Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
30 Day Fasting with Dr. Alan Goldhamer: Rational Wellness Podcast 116
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Dr. Alan Goldhamer discusses the benefits of long term fasting with Dr. Ben Weitz.

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Podcast Highlights

4:14  Some of the benefits of doing a water only fast are to reverse the consequences of dietary excess, including obesity, high blood pressure, diabetes, autoimmune diseases, and conditions like lymphoma.  Fasting is a way to reboot the body and allow it to heal.  Dr. Goldhamer explained that they did a study with Cornell University in which they took 174 patients with high blood pressure and all 174 achieved pressure low enough to eliminate all medication with fasting and a whole food plant based diet (Medically Supervised Water-only Fasting in the Treatment of Hypertension).  A high percentage of type II diabetics were able to achieve normal blood sugar without medication with fasting and this result was maintained using diet and exercise.

7:24  The fasting patients drink a minimum of 40 ounces of water per day, but not so much water that they flush out their electrolytes. Their blood and urine is being monitored to make sure their electrolytes are being maintained and that they are safe. The patients drink fractionally steam-distilled water while fasting, which Dr. Goldhamer says is safe and they have published a fasting safety study showing that this protocol can be done safely. (Is fasting safe? A chart review of adverse
events during medically supervised, water-only fasting.)  Dr. Goldhamer said that they do not believe in giving the patients electrolytes or other supplements during the fast, which could imbalance their system.

9:52  There are a number of patients that are not eligible for this long term fasting protocol, including pregnant or lactating women, patients who have recently had a stroke, heart attack, dysrhythmia, who are on anti-coagulant therapy, who are on drugs that you cannot stabilize people off of, or who have neuropsychiatric involvement that might prevent them from providing informed consent. Every patient goes through a careful history, exam, lab monitoring, and screening prior to being accepted into the fasting program.  Patients who are on anti-hypertensive meds are not a problem, since by placing patients on a whole plant food diet prior to fasting, you can start weaning these patients off their meds.  Most patients are being medicated for the diet that’s causing their hypertension and the fasting has a very powerful diuretic effect that lowers blood pressure better than the medications.  Many patients enter the program with blood pressures of 220 over 120 and are capped out on medications and they’re 100 over 60 by the time they leave without medications.

12:09  Some patients with cancer can respond well to long term fasting as long as they are not in a cachexic state where weight loss is problematic.  Patients with lymphoma may be particularly good candidates, since these patients sometimes go through a prolonged period before they enter conventional treatment, so this is a particularly good time period to do conservative treatment. Dr. Goldhamer explained that they have published a case study in British Medical Journal of a patient with a Stage 3 Follicular Lymphoma who underwent 21 days of fasting and his tumors completely resolved. (Water-only fasting and an exclusively plant foods diet in the management of stage IIIa, low-grade follicular lymphoma.)  They also published a three year follow-up study that she continues to be cancer free. (Follow-up of water-only fasting and an exclusively plant food diet in the management of stage IIIa, lowgrade follicular lymphoma.)  Dr. Valter Longo published a study in 2015 in the Journal of Metabolism showing that when you fast rats prior to and during chemotherapy they get much better results and they demonstrate much improvement in many biomarkers.  But this involves short term, intermittent fasting, which is different than the long term fasting that Dr. Goldhamer is recommending.

17:07  The length of the fast that patients undergo is often dependent upon their response. In the case of patients with high blood pressure, Dr. Goldhamer said that he wants patients to fast until their blood pressure is normal. Occasionally patients may need to faster longer than they have the reserves for, so he will have them terminate a fast, rebuild their reserves, then start over with a fast, until the condition is resolved.

17:59  Patients do not do any vigorous exercise while fasting, since once the glycogen stores are depleted, the only source for extra muscle or brain use would be breaking down proteins or gluconeogenesis.  The goal is to minimize protein utilization and maximize fat loss and detoxification, so fasting should be done in a resting state.

18:28  There is a patient who has a testimonial on Dr. Goldhamer’s website who had bulimia and went through the fasting program.  Dr. Goldhamer explained that bulimia and anorexia are completely different conditions and patients with bulimia can benefit from fasting, while patients with anorexia would not. In a patient with bulimia, a short period of fasting can reboot the mechanism, increase leptin levels, normalize blood sugar levels, and get rid of some of the biological triggers that stimulate bulimia.

20:40  Dr. Goldhamer admitted to having had some challenges running a fasting program, esp. as a chiropractor over the years.  As a chiropractor in 1984, when he went into practice, they hadn’t had the Wilk decision in which the American Medical Association was found guilty of having organized a Committee on Quackery in order to contain and eliminate the chiropractic profession by claiming that chiropractic was unscientific and by concealing evidence of the effectiveness of chiropractic. So just being a chiropractor was considered outside the box and recommending fasting was seen as even more extreme.  Dr. Goldhamer says that he was the first person in his family who needed the services of a criminal defense attorney.  Fortunately now that Dr. Valter Longo and others are doing really good research on fasting, fasting is gaining some interest and notoriety and he has gone from being a criminal quack to a cutting edge researcher. He’s half way through a study with Mayo Clinic looking at the prevention of stroke with fasting and diet. They’ve completed a study with Washington University looking at biomarker changes in fasting. They are looking at the number of mutations in B lymphocytes, at autophagy, and at the gut microbiome. They completed a study looking at the perception of the taste of food before and after fasting. They are working on a project with Kaiser Permanente to add a model of intense education and nutritional management to help manage patients with high blood pressure. And they have published a number of papers including the safety of fasting, on follicular lymphoma, and on the chriopractic management of subacute appendicitis using fasting and dietary changes rather than surgery. All of these papers can be found at the True North Health Center website

24:18  Dr. Valter Longo from USC has been researching the benefits of doing a low calorie regimen by eating packaged food that he calls Prolon and Dr. Longo claims that you get similar benefits to what you get with fasting. Dr. Goldhamer says that you cannot get all of the changes that you can get with water only fasting, but it does prove that not eating the greasy, fatty, slimy processed crap that constitutes the Standard American Diet for five days a month is enough to start inducing positive biological changes in people. 

25:50  Besides fasting, Dr. Goldhamer recommends a whole plant food, SOS diet. SOS stands for no added sugar, oil or salt. I described Dr. Goldhamer’s approach as a high carb, low fat approach, but he states that since it includes 15-18% of calories from fat that it is an intermediate fat diet.  He says that a low fat diet would be less than 10% fat.  I mentioned that a high fat, ketogenic diet has been found to be very beneficial in helping to manage diabetes by lowering glucose and insulin levels, inhibiting mTOR, and stimulating AMPK and autophagy.  Dr. Goldhamer said that a ketogenic diet will result in a lowered glycemic response, but it’s not a healthful, sustainable, long term diet, in his opinion.  Dr. Goldhamer recommends eating modest amounts of nuts and seeds and avocado for those who can tolerate them, but to keep fat intake to around 15-18% of calories.  He feels that eating more than that amount of fat is unhealthy for maintaining their weight and for cardiovascular health.  Dr. Goldhamer argues that his recommended whole plant food diet will allow you to sustain your blood sugar improvements and he considers it a sustainable long-term, health-promoting diet consistent with our biology.

28:40  Dr. Goldhamer says that his recommended plant food diet should include carbohydrates like squash, potatoes, sweet potatoes, and non-glutinous grains like rice, quinoa, and millet. And for patients who can tolerate it, there’s lentils, peas and beans.  He does recommend to avoid eating gluten.

31:53  Dr. Goldhamer recommends a low salt diet because he feels that it helps to normalize blood pressure and his data shows that it works.  He understands that sodium is an essential nutrient that is needed but that is no justification for adding a chemical in the form of sodium chloride to our food. A whole foods diet contains about a gram of sodium per day.  Adding salt to your food tends to make you overeat as it overrides your normal sense of satiety.  He also does not think it is necessary to eat salt to get iodine, since most vegetables contain iodine and especially sea vegetables.  Dr. Goldhamer also does not advocate taking a multivitamin that includes iodine.  He believes that the best source of most nutrients is food and you should only supplement nutrients that are necessary, like B12 with patients not eating animal products. Dr. Goldhamer criticized some of the studies that show lowering sodium intake don’t help with lowering blood pressure is because they lower the sodium intake from 3,000 to 2,400 mg per day, which is not enough of a reduction to see an effect.

39:57  To get enough omega 3 fats, Dr. Goldhamer recommends eating plant foods that are rich in linoleic acid and that is sufficient to achieve acceptable levels of DHA.  If not, you can get lichen or algae-based, vegan DHA supplements.  Dr. Goldhamer said that a lot of Functional Medicine practitioners are using DHA pharmacologically to suppress inflammation associated with autoimmune disease but he feels that he is going a step further by getting rid of the root cause of autoimmune disease and once this cures the problem and there is no more inflammation, then you don’t need to take pharmacological doses of DHA, which is a less toxic substance than traditional anti-inflammatory medications.  Dr. Goldhamer said that we need to get down to the basics, which are diet, sleep, and exercise, which are the things we have the most control over.  When you do that you’ll see that the pills, potions, powders and treatments are the feathers on the rattle and are not really necessary.  Dr. Goldhamer feels that many practitioners in the medical and even in the Functional Medicine world are too focused on the pills, potions, powders, and treatments and if they took the time to fully implement the first order interventions–diet, sleep, and exercise–like they do at True North Health Center–these other interventions would not be necessary.  On the other hand, Dr. Goldhamer admits that his approach involves patients living at his center and this approach may not be practical in an outpatient setting like most doctors or nutritionist’s offices.

50:32  While there are quite a number of studies documenting the benefits of the Mediterranean diet and the paleo diet and the ketogenic diet, Dr. Goldhamer says that “anything you compare to the standard American diet is likely to demonstrate some improvement. Something being less bad doesn’t necessarily make it good.”  He said that when you place patients on a high protein, high fat diet, they do well for a while but long term there are devastating consequences with their gallbladder, their digestive system, and with increased risk of cardiovascular disease. Dr. Goldhamer advocates for a whole plant food, SOS diet and he is publishing data to back up the health promoting benefits of this approach.

                                       

 



Dr. Alan Goldhamer is a Doctor of Chiropractic who founded and runs the TrueNorth Health Center, a state-of-the-art facility where you can stay to be monitored while doing a water only fast for up to 40 days.  He is the author of The Health Promoting Cookbook and co-author of The Pleasure Trap: Mastering The Hidden Force That Undermines Health and Happiness.  Dr. Goldhamer has supervised the fasts of over 20,000 patients and he can be reached through his website, HealthPromoting.com.

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



 

Podcast Transcript

Dr. Weitz:                            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 our Rational Wellness Podcast, please go to Apple Podcasts and give us ratings and review. That way, more people will find out about the Rational Wellness Podcast. Also, there’s a video version on YouTube if you look up right chiro or Rational Wellness and if you go to my website, you can find show notes and a complete transcript.

                                                So our interview today is with Dr. Alan Goldhamer and we’ll be talking about fasting. There’s been a lot of discussion in health and nutrition world recently about the benefits of a complete fast of intermittent fasting and other variations such as the fasting mimicking diet and even the ketogenic diet. In recent weeks, I have interviewed Dr. Josh Axe and Dr. Christopher Shade about the benefits of the ketogenic diet and we discussed its antiaging benefits as well as its potential benefits as a therapeutic diet that may be a benefit for diabetes, hormonal imbalances for brain health such as Alzheimer’s as well as for weight loss and even cancer.  Now, we will be speaking to Dr. Alan Goldhamer about fasting for as long as 40 days with supervision followed by a plant-based diet, and they have many of the same benefits including for hypertension, diabetes and autoimmune diseases.

Dr. Alan Goldhamer is a doctor of chiropractic who founded and runs the TrueNorth Health Center, a state-of-the-art facility where you can stay to be monitored while doing a water-only fast for up to 40 days.  He’s the author of The Health-Promoting Cookbook and coauthor of The Pleasure Trap: Mastering the Hidden Force that Undermines Health and Happiness. Dr. Goldhamer has supervised the fast of over 10,000 patients. Under his guidance, the center has become one of the premier training facilities for doctors wishing to gain certification in the supervision of therapeutic fasting.  Dr. Goldhamer was the principal investigator in at least two published studies, medically supervised water-only fasting in the treatment of hypertension and medically supervised water-only fasting in the treatment of borderline hypertension. Okay. And he has several other studies currently being conducted. Dr. Goldhamer, thank you for joining me today.

Dr. Goldhamer:                 My pleasure.

Dr. Weitz:                         Can you tell us about your background and how you became involved in treating patients with nutritional invention … interventions especially using water-only fasting?

Dr. Goldhamer:                 Well, I went to Western States Chiropractic College and after that, I attended the Pacific College of Osteopathic Medicine in Australia where the gentleman I trained with had an osteopathic hospital that specialized in medically supervised fasting so I got to see a lot of patients that were sick get well by essentially using fasting followed by a whole plant food SOS-free diet. So that was my initial exposure.  When I came back to the United States in 1984, my wife, Dr. Marano, and I opened up the TrueNorth Health Center, and we’ve been doing this ever since. We’ve had over 20,000 people now go through medically supervised fasting in the last 35 years and we’ve had a chance to see just how good a job the body does at healing itself if you get out of the way.

Dr. Weitz:                          Interesting. So what are some of the benefits that you’ve seen of doing this water-only fast?

Dr. Goldhamer:                 Well, it turns out that a lot of people are sick today as a consequence of dietary excess. So they have obesity and high blood pressure, Type 2 diabetes, autoimmune disease and conditions including things like lymphoma. And when you do fasting, it gives the body a chance to mobilize and eliminate those consequences of dietary excess. So we treat a lot of patients with high blood pressure. In fact, we did a study with Cornell University.  It took 174 consecutive patients with high blood pressure, 174 people achieved pressure low enough to eliminate all medication. It’s the largest effect sizes that have ever been shown in treating high blood pressure in humans using fasting and a whole plant food diet.

Dr. Weitz:                          Interesting. What are some of the other conditions?

Dr. Goldhamer:                 Well, we treat a lot of Type 2 diabetics where insulin resistance allows blood sugar levels to rise and insulin resistance is reversed with fasting and maintained with diet and exercise. So it’s not surprising that a high percentage of Type 2 diabetics were able to achieve normal blood sugar without medication. We also treat a whole host of autoimmune disease where it’s actually the immune system attacking their own tissue.   So, for example, in arthritis, or rheumatoid arthritis, it’s actually the body’s immune system that’s creating the inflammatory process associated with the pain and deformity. And in part, that may be triggered by processes including gut leakage where proteins were absorbed to the system simulating genetically vulnerable people’s immune system to attack itself.    With fasting, it’s like rebooting the hard drive in a computer that’s become corrupted. A lot of stuff clears away. You don’t always know exactly the mechanisms, but it works very similar in autoimmune disease.  Gut leakage tends to be reduced and then followed by a low antigenic diet, you can actually manage these conditions without the devastating effects of long-term anti-immunological drugs, including steroids, methotrexate and the rest of it.

Dr. Weitz:                          When you say gut leakage, you mean what we often call leaky gut or hyperpermeability?

Dr. Goldhamer:                 Yeah. The idea that there’s a membrane in the intestinal tract that prevents larger molecules from being absorbed into the body, unless that membrane becomes damaged. One of the common thoughts, damaging the-

Dr. Weitz:                          Which is the gastrointestinal mucosa?

Dr. Goldhamer:                 Absolutely. So it works very much like a screen works to keep flies out. As long as the holes are small enough, only the stuff that’s supposed to get through does, but if through for example exposure to free radicals or other sources of irritation, inflammation, that membrane becomes damaged, you may see particles being absorbed in the immune system that shouldn’t normally be there. And initially, that’s not a big problem, the body’s immune system reacts, but for reasons still to be determined in genetically vulnerable people, that immune system can become overwhelmed or confused and begin to react to its own tissues.    And maybe this mechanism is … can be the reason we see such improvement in fasting because you get a chance to reduce that inflammatory response. We know that’s happening because acute phase reactive proteins consistently go down during fast.

Dr. Weitz:                         Yeah. We usually think it’s because of cross-reactivity, so proteins like gluten cross-react to proteins in the body that look similar. So do the patients drink unlimited water or is there a danger drinking too much water?

Dr. Goldhamer:                 Well, too much water … Well I guess ultimately, too much water would be called drowning, wouldn’t it? So no. We do monitor patient’s fluid intake. We want a minimum of 40 ounces a day but not so much that they flush out their electrolytes. We’re monitoring blood and urine testing in order to maintain … make sure that people are maintaining a reasonable balance. But most of the detoxification that occurs, occurs because the blood is being processed by the kidneys and is going to show up in the urine.   So you need enough of a solute in order to be able to have a place for the intermediary products of metabolism, exogenous toxins that are being mobilized that can be processed and eliminated. Too little is not good. You get dehydrated too much, can be a problem if you flush the system out excessively.

Dr. Weitz:                          What kind of water do you give them? Is it-

Dr. Goldhamer:                 We use pure water which is fractionally steam-distilled water, although you could use probably any type of purified water.

Dr. Weitz:                          So if you do that, that water is depleted in minerals, right?

Dr. Goldhamer:                 It is depleted in minerals. It’s just pure water which is what rain water would be if you didn’t have a polluted atmosphere. But the gut is not a two-way gradient in a clinically significant way. So you’re not sucking the minerals out of the body through the intestinal mucosa, you’re able to maintain balance including on 40-day water fast on distilled water only.

Dr. Weitz:                          Really? So even without any food, aren’t some of these people getting electrolyte-depleted?

Dr. Goldhamer:                 Well, we monitor electrolyte balance on every patient and ensure that potassium, sodium and the other electrolytes are maintaining normal course. And of course, in appropriately selected patients, they’re able to maintain electrolyte balance through the … up to 40 days.

Dr. Weitz:                         Do you ever give them electrolyte or other supplements?

Dr. Goldhamer:                 Well, we do not supplement during fasting. In fact, you want to use … We use potassium and other nutrients as rate limiting nutrients. If you supplement just those isolated nutrients, the 20 other downstream less sensitive reactants that you wouldn’t be monitoring for could become a limiting factor. That would be very dangerous. So by not supplementing, you actually eliminate the risk of overall imbalance in the system.  And that’s how we’ve been able to do this 20,000 times. In fact, we published a fasting safety study that’s really scientifically analyzed, the safety and efficacy of fasting, and we’ve shown that using this protocol, it can be done safely.

Dr. Weitz:                         Which patients do you find are not eligible for such an approach?

Dr. Goldhamer:                 Well, there’s a wide variety of people that fasting would be contraindicated, not at least of which would be pregnant and lactating women, people that have had recent problems with stroke, heart attack, dysrhythmia, people that are on any coagulant therapy, drugs that you can’t stabilize people off of, people that have neuropsychiatric involvement that might prevent them from providing informed consent.   There’s a whole host of people that you wouldn’t be a good candidate for fasting that’s why every patient we see goes through a careful history exam, lab monitoring and screening.

Dr. Weitz:                         Well, what about patients who are on hypertensive meds? You mentioned hypertension-

Dr. Goldhamer:                 Well, there’s really no problem with hypertension meds because what we do is we get people on a whole plant food diet. In the days prior to fasting, you are able to wean those medications and then as soon as you go on the fast, there’s a precipitous drop in blood pressure so we’re able to safely wean people off blood pressure medications with limited challenge. The diuretic effects of fasting are so powerful. They’re much more powerful than the medications people use so within short order, people’s blood pressures begin to normalize.  In fact, most people are not even medicated for their hypertension, they’re medicated for the diet that’s causing the hypertension. And literally, the day you change the diet, blood pressures begin to respond. Many of our patients come in 220 over 120 capped out on medications and yet, by the time we’re done, they’re 100 over 60 and maintaining that level essentially as long as they’re willing to do the diet and lifestyle change.  It’s much like obesity. If you eat well and you live right, you maintain the result.

Dr. Weitz:                         So during the fast, you have an MD on staff who’s monitoring who’s … lowers or takes them off their blood pressure meds?

Dr. Goldhamer:                 Every patient in our facility has an attending … We have six medical attendings that are full-time employees of the TrueNorth Health Center.

Dr. Weitz:                         Right.

Dr. Goldhamer:                 So every patient has an intake and exit. Example an attending which is responsible for monitoring their care and managing their medications. Our daily rounds are typically done by Doctors of Chiropractic or Doctors of Naturopathy. Each patient is seen twice a day by one of our staff doctors. All that information is reported to the attending that’s responsible for ongoing medical management of their care.

Dr. Weitz:                         What about patients with cancer? Are they good candidates for this?

Dr. Goldhamer:                 Well, it depends on the patient. But we just published a paper recently which is a follow-up to a paper we published four years ago in the British Medical Journal on the treatment of follicular lymphoma with cancer. And this was a … This case report was a patient with a Stage 3 follicular lymphoma, that has been confirmed by excisional biopsy, monitored for two years of progression. Underwent 21 days of fasting, completely resolved for tumors. Ten days of refeeding back to the medical school for follow-up.  Now only did she eliminate her lymphoma cancer, but now on three-year follow-up, we were able to demonstrate she remains cancer-free and we published a follow-up in British Medical Journal to that case report. And those papers … In fact, all of the studies I’ll be citing are available on our website, healthpromoting.com. People can download any of the papers and look for themselves and see what kind of results we’re using with fasting and dietary intervention.

Dr. Weitz:                         When you’re dealing with cancer patients, sometimes weight loss is a problem. How do you avoid them losing too much weight while being on a fast?

Dr. Goldhamer:                 Yeah. Well of course, weight loss is a problem in patients that are in cachexic stages of cancer. They may not at that point, necessarily be a candidate for water-only fasting. Most of the patients that we’re seeing as particularly with lymphoma, these are patients that weight management isn’t generally the limiting factor.  Usually, what you’ll see … You’ll see a lot of patients that … particularly that when they’ve gone through medical treatment, end up with cachexia and have problems because of devastation not only from the cancer but from the treatment. Generally, these are pre-treated patients. With lymphoma, the medical management has some great limitations and a lot of side effects. It’s generally deferred which makes it a very convenient case for us to treat conservatively because they’re really not doing anything for a while.  So it’s not considered unethical to intervene from a chiropractic perspective and actually get the person well.

Dr. Weitz:                            Yeah. And I do know that some oncology centers will have patients fast around the treatment, maybe a day or two prior to their getting a chemo infusion, the day of, and maybe a day or two afterwards.

Dr. Goldhamer:                 So Valter Longo was the first person who published 2015 an article in Journal of Metabolism resulting some animal studies that he had done, 30 rats with cancer given enough chemotherapy to kill all the cancer cells, kills all the rats. Picks the same rats, same cancer, but now fasting rats, before and during chemotherapy, all 30 rats survived, dramatic increase of survival.  So he was the first person that I saw talking about the idea that fasting actually helps protect healthy cells from the ravages of chemotherapy and makes cancer cells more vulnerable to treatment, alternative or conventional. It’s interesting to note that many of the biomarkers associated with cancer also turn off whether you do chemotherapy or not just in response to fasting.

Dr. Weitz:                          Wait, which biomarkers are those?

Dr. Goldhamer:                 There’s a whole host of … Ranging from acute phase reactive proteins on down. So there’s a whole host of markers, he talks about in his article in Journal of Metabolism 2015. And his conclusion was that the use of fasting in conjunction with chemotherapy dramatically enhanced cancer-free survival and so now, people are beginning to apply these principles in humans as well. And that would be more short-term intermittent fasting. A little different than the long-term medically supervised fasting that we’re … we’ve been discussing up to this point.

 





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, 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 manufacturing of clinician-designed cutting-edge nutritional products with therapeutic dosages and scientifically proven ingredients to help our patients prevent chronic diseases and feel better naturally.

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Dr. Weitz:                         And now, back to our discussion. How do you decide what length of fast is appropriate for a patient who comes to see you?

Dr. Goldhamer:                 Well, a lot of times, you don’t know when you start to fast what’s going to be ideal until you see how the person responds to fasting. Fasting is therapeutic as well as diagnostic. In the case of blood pressure though, we want to fast people until their blood pressures are entirely normal after medication. So it can range anywhere from five to 40 days.  Occasionally, people need to fast longer than they have the reserves for and so we’ll have to terminate a fast, rebuild them and then start over again and do it again and you continue that process until the condition is resolved.

Dr. Weitz:                         How do you determine that they’ve depleted their reserves?

Dr. Goldhamer:                 Well, we’re monitoring their electrolytes, we’re monitoring their clinical picture, they’re being examined twice a day. So between blood, urine and physical examination, there’s a number of parameters that we use to determine status and fitness and appropriateness for fasting.

Dr. Weitz:                          Are these patients allowed to exercise while they’re fasting?

Dr. Goldhamer:                 We restrict activity during fasting. We do have some stretching classes and chair yoga and different things that we encourage them to do, but we do have to limit aerobic activity because once you’ve depleted glycogen stores, the only source of energy for extra muscle or brain use would be breaking down proteins or gluconeogenesis. We want to minimize protein utilization and maximize fat loss and detoxification. So that requires that fasting be done in a resting state.

Dr. Weitz:                          I saw a testimonial on your website from a woman who had bulimia who went through your fasting program. I thought that was unusual. I wouldn’t … Putting somebody on a fasting program who has bulimia tend to encourage anorexia or more bulimia?

Dr. Goldhamer:                 Well to be clear, anorexia nervosa and bulimia are completely different conditions. We don’t use fasting for anorexia nervosa which is a neurological condition where people have dysmorphia. It’s a whole different category of illness. Many bulimics or bulimic has a maladaptive response to their dietary issues. They don’t want to be fat, but they are addicted to the pleasure trap, the artificial stimulation of dopamine in the brain that cause … chemicals added to their food like oil, salt and sugar.  So a short period of fasting can reboot that mechanism, increase leptin levels, normalize blood sugar levels, get rid of a lot of the biological triggers that stimulate bulimia and so it is possible to use fasting in appropriate selected patients as a means of helping mitigate this aberrant behavior pattern. But typically, the focus in eating disordered patients is teaching to eat healthfully. So generally, fasting wouldn’t necessarily have to be used to be effective in managing their condition.

                                          We do have behavioral cognitive clinical psychologists that do the job of helping people address psychological aspects of it and diet and lifestyle and exercise often help address the physical aspects with fasting does sometimes have a role in helping … Just like for example, in cigarette smoking. If you fast a cigarette smoker by the second or third day, there’s really no cravings for cigarettes anymore. So it’s a way of facilitating that transition off in nicotine.    Now, some people say, “Yeah, well they’re so miserable fasting. They don’t even think about cigarettes”, but that’s not really the case. The fact is, the adaptive processes that occur in normalizing function often happen much quicker in fasting. It’s a faster way to get to the end result.

Dr. Weitz:                          Interesting. So you really see bulimia as completely different than anorexia?

Dr. Goldhamer:                 It is completely different.

Dr. Weitz:                          I think most people tend to put in the same bucket of-

Dr. Goldhamer:                 Most people are mistaken though if you look at the actual condition. There’s a completely different condition.

Dr. Weitz:                          Okay. So have you had any challenges running a fasting program as a chiropractor?

Dr. Goldhamer:                 Well, I think running a fasting program as any type of doctor is going to present problems particularly in the past. As a chiropractor in 1984 when I went into practice, they hadn’t had the Wilk decision at this point so the Committee on Quackery or the committee to eliminate chiropractic was still in full force. So doing anything as a chiropractor, that was considered outside the box. Up until even relatively recently, the California Board of Medical Quality Assurance had suggested that fasting or recommending fasting to a patient might constitute such a gross violation to the standard of practice that rose to level of criminal negligence.  At one point, I was represented by a criminal defense attorney. So I remember being the first person in my family ever that needed the services of a criminal defense attorney, and my father was very proud. But I did get a lot of advice from other chiropractors though that had served time in prison for practicing chiropractic around in the ’50s. And they said, “Well, just treat the guards and they’ll take care of you”.  Fortunately, it never came to that because they cited actually on review at that time, even Medicare had a provision to reimburse fasting but it was … only if it was necessary for rapid weight loss for urgent surgery. So if the patient fasted and got well, it wouldn’t be considered a covered benefit. As far as any hospital in this country to this day will be fasting for certain conditions like if you come in with acute pancreatitis, they’ll put you on IV fluids and no food and use fasting in order to manage the condition.

                                                So once we really got into the weeds on it, I realized that recommending fasting really wasn’t criminal behavior. Now, what’s interesting is recently in large part, because of people like Valter Longo and a gentleman we’ve done some research with, Luigi Fontana at Washington University, we’ve gone from being criminal quacks to cutting-edge researchers because fasting has gained some notoriety and some interest.  So we’re doing the exact same things we’ve always done but now, it’s viewed differently and so we’re currently working on a study. We’re about halfway through with the Mayo Clinic. We’re looking at the primary preventing of stroke through the use of fasting and dietary change. We’ve completed a study with Washington University looking at biomarker changes in fasting. They’re counting the number of mutations in B lymphocytes and looking at autophagy. And the gut microbiome, the 1,000 strains of bacteria that live in the gut and how they’re influenced by fasting.

                                                We have completed a study which is called taste neuroadaptation study that looks at the changes in the perception to food before and after fasting. And we’re working right now on a project that we hope to do with Kaiser Permanente where we look at adding to standard Kaiser care this type of a model of intense education and nutritional support at the management of high blood pressure and compare what happens when you educate patients to get them eating well compared to standard medical management.  So lots of interesting things going on. We published a number of papers. In addition to our papers in hypertension, we published the fasting safety study. The patient reports in the British Medical Journal on the follicular lymphoma. We have one paper we published on the chiropractic management of subacute appendicitis using fasting and dietary change rather than surgery. We’ve got additional papers on a number of subjects all of which can be found on our website.  In fact, our foundation, the TrueNorth Health Foundation is a 501(c)(3) nonprofit research foundation. It has a website, fasting.org, and everything about fasting that people might want to know, they can find just by going to fasting.org.

Dr. Weitz:                          So you mentioned Dr. Longo. And he’s recommending a super low-calorie program that you do for five days on a monthly basis or something like that. And he claims to get the same benefits that you do with fasting-

Dr. Goldhamer:                 Well, he doesn’t claim that you get the same benefits that you do with fasting. What he claims is that even just doing prolonged, five days a month which is a 600-calorie, higher fat, low carbohydrate substance, even that is enough to induce some of these changes that are associated with fast. And this is something that patients can do on their own. They purchase this product, they take the product and he’s got some evidence to suggest that that might be helpful.  So even not eating greasy, fatty, slimy processed crap five days a month is enough to start inducing biological changes in people. But I don’t think anybody is going to compare a five-day intermittent fasting mimicking diet with long-term water-only fasting. Now, what’s interesting is the Longo group has approached us and we are going to be trying to do some collaborative comparative research looking at long-term fasting which really needs to be on a medically supervised setting, like the TrueNorth Health Center. And the intermittent fasting with products like ProLon and we’ll compare and contrast and see how they can be used independently or possibly together.  One of the suggestions they made is we may want to use a product like ProLon as an ongoing source of … to improve long-term compliance, et cetera.

Dr. Weitz:                          I understand that you believe in a high starch, low fat, low sodium, plant-based dietary approach.

Dr. Goldhamer:                 Well, a whole plant food diet is about 10% to 12% in calories from protein, about 15% to 18% in calories from fat, with the balance coming from whole plant carbohydrates.

Dr. Weitz:                          So that’s a high carb diet, a low fat, high carb diet essentially?

Dr. Goldhamer:                 Well, I think many low-fat diets are advocating less than 10% of calories and fat. So this wouldn’t technically be considered a low-fat diet because there’s still nuts, avocado, other plant-rich sources of whole fat in the diet. So it’s 15% to 18% of calories from fat is more of an intermediate fat diet compared to the lower fat, no sources of plant fats in the diet-diet.

Dr. Weitz:                          Well, one of the benefits of fasting is to lower blood sugar levels which is why you mentioned that it’s beneficial for Type 2 diabetes. And many advocates of a high fat, super low carb ketogenic diet claim very similar benefits to fasting including improving insulin resistance, inhibiting mTOR, stimulating AMPK, stimulating autophagy as part of an antiaging approach.

Dr. Goldhamer:                 Okay. So there’s no question that high fat, high protein … and/or high protein diet alone, carbohydrate short term will result obviously in lowered glycemic response, but it’s not a healthful, sustainable long-term diet in my opinion. So when you put people on a high fat, high protein diet particularly, over the long run, there’s all kinds of clinical problems that occur. And even many of the people that advocate these diets advocate them more short term as a fast mimicking kind of effect because they don’t have the ability to say … actually, put a person on an actual fast. Water-fasting isn’t something people are going to be doing on their own at home.

                                          So they’ll implement these diets and over the short run, they’ll demonstrate some good results just getting all the refined carbohydrate diet, just tremendous benefit for everybody. But you need to differentiate an 80% calorie of refined carbohydrates from sugars and processed foods from a whole plant starch-based diet which is the way human beings … what they’re designed to eat. And you can sustain this whole food plant-based diet indefinitely.  And we published a data to show what happens when you treat for example, high blood pressure with this approach. You normalize blood pressure and you sustain it indefinitely. We’ve demonstrated the effects of not only normalizing blood sugar levels but the fact that you can sustain those levels as long as you are willing to comply with the health-promoting diet. And I’ve never seen anybody produce the results that we produced in treating autoimmune disease long term.  So I think we have to be careful about therapeutic interventive diets that are high in fat and protein versus a sustainable long-term, health-promoting diet consistent with our biology.

Dr. Weitz:                          So what types of starches do you recommend as part of your program?

Dr. Goldhamer:                 Whole plant foods. So things like-

Dr. Weitz:                          What?

Dr. Goldhamer:                 You have a host of tubers vegetables like Hubbard squash, butternut squash, kabocha, sweet potatoes, potatoes. There are for patients that are not lectin-sensitive. They may be able to eat non-glutinous grains like rice, quinoa, millet, et cetera. And there are also … Again, for people that are able to tolerate beans, there’s lentils, peas and beans. Some patients don’t do well with those products and so we’ll use starchy vegetable materials instead, mostly, your tubers, squash and sweet potatoes.

Dr. Weitz:                          Sweet potatoes and squashes. And which patients are sensitive to lectins, or how do you determine that?

Dr. Goldhamer:                 Yeah. Some of the patients that you see having autoimmune-related symptomology, particularly people with gastrointestinal inflammation, ulcerative colitis, colitis, Crohn’s, these conditions, some of the patients that have other manifestations of autoimmune response find they’ll do better at least initially getting rid of some of the more complex products like particularly glutinous grains, but even some standard grains and beans.  Again, frankly, for most of our patients, once we get them fasted, get rid of the gut leakage and rotate food back in, some patients can have food once a week but they may not want to eat them every single day because they have some sensitivity issues. But they can get on that whole plant food rotational diet, maintain good clinical outcomes and not have to be as restrictive as maybe other people that have not had the benefit of fasting.  If you’re going to do this change without fasting, it can take weeks or months to get the changes that you see in days or weeks of the fast.

Dr. Weitz:                          Do you recommend whole wheat bread?

Dr. Goldhamer:                 We don’t use any glutinous grains with any of our products. All of our cookbooks are whole plant foods, SOS-free, so salt, oil and sugar-free and also gluten-free. So we don’t use wheat, rye or barley as grains for any of our patients. And particularly for the third … the patients that are particularly sensitive to that.

Dr. Weitz:                          All right. Do you advocate eating nuts and seeds and other source of fat like avocado, olives, coconut?

Dr. Goldhamer:                 For patients that are able to tolerate those, and most people are, we’ll use up to a half an avocado or up to an ounce of dry nuts or seeds today. But we do limit them in the sense that we want to keep the fat around 15% to 18% in calories and fat. If you use unlimited amount of nuts and seeds and avocado, they’re very rich. Percentage of calories and fat goes higher than we think is probably long term ideal and sustainable.

Dr. Weitz:                          What’s wrong with having a lot of fat?

Dr. Goldhamer:                 Well, we believe that the patients that maintain the best both weight balance as well as cardiovascular and autoimmune health have fat in the 15% to 18% of calories from that range. You may be able to demonstrate a higher percentage of that intake for some individuals and maintain good clinical results but our general observation has been that when we get the percentage of calories and fat higher, it’s harder to maintain optimum weight control. It’s harder to maintain optimum immunological function.  But obviously, there’s a range in people and a range in sensitivity and these are the basic dietary standards that we’ve implemented at the clinic and they seem to work very well.

Dr. Weitz:                            So why do you recommend a low salt diet? Dr. Nicolantonio’s book, The Salt Fix, where he lays out some pretty compelling evidence that a low salt diet is actually harmful, that a low salt diet increases LDL cholesterol, activates our renin-angiotensin system which actually makes high blood pressure worse.

Dr. Goldhamer:                 Yeah. Of course, that’s not at all what our experience has been. And again, I think I’ll point to our data. We not only achieved the highest effect sizes ever shown in normalizing blood pressure, we’re able to show you can sustain it. And we do that on a diet that’s between a half a milligram and a milligram of sodium per calorie which is consistent with what any all-natural food diet would be without adding a chemical in the form of sodium chloride to the food.  You don’t need to add salt to your food any more than you need to add sugar to your food or you need to add oil to your food. The fact is a whole food diet has a gram … around a gram of sodium naturally inherent in the food which is going to mean everybody except your rare person with hyperparathyroidism or some problem producing glucocorticoids or absorbing sodium. So the idea of salt though, you want to be real clear about it, salt is a essential nutrient without which you die.

                                                But you don’t need to add any added fraction of salt, you get the sodium in your food. That’s one of the reasons you are very sensitive to sodium intake is you … if you pick that up, it’s one of the essential nutrients you need. The problem is that salt, if you think about it was used as a preservative. So in those times, before refrigeration was a viable commodity, salting the food allowed to be antibacterial.  When you add a high salt diet, think about the five pounds of bacteria that live in your intestinal tract. It may not be the very best thing to be doing is putting a concentrated preservative agent into the intestinal tract and you’re trying to maintain normal balance of 1,000 strains of bacteria. Salt also has a powerful stimulation of passive overeating. So one of the reasons why excess salt makes people fat is because of the stimulatory effect it has to the apathetic mechanisms.  For example, if you’ve given an animal or a human, let it eat its satiety … to satiety of a certain thing, say, you’re eating rice or something, whatever. You’ll eat a certain amount and you … eventually, you feel satiated or full. If you take that same animal or that same person, everything else being equal the next day, give it the same exposure but salt it up, they’ll eat significantly more before they reach satiety.  And some people say, “Well, that’s because it tastes better”. Yeah. Well, that’s what tasting better means, is stimulating dopamine production in the brain. And it can lead to stimulating the cram circuits and overeating. When you do that consistently, it helps make people fat. Salt causes people to retain fluids particularly the third of the population that’s highly salt-sensitive. And if you look at hypertensive patients, it’s the majority of them. So what happens is until you reduce that sodium intake, it’s very difficult to achieve and maintain normal blood pressure.  So the idea that adding … not adding chemicalized salt into the diet is some kind of limiting factor I find inaccurate and inconsistent with our experience.

Dr. Weitz:                         Now, isn’t salt a way that we supplement our population with iodine to prevent goiter?

Dr. Goldhamer:                 Yeah, it is. We’ve decided to add one chemical to another chemical and so that’s common with getting … And for people that live for example in the Midwest where the soils aren’t naturally high in iodine because they’ve never been covered by the oceans, that could be a serious problem if you didn’t supplement iodine, or if you didn’t use foods that are naturally high in iodine like for example sea vegetable materials. If you include a little bit of kelp or a little bit of dulce things, you’re going to get some additional iodine that way.  If you get vegetables growing on soil, it is iodized, and vegetables do contribute significant quantities of iodine. But it is a theoretical limiting nutrient because plants don’t have to have iodine in order to survive so like Vitamin B12 which needs to be supplemented on a whole plant food diet, iodine and Vitamin D or other nutrients have to be evaluated to make sure that you’re getting enough sun exposure to form your D.  You’re getting plants that have iodine or take an iodine supplement or sea vegetables in order to ensure that iodine is adequate in the diet, you don’t need to add salt though, is the only source of getting iodine, and I think it’s a poor choice.

Dr. Weitz:                         So do you advocate everybody take a multivitamin that contains iodine-

Dr. Goldhamer:                 I do not recommend a multivitamin because there’s many nutrients in multiples that are frankly harmful. And not the least of which would be iron, some limitation at males for example, Vitamin A is-

Dr. Weitz:                         Well, most of us are not putting men on multivitamins with iron in it.

Dr. Goldhamer:                 Yeah. So the point is we wouldn’t recommend taking any nutrient other than the nutrients that you think you have clinical justification for recommending for that given individual patient. So the only nutrient we recommend routinely in the inpatients is Vitamin B12. And then beyond that, it would depend on patients, their diets. I think the best source of most nutrients is diet and for people that get all of their calories from whole natural foods, concentration of most common nutrients can be good.  If it’s not, then you can supplement nutrients that are necessary but the host cell just to be sure I think has as many potential problems as it has benefits.

Dr. Weitz:                         Now, don’t we see in some of the healthiest populations, dietary patterns that are much higher in sodium like the Japanese diet, the Korean diet, and the Mediterranean diet, these all contain moderate to higher amounts of salt than you’re advocating?

Dr. Goldhamer:                 Yeah. You do see differences in population and different disease patterns. What I’m really talking about here is what we found as the most effective way of both achieving and then maintaining health long term. And a lower sodium intake offered to thousands of patients that we’re monitoring now appears to be a very helpful way. And when you really think about it, right now, salt is more popular to think as a critical … they’re adding to the food.

                                          You could make the same kind of argument for sugar, you could make the same kind of arguments for oil. People like to hear good news about their bad habits and it’s difficult to adapt to a low-sodium … It takes people about a month to adapt to a low-sodium diet without fasting. It happens a little bit quicker with fasting. Once people make the adaptation though, then they like their food without adding this artificial stimulatory chemical to the product and they function and do quite well.

Dr. Weitz:                            I think one more thing on the sodium is I think there’s been quite a number of studies showing that lowering sodium intake had no appreciable benefit for hypertension.

Dr. Goldhamer:                 Yeah. Lowering sodium intake from very high to only moderately high doesn’t seem to have much of a threshold. They’ll say the same thing with eggs. If you’re already on a high fat diet and you add a couple more eggs, it doesn’t make much difference. You have to look at those studies with a little bit … kind of a greener kelp because what they’ve never done is actually look at what happens when people actually go on a health-promoting diet?   They’re talking about, “We’ll drop the sodium from 3,000 to 2,400 milligrams. We don’t see appreciable changes”. Look at our outcome data. A hundred seventy four out of 174 people with hypertension achieved normal blood pressure and the people that sustained the diet sustained the results. If you can give me better data, then I’ll look at modifying the program but right now, that’s the large effect size that I’ve seen and it’s certainly consistent with the results we’re seeing at the TrueNorth Health Center.

Dr. Weitz:                         So you think eggs contribute to heart disease?

Dr. Goldhamer:                 Well, I don’t know. We don’t use any kind of animal products. Meat, fish, eggs or dairy products in any of our food so I’m not an expert on what does or doesn’t happen with these … not something that we use in the diet at all.

Dr. Weitz:                          And why don’t you use any animal products?

Dr. Goldhamer:                 Because I believe that the negative effects, the biological concentration concerns with animal products, the excess fat and protein and the effect that that has on heart disease and cancer, not to mention the moral, ethical, spiritual, environmental impact to the animal-based diet. Make it better to adopt the whole plant food, SOS-free diet than it does to dabble in the biologically concentrated that became flesh, coagulated cow pus and chicken [inaudible 00:39:57].

Dr. Weitz:                          How do you get enough omega-3 fats?

Dr. Goldhamer:                 Well, there are some foods that are very rich … some plant foods, very rich in linoleic acid. For example-

Dr. Weitz:                          Yeah, but very small percentage of that gets converted into EPA, DHA.

Dr. Goldhamer:                 Well actually, I’m not … I don’t think I completely agree because there is a difference in some people. Some people do have conversion issues at the … where their percentage are going to be small than others. But in our experience, most patients during … getting a 15% to 18% of calories from whole plant food diet are able to maintain acceptable levels of DHA. If you were concerned about it, you can use a vegan DHA supplement from our tech. They have lichen-based DHA supplements or DHA, EPA supplements.  So if you’re concerned about it, that would certainly be a way of increasing DHA without necessarily having to use higher fat intake foods. But in most of our patients, they’re able to maintain normal essential fatty acids without having to resort to supplementation but certainly an option if a person has conversion issue.

Dr. Weitz:                         Well I mean my understanding is, even at best, you’re looking at 12% to 15% in somebody who’s really efficient so that means depending upon what you think is optimal level for-

Dr. Goldhamer:                 Well, that’s the debate, isn’t it? There is no real clear-cut scientific literature of what’s optimum levels of circulating DHA. So even when you’re doing testing, it’s not absolutely clear yet.  What’s optimum?  What’s suboptimal?  There’s legitimate debate amongst people.  But my point is the answer would be … could be supplementing with a pre-formed DHA from algae.  That’s where fish and other animals make their DHA.  You can go to the source and use the supplementation of DHA, EPA that’s perfectly acceptable at any those that you decide clinically that’s necessary.

Dr. Weitz:                          Sure.

Dr. Goldhamer:                 A lot of people are using these pharmacologically. They’re trying to increase DHA in order to suppress inflammation associated with autoimmune disease. We’re actually going a step further which is getting rid of the source of the autoimmune disease and once the pain is gone and people are less concerned about pharmacologically managing it with a less toxic substance.

Dr. Weitz:                          Well, many of us are trying to get to the root cause of autoimmune disease. Some people see inflammation as one of the causes, other people … in some people, it’s probably a series of different triggers including food sensitives and then … So-

Dr. Goldhamer:                 When we really get down to the basics, the things that we have the most control of are diet, sleep and exercise. And the point I’m making is if we control diet, sleep and exercise, oftentimes, we get significant improvement clinically so the need to for example, get rid of the pain because we’re taking high dose of DHA trying to suppress … that goes away. So their CRP is normalized, their acute phase reactive protein is normalized whether we’re dosing it or not.  If they don’t, I got no problem. Do whatever you have to do clinically to get clinical control. But a lot of times, people have never gone the extra step to get people on a whole plant food, SOS-free diet, get them sleeping adequately, get them exercising appropriately and until … And that’s one of the advantages of an inpatient facility is we have highly motivated people that will do all these things. And when you do that, you start seeing all the pills, potions, powders and treatments are really the feathers on a rattle.  They’re not the core. The core is diet, sleep and exercise. And when you fully implement diet and sleep and exercise, you get the results that we see at the TrueNorth Health Center. I’m not saying it’s practical. If you enter an outpatient practice working with people that are … you’re having trouble getting … even quit smoking, our approach is going to be necessarily useful.  But for the people that are really serious about getting healthy and they’re willing to do anything, even eat well or exercise, go to bed on time-

Dr. Weitz:                          Wow.

Dr. Goldhamer:                 See a chiropractor. Do a fast. Really radical things. These are the results that are possible. So again, I don’t pretend that you could extrapolate this to the whole population. That’s not what I’m suggesting. But in the appropriate people, this is a really cool approach and it doesn’t prevent you from saying, “Okay. We’ve done all that and now, we’re still having some stuff. Let’s look at our options whether they’re medical options, whether they’re nutritional medicine, Functional Medicine”, that’s no problem.  I have no difficulty doing whatever you have to do clinically to move a person the right direction. But let’s not pretend that the answer is of the pill, potions, powders, that that’s the fundamental problem. It may be the necessary clinical application, but it’s not the fundamental deficit. That’s going to come back down to first level therapeutic order interventions in the naturopathic world.

Dr. Weitz:                          I think most of us, at least most of the people in the Functional Medicine world, integrative medical world and I know and speak to all agree that the fundamentals are sleep, exercise, nutrition, stress reduction, et cetera. And using things like nutritional supplements are only to be used once those pillars are in place.

Dr. Goldhamer:                 Absolutely.

Dr. Weitz:                         The question is what is the best dietary approach? What is the best exercise approach?

Dr. Goldhamer:                 Right. Right, and I think those are all perfectly legitimate debates. But I also think that it’s up to those of us that are advocating radical interventions and what we do is considered radical to prove it. That’s why we have federally chartered IRB and we’ve got a nonprofit research organization. We’re trying to publish the results of what we’re seeing.  If it can be done better, that’s great.  We’d love to know how to do it better.  We’re open to that but at this point, for example, when we treat something like high blood pressure, I haven’t seen anybody that’s getting better consistent results than we’re demonstrating using this model.  Until we do, it’s hard to rationalize doing a lot of intervention and unfortunately, there’s a big bias including in Functional Medicine where practitioners are making their living off of selling the treatments and the pills and the potions. Whether they realize it or not, sometimes there’s a bias there that involves what those recommendations are making.

                                            There’s also a problem of practicality. Because people don’t want to quit smoking and drinking, they don’t want to give up their meat, fish, fowl, dairy products and sugar and processed foods, they’re trying to do the next best thing. Dr. Longo, for example, tells people look, you eat whatever diet you’re going to eat but just five days a month do ProLon.  Why? Well, because he knows that it’s very difficult to tell people what to eat, do ProLon and then in between let’s adopt this health promoting diet, regardless of what your individual beliefs might be.  Our program trains doctors.  We have, for example, Texas A&M has a functional medicine training program for physicians.  They have their family medicine functional medicine focus and their students can rotate for a month, spend some part of their training at the treatment health center.  One of the most common things that these doctors say when they come through is they say, “Wow. It’s the first time I’ve ever seen patients with these conditions actually getting well.” We’re essentially doing nothing. We’re getting out of the way. We use fasting to normalize the system. We feed them a whole plant food diet. We get them to exercise appropriately, use their body properly, try to get them sleeping properly. There’s no magic pill, potion, powder stuff and yet we’re seeing consistent results in the conditions that we’re selecting for.  The conditions that respond best to this are conditions caused by dietary excess. That’s why high blood pressure and diabetes respond so well. There are other conditions, neurological conditions. Conditions that are primary mechanical in nature.  You wouldn’t just … That’s why we have chiropractors and naturopaths and acupuncturists, people that do different kinds of intervention when that’s necessary.

Dr. Weitz:                            I think what you’re doing is extremely admirable, commendable, the fact that you’re doing the research to actually prove that the interventions you’re doing are effective. I think that’s great. We need a lot more research in that regard. But I would like to stand up for some of the other Functional Medicine practitioners who are not using your fasting approach. We all have our tendencies in the things that we have found to be useful and a lot of us have found that when you take somebody who’s on a typical standard American diet and they’re suffering from all these different chronic diseases, which we know are all related to problems with the way they’re eating and lack of exercise, et cetera, et cetera, and exposure to toxins and exposure to mold and all these other things and most of us have found that, at least in a big chunk of patients, 50% or more, we use some of these interventions and people feel better for the first time in years and decades.  Just like you are prejudiced towards fasting and have found great results, a lot of us have found great results using different sorts of nutritional interventions including the prudent use of nutritional supplements.

Dr. Goldhamer:                 Sure.

Dr. Weitz:                         We’re not necessarily only using nutritional supplements because that’s how we make our money or because we’re prejudiced towards those.  We’re using those because we found that they’ve been really efficacious for our patients.

Dr. Goldhamer:                 Right, so the thing I would challenge doctors though to think about is that–I teach at a lot of the naturopathic colleges, and they talk about first level therapeutic order intervention. You don’t really get paid to do first level therapeutic intervention.  You get paid to do procedures and provide product and so what happens, a lot of times, is there’s a skipping over the time-consuming, difficult educational part of really teaching people how to live healthfully or the advice that we’re giving them.

Dr. Weitz:                         That’s only if you’re in the insurance model, right?

Dr. Goldhamer:                 Yeah, whatever. The naturopaths are not an insurance model because they’re not covered by insurance. They’re in a cash-based model and yet, they’re still skipping over that time consuming, in my experience, and jumping into the pill, potion, powder stuff.  I think the power of naturopathic medicine is really in that first level therapeutic order of intervention which is what we try to do at TrueNorth Health where we have the luxury of having patients living with us for anywhere from a week to a year.  You can really see what happens when you fully control that environment. It’s very empowering. I’m not sure what the best strategy is on an outpatient basis. That’s 35 years of inpatient work, but I do see that the results that I’m seeing and that we can demonstrate and document are very consistent. I don’t see a lot of stuff coming out of the outpatient practice that’s documented to the level where it makes us want to try to implement those recommendations.  You hear a lot of stories but I’d like to see those documented. I’d like to see the outcome data and I think that’s weak.

Dr. Weitz:                          There’s quite a number of … I guarantee there’s a lot more studies on the Mediterranean diet than there is on fasting. There is now quite a number of studies on the Paleo diet or the ketogenic diet or different dietary interventions.

Dr. Goldhamer:                 Yeah, I’ve looked at those studies and the good news is, anything you compare to the standard American diet is likely to demonstrate some improvement. Something being less bad doesn’t necessarily make it good. I think, again, in terms of critical evaluation about long-term sustainability, you’ll see a lot of the stuff. When people put people on high protein, high fat diets is they do well for a while because they get the fasting blunting effect of ketosis, whether they’re getting into ketosis, that they’re not as hungry, they lose some weight for a while, but then long-term, you see the devastating consequences.  Their gallbladder, their digestive system, increased risk of cardiovascular disease, iatrogenesis, I’m not so sure depending on how you implement it.

Dr. Weitz:                         That’s not necessarily the case. If you monitor patient’s lipids, they don’t necessarily have devastating effects on lipids.

Dr. Goldhamer:                 I’m talking about more long-term effects and particularly for the patients right now that we’re seeing coming in that have made it a good faith effort with high protein and high fat animal-based diets. We definitely see consistent and predictable results they’re having long term.

Dr. Weitz:                         Since most cholesterol in the body is produced by the liver, then what’s the problem with having a high animal fat diet?

Dr. Goldhamer:                 Well, I think that the problem is a question of super saturation. Yeah, most of your cholesterol’s made by your biotin, a necessary and essential nutrient, but when you super saturate the system then you begin to develop the problems. It is pretty well demonstrated that an association between higher or both refined carbohydrates and higher fat, high protein diets.  We see it in patients when they’re trying to regulate these conditions particularly the autoimmune conditions and we can turn it on and off depending on what you’re putting in their mouth.

Dr. Weitz:                          I’m with you on the high refined carbohydrates and sugar, but I don’t think we’ve really settled the question of whether higher animal fat diet is associated with more heart disease or not.  The American Heart Association is still relying on some of the same studies from the 1960s to advocate for a low fat, higher carbohydrate diet and consider the fact that the liver is producing cholesterol from glucose, not from saturated fat.

Dr. Goldhamer:                 Well, we’re not arguing with you on that point. I agree, refined carbohydrates are one of the things we eliminate. We also eliminate animal products and oil, salt, and sugar. What we’re down to is just whole plant foods, fruits, vegetables, grains, legumes, nuts and seeds.  I think that although grains and legumes are not necessarily going to work well for all patients, some people do have sensitivity issues. The idea of eating those whole plant foods, you can debate whether you want to include animal foods in there or you don’t want to include animal foods in there but this idea of a whole plant food diet I think is finding at least some general consensus amongst most people.  Certainly, people that experiment with diet will find, I think, the simpler they get their diets and the more they get it back to whole foods, not highly processed, fractionated foods. I get into trouble with the National Vegan Conferences that I lecture at saying that as bad as animal foods might be, with various issues, a lot of these highly processed vegan food may be actually even worse. When you tell people they’d be better off eating meat than some of these processed, you get into a lot of trouble.  Basically, I don’t like any of it other than whole foods. I would argue on the idea that animal foods themselves, not dairy products so much but meat and stuff is a whole food. If you’re going to eat meat just like you eat anything, we recommend, obviously, you get animals that haven’t been fed garbage and et cetera, et cetera.  I do think like nuts and avocado and other rich foods, you can overdo it.  When you do overdo it, we see consequences physiologically.  Now then the only question is, what’s over doing it?  Maybe there’s some variation amongst individuals too about what their tolerance to these factors.

Dr. Weitz:                          I think there clearly is.

Dr. Goldhamer:                 Yeah, that may very well be the case. We have a model with the conditions that we treat that we use universally and that is a whole plant food, SOS-free diet. We know what those constitutes are and we’re able to monitor the outcome data and the outcome data is consistent.  It doesn’t mean it’s the only way to do it. It doesn’t mean it’s the best way to do it but we’re at least making an effort to publish the demonstrable results. We lay out the protocol and then people can decide for themselves whether that’s going to be appropriate for them or for their patients.

Dr. Weitz:                         Great and the more data we get, the better.

Dr. Goldhamer:                 Absolutely, but I think that we certainly don’t have enough data arguing our case but I think that people have this impression that there’s this vast amount of clinical outcome data on these nutritional issues and there really isn’t.  Some of the data that’s there isn’t as strong as it should be so we’re trying to do our part of improving that and particularly looking at long-term outcome data.

Dr. Weitz:                         It’s very difficult to get good nutritional data, especially when so many of these studies are using these food frequency questionnaires which are like a joke. I just saw something about … I think the headline was red meat causes something bad and they followed people for five years.  The way they monitored this was they gave them a four-day food frequency questionnaire at the beginning of the study and after five years that’s supposed to account for the way they were eating. I mean that’s not accurate.

Dr. Goldhamer:                 Yeah, of course, it’s not rocket science. The conclusions that are driven are often times weak as well. We are in the process right now of validating a food questionnaire for this type of a diet. We are doing this with our colleagues from Cornell.  It’s very difficult. It’s challenging to come up with reliable and then validating the data takes a lot of effort and work and you can’t do studies that, like you said, where you have a single intervention and then try to do long-term conclusions.   You have to be able to do ongoing monitoring. We’re fortunate though we’re in a position where we have a long-term relationship with these patients that are involved in these studies because we have to, for example, in our lymphoma patients, 10% of the patients go through spontaneous remission with lymphoma but they typically don’t sustain it.  Unless you have good long-term outcome data, nobody is really that impressed. We are in a position to be able to do long-term tracking and monitoring of these patients. We’ll find out if we’re right and everybody else is wrong or if we need to improve or modify our stand.   I would say that if the data is strong, we’re happy to evaluate, modify and we’re happy to study whatever it is that makes some kind of logical sense. We believe that what we do makes sense. We’ve written a book called The Pleasure Trap. We’ve laid it out. We’ve referenced it and we’re open to whatever suggestions or criticism people want to give us.

Dr. Weitz:                          Awesome. How can our listeners find out about your TrueNorth Health Center and what do they need to do if they want to come there?

Dr. Goldhamer:                 We have a nice service for your listeners. If they’re interested in knowing whether we think fasting and this approach might have some use to them, they can go to our website at healthpromoting.com.

Dr. Weitz:                          Say it again. What is it?

Dr. Goldhamer:                 healthpromoting.com

Dr. Weitz:                          healthpromoting.com. Okay.

Dr. Goldhamer:                 If they go in and they fill out the registration forms, it gets me their medical history, we offer a no cost phone conversation where I’m happy to review their history with them and talk to them about whether or not there’s anything we do that might be relevant. If they don’t live near us, we have a number of doctors that we’ve trained around the country we can refer them to their medical facilities that do medically supervised fasting if that seems to be appropriate.  All of our studies, all of our papers, are freely available on our website. There’s also something called TrueNorth TV on there. It has all the video links. There’s a lot of information that people can get. We have three cookbooks out there. There are vegan, SOS-free cookbooks so you can show people how to make food simple, even simple enough I can make it. That’s kind of cool.

Dr. Weitz:                          Awesome. Thank you Dr. Goldhamer.

Dr. Goldhamer:                 It’s my pleasure. It’s nice talking to you.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Hormonal Health with Dr. Howard Liebowitz: Rational Wellness Podcast 115
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Dr. Howard Liebowitz discusses Hormonal Health for Women 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

4:10  Why shouldn’t women simply go through menopause and let their hormones decline naturally?  Dr. Liebowitz argues that hormones are about procreation and when women are no longer able to procreate, they hit menopause and their female hormone production shuts down. When this happens, their health starts to decline, as if mother nature is tossing women out the window.  Dr. Liebowitz feels that bioidentical hormones are not just for alleviating night sweats and hot flashes and brain fog, but also for preventing the heart disease, insulin resistance, high blood pressure, autoimmune diseases, and even the incidence of cancer that tends to occur in women after menopause.   

6:26  Women who take bioidentical hormones starting in perimenopause or menopause are better able to maintain their bone density, their metabolism, insulin sensitivity, and are better able to maintain optimal weight. Dr. Liebowitz said that he’s seen bone densities improve in women on hormones without any bone density drugs, just good diet, exercise, and hormones. Their bodies continue to function like a younger woman’s body would.

8:56  Dr. Liebowitz noted that thyroid hormone tends to decrease in women with age and they may need to add thyroid hormones as well. If your thyroid hormone is low, your other hormones don’t work very well.  Dr. Liebowitz pointed our that to accurately assess your thyroid status, you should not just rely on measuring TSH levels.  If you have elevated levels of reverse T3, which is an inactive form of T3, you can have an underperforming thyroid with a normal TSH.  He recommends running the total T3 and the reverse T3 and a healthy ratio should be between 10-14.  If this ratio is too low, even if the TSh is normal, then this can be a problem.  Dr. Liebowitz said that he also likes his patients to measure their basal body temperature to assess their metabolism and their thyroid function. This is done by putting a thermometer under your arm pit immediately upon rising. Normal basal body temperature should be 97.8 degrees or higher.  He likes his patients to test it over a 7 to 10 day period, and if it averages too low, this patient may benefit from taking thyroid hormone, esp. if they have symptoms of low thyroid. 

12:25  Dr. Liebowitz does not like to use Synthroid, which is a synthetic form of T4, and he thinks that Synthroid should be taken off the market.  He starts his patients off with dessicated porcine thyroid, like Armour, and he likes the fact that these products contain T4 with some T3.

13:29  Some doctors and patients are fearful of women taking hormones after menopause since the 2002 Women’s Health Initiative study, the largest randomized clinical trial done on hormone replacement therapy, found that women who took estrogen and progesterone had an increased risk of heart attacks, strokes, and breast cancer.  Dr. Liebowitz explained that this study used estrogen that was extracted from the urine of a pregnant horse–Premarin, along with Prempro, a synthetic progestin, which do not have the same effects as using bioidentical estrogen and progesterone, which are believed to be much safer. Also, this study included a subgroup of women who had had hysterectomies and were not given the progestin, had a lower risk of breast cancer and heart attack: A Reappraisal of Women’s Health Initiative Estrogen-Alone Trial: Long Term Outcomes in Women 50-59 Years of Age.  In addition, Dr. Liebowitz noted that in the group taking estrogen plus progestin, they did not cycle the progestin 2 weeks on and 2 weeks off like what happens with natural progesterone levels.  In addition, the Women’s Health Initiative did not start women on hormones until approximately 10 years after menopause, and the most protective way to take hormones is to start right around the time of the onset of menopause or during the perimenopausal period. These women do the best.  

16:46  Dr. Liebowitz said that he prefers to prescribe bioidentical hormones that are extracted from wild yams, which are chemically identical what the human body makes.  He usually recommends the estrogen in a transdermal cream or a pellet implanted under the skin. This form of estrogen does directly into the bloodstream and avoids the first pass through the liver, which happens with oral forms of estrogen, and which can increase clotting factors and could increase the risk of stroke.  The only hormone it is safe to take orally is progesterone and he will have women take a progesterone capsule once a day for 14 days and then not for 14 days. At that point, he has women continue to take estrogen and testosterone.  Throughout their lives, except during pregnancy, women have their progesterone cycle on and off and this leads the body to slough off the uterine lining, which is healthy and reduces the risk of endometrial cancer. If you give progesterone continuously, you make women pseudo-pregnant and when women are pregnant, they tend to have high blood pressure and insulin resistance and gain weight and have a higher risk of stroke.  The downside of prescribing cyclical progesterone is that a woman is likely to get her period back, which most women would rather avoid.  Dr. Liebowitz acknowledged that is the biggest argument to the cyclical use of progesterone, but he said that since he doesn’t replace the hormones to the levels they were when the women were younger, they may have a very light period or no period at all.

22:26  Dr. Liebowitz prefers to use estradiol, since estriol is not absorbed that well transdermally, though he will use vaginal estriol.  He used to use a Biest pellet containing estradiol and estriol and that worked very well, but he hasn’t been able to find that formulation anymore, so now he usually uses mostly estradiol.  Henoted that he usually recommends the women he treats to take 6.5 mg of iodine, which has been shown to help convert the estradiol into estriol, which is a more protective estrogen and women with good levels of estriol tend to have less breast cancer.  By the way, the amount of iodine in a multivitamin is typically 150 mcg, which is not enough for this benefit.

25:25  Dr. Liebowitz also often recommends testosterone for menopausal women because it stimulates their libido, helps their brain, helps with energy, it’s a neurotransmitter, it helps with bone density, it helps with metabolism, it helps with maintaining muscle, it helps women to exercise better, and it even reduces the risk of breast cancer.  So testosterone is very beneficial for women and also very safe.

27:02  For women who complain about vaginal dryness and atrophy, Dr Liebowitz finds that the best thing is to raise their levels of estradiol and monitor the FSH levels.  He recommends giving enough estradiol to drive the FSH levels down by 50%.  If the women he treats still have vaginal dryness, he may add in some vaginal estriol.  He has not recommended vaginal testosterone or DHEA.  He has not found it helpful to recommend pregnenolone.  He does sometimes recommends DHEA for women, which can also be a libido booster for them.

30:19  Dr. Liebowitz typically tests for hormones using blood, but he said that it is important that the testing be done at the right time with respect to the application of the hormones.  He admits that these hormones do fluctuate, but he finds serum testing, esp. for the FSH levels to be quite accurate. Dr. Liebowitz also likes to test using a 24 hour urine collection, which allows you to look at hormone metabolites, like the 2, 4, and 16-hydroxyestrone levels, as well as levels of estradiol and estriol, the E2:E3 ratio, which can impact the risk of breast cancer. We can intervene if the E2:E3 ratio is too low, we can have women supplement with iodine, which can help raise estriol levels. And if the 2:16 ratio is off, we can use DIM and Indole-3-carbonol supplements to improve it. In fact, Dr. Liebowitz likes to put all his women patients on DIM and iodine even without testing to lower their risk of breast cancer.

33:39  Dr. Liebowitz prefers the paleo diet for post-menopausal women because it is the diet that we evolved to eat over hundreds of thousands of years this is the diet that allowed us to survive.  He does not like his patients to eat soy, because it is a poor quality protein and it is highly processed.  Some would argue that the phytoestrogens are protective against breast cancer, but Dr. Liebowitz said that if patients need estrogen, he prefers to give them estrogen and not soy.

38:18  Dr. Liebowitz described his approach to hormone replacement for men and women is that hormones make us healthierAnd when we lose our hormones, our health starts to decline.

 



Dr. Howard Liebowitz is an internal Medical Doctor whose practice is focused on anti-aging, including the use of bioidentical hormone replacement therapy, ozone, and IV vitamins, among other treatment approaches. He is trained in Functional Medicine and believes in the importance of a healthy diet, exercise, and lifestyle.  His website is Liebowitz Longevity.com  and his office number is (310) 393-2333.

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



 

Podcast Transcript

Dr. Weitz:                            This is Dr. Ben Weitz with The Rational Wellness Podcast bringing you 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 … It’s no longer iTunes. Go to the Apple podcast app, and give us ratings and review. That way more people can find out about The Rational Wellness Podcast.  Also, if you’d like to see a video version, you can go to my Weitzchiro YouTube page. And if you go to my website, drweitz.com, you can get a complete transcript and detailed show notes.

Our topic for today is hormone replacement therapy with Dr. Howard Liebowitz. Hormone replacement therapy is typically recommended for women after menopause.  Menopause is when a woman’s body is shutting off its reproductive capabilities. It’s a sharp decrease in estrogen and progesterone production by the ovaries resulting in a host of symptoms including hot flashes, night sweats, brain fog, mood swings, depression, weight gain, vaginal dryness, hair loss, and fatigue. The technical definition of menopause is when a woman goes 12 months without a menstrual period.  The long-term effects of menopause include an increased risk of osteoporosis and of cardiovascular disease. One approach to help women with the symptoms of menopause is to replace the estrogen and progesterone, another hormones that have declined with menopause.

Dr. Howard Liebowitz is an internal medical doctor who practice emergency and trauma medicine for 25 years before training in functional medicine. He worked as a physician at the Pritikin Longevity Center for a number of years. His practice today is focused on anti=aging including the use of hormone replacement therapy among other treatment approaches.  Dr. Liebowitz, thank you so much for joining me today.

Dr. Liebowitz:                    Thank you, Dr. Weitz. I’m happy to be here.

Dr. Weitz:                           Excellent. So how did you find your way to functional medicine from a traditional medical practice?

Dr. Liebowitz:                    Well, it was a long journey. At that time I was married and my ex-wife was a gynecologist. And her practice started at the age where she was doing mostly delivering babies and things like that. She started getting interested in hormone replacement as our patients needed it, and I’ve been working the emergency room for 20 or 25 years and was starting to get a little burned out.  So I started to tag along with her in some of these conferences. I found them very interesting. And then it led me to the A4M conferences. And one thing leads to another and I started to network with people and meet people. And then I ended up with The Jeffrey Bland IFM Conferences, the Institute of Functional Medicine Conferences. I thought those were fascinating.  And little by little, I just gradually got more intrigued and curious about this approach to medicine which was so different than the traditional approach to medicine. And I started to see as we started to treat some people some amazing improvements that you don’t normally get by just writing prescriptions.  So I became more and more intrigued by this and curious by this, and it just led me down the path.

Dr. Weitz:                           Cool. Why shouldn’t women simply go through menopause gracefully? Let their hormones decline naturally, wouldn’t that be the natural way to do things?

Dr. Liebowitz:                    Yeah. It is the more natural way to do things, and I get this question from a lot of women especially women who particularly want to be “more natural” about it.  But the problem with that is that I think mother nature kind of plays a dirty trick on women because hormones for women are all about procreation. And when women are no longer able to procreate, when they hit menopause and their ovaries shut down, a lot of their other health parameters start to decline.  It’s like mother nature almost tosses them out the window and says, “Well, you’re not really going to be contributing to society anymore so we don’t need you around,” and their health starts to decline. So it’s not just a matter of dealing with night sweats and hot flashes and memory and brain fog and things like that, we also see an increased incidence of heart disease which is tremendous in women.

Their incidence of heart disease approaches that of men when they lose their hormones and it’s well-known that estrogen can be cardioprotective for women. Their incidence of osteoporosis skyrockets and this is huge problem as women age because the risk of fractures dramatically goes up for them. As well as other things like autoimmune diseases and insulin resistance, and high blood pressure and even the incidence of cancer.  If you look at the incidence of breast cancer, most women will get breast cancer in their later years not when they’re young, not when they’re ovulating and not when they’re of reproductive age. It’s when they are beyond the reproductive years that there’s a dramatic increase in the incidence of breast cancer.  When I approach women and men for that matter with hormones, it’s not just to get rid of those symptoms which is easy to do. I call that the tip of the iceberg, but it’s really to put women’s health back and help them stay healthier as they age and avoid what I call age-related diseases.

Dr. Weitz:                          What are some of the benefits that can result from a perimenopausal or postmenopausal women taking hormones?

Dr. Liebowitz:                    Well, the biggest two I approach is really reducing the risk of heart disease, I think is dramatic, and helping them maintain bone density. And my women who are on postmenopausal hormones and they go on their hormones right around the time of menopause. In other words, there’s not a long gap with no hormones and we’ve monitored the bone densities and I’ve seen women on hormones with their bone densities actually improving without any of the bone density drugs, just good diets and exercise and hormones, maintains optimal health and their bodies continue to function like a younger woman’s body would.

Also, I find that it helps maintain their metabolism and in addition to looking at the female reproductive hormones, I look at all the hormones. So the thyroid plays a big role in there as well. And I keep an eye on that, and replace that as needed but it helps with metabolism as a lot of women start to gain weight as they go through menopause because things happen in the metabolism that slows down and they don’t change their eating habits and they slowly start to gain weight.

Maintaining optimal weight is important because it helps avoid things like insulin resistance and potentially, even adult onset diabetes which can contribute also to high blood pressure and the increased incidence of heart disease. So it’s a whole big sort of approach to general health. It’s not just a one-problem, one-fix kind of an issue. It’s part and parcel to maintaining optimal health as women age.

Dr. Weitz:                          It’s almost like a whole symphony of different hormones that are all involved.

Dr. Liebowitz:                    Yeah. I mean, a lot of people refer to it that way, the symphony. You have all these instruments on the stage playing music together and if one of those instruments, say, is represented by a hormone and that one instrument is out, the rest of the symphony doesn’t sound very good, and that’s kind of the way hormones work together. You really need to look at them all. You really need to balance them all because the human body is very complex and you can’t just go in there and fix one thing and expect everything else to be corrected.

Dr. Weitz:                          Does thyroid hormone tend to decrease with age as well?

Dr. Liebowitz:                    Yes, it does and it’s very well-known that it decreases with age. And I’ve heard people talking at lectures and things like that where they say that up to 80% of the population as we age are going to end up requiring some hormone supplementation. And the way we look at thyroid hormone today is not even very accurate because a lot of people will only look at the pituitary response called the TSH, the thyroid stimulating hormone. And it’s not always very revealing in terms of what’s going on with the total body thyroid.  And without having a good thyroid level, a lot of the other hormones don’t work very well.

Dr. Weitz:                          So how do you monitor thyroid? What’s the key thing that you look at? What are the key levels that you’re concerned with?

Dr. Liebowitz:                    There are two primary hormones I like to get. One is the total T3 and the reverse T3. And I look at the ratio of those. So, the total T3 to reverse T3 ratio should be around 10 to 14. And I find a lot of my patients extremely low with normal TSH. So what can happen is your thyroid can start to produce this inactive form of thyroid called reverse T3, and it can help to lower your TSH. So if you’re just looking at TSH, you can miss the boat on a lot of these patients.

The other thing I have a lot of them do is what’s called the basal body temperature. So the basal body temperature is a very sensitive way to check your metabolism. And as our metabolism slows down, our body will run cooler. So checking the basal body temperature over a period of, says, 7 to 10 different readings and then averaging them out, I like to see that they’re in the normal range. Our normal basal body temperature is 97.8 or higher. And if they’re not averaging over that number, that’s a very good indicator that the thyroid is low.

Dr. Weitz:                            Let’s say you have a woman who averages lower than the normal level on the basal body temperature, but their TSH is, say, I don’t know, three, three and a half, would you consider adding thyroid hormone in that patient?

Dr. Liebowitz:                    That person sounds like the type of person who would benefit from having some thyroid hormone. And lot of people are afraid of the thyroid hormone but it’s like all of our other hormones. As we get older, hormones decline. It’s just a fact of life. There’s nothing in our body that’s going to be maintained at an optimal useful level when we start getting into a 50s and 60s and 70s. It’s very, very common that these hormone productions are starting to deteriorate.  So you put the whole picture together where you look at the numbers, you look at the lab, you look at the basal body temperatures and then there’s a whole list of symptoms associated with low thyroid. And I go through the symptom list with my patients, and you get a feeling for how their metabolism is based on all this information. And then I make the decision of whether they need to be placed on thyroid or not because it’s not a cavalier kind of a decision. It ends up being a lifelong decision to start taking thyroid.

Dr. Weitz:                            Do you typically start them with a desiccated porcine thyroid product or do you tend to use Synthroid?

Dr. Liebowitz:                    I never use Synthroid. I think Synthroid should be taken off the market. The porcine, like you mentioned, the desiccated porcine hormones are the best. They’re very similar to our human hormones, and you need to give a T3 product in addition to a T4. The body is supposed to convert the T4 into the active form of T3. Synthroid is a synthetic T4 and many times, it does not get converted to the active form of T3, yet it will lower the TSH.  So a lot of patients I see are taking Synthroid and they have a low TSH and their doctors are telling them that they have a good thyroid level but then lo and behold, they don’t because they’re not making any T3.

Dr. Weitz:                            Getting back to female hormones estrogen and progesterone, didn’t the 2002 Women’s Health Initiative, the largest randomized clinical trial done on hormone replacement therapy show that women who take estrogen and progesterone have an increased risk of heart attacks, strokes and breast cancer?

Dr. Liebowitz:                    Yeah. This is a terrible study. It was very poorly done and there was actually a subcategory of women in that group that had hysterectomies that they didn’t give the equine progestin to. And actually, that group of women did not have any increased incidence of breast cancer and nobody seems to want to talk about that.  But it doesn’t seem like replacing women’s estrogens causes breast cancer. It seems like the combination of using an estrogen and in this case, they’re horse hormones. They’re not even the hormone the horse wants because they come out in the urine so there are metabolite of the horse hormones of the pregnant horse. That’s where the word Premarin comes from. It’s pregnant mare, comes up with the word Premarin.

So these are pregnant horses with metabolic urinary estrogens combined with a metabolic and product of progesterone called progestin, and they took that hormone every day, and they took it orally so there’s a lot of aberration to the protocol that they were using because, number one, women don’t have progesterone every day. They only have it for half of the month. They go on progesterone. They go out on progesterone. So it wasn’t cycled, because cyclical progesterone has been shown to cause cellular turnover so there was continual stimulation of the breast tissue with these hormones the way they were given.  And the group that didn’t take the continuous progesterone or the progestin did not have any increased incidence of breast cancer. So to me, it’s a useless study. It doesn’t tell me anything actually. If anything, it encourages us to use estrogen if you do it correctly because there isn’t any increased risk of breast cancer.

Dr. Weitz:                          Not only that but most of the women weren’t even started on hormones until approximately 10 years after menopause.

Dr. Liebowitz:                    Yeah. And if we look at when women get breast cancer, it’s after menopause. So these women probably had already started to develop a breast cancer that was very early. It was very undetected and unfortunately, a lot of breast cancer is hormone sensitive. And if you put somebody on a hormone who has already developed the breast cancer, you potentially are going to make that cancer grow.  So waiting is actually the worst thing you can do. I recommend women start their hormones right around the time of menopause or even before they hit menopause, in the perimenopausal period. And there are some studies going on that are actually demonstrating that those women do the best, the women who actually start their hormones before they’ve lost their hormones. They sail right through menopause and their body never even knows they hit menopause.  We replace it as it’s going down and the body never even experiences that drop of hormone. Those women do the best.

Dr. Weitz:                          What type of hormones do you prescribe to women who need them?

Dr. Liebowitz:                    Well, they’re called bioidenticals. They’re extracted from wild yams. The reason they’re called bioidentical is because they’re chemically identical to what the human body makes. And I don’t know why yams make hormones the same as humans do but they’ve been studied and they chemically are virtually identical. The body can’t distinguish one over the other, and if you give those to women, I generally do it with transdermal creams or I used pellets which are implanted under the skin.  So these go directly into the bloodstream. I like to bypass the digestive tract because we avoid what’s called first pass through the liver. Sometimes if the hormone goes to the liver in a high concentration orally ingested, it can increase clotting factors and it can increase the risk of the strokes and things like that.

Although I just spoke to a pharmacy today and they were talking about an oral preparation they have that’s a lipophilic formula. And it also is able to be taken orally and bypasses the liver, which I’m just very interested. I just heard about this today, so I’m going to look into this a little more. But most of the hormones we don’t do orally. We do them transdermal creams or pellets under the skin.  The only hormone that’s safe to take orally is progesterone. It hasn’t been shown to cause any problems orally, so I have women take a progesterone capsule once a day for 14 days each month. And then the rest of the time they’re using estrogen and testosterone.

Dr. Weitz:                          So you have them cycle the progesterone?

Dr. Liebowitz:                    Yeah. They go on it for two weeks and they go off it for two weeks. If you look at normal female hormone patterns before women hit menopause, that’s what their bodies have always done. I have a chart here. I don’t know if you can see this.

Dr. Weitz:                          Okay.

Dr. Liebowitz:                    But this bottom line is progesterone and this is estrogen. You can see estrogen goes up. It’s spiked on day 11 and then it dropped right around the time of ovulation. After the woman ovulated in the middle of the month, this is when the progesterone went up. This is the progesterone curve and the estrogen went up again.  So both hormones went up and they spiked on day 21, and that was their most fertile time of the month. And if they didn’t conceive around day 21, then from 21 to 28, both hormones drop very quickly and that withdrawal of hormone allow the lining of the uterus to come out. So the menstrual cycle is actually withdrawal bleeding from the hormones declining like this.

But the important thing from this graph you can see is that women only had progesterone for two weeks. They had progesterone for two weeks on and they had no progesterone for the first two weeks. This is day 1 to 15, there’s no progesterone. That’s the way I give women their hormones back. It’s very simple. I just put back what they had before. I can’t recreate the human anatomy, so I just put back what they had before.  If you do it any other way, you’re basically creating some entity that doesn’t exist in nature except when the woman is pregnant. So women who are pregnant, they have continuous progesterone and the progesterone sustains the lining of the uterus so it supports the pregnancy.

What you’re doing if you give women continuous progesterone is you’re making them pseudo-pregnant. And they’re going to have consequences from that, so women in pregnancy have high blood pressure often. They have insulin resistance. They gain a huge amount of weight. They sometimes have strokes. I mean, there’s all sort of complications of pregnancy. We used to joke about it in school. We used to call it the disease of pregnancy because pregnancy causes a lot of medical problems and when you deliver the baby, all those problems go away.  So if you’re going to give women continuous progesterone, you’re going to potentially recreate the problems of pregnancy.

Dr. Weitz:                          Now, the downside of cycling their progesterone is that a woman is liable to continue to get her period or start getting her period back again. And a lot of women will tell you that one of the few benefits of menopause is that they stop getting their period.

Dr. Liebowitz:                    That’s probably the biggest argument I hear to the process I’m doing. But I think when I explained to the women why we’re doing it this way and I showed them that chart, and I explained the physiology of what we’re trying to accomplish, most of them are very happy to accept the consequences of having some type of a menstrual cycle.  And a lot of times because I don’t put the hormones back all the way to the level they had them when there were young, they don’t have to have hormones that high. Many, many times the women have a very light period and some women feel really good with the hormone replacement that’s a little lower with no period. But the most important thing is really to put the hormones back in that rhythm. That cyclical rhythm is what the body was programmed for.  And regardless of how high or low the hormones are, it’s the pattern of hormones that I think is the most important.

Dr. Weitz:                          Now, in terms of estrogen, do you prefer recommending estradiol, estriol, or a combination of those two?

Dr. Liebowitz:                    I primarily use estradiol. But estriol doesn’t go into the skin very well as a transdermal cream. I do give a lot of women vaginal estriol but also it doesn’t absorb that well. And we used to be able to get a Biest pellet which is estradiol and estriol, and that worked really well. I really liked those and I was using those exclusively. But now, the pellet formulations for some reason have changed, and I haven’t been able to find the estriol in the pellets anymore. So the applications are mostly estradiol.

I do recommend women take iodine, and I have them take iodine at fairly good doses because iodine has been shown to help convert the estradiol into estriol naturally in their body. So we tried to do that. Estriol, as you probably know, has been shown to be what we call a protective estrogen. It’s been shown to help lower the risk of breast cancer and the women who have good estriol levels actually have less breast cancer.

There’s a great study done on Japanese women because the Japanese women have the lowest incidence of breast cancer in the world. And the Japanese eat a lot of kelp and seaweed so they have a lot of iodine in their diet, and those women have been shown to have a very low incidence of breast cancer. So iodine as a supplement is what I recommend all women on hormones take.

Dr. Weitz:                          What level of iodine?

Dr. Liebowitz:                    I’ve been using about 6.5 milligrams. Their initial study said that the Japanese women eat between 15 and 25 milligrams a day but then I read another study that said that some of these numbers were overinflated and that those numbers are too high and that it’s probably more around 5 to 10 milligrams a day. So I have a preparation from one of the companies that actually makes the thyroid that’s at 6.5 milligrams, and that’s what I have women taking now.

Dr. Weitz:                          Interesting. So just for people listening who are taking a multivitamin that has iodine in it, the typical dosage found in a multivitamin is 150 micrograms. And you’re talking about 5 to 10 milligrams, so that won’t be sufficient.

Dr. Liebowitz:                    Yeah, exactly. And a lot of times, people get misinformation. They tell me, “Oh, I have iodine in my vitamin supplement,” but their iodine, what’s the recommended daily allowance which is minimal compared to what’s needed to actually have an impact on estrogen metabolism.

Dr. Weitz:                          Right. Do you typically recommend testosterone for menopausal women as well?

Dr. Liebowitz:                   Yeah. Testosterone is a fabulous hormone for women. And I think it’s overlooked by a lot of practitioners because it’s always felt to be a male hormone. But it’s not on this chart that I showed you, but testosterone would generally tend to rise around ovulation which is right around here and it goes up and it kind of follows the progesterone curve here.  And the reason testosterone goes up in women is because it stimulates their libido, so mother nature wanted women to be more interested in having sex when she’s ovulating obviously because that increases your chances of conceiving. But we found that testosterone has a lot of other benefits for women in addition to libido.  It actually helps the brain. It’s a neurotransmitter. It helps with energy. It helps with bone density. It helps with muscle development and maintaining lean body mass. It helps with metabolism. It helps women exercise better, and it’s also been shown to even help lower the risk for breast cancer.  So it’s a fantastic hormone for women and there’s no downside to it. I’ve had women taking very large doses of testosterone with no adverse consequences other than sometimes they would get a little facial hair or acne problems, and that’s very easy to deal with. But it’s a very safe hormone for women and very beneficial.

Dr. Weitz:                          Interesting. So, for women who are having difficulties with vaginal atrophy and dryness, you mentioned topical estriol. I’ve heard practitioners who use or recommend topical testosterone and there’s even supplements of topical DHEA. What do you think is the most effective for that use?

Dr. Liebowitz:                    Well, I think the best thing is to get a woman’s estradiol level up. When you replace a woman’s estrogen postmenopausally and you get the level to a good therapeutic level, and I document that by following the FSH. It’s a pituitary hormone. And estrogen will drive down the FSH. So, when I see the FSH reduced, I know that woman is getting enough estrogen.  And usually if she’s getting enough estrogen to lower her FSH about 50% from where she’s starting, most women won’t have any more vaginal dryness. They don’t even need anything topically or locally or vaginally. They have enough systemic estrogen like they were when they were younger. They don’t have vaginal dryness when they have good levels of estrogen.

Occasionally, I have women who, for one reason or another, can’t accomplish good levels of estradiol and then I add in some vaginal estriol that they apply vaginally which helps the lining of the mucosa, and sometimes even vaginal estradiol will do it. I have never used DHEA or testosterone vaginally. I accomplish what we need to accomplish usually with estradiol or estriol.

Dr. Weitz:                            Okay. Do you recommend for some women DHEA and/or pregnenolone?

Dr. Liebowitz:                    I haven’t been using pregnenolone. Pregnenolone, if you look at the metabolic pathway chart of the adrenal gland hormones, and I actually have a copy of that here too although I don’t know if you’d be able to see it on here. But these are the metabolic pathways of renal glands hormones. You’ve probably seen this.

Dr. Weitz:                            I have many times, of course.

Dr. Liebowitz:                    Pregnenolone is way up here at the top. We call pregnenolone the mother of all hormones. So when I give somebody hormones, I like to know what I’m giving them. I like to be able to say, “I’m giving you this for this specific reason.” And when you get somebody pregnenolone, you really don’t know what it’s going to end up. It’s going to go down these pathways and it could go this way, this way, this way. It’s the mother of all hormones and you really can’t control where it’s going.

So I’ve never found it to be particularly therapeutically helpful. I do give women some DHEA sometimes, especially for women who are complaining of a lot of libido problems. I think for women, DHEA can be a good libido booster. It’s also a good libido booster for men although a lot of men because they usually have much higher testosterone, I think the testosterone overpowers the DHEA. And a lot of men don’t feel anything from DHEA. And I think DHEA can be helpful for women, and I have used it. I do use it.

Dr. Weitz:                            What is the best way to test for hormones, especially while women are taking bioidentical hormones? We have serum. We have the urine. We have dried urine. We have saliva.

Dr. Liebowitz:                    I like to test primarily with blood. And you need to time the blood test correctly so you don’t get false elevated readings especially when women are on their hormones. So I give my women patients very specific instructions about when to apply the hormones and when to draw the blood tests. But you get criticized a lot because people say, “Well, the hormones fluctuate. The blood tests aren’t accurate.”  But if you’re looking at pituitary hormones, if you’re looking at FSH for estrogen and you’re looking at TSH for thyroid, those hormones don’t fluctuate that fast and you can get a very good idea especially with FSH as to how much estrogen these women are absorbing and if they need more or not.

And then the other way that I like to look at hormones which I think is even better is with 24-hour urine collections because those give you big window picture of what hormones look like over a 24-hour period. It’s great for the thyroid and of course, it’s excellent, maybe one of the only good ways to look at the adrenal glands. And then it also very helpful to look at female hormones because you can also see how the estrogen is being metabolized and that it’s being broken down into metabolites that have been identified as being harmful and increasing the risk of breast cancer.  It’s nice to be able to see that metabolism because we can intervene, and we can lower the risk of breast cancer by having an impact on these metabolites.

Dr. Weitz:                            So what would you see that might indicate that a woman has had higher risk of breast cancer?

Dr. Liebowitz:                    Well, one of the things we look at is the 2/16 hydroxyestrone ratios and then we also look at this. There’s an E2:E1 ratio that we look at. E2:E3 ratio, the E3 is the estriol. And when the estriol is low, you’re going to have very low E2:E3 ratio will be too low and what we try to do is raise estriol. And that’s what iodine does.  And then when the 2/16 ratios are off, we use things like DIM as a supplement and we use five indole carbinol. And there are other supplements that we can have an impact on those ratios also. So I get a lot of women … Actually I put women on these supplements anyway even without measuring them because I figure the cost of taking those supplements far outweigh … It increases the benefit of the risk of developing breast cancer. So I think it’s worth it to take these supplements.  All my women patients, I put on DIM and I put on iodine just empirically even if they don’t do the testing just to lower the risk of breast cancer.

Dr. Weitz:                            Interesting. What’s the best diet for menopausal women to follow?

Dr. Liebowitz:                    Well, I am partial to the paleo diet. There’s a lot of different diets out there these days. I happen to like paleo diet because I like the sort of genetic evolutionary component to it. The theory behind it is that humans evolved hundreds of thousands of years ago and the food that we were eating at that time is what helped make us a successful species and allowed us to survive.

And now what we’re eating is very different. We’re eating a lot of processed foods, a lot of man-made foods. And a lot of our diet changed 7,000 to 10,000 years ago when we went through what’s called the agricultural revolution. So, up until that time, there was no baking and there was no dairy, no cheese, no cream, no milk. So we started eating dairy products and wheat and baked goods only 7,000 to 10,000 years ago and our genes go back hundreds of thousands of years.

So I like to eat a diet that’s more representative of where we were genetically in an evolutionary cycle rather than something more recent. And then although 7,000 to 10,000 years ago sounds like a long time, when you look at that compared to 400,000 or 500,000 years, it’s nothing. It’s a blink. And yet it had dramatic change to the way we eat.  So the paleo diet takes us back to that era of eating before the agricultural revolution. And I think it’s a much healthier way for everybody, men and women, to eat. And I try to encourage my patients to follow that as much as they can.

Dr. Weitz:                          All right. Should women be including soy in their diet?

Dr. Liebowitz:                    I don’t particularly like soy. I think it’s a poor quality protein, and it’s a highly processed form of protein. You have to extract it from the soybeans and things like that. I don’t encourage it, no.

Dr. Weitz:                          What about the fact that it has phytoestrogens?

Dr. Liebowitz:                    Well, if women are needing estrogens, I give them estrogen. I don’t seek out some other random source for it. I go right to what we’re trying to accomplish and just give them what they need.

Dr. Weitz:                          Yeah. I guess some people have argued that there have been some studies that have shown that women who consume the most soy had the lowest risk of breast cancer. The argument being that these plant-based estrogens, these phytoestrogens glom onto the estrogen receptor sites and block stronger estrogen, so therefore they may decrease risk of breast cancer.

Dr. Liebowitz:                    Well, there’s a lot of different things that will impact the risk of breast cancer and that’s only one of them. I mean if we look at all the pollutants, the toxins and the insecticides and everything else and all of the toxic exposures, I mean there are so many things I think that really increase women’s risk of breast cancer. And I think that’s just one of them.

Dr. Weitz:                          Yeah. You’re talking about all the environmental estrogens that are found in these bisphenol A and pesticides and all of these other chemicals that we come into contact with.

Dr. Liebowitz:                    Plastics and I mean-

Dr. Weitz:                          Flame-retardant chemicals, Teflon.

Dr. Liebowitz:                    Yeah. It’s all over the place. And it’s very difficult in our modern day and age to avoid these toxic exposures, it’s impossible.

Dr. Weitz:                          Yeah, I know. I was reading about these chemicals PFOA and PFOS which are produced when they make Teflon and some of these waterproof coatings. And these companies have been dumping them into the waters and they’re found in the waterways in more than half the states around the country.  Recently, there was a report that came out that they’re actually much more dangerous in much lower levels. And we thought they were, so we decided to stop even testing for them. It’s a great response.  

Dr. Liebowitz:                     Just hide our head in the sand.

Dr. Weitz:                          Exactly.

Dr. Liebowitz:                    And think the problem will go away.

Dr. Weitz:                          Yeah, toxic world. That’s why it’s probably a good idea to do some detox from time to time.

Dr. Liebowitz:                    Yeah, exactly. I agree.

Dr. Weitz:                          Okay, Dr. Liebowitz, this was really good information. Any final thoughts you want to leave our listeners with?

Dr. Liebowitz:                    Just in general, I think that hormones get a bad rep. I think there are too many people out there who claim that hormones cause cancer. I don’t think hormones cause cancer. My approach to hormone replacement both for men and for women is that hormones make us healthier. And when we lose our hormones is when our health starts to decline.  My approach to hormone replacement is basically just that, is putting back hormones that we had before, putting them back in a way that we had them before and the whole approach and the reason and the idea to do that is because it keeps our body functioning like we did when we were younger and that’s the period of time when we’re the healthiest.  My approach to hormones is to replace missing hormones to help us function and stay healthier as we age. It’s very well-known and maybe we’ll do a talk like this on testosterone for men because it’s very well-known that testosterone makes men healthier. And I believe the same thing at some point is going to come out about hormones for women. It just hasn’t been proven yet.

Dr. Weitz:                          Great. How can our listeners and viewers get hold of you and find out about seeing you or et cetera?

Dr. Liebowitz:                    Well, they could Google my name. It’s Howard Liebowitz, L-I-E-B-O-W-I-T-Z, MD. I have a website [Liebowitz Longevity.com.]and my name will pop up on the website. It will pop up. I have an office in Santa Monica on 6th street. And that’s probably the best way to find me, is just to Google my name. I do have some YouTube videos like you do, and that’s probably the best way. All the information about my office will be on my website.

Dr. Weitz:                          Excellent. Thank you.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Bone Health with Dr. John Neustadt: Rational Wellness Podcast 114
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Dr. John Neustadt discusses the Bone Health with Dr. Ben Weitz.

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

 

Podcast Highlights

3:32  The reason we are having an epidemic of osteoporosis and osteopenia in the US is that we are getting older, according to Dr. Neustadt.  This is largely with women since estrogen is anti-inflammatory and is protective of bone and estrogen levels drop after menopause. In fact, the first 10 years after menopause is the fastest period of bone loss for most women.

4:33  There is a recent study that indicates that men in their 30s and 40s also experience a significant loss of bone.  (Bone Mineral Density Among Men and Women Aged 35 to 50 Years.Dr Neustadt says that this study contradicts most other research that shows that 80% of adults with bone loss are women and that men are much less frequently affected.  This new research is very alarming and what may be happening is that men and women both show some loss of bone in this younger age group, but thus far, all the research has focused on osteoporosis, whereas this study looked at osteopenia.  Men are not normally screened for bone density at all.  It might be that there is some loss of bone in both men and women and then after menopause, the loss accelerates in women.  But when it comes to making recommendations, we should focus not just on bone density, but on fracture risk.  If you fracture a hip, there’s up to a 40% chance that you’ll be dead within six months.  If you happen to survive the first year, there’s a 20% chance that you’re going to end up in a nursing home and you’re going to suffer chronic pain or other complications from that fracture.  A bone density test only predicts 44% of women who will break a bone and only 21% of men because fracture risk depends upon factors other than just bone density.  Medications are a huge factor and proton pump inhibitors, like Protonix, Prilosec, and Zantac, were only approved by the FDA for short period of times, yet they are being prescribed or taken over the counter for years for acid reflux and other stomach pain.  Research shows that after fours years of taking them the risk for a hip fracture increases by 60%.  Another common medication, Prednisone, can strip minerals like calcium from bone and cause osteoporosis. Tamoxifen, taken by women after breast cancer surgery to prevent recurrence can also cause such bone loss.  Diseases like Crohn’s disease, ulcerative colitis, and celiac disease can cause malabsorption of nutrients and these increase fracture risk.  Autoimmune diseases, which result in increased systemic inflammation, are also risk factors for fracture risk.  Sedentary lifestyle is a factor because if somebody doesn’t have balance and strength, then they’re more likely to fall and fracture.  Poor diet is also a risk for fracture.

12:24   Fractures typically occur after someone loses their balance and falls. But pathological fractures can result from taking bisphosphonate medications like Fosamax and Zometa, which are the most prescribed medications for osteoporosis and osteopenia.  Bisphosphonates have been shown to reduce fractures by 45%, but these are primarily spinal fractures, which are painful, but they do not typically kill you like the hip fractures.  And these drugs have not been shown to prevent primary hip fractures.  Bisphosphonates work by poisoning the osteoclasts, which are the cells in the bone that clear away old, junky bone.  The bone remodeling process requires that the osteoclasts that clear away the old, used bone, and the osteoblasts that make the new bone, to be in balance.  With bisphosphonates, you get more bone, but it tends to be an abnormal, weaker bone. This is why sometimes you get unusual fractures, like unicortical fractures of the femur, and while taking these medications these patients have a reduced ability to heal from such fractures.

15:51  While bone density tests are beneficial and do have some predictive value for fracture risk, they only measure the mineral content of the bone and not the quality or flexibility of the bone, which has more to do with fracture risk.  The minerals give the bone its hardness. It’s the bone collagen, the connective tissue of the bone, that is not measured on the bone density test, that allows bones to have some flex and gives bones their ability to resist fractures. There are urinary markers for bone resorption, like N-Telopeptide (NTX) and the C-Terminal peptide (CTX), but there are no prospective studies showing that changing it improves fracture risk, so Dr. Neustadt doesn’t recommend these tests.  You can measure undercarboxylated osteocalcin, which has been described as a marker for bone quality as well as a marker for vitamin K status and which some studies have shown is a good marker to predict hip fracture risk (Serum undercarboxylated osteocalcin is a marker of the risk of hip fracture in elderly women).  But Dr. Neustadt explained that one study in rats showed that rats that did not produce osteocalcin actually had stronger bones, so he does not run this test.

20:13  Dr. Neustadt usually measures vitamin D in patients with osteopenia and osteoporosis but he does not usually measure vitamin K status.  He likes a vitamin D level of above 60 ng/mL.  There are only 4 nutrients that have been shown to significantly reduce fracture risk: vitamin D, calcium, a form of vitamin K known as MK-4, and strontium.  Here is one paper showing that adding MK-4 to calcium reduced fractures by 60% compared with the calcium-only group, including a 54% decrease in vertebral fracture. Vitamin K2 (Menatetrenone) effectively prevents fractures and sustains lumbar bone mineral density in osteoporosis.  Here is another review article on this: Vitamin K2 therapy for postmenopausal osteoporosis.  Calcium and vitamin D have been shown to reduce fractures by about 20%.  Strontium has been shown to reduce fracture risk by 45%, which is no better, no worse than Fosamax, but he usually does not recommend strontium initially.  Dr. Neustadt recommends 45 mg per day of MK-4, along with appropriate amounts of vitamin D and calcium as first line therapy for his patients.  He does not recommend MK-7 even though it has a longer half life in the body, because it has not been shown in studies to reduce fracture risk.  MK-7 has been shown to promote arterial health and to help decalcify arteries.  MK-4, unlike MK-7 seems to have some anti-cancer effects and is being used in phase 2 clinical trials in Japan for acute myeloid leukemia and other blood cancers and also liver cancer.  Dr. Neustadt said that while he is a fan of taking magnesium and that studies show that most people don’t get enough magnesium, but he does not recommend supplementing with magnesium for bone health, other than the 150 mg of magnesium that’s in the multivitamin that he has formulated.  A healthy, Mediterranean diet includes adequate amounts of magnesium.  Dr. Neustadt also does not recommend boron, since there are no studies showing that it reduces fracture risk.

27:11  Dr. Neustadt said that despite the fact that you often see magnesium, boron, vitamin C, and other nutrients in bone formulas, none of these have been proven to reduce fracture risk.  He said that taking magnesium is a good thing, but there is no research showing that you need to take it in a 2 to 1 ratio with calcium to reduce fracture risk.  Dr. Neustadt also said that there is no reason to take glucosamine sulfate or bone broth or collagen protein in order to potentially strengthen the collagenous part of bone, since there is no study showing that it decreases fracture risk.  he also said that he would not use peptides, like BPC-157, unless there are studies showing a decrease in fracture risk.  Studies that show increased bone density is not enough.  We need studies to show that there is a reduction of fracture risk.

32:57  We know that estrogen is protective of bone and while there is some research showing that taking estrogen or selective estrogen response modifiers, like Evista, can reduce fracture risk, there are some concerns about using them in terms of cancer and heart risk.

33:51  Since there are such problems with bisphosphonates, salmon calcitonin can be used to help patients heal from fractures.  But it is not that effective as a long term solution to reduce fracture risk. 

34:15  One thing to consider is that heavy metals may be stored in bones, so if you are working with a client to reduce heavy metals and they are losing bone, they may be liberating more metals into the blood. So if you are treating a patient for heavy metals with a Functional Medicine approach, you may want to make sure they are in state of bone stability or you should incorporate a bone building protocol into your treatment. 

35:45  According to Dr. Neustadt, the best type of diet for increasing bone density is the Mediterranean pattern of eating (the Mediterranean diet). This diet is high in whole grains, lean proteins, green, leafy vegetables, legumes, fish, olive oil, etc.  Dr. Neustadt is not a big fan of drinking milk and eating dairy, as there are many allergies to dairy and there are issues with growth hormone in the dairy.  You should try to consume 30 gms of fiber per day. You should also eat organic to avoid glyphosate and pesticides. 

40:37  The best type of exercise to improve bone density and prevent fracture is exercise that improves your balance and prevents falls, according to the research.  This can be yoga, Qi Gong, or going for a walk on uneven terrain. Balancing on one leg, the stork exercise, can be helpful, such as while you are brushing your teeth.  Weight training has been shown to be helpful in stimulating the bones to become stronger.

43:44  The alkaline diet has been proposed to help bone density, since eating acidic foods could result in the body stripping calcium from the bones to alkalinize the system in response.  Trying to create a higher pH, such as by eating an alkaline diet, drinking alkaline water, and/or including potassium citrate in your bone formula supplement as an alkalinizing agent, has been theorized to help with calcium balance and bone health.  Dr. Neustadt said that he likes the alkaline diet only in the sense that it motivates people to eat a more plant-based diet. He said that studies do show that if you eat a lot of meat, you will excrete more calcium in your urine.  Eating a lot of meat means that you are not eating a plant-based, whole foods diet, which is a risk for osteoporosis.

 



Dr. John Neustadt is the founder and Medical Director of Montana Integrative Medicine and he is the founder and President of Nutritional Biochemistry Inc. (NBI).  He has written four books, including A Revolution in Health Through Nutritional Biochemistry, and he has published over 100 research review articles. 

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



 

Podcast Transcript

Dr. Weitz:                            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 will find out about the Rational Wellness Podcast. And for those of you who don’t know, we also have a video version so you can go to my YouTube page, weitzchiro, and watch that and if you go to my website, drweitz.com, there will be a complete transcript and show notes.

Our topic for today is osteoporosis with Dr. John Neustadt. Osteoporosis literally means porous bones, and it refers to a condition in which the bones become fragile and the risk of fracture is increased. In fact, according to the National Osteoporosis Foundation, studies suggest that one out of two women and one out of four men over the age of 50 will break a bone due to osteoporosis. The most common sites of these fractures are at the hip, the spine, and the wrist.  If you have osteoporosis and break your hip, there’s a 40% chance that you’ll be dead within six months. When you look at a bone density scan, if there is a T-score of 2.5 or greater, this is defined as, -2.5 or greater, this is defined as osteoporosis, and a score of -1 to -2.5 is termed osteopenia, which is a loss of bone, though not as severe as osteoporosis. Thanks to a new paper that Dr. Neustadt just sent me, we now know that even patients in the 35 to 50 year old range are suffering with bone loss. In fact, 28% of men and 26% of women in the U.S. in this 35 to 50 range have some loss of bone. As I understand it, one of the ways that we should understand osteoporosis is that throughout our lives we have a balance of both cells that build new bone, osteoblasts, and cells that clear out old, junky bone, osteoclasts. When we are younger, there’s a tendency for the osteoblasts to dominate and we tend to build more bone over the osteoclasts. And then when we get older, there’s a tendency for this to become reversed.

                                        Dr. John Neustadt is the founder and medical director of Montana Integrative Medicine, and he’s the founder and president of Nutritional Biochemistry Incorporated, and also NBI Pharmaceuticals. He’s written four books, including A Revolution in Health Through Nutritional Biochemistry, and he’s published over 100 research review articles. Dr. Neustadt, thank you so much for joining me today.

Dr. Neustadt:                     My pleasure. So great to be talking with you.

Dr. Weitz:                          Excellent. So, why do you think we’re having such an epidemic of osteoporosis and osteopenia in the U.S. today?

Dr. Neustadt:                     Great question. It’s typically understood to be a disease of us getting older, and with the baby boomers getting to 65, 70 year old range the general population United States skewing older, it makes sense that as we get older and we are more likely to lose bone that the prevalence of osteoporosis and the risk of osteoporosis goes up. In fact, the fastest rate of bone loss for women is after menopause, the 10 years after menopause is the fastest, the time when women lose bone the fastest.

Dr. Weitz:                          And that’s because it’s related to estrogen levels?

Dr. Neustadt:                     Correct.  Estrogen is considered anti-inflammatory.  It also helps to build bone and maintain bone, and when that gets lost, you can get bone loss.

Dr. Weitz:                          Now, you know, we understand that women are programmed essentially for their hormone levels to drop after menopause a lot, their estrogen and progesterone levels, but men are not really programmed for that to happen, so why should men necessarily have a similar sort of risk as women?

Dr. Neustadt:                     Well they really don’t actually, and this new study that you quoted is new research. It’s groundbreaking research.  I think there needs to be continuing studies, but it is incredibly alarming.  The understanding currently of osteoporosis in men is that it affects about, you know, 20% of osteoporosis cases are in men, and 80% are in women-

Dr. Weitz:                            Oh, okay.

Dr. Neustadt:                     … so, disproportionately women are affected. This new research is very alarming though in that it’s showing first that bone loss is occurring much younger than we had anticipated and thought, and second, that it is occurring potentially at a rate much higher in men than we thought as well. What may be happening is that the rate of bone loss or the risk for osteoporosis, I’m speculating here, based on the research, may be similar for men and women.  In the study the loss of bone was very similar in terms of the percentage of men and women in that 35 to 50 year old age group who had lost bone and became osteopenic, had pre-osteoporosis.  And then as they get older and into menopause, that you get that drop in estrogen, what may be happening is then women actually start losing bone faster than men because they have, they’ve lost that estrogen, and at that point they’re actually outpacing the men in terms of the rate of the onset of osteoporosis.  And we wouldn’t know if men are more susceptible that younger because all of the research to date has really been with osteoporosis, not osteopenia. And the screening guidelines the United States Preventative Task Force for osteoporosis doesn’t even recommend that men get screened for osteoporosis because it appears to be, based on the research that they looked at, so infrequent in men compared to women.

Dr. Weitz:                          Well, it may reflect a sedentary lifestyle and poor diet.

Dr. Neustadt:                     Absolutely, absolutely.  And there is definitely that component to it.  And I think it’s important to note that the most important risk with osteoporosis is not the low bone density.  That’s a number on a test, or what’s called a surrogate marker.  That’s not clinically the most dangerous thing about osteoporosis, or the most important that people need to worry about.  The most important risk with osteoporosis is breaking a bone, as you correctly pointed out. If you fracture a hip and you have osteoporosis then there’s up to a 40% chance that you’re going to be dead in six months.  If you happen to survive the first year, there’s actually a 20% chance that you’re going to end up in nursing home care and you’re going to suffer from chronic pain or other complications from that fracture.

                                          So, anything that we do clinically and everything should be interpreted, both the testing and any recommendations, through that lens of how predictive is the test for predicting a fracture? And what does the research show in terms of what my doctor, or what I’m reading, is recommending I do? What does the research show in terms of its ability to actually prevent a fracture, not just change bone density, because since the 1990s we’ve known that a bone density test only predicts 44% of women who will break a bone and only 21% of men, which is shockingly low. It’s neither specific nor sensitive. The World Health Organization, the American College of Obstetricians and Gynecologists, anyone essentially that’s looked at the research has published position statements on this, have correctly concluded that fracture risk depends on factors largely other than bone density.

Dr. Weitz:                            So, what are some of those factors?

Dr. Neustadt:                     Great question. So, medications is a huge factor. We live in a completely overmedicated society. A lot of people don’t know and they’re popping these like candy and taking them for years and years, acid-blocking medications, the Protonix, the Prilosec, Zantac, those were never approved by the FDA for long term use, yet not only are they being prescribed for years for symptoms of acid reflux to suppress the acid, but now they’re available over the counter without a prescription. The research shows that after four years of taking them, over time, the risk continues to increase for osteoporosis and hip fracture, the most dangerous fracture, then after four years of taking them that the risk for a hip fracture increases by 60%.

                                                Another common medication, Prednisone, oral Prednisone, can strip the bone of its minerals, calcium, and cause osteoporosis and increase the risk of fractures. Premenopausal Tamoxifen, if someone’s had breast cancer, been treated with Tamoxifen prior to going through menopause, that’s also a risk. There’s quite a list of medications that can cause that.  The number one predictor of a future osteoporosis fracture is if you’ve had one already.  So, if you have osteoporosis, you’ve had a previous fracture with osteoporosis, that’s the number one predictor of a future fracture.  Medications are an issue. Other diseases that you may have, anything that causes malabsorption, like Crohn’s disease, ulcerative colitis, celiac disease, those are risk factors as well.

                                                So, autoimmune diseases where there’s systemic inflammation, that’s a risk factor as well. And one of the, you know, sedentary lifestyle, not exercising, that’s a risk factor. Poor diet is a risk factor. There’s good research also showing in terms of risk factors for osteoporosis that what we want to prevent is falling because the number one event to occur just prior to breaking a bone typically is somebody falling, right? So, that’s where the sedentary lifestyle, the not exercising, comes in, that if somebody doesn’t have that balance and strength, then they’re more likely to fall and fracture.

 



 

Dr. Weitz:                            I’ve really been enjoying this discussion, but now I’d like to pause to tell you about the sponsor for this episode of the Rational Wellness Podcast. This episode is sponsored by Pure Encapsulations, which is one of the few lines of professional nutritional supplements that I use in my office. Pure Encapsulations manufactures a complete line of hypoallergenic research-based dietary supplements.  Pure products are meticulously formulated using pure, scientifically tested and validated ingredients. They are free from magnesium stearate, gluten, GMOs, hydrogenated fats, artificial colors, sweeteners, and preservatives.  Among other things, one of the great things about Pure Encapsulations is not just the quality products, but the fact that they often provide a range of different dosages and sizes which makes it easy to find the right product for the right patient, especially since we do a lot of testing and we figure out exactly what the patients need. So, for example, with DHEA, they offer five, 10, and 25 milligram dosages in both 60 and 180 capsules per bottle size, which is extremely convenient. And now, back to our discussion.

 



 

Dr. Weitz:                           You know, some people say that what appears to be a fall that results in a fracture is actually a pathological fracture of the hip that then results in a fall. Is that true or is that not really true?

Dr. Neustadt:                     So…

Dr. Weitz:                           Does that occur in some cases?

Dr. Neustadt:                     Yeah, the only cases where it’s really noteworthy is when people are taking bisphosphonate medications, right?  It’s pretty rare unless you’re running, you have really weak bones, you come down so hard, but most people who fall, they lose their balance.

Dr. Weitz:                            Okay.

Dr. Neustadt:                     There’s no evidence to my mind. It’s sort of a chicken and the egg thing, what came first?  It is understood that typically a fall precedes a fracture, and when that doesn’t happen, when the fracture happens first, what we’re looking for is medication-induced fractures, like if somebody is taking Fosamax for example, and that provides the pattern of fracture in a bisphosphonate break is a very specific pattern of fracture, and it’s a non-traumatic fracture so that can be differentiated.

Dr. Weitz:                            So, let’s clarify for people who are listening. Bisphosphonates are a classification of drugs that are prescribed for osteoporosis, correct?

Dr. Neustadt:                     That’s correct. They’re the most prescribed medication. They go by names of Fosamax, Zometa, for example. And like anything, the end goal, hopefully the end, the goal clinically is to reduce fractures, so the question is well, how much do these reduce fractures? The bisphosphonate category medications reduce fractures about 45%. Those are hip fractures with, I mean, vertebral fractures. Vertebral fractures can cause pain, but they’re not going to kill you. It’s the hip fractures that kill you. What’s been shown is Fosamax actually doesn’t even prevent what’s called a primary hip fracture. If you’ve never had a fracture before, it has not been shown to actually prevent a first fracture. And paradoxically, which I think is a little insane, that even though it’s rare, these medication are supposedly are supposed to prevent a fracture actually in rare cases, actually increase people’s risk for fracture. Not something we really want to do clinically.

Dr. Weitz:                          Like unusual fractures like femur fractures?

Dr. Neustadt:                     Correct. It’s called a unicortical break in the femur. Non-traumatic so there are cases in the medical literature of some woman actually, she was watering her plant, she’s on a stepstool and she just, she stepped down, she didn’t fall, she stepped down and twisted a little bit, and her leg just broke. And what happens when somebody is on the medication, and it breaks, it actually reduces their ability to heal from that, so it takes them longer to heal.

Dr. Weitz:                          Now can you explain how these bisphosphonates work, the mechanism of action?

Dr. Neustadt:                     Yes, they poison the osteoclasts. So, as you mentioned, there are two main cells in the bone, and, osteoblasts and osteoclasts. Osteoblasts build bone, osteoclasts break bone down. It’s a process called bone remodeling. And it’s important, it’s necessary. It has to be in good balance to break down old, used up bone and build new fresh bone to maintain healthy bones. That’s important. And what the bisphosphonates do is they poison the osteoclasts so the osteoclasts stop working and so you get a, the osteoblasts keep working and they keep building up bone but it’s abnormal bone, it’s weaker bone.

Dr. Weitz:                          You’re not clearing out the old, junky bone that should be cleared out to make stronger bone.

Dr. Neustadt:                    Correct.

Dr. Weitz:                         Now I’ve heard you talk about the fact that to prevent fractures, you mentioned the fact that bone density tests are not the most accurate tests and that’s because there’s a flexible part of the bone, right, that’s not-

Dr. Neustadt:                    Correct.

Dr. Weitz:                         … measured by the density. Can you explain what that flexible part of the bone is?

Dr. Neustadt:                   Absolutely. It’s the connective tissue in bone. So, bone is a tissue and like all tissues in the body, it’s made up of different substances. The bone density test only measures the mineral content of the bone. The minerals in the bone give bone its hardness, but there’s collagen, bone collagen, that gives bone its flexibility and actually gives bone what’s called its quality, its ultimate strength. If you were to take, and in fact when I was in medical school my histology class, the professor soaked a chicken leg, a chicken bone in acetic acid, in vinegar, and what that does it strips all the minerals away from it. And when all the minerals are gone, all that’s left is the collagen, the connective tissue. And he brought it in, and it’s like it’s a rubber chicken bone. It flexes, it bends, but it doesn’t break. And so that bone collagen, that connective tissue, is crucial and that’s not measured on a bone density test, nor is it taken into consideration typically in the conventional approach to looking at bone health and treating osteoporosis.

Dr. Weitz:                         So, if bone density tests don’t tell us about the true ability of a bone to resist fractures, are there any tests that do? What about urinary tests for bone resorption markers? What about measuring serum osteocalcin or undercarboxylated osteocalcin?

Dr. Neustadt:                   Great question. So, I want to make sure that I’m very clear in what I’m saying, that I don’t completely discount a bone density test. It does have some predictive value, but I think it’s important to put it in its proper perspective and place. It’s one piece of the puzzle. It’s one piece of data to consider, but most times when people come to me with their bone density test, there’s a lot of anxiety. They’ve got the diagnosis of osteoporosis. They’re very scared, and that’s all they’re focusing on. So, it’s important just to step back, and I think put it in its proper perspective, that it is one piece of the puzzle, and by no means is it the most important piece of the puzzle.

                                        Yes, there are other tests that can, that are, again are what’s called surrogate markers. They’re markers that can look at different indicators of potential collagen or connective tissue health in the bone. They go by names that you said, osteocalcin or undercarboxylated osteocalcin, N-telopeptide, which is NTX, or CTX is another one, C-terminal peptide. And the challenge with those and why I don’t test those anymore is because there are no perspective studies showing that changing that value actually changes fracture risk. And in fact, with the undercarboxylated osteocalcin there was an animal study done some years ago in mice, in rats, where there was what’s called a wild type, just a normal rat that produced normal amounts of osteocalcin, and there was a genetically altered rat that was created that didn’t produce the osteocalcin. And after six months the rats that did not have the osteocalcin actually had stronger bones.

                                         And it just shows that the story that we’ve learned about, you know, one marker leading, and one result is maybe too simple when it comes to bone, and we need to look a little more holistically. And why I don’t test is because is doesn’t, the only reason we should test any patient and run any test if it’s going to change our approach to treatment. And what I’ve learned over the years and working with thousands of patients, and doing my research, and lecturing and digging into the research, is that none of those tests except a bone density test will change my recommendations in terms of my approach.

Dr. Weitz:                         One of the companies is offering the undercarboxylated osteocalcin as a functional measure of vitamin K status.

Dr. Neustadt:                   Yes, that is a functional measure of vitamin K status, because vitamin K is required to carboxylate it.

Dr. Weitz:                         So, is it valuable for that purpose or is it valuable to measure serum vitamin K and do you also monitor vitamin D levels?

Dr. Neustadt:                   So, I do monitor vitamin D levels. I don’t typically monitor vitamin K levels. If there is, if they have osteoporosis, they come in with a diagnosis of osteopenia and osteoporosis, and by the way why osteopenia is for me such a huge red flag with that research that we talked about is because there was two studies that came out years ago that showed that people with osteopenia are actually at higher risk for fracture than people with osteoporosis.

Dr. Weitz:                         Really? How can that be?

Dr. Neustadt:                    Well that’s a great question, and people ask me that a lot.  I don’t have a definitive answer.  I think that there are a couple different potential answers.  One is people may not be taking it as seriously.  They get the diagnosis of osteopenia so maybe they’re not as protective with their bones, they’re not as proactive with their diet and exercise and maybe dietary supplements, or medications if that’s indicated, than people with osteoporosis are.  So, that’s one potential explanation. I think that’s probably the simplest explanation, but I don’t know for certainty that that is the correct one.  Nobody has really teased that apart. But with respect to testing, if somebody comes in with osteoporosis I don’t really, the only thing that I would test is vitamin D to see if I need to supplement at a level much higher than I normally would.  But vitamin K I don’t test because what I go off of, what do the clinical trials show, are the nutrients that people can take that have been shown consistently to reduce fractures?

                                         So, there are four nutrients that have been shown to reduce fractures and only four in clinical trials. So, calcium and vitamin D have been shown to reduce fractures about 20%, which is okay. The strontium has been shown to reduce fractures about 45%, which is no better, no worse than Fosamax, and I’m not a fan of using strontium as a first line, and I can go into that a little bit if you want after this, I talk about the next nutrient. But my first line therapy is a specific form of vitamin K called MK-4–45 milligrams per day. That’s been approved as a medication in Japan since 1995 for the treatment of osteoporosis and bone pain caused by osteoporosis. There have been over 7,000 volunteers studied and followed for up to eight years on that dose and higher. People with postmenopausal osteoporosis, osteoporosis from medications like Prednisone, and bone loss in children, people with autoimmune diseases and bone loss, and it’s consistently shown that not only can it stop and reverse bone loss as indicated by a bone density test, but again, that’s not the most important clinical thing, it’s does it reduce fractures?  But repeatedly it’s been shown to reduce fractures by over 80% when combined with the calcium and vitamin D. So, my go-to is that MK-4. There are different forms of vitamin K, but it’s only the MK-4 form of vitamin K that’s been shown to reduce fractures. All forms of vitamin K will change that osteocalcin marker blood test, but again, that’s not the most important thing clinically, it’s what’s been shown to reduce fractures. And it’s only that MK-4 form that’s been shown to reduce fractures and there are over 25 clinical trials on osteoporosis and five of them specifically looked at fracture reduction as the endpoint that they were evaluating.

Dr. Weitz:                           The use of the MK-7 version of vitamin K2 is much more common, more popular in the U.S. right now, and this may be since serum levels of vitamin K stay elevated longer after consuming MK-7 than MK-4.  And since MK-7 is converted into MK-4, shouldn’t taking MK-7 be as effective as MK-4?

Dr. Neustadt:                     So, great question. First of all, MK-7 is not converted to MK-4. Vitamin K1 is converted into MK-4 in the body.

Dr. Weitz:                           Okay.

Dr. Neustadt:                     The MK-7 is not produced by mammals, humans. It’s produced by bacteria. So, gut bacteria will produce some amounts of MK-7 and then it gets absorbed into our bloodstream.

Dr. Weitz:                           Okay.

Dr. Neustadt:                     Vitamin K1 can be converted through a specific enzymatic pathway in our body into MK-4 which then gets stored in different tissues in the body throughout the body. I’ve heard that argument before that MK-7 lasts longer in the body. It’s got what’s called a longer half-life, therefore it must be superior, must be better, but again, is that the most important thing with osteoporosis? The half-life of a substance. If that were the case then Fosamax would be the best thing to take because it’ll stay in the bone for years and years. No, the most important thing is does it reduce fractures. And again, MK-7 has never been shown as an endpoint in a clinical trial to reduce fractures. And they are different molecules. They are both vitamin K, but vitamin K is a category, and as different molecules they have a little bit different effect on the body.

                                           MK-4, for example, has been shown as to have anti-cancer effect that MK-7 does not have. In fact, they’re up to phase two clinical trials in Japan with MK-4 45 milligrams and up to 135 milligrams per day for acute myeloid leukemia and myelodysplastic syndrome, blood cancers, also liver cancer. And MK-7 in contrast has been shown, if someone were coming to me and says, “I have coronary artery disease. I’ve atherosclerosis,” and that’s all they were worried about, “Should I take MK-4 or MK-7?”, I would tell them to take MK-7 because the research supports MK-7 more than MK-4 for being able to potentially promote arterial health and decalcify arteries, but with respect to bones and osteoporosis and fracture reduction, the research overwhelmingly supports MK-4.

Dr. Weitz:                           Wow. So, if we really wanted a comprehensive anti-aging program, we should probably be taking K1, MK-4, and MK-7.

Dr. Neustadt:                     You could, but there are other nutrients. You know, the anti-aging program-

Dr. Weitz:                           No, I know. Just in terms of the vitamin K part.

Dr. Neustadt:                     Yeah, it’s a yes. You could, but frankly I think that it’s, to get the clinical doses of all of that gets very expensive.

Dr. Weitz:                          Right. So, in terms of supplementing for osteoporosis, you mentioned taking the MK-4, calcium, and vitamin D.

Dr. Neustadt:                     Correct.

Dr. Weitz:                           What level do you try to get the vitamin D level up to? Do you try to get it up to 60 to 80? What’s your-

Dr. Neustadt:                     I love it. Anything above 60 I think is great. Yeah.

Dr. Weitz:                           Okay. What about adding magnesium? What about adding boron? What about adding strontium, vitamin C, antioxidants?

Dr. Neustadt:                     Great questions. Great, great questions. So, you find a lot of those in bone health supplements. And frankly you find them in multivitamin and mineral supplements too and in a good high quality vitamin and mineral supplements those nutrients should be there in adequate amounts for broad spectrum support.

Dr. Weitz:                           But you don’t get a lot of magnesium in a multi really.

Dr. Neustadt:                     Depends on the multi. The one that I created has 150 milligrams of magnesium per serving. So, I don’t know if that’s a lot to you or not.

Dr. Weitz:                           I guess it’s not, to me, no.

Dr. Neustadt:                     Right. So, it depends on what the target is. But here’s the bottom line, the most important question is has magnesium, boron, the other nutrients that you mentioned, have they-

Dr. Weitz:                           Strontium.

Dr. Neustadt:                     Well, strontium I said has been shown to reduce fractures, but have magnesium and boron, or other vitamins, have they ever been shown to reduce fractures?

Dr. Weitz:                           Right.

Dr. Neustadt:                     The answer is no. They’ve never been shown to reduce fractures. And so for me clinically when I’m working with patients and wanting to use what I think is the highest evidence, which is the randomized, you know, clinical trials, and we can get 80 plus percent fracture reduction verified in multiple clinical trials just with the combination of MK-4, 45 milligrams a day, calcium and vitamin D, and I’m targeting bone health and just osteoporosis. As an osteoporosis supplement, that’s what I would use, and in fact that’s what I created because I needed it to help my patients, and I couldn’t find one that works so I created the product. I couldn’t find, not one that worked, I couldn’t find one that had the nutrients, the combination, the dose of nutrients shown in the studies to work, so I created it.  But, and then the other nutrients that you mentioned, if, I’m a big fan of magnesium, huge fan of magnesium, and I think and the research has shown that, you know, over half of the population don’t get enough, don’t consume adequate magnesium in their diets, that having it as a supplement is important but if we’re just targeting osteoporosis, there’s no research showing that it reduces fracture risk. And so, I like to move people more towards a whole foods diet, magnesium, green leafy vegetables. Every center of the chlorophyll atom has a molecule of magnesium in it so that whole foods, Mediterranean style dietary pattern whole foods diet, very rich in all those nutrients we’ve just mentioned except for the strontium.

Dr. Weitz:                           So, there’s no reason to get two to one ratio of calcium magnesium or anything like that?

Dr. Neustadt:                     So, there’s no study showing that that actually affects absorption that I’ve ever seen. I keep asking people please send me a citation, send me a study. For me, it’s reached the status of myth out there and I’ve yet to have anybody actually be able to send me a study. It’s theoretical that one may compete with the other or you need them in a certain ratio, but in terms of fracture reduction to get that 80 plus percent, it was MK-4, 45 milligrams a day, vitamin D, and calcium, and that’s it.

Dr. Weitz:                           If the key is the collagenous part of bone, if there’s going to be more about supplements, is there any benefit in taking things that are known to help with collagen like glucosamine sulfate, bone broth, collagen protein?

Dr. Neustadt:                     Great question. So, for me the question I’m going to always go back to and that I really work with a lot of people that, osteoporosis-

Dr. Weitz:                           Let me guess, is there any study showing that they decrease fracture risk?

Dr. Neustadt:                     That’s exactly right. That’s it. It’s not complicated in my mind. What are the studies showing it reduces fracture risk? And dietary supplements and taking supplements can get very expensive for people, and so what we know in terms of maximum fracture risk reduction are those three nutrients that I mentioned, medications if necessary. I’m not opposed to them but I think the best fracture reduction on a medication is on Forteo, which is only available by injection, but, you know, what has been shown to reduce fractures, or falls, and fall related injuries in osteoporosis? It’s diet, exercise, MK-4, 45 milligrams a day, calcium, and vitamin D, and strontium, but I don’t like to use strontium.

Dr. Weitz:                            Peptides have become very popular, and there’s one called BPC, Body Protective Compound-157 and that’s been shown to stimulate bone healing at least in some of the animal studies.

Dr. Neustadt:                     I think that’s wonderful preliminary research and I’m definitely open to learning of new things that actually work but as a clinician, I’m going to go back to that same question, you know, just because it’s in an animal study doesn’t mean it translates into humans, and we see that over and over in medical research. And what happens is you see a lot of these companies that are coming out with these raw materials like AlgaeCal, for example, or the MK-7, and they’ll have studies and every time the study will report, you look at it, it’ll report increase in bone mineral density, increase in bone mineral density. Well ask the question has it been shown to reduce fractures? Because we know that a bone mineral density test only predicts 44% of women and only 21% of men who will fracture.

Dr. Weitz:                            Since estrogen is protective of bone, should postmenopausal women take bioidentical estrogen?

Dr. Neustadt:                     I think that if they are showing symptoms of hot flashes and insomnia and other symptoms of low estrogen and issues with that then that is a good clinical indication to potentially supplement them. There is research taking estrogen and what are called selective estrogen response modifier, those category of medications, Evista, for example, is one of them, can reduce fracture risk. So, should they take it? There can be some risks with taking those so that would be something to be decided only in consultation with their healthcare provider who knows their medical history and their risk profile.

Dr. Weitz:                            Since there’s such a problem with these bisphosphonates, what about salmon calcitonin?

Dr. Neustadt:                     You know, salmon calcitonin I’ve used to help people heal from fractures within the elderly, and it’s got some good research on it, but as a longterm solution, the fracture reduction is not great.

Dr. Weitz:                            Okay. One thing I thought that was interesting I heard you say in one of your talks, this is a little bit of a tangent for those of us in a functional medicine space is that if you have a patient who’s in a condition where they’re losing bone, we may see an increase in heavy metals in the blood since some of these metals tend to get stored in the bone, and I think that’s pretty interesting because a lot of us are dealing with chronic patients, some of whom have heavy metal toxicity, and we may find that sometimes their heavy metal toxicity continues even though we’re using some protocols that should be reducing their heavy metals, and we may not be considering the fact that if they’re in a state where they’re losing bone, they may be continuing to liberate more heavy metals into their bloodstream, and so, you know, if we’re dealing with a patient like that, especially with a postmenopausal woman, we might consider the importance of trying to get their bone situation stabilized.

Dr. Neustadt:                     Absolutely. Absolutely. So, and there are risks, you know, for osteoporosis and if somebody does have one of those risk factors even the U.S. Preventative Task Force says any, you know, women under 65 who are premenopausal with risk factors for osteoporosis should be screened for osteoporosis. So, they don’t really, on their radar it’s not the heavy metal toxicity but definitely on mine it is and it sounds like it’s on your radars as well.

Dr. Weitz:                            Yeah. So, what’s the best kind of diet for increasing bone density?

Dr. Neustadt:                     So, the best, over 60 years of research without a doubt the Mediterranean pattern style of eating. And I really, it’s something, it’s referred to as a Mediterranean diet, but I really want people to understand it’s not as if you’re going on a diet, it’s an eating pattern. It has its own food pyramid, and it’s really basically a whole foods diet. Getting those nutrients that we talked about, the minerals, the vitamins, from whole plant foods. Very high in whole grains and at the base of the pyramid, vegetables, like I said, whole foods. As you go up, lean proteins, you know, you’ve got legumes in there, chicken and fish maybe weekly. It’s the opposite of the standard American diet which is a lot of red meat and highly processed foods. And in the Mediterranean eating pattern red meat is consumed, you know, less than weekly, maybe once every couple weeks, and all in moderation. Water, ample water, exercise, it’s really an eating pattern but it’s also a lifestyle.

Dr. Weitz:                            It’s kind of hard to know when you start reading all the articles on the Mediterranean diet, and don’t get me wrong, I’ve seen a lot of positive studies, but there’s a lot of confusion from study to study exactly what constitutes a Mediterranean diet. You mentioned whole grains, you know, how much pasta, how much bread is there? People talk about legumes, you know, is cheese part of it? You know, olive oil, red wine. I’m not so sure it’s that clearly defined a diet, but, you know, I get your general point about it.

Dr. Neustadt:                     I totally agree with you, and you hit such an important point of how confusing this research can be for somebody. So, here’s my, my overall emphasis is that typically people when they come to me and probably you as well, you know, where they’re at in their eating is really far from where it should be. And a lot of it is just starting, people becoming aware of it. And so the first thing I do with people is I have them quantify. I break it down to the number of grams of total fiber and the number of grams of protein they’re getting a day. And that total fiber needs to come from whole foods, not a supplement. So, that would be the green leafy vegetables, that could be some legumes, and I shoot for a minimum of 30 grams of total dietary fiber a day, and they have to quantify it.   And for a couple days without changing their diet, and same with their protein requirement is calculated based on their body weight. And so, over six weeks or so I work them to transition into eating more of a whole foods diet. I’m not a fan of dairy, as you and I discussed prior to the podcast. The biggest reason is I don’t think it aids a great source of nutrients, but there’s so many hormones in there that I don’t think are real, they’re not healthy. And a lot of people react to dairy. They can have allergies to them that they’re not even aware about. They get stuffy nose, post-nasal drip, gas and bloating, that sort of thing.

                                                So, I’m not a fan of dairy, and the dairy in Europe and the Mediterranean’s very different. They have a different regulatory environment for the hormones that they allow, what they allow on their crops. And our crops are, unless it’s organic, are quite poisons with glyphosate pesticides and recombinant growth hormones in the beef, and it gets into the dairy, and so I counsel people eat as organic as possible if you can. If you feel that you can’t afford 100%, you know, stay away from what’s called the dirty dozen, the 12 most pesticide-laden fruits and vegetables. And if you can see what it was-

Dr. Weitz:                            For those of you who don’t know, that’s from the Environmental Working Group publishes a list on dirty dozen of the fruits and vegetables that are most likely to have a lot of pesticides.

Dr. Neustadt:                     Exactly. Exactly. And, you know, and then there are just some general rules of thumb that I guide people on. If you can see, look at it and know where it came from, it’s a whole food.

Dr. Weitz:                            What about soy? Should women be eating soy?

Dr. Neustadt:                     In moderation I don’t have a problem with it. I’m a big fan of moderation. Like, if somebody wants to have a little dairy every once in a while, okay. I’m not really fanatical about most things.

Dr. Weitz:                           Could soy be beneficial because of phytoestrogenic effect?

Dr. Neustadt:                     It can actually. It can. Again, it’s never been shown to reduce fractures, but yes, soy does have some benefits. But then it is the question of how much do you really need to eat to get those benefits?

Dr. Weitz:                           What’s the best type of exercise for improving bone density, improving bone, preventing fracture of bones?

Dr. Neustadt:                     Yeah, great question. The best exercise is one that helps people improve their balance to reduce their risk of falling and fall related injuries. So, a lot of people think that when they get the diagnosis, or they got to start exercising, they have to go to the gym, they’ve got to start pumping iron. And that’s what people want to do, great. But, for a lot of people who don’t want to do that it becomes an impediment to them doing anything because they’re under that impression that that’s what they need to do. But, the research shows that anything you do to improve your balance will reduce the risk of falls and fall related injuries. So, that can be gentle yoga, that can be Qi gong, even going for a walk on uneven terrain where you’re walking up and down, you know, over a curve, you know, anything that sort of improves that balance.

                                                And I love and I read a blog on it what’s called the stork exercise. I love things that people can do in their house. There are ways to work exercises into people’s daily routine so it just becomes part of their life. So, the stork exercise, while you, you know, storks, they stand on one leg, while somebody brushes their teeth, and brushing your teeth should be two minutes a day. While you’re brushing the bottom teeth for a minute in the morning you stand on one leg and you can kind of hold the sink if you want a little bit to balance yourself, but try not to use it as a crutch, not too much. And you stand on one leg in the bottom teeth for a minute and you time it, and then when you switch to the top teeth, if you’ve got a Sonicare or something it times it for you. Switch to the top teeth, you switch legs. And you do that twice a day. And that’s been shown to improve balance. They’re just little things that people can do.

Dr. Weitz:                           But, hasn’t resistance training, weight training, doesn’t that stimulate the muscles to pull on the bones which causes the bones to become stronger?

Dr. Neustadt:                     Absolutely. Weight training and that sort of training has been shown to improve bone density and absolutely, it has benefits. And I do encourage people to do that. It can be isometric. It doesn’t necessarily have to be weights. It can be somebody’s body weight as well. But I’m also a fan of trying to meet people where they’re at, and not, it’s, treating the individual because there’s a lot if somebody doesn’t want to go into a gym or maybe they can’t afford it or it doesn’t fit into their day or they’re not motivated enough to do it, there are ways to get them to start doing things proactively that can be incredibly beneficial and then maybe over time, maybe they get the exercise bike and they want to do a little bit more. It’s what I hope. And they can always build on those successes.

Dr. Weitz:                           Great. I think that’s all the questions I have. Any final thoughts you want to leave our listeners and viewers with?

Dr. Neustadt:                     This has been fantastic, lot of fun talking with you, and hopefully your viewers have gotten a lot out of it. I think it really boils down to that one question I kept going back to, and I try and educate people over and over. The most important question, whether, if it’s a test, to ask the clinician is, how predictive it this that I’m going to break a bone? How well does it predict my fracture risk?

Dr. Weitz:                           Right. Oh, you know what, there is one more thing I wanted to touch on.

Dr. Neustadt:                     Sure.

Dr. Weitz:                           The idea of trying to eat a more alkaline diet.

Dr. Neustadt:                     Yeah. So, I’m a fan of that only in the sense that what is an alkaline diet? It’s a whole foods diet. It’s a whole foods plant-based diet. So, if that’s what people like and it’s really popular. They like that you can test it at the pH strip. You can test your urine to see if it’s getting more alkaline. I think that’s great. Whatever’s going to motivate somebody to take charge of their health, to take more responsibility and get excited about eating well. I think it’s fantastic.

Dr. Weitz:                           But is there really something to, if your body is more acidic, you’re going to strip calcium off the bones to balance out the pH in the blood, is there anything to that?

Dr. Neustadt:                     So, there’s research that’s been shown looking at people who consume meat, and meat tends to be rather acidic, and that’ll strip, that’ll increase calcium excretion in the bone.

Dr. Weitz:                           Okay.

Dr. Neustadt:                     But that’s very different from saying you’ve got increased calcium, I mean sorry, it’ll increase calcium excretion in the urine. So, you’re peeing out calcium. But it’s very different to say, there haven’t been studies that I’m aware of at least that make that next connection to say, okay, people eat an acid diet. Their calcium is increasing in their urine. Well, is that because the calcium that they’re absorbing, they’re just peeing more of it out, or are they actually stripping it from the bone, and is it creating osteoporosis? So, if you’re eating that way, regardless of if people want to characterize it as acid or not, which it is if you’re eating a high meat diet.  The research is very clear. That’s not a plant-based whole foods diet. And that is a risk for osteoporosis. Whether the mechanism is the acid or not, I’m not sure. Maybe there are people who are more expert in that that can more definitively answer that question, but the bottom line is that is a dietary pattern that is not a whole foods plant-based diet that has been shown to create osteoporosis, and it could be because of the acid, but it could also be because of nutritional, mineral deficiencies.

Dr. Weitz:                           And you know, besides meat, the other area of controversy, you keep mentioning whole food plant-based diet, or, is like grains and beans.

Dr. Neustadt:                     Correct.

Dr. Weitz:                           You know, grains generally are considered to be acidic.

Dr. Neustadt:                     Correct. Everything in moderation. It’s a balance. I’m not saying eat grains with every meal. I’m not saying eat that, that’s the majority of your meal, or majority of your nutritional source. It should be a balanced diet. So, for me, you know, I love, you know, I’ll have, you know, spinach and green leafy vegetables, and a rainbow of colors from bell peppers and carrots and you know, other fruits and vegetables, and then maybe I’ll also have on there some, a sweet potato, for example, for my starch. Not always a grain. There are other ways to do it. And a lean protein like fish, like soy, tofu or something like that. There are different ways. But there’s also protein and vegetables, and I think people lose sight of that. Vegetables do have protein in them.

Dr. Weitz:                           Okay. Good, good, good, excellent. So, yeah, I think you’ve provided us with a lot of great information to think about in terms of improving our bone density, reducing our risk of fractures, and helping those of us who are practitioners for helping our patients to reduce their risk of fractures. What’s the best way to get ahold of you?

Dr. Neustadt:                     The best way would be through my website, nbihealth.com. NBI stands for Nutritional Biochemistry Incorporated so it’s nbihealth.com if they want to reach me. There’s a contact forum or a toll-free number on there, and they can reach me through the forum or my staff can always forward any messages to me from-

Dr. Weitz:                           Are you still seeing patients?

Dr. Neustadt:                     I do all pro-bono consulting work now by phone with people.

Dr. Weitz:                           Oh, okay.

Dr. Neustadt:                     I’ll see people by phone, maybe two or three a week, to help them, but they’re not officially my patients. I help them understand what questions like this they can go back and ask their doctors. What tests, maybe they’re missing. I synthesize things that have been going on with them, help them understand, reframe what’s going on. I’ll recommend dietary supplements, lifestyle, diet, have them talk about medications or testing further with their healthcare provider.

Dr. Weitz:                           Great. Excellent. Thank you, Dr. Neustadt.

Dr. Neustadt:                     Thank you so much.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Brain Body Diet with Dr. Sara Gottfried: Rational Wellness Podcast 113
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Dr. Sara Gottfried discusses the Brain Body Diet with Dr. Ben Weitz.

[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

5:16  Dr. Gottfried decided to stop practicing McMedicine when she felt she had hit the wall.  She was practicing in a conventional medical model and she was seeing 40 patients a day and she was trying to incorporate some Functional Medicine concepts that she learned from listening to the audiotapes from Dr. Jeffry Bland. She had a couple of kids in her 30s and she had PMS and depression and had gained weight and was on the path to burnout. And she wasn’t able to practice the quality of medicine that she was trained to deliver.  She had to step away from this insurance-based system, since it had driven up the number of patients doctors have to see each day.  Reimbursement has come down to the point where it is abusive to doctors and it has led to burnout and triple the rate of suicide among US physicians that’s even higher than war veterans!  

10:32  Dr. Gottfried was a practicing gynecologist and her focus was mostly on using bio-identical hormone balancing and she had come to realize that this was just one node in the Functional Medicine matrix, which led her to write this Brain Body Diet book.  She realized that so much of hormonal balance is mediated by the gut and she needed to pay more attention to the microbiome in her patients.  Often they may not have any gut symptoms, but they may have increased intestinal permeability (leaky gut) or dysbiosis and decreased microbial diversity.  Dr. Gottfried does a careful history and asks about exposure to toxins, such as glyphosate.  And she may test for glyphosate with the Great Plains urine test.  Dr. Gottfried likes to look at serum markers of hormones, thyroid, CBC, and glucose metabolism. She also likes to look at the microbiome by running Rob Knight’s American Gut stool test. Dr. Gottfried used to use uBiome, but the FBI just raided them.  She may also do a basic comprehensive stool analysis like with Genova or Doctor’s Data.  Dr. Gottfried also likes to look at functional tests like calprotectin, lactoferrin, and sigA. 

17:15  Dr. Gottfried talks about toxins in her book that affect brain health, including glyphosate, heavy metals like lead (which is a dementogen), cadmium, and arsenic, and EMFs. We know that EMFs are associated with brain cancer and increased oxidative stress.  There is also Bisphenol A, which is an endocrine disruptor, a disruptor of insulin, and an obesogen. Other toxins include household cleaners with phthalates, flouride in toothpaste, flame retardants in furniture, sunscreens with PABA, and mosquito repellants with DEET.  Also that new car smell that comes from pthalates is a toxin.  Pesticides, herbicides, and fungicides in food.  Toxins in our air and our water. 

20:20  In order to help detoxify heavy metals and other toxins, Dr. Gottfried likes to use glutathione to mobilize the toxins and then binders like activated charcoal to bind to the toxins and take them out of the body in the stool.  Modified citrus pectin and chlorella can both also be helpful.  Leeks can help the body with glutathione production and N-Acetyl Cysteine is the precursor for glutathione and is very helpful, including the Metagenics product GlutaClear.

24:28  If a patient comes in complaining of brain fog and memory problems and there are no gut symptoms or other obvious causes, besides gathering a detailed history, what would be some of the lab panels Dr. Gottfried might order?  She said that she always looks at hormones and she will often order a serum panel, but she is now a big fan of the DUTCH (dried urine) panel, which tells you about estrogen metabolism, metabolized cortisol, and the total cortisol load. She also likes to use the Genova NutraEval, which is a really comprehensive Functional Medicine panel that looks at vitamin and mineral status, antioxidants, fatty acids, amino acids, and heavy metals. Dr. Gottfried believes that carefully monitoring glucose is very important since so many patients have disrupted glucose metabolism. But just doing a morning fasting glucose does not tell you the whole picture.  She wears a continuous glucose monitor as a way of measuring abnormal glucose signaling, since she may have good fasting glucose but she may eat a sweet potato and her glucose spikes up to diabetic range, so it gives such a more accurate picture.  She may also order stool testing to map the microbiome and look for dysbiosis. If she wants to focus more on heavy metals, she used to do provocative urine testing for heavy metals [give the patient an oral chelator like DMSA and then measure a 6 hour urine] but now she tends to use Chris Shade’s Quicksilver heavy metals serum panel.

30:54  Sleep is super important for brain health. Dr. Gottfried cited sleep researcher Matthew Walker, who found that it is the deep sleep that’s associated with clearing amyloid beta and other toxins from the brain through the glymphatic system.  Dr. Gottfried describes the gymphatic system as like a shampoo for the brain and she noted that it works best when you sleep on your side, esp. your right side.  Deep sleep is also where neurogenesis and memory consolidation occurs.  REM sleep is very important for emotional regulation and for prevention of depression and anxiety.  She likes to track sleep using an Oura ring.

35:97  Food sensitivities and intolerances can play a role in brain health and gluten and diary are two of the most common sensitivities, though not everybody needs to avoid them.  Dr. Gottfried has used Cyrex food sensitivity testing.  For many patients, food sensitivities are caused by leaky gut, so she usually focuses on improving intestinal permeability, but that is a fairly difficult project.  If you do an elimination diet, one of the difficult parts is when you start phasing foods back in and it is difficult to get patients to do it slow and gradually.  If they add all the foods back in at once that they took out, they are more likely to relapse.

40:05  Hormone deficiencies in menopause increase the risk for dementia and Alzheimer’s in women.  Dr. Gottfried explained that if she is seeing a woman in her 40s with brain fog. She will do a careful history and do some testing to look for nutritional deficiencies and probably put her on an elimination diet. If that doesn’t resolve symptoms, then she will usually look at hormone balance. In the first phase of perimenopause, where progesterone tends to drop first. She will often find that chasteberry is a really good solution.  Dr. Gottfried also likes to do some genetic testing and look at the risk of clotting and of cardiovascular disease. And then she finds that having women start taking bioidentical hormones in their later 40s and early 50s, since cerebral hypometabolism starts in women at this age, and it is more effective and safer than giving hormones later. The Women’s Health Intitiative showed us that giving hormones to women in their 60s, esp. synthetic hormones, increases the risk of dementia and Alzheimer’s Disease. Dr. Goffried tends to prescribe estradiol in the Vivelle patch together with Prometrium, which is most proven.

 

 



Dr. Sara Gottfried is an MIT and Harvard trained Medical doctor, a board certified gynecologist, and she is also board certified in Preventative and Anti-Aging Medicine. Dr. Gottfried is also now the Chief Medical Officer of Metagenics. She has just written her 4th NY Times best selling book, the Brain Body Diet, and the book is available here.  Her other best sellers are The Hormone Cure, The Hormone Reset Diet, and Younger.

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



 

Podcast Transcript

Dr. Weitz:                            This is Dr. Ben Weitz with the Rational Wellness Podcast. Bringing you the cutting edge information on health and nutrition from the latest scientific research, and by interviewing the top experts in the field.  Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free ebook on my website by going to drweitz.com.  Let’s get started on your road to better health.  Hello, Rational Wellness Podcasters. Thank you so much for again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to Apple Podcasts, which replaced iTunes, and give us a ratings and review. That way, more people can find out about the Rational Wellness Podcast.  Also, if you want to see the video version, you can go to my YouTube page, Weitz Chiro, or put in Rational Wellness Podcast into YouTube. And if you go to my website, drweitz.com, you can find show notes and a complete transcript.

Our topic for today is the brain-body connection, which is discussed in The Brain Body Diet, Dr. Sara Gottfried’s latest bestselling book, about how to understand and improve your brain health by improving the brain-body connection.  Brain health tends to deteriorate for women as they age. And this can be related to toxins, gut problems, diet, lack of exercise, sleep deficits, blood sugar imbalances, stress, hormones, nutritional deficiencies, and other factors.  One fact that Dr. Gottfried discusses that I found particularly interesting is that the enzyme that removes beta amyloid from the brain, and beta amyloid, as it accumulates, increases your risk of Alzheimer’s, is the same enzyme that clears out insulin, insulin-degrading enzyme.  So, if you have higher insulin levels due to a lot of blood sugar spikes, your insulin-degrading enzymes won’t be available to break amyloid beta. Dr. Gottfried mentions in her book that a study from Harvard shows that only 13% of women can be classified as healthy agers, which means that they have no impairment of memory, physical fitness, or mental health, and are relatively free of major chronic diseases.  She then lays out a series of steps that women can take to promote healthy aging of their brains and their bodies.

Dr. Sara Gottfried is an MIT and Harvard-trained medical doctor, a board-certified gynecologist, and also board-certified in preventative and anti-aging medicine.  Dr. Gottfried is also now the Chief Medical Officer of Metagenics. She has written her fourth New York Times bestselling book, The Brain Body Diet, to go along with The Hormone Cure, The Hormone Reset Diet, and Younger, her three prior bestselling books.  Dr. Gottfried, thank you so much for joining me today.

Dr. Gottfried:                     Oh, I’m so happy to be here.  That was the most thorough bio I’ve ever heard in my life.  And I love that you took maybe the most important takeaways that I have in my book.  It just warms my heart that you noticed the insulin-degrading enzyme, and this fact that so few women are healthy agers.  I think that’s alarming.

Dr. Weitz:                          It is.

Dr. Gottfried:                     So, thank you. Thank you for your careful intro.

Dr. Weitz:                          Oh, absolutely. I’d actually like to start this interview with a comment. I was preparing for this interview on Sunday afternoon, by reading your Brain Body Diet book, and I was sitting on my deck in my backyard, and I was sipping some organic red wine. And I came to your section on memory, and you wrote, “Alcohol impairs memory, erodes mental function, reduces brain size, and causes brain cell dysfunction. Makes you want to put down that glass of wine, doesn’t it?”  So, if I have any trouble remembering what I want to say today, I have an excuse.

Dr. Gottfried:                     That’s so funny. Well, yeah, I don’t like to start with my feeling about wine, because it’s maybe the least popular message that I have. But let me say this. I think that, based on the epidemiology that we have, on especially red wine, in places like Italy, and Europe, Framingham study, we know that men probably do better with alcohol than women do.  I think there’s certain reasons for that.  Women have different sex hormones, we’ve got a different process in the liver. And I think part of the issue for women is that alcohol raises the bad estrogens, and leads to a greater risk of breast cancer, as well as other things. As little as three glasses of red wine per week.  I think men can often get away with one to two glasses a day, without any adverse outcome. I just want to reassure you that I think you were okay in the backyard.  It sounds like you were getting a little nature, maybe some vitamin D. All those things are good.

Dr. Weitz:                            Thank you. Dr. Gottfried, why did you decide to stop practicing McMedicine medicine, in your words, and switch to Functional Medicine, or integrative approach?

Dr. Gottfried:                     Well, I wish it were as simple as just deciding to stop, because, in some ways, I think I was forced to stop. My body forced me to stop. And I think a lot of clinicians come up against this. I imagine you have some listeners, a listener in particular, who’s got one foot in the allopathic medicine world, and one foot in the functional medicine, holistic medicine world.  Trying to figure out how to reconcile those two worlds can be very tricky. For me, I was practicing some of the concepts that we have from functional medicine. I was listening to the Jeff Bland tapes in the ’90s, and I-

Dr. Weitz:                           I listened to every one of those.

Dr. Gottfried:                     You listened to them too? Yeah, you’re one of the-

Dr. Weitz:                           I had the little cassettes I used to listen to.

Dr. Gottfried:                     Right. I mean, there are people listening to this right now who don’t even know what a cassette is. I’m with you on that.  But what happened for me is that I hit a wall. I hit a wall physiologically. I had so much stress, I had a couple of kids in my 30s, I was seeing 40 patients a day, and it just got to a point where I couldn’t practice the quality of medicine that I was trained to deliver.  And I felt like I was failing my patients. I had patients who were coming to see me, and saying, “This antidepressant isn’t working. I have PMS. It doesn’t make sense to me that I would take Prozac every day.”  Or, “I’m trying to deal with stress, and I’m not just going to go sit in a corner and meditate on a cushion. That’s not going to solve it. What else do you have for me?”

What I did is … I had my own health crisis. I went to my primary care provider, realized that what he was offering was totally wrong. Antidepressant birth control pills, because supposedly that helps with every hormonal imbalance.  And I was overweight. I had issues probably with insulin-degrading enzyme. And so I decided, at that moment, that I couldn’t continue in McMedicine. That I was on this path towards burnout. And so I built a bridge, an 18-month bridge, to get out of there, and to build my own practice, the kind that would really serve patients the way that I felt like they needed to be served.

Dr. Weitz:                          Great. What did that bridge look like, if you don’t mind maybe just taking a minute.  Because there probably are practitioners listening to this who are trying to figure that out.

Dr. Gottfried:                     Sure. Well, the cool thing is, you can start the education while you’re still in that allopathic realm.

Dr. Weitz:                          Of course.

Dr. Gottfried:                     I was listening to Jeff Bland, I was starting to do some of the things he talked about. I was starting to do really basic things, even in a seven to 15-minute appointment, I could talk about the elimination diet. I could order a fasting glucose and a fasting insulin. I could order a hemoglobin A1C. And so I could have conversations about those things, and we all know that something simple, like an elimination diet, which we’ve been using for almost 100 years, that can reduce symptoms, based on the MSQ, by 50%.  It’s a pretty strong tool. So I started to practice in that way with education first, and then I built, with a coach, how to step away from the security of this insurance-based system, to opening-

Dr. Weitz:                          That’s the hard part, is when you’re taking insurance for your medical practice, how do you start building that functional practice, which is not insurance-based?

Dr. Gottfried:                     Well, it’s hard, and in some ways it’s very liberating, because the reality is that taking insurance has become increasingly difficult. It’s driven up the number of patients we have to see each day. Reimbursement has come down. And so it’s not a sustainable model. In fact, I would even say it’s abusive.

Dr. Weitz:                          Yes.

Dr. Gottfried:                     And it’s serious. It’s led to burnout, to the level that we have something like triple the rate of the baseline suicide rate among US physicians right now.

Dr. Weitz:                          Wow.

Dr. Gottfried:                     It’s higher than war veterans.

Dr. Weitz:                          Wow.

Dr. Gottfried:                     We have post-traumatic stress disorder. So we have a real crisis on our hands, and I think that the kind of medicine that we practice, Ben, lifestyle medicine, precision medicine, functional medicine, integrative medicine, whatever you want to call it, this is a solution to the burnout. And it’s also a solution that serves our patients better.  It took me about 18 months to figure this out, to figure out, okay, where’s the location? What’s the minimum, the MVP, the minimal viable product? What’s the pared down number of staff that I would hire? Malpractice insurance, all those kind of pieces, it took a while. It took 18 months to get those together.

Dr. Weitz:                           Okay, cool. Thanks for some of those insights.  I’m sure that could be a long conversation at another time.  Why did you decide to write this new book, the Brain Body Diet?

Dr. Gottfried:                     I wrote it for a couple of reasons. I’m a board-certified gynecologist, from my allopathic days. And so the way that I tend to take care of patients is starting with hormones. The way that … my focus has been, for 20 years, bioidentical hormone balancing. But what I realize is that it’s only really part of the story, especially when you consider the matrix of the Functional Medicine model, and you realize that hormones are just … it’s one node in the matrix.  I realized, based on my own health issues, which always feels like a message from the universe about what I need to pay attention next, I realized that so much of hormonal balance is mediated by the gut. And I needed to pay more attention to it. And maybe most importantly, I realized that my patients who had no gut symptoms, so they didn’t have gas or bloating or constipation, or diarrhea, or irritable bowel syndrome, they had gut issues. They had increased intestinal permeability, they had reduced microbial diversity. And they had dysbiosis, even in the absence of GI symptoms.  This is what got me to pay attention to this.  And as I started to dig deeper, I realized, oh my gosh, the way that we’re treating anxiety, the way that we’re treating depression, the way that we think about cognitive decline, really needs to be reset.  We have to change the paradigm. And we really have to put the gut, microbiome brain access, at the center of this.

Dr. Weitz:                          Yes. That’s great. How do you try to analyze the gut to see what might be going on that might be affecting brain health?

Dr. Gottfried:                     Well, I still think it’s helpful to ask, to do a thorough history and physical. I think you can get a lot from that. I use the MSQ for all of my patients. Do you use it too?

Dr. Weitz:                          Yes, absolutely. It’s incorporated into the initial paperwork, yeah.

Dr. Gottfried:                     I find that so helpful. But when I go back and I look at my patients, so few of them have gut symptoms. So the way that I assess it, in the history, I’m thinking, in particular, about the gut disruptors.  I’m thinking about antibiotics, how many courses have you had?  Because we know, even a single course of antibiotics is associated with a greater risk of anxiety, depression, insulin resistance, obesity, diabetes, learning and memory problems.  And multiple courses, the rate goes up.  I ask about that on history.  I ask about food, of course.  I’ve got a food-first philosophy.  I imagine you do, too.

Dr. Weitz:                           Sure.

Dr. Gottfried:                     And then I also ask about other toxins. Things like glyphosate. Things that disrupt the integrity-

Dr. Weitz:                          Glyphosate’s contained in Roundup, which is an herbicide, a pesticide, that’s often sprayed on foods, and especially in genetically modified crops.

Dr. Gottfried:                     That’s right. And when I started to test my patients for glyphosate, I was really surprised at how many of them had a toxic load of glyphosate, even though they were eating primarily organic food.

Dr. Weitz:                          You use that Great Plains urine test?

Dr. Gottfried:                     I use Great Plains. You asked about assessment.  I start first with some of the blood biomarkers that I think are helpful.  I want to know about stress, and cortisol, and the hypothalamic-pituitary-adrenal-thyroid-gonadal axis, of course, that’s my focus.  And we know that, if you are someone who’s chronically stressed, the high cortisol can poke holes in your gut lining, can disrupt the integrity of your gut lining.  And then I look at other things too. I want to measure inflammation.  I want to look at white blood cell count, I want to look at leukocytes and neutrophils.  I want to look at glucose metabolism, because the gut is so intricately involved in insulin resistance.  I do look at the microbiome.  I think this is somewhat controversial, and a lot of people would say it’s not quite ready for prime time.  But what I tend to use is Rob Knight’s test (American Gut), which also is one of the most affordable.  I previously used uBiome, but the FBI just raided them, so I don’t use them anymore.

Dr. Weitz:                          Really? I didn’t hear about that.

Dr. Gottfried:                     Yes. I do some of the basic, comprehensive stool analyses, like with Genova, or Doctor’s Data. I try to mention at least a couple of labs here, so that I’m not associated with just one. And I like to look at functional tests, things like Calprotectin, as well as lactoferrin, sigA.  I’ve done a lot of testing of intestinal permeability.  I wish we actually had better tests of intestinal permeability.  I end up with a mix, and I want you to answer this question, too.  I end up with lactulose-mannitol as the gold standard, although I wouldn’t really say it’s gold, I think it’s more aluminum or tin.  And then I look at things like zonulin, Cyrex array. But tell me what you do. What kind of testing do you do?

Dr. Weitz:                          A lot of times we’ll do a stool test that includes zonulin. But a lot of times it’s not positive, even when we’re pretty sure that they have leaky gut. In most of the patients who have any kind of dysbiosis, I’m just assuming that they have leaky gut, because it’s so common.

Dr. Gottfried:                     Sure.

Dr. Weitz:                          We used to do the lactulose-mannitol test, but it’s not my priority right now.  So I’d rather know what’s going on in the gut that we can try to rebalance things first.

Dr. Gottfried:                     Absolutely.

Dr. Weitz:                          I’m more interested in doing a good stool test.

Dr. Gottfried:                     I agree with that. I think about the lactulose-mannitol test, and I’ve been using it for maybe 15, 20 years, whenever I first started doing this, and I think about sitting on your back porch, drinking a glass of organic red wine. And I know, if I do the lactulose-mannitol test on you before you have that glass of wine, versus after you have the glass of wine, it’s probably going to be different.  Because we know that alcohol is what we feed animals to test for leaky gut-

Dr. Weitz:                          But I sprinkled some probiotics in my wine.

Dr. Gottfried:                     Oh, good. Okay. You’re well-covered. A little bone-broth chaser.

Dr. Weitz:                          Exactly.  You talk about various toxins in your book that can affect brain health. What are some of the most common toxins that affect brain health that Americans come into contact with?  I know you just mentioned glyphosate. What are some of the others?

Dr. Gottfried:                     Well, unfortunately, the list is very long. I think heavy metals are at the top of the list. We all know about mercury toxicity, that’s something that I’ve talked about a lot in my books. But I was amazed to find, in myself as well as in my patients, higher lead levels, higher cadmium levels, higher arsenic levels. And I think, increasingly, our food and water is exposing us to some of these toxins.  We know that EMFs, for instance, have some modest data. It’s not as strong as I would like it to be, but it’s a little tricky with EMFs. 

Dr. Weitz:                          Right. So you’re talking about the radiation from cellphones, and laptop computers, and wifi in our home, et cetera.

Dr. Gottfried:                     That’s right. That’s associated with a couple of different brain cancers. We know that it increases oxidative stress, especially if you’re holding the phone next to your head. We think that probably increases risk.  Bisphenol A is another one. BPA is brought up anytime we talk about endocrine disruptors. But it’s much deeper than just a xenoestrogen or a disruptor of insulin, which it is, it’s an obesogen that makes you fat, and insulin resistant.  It’s also, it does other things to the brain. In terms of disrupting the hypothalamic–pituitary–adrenal axis. It’s one of the bad players. I’ve got a list. You made me think of the table that I have in my book, where I go through a list of these toxins.  The other thing I think about with lead is that it’s a dementogen. It’s one of those toxins that robs you of IQ points. And we don’t want to be exposed to this, but we know, from the example in Flint, Michigan, that many-

Dr. Weitz:                          Yeah, horrible.

Dr. Gottfried:                     … of us are exposed in our food supply. I found it in my lipstick. So, for those of you who are listening, and you are a woman, or maybe gender non-binary, and you wear lipstick, take a look at your lipstick. Because if it’s not organic, there’s a good chance it contains lead.

Dr. Weitz:                          Absolutely.

Dr. Gottfried:                     I have a few others listed here. Household cleaners that contain phthalates. Fluoride in toothpaste. Flame retardants that are in furniture. Sunscreen that contains PABA. Mosquito repellent with DEET. That new car smell, that’s a toxin for the brain. It disrupts thyroid function, too, which can affect your brain’s ability to focus.  And then there’s a long list of food. But I think water and air are some of the exposures that I think we really need to be thinking about, not in a doom and gloom way, but how do we reduce exposure on the one hand, and then how do we detoxify?

Dr. Weitz:                          How do we detoxify? What’s the best way to get rid of heavy metals, and some of these other chemicals?

Dr. Gottfried:                     Well, this is a great question. This is fun to riff with you, because I imagine you’ve been dealing with this for a few decades.

Dr. Weitz:                          Of course.

Dr. Gottfried:                     And when I first started dealing with it-

Dr. Weitz:                          I’ve been in practice for 30 years, yeah.

Dr. Gottfried:                    You’ve been in practice for 30 years, so longer than me. And I was taught, when I went through my training, to use chelators. And so I had a whole system for how to do that. And what I’ve learned, especially from Chris Shade over the years, is that it maybe be better to focus on glutathione, and to support the detoxification pathways in the liver.  I’ve shifted. There’s still some … there’s a time and a place for chelators, but I have shifted toward really focusing on glutathione as the master detoxifier and antioxidant. But I’m curious what you would say in response to this.

Dr. Weitz:                            Well, no, I totally agree. After finding out about so many patients that we referred for a chelation, who got worse, or had all sorts of adverse symptoms, and even after long courses, that the glutathione, and then binders to capture it, seems a much better strategy.

Dr. Gottfried:                     Yes. I’ve been using his PushCatch quite a bit recently. And I like his binder. I looked at the data on binders, and I wish we had more robust data on the binders. I use them. I think activated charcoal is probably the most proven, but I like his PushCatch system.  I can’t think of an alternative that’s similar to that. There’s lots of companies that make activated charcoal and other binders. Do you have any other supplements that you use for binding?

Dr. Weitz:                          We’ve used modified citrus pectin, I got into a whole discussion with Chris about this. He doesn’t think that’s a very good binder. But Isaac Elias, he has some data showing that it binds lead and certain other heavy metals pretty effectively, so that’s one we’ll throw in there.

Dr. Gottfried:                     Yeah.

Dr. Weitz:                          Chlorella.

Dr. Gottfried:                     Right. Yeah. There’s hope that that makes a difference.  There’s certain foods that I think can really help you with glutathione. I don’t think, for some of us, that it’s quite enough.  I’m someone, I don’t have glutathione S-transferase, and so I just need to take liposomal glutathione.  And I have a fair number of patients … the ones, the canaries in the coalmine, the ones who really have the symptoms from toxic overload, tend to have trouble producing glutathione.  So, yes, you can get it from your food.  Always a good idea to start there first, but I think a lot of people who have to detoxify, need something more.

Dr. Weitz:                          Right.  A lot of people talk about onion, garlic …

Dr. Gottfried:                     Leeks.

Dr. Weitz:                          Leeks, yeah, as being beneficial for stimulating glutathione production.

Dr. Gottfried:                     Right.

Dr. Weitz:                          And of course NAC, which we’ve used for years, which is an amazing compound for so many things.

Dr. Gottfried:                     I love N-acetylcysteine, because it’s got such a great safety profile, and yet it’s so well-proven. This is one of the few supplements that I would say mainstream medicine has actually embraced, because we use it in the emergency room, when someone comes in with Tylenol poisoning, as an example.  So, I think it’s one of the … I’m always looking to, how do we build bridges between the allopathic world, and this more integrative, functional world. And I think, with proven supplements that have randomized trials, like N-acetylcysteine, that’s where we start.

Dr. Weitz:                          Yeah. Well, good luck.

Dr. Gottfried:                     Exactly.

Dr. Weitz:                          I’m sure there’ll be-

Dr. Gottfried:                     How much energy do you have?

Dr. Weitz:                          I’m sure there’ll be a negative study on NAC next week, and then …

Dr. Gottfried:                     Exactly.

Dr. Weitz:                          In the American Journal, in the AMA Journal.

Dr. Gottfried:                     That’s right.

Dr. Weitz:                          If you have a … what would be a set of tests that you might do? Let’s say you have a patient who comes in, they’re complaining of brain fog and memory problems. And you go through their history. What might be a set … we’ve talked a little bit about panels, but I’m wondering, what would be some of your go-to panels?

Dr. Gottfried:                     Sure. Let me just apologize, because I have no air-conditioning, and it’s 100 degrees outside. Because my power just went out, so I’m going to strip here.

Dr. Weitz:                          Oh, okay.

Dr. Gottfried:                     It might make more people go to the video, we’ll see.

Dr. Weitz:                          Exactly.

Dr. Gottfried:                     Maybe not. This is such a good question. Again, I’m a hormone doctor, so the way that I think about this, especially in a woman over the age of 40, is I’m thinking first about estradiol. Because estradiol is the master regulator in the female body. We know that when it comes to perimenopause, even the most subtle, early changes that begin at 40, that there’s a central effect with cerebral hypometabolism, as a result of the loss of estradiol.  And you may not measure it peripherally. You could do a serum test, a blood test, measuring estradiol, and you may not see a change. But there are brain effects that have been documented very well by Lisa Mosconi at Cornell, showing that 80% of women have cerebral hypometabolism, so they start to have the symptoms that you’re describing. Brain fog, they walk into a room, and they can’t remember why. They start to have vasomotor symptoms, maybe sleep becomes disrupted, and it becomes this snowball, that I think leads to much greater health risk as they get older.

What kind of panels do I do? I start with serum panels, because again, that’s part of building this bridge. I think we’ve got good evidence with serum estradiol levels, as well as other hormones, like cortisol, and DHEAS, and testosterone, free and bioavailable, in total. I look at progesterone, and then I’m a big fan of the Dutch test. I wonder if you do this too? I think it gives you so much more information in terms of-

Dr. Weitz:                            Yeah.

Dr. Gottfried:                     … estrogen metabolism, how much metabolized cortisol, the total cortisol load. How do you use that?

Dr. Weitz:                            We just started using it. I was doing the 24-hour urine test, because I like to look at the metabolites, because I think that’s super important for breast cancer risk and everything else. So we just started using the Dutch test more. And I think it’s great, and it’s so convenient, easy for patients to use.

Dr. Gottfried:                     It’s easier than saliva testing. I actually think, at least what I’m seeing in my patients, I think the data is more reliable. And it’s … I’ve just found that it’s been a real game-changer in the way that I take care of patients.  That’s one of the panels. The other basic functional medicine panels that I do, I tend to use a Genova NutrEval. Other people use the ION.  Other people are religious about organic acid testing. I do that as well. But I tend to start with a combination of serum testing of sex hormones, as well as a larger panel.  I always think about glucose metabolism, because we know it’s disrupted in at least half of our patients, if not more. In fact, I wear a continuous glucose monitor, because-

Dr. Weitz:                          Oh, cool.

Dr. Gottfried:                     Because I think glucotype is so important. Our ways of measuring abnormal glucose signaling, I think are 30 years ago. They’re so 30 years ago. Fasting glucose, fasting insulin, hemoglobin A1c, we miss a lot of patients who are like me, who have a sweet potato, and my glucose goes up to the diabetes range. And that’s … I can talk about the reasons for that, but I think understanding how this might map onto symptoms like brain fog, and this gut-brain axis issue, is really essential.  So those are some of the tests that I tend to start with. What about you?

Dr. Weitz:                          That’s great. Yeah, no, I love the NutrEval. I love the fact that it includes organic acids, amino acids, fatty acids, it’s got some heavy metals, it’s got some oxidative stress markers. It’s a really neat, general screening tool. I love that test-

Dr. Gottfried:                    It’s kind of one-stop shopping.

Dr. Weitz:                         Yeah. Yeah, yeah, yeah.

Dr. Gottfried:                    And I like to keep this as simple as possible, and it also, I think, for the most part, for patients who have insurance, it’s well-reimbursed. So they have a good pay assured price.  I like to do that to start with. Often you end up dissecting after a NutrEval. I tend not to do serial NutrEvals. I use that as a screening test. And then, from there, I’ll order organic acid testing, from Great Plains, and then I’ll do some additional stool testing, and I’ll look more at heavy metals.  I tend to use Chris Shade’s quicksilver testing to look at heavy metals.

Dr. Weitz:                            Oh, okay. Have you done provocative urine testing?

Dr. Gottfried:                     Well, I’ve done a lot of provocative urine testing over the years. I do less of it now. I still think there’s a time and a place for it, because I believe in Chris Shade’s science, for the most part. And I think his way of measuring heavy metals makes a lot of sense to me.  There’s mixed data on provoked testing. Here’s where I think it’s helpful. We know, especially for women who reach their peak bone mass at somewhere around 30 to 35, that they tend to store a lot of heavy metals in their bones. And so I think provocative testing, especially in a woman before age 50, can be very helpful to try to unroof some of that heavy metals that are hiding behind the bone matrix. How about you?

Dr. Weitz:                            Yeah, I think that’s actually one of the keys for detox, is if you’ve got a woman who’s losing bone, and she’s liberating more heavy metals, you’re never going to get rid of the heavy metals until you stabilize her bone metabolism.

Dr. Gottfried:                     That’s right. Totally agree.

Dr. Weitz:                           Let’s see, we talked about that. You write about the importance of sleep for brain health. And you write in your book, “Lack of sleep affects neurogenesis, particularly in the hippocampus. You can even develop false memories if you lose sleep.”  So, if you were to stay up half the night tweeting, you might think that thousands people who are protesting you were actually cheering you.  Just kidding.

Dr. Gottfried:                     Oh, that’s very funny. I didn’t realize we’re going to be-

Dr. Weitz:                           No, no, but-

Dr. Gottfried:                     … talking about politics, too. This is going to be funny.

Dr. Weitz:                           No, no, I’m kidding. But can you talk about the importance of sleep?

Dr. Gottfried:                     Sure, sure. Absolutely. I’m also happy to talk about politics.

Dr. Weitz:                           No, no, no, no. I don’t talk about politics.

Dr. Gottfried:                     The power just came back on. So I’m taking over here. I was just listening to a podcast with Matthew Walker, where I felt like he got into the details of sleep in a way that I found really captivating.  What he talks about, he’s a sleep researcher, a PhD, so he doesn’t have clinical experience, but what he believes is that it’s your Deep sleep that’s associated with clearing amyloid beta and other toxins. So we know that the glymphatic system becomes its most effective when you sleep at night, and you have to have that full conversation with the glymphatic system.

Dr. Weitz:                            Can you explain what the glymphatic system is?

Dr. Gottfried:                     Yeah, so the glymphatic system is kind of like a shampoo for the brain, that’s how I describe it to my patients. It’s where the spaces, the interstitial spaces in your brain open up, and this cleansing process happens through your brain.  It’s not the lymphatic system, it’s got a G in front of it. The glymphatic system. And it was only discovered, I think, 10 years ago. It’s a relatively new thing that we’ve found.  The glymphatic system seems to work the best when you sleep on your side, especially the right side, and deep sleep is really essential for this.  I use an Oura Ring to track my sleep.

Dr. Weitz:                            Cool.

Dr. Gottfried:                     And it’s not quite the same as a sleep lab, but I think a sleep lab is often very artificial. And I don’t know that it gives you the best data, other than to tell you whether you have sleep apnea or some other clinical diagnosis.  But for the average person who’s trying to improve their sleep, like their deep sleep and the REM sleep, I think sleep tracking can be very helpful. You don’t have to do it every night. I think just getting a sense of what your issues are, and then working on them, designing an N of 1 experiment, can be very helpful.

And then REM sleep, we know, is really important for emotional regulation, and for prevention of things like anxiety and depression, as well as other what are called mental health issues, and I think are basically health issues.  I think of deep sleep also as that place, as you mentioned, it’s where neurogenesis occurs, and it makes sense to me that not only are you clearing amyloid beta, but you’re also doing memory consolidation, and you’re working on emotional regulation. Those are some of the things that happen with deep sleep.  Do you track your sleep?

Dr. Weitz:                            I have in the past, I haven’t recently, but I definitely … of all the things I do to promote long-term health, it’s the one I’m least good with.

Dr. Gottfried:                     Well, I think it’s close to a panacea as we have. And it’s interesting to me, because I feel like there’s certain topics, Ben, that people’s eyes glaze over when we talk about them. And I would say sleep is one, stress is another, sometimes food. People are just like, “Oh, yeah, yeah, I got that.”  And yet, we know that common sense is not common practice, and so I feel like it’s on us to talk about sleep in a way that really magnetizes people to understand how it’s going to help their health, and what concrete steps they can take to make a change.

Dr. Weitz:                          Right. You mentioned food. What role do food sensitivities play in our risk for diminished brain health? Should we all avoid gluten and dairy?

Dr. Gottfried:                     Well, certainly, gluten and dairy are the most common food intolerances. And I see that all the time in my patients. I don’t know that all of us need to avoid them. I can tell you that I’ve got two daughters, and they both do fine with gluten and dairy, especially the gluten in Europe. They do especially fine with the gluten in Europe.  They don’t have food sensitivities, and I think it’s remarkable, given how stressed teenagers are right now, with social media, and iPhones, and other pressures that they experience.  I find that food sensitivities are incredibly common. The way I think about it is that it tells me that someone has increased intestinal permeability. And so I want to always be thinking of, okay, what’s the root cause? How do I help them with their symptoms? But how do I also address the root cause? How do I improve the integrity of their gut lining?  I’m curious what you would say about this, because I’ve found, over the years, that it’s kind of a big project to improve intestinal permeability. It’s not the kind of thing where you just give them a jar of glutamine, and say, “See you in six weeks,” and they’re done. It’s not like one and done. It’s a much bigger project than that.

Dr. Weitz:                          Yeah, multi phases. You’ve got to try to see what’s out of balance in their gut, and you got to try to reduce the pathogens, and dysbiotic bacteria, and fungal overgrowth, and get the inflammation down, and strengthen the immune system of the gut, and do all those things.  And then you’ve got to try to repair the gut, and then sometimes food sensitivities become a problem, so you’ve got to sort through those. How do you like to sort through food sensitivities?

Dr. Gottfried:                     This is another one of those moving targets, I think.

Dr. Weitz:                          You use Cyrex food sensitivity testing?

Dr. Gottfried:                     I use Cyrex. I sort of, honestly, I somewhat reluctantly use Cyrex. I think it can give me some helpful information, but often, what I find is, it just tells me what I know already, which is that I have to work on a 5-R protocol for the gut, and we have to focus especially on intestinal permeability.  I used to use Alcat. I used to do …

Dr. Weitz:                           There’s many food sensitivity tests out there.

Dr. Gottfried:                     There’s many different food sensitivity tests, and so I used some that were more convenient than others. There’s some that allow you to do home testing. And I’ve found, over time, that they’re less useful than understanding that the patient in front of you has increased intestinal permeability. In pretty much anything they’re eating, they’re going to become somewhat intolerant to.  To me, I think the name of the game is to understand what someone’s triggers are, and to help them, as close to the root cause as you can. But I also am careful not to do what I think of as root causeism, where all we’re doing is addressing the root cause, and we’re not helping the patient feel better as fast as they want to. Because they have to see results to continue to buy in.

Dr. Weitz:                           Yes.

Dr. Gottfried:                     So I think we do have to treat symptoms, along with addressing the root cause.

Dr. Weitz:                           Absolutely. Yup, yup, yup. And then, of course, we always have the elimination diet, which is the true-

Dr. Gottfried:                     And I actually … I’m a huge fan of the elimination diet. I was just looking at some data from so long ago, on rheumatoid arthritis, and the use of the elimination diet. Really strong data showing this is so beneficial. And I read that, and I think, “Oh my gosh, why doesn’t every rheumatologist know this?”  I’m a huge fan of elimination provocation. I think that’s, in many ways, more useful information than an expensive Cyrex array, or some other food sensitivity testing.  The problem is, a lot of patients, by the time they do three weeks, or three months of a food elimination diet, when they’re adding food back in, what I find, time and again, is they are not patient. They don’t do that one dose a day, watch for three days to see the response. They lose their minds, and they have a piece of pizza, and they have gluten and dairy, and tomatoes, and nightshades, and it’s-

Dr. Weitz:                            And they get symptomatic all over again.

Dr. Gottfried:                     And they get symptomatic, and you just lost all that time. So I’m a huge fan of a carefully constructed elimination provocation, where the patient really understands, okay, you have a clean canvas now, at the end of your three weeks or three months. And we need to take our time, and really understand your response to these test foods.

Dr. Weitz:                          Yeah. Let’s talk about hormones, and their relationship to brain health.

Dr. Gottfried:                     Yes, what would you like to know? I can talk about this all day long.

Dr. Weitz:                          I know, that’s your favorite topic.

Dr. Gottfried:                     Yes, it is.

Dr. Weitz:                          Perimenopausal, menopausal women, you’re having symptoms related to hormone deficiencies, estrogen, progesterone. Should we substitute bioidentical hormones? How much is that going to benefit their brain health? Which women should have that done? Should we try other alternatives first?

Dr. Gottfried:                     That’s a great question. The way that I think about this is a pretty simple network medicine, functional medicine, precision medicine formula, which is, I start first with what symptoms she’s having. Maybe it’s a 40-year-old with brain fog.  I’m going to start first with doing testing, and understand what the root cause is, as well as addressing the symptom. I’ll probably put her on an elimination diet.  For me, step one is to fill any nutrient gaps. We may find that she’s a little low on B12, or B6, or folate, and so we may top off some of those nutrients that she’s missing. Maybe she’s low in vitamin C, and so she’s not making enough progesterone. That’s often a low-hanging fruit for someone who’s 35 to 50.

Dr. Weitz:                          That’s a great clinical pearl.

Dr. Gottfried:                     Yeah, and then step two, if that doesn’t resolve symptoms, I’ll start to look a little deeper at what’s going on with hormone balance. And what I find, in the first phase of perimenopause, which is where progesterone drops, but estradiol can be fluctuating wildly, what often find is that chasteberry is a really good solution, because it modulates progesterone levels, it’s been shown to raise serum progesterone in randomized trials, and it’s one of the most proven herbs that we have in perimenopause.  It doesn’t work once you stop ovulating, but there’s a window of time where I find it works really well.  And then, if that doesn’t resolve symptoms, then I move on to bioidentical hormones. And I’m someone who’s pretty careful about it. I would say I’m not … on the spectrum of the people who are really heavy-handed with bioidenticals, and use … well, we can get into that topic, versus people who are scared to death of prescribing hormones, I would say I’m in the middle. Where I like to do genomic testing, I want to understand what’s your risk of clotting, what’s your risk of cardiovascular disease? How do we make a risk balance alternative balance sheet for you, and have a sense of here’s what your individualized risk is, and here’s why I am coming out in favor of or against using hormone therapy.  But at the same time, I would say it’s not a yes/no question. I think it often is what type, what dose? What’s most proven?

You asked specifically about the brain, and I know you asked that for a specific question, because we know that … the emerging data is that there’s a window of opportunity for taking exogenous estradiol. And the window is much smaller, I believe, for brain health, than it is for, say, cardiovascular disease.  We know from the Women’s Health Initiative, as well as some other trials, that the window’s about 10 years for cardiovascular disease, and it’s potentially dangerous and provocative to give it beyond that 10 years for menopause, so after age 60, although I have patients who consent to that, they understand the risk.  But I think, when it comes to the brain, there are these subtle changes, the cerebral hypometabolism that I mentioned, that starts in 80% of women over the age of 40, and I think that’s the window for getting estradiol.  I think we have to consider this as more a problem of middle age, a problem of women in their 40s and 50s, and really consider the benefits and the risks of prescribing bioidentical estradiol in that population much earlier.  And we have data on this from women who go through surgical menopause, that earlier treatment makes a big difference in terms of brain health. The problem is, we have the wrong study, which is giving Premarin and Provera to older women over the age of 60, and it increased the risk of dementia.

Dr. Weitz:                          You’re referring to the Women’s Health Initiative, which used these synthetic forms of estrogen and progesterone, and give a lot of them to women who were in their 60s, or 10 years or so past menopause.

Dr. Gottfried:                     That’s right. And what we found is that it actually increases dementia, it may increase Alzheimer’s disease. But I would say the problem is, it’s too late. And we know that when you put estradiol together with neurons, there’s a point, almost like a switch point, where the neurons respond well to the estradiol. We don’t know what that age is. It might be sometime in your late 40s, maybe early 50s.  And then, when you give it after that, it can actually accelerate the decline of those neurons. So there’s this window of opportunity that we have to define better. And as we wait for better data, I can tell you that I prescribe estradiol to my patients. I usually give a three-quarters dose, like a estradiol patch, Vivelle patch, .0375 milligrams is one of my favorites, together with Prometrium, is what I think is most proven. That’s a standard prescription that I give for my patients who are in their 40s.

Dr. Weitz:                           Okay, great. We talked a little bit about nutritional deficiencies. I think that’s pretty much all the questions I had prepared for today.

Dr. Gottfried:                     All right. Well, it was a fantastic list of questions, I really appreciate it.

Dr. Weitz:                           Thank you, thank you. Any final thoughts, or insights for our listeners, about the brain body connection?

Dr. Gottfried:                     Yeah. I’ll finish with a quick story, because I love how Brené Brown talks about how stories are data with soul. In 2017, I took a month of antibiotics. I’d never had antibiotics before. And I turned this into an NF1 experiment, where I measured my microbiome before and after.  But after that month of antibiotics, I had anxiety for the first time in my life, and I gained about 15 pounds. I had insulin resistance, and a lot of trouble with my fasting glucose and fasting insulin.  And so that’s what got me to go to the literature, and that’s where I found this association between a course of antibiotics and the increased risk of anxiety, depression, learning and memory problems, obesity, insulin resistance. And I can tell you, when I went through my medical training, I was never told to give this kind of informed consent.  I feel like this is a real game-changer. And I’ll give you one teeny little piece of data from my N of 1 experiment. When I measured my microbiome before and afterwards, I had an 87% reduction in the diversity of my microbiota. That’s pretty huge. And that’s anecdotal information, it’s only one subject, but it’s a subject who was studied over time in a scientifically valid manner.

And in many ways, what I was taught at Harvard is that randomized trials are really important. But the N of 1 study is even higher in terms of evidential hierarchy, because it allows you to personalize, it allows you to really know the individual, and not base your decisions on a population.  I feel like that’s where we’re heading. That was part of what motivated me writing this book, and really diving into the literature. But I feel like that’s where we’re heading, with the way that we practice medicine, is to understand … we’ve got to think about how to address … the reason why I took these antibiotics after my surgery, there might be a better way to do this that isn’t a nuclear bomb for my gut microbes, and for those of our patients.  It’s not me that’s so interesting, it’s that so many of our patients go through this. I’ve been prescribing antibiotics for 25 years, right? This is news to me, and it really changes clinical practice. I pay attention to those things that have really changed since we went through our medical training.

Dr. Weitz:                          Right. Are you still in clinical practice?

Dr. Gottfried:                     I am. I went on sabbatical, but I have to tell you, I have 10 patients that just would not let me go, so I still have these 10 patients. And then I’m planning to open my practice again next year. We have a clinic that’s opening in Aliso Viejo, kind of a clinic of the future.  So I’m planning to see patients again, starting next year.

Dr. Weitz:                          Okay, great. So how can listeners find out about your book? And find out more information about you, through your website?

Dr. Gottfried:                    Yeah, the best place to go is BrainBodyDiet.com. That’s where we have a lot of information. We’ve got an anxiety documentary coming up. And that’s where they can learn more about the book.

Dr. Weitz:                          An anxiety documentary? Cool.

Dr. Gottfried:                     Yes. Which is basically functional and integrative medicine, to address anxiety, instead of just throwing benzodiazepines at it.

Dr. Weitz:                          Awesome. Thank you so much, Dr. Gottfried.

Dr. Gottfried:                     Thank you. Such a pleasure to be with you, Dr. Weitz.