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Dr. Karin Duncan discusses How to use a Functional Medicine Approach for patients with Parkinson’s disease at the Functional Medicine Discussion Group meeting on March 23, 2023 with moderator Dr. Ben Weitz.
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Podcast Highlights
6:17 What is Parkinson’s disease? Some define it as the degeneration of the substantia nigra in the brain and the loss of the production of dopamine. There are four symptoms that are usually seen in Parkinson’s and those are the bradykinesia, the stooped posture, the masked facies, and the pill-rolling tremor. The research shows that it can actually start 10-20 years prior to the motor symptom presentation. This degeneration of the dopaminergic neurons in the brain is a long term process and by the time the motor symptoms show up, the substantia nigra is already 70-80% depleted of its ability to produce dopamine. The early symptoms that show up years earlier are the loss of a sense of smell (anosmia), constipation, and REM sleep disorder. The question is if we identify these patients early and help them with these conditions and reduce the underlying inflammation, will we prevent Parkinson’s? We don’t know the answer to that, but it makes sense to try.
10:25 Constipation indicates some gut imbalance or dysbiosis and for patients who end up getting Parkinson’s, it usually is extreme. When the intestines are inflamed, they release a protein into the blood stream called alpha synuclein and patients with Parkinson’s have misfolded alpha synuclein protein aggregated in the substantia nigra. If we want to help patients with Parkinson’s disease with their brain function, we need to help them with their gut. If they are taking oral medication and they have a dysfunctional gut, they will likely not be absorbing it as well and when we improve their gut health, we see a drop in the need for Sinemet or Carbidopa/Levodopa by up to 30-50%.
15:19 Cholesterol. Lower levels of cholesterol and taking statins increases the risk of Parkinson’s disease. Research indicates that total cholesterol should not go lower than 150-175.
18:48 Environmental toxins. Trichloroethylene (TCE) is a dry cleaning chemical that was also used as a solvent including at Naval shipyards and military bases that is linked with a drastically increased risk of Parkinson’s disease. [Solvent exposures and Parkinson’s disease risk in twins.] Pesticides and glyphosate can be triggers for Parkinson’s disease. Mycotoxins from mold may also play a role. Dr. Duncan likes using Great Plains lab to test for environmental toxins and mycotoxins. If a patient is 80% deplete in dopamine, they are likely 40-60% deplete in glutathione. When cells die, like the dopaminergic neurons, they go through apoptosis and they release their toxins, which causes oxidative stress on neighboring cells that leads to progression of the disease. This is one reason why supplementing with glutathione can be helpful.
23:42 Reactivation of Viral Infections. Viral infections like Epstein-Barr virus (EBV) or Herpes Simplex virus (HSV) can be triggers for Parkinson’s disease. So can Lyme disease. If you test for EBV you need to make sure to test for EBNA, Epstein-Barrr nuclear antigen, which is more indicative of reactivation than IgG antibodies.
28:57 Lab testing. Dr. Duncan has a standard lab panel that she runs for most patients with Parkinson’s disease that includes a CBC, a metabolic panel, glucose, insulin, Hemoglobin A1C, fructosamine, an iron panel plus ferritin, an extended thyroid panel, folate, vitamins B6 and B12, vitamin D, DHEAS, HsCRP, uric acid, F2-isoprostanes, and a fatty acid profile/omega check. Higher levels of iron tend to make Parkinson’s disease patients worse. Higher levels of uric acid are actually protective of Parkinson’s disease. Dairy inhibits uric acid, which is one of the reasons Parkinson’s patients should avoid dairy. Inosine is a supplement that’s commonly used with Parkinson’s that can boost uric acid levels and alleviate some symptoms.
31:58 Pharmaceutical approaches. The most familiar drug is Sinemet or carbidopa and levodopa. When Dr. Duncan has patients who don’t want to take any drugs and just want to use natural supplements, while there is Macuna Pruriens that increases dopamine levels, the dosages cannot be standardized even from pill to pill within the same bottle. It makes sense to take synthetic carbidopa and levodopa, which can slow down Parkinson’s disease and allow patients to perform normal functions like preparing food and eating and exercise. There’s also an extended release form, called Rytary. You slowly increase the dose till you reach the max and it tends to stop working as well after about 10 years, though when you use a Functional Medicine approach, you often get an extended benefit from synthetic dopamine. When we take care of vitamin B12 deficiency, help with restoring gut motility, make sure that you are producing enough hydrochloric acid, that you are taking it with protein, that you are not taking magnesium at the same time, that you are taking CDP choline, and that you are taking vitamin C with it. Another medication that can be helpful is Rasagiline or Azilect, which is a novel MAO B type inhibitor. This is the only drug that has shown some slowing of disease progression. By the way, turmeric is a natural MAO B inhibitor. There is also Imbrija, which is an inhaled form of levodopa, that allows you to bypass the gut, that can be used as a rescue medicine.
33:07 Previous head trauma has a relationship with most neurological issues, including Parkinson’s disease. Patients with Parkinson’s who have a history of traumatic brain injury or CTE tend to have a fast progression of their condition and tend to be medication resistant. Dr. Duncacn may recommend Deep Brain Stimulation for such patients.
34:43 Neurological testing. You want to look for cogwheel rigidity. You also want to check the gait and have them turn around as fast as they can and have them walk heel to toe. Parkinson’s patients often have a lack of arm swing on one side and may have a head tilt to the side that’s affected. You should also learn the tests that are included in the UPDRS. You should have them stomp and move their feet as fast as they can. The finger to nose test will test intention tremor and coordination. You should have patients sign their name on a piece of paper, and just look if they’re having that agraphia to see if their handwriting has gotten smaller.
Dr. Karin Duncan is a board certified Naturopathic physician with a focus on integrative neurology. Dr. Duncan is a specialist in treating patients with Parkinson’s disease with an Integrative Approach. Dr. Duncan works at Coeur d’Alene Healing Arts in Idaho and the website is cdahealingarts.com.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.
Welcome, everybody. I’m Dr. Ben Weitz. Welcome to the Functional Medicine Discussion Group meeting tonight. I’m very excited that we have Dr. Karin Duncan, joining us for what should be a fascinating discussion about a functional medicine approach to Parkinson’s disease. We have all probably heard quite a bit about a functional medicine approach to Alzheimer’s disease with Dr. Dale Bredesen, Dr. Kharrazian, Dr. Perlmutter speaking and writing about this, but I feel that Parkinson’s disease is a forgotten neurodegenerative condition. This is why I’m so excited to take a deep dive into how we can help patients with Parkinson’s disease with the natural approach. I want this meeting to be interactive, so please participate by typing your questions into the chat box, and then I’ll either call on you or ask Dr. Duncan your question when it’s appropriate. I hope that you’ll consider joining some of our future meetings. April 27th, Fiona McCulloch is going to join us from Canada for a discussion on menopause and hormone replacement. May 25th, Dr. Mark Pimentel will join us. He apologizes for missing last month’s meeting. He’ll be joining us for a discussion on SIBO and IBS. We haven’t figured out June, but July 27th, Dr. Bredesen will be joining us for a discussion on Alzheimer’s disease.
If you’re not aware, we have a closed Facebook page, the Functional Medicine Discussion Group of Santa Monica, that you should join. If you’re listening out there, this page, it’s just for practitioners, so we can continue this conversation when this evening is over. I’m recording this event. I’ll include it in my weekly Rational Wellness podcast, which you can subscribe to on Apple Podcasts, Spotify, or YouTube. If you enjoy listening to the Rational Wellness Podcast, please give me a five-star ratings and review.
Now, I want to thank our sponsor for this evening, Integrative Therapeutics. Steve Snyder, who normally comes and tells us about a few of their products, is unable to join us, because he got tickets to go watch UCLA in Las Vegas. I’m jealous, but I want to tell you about a few Integrative Therapeutic products. They have a great brain formula called Neurologix, which is a non-stimulant neurotropic supplement for enhanced cognitive performance. It contains neumentix, spearmint extract, which contains phenolic compounds for sustained mental focus and to support working memory. It contains cognizin citicoline to support brain energy and metabolism, enhanced frontal low bioenergetics, and increase ATP levels in the brain, and saffron extract, which supports positive mood.
They also have a great highly absorbable curcumin product, Theracurmin, which is a water-soluble form. There’s actually been a lot of research done using this particular product. One of the advantages is you get a therapeutic dosage with only two capsules a day, and there’s studies showing that it reduces dementia, and promotes brain health. Our speaker for this evening, Dr. Karin Duncan, is a board-certified naturopathic physician with a focus on integrative neurology. She’s a specialist in treating patients with Parkinson’s disease using an integrative functional medicine approach. Dr. Duncan practices at Coeur d’Alene Healing Arts in Coeur d’Alene, Idaho. Dr. Duncan, thank you so much for joining us.
Dr. Duncan: Thank you for having me, Ben. Thanks for being here, everyone.
Dr. Weitz: Absolutely. So, how did you first become interested in treating patients with Parkinson’s disease?
Dr. Duncan: Well, my mom used to tell me as a kid, “18 words or less,” because I was a chatterer. So if I get going here too, just throw something at me. Long story short, I actually became a caregiver at the age of 14 for my dad who had a neurologic condition, and for 25 years, advocated for him in the conventional realm, and worked with physicians, and had this really deep passion for neurology. Then, when I went to school, I knew I wanted to focus on it, and I met Laurie Mischley. She is really the one out there spearheading the research. She’s funded by the Michael J. Fox Foundation, NIH. She presents at the World’s Parkinson’s Congress every year. So at the beginning of every talk, I always want to say I don’t have any conflict of interest. I just have this incredible relationship with this woman who’s really spearheading the integrative approach for Parkinson’s. She invited me to be a part of the Parkinson’s disease summer school through Bastyr University, my alma mater, and Kenmore. On day one, I said, “Hey, Laurie, I don’t know how you do what you do. All you see is people with Parkinson’s. Don’t you get bored?” She was just like, “Give it a week.” At the end of that first week, I went up to her with tears in my eyes. I’m like, “This is what I want to do.” It was such a profound experience for me to witness these people come in, share their stories, recognize that no two people were the same with Parkinson’s disease. There’s so much promise in the therapeutics that we’re doing, so it was exciting to join the team. Then the longer I do it, the more I enjoy it. Neurology has been in my blood since I was young, and here I am.
Dr. Weitz: That’s great. So, what is Parkinson’s disease? How is it defined? How do we diagnose it?
Dr. Duncan: Oh, well, really, I’d love to take this opportunity to open up to the crowd. If anybody wants to tell me what they think Parkinson’s disease is, I’d love to hear somebody else’s definition.
Dr. Wasserman: I guess the simple degeneration or lack of dopamine, the substantia nigra, and any disease or entity can affect that. That’s my very light definition.
Dr. Duncan: I like that one. What you’ll hear in most conventional terminology, or if you Google Parkinson’s disease, it’s your four symptoms, the bradykinesia, the stooped posture, the masked facies, and the pill-rolling tremor. When I talk to my patients or when I talk on these lectures, I always like to say when Parkinson’s disease is diagnosed dependent on motor symptom presentation, because we’re diagnosing it based on motor symptom presentation, but the research is showing that Parkinson’s disease can start as early into 10 to 20 years prior in the human body. So, it is in short the degeneration or the death of dopaminergic neurons, but the symptom presentation that we’re looking at and how we’re defining it by autopsies is really far off. I think Ben and I have talked before. Until we redefine what that looks like for people so we can recognize it earlier, we’re going to be stuck in this hamster wheel of being too late to the diagnosis.
Dr. Weitz: I think the most common symptom people think about is the tremor. That’s actually not something that always occurs, and sometimes occurs quite late, right?
Dr. Duncan: Absolutely. I mean, what we’re recognizing is that by the time of diagnosis, depending on motor symptom onset, the substantia nigra is 70% to 80% depleting dopamine already. So by the time the motor symptoms show up, we’re so late to the game.
Dr. Weitz: Right. Now, what are some of the common symptoms that happen early? Patients often have constipation. I understand that’s a big thing. I was thinking about the fact that one of the other early, early symptoms is a loss of taste. Now, we’ve got all these patients out there who’ve had COVID, and they have a loss of sense of smell and taste.
Dr. Duncan: That one bit me in the ass, Ben, because I was lecturing and raising awareness about… Actually, the loss of sense of smell is what we recognize in people with Parkinson’s, not so much-
Dr. Weitz: Oh, the sense of smell, I’m sorry.
Dr. Duncan: Some anosmia early on. When COVID happened, I’m out there lecturing saying, “If you have this triad of non-motor symptoms, constipation, anosmia, and REM sleep disorder, we need to treat you as if we would treat somebody who is at risk for heart attack. You’re sedentary. You’re a smoker. You’re heavy overweight.” So, when I started lecturing about that, and then COVID happened, you should have seen the messages, “Oh my God, I lost my sense of smell. Am I going to get Parkinson’s disease?” But yes, when we look at that, those are the triad of symptoms that we’re really trying to stand on the rooftop and say, “If we are all aware that this triad of non-motor symptoms predates the diagnosis by up to 10 to 20 years, and we do something about it, could we actually cure Parkinson’s disease?” I mean, that’s the big question, right? If we can slow those inflammatory processes down, and treat those, would it continue to degenerate? Of course, we don’t know the answer yet, because we’re not doing it. It’s a huge passion of mine. I have, I would say, five to seven patients in my practice right now that I’ve identified, and actually had that conversation with, and said, “Hey, you’re meeting these risk factors.” Most of them have somebody in their family who’s had Parkinson’s or a neurologic condition. We’re seeing vitamin D deficiencies. So, as things are piling up in the investigative work, I’m sitting them down and saying, “I want to be really upfront with you, because I’m passionate about this. I’m not saying you’re going to get it. I don’t have my crystal ball, but here’s what I know, and I’d be doing a disservice if we didn’t address this.”
Dr. Weitz: One of the really interesting ones is the constipation, which indicates that there’s some gut imbalance, gut dysbiosis. What have you found is something that might make sense as an intervention? Do you find some of these patients have methane SIBO, or what would be the intervention that might make a difference?
Dr. Duncan: Can I just say yes? Yes, any, and all. I mean, we’re finding so many GI dysfunction and inflammatory conditions in people with Parkinson’s, and they’re extreme. They’re really severe. I have a patient who he can’t sit down and watch a movie with his family just because of his gut inflammation and pain. So, to roll back, because as I understand it, Ben, these are all medical professionals here on this call, correct?
Dr. Weitz: Yes. Yep.
Dr. Duncan: Yeah, so I’m going to get a little nerdy here for a second.
Dr. Weitz: Great.
Dr. Duncan: The inflammation in the intestines, when the intestines are inflamed at ages studied as young as five years old, we’re seeing when the intestines are inflamed, they release a protein into the bloodstream. The name of that protein is alpha synuclein. If you’re familiar at all with the pathology of Parkinson’s disease, and autopsies of the people with Parkinson’s, we’re finding this misfolded alpha-synuclein aggregated in the substantia nigra. So, all of these pharmaceutical targets are how do we get rid of alpha-synuclein? How do we get rid of this? But really, the question is why is it there to begin with?
It’s an intentional compensatory response mechanism from the intestines saying, “SOS, we’re pissed. We’re going to send out alpha-synuclein.” Then anybody who wants to yell out to mute, what’s the nerve that connects the gut in the brain? We know the vagus nerve is doing that. There’s a huge hypothesis being accepted in the conventional world that that protein can travel up, and then the vagus nerve originates near the substantia nigra, and deposit there. So, when we’re looking at gut health and PD… We could take the rest of the hour talking about it, and I’ll try not to. So, throw something at me if I just keep going.
Dr. Weitz: I would definitely. That’s a rabbit hole I would like to travel down as well.
Dr. Duncan: Well, it is. I pump the brakes, and so many people will come into me, and say, “Hey, I want to work on my Parkinson’s disease. What meds should I take? What do I do for my brain?” I say… I think I told you this before, Ben. Excuse me. I consider it borderline malpractice to prescribe somebody an oral medication that they cannot absorb. If their gut is that inflamed, and they’re resistant to the use of oral medications, then I pump the brakes. As frustrating as it may be for patients to hear, “Wait, I’m not seeing an improvement in my symptoms yet,” I will say, “Hey, stand by.” What I’m noticing in my patient population is once we treat the gut, whether it be SIBO or IBS, Crohn’s, I mean, IBD, Crohn’s, things like that are just your run in the mill low gastric motility, because of autonomic dysfunction.
We are actually seeing a drop in the need for Sinemet or Carbidopa Levodopa by up to 30% to 50%. So, operating well, lower symptom presentation with a lower dose of the medicine that their neurologists are pretty much maxing them out on and saying, “You’re done. This is the end of the efficacy.” So, that gut health, it has to be first, because that’s where we’re getting all of the effect of our medicine and our nutrients.
Dr. Weitz: I got to get my mega phone. Researchers on Parkinson’s, before we spend the next 20 years spending billions and billions of dollars developing drugs, blocking the formation of this Alpha-synuclein protein, take a look at the research on Alzheimer’s. Even though they have drugs that clear out the amyloid plaque, it doesn’t cure Alzheimer’s, and a lot of the patients get worse. So before we make the same mistake with Parkinson’s, and spend billions and billions of dollars trying to block this one protein…
Dr. Duncan: Understand why the body’s making it.
Dr. Weitz: Exactly.
Dr. Duncan: I mean, in the beauty of the human body, when you really sit there and think about, it’s this gorgeous process that the body’s saying, “We’re putting out our distress signal. Why aren’t you listening?” We’re like, “Let’s kill your distress signal.”
Dr. Weitz: Somebody asked about Alpha-synuclein, the protein I just mentioned. Dr. Duncan just mentioned that some of the drugs for Parkinson’s are designed to clear out this alpha-synuclein protein. It sounds very much like the Alzheimer’s story in that sense.
Dr. Duncan: They’re already billions in, Ben, honestly.
Dr. Weitz: Oh, I’m sure. Now, it’s interesting. You mentioned that we should be treating this like heart disease in terms of prevention. I was digging through some of the research on Parkinson’s today in between patients, and I saw several articles showing that lower levels of cholesterol are actually related to increased risk of Parkinson’s, and taking statins seems to increase the risk of Parkinson’s. So, maybe we don’t want to treat it the way we treat heart disease.
Dr. Duncan: No, I don’t want to take a similar approach. You could pick anybody off the side-
Dr. Weitz: No. No, I know. I know what you’re saying.
Dr. Duncan: [inaudible 00:16:04].
Dr. Weitz: I just wanted to point that out that that’s really interesting that cholesterol, which I think most of us in the functional medicine world know is super important for brain health. Yet, the conventional cardiology world would tell us that cholesterol is… that lowering cholesterol through taking statins has no effect on brain health at all. I recently heard a very popular podcast host who talks a lot about cardiovascular disease saying the goal should be to get ApoB or LDLC down to 30 or 40. Just drive it as low as possible using whatever pharmaceuticals are necessary, and claiming that there’s no problem with brain health, because the brain produces its own cholesterol.
Dr. Duncan: You can get even more detailed than that, but the cholesterol levels are really important. I’m a huge proponent of collegiality. I’ve reached out to cardiologists time and again, and I’ve only gotten pushback once, to be honest. So, I really want to be a sounding board, just saying, “Bridge the gap. Have the conversations. Alleviate patient advocacy. Pick up the phone and call the team.” It’s such a great way to connect with that patient’s team. I’m a huge proponent of patient advocacy, but when I talk to this cardiologist, I’m saying, “Hey, here’s what the research is showing here. I respect what you’re doing. I understand what you’re doing. Can we set a goal?” In the labs research that we’re finding, the cholesterol goal of 150 to 175 is really as low as we want to go. So, when you set that goal out there… Like I said, I’ve only had pushback once, and it’s, “Hey, let’s set this goal. Let’s lower the risk for statin. What are you doing over there?” We’re doing diet and lifestyle, and we have red rice on board, or we have some other botanicals and, “Hey, can we recheck in six months, and then collaborate and see if you feel comfortable with the plan?” It’s a really effective conversation. Like I said, I just don’t get pushback.
They’re most of the time… I’m not taking anything away from they prescribe it, and then they refill it, and then there’s not really that follow through. So when you bring their attention to it, “Hey, patient A’s cholesterol is at 110, and they’re really declining here.” We need to reduce that. Then when you talk about cholesterol in the brain, and fat and everything like that, that’s really what we want to be supporting and supplementing with if we need to.
Dr. Weitz: We know that there’s lots of environmental triggers that can trigger the onset, or make Parkinson’s worse. What are some of the most important environmental triggers?
Dr. Duncan: The ones that are proven as a dry cleaning agent, and then there’s a toxin. I think I stumbled on this last time you asked me. You think I’d be more prepared, but the toxin in the Navy that was used in navy yards and on navy ships, that has been a known causative now. It’s not even correlative for Parkinson’s disease. Other factors, pesticides, glyphosate is out there. There are some theories on mycotoxins. There’s a lot of theories on mycotoxins. I just… Anybody want to send me a link for a lab that true blue and accurate and hasn’t changed their reference ranges in the last two years, I’d love to see it, because those are tough ones to test. Then you repeat testing in the lab, change their reference range or what is normal. So with that, there’s… But there’s a ton of-
Dr. Weitz: What lab do you like for toxins and mycotoxins?
Dr. Duncan: I’ve most consistently used Great Plains.
Dr. Weitz: Okay.
Dr. Duncan: That’s usually the one that I’ll use for that one. Environmental, or, sorry, elemental toxins, or when I’m looking at the essential toxins or toxic minerals, I’ll use the Doctor’s Data.
Dr. Weitz: We’ve been using Vibrant. They have a total tox burden that includes 20 heavy metals, a bunch of environmental toxins and mycotoxins all through urine.
Dr. Duncan: Great. No, I’d love to learn more about it. Testing is… There’s so many out there. Just trying to know what’s best, but that’s what we’re looking at there. An interesting thing on the toxin thing, Ben, I think I told you this too, but back in school, you take this environmental medicine class, and everybody leaves like, “I’m not touching anything. I’m not going to breathe the air. I’m not going to go out of my… I’m going to be bubble boy.” I was a little older. I went through med school. I had been in the military, and I was like, “Well, I’m screwed. I got every toxin out there that I-
Dr. Weitz: Toxic think burn pits.
Dr. Duncan: So when I’m looking at it, I’m saying, “What can we do to enhance the terrain of the body to eliminate toxins?” A really interesting fact is, like I said, by the time of diagnosis, because of motor symptom onset, if we’re 80% deplete in dopamine, we also have evidence that shows we’re 40% to 60% deplete in glutathione. Glutathione is the primary antioxidant of the central nervous system. So, in layman’s terms, what I tell my patients is, “If you have this degenerative disease because of the death of dopaminergic neurons, and we know that when cells die and go through apoptosis, they release their toxins into the environment or the debris, which causes oxidative stress on neighboring cells, that creates a domino effect or a faster progression of the disease.” Now, we don’t have the dump truck. We don’t have the thing that’s going to come clean it up, so it’s perpetuating that pathophysiology there, if you will. So, when we talk about toxic burden, it is really important to recognize what each patient has, one for diagnosis confirmation, because there’s been a handful of people that I’ve undiagnosed with IPD to Parkinsonism based on heavy metal toxicity or toxic burden, but also for treatment. Many of the people with Parkinson’s that walk into my practice aren’t vital or resilient enough to even go through the detox process if they are burdened. So, it’s nice to know, but it’s also, in my opinion, more important to boost up that vitality and the resilience of the patient and their physiology. Say, “What’s your glutathione levels? How can we help your liver support?” Of course, that brings us back to the GI, right? “Are you pooping? If you’re not getting rid of your toxic waste products, then we need to work on those emunctories first.”
Dr. Weitz: Those are part of most functional medicine detox programs anyway.
Dr. Duncan: Right. Exactly, but I’ve seen… I’ve had patients come in who’ve been through detox protocols, and they just weren’t ready for it yet, and they get really sick, and it can aggravate Parkinson’s. It’s inflammatory, so we have to be really cautious with this population, how hard we go into any treatment. I mean, even something as relatively benign as SIBO can really put that dent in the Parkinson’s symptoms, and when it’s degenerative, we want to avoid that risk very carefully.
Dr. Weitz: I think the strategies that are going to tend to really make patients worse are when we’re using these oral chelating agents or IV chelating agents. I think the more modern approaches use liposomal glutathione and maybe some binders and liver support and things to support bile production,
Dr. Duncan: Broccoli and selenium, Ben.
Dr. Weitz: There you go.
Dr. Duncan: I mean, don’t underestimate those types of things too, that can really help with that removal of those toxins.
Dr. Weitz: Now, I’ve also seen some data that viral infections like Epstein-Barr can be triggers for Parkinson’s. Interesting, now coming back to that, we’ve been through this pandemic, and we’re finding that reactivation of dormant viral infections like Epstein-Bar are very common for patients as part of the long COVID process.
Dr. Duncan: I mean, in my opinion… I won’t dive into the long COVID thing, because that’s a whole another podcast. But in my opinion, what I am seeing is that’s what we’re missing, in the biggest sphere of medicine in general, is we’re missing what else? Once we get to a diagnosis… I do this lecture to my patients so many times in online forums is, “Once you get this diagnosis of Parkinson’s, we’ll stick to that.” It’s really easy then for everybody to grab this big umbrella, and say, “Oh, you’re not pooping. That’s Parkinson’s. Oh, this is happening. That’s Parkinson’s.” Let’s just dump it all in this Parkinson’s bucket, because that’s a lot easier. The same thing I think happened with the pandemic. When we start to say, “Oh, the body’s capable of having more than one disease or more than one dysfunction, and teasing that out,” what I tell people is, “If we diagnose you with hypothyroid, and some sort of food sensitivity, and B vitamin deficiency, now the diagnosis of Parkinson’s becomes a lot lighter and smaller, and we’re managing these other symptoms.” So, when we’re talking about EBV, just in general comorbidities, it’s really important to test for those, especially if we’re seeing the lab values show up that way. We do have a history of seeing low lymphocyte values in people with Parkinson’s disease. If that continues to show up in monitoring, then that’s the next step I take is say, “What else is affecting your nervous system? EBV. Is it Lyme? Is it HSV?” There are so many potentials out there.
Dr. Weitz: Absolutely.
Dr. Duncan: With EBV, the last thing I want to say is knowing how to test is really important. I’m definitely not the end all be all, but I dove in really deep on this one, because so many people come and say, “I have EBV. I’m on all these supplements. I can’t afford.” It’s just it’s this long rigamarole, and I’ve never seen a reactivated EBV panel run. So, remember when you’re running EBV panels to do the thorough panel, and remember that if they’re IgG antibodies, and that’s not necessarily indicative of a reactivation unless you’re running that EBNA, and that one, if that’s showing up, is more indicative of reactivation, but not 100% specific there.
Dr. Weitz: Can you tell everybody exactly what that test is you’re talking about, because I think a lot of us are relying on IgG?
Dr. Duncan: Yep, they do. There’s the IgG, IgM for the viral capsule-
Dr. Weitz: IgA.
Dr. Duncan: There’s one more IgG, but then there’s a whole other brand, and it’s the Epstein-Bar nuclear antigen, the EBNA. That has also an IgG test, but if that’s elevated, that’s more indicative of a reactivation. The other ones are more indicative of a past infection. So, to determine whether or not you’ve had been exposed or not to whether or not it’s actually reactivated in your body, that fourth lab test is pretty important.
Dr. Weitz: Right. Now, one of the things I’ve been seeing and some other practitioners have been talking about is a immune system dysfunction. We’ve been running some tests to look at immune system function like the… Cyrex has the lymphocyte map test, and then their cytokine test. That seems to be one strategy to helping patients with some of these reactivated viruses by trying to support the immune system in whatever way it’s imbalanced.
Dr. Duncan: Right. There’s theories out there that Parkinson’s even originates as an autoimmune variant. What I tell, again, most of my patients, if they have the diagnosis, is that you’re technically under the classification of immune compromise by nature of your disease for whatever reason and however you reflect. It’s something to understand for themselves and their family that their immune systems are more vulnerable, and need to be protected.
Dr. Weitz: Steve asked about have we seen an increase of Parkinson’s since COVID? I think in general, we’ve seen an increase in autoimmune diseases, haven’t we?
Dr. Duncan: In general… I mean, in my clinic, I can speak to that for sure. I don’t know the epidemiology of Parkinson’s since COVID. I haven’t looked at that data, but Parkinson’s has spiked into being the leading disease in the population. I think that’s just by age as our boomers get into that generation, and the risk factors have increased in our society, I think.
Dr. Weitz: Right. Dr. Vojdani has published a paper showing that COVID is the most autoimmune reactive virus that exists.
Dr. Duncan: I haven’t been in practice long enough to know that, to be honest, because the flu’s really old but-
Dr. Weitz: No. No, he’s actually done a study to show the number of different… What are some of the most important lab tests for us to do when we’re assessing potential patients with Parkinson’s?
Dr. Duncan: I have a standard lab panel for most of my people at Parkinson’s. You’re going to do your blood count and your metabolic panel. I usually pair an A1C with insulin. Rarely do I run an A1C by itself anymore. I’ll always do A1C with insulin. Again, in the aging population, we tend to see numbers of your hemoglobin and red blood cells. There’s a lot of inflammatory anemia happening. So if you need to back up the blood sugar regulation with the fructosamine, that’s also something I add on. There is some theories out there, because it’s metabolic in nature that Parkinson’s being a type three, similar to what we’re saying about Alzheimer’s disease type three diabetes. An iron panel plus ferritin, iron is hugely correlated with Parkinson’s disease, development of, progression of, so always running a full iron panel with ferritin. I do an extended thyroid panel.
Dr. Weitz: By the way, iron generally increases risk, right?
Dr. Duncan: Yes. An elevated iron increases risk. I have four now in my practice that I’ve diagnosed with hereditary hemochromatosis for the first time in their life. So, it’s a non-standard lab, and it’s just essential for not just neurologic health, cardiovascular health, and liver health for sure, but then we’re looking at expanded thyroid panel. I do an expanded thyroid panel, and everybody who comes in as a first patient, if it’s good to go, then we can cool it from there. I look at your B vitamins, B12 and B6, and your folate. We know that the use of levodopa can deplete the body of folate and b12, so looking at those for sure, vitamin D.
Dr. Weitz: Do you prefer-
Dr. Duncan: I’m walking through my lab for vitamin D and then DHEA with a high sensitivity, CRP, uric acid, F2-isoprostanes, and an omega check. That’s my standard, and then of course, patient specific add or subtract.
Dr. Weitz: Uric acid, we’ve learned from Dr. Perlmutter That even slightly elevated uric acid levels above 5.5 are associated with metabolic disease. But for Parkinson’s, elevated levels of uric acid are actually protective. Isn’t that right?
Dr. Duncan: They are. Yeah, it’s really fascinating, and we see that when we avoid dairy. Dairy inhibits uric acid. We actually get an increase in uric acid levels, which are protective for Parkinson’s disease. We have to be a little bit careful, of course, patient specific, because they can be inflammatory. Inosine is a supplement that’s commonly used with Parkinson’s disease that can boost uric acid levels, and alleviate some symptoms.
Dr. Weitz: Interesting. Is that one that you use?
Dr. Duncan: On occasion. I don’t have a ton. Mostly, I joke most of my patients in the aging population have plenty of uric acid. I’m not seeing a big depletion here.
Dr. Weitz: Let’s talk about some of the most common pharmaceutical approaches. Oh, somebody asked, can you repeat dairy inhibits? Did you say something about dairy?
Dr. Duncan: Dairy will inhibit uric acid and with… There’s twofold there. Dairy is one of the major food groups that we do recommend avoiding for people with Parkinson’s. When I first started in my practicing, you learn it, and you’re gaining ground here. I was like, “Let’s try to avoid dairy, and here’s what we know.” Now, my poor patients, I’m like, “Nope. Dairy done. Get it out.” We have so much evidence to show it’s a risk factor for development of and progression of Parkinson’s disease. Then everybody wants to ask about goat and sheep.
My answer there’s they’re never going to do a randomized control trial of cow’s milk dairy versus goat milk dairy. So, go plant-based if you can, and boot it out of the house. Those are pieces of information we’re not going to know. Again, we know uric acid is protective, so it’s a twofold reason to avoid dairy. We want to boost up those uric acid levels, and we have these independent clinical evidence to show the progression [inaudible 00:33:07].
Dr. Weitz: Actually, let’s pause on the drugs. We got a few questions, I think, we should try to address. Bernie asked about the relationship between head trauma and Parkinson’s, and most neurological diseases, Alzheimer’s including.
Dr. Duncan: Bernie, I appreciate that question. Yes, head trauma definitely has a relationship to Parkinson’s. It makes it very challenging to treat. A lot of my people with Parkinson’s who have a history of TBI or CTE are either medication resistant, or their progression is quite fast that it’s hard to catch up with. So in that realm, we get a huge team on board neuropsychiatry. We have a functional medicine doctor that’s working on neuroinflammation. We’re doing trials of different Parkinson’s medications. Then if it’s a motor symptom prominent presentation, then I’m usually recommending DBS for some of those folks, but it makes it really challenging when there’s confounding neurologic trauma happening there.
Dr. Weitz: On the testing, Steve asked about do you run organic acid testing?
Dr. Duncan: On occasion. Yep, so I will check for metabolite function or presence in the urine. If I do, I use great… Hold on. Do I use? Yes. No, I use Dutch. I use the Dutch test for that one. Great Plains at PD summer school. But yes, we will run OATs testing on occasion to see how some of those metabolites are functioning.
Dr. Weitz: Sherry asked, “What are the best neurological tests to run?” Now, we’re talking about the neurological exam part, which is separate from the lab testing.
Dr. Duncan: Oh, like for physical exam?
Dr. Weitz: Yes. I assume that’s what you mean, Sherry, right? Okay. So, you’re seeing the twitching-
Dr. Duncan: I’ll answer that one. Your neurologic test is going to be really important. I always look for Cogwheel rigidity. I think that’s one that’s missed a lot in the diagnosis. They can actually show up a little bit before motor symptoms. So, people are diagnosed, but they’re not really strong in the motor symptoms, the tremor. You’ll often see that Cogwell rigidity in their shoulder or elbow joints. Then the gait analysis is really huge. Gait analysis, people get diagnosed on their walk all day every day by neurologists. So, having them turn around, walk your normal gait away from me, turn around as fast as you can at the end of the room, come back heel to toe. You can do the shin slide, but making a really thorough gait and posture analysis. I will check gait. I will-
Dr. Weitz: What are some of the most common gait abnormalities you’ll see?
Dr. Duncan: Shuffling a little bit later on, but that lack of arm swing on one side is really the most early sign there, and then a head tilt, believe it or not. Oftentimes, people will have that head tilt to the side that’s affected when they’re doing their gait analysis. DTRs are always going to be important, that repetitive rapid alternating movements. If you really want to dive in, you can go to the MDS website, and learn the UPDRS, or just a few tests from the UPDRS. You don’t have to be qualified to do the entire test. I nickname it the chicken dance, but it’s really this. Can you stomp and move your feet as fast as you can, so you can check those movements? The finger to nose test will test that intention tremor and coordination. I mean, those are really the big ones. Oftentimes, they’ll have people sign their name on a piece of paper, and just look if they’re having that agraphia to see if their handwriting has gotten smaller.
Dr. Weitz: Some of you guys-
Dr. Duncan: I also use that for signs of improvement. Hey, I need you to do sign again. Let’s see if these things are helping and if we’ve gotten better control of your motor symptoms.
Dr. Weitz: Now, is there a quantitative score patients can get on that neuro test, or any-
Dr. Duncan: The UPDRS is very detailed. That’s what movement disorder specialists are using for diagnostic and prognostic testing. It’s a very useful test when not used in isolation. I think the frustration is they’ll go in, and they’ll do excellent at the test, and they’ll be feeling like shit. They’re like, “Hey, my neurologist said I’m doing great. I don’t need anything else, but I haven’t pooped in four days, and my anxiety’s through the roof. Here’s how I’m really feeling, but my UPDRS was great.” So, again, taking that all into consideration.
Dr. Weitz: Right. Always treat the patient. Somebody asked about isoprostane labs. Is that… Did you mention it?
Dr. Duncan: Yeah, F2-isoprostane is a urine lab. As my mentor told it, it tells us how rancid somebody is, and it truly will tell you if there’s rancidity in the body, and if it’s in that toxic state. That can lead me to say, “Okay, we need further testing maybe on the toxic levels, heavy metals or mycotoxins if there’s something else at play here.” I also correlate that with the omega check. Are we getting enough of the omega-3s? Are we getting these anti-inflammatories? What is the burden there?
Dr. Weitz: When you look at the omega levels, what are you looking specifically? What do you focus on the most? Do you just look at the omega-3 index? Do you look at the Omega-6:3 ratio? Do you look at the arachidonic acid omega-3 ratio, the EPA, the DHA levels? What do you think is most significant to focus on?
Dr. Duncan: Yes. No, really, the big one… All of those things, of course, and you’re looking at those levels to be in favor of the omega-3, the anti-inflammatory markers. The DHA is really what most highly studied in people with Parkinson’s. I always say for DHEA or, I’m sorry, DHA, it’s the four Ds, and we’re looking between two and four grams of DHA at a daily dose to help with these things. The four Ds we’re looking for with Parkinson’s disease is depression, dementia, dyskinesia, and death. Those are four big Ds that you really want to address. So, I have three nutrients, natural medicines that most everybody in my practice will get prescribed at some point in time early on. That’s one of the biggest ones is because, again, the brain’s made out of fat. The DHA is the prominent fat in the brain, and we really want to promote those high levels there.
Dr. Weitz: What lab do you use for the F2-isoprostane?
Dr. Duncan: I run mine through LabCorp, and it’s a urine lab. That’s the big thing to remember is that’s urine. You’re not going to find it on a blood panel.
Dr. Weitz: Okay. Steve, you’re asking about CoQ10. Hold that. We’re going to go into drugs, and then we’ll go into diet and then supplements, if that’s okay. Can you talk about pharmaceutical approaches to Parkinson’s?
Dr. Duncan: Yeah. Give me one second here. My son’s nest just went off or hatched. If anybody knows what a hatch is, then you know. Pharmaceutical approach to Parkinson’s disease, it’s growing. There’s many, many out there that are available. The biggest one that you’re most familiar with is Sinemet or carbidopa levodopa. My approach to that, I always like to take a couple minutes, and talk about it. As a naturopathic doctor, as a functional med physician or practitioner, I’m sure you get most of your patients come and say, “I don’t want to take drugs. I don’t want to take meds. Give me anything.”
Then the conversation ensues of, “If you have somebody who has type one diabetes, and their pancreas cannot make insulin, the most natural thing, an effective thing that you can give to these patients is insulin. You have Parkinson’s disease, and your body cannot make dopamine. The most natural and effective medicine that I can prescribe to you right now is dopamine.” So, we have those conversations, and there are natural supplements for dopamine. We’re talking about Mucuna Pruriens. Unfortunately, with the supplement industry not being regulated, we are seeing that that dosages cannot be standardized sometimes even from pill to pill within the same bottle.
So when I’m starting somebody on a medicine, I really do promote the use of synthetic carbidopa levodopa, because, I mean, we’re trying to fill up a bucket blindfolded. We don’t know how empty it is, and when we’re repeating the body of dopamine, what I’m seeing the most is that it’s not so much the medicine taking care of the symptoms of Parkinson’s disease, but it’s aiding in their ability to do the things they need to do to slow down Parkinson’s disease, so again, the non-motor symptoms like apathy, lack of motivation to do what they can, pain, anxiety. When we give these patients the dopamine that they need, then they can start to overcome some of those, and go do the exercise, and eat and prepare their food, not to mention the huge effect it has on motor symptom presentation. So, there’s a couple different varieties up there, your immediate release, your extended release, controlled release, Sinemet, Rytary, generic. That’s really the first one that we come to the table with. [inaudible 00:42:21].
Dr. Weitz: Now, something you told me last time we spoke, which I thought was really fascinating is it’s common for patients to be told by their neurologist. Let’s hold off on starting to take dopamine or carbidopa levodopa, because it will stop working after a certain period of time. You have found that when you use a functional medicine approach, that doesn’t happen.
Dr. Duncan: I’m not going to say it doesn’t happen.
Dr. Weitz: Well, it doesn’t happen as often.
Dr. Duncan: Yeah. I mean, the goal is… Like I said, when we are taking a whole person approach, the theory out there is that carbidopa levodopa has a 10-year shelf life in the body. You’re going to keep increasing the dose until you hit max dose, and then it’ll start to wear off, and not be useful anymore. So, what I talked to people about is, one, “You can get 10 good years out of this. Do you want to take it?” I would. Let’s give it 10 good years, and let the researchers go do their job to see what else they can come up with in the meantime. Two, the majority of the time, what I see is in that line of thinking or philosophy, let’s prescribe this, and let’s keep increasing the doses.
Symptoms worsen and worsen and worsen without thinking of, “Hey, are you taking magnesium? That interferes with levodopa? Hey, do you have a B12 deficiency? Do you have slow gut motility? Are you taking it with protein? Do you have CDP choline on board? Are you taking it with vitamin C? Do you have enough hydrochloric acid?” The list goes on and on and on how we can make this medicine more effective for our patients. When that’s left out, then we’d need more, and it runs out of efficacy. When it’s brought in, that’s what I was mentioning before. We see the need for that medicine decreased by up to 50% while still managing symptoms.
Dr. Weitz: That’s awesome.
Dr. Duncan: It is. It’s incredible. I mean, I said, I’ve taken people right off the ledge. I’m at max dose. They’ve got nothing else. They’re on four or five different anti Parkinson’s meds, and we… Let’s pull this back a little bit, and they’re managing really well.
Dr. Weitz: Awesome.
Dr. Duncan: The other medicine I really want to hit on that comes right out of the gate from naturopaths office, which often astounds people, is Rasagiline or Azilect. It’s an NMAO B type inhibitor. Why I prescribe that or promote that is it’s the only pharmaceutical on the market right now with some research to show that it slows disease progression. All of the pharmaceuticals at this point in time are there for symptom management. This is the only one that actually shows a slight improvement in disease progression. So, again, I look at every single patient. Is it me? Is it my mom? What steps do I want to take to slow this disease down, and buy all of us idiots over here more time to do the research, and figure out what else we can do?
Dr. Weitz: Great.
Dr. Duncan: My least favorite pharmaceutical, I’ll just go right into that if you want me to keep rambling, are the agonists. The agonists are tough. They’re effective, but they have a laundry list of side effects that I would say most patients experience. So, impulse control, behavioral changes are really pronounced when we’re using those agonists. They’re most often prescribed for people who have restless leg syndrome or the REM sleep disorder symptoms. As you all know, I mean, we’ve got oodles and oodles of tools to use for those symptoms.
So, again, if we can take those out of the Parkinson’s bucket for a hot minute, and address those in a different way, then we don’t necessarily have to use those medicines as often. Some non-standard medicines that I really am loving using, especially when we have GI issues, are Inbrija. It’s an inhaled levodopa. I use that as a rescue medicine. Then you have your new ProPatch, which also bypasses the gut, and can be helpful for managing symptoms of Parkinson’s.
Dr. Weitz: Steven asked if ARBs like Cozaar are neuroprotective.
Dr. Duncan: That’s a good question. I honestly don’t know. I’m sorry. I can do some research on that if you ever want to email me, and I can get back to you, but I don’t know right offhand if that’s a direct correlation.
Dr. Weitz: Can you just repeat that med that you said is your favorite?
Dr. Duncan: Dopamine.
Dr. Weitz: No.
Dr. Duncan: Sinemet, but the one that shows disease progression growing is Rasagiline or Azilect.
Dr. Weitz: Yes. Thank you.
Dr. Duncan: Interestingly enough, as a MAOB type inhibitor, just fun fact, turmeric has properties of an MAOB inhibitor too. So, all the other lovely things that we all love turmeric for also shows properties of the MAOB. So, I usually want-
Dr. Weitz: Awesome.
Dr. Duncan: Some form of turmeric in there.
Dr. Weitz: One of the most amazing nutraceuticals for sure. So, what about diet? What are the most important dietary considerations?
Dr. Duncan: The most important dietary consideration, as I mentioned to you before, Ben, is a healthy relationship with food. I’m a huge proponent of screening for disordered eating habits, body image dysmorphia. I don’t know off the hand… Of course, I don’t have these, but I would say probably 50% of my male and female patients over the age of 65 have battled with some disordered eating, whether it’s back in their teenage years or in their 40s or… Men aren’t exempt from this. Body image for men tends to be this very deep shame issue, so don’t not ask. Ask first. If they laugh at you, then great. Move on, but those conversations are really important, because when we’re talking about neurologic disorders, anxiety and vagal nerve dysfunction are hugely important in the healing process.
Dr. Weitz: We need the restrictive diet specifically for Parkinson’s. We need to be able to tell patients, “Don’t eat broccoli and cauliflower.” No, I’m kidding.
Dr. Duncan: No, eat… Those exist. Once you pass that gate of, “Can you eat these healthy, and it’s not going to create stress and anxiety for you?” Because my motto is if eating the food or not eating the food causes you more stress than the food itself, then eat the food. We can do things to detox the food, but that stress and vagal nerve dysfunction is important. But when we’re looking strictly at diet, most of the research is coming back to that Mediterranean mind diet that we’re really aware of that’s been published over and over again. I have a colleague who’s a MDS over in Seattle who’s hugely promoting a vegan diet. I don’t necessarily see that to be true in all of my patients. So, we ease our way into it. If they’re really willing to go there, then absolutely, especially if there’s cardiovascular risk, but I really start talking about what to avoid and what to focus on. So, my patients will leave my office with, “Here’s your goal. I want seven to nine servings or fruits and veggies. I want you to eat mushrooms. I want you to focus on wild caught salmon.” By the time they get through the list of what I want them to focus on, they’re full. So, it’s less about restricting, and it’s more about, “Let’s make your grocery list. Let’s make your meal plan with these foods that we really want to get in your system. That way, it doesn’t feel so restrictive,” but dairy is the big one. Pork, red meat definitely has been shown to increase the progression. The other thing that I like to talk about is smoothies. What we’re asking people to do with the nutrient density and low protein is, “Can we put it all in a smoothie?” There’s a lot of people with Parkinson’s who have dysphagia, difficulty swallowing. So, can we get some of your medication and your supplements in your smoothie with you? How can we make this easier for you to get and assimilate your medicine, and promote healthy bowels and water? Let’s add some water to your smoothie. Now, we can really amp it up. Diet’s a huge, huge aspect of health for people. It’s just it’s really touchy and really important, so tread with caution.
Dr. Weitz: There’s some interesting data on the benefits of exercise for Parkinson’s.
Dr. Duncan: Yeah.
Dr. Weitz: Aerobic exercise, there’s some data even for strength training.
Dr. Duncan: The most important thing I think for exercise is it’s dose dependent. So when I tell my patients that… We always joke that if I had a pill bottle to give you that said exercise on it, you would take it, but going out and doing it is much more difficult. So, when I tell them, “This is dose dependent. It’s dose and frequency dependent is how much you do exercise, how much benefit you’re going to get from it.” It’s a huge motivator for folks. We are seeing the evidence that if you exercise less than three days a week, there is no benefit in the slowing of progression. So, it is a three plus days a week where you’re seeing an increased benefit in symptoms and disease progression.
The most studies exercise is for Parkinson’s disease is going to be things like boxing. There’s rock steady boxing programs all throughout the nation. It’s a phenomenal program. It’s utilizing both sides of your body. It’s a great community the instructors that are familiar with Parkinson’s disease, so they know how to challenge and work with people. Then as I always like to say, as a former amateur golden glove boxer, you get to hit the shit out of something, and get out all your frustration. So, it’s a really great exercise to go into.
Tai Chi is deeply studied. Cycling and dancing, those are the top ones that you’re going to see in the research, but what I tell people is find something you enjoy to do that challenges your brain, because it’s something new. Get that BDNF going and flowing, and do something new, and do it regularly.
Dr. Weitz: Going back to diet, Bernie asked about what do you think about gluten?
Dr. Duncan: Oh, gluten, it’s going to be… Again, it’s going to be patient dependent. I often try to tell people to avoid gluten. It’s going to be under my recommendation to take that out as best as they can. If we need to do deeper studies, I have diagnosed a few people with Parkinson’s with celiac disease, again, in their sixth and seventh decade. I know we all know the stories, but you’re talking GI inflammation, and that’s been going on for that long. So, we do try to eliminate or avoid gluten as best as we can. Then if something where you can’t do it, then I will often prescribe a digestive enzyme to help break that down.
Dr. Weitz: Bernie also asked about Pilates as a form of exercise.
Dr. Duncan: Yes. I mean, there’s not really anything I’m going to say no to as long as it’s safe and effective. But one of the… As practitioners, do you get somebody with Parkinson’s in? What I really do want to say is help them build their team. One of the very first referrals that anybody should get with the diagnosis is to a Parkinson’s specific physical therapist. Strengthening those intrinsic muscles, reducing the risk of fall, even if they’re not there yet, is going to be really, really important for everybody. I think as we recognize that, we need to build this team for our patients. That’s one of the very first referral. “Hey, do you have a referral out for PT? Have you done it?” “Nope.” “Okay, let’s get you one. Let’s get going on this building of your team and resources.”
Dr. Weitz: Let’s go into nutraceuticals. What particular nutritional products have you found to be helpful in slowing the progression, and modulating some of the different factors involved?
Dr. Duncan: What I like to say is people walk into my office with Parkinson’s disease. They’re typically going to walk out with three natural prescriptions, and that’s glutathione, high potency DHA fish oil, and CoQ10. What we’re seeing with glutathione, the research states back to the ’80s. I already touched on the deficiency that we’re seeing by the time of diagnosis based on motor symptom onset, and as the primary antioxidant of the nervous system. We really need to be proactive in getting that repleted in the body, help with the detoxification system in supporting neuroinflammation.
I typically don’t rely on NAC as a precursor to glutathione. Most of the evidence is showing, “Just give them straight up glutathione.” IV glutathione has been researched, like I said, since the ’80s. It’s not accessible. It’s invasive. It’s painful, and the effects aren’t always long-lasting. My mentor, Laurie Mischley, did some studies on intranasal glutathione. We are seeing a larger increase in… I guess a larger decrease in symptom presentation patient reported when we use intranasal. The tough part about intranasal is that it’s also not as quite as accessible.
You have to do that through a compounding pharmacy. Then patients aren’t always compliant. It tends to burn a little bit. They have to lay on their back for a couple minutes, and they’ll report half of it goes down their throat anyway. We like intranasal. It’s a direct route to the brain. So when possible, it’s a really great tool to use. Otherwise, I’ll use a liposomal oral bucally-absorbed glutathione to get that process going for my patients. The hiding… Oh, go ahead.
Dr. Weitz: How did they get the intranasal? You said use a compounding pharmacy, and then is it use one of those machines to put it in?
Dr. Duncan: They do that. I send you the compounding pharmacy, and then they send him home with the inhaler and the spray bottle and everything like that.
Dr. Weitz: Oh, okay, so they put it in an inhaler.
Dr. Duncan: Yeah.
Dr. Weitz: Then as far as-
Dr. Duncan: Never in my-
Dr. Weitz: Do you have a particular brand and dosage for the liposomal glutathione that you prefer?
Dr. Duncan: Dosage is going to depend patient to patient. I tend to use designs for health. The pump, that’s the one that’s been most well absorbed for people, but I use consumer lab reports to run my natural medicines through. So, again, as a functional or naturopath or integrative provider, I think I mentioned to you this before, Ben, I never thought my epitaph was going to be safely prescribed natural medicines, but I cannot say it enough. We have to be the gatekeepers of these medicines. They are not always safe. They’re not always indicated, and they contraindicate with pharmaceuticals. I mean, I don’t know how many of you knew that magnesium will inhibit the absorption of levodopa, and the very first thing we want to give somebody for constipation is mag oxide, right?
Dr. Weitz: Right.
Dr. Duncan: So, really knowing these interactions, and understanding your nutraceuticals is really important. The DHA fish oil, again, I tend to go liquid on that, because you can throw it in a smoothie. It’s really beneficial. I like Pharmax and Genestra. Those tend to be one to two teaspoons a day to get that high potency dose.
Dr. Weitz: What’s the dosage you like?
Dr. Duncan: Two to four grams. That’s really what we’re looking at.
Dr. Weitz: Of DHA.
Dr. Duncan: Of DHA. Yeah, DHA, so really understand it’s when you look at the front of the bottle, they don’t have to meet label potency, right? Again, this is my epitaph that I didn’t ask for, and, again, patient specific, right? Fish oil’s a blood thinner, so we have to be aware of all those of different contraindications there. Then CoQ10, we’re all recognizing the mitochondrial effect of Parkinson’s disease. How I like to frame it to my patient is you’re burning a lot more ATP than I am just sitting here, because you have a motor disease, a motor… What am I looking for? A motor disease.
You’re going to burn that fuel a lot faster. There’s a ton of other research about CoQ10 and mitochondrial health and Parkinson’s disease that when I’m talking to a patient, this is how I like to say it, “Let’s keep your gas tank full. If you’re going to use it, let’s give it to you.” It’s really hard to make that much, but then we also know that membrane stability and providing those resources for the mitochondrial. There’s been studies with CoQ10 ubiquinol. Up to 900, 1,000 milligrams a day, and the evidence to show symptom improvement isn’t there to match, and it’s really expensive. So, I typically stay between one and 300 milligrams, and I like-
Dr. Weitz: Did you say ubiquinol versus ubiquinone?
Dr. Duncan: I usually use a ubiquinone instead of the CoQ10 just for the bioavailability aspect.
Dr. Weitz: You said 300 milligrams?
Dr. Duncan: Between one and three.
Dr. Weitz: Between one and three, okay. By the way, I think the design health glutathione is private labeled from Quicksilver for whatever that’s worth, but… What else?
Dr. Duncan: Somebody asked me, my youngest patient 41, just wanted to answer that on the chat, but it was too late to write 41, so I didn’t know if they would know who that was the answer for.
Dr. Weitz: Oh, okay. What about vitamin D?
Dr. Duncan: Vitamin D, we like those ranges to be between 40 and 60. I don’t get super scared of high vitamin D. I’m always checking that calcium. You can double check at PTH, but really ubiquitously. You look at the Venn diagrams of neurodegenerative diseases, and vitamin D is implicated in all of them. It’s really come out as a shining star after the pandemic too for immune health. So, absolutely, vitamin D is something that we check and supplement with patient specific.
Dr. Weitz: You mentioned B12. We all know that B12 is super important for brain health, but I personally have found that serum B12 levels are not particularly accurate, and tend to rely more on homocystine and methylmalonic acid.
Dr. Duncan: Same. Those are… Sorry, and I didn’t even include those. Those are in my lab order, the very first ones. I do run an MMA, and I run a homocysteine. Absolutely. We know there’s B12 in the blood, but are we using it is the question. So, we want to check this homocysteine levels. We know homocysteine elevation. The interesting thing is I actually have a lecture up if you go to either my website or Northwest Parkinson’s Foundations, where I did a lecture just on lab values and reference ranges. We take these standard reference ranges that are made for white man age 40 to 50, and say, “It doesn’t apply,” maybe to you Ben, but doesn’t apply to most of us or most of our patients.
So, we narrowed in those reference ranges based on the clinical data that we have to say, “Here’s what our goal is.” In the literature, we know that homocystine above 11 can be neurotoxic. Yet, the reference range on most labs is 14, 14.9, so the goal for people with Parkinson’s is below 10.
Dr. Weitz: I just had a patient yesterday with a homocysteine of 90.
Dr. Duncan: Ooh.
Dr. Weitz: I know.
Dr. Duncan: You don’t even have to test MTHF on that guy, right? That’s-
Dr. Weitz: Right.
Dr. Duncan: You’ve got homozygous there. We’re definitely… Those B vitamins… Interestingly enough, like I talk about, we all know if you prescribed Metformin, you dose B12. These are things that aren’t happening. If you’re going to prescribe levodopa, you prescribe B12. We know that it depletes the body of B12. Other things that can elevate homocystine levels, not just B12 and folate, but B6 and betaine. There is a product out there that I really like called homocysteine factors. Super easy.
Dr. Weitz: I use the designs for health product homocystine supreme, but there’s a lot of similar products out there.
Dr. Duncan: It’s great, but be cautious with your B12. Again, neuropathy is a really common symptom of people with Parkinson’s and too much B6, because a lot of our patients come in on these… They’re self prescribed medicines can actually cause that as well. So, checking labs, making sure that you’re not putting everything in this one box. There could be a lot of different aspects at play. There’s a lot of clinical research out there about high doses of B1. I wanted to hit on that. I have had four patients who went into some trials with that. Only one saw benefit. I’m not dogging it. I’m just… I don’t think it’s going to do a whole lot of harm, and people often will burn out from not seeing the effects, or maybe have a few side effects from it, but I’m really interested to see what else comes down the pipe about high dose thiamin supplementation.
Dr. Weitz: Low dose lithium has some data.
Dr. Duncan: Oh my gosh, lithium has so much data, either hair or urine test. I prefer a urine test for lithium, but that is definitely something to test. There was… What am I thinking? Not a protest, but a motion to actually lithinate water in the Pacific Northwest at one time like we do.
Dr. Weitz: Oh really?
Dr. Duncan: Yeah, because there’s so much deficiencies, and if you look through the literature, low lithium levels are correlated with a lot of neurologic diseases including schizophrenic and bipolar disease, so the list goes on. But yes, low lithium levels are often implicated with people with Parkinson’s, and lithium is an important co-factor for BDNF, the brain drive neurotropic factor. So, we like lithium. I prescribe lithium. You’ll often get a side eye from your conventional counterparts. How I usually phrase it to patients and put it in their notes, “This is a physiologic dose of lithium. This is not a pharmacologic dose of lithium.” You can always check their blood levels or their urine levels again. It also has evidence to show that helps with dystonia or that muscle cramping and pain that can happen in off periods. I really like lithium. I would say after my top three, that’s probably my next most prescribed nutraceutical.
Dr. Weitz: I looked up other nutraceuticals. There was some data on resveratrol and also lycopene.
Dr. Duncan: I haven’t actually heard about the lycopene thing to be honest, but antioxidants, if you put a big umbrella there, the antioxidant use is going to be huge, those bioflavonoids. I really like resveratrol. You can prescribe that. You can really dive into food. Once they start meeting some of those food goals, they’re going to be getting some of those nutrients naturally, and spices. We really can’t pass up the importance of spices in our life, and how they affect our health. That’s where we can get a really good healthy dose of resveratrol. So, I like spices.
Dr. Weitz: You’ve talked about inflammation. We know that’s a really important factor. We’ve been using the SPMs, the fish oil derivatives for inflammation. What do you think about those?
Dr. Duncan: I haven’t used those before. It’s a good question, but I’d like to learn more. So if you can shoot me a message about that, probably, I’d love to learn more about that.
Dr. Weitz: You got it. What about some of the supplements that are specifically for brain function? You did mention citicoline. Do you have a dosage you like for that?
Dr. Duncan: Yeah, and it’s interesting. The Neurologix is a product that I use you mentioned by IT-
Dr. Weitz: Oh, okay.
Dr. Duncan: They also have a product called ProThrivers Wellness, and that has lion’s mane in it. I really like their ProThrivers Wellness Brain brand. Again, I have no conflict of interest here. I’m not sponsored, but the formula there, lion’s mane has a huge batch of research behind it for cognitive support and immune function. Then the CDP-coline that’s involved in that formula is at two caps twice a day, so you’re getting 250 milligrams. That’s a really great proponent to use. We’re using that for cognitive function anyway. A lot of people are supplementing with it.
What we are seeing with people with Parkinson’s specifically in this population is when we dose citicoline with carbidopa levodopa, we’re seeing enhanced efficacy of the medicine. So, again, another way that we can reduce dose or the need for dose, and expand that 10-year timeframe out, and with continued use of citicoline, we’re actually seeing an improvement of 30% to 50% efficacy in four to six weeks. So, it’s pretty great evidence there in support.
Dr. Weitz: Wow. In what dosage?
Dr. Duncan: 250 milligrams.
Dr. Weitz: Okay, twice a day.
Dr. Duncan: I’m going to say twice daily.
Dr. Weitz: Twice a day. What about some of the other specific brain formulas? There’s vinpocetine. There’s a whole bunch of them out there.
Dr. Duncan: There’s a chance that we’re talking cognitive function and DLB, things like that that are starting. Now, you’re diving into a whole different approach, I would say, in that realm, so really diving into the mushrooms, into the nutrients. You can do some intermittent fasting, and those are… I take a way more aggressive approach with those folks for sure. I often will use a proteolytic enzyme for somebody who has DLB or any inflammatory aggregates if it’s safe, something like nattokinase. That’s going to help with some of those inflammatory markers.
But some of the other, what did you say, cognitive, I’m a big herbalist gal. I love my herbs. They work really well. So, the ginkgo, rosemary, and bacopa, gotu kola or Centella, those herbs are powerful. They’re robust, and they’re multifaceted. But when you’re talking neotropics, in my opinion, you can’t get much better than herbal medicine for some of those functions.
Dr. Weitz: Just [inaudible 01:07:39].
Dr. Duncan: Then we can customize formulas then, right? We can use those, and we can add in some cardiovascular tonics and some anxiolytics like kava or skullcap, and help with urinary frequency. So, it’s really fun to formulate on that level, and make sure that we’re getting those herbs in there. Then you get your adrenal support. When we’re talking cognitive function, now, you’re diving into that vagal nerve dysfunction. How’s your dysautonomia? How’s your blood pressure? How’s your stress response? Are you screening for ACEs? Have you talked to your patients about their adverse childhood events or traumatic history?
A huge portion of my people with Parkinson’s will come into my practice. I say, “Hey, when did this start?” “I got diagnosed five years ago.” “No, when did this start?” “Well, I got divorced 15 years ago, or I lost my mom 20 years ago,” or there’s this trauma in their life, and then they can start to see how their health declined. We can trace it back to something like that. So, when we’re practicing root cause medicine, even if we can’t change the root, it’s important to address it, and have that conversation.
Dr. Weitz: You mentioned vagal nerve several times. In my office, we’ve been experimenting with using a laser to stimulate the vagal nerve. Somebody came by my office today, and demonstrated this electrical stimulation machine that’s been shown to work on the vagal nerve, and have therapeutic benefits. Have you experimented with anything like that?
Dr. Duncan: I’ve prescribed a couple vagal nerve stimulators. I use the earlobe technique with the Stim machines, but really, I follow Dr. Stephen Porges in his polyvagal theory and tracing our breath work. We know that when we exhale, we stimulate the vagus nerve. Vagal nerve function is not passive. It’s intentional in the body. We could cut it and survive. So when I tell people that the intention to stimulate it, and put yourself in the parasympathetic nervous system is intentional, and our exhales are going to stimulate that vagus nerve. So, doing a four, seven, eight breath technique, humming, gurgling water, contrast hydrotherapy, contrast showers can stimulate the vagal nerve function.
There’s a lot patients can do in their lifestyle that doesn’t necessarily add to their plate of go do this, or put this buzzer on, or take a supplement or something like that. Then finding a biofeedback practitioner if it works, finding a counselor really addressing the mental emotional aspect of Parkinson’s. Again, I mean, you guys all know as well as I do in this field of medicine, people walk in and say, “Oh, my doc said it’s all in my head.” I said, “Cool, your head’s attached, right? Let’s work on that. Let’s do something about that.” More often than not, you talk about this hypervigilance or amygdala overactivation. Once we start working on that too, we see gut motility improved. So, there’s so much that we can do as functional medicine or integrative medicine providers that supports a patient’s wellbeing and quality of life with Parkinson’s disease.
Dr. Weitz: Wendy asks, “Are you accepting new patients out who don’t live in Idaho?”
Dr. Duncan: Yes. I do telemedicine, and I accept patients from wherever they want to come from.
Dr. Weitz: That’s great.
Dr. Duncan: I’m going to put my website on there.
Dr. Weitz: Those are pretty much the questions that I had prepared. Is there anything else you wanted to talk to us about?
Dr. Duncan: Oh, we;;, that’s-
Dr. Weitz: I think we pretty much covered it.
Dr. Duncan: Are we going to be here till midnight for some of these folks then?
Dr. Weitz: Okay, great.
Dr. Duncan: No, I mean, really the biggest thing I want to say, Ben, is the biggest thing I say is I’m passionate the more people we have with information to treat Parkinson’s. I don’t want all the referrals. I want everybody to have the information. Laurie Mischley has an online training program that you can go on through-
Dr. Weitz: How do you spell her name?
Dr. Duncan: Mischley, M-I… I’ll put it in the chat box.
Dr. Weitz: Okay.
Dr. Duncan: I can type it better that I can spell it. Laurie Mischley. There’s a ton of resources out there. If it seems like too much to take on somebody with Parkinson’s, then find somebody who is familiar with it, because we are trying to create this whole group of people who understand the integrative approach and who want to do more research on it and more boots on the ground as Laurie likes to call it. So, if you’re seeing these people, and you have questions, I mean, reach out to me. I’m happy to share my email, my website. I’m collegial. I’m nice. I like to think I’m charming on occasion, so reach out. Ask questions-
Dr. Weitz: [inaudible 01:12:12] myself.
Dr. Duncan: Present cases. That’s why I said when I make bad jokes, I need to see if people laugh or not. So, please reach out.
Dr. Weitz: Awesome, thank you so much. This was a awesome presentation. You put your website, which is cdahealingarts.com, how people can contact you, right? That’s the best way.
Dr. Duncan: It is. Ben, just really quick, I see that Bernard wrote a couple times here, “Summarize the causes of PD.” I can summarize it really quick. We do not know, unfortunately. The Parkinson’s diagnosis is IPD, idiopathic Parkinson’s disease, so there’s a lot of theories from autoimmune to metabolic, obviously genetic, environmental toxicity. What I’m seeing in my practice with the hundreds now of people that I’ve accumulated is a combination of all of it. So, as much as I wish I could say, “Here’s the causes,” if I did, I’d be a Nobel Peace Prize winner, and I wouldn’t be sitting here talking to you guys.
Dr. Weitz: Thank you.
Dr. Duncan: Of course. Thank you all for being here. Please reach out, ask questions, send emails. Thank you for the work you’re all doing.
Dr. Weitz: Great. We’ll see everybody next month.
Dr. Duncan: I’m excited for Dr. Bredesen.
Dr. Weitz: Great. I’ll make sure to add your name to the mailing list.
Dr. Duncan: Please do. You got some big names there. Man, I was sweating when we started. I was like, “What? You’re talking to Dale Bredesen. What am I doing here?” Man, this is-
Dr. Weitz: This is awesome. Thank you.
Dr. Duncan: Got home, took a shot of whiskey before I signed on.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcast or Spotify, and give us a five-star ratings and review. That way, more people will discover the Rational Wellness Podcast. I wanted to let everybody know that I do have some openings for new patients, so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity, and take a deeper dive into some of those factors that can lead to chronic diseases along the way. That usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing. We’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So, if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.