the way, correlates with telomeres.  It’s called 8-oxoguanine. It’s a urine spot test and it rounds out, it adds the only other piece that wasn’t covering everything in your lifestyle.

So now, let’s go back through the eight, and I’m gonna give you the best outcome goal value and how we know that that’s true. So hemoglobin A1C should be less than five percent. I can tell you that mine was getting up into the high fives and that means pre-diabetic, that means fluffy, et cetera. It means insulin resistance, it means metabolic syndrome. And now I can tell you the last two tests I had, I have my tests done about every six months, was four point five percent. And what did I do, well I ate the foods that I could digest, assimilate and eliminate, and I stopped adding sugar. I’m sweet enough as I am and so are you. We don’t need to add sugar in our diet. And just to nail that point, the average American today eats as much sugar in a week as our great grandparents ate in a year. That is a metabolic formula for problems. So hemoglobin A1C, less than five percent, and every one of these tests as I said had been studied on every ethnic group, every socioeconomic group, every geographic area, and they are all caused morbidity mortality tests. That’s a very high bar standard. But-

Dr. Weitz:            Now, why did you pick hemoglobin A1C versus fasting glucose or postprandial glucose or fasting insulin?

Dr. Jaffe:           Right. Now, when we did our studies and we have successful published studies in type one diabetes and type two, starting from best standard of care, our approach, this comprehensive integrative approach, lowered their hemoglobin A1C by one percent which adds 20 quality years to life, and we measure the glucose and insulin. We measured the HOMA IR, the ratio, we measured the kinds of things you’re asking about.  As you know, I was just at the Integrative Health Symposium in New York and was talking about this subject, and the American Diabetes Association was the other half of the hotel conference area and they now agree that we know about white coat hypertension but we need to remember about white coat hyperglycemia. Because just the stress of seeing a needle or going to a doctor causes an adrenaline release in most people, enough people that this is a known phenomenon, and so it turns out the fasting blood sugar overstates the issue of concern and is not predictive, is not anywhere near as predictive as hemoglobin A1C, because hemoglobin A1C, this is Paul Gallop from the 1960s, this has to do with how much extra sugar gets stuck onto proteins, including hemoglobin. And if you have healthy red cells that live three to four months and you’re a very calm person who meditates every day, and you’re well hydrated and so forth, well then you can measure glucose or insulin or the ratio.  But, if you want the most predictive tests, the high-value tests, the one that isn’t all cost morbidity with very few quote pre and post-analytic complications, it’s hemoglobin A1C. Absolutely.

Now the second test, same parallel discussion, Paul Ridker and Nader Rifai noticed that C-reactive protein was an index of repair need or inflammation.  And they noticed that at the low end was very important information, that the standard CRP was missing because it wasn’t very sensitive, in fact it was very variable, at the low end.  So we want HsCRP, high sensitivity C-reactive protein.  And the goal value is less than .5. And above that, you have repair deficit, known as inflammation, and I’ve seen numbers way above that indicating substantial and continuing, pervasive repair deficit where the quality of life goes down, and as my grandmother used to say the rents are going up and the ceilings are coming down.  Now you want to take in enough polyphenolics and enough ascorbate based on your C-cleanse and enough of the essential B-complex and other nutrients, full B-complex, super B-complex, enough to keep your urine sunshine yellow. Most people have glass clear urine, indicating a deficit of B-vitamins. So HsCRP-

Dr. Weitz:            That’s kind of interesting, ’cause everybody talks about, “oh you have expensive urine,” as though that’s a bad thing, and so what you’re suggesting is if you have clear urine, that’s a problem.

Dr. Jaffe:           And I got to say that to Abe White, the man who was quoted as saying, “taking supplements makes expensive urine,” and I said, “Abe, does that mean that eating food makes expensive poop?” And he was a nice guy! He liked to be quotable. And he was. Anyway yes, the body gives us many opportunities to make simple self assessments or measurements, test measurements, compare them to the best outcome or known goal value, that is what healthy people have, because that optimizes your short and long-term survival.  It’s only about quality of life and survival and I hope that’s of interest to everyone who’s listening.

Dr. Weitz:            And just because you’re urinating out vitamin C, doesn’t mean that on its way through your body it’s not quenching free radicals and then taking those out of your body, so .

Dr. Jaffe:           Or corrective, we have one little footnote, we had just one little footnote. You need to protect the kidney, the bladder and that whole genital urinary system by bathing it in ascorbate. So you need ascorbate in the urine. And some other time I’ll talk to you about how I came as a skeptic to ascorbate and how I met Linus Pauling and why I’m not a big advocate for the C-cleanse, the next generation after bowel tolerance, Bob Cathcart’s approach. So you very quickly ramp up and then flush out waste, water and toxins that get pumped by the rectum because remember that’s kind of like the kidney embryologically.  Pumped by the rectum when you do a C-cleanse.  And you might want to measure your transit time to see from consumption to elimination.  It should be 12 to 18 hours.  You can do it with charcoal capsules.  Yes, you can do it with beets, you know when we have roast beets for dinner, and that’s the main course, I often see red in the commode in the morning but I’ll tell you after these years, first time I see red in the commode, my first thought is, “oh, I had beets last night.”  Do it with charcoal.  And we have this written up online, people can download it from Perque, p-e-r-q-u-e dot com. You can also get information about these tests from betterlabtestsnow.com, betterlabtestsnow.com. That’s all one website.

Dr. Weitz:            Yeah.

Dr. Jaffe:           That has information and will go into much more simple detail about why this can save your life or the lives of people you love.

Dr. Weitz:            Okay.

Dr. Jaffe:           So, gotten through most of them in terms of what their goal value is. With regard to the LRA test, the goal is to be tolerant. The goal is to have no delayed hypersensitivities. To have your innate immune system repairing you and defending you sufficiently that you don’t need to call in the reserve troops. So that’s the LRA test. Now, with regard to the first morning urine pH, so that we can measure the risk of magnesium deficit in the cells which everyone agrees is important but most physicians and scientists correctly for years have said we don’t have a simple way of measuring that, we don’t have an inexpensive way of measuring that. You can’t do arterial or venous pHs on everybody all the time, it’s just too cumbersome, too expensive and I think that’s probably true.  But it turns out, Mother Nature almost always gives you a window of opportunity into some aspect, and in this case it’s your magnesium which is the alkaline element and mineral like potassium that is mostly inside the cell. And, if you’ve ever heard of ATP in the work molecule of the cell, you need one molecule of magnesium for every ATP molecule, otherwise the ATP just lays there. And the cell shifts from elective-protective mode which is what you want, ’cause it can repair you and defend you. It shifts from elective-protective to survival mode. It just hunkers down in its slightly acidotic state, protein synthesis is not very efficient, the cell energetically is depleted, the mitochondria cannot push more energy in because the so-called proton gradient. And that is complicated, they gave Mitchell the Nobel Prize for figuring out that you need magnesium so that the cytoplasm, the juice of the cell can accept the acid proton along with the ATP and then kick that acid proton out with the help of magnesium.

When you lack magnesium and or potassium then the cell becomes more acidic and small changes in pH have dramatic effects on the vitality, the functionality of the cell. So morning urine pH, 6.5 to 7.5 is the healthy range. Below that means acidosis, metabolic acidosis, cellular acidosis. It means functionally you need to increase magnesium. And we’ll come back if it’s okay to talk about, what are the first line comprehensive care approaches if you’re above the goal value for any of these tests. But we’re at the pH and the next one is vitamin D and the goal value is 50 to 80. Now, the vitamin D council has a slightly different range but almost the same. My colleague and other experts in vitamin D research, including my colleague Susan Brown, she and I have written articles about building new bone by having a healthy vitamin D level. 50 to 80 is the range. And that gives you some latitude, if you’re a little above that or a little below that it’s probably okay but 50 to 80 is the goal range for 25-hydroxy-D, that’s clearly the right analyte, that’s what you measure.

Dr. Weitz:            Whereas most labs would say 30 or 32 put you in a normal range. We’re looking for the optimal range, not the normal range.

Dr. Jaffe:           Yes, and one of the things I did when I was at the clinical center is I changed all the reports, ’cause we were using the term normal range, and I knew that was a mathematical term, that it was statistics that doctors, so it had to do with normality, like common parlance. Normal. So I changed the reports and they all said usual range ’cause that’s accurate. All over NIH doctors called up and said, “we don’t want the usual range, we want the normal range,” and so I had phone banks of people who just explained to the doctor, “it’s the same thing doctor, we want you to know that this is a statistical range. It has nothing to do with function, it has nothing to do with a healthy value.” So you’re right. America, probably the upper range for most labs is 30, some of that time….

Dr. Weitz:            Wait, you were causing trouble back then, doc!

Dr. Jaffe:           Yes, yes, yes. And again, it was out of a combination of skepticism but also, I went to people who knew a lot more than I did about these issues and I was just the messenger of the message but if you give me a message, my mother said, “stand on the street corner and sing! Get people to pay attention.” And fortunately, when you’re on the permanency of your staff of NIH you can get people to pay attention.  So, very important point. You want the healthy value, not the quote normal statistical range. In fact there was an article not too long ago in the New York Times that said because it’s normal to have a low vitamin D, you shouldn’t even measure vitamin D and it’s normal to have a low vitamin D. And I did write a response, and if anyone wants you can see online why that makes you into a statistic and increases your risk of pain, it increases your risk of cancer. It turns out that vitamin D is really a neurohormone, we call it a vitamin but it’s really a neurohormone. And it has two arms, and what it does is one arm touches a cell over here, the other arm touches a cell over here and vitamin D says to them, “we have enough of you, I can reach across and touch, my two arms are now each touching a different cell. We have enough cells. Stop dividing.” That’s a neurohormone function. That’s a very important function. That’s an anti-cancer function. That’s a pain-relieving function. So vitamin D, very important, 50 to 80 is the goal value range.

Then omega 3 index. Bill Harris was sitting with my colleague Patty Deuster, who helped do that double bind study of the Perque Life Guard tabsule and he was complaining to her that there are too few people taking enough omega 3 to be in the healthy range, which is more than eight percent, and Patty, without missing a beat, just pointed at me, he took a lancet out, took a little spot of blood, analyzed it in his lab and sent back that mine was 13 percent. And I said, “well is that better than eight?” Sometimes you plateau at a certain value. He said, “oh no no no, 13 is definitely better than eight.” I said, “well next time someone is higher than 13 let me know.”  And it turns out someone else, actually a relatively young person with attention deficit disorder and some special needs, had a mom that was just getting an awful lot of omega 3 and then when you asked her, she said, “because it helps him think, sleep and be kind.” And I thought that was a good reason to have, okay. So omega 3 index, more than eight percent. And what does that mean, it means reducing or eliminating edible oils. As a hint, we cook with wine, broth and a little juice from time to time, usually fresh made. And we don’t use edible oils. I think edible oils is kind of a term to make you think that it’s edible.

But it turns out that seeds and nuts protect the oil that’s inside with antioxidants and other protectors. And when you express the oil, air, oxygen begins to make it rancid. And what commercial companies do is they mask the rancidity in edible oils, and we don’t include those in our diets. Not even EVO, not even extra virgin olive oil. Talk to anyone who really knows EVO or has been to Tuscany as my family and I have at the time when you harvest the olives and you bring them to the Oleandro and at night they crush the olives and make this dark green, cloudy, delicious olive oil. So what we see as EVO on the market is something that were totally another commercial companies call EVO, but talk to any Italian who knows their oil and they’ll tell you that extra virgin olive oil is a kind of made-up situation, it’s like a fraud waiting to be exposed.

 So, edible oils, take a pass. But cook with wine, with juice, cook with broth, cook with what nature provided great chefs the opportunity to concentrate flavor and nutrition. So that’s the value of more omega 3, less omega 6 and if you just reduce or eliminate edible oils, that’s most of the omega 6 and if you increase your omega 3, taking say Perque EPA/DHA Guard, to still under nitrogen because the fish are swimming in the ocean, and yes there’s red mercury and other shmootsy stuff in the raw oil but if you take the middle fraction, the pharmaceutical-grade EPA/DHA it’s near-pure EPA/DHA. Now, you have nature’s original omega 3, it turns out the precursor, there is an upstream molecule that most people cannot convert into the active EPA/DHA and while your brain has a lot of DHA, I say and I think most omega 3 researchers agree with me on this, you need DHA for brain and body, you need EPA for body and brain.

And don’t assume they inter-convert. Don’t assume that these very easily inhibited enzyme systems will be operating at peak capacity or efficiency. In fact, just take the distilled under nitrogen EPA/DHA, isolyzed in a soft gel because that gets the uptake, enhances the uptake and then chaperones the delivery to the cells who then use the EPA and DHA to build their membrane, to build their very fundamental structure. And about one third of the white matter of your brain is DHA. And a lot of people who get forgetful, and are diagnosed as having a neuropathy to be polite, or forgetfulness episodes or senior moments, they’re just deficient in DHA and I’ll bet they’re also deficient in EPA.

So that’s the importance of the omega 3 index test, and then we have the last, this is the urine test, the 8-oxo-guanine, that’s eight, dash, O-X-O, dash, G-U-A-N-I-N-E. See, I really am a biochemist. 8-oxo-guanine, it’s the measure of oxidative damage in your DNA, in the nucleus of your cell, including the DNA in the mitochondria and so it’s a very important test that’s been validated. It may be unfamiliar but it is just a non-invasive urine test and since you were good enough to raise the question of telomeres, I’ll mention again that a low 8-oxo-guanine correlates with longer telomeres. I can tell you from both personal and professional experience. And so we recommend at this point the 8-oxo-guanine. If a colleague wanted to do telomeres and omit 8-oxo-guanine I’m happy to consult with them and applaud. But the 8 that I’ve listed are what we published as the ones that cover epigenetics. It turns out that while the telomere test is one that I would support and encourage people to do, it’s just coming into its own. It’s not yet clear that it really has the ten year morbidity, mortality, all-cause kind of thing that the 8-oxo-guanine has.  And so now, if you want to we can go back to the 8 and very briefly say what are the headlines, or what would you do if you were not at your goal value for hemoglobin A1C.

Dr. Weitz:            Yeah, great. Let’s do that.

Dr. Jaffe:           Okay. So I already gave you the headline which is, “You’re sweet enough as you are. Cut out added sugar.” Now that means cutting out almost all packaged and processed foods but that is helpful because they look like food and they have a long shelf life, that’s a hint. And I’m recommending that you eat whole foods, that you know everything that you’re eating, you know every ingredient on the package, if you buy anything with ingredients and we do occasionally, but I want to see whole ingredients. I’m very skeptical, having worked with the food industry at their request, I am very skeptical about these crisped, chipped, and extruded foods. They look like foods, they have calories but they usually have too much sodium, too little potassium. Too much calcium, too little magnesium. I could go on and on about why whole foods are made for people and, and here is to me the surprise and the pleasant surprise. Come into my kitchen, you will see lots of whole foods that are easy to make into really yummy things, and fairly quickly. So this notion of oh, fast foods are convenient. Well, fast foods feed diabetes and fluffiness and a sedentary lifestyle so I’m skeptical of fast food-

Dr. Weitz:            And with avoiding the sugar I’m assuming that you want to stay away from high glycemic carbs in general, right?

Dr. Jaffe:           That’s correct. Now, I’m a big fan of complex carbs and fiber. You need prebiotic fiber, 40 to 100 grams a day. You need probiotic organisms, 40 to 100 billion a day. Easy to remember. 40 to 100 grams of fiber, that means chewing your food, and 40 to 100 billion probiotic organisms but then there’s the symbiotic, recycled glutamine, what we call Perque Endura/PAK Guard, E-N-D-U-R-A, P-A-K.  It recycles the glutamine ten times.  It gives the energy to the lining cells of the intestine that use glutamine for energy. They need energy so fast they have to pull the amine off the glutamine creating a glutamate. With the help of PAK, you pick up the amine, transfer it back to the glutamate so you never build up glutamate, excito-neurotoxin, and now the cell can use the glutamine to extract the energy again. It’s a recycle ten times, so now one and a half grams on rising and before bed, because you want amino acids taken on an empty stomach. One and a half grams is equivalent of fifteen grams of free glutamine but now you keep the physiology, you don’t use it pharmacologically with the potential collateral adverse effects.

So a very important, simple message, that nature, nurture, and wholeness will bring you lifelong good health. Especially if you eat what you can digest, assimilate, and eliminate without any burden. And that would relate to the LRA test where your goal is to have no reactions, no intolerances. And I’ll give an example, a friend called me up and said that her friend, dear friend, had multiple sclerosis, was in a wheelchair. Multiple sclerosis is known as an autoimmune condition. She went through four six-month cycles and at the end of two years, she sent me a photograph of herself rock-climbing. Not only did her MS go into remission but she was able to physically get back to climb … She wasn’t going to climb Yosemite, but she was rock-climbing and enjoying her life. 

Dr. Weitz:            Right. That’s great.

Dr. Jaffe:           Yes. And we see that all the time, we’ve got 80,000 cases in our database, we did the signs first before we came forward to talk the message, to carry the message. But at this point we’re very excited about the possibility of restoring tolerance in the immune system, and as a consequence, restoring digestive health, restoring the ability to repair on the inside so your innate immune system activates and does what it’s supposed to do, defends you and repairs you. And you can think of it this way. During the day, on the defense. At night, restorative sleep is the time when abnormal cells and things that are worn out need to get repaired. And if they don’t get repaired, you get inflammation. And if you get enough inflammation, you can have autoimmunity, self at that.

Dr. Weitz:            So just to clarify, you’re talking about a food sensitivity test that tells you which foods that your body doesn’t digest and doesn’t process properly and so then you eliminate those foods for a period of time and …

Dr. Jaffe:           Six months to restore digestive competence, metabolic detoxification abilities. It includes good hydration and you can do a self-test for hydration. It means improving your digestive competence and transit time. It means exactly what you said. Eating the foods you can digest. Assimilate and eliminate without immune burden or distraction.

Dr. Weitz:            Okay, so now HSCRP is the next one, that’s a marker of inflammation.

Dr. Jaffe:           Right, HSCRP is exactly right. It’s a marker of inflammation. Less than point five is the goal value which means your innate immune system is able to repair you.  And your liver-

Dr. Weitz:            And point five is kind of an extreme figure. A lot of labs

Dr. Jaffe:           No.

Dr. Weitz:            Say under three is normal. Most functional medicine practitioners say under one is the goal. Under point five is really pushing it.

Dr. Jaffe:           With respect my friend, I’ve reviewed 300 scientific articles about HSCRP. I know who Ridker and Rifai are. He’s the editor-in-chief of Clinical Chemistry, that’s where you want to publish if you have something really worthwhile for clinical laboratorians like me. The literature’s very clear. Healthy people all over the globe, at any age, of any ethnicity, healthy people, there are not many of them, but the healthy people have less than point five. And I’m glad to tell you that mine has been less than point five for some time.

Dr. Weitz:            Mine too.

Dr. Jaffe:           Great! Now, with respect I understand statistics enough to know why some labs will say less than three is quote normal. Statistically normal. I’m sorry, I don’t take care of statistics. And I don’t even any more use statistics when there’s one individual sitting in front of me and I know the limitations of lab ranges. In fact, that individual may not be among the population where the range was standardized.

Dr. Weitz:            Right. What’s the best way to lower CRP?

Dr. Jaffe:           Yeah. Best way to lower CRP is to have enough of the good stuff and less of the bad stuff. So you might start with the self-test that I mentioned, including the urine pH. And take enough magnesium and choline citrate. ‘Cause only choline citrate uniquely enhances the uptake and chaperones the delivery of magnesium to the cell, correcting the metabolic acidosis and the metabolic syndrome, recharging the cell’s ATP, protecting essential fats in transit where magnesium functions as an antioxidant. And allowing the battery of the cell to recharge. And other things as well, including hundreds of enzyme catalysts that require magnesium to work, and if magnesium runs down, they’re pro-enzymes. They’re potential enzymes.

Dr. Weitz:            But if we take supplements of choline won’t we have elevated TMAO levels which will increase our risk of heart disease?

Dr. Jaffe:           Oh I’m so glad you asked. If you had a long transit time, which you won’t if you keep a C-cleanse and have enough prebiotic and probiotic fiber and good bugs. If you have a long transit time, and you have toxic metabolites, of quaternary amines, of all sorts in the colon, you too can produce TMAO. But I can tell you how to make it zero, how to make it go away, have a transit time of 12 to 18 hours, do a C-cleanse once a week and take three quarters of that amount on a daily basis to cover antioxidant needs because as you know, and I think people will be interested in this, ascorbate is the maternal antioxidant that protects and regenerates all the others.

So if you want glutathione, look at Alton Meister’s work. The best way to raise glutathione is to have enough ascorbate. But it must be the fully reduced, fully buffered L-ascorbate. 90 percent of what is sold as vitamin C or ascorbate acid or ascorbate is synthetic, half of it is D, if you take enough of it it’ll irritate the intestines, ’cause D-ascorbate isn’t taken up, believe me, I’m a biochemist. And the point is that when you respect nature and therefore use the fully buffered, fully reduced L-ascorbate, based on your individual oxidative burden or antioxidant need you have, as you correctly said, lots of systemic benefits and you now reduce the potential of the oxidation of the quaternary amine into the TMAO so you can make the TMAO you should go away. And if anyone is interested, I think there’s a Youtube video of me talking at length about the subject of why choline deficiency is a big problem in America. So get the choline, but it must be choline citrate, not choline bitartrate for a lot of reasons. Get the choline as the citrate and have a healthy transit time so you don’t have to be at all concerned about the TMAO. But I’m glad you asked about that because that is very, very important.

Dr. Weitz:            Cool. So how do we lower homocysteine levels?

Dr. Jaffe:           Right. Thank you. Homocysteine should be less than six. Now, very important that the plasma homocysteine be measured, not the serum. And very important that you process the specimen and the labs will tell you this within half an hour because once you draw the blood, homocysteine tends to leak out of cells into the plasma giving an artifactual elevation. So follow the instructions, measure the plasma homocysteine, you want it to be six, which is low. Most lab ranges go up above ten, which is well into the cardiovascular and stroke risk and heart attack risk, autoimmune risk zone.

Dr. Weitz:            A lot of labs say over 12 is abnormal?

Dr. Jaffe:           Okay.

Dr. Weitz:            Yeah.

Dr. Jaffe:           Okay. Kilmer McCully, the man who wrote the Homocysteine Miracle with his daughter, the man who put homocysteine on the map in the 1960s. What he pointed out is that really it’s the ratio of methionine to homocysteine and you want the methionine to be up and the homocysteine to be down. And why do you want that, well because this is what regulates methylation. Now we’re not gonna get into the details, but trust me, methylation is very important. More important in regard to translating the DNA through the RNA to the products, the proteins and the glycoproteins and the lycoproteins that need to get made. So very important. We want the methionine to be up, you want the homocysteine to be down. And there’s lots of literature that less than six is clearly the healthy range for healthy people. Again, all over the planet. Every ethnic group, all-cause morbidity and mortality measure. Just get an accurate homocysteine.

Dr. Weitz:            And so we lower it by taking methyl-B vitamins, B6, B12, folic acid and …

Dr. Jaffe:           Well yes, we start with enough of super B complex and full mineral complex such as the Perque Life Guard tabsule to keep your urine sunshine yellow, so now you got enough B-complex. Then, in order to get the homocysteine down you wanna have a lot of sulfur foods that are nature’s detoxifying foods. This is GGOBE, that’s the acronym for those who like little memory hooks. GGOBE stands for garlic, ginger, onions, brassica sprouts, that’s broccoli sprouts. Now all sprouts are good but broccoli sprouts are particularly good. And eggs. And I can tell you in my home, we have goose eggs, we have duck eggs, we have quail eggs when they’re available. We’re skeptical of chicken eggs. If they’re biodynamic chickens, if I know the chicken then I would have a chicken egg. But I can tell you they’ve done terrible things to chickens and to chicken meat and be careful.

The healthier the food, the healthier the fuel of your body. The more caring you are of your body. And therefore, we can be even more friendly with each other because this is information we had to uncover, recover, validate. It took years to find the eight and cover all about your genetics. And I’m glad to tell folks what the healthy people’s value or range is. So now we’ve covered hemoglobin A1C, HSCRP, homocysteine and LRA, now let’s move onto urine pH. Six and a half to seven and a half is the goal range, and you take two or more doses of Perque Mag Plus Guard and Perque Choline Citrate. Two capsules and a teaspoon. The teaspoon goes into the liquid or water of your choice. You can put vitamin C in there if you want, you can put most anything else in there if you want because the choline citrate is going to marry up with the magnesium and form little inverted micellar nanodroplets, (I really am a biochemist), and we have the global patents on enhanced uptake and chaperoned delivery of magnesium to the cells that are hungry for them.

Dr. Weitz:            What about taking baking soda?

Dr. Jaffe:           Right. Can we fool the body by taking baking soda? No. Any time you try to fool the body you’ll end up fooling yourself. The body has a very elegant control of bicarbonate and CO2 called the carbonic anhydrase system. Those of you who are technical will have heard of it. But for everyone’s knowledge, if you take bicarbonate by mouth, you reduce stomach acid which impairs the uptake of minerals and B vitamins. You decrease the quality of digestion because the stomach should be very acidic. It should have a pH very low, like 2 or below so that the acid product of the stomach stimulates the bicarbonate and digestive enzymes from the pancreas. So there’s lots of reasons why you don’t want to swallow bicarbonate to try and alkalinize yourself. I know that people use, there are tri salts out there they’re trying to use instead of sodium bicarbonate, they use potassium and other salt bicarbonate. But bicarbonate, it impairs digestion and it doesn’t do the job.

Dr. Weitz:            Okay.

Dr. Jaffe:           You want minerals to alkalinize you, you want short and medium chain fatty acids like butyrates that you’d find in ghee, clarified butter and other natural foods. And, let’s see, the third alkalinizing element I should remember, and when I do I’ll bring it up but anyway, you want to alkalinize or, well Shelley Rogers wrote a book called …

Dr. Weitz:            Green vegetables, right?

Dr. Jaffe:           Yes, yes. Fruits and vegetables, whole foods will alkalinize you. Then eat the foods that you can digest to assimilate and eliminate without any immune burden.

Dr. Weitz:            Okay. I have to rush you along ’cause we only have a few minutes minutes here. So we got vitamin D, omega 3 and oxidative stress.

Dr. Jaffe:           Let me combine them all because what you’re hearing and what our message, our takeaway message, our cold action message. If your body is efficient, everything locks together and it works really well and now you’re in the moment to thrive, not just survive. You wanna be in elective-protective, not survival. Now the last three tests all have to do with either lipids, fat, and you want to increase the good fat. The deep water oily fish, have fish. Maybe the collar of the fish if you can get it ’cause that’s really oil. But the eye of the fish should be clear when you get the fish. If it’s been frozen and the eye is now cloudy like it has a cataract, uh, I’m not so sure that’s still a healthy fish. And when we go to the market to buy a whole fish to poach in our fish poacher in our nice little kitchen, there’s only, usually there’s only one or two. And the people behind the counter know the never-frozen, clear-eyed fish. So the last three tests have to do with optimizing your diet and attitude and lifestyle.

So we’ve talked about the eat and drink part. Be well hydrated. I do like wine, that’s an option. Do not take a lot of juice because the fiber goes away when you make the fruit juice. But have a lot of fruit which has pectin and fiber, and now you get your 40 to 100 grams of fiber, turn into 100 billion fermented organisms. How about like kimchi, you get that in many ethnic markets. Any fermented food. How about a pickle, it’s such a delicious dill pickle but it’s gotta be a live pickle. If it’s been pasteurized or simonized it’s no longer a pickle. So the takeaway message is, have these eight predictive biomarkers done through your office or through Better Lab Tests Now or through Perque Integrative Health or ELISA/ACT.com or DrRussellJaffe.com. There are many ways of finding our work and we’re grateful for the opportunity to serve and especially to be with a colleague like you today. So thank you.

Dr. Weitz:            Excellent. Thank you so much, Dr. Jaffee. And you’ve given us your contact information and so-

Dr. Jaffe:           If I could give a toll-free number I’ll do that too.

Dr. Weitz:            Oh sure, absolutely. Go ahead. Yep.

Dr. Jaffe:           Please call now, or soon. You have two. 1-800-525-7372 or 1-800-553-5472. 1-800-553-5472. And those-

Dr. Weitz:            Alright, are those the numbers for your office or your lab, or your-

Dr. Jaffe:           That’s for the lab. That’s the for the lab and for Perque Integrative Health.

Dr. Weitz:            Okay.

Dr. Jaffe:           For full disclosure, I’ve had the privilege of teaching and doing research but I do not have a private practice. We have a referral network of doctors who are certified in the Well Guard Program through the Health Studies Collegium and that keeps me off the streets and out of trouble.

Dr. Weitz:            Excellent. Thank you so much. Talk to you-

Dr. Jaffe:                Thank you. Thank you, Doctor.