Parasites and Gut Health with Dr. Ilana Gurevich: Rational Wellness Podcast 176
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Dr. Ilana Gurevich speaks about Parasites and Gut Health with Dr. Ben Weitz.
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Podcast Highlights
3:45 Dr. Gurevich said that she finds that in her speciality GI practice 60-70% of patients that she sees with functional GI disorders also have a protozoa or another form of parasite.
4:17 If the testing shows multiple problems with the GI tract, such as SIBO, a parasite, fungal overgrowth, and bacterial overgrowth, it can be a diagnostic conundrum which to focus on first. Dr. Gurevich finds that the patient’s history can help determine if the focus should be on the small bowel or the large bowel. If the patient has had lifelong symptoms, then you should focus on restoring the microbiome in both the small and the large bowel. If the symptoms came on after a recent onset of food poisoning, it might be small bowel IBS. If it came on after international travel, then you should suspect parasites. If there is a lot of bloating and abdominal pain, then you might want to focus on the small bowel. We have effective testing for bacteria in the small bowel (SIBO breath testing), but there is no good way to rule out parasites, protozoa, or yeast in the small bowel without doing a small bowel aspirate, which is not commonly done in clinical practice. Dr. Gurevich said that she will prioritize treating worms first, parasites next, protozoa next and microbiome and biofilms next. It’s interesting what giardia does in the lumen of the intestine, which is that it changes the microbiome. [Here is a paper describing this phenomenon: Barash NR, Maloney JG, Singer SM, Dawson SC. Giardia Alters Commensal Microbial Diversity throughout the Murine Gut. Infect Immun. 2017;85(6):eoo948-16.] If the patient has microbiome issues and giardia, then it makes sense to get rid of the giardia, which then may fix the microbiome problems.
8:09 Some practitioners will also do a second stool test that focuses more on the microbiome, but Dr. Gurevich said that we still don’t know enough about the microbiome to really make too much of a definitive analysis from this. But if she is looking at a microbiome stool test and she sees pseudomonas, she will suspect that there’s a biofilm, which means that there could be parasites, protozoa, and worms that are hiding in the biofilm. If staph and strep are present, that will also make her suspect that there is a biofilm present.
11:52 There are certain parasites that can show up on a stool test like blastocystis hominis and dientamoeba fragilis that may or may not be pathological. [Dr. Hawrelak recently appeared in episode 169 of the Rational Wellness podcast and he feels that these protozoans–blasto and D. fragilis–when found are not usually pathological and do not warrant treatment.] Dr. Gurevich noted that she tried not treating blasto and D. Fragilis after hearing Dr. Hawrelak speak and she was not getting great results, so she went back to treating such patients and this worked better. She often uses the antiparasitic drug, Alinia, usually for 21 days. For the parasite, Giardia, she will use two 10 day courses separated by 10 days. Her treatment protocol will vary depending upon when the full moon and the new moon are. She will do 10 days of Alinia and then the next 10 day cycle she may start 7 days before or 3 days after the next new moon or full moon. She might use herbal antimicrobials in between these treatment cycles. Her favorite antifungal product is Clear Four by Pharmax. Dr. Gurevich notes that she has not had good success using herbal protocols for treating parasites. She has tried mahonia, wormwood, black walnut, though she has not tried mimosa pudica. She tried using Paraguard, a popular herbal combination product for parasites and not had much success. Dr. Gurevich also finds it helpful to treat Dientamoeba Fragilis, though she is not so sure about endolimax nana, which she thinks may be a normal variant.
27:35 Calprotectin is a marker for inflammation on the GI Map stool test that I have found does not always correlate with the symptomatology and what would appear to be a lot of inflammation in the gut. Dr. Gurevich likes to run zonulin on all of her patients because if it’s positive it indicates that her treatment protocols should focus more on the small bowel than the large bowel.
29:42 Dr. Gurevich noted that quercetin works really well in healing leaky gut. She recommends quercetin at a dosage of 2000 mg three times per day for one month. She noted that if you use such a high dosage of quercetin, it can interfere with thyroid conversion of T4 to T3. Quercetin is also a zinc transporter, so it helps in immune protocols and there is on study showing it helps to heal leaky brain barrier, so it is helpful for patients after concussions.
Dr. Ilana Gurevich is a board-certified naturopathic physician and acupuncturist and is currently co-owner of two large integrative medical clinics, one in northwest Portland and one in northeast Portland. She runs a very busy private practice specializing in treating inflammatory bowel disease as well as IBS/SIBO and functional GI disorders. She lectures extensively and teaches about both conventional and natural treatments for inflammatory bowel disease as well as SIBO. She is one of the foremost experts on the intersection of IBD and IBS and how treating one resolves the other. She can be contacted through her website, naturopathicgastro.com
Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.
Podcast Transcript
Dr. Weitz: Hey. This is Dr. Ben Weitz, host of The Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to The Rational Wellness Podcast for weekly updates and to learn more check out my website drweitz.com. Thanks for joining me and let’s jump into the podcast. Hello, Rational Wellness podcasters. Thank you so much for joining us today. For those of you who enjoy the podcast please give us a rating and review on Apple Podcast. There’s a video version on my YouTube page and if you go to my website, drweitz.com you can find complete show notes and a detailed transcript.
Today, we’ll be discussing stool testing interpretation, parasites, and gut health with Dr. Ilana Gurevich. I recently had a fascinating discussion about parasites with Jason Hawrelak and I really wanted to get another perspective on how we should view parasites when they show up on a stool test and how best to treat or not treat them. Dr. Ilana Gurevich is a board certified naturopathic physician, an acupuncturist, and she currently co-owns two large integrative medical clinics in Portland. She runs a very busy private practice specializing in treating inflammatory bowel disease as well as IBS and SIBO, and other functional GI disorders. Thank you Dr. Gurevich for joining me today.
Dr. Gurevich: Thank you Ben for having me again, and I would also just like to say in person your questions, because I listen to a lot of your podcasts, the amount of knowledge that goes into the questions I stop listening and I get so excited. You did an osteoporosis podcast and I swear to God I probably sent it to 10 people.
Dr. Weitz: Wow, cool.
Dr. Gurevich: It’s like the breadth of knowledge that goes into your questioning I’m sure that you are busting your butt and it is a ton of work doing the podcast-
Dr. Weitz: Absolutely.
Dr. Gurevich: … so you can get it done.
Dr. Weitz: Yeah.
Dr. Gurevich: For all the people who are listening get it done.
Dr. Weitz: You know what? For me, it’s kind of cool because I always loved school and I feel like I’m always in school because-
Dr. Gurevich: That’s funny because what I love about podcast, especially yours, is I feel like I’m going to a webinar, tossing me on my butt and driving somewhere before doing my dishes.
Dr. Weitz: Right.
Dr. Gurevich: So thank you.
Dr. Weitz: You’re welcome. Thank you. Thank you. I thank you for noting that. So as an introductory question how’s your practice doing in the midst of this continuing coronavirus pandemic?
Dr. Gurevich: So the positive thing is because since I’m so specialized really my practice very easily transitioned to online. The bummer is what I also do is acupuncture and that does not transfer online. What I have been noticing is a lot of the mental health stuff that people are dealing with in COVID in isolation I was trying to put them on meds, lots of people are suffering from anxiety, through insomnia. I was trying supplementation. I was trying medication. And at some point I was like, can you just come in for some needles, because acupuncture and getting people back in rhythm that fixes a lot of the mental health that suffering people are dealing with right now.
Dr. Weitz: Yeah. Yeah, absolutely. All this isolation, especially older people it really makes it difficult.
Dr. Gurevich: Yeah, and our clinic I think just like your clinic and every other clinic is taking crazy high end precautions, but sometimes a virtual visit which is totally doable does not replace an in person visit.
Dr. Weitz: No, absolutely. I totally agree with that. The chiropractic there’s no way to have a six feet distance giving chiropractic, so we sanitize and we use masks and require everybody else to use masks. So far, we’ve been good, so knock on wood.
Dr. Gurevich: Yeah. I’m with you.
Dr. Weitz: So how often in practice do you see a parasite on a stool test that may be playing a role in a patient’s health?
Dr. Gurevich: Okay, so I’m going to qualify that with my practice is very specialized.
Dr. Weitz: Okay.
Dr. Gurevich: So by the time somebody waits to see me they’ve probably seen their standard medical GP. They might have even seen another functional medicine provider, so by the time they get to me they’ve been through the ringer, and in my practice for the functional GI disorders 60%, 70% I find is linked to some kind of protozoa or parasite.
Dr. Weitz: Wow.
Dr. Gurevich: Yeah.
Dr. Weitz: So in general, what if you find multiple things, because I know one of my standard protocols a lot of times for gut problems if patients are willing is when they have these sort of IBS type symptoms, gas, or bloating, or diarrhea, or some of the other type symptoms we’ll tend to screen them for SIBO as well as doing a good stool test and it’s not unusual to find several different layers and it’s always a diagnostic conundrum, what do you identify as the primary thing to focus on?
Dr. Gurevich: So I actually have a priority. It all comes down to taking a really good history. In that history you want to figure out when their symptoms, has it been lifelong, because if it’s lifelong ever since they’re a kid you’re thinking microbiome. It’s not likely that a newborn baby had some kind of parasite infection, so if it’s lifelong now I’m thinking microbiome. I’m going to think small bowel and large bowel. If it’s some kind of after a recent onset of some kind of foodborne illness that would lead what kind of testing I’m going to do. If it was after some kind of international travel that’s going to lead to the kind of testing I’m going to do. And then, based on also their conglomeration of symptoms, is it really a lot of bloating, distention, pain, small bowel like things? There is no good way to rule up protozoa, or parasites, or yeast in the small bowel. We have really effective testing for bacteria in the small bowel but that’s it, unless you’re going to do a small bowel aspirate, which no one’s going to do.
Dr. Weitz: Right.
Dr. Gurevich: If it’s sounding like way more of a large bowel issue then I’m going to think, okay, I want to go down that path and work up the large bowel. When I get results I will always prioritize with treating parasites, protozoa, and worms, and the reason for that is I feel like it’s really well documented that those things change the microbiome. And so, why start anywhere else if sometimes resolving the protozoa or parasitic infection is going to fix the microbiome small bowel issues or the microbiome large bowel issues? And there was a really interesting study and I can get it for you to put in the show notes.
There’s a really interesting study on giardia in particular where they looked at how giardia behaves in the lumen of the intestine. There are parasites that will go and get themselves in the intestine of the human and they’ll be blood, and they’ll be mucus. That’s not what giardia does. What giardia does is it changes the microbiome, right? And so, I’m not going to go after treating a microbiome issue if it’s going to be caused by a parasite that will then correct if you give the body the right enviroment. And so, I always start there, and worms come first, parasites come next, protozoa come next, microbiome and biofilms come after that, and so that’s my triangle of care.
Dr. Weitz: And what’s your preferred stool test or do you use multiple tests?
Dr. Gurevich: I really don’t. I really love the GI-MAP.
Dr. Weitz: Right.
Dr. Gurevich: I love the GI-MAP. I love it for the money because they have some insurance coverage so like 250 with insurance coverage, 450 without. I love it because it also gives me functionality and the one thing, I had this ah-ha moment maybe a year ago that I was way under diagnosing exocrine pancreas insufficiency and bile acid malabsorption. I was missing it and these chronic diarrhea patients were not getting better. And then, what I always do is I convince somebody to pay me to give them a talk and then I go and do this really deep dive into what do we know about it in the literature, what do we know about it naturopathically, what are our mentors doing empirically with treatments, and when I started realizing this was a huge chunk of my IBS patients and a little bit of my IBD patients it just changed everything, and so the GI-MAP gives me that too.
Dr. Weitz: Right. I know some practitioners will do a separate test that’s maybe more specialized on just the microbiome.
Dr. Gurevich: I feel like what we are assuming we know about the microbiome is way more than what we actually know about the microbiome.
Dr. Weitz: Right, yeah.
Dr. Gurevich: But I will also say when I’m looking at the microbiome stool tests there are a couple of things that trigger my thinking. One, is pseudomonas. I feel like with pseudomonas, like I am assuming that if I see pseudomonas on a sample there’s going to be a biofilm there, and then that will shift my thinking to, A, if there’s a biofilm there I could be really missing protozoa, parasites, and worms because they’re hiding, and B, the whole test, like the whole pathology test is a little bit of a question mark because I think things are hiding behind the biofilm. Strep and staph are the other things that sometimes peak my thought process about biofilm. Pseudomonas always does. Strep and staph if they’re high then that will also inform my thinking.
Dr. Weitz: So if staph comes up at all, but maybe it’s still within the reference range do you worry then?
Dr. Gurevich: I think it depends. I think it depends on what the rest of the test is looking like.
Dr. Weitz: Right. And do you think there’s a problem with false positives with PCR testing for parasites?
Dr. Gurevich: I think that there’s a bigger issue with false negatives then there are false positives, but I think there is a likelihood for having false positives as well.
Dr. Weitz: Right, because there’s kind of been a debate over the years about what’s the best way to determine parasites and one of the thoughts or criticisms of PCR is there could be potentially evidence, DNA evidence, of a parasite that’s no longer there.
Dr. Gurevich: That seems very counterintuitive to me because if they’re segmenting, if they’re taking the DNA segments-
Dr. Weitz: Right.
Dr. Gurevich: … and I will be honest I have not looked at the literature for this.
Dr. Weitz: Right.
Dr. Gurevich: But if they’re taking the DNA segments then I feel like if it’s not there what am I seeing. There’s a study that really changed my mind about DNA PCR which was in 2016 that it’s my favorite study. They compared ova and parasite sugar salt stain, immunofluoroscopy, and DNA PCR with known giardia, and it was so gross. The ova and parasite was something like 17 cysts per sample. The sugar salt stain was like 300 something cysts per sample. Immunofluoroscopy found 117,000 segments, and DNA PCR found 300 and something thousand segments. And so, then I was like, okay, well that’s amazing, and that tells me that’s the best one to use, but they also found that the testing was 64% sensitive, so 56% false negatives.
Dr. Weitz: Wow.
Dr. Gurevich: Was my math … No. 46% false negatives.
Dr. Weitz: False negatives rather than false positives.
Dr. Gurevich: False negatives on that particular study, and I looked, I tried to find any literature that I could on comparatives of the different stool testing essays and that was the only study I could find.
Dr. Weitz: Yeah.
Dr. Gurevich: But I haven’t looked in a couple years.
Dr. Weitz: Yeah. No, we’re big fans of the GI-MAP as well, but I know some practitioners like to use two stool tests. I know Ruscio always talks about using-
Dr. Gurevich: [crosstalk 00:11:36].
Dr. Weitz: … like a PCR test and a culture test.
Dr. Gurevich: I mean, I’m thinking it would be amazing and expensive.
Dr. Weitz: Right. Yeah, yeah, yeah. That’s always an issue.
Dr. Gurevich: Yeah.
Dr. Weitz: Okay, so let’s talk about some parasites that show up on a stool test like blastocystis hominis and dientamoeba fragilis that may or may not be pathological depending upon what article you read or who you listen to.
Dr. Gurevich: Mm-hmm (affirmative). Mm-hmm (affirmative). So I do generally go after those and treat those. I’ve listened to Jason Hawrelak. I think he’s an amazing amazingly intelligent person. I think he’s been in practice for a long time, and after I started listening to his talk because he’s out now talking a lot about blastocystis hominis and dientamoeba fragilis, and I pulled back on treating them and I tried to do a lot of the other things and I just was not getting a great amount of efficacy and I have been really narrowing into parasites and protozoa for probably the last seven to eight years. I feel like the time they come to me and they have these unresolved symptoms going after the parasites and protozoa it does make a big clinically difference. It really does. So for blastocystis hominis I usually use a longer course of Alinia. I find that it’s been the most successful.
Dr. Weitz: How long a course is that?
Dr. Gurevich: 21 days.
Dr. Weitz: Okay.
Dr. Gurevich: I use 21 to 30 days straight. For giardia, I’ll use two 10-day courses.
Dr. Weitz: So do you do like 10 days, stop for 10 days, and do another 10 days.
Dr. Gurevich: Around the full and new moon because I’m still a naturopath. What I do is I look at the full and the new moon because there is so much empiric evidence and such a history of parasites and the moon, so-
Dr. Weitz: So maybe you can explain where this is coming from.
Dr. Gurevich: Okay. So there’s a huge amount of empirical information about during the full moon and during the new moon the parasites are going through their cyclical cycle of hatching and laying eggs. I will also say that I come from a long line of psychiatrists and my father happens to be an incredible holistic psychiatrist, and he will always say it’s a full moon. Everybody who’s teeter tottering on that edge of sanity they’re going into the hospital. And so, I come from this history and then as a naturopathic physician you just see that people feel worse, they get crazier. It feels like the water is boiling a little bit hotter around the full moon. And so, what I’ll do, the way I’ll cycle it out and it’s a little bit confusing is I like to treat for 10 days, so I’ll look at the next full or new moon and start treatments seven days before, and go three days after, right? So a 10-day cycle, and then we give them a break until three days before the next new moon or full moon, start then, and go for 10 days. And in the interim of that-
Dr. Weitz: And by the way, the rational is that the parasites … First, you’re killing the parasites and they may have laid eggs and that the eggs are not going to hatch while you have the antiparasitic drugs in the system, correct?
Dr. Gurevich: Right. And then, if they have fungal overgrowth that comes up too, or maybe some kind of microbiome stuff. I might use herbs in the middle of those 10 days just to really try to cover as much because remember parasites and protozoa change the microbiome, and if you’re trying to get much more to a functional microbiome help supporting that with herbal antimicrobials can help.
Dr. Weitz: Now, I know a lot of patients are kind of apprehensive about taking antifungal drugs and there are a certain amount of side effects that occur depending on the patient, so what are your favorite herbal protocols?
Dr. Gurevich: You know what my favorite, favorite, favorite product is, which I can’t get right now? My favorite herbal fungal product is something called Clear Four. It used to be called Candaclear Four.
Dr. Weitz: Oh, okay.
Dr. Gurevich: It’s by Pharmax. I swear to God there is some kind of magic in that product. And so, the way that product works is it’s like garlic, cinnamon, oregano, and a probiotic, and there are four tablets, or there’s a tablet and three capsules, and I think maybe it works so effectively because I’m dosing it three times a day. The tablet which is mainly garlic in the morning, the two middle capsules with lunch, and the probiotic for dinner, and it’s a 30-day course, but for fungus I find that there is nothing that I find as effective as that particular product for fungal overgrowth.
Dr. Weitz: And what about for the parasites instead of Alinia?
Dr. Gurevich: I have never had good success with parasitic treatment and not using drugs, ever.
Dr. Weitz: Ever?
Dr. Gurevich: Ever. And I tried, but I’m not a herbalist. I think that herbalists are probably going to be more aggressive than I am. How much mahonia can you really have somebody drink before they want to kill you and they’re not compliant? So I feel like I’ve heard things about Mimosa Pudicas.
Dr. Weitz: Right, yeah.
Dr. Gurevich: I’ve heard about that. I’ve tried wormwood. I’ve tried black walnut, ParaGuard, it just never. I tried it for years. Sorry.
Dr. Weitz: Yeah. No, that’s okay. Everybody has their own experience. We get pretty good results with wormwood and some of the combination products. We use ParaGuard and a concentration-
Dr. Gurevich: Yeah.
Dr. Weitz: … of wormwood and garlic. I guess some of the data shows garlic can be very effective.
Dr. Gurevich: Yeah. I will also cop to the fact that I might be lazy. There is definitely that possibility.
Dr. Weitz: Right. Right. And so, if you have a patient who has SIBO and a parasite and you treat the parasite with Alinia do you find that the SIBO resolves, or do you-
Dr. Gurevich: At times, for sure.
Dr. Weitz: Like what percentage of cases do you have to go ahead and treat the SIBO afterwards?
Dr. Gurevich: So that’s a really interesting question because if they come in and they look like they have a large bowel predominant issue I won’t test for SIBO, so sometimes they come in-
Dr. Weitz: What does that mean, they look like they have a large bowel predominant problem?
Dr. Gurevich: For me to do a small bowel workup I’m looking for bloating. I’m looking for belching. I’m looking for reflux or GERD. I’m looking for some kind of distention. Diarrhea might be there but there’s something that’s telling me that the small bowel is trapping some kind of gas, because I feel like you have air in your stomach you burp, you have air in your large bowel you fart, you have air trapped in your small bowel you bloat, and there is an appropriate amount of bloating that happens to all of us after eating but if it seems excessive, and people are showing me the pregnant abdomen pictures of just bloat, that’s a small bowel workup for sure. If bloating is not their issue, if it’s more constipation, if it’s more diarrhea but there doesn’t seem to be a big small bowel component I’m going to start by looking at the large bowel.
Dr. Weitz: I always have trouble with this whole bloating thing. It’s hard to sometimes correlate when the patients complain about bloating with what we see, and some patients complain about bloating and we sometimes have a tough time figuring out exactly what’s meant by bloating. Sometimes they say they have bloating and it doesn’t appear to be any bloating and they feel it, and then we have some patients that complain about bloating and I think they’re probably just in some cases overweight, not really bloated.
Dr. Gurevich: I totally agree with you. Ruscio had this podcast a couple of years ago with this doctor out of the UK. He was like a tertiary specialist, like to get through the IMH, to get [crosstalk 00:19:49].
Dr. Weitz: Oh, yeah. I think I heard that guy.
Dr. Gurevich: He was really interesting because he basically was like there are two forms of bloating, and he had this belt that was created called the Bloat-O-Meter. Yeah.
Dr. Weitz: The Bloat-O-Meter?
Dr. Gurevich: Basically, exactly what you’re saying, there’s the internal pressure that people feel but don’t look distended and then there’s the physical distention that you can see that you can measure with belt loops.
Dr. Weitz: Because theoretically the small intestine doesn’t really expand very much and that’s why they feel bloating when there’s gas in the small intestine whereas they don’t feel the bloating when it’s in the large intestine because it’s able to distend, so I always wonder how can it really be that they have this big bloated stomach if it’s coming from the small intestine which really can’t expand very much.
Dr. Gurevich: I mean, I think it depends on their morphology. I had a patient who I saw yesterday and she was complaining of bloating. That’s her biggest complaint. She was like this is about average, and I’m looking at her abdomen and I was like, “That looks completely normal.” I think that there’s also that picture of dysmorphia which also plays into some of this.
Dr. Weitz: Right.
Dr. Gurevich: So I think it is a tricky, tricky thing, but if they’re telling me that that’s one of their symptoms I’m going to start with the small bowel first. If they’re telling me that their symptoms are more defecation related then I’m going to start with the large bowel first and I’m going to start looking at what I can find in there. And then, if we treat and they’re not getting a lot better then I might reflex to a small bowel test. So that’s where it’s tricky for me to give you a percentage because it depends on their history of where I’m going to start a workup.
Dr. Weitz: So when you say a small bowel test essentially you’re talking about the SIBO breath test?
Dr. Gurevich: Yeah. I’m talking about the SIBO breath test.
Dr. Weitz: Okay. Are there any other small bowel tests that you utilize? No?
Dr. Gurevich: No. There’s a lactulose mannitol-
Dr. Weitz: Okay.
Dr. Gurevich: … which I think is a small bowel marker. I don’t use it very much despite the fact that I think it is the gold standard for intestinal permeability.
Dr. Weitz: Right. Now, I want to change the topic a little bit. H. pylori is something that shows up on stool tests.
Dr. Gurevich: Mm-hmm (affirmative).
Dr. Weitz: And the GI-MAP does a good job of having these virulence factors too, but if you get a stool test back with elevated H. pylori and let’s say maybe in patient one there’s no virulence factors do you do additional H. pylori testing? Like some doctors will order the antibody test or … What’s the other test? The breath test for H. pylori. Yeah.
Dr. Gurevich: I feel like if I see a virulence factor, if I see the CAGA, or the VACA virulence factor I’m going to move forward with treatments.
Dr. Weitz: So only those two?
Dr. Gurevich: One those two. One those two, yeah.
Dr. Weitz: Really?
Dr. Gurevich: Because it has been shown that those two are the ones that are most likely to cause issues. What ended up changing my mind on this was, did you ever read that book Missing Microbes?
Dr. Weitz: I know about it but I never read it.
Dr. Gurevich: Read it. I mean, he made a really good case for the fact that if they’re not symptomatic H. pylori might really be one of the controllers of the microbiome.
Dr. Weitz: Right.
Dr. Gurevich: And so, if they’re not symptomatic and I see H. pylori I don’t want to kill anything that I don’t … That’s triple antibiotic therapy. You know what I mean? I’m not going to go after it.
Dr. Weitz: Right. I mean, we use herbs, but yeah.
Dr. Gurevich: Yeah. I mean, I’m not going to go after it. If they’re symptomatic I think it’s a different conversation.
Dr. Weitz: Right.
Dr. Gurevich: If they’ve had ulcers in the past I think it’s a different conversation, and if they have those two virulence factors I think it’s a different conversation, but generally speaking if I see it I say I’m not worried.
Dr. Weitz: So for people listening to this podcast who might not know H. pylori is generally understood to be the cause of ulcers in a significant percentage of patients and it was something that took a long time to finally be discovered, and the doctor who originally discovered this, Dr. Marshall, had a tough time with the medical community accepting it, and he had himself scoped and he drank H. pylori and then had evidence of an ulcer, and then took this triple antibiotic therapy and had evidence of improvements. H. pylori is now considered a significant potential pathogen, and it usually operates in the stomach rather than in the intestines and it burrows into all of the intestine and leads to acid production and ulceration and stuff. But maybe it’s a question of degree. Maybe we want a certain amount of H. pylori-
Dr. Gurevich: Yeah.
Dr. Weitz: … as important for the health of the stomach.
Dr. Gurevich: That was his theory, and I feel like symptomatic is very different than a random finding on a test.
Dr. Weitz: Have you used the herbal protocols for H. pylori?
Dr. Gurevich: I have a couple patients who had. It’s a lot of work but they actually have had success.
Dr. Weitz: Right.
Dr. Gurevich: I have one in particular she was using mastic gum.
Dr. Weitz: Yes. Yeah.
Dr. Gurevich: She was using oregano. She was using meadowsweet. Actually, she was one where I was like, “Girl, we had a positive H. pylori with virulence factors.” She was scoped. They found it on scope. She treated it, she was re-scoped, and it was gone, so I think you can totally do it. I think it’s a lot of work, but I think you get a lot less side effects doing it that way than doing it with a drug.
Dr. Weitz: Right. Yeah. I know in my practice we have a lot of patients who have a history where somewhere along the line they got put on some antibiotics that seemed to play a significant role in their gut health getting much worse.
Dr. Gurevich: Worse. Yes.
Dr. Weitz: Right. So let’s see, any other parasites we want to talk about?
Dr. Gurevich: Dientamoeba fragilis is an interesting one.
Dr. Weitz: Okay.
Dr. Gurevich: I feel like that also is the one that causes a lot of symptoms.
Dr. Weitz: And that’s another one that some people say is… normal to a healthy gut.
Dr. Gurevich: Yeah, so that one sometimes responds to Alinia. There’s one study that says that … God, I never remember how to pronounce this medication. Praziquantel palmitate works a little bit better. I also will offer that one sometimes. I feel like it will change the microbiome and so that’s why I go after it. And then, often times treating it gets improvement.
Dr. Weitz: Right. Any other parasites that you see regularly?
Dr. Gurevich: Yes. I see endolimax nana as a tricky one-
Dr. Weitz: Okay.
Dr. Gurevich: … because I’m not sure. I feel like I’m more on Hawrelak’s side with endolimax nana. I feel like I’ve seen it and it doesn’t present how I expected to see, and sometimes I treat it and they don’t get better, so that one I won’t go after with drugs. I might give them some antimicrobial herbs for that one, so that one’s a little bit of a question mark for me. Those are the three that I see more than anything else.
Dr. Weitz: Okay. Do you see giardia?
Dr. Gurevich: But that’s a parasite. I don’t think anybody’s going to argue with you.
Dr. Weitz: Right. Right.
Dr. Gurevich: You treat giardia, you treat crypto-
Dr. Weitz: Right.
Dr. Gurevich: … you treat entamoeba histolytica. I don’t think anybody’s going to argue about that.
Dr. Weitz: Right. Right.
Dr. Gurevich: That’s not even controversial.
Dr. Weitz: Right. Now, one thing I find interesting coming back to the concept of the stool test is there’s at least one marker on the GI-MAP for inflammation, and it’s not unusual for my practice to see patients who have some significant issues in their gut, a lot of symptoms, and you sort of assume they’d have a lot of inflammation, and they may not at all.
Dr. Gurevich: Are you talking about the calprotectin or the-
Dr. Weitz: Yeah, yeah.
Dr. Gurevich: … zonulin?
Dr. Weitz: Yeah.
Dr. Gurevich: Are you running zonulins also, or no?
Dr. Weitz: Do you run zonulin regularly?
Dr. Gurevich: I run it on everyone, yeah.
Dr. Weitz: So now, that’s a measure of leaky gut, right?
Dr. Gurevich: Right. The reason why I find that useful is it’s the only small bowel marker on that entire test, like that is a large bowel test except for the zonulin because zonulin is literally a small bowel marker. The controversy with zonulin, there’s a couple controversies with zonulin, one all the research is coming out of this one particular lab, and so that’s always a question if people can revalidate what that lab has found.
Dr. Weitz: Is that Fasano’s lab?
Dr. Gurevich: Mm-hmm (affirmative). Yeah. And then, the other controversy with zonulin is there’re a couple of studies that are looking at zonulin and things that you would expect to make improvement in the zonulin doesn’t always, and I’m thinking dietary interventions in particular.
Dr. Weitz: Right.
Dr. Gurevich: So I feel like that lab’s an asterisk, and I feel like it doesn’t add very much cost, and that is the only that guides me towards … should I be also looking at the small bowel?
Dr. Weitz: I guess for me I started running it and it seemed like we didn’t get a lot of positives and I felt like most of these patients must have leaky gut based on their symptoms and history, and yet this test is saying they don’t so I wondered if this is really worth it.
Dr. Gurevich: So that’s funny because I had the opposite thinking with it. My thinking was, okay, so if it’s not positive that means that most likely I need to focus all of my attention on the large bowel.
Dr. Weitz: I see.
Dr. Gurevich: And if it is positive then I need to start thinking about the small bowel. And the other thing that I’ve discovered kind of haphazardly through clinical practice is quercetin works incredibly to heal up zonulin, which is interesting is I feel like-
Dr. Weitz: Just by itself, quercetin?
Dr. Gurevich: Just by itself. I use it at really high doses for a short amount of time.
Dr. Weitz: What’s a high dosage?
Dr. Gurevich: 2,000 milligrams three times a day.
Dr. Weitz: Oh, wow. 2,000 three times a day. Wow.
Dr. Gurevich: For one month, because it does interfere with thyroid conversion of T4 to T3.
Dr. Weitz: What?
Dr. Gurevich: Mm-hmm (affirmative). Yeah, yeah, yeah.
Dr. Weitz: Quercetin reduces thyroid conversion?
Dr. Gurevich: Especially at those levels. Especially at those levels.
Dr. Weitz: Well, I’ve never used those levels but it’s interesting because we’re using quercetin a lot in the immune strengthening protocols.
Dr. Gurevich: I’m using it a lot with viral slash COVID.
Dr. Weitz: As a zinc transporter, yeah.
Dr. Gurevich: Yeah, and it’s phenomenal. It is phenomenal for that [inaudible 00:30:33] viral conglomerate.
Dr. Weitz: Right, but what are you usually 250 or 500 two or three times day?
Dr. Gurevich: Yeah. What? Ten times more [inaudible 00:30:42].
Dr. Weitz: Oh, really. Wow.
Dr. Gurevich: I ran 2,000 three times a day, and that’s what I’m using for the acute viral/COVID protocols also, but it works phenomenally. It also works phenomenally. There’s one study that showed that it’s really good for healing up the leaky brain barrier also.
Dr. Weitz: Really?
Dr. Gurevich: Mm-hmm (affirmative).
Dr. Weitz: Interesting.
Dr. Gurevich: I mean, for post-concussion syndrome … I have a great doctor I work with, Dr. Laurie [Mengado 00:31:06] who is very, very well versed in post-concussion syndrome where I send all my MCAS concussion people too. Also, I have this one patient that I sent to her, I saw her for GI, but she had a post-concussion history for like five years, and she was like, “Start her on quercetin. It’s amazing to heal up the brain barrier as well.”
Dr. Weitz: Wow. Well, you would expect that something that could help heal the leaky gut would also potentially help-
Dr. Gurevich: Heal the brain.
Dr. Weitz: … a leaky brain. Yeah.
Dr. Gurevich: Totally. And so, basically, the way I’ll use that in the format of a GI-MAP test is I will look, if I treat the large bowel I’ll figure out what’s there, and then I’ll do a GI restoration protocol and if zonulin is elevated I’ll really push quercetin in that protocol.
Dr. Weitz: You’ll do that after you’re done getting rid of-
Dr. Gurevich: Yeah.
Dr. Weitz: … the bacteria or parasites.
Dr. Gurevich: Because you kind of have to change the terrain to kind of heal everything up in there.
Dr. Weitz: Right. So what’s your favorite gut restoration protocol?
Dr. Gurevich: Oh, okay, so quercetin is definitely in there.
Dr. Weitz: Okay.
Dr. Gurevich: I love zinc carnosine. Are you using zinc carnosine?
Dr. Weitz: We go back and forth on it. We tend to use a combination formula that had some zinc carnosine in it.
Dr. Gurevich: How many milligrams?
Dr. Weitz: It has glutamine.
Dr. Gurevich: Oh, like Endozin by Klaire? Do you use that one?
Dr. Weitz: I haven’t used that one. No. We usually use the … What’s it? GI Effects.
Dr. Gurevich: That one’s got a lot of things in it.
Dr. Weitz: GI Revive. Right. Designs for Health.
Dr. Gurevich: Designs for Health, yeah. That one has a lot of things in there. My only issue with that one is it doesn’t have high enough quercetin. That’s my only issue with it.
Dr. Weitz: Interesting. So you said how much of zinc carnosine are you using?
Dr. Gurevich: 75 once to twice a day.
Dr. Weitz: Okay.
Dr. Gurevich: If they have a lot of small bowel stuff glutamine’s always on my differential.
Dr. Weitz: Now, that zinc carnosine is not going to raise your intracellular zinc levels because it’s acting in the gut, right?
Dr. Gurevich: No. Zinc Carnosine, it’s not naturally produced at all. They take a zinc molecule and they bind it with an L-carnosine. It’s made in the lab, and the reason why I like it so much is because they have a couple of studies that basically show that for ulcers that were created because of radiation, so these are esophageal cancer and stomach cancer patients. They use zinc carnosine after treatment and before treatment and it took these radiation induced ulcers from a grade four to a grade two, or it stopped them from producing as actively. And so, if they’ve shown that with radiation ulcers there’s no way that they [crosstalk 00:33:59].
Dr. Weitz: Oh, that’s interesting.
Dr. Gurevich: It’s amazing.
Dr. Weitz: What about the patients who have like fibrosis from radiation that they had?
Dr. Gurevich: I think it could be too late. I’m not sure.
Dr. Weitz: Too late, yeah. Yeah.
Dr. Gurevich: Yeah.
Dr. Weitz: We’ve been using a modified citrus pectin because that supposedly helps with fibrosis.
Dr. Gurevich: Is it working?
Dr. Weitz: A little bit.
Dr. Gurevich: You know what I think about for those people?
Dr. Weitz: Yeah.
Dr. Gurevich: Is frequency-specific microcurrent.
Dr. Weitz: Oh, okay.
Dr. Gurevich: Just because I feel like I don’t know if anything I’m going to give them orally, because it’s so scared over.
Dr. Weitz: Yeah.
Dr. Gurevich: I feel like it’s changing the way the cells work, which is what frequency-specific microcurrent does.
Dr. Weitz: Yeah. I wonder about maybe infrared light too.
Dr. Gurevich: Yeah, exactly. I’m thinking more like that, so like re-turn on the cells to function.
Dr. Weitz: Right, yeah. Yeah. There’s actually some interesting studies using infrared light for hypothyroid, Hasimoto’s.
Dr. Gurevich: Oh, really? Like localized over the thyroid?
Dr. Weitz: Yeah, exactly. Yeah. There’s some group out of Brazil that did several studies and got really interesting changes in the [inaudible 00:35:01] cells in the thyroid, actually significant reversal of this autoimmune process.
Dr. Gurevich: And you know, that’s not a very expensive intervention.
Dr. Weitz: No, I know. Exactly.
Dr. Gurevich: Wow. That’s really interesting, actually.
Dr. Weitz: Yeah.
Dr. Gurevich: Huh. That’s really interesting.
Dr. Weitz: So what else is part of your gut restoration protocol?
Dr. Gurevich: So quercetin, zinc carnosine, glutamine maybe, probiotics are always going to-
Dr. Weitz: What do you mean glutamine maybe?
Dr. Gurevich: So glutamine if it’s a small bowel. I’m not using glutamine so much for the large bowel because I feel like the enterocytes glutamine is their preferential treatment for food, but the colonocytes it’s something like 10%. Colonocytes really prefer butyric acid for their food. The trick with that is I’ve never seen butyrate ever. I’ve never seen butyrate do anything helpful.
Dr. Weitz: Okay. You’re talking about taking short-chain fatty acids like butyrate separately as a supplement.
Dr. Gurevich: Exactly. And I mean, maybe rectally, but that’s also expensive and uncomfortable.
Dr. Weitz: Right. So then, you’ve got to feed them the right prebiotics to produce-
Dr. Gurevich: Right.
Dr. Weitz: … the short-chain fatty acids.
Dr. Gurevich: And they have to have a microbiome that will accept the prebiotics.
Dr. Weitz: Right.
Dr. Gurevich: Or the patients to go through the die off that happens when they’re converting their microbiome. But I am loving prebiotics right now. I would agree, yeah.
Dr. Weitz: What’s your favorite prebiotic?
Dr. Gurevich: So I use two, Life Extension, it’s called Florassist.
Dr. Weitz: Okay.
Dr. Gurevich: Which is a chewable. I think XOS. And then, I use a lot of Microbiome Labs, they have-
Dr. Weitz: Right.
Dr. Gurevich: … a prebiotic, but that one people who don’t tolerate dairy won’t tolerate that one.
Dr. Weitz: Right. It has FOS, XOS, and-
Dr. Gurevich: GOS, I think.
Dr. Weitz: … GOS. Yeah.
Dr. Gurevich: Yeah.
Dr. Weitz: Yeah, yeah, yeah.
Dr. Gurevich: So those are the two that I use and it really is if you tolerate dairy or not.
Dr. Weitz: Right. And then, do you have problems with patients who have SIBO taking some of these prebiotics?
Dr. Gurevich: I don’t start there.
Dr. Weitz: Right.
Dr. Gurevich: So I’ll go through a treatment round, and then one of the things that I have been really, really playing around with, which is interesting is using all three or four classes or probiotics simultaneously, so I’ll start them in a class, one lactobacillus bifido, at like 75 to 100 billion.
Dr. Weitz: This is like Rusio’s class system?
Dr. Gurevich: I totally got it from Rusio. I mean, he’s a very smart thinker.
Dr. Weitz: The problem I have with that system is when you look at all the data on probiotics so much of the data is strain specific, so to just basically take 90% of probiotics and go lacto bifido.
Dr. Gurevich: Okay. Yes, I agree with you. That being said, I feel like the goal is just diversity, right? How do we get any amount of anything? Like when I’m using my class one, the one that I’m using is Probiotic 10 by Protocols for Life Balance, or Super Pro-Bio by Kirkman, right? I like those, and they’ve got like 10 strains. You know what I mean?
Dr. Weitz: Right, but the thing is this is getting back to the same concept as there’s actually been really fascinating research done with lactobacillus, NCMF, 1463-
Dr. Gurevich: Right.
Dr. Weitz: And that particular one has a certain therapeutic value that just having 10 different ones in that category are necessarily going to have.
Dr. Gurevich: Absolutely, and there’s also been really interesting studies that take these combination formulas with like stenotrophomonas and a couple of the species lactobaccilus, and some bifido, and maybe some S. boulardii, and those seem to have efficacy too.
Dr. Weitz: Right.
Dr. Gurevich: I feel like it’s never in the human body which is so complex-
Dr. Weitz: Right.
Dr. Gurevich: … you’re never going to be able to isolate from one strain of probiotic.
Dr. Weitz: Right.
Dr. Gurevich: Which is why I’m like, okay, let’s throw it all at you, and then let’s throw in a prebiotic.
Dr. Weitz: So when you say three strains you said a combination product, a saccharomyces boulardii, and then a bacillus.
Dr. Gurevich: Four.
Dr. Weitz: Yes, four-based, yeah.
Dr. Gurevich: And then, sometimes E. coli Nissle 1917.
Dr. Weitz: Okay.
Dr. Gurevich: And so, I’ll do that for a month and then I’ll throw in a prebiotic for a month, right? Because I’m trying to get it to hold because the problem with probiotics, at the end of the day the problem with probiotics is they’re kind of like air conditioning. When you take them you can get people to feel better. When they stop taking them they go back to the diarrhea they were having before. That’s just a waste of money. I don’t want somebody on a pill.
Dr. Weitz: Well, it’s also because you’re taking some grass seeds and just throwing them across the ground.
Dr. Gurevich: Right.
Dr. Weitz: Right? So they’re not necessarily going to take root.
Dr. Gurevich: [crosstalk 00:39:41].
Dr. Weitz: So you need the prebiotics which is-
Dr. Gurevich: Right.
Dr. Weitz: … the fertilizer.
Dr. Gurevich: Right, and you obviously need the foundation of every kind of functional medicine. You need them to have a good diet. You need them to be eating fermented foods. The more the better. You need them to be eating fiber naturally in the diet so they’re not relying on a pill. All of that goes without saying. You know what’s interesting?
Dr. Weitz: It’s really hard to get like 40 grams of fiber a day not taking an additional product.
Dr. Gurevich: I would agree, and I think that patients who seek out functional medicine or naturopathic medicine are way more motivated than the standard American patient, and so if anybody’s going to do it, it’s totally going to be them.
Dr. Weitz: Right. Right.
Dr. Gurevich: And a smoothie can get you … It’s amazing how much you can shove into a smoothie.
Dr. Weitz: Yeah. Yeah. What I have in the morning I don’t think you could actually call it a smoothie but-
Dr. Gurevich: Exactly.
Dr. Weitz: … kind of like just black goopy mess.
Dr. Gurevich: But you’ve met all of your dietary needs in one meal.
Dr. Weitz: Exactly. Okay. So I think that about wraps it for me. Any final thoughts you want to leave our listeners and viewers?
Dr. Gurevich: Yeah. I just really want to say it’s complicated. It’s complicated, and the nice thing, the luxurious thing for me being as specialized as I am-
Dr. Weitz: It’s complicated and you’ve got to be patient if you want to restore your gut health, right?
Dr. Gurevich: There’s this one clinical case that just kind of blew my mind. There was this patient, she came into see me, and she flew in to see me so I can manage all her meds and all her labs, and all that, and she was on like, I don’t know, 40 supplements, 50 supplements.
Dr. Weitz: Wow.
Dr. Gurevich: Every supplement under the gun. And then, I was talking to her and I was like, “You’re also having all of these crazy menopausal symptoms. You also are osteoporotic. It’s actually not even safe for you to be with no estrogen.” Right? And so, really I took away, I don’t know, two thirds of the supplements and I started her on bioidentical hormones, and that was the missing link of getting her to poop. You know what I mean?
Dr. Weitz: Right.
Dr. Gurevich: It’s so complicated, and getting a good history, and working with somebody who actually does this on a regular basis it’s really helpful. It’s really, really helpful.
Dr. Weitz: Well, part of this I think is because treatment by Google and the patients start layering, and they start chopping practitioners. I’m sure you’ve had patients that do that to you, and they call you us, and they get a consultation, and you’re now number 17 in a line of practitioners-
Dr. Gurevich: [crosstalk 00:42:17].
Dr. Weitz: … which is a part of what everyone has put them on, and so they’re layering this group of supplements on top of this one, on top of this one, and they were not meant to be taken simultaneously with that practitioner or that article’s recommendations. This would be your protocol, not to take that plus this one, plus this one, plus this one, and the same thing with diet where you follow this particular diet that takes out these three food groups, and then another diet that takes out four more food groups-
Dr. Gurevich: Yeah. Yeah.
Dr. Weitz: … and a third diet, and pretty soon there’s no foods to eat.
Dr. Gurevich: Right. I mean, you didn’t even mention that they’re paying a mortgage in supplements.
Dr. Weitz: Right.
Dr. Gurevich: I mean, I think that’s why, granted I’m biased, but I feel like working with a clinician because supplements are not made for, okay, if A then B. You know what I mean? Supplements are made for, this is the whole picture, this is obviously the priority, why would we do anything else if the priority isn’t working because you are literally just pooping money out your butt.
Dr. Weitz: Right.
Dr. Gurevich: I mean, it’s difficult because the internet is so accessible and not everybody has access to care. I live in Portland, Oregon. I have 13 naturopaths in my practice. You know what I mean? People who live in Florida. They see some functional medicine doctors who run all these tests and then put them on all these supplements based on the tests but not looking at their symptoms. I understand it is not easy, and I also think if you want to try to figure it out yourself I totally respect you trying, and if you’re flattening out I think getting some extra support is really helpful.
Dr. Weitz: Absolutely. And I also think if you can find a right clinician who’s giving you a reasonable treatment protocol based on some reasonable amount of tests being done that makes sense you should stick with that practitioner because I think sometimes all these different, you’re talking about 50 different supplements, comes from I did a consultation with this person who put me on these six different things, and then I read this article that said take these, and then I did another one with this one.
Dr. Gurevich: Yeah.
Dr. Weitz: I think that’s part of the problem.
Dr. Gurevich: Yeah. And also, I just want to say we live in this amazing world where information is so accessible, which is amazing. Never in our history have patients been this empowered to take their own care in their own hands and really guide their treatment plan, and we no longer live in the world where doctor is God, and whatever doctor says I’m going to do.
Dr. Weitz: Right.
Dr. Gurevich: Which by the way I would love for somebody to be like, yeah, you just tell me what to do and we’re done. It would make my job easier, but we don’t live in that paradigm anymore. It’s really important to educate yourself.
Dr. Weitz: Right.
Dr. Gurevich: And it’s also really important to understand where your education falls short on the internet.
Dr. Weitz: Right. Yeah. And I think at this point there’s so much information out there that our job is really to try to streamline and teach the importance of the right information-
Dr. Gurevich: Yep.
Dr. Weitz: … rather than just provide more information.
Dr. Gurevich: Right, which is I feel like what is luxurious about my job specializing.
Dr. Weitz: Right.
Dr. Gurevich: Because I only need to know about … I’m like an inch wide and a mile deep. I don’t need to know about your kidneys. I know you have kidneys and I know they’re important, but I know what I know, and so I love staying in my lane, doing this thing, and then go.
Dr. Weitz: That’s right.
Dr. Gurevich: Let’s get you something that’s more of a generalist.
Dr. Weitz: So how can patients contact you if they want to utilize your services?
Dr. Gurevich: So you can find me on naturopathicgastro.com, and the nice thing about my clinic is I do have residents who work under me, so if it’s cost prohibitive the residents are much cheaper and we will do educational consults, which means that we can talk to you, do a FaceTime visit, or do a Zoom visit, and then get your history and kind of give you our thought process. If you come into see me then I can run your show for a year and do all the labs and all the pharmaceuticals and all that, but we can definitely give you our brain, and when you work with me or the residents you work with a whole team so you’ve got three brains on your case as opposed to one.
Dr. Weitz: And do you offer training programs for clinicians?
Dr. Gurevich: So I did. I did my first one. I did nine and a half hours on inflammatory bowel disease, standard of care, and naturopathic interventions for inflammatory bowel disease.
Dr. Weitz: Is this part of [Nurala’s 00:46:55] program?
Dr. Gurevich: No. I did one for Nurala.
Dr. Weitz: Okay.
Dr. Gurevich: I did four and a half hours for her.
Dr. Weitz: Okay.
Dr. Gurevich: And then, I bloomed it into nine and a half hours.
Dr. Weitz: Okay.
Dr. Gurevich: I did a one class specifically on rectal ozone, which might be my favorite, favorite treatment for inflammatory bowel disease. I did a naturopathic protocols. I did drugs for inflammatory bowel disease, and that one is probably my biggest soapbox because one of the things that I feel like naturopaths and functional medicine doctors do wrong is they’re in this big hurry to get patients off their biologics, and that is very, very risky because biologics form antibodies and if they’re well tolerating their biologics and they’re not having any side effects there is no point of taking people off the meds. The meds are not the enemy. The enemy is the bowel deteriorating and wasting away within the human causing pain and symptoms. Go on.
Dr. Weitz: No, go ahead.
Dr. Gurevich: So that you can find also on my website naturopathicgastro on “Online Teaching” and that is approved for a continuing ed for naturopaths in the whole country through April 2021 I think.
Dr. Weitz: Oh, wow. Cool.
Dr. Gurevich: [inaudible 00:48:05].
Dr. Weitz: That’s great.
Dr. Gurevich: I was like God bless you for listening to me talk. I think anybody hears me talk and they immediately become anxious because it’s so fast, so God bless you for listening to me talk.
Dr. Weitz: I’m from New York so it’s normal for me.
Dr. Gurevich: That’s the problem. That’s the problem. That’s exactly the problem, if I was from South Carolina nobody would be anxious around me. Thank you Ilana.
Dr. Weitz: Thank you so much Dr. Weitz. I really appreciate it.
Dr. Gurevich: Okay. I’ll talk to you soon.
