Fatty Liver Disease with Dr. Yousef Elyaman: Rational Wellness Podcast 380

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Dr. Yousef Elyaman discusses Fatty Liver disease with Dr. Ben Weitz.

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Podcast Highlights

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Dr. Yousef Elyaman is a board certified Internist with a speciality in Functional Medicine.  Dr. Elyaman is the founder and Medical Director of Absolute Health, a primary care functional medicine practice in Ocala, Florida. Dr. Elyaman also serves as the Medical Director for HumanN, a leading nutraceutical company, and as a consultant for Quest Diagnostics Laboratory’s Wellness Division. He’s teaching faculty for the Institute for Functional Medicine, specializing in their Cardiometabolic module.  His website is AbsoluteHealthOcala.com.  Dr. Elyaman offers a detailed course on Fatty Liver for practioners, The Functional Medicine Practitioner Essentials course on Fatty Liver.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.

 

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Podcast Transcript

Dr. Weitz: [00:00:00] Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast. Hello, Rational Wellness Podcasters. Today, we’ll be having a discussion about a very important condition which had been known as non alcoholic fatty liver, but is now known as metabolic associated liver disease, I think. Is that correct?

Dr. Elyaman: Metabolic, yep, metabolic dysfunction associated fatty liver disease.

Dr. Weitz: Okay.

Dr. Elyaman: Actually, metabolic, now it’s Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD). 

Dr. Weitz: But it’s a very important condition and everybody needs to know about it because this is going to be the leading cause of liver failure for millions of people around the world and we’re already in the midst of an epidemic of this condition as a result of our metabolic health, and we already know from recent research that over 70 percent of Americans are metabolically unhealthy.

Dr. Elyaman: Correct.

Dr. Weitz: So we have Dr. Yousef Elyaman here with us. So Dr. Elyaman, can you tell us about yourself, about your background a little bit and what you’ve been up to?

Dr. Elyaman:  Yeah, I’m an internist, I’m a pediatrician. I belonged to the first graduating class of the Institute for Functional Medicine. I have my own practice here in Ocala, Florida.  We have over seven providers, we have a insurance based functional medicine practice. We have health coaches. We have actually over 60 employees. I also am a faculty, teaching faculty for the Institute for Functional Medicine, so I do various talks across the world, actually, on functional medicine, on getting to the root cause.  I live on a horse and cattle ranch in Ocala, Florida. Happily married, got seven kids. The oldest of 15. So, that’s about it.

Dr. Weitz: Yeah, that, that ought to keep anybody busy.

Dr. Elyaman: Oh yeah.

Dr. Weitz: So, tell us why fatty liver disease is so important.  I teased the audience a little bit already.

Dr. Elyaman: Yeah, so you already kind of mentioned it, but But if you look at statistics, between 25 and 30 percent of people have fatty liver disease already.  And that, I mean, you think about that means one in every four people have it. It is, not only can fatty liver lead to liver cirrhosis, meaning failure, and liver cancer, but the liver is the center of metabolism. All the stuff, in functional medicine, we’re learning about, like, Methylation issues, elevation of Homocysteine, inflammation, oxidative stress.  Most of those things are happening at the level of the liver. So when the liver, when there’s a problem with the liver then the, and the liver isn’t functioning properly, it causes other issues. So, many, so when they have fatty liver disease, they have a high chance of dying from a stroke or a heart attack.  They have a high chance of having high blood pressure just because of what the liver does. So it’s I think because it covers most of our or at least a quarter of our population, plus it leads to all kinds of other issues, we really do want to know about it.

Dr. Weitz: Absolutely. So, how do we know if we have fatty liver?  How do we know if a patient has fatty liver?  I’ll give you an example.  I just talked to a patient and she had a CT scan of her abdomen and it showed [00:04:00] some fatty infiltration of her liver.  Now, is that technically fatty liver or we need additional testing to really nail that down?

Dr. Elyaman: Yeah, we may need to do some additional testing.  So now it’s called MASLD. So the S is with a is kind of pronounced with a Z. Right.

Dr. Weitz: So the condition had been called Non-Alcoholic Fatty Liver and now…

Dr. Elyaman:  Yes. Now it’s called MASLD and actually it does sound a little bit cooler. I was very upset when the name changed and then it changed again because like I created a course on fatty liver.  I have over 10 hours of teaching practitioners how to deal with fatty liver and it wasn’t called mazzled. I actually had to change the name of my course and kind of throw in fatty liver and mazzled but we can I know you, you were, you asked a follow up question but just…

Dr. Weitz: Yeah, let’s talk about the name and why it’s changed.

Dr. Elyaman:  Yeah so the reason was, is that when you call something by what it’s not, like non [00:05:00] alcoholic, that it kind of doesn’t make sense to call it what it’s not. It turns out, it just, it didn’t. When the liver gets inflamed, one of the things that can happen is it can turn to fat.  So what, that’s what they’ll see when they do a biopsy and under a microscope, they’ll see that the liver is turning to fat.  So it was one of the most common causes back then of the liver turning to fat was alcoholism when or not even alcoholism when certain people, when they drink alcohol, different people have a different threshold, but that some people, it might be one drink a day, it would start turning that liver to fat.  So they just called it by what it wasn’t, the most common cause at the time. Oh, non alcoholic. And then so naming it by what it’s not, kind of didn’t make sense. So now what it is. Metabolic Dysfunction Associated, because like you mentioned, metabolic disease, it’s associated with [00:06:00] metabolic disease, and metabolic disease is like driving this.  And then the other part of it is steatotic, so metabolic dysfunction associated, steatotic is Latin for fat, and what people were saying is that. We were being stigmatized, or patients that had this were being stigmatized.  Calling somebody fat or saying that, hey, this is fatty, is, was a little bit of a shaming thing. And also, even though they called it non alcoholic, people would go home, tell their family, and their family think, oh, you’re drinking too much. Even hough it’s non alcoholic, they’re like, oh yeah, it is alcoholic.  So that’s where non alcoholic metabolic dysfunction associated, steatotic is the Latin word, and then liver disease. So that’s where the name came in. And then back to your case, you were talking about, you did, was it a CAT scan you mentioned?

Dr. Weitz: Yes.

Dr. Elyaman: Alright, so there’s a CAT scan, and the CAT scan shows that somebody has fat in the liver.  Well, we know that they have liver, that they have fatty liver infiltrate, but various conditions can cause the liver to turn to fat. And that’s why, in order to make that diagnosis, you do have to rule out other conditions.

Dr. Weitz: Now, is there a difference between alcoholic fatty liver and metabolic associated liver?  Is there a different mechanism of what’s happening? Because my understanding in metabolic associated liver disease is that as a result of having too much glucose in the system, that glucose is converted into triglycerides and then stored in the liver.

Dr. Elyaman:  Yeah. So it’s interesting. There are about what, like digging in the research, about ten really common causes that of fatty liver disease.  And because alcohol can cause the liver to start turning to fat, that’s just one of [00:08:00] the, one of the reasons for it, and because drinking alcohol is pretty common, they now, there’s actually a there’s a version of MASLD called AC, meaning alcoholic associated as well.  So alcohol is a toxin and that toxin is causing the liver to start turning to fat. Now alcohol also,…yeah, alcohol will cause your homocysteine, which is that met, that level in the blood when that’s high, that means that you’re not doing what we call methylation properly. And methylation is kind of one of the ways that we break down different hormones and we detoxify.  So that homocysteine can also go up, which can cause that liver to start getting inflamed and turn to fat.  But like you were saying that, one of the primary causes in MASLD, take away the alcohol piece to it, is insulin resistance. But here’s what’s interesting about the insulin resistance. Insulin resistance.  When you start taking lots of sugar and lots of carbohydrates, then the pancreas has to make up for it.  It has to do something about it because we don’t want our blood levels to be filled with sugar.  So the pancreas creates insulin, and that insulin is going to drive your glucose or your sugar into the cells. Now, what happens is that whenever our body gets too much of a hormone, like it’s just oversaturated, whether it’s testosterone and people are roiding up too much, whether it’s estrogen, what happens is those, the body just can’t handle, or the cells can’t handle it. So they start to get resistant to where you need more and more insulin for those receptors to work.

So now let’s go back to MASLD.  People will have lots of sugar, and then they keep getting this, these spikes of insulin, and then they start getting resistant. And that, what would happen is now the insulin is not working, and they’re needing more and more insulin. That insulin resistance will cause an enzyme called hormone sensitive lipase, found in our fat cells to be overactive. And what that does it starts tearing up fat in the fat cell and start sending it to the liver. So now the liver gets overwhelmed not only with what they are eating, but also with all of these fatty acids that are like overwhelming the liver. So then the liver starts like trying to make, try, trying to repackage it. And it repackages it in something called VLDL and triglycerides. Now VLDL is what becomes LDL, which they usually call bad cholesterol, but we know in Functional Medicine that it’s not always bad.  You actually need to have LDL, but it makes the [00:11:00] really tiny bad cholesterol. And the really bad, tiny bad cholesterol is what ends up causing clogging of the blood vessels or heart disease and a lot of the issues that we see. So from that mechanism, one of the primary mechanisms of MASLD is going to be that insulin resistance. Now you add toxins to the liver, you’re kind of pouring more fuel on it, and then that can make, can happen, that can add a little bit more. But what’s interesting is, those are just parts, there are so many other causes of mazzled, and if we just, we can’t just look at people that have fatty liver and are MASLD, and we’ve ruled out, and we can at some point, talk about how to rule out other causes to make sure you actually have the diagnosis, because I think that’s important. But there’s many other things that may be causing MASLD for our patients that, that we’re not picking up on. And we’re just saying, Oh, just lose weight. Like that’s not the answer. 

Dr. Weitz: Or what are so many other causes?

Dr. Elyaman:  Okay. So one of the other causes is an elevation of uric acid. So uric acid. Yeah, uric acid is a particle that’s found in the blood and it is usually associated with gout.  So, really high amounts of uric acid in some people, because some people it doesn’t really cause that. They’ll get gout attacks where they get inflamed, painful joints.  But that uric acid, if it’s elevated, it can actually cause other things. For example, it can cause fatty liver and it can cause the body to start storing fat. Now, the question is that why do we have this elevation of uric acid?  And the answer is, so we think that it has so traditionally, 

Dr. Weitz: So high uric acid is actually a metabolic issue, right?

Dr. Elyaman: Exactly. So it’s because of, so when we consume large amounts of fructose…

Dr. Weitz:  Correct.

Dr. Elyaman:  which is found in high fructose corn syrup. When it’s found, it’s also found in [00:13:00] in fruit juices. Then, and actually, you can get high uric acid from drinking alcohol, but what happens is that now the body, when it gets too much fructose at one time.  Then the body has to use ATP to break it down or to process it. And that ATP, the A and the A in ATP gets broken down into and it increases uric acid. And then uric acid makes us start building more fat. It makes the liver not able to break fat down and it makes our body store more fat.

Dr. Weitz: So it’s not a coincidence. That fructose, which has a low glycemic index because it has to go through this circular route through the liver to finally get metabolized.  And the exact same pathway is needed to break down alcohol.

Dr. Elyaman: Are you reading my mind or something here? No, not at all. I thought I was the only one that knew this stuff.  No, it is not. It is not a coincidence.  Yeah, no, it is not. It is not a coincidence. It is. It is. And what’s happening is this. If you look at the way we would eat, consume fructose in nature, it was kind of with you. There was fiber with it. There were other things, other. The different colors in the fruits and vegetables or phytonutrients had different healing properties.  But in reality, if you look at our Stone Age ancestors, we had a mechanism to build or to acquire fat. So what would happen is that in springtime, we would get access to fruits.  We would eat a whole bunch of fruits, because you never know, you don’t know how long that’s going to last. And then those fruits, one of the things that would happen, they would have sugar in them and sugar can increase insulin and make us gain fat.  But then on the other side, the [00:15:00] fruits were caught, can cause uric acid to go up. And then the uric acid to go up would, would also then push us to store fat. And then what would happen is that winter would come. And when winter would come, then, unfortunately, a lot of vegans would change their minds really quickly, and then not, I mean, hey, we’re not in the Stone Ages, so you can, you can definitely be vegan and survive.  But back then, what would you have access to?  Nuts and seeds, and meats.  And then, the nuts and seeds and meats, would then push our body into muscle storage and fat burning, to make us, kind to kind of change our body composition until spring would come again.

Dr. Weitz:  Now why don’t bears die from fatty liver?

Dr. Elyaman:  Oh. Because they’re too busy sleeping, man, not moving around.  Bears are so that, that’s right. Bears eat. Bears.

Dr. Weitz: Bears eat the fruit.

Dr. Elyaman: Yes.

Dr. Weitz: To store fat to last through their hibernation. Right?

Dr. Elyaman: No, [00:16:00] absolutely. So actually this is just a theoretical thing or so. I’m sure the audience knows this is for entertainment purposes only, and don’t use this and whatever.  But so if you think about it, human beings, we’re not supposed to… 

Dr. Weitz:  Make sure you check your bear for fatty liver.

Dr. Elyaman:  Definitely check the bear for fatty liver. So humans, we are not supposed to store fat in our liver… 

Dr. Weitz:  Do you think Bobby Kennedy checked the bear in the back of his car for fatty liver?

Dr. Elyaman: I don’t think he, nope.

Dr. Weitz: Just kidding.

Dr. Elyaman: But I don’t think it happens in bears. I think it’s more of a human thing because we kind of overdo it a little. Like I, we didn’t really 

Dr. Weitz: Human beings overdo things?

Dr. Elyaman: I know it’s shocking, but yes. Sometimes, some humans, not me. I don’t know what, I don’t, I would never ever overdo things, but some humans would overdo things, yes.

Dr. Weitz: Okay, I’m sorry for messing up your train of thought. I

Dr. Elyaman: did not at all. This is this. I love [00:17:00] this. This is how science can be fun. See, science is fun.

Dr. Weitz:  I agree. I love science. So how do we test for fatty liver?  How do we analyze people? What are the labs we want to look at?  What are the tests we want to run?

Dr. Elyaman: Absolutely. So first of all, we’ve got to rule out other causes, right? So how do we rule out other causes? Well, we’re gonna we’re gonna get, one of the things we look at is a CBC or a blood count. And when you look at that CBC or blood count, you can look at what’s called the mean corpuscular volume or MCV.  And if MCV is high, if the number is high, then that means your red blood cells are large.  And what can cause your red blood cells to be large? B12 Deficiency, Folic Acid Deficiency, and also, in some people that drink alcohol can cause that to happen as well. Because it poisons the system, and makes your red blood cells larger.  So, that would be a clue that there’s an issue with alcohol. With, that there’s an alcohol component to it, and that’s something you would talk to patients about and see, is this alcoholic fatty liver, or is it MASLD or is it a combination of both? The other thing that you can see when you’re looking at the blood count, is you can look at platelets.  And your platelets are, if you’re and there is a test that you can do called a FIB4, and it’s really not a test, but what it is a calculation where they look at liver enzymes, your AST, your ALT, your age, and your platelets. And if your platelets are low compared to the, to, to what they should be based on what your liver enzymes are, then that can tell you that there is some fibrosis happening, meaning that there’s a hardening of the liver.  Why? Because the liver is one of the, its functions is it makes a hormone called thrombopoietin. And thrombopoietin’s job is to go to the bone, to your bone marrow, [00:19:00] to tell your bone marrow to make platelets to help the blood clot. But if your liver is damaged, it can’t make it as well, and then those platelets are going to be lower.  The other thing though, is that it could be a clue to alcohol as well. Because alcohol will poison your bone marrow and not allow it to make those platelets. So those are kind of some of those initial clues. So definitely a good history, find out if they’re drinking alcohol. You can do a viral Hepatitis Panel.  And a viral hepatitis panel is to see if they have these chronic viruses that can infect the liver, like Hepatitis C, Hepatitis B, those are the common ones. You also can do something called an autoimmune hepatitis panel. And an autoimmune hepatitis panel is looking to see if you have an issue with autoimmune hepatitis.  Autoimmune hepatitis is where the body is attacking the liver, it’s attacking itself. You can also get, and this is just kind of the initial, we have more of a functional medicine approach, of course we will look more. But this is just the initial test. So you check that Autoimmune Hepatitis panel and you can also check something called Alpha 1 Antitrypsin.  And it’s a genetic condition and what happens is they can get problems with their liver and problems with their lung.  You can also check an iron panel with ferritin because if you have iron overload, that can cause the liver to turn to fat. So that’s another thing that we would look at. And then you can also check copper levels. And if your copper is and it’s a little confusing, but if your copper is low, it could mean you have high copper, high free copper.  So then you would follow up by getting a ceruloplasmin level, which is the carrier molecule for copper and a 24 hour urine copper.  But bottom line, if you have too much free copper, that also can turn your liver to fat.  And that’s the workup you do to rule out other causes.  And then in the regular CMP, you’re going to look at something called an [00:21:00] alkaline phosphatase and a bilirubin. And if the alkaline phosphatase is high, then that’s kind of a clue that you have another liver issue…you need, you probably get to get them to a subspecialist…it’s not just the typical fatty liver or now called MASLD.

Dr. Weitz: What does it mean if the alkaline phosphatase is low?

Dr. Elyaman: It means that you have a problem with, you have a problem with kind of the bile flow. We call it cholestasis, so the bile ducts are kind of clogging up and the bile is not flowing properly. 

Dr. Weitz: Ah, interesting. Okay.  So, we’re gonna do those tests, and then what’s the next step if we’re suspecting that there might be fatty liver?

Dr. Elyaman: Yeah, so I, nowadays, we have readily available this amazing technology called FibroScan technology. And a FibroScan is an ultrasound technology, [00:22:00] but it’s specified. And what it can do is it can tell me two things. It gives me what’s called a CAP score and a fibrosis score. The CAP score is telling me how much fat is in the liver.  And you’re supposed to have less than five percent fat in your liver. The fibrosis score tells me how much hardening is happening in the liver. And I can take those numbers without a biopsy because before you had to do a biopsy to know this. That’s the exciting piece. With non invasive tests, no biopsy, and based on that, I can actually tell the patient your liver is supposed to be less than 5 percent fat, you’re at a 37 percent fat, we need to get this down, we need to work on your liver.  And I’ll tell you something, I have not seen people as motivated to make changes with, in their life, or in their lifestyle, in their habits as, I haven’t seen anything as powerful to make them, have, see them, have them make changes, as when you show them that there’s something going on with their liver.

It’s interesting, you’re like, oh yeah, your arteries are clogged up. Okay, we’ll try to make some changes. You tell ’em the liver and for some reason, they pay attention. But the FibroScan is a definite must that and the fibro, if you can. And the FibroScan also gives you a fibrosis, a hardening number.  ’cause we want to see. Is the liver hardened? There’s another blood test. It’s kind of a newer test, but it’s part of the guidelines that you can look at called an ELF test. ELF. And the ELF test, when that’s high, that also can indicate that you have fibrosis or hardening of the liver. Why is that important?  Because if you have hardening of the liver, that then step after that. So you go from fatty, you start getting hardening of the liver, to liver cirrhosis, and cirrhosis goes to liver failure. And that’s why to be able to pick up on that, and to be able to give them a number, and to be able to give them some things to do and see that improve, is a game changer.

Dr. Weitz: Now, it’s interesting that you get fat infiltration that leads to fibrosis. Why is that, how does that result from fatty infiltration?

Dr. Elyaman: Yeah because the liver gets all jammed up with fat, you can’t, and because of the mechanism behind it, because that insulin resistance can also cause some inflammation coming from fat cells, you can get something called oxidative stress, so you can get, you can get glycation, where, caramelization is happening in the liver, in the body.  You get oxidative stress, so that’s where rusting is happening in the body. So, you have those things, you have that process happening, and you have the liver, man, you back that sucker up enough, and then you start getting inflammation, so it gets inflamed, and you start backing that thing up enough, it’ll start getting harder, and it’ll start getting that fibrosis.

Dr. Weitz: And a similar process happens in the vascular system, in the [00:25:00] arteries, in the heart, where you get oxidation and inflammation, and then you get hardening of the arteries, and you get fibrosis of the heart. And interestingly, you can have fatty infiltration of other organs besides the liver, right?

Dr. Elyaman: Right, and I’ll tell you what’s interesting.  So I remember when I first started learning about functional medicine. First I was a skeptic, then I was a fan in awe, right? And I remember hearing people mentioning these pathways, and I’m like, how do they know so much? But it turns out that they’re the body is pretty similar, and there’s only a certain amount of ways that the body can go bad, which is why, you mention, just mentioning the process of fibrosis, you as a functional medicine practitioner can say, yep, that actually happens over here and over here.  But that’s but yes, to your point, to your point the body has a finite amount of ways that it can go bad. And depending on where it’s, that process is happening, that’s [00:26:00] the disease condition that they’ll end up naming it or calling it.

Dr. Weitz: Right. Dr. Mark Houston is fond of saying there’s only three finite responses, oxidation, inflammation, and immune dysfunction that can result from an infinite number of causes.

Dr. Elyaman: Right. And you can call it three or you can call it 10, right?  It depends on how you want to break it down and look at it.  But yes, and Mark Houston is very famous for that. For mentioning, focus on these three things, right? Yeah.

Dr. Weitz: And so a lot of patients probably with fatty liver may have fatty pancreas, or fatty other organs.

Dr. Elyaman: Right, right.

Dr. Weitz: So what do we do when we discover that a patient we’re working with has fatty liver?

Dr. Elyaman: Right. So I’m going to want to, I’m going to want to now to take a deeper dive of their chemistry, right? So I’m going to, I’m going to want to get a something called the insulin resistance panel, where not only am I looking at those insulin levels, but I’m [00:27:00] also looking at I can get a score, an insulin resistance score, and I can see if, and based on that test, I can see if they, how much insulin resistance they have.  I’ll tell you, there’s many…

Dr. Weitz:  And is it, you usually get that from Cleveland Heart Lab?

Dr. Elyaman: Cleveland Heart, you can get it from CardioIQ. I actually, I’m a independent contractor with Cleveland Heart and CardioIQ. I actually work with them. I just I, it’s not released yet, but I gave them a talk on fatty liver recently.  And so that’ll be coming out soon. But yeah, you can get it from them. There’s many specialty labs that you can get an insulin resistance score from. You can also you, another test, speaking of Cleveland Heart and CardioIQ, There’s a there’s a test called Small Density LDL.

Dr. Weitz:  Yeah, we run that all the time, of course, yeah.

Dr. Elyaman:  Right, now when you look at it from this aspect, insulin resistance causes in the fat cell the hormone sensitive [00:28:00] Lipase, to be overactive. Now you start to get, you start to get those fatty acids that are released into the bloodstream. Fatty acids going into the bloodstream go into the liver. In the liver has to do something about it, so it repackages it.  But it, it repackages it into VLDL. VLDL can be Triglyceride rich or Triglyceride poor? Triglyceride rich VLDL is from that process that’s happening. Because there’s all these, all of these fatty acids. So you get Triglyceride rich VLDL. And this is why it’s important. As the VLDL starts turning into LDL, IDL and LDL, and releasing the Triglycerides.  If it’s Triglyceride rich, you get lots of small density LDL, the one we look at as a risk factor for cardiovascular disease. Why is that important? For various reasons, and we can go into it later, but [00:29:00] various reasons, your triglycerides could look normal even though you have fatty liver disease, but one of the biggest markers of your fatty liver disease.  So if you have fatty liver disease, if you look at this test, if this number goes down, your fatty liver disease is getting better. And that’s small density LDL. So I’m going to want to get a small density LDL. I’m going to want to get a uric acid. And I’m not going to go by the lab’s definition of high uric acid.  The lab basically is looking for what is a risk factor for gout.  I’m worried about metabolic disease.

Dr. Weitz: So 5.5?

Dr. Elyaman: 5.5 or less.  You did it. You did it again. Stop reading my mind. Absolutely. I go 5. 5 in younger people. We actually want younger women. We’re thinking 4.5. So I’ll look at, I’ll, I look, I check a uric acid every time I do a lipid panel.

Dr. Weitz: It’s just part of my panel right? Yeah. If you do an advanced lipid [00:30:00] profile, which we always do, we always include uric acid.

Dr. Elyaman: Perfect. Yeah. We do the same at our office. So then I look at it. And I’m, I see the uric acid and I’m like, Hey you’re taking, this is too much fructose. You’re taking in too much sugar.  So we do these tests, we check the iron, we check, so we check these things. And then we like checking a homocysteine because if it’s high, then they might need some methyl B vitamins. And then based on that, we will put them on some sort of a treatment plan. So you’re so let’s start with nutrition.

Dr. Weitz: By the way, I recently had a conversation with Mark Houston who informed me that your risk of coronary artery disease goes up with a homocysteine level of above 5.

Dr. Elyaman: Wow, well, I shoot for 7 or less because of that.

Dr. Weitz: Right, I do too.

Dr. Elyaman: Yeah, we’re in America, man. If I can get you to seven, man, I’m a winner.

Dr. Weitz: Exactly. It’s like trying to get everybody’s blood pressure to 110 over 70. You’re not likely to do it.

Dr. Elyaman: Yeah. That homocysteine can [00:31:00] be an ugly little thing. Like it causes atherosclerosis in the Bredesen protocol for those people. Like we do the Bredesen protocol in our office when it comes to dementia.  Right. You want that less than seven. So that homocysteine is a important piece.

Dr. Weitz: Yeah, okay, go ahead.

Dr. Elyaman: So back to, yes, weight loss, in the beginning, weight loss should end up lowering fatty liver. Why? Because now your body’s metabolizing fat, right? It’s breaking it down. But you gotta be careful, because if somebody loses weight, and then they maintain that weight by eating garbage, eventually what happens is the liver will let go of a lot of its fat.  And it will, the fatty liver will start, will reverse, and then they maintain the weight, but they’re doing all of the junk stuff that they really don’t want to be doing. Guess what? The liver can refill with fat again at that weight. [00:32:00] So that’s the thing, they’re just like, oh, just lose weight and you’re fine.  No. So we got to look a little bit deeper than that.

Dr. Weitz: So what you’re trying to tell us is if you just eat less junk because you’re taking Ozembic. Yes. That’s not really a good solution.

Dr. Elyaman: Right. So, so less junk because you’re taking Semaglutide.

Dr. Weitz: Right. In other words, a person who doesn’t change their diet.

Dr. Elyaman: Ozembic probably has a lot of money to come after me, but I didn’t say it. 

Dr. Weitz: Okay. Okay. So let’s just say somebody who loses weight by taking a GLP 1 agonist without a change in their exercise or eating healthier or doing any of those things.

Dr. Elyaman:  Why don’t you just say Ozempic? So absolutely, that’s one of the biggest issues.  So do we put people on semaglutide? Do we put people on Ozempic?  We do, but we’re not going to just say, Take this shot and see you later. We’re saying if I’m putting you on this [00:33:00] as a tool, I’m putting them on it as a tool, already planning for when I’m taking you off of it. Because yes, you just eat less junk, then the body will release fat, and when the body starts to release fat, then the bo then the liver will release fat, and then you stabilize, you could potentially then refill that liver up again because of the nine or ten potential causes of MASLD. So what is, what was I getting to? What we want is not to just say lose weight and that’s it. We want to say, well, what type of a food plan, and I like calling diets food plan because it’s, this is kind of the, what you eat, right?

So what kind of a food plan will cause weight loss? I’m sorry a decrease in fatty liver, independent of weight loss. And what I mean by that is, is that they can stay exactly the same on a scale. but their fatty liver starts to go down. And that’s the [00:34:00] Modified Mediterranean Food Plan. And that’s in IFM, we call it the Cardiometabolic Food Plan.  We have kind of our own version of that.

Dr. Weitz: Right. Yeah. By modified, it’s basically a lower glycemic version, correct? 

Dr. Elyaman: Correct. So that’s eating, and that’s the thing, they’re having, they’re eating healthy fats, they’re eating they’re consuming olive oil they’re getting all the different vegetables in, they’re nuts and seeds.  So things that certain conventional literature may not be endorsing, but they’re, nuts and seeds are high in fat, well you know what, they can be healthy if you’re not, if they’re not roasted and not salted. Right? So, but a modified Mediterranean food plan is really nourishing the body, and you can start to see that.  The other thing is that if you can get people to exercise, you can actually decrease fat in the liver independent of weight loss. So if I can just get someone to stay exactly the same weight, But do some sort of exercise. Cardio does some [00:35:00] things and resistance training does others. Because what happens, you tell people lose weight or you’re toast, and then they’ll start to lose weight and then they’ll get hungry and they’ll gain a little weight and then they’ll start to feel like depressed.

So then they’re going to eat more, right? And their fatty liver gets worse. And no. So this is not, we meet people where that we’re at. Everybody’s on their own journey, everybody has their own things, but why don’t we try to increase more of these foods? And why don’t we add a little bit of a wok to your Doritos?  And why don’t we, and why don’t, and why don’t we also get some resistance training in there? So nutrition is gonna be key, because we’re looking for not to lose the fat in it and then the fat pops back. We’re looking for a long term. And hopefully they will lose fat as well, and their body composition will change.

Dr. Weitz: Resistance training, I think, is crucial for increasing metabolic rate.

Dr. Elyaman: It’s huge. Yep.

Dr. Weitz: and not to mention preventing loss of muscle and loss of bone as we get older.

Dr. Elyaman: [00:36:00] Right. Resistance training is every, you know, every one of our patients should have some sort of a cardio plan, even if it’s just walking 20 or 30 minutes a day, how many patients have I taken off so many different medicines, just because they go, I can get them to go for a 30 minute walk a day.  Then the resistance training, Something to something about stretch, maybe some sort of like stretch and body. I mean, listen you’re a chiropractor, so you won’t know about this stuff, but let me help you. So I’m like preaching to the guy.  I read your mind, didn’t I? It was my turn.

Dr. Weitz: What else can we do to treat these patients? What about you mentioned diet, you mentioned exercise, what are some of the other lifestyle factors? And let’s go into nutraceuticals.

Dr. Elyaman: All right, so let’s talk about nutraceuticals. Of course, nutraceuticals are not FDA approved to treat any disease and we’re looking at imbalances, right?  So from an imbalance [00:37:00] point of view, insulin resistance, there’s some go to nutraceuticals. One of them would be berberine. Berberine can help with insulin resistance. Berberine can help kill bad bacteria in the gut. And one of the things that causes fatty liver that we didn’t talk about is something called SIBO, Small Intestinal Bacterial Overgrowth.  And that, what happens is that those lipopolysaccharides that are in the gram negative bacteria that overwhelm the gut can get absorbed and they can cause inflammation in the liver. So, berberine is a go to because it helps with that. Now, one of the tests that we look at is something called GGT.

Dr. Weitz: By the way, I just saw a paper, berberine has been shown to reduce kidney damage from high Uric Acid.

Dr. Elyaman: Amazing. Amazing.

Dr. Weitz: Berberine is amazing.

Dr. Elyaman: It is. It is. It is great stuff. It is. It is definitely the go to. So, the GGT is a marker. [00:38:00] We check it, usually, what practitioners usually look at GGT for is, if it’s high, it means that it’s your liver enzymes that are elevated  are coming from your liver and not from, not from other tissue, or not from or your alkaline phosphatase, if it’s high, it’s coming from the liver, it’s not coming from the bone. But the reality is, is that if we really look at what GGT is looking at, it is looking, it’s a byproduct of glutathione, our body’s most powerful antioxidant, or rust buster.  And when you see that GGT high, you know there’s oxidative stress happening. 

Dr. Weitz: By the way, what number do you like to see for GGT and why don’t you throw in ALT and AST as well? Because depending upon the lab, the normal range changes. And I’m always trying to explain to patients, forget about the normal range because that’s just reflecting the average American.

Dr. Elyaman: [00:39:00] The secret to the optimal numbers they can get if they read my book. I’m just kidding. I don’t even have a book. All right. So if I have a book one day, no, you make a good point. There were population studies. So let’s look at AST and ALT. AST and ALT are, Those are those are the traditionally what we call the liver enzymes for women, you want your ALT to be 25 or less men 35 or less not what the lab says for a GGT I want to see it less than 35 better than less than 30.

So if my GGT so if my if someone’s GGT is in that higher end of normal or high, then I’m gonna think they have oxidative stress. So what are our go-to you? And that if they have insulin resistance and o oxidative stress, alpha lipoic acid may be helpful, right? Because it helps with glucose and it helps with that.

If they have high GGT, you can think about N acetylcysteine or NAC because that increases glutathione, but that’s not [00:40:00] fixing the problem, the underlying problem. But I’ll tell you there, there’s a study that was showing. that CoQ10, and I like the ubiquinol form, also can help when you have that elevation in GGT.

Dr. Weitz: Interesting.

Dr. Elyaman: Probably curcumin as well. Curcumin. Man, curcumin, like, everything you look at curcumin helps with.

Dr. Weitz: Absolutely. Curcumin. 

Dr. Elyaman: As a matter of fact, probably this podcast is doing so well because you take a lot of curcumin.

Dr. Weitz: Absolutely.

No wonder I’m orange. No I don’t know. Sometimes no matter how I set up the lighting, my, I look a little orange or a little pink or something like that. And you never quite figure it out. But

Dr. Elyaman: it’s the curcumin. You’re probably having a lot of carrot juice too.

Dr. Weitz: No carrot juice. No, gave up the juice.  So what other nutraceuticals are beneficial?

Dr. Elyaman: Yeah. So that just, you kind of, you take a look, you [00:41:00] see what the imbalance is. If you’re, so we talked about insulin resistance, we talked about oxidative stress and elevation in uric acid. So things like I actually work on the medical director for a company called Human N.  They’re the ones that make Neo40 Professional and whatnot. And we actually designed a a capsule that has four ingredients in it that have been found to lower uric acid. One is, one is is Cherry, Tart Cherry Extract, which may help lower it.

Dr. Weitz: The other

Dr. Elyaman: one is Vitamin C, because Vitamin C may lower it.

The other one is going to be a, like a Green Tea Extract. The fourth one tart cherry, vitamin C. The fourth one is a surprise . ’cause I can’t remember. Or

Dr. Weitz: a 10 maybe .

Dr. Elyaman: No. It was yeah. Yeah. It’s a surprise. This is a, that’s okay. This is homework for the audience to look at. Okay. Uric acid balance.

Dr. Weitz: Yeah. We’ve been using either Uric X from Designs for [00:42:00] Health or a few other Nice. Other professional companies have uric acid products.

Dr. Elyaman: So low, so that’s kind of for the uric acid.

Dr. Weitz: Okay.

Dr. Elyaman: Oh, I’m sorry. The fourth ingredient was quercetin, because quercetin can lower it as well.

Dr. Weitz: Correct.

Dr. Elyaman: And quercetin can help with people that have allergies and people that have, so it can help, it’s a mast cell stabilizer. And actually, and people that have issues with kind of like fibro, a lot of times it’s a mast cell issue, so it can help with that. So the only reason I’m mentioning these other conditions is because in functional, you can’t, you can only take so many pills.  So what we’re looking for is, What other associated conditions do they have? Let’s try to find that one supplement that will help with all of those things. So we talked about high homocysteine. So definitely with homocysteine, you’re going to look at your methylation, your B vitamins. Certain B vitamins need to be activated to what’s called the methylated form.  So your B6 to P5P, your B12 to methyl B12, your folate to [00:43:00] methylfolate, your 5 phosphate you also, so all those four things, if you can get them in the already activated methylated form, then they may actually help lower homocysteine, and then, or with homocysteine balance, and then the, then there’s something called trimethylglycine, or betaine, and that also can lower it so sometimes we’ll do that.

Sometimes we’ll give taurine. Taurine is a cool one because taurine may help with work on GABA receptors to help people relax a little bit. And taurine may help with with regulate heart rhythm as well. And taurine is needed to conjugate bile acids. And one of the imbalances that cause fatty liver MASLD is you can have you can have this abnormal bile acid.  That, that’s the cool thing about it. It’s not just there’s one imbalance. Most people, even functional medicine practitioners, they think, Oh yeah, fatty liver. It’s just like insulin resistance. No, dude, there is like so many different things. That, which is why, which is why, I don’t know why the [00:44:00] first course I made on my own was fatty liver.  I think I started going down that rabbit hole, and then I’m like, no, this is so freaking important. I don’t care if the world doesn’t know it. I know it.

Dr. Weitz: Probably herbal bitters would be good for bioflow. Which one? Bitters. Oh yeah. Bitters is part of it.

Dr. Elyaman: Yeah. Bitters could be part, can, can help with bile flow.  Cleaning out the gut because because what happens is if you have a lot of bad bacteria, you get these secondary bile acids that worsen fatty liver. Things to kind of help the composition. So phosphatidylcholine. I’ve seen amazing improvements in liver, in fatty liver content from putting people on phosphatidylcholine and there’s research to, there’s, there’s research to support that, not as robust as we’d like, but there’s research to support it and part of what it could do is it’s changing the composition and helping bile acids have less cholesterol in it.

Dr. Weitz: Right. That’s why when I have a patient with fatty liver I usually use a curcumin that’s bound [00:45:00] up with phosphatidylcholine.

Dr. Elyaman: Two for

Dr. Weitz: one. Two for one.

Dr. Elyaman: Yep. Yep. And sometimes we’ll give, we’ll end up, we’ll end up giving about 1800 milligrams of phosphatidylcholine divided twice a day. And we see great results.

Also the vitamin E Everybody’s different, but one of the things that happens in fatty liver is that people will start to deplete their vitamin E. They’ll also deplete glutathione. And the challenge with vitamin E is that the type of vitamin E that they usually get over the counter is D alpha tocopherol.

Yes. You see, there’s studies that show that taking, yes, exactly, right down. throw it down the drain, don’t even give it to your animals. Because what happens is that, that you look at the literature and what you see is that vitamin E may be amazing, but it also may cause all kinds of problems.

And one of the things we think is that because it depends on what the type of vitamin E, your vitamin E, there’s an alpha, beta, delta, gamma, [00:46:00] tocopherol, alpha, beta, delta, and a gamma tocotrienol, eight forms. And if you start taking that one form, you could block the other seven from getting in. Yes. Yeah,

Dr. Weitz: I’m big on the tocotrienols.

Dr. Elyaman: Since you’ve been reading my mind so much, I need to get you on my podcast, brother. I really need you. Yeah, very good. Yeah, so, so I think those are, there, there is a, there’s another supplement that I’ve been a fan of as well, and it’s called Tudka. And Tudka is, yeah, it’s the taurine bound ursodiol.  Ursodiol is also, could be a supplement, but it also is a it also is a prescription that you can get, and there’s data that shows it may help with fatty liver. But Tudka is 1 C. step further. And what it really is like doing is it’s like, if you think of your bile as the oil of your car, it’s that treatment to the oil.  So it helps improve [00:47:00] the quality of the oil. And it may also help. So for my challenging patients, they’re going to have, I like Tudco. I like Phosphatidylcholine. I like mixed tocopherols and tocotrienols. These are those challenging patients, but I don’t, I don’t think we should throw all of these supplements at people at once.  Find out what’s the problem, work on nutrition, work on exercise, follow the tests, follow, and then maybe add a little something here and something there. You got to keep it interesting.

Dr. Weitz: You got it. Yeah, it’s easy to get excited and overwhelm them with too many supplements at one time. Right, right. Now, me, myself, I take about 30 twice a day.

Dr. Elyaman: That’s it. That’s the problem. 

Dr. Weitz: I’m hedging my bets.

Dr. Elyaman: You read about it and you’re like, man, this is so amazing. I need this. And then you look at it. Yeah, we should probably just show a picture of our supplement cabinet. I have my own supplement cabinet. That’s [00:48:00] mine. And then I have the family supplement kit.  I’m like, it’s nuts. Every once in a while I go into their supplement cabinet. But I try to, I, for patients, I, you, between three to five. And then you kind of give them the options. Never give, I never give more than three supplements at once, or I try not to. Oh, I missed one supplement. So actually, especially one supplement that that I like using to rebalance is going to be the Omega 3s.  So we’ll check Omega 3 levels. And we try to optimize omega 3s as well.

Dr. Weitz: Yeah I think a multi, omegas, vitamin D with K, probably a probiotic. That’s baseline. That’s not even going into supplementation. That’s just essential.

Dr. Elyaman: That’s just replacing what we normally would have gotten if we lived in Stone Age times, right?  We would have gotten our vit We would have gotten a bunch of greens, right? [00:49:00] And when in the spring, we would have gotten our Omega 3 composition would have been much better. We would have been getting sunlight, so our D would be, do it, we’d get the vitamin D. The greens we would get our vitamin K from.  So yeah it’s the processing that’s happening. I agree with you. Those are my bare bone baseline as well. Just, this is like just normal. This is just replacing what normally is missing in everybody in our food.

Dr. Weitz: Right. If we were eating fruits and vegetables that were organic, that weren’t grown in soil, that was depleted of nutrients, and wasn’t over farmed, the same you know, foods grown over and over again, stored in frozen containers, shipped long distances to get to the supermarket, and Yeah.

Dr. Elyaman: And it’s not that hard. And you’d need a time machine, because even with all that, it could still be garbage. So, you go back in time, and then you harvest, and then you get back in the time machine, and I mean, that’s, that’s what we’re working towards, but till then, take those supplements. [00:50:00]

Dr. Weitz: Yeah, I got my time machine in the back.

I’m working on it. I got,

Dr. Elyaman: I have a little, a couple

Dr. Weitz: tweaks

Dr. Elyaman: to make, but I’m not there yet. I’m not there yet. I’m not there yet.

Dr. Weitz: Yeah, what’s happened in the experiment so far? You meet a few of your friends?

Dr. Elyaman: Listen, I can’t talk about it. I can’t talk about what happens in my backyard, okay? You want to come over?  Come to Ocala.

Dr. Weitz: All right. So final thoughts about MASLD?

Dr. Elyaman: Yeah. Final thoughts. You know, now that we have, for those functional medicine practitioners, look up, look up the FibroScan and and figure out where you can get one. A lot of times you can get it for free at a research center because they’re researching different drugs for for fatty liver disease.  There is a new drug that was the first FDA approved drug [00:51:00] Four fatty liver and the and it’s for, they have to have fibrosis, F two and F three. And it’s called ResMed, huh? It’s what’s, what we call, it’s a thyroid beta agonist. So if you look, I can see something about that. Yeah.  It’s o only $4,000 a month . So if you are. Here’s the thing, so the thyroid hormone is, there’s different receptors throughout the body for the thyroid hormone. You have alpha and you have beta. The alpha is found in the heart, the beta is found in the liver, and then throughout the body it’s different, right?

So what this is it’s specific for beta, so it doesn’t increase the heart rate. So basically what you’re doing is trying to give people thyroid hormone without increasing the heart rate. Now, as functional medicine practitioners, we are checking advanced thyroid panels, and we are optimizing thyroid. We know, like if you look at the research, low T3 is a risk [00:52:00] factor for having fatty liver disease.  Which is one of the other imbalances that cause fatty liver. Which is why I twitch a little when people say, oh yeah, that’s just insulin resistance. No bud, it could be toxicity and it could be thyroid dysfunction.

Dr. Weitz: You know what, real quick, could you just go through the 10 different causes of fatty liver?  Because we hit some of them, but I don’t know if we hit all of them.

Dr. Elyaman: Let me try from the top of my head. Okay.

Dr. Weitz: Okay.

Dr. Elyaman: We did plan for this, right? , I think they need to know our planning. Did I think they need to know how much we planned for this. I texted you this morning. We both had like, work to do and then we just jumped on, right?  So, exactly. So insulin resistance uric acid dysregulation iron overload is, it can be a cause. A discordance between your omega 3s and your omega 6s can be a cause methylation disorders and hyperhomocystinemia. Now this, these are parts of the process or [00:53:00] causes, but you can also have the Inflammation, Oxidative Stress can cause it as well.  Small Intestinal Bacterial Overgrowth or Dysbiosis can be a cause of it. And also Bile Dysregulation. And also certain food intolerances. So like people, Some people, their fatty liver is caused because by celiac disease, like a subclinical celiac, then their problem is gluten. I think those are the major ones.

Toxicity, so toxicity can be a component, and there’s actually a condition called Taffled, or maybe it’ll be called Tazzled now with a new name change, and that’s basically, they are exposed to some sort of toxin. These are the people that don’t have the typical like metabolic syndrome factors and, but they have fatty liver and that would be tasseled as well.

So I think those are the main causes and those are the main things that we’re going to want to look at. And then based on your patient’s individual imbalance, [00:54:00] that’s what you’re going to go after. And that’s what you’re going to follow up on.

Dr. Weitz: That’s great. For fibrotic Liver, do you, are there any things that you use?  I’ve used Modified Citrus Pectin.

Dr. Elyaman: Right, so, and Modified Citrus Pectin is helpful probably in all stages because a subclinical cholestasis is part of is part of the issue and it can help with growing good bacteria. So yes, but I’d say when they have that fibrosis, I’m going to number one, get their iron levels optimized.  Their ferritin, I need less than 150. I’m going to make sure that they don’t have, I’m going to say absolutely no alcohol. I’m going to make sure that I’m going to look at like the, get homocysteine and all that stuff down. But I’m also, but I’m, I like Tudca. I like mixed Tocopherols and Tocotrienols 800 and Phosphotidylcholine, and that’s when we start hitting it really hard.

Dr. Weitz: What [00:55:00] about milk thistle? Glutathione. NAC. Oh yeah. You can mention NAC.

Dr. Elyaman: Yeah. Yeah. We can use some NAC I’ll tell you. So. If they have elevated liver enzymes based on the numbers that we mentioned, not based on what the lab says, then I usually am going to put them on a mix with Milk Thistle and NAC and just different things that are going it’s all put together in the same supplement and that’s just kind of a base.

Dr. Weitz: Like a liver support formula. Yeah,

Dr. Elyaman: just a baseline liver support. Right. And then you start hitting it hard with the one supplement prescriptions. Yeah.

Dr. Weitz: Cool. Great. So that was incredible. We covered a lot of information in an hour, Doc.

Dr. Elyaman: Nice. Yeah, I know. And I had a lot of fun with it. So that’s excellent.  That’s excellent.

Dr. Weitz: So tell us about your course that you offer.

Dr. Elyaman: Yeah, so we have, so it’s still fairly new. We have the FMP Essentials, Functional Medicine [00:56:00] Practitioner Essentials. com, and the first course we launched was the Mazeld course, the Reversal of Mazeld course. It’s over 10 hours, taking a deeper dive in all of these different imbalances and kind of what we just went over, but the kind of, more of a systematic, all right, do these labs.

This is why I recommend these things. It kind of goes more in detail and elaborates more on what we talked about. And how do you and the beautiful thing about it is that once you’ve went through the course, you not only learned how to deal with fatty liver, but you also learned how to deal with diabetes and coronary artery disease and some of the because that’s the secondary benefit you’re going to get.

is how to deal with these functional medicine balances. So yeah, we would love to have it’s one of the things I’m very proud of, would love to, to have you there. If you guys want to keep in contact with me social media wise so across social media, I’m still learning the social media thing to be honest.  I’m not like one day [00:57:00] I’m going to be more, better at it, but across the platforms. 

Dr. Weitz: And one day you’re going to be Mark Hyman.

Dr. Elyaman: Yes. Well, I’m not there yet, but I’m coming for you, Mark. So at, I’m going to still stay in his shadow, right? Dr. Eman for myself at Dr. Eman. And then at FMP Essentials HQ for the, for our functional medicine practitioner essentials.  And we’re right about to launch a mastermind for functional Medicine practitioners. We’re, it’s gonna, there’s gonna be a free mastermind that everybody can jump in and we’ll have our own kind of our own platform, social media platform. And then there’ll be kind of like paid tiers. So.

Dr. Weitz: That’s very cool.

So how about patients who want to have you help

Dr. Elyaman: them? Patients that want to have me help them? Currently, I’m not seeing new patients. Oh, okay. Yeah, so they might, if they live in Ocala, if they live in Florida, they can come check out the practice and see one of our providers and [00:58:00] that’s absolute health. Do they need to go to remote

Dr. Weitz: care?

Dr. Elyaman: We’re not doing remote care. No, we, there’s licensing. You got to get the license throughout.

Dr. Weitz: Okay.

Dr. Elyaman: So

Dr. Weitz: cool.

Dr. Elyaman: So you stay in California. I will stay in Florida and take care of the people here. The other 48 States covered and we’ll be good.

Dr. Weitz: Okay. Sounds good, doc. Thank you so much.

Dr. Elyaman: You’re welcome. My pleasure.  Thank you for having me.

 

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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 very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review.  As you may know, I continue to accept a limited number of new patients per month for functional medicine. If you would help [00:59:00] overcoming a gut or other chronic health condition and want to prevent chronic problems, and want to promote longevity, Please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310 395 3111 and we can set you up for a consultation for functional medicine.  And I will talk to everybody next week.