Dr. Ilya Dubovoy discusses Functional Neurology with Dr. Ben Weitz.
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Podcast Highlights
Dr. Ilya Dubovoy is a board-certified Neurologist and trained medical Acupuncturist. He received his MD degree from Tulane University School of Medicine and he also did a residency in neurology. His current practice is focused on Integrative and Functional Medicine, nutrition, and applied biology. His office is Dubovoy Integrative Health, PLCC, and his website is VAIntegrativeHealth.com.
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
Dr. Jeffrey James discusses Hypothyroidism with Dr. Ben Weitz.
[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.]
Podcast Highlights
3:17 Hashimoto’s thyroiditis is the most common form of low functioning thyroid or hypothyroidism. Dr. James noted that he has seen hundreds of women suffering with hypothyroidism and most of these women don’t even get tested for Hashimoto’s, since from the perspective of conventional medicine, if the woman has low functioning thyroid/high TSH levels, they will be treated with Synthroid or levothyroxine, which is synthetic thyroid hormone. If it has an autoimmune origin, it doesn’t change the pharmaceutical outcome. But if you have Hashimoto’s thyroiditis you have an immune system problem rather than a primary thyroid problem. We need to try to understand what would cause your immune system to dysregulate and want to attack your own body tissues? Unfortunately, once you have one autoimmune disorder, you’re 50% more likely to develop another one. Dr. James explained that a lot of women complain that they’re exhausted, they’re putting on weight, they’ve got brain fog, they’re losing their hair, they’re constipated, their skin is dry, they’ve got brain fog, they have this constellation of symptoms, and they’re cold. When they go to their doctor, out comes the prescription for Synthroid. Unfortunately a majority of women end up back in their doctor’s office after a few months or a few years and they don’t feel any better. Their primary MD or endocrinologist then tries to dial in their TSH. If they are depressed, then they get prescribed an antidepressant like Effexor or Cymbalta. If they have headaches, they get prescribed Imitrex. If their blood pressure goes up, they are prescribed antihypertensive medications like Lisinopril or Amlopidipine or hydrochlorothiazide. Dr. James sees a lot of these women who feel like they are not being seen or their complaints are not being addressed by their physician.
9:10 Functional Medicine practitioners are not simply treating each symptom with a pharmaceutical drug to ameliorate that symptom but are looking at your underlying metabolism, physiology, endocrinology as well as the root causes of the autoimmunity that is often driving these imbalances that can often be corrected with diet and lifestyle changes. The patient with hypothyroidism could have an underlying GI infection or a biotoxin illness. They could have a genetic susceptibility to not being able to process mycotoxins that are either in their environment or that are in their foods that they’re eating. They could have a Lyme infection. They could have a viral infection or a gut infection, a parasite or a bacterial infection in their gut that’s driving an immunological response. Any of these things can create a low level inflammatory response that can affect thyroid production, conversion, or uptake, all of which create symptoms that are very similar. From a Functional Medicine perspective we want to see which way the physiology is tilting and we want to see if their lab values are optimal and not just normal or not.
11:05The medical system in our country where once per year you go in for a physical exam with very minimal testing only to look for a pharmaceutical intervention is a failed system. Just look at how poor the health of our country is. We need to test more widely to see how well our bodies are functioning. For thyroid, we need to look at not just TSH but total T4 and T3, free T4 and Free T3, and reverse T3 as well as the thyroid antibodies. We need to trace everything back to the mitochondria of the cell and how our bodies produce energy. We eat a meal and breathe some oxygen in and that glucose and oxygen mashes up against the mitochondria to produce ATP. Even if you want to be energetic if your mitochondria are having trouble producing energy, then will make you down-regulate your energy use and your body will tend to keep you in bed and this may occur through thyroid under-conversion and you may see a low TSH and a low T4.
We also need to look at the immune function and the level of natural killer cells, which are what might go in and attack the thyroid gland. We need to look at liver enzymes. If there are gut symptoms like constipation or diarrhea we might want to do SIBO breath testing and/or stool testing. Dr. James also often runs genetic testing, including a DRB1, 3, 5, and a DQB test from LabCorp, which will tell you if you are susceptible to mycotoxins or other biotoxins. If they have susceptibility to toxins, then he will run the Total Tox Burden test from Vibrant America.
Dr. Jeffrey James is a Doctor of Chiropractic, a Chiropractic Neurologist, and a Functional Medicine practitioner and his office is LA Functional Neurology. He has been in private practice in West Los Angeles since 1989. His website is DrJeffreyJames.com. His office phone is 310-396-3100.
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates 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 speaking with Dr. Jeffrey James about Hashimoto’s thyroiditis. The thyroid is a butterfly-shaped gland in the neck that’s responsible for the metabolism of every cell in our body. When the thyroid is functioning sluggishly, we refer to it as hypothyroidism. Hashimoto’s thyroiditis is the most common form of hypothyroidism in the US now that iodine deficiency is fairly rare since we started adding iodine to salt in the 1920s. Hashimoto’s thyroiditis is the most common autoimmune disease in the US. From a conventional medical perspective, Hashimoto’s is easy to address. Simply prescribe synthetic thyroid hormones, Synthroid, end of story. But from the functional medicine perspective, it’s much more complicated. We want to know what are some of the triggers and causes of this autoimmune disease. What has led to a thyroid not functioning properly? What’s led to the progressive damage to our thyroid gland? We want to know what things might be inhibiting the proper production of thyroid hormone and what we can do to help the thyroid to work better and produce optimal levels of thyroid hormone. We want to know what factors are involved in the conversion of T4 to T3, et cetera. Dr. Jeffrey James is here to provide us with some answers. Dr. James is a doctor of chiropractic, a chiropractic neurologist, a functional medicine practitioner, and his office is LA Functional Neurology. Jeffrey, what else do you want to tell us about your background and yourself?
Dr. James: So actually, the office is actually drjeffreyjames.com if patients want to look.
Dr. Weitz: Oh, okay.
Dr. James: Like you have two practices, the functional medicine side and the structural side. So the functional medicine side, they’re going to want to go to drjeffreyjames.com.
Dr. Weitz: Okay.
Dr. James: What do I want to add to that, about me? Nothing. You did a good job, Ben. You did a good job. That’s good. People don’t want to hear about me. I don’t care. They want to hear about what they can do for themselves, right?
Dr. Weitz: Sure. But you’re the expert, so they want to know who you are. So tell us what is Hashimoto’s thyroiditis, what should we think about it?
Dr. James: So you already said it, so I didn’t know we were only going to talk about Hashimoto’s, but-
Dr. Weitz: Oh, well, did you just want to talk about hypothyroidism in general?
Dr. James: I think we should riff on all of it so people get a better understanding of what-
Dr. Weitz: Sounds good.
Dr. James: Hashimoto’s is the number one, the leading cause of hypothyroidism, at least in the United States right now. And as you said, the traditional medical treatment for that… By the way, I don’t know how often you see this, but I am specialized in hypothyroidism, Hashimoto’s for, I don’t know, a long time. I’ve seen hundreds of women with this. It’s primarily a female issue, but like 10, 15% of the cases are even tested for Hashimoto’s. So I guess, it begets the question of, first of all, if it’s the number one cause, why is it not the number one thing being tested? And what I’ve come to realize is because it doesn’t really change the pharmaceutical outcome.
Dr. Weitz: Exactly.
Dr. James: So if you have a tool in the toolbox and that tool is Synthroid or levothyroxine, generic form, it doesn’t matter whether you’re diagnosed with your TSH is high and you’re diagnosed with hypothyroidism or Hashimoto’s, the prescription’s going to be the same.
Dr. Weitz: Exactly.
Dr. James: But what your listeners need to understand, I mean, I think a lot of your practitioners will understand everything I’m talking about, nothing new there. But if you’re a patient and you’re dealing with this, then what you really need to understand is that if you have Hashimoto’s, you don’t have a primary hypothyroid problem, what you have is an immune system problem. It may eventually cause a primary hypothyroid problem, but really what you have is a dysregulation of your immune system. And then, you really have to start to understand, well, what would cause your immune system to dysregulate and want to attack your own body tissues? And the unfortunate thing is, according to the research, is that once you have one autoimmune disorder, you’re 50% more likely to develop another one and another one. So that’s a good starting place for them, right?
Dr. Weitz: Yeah.
Dr. James: Synthroid or levothyroxine apparently does have some protective properties in protecting against autoimmunity against the thyroid, but I think it’s pretty small. I think the bigger thing is is looking at if you’ve been diagnosed with Hashimoto’s. Well, first of all, let’s take a step back. A lot of women come and they’re like, they’ve been dealing with this for years, is the biggest issue, where they’re exhausted, they’re putting on weight that isn’t going away. They’ve got brain fog, they’re losing their hair, they’re constipated, their skin is dry, they’ve got brain fog, they have this constellation of symptoms, they’re cold. It really doesn’t take a rocket scientist and go, “Well, that sounds like hypothyroid symptoms.” So they go to the doctor and the doctor runs their lab tests and it says, “Oh, your TSH is high,” which means you’re hypothyroid. So out comes the prescription for Synthroid.
Dr. Weitz: Correct.
Dr. James: So a portion of those patients, as you’ve probably seen them, they get well. The doctor says, “Come back in a couple of months and let’s check you again.” So if you go back in a couple months and everything, you feel good. And your TSH is in that range. And in California, the lab range of LabCorp is 0.45 to 4.5, which is big enough to drive three trucks through side by side. It’s kind of a crazy range. But if you’re in that range and you feel fine, then you’re done. Then you go off to the races. You go off and enjoy your life. But what happens is a large majority of women go back to their doctor after a bit and they’re like, they don’t feel any better. So the doctor is then playing the game, typically of just trying to dial in the TSH. So if it’s too low, then he’s going to back off on your TSH. If it’s too high, isn’t going to give you a bit more. He might move it from 88 micrograms to 100 micrograms or whatever’s starting places. And they play that game of just trying to dial in your TSH, which is one of about 24 different patterns of hypothyroiditis.
Dr. Weitz: Correct.
Dr. James: There are five real primary ones, but there’s 24 different patterns. So once he’s got that TSH dialed in, the woman goes back and goes, “Well, I still feel like crap and I’m not losing the weight.” Well, you must just be depressed. So now, out comes the Effexor or the Cymbalta, and the antidepressants. And then, they start getting headaches. Well, now here comes the Imitrex. Well, now another 10 years go by, the blood pressure’s getting worse, so here comes lisinopril and amlodipine or Diovan or hydrochlorothiazide or one of those. And then, what I see is a lot of the women that I get to see are typically, they’ve gone down this road for so long, they feel gaslit by their practitioners. They don’t feel seen. And our culture, it’s doubled down for women because our culture doesn’t really honor women as they age, let’s say, so they don’t feel seen in public. I remember my brother saying this to me. It made me laugh really hard, but I was like, “Wow, this is how women feel.” My brother, when he turned 60, he’s like, he goes, “I’m sitting in a restaurant alone.” He goes, “Women don’t even walk in and go look at me and go attractive, unattractive, because it’s like I’m a potted plant.” They don’t even notice.
I laughed at him, but I’m like, “God, this is how I think a lot of women feel.” And then, they don’t feel, maybe the health issues and other things are creating conflict in their marriages. They don’t feel seen by their husband, their spouses, their partners, and they go to their doctors and doctors are like, “Everything is fine.” Why? Because they’re looking at the TSH and that’s dialed in, and yet they still feel like crap. So by the time they hit 60s, then the number one thing I see happening with women, and maybe you see this too, is they’re either pre-diabetic or they’re diabetic. So now, out comes the metformin with the glyburide or the glipizide are now the new wonder drugs, Ozempic and Wegovy, and all these new things that are GLP, GLP-1 agonists.
Dr. Weitz: Of course, you can’t get a prescription of those for diabetes because so many people are taking them for weight loss that there’s none available.
Dr. James: And you hear about the people who are complaining of freaking out because it causes gastric paralysis.
Dr. Weitz: A whole series of GI problems. Causes gallstones, causes pancreatitis, gastric paralysis, intestinal obstructions. When a large number of people are taking a drug for a reason other than what it’s prescribed for, you’re sort of asking for trouble.
Dr. James: Agreed. And even if you’re taking it for what it’s prescribed for, what we do as functional medicine practitioners is not just go, “Oh, that’s not working. Well, let’s give you a drug to replace the thing that’s not working.” Is to go, “Well, why is the thing not working?”
Dr. Weitz: Right. So basically, what you’re describing is the problem that a lot of people are facing chronic health problems with conventional medicine, which is simply treating each symptom with a pharmaceutical drug instead of looking at the underlying cause of what’s happening to your metabolism, your physiology, your endocrinology, and what can we do to change your diet and lifestyle, et cetera, to get to some of these root causes.
Dr. James: Yeah, right. So that’s certainly one level of it. And then, the other level of it is, so autoimmunity is its own beast. But then, the problem is is that I think what I see because I treat a lot of thyroid patients is, number one is that we’re often blaming the thyroid for other issues that are going inside the body. It’s a little bit like blaming the thermometer for the weather. So sometimes, the thyroid is dialed in, but the symptoms look the same. So somebody could have a GI infection, they might have a biotoxin illness. They could have a genetic susceptibility to not being able to process mycotoxins that are either in their environment or that are in their foods that they’re eating. They could have a Lyme infection. They could have a viral infection or a gut infection, a parasite or a bacterial infection in their gut that’s driving an immunological response. And any of these things that create these low level inflammatory responses, not only do they affect thyroid conversion and thyroid uptake and the manufacture of thyroid hormones, but a lot of these things cannot affect the thyroid and just in and of themselves create symptoms that look very, very similar. So this whole idea of this once a year physical is clearly a failed system. Look at the health of our country. It’s just a failed system to run minimal tests. So you have to look wide to go what’s going on with the patient’s body? So I think the model that we’ve all been brainwashed and grown up inside of is one where doctors test in a limited fashion because they’re looking at like, is there a pharmaceutical intervention? And what we as functional medicine doctors are doing, we’re looking at, well, where’s the physiology tilting?
So if I see a few things off over here, even if they’re in range, doesn’t mean they’re optimal. And how is that impacting and how does that affect what’s going on over here? Are your liver enzymes too low? Are they too high? How’s your kidney functioning? How’s your carbon dioxide? Oh, one of the things that I see commonly is how if you trace everything back to the cell and you go back to our eighth grade biology, and you look at the mitochondria as an example. So the way that we make energy is we eat a meal, we breathe in some air, and that glucose and oxygen mashes up against the mitochondria to produce ATP. The byproduct of that is two things, well, free radicals and carbon dioxide. So you look at like, well, there’s a lot of free radical production. So if you drive a car and you don’t change your oil regularly, what happens? Your car becomes less efficient, and maybe you start screwing up your engine. You get less miles per gallon, and maybe it eventually it seizes up or it stops working entirely. And our bodies, when we’re producing free radicals and we live in a more and more toxic environment, and we start to accumulate these in our body, then what I see often is the body is downshifting. It’s saying, “Hey, man. I don’t want to make energy because my primary goal is to survive. So if I increase my metabolic activity, it’s a kamikaze run for me.” If you wake up in the morning and decide and looks up and goes, “Come on, I want to wake up with energy today and I want to lose weight.” And your mitochondria look up and go, “Yeah, I’d rather make you fat, lazy, and stupid, but I’m going to stay alive, so I’m going to keep you in bed.”
So the body has a way of compensating. It may create thyroid under conversion patterns. It may create what I would call a pituitary suppression pattern where you see a low TSH and a low T4, you go, “That doesn’t make sense. If you’re going to see a low TSH, you should see the T4 cranked up. I regularly see that.” You’re not going to see this in the books. I call it like a pituitary suppression pattern where it’s almost like your hypothalamus and pituitary see so much inflammation in the body. It’s like, “Oh, there’s enough T4 and T3, we’re just going to keep it like that.” So it’s not cranking out, yet the T4 is low. That’s not a normal pattern. Even if it’s inside of a lab range, it makes you wonder, well, what the heck is causing that? Why would the TSH be on the low end and see maybe your T4 is like-
Dr. Weitz: Those who are listening, you’re talking about some of these labs like the TSH, the T4, the T3. How about if we do a little defining exactly what those are?
Dr. James: Sure. So TSH is a hormone produced by your anterior pituitary gland, it’s called thyroid stimulating hormone, so it stimulates your thyroid. The pituitary, if you look behind that, is dependent upon hormones being produced by your hypothalamus, which is dependent upon adequate levels of serotonin and dopamine, iron, all these things behind it. But let’s just stay here at the pituitary level. Rabbit holes go-
Dr. Weitz: Pituitary’s the master gland that’s kind of directing the other glands like the thyroid.
Dr. James: It’s the conductor, right?
Dr. Weitz: Right.
Dr. James: So pituitary secretes this thing called thyroid stimulating hormones. So it stimulates the thyroid to make two hormones called T4 and T3. The majority, as you know, 94% or something, depending upon who you look at, is T4. A small minority of it is T3, but T3 is the active hormone that every cell in our body has a receptor site for. So really, the T4 is really used for the feedback loop. There’s some T3 there too. So as long as the thyroid’s producing enough T4 and T3, you see that thyroid stimulating hormone inside LabCorp’s range of what, 0.45 to 4.5. For years, we used to say, the endocrine society said the optimal range is 1.8 to 3.0. And lately what I’m seeing is 1.5 to 2.0, very hard to keep somebody, you’d have to be tested them every month to keep them inside that tight little range. I personally feel better when my TSH is closer to one. I just feel better. So we treat people, not labs, but we use the last foremost of what’s really showing up there. So anyway, so the thyroid produces T4 and T3. So if the majority of it is T4 and the minority of it is T3, but yet every receptor site in our body or every cell in our body has a receptor site for T3, then we obviously need to convert that T4 to T3. So the majority of that occurs in the liver, again, why liver function is so important as it relates to thyroid function. And then, another percentage, that 20% or so is converted in the gut, the rest in the peripheral tissues. So that’s sort of the big story.
Now, if somebody has Hashimoto’s, this means that their immune system has targeted the thyroid for destruction. So I don’t know if everybody understands this concept, but having high antibodies is not equivalent to high natural killer cell activity. So natural killer cells are the cells that actually go in and destroy the thyroid. So you can have very high antibody counts and have very low natural killer cell activity. You can have very low antibody counts and have very high natural killer cell activity.
So I, like you, meet with practitioners, you’ve been amazing in terms of how much you’ve given of yourself to put all of us practitioners together and invite experts in to speak and it’s been very selfless of you. But sometimes I’ll hear people go like, “Oh yeah, I cure Hashimoto’s.” I’m like, “Really? How do you know?” “Why, I don’t see the antibodies anymore.” I’m like, “You don’t understand how the immune system works. That’s not how this works. Nobody’s found the cure for this.” So I want people to be careful. If you could attest Hashimoto’s, you can see antibodies one day and not see them the next. They can be high and then they could be low. And you go, “Aren’t I amazing?” Well, maybe, or maybe you’ve just screwed up the patient’s immune system’s ability to fight something. So it’s just again, a small piece of the picture. Let me come back to where we-
Dr. Weitz: Yeah, I do think when it comes to measuring the antibodies too, we have to be careful not to freak out if the antibodies are slightly elevated as compared to elevated a lot.
Dr. James: Correct, because of that dysrelationship between natural killer cell activity. Now, if somebody has had Hashimoto’s for 25 years and they’re hypothyroid symptoms, then we need to be concerned. And these people would go like, “I don’t want to be on thyroid hormones.” If half your thyroid’s destroyed, you’re going to need to be on some sort of thyroid replacement. There’s no natural equivalent to that. Just like I tell my patients, “If you have type one diabetes, you need to take insulin. Your pancreatic islet cells don’t make insulin. You need some sort of source or you die.” But let me come back to the Hashimoto’s model. So what gets confusing for patients who have Hashimoto’s is the TSH levels, I don’t know if you see this, they’re up and down, up and down, up and down.
Dr. Weitz: Sure.
Dr. James: So somebody has a flare up, their immune system gets activated by either a food they eat, something exogenously walk into a room where it’s formaldehyde off gassing, who knows? They’re exposed to mold. So their immune system flares up and it goes after the thyroid. And now, you have this natural killer cell activity. And what happens is in that moment of the flareup, it’s poking holes in the thyroid. So it’s destroying the thyroid, but it’s not destroying the thyroid gland. So it’s like popping a water balloon. So you pop a water balloon, the balloon is destroyed, but you get water all over yourself. So in that moment, you have the normal production of thyroid hormone, and then you have this excess production from the destruction of the thyroid. And you may have 10 days a week, two weeks, a month of feeling hyperthyroid, where a patient feels anxious and they have this inward trembling and their heart’s beating fast, and they’re wired and tired, and they got all this stuff. And then, when the immune system flare wanes down, and by the way, if you were to do a test, TSH, in that moment, you might see the TSH being really suppressed. So they go to their doctor and they go, “Wow, the TSH is really low. Now we’ve got to back off on your Synthroid.” So they lower the dose of the Synthroid, and then when the immune system flare wanes down, they’re just, “I’m so depressed, I’m so tired, so I can’t move.” And now, they’ve lowered their thyroid hormone down. Now, if they ran their TSH, it’s actually really high after the flare up, and the doctors in effect made them even more hypothyroid but backing off. So a lot of patients are going and seeing, and the doctors aren’t really necessarily paying attention to that mechanism because they’re just adjusting for TSH.
Dr. Weitz: Sure.
Dr. James: So this is one of the big things that I think women in particular need to be paying attention to and looking at. So if you’re feeling anxious, then you’re cranked up and then you’re exhausted, then you feel anxious, and then you’re exhausted, you’re going back and forth that, that sounds very much like a Hashimoto’s patient. You’re not crazy and your doctor’s just trying to dial in the TSH, and the problem is nobody’s really paying attention to why is your immune system flaring.
Dr. Weitz: Right. So let’s talk about that. When you see a patient who comes in and they have elevated TSH, maybe they’re already on thyroid and you measure their antibodies or TPO, their TGB antibodies and you realize that they have Hashimoto’s, what’s your next step?
Dr. James: Well, I look at the rest too. So you’re looking at T4, you’re looking at total T3, you’re looking at free T3, you’re looking at reverse T3. You want to see what the body’s doing. I’m looking at a liver panel. I’m looking at liver enzymes. I’m looking at everything to go, “Well, what’s going on here?” So if they have Hashimoto’s, well, we know there’s autoimmunity, and the concern is based upon the patient’s history, are there any other potential autoimmunities? If there are, maybe we’re looking at doing some other antibody testing to see what’s going on there. But then, really to get to the root of it, it’s based upon a consultation, Ben. So you talk to the patient, they’re like, “I feel like after I eat, I’ve got a brick in my stomach. I’m really gassy. I have alternating constipation, diarrhea.” Well, I don’t know, maybe you’re doing some SIBO testing. Maybe I’m doing a stool test to find out what’s going on there. I also do genetic testing. So I do this with almost every patient now. I always look for any kind of susceptibility genetically to mycotoxins or any biotoxins, really.
Dr. Weitz: Which genetic panel are you running?
Dr. James: So I do a DRB1, 3, 5 and a DQB test. And then, you just go, you plug it into a calculator and it tells you, “Hey, are you multi-susceptible? Are you not susceptible?”
Dr. Weitz: So which test is that and which lab is that from?
Dr. James: I just use LabCorp. We can just go in there and Google it. I can send it to you off. It’s not a problem. So you run that and you go, “Okay, this is a patient who maybe has a potential for biotoxin illness.” But based on the history, you go, “Is this something I need to be looking at?” If so, then I’m probably running a total tox panel on them.
Dr. Weitz: Right, the Vibrant America one.
Dr. James: I like Vibrant America. I used to use Great Plains, but Vibrant America tests more analytes for less money. So you can do, I look at mycotoxins, environmental toxins, and heavy metals altogether.
Dr. Weitz: Right. I like that test too.
Dr. James: They’re great tests. You run on yourself, it’s kind of shocking. For me, it was. I ran one 10 years ago and I was pretty good. And then, I ran one four years ago and I went, “Oh, no. Oh God, where’d all this plastic come from in my body?” In any event, so you look at those things because a lot of these things are endocrine disruptors. A lot of these things are carcinogens. A lot of these things affect your kidneys, your livers… Your livers, your liver. So you got to look like… You could have two livers. You could. Unlikely, but you could. Never 100% sure that you don’t. So you start looking around the body and going, “Okay, well, are they regulating their blood sugars or anything going on there? Do they have insulin resistance?”
Well, why do you have insulin resistance? Again, I mean, I’m sure you see people particularly out here, some people eat really, really well and you go, “What the heck is going on that they’ve got a high fasting glucose, but their insulin is okay, and their HbA1c is okay, or they’re eating well and their insulin’s really high and their glucose is high, and their HbA1c is high.” And you’re like, “What the heck is going on?” Well, maybe that’s a compensation, as we talked about before, where the mitochondria going, “I’m going to create insulin resistance here. I’m going to shut down some thyroid production because I want to shut down metabolism, otherwise I’m destroying myself.”
So I think conceptually, I’m always looking at, is this the body’s compensation or is this a primary issue? And if it’s a compensation, well, from where? So autoimmunity is fairly near and dear to my heart because many years ago I diagnosed my daughter with PANDAS. So for those who are listening, it stands for pediatric autoimmune neuropsychiatric disorder associated with strep, but the strep heart is like nonsense because really it could be any vector. So my daughter never tested positive for strep, but she had the antibodies against her brain, and that’s antibodies against your basal ganglia is not a cool thing. So basal ganglia are what really? Gate perseveration of thought and motor control. So kids can develop ticks, their behavior goes out.
I remember my daughter is really bright, and I remember years ago showing her something, and I think it was the word cat, and she was like, “Dad, I don’t even know what I’m looking at.” I’m like, “Oh, wow.” That’s heavy, right? It’s scary. She’s doing great now, but it was like, I took her to the top neurologist, I will not mention on the East Coast, I want to strangle her. And I had done a bunch of tox panel tests on her, and there was a lot of crap in my daughter. And you’re like, “At that young age?” And she goes, “Oh, it doesn’t matter. It’s just in her urine.” I said, “Well, what comes before the urine? Why is my daughter spilling signs?” “No, no, it doesn’t matter.” “What do you mean it doesn’t matter? How can you be a pediatric neurologist and say that?” I was like, grab my daughter-
Dr. Weitz: Doesn’t fit into her paradigm.
Dr. James: Made me so depressed. Made me so depressed. We’re like, “We’re on our own here. We’ve got to figure this out.”
Dr. Weitz: Well, she wouldn’t know what to do with it anyway.
Dr. James: Well, and I said, “I didn’t even chelate this out. It wasn’t like I gave my daughter glutathione for four days and then did the test. She’s literally spilling this much crap out of her system. How can you say that this doesn’t have an impact on her immune system?” She didn’t have an answer.
Dr. Weitz: It’s just not a test that’s part of her worldview.
Dr. James: Clearly, right? And it’s interesting to me because as a neurologist, what got me interested in all this other stuff was when you start to study neurology, then you’re like, “Oh, God, there’s so much to know in neurology.” And then you’re like, “It gets worse, because now you got to understand everything that impacts the nervous system,” which now, you step into the world of functional medicine and look at all these different inflammatory models because there is the neuroendocrine immune system. There’s the psycho-neuro-endo-immune system. This isn’t like the system of neurology only. And I’m looking at this woman going, “Really?” It’s astounding to me that in this day and age, that you could be that locked in.
Dr. Weitz: Unfortunately, conventional medical specialists are siloed. Neurologists are just looking at the nervous system and the brain and that’s it.
Dr. James: Yeah, some are. There’s a great guy here in Santa Monica refer crazy cases to, who’s really a terrific neurologist. But I mean, and endocrinology, my mother, part of why I have this interesting is my mother had her thyroid removed when I was probably seven or eight years old, late 60s. And I watched her yo-yo, man. I mean, she was angry and just overweight, and she drank two half gallon bottles of Tab every day, sugar-free type. Remember that stuff? You’re old enough, right?
Dr. Weitz: Yeah. Absolutely.
Dr. James: Right. I mean, she did the Atkins diet, she did the grapefruit diet, she did fricking everything, and died at 63. I’m two years away from that. She had cancer. Do I have evidence that the Tab caused that? No. But her diet and everything in her thyroid dysfunctioning, and I guess the point is is I don’t see endocrinology being practiced a whole lot differently today than it was 50 years ago. I just don’t see it. And in what other realm, really, in what other the realm do we not see advances in technology, medicine, science, et cetera? It’s the same game. It’s the same well, we’ll adjust your T4 and your T3. And that’s the scary thing.
So I do webinars and stuff and people say, “Well, what’s the ideal range of T3?” I’ll tell you, “It’s 3.2 to 4.3.” But I’m scared to say that sometimes, because then they’ll go to your doctor and go, “Give me Cytomel so that I can dial this into 3-point…” Again, what if your body is downshifting and trying to say, “Hey, there’s too much crap in the system. I’m going to slow down the conversion.” But we’re smarter than our bodies, so we’re going to override that and give you T3 and burn the engine out.
So I think when we start to look in those silos, when we start to look at these labs and try to go like, “Well, what are the ideal numbers?” I mean, it’s a good idea to know what they are, but it’s also a good idea to know, well, what’s influencing those numbers and why is the body doing what it’s doing? Is it a primary issue where the body just can’t convert. No matter what, everything else is clean, fine, do a T4, T3. But if it’s not, well, maybe you’re screwing the body up by actually putting them on a synthetic hormone of T3 as an example. Off my soapbox about that.
So to answer your question, so the initial question was like, so what do you do? You listen to a patient, I listen to my patients and go, after doing this for a long time, you get a sense of like, well, what direction, what test do I need to go? What roads do I need to go down? What do I need to test to look? Every now and then, it’s pretty rare these days where I don’t find what I think is one of the primary issues in the first round of testing. And I go, well, I need to look further. Every now and then, you get somebody who’s complicated.
Autoimmunity is really complicated. Autoimmunity in and of itself is an inflammatory condition, as you know. So if somebody has Hashimoto’s, then in and of itself is an inflammatory condition. And inflammation, we’ve known this since the ’90s, I have an old, somewhere around here, I have a laminated, think in the LA Times like being published, a patient brought it into me because I was talking back in the ’90s about how inflammation connects all chronic diseases together, and somebody brought it into me and I laughed. I was like, “See?” I mean, it’s so cool 25 years later. But we know that. Why do we pretend that that’s not the issue, Ben? In our system, we pretend that chronic inflammation isn’t at the root cause of whether it’s diabetes, it’s hypothyroidism, it’s heart attack, it’s stroke, it’s cancer. That’s what it is. So the name of the game ought to be, ought to be, that’s what we do, is looking for that thing that’s driving the inflammatory.
Dr. Weitz: I think what’s happened is it’s become a buzzword. People say, “Yeah, it’s inflammation.” And then, they just prescribe the Synthroid and move on, because it’s complicated, because it’s expensive to do all this testing to figure out what’s going on. You have to spend time, you have to make changes to your diet and lifestyle, et cetera, and it’s a lot easier to just take a pill.
Dr. James: I agree. But the in amenity of it, is it really expensive to get sick?
Dr. Weitz: Absolutely. Look-
Dr. James: I think you have a byline in your emails that speaks to that, right?
Dr. Weitz: Yes, absolutely.
Dr. James: What does that say again?
Dr. Weitz: Sorry, I forgot. But it-
Dr. James: Tell me if you’re like, those who don’t like to take the time to take care of their health now, certainly will like-
Dr. Weitz: Exactly. Yeah.
Dr. James: … find out it’s more expensive to take care of it later.
Dr. Weitz: Exactly.
Dr. James: I think… Go ahead. Sorry.
Dr. Weitz: Yeah, I’d like you to address, there’s kind of two issues with this testing thing that I think doesn’t get talked about from the perspective that we have enough, which is on the one hand, patients go to their primary care doctor and get a set of labs, and somehow they’re convinced that all the tests that could possibly be run are run. And I think it needs to be emphasized to people who are listening to this that when you go to your primary care doctor in general and get your labs done, it’s a very limited number of labs, it’s only what the insurance wants to pay for. Typically, about all you’re getting is a CBC, a chem screen, maybe they’re going to do your TSH, maybe you’re going to get a basic lipid profile, and that’s typically all you’re going to get. Now, they might put each test on a separate sheet of paper and make it seem like a lot of labs.
Dr. James: That’s so annoying, right? Patients come with their phone and go, “Look.” And you got to look at-
Dr. Weitz: Exactly, you got to go through one thing, WBC on one page, RBC on the next page, and then I show them a Vibrant America labs that we’ve done, and the whole chem screen is on one page, and this is out of 20 or 30 pages of labs. So first of all, patients need to know that the labs that you’re going to get from your typical primary care doctor physical exam are very limited. And that labs can be very helpful in trying to get an idea of what’s going on in your body, trying to determine some of the underlying physiology. I also think there’s a trend in functional medicine where there’s a relatively small number of functional medicine doctors who get on this high horse and say, “Oh, all the other doctors do too much testing. We don’t really need to do testing and just take this probiotic and you’ll be okay.”
And so, I think that’s also a limited way of looking at things. And so, I think judicious professional doctors like you and me, we are doing more detailed testing and we’re careful with how much is being spent. We understand that patients have finances, but it’s important to get an idea of what’s going on with your underlying physiology, with these different processes, with toxins, with these things that are affecting your health and over a period of time can lead to all these chronic diseases. And that’s why your patients are just getting treated with one drug for a different symptom after the other.
Dr. James: Yeah, I mean, we live in a disease management system.
Dr. Weitz: And the functional medicine model is reasonable and rational and is really the only way to figure out some of these underlying things going on inside our patients.
Dr. James: Agreed. So there are some doctors, I know some functional medicine doctors that charge, they want $3,500 in testing before a patient even walks in the door. I mean, good for them that they have that kind of practice. I mean, I don’t do that, but patients need to understand that if they want to get well, they’re going to have to spend some money. And I don’t know what’s more important than your health. Honestly, so many people can’t make their health their number one priority and everything in their world falls apart as a result of that. When you offer yourself and you take care of this first, everything else seems to fall into place somehow.
And it’s like this lack of, or this expectation, as you said, I guess insurance will pay for my doctor. I mean, I have this saying around here, that was a waste of poke and a hole in your vein, that blood test. A CBC without a differential, a TSH, maybe a T4. And then, you go back or patients will say, “Well, can I get my doctor to run these labs?” Sure. And 99 out of 100 times, we get a third of what we asked for. And then, you go back and you ask them, “Why?” It says, “Well, it wouldn’t change the pharmaceutical outcome.” So we’re looking again, as a functional medicine doctor, we talk about root cause all the time. What does that really mean? It means we’re looking at where is your body not functioning? Where is it functioning and where is it not functioning? Because it tells a story to us of where there’s a breakdown in your physiology and then where to look down, what rabbit hole to go down.
Dr. Weitz: The other thing has to do with the fact that, I am not sure if everybody’s aware of this, but doctors are not running the healthcare system. It’s insurance companies. And so, I have a good relationship with my primary care doctor and he refers me patients, and I refer him patients back. And patients sometimes come in and want these functional medicine labs and he says, “Look, I can’t do it.” And occasionally, when he tries to run some additional labs, the insurance companies threaten him and they threaten to actually decrease the amount they’re going to pay him because he’s spending more of their money.
Dr. James: Right. So I don’t like spending a whole lot of time fighting a system that’s way bigger than me. I’m one guy, I can’t fight that. So it’s more of like, “Listen, Mrs. Jones, this is what needs to get done to figure out what’s causing you the last 30 years of your suffering.”
Dr. Weitz: Right. Yeah.
Dr. James: “You want to suffer for the next 20 and 30, or do you want to, and just close your eyes and just throw a dart in the dark and shoot in the dark, or do you want to really target and figure out what’s going?” It’s a bit like to continue metaphors. It’s like you go to your mechanic and your car’s making noise and you go, “How much is it going to cost and how long is it going to take to fix it?” Well, the mechanic say, “I need to open up the hood.” “No, no, no. Just like you’ve done this long enough, can you just tell me?”
Dr. Weitz: Right. So let’s get back to the topic. So how can we help these patients with hypothyroidism? And so, the ones that have autoimmunity, which are the most common form of hypothyroidism in the US, you’ve been talking about toxins, so we can screen for toxins. There’s food sensitivities, we can test for food sensitivities, we can put them on an elimination diet. How do you usually like to handle the food sensitivity issue?
Dr. James: So depends on the patient’s budget. So an elimination provocation diet is really good, but what I’ve really found recently is I’m seeing a lot of patients come back who don’t notice the change with eggs, for example. And then, I run a food sensitivity panel because I’m not seeing the changes I want. I’m like, “Shoot, there it is.” And then you’re like, “God, if I had done that three months earlier, would I have gotten to it?” I might’ve, but the food sensitivity tests, you can run them all over the place. I do a lab that’s very comprehensive. It’s 450 bucks.
Dr. Weitz: Which panel do you like?
Dr. James: I use Infinite Labs because they do IgE and IgG and IgA and IgG3, IgG4. And there’s some correlation between an IgG4 showing up and an IgE where it sort of suppresses the symptomatic experience of an actual allergy. So it’s sort of an interesting test, but if I do a screening, sometimes I’ll just do LabCorp and run a few different basic ones, or use, what’s that, anylabs.com or something. So you can get a few that are, they’re only like six bucks each to run them to get a few. I start typically with an elimination provocation diet to see how they’re doing.
Dr. Weitz: Fibrin actually has, besides the Zoomer panels, they actually have a multi food sensitivity panel, one that’s pretty reasonable price, I think maybe a couple hundred bucks.
Dr. James: Yeah, I used to use Cyrex a lot. I’ve not used them for that as much. There’s a variety of different, and every practitioner has a favorite to use. There’s variety, different ways of going about that. I’d say the typical hypothyroid patient, diet’s going to be 40 to 50% of it. The other 50% of it is going to be going down these different rabbit holes and unwinding the physiology and figuring out, well, what’s broken and why did it break and what needs to work. And for some people, they’ll get fixed in better in a few months. And some people, it’s going to take a couple of years. I mean, it just is, depends on how-
Dr. Weitz: Right. How do you approach these food sensitivities? Let’s say you have a patient who tests as sensitive to gluten or eggs. Do you take them off that food? Do you ever bring the food back or you tell them they have to stop for the rest of their life, or how do you approach that?
Dr. James: Sensitivities, I have them, eliminate them hardcore for six months. And then, in six months, add it back in and go, “Is there a problem?” If they’re really addicted to something and they want to spend the money, they can go back and retest. Allergies, sorry, it looks like that’s probably a lifelong thing for you.
Dr. Weitz: And by allergy, we’re talking about IgE.
Dr. James: Correct. So an IgE is like, yeah, you probably don’t want to go near that. And again, it depends on, we’re always dealing with, I find we’re having this conversation just prior to the podcast. I find that a lot of what occurs for patients, particularly when they start getting to their 50s, 60s, and 70s, is you’re dealing with a lot of psychology. So there’s a lot of unresolved emotion here from just the medical system of feeling gaslit for a lot of women, where they just don’t feel seen inside the system. Most of the thyroid patients are women. So it clearly tells you that there’s a hormonal aspect of that. We haven’t even discussed that. And then, most of the endocrinologists and the doctors seeing are men who were just looking at them like, “You’re fine. Your TSH is fine. It’s all on your head.”
And they go back to their husband and the husband’s like, “The doctor says you’re fine.” And so, there’s 30 years of being suppressed and feeling angry about all this, and it’s really frustrating to them. And then, when I start showing labs and showing their husband, a lot of times the husband’s like, “Oh, God. Am I a heel, man? I suck.” Or sometimes they’re still stubborn and antagonistic. And those patients, I often don’t like to take on because I don’t want to create issues in the marriage. There’s got to be like a, “Hey, we’re all in this together.” And that’s really the bigger difference too. This, when we’re talking about lifestyle and diet and fixing things the way that we do is that it takes a village. Everybody has to be on the same page with it.
So we’ve got to deal with women’s and men’s, also, psychology and the psychology around food. Because how many people come and go, “I’m a foodie.” I don’t know what that even means. We all love food. There’s like 1 out of 1,000 who goes, “I don’t really care. I do it for fuel.” But most of us really enjoy eating and we enjoy eating what we enjoy eating. And it really sucks when you find out that there’s a food that’s causing you a health problem because you really enjoy that food. “But when I eat it, I feel so much better.” Right, probably because you have an allergy to it and it’s causing a cortisol response, which makes you feel good temporarily, or it’s creating an epinephrine response because your adrenals are fatigued or beat up or whatever vernacular you want to use around it. It creates that kind of a sympathetic response, which makes you feel like awake and alive for 15 minutes. It’s like beating a tired horse.
But there is a lot of dealing with that. And then, there’s a lot of ways in which people are disappointed in how their lives turned out and they get to be in their 60s, 70s, it’s like, “This isn’t what I expected.” So now you want to take away the one thing that allows me to feel good, which really equates to really not necessarily feeling good, but maybe being numb and not having to feel what they don’t want to feel. So I would not underestimate how much psychology and emotional stress also plays into thyroid patients, particularly when they’ve been dealing with this for 30 years. Because that emotional stress, that inability to feel self-expressed is an internal type of stress that’s going to dysregulate your blood sugar, cause more cortisol response, which is going to affect your hippocampus, which is going to give you brain fog and short-term memory, which is going to dysregulate the hypothalamic pituitary adrenal axis, which is going to cause your cortisol to be high in the evening and low in the morning so you can’t sleep. And now, you’re all effed up.
Sorry, that’s not clinical, but this is for me, I think that helping people restore their health, when we talk about people throw the word alternative and holistic around. To be holistic means you do have to address that aspect of it too. You have to address the emotional aspect. You have to address sleep hygiene, you have to address your relationships or you’re miserable.
Quick story here. I had a patient I was treating years ago. She had MS and Hashimoto’s, and those two things you do see a lot together. It’s scary, it’s unfortunate. So I’m treating her, and it was like the end of the summer, and I looked at her after a consult and I was like, “You’re not looking good today.” She goes, “I’m not sleeping.” I said, “Why aren’t you sleeping?” She goes, “Because it’s so damn hot.” I go, “Well, turn on the damn air conditioner.” She goes, “I can’t, my husband won’t let me.” I said, “What do you mean he won’t let you?” He goes, “It’s too noisy. And he says like 73, 74 is cool enough.”
And I go, “Let me talk to him.” “No, no, no, I don’t want you to talk…” I said, “He said he was supportive of you in the initial consults.” “No, no.” I said, “Listen, you’ve got MS. You need to sleep and rest. If he gets cold, he can put on… There’s only so many clothes you can take off.” And she goes, “I’m literally lying in a pool of sweat at night.” I’m like, “Well, how about…” Said, “No, it would create conflict.” So this is what I was dealing with at the end, which was her relationship was not good. And what a selfish dude to be like, “Yeah, I don’t want to hear the noise so you suffer with your MS.” Really? Put earplugs in, dude. Put on pajamas.
Dr. Weitz: He probably didn’t want to spend the money.
Dr. James: On earplugs or pajamas?
Dr. Weitz: No, no. I mean, for the electricity.
Dr. James: Oh, maybe. Here’s the interesting, she had kids in England. She went away to England for a month on a vacation. Her symptoms were magically like 100% better. Not only was she sleeping, but the stress of her relationship. As she came back, “I get this is really confrontive for you. I get it. You’ve really got to look at what your marriage is doing to your health.” And she said, “I know. I’m praying about it.” You can pray, but I think you know what you need to do. Pray about what the next step is for you. But it’s no joke, when somebody’s got a life with a partner for 30 years and you’re looking at the dissolution of that, that’s no joke. So we laugh about it. I’ve been divorced. It’s not a joke. It’s not fun. But if you don’t address those things, it has a really terrible effect on your health.
Dr. Weitz: Absolutely.
Dr. James: You know the author, the psychologist, Gabor Mate, have you heard of him?
Dr. Weitz: I’ve heard of him.
Dr. James: So he wrote a book called When the Body Says No, and it’s all about how there’s all this research coming out, not a surprise, how when we suppress our emotions and our inability to say no to things, that it creates disease in the body. Anyway, end of that part.
Dr. Weitz: Yeah, no, very important. Okay. And where else do you want to take this discussion? Any other parts of dealing with thyroid that you want to talk about?
Dr. James: I think there’s two things that, particularly if you’re a woman listening to this podcast right now and you’ve been suffering for a lot of years and you don’t know where to go and you’re feeling like some of the things that we talked about, what really needs to be addressed, and you’re probably not going to find it unfortunately, your general practitioner, what needs to be addressed is do you truly have a hypothyroid problem? If you have Hashimoto’s, you know that your thyroid is affected, but then you have to look at what’s causing the immune system to be overactive. So you have to look at blood sugar issues. You’ve got to be looking at your joint. You’ve got to be looking at these toxins, digestive issues. You got to look at hormones. We haven’t even talked about hormones today.
Dr. Weitz: Right.
Dr. James: All of these things have a really big impact on your immune system and therefore your thyroid. But also, even if you don’t have Hashimoto’s, all of those things can impact thyroid production, thyroid conversion, thyroid uptake, and in and of themselves create symptoms that look just like a hypothyroid patient, but aren’t being addressed. So your thyroid actually is dialed in, but you have these other issues that typically, again, don’t get looked at. So when you’re in a traditional model, as long as things fall inside of the lab range, you’re fine. But you and I know that just because something falls inside of a lab range doesn’t mean it’s optimal. And so, it’s not typical that somebody’s health is dynamite and then they just fall off a cliff. There’s patterns that you see of things shifting and moving over time that you go, “You’re not going in the right direction, pal. We need to change some things up.”
So you’re going to need to just grab the snake by the head and go, “Okay, I obviously have to bite the bullet. If I want to get, well, A, I’ve got to make it my number one priority. B, I’m going to have to do some testing so I can get to the accurate root cause of where the dysfunction is. And then, C or three, I’m going to have to be patient with the process of unfolding and healing, because healing is a process.” Injuring yourself and getting injured as an event. Getting sick is often a process too. So can be an event, you can get COVID, and then that wreaks havoc with your body and does all this other stuff. And that’s another podcast, happy to talk to you about that. But there’s all these different influences impacting us right now in the environment. And so, it isn’t always… The thyroid is not a simple problem.
Dr. Weitz: Sure. You’re talking about toxins. One thing, I don’t know if everybody’s aware of it, but there are substances like fluoride, which is added to the drinking water, which people are brushing their teeth with, chlorine, which is added to the drinking water as an antiseptic, bromide-
Dr. James: Bromides in flour.
Dr. Weitz: Exactly. And so-
Dr. James: Can I interrupt you here? Because you said-
Dr. Weitz: Yeah, go ahead.
Dr. James: … in the beginning and I made a mental note of it, and then we went off and I forgot. And that is actually, I see a fair amount of iodine deficiency these days. So I would not say that we’re iodine-sufficient, but that’s another tricky game when you have Hashimoto’s. I don’t recommend iodine for my patients who have Hashimoto’s. If I’ve tested multiple times and it’s not there and I’m no longer suspicious, and there’s other things, I may do like a urinary test to look for, are some of these halites interfering and blocking iodine uptake. You mentioned fluoride, bromide, right? So that’s an important aspect of it too so I’m so glad you came back to that again. Thank you.
Dr. Weitz: Yeah, I have Hashimoto’s. I don’t really have any of the symptoms, but I’ve had elevated TSH for years. And so, one of the things I tried was the high dose iodine because we have certain doctors who are really big on recommending a typical dosage of iodine that you’ll find in a multivitamin is maybe 150 mcg, so that’s like 0.15 of a milligram. And so, these doctors are recommending 15, 20, 30 milligrams of iodine. So my TSH stays somewhere around 7, sometimes I can get it down to 4.5, and it had gone up to 9. So I decided to take 12.5 milligrams of iodine and it went up to 25. So I got off that, added selenium, added some more magnesium. I got it down to 4.7.
Dr. James: So you’re getting there. You just reminded me of another thing I want to talk about. And that is another thing that happened with me is many years ago I went through a really stressful event and my TSH went up to 95.
Dr. Weitz: 95. Wow!
Dr. James: I was freezing all the time. Like, “Oh, I don’t feel quite right.” And the denial factor went in really strong. And then, I ran my own blood and I was like, “Oh shoot, I’m going to have a heart attack.” And it’s the same fricking thing. They’re just trying to dial in the TSH and they didn’t fix any of that. I’ve tested myself 50 times, never tested for Hashimoto’s. I take 50 milligrams of iodine every day. It works for me.
Dr. Weitz: 50.
Dr. James: Like massive amounts. But I ran those tests. So it’s important to look at, and then you think like, “Oh, Brazil nuts are great because they’re high in selenium.” So I ran a food sensitivity test on myself. Guess what I test positive for in terms of food sensitivities?
Dr. Weitz: Brazil nuts.
Dr. James: Right. So when people go like, “Well, what’s the thyroid diet?” I don’t know how it is for you. For me, there is no general diet, there’s what’s right for you, because what I said, just have a Brazil nut every day. Now, I’m causing an inflammatory disorder for myself. There is maybe a general thing, and everybody knows if it’s an inflammatory issue, you go on an autoimmune paleo diet, but then that has to be dialed in more perfectly for what’s specific for you for it to work for you. So you found out iodine didn’t work for you. I see that pretty classically with Hashimoto patients. And I know the doctor you’re talking about who likes to use high dose that way.
Dr. Weitz: Dr. Brownstein, right?
Dr. James: I wasn’t going to mention his name, but I tested myself and I was really freaking deficient. I was kind of mind blown by it. So I started taking a really high dose and it seems to stabilize me and do really good when I’m like that. I rarely use that with patients, rarely. But sometimes, I have patients who are-
Dr. Weitz: You got to find what works for each person.
Dr. James: So this is the key to it, which is there is no generalized, let’s give everybody levothyroxine and have it elevate their TSH. That gets a very small percentage.
Dr. Weitz: And same thing with diet. There’s some people put out the thyroid diet or don’t eat these cariogenic fruits like broccoli because that will inhibit-
Dr. James: You have to eat so much freaking broccoli. Who eats that much broccoli? You put in a blender and drink broccoli soup all day long. I know, I love that. I get that on webinars like, “Isn’t broccoli a goitrogen?” Or I’ll have an ad up and it’ll have broccoli. “That’s a goitrogen and you’re a thyroid [inaudible 00:53:15].” Yes, yes, true, it is.
Dr. Weitz: Okay, great. I think we hit the topic pretty good.
Dr. James: I think we did. Thank you, Ben, for having me. This was fun.
Dr. Weitz: Good, good.
Dr. James: I hope your listeners got something out of this conversation.
Dr. Weitz: I’m sure they did. Those who want to get a hold of you to have you help them. What’s the best way to get a hold of you?
Dr. James: Thank you. They can call the office 310-396-3100, 310-396-3100. They can also go to drjeffreyjames.com.
Dr. Weitz: That’s great.
Dr. James: [inaudible 00:53:54] there. Thank you.
Dr. Weitz: Thanks, Jeff.
Dr. James: Thank you for the plug.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way, more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica White Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
Dr. Jeffrey Gross discusses Regenerative Medicine with Dr. Ben Weitz.
[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.]
Podcast Highlights
Dr. Jeffrey Gross is an MD
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
https://drweitz.com/wp-content/uploads/2023/11/rwp-335-website.jpg350785drweitzhttps://www.drweitz.com/wp-content/uploads/2017/06/drweitzdsamplelogo-withtext.pngdrweitz2023-11-21 17:15:112023-11-24 10:30:28Regenerative Medicine with Dr. Jeffrey Gross: Rational Wellness Podcast 335
Dr. Howard Elkin discusses an Integrative Approach to Cardiology at the Functional Medicine Discussion Group meeting on October 26, 2023 with moderator Dr. Ben Weitz.
[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.]
Podcast Highlights
Dr. Howard Elkin is an Integrative Cardiologist with offices in Whittier and in Santa Monica, California and he has been in practice since 1986. While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for diet, lifestyle changes, and targeted nutritional supplements to improve their condition. Dr. Elkin has written an excellent new book, From Both Sides of the Table: When Doctor Becomes Patient. His website is Heartwise.com and his office number is 562-945-3753.
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast. Welcome to our first live functional medicine discussion group since before COVID. So thank you so much for joining us. Also, this event will be recorded, and it’ll be included in my weekly Rational Wellness Podcast, which you can listen to on Apple Podcasts, Spotify or YouTube. Let’s see what else. We usually meet on the fourth Thursday of the month. Next month, we’re going to meet on the third Thursday because the fourth Thursday is Thanksgiving, so that’ll be the 16th. We have Dr. Akash Bajaj is going to be speaking about regenerative medicine and stem cells and PRP, et cetera.
We’re going to take December off. And then January 25th, we have Dr. Vojdani. And then we’ll go from there. We are being sponsored tonight by Integrative Therapeutics. Steve, would you like to come up and say something about Integrative?
Steve: I don’t want to come up there, but …
Dr. Weitz: Okay. Well, I’m going to bring the microphone to Steve.
Steve: I don’t think you need the microphone, do you?
Speaker 3: No, we can hear you.
Steve: So thanks for coming, everybody. It’s weird to be live again. Thanks for filling up the room.
Dr. Weitz: Can you speak on the microphone?
Dr. Elkin: Yeah, it is hard to hear.
Dr. Weitz: [inaudible 00:01:54] up by the recording.
Steve: Oh, I’m sorry. Is that okay?
Speaker 3: Yeah.
Steve: We have some samples of some products back here that we do a lot with the cardiologists that we work with. You probably know most of them. The big one is Cortisol Manager for stress. Stress relief is a big part of all this cardiovascular stuff, so the Cortisol Manager. Allergy relief capsules are back there. That’s a nighttime reduction cortisol so you can sleep better. There’s also HPA Adapt, which is our daytime cortisol stress management product.
We also have Curalieve, which is our brand-new curcumin technology. This stuff is going to blow you away. It’s way better than our own curcumin, which has been the number one seller at Fullscript for the last eight years. So take samples of everything. There’s also some little bottles of Neurologix, which is our new cognitive improvement product. Those are seven-day trial bottles. Take two, because two weeks you’ll really notice the difference. It’s spearmint extract, citicoline, and saffron. Within two weeks, you’ll get anybody noticing an improvement. So knock yourself out. Have fun.
Dr. Weitz: Thank you so much, Steve. Tonight, we have Dr. Howard Elkin, integrative cardiologist, and he’s going to help enlighten us about how to manage patients with cardiovascular risk factors. So, Howard, you have the floor.
Dr. Elkin: Thank you. All right. It’s great to be back here after, what, over three years? I don’t know about you guys. I got really Zoomed out off of all these months of Zoom calls. Anyway, it’s good to be back. So I’m going to talk about heart disease and why are we still dealing with the numbers? Well, let me show you. It’s still the leading cause of death. I don’t care what anyone says, but more than COVID, more than cancer, more than all the cancers combined. The biggest cause of death in this country is still heart disease, no matter how you slice it, and it affects women and men basically equally and crosses over all ethnic groups. It’s remained the leading cause. We have about close to 700,000 people dying every year of heart disease in the United States. That’s one out of five deaths. One person dies every 33 seconds. That always just amazes me when I hear that. Every 33 seconds someone is dying of heart disease. Between 2018 and ’19, look at the cost. I mean the direct cost, 407.3 billion, 251 billion in direct costs and 155.9 billion in lost productivity, people that are out of work because of heart disease. More statistics. In 2020, coronary artery disease, the leading cause of cardiac death, which, of course, makes sense. Stroke, 17.3%. Hypertension followed by heart failure and then diseases of the arteries including peripheral artery disease and [inaudible 00:05:01] circulation.
Coronary artery disease is the most common type of heart disease, killing about 376,000 people in 2021. Two out of 10 deaths occur in CAD people less than 65. It’s not an old person’s disease. I’ve had many patients in the course of 36 years that had heart attack, bypass in their 30s and 40s. So it’s not just about elderly people. 805,000 people have heart attacks in this country every year, 605,000 with their first heart attack and about 200,000 of those with previous heart attacks. This tends to be a progressive disorder. It’s like cancer. It does not get better with age. I can promise you that. This is important to know. 40% of the heart attacks are silent. So as opposed to Kaiser and a lot of HMOs that really don’t deal with preventative medicine, I am very scrupulous about my patients and coronary disease. They’re automatically high risk. I study them scrupulously because of the fact that the silent heart attacks are so common, 45%. It was about 25% when I was a student. So it’s increased incrementally since 1980.
What about women? Well, over 60 million women, 44% in the United States are living with some form of heart disease, and it’s the leading cause of death in women more than all cancers combined, more than all cancers combined. Now, about 250,000 women die every year of heart disease. About 42,000 die of breast cancer, yet breast cancer gets so much awareness when it comes to women and mortality. Over 310,000, almost 311,000, so pretty equal with men if you look at the big picture. But again, cancer, 42,000. Now this is important and I didn’t know this until recently, but 56% of women, only 56% recognize that heart disease is the number one killer. Nearly half of the population of women do not really feel that heart disease is their main problem, their main villain, and it is. [inaudible 00:07:19]-
Dr. Weitz: What do they think is the main killer? Is it breast cancer? Is that what they’re most fearful of?
Dr. Elkin: Breast cancer always takes the lead because it’s so ominous sounding. I don’t know. It’s always been this way as long as I can remember, but the death rate is quite disparate. Now, so we talk about risk factors like the primary players. These are risk factors that have been unequivocally been shown to be a risk factor of heart disease, unequivocally. So I always mention hypertension first because I think it’s the most important risk factor of all. And then we have smoking, hyperlipidemia, diabetes, physical inactivity or lack of exercise, and obesity. We’re going to break these down now. So those are the six primary players that I think any cardiologist or any in the health field would recognize as being unequivocally shown to be a causation of heart disease. Now, hypertension, my favorite, it remains the number one primary player when it comes to heart disease, and the reason why … It’s not just heart disease. It’s also stroke, kidney failure, and dementia. Now it’s been shown that people in midlife that have hypertension, they really have a higher incidence of dementia. So it’s not just about the heart. It’s the brain, too.
The reason why I’m so big on hypertension is that the big thing now is endothelial function or endothelial dysfunction. You all heard of that. That’s really the beginning of it. I think most doctors don’t really deal with endothelial. They just deal with numbers, blood pressure, cholesterol. We’ll talk more about that in a minute. But that’s the number one thing that hypertension does. It causes endothelial dysfunction, which will set the stage for inflammation and coronary disease. About half of the adults in this country have hypertension. That’s a phenomenal number, so about 47%. Most are clueless, meaning they don’t know or they’re undertreated. Part of the undertreatment of the patients are the doctors, they’re not that strict about it. I have patients come to me that their blood pressure’s like 148, 150 over 85. It’s not normal. I don’t care how you slice it, it’s not normal. If you want to have a nice long life, you really need to know your blood pressure. People need to know their numbers. It’s usually called the silent killer because you don’t have to have any symptoms whatsoever. So most patients don’t know they have it, and it’s undertreated because a lot of people don’t want to take medications. A lot of doctors say, “Oh, your blood pressure’s okay,” when it’s really not.
Dr. Weitz: All right. In terms of the numbers, let’s say we have a patient. What exactly is the number where it’s okay to try to change your diet and use some lifestyle changes?
Dr. Elkin: Great question. Exactly. What are the ideal numbers? I always tell the ideal blood pressure is 120 over 70, whether you’re 30, 40, 50, 60, 90 or 100. Now, does that mean I actually try to get that number? Of course not, because I would have people on three different medicines. They’d have to see me every six weeks. But that still is the ideal number to shoot for. Now, of course, that’s idealistically speaking. Now, when I was a student years ago, 140 over 90 was considered borderline. 140 over 90 now is considered unequivocally hypertensive. But the newest guidelines that came out in 2017 or maybe ’18 now, is that the blood pressure should be 130 over 80. That’s still considered high normal. So if you’re 131 over 81, you’re hypertensive. I don’t think it’s some [inaudible 00:11:13] plot to make everybody take more medication. I think we have outcome studies that have shown that numbers higher than that definitely increase your chance of developing heart disease.
Dr. Weitz: But what’s the number you’re going to insist that they have to take medication?
Dr. Elkin: Well, okay, good question. First of all, I get to know the patient. If I see someone for the first time, and unless their blood pressure’s like 180 over 110, I’m not going to treat because I don’t really know much about the patient. So I really talk about lifestyle.
Dr. Weitz: Let’s say they’re 140 over 90 and-
Dr. Elkin: I don’t rush to treat. I work with lifestyle-
Dr. Weitz: What’s that?
Dr. Elkin: I do not rush to treat 140 over 90. It’s hypertensive, and I tell the patient that. But I-
Dr. Weitz: What about 150 over 100? Is that still okay to use lifestyle? What’s the safer way-
Dr. Elkin: See, a lot of people come in and when they see a doctor for the first time, especially a cardiologist, even though I think I’m pretty un-intimidating, they’re nervous. What happens? The nurse takes the blood pressure initially. Then I come, and I meet the patient. I talk to them and kibitz around with them. And then I’ll take the blood pressure when I’m doing part of my physical exam, and I creep up on them. They don’t know I’m going to take the blood pressure and, invariably, I get a lower blood pressure reading than the nurse. But most doctors do not repeat the blood pressure. They just go by what the nurse does.
Dr. Weitz: Now, for patients at home, do you often recommend the patients monitor their own blood pressure?
Dr. Elkin: Yeah.
Dr. Weitz: And if so, what’s the protocol? Do you ask them to take it three times in a row? Once? Twice? Also, how important is it to have your arm at the level of your heart?
Dr. Elkin: You want to have the arm at the level of the heart.
Dr. Weitz: But most medical doctors that I’ve been to don’t do that.
Dr. Elkin: But that’s incorrect. That’s the way it should be done. I get them involved. If the blood pressure isn’t really within a good number, then I will have them monitor it … I want the patients involved. That’s part of being a medical advocate. Know your numbers, and follow your numbers because they’re seeing me but so often. So I really go by what they’re getting. I usually have them bring their apparatus into the office and let’s check it against ours because some of them, if it’s within 10 points, I’m happy. If it’s 30 points difference, then it’s time to get a new monitor or that monitor is crap.
Dr. Weitz: Can [inaudible 00:13:31] also be a significant variation throughout the day? Some people’s blood pressure maybe goes up in the morning when you’re more likely to have heart attacks.
Dr. Elkin: Characteristically, your blood pressure is highest in the morning because that’s when our stress hormones are raging, epinephrine, norepinephrine, and cortisol. So typically speaking, evolutionarily speaking, blood pressure’s going to be higher in the morning. As the day goes by, it will drop usually. Some people have a paradoxical rise in the evening, and I can’t figure out why. It is the way it is.
Usually, after exercise, you can check their blood pressure a half hour after exercise, it’s going to be the lowest because exercise actually dilates the vessels. There’s less stress, and the blood pressure comes down. So it is important. When I have patients do their own blood pressure, I say, “Okay, make a chart, AM, PM, post-exercise.” So they get to see themselves what’s happening. So I get the patients involved.
I don’t think most doctors do that. They just keep them on the medication. The reason I don’t jump on medication unless it’s really high is because it’s like saying, “We know you can’t do this on your own, so we’re just going to start you off on medication.” That really dis-empowers a patient, which is against the way I like to practice.
Dr. Weitz: When is it appropriate to measure 24-hour blood pressure?
Dr. Elkin: 24-hour blood pressure is a great thing. I haven’t done it because I haven’t found a company that I can really rely on. Patients don’t really want … They don’t want to be inflating, deflating all throughout the night and so forth. But I think it’s a great idea. I’m not doing it myself because I’ve not found a good support of a company. I had a couple in mind and wasn’t happy. But I think it’s a good way to monitor. But even if they do their own spot checks, get your patients in the habit of taking their own blood pressure. If you have any question, they bring the apparatus in and you check it against yours. I’ve had pretty good success that way. Getting the patients involved with their own blood pressure is really important.
So moving on. Seven out of 10 people with first heart attacks are hypertensive. Eight out of 10 strokes are hypertensive. So they kind of go hand in hand. Now, it may be quiet. Let me see. Blood pressure is quiet. You don’t have to have any symptoms at all. I actually like when people have symptoms because it’s kind of a barometer for me if they have headaches or some patients, “I know when my blood pressure’s up.” I don’t know how they know, but they know. I’m glad because it’s very pervasive, and it kills. It’s a silent killer.
I think next is what is blood pressure? So this is really systolic, the first number, that’s when the heart is actually contracting. And then the diastolic or the second number is when the heart is relaxing. So that’s what really we’re measuring. Hypertensive statistics, this is important to keep it relative. It’s a genetic component here, guys. So if one parent has hypertension, you have a 24% chance of having it yourself. If both parents have hypertension, it’s a 50% chance.
We don’t live by our genes, but we do have to keep them in mind because a lot of people just do have hypertension and it runs in the family. Even though we still don’t know what causes it after all these years, we do know that it has a genetic tendency. It tends to be highest in the morning. It’s not really curable, but it’s treatable. [inaudible 00:17:14]-
Dr. Weitz: What are the most important dietary factors related to hypertension?
Dr. Elkin: Okay. Well, interesting enough, this whole thing about salt has been debated forever. I was going to get into this later, but there’s a new test out there, a new genetic test. It’s by, they’re in the Bay Area, Vibrant. Now they have a Vibrant Wellness Connection. This new test, it’s called Cardiax, C-A-R-D-I-A-X, and it tests for 25 different genes. It’s really interesting. So with this new test and I’m just getting used to it, I’m not that experienced with it because it’s relatively new. I think it’s about $300 for the … It’s out of pocket. It’s not covered by insurance. But you can learn what diet does this particular patient do well with based on their genome? Same thing with pharmaceuticals. When is a diuretic indicated? When is a beta blocker or a calcium channel blocker? It’s really fascinating. So I think we’re going to hear more about this in the future as to what is the best.
As far as diet’s concerned, I don’t think you need a low-salt diet across the board. It depends if you’re a salt retainer. How do you know if you’re a salt retainer? There’s no test for that. But if they start getting puffy, they start seeing an increase in blood pressure, they’re salt-sensitive and they generally need to reduce their salt. It’s more common-
Dr. Weitz: With a patient with hypertension. Is it worth if they haven’t tried salt restriction, trying salt restriction? And on the other hand, is potassium, magnesium, the other types of ions, is it beneficial to bring those up as you bring the salt down?
Dr. Elkin: First of all, I use potassium, which helps to lower blood pressure. Magnesium is also very useful. They’re the two things that I use. Also, I use some other supplements we’ll talk about later. But I always go with weight loss is very important. If your patients lose 10% of their current body weight if they’re overweight, and most of them are, then they’ll drop their blood pressure almost across the board. Almost across the board. Two things I found in maybe my anecdotal experience in 36, 37 years. Number one is weight loss. Another is retiring from your work. It almost always drops.
Dr. Weitz: One more quick question in terms of hypotension, what is the number that you worry about if the blood pressure is below?
Dr. Elkin: Good question. When do I worry about hypotension? I don’t worry about it unless the patient’s symptomatic. I mean some patients have blood pressures at 90. My blood pressure’s 100, 104 systolic. My daughters both have low blood pressure. So it really depends. If they’re not symptomatic, if they’re not complaining of dizziness, I don’t really worry about it. I have a lot of people with heart failure, and these patients tend to have really low blood pressures because they’re on medication. First of all, their pumping function is decreased. Second of all, they’re on medications which can lower their blood pressure. So I have to be especially careful with them. There’s a new device that I’ll be using soon that can actually help with volume status because we don’t really know the volume status. One of the things I tell people with heart failure is to weigh yourself naked every morning. Just keep a chart. If it waivers between three points, you’re fine. If all of a sudden, you see a blood pressure rise of five points, it’s water. So those are the kind of tricks that I’ve learned to use over the years.
Okay, let’s see what’s … Okay. So get this, folks. 22% of population ages 18 to 39 are hypertensive. So we see it in young people. We’re seeing it in teenagers and school-aged kids now. This is really sad. 54% in the middle age, 49 to 59. And then, of course, 74% for age 60 and over. Though it is age-related, it’s higher in the Black population versus Caucasians. That’s a known fact, and they tend to be salt retainers, for sure. Okay, smoking. More than 50% of adults who smoke-
Dr. Weitz: By the way, if do you recommend salt restriction, what’s the milligrams?
Dr. Elkin: I rarely do. I rarely do. Unless once I get to know the patient, if I can discover that they are salt-sensitive, then yes.
Dr. Weitz: What milligrams? Is it 1,500 a day?
Dr. Elkin: Yeah. I try not to go really low, maybe 1,500 to 2,000. I don’t make a huge deal about salt restriction. Now, if they’re at heart failure, it’s a little different. But if they’re just walking around and they’re doing okay, I don’t worry about it because I follow the trends. I’m really big on that. So again, smoking is still a major risk factor. Smokers are almost twice likely to die of a fatal heart attack or a stroke when compared to normies, people that don’t smoke.
Speaker 5: We’re talking about-
Dr. Elkin: They’re more likely to die from heart disease than lung cancer, believe it or not.
Speaker 5: When we talk about smoking, nicotine smoking, right? We have to-
Dr. Elkin: You mean like vaping and stuff?
Speaker 5: Well, people vape. People smoke weed. So when you say smokers, I always want to know what you’re talking about.
Dr. Elkin: We’re getting in reports now about smoking weed, marijuana, and there are no strict recommendations at this point. We’re collecting data. It probably isn’t great for you, but I don’t think it mirrors what we see with nicotine at this point.
Speaker 5: Right. It’s not [inaudible 00:22:45]-
Dr. Elkin: We may find out more. Now, since there’s a dispensary in every block, we may find out more in five or 10 years because there are some warnings out there.
Dr. Weitz: And what about vaping?
Dr. Elkin: Huh?
Dr. Weitz: Vaping. Vaping. What about vaping?
Dr. Elkin: Vaping isn’t any better than smoking. That’s the consensus that I’ve heard. Okay. The good news, the body starts to recover within 20 minutes of quitting smoking. That’s 20 minutes. 50% decrease in risk of smoking-related heart attack within a year of stopping. 15 years of being smoke free, the risk of dying is the same as if you never smoked to begin with. So that’s promising news for smokers. But it’s not an easy thing to kick. It is an addiction, and you have to know a little bit about addiction. You can’t just say, “Just quit.” I mean they have to quit, but it’s not so easy. I used a myriad of different techniques, biofeedback, just different things to help with … But the important thing is to have a close relationship with the patient, you and your staff, because they do need support.
I write, “The cholesterol issue,” because I don’t know about you guys, I’m so tired of … I’m pretty active on social media, and I see so much doctor bashing these days and statin bashing these days. I’m inclined to answer these because I hate doctor bashing and all we do is do sick care and we don’t do well care. I beg your pardon? Some of us do both. I’ve been doing it for a long, long time.
Speaker 5: Not your thing.
Dr. Elkin: So the controversy, and I want everybody to really be clear about that. I want to be clear about this because I don’t treat … Oh, that’s good.
Dr. Weitz: Oh, right there in the corner.
Speaker 5: Yeah, I couldn’t get that right.
Dr. Weitz: Perfect. Thank you so much.
Speaker 5: Thank you.
Dr. Weitz: Thanks.
Dr. Elkin: So I tell people when they come into my office, “I don’t treat your numbers. I treat your risk.” There’s a difference. Most doctors treat numbers. I had a lady that came to me yesterday. Her cholesterol was barely 200, and her HDL is high and LDL is like 138 or something like that. She’s healthy. She’s in her mid 50s. She exercises. Incredibly, her doctor wanted to put her on a statin because it’s going to get worse as she gets older. That was the excuse he gave her, “So you’ll need it eventually.” That’s such BS.
Anyway, so if you’re talking about primary or secondary, you have to know the difference between primary prevention and secondary prevention. I know that Ben and I have talked about this. So if you have had a previous event, let’s say you’ve had a heart attack or a stroke or a stent, I’m one of those, anything like that or if you have carotid artery disease or peripheral artery disease, which is the same basic process, just different locations, then it is important.
We have plenty of outcome studies with people that have had previous events since the ’90s. The 4S study was the biggest one that I remember quite well. So it’s still unequivocal in my mind. These patients do better on statins as at least part of the therapy. It doesn’t mean we ignore diet and exercise and lifestyle, but we need to get their cholesterol much lower than a person who doesn’t have a history. So that, to me, is a controversy.
When I see people on Instagram saying, “Well, there’s no room for statins,” it’s just hogwash. Yes?
Speaker 6: How about people with diabetes? Do you automatically [inaudible 00:26:12]-
Dr. Elkin: Yes. Now, diabetes is another high-risk group. Why? Because 70% of diabetics will have a heart attack or a stroke in their lifetime. So I do treat them as high risk. I treat them as if they have heart disease, even if they’ve never had any clinical event or anything like that. Good question. Okay. Now HDL is the healthy cholesterol, and LDL is the lousy cholesterol. That’s kind of how I name it. It’s not quite that easy or simple. Now, if you’re low to moderate risk, so here’s the basic goals. 220 for total cholesterol, less than 220. LDL less than 130, HDL greater than 40 in men and 50 in women. That’s the average population that is considered low risk. I think most people would agree to that. I would not put these people on statins at all, but I would follow them carefully and work on lifestyle. Now-
Dr. Weitz: Howard, do you think that there’s a number for some of these things like LDL, whether you use LDL-C or LDL-P or whatever, below which there’s no way you’re going to get any atherosclerosis? Is there a way to-
Dr. Elkin: Okay. This is also-
Dr. Weitz: Also, in the context, we’ve had discussions about Peter Attia who’s recommending an LDL of 30 and using whatever medication-
Dr. Elkin: Not just him. Let’s say Steven Nissen, for example. He’s with the Cleveland Clinic, very well-known cardiologist, very conservative. His feeling is that keep the cholesterol as low as you can. 20, 30 is fine. We have outcome studies, those outcome studies for people that are on statins for two or three years. Now, people who are on statin for 20, 30 years, I don’t know about you guys, but I don’t want a good heart with a bad brain and I really worry about that because the brain needs LDL cholesterol.
Cholesterol doesn’t just float around in your bloodstream. It needs to be attached to a protein called lipoproteins. So if you didn’t have LDL, you wouldn’t have blood going to the brain. You wouldn’t be able to make new neurons, neuroplasticity, and also myelin sheaths. They’re all dependent on cholesterol. So it’s getting [inaudible 00:28:23] to the brain. That’s a function of LDL.
Dr. Weitz: The argument that Peter Attia makes is he says all the cholesterol that the brain needs is made in the brain.
Dr. Elkin: That is not universally accepted. I don’t accept it. It’s got to be really clear cut. Peter Attia is very smart. I’ll say a lot of good things about him, but a lot of it is also his opinion and not always based on what other cardiologists think. He’s not a cardiologist, but he’s very bright, and I’ll give him credit for that. So I’m moderate. Now, let’s look at the high risk group. So who’s high risk? Confirmed coronary disease, previous heart attack, balloon angioplasty stent, bypass graft surgery, coronary artery calcium scan. Let’s look at the scans. The ideal score is zero. The only time in your life you want a zero score. One to 99 is considered low risk. 100 to 400 is considered moderate risk, and over 400 is considered high risk.
But that’s one way to look at it, but you also have to look at the age of the patient. So since I do all my studies at Harbor-UCLA. They have a huge database of 30,000 people. I have a 44-year-old guy that I saw yesterday. 42-year-old guy. He’s got a lousy family history on the paternal side. His father, grandfather, and great-grandfather, they all died early age of heart attacks. So he came in to me because of prevention.
So I did this scan on him. He’s got the bad pattern, and his score was like 45, which is considered mild, right, but not when you’re 42 years old. Because they have that database, he was in the 90th percentile. He said, “My score is only …” I said, “Yeah, but it depends on your age.” So that’s why I really like getting all that information. I don’t always just treat to the results of the scan, but if it’s really high … I’ve had patients the score’s over 3,000. Over 3,000, yeah. Yes.
Speaker 7: Dr. Elkin, isn’t there two different kinds of scans? One’s for hard plaque. One’s for soft plaque. I always mix up which one is which.
Dr. Elkin: Could you say it a little louder?
Dr. Weitz: She’s asking the coronary calcium scan for hard plaque-
Speaker 7: That’s for hard or soft plaque though?
Dr. Elkin: Yes. Well, I’m going to tell you about a new scan that’s very exciting in a few minutes. We’re going to get to it. Okay, you’re right. The coronary calcium scan only detect calcified plaque. Now, most plaque is not calcified. So it is helpful, but it’s not the end all be all. But I’ll tell you about something else.
Dr. Weitz: Not only that, but hard plaque, it’s stable and probably less risky.
Dr. Elkin: If you have calcific plaque, it’s going to be pretty hard for that to break off and cause a stroke or heart attack because it’s hard. There’s somewhat of a protective aspect of having calcified plaque.
Speaker 5: But that’s different than a carotic ultrasound?
Dr. Elkin: Well, yes and no. I say peripheral artery or carotid artery disease does also merit statins or a more aggressive approach. It’s really the same process, just a different location. Most people with peripheral artery, they die of heart disease even though they never had an event.
Speaker 5: Right. But I’m saying when they do the coronary artery calcium scans, it’s different than when they ultrasound your carotid-
Dr. Elkin: Right. Exactly.
Speaker 5: That checks for-
Dr. Elkin: Now, with an ultrasound of the carotid, you can actually see mixed plaque. You could see soft tissue and calcific. But because it’s so easy to detect, you can’t do that with a regular scan with a heart because you’ve had so many things overlapping it. But I’ll talk about this new scan. You’ll be excited to hear. Diabetes, that you mentioned, that is a number one risk factor for me to consider high risk.
Come on. Okay. The truth about cholesterol. To put all this stuff over here, you can’t live without it. We need it. Have sex hormones, vitamin D, bowel acids, cell membranes in the brain. So I’m agreeing with all those people on social media that say cholesterol is not the villain. It’s not the villain, but we’re going to talk about the villain in a minute.
Culprit, oxidized LDL. I don’t care about your LDL, but if it’s oxidized, I do have to care about it because that means it’s been altered in the body. It’s like igniting a fire. Once you have LDL that’s oxidized, that can get easily into the endothelium, especially if there’s endothelial disruption or dysfunction, and that’s when the whole inflammatory process begins.
I’ll tell you, when I was a fellow several years ago, we didn’t know about inflammation. We never even talked about it. You got plaque 50%. Then it becomes 60. Then it becomes 70. Then it becomes 80. Then it becomes 90. Then the patient clots off, and they have a heart attack. It’s not that at all. Most plaques that lead to heart attacks are actually 40 to 50% plaques. But the difference is the stability or the vulnerability of the plaque itself, and that’s where oxidized LDL comes in because with oxidized LDL, it’s clearly more likely to form inflammation and plaque in the arteries.
Then it’s the particle size. You’ve all heard this before. Large, buoyant, large, fluffy. Bigger is better. That’s all you got to remember. Bigger is better. We don’t like small dense. Small dent is the kind that is more likely to form plaque. So that really is what we’re really talking about. Small dense promotes inflammation because it can easily get into the endothelial layer, and that’s when it all starts. There’s a cascade of events that takes place.
It’s all about inflammation, which I knew nothing about when I was a fellow. By the way, we started treating with statins. I was finishing my fellowship. It was in the mid ’80s. The first one that came out was Mevacor, was lovastatin, and it was derived from the red yeast rice plant from China, which is not surprising because a lot of pharmaceuticals originally derived from botanicals, and they’re altered, of course, in the lab.
But interesting about it is that we just thought, okay, it lowers LDL really well. We did have outcome studies, but what we didn’t know back then is that also there’s an anti-inflammatory effect that you get with statins that we did not know about until … I forgot the name of the study now, a study with rosuvastatin maybe about 15, 20 years ago. Then we learned, wow, there’s really an anti-inflammatory effect. So it’s not just lowering LDL, it’s also aiding-
Dr. Weitz: I think it was the JUPITER trial.
Dr. Elkin: What?
Dr. Weitz: I think it was the JUPITER trial.
Dr. Elkin: Yes, JUPITER trial. Thank you. Great trial. It opened up our eyes to what was happening. What causes oxidation? Trans fats. Nobody should be eating trans fats anymore. Smoking, of course, diabetes, metabolic syndrome. Those two are often linked together. Genetics, I would say a lot of it is genetic, and we’ll talk about that in a minute, too. So small dense LDL is about 35, 40% of the population.
How do you know if you have it? You don’t know. You have to get it checked out. Now, if you see someone with low HDL and high triglycerides, which is a metabolic problem, more than likely they’re going to have preponderance of small dense, but not necessarily. So you have to measure to really see, and we’ll talk about testing in a few minutes.
At risk for small dense. Genetics, again. High carbohydrate intake, especially starchy carbs, sugar. High trans fat intake, uncontrolled diabetes and high triglycerides and low HDL. So there are things we can do. It’s not just it’s written in your genes. There are things we can do diet-wise to actually lower the amount of oxidized LDL. And of course, metabolic syndrome.
Speaker 7: Can I ask you a dumb question?
Dr. Elkin: Yeah.
Speaker 7: LDL stands for low density?
Dr. Elkin: Right. Or lousy.
Speaker 7: HDL stands for high density. We’re talking about high density LDL. I’m confused.
Dr. Elkin: Okay. So how was this derived? There was a special testing method, and they’re actually measured in angstroms. I’m not a biochemist or a chemist at all. But it’s derived by the density, and it’s a measurement. There are different ways of testing this. We’ll get into that in a minute. But it’s really your standard lipid panel that most doctors, including cardiologists, do is total cholesterol, HDL, LDL, and triglycerides. The LDL, by the way, can’t be measured if the triglycerides are over 400 because it’s a calculated result. So if the triglycerides are over 400, you can’t really tell.
Now, with the testing that I do, you can tell, and we’ll get into that in a minute. Good questions. Okay. apoB and LDL particle number, these are more refined ways of looking at LDL cholesterol. If you do specialized tests, they’re going to include these, too. Some people think that it’s more prognostically important that if you have … Because you can have an LDL particle number that’s higher than the actual LDL.
So here’s a good way to cheat, guys, is take your LDL. Let’s just say it’s 100. And then what you do is you add a zero on it, and that’s what your LDL particle number should be. So it should be 1,000. What you’ll see when you add that zero, it could be four or five points greater than what you would expect. So LDL particle number is probably more significant. I look at it synonymously together because if you start explaining apoB and LBL particle numbers to patients. They’re not going to get it.
Everybody knows the LDL. So I may say to you, “Look at LDL.” But these are definitely considered to be a little bit more accurate and also maybe more prognostically-
Dr. Weitz: apoB seems to be the new trendy number though.
Dr. Elkin: Do what?
Dr. Weitz: apoB seems to be the new trendy thing to look at, the most significant factor.
Dr. Elkin: I get it with all my testing, so I know what it is. I look at it. But since I do a lot of teaching, I like to teach all my patients, I just talk about LDL. If they get that, I’m satisfied.
Speaker 5: So if you have an apoB that’s higher than average, does that warrant to do on a statin?
Dr. Elkin: Yeah. Well, yeah. Yeah.
Speaker 5: Because the seems-
Dr. Elkin: But here’s the thing. If your LDL is high, I can guarantee you in almost all cases that your apoB and your LDL particle number are going to be high.
Speaker 5: So if it’s high, it’s better than just your HDL?
Dr. Elkin: Right.
Speaker 5: So if you have high HDLs but your apoB is high, still a statin?
Dr. Elkin: The thing about HDL, I don’t know [inaudible 00:38:58]. But you also want to know the functionality of your HDL. You’ve heard reverse transport?
Speaker 5: Mm-hmm.
Dr. Elkin: So it takes cholesterol from the periphery, brings it back to the liver for disposal. Now, we figured all HDL is great. Not necessarily, really the best numbers for HDL are between 60 and 80. I say, “Well, I see a patient with 120.” It’s like, “Wow, that must be really good.” We found out there was a study about two years ago. I think it was out of Europe, and they said the numbers between 16 and 80 are ideal and if it’s functional. So the higher the number doesn’t really mean that you’re overly protected. Now, what Cleveland Heart Lab does, they actually do the functionality test. So you could just see not only the number of the HDL, but whether it’s functional. So there’s about three different things that they look for in it, which brings it back to the liver for disposal.
Dr. Weitz: Just to clarify, maybe to help a little bit, HDL, its main benefit is that it can do reverse cholesterol transport. It can take the cholesterol from the arteries back to the liver. So that’s its functionality. You can have a lot of HDL, but if it’s not doing its job, it’s not picking up any passengers.
Dr. Elkin: Cholesterol doesn’t just float around in your circulation. It has to be carried by a protein molecule, HDL, LDL, whatever. So the big thing is is it really functional? Because all we had before were the numbers and we thought the higher the better it is for you, but not necessarily.
Dr. Weitz: Now, Howard, apoB also includes VLDL.
Dr. Elkin: Yes, it does.
Dr. Weitz: You hardly ever hear anybody talk about VLDL. What is the significance of it?
Dr. Elkin: Well, it’s usually when you have a high VLDL, it’s a precursor to triglycerides. That kind of goes to the triglycerides. Well, I’m going to talk about metabolic in a minute, so hold on to that question.
Lp (a), everybody should know their Lp (a). Why? Because about 25% of the population has it. It’s not uncommon. It’s a fragment of LDL. It’s genetic. It doesn’t respond to medication, to exercise, to diet. Niacin can be helpful. I’ve had a lot of success with niacin in decreasing Lp (a). That’s it. Also, estrogen. So if for you women, maybe that might be helpful. Estrogen can be helpful in decreasing your Lp (a). There is a biologic that will probably be coming out in the next two years. It doesn’t work like Repatha and the PCSK9 inhibitors. It’s specific for Lp (a), and it can decrease it by as much as 40, 50% in as little as six weeks. It’s really important because if you have young people with coronary disease and young people that have had heart attacks and strokes, oftentimes you’ll see the Lp (a) is the culprit. I have a couple patients with levels of over 400.
Speaker 7: So when you see Lp (a), you’re seeing a genetic predisposition to high LDL?
Dr. Elkin: Exactly. I tell the patients because they need to know. Part of this is genetic, and there may be some help in the near future. I think that will be coming out within a couple of years because they’ve been really working on this.
Dr. Weitz: Because there’s no drug, most doctors don’t test for Lp (a).
Dr. Elkin: Most cardiologists don’t test for Lp (a) because there’s no drug for it. So why do it? There’s no money in it.
Speaker 7: That’s pretty-
Dr. Elkin: But I think it’s important for especially young … All my patients that are cardiac patients get at least one Cleveland or Boston Heart, which we’ll talk about. It will definitely demonstrate that.
Speaker 8: Doctor, I’ve seen the Lp (a) change.
Dr. Elkin: Do what?
Speaker 8: I’ve seen the Lp (a) change from year to year.
Dr. Elkin: Yes.
Speaker 8: What does that mean? If it’s genetic, why does it change?
Dr. Elkin: Some people say, “Just do it once. You never have to do it again.” But I agree with you. I’ve seen it change. I’ve seen it change by 100 points or so.
Speaker 8: What makes it change?
Dr. Elkin: But usually, it’s with niacin. By itself, it may deviate a few points. I had one patient actually 200 points with niacin alone. It’s variable. Yes?
Speaker 9: How much niacin do you recommend?
Dr. Elkin: Okay. It usually requires quite big doses. But the highest I ever go is two grams in the amount of doses. Most people can tolerate 1,000 milligrams twice a day with food. I take niacin. I’ve never flushed ever because I always take it with food. So I don’t even know what the flushing is like. For me, I don’t get it. I take the regular-
Speaker 9: I remember you talked about this because I listen to your YouTube a lot. I’m a fan. You said the non-flushing kind is junk. Don’t use it.
Dr. Elkin: It doesn’t work at all.
Speaker 9: Okay.
Dr. Elkin: Avoid it. Usually, if you go to Rite Aid and CVS, they sell all the non-flush. But even in vitamin stores, they’ll show it because it sounds good, no flush. But it also doesn’t work.
Speaker 9: No flush-
Dr. Weitz: I tried everything with niacin.
Dr. Elkin: Some people are more sensitive than others.
Dr. Weitz: I tried 50 milligrams, 100 milligrams, flushed like crazy.
Dr. Elkin: With food?
Dr. Weitz: I tried it with food. I tried everything, every strategy.
Dr. Elkin: Some people are exquisitely sensitive.
Dr. Weitz: I just couldn’t tolerate it.
Dr. Elkin: Why? I don’t know. But yeah, I’ve had patients who did the same.
Speaker 5: It could raise blood sugar, too, like it did-
Dr. Elkin: Do what?
Speaker 5: How it raised Carol’s blood sugar?
Dr. Elkin: Yes. Well, we saw that, right?
Speaker 5: Yes.
Dr. Elkin: It can also increase your blood sugar. We saw it with some person who we know quite well.
Dr. Weitz: Well, of course, statins can raise blood sugar, too.
Dr. Elkin: I definitely have seen it with niacin. I think that’s over exaggerated with statins. Again, people want to bash statins. It causes diabetes. It causes this. It causes that. Okay. I tell people it’s a risk-benefit ratio. If the benefit outweighs your risk, you do it. But we don’t want the treatment to be worse than the problem.
Speaker 8: Maybe it depends on the dose of statin. Maybe if your full treatment-
Dr. Elkin: Yes.
Dr. Weitz: Absolutely.
Speaker 8: Sometimes five milligrams does the trick, but then they put you on 20.
Dr. Elkin: Right, right. I usually start pretty low. If someone’s really fentanyl, I’ll start even 250. You can get 100 milligrams in Vitamin Shoppe and stuff like that. [inaudible 00:45:16] I don’t have a dose that small.
Speaker 8: What are you talking about, the-
Dr. Weitz: You’re talking about niacin.
Speaker 8: I was talking about-
Dr. Weitz: She’s talking about statins.
Dr. Elkin: I’m sorry. Statin.
Speaker 8: You said 250. I was going to-
Dr. Weitz: Oh, no, no, no, no, no. Statins. Statins people tolerate. Most people tolerate well. But here’s the thing, I never start a statin without CoQ10, never ever. I tell them you have to take CoQ10 because it’ll obviate the muscle soreness and myalgias that you can get. Yeah?
Speaker 8: Are you seeing that blood sugar rise with niacin in everybody or in some?
Dr. Elkin: Well-
Dr. Weitz: I think it’s a small percentage.
Dr. Elkin: Yeah. Well, what type of niacin-
Dr. Weitz: Well, it depends how high you go, too. I use 500. I almost never see it.
Dr. Elkin: Right. But I knew a patient that was taking 3,000 or more on his own. He was wondering why he’s getting palpitations and getting all these weird symptoms. I said, “Dude, you’re taking more than 2,000. That’s max dose, and you take it in divided doses.” But niacin is basically safer than most statins. I mean every now and then, you’ll get a rise in liver enzymes. So I always check that. Not as commonly as you would get it with statins. But I think despite all the BS you hear about statins and I’ve been using them since they came out, that’s when I was a new cardiologist, they’re pretty well tolerated. But there’s about 20% or so that don’t tolerate it well. It’s usually the muscle myalgias and that kind of stuff and also the liver enzymes.
Dr. Weitz: Now, some integrative doctors, like Dr. Huston, a lot of times will put somebody on a statin three days a week.
Dr. Elkin: Yeah, there’s ways of doing it. I tend to try to do it every day because patients, once you start do it every third day, do it every fourth day, I’m lucky if they take it on a regular basis. So I try to make my drug schedules really easy to follow, even when I do things like blood thinners and Coumadin.` We used to use Coumadin all the time. I hate split doses because it’s so confusing. Yes?
Speaker 8: Sorry for so many questions, but what’s the minimum dose of niacin that you have seen be effective for lowering Lp (a)?
Dr. Elkin: Good question. There’s not really definitely a lower … I usually start, again, with 500. But if it’s someone who’s really sensitive, I’ll take their score. I can always have them take 250.
Speaker 8: So for a whole day, not twice a day?
Dr. Elkin: Yeah. Well, yes. Well, I’ll have them titrate up on their own as tolerated. So if you’re taking 250 for, let’s say, two weeks and you’re doing well with it, then take the full tablet. But I do it twice a day. So if I start them low at 250, which is lower than my normal starting point, I’ll do it twice a day.
Speaker 8: So you’ve seen that be effective, even that low? Let’s say someone only took 500 milligrams of niacin a day, but they were consistent. Have you seen their Lp (a) go down?
Dr. Elkin: Yeah. You may get a response. It’s really funny. I’m using lower doses of statins now than I ever have, and I’m seeing pretty decent … Some people, well, their LDL will drop significantly with 10 milligrams of CRESTOR, rosuvastatin. Now, if you go to the hospital and you get a stent, I can guarantee you’re going to walk out of there with 80 milligrams of LIPITOR-
Speaker 8: 80? Wow.
Dr. Elkin: … an aspirin, a beta blocker, an ACE inhibitor, and Plavix. All of a sudden, you’re on five medicines. Do you need them? I don’t think so. But you do need the aspirin and the Plavix. But everybody’s put on a beta blocker and ACE inhibitor. It’s just crazy. I can almost guarantee you that patients are going to come back with all those medicines when they have been in the hospital. You’ve seen it.
Speaker 5: What do you think about red yeast rice as compared to statins?
Dr. Elkin: Okay. Red yeast rice was the precursor to statins. Yeah, you can try it. If it says on there two at night, I usually tell patients take three because it’s a weaker form of a statin. But it’s always worth trying it.
Dr. Weitz: You got to take four to eight.
Dr. Elkin: Yeah. How many?
Speaker 5: Four to eight?
Dr. Weitz: Yes.
Dr. Elkin: You take how many?
Dr. Weitz: Four to eight.
Dr. Elkin: Wow.
Dr. Weitz: You got to do 24 to 4,800. So I think most of the products out there are about 600. So you got to take four to get to 2,400. I think that’s [inaudible 00:49:24]-
Dr. Elkin: Now, a lot of patients, truthfully say they’d rather just take one tablet than taking six. I mean I don’t want to take eight of one thing. I take enough something as it is, but I’m also higher risk because I’ve had a stent before. So I take a statin. I’ve never had a problem, but I always take CoQ10. But some people do have issues.
Okay. So let’s go on. I want to get into some of the testing. Do I have to face the computer for this to work?
Dr. Weitz: You know what? You’re probably behind that little thing.
Dr. Elkin: Yeah, I’m probably behind it. I’ll be over here. I’ll sit here. Okay.
Speaker 8: There you go. You got it.
Dr. Elkin: This is more about apoB. Detects the presence of all the atherogenic particles. In contrast to LDL, this may be better suited to guide lipid-lowering therapy. I don’t really abide by this because, again, since I’m instructing patients, I got to make it really digestible.
Dr. Weitz: It’s okay.
Dr. Elkin: But purists do believe that apoB is the best way to take it and also LDL particle. So I would say it is more important, but is it necessary? Probably not. Okay. apoB is a more accurate marker that can actually identify potential high-risk patients. Now, particle number, same thing. [inaudible 00:50:54], cholesterol present in the blood, does not … When you do the particle number, you’re varying the number of particles. And again, it’s often used as a more accurate number. If you do specialized lipid testing, you’re going to get apoB and you’re going to get an LDL particle number. So you’ll get it anyway. Here’s another out of context. Genetic is 20. It’s a fragment of LDL. I already said all that stuff. Now, physical inactivity, that was the last risk factor that was made into a primary risk factor in the ’90s, I believe, and for good reason, because only 20% of the adult American population exercises on a regular basis or what we recommend by the American Heart Association, the American College of Sports Medicine. Most people are very sedentary and don’t exercise on a regular basis. So it’s important.
So again, it was elevated to major risk factor in the ’90s. Bottom line, the more active and fit you are, the less incidence of heart disease or complications of heart disease. Failure to exercise on a regular basis is as bad as smoking. Okay. Next one is-
Speaker 8: I’m sorry. Do you agree that sitting is the new smoking?
Dr. Elkin: Do what?
Speaker 8: Do you agree that sitting is the new smoking?
Dr. Elkin: Sitting [inaudible 00:52:15]-
Speaker 8: Sitting-
Dr. Weitz: Is sitting the new smoking?
Dr. Elkin: What?
Dr. Weitz: Is sitting the new smoking?
Dr. Elkin: Oh, yeah, absolutely. Yes. Inactive people are twice likely to develop heart disease than people who engage in regular … I mean twice as likely. Why would you not want to exercise? But then again, we’re not the average. 250,000 deaths a year attributed to physical inactivity and it’s not just due to heart disease, but also other diseases such as adult 2 diabetes, hypertension, osteoporosis, and various cancers. It’s a dismal situation.
It’s the easiest risk factor to correct, but not everybody does it. Obesity, diets high in fat … This is funny. Now, in 1965, 40% of your calories came from fat, down to 34% in the mid ’90s. And guess what? We got fatter than ever, and we have more diabetes than before. So that was the big low fat, high carb stage during the ’90s, which also popularized by Ornish and so forth. That may be helpful for certain people, but they didn’t know about particle sizes and they didn’t know about the role of metabolic health. I think we know a lot more now.
42% of the population in this country is obese. Nearly 79% is overweight. So that takes into consideration the obese and everybody else who’s overweight. That’s two thirds of the population. Sugar is a culprit. It’s not fat. It’s sugar. When people ask me about my diet, first thing I say is sugar. They wonder if you need to go buy low cholesterol and low fat. I say no. I mean I might eventually, but it’s not my number one concern because eating sugar and starchy carbs is like pouring gasoline over fire, and we’re igniting a fire within our arteries. That sets the stage for inflammation. So I’m very upfront about that. It ties into metabolic health.
Drugs for weight loss. This is a big craze now, right? Now we’re getting more and more reports about the semaglutide and Ozempic and Wegovy. The new one is Mounjaro. I believe in those drugs for high-risk patients that are obese and diabetic because it does open up a new avenue for treatment. Again, they’re very high risk. But people wanted to lose 10 to 15 pounds and they’re going on this. A lot of people are doing this. They can get it.
It’s just ridiculous because now we’re getting more and more reports of complications, things like gallstones, pancreatitis. I don’t know. This could be a precursor to pancreatic cancer. They haven’t been around long enough. We don’t know the full story. But these drugs bother me on a global basis. So yes, I would use them for … I have a few patients, but they’re all diabetic and they’re high risk to begin with, and they’re usually very overweight. Oh, sorry. Going the wrong direction. All right. Diabetes, bad disease. Need I say more?
Speaker 7: [inaudible 00:55:24] disease?
Dr. Elkin: The numbers are getting worse. Right now, I think there’s 10 million diabetics in the country. There’s, I think, 70 million pre-diabetics. Most of them don’t even know it because they don’t know what’s going on. And again, that’s their number one cause of death in diabetics. They have a threefold increase incident of heart disease, and two to four times more likely to die from heart disease. They do not do well. It sticks.
Okay. Heart attack symptoms. I’ll try to go fast now. 45% of heart attacks are silent. So if you don’t test these patients and watch them carefully, they will have a heart attack on you. That’s why it’s so important to look at these risk factors. [inaudible 00:56:12] in pain, and dyspnea, shortness of breath, diaphoresis, sweating, nausea, vomiting, lightheadedness. But watch this.
This is supposed to be women. Somehow that didn’t get in there. Women with heart disease present differently. They might have pressure in the chest, but oftentimes they don’t. [inaudible 00:56:34] their arms. They get short of breath. They could have just plain fatigue, nausea. The big one is if you have discomfort in the jaw and the teeth, for some reason, that tends to be a thing about women. Cold sweat, nausea, and vomiting.
So here’s my dictum about women and heart disease. Anything above the navel, belly button, in a woman is heart disease until proven otherwise. That’s how I look at it because all bets are off. Like you say, most women don’t even think. Well, not most, but only 54% of women in this country really think that heart disease is in their future or their major worry. So it’s a big deal. I mean I think we’ve done a lot better.
But when I was a fellow, all the studies done were middle-aged men. If you were childbearing age, you were just excluded and, if you were over 65, you were too old. Women live 30 years more past menopause, right?
Speaker 5: Question about there’s a lot of confusion around estrogen preventing heart disease in women or bioidentical estrogen. I read everything. Yes? No? What’s your thoughts on that?
Dr. Elkin: But estrogen you mean? Yeah.
Speaker 5: Yes.
Dr. Elkin: Yeah, I’ll talk about that in a minute. In the old days, we thought that you treat with hormones to relieve symptoms, hot sweat, night sweats, hot flashes, insomnia, anxiety. Those are good reasons to treat because I don’t think any woman should have to go through a painful menopause in this day and age. But I also do it for the health benefits, the heart-
Speaker 9: Exactly.
Dr. Elkin: … the brain and bones.
Speaker 9: [inaudible 00:58:09]-
Dr. Elkin: What I’m really hot on is that it’s one of the best ways to preserve endothelial health is estrogen, and I don’t think most gynecologists even know this. Okay, let’s see. 21st century terms. This is my traditional medicine versus functional, since we’re all functional. If you are a traditional doctor, you’ve got symptoms here. We go immediately to treatment. But our way of doing it, symptoms, we try to get the cause and then we go to treatment.
It sounds really simplistic, but this is really the reality of how things are treated. So I always tell people I’m an integrative cardiologist practicing functional medicine. I use functional medicine as the basis for what I do. So let’s look at testing quickly. Treadmill testing is, no one should be doing that. I mean when we have certain insurances, my opinion, we have to get authorization for everything these days, which is ridiculous. They want me to do a regular stress test. On a woman, it’s worthless because there are so many false positives on routine stress testing with women.
So I have to fight to get a stress echo, which is a stress test with imaging with the ultrasound. The nuclear stress imaging is with the nuclear. Instead of looking at wall motion, we’re looking at uptick of radiopharmaceuticals and your heart muscle. If there’s normal arrest and if there’s a hole we see with exercise, that means it’s tagged to your red blood cells. So it’s not going anywhere because of a blockage.
Nuclear stress test adds about 15% more sensitivity when you compare it to a stress echo. But it’s radiopharmaceutical, so you are getting some radiation. I use nuclear stress testing on the higher risk patients and stress echo more routinely for those that are not. Now, here’s the fun part, ancillary testing. The coronary scan we talked about. It’s really great, but all it does is really tests for calcified blockages.
Coronary CT, that’s a great test. Now, it’s an angiogram, but it’s still with a peripheral IV. So it’s not nearly as much contrast, and it’s just a peripheral IV, so you don’t have to lie still for six or eight hours. You’re not getting anesthesia for it, so it’s easier to perform. It’s not as good as routine angiography. It’s pretty good for people that have had bypass surgeries because we really want to know are the grafts open or they closed. Also with stents, are the stents open or closed? So they’re good for that. It’s nothing that I would gravitate toward, at least not initially.
But here’s the new kid on the block, the Cleerly scan. Have any of you heard of this? Cleerly combines coronary CT with artificial intelligence, and the images are phenomenal. I’ve done about seven or eight already. I think I’m putting Harbor-UCLA on the map now because I’m ordering so many because now that I’ve done a few, I really see the utility. So what it does, now we can look at things like plaque volume and plaque composition. Before, we couldn’t tell.
Now, we can say, “Okay, hard plaque. That’s what the other scan shows us.” Then we can see soft plaque. And then there’s another one which is very scary, that’s called low density soft plaque. That’s vulnerable plaque that is ready to burst. How do we know that unless we did the scan? But I wish I had images because it’s so new that I don’t have any images yet. I’ll get them next time I do this talk. But here’s the important thing. Let me give you an example.
I have this 65-year-old guy. He looks 50. He looks great. But on the outside, he looks great. He had a calcium count of over 3,300. That’s the highest I think I’ve had in the practice. I did a nuclear stress test. I think these numbers are going up. This is not looking good. So we did a nuclear stress test. Negative. I said, I’m bothered by this. The numbers are going up every two years, and he doesn’t have symptoms.” So I did the Cleerly he was my first Cleerly scan.
Part of his left main and the widowmaker, the left anterior descending artery, have major low density soft plaque. So that puts him at very high risk of plaque rupture and heart attack. So it’s scary. I talked to his wife. He’s been my patient for many years. She said, “Well, I think we should get a second opinion.” I said, “Be my guest. Ain’t nobody around here doing this test, so you’re going to have a hard time getting a second opinion with someone who’s familiar with the test.” But I never heard back from them.
Speaker 8: How do you treat once you see that?
Dr. Elkin: if it’s that easily discernible, I would probably do an angiogram. That’s the patients [inaudible 01:03:00] that, even though they don’t have symptoms. This may supplant stress testing in the future. If they can get the price affordable so that insurance covers it, this may supplant stress testing because I’ve had another patient just like every other patient with normal stress test, nuclear stress, which is a pretty important test. And yet, the Cleerly test told me that he’s really vulnerable … I think it’s real. You can see it. You can visualize it. So again, it’s plaque volume and plaque composition. I mean you never heard those terms before when you’re talking about patient’s risks. So this is brand new. Most people are not doing this.
Speaker 9: Can you go for imaging on this the same place where you’re sending your patients, the coronary calcium scans?
Dr. Elkin: Well, I had already done scans on this guy before, and his levels were over-
Speaker 9: Where do you go for the Cleerly?
Dr. Elkin: [inaudible 01:03:56] does it really as well as Harbor-UCLA. I’ve been using them for many years just for my routine coronary artery calcium scan.
Speaker 9: Because it’s so new, are there fewer places that-
Dr. Elkin: Yeah, they’re doing it. If you look up, it’s C-L-E-E-R-L-Y. But you google them, you’ll see what hospitals. I don’t know if Cedars is doing it or not. I know that since I’ve been working with Mark Rudolph for several years with the calcium scans, they also do really good CT angios. This is an extension of that.
Speaker 9: How much?
Dr. Elkin: Okay, good question. If you are Medicare, they will cover a CT angio if you have symptoms. So I often fudge it. They had short of breath. And then I can get them to tag on the Cleerly for sometimes no charge extra. But if you’re going to pay out of pocket, I think their price is going to be, let me think, like 1,200 for the two combined, which is not bad.
Speaker 9: Yeah. But the CCS, it ranges from 120 to 300 locally?
Dr. Elkin: That’s a calcium scan.
Speaker 9: Correct. Out of pocket?
Dr. Elkin: Yeah.
Speaker 9: That’s the issue, getting the patients to do it for that reason.
Dr. Elkin: Yeah. Well, I have, fortunately, a lot of patients that will spend the money for it. The average probably won’t. But when I tell them, “Listen, this is what you’ve got.” So it could be a lifesaver. I think it will be, I think it will be a lifesaver in the future. Here we are. This is your standard lipid panel that every doctor gets. This is apoB 83, particle number. Boston looks at the concentration of small dense. You want them to be less than 20, and this person has 25. The reason I did the slide, they do called a cholesterol balance test. Cleveland doesn’t do that. It looks at two markers for hyper production, and these markers are for hyper absorption. So we can find out is the problem over production or over absorption because the treatment can be different.
Okay, let me see. I’m going to get real fast. This is the metabolic panel down here. Everything looks good. C-peptide insulin. So I’m always interested in the fasting insulin, and I like to see peptides. They test me how hard the pancreas is working because you could have a person who’s got a normal A1C, but the insulin level’s high. The HOMA-IR, which is a homeostatic mechanism for insulin resistance, that’s a calculated number. If that’s high and the c-peptide is high, it means the pancreas is working its butt off to not make you a diabetic. So it’s really important to get that. Then real quick, I just want to show how Cleveland does it. I got to go over here, don’t I?
Speaker 6: I have one question. [inaudible 01:06:40]?
Dr. Elkin: This is genetic testing. So it’s very interesting. Statin-induced myopathy gene, Boston seems to have the patent on that. We can actually find out if a patient is a slow metabolizer to a statin, in which case, depending whether they’re heterozygous or homozygous, you might want to avoid statin completely in a particular group. apoE, you’ve all heard about that. These people tend to have, if they’re apoE, this E3/E3 is the most common genotype, and it’s the best one to have. But if you have a three and a four or two fours, that means you may tend to hyper absorb cholesterol from the gut, and it’s also a gene for Alzheimer’s disease. Factor V and Factor II are blood things and MTHFR. 60% of us, me included, have one or two variants of the MTHFR gene. Look at this one. The small dense is 60, and that’s huge. We want it to be less than 30. It is 30. I’m sorry. I’m not much on ratios, but let me get to what I wanted to show you.
Okay, it’s inflammatory. So CRP protein is 1.6, I think, there. Interleukin-6 is 6.2. So we’re getting a lot of inflammatory markers as well as function tests and metabolic. Let me go back real quick. Look at this, insulin 32. C-peptide 4.77. I mean everything is off the wall. This is a metabolically unhealthy person. Okay, let me move on. I’m going to show you what it looks like with another test that I find quite useful. It was called the PULS test, P-U-L-S. Now it’s called SmartVascular Dx.
This is telling me the health of your endothelium where everything begins. So when I say I don’t care about your numbers, I’m being truthful. I care about your risk. I care about the health of your endothelium because if you have endothelial dysfunction, that sets the stage for coronary disease. This person has a score of 14.5. Expected score for his age and sex is 2.82, which gets him both. He’s high risk, both relative risk and absolute risk, for an event over the next five years. it’s not a standalone. I use this with the Boston or the Cleveland.
Speaker 5: It’s a blood test?
Dr. Elkin: Yeah. Here let me show you. This is what I’m interested in. This is a map. It tells you where they started. This is pointing out where … See, they went down. And then they went way up. You don’t want to go up. You want to keep on going down. So once you go up, you’re increasing your risk. Endothelial dysfunction will change according to your blood pressure and all these other things that we’ve mentioned. So it’s a great test, and I use it very frequently.
This is what the coronary calcium report looks like. This is the one with over 3,000. This tells in each artery, the calcium count in each particular thing. Now we’re talking, this is Boston Heart. No, this is Cleveland I think. But look, all the inflammatory markers are off the wall. 3.4 CRP. ADMA is a marker of endothelial health. That’s abnormal. This is at Cleveland. So what they do differently in Cleveland, they actually measure the size of the LDL particle as opposed just the concentration. So they’re measuring in angstroms.
If you see next slide, the pattern is pattern B means bad and it’s 210.3. You want it to be greater than 222.9 angstroms. So it’s easy to follow this. I like Cleveland because it’s easy for a patient to understand where their number is versus concentration. It gives you Lp (a). This is the functionality. I’m not sure what all those numbers mean. But in the green, 0.65 is a normal functionality for HDL. So they do a lot of the same thing.
Instead of HOMA-IR, they do what’s called insulin resistance score. Same thing, it’s measuring the degree of insulin resistance. Homocysteine is, again, usually that goes along with the MTHFR, and I do treat it. Now it’s been thought that elevated homocysteine levels are definitely not just a risk factor. My secondary risk factors didn’t show up, did they? Anyway, it’s a secondary risk factor, but it’s definitely associated with endothelial dysfunction. So again, everything’s about the endothelium.
They do the fatty acid balance test, which is good. That can help people with their nutrition. And again, this is another way of doing the genetics. KIF6, that was kind of put together by Robert Siburko at Berkeley Heart Lab several years ago. 9p21 is considered the, quote-unquote, “heart attack gene.” His person is actually homozygous carrier. So not good. 4q25 is that you’re at risk for atrial fibrillation down the line, and the Factor V Leiden, MTHFR. That’s basically it.
The summary prevalence of cardiovascular disease, it’s an equal opportunity killer in both men and females. It’s the number one killer in this country. Women present differently. We didn’t go over the secondary risk factors. Somehow I lost the slide. We went over the six major ones. The cardiac testing for symptoms, for scheming and specialized lab testing, which we discussed. I have a book that I put out last night about this time last year on both sides of the table and contact information from me. I appreciate having the opportunity to speak to you guys. I guess I’m the first speaker since we’re back.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. That way more people will discover the Rational Wellness podcast. I wanted to let everybody know that I do have some openings for new patients, so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. That usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing. We’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
https://drweitz.com/wp-content/uploads/2023/11/rwp-333-website.jpg350785drweitzhttps://www.drweitz.com/wp-content/uploads/2017/06/drweitzdsamplelogo-withtext.pngdrweitz2023-11-16 17:57:072023-11-24 11:01:14Integrative Cardiology with Dr. Howard Elkin: Rational Wellness Podcast 334
Dr. Robert Hedaya discusses Integrative Psychiatry with Dr. Ben Weitz.
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Podcast Highlights
1:38 Dr. Hedaya noted that from his time in medical school he was always oriented towards getting to the root cause of things. After writing his first book, he was on the edge of chronic fatigue and he dove into the metabolic medicine approach of Dr. Jeffrey Bland, which later was changed to Functional Medicine. Dr. Hedaya was a neuropharmacologist trained in cognitive behavioral therapy and after bringing Functional Medicine into the mix he found that he was no longer doing this medication merry-go-round and most of his patients were now getting better. Dr. Hedaya explained that after writing his second book, he hired a statistician to assess the patients he had treated for treatment-resistant depression. All 23 of these patients when they started had a mean Beck Depression inventory of 34, which is in the severe range, and by about 10 months everyone was normalized with only one change in medication but also adding the Functional Medicine approach.
4:18Insights into a Functional Medicine approach to psychiatry. The key to using a Functional Medicine approach is to be a medical detective and to also understand that psychiatric problems are not primarily psychological, but more related to physiology and infections and hormonal problems and genetics and epigenetics and gastrointestinal things, etc.. The mental realm is directly part of the physical realm. If your physical health is lacking, if you’re lacking in nutrients, if you’re having toxins and infections and other things that are affecting your physiology, that’s also going to affect your mind. Dr. Hedaya recalled his first patient from 1984 who was a 50 yr old woman with panic disorders and she did not have a great marriage and had bunch of things going on, but she didn’t get better despite psychotherapy and medications. He determined that she had a vitamin B12 deficiency and after her first injection, her panic went away and that’s when he realized how powerful the Functional Medicine model could be. When assessing B12 status, if your serum B12 is low normal, you probably have a B12 deficiency. But you can also look at the size of the red blood cells, the MCV, on the CBC. If you are B12 deficient, your red blood cells will get larger because they hang around longer–macrocytic anemia. If you are iron deficient, your red blood cells will be smaller–microcytic anemia. But you could have normal size red blood cells if you have both iron and B12 deficiency, because they will offset the effects on the red blood cell size. We should also look at methylmalonic acid (MMC) and homocysteine as measures of B12 status, though MMC only accounts for 17% of B12 status. You also need to look at medications that interfere with B12 status and if they are older they tend not to absorb as much B12 because of reduced HCL production.
10:57 Iron. Dr. Hedaya looks at serum iron and TIBC (total iron binding capacity) and also the CBC. And he will also look at ferritin levels.
11:29 Other nutrients. Fish oil is a very important preventative for depression as is vitamin D status. Zinc is also a very important nutrient and this needs to be balanced with copper levels. It is also very important to make sure the patient is eating and digesting enough protein, since these amino acids are necessary for neurotransmitter production.
12:12Thyroid adrenal axis. Another clinical pearl is the thyroid adrenal axis. We need to do a thorough physical exam and look for evidence of adrenal insufficiency and low thyroid. The mean TSH in the US population based off the NIH study is about 1.5, though the upper limit of most labs is 4.5. When dealing with neuropsychiatric problems you should look to be closer to 1.5 or even 1, esp. for depression. There’s plenty of evidence that for treatment resistant depression, that hypermetabolic doses of thyroid hormone, particularly T3, will help people come out of depression. Some of this has to do with SNPs variance in the deiodinse 2 genes that control the conversion of T4 to T3 in the brain. Dr. Hedaya used to use Armour thyroid, which contains a combination of T4 with some T3 from pigs, but now he uses a combination of synthetic T4 with some T3. If there is a perceived threat, the body will stop converting T4 to T3 because it perceives that the adrenals can’t handle it.
15:30Genetics. There are various genes that you can test for that include NR3C1, FKBP5, CRH receptor 1 and 2, CRH binding protein, these control proteins that control the effective steroids inside your cell at the level of the nucleus. Dr. Hedaya has found that a lot of his patients have variants in these genes, which means that when you’re stressed for whatever reason and you release cortisol, your cells at the level of the nucleus can’t convert the stress signal efficiently to the genome, and then your genome doesn’t respond properly, and now you’re vulnerable to stress, to immune dysfunction, to depression, and even to suicide. So these genes are really important since they indicate a genetic cortisol resistance. You can get glucocorticoid resistance from having infections or from over methylation, the different pathways to glucocorticoid resistance and that’s not really recognized. I think that’s part of the reason people are having trouble responding to treatments for Lyme disease, for example, chronic Lyme and certainly chronic long COVID, that’s part of the picture. Dr. Hedaya likes to run the Opus23 genetic panel, which is offered by Diagnostic Solutions Lab as the GenomicsInsight test, though there is also the Intellxx panel.
18:18Gut Health. The gut is called the second brain and it sends signals to the brain through multiple pathways and of course communication from the brain to the gut. The gut, the brain, and the endocrine system work together seamlessly. We are our microbiome and changes to our microbiome can change behavior.
25:32Ketogenic diet. Dr. Hedaya will use a ketogenic diet for certain patients, esp. if they have evidence of having seizures, such as seen on quantitative EEG. Dr. Hedaya will use an experiment in his office by having a patient consume a couple of tablespoons of MCT oil while in the office and then see how they feel in 30 minutes. This mimics the types of ketones that are produced by a ketogenic diet. If the patient notices some improvement, he will lean towards a ketogenic or low carb diet or using MCT or beta-hydroxybutyrate. Even if he doesn’t use a ketogenic diet, Dr. Hedaya thinks it is important to balance blood sugar by properly balancing healthy proteins and fats with carbs. He may also recommend 5-HTP to help with serotonin production, though he does not recommend taking tryptophan as this may go down the kynurenic and quinolinic acid pathway and increase glutamate, which can increase anxiety and agitation.
30:24HYLANE technology. Dr. Hedaya has an advanced set of protocols that he uses that includes includes hyperbaric oxygen, EEG-guided laser, and neurogenic exercises that he refers to as HYLANE technology. Hyperbaric oxygen has been used for many conditions, including for traumatic brain injuries and strokes. Hyperbaric oxygen does increase oxygen delivery to the tissues, but the main ingredient seems to be the pressure that opens up the capillaries and increases the oxygen perfusion and delivery. You would not want to use hyperbaric oxygen if the patient has Babesia, as this may increase the growth of Babesia. Dr. Hedaya also uses EEG-guided laser and he noted that he usually uses a class four laser, either an 810 nm or a 1064 nm. Approximately 2.6 to 2.8%of the light from the laser will likely penetrate the brain. The QEEG allows Dr. Hedaya to target the regions of the brain that are the most abnormal.
Dr. Robert Hedaya is an MD/Psychiatrist who is board certified by the American Board of Psychiatry and Neurology and he also teaches Functional Medicine approaches to psychiatric disorders with the Institute of Functional Medicine. He is also a Clinical Professor of Psychiatry at Georgetown University Medical Center. He wrote a number of books, including Understanding Biological Psychiatry, The Anti-depressant Survival Program, and Depression: Advancing the Treatment Paradigm. He treats patients with psychiatric disorders with a Functional Medicine approach, pharmaceuticals when indicated, and he has now pioneered the use of the HYLANE program, which includes Hyperbaric Oxygen, EEG guided laser, and neural exercises. His website is WholePsychiatry.com.
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, 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 discussing integrative psychiatry with Dr. Robert Hedaya. Dr. Robert Hedaya is board certified by the American Board of Psychiatry and Neurology, and he also teaches functional medicine approaches to psychiatric disorders with the Institute of Functional Medicine. He’s a clinical professor of psychiatry at Georgetown University Medical Center. He wrote a number of books including Understanding Biological Psychiatry, the Antidepressant Survival Program, and Depression: Advancing the Treatment Paradigm. He treats patients with psychiatric disorders with a functional medicine approach, pharmaceuticals when indicated, and he’s now pioneered the use of the HYLANE program, which includes hyperbaric oxygen, EEG-guided laser, and neural exercises. And now, I’ve been informed that he’s added ketamine therapy to this program. Dr. Hedaya, thank you so much for joining us.
Dr. Hedaya: Oh, thank you for very much for having me, Ben. It’s a pleasure to be here.
Dr. Weitz: Absolutely. So you’re a giant in our field. Perhaps you can tell us how you found your way to the functional medicine approach of psychiatry.
Dr. Hedaya: Well, it’s an interesting question. It’s a story that was unfolding before I knew it, really. It goes back to my very early training in medical school and even in my internship. I was just oriented, I guess, to get to the root causes of things. And when you start to do that, you can’t help but end up in functional medicine. What really propelled me ultimately was my own, after my first book, I was on the edge of chronic fatigue, took a lot out of me, and then I really dove in deeply. And that’s when I discovered what was then called metabolic medicine, which was later changed to functional medicine with Jeff Bland. And that one thing led to another, and I was a psychopharmacologist trained in cognitive behavioral therapy, family systems, et cetera, and doing a lot of psychopharmacology.
And then, when I started to bring functional medicine into the neuropsychiatric realm, I was like, after three, four years, I was blown away. I’m like, “Wait a second. I’m not doing this whole medication merry-go-round thing.” Not anti-medicine, but I used to be like, “This isn’t working, try this, add this, all the whole medicine thing.” And everyone’s getting better. I’m like, “Wait, maybe I’m lying to myself.”
So after about three years after my second book, I hired a statistician to assess the patients that I had treated for treatment-resistant depression over the course of, I think it was like two years or three years. And just like no cherry-picking, just every sequential patient and see how they did because we track their objective monitoring of their symptoms, et cetera. And it turned out I was not lying to myself. Everyone, 23 patients, the mean Beck Depression inventory when we started was about 34, which is in the severe range, mild part of the severe range. And by 10 months, everyone was normalized, and I only made one change of medication, which was to put someone who was suicide risk on lithium. And other than that, no medication changes, and their diabetes went away, and their osteoporosis went away, and the depression went away, and blah, blah, blah. And I was like, “Holy moly. So this was really pretty astounding.” It really was very powerful.
Dr. Weitz: Yeah, that’s one of the great advantages of functional medicine or lifestyle medicine is not only can you potentially help the problem they’re coming in for it, but you can make their overall health better and reduce their risk of chronic diseases.
Dr. Hedaya: Yep, absolutely, absolutely.
Dr. Weitz: So I’d like to pick your brain about some of your insights into the functional medicine approach for psychiatric disorders. And I listened to a discussion you did at a grand rounds at Cleveland Clinic and you had some really great pearls of wisdom I think a lot of people could benefit from. Maybe you can talk a little bit about the functional medicine approach, and if you want, I can ask you some specific questions.
Dr. Hedaya: Well, I mean, I think the main thing is you have to be a medical detective and your mental set has to be medical detective. And yet I’m very data oriented, so I don’t like to say, “Hey, I think you’ll need some magnesium. I like to know if the magnesium’s low and then it’s low, great, I’ll treat it and then I’ll retest it, make sure I’ve normalized it.” So basically, be a medical detective. The second thing I would say that I’ve learned is that most it’s what we call psychiatric problems, they’re really, I want to be careful how I say this, but I would say they’re not primarily psychological. In other words, there’s a lot of physiology and infections and hormonal problems and genetics and epigenetics and gastrointestinal things, et cetera. There’s a lot of factors going on. And once you normalize those and treat those things, you still have work to do.
Some people have character problems that they can work on, but that’s modifiable. Personality and temperament, you’re born with those, but those could be managed. If you’re harm-avoidant and fearful, you’re kind of born with that. I wouldn’t call it psychological, it’s not your fault. It is just like what you’ve been born with. And then, there’s the trauma thing that I wouldn’t even, it is psychological, but it’s put on you by the circumstances. Now, you’ve got to manage that. So the whole idea that, “Oh, you have some psychological problems, there’s something wrong with you.” No, there’s nothing wrong with you. You’re dealing with stuff. You’re climbing up the Mount Everest like we all are with some rocks in your backpack, but there’s nothing wrong with you. The only thing you may need to work on for you is your character and your spiritual development, but the rest of it is stuff that rocks that were put in your backpack, let’s say.
Dr. Weitz: Right. In other words, the mental realm is directly part of the physical realm. And if you’re physical health is lacking, if you’re lacking in nutrients, if you’re having toxins and infections and other things that are throwing off your physiology, that’s going to be affecting your mind.
Dr. Hedaya: 100%.
Dr. Weitz: And those are the things that we can easily access and change.
Dr. Hedaya: Yeah. Well, my first patient, you can ask how had this happened. Well, one of the very biggest things that happened to me is, I think it was ’84. I was in practice since ’83, training ’79. ’84, I saw this woman, 50-year-old woman with panic disorder, and she had not a great marriage. Her only kid was going off to college, and my assumption was that she was having panic because of separation anxiety of a bad marriage, she might have to leave her marriage, child was leaving, et cetera. Psychotherapy, medications, long story short, one year, she didn’t get better, and it turned out that she had a B12 deficiency with her first injection. Her panic went away, and I was like, “Whoa, this looked so psychological and it wasn’t it.” And that was, I thought, “Wow, what else am I missing?” And there’s obviously hundreds of things that are involved in how the brain functions.
Dr. Weitz: So I listened to you talk about B12, and you mentioned in that talk at the Cleveland Clinic that a lot of us measure B12. I think conventional doctors look at serum B12, and most of us in the functional medicine world know that’s not a very accurate test, but we think we’re doing better by doing methylmalonic acid and maybe homocysteine, but I think that you have some pearls to tell us about that, right?
Dr. Hedaya: Yep. So who are your listeners? Are they docs or?
Dr. Weitz: Well, I think they’re more educated, functional patients, more educated list, people involved with health, but I think a lot of them are functional medicine practitioners.
Dr. Hedaya: Okay, great. So I’ll go into a little more detail. So if your B12 level is low normal, you probably have B12 deficiency. That’s not so difficult, but most of the time that’s not really the case. We’re looking at what’s the B12 function? So in order to assess that, you’re in the broad scheme of things. You’re looking at two broad categories. You’re looking at the methylation B12 folate, and on the other side you’re looking at the iron, because then what do you want to look at is you want to look at the red blood cell count. Are they tending towards anemia? Maybe not anemic yet, but tending towards anemia. And also, what’s the size of the red blood cells, the mean corpuscular volume? What’s the size? Now, that’s where the tricky part comes in, because if you’re B12 deficient, your red blood cells will get larger because you need B12 to make red blood cells, and if you’re not making them, they hang around longer and the spleen doesn’t get rid of them, so they get bigger. So you’re can have larger red blood cells because you’re B12 deficient. But if you’re iron deficient, you’re going to have small red blood cells, a microcytic red blood cell, microcytic anemia. And so, here you are, you’re going to have the two offsetting each other. You could have normal size of the red blood cells. You got to really remember, you always got to look at the iron because it could be masking a B12 deficiency. Then, you of course look at the homocysteine, where is that going? And then, of course, look at medications that people are on. How old are they? If they’re over 50, they’re more likely to have trouble absorbing B12. So I call it a dynamic assessment of B12, and methylmalonic acid only accounts for about 17%, I believe it is, of the level of the, I’ll put it a different way. Methylmalonic acid is only affected by B12. There’s 83% of the methylmalonic acids affected by other factors other than B12, put it that way. So it’s really not a great measure.
Dr. Weitz: And then, how do you assess iron? Do you look at ferritin? Do you look at serum iron? What are you focusing on?
Dr. Hedaya: I look at serum iron and TIBC primarily, and just look at what’s the iron and how much binding capacity is there, and basically how much iron is stored on the bus and not active, and how much is free roaming around the streets and the blood vessels. And that’s what I use. Sometimes use the ferritin, but basically those two, and of course, CBC.
Dr. Weitz: Right. Maybe you could give us some other clinical pearls about the functional medicine approach. How about the importance of fish oil or omega-3s?
Dr. Hedaya: I would say just the American Journal of Psychiatry did a review of the, what’s the evidence for some nutraceuticals in psychiatry and would come up with vitamin D, very important. Fish oils, very important. These are not treatments for depression, but they’re preventative. Zinc, very important. Zinc has to be managed with copper, and obviously a good balanced diet with adequate levels of protein and ability to digest and absorb your protein. But those are probably the main things there. Another clinical pearl I think is really important is the thyroid adrenal axis when you look at neuropsychiatric problems, and you can’t just say, “Oh, look, the TSH is normal.” You really have to look, well, I look much more thoroughly.
So obviously, first of all, physical exam, symptoms of low thyroid adrenal problems, usually adrenal insufficiency. So the physical and symptoms very, very important. Then, you corroborate it with testing. On the thyroid, interestingly, that the mean TSH in the US population about 1.5, that’s based off the NIH study, which is I think it was 16,000 people. So that’s your mean TSH. So as your TSH rises above 1.5, you’re actually going outside of the moving out of the norm. But the upper limit at most labs is 4.5. Some endocrinologists think that it should be 2.5. In neuropsychiatric problems, you definitely want to be closer to 1.4, 1.5, or even one.
Now, there’s plenty of evidence for depression, treatment resistant depression, that hypermetabolic doses of thyroid hormone, particularly T3 actually will help people come out of depression. Part of that has to do, I believe, with the genetic vulnerability abnormalities in the deiodinase 2 genetics that control the conversion of T4 to T3 in the brain. We obviously can’t stick a needle in the brain to measure the T3 so we rely on their symptoms and on their genetics. So if they have a lot of SNPs variance in the deiodinase 2 genes, then we’re concerned about that. And the other thing, and it could be too technical, what I would say-
Dr. Weitz: By the way, on the thyroid, do you often supplement with T3 as well as T4, or do you try to push the ability for the body to convert to T4 and T3 with nutrients?
Dr. Hedaya: Yeah, I actually often use a combination of T4, T3. I used to use Armour, for example, but a little concerned, I don’t have evidence for this, a little concerned that you’re taking in, first of all, how do they standardize it? Second of all, you’re taking in proteins that come from an animal, a pig, and are those proteins going to cause any kind of autoimmune reaction for some people? So I say, “Well, let me just give the T4 and T3.” So that’s what I’ve settled down to. And it depends on the conversion. Some people convert, some people don’t convert. You have to look at it. Sometimes the body’s not converting to T3 because it’s protecting the body because the adrenals can’t handle it. So you have to think about that. The adrenal system, probably most people know how that HPA axis works. The thing that I would like to point out is one is that perceived threat, doesn’t have to be a real threat, could be a perceived threat, maybe based on trauma, misperceived, we could say, based on trauma. That can throw off your HPA axis.
Dr. Weitz: How about the fear of dying from viral infection?
Dr. Hedaya: Yeah, it could be anything. It could be anything. And then, on the downside, on the genetic side, very, very interesting. There are genes which you can test for NR3C1, FKBP5, CRH receptor 1 and 2, CRH binding protein, these control proteins that control the effective steroids inside your cell at the level of the nucleus. And it turns out that a lot of my patients, not all, have variants in these genes, which means that when you’re stressed for whatever reason, and you release cortisol, your cells at the level of the nucleus can’t convert the signal, the stress signal efficiently to the genome, and then your genome doesn’t respond properly, and now you’re vulnerable to stress, to immune dysfunction, to depression, to suicide even. And so, these genes are really important. This is a deep level of, in a way, it’s a cortisol resistance that’s genetic. You can get glucocorticoid resistance from having infections or from over methylation, the different pathways to glucocorticoid resistance and that’s not really recognized. I think that’s part of the reason people are having trouble responding to treatments for Lyme disease, for example, chronic Lyme and certainly chronic long COVID, that’s part of the picture.
Dr. Weitz: Are you doing a salivary adrenal cortisol test, and what’s your favorite gene panel?
Dr. Hedaya: So salivary cortisol, that’s fine. I use the DUTCH now, but I used to use diagnostics. They’re fine as well. And for genes, I use something called Opus23. You got to get trained on it, but I just really love it. There are other gene programs. Intellxx is very good, which worth looking into. I haven’t had the time to really look into it, but you get other stuff there that you don’t get in Opus23. But Opus23 is a wonderful tool, just a wonderful tool. And you can get the NR3C1, et cetera, on Opus23, which you cannot as of six months ago anyway, get on Intellxx.
Dr. Weitz: Okay. How about diet? How important is diet for functional medicine approach to psychiatry?
Dr. Hedaya: So diet’s essential, foundational, and you’re probably not going to get too far without diet. You’re not going to get too far without getting rid of mold if you have mold. Diet’s essential, and obviously everyone has a specific dietary need. It’s a little different for everybody. Diet is essential foundation, really an essential product.
Dr. Weitz: Gut health?
Dr. Hedaya: Generally, we start with the gut. Gut is they call it the second brain, and it’s obviously sending signals to the brain through multiple pathways and the brain to the gut. It’s a round trip kind of thing, a two-way street, and not really separate, but that’s the thing. Remember, we used to talk about nature versus nurture, and now we know with epigenetics that there is no nature versus nurture. It’s one thing, it’s seamless, and it’s the same with the gut and the brain and the endocrine system and the brain. And it’s all seamless. Everything’s affecting everything.
Dr. Weitz: I mean, to some extent, we are our microbiome.
Dr. Hedaya: To some extent, we are. It’s pretty scary. When you look at the [inaudible 00:19:08] it’s pretty scary. You see some of these studies that show that changes in the microbiome change your behaviors or animal behaviors, at least, social behaviors. Holy moly. Wow.
Dr. Weitz: And then, every time I think about that, and then I have some patient who just had their colon removed or something because they have Crohn’s, and I think, “Oh, my God. That’s got to affect their long-term health.” And it’s hard to say. What do you think about that? So we haven’t talked about the neurotransmitter theory of depression, which I know has all sorts of issues, but it’s often stated that 80% of the neurotransmitters are produced in the gut, but yet the neurotransmitters in the brain are produced in the brain. So what do we think the relationship between the neurotransmitters in the gut, which seem to have an effect on the neurotransmitters in the brain, how do they interact?
Dr. Hedaya: Well, that’s a really good question. And in terms of serotonin, probably 95% of serotonin is produced in the gut, the vascular system, other non-brain systems. But in the brain, there are specific areas like the dorsal raphe nucleus, for example, that produces serotonin, and it’s specifically responding to what the body needs, et cetera. So you can’t, I would say, actually, I moderated a debate between Jay Lombard, very bright guy, and one of the people who was running one of the neurotransmitter labs, this might be six, seven years ago, at IFM, I moderated this debate, and we knew this actually when I was at NIH. You cannot look at the urinary neurotransmitters like 5-HIAA and see what’s going on in the brain. It doesn’t tell you anything about the brain because it’s just mostly the body and it doesn’t correlate. For example-
Dr. Weitz: I thought with serotonin, there was a fairly close correlation.
Dr. Hedaya: No, no, no, no. For example, at NIH, we used to do this. You had to do a cerebral spinal 5-HIAA level to see and see there’s a correlation with suicide, and there was a correlation there. But in terms of the gut, serotonin is not really a correlation with the brain. This is a Venn diagram, so it’s not a complete, oh, this is-
Dr. Weitz: But how are they related? Is there some sort of communication? Does some of the serotonin from the gut or the circulation get into the brain because you have leaky brain?
Dr. Hedaya: So that’s what I was getting. So you have, it’s like a Venn diagram. You have two circles. So what’s the overlap is what you’re asking, right?
Dr. Weitz: Right.
Dr. Hedaya: And there is an overlap because connected to everything. So there’s got to be an overlap. But how much is that overlap? I don’t know, I really don’t know. I mean, there are transporters for serotonin in the blood-brain barrier. Sometimes they’re impaired by genetics. Can they be impaired by leaky barrier? They could. They could, certainly. That’s the best I could give you. I don’t know if people ever really studied that. Maybe you have, I don’t know.
Dr. Weitz: Yeah, I’ve been looking into it, but it’s not clear. Another similar substance that seems to have a similar type of issue is cholesterol. We know that the cholesterol that’s used in the brain, which is essential for producing neurotransmitters, for brain function, is the cholesterol is produced in the brain, and yet we have cholesterol in the body that’s produced in the liver. And then, a lot of us are trying to drive our cholesterol levels down as low as possible to reduce the risk cardiovascular disease. And there seems to be correlation, I’ve seen quite a number of studies showing some correlation between getting your cholesterol levels below a certain level and problems with brain health and increased risk of dementia. And yet others say, “No, no, the cholesterol that’s produced in the brain is totally separate. You’re perfectly healthy driving your Apo B below 40 if you can.”
Dr. Hedaya: Below 40. I don’t know if you could do that, but-
Dr. Weitz: Well, you can if you use PCSK9 inhibitors on top of statins.
Dr. Hedaya: Right. So I think the cholesterol, first of all, just for the listeners, as you know, is the mother molecule of all steroid hormones, and it’s in mitochondria. A lot of these steroids are made actually in mitochondria as well as in adrenal glands, et cetera. Pregnenolone is the next molecule, and then we have the whole sequence down. So it’s a big concern. I don’t know the answer either. Actually, for myself, it’s funny and Bredesen, I was just thinking is my cholesterol okay, it’s normal. But my cardiologist says, “Nah, you got to bring it down.” And he wants to [inaudible 00:24:27] me on one of these inhibitors, and that’s good because they only work in the liver. But I’m like, “Well, what else is it going to do? And what am I going to do?” And I’m in that quandary myself, and I don’t know the answer to it. Obviously, if you have a family history of a risk of neurodegenerative disease, depression, et cetera, you might want to be more careful. On the other hand, like you said, there are some studies that say, “No, there’s a benefit.” And it’s tough because it’s not like you take it and a week later you notice symptoms. It’s a tough-
Dr. Weitz: Absolutely. And heart disease is still the number one killer. So we certainly don’t want to minimize that or decrease somebody’s ability to reduce their risk of heart disease. But I know Dr. Bredesen, I’ve talked to him, and he is convinced that statins can have a negative effect on the risk of dementia.
Dr. Hedaya: Yeah. So he’s a smart guy, and if he says that, that weighs more in line of be careful. So then, you pick your poison, you want to die of a heart attack.
Dr. Weitz: Now, have you experimented with a ketogenic diet for psychiatric disorders?
Dr. Hedaya: Oh, yeah. Well, we use it specifically with certain types of patients. We use it for people who, well, we do the quantitative EEG, for example, and I look very carefully with my patients who had seizures and temporal lobe seizures, and absent seizures, partial complex seizures, fairly common. And so, if we see a signature of that on the qEEG and we have symptoms of that, then we’re going to move towards ketogenic diet, it’s a tough, long-term sell. Obviously, nobody’s going to live on that for… Most people are not going to live on it for 20 years, but we do find it helpful. And there’s a nice easy test, I think, that I do in my office when I see someone for an evaluation. I’ll have some brain octane, the MCTC, the eight-carbon caprylic acid, MCT oil in my office, and about whatever, an hour into my evaluation which is usually about three, four hours, I’ll say, “Let me give you a trial of this and give them a little, couple of tablespoons of this, teaspoons or whatever,” depending on their gut health because it kills yeast so you can get cramps. And I’ll do this, and then I’ll set my watch for 30 minutes, and then, I’ll ask them how they feel in 30 minutes. And if they say, “My pain is less or my headache went away, or I feel more clearheaded,” then I’m like, “Okay, now I know we’ve got some kind of a mitochondrial problem going on here, and that’s some percentage of your problem.” Gives me a little clue, and I might lean more towards either ketogenic or using more MCT or beta-hydroxybutyrate or something like that.
Dr. Weitz: Right, because the ketones are produced when you’re on a ketogenic diet, and some of the data shows that the brain works better on a ketogenic diet that it burns ketones instead of sugar. And obviously, blood sugar is a big factor in mood and psychiatric disorders.
Dr. Hedaya: Absolutely. No question about that because there’s an interesting way of looking at this. Actually, when I was in my training, I saw this most fascinating thing. It was a diabetic guy who went into a diabetic coma, his blood sugar dropped, he went into a coma, and then we put a IV in and give him glucose. As his glucose came up, first he talked like a child, then he talked like an adolescent, then he talked like a young man, then he talked like an adult. I was like, “Wow. It’s like the lower your glucose is, the core parts of your brain that need the glucose, so your animal self, your limbic brain is going to be in charge when your blood sugar’s low.” That means when you were a kid, if you were afraid or you were angry or aggressive or the world was a dangerous place or whatever, that’s how you’re going to see the world. When your blood sugar comes up, you’ll be more like a rational adult. And this can happen through the day when you hear someone going through mood swings through the day, think blood sugar, think diet 95% of the time.
Dr. Weitz: Right. So at that point, you can remove the higher glycemic carbohydrates, even if you don’t put them on a full ketogenic diet.
Dr. Hedaya: And obviously balancing the fats, the carbs, and the proteins balance well, so you keep the blood sugar stable over the course of [inaudible 00:28:58].
Dr. Weitz: And the importance of proteins and amino acids, because I’ve heard you talk about the importance of tryptophan for producing serotonin.
Dr. Hedaya: Yeah, yeah. So we never use tryptophan. We use 5-HTP, 5-hydroxytryptophan is the next step because if you’re inflammatory, which most people are, you’re going to take the tryptophan and that’s going to go down the kynurenic and quinolinic acid pathway and increase your glutamate, which causes anxiety and agitation. So you want to use 5-HTP, which bypasses that step because the activation of 2,3 indole dioxygenase. And so, you give 5-HTP, 5-HTP will go down into serotonin, melatonin, et cetera. I never use tryptophan anymore.
Dr. Weitz: Oh, interesting. I just talked to another doctor who said that he uses 5-HTP during the day sometimes and tryptophan for sleep.
Dr. Hedaya: Yeah, I would never use tryptophan because of the inflammation. If there’s inflammation, which like I said, almost everybody’s in a pro-inflammatory state, you’re going to drive the glutamate up. Glutamate when it goes too high is neurotoxic actually, and GABA goes down. And so, I used to, when I was at NIH, we actually did a study on tryptophan and blah, blah, blah, but I wouldn’t go near it anymore.
Dr. Weitz: Okay. So let’s get into some of the advanced stuff you’re doing now with some of your patients involving hyperbaric oxygen, EEG-guided laser, et cetera.
Dr. Hedaya: Okay. What would you like?
Dr. Weitz: Why don’t we start with hyperbaric oxygen? So what’s the benefit of that and what exactly are we accomplishing with that?
Dr. Hedaya: Okay, so hyperbaric oxygen is a treatment, obviously has been around for a long time. It is used for air embolism, gas, gangrene, diabetes, wound healing, skin grafts, carbon monoxide part. It’s a long history. Now, it’s being used for traumatic brain injury, strokes, in sports medicine I’m sure you’re probably aware, COVID-19, some tick-borne diseases, PTSD. In Israel, they’re using it a lot. And so, basically how does it work? It actually helps increase the delivery of oxygen to the tissues and nutrients to the tissues, because you’re putting oxygen and pressure to open up those capillaries. There are secondary mechanisms like increased catalase and SOD and glutathione peroxidase, et cetera, but it seems like increasing perfusion, nutrient, oxygen delivery through mainly the main ingredient is the pressure that that seems to increase flexibility of red blood cells as well. And so, you can get healing of tissues.
And we have seen actually healing of brain injury, traumatic brain injury years afterwards. It doesn’t mean the tissues are completely normal because you have a TBI, traumatic brain injury. The cell is dead, the cell is dead. But there are cells that are in a liminal state, they’re alive, but they’re barely functional. And those cells actually, you can rehabilitate those cells. And so, we have seen on the qEEG normalization actually of the qEEG pre, post HBOT with TBI. I’m going to be giving a talk at IMMH actually in about a month, show some pictures of the woman who was a really internationally known athlete who was just so clear on her quantitative EEG. You could actually see the line of demarcation, the shock wave from the head injury. And you can see how it healed.
Dr. Weitz: There’s a number of ways to increase oxygen. So besides hyperbaric oxygen, we have ozone which can be injected or put into the body in different ways. There’s increased, decreased oxygen, training with exercise. I forgot the name of it, but there’s this device where you’re exercising and you increase the oxygen, you decrease the oxygen, and these are other strategies. What do you think about various ways of trying to increase oxygen?
Dr. Hedaya: I don’t have any training the ozone, so it’s hard for me to comment on it. There’s a limit to what I can learn. So I have been interested in it, but I haven’t really explored it. So it’s hard to really know. The exercise with oxygen, I actually tried it, got this, so they actually sent me the unit and I don’t want to disparage it because maybe great may be great, but my experience wasn’t great with it, so I can’t comment on it. I read a book on it, very detailed book, and it was very impressive. So that’s the limit of my experience with that. So I would say people should explore these things, but the HBOT is something that I like because, well, I’ve used it successfully and I’ve seen rapid responses, and so I’m happy with it. So maybe those things are complimentary, maybe they do different things, or maybe they would supplant HBOT. I’m sorry, I can’t really give you my opinion on that.
Dr. Weitz: Right. And HBOT, there’s hard chambers, soft chambers. I think I’ve heard you say that you use a soft chamber?
Dr. Hedaya: Yeah, we use a soft chamber. I don’t think you need that much pressure. The evidence seems to be 1.4 atmospheres, good for most people. And although we do have some people, I know some people are using hard chambers, obviously have to be a little more careful, et cetera.
Dr. Weitz: So let’s talk about the-
Dr. Hedaya: HBOT by the way, you would not want to use if someone has Babesia, which is fairly common, right?
Dr. Weitz: Okay. Because the oxygen would increase the growth of the Babesia?
Dr. Hedaya: Right. Exactly.
Dr. Weitz: And for those who don’t know, Babesia is a microorganism often related to Lyme disease.
Dr. Hedaya: Right.
Dr. Weitz: So let’s talk about the EEG-guided laser. Now, there’s a number of, a lot of us in functional medicine world, I’m a chiropractor, a lot of us in the chiropractic world are using lasers. We got class three lasers, we got class four lasers, we got a class three laser. There’s one company that actually has a set-up where you, it’s like a class three laser and it goes around your head. And some practitioners have found good benefits with that. Tell us about the type of laser and why it’s guided by EEG and exactly how that works.
Dr. Hedaya: Okay, well, so we started out using an 810 nanometer laser class four, and now we use a 1064, sometimes 810. But 1064 seems to penetrate the brain better. And the question is, where do you aim? What are you going to do? Where do you aim?
Dr. Weitz: And does it penetrate the skull into the brain?
Dr. Hedaya: Yes, exactly. So Henderson did a very nice study.
Dr. Weitz: Does it depend on how thick your skull is?
Dr. Hedaya: Well, it does to some degree. And a lot of people are thick-skulled, right? But Henderson did a very nice study. He found roughly about 2.6, 2.8% of the light from a laser actually penetrates the brain. So you’re at the surface of the brain, you reap and receive about that percentage of the light. And so, now there’s a little debate about whether the LEDs penetrate the brain or not. And I don’t know, I’m up in the air about that. I’ve tried these things with people, I don’t know yet. There’s some evidence that it does and that people get better. But the problem is that the studies that are published are published by the people who are making the device. So that’s the same problem we have with the pharmaceutical companies, so we don’t know. So what we do though with the QEEG is we can actually map the surface areas of the brain that are abnormal, the nuclei of the brain that are abnormal, the circuitry, specific circuitry and pathways, specific pathways of the brain that are abnormal. And then, we can decide based on that and based on the symptoms where we want to point the laser. And that is obviously more specific and it can be quite astounding actually.
Dr. Weitz: So give us an example.
Dr. Hedaya: Well, my first case really, this was 2017 who I was treating her for early dementia, let’s say, or MCI, let’s say. But she had APOE homozygous and strong family history, head injuries and absent seizures, which had never been diagnosed. It had a lot going on, treated her with functional medicine. And then, actually after that, she was much better, but she still had symptoms. And so, what I did is I said, “Well, I finally learned the qEEG.” Actually, if you want, I’ll share my screen. I could show you. This is her qEEG, so basically, well this is a derivative of her qEEG actually. Everything in gray is normal. Everything in yellow or blue is abnormal. Yellow or orange or whatever is unstable and blue is slow. So what we see here is this is, her eyes are up here, ears are over here, back of the head is here. We’re looking here at the entorhinal cortex here, the base of the brain, the frontal lobes, temporal lobes, occipital. This is the cerebellum. So we’re kind of low at the lower, kind of below your ear lobes with a slice here. This is a side view of the brain here, her eyes, and here is the base of the brain here. And you can see all this gray stuff is normal. This is after functional medicine. And then, this is a slice vertically like this, a coronal section.
Here is the hippocampi, which we know in Alzheimer’s and she had those genes, the APOE4 genes. Her hippocampi, clearly abnormal. You can see that here, the hippocampus. And she’s actually 2.7 standard deviations from the mean. So that’s still pretty abnormal after her functional medicine treatment. And here, this is information flow through different areas of the brain from this particular area, you could actually analyze all these lines. The information flow is poor. Here, this excessive attempt at inflammation flow is really doesn’t work very well. And here’s slow information flow, different areas, and this is telling us the different surface areas of the brain. And here, what we’re looking at is 6 hertz, there’s theta. So this is where she was after functional medicine, but before the HYLANE treatment, which in her case was in particular was laser. We did 30 laser treatments and based on a more thorough analysis than this, we decided where to point the laser.
Dr. Weitz: Now where did you point the laser with her?
Dr. Hedaya: I was on the left temporal area.
Dr. Weitz: Why the left temporal area based on that EEG?
Dr. Hedaya: Well, I’d have to actually, I couldn’t explain it to you from what I just showed you. Really, I’d have to pull up her qEEG and her pathways, which I came up to. But this is after 30 treatments.
Dr. Weitz: Wow.
Dr. Hedaya: You see, she’s completely normalized here.
Dr. Weitz: That’s pretty amazing.
Dr. Hedaya: Yeah, a little. When I saw this, I came home and I didn’t know. My mind was blown. My mind was blown. Now, here’s really where my mind was blown because after the first laser treatment, the first laser treatment, I treated her for maybe three minutes, four minutes. Then, I brought her into my office to make an appointment the next appointment. And she says, “Oh my, God.” She had an accent. She goes, “Oh my, God. I can remember the face of the person I saw last week. Oh, my God, I remember her wife. I remember the dimple on face.” She was like, and I didn’t know she had facial blindness until that moment.
I did not know she had, it’s called prosopagnosia. I did not know she had facial blindness. Now she’s telling me my facial blindness is gone. I’m like, “What?” This was mind-boggling. So I actually had her do this Cambridge facial recognition test, and she came back normal and right here. And then, I was so blown away. We actually published, this is the first case of reversal, of acquired, meaning she wasn’t born with it, prosopagnosia, facial blindness using qEEG guided laser therapy. We published this case. And that’s just one example. That’s the first example. But since then, we’ve reversed partially, like 75% aphasia, visual problems, depression. I could show you, actually, I’ll show you something else here.
Dr. Weitz: So your approximate amount of time of using the laser on patients is how long?
Dr. Hedaya: About six years, maybe a little more than.
Dr. Weitz: And then, when they come in for a treatment, did you say three to four minutes?
Dr. Hedaya: Well, in her case, it was the first treatment we did very slow, very careful. Usually, it’s a 10 to 20-minute treatment.
Dr. Weitz: And normally, the laser is just focused in one place and held in that place?
Dr. Hedaya: No, it’s not held because you don’t want to create excessive heat. You’re going to move it. Right. And it depends on what’s going on because we could treat multiple areas at one time.
Dr. Weitz: Okay. Do you think a class three laser can have benefit?
Dr. Hedaya: I don’t know. I don’t know enough about them. What’s the difference between a class four and a class three?
Dr. Weitz: I think it has to do with power. The class three doesn’t produce a lot of heat and it doesn’t risk injuring the eye, so it’s a little bit easier to use.
Dr. Hedaya: It’s mainly wattage, but you can get the same nanometers, you can do 1064. It should, you might, obviously the time, how long it takes is longer. So you’re going to have to calculate how much you’re delivering to the tissue. There’s a therapeutic window for this. Now, so if you get too much light, you can actually inhibit ATP production too little. It doesn’t work. So there’s a therapeutic range and you kind of get roughly one to two joules at the tissue level.
Dr. Weitz: And are you using infrared or red or what color?
Dr. Hedaya: 64. So it’s specifically an 810, so it’s infrared. It’s not invisible.
Dr. Weitz: Okay, cool. And then, the third part of your program has to do with neural exercises?
Dr. Hedaya: Yeah, so neurofeedback is one type of neural exercise. There are other types of neural exercises, so you could use brain training. One of the things I really like is to have people increase their novelty. So for example, he might have somebody, I just assigned this to somebody last week, for a husband to take his wife to a new neighborhood. She has spatial problems. Let her walk around the neighborhood, let her find her way back to the car, and obviously not for hours, give her 15 minutes or something like that. Enjoy the novelty, try new neighborhoods, do that kind of thing. But we use neurofeedback suit because we can actually look at specific networks in the brain and we can say, “Well, how are they doing?” So for example, we might be able to show you here, actually, I’ll show you if you want, I’ll share my screen again here.
Dr. Weitz: Sure.
Dr. Hedaya: This would work anyway. Let’s just say for example, this is a guy pre-post laser, so it’s different. But let’s just say that this here on the right here, where this red circle is is a specific network, we’ll call it the salience network. Salience network tells you, “Well, where should I pay attention? Should I pay attention to the world out there or should I pay attention to what’s going on inside?” Like a toggle switch. And in some people, salience network is telling you no pay attention inside, sometimes outside. Then, we have the default mode network, which is your inner world. And then, we have the executive network was outside. So let’s just say that this is for example, the salience network. Then we treat this with neurofeedback at a specific frequency, and then this would be what it would look like after the neurofeedback, meaning it’s normalized. The black is normal. This means it’s functioning slowly under functioning. Now, as I said, this slide does not really demonstrate that it is specific network, but it is not, we didn’t do neurofeedback. This was after hyperbaric oxygen laser.
So I think that it’s like weight training in the gym. We can actually say, “Okay, we can measure what’s going on. Let’s say in your salience network, let’s say it’s overactive or underactive, and we can measure it and we get you to watch a movie. You pick a movie that you like.” And then your brain says, it tags it and says, “Oh, this is a reward. I want to watch this movie.” And so, now, what we do is as that network is doing what we want it to do, you get to watch the movie. And as a network stops doing what we want it to do, the movie kind of gets gray, the sound goes down. And pretty soon after four or five sessions, your brain has figured out, not you, not consciously, your brain has figured out, “I want that. I want to hear the rest of this movie. Oh, I know what I got to do.” And it starts working. It’s like weight training and it starts working and it actually gets stronger. And that’s simply put, that’s neurofeedback.
Dr. Weitz: Right. We often tell patients if they don’t dance, take a dance class, they take a dance class, take a different dance class, pickleball, do some novel activities.
Dr. Hedaya: Ballroom dancing is great. Zumba, great. Exactly.
Dr. Weitz: What do you think about the neural exercises on some of the computer programs?
Dr. Hedaya: We use them. We use them. The question in my mind has always been, how generalizable are they to the world? They seem to claim that they are. Again, the study’s done by the companies, but we do use them.
Dr. Weitz: What about some patients say, “Oh, I like to do Sudoku, or I like to play jazz,” things like that?
Dr. Hedaya: Great.
Dr. Weitz: Those would qualify as neuro exercise.
Dr. Hedaya: Yeah. Also learning another language. And really one of the strongest things is being fluent in another language. If you can really be fluent and use other languages fluently, that’s actually shown to actually reduce the risk of neurodegenerative disease, or at least the onset will show up later.
Dr. Weitz: I bet you if more people knew other languages, probably reduced the risk of war too because we know more about each other.
Dr. Hedaya: Yeah, I love that. That’s really true.
Dr. Weitz: Okay, great. Dr. Hedaya, how can listeners, practitioners, et cetera, get in touch with you? Do you have courses available for training for practitioners?
Dr. Hedaya: No, we’re treating patients pretty much.
Dr. Weitz: Okay, great. So how can patients get in touch with you?
Dr. Hedaya: So patients get in touch with me through the website. It’s like Whole Foods, only it’s Whole Psychiatry, W-H-O-L-E, not H-O-L-E. W-H-O-L-E.
Dr. Weitz: Are you willing to sell out to Amazon for $2 billion?
Dr. Hedaya: I don’t know. I’ll consider it.
Dr. Weitz: So I’m sorry. Whole Psychiatry.
Dr. Hedaya: Wholepsychiatry.com. There’s a lot of information on the website. It’s a very rich website that we’ve got sample reports, we have videos, we have my radio shows I used to do. We have a lot of stuff. And then, there’s a contact form of people who want to contact. It’s an intensive program, I have to say. We really, really work hard to get to the root causes of things. Sometimes we like to work very intensely. Sometimes we try to get the low hanging fruit, depends on the patient and et cetera. But if you’re looking to get to the root cause and avoid medicine or the medicine’s not working, then that’s our niche.
Dr. Weitz: Great. Thank you, Dr. Hedaya.
Dr. Hedaya: Well, thank you very much, Ben. It has really been a pleasure and I have to congratulate you because done a lot of podcasts and you dove deeper than most thank.
Dr. Weitz: Thank you.
Dr. Hedaya: Really nice. And that’s a tribute to what you do, because obviously you’re interested in really how things tick. Really, really-
Dr. Weitz: I am. I pride myself on that. Thank you very much for recognizing that.
Dr. Hedaya: Yeah, very good. Very good. It was a pleasure.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way, more people will discover the Rational Wellness Podcast, and I wanted to let everybody know that I do have some openings for new patients so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
https://drweitz.com/wp-content/uploads/2023/11/rwp333a-website.jpg350785drweitzhttps://www.drweitz.com/wp-content/uploads/2017/06/drweitzdsamplelogo-withtext.pngdrweitz2023-11-07 18:35:502023-11-25 11:16:41Integrative Psychiatry with Dr. Robert Hedaya: Rational Wellness Podcast 333
Dr. Jill Carnahan discusses her Unexpected Health Challengeswith Dr. Ben Weitz.
[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.]
Podcast Highlights
Dr. Jill Carnahan is a
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
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Dr. Jesse Armine discusses Leaky Gut with Dr. Ben Weitz.
[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.]
Podcast Highlights
Dr. Jesse Armine is a Doctor of Chiropractic and a registered nurse. He has specialized training in methylation, genetic research, Neuro-Endo Immunology, Functional Medicine, Nutrigenomics, Applied Kinesiology, and Nutritional Counseling. He specializes in diagnosing and treating complex, multifactorial illnesses with a concentration in neuropsychiatric expressions/autism and chronic illnesses. Dr. Jess lectures worldwide and continues to treat patients mostly remotely. He co-authored a book with Elizma Lambert ND entitled, “Leaky Gut, Leaky Cells, Leaky Brain”. His website is DrJessArmine.com.
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, dr whites.com. Thanks for joining me, and let’s jump into the podcast.
Hello Rational Wellness podcasters. Today, we will be speaking about leaky gut with Dr. Jess Armine. Leaky gut is a controversial concept in the functional medicine world. No, I’m not talking about the controversy in conventional medicine about whether leaky gut exists at all. Most of us understand that there’s tons of research substantiating that leaky gut exists and that it’s a problem, but there are differences about how to test for leaky gut. There’s the old lactulose mannitol intestinal permeability test, but most of us today are either using a serum test for zonulin or a stool zonulin test, or a serum test for zonulin antibodies, and there’s a lot of controversy whether any of these are accurate. I personally run a stool zonulin as part of a stool test, but quite frankly, I assume that most of my patients with gut problems have leaky gut. There’s also controversy about the best strategies for healing leaky gut and whether probiotics, and which ones, prebiotics, which ones, bone broth, et cetera, et cetera. How should we heal leaky gut? I’m hoping that Dr. Jess Armine can give us some clarification and guidance for how to understand leaky gut and how to treat it.
Dr. Jess Armine is a doctor of chiropractic. He graduated in 1986, a year before me, and a registered nurse. He has specialized training in methylation, genetic research, neuro-endo immunology, functional medicine, nutrigenomics applied kinesiology and nutrition. He specializes in diagnosing and treating complex illnesses. Dr. Jess lectures worldwide and continues to treat patients mostly remotely. He co-authored a book with Elizma Lambert, ND entitled, Leaky Gut, Leaky Cells, Leaky Brain. Jess Armine, thank you so much for joining us.
Dr. Armine: Thank you for inviting me. Basically all that stuff means I don’t know what I want to be when I grow up.
Dr. Weitz: Me too. Personally, I hope I never grow up.
Dr. Armine: No. I’ll tell you something. I have multiple, multiple interests, and like you said, we’re going to talk about leaky gut today, and leaky gut is more of a euphemistic term. And I have a little presentation. I’m going to zip through it and stop at the areas that are important because you’ve already gotten my qualifications and so forth. And I want to tell you some really important things about leaky gut that most people don’t realize. It’s not that difficult to fix, a little patient with it, but why it’s so important to fix it, whether a test positive for it or not. Okay, so can I start the presentation?
Dr. Weitz: Yeah, yeah, go ahead. And I just want to tell everybody who’s listening, if you happen to be listening to this on your phone, you can go to the YouTube page, Weitzchiro YouTube page, and you can see Jess’s presentation there if you want to see the slides.
Dr. Armine: So this is me. I’m from Brooklyn, as some people might tell by my accent. There’s all my qualifications. This was originally made for clinicians and learning to be a clinician, but in order to be a clinician… So this is how you know your doctor’s good. This is the way you should take this. Somebody who just uses signs, the double-blind foreseeable controlled studies, that’s not the way to run a practice. You have to use your clinical acumen, in other words, what you’re observing, what you’re hearing, and your intuitive sense. You put those three together and they agree, you’re all set.
Albert Einstein… I think the reason that we have so many problems in healthcare today is that we base our treatment just on scientific evidence. We don’t take observational or anecdotal evidence into consideration. How many moms out there go to the doctor and say, “I think it’s blah, blah, blah.” And the doctor just laugh at you and go their own way. We ignore intuitive insight and we forget the wisdom of Albert Einstein. He said, “The intuitive mind is a sacred gift, and the rational mind is a faithful servant.” And we’ve created a society that honors the servant, and has forgotten the gift. So you know, have a good doctor when they’re eclectic and they listen to you and they consider all possibilities of everything. So guess what? I just gave you a big gift there.
Dr. Weitz: So what you’re saying is if we just feed our symptoms into artificial intelligence and it spits out a pharmaceutical prescription, that’s probably not the best medicine?
Dr. Armine: That’s the way of the world now, and that started in the 1970s. The reason that we have these things that we call diagnoses, OCD, ADD, ODD, oppositional defiance disorder, are diagnoses, which are not diagnoses, they’re descriptions that are put in place so that we will have a pharmaceutical protocol to follow, not for any other reason, not for saying, “Hey, why is that like that?” And go backwards. They just say, “Okay, here’s the end result. This is the way we want you to treat it.” We could get into that for hours, by the way, so what you’re always looking for is a doctor who’s going to put the puzzle pieces together because honestly, it doesn’t really matter how many courses you’ve taken, how many degrees you have, how much you know, if you can’t put those puzzle pieces together, it’s all for naught. And really, leaky gut is an importance of the cell membrane. The cell membrane is the thing that covers the cell. We think of it as a piece of cellophane, but it’s not. The cell membrane is critical. It keeps what’s supposed to be out, out, what’s supposed to be in, in. It has all the various receptors on it, and I won’t get crazy with it, and it’s made of phospholipids. In other words, if you can’t conjugate your fats or lipids, you’re not going to be able to make your cell membranes. I was putting this here for the doctors because the next one was for the mitochondria, that thing that makes your energy… And that uses a different kind of phospholipid, and again, I’m not going to get into that. All energy comes from the mitochondria and is run through the cell membrane through this particular organelle called ATP synthase. Again, I would love to give you a long explanation of it, and it’s not all that hard because I make everything easy, but it does take a bit of time.
So the fact is that I want you to remember… This is the takeaway before we even get into leaky gut, that the master of the cell is not the nucleus, it’s the cell membrane. If your cell membranes are, I’m sorry, holy or leaky, nothing is going to work because it involves everything. But in the good gut, by the way, you see the cell membrane over in here, and that prevents all these bad guys from getting through, and everybody’s talking about the tight junctions or the mucus layer and so forth. The fact is that once this opens up, all this bacteria, all the antigens and stuff can get in, and what happens then? What causes this, by the way, things like bacteria, medications, too much alcohol, lots of inflammation. We are an inflammatory society. Chemicals, lack of fibers, lack of something that creates butyrate and a lack of friendly bacteria, and you can see here where a normal gut has these little hairs here, and that just creates more area for absorption. Whereas, let’s say, a celiac intestine, it’s so inflamed that you have not much area for absorption.
Dr. Weitz: So those are called the villi?
Dr. Armine: Yes, these are called the villi. I like to call them fingers because it’s easier to remember than villi.
Dr. Weitz: Those are on the inside of the intestine and allow for greater absorption of nutrients.
Dr. Armine: Exactly. The more room you have here, the more absorption of nutrients you have, but when you get an allergic reaction, like gluten, it starts looking like this, and you just don’t have enough area, and you’re not only going to get a pain, but you’re not going to get the absorption you’re looking for.
Dr. Weitz: Yeah, you’re going to get nutritional deficiencies significantly.
Dr. Armine: Absotively. And this is super advanced, but I’m going to just run through with you. What happens is once the antigens get through, once these cells start dying and that separates the cells, the antigens get through and they interact with the immune system, and that’s where you get a lot of T-cell or B-cell, a lot of antibody, just think about as antibodies being created, and that’s what creates inflammation. The more this happens, it starts creating things called memory cells, and those memory cells, every time the antigen is seen, it starts producing more and more and more antibodies, and that’s more and more inflammation. And the reason for all of our problems these days is chronic inflammation, which is coming from a progressively worse leaky gut syndrome.
So if nutrients and toxins can’t move in and out freely and they get stuck along the way, we end up with nutritional deficiencies, like Ben just said, toxin accumulation expression of genetic predispositions. Real fast about genetics, the presence of a polymorphism, a snip, an allele, whatever words you want to use, doesn’t make a difference. Something’s got to make it express. This is one of the things that will make it express. Just because you could look at, let’s say, a folate pathway and it doesn’t look so hot to you, it doesn’t mean you’re not going to be producing at the end five methylfolate. What it means is that if you don’t give that pathway what it needs to work, that’s when you’re going to see an expression of genetic predispositions. It’s an interesting subject, but we tend to look at a gene and say, “This is what’s going to happen,” and that’s not true.
Dr. Weitz: By the way, Jess, in terms of nutrient deficiencies and toxins getting in, logically, you might think if the junctions are open, short toxins are going to get in, but nutrients are going to get in more easily. Why is it that we have nutritional deficiencies?
Dr. Armine: For a couple of reasons. Number one, when we’re digesting, we’re not digesting completely down to the point of the constituent parts. For instance, if you have a protein and you break it down to the amino acids, how does it actually get into the body if you have a good gut? It goes right through the cells. But since we’re not digesting completely, what we’re doing is creating short chain proteins that are antigens. So yes, it’ll get in easily, but what’s getting in? What’s getting in are the antigens or what are antigens like.
Dr. Weitz: Right. In other words, instead of break in the proteins, instead of the proteins staying in the intestinal tract, until they’re broken down into individual amino acids, which is how they’re supposed to be absorbed, the entire protein or some part of that protein is getting absorbed through the intestinal lining, and that’s not a form in which our body is prepared to deal with it, and that’s why the immune system tends to attack it and create antibodies.
Dr. Armine: We have a real problem with that these days. After 35 years of age, we usually don’t have enough hydrochloric acid. We are doing exactly what you said before, too much alcohol, too much junk, too much this, too much that, so-
Dr. Weitz: Chronic use of proton pump inhibitors like Prilosec and acids and et cetera, et cetera.
Dr. Armine: So all those things, all those things, and combine them, you get a stomach ache, you start throwing Maalox from Mylanta down. If that doesn’t work, you go to the doctor and he gives you a proton pump inhibitor, like a omeprazole or so forth, and what does that do but slow down or stop the production of hydrochloric acid, and often I’ll treat my patients with hydrochloric acid or some digestive enzymes actually making them better. Because if you think about it, if you don’t produce enough hydrochloric acid, aren’t you making the condition worse? You’re creating more antigens. This is a little complex. I’m not going to go through it. For those of you who love genetics, live by genetics, you won’t hear me sit here and explain it, but I put the genes that are associated with leaky gut syndrome and their explanation. So when you want to repair, why do we want to repair a leaky gut?
Dr. Weitz: Wait a minute, let’s go back to those genes.
Dr. Armine: You bet.
Dr. Weitz: I want to talk about… There we go. So let’s highlight a few of these genes.
Dr. Armine: I did.
Dr. Weitz: I know. I want to talk about the first one, PEMT. Tell us a little bit about that. It looks like it would be an important gene also for brain health.
Dr. Armine: Absolutely. Anything that creates a cell membrane is going to stop leaky gut, leaky cells and leaky brain.
Dr. Weitz: Because there’s a similar membrane in the brain that prevents bacteria and toxins from getting into the brain, just like-
Dr. Armine: The exact same reason for the gut is for the brain. The only thing that’s a little different is the mitochondrial in a membrane that uses cardiolipins, but let’s not get into that. PEMT, phosphatidylethanolamine N-methyltransferase is part of the process that we create phosphatidylcholine, which is what we use as a cell membrane, and this is part of your methylation pathway. Just if you would see where SAM is, S-adenosyl methionine, on one side you would see GAMT, which creates creatine, which creates muscle, and on the other side, you’d see PEMT, which creates your cell membranes. Now, if you don’t have enough SAM, if that particular enzyme is working slowly, if you have the inability to properly conjugate breakdown your lipids, you’re not going to be able to create your phosphatidylcholines. And if you can’t, it’s going to affect every cell membrane in the body.
And if you want to know how many cell membranes we have, we have 30 trillion cells, 200 to 2000 mitochondria per cell, and within the mitochondria, there’s something called the electron transport chains, and there’s about 30,000 per mitochondria. I’ll let you do the math. Now, here’s a little secret for you. If you’re looking at your genetics and you see FADS1, FADS2, may alter the metabolism of phosphatidylcholine, and the conversion of fatty acids, fish oil, microalgae oil, flaxseed oil to the phospholipids, we tend to think that omega-3s are the better way to get our phospholipids. And yeah, that would be correct, but if you happen to have these guys on board, these polymorphisms, that’s going to alter the conversion. So if you have PEMT and the FADS, you’re going to have to consider your diet, consider what co-factors allow this to work, make sure you’re digesting things correctly, and maybe lean towards the oils that create the phospholipids rather than the oils that don’t.
Dr. Weitz: What oils would those be?
Dr. Armine: Well, some people are going to throw rocks at me, I know. Omega-3s, whether they’re microalgae oils or whatever, are the easiest ones to create phospholipids. They also create an anti-inflammatory prostaglandin. Whereas things like omega-6s and omega-9s, and I won’t say the product, they have to go through a series of changes via dismutases and one of the stops is… Well, the last stop is omega-3s, but just before that, you have arachidonic acid. Put enough or arachidonic acid in and that goes into inflammatory prostaglandin pathway, which is why arachidonic acid has been demonized. We need it for our cells, but we don’t need as much as we’re taking in. So when you’re looking at your oils, the common wisdom is if the oil is solid at room temperatures, probably not the best thing for you, so if you want to use that as a guideline. Butter is solid, but that’s solid because it’s been churned, but margarine has had hydrogen bubbled through it in the presence of a metal, and that’s what makes it solid.
Dr. Weitz: That’s a hydrogenation process.
Dr. Armine: Exactly, exactly.
Dr. Weitz: Which is why you don’t want to eat margarine, but butter might be okay, depending upon your cardiovascular risk.
Dr. Armine: Even with a reasonable cardiovascular risk, the less natural it is, if you will, the more the risk is. The other part of-
Dr. Weitz: So for patients who say have polymorphisms in these genes and they can’t produce the PC, does that mean it’s better for patients to consume polyene phosphatidylcholine directly or other forms of choline?
Dr. Armine: Well, there’s other forms of choline that produce acetylcholine, which is a different story, but one of the old ways of doing this, and it still works, is to use lecithins.
Dr. Weitz: Right, which is phosphatidylcholine, right?
Dr. Armine: Which is phosphatidylcholine, phosphatidylinositol, and phosphatidylethanolamine.
Dr. Weitz: Right.
Dr. Armine: Okay, the problem these days when I was first starting this and everybody was using soy lecithin and-
Dr. Weitz: Now everybody’s using sunflower lecithin.
Dr. Armine: Exactly. But you know what? There’s another lesson then you can use if you’re not allergic to it is egg lecithin. That works just as well.
Dr. Weitz: Okay.
Dr. Armine: But given what you have either are liposomal PC out there, there are emulsified PCs. Emulsification is when the lipid is broken down to a small little drip drop called a micelle, and where you see those villi, that’s where they fit in. So there are ways around this. There’s a lot of tricks up the sleeve to start getting your… but, what do you really need to do? Fix your digestion.
Dr. Weitz: Right.
Dr. Armine: Fixed digestion and then-
Dr. Weitz: Let’s just touch on this one other gene too, because this is another important one, is this diamine oxidase, and this is often mentioned when we’re dealing with patients with histamine intolerance or mast cell activation syndrome that they may lack this enzyme that helps break down histamine.
Dr. Armine: There’s two paths to breaking down histamine, the extracellular and intracellular. The extracellular, the first enzyme you’re going to run into is diamine oxidase, which is also known as APP, the AOC1, you’ll see it like that. And what that does is start breaking histamine down to an aldehyde. Now, understand that it also produces ammonia, so then when it gets down to the aldehyde stage, there’s a big long word with the ending aldehyde. So whenever you see that, just think of formaldehyde, it’s much easier. Seriously, you ever try and pronounce one of those words? And even acetaldehyde or acid aldehyde, there’s only one carbon off, and it sounds like, oh, I’m saying this big scientific word. But if they say formaldehyde to people, they understand that. It may not be as injurious as formaldehyde, but you get the idea. The next set of enzymes is the aldehyde dehydrogenase family, which breaks the aldehyde into acetic acid, which is vinegar, and that’s much more easily excreted by the body. That’s the whole idea.
Internally, intracellularly, we use HNMT, which SAM is the co-factor. That creates N-methylhistamine, and that is broken down by MAO A and B to another aldehyde with big long name, and then the aldehyde dehydrogenase family breaks that down into acetic acid. There’s a side pathway that’s run by NAT2, which uses B5, and that creates acetylhistamine, which is for some reason more easily excreted. But there’s two things about histamine you have to know. One, what’s creating it? It’s not just a matter of how well we break it down, it’s what’s causing the extreme stimulation of one of the receptors to release it and why it’s being created, which is because of what a particular condition you have, and then it’s a matter of how quickly you can break it down. Most people are concentrating just on this, which is not a good idea.
There’s your HNMT, NAT2. Your FAT2 is going to get smacked around about this also, has mainly to do with your B12 conjugation, and I know that this is secretor and a non-secretor type, but I think the people who concentrate on that are concentrating too much on it, and this has more, in my opinion, to do with B12 than anything else. So repairing leaky gut, why do we want to repair it? Well, let me tell you a secret. You had mentioned before that there’s been a lot of testing out there.
Dr. Weitz: Right. And should we test for leaky gut?
Dr. Armine: I’m going to tell you no, and I’m going to tell you why. If anybody has a chronic illness that got leaky gut and that one-tenth of 1000000th of 1% that don’t, this is why it’s not dangerous.
Dr. Weitz: Well, let me just put you on the spot for a second. How do you know that?
Dr. Armine: How do I know what?
Dr. Weitz: How do you know that most people have leaky gut? What’s the gold standard? Is the lactulose mannitol the gold standard?
Dr. Armine: By chronic inflammation.
Dr. Weitz: But you can have inflammation without leaky gut, right?
Dr. Armine: Really? Listen to my explanation first and then decide whether my rationale is reasonable. If you have leaky gut, you’re going to create progressively more inflammation. It’s going to start out as food intolerances and overactive immune systems and autoimmunity of all sort, and then dysautonomia. That’s the way it’s going to go.
Dr. Weitz: Yeah, I have no argument with that.
Dr. Armine: Well, that’s good because we’re all in agreement that yeah, it’s a little complex when you think about it, but-
Dr. Weitz: I’m just saying from a scientific perspective, we want to make sure we’re on firm ground when we say most patients have leaky gut.
Dr. Armine: Okay, so whenever you decide to treat someone, the very final arbiter is the risk benefit factor.
Dr. Weitz: Okay.
Dr. Armine: So if what you’re going to do has very little risk and a very high probability of improvement, then you go, “Okay, that’s going to be all right.” When I go to tree leaky gut, I’m going to try and recreate a mucus layer. That mucus layer can be created by fructooligosaccharide, [inaudible 00:28:39] oligosaccharide, things like slippery elm, Sialex, [inaudible 00:28:45] oligosaccharides. They’re all over the place. I’m going to provide for cell physiology by using butyrate, maybe support the tight junctions with zinc-L-carnosine. And if the person’s been ill for a long time and their gut is not working as well just by listening to them, I might start using serum-derived bovine immunoglobulin isolates, which are big long words from mega mucosa, and those products have been known to fix the guts of HIV patients.
And then we can go back and forth with the probiotics of what creates what or who creates where. And that’s a big long discussion. So if I do that, if I do nothing but give somebody some digestive enzymes so you don’t create your antigens, give them something for the mucus layer, provide for the cell physiology, which is the butyrate, and maybe give them something for their tight junctions, am I hurting them in any way?
Dr. Weitz: No.
Dr. Armine: Okay. All right. Now, if someone has leaky gut and they took a zonulin test and the zonulin test was negative or below whatever, so forth and so on, for whatever reason, you know how tests are, and I don’t treat the leaky gut, am I hurting that person or not? And the reason I would say I’m hurting them is because since most people, they’re going to be hurting their guts and antigens are going to go through and inflammation’s going to build up, that inflammation will constantly get worse and worse and worse until, yes, your tests will become positive, but you’re not helping them as much as if you treat them at this real basic level with these real simple things that need to be done anyway. And the probability that’ll hurt them is very little, but if the probability of not treating it, the probability of them getting hurt is quite high.
Dr. Weitz: Well then another question that comes out of this same way of thinking is if we are just assuming they have leaky gut and there’s no reasonable way to test for it to be sure that they have it, how do we know how long to treat them for this? How do we know when the leaky gut is better or are we just basing it on symptoms?
Dr. Armine: Well, to a certain degree, you’re basing it on symptoms. To a certain degree, when you give somebody vitamins and minerals that are getting into the cells, when do you stop doing that?
Dr. Weitz: Well, vitamins and minerals, a lot of them I consider just something that you should take for the rest of your life.
Dr. Armine: I agree. And if somebody has a job that has a lot of stress, they may need to do a lesser version of this so that it doesn’t keep going back. Personally, I will stop treating a leaky gut and if a certain symptoms start coming back, you start seeing the buildup again, then one of two things. Either you haven’t fixed the leaky gut or it’s whatever is causing the leaky gut is taking over again. And remember, it’s not just this. We still have to look at things like H. Pylori. We have to look at dysbiosis. You have to look at SIBO. I’m just talking about real basic bio-terrain work that is normally ignored. That’s the problem. It’s normally ignored, and that’s why people don’t get better. It’s not just leaky gut.
It’s the whole bio-terrain thought pattern where you’re not giving people absorbable vitamins and minerals. When I say absorbable, if you takes it like that little one a day pill, which is Italian for… Seriously, if you take something… I’ll give you a real good example. Ladies are being told that they’re going to get their calcium to prevent osteoporosis by taking what? Calcium carbonate. Okay, well, I’m sorry, calcium carbonate, the last time I took chemistry, when you put calcium carbonate in hydrochloric acid, you get the bicarbonate ion, which neutralizes everything, which is why it’s Rolaids and Tums, but the calcium combines with the chloride becomes a rock, becomes limestone. And when it becomes limestone-
Dr. Weitz: That’s a white stuff that builds up in your pipes.
Dr. Armine: That’s right. So you’re not getting ionic calcium are you, that you need for your bones? So let’s face it, not only do you have to do your own thinking, you can’t trust the vitamin companies. You have to get a vitamin that has been made to absorb really, really well so it gets into the cells. Now, there are liposomal vitamins, there are liquid vitamins, there are some very well-made powdered vitamins that will actually preferentially get into the serum and then get into the cells. If your vitamins and minerals don’t get into the cells, you’re not going to get better. Why? Because all those biochemical processes, they need those co-factors in order to run.
Dr. Weitz: I would like to say that I think everybody should take a multivitamin and better to take a higher quality, more absorbable one, but even taking just the basic multivitamin… We just had a study showing that taking Centrum, not that I’m a big fan of Centrum, but people who took a Centrum had a significantly decreased risk of dying from cardiovascular disease.
Dr. Armine: So the people who did the studies, let’s not go down there, all right?
Dr. Weitz: Well, who pays for studies?
Dr. Armine: Who pays for studies? Way back when we were in school, way back when, when you listened to a scientific study, it was the greatest thing for insomnia because you had this guy talking blah blah blah, but now you got to be careful in who is doing the study. And when I look at a vitamin, I’ll look at each form of vitamins to see if in my head it’s absorbable. And that’s fine. And yes, if you are not ill and you have a need and everybody does for vitamins and minerals, you’re going to have certain improvements. I don’t know I’d go as far as saying that it’s going to prevent cardiovascular disease or is it less of an incidence? I’d read the study over again, then I’d see who is doing the study and how they did it and yada, yada, yada. Is it right? Yeah. Is it right to say that somebody gets a good absorbable vitamin and Centrum is not, I’m sorry.
Dr. Weitz: No, I’m not a big fan of Centrum. I don’t like-
Dr. Armine: The fact is that the principle is correct. The product is wrong.
Dr. Weitz: So now in terms of healing the leaky gut, a lot of us in the functional medicine world are using some version of what Jeffrey Bland called many years ago, a Four R program. Dr. Bland explained it as replace, remove, reinoculate and repair. And there’s different versions of that. And so I think a lot of us are using some version of leaky gut repair, but we’re typically using it in the repair stage.
Dr. Armine: The problem with that is that we all learned it that way, and then the argument came out, should we treat the dysbiosis or treat the leaky gut?
Dr. Weitz: Right.
Dr. Armine: And then it becomes an argument of-
Dr. Weitz: Right, the fungal infection, SIBO, et cetera. So what you’re saying, treat to leaky gut first?
Dr. Armine: I’m saying that’s the way I usually start… In my head and it’s only in my head, there’s no Armine method out there, by the way. You’ll see a lot of stuff that I’ve written, but in my head I say to myself, what has not been done? Because when I see somebody, the reason I’m successful, what I do is I actually take a history and my history is take a good hour and a half and I’ll see what has been done, just ticking it off, what has worked, what hasn’t, and so forth. There are some people, I’ll treat them simultaneously. There’s some people, I’ll treat the bug first, and there’s some people, which is most of them, I’ll treat the leaky gut first, which includes the vitamins and minerals and maybe some liver cleansing and so forth, so I can get their body to a more alkaline state, to a more healthy state, which makes it easier for me to go after the bugs. The fact is, the bugs love an acidic environment. You make that environment inhospitable for them, you won’t kill them, but you’ll slow them down.
See, in the 1980s, if you remember everything was candida, candida, candida, candida. And they used to put people on these horrible, horrible, strict diets and everybody stopped because it was too strict and it didn’t kill the candida, slowed them down to a crawl, but it didn’t kill them. You can’t starve them out because all they’ll do is go back into their little capsules and hang out like this because they’ve taken those capsules out of the intestines of mummies, put them into a nutrient broth and they start replicating. So you’re not going to get away with it, all right? And that goes for most things, but if you want to make the fish better, you treat the water. You want to make the body better, treat the body, then treat the bug. That’s not always true.
Dr. Weitz: Yeah, so essentially what you’re telling us that what we want to do is do the repair first, then do the remove.
Dr. Armine: Excuse me, yes. That’s the way I usually do it, but that’s the way I-
Dr. Weitz: How do we fix these cell membranes? You’ve given us some of the things to do, now we have using phospholipids?
Dr. Armine: Well, you want to fix the cell membrane, you want to give it what it needs to fix. So aside from the vitamins and minerals and everything else I said, if you want to supply people with phospholipids, you can either give them phospholipids or they’re going to need, and I know I’m going to get it, they’re going to need animal fats or they’re going to need a arachidonic acid. I know my vegan patients will really go after me for it. You also want to think about butyrate, and there’s a liquid butyrate that I suggest, which because if you open butyrate capsules, it smells like somebody dragged a dead body into your house and left it there for two weeks, or Gut+ or Tributyrin 350 is butyrate that’s been put into a triglycerides, so it spreads it out, time releases it.
If the immune system is weak in your opinion, or you have a test that you’re looking down, you say, “Oh my god, this is a weak immune system,” you can safely help that by using the serum-derived bovine immunoglobulin protein isolates, and they’re sold as SBI or EnteraGam, Mega IgG2000, SBI Protect, MegaMucosa, which I misspelled, and the study is right there. I have found that if somebody has a hyperactive immune system, just reacts to everything, this is probably not the thing you want to use. You want to just keep using the butyrate. If you have somebody whose immune system has been weak for a very long time, like I said, like an HIV patient… You know the worst looking food allergy test I’ve ever seen?
Dr. Weitz: Oh, patients who have leaky gut.
Dr. Armine: Yeah, but you have somebody who-
Dr. Weitz: But see, everything comes up positive.
Dr. Armine: Thank you, but it’s the opposite. The worst ones are the ones that show nothing.
Dr. Weitz: Oh, okay.
Dr. Armine: That means the immune system’s not working.
Dr. Weitz: Oh, okay.
Dr. Armine: Okay. So when I look at that and I’m like, “Mm, okay,”
Dr. Weitz: Got to strengthen their gut immune system.
Dr. Armine: Yeah, so some of the source of phospholipids, phosphatidylcholine, the lechtin, phosphatidylethanolamine, phosphatidylinositol, there’s sunflower lecithin, soil lecithin, egg lecithin. There’s liposomal PC. I know Quicksilver Scientific has that. For the mitochondria, there are wild caught fish eggs because they use fish eggs or cardiolipins for the inner membrane, that can be gotten. There’s two different products out there, and what they do is they freeze dry it without de-fating it.
Dr. Weitz: So you say caviar will fix our leaky gut?
Dr. Armine: Exactly. If you’ve got the money for it, use the caviar. I have a lot of patients… This actually was a lecture that was given to the Japanese doctors, and they had no problem. They were like, oh, salmon roe, they get in a bottle like that. I’m like, “Salmon Roe, we get a bottle like this and we empty out our bank accounts.” Some of the animal will be organic ghee, organic butter, and believe it or not, organic lard. And if you are looking for arachidonic acid, protein from fish, fowl, so forth, as long as it’s organic.
Dr. Weitz: Bring on the yak.
Dr. Armine: Bring on the yak, exactly. I put it in there as a joke because one day when one of my sons was young, he wanted to have a special party. So I emailed this place and they sent me all these different exotic meats. So if you wanted a yak burger, I could give you a yak burger. They never forget that. They never forgot that party, I’ll tell you.
Dr. Weitz: They yacked it up.
Dr. Armine: They yacked it up. Listen, with probiotic strains, you mentioned it before, the reason I didn’t jump right into it is because there’s so much research out with so many different strains of probiotics that do different things like inflammation, constipation, for diarrhea, for anxiety, depression. If you don’t know what to use, a simple combination of lactobacilli and bifidobacteria probably is a good way to start because that’s your basic microbiome. I personally use something that’s a spore based biotic because they tend to hold on to the insides better, make a spore biotic, stuff like that, but that’s just me.
Dr. Weitz: Right.
Dr. Armine: But if you don’t know what to use, a simple lactobacilli, something that has just a long list of lactobacilli and bifidobacteria, I would start with, if you want to do it at all because sometimes things like Gut+ have certain prebiotics in there that tend to feed your microbiome and start building that up. People forget that microbiomes were very, very local. You ate locally, the bugs that you were eating were in the food and so forth. It’s only when we became a worldwide society do we have a lot of problems with this. So just remember that this is what you use. This is my big thing is whatever you learn, you can use it on Monday morning. Some membrane integrity is an integral part of life’s function. You can’t ignore it, and most people do. You can’t heal without patent cell membranes.
Dr. Weitz: You just mentioned probiotics. We now have some newer probiotics on the market such as akkermansia and muciniphila. Is that something that can be helpful as far as mucus membrane restoration?
Dr. Armine: Yeah, there’s a bunch of them that are new. I’m not passing the buck, but that’s one of those things you should discuss with your practitioner because there are real good new ones. If you have a lot of oxalate crystals, HU58, which is a very large amount of either [inaudible 00:47:57], I forget the exact name, but what it does is it’s… [inaudible 00:48:11]. Now you can see that I really am Sherlock Holmes. Sorry, I’m getting blind to my old age. Bacillus subtilis, its byproduct, its metabolism produces the oxalate degrading enzyme. They used to have that out as Nephure, but that company went the way of the dark side and sold it to big pharma, in which case you’ll never see it, but for those people who have oxalate problems, and there’s lots of them-
Dr. Weitz: You’re saying take spore-based probiotic for patients with oxalates?
Dr. Armine: No, I’m saying take this, which is bacillus subtilis right now. In the MegaSporeBiotic, there is bacillus subtilis. This I give one bottle for a month because it has an enormous amount in it.
Dr. Weitz: Okay. And the name of that product is called HU-
Dr. Armine: HU58.
Dr. Weitz: 58.
Dr. Armine: You want to give people a high dosage of bacillus subtilis, so it’s for about a month, and then they go to the other product.
Dr. Weitz: MegaSpore.
Dr. Armine: MegaSpore, thank you.
Dr. Weitz: Okay, great.
Dr. Armine: That works really well. But in my opinion, that’s where you start and it’s really not hard to reestablish your cell membrane because the body wants it and it’s going to suck it right up. So basically if you follow fix the cells and the membranes using absorbable vitamins and minerals, sources of phospholipids, cardiolipids, fix the gut, the mucus layer using some kind of… There’s several different things. Some people are allergic to the fructooligosaccharides, in which case you can use oligosaccharides. If they are allergic to everything, try something called Sialex. The enterocytes can be healed with the SBI maybe and butyrate, and you go on from there. But liver cleanse microbiome, you can’t go wrong, and I should have put digestive enzymes on the top, you can’t go wrong by doing a core treatment on somebody.
Dr. Weitz: So on the average, how long should a course of leaky gut treatment last?
Dr. Armine: Well, you know something, you ask a really great question because when you and I first started, it would’ve taken a year or two years, whatever. Now anywhere from three to nine months.
Dr. Weitz: Do you remember the Model T cars?
Dr. Armine: Actually, I’ve been doing, just like you have, I’ve been treating leaky gut before it was called leaky gut, and then I was treating leaky gut when everybody was laughing at me, and then I was treating leaky gut when… You can always tell the pioneers because they have the arrows in their backs, and then it became a thing and lots of different products started coming out. I remember the Neuroscience Corporation had a box of products that you did one thing after another after another, and were just progressing along with each portion that can be fixed. The biggest research right now is in mitochondrial function. If you can get the mitochondrial function back, if you can fix the inner membrane, then you don’t lose all those protons, then you run ATP synthase. Now, I didn’t go through that, that’s why it’s not understandable, but the fact is that it’s getting shorter and shorter, depending, of course, on how sick the person is.
Dr. Weitz: On the average one to three months?
Dr. Armine: No, more three to six.
Dr. Weitz: Three to six, okay, great.
Dr. Armine: Yeah, I wouldn’t count on one to three months. That’s an unusual thing. And always remember the Chinese proverb. The person who says it cannot be done should not be interpreting the person who’s doing it. Here’s, for your practitioners, some-
Dr. Weitz: Want to look up the references.
Dr. Armine: Yeah, there you go. And I’m always happy to answer questions. My partner in Japan is Yoko Arima, who’s a certified nutritional therapist and one very intelligent woman, and basically what people ask me what I do, I say, “If your doctors told you that there’s nothing else that could be done, if you’re getting the impression your doctors think it’s in your head and you feel like nobody can help you, that is definitely in my court.” And the way you get in touch with me is just go to my website. You can schedule a 30-minute free conference and we can just chat and I can let you know if we can do anything about it. If not, I can point you in the right direction.
Dr. Weitz: Thank you so much, Dr. Armine.
Dr. Armine: Are you kidding? That was great. I enjoyed being with you. I appreciate you letting me be here, seriously.
Dr. Weitz: Absolutely. And we enjoy your pearls of wisdom. Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients, so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. That usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
https://drweitz.com/wp-content/uploads/2023/10/rwp-331-website.jpg350785drweitzhttps://www.drweitz.com/wp-content/uploads/2017/06/drweitzdsamplelogo-withtext.pngdrweitz2023-10-28 14:02:442023-11-10 20:37:23Leaky Gut with Dr. Jesse Armine: Rational Wellness Podcast 331
Dr. Maggie Ney discusses Bioidentical Hormone Replacement with Dr. Ben Weitz.
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Podcast Highlights
2:38 Perimenopause and Menopause. Menopause is technically one year since your last menstrual period and the average age for most women is age 51. Of course, there are exceptions such as if you’re on an IUD or have had uterine ablation. Perimenopause is when your cycle starts to change a bit, such as coming a day or two late or early and is the time basically leading up to menopause. You might notice that you can’t handle stress as well as you did and you don’t bounce back as quickly from stressors. As we get into later perimenopause, you might notice your cycles skipping. You start getting hot flashes and night sweats and vaginal dryness. There are over 40 different symptoms that have been attributed to perimenopause and menopause. There is a huge emotional piece, including depression and anxiety. Other symptoms include insomnia, joint pain, muscle twitches, worsening headaches and migraines, burning tongue, burning skin, and itchy skin.
8:46The Women’s Health Initiative Study first published in 2002: Is Hormone Replacement Therapy Dangerous, Increasing the risk of breast cancer, heart disease, and stroke? A lot of women are now afraid of taking hormones because they think that they will have an increased risk of breast cancer. And a lot of doctors are still afraid of prescribing hormones because of this study. But this is a mistake because there were many flaws with this study. To begin with, the average age of the women in this study who were starting to take hormones was age 63, which not when most women start to take hormones. 70% were overweight and 60% were obese and a lot of them were past smokers and had hypertension. The estrogen used was an oral form of conjugated equine estrogen (Premarin) and synthetic form of progesterone known as a progestin (Provera). There was a group of women who did not have a uterus, who were given only estrogen/not progestin and they actually had about 18% less breast cancer, so clearly estrogen does not cause breast cancer. Dr. Ney feels that this study has done but it did irreparable harm for a generation of women and 21 years later we’re still trying to educate women and doctors about bad hormone replacement therapy. (Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women’s Health Initiative Randomized Controlled Trial. JAMA. 2002;288(3):321–333. doi:10.1001/jama.288.3.321)
16:24Relative risk vs absolute risk. In the women who took the Premarin and Provera they had a 26% increase in breast cancer and this sounds like one in four women got breast cancer. But this was the relative risk. The absolute risk is that after five years 9 extra women per 10,000 were diagnosed with breast cancer, which comes out to about one out of every 1000 women who got breast cancer, so the absolute risk is one in a thousand and not one out of four.
19:30 Dr. Ney’s favorite recommended options for hormone replacement therapy includes the FDA-approved options for estrogen, including a patch, a gel, a spray, or the Femring. Dr. Ney usually starts with estradiol in the patch form. And then she usually recommends a bioidentical progesterone in an oral, micronized pill form, such as Prometrium. You can also recommend hormones made from a compounding pharmacy that are typically in a a cream, though while estrogen works well in a cream, progesterone works better in a pill. She used to use the BiEst cream, but not as much any more. She is also not a fan of pellets since if the dosage is too high, you can’t remove them.
Dr. Maggie Ney is a licensed naturopathic doctor and a Menopause Society certified practitioner. She’s a director of the Women’s Clinic at the Akasha Center for Integrative Medicine in Santa Monica, California, where she has been supporting women through perimenopause and menopause since 2006. Dr. Ney is co-founder of HelloPeri, (TheHelloPeri.com) an online resource for women going through perimenopause, and she’s been featured on The Doctors show and Goop for expertise on women’s health and hormones. Her website is DrMaggieNey.com.
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. 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 will be discussing bio-identical hormone replacement therapy with Dr. Maggie Ney. Today, we’ll be discussing the potential benefits and drawbacks of recommending hormone replacement therapy in postmenopausal women. After menopause, women often experience a number of symptoms, including hot flashes, night sweats, sleep problems, vaginal dryness and atrophy. Postmenopausal women also have an increased risk of heart disease and osteoporosis. It was common for MDs to prescribe hormone replacement therapy prior to the Women’s Health Initiative, which in 2002 reported that postmenopausal women who take hormone replacement therapy have an increased risk of heart attack, strokes, and breast cancer. After the Women’s Health Initiative study was published, most MDs stopped prescribing hormones to postmenopausal women. However, additional analysis of this study has led quite a number of doctors and researchers to conclude that these conclusions may only apply to women who take estrogen derived from horse urine and synthetic progestins, and who don’t start taking hormones until an average of 10 years after menopause. We could probably add some more caveats to that as well.
Dr. Maggie Ney is a licensed naturopathic doctor and a Menopause Society certified practitioner. She’s a director of the Women’s Clinic at the Akasha Center for Integrative Medicine in Santa Monica, California, where she has been supporting women through perimenopause and menopause since 2006. Dr. Ney is co-founder of HelloPeri, an online resource for women going through perimenopause, and she’s been featured on The Doctors show and Goop for expertise on women’s health and hormones. Dr. Ney, thank you so much for joining us.
Dr. Ney: Thanks for having me. I’m happy to be here.
Dr. Weitz: That’s great. Before we get into hormones, perhaps we could define a few of the terms like perimenopause and menopause.
Dr. Ney: Absolutely. Yeah, there’s a lot of confusion, especially since I’ve been really diving into perimenopause and talking about it more. A lot of people are like, “What the heck’s that?” So, menopause is technically one year since your last menstrual period, and the average age for most women is around 51 years old. But again, that definition of one year without your period is tricky if you don’t have a uterus or if you’re on an IUD or uterine ablation. It gets a little confusing if you don’t have your period as a barometer. So, in that case, there’s certain lab testing, and we go by symptoms to determine if you’re in menopause. And specifically if you’re curious and you’re not getting your period, generally two readings of an FSH over 35 and an estradiol under 30 or so are pretty confirmatory that you’re in menopause. So, technically menopause is one day, right? It’s one year since your last menstrual period. Everything after that is considered post-menopause. I consider it the menopausal years because post-menopause gives this idea and perpetuates this myth that menopause is over, and maybe we’ll talk more about that. But it’s really you’re living the rest of your life in these post-menopausal low hormone years, and that can have different symptoms and affects everyone a little differently. And then, perimenopause is the time basically leading up to menopause. It’s around menopause when hormones start to shift. They start to shift, and it can be very subtle. And it can last for some people a decade before your final menstrual period. And I see perimenopause as this just forgotten, neglected time for women where women are having all these new symptoms that they haven’t had before. And then, they see their healthcare practitioners who aren’t really aware that these hormonal changes can be affecting their health, and women feel unheard, and maybe they’re referred to a psychiatrist, a gastroenterologists, a neurologist. I have so many people who’ve had all these specialists, cardiologists, and really it’s this perimenopausal year.
So, it’s like my mission, it’s my joy, it’s my passion to share this so that every woman is knowledgeable and empowered as they enter this time. And I should say some of the major symptoms of perimenopause, the main ones are your cycle starts to change a little bit. And again, I divide perimenopause into early and late. So, early perimenopause, maybe you’re starting to notice your cycle coming a day or two early, or you might be noticing a big one is feeling less resilient, right? So, the stress you used to be able to handle a lot and now it just becomes too much. You don’t bounce back as quickly or stressors that you used to be able to manage now just feel very overwhelming. And then, as we get a little later into perimenopause, you might notice your cycles are skipping. You’re getting more hot flashes and night sweats, vaginal dryness. But really, there’s over 40 symptoms attributed to perimenopause and menopause, and it truly does affect everyone differently.
Dr. Weitz: Maybe you can highlight a few that are often overlooked.
Dr. Ney: Yeah. Really, the emotional piece is so huge. So, depression, anxiety, I mean, 70% of women going through the menopause transition have some mood change that’s significant. And about 60% of women who have a history of depression will have a recurrence. So, a lot of the mood symptoms, the inability to sleep. So, insomnia may be the first symptom to come up, but there’s other ones really, because there’s estrogen and progesterone receptors all throughout our body. So, joint pain, you can get tingling. I have someone with muscle twitches, worsening headaches, worsening migraines, burning tongue, burning skin, itchy skin. There’s a long list.
Dr. Weitz: So, on perimenopause, is progesterone the first hormone that really drops, or is it estrogen?
Dr. Ney: Yeah. Really, we consider progesterone to be the first hormone to begin to drop during a perimenopause. And so, some of those symptoms can be a little bit more anxiety, difficulty sleeping, but also some more spotting or earlier menstrual bleeding, like your period coming a day or two early.
Dr. Weitz: Okay. Yeah. Because you mentioned measuring estrogen as a way to know if you’re in perimenopause. What about measuring progesterone?
Dr. Ney: So, I was speaking before about if you’re unsure if you’re in menopause and you’re not getting your period.
Dr. Weitz: Oh, if you’re in menopause. Oh, okay.
Dr. Ney: Okay. Testing for hormones, again during perimenopause is a little tricky because hormones do naturally fluctuate.
Dr. Weitz: Yeah, they’re going all over the place.
Dr. Ney: Yeah. You don’t need a blood test to diagnose you as being in perimenopause, which again, controversial. I mean, controversial in the sense that some doctors are like, “Oh, your labs are fine. You can’t be perimenopausal because you can have normal looking labs.” But again, there are certain times of your cycle that if you’re really trained in this, you can test and get an idea of where someone is. But with the perimenopause, you got to take with a grain of salt because you can know from one cycle to another cycle, it can be vastly different. So, if you’re looking, you asked about progesterone, typically, we would want to look about a week after you ovulate, which is generally a week before you expect to get your period. You can check your progesterone levels and you want to see it around 10 or above, and you can really confirm ovulation. Sometimes during perimenopause, that will be lower like seven or eight or five. You can tell you ovulated, but the production of progesterone is low. But really with perimenopause, while labs can be helpful and useful, it’s your story. It’s your symptoms, and it’s working with a trained clinician who can really help guide you through this.
Dr. Weitz: I talk to a lot of women that are afraid of taking hormones. They think they’re going to have an increased risk of breast cancer, and a lot of doctors are still not okay with prescribing hormones. So, what did we learn from the 2002 Women’s Health Initiative? Is taking hormones going to increase a women’s risk of breast cancer, heart disease, and blood clots?
Dr. Ney: All right. We learned a lot from the Women’s Health Initiative, and I will share just a personal story that the summer of 2002, which is when the Women’s Health Initiative results were aired. I remember where I was… I don’t know if you remember this then, but it was the summer before I started medical school. I was sitting on my mom’s bed. I think I was watching Days of Our Lives and TV was interrupted. This was the age when we interrupt this television show for an important word from your network. And it was someone standing up there saying Women’s Health Initiatives stopped short. There’s a higher rate of breast cancer, heart disease, stroke. It was scary. And I remember sitting there and being like, “Thank goodness I’m going to naturopathic medical school. I can learn about all these other therapies.” So, as I was diving into this and looking at the research and following the research, we really know now that there were a lot of flaws to that study. We can spend probably hours unpacking it, but let’s get started a little bit to what’s most relevant.
Prior to the Women’s Health Initiative, most doctors were giving hormones because they were noticing women were doing really well. They felt really good, and it seemed like there was less heart disease and women were living longer, but there were no double-blind placebo controlled study. And came the Women’s Health Initiative that started in the late ’90s, and it was the first double-blind placebo controlled study looking at hormones. So, very big deal. It was stopped short a little bit after five years because of a higher incidence of breast cancer, heart disease, and stroke. Obviously, big deal. This announcement, I should say, came out before any doctor really had a chance to look at the study, but it did irreparable harm and for a generation of women, we’re still trying to educate women and doctors about bad hormone replacement therapy. So, basically when we look at the study, there were some flaws in hindsight, like people criticize the study. I mean, I think there were a lot of good things we learned about hormones, a lot of the benefits we talk about hormones come from this study, but you got to look at where there were mistakes and errors.
So, first of all, because they knew that hormones really did help with symptoms like hot flashes and night sweats, and they were mostly concerned of like, “Hey, people are doing great. They’re living longer, they have less heart disease. Does it really do this?” So, the average age of participant was much older. Most women did not have any symptoms. So, the average age was about 63, which is not when most women start hormones. And then, if you look at a little bit more detailed, a lot of the women, like 70% were overweight, 60% were obese, where a lot of them were past smokers. A lot of them had hypertension. So, there were some preexisting cardiovascular conditions to begin with. And again, most women were older. And then, you look at the forms of the hormones used. So, the estrogen was an oral estrogen. It was conjugated equine estrogen, often labeled CEE or Premarin. And there were two groups to this study. There was this group of women that had a uterus and a group of women that did not have a uterus, because we learned before this study that if you give estrogen alone to women with a uterus, you’re increasing their chance of getting uterine cancer. But when you give progesterone, or progestin or progestogen. Progestogen is this umbrella term that encompasses progestin, which is a synthetic progesterone and a progesterone. But they discovered if you gave a progestin that uterine cancer, that risk is negated. So, it’s back to baseline.
So, they had a group of women who had a uterus. They were given Premarin, which is the conjugated equine horse urine metabolites of estrogen. And they were given Provera, which is an oral progestin, which really is not used much today. And the other arm of the study was just given Premarin. A little after five years, they saw that there was a higher incidence of breast cancer. So, more women were being diagnosed with breast cancer in the estrogen and progestin arm, not in the estrogen only, which below people’s mind. So, I’m going to say it again. The women who just took the Premarin actually had about 18% less breast cancer. It wasn’t the estrogen that we know. Estrogen does not cause breast cancer. So, you look at the arm that did have, it did show a little bit more, and I say a little. I’m going to go into how the media took the data and really went wild with it.
Dr. Weitz: Now, let me just challenge you a little bit, not from that study, but to some of the women’s fears about taking estrogen is they’ve also heard that there’s estrogen receptor-positive breast cancer. And we also know that giving drugs to block estrogen is often a treatment for women with breast cancer.
Dr. Ney: Yes, true. Very good point. And that makes a lot of sense intuitively. Well, if you’re taking a drug to block estrogen, why would give estrogen not cause an issue? Breast cancer is very complicated. A lot of variables are involved, and certainly there are breast tumors that grow in the presence of estrogen. So, giving estrogen would cause that tumor to grow, which is one argument of why perhaps the tumors were showing up maybe a little earlier because maybe it was being diagnosed earlier, but estrogen doesn’t cause the tumor to grow. But if you had a tumor that grew in the presence of estrogen, it could stimulate its growth. So, what they found in the arm that took estrogen, the Premarin and the Provera, was that there was about… sorry, there was a higher incidence of breast cancer diagnosis, not death, but diagnosis. So, that stopped people short. And we also found in both groups that there was a higher incidence of heart disease and stroke. So, in unpacking, let’s talk a little bit about breast cancer, because we know that with the Premarin only, there was a reduced risk. And with the estrogen, the Premarin and Provera, there was a slight increased risk. So, when we look at that arm, then it seems logical it was the Provera, the synthetic progesterone, and we know that Provera isn’t as breast or metabolically friendly as our bioidentical or oral micronized progesterone. That’s one leading theory that why there was more breast cancer. The other one, and this is Avrum Bluming who wrote Estrogen Matters, great book, but he talks about how in the control group, so the group that didn’t have any hormones, but that was comparing to the people who took the Premarin and Provera. The people in that group actually had a history of taking hormones. So, their baseline was actually lower. And when you take that into consideration, there wasn’t…
Dr. Weitz: Oh, interesting.
Dr. Ney: Yeah. Isn’t that fascinating?
Dr. Weitz: Wow.
Dr. Ney: So, those are the two leading theories that it was the Provera or both, that maybe the control group had a lower risk to begin with.
Dr. Weitz: Interesting.
Dr. Ney: So, the news came out, 26% increase in breast cancer. Whoa, that sounds a lot, right? It sounds like one in four women got breast cancer. Again, when we look at the data, we have to look at how the research and data is being presented. And there’s this idea of absolute risk and relative risk when we’re presenting and looking at research. And we know from the Women’s Health Initiative, and at least that 26% increased risk of breast cancer that was on every newspaper and every newscaster, which sounds to me and everyone else like it’s one in four women was the relative risk. The absolute risk is the actual number. And it was after year five, nine extra women per 10,000 women that were diagnosed with breast cancer. So, that comes to about one out of 1000 women. Every patient counts. That’s something, one person per 1000.
Dr. Weitz: But it’s not one out of four.
Dr. Ney: It certainly sounds a lot different than one out of four. So, it’s the relative risk, absolute risk that really needs to be looked at when we’re interpreting data.
Dr. Weitz: And we also know that oral estrogen tends to lead to blood clots, which is why very few functional medicine, integrative doctors are recommending oral estrogen. And yet I still see oral estrogen. Often when primary care doctors, or when conventional doctors do recommend hormones, they typically use an oral estrogen still.
Dr. Ney: Interesting. Yeah. If they’re going to use oral, they’re usually not using Premarin anymore. They’re using oral 17 beta-estradiol or bioidentical estradiol. We know that oral estrogen from the Women’s Health Initiative does increase risk of blood clots. When you take oral estrogen, like one out of 1000 women extra cases of blood clot is significant because when you take oral estrogen, it has to be metabolized through the liver. And when it gets metabolized through the liver, it creates more clotting factors that increases your risk. I do always use transdermal. There’s a few cases when oral because transdermal isn’t working. We might try oral. For the vast majority of women that have no health history, had no heart disease who’ve been pregnant, who’ve maybe been on a pill and have never had a clot, it actually could be okay. But because you can be on hormone replacement for the rest of your life, and risk of clot does increase as you get older, why start? It’s the way I see. If it was a short term, and for some women it is, but for most women, it’s a lifelong journey of being on hormones to optimize their health for women. So, if it was a couple years and oral was, they want it because it’s easy, it’s cool. But because it’s a long time, I prefer just getting people started on the transdermal route and there’s a lot of options.
Dr. Weitz: So, what are your favorite options?
Dr. Ney: Well, I educate. I really do. I think this education piece for women about what their options are is not often given. We always use bioidentical hormones. I should say that bioidentical hormones for many conventional practitioners, it’s cringey. It causes this emotional reaction because they’re like, “It doesn’t even mean anything.”
Dr. Weitz: I just had a whole discussion with my primary care doctor about that. It doesn’t really mean anything. I said, “Yes, it does.”
Dr. Ney: And they’re like, “It’s a true medical definition.” Bioidentical, that term came after the Women’s Health Initiative, and it came out as like, “You’re not using those. You’re using something safer and more natural.” And that led to more compounding pharmacies and some pellets. Anyway. So, the definitions, no one really knows what it means, but I’ll tell you what it means. When we are using it, it’s hormones that have the same molecular structure as our own hormones.
Dr. Weitz: Conjugated equine estrogen is completely different.
Dr. Ney: Completely different, yet it bind to the same receptors, but it has a different response in the body. So, bioidentical hormones, and this is important that I think is often confused. There are FDA-approved bioidentical hormone options that you can get through any pharmacy. And then, there’s compounding bioidentical hormones. I educate people on both, and I think what I see most is that a lot of women think you can only get bioidenticals from compounding pharmacies. They do do compounding. I mean, you can but you can also get it from your CVS or Rite Aid or Costco. There’s options. So, the FDA-approved options for estradiol can come in a patch, can come in a gel, can come in a spray, and can come in a ring. And then, usually, the bioidentical progesterone can come in as an oral form, oral micronized progesterone. And then, there’s some combination patches that have the transdermal estradiol combined with a progestin, so not the bioidentical, but usually which one of the progestins, like levonorgestrel. I’m blanking on the other one, but a progestin combined with the bioidentical estradiol.
So, those are the FDA-approved, and then there’s a ring called Femring that delivers bioidentical estradiol. So, you can get all those from your regular pharmacy. Compounding pharmacies, again, can deliver the estradiol and progesterone in various forms. I am a promoter of oral progesterone rather than the creams for the uterine protection. It works really well. It also helps more with sleep and the nervous system response because of its increased production of, or stimulating the GABA receptors. But compounding estradiol, it can come in a lozenge or cream, comes in many different forms.
Dr. Weitz: So, what’s your favorite form of estrogen to use? And a lot of doctors who use compounded typically are using the Bi-Est which is a combination of estradiol and estriol.
Dr. Ney: Yeah. I usually start with estradiol. I usually like the patch, to be honest with you. It’s well tolerated. It’s covered by insurance, and it’s been really easy for my patients. So, that’s usually what I’ll start with. I’ll usually start with the patch and Prometrium or oral micronized progesterone. These are the FDA-approved hormones. I usually start with that. I don’t do as much Bi-Est. I used to when I first started out, did more Bi-Est. I don’t anymore. It’s more harder to… first, I don’t know if it’s really needed to add in that estriol. I think our body can convert estradiol to estriol with good liver function. I think estradiol is the one that has the most potent effect in the body.
Dr. Weitz: Well, the other reason for recommending the Bi-Est is with the idea that the estriol is a weaker estrogen, and maybe it makes it even safer.
Dr. Ney: Exactly. That’s the argument for the Bi-Est. It can be harder to titrate because if you want to go up a little bit, then you’re upping… sometimes estriol can be at a higher dose. It might be too much. So, I don’t tend to go to Bi-Est, but it is an option. I have people who want it, and I discuss pros and cons. And I certainly have some patients that are on it, for sure.
Dr. Weitz: Okay. So, you like the patch. What about some of the other forms? What about pellets?
Dr. Ney: I’m not a fan of pellets personally, because I see the woman in my office that come in with side effects. They come in with their testosterone in the 200 range. It really should be under 70. And they’re irritable and they’re angry and their hair is falling out, and they have acne. And I can’t do anything about it, really. I can support their liver. I can give them emotional support, but you really have to wait those about three months. I know some people really love pellets. It’s not something that I recommend because there is, I feel a lack of safety data. And you’re getting super physiological doses of these hormones. How do you feel about pellets, Ben?
Dr. Weitz: I think as you said, the problem is once you put the pellet in, if it turns out that it’s too much, there’s nothing you can do about it until it takes three months or so. So, I think it’s a problem. I guess some women like the pellets because they don’t have to apply the cream. They don’t have to worry about taking a pill every day. You just forget about it. But I think if you are going to use pellets, you probably need to start low and slowly build it up. But who wants to wait?
Dr. Ney: Yeah. I just don’t do it. I don’t like giving something that I can’t reverse quickly. A lot of women on pellets actually don’t know that there are other options that that’s not really an FDA-approved option. Yeah, it’s something I don’t feel comfortable doing. I’ve talked to women. I was just at a talk this last weekend and some doctors on it and promoting it. It’s something I just don’t feel comfortable. And you know what? My patients feel amazing. I don’t feel like I’m missing something in my toolbox to help people feel sensational. My women feel amazing doing something safe and studied and feel good about that.
Dr. Weitz: So, when it comes to progesterone, there’s normal fluctuations in progesterone, and typically progesterone is higher for two weeks out of the month, and so some doctors feel that you want to try to duplicate that natural rhythm of the body. So, they’ll give women progesterone for two weeks instead of every day. What do you think about that?
Dr. Ney: Let’s divide it up into perimenopause and post menopause. So, yes, our natural cycle has progesterone that’s being produced two weeks out of the month. So, it does make sense. Why don’t we just dose it and match the cycle? That intuitively makes sense. I do present that to women as an option because for the uterine protection, you really need it for like 12 days out of the month minimum. A lot of women actually love their progesterone. They’re sleeping better. They want to take it every night, in which case police take it. I usually give people the choice to see what resonates with them. You give women good information, they tend to are able to make the decision that feels right to them. So, I usually present it as both. There’s no studies… I do, I am research-based. There is no studies that say taking it two weeks out of the month is better than every day. So, I do present the option. For some women, that idea of cycling, it really resonates with them. For other women, they actually don’t like progesterone. A small percentage of women do feel worse on progesterone, in which case they want to take it for the fewer days of the month. So, that’s an option.
Dr. Weitz: One of the downsides is you get your period back, right?
Dr. Ney: No. You don’t, because we don’t dose estrogen high enough. You have to go really high in estrogen to really get your period back. But there is maybe a more chance of spotting, right?
Dr. Weitz: Spotting. Okay, I see.
Dr. Ney: Yeah. Certainly if you’re finding that you’re spotting, we would definitely do it nightly to prevent that from happening. But the dose we use for hormone replacement, technically it’s called MHT, menopause hormone therapy. Because those doses are really quite low. And then, in perimenopause, again, I get the option. Sometimes cycling it can help elongate that luteal phase the last two weeks. You take it for a full two weeks, it can help stretch that cycle out. It can help prevent spotting. I often find that because the cycles are a little irregular, it gets to be annoying for people and confusing of like, “When do I start? When do I do it? Do I stop? I got my period three days early.” So, I usually will say, “Totally fine. You can take it every day or just don’t take it during your bleed week and then start taking it.” It can be a little confusing during perimenopause when your cycles are irregular to cycle it, but some people do and they really like that.
Dr. Weitz: Now, for women who are taking estrogen and progesterone daily, do you periodically give them a week off?
Dr. Ney: Again, individualized, not routinely. If they’re getting their periods, sometimes we’ll say, “You can stop the hormones that week,” for some women, but you just certainly don’t need to.
Dr. Weitz: Yeah. I guess the concept is because hormones normally fluctuate and now you’re taking the same identical level of hormones every single day by not taking it for a week, or somehow you’re producing something that’s more natural.
Dr. Ney: Right, that’s the idea, really mimicking our body’s natural cycle. So, yes, you could take that bleed week off. You can then start up with estrogen and then add in progesterone for the second half of your cycle. Again, I do discuss that as an option. A lot of women just feel so much better on the hormones, so they want to take it, and I think it’s safe. The research is daily. It doesn’t show any difference in safety data. But I understand that idea of matching the cycle resonates with a lot of women.
But I should also say, and especially during perimenopause, we can have worse symptoms when our estrogen levels drop like headaches, worsening hot flashes, and some of that happens on the first few days of your cycle, in which case sometimes for women who get that headache during perimenopause right before their cycle, a little transdermal estrogen getting into your period can actually be really helpful because it just gets cuts that keeps that. It’s the drop in estrogen for many women that trigger a headache. And that happens before your periods. You give a woman a real low dose estradiol level during that drop and some of the headaches can go away.
Dr. Weitz: Do you have any women just taking progesterone only?
Dr. Ney: Totally, yes. Both during peri and post menopause, I like to stagger in producing hormones so women can know how it’s affecting their body individually. So, generally during perimenopause, especially early perimenopause, sometimes progesterone is all you need. I have a lot of women just on progesterone. If they have heavy menstrual flow, spotting, insomnia, the progesterone can be all you need.
Dr. Weitz: What do you think about a woman in her 70s take who wants to initiate hormone replacement, either because they’re still having hot flashes or they want to prevent Alzheimer’s or they’re still having trouble sleeping?
Dr. Ney: Yeah. Unfortunately, there’s a massive group of women who were really denied this option. And now with more education coming out with having more women talking about it, we were like, “What the heck? I missed out. I want it.” It’s a different conversation. It’s a different conversation than what I’m having with you because right now, I’m going to answer your question, but I’ll step back and say what we know is that when you start within the first 10 years of your last menstrual period, or generally before age 60, women have less risk of heart disease, less risk of diabetes.
They live longer, 30% longer perhaps because of the less risk of heart disease, which is the number one killer of women. And what we know, and even the research with brain health, it’s really about starting early because of two theories, the timing hypothesis, which is like there’s this optimal window of starting, which is why I’m so passionate about educating perimenopausal women. So, they have all the information before they sometimes even get to the point of needing it because there is this optimal… hormones are good for you when your cells are healthy, when your vasculature, it’s healthy.
It’s called timing hypothesis. So, you want to start within the first 10 years of menopause, or healthy cell bias, which is like hormones are good when your cells and vasculature are healthy, but they can start to potentially lead to symptoms when you go longer without your body seeing hormones. So, the conversation is definitely different if I’m talking to a 70-year-old woman. By that time, we know that hormones can actually increase your risk of strokes. And the data is a little nuanced, but it seems to not be as good for brain health. And I think it all just comes down to the vasculature.
Estrogen is so good at keeping our blood vessels buoyant and helping produce nitric oxide, and then when you go a long time without seeing estrogen, they can develop more plaque, which naturally happens with age, get a little harder. And then, it seems that when you introduce estrogen later after that 10-year window, instead of the normal anti-inflammatory effect, it has more of a pro-inflammatory effect. It shakes things up a little. The vessels are like, “Ooh. What’s going on? Hello? They haven’t seen estrogen in so long.” And sometimes those little plaques can be chipped off a vessel and can lead to the strokes or heart attack. The risk is not huge.
Dr. Weitz: Yeah. I did hear somebody discussing the concept that plaques might become softened and unstable as a result of introducing estrogen.
Dr. Ney: Yes. I will say the risk is highest in the first year, and then it doesn’t just increase the longer you take hormones. I think it’s the first six to 12 months that the risk of an adverse effect like that happening. So, it’s a different conversation. The benefits aren’t as big, the risks are greater. I really believe in shared decision making. I give my opinion. I go over all the research, and together we make a decision that feels right for the person. When they understand risks, benefits, women can make the best decision for themselves, and I support them.
Dr. Weitz: Yeah. Dr. Dale Bredesen, who’s a neurologist, who’s pioneered a functional medicine integrative approach to preventing and reversing Alzheimer’s, is finding that using hormone replacement even in, women in their later years initiating it then can be very helpful for brain health.
Dr. Ney: Yeah, no, I’ve heard that. I’ve heard from him. And yeah, estrogen does help brain cells neuroplasticity. He’s really pioneering that.
Dr. Weitz: Right, yeah. Let’s see. For women who never took hormones, but they want to do something about the vaginal symptoms, the dryness, the atrophy, what do you recommend for that?
Dr. Ney: Okay, such a good question. So, under talked about and appreciated in the medical community, well, there’s a few options, but I’m just going to say vaginal estrogen is good for all women. Every woman will experience changes in their vulva, vestibule, vaginal tissue. It can affect the bladder. Sometimes if a woman’s only having those vaginal symptoms, then you can give local estrogen. There’s a lot of options.
Dr. Weitz: Estradiol, estriol.
Dr. Ney: Yeah, either one. Let’s go through the FDA and the compounding, I definitely use both here. The FDA A approved, there’s a vaginal cream, which works beautifully. I would like to share with people. The general recommendation is to insert it vaginally. I always have people put it on the outside too. That’s what’s so great about the cream is you can massage it into your labia and your clitoris, your urethra, and it really can be beneficial. So, there’s estradiol cream, very low dose. There is tablets that you can insert vaginally. Again, that doesn’t always address the outside.
So, sometimes if someone doesn’t like the leaking with the cream when they put it inside, I’ll have them do the tablet inside and the estrogen, the cream on the outside. There’s a ring, Estring, which works, set it and forget it. You put it in for three months and take it out. And that’s the local one. There’s the Femring that’s systemic estradiol, but the Estring is local estradiol. Again, even with that, I still will encourage people to put a little cream on just the outside. And there is now FDA-approved form of DHEA.
Dr. Weitz: Right. I was going to ask about that. Yeah.
Dr. Ney: So great. So, our vaginal tissue is loaded with estrogen, testosterone receptors.
Dr. Weitz: There’s even one DHEA vaginal product that’s over the counter.
Dr. Ney: I know, I heard actually. I think you had someone on your podcast.
Dr. Weitz: Yes, yes, yes.
Dr. Ney: And I was, “Oh, my God. What is that product?”
Dr. Weitz: Fiona McCulloch.
Dr. Ney: Yeah. She was talking about… I got to find that. I know that also there’s a doctor who sells a cream that has a DHEA in it. So, there are some over the counter options. So, what DHEA does, some people are drawn, well, sometimes DHEA, the androgen, which is considered, and androgen is to DHEA, testosterone. It’s considered the male hormones which is just wrong because women have plenty of it and need it. But sometimes that works better for women. Women need that, they respond better. So, the DHEA vaginally gets absorbed and then the cells makes estrogen and testosterone.
Dr. Weitz: Yeah, it’s Bezwecken DHEA Cubes.
Dr. Ney: Okay, amazing. How much DHEA is in there?
Dr. Weitz: B-E-Z-W-E-C-K-E-N.
Dr. Ney: Amazing. Do you know how much DHEA does it say is in there or they just say it? We can look later.
Dr. Weitz: Yeah, it’s cocoa butter, DHEA, vitamin E, beeswax.
Dr. Ney: Yeah. Some nice soothing ingredients. The one that’s FDA-approved is 6.5 milligrams. You do it nightly. There is also an estradiol insert, it’s with cocoa butter too, so it can melt a little, address the outside. Those are all FDA-approved options. Compounding, you can get that estriol. Estriol again, is that hormone we talked about that’s a little weaker.
Dr. Weitz: Yeah, it looks like 13 milligrams of DHEA.
Dr. Ney: Oh, okay. All right.
Dr. Weitz: There’s also a vaginal testosterone.
Dr. Ney: Yes. Not over the counter? I mean. I prescribed it through-
Dr. Weitz: Yeah, not over the counter.
Dr. Ney: Yes. Through compounding pharmacy, it can be so helpful for women that test their, it’s really the lower third of our vaginal canal is just loaded with testosterone receptors, and so adding that to a little estradiol or a little estriol, you do have to get it compounded, can be such a powerful therapy to address the dryness and sexual discomfort. Because really, no woman should have to go through that, and it doesn’t have to be this normal part of aging. There are so many options. Also, increased urinary tract infections, which we see with women during this time can be due to the lower estrogen. So, really supporting that is important.
Dr. Weitz: And hyaluronic acid can also be beneficial for lubrication.
Dr. Ney: Yeah, so hyaluronic acid helps to retain moisture, so it can be very helpful and you can get through a compounding pharmacy. You can compound estriol with hyaluronic acid. It’s a nice addition. It works beautifully.
Dr. Weitz: Okay, cool. So, how do we track hormones? What’s the best way to test for hormones?
Dr. Ney: Let’s break it up into peri and post. During perimenopause, our hormones fluctuate so much that you don’t really, I mean, I always do get a baseline, but you don’t need to, I should say get that baseline because they do change so much. And you can go by symptoms and see how a woman feels. But generally, if you want to get an idea where your hormones are at the second or third day of your cycle, you can get a hormone panel. Generally, progesterone will be low there. I see so many women are like, “Look, I have no progesterone. Help me.” And I’m like, “This was done on a part of your cycle when you don’t make any.” I can’t tell how many times.
I even have to correct doctors on that. So, you do hormone second, third day. That’s because that FSH, that follicle stimulating hormone, that’s the time of the cycle where if there is decreased egg quality, egg reserve, or you’re approaching perimenopause, that FSH starts to increase. So, generally, if your FSH is above 10 on that second or third of your cycle, you can assume you’re in this process. But next cycle, it could be normal. Another cycle, it could be super high. It does fluctuate a lot. And then, in post-
Dr. Weitz: And the best day to test to manage progesterone?
Dr. Ney: It’s generally a week after you ovulate or a week before you expect to get your period. So, if you have a 28-day cycle, generally like day 21, 19, 20, 21, 22 is that window where you can look at progesterone. And you can confirm ovulation, which is really helpful because some women don’t know if they’re ovulating. So, that’s an easy test to do.
Dr. Weitz: And we have different ways of testing hormones. We have serum. We have blood spot. We have urine. We have saliva.
Dr. Ney: Yes, we do. And I think every practitioner feels strongly or maybe not about this or has their test they really like. I tend to do blood. It’s easy. They have solid reference ranges. There’s pros and cons. I know that saliva can look more at the bioavailable hormone. The urine test, which I’ll use sometimes, looks at how you’re metabolizing hormones. But I’ll say in my clinical experience, because I’ve been doing this for 18 years and I’ve dabbled with all of those tests, I really find that listening to someone’s story, getting them feeling amazing, getting them on hormones, I don’t need it in their out-of-pocket expenses. And I know that people will argue with this with me.
I’ve had big discussions with people that I should be doing the DUTCH tests on everyone. But if someone’s feeling amazing and I can assess like breast tenderness, any of these symptoms that suggest that I need to really dive deeper. Sometimes if I’m reaching obstacles for someone feeling sensational, really, maybe I’ll do it to see what’s going on. But overall, I can learn a lot from symptoms. I understand some of the therapies that might be used, if you push down the two, the 16, the four pathway to support COMT. You can gain so much from someone’s story.
I just don’t want to devalue that and their symptoms and the dose you’re putting on someone that I often find that I just don’t need it. And some people want it because they’re so educated. They listen. They know what it can provide, and we do it. And I can analyze the test. But I haven’t found, for me personally, that it’s been a game-changer that I’ve needed it to really help people get to hormonal balance. I do look at the gut microbiome. That’s huge. So, yeah, I usually do blood unless I really am like, “What’s going on here? I’m reaching this obstacle.” Then I may do one of the more functional tests. It’s covered by insurance. It’s pretty easy. I do let people know everything. Again, I do a lot of educating, let people know of all the tests. I don’t get a lot of pushback. People feel good. People feel good.
Dr. Weitz: So, besides prescribing estrogen and progesterone for menopausal women, do you ever prescribe testosterone, DHEA, pregnenolone, oxytocin?
Dr. Ney: I do prescribe testosterone. I usually start estrogen, progesterone because that can affect testosterone levels and I see how women do, but I will prescribe testosterone. It’s crazy, but it’s not FDA-approved for women, even though it’s such an important hormone for energy, mood, metabolism, brain health, musculoskeletal health, bone health. But it’s not FDA-approved for women. I will recommend it. I do get a compounded. You have two choices when it comes to treating with testosterone.
You can use the FDA-approved option for men, AndroGel, at 1/10 the dose. Women don’t like that. It’s confusing. Everyone’s like, “Just get…” I always educate but yes, I’ll usually get a compounded testosterone cream. I do test for testosterone. I do want the baseline, and it is a controlled substance too, so you need that data. But I prescribe testosterone a lot for women.
And then, DHEA, yes, I again test and see if they are low. So, generally, if it’s under 100, I may give a little DHEA. It’s one of those things that’s not as well researched. There is some data in animals and elderly that it does increase longevity and wellbeing. It is a precursor hormone. That’s for sure. We know it works vaginally.
Dr. Weitz: Yeah, it was included in that phase study that was the first study that showed a reversal of epigenetic aging.
Dr. Ney: Yeah, it has definitely. I consider it almost like this indirect biomarker of the aging process. It’s interesting when you start testing. Some people are in 20s and 30s and it’s like, “Let’s just get that up there.” I think the issue with this DHEA, which I find interesting is that it’s available over the counter. Amazing. Great. I think all options should be available, but at like 50 milligrams, you could easily get that. And that to me is too high to start a woman on [inaudible 00:46:01].
Dr. Weitz: Oh, you can get it at five, 10.
Dr. Ney: Right. But it’s available. So, some women reach for that.
Dr. Weitz: Oh, okay.
Dr. Ney: So, I like to just educate, hey, if you’re a woman, start with a five or 10 milligrams because that’s the place to start. I have seen side effects at too high of a dose, like anger, irritability, or acne. So, I just like to educate women on that. But overall, I either see people who don’t notice a difference or they notice that they have even more energy, more stamina with the DHEA. But sure, it is something I’ll try for women when they test. Generally under a 100, and I’ll give a little DHEA and see how they respond.
Dr. Weitz: Is there a benefit to pregnenolone?
Dr. Ney: Some doctors love pregnenolone. I just don’t use it a lot. I know that there are, because it depends on [inaudible 00:46:48].
Dr. Weitz: It also depends on whether or not you test for it.
Dr. Ney: True. True. I don’t always test for it. Do you use pregnenolone a lot?
Dr. Weitz: Well, as a chiropractor, right, we can’t prescribe anything. But pregnenolone is available over the counter, so we do use it sometimes.
Dr. Ney: Yeah. Some of my patients notice when we do use it, they notice better-
Dr. Weitz: I feel like it rounds out the whole hormone picture as a precursor.
Dr. Ney: Yeah, it definitely makes sense like that. Yeah. And again, it’s not one of my go-tos, but I have patients on it. I have dabbled in it. It’s just not usually something that’s my go-to.
Dr. Weitz: Right. Okay. Let’s see. What about nutritional supplements for women in menopause?
Dr. Ney: Yeah, again, very individualized, but generally, I really like, well, mitochondria support, I do like because really important for healthy aging. It’s important for hormones and cellular energy, cellular health. So, I love supporting mitochondria. Generally, a B vitamin I find helpful, a magnesium I find helpful. And adaptogen I think is helpful like maca or ashwagandha. I like that as a baseline. Also, vitamin D levels. Most people need to be on a maintenance dose of vitamin D to keep levels optimized and like an omega-3 fatty acid.
Dr. Weitz: What do you like for a typical maintenance level for vitamin D?
Dr. Ney: Fifty to 70, 50 to 80, around there.
Dr. Weitz: Oh, you’re talking about blood levels, right.
Dr. Ney: Oh, I’m sorry. You meant dosing levels?
Dr. Weitz: Yeah, dosing like 5000, 2000.
Dr. Ney: I find that it’s individualized, to be honest with you. I will track people and figure out what we need to do. So, it’s either 2000 or 5000. I think some people don’t take it every day too. So, I track them and I’m like, “What are you taking? Okay, keep taking that.” If they start to get a little higher like above 60, 70, I’ll definitely move them to 2000. During COVID, I don’t know if you’ve been seeing this, but I saw people with way too high vitamin D levels, like way above 100. So, I had to bring them down. People are really loading up on D. But yeah, you want to be in that optimal range.
It’s not a water-soluble vitamin. It’s a fat soluble vitamin, so it can get stored in the fat. And when it’s way too high, like when it’s above 100, it can lead to symptoms. So, it is something you do want to track if someone’s taking. You just want to make sure 5000. Most of the time, 5000 is great for a maintenance dose, but for some people, it’s too high and 2000 is the safe one. And if you’re not testing, generally 2000.
Dr. Weitz: Right. Sometimes 5000 is not enough. I know for me, if I only take 5000, it drops in the 40s or low 50s. So, I got to-
Dr. Ney: And that is why testing can be really helpful.
Dr. Weitz: Exactly. I’m a big proponent of testing, not guessing.
Dr. Ney: Yeah, absolutely. Certainly for these nutrient levels.
Dr. Weitz: Now, some doctors who prescribe bioidentical hormones automatically put women on some of the supplements like DIM to increase the potential that it’s going to be metabolized safely.
Dr. Ney: Yeah, I do use DIM. It’s not like you’re on hormones, I put you on DIM. And this is sometimes where the DUTCH test can be helpful. So, you can really test not guess. You can really see what pathway you’re going down, the two, the four, the 16. And what DIM does is it helps convert that to pathway, which is the safest pathway. And that’s the pathway we want to, I mean all pathways, we’re going to go down all of them. But certainly if you’re really heavy in the four, which is the one oxidative damage, DNA damage, you want to push the two. Giving DIM just for everyone, it does lower estrogen levels, so you just want to be mindful of that. It seems like everyone should take DIM, but if you’re not on hormones and you’re menopausal, you probably don’t need DIM because it can pull out whatever estrogen you have and make it even lower. Sometimes without testing and if I see someone who started hormones and they’re getting used to it and they feel really good, but they have this breast tenderness and lowering the estrogen is not really the best choice, I’ll do a trial of DIM. And people respond well. So, DIM is something that comfortably testing is nice to know if you actually do need it. We’re looking at estrogen metabolism. There’s a lot you can do lifestyle-wise to promote these healthy pathways. And I always will emphasize that too. If you want to be having daily, well-formed bowel movements, you shouldn’t be bloated or gassy or burping. You should have really good digestion. That says a lot about your gut microbiome, which is really important for metabolizing estrogen. Cruciferous vegetables, which is the precursor to DIM, the indole-3-carbinol, which is found in the broccoli and cauliflower. All of that really helps with phase one. I encourage women to have broccoli sprouts, which is the sulforaphane, which helps with phase two. So, I’m always doing those baseline lifestyle pieces to help with estrogen metabolism.
Dr. Weitz: Right. I’m starting to see estrogen and progesterone over the counter now.
Dr. Ney: Yeah, I know progesterone cream, you can get over the counter.
Dr. Weitz: I’ve seen estrogen now over the counter, one of the popular supplement manufacturers, and I was surprised.
Dr. Ney: Yeah, I know I’ve seen some estriol, I think in some of the Bezwecken product. I don’t know. I probably need to double-check that, but there is some estriol over the counter that I know is available. I don’t know much about estradiol. I’ll have to see what these products are.
Dr. Weitz: Yeah. Okay. I think those are the questions I have. Any other things you want to tell our viewers and listeners? And then, tell us how we can get in touch with you.
Dr. Ney: Yes. I want all women to know that they have a toolkit of treatment options. And I want women to know that this isn’t a normal process. This is not a disease state, but it does require a check-in. And I want women to know that you can continue to age with the same level of energy and vitality and libido and feel really amazing, but how we treat our body does change. So, we need to really, really emphasize those lifestyle pieces become even more important. And we have a suitcase of tools to address perimenopause and menopause from nutrition and sleep to supplements and microbiome support. There’s so much, and hormones.
So, I want people to know there’s options. This is not something they need to suffer through and deal with because I think when you feel your best, you can truly get after all the things in life that light you up. And that is why I want people to not just be… I don’t want their health to be an obstacle to achieving what they want in life. And when you feel good, you can really get after it. And I do think this is our time. Maybe the kids are older. We have a little bit more time, and this is our time to step into our passion and really get after it. But geez, it really helps when we feel good and our hormones are balanced. That’s really what I want all women to walk away with, is knowing there’s options and that they get to write their own script, that they don’t have to live someone else’s script. They can live the life of their dreams.
Dr. Weitz: That’s great. And how can viewers get ahold of you if they want to seek you out?
Dr. Ney: I have a private practice at the Akasha Center for Integrative Medicine, which is in Santa Monica. I’m licensed in the state of California. I see patients all over for educational, for telemedicine. I have a big telemedicine practice as far as prescribing and all of that in the state of California. I see women all over California. So, that’s at the Akasha Center for Integrative Medicine. I also co-founded HelloPeri, which we’re on Instagram, @thehelloperi, which has a lot of information on menopause, perimenopause, everything that has to do that. So, you can find me. On Facebook, I think we’re @thehelloperi as well.
Dr. Weitz: Okay. Thank you, Dr. Ney.
Dr. Ney: Thank you so much for having me on. This was so fun. And for anyone listening, questions, please feel free to DM me. I love to connect with everyone.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. That way more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients, so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So, if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
Dr. Jason Hawrelak discusses Probiotics and SIBO with Dr. Ben Weitz.
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Podcast Highlights
4:30 When Dr. Hawrelak was studying for his PhD, which was focused around dysbiosis and irritable bowel syndrome, he did a literature review on IBS and probiotics and he found studies dated back to the 1950s showing that probiotics were successful in treating IBS. When we discovered that SIBO is the main cause of IBS in the early 2000s and we have 50 years of research showing that probiotics successfully treat IBS, then why wouldn’t we use probiotics to treat SIBO? Some would say that it is counterintuitive to take probiotics if SIBO is a condition where you have too many bacteria in the small intestine. But it’s not just that you have too many bacteria, but that you have too many problematic bacteria. It’s too many E. coli or Klebsiella or streptococci, which means that it is more about dysbiosis than it is just about overgrowth of bacteria. We also need to understand that when we consume probiotics they don’t colonize, so they don’t stay there long term. This is why when we talk about the 4R program and we come to the reinoculate phase, this just doesn’t happen. You can’t just take lactobacilli probiotics and increase the amount of lactobacilli in the gut. On the other hand, while these probiotics pass through, they may secrete some bacteriocins or other antimicrobial compounds that reduce levels of pathogens. They might just secrete short-chain fatty acids or lactic acid, which changes the environment, which reduces levels of pathogenic bacteria. These probiotics may also secrete short-chain fatty acids or lactic acid, which changes the environment, which reduces levels of pathogenic bacteria. Some probiotic strains can stimulate the migrating motor complex and help with motility, which is the underlying issue with SIBO. Some can certainly help heal up and regenerate small intestinal cells, and help the healing process after the treatment of SIBO. Some strains or probiotics can reduce visceral hypersensitivity, which is one of the core conditions underlying IBS, where the nerves are hypersensitive to the sensation of gas, or the sensation of feces moving through the colon. Some can decrease inflammation and some can enhance secretory IgA production. We just have to use the specific strain of probiotic for the specific benefit we are looking for.
9:27 Probiotics can be antimicrobial. For decades we have had case studies of kids with severe SIBO who were hospitalized and antibiotics were not working and they gave them probiotics and the kids got better and got out of the hospital. Unfortunately, there have been meta-analyses of probiotics that have just lumped studies of various strains of probiotics together, which is like lumping all drugs for hypertension and concluding that drugs successfully treat hypertension. We need to be specific with strains if you want them to be effective. There are definitely a handful of studies published each year that show that probiotics effectively treat SIBO. Lactobacillus reuteri DSM 17938, which produces an antimicrobial substance called reuterin, and is sold around the world as BioGaia, has been shown to reduce the risk of SIBO in kids treated for GERD who were given proton pump inhibitors.
17:31 When Dr. Hawrelak treats patients with SIBO he will generally choose selectively acting antimicrobial herbals and a prebiotic like partially hydrolyzed guar gum. And then for methane, he might use the BioGaia and Lactobacillus reuteri as well.
Dr. Hawrelak: Yeah, it’s an interesting fiber, I think. We just did a systematic review of this just recently, actually. But I think there’s nine studies using it for irritable bowel syndrome, and all of them were positive. So that’s what got me excited when I read these studies on IBS, this goes back to 2016 when I first came across it, 2015 or ’14. Not that long ago, but unaware of it before then, do a literature search. I’m like, “Oh, my God. Look at this substance I was completely ignorant of.” And it’s got all these studies showing it not only reduces bloating and distension, and normalizes bowel pattern in patients with IBS. And it works for constipation from IBS or diarrhea from IBS. So we’ve got that data. And then there are studies using it for showing that it decreases methane output in people that have high methane. And then we have studies where they gave it alongside Rifaximin to treat SIBO. And I think from memory, the eradication rate with partially hydrolyzed guar gum was 85, 86% versus 60% with just Rifaximin on its own. So it significantly improved the outcome. And this was hydrogen dominant SIBO. So for me, PHGG is integral whether I’m treating hydrogen dominant SIBO or methane. And it is tolerated by most people with SIBO, not all, there’ll still be some that react to it. But compared to other prebiotic fibers like inulin, FOSS, or galacto-oligosaccharides, it is definitely better tolerated from a gas production perspective.
Dr. Jason Hawrelak is a researcher, lecturer, naturopath, and nutritionist with over 20 years of clinical experience with a focus on the treatment of gastrointestinal conditions. Dr Hawrelak is the Head of Research at ProbioticAdvisor.com, which is an incredible database of information about probiotics. Dr. Hawrelak completed his PhD examining the capacity of probiotics, prebiotics, and herbal medicines to modify the gastrointestinal tract microbiota. He teaches and lectures on probiotics and the microbiome all over the world. He has written many papers and over 20 textbook chapters. Probiotic Advisor can be found here: https://www.probioticadvisor.com/. Dr. Hawrelak continues to work with patients at Gould’s Natural Medicine clinic in Hobart, Australia.
Dr. Ben Weitzis 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. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey. This is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. 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. Our topic for today is probiotics and SIBO with Dr. Jason Hawrelak. SIBO, small intestinal bacterial overgrowth, is believed to be the most common cause of irritable bowel syndrome, or IBS. And SIBO is a condition of too many bacteria in the small intestine. Now, why would you want to treat it by ingesting more bacteria when you already have too many? But some studies do show that taking probiotics are helpful for both IBS and SIBO. And while some studies show that specific strains such as Bifidobacterium infantis strain 35624 helps with IBS, other studies and meta-analyses just lump various probiotics and often of unspecified strains or mixtures together. This has created somewhat of a mishmash of research confusion. I’ve talked to Dr. Mark Pimentel about probiotics for SIBO. And he basically dismissed it, partially because how can you talk about a group of substances? It would be like saying antibiotics are good for a certain condition. So saying probiotics are good for SIBO from a scientific perspective, really doesn’t seem to make much sense. Now, there’s one prominent doctor in the SIBO world who recommends taking triple probiotic therapy, taking a Lacto/Bifido blend of unspecified strains, a Saccharomyces boulardii product, and a spore based probiotic for patients with SIBO. And he says that specific strains don’t matter, just take one from each category. Some Functional Medicine practitioners have concluded that the best type of probiotic for patients with SIBO, is to take a spore based probiotic, since it won’t open up until it gets into the colon, and therefore will not add to the bacteria in the small intestine. On the other hand, many functional medicine practitioners in the SIBO space do not recommend taking probiotics while treating SIBO, until after you’ve reduced the number of bacteria with appropriate antibiotics or herbal antimicrobials. And of course, this would make sense based on the Four R or Five R strategy pioneered by the father of Functional Medicine, Dr. Jeffrey Bland, who taught us to remove, then replace, then reinoculate, and finally repair the gut. And so there you would only use probiotics in phase three, the reinoculate phase.
So who better to help us understand this confusion about probiotics for patients with IBS or SIBO than Dr. Jason Hawrelak, joining us from Australia? Dr. Jason Hawrelak is a researcher, lecturer, naturopath, and nutritionist with over 20 years of clinical experience with the focus on the treatment of gastrointestinal conditions. He’s the head of research@probioticadvisor.com, which is an incredible database of information about probiotics. And he also offers a series of courses, that are available adjacent to that program as well. Dr. Hawrelak completed his PhD examining the capacity of probiotics, prebiotics, and herbal medicines to modify the GI tract. He teaches and lectures on probiotics and the microbiome all over the world. He’s written many papers and over 20 textbook chapters. Dr. Jason Hawrelak, thank you so much for joining us.
Dr. Hawrelak: Hey. You’re very welcome, Ben.
Dr. Weitz: Thank you.
Dr. Hawrelak: I’m glad to be here chatting with you again, about a very interesting and apparently controversial topic, that we’re delving into. Yeah.
Dr. Weitz: So why don’t we start by talking about SIBO and IBS? So let’s focus in on SIBO, which a lot of the data seems to show is the most common cause of IBS, probably accounting for 60, maybe as much as 70 or more percent depending upon how we’re able to determine if you have SIBO. And the way we generally determine if you have SIBO, is with a SIBO breath test. And I’d like you to comment about the SIBO breath test? And especially about the various substrates that are available, that are used in the test including lactulose, glucose, fructose?
Dr. Hawrelak: Gosh, I don’t know where to start even.
Dr. Weitz: So-
Dr. Hawrelak: Maybe I’ll take a step back and go.
Dr. Weitz: Yeah.
Dr. Hawrelak: Listen, my PhD was specifically around dysbiosis irritable bowel syndrome.
Dr. Weitz: Okay.
Dr. Hawrelak: We were running clinical studies in IBS, giving them prebiotics, and probiotics, and herbs to try to influence their microbiome. This was back, I started my PhD and my honors degree, which followed my PhD in the year 2000. So before people were talking about SIBO as being anything but this really rare condition. And so I had a chance to do this lovely literature review into irritable bowel syndrome and probiotics. And look back, and found the first studies going back to 1950s, showing probiotics were successful in treating IBS. And not every single strain is, obviously. But the bulk of data suggests that probiotics are helpful for treatment of IBS. That was clear in the early 2000s, when this idea of SIBO came out of… So for me, and then SIBO came out as the cause of IBS. And I’m like, “Well, is SIBO is the cause of IBS, and we’ve got 50 years of research showing that probiotics successfully treat IBS, then why on earth wouldn’t we be using probiotics to treat this, when we already have 50 years of data showing that apparently it successfully treats this condition?” So that’s what my background was from where people were like, “Oh, don’t use probiotics.” But it’s like if you’re saying this is the cause of IBS, and we’ve got all this data showing probiotics work on IBS, it just doesn’t make sense that we say we should not take probiotics.
Dr. Weitz: But it’s counterintuitive, if the problem is too many bacteria, why are you going to put more bacteria in?
Dr. Hawrelak: I think it’s counterintuitive if that’s the big viewpoint. Rather than, “Okay, it’s actually not just too many bacteria, it’s too many problematic bacteria.”
Dr. Weitz: Right.
Dr. Hawrelak: Or it’s too many streptococci, or too many E. coli, or Klebsiella that are there. And when you understand that differently, that changes things. Because it’s like, “Okay.” Because I think that conception around SIBO is changing. And in fact, there’s more of a thinking now that it’s more about dysbiosis than it is about just overgrowth of bacteria. And you could have overgrowth of some bacteria and never have an issue with it. And you have overgrowth of Klebsiella, or E. coli, or Streptococci and you get symptoms associated with it. And potentially gut damage too in the small bowel. So I think with that understanding, it’s like, “Okay. Well, what do we know that probiotics can do?” I think there’s this misconception, and this goes back probably to the Four R or Five R type stuff with reinoculation. You can’t reinoculate with probiotics. This is an old myth that we should really make sure we toss out. And certainly I teach within the functional medicine program at the University of Western States, and we change that reinoculate to restore. It’s like, get with the new century, we can’t reinoculate with Lactobacilli, and Bifidobacteria, and products, it’s not reality. We can help restore populations that are too low, but it gets into that idea of colonization. So I think the idea that, “Oh, we’ve got more bacteria. We just add more and then they just permanently live there,” that’s not reality. That’s not what happens when we take Lactobacilli, or Bifidobacteria, or Saccharomyces, or et cetera. They do not permanently live in your small bowel or large bowel. They’re temporary visitors, so they’re passing through. But while they pass through, they may well secrete some bacteriosins or other antimicrobial compounds that reduce levels of pathogens. They might just secrete short-chain fatty acids or lactic acid, which changes the environment, which reduces levels of pathogenic bacteria. Some probiotic strains can stimulate the migrating motor complex and help with motility, which is the underlying issue with SIBO. Some can certainly help heal up and regenerate small intestinal cells, and help the healing process after the treatment of SIBO. Some strains can reduce visceral hypersensitivity, which is one of the core conditions underlying IBS, where the nerves are hypersensitive to the sensation of gas, or the sensation of feces moving through the colon. Some can decrease inflammation, some can enhance secretory IgA production. So if we start looking at the possibility of what probiotics can offer here, it makes total sense that we can use them as tools to actually help. So there’s different ways of reducing or changing bacterial ecosystems. Antibiotics is one way, sure. But probiotics is another way, and herb medicines are other ways of actually changing ecosystem composition. And I think-
Dr. Weitz: So would it be accurate to say in some cases that probiotics are antimicrobial?
Dr. Hawrelak: Yeah. Well, it would be from a SIBO perspective. And I think again, maybe 20 years ago, it would’ve been there was a lack of research around probiotics in SIBO specifically. Yes, the use of probiotics in IBS, the dataset was all clear around that. There were successful case studies of kids with severe SIBO who were hospitalized, and antibiotics weren’t working where they gave them probiotics, and the kids got better and got out of hospital. So there were successful case studies of treatment with probiotics of severe life-threatening SIBO in the 1990s that were published too. So there was already some preliminary data that suggested that probiotics would be helpful. But skip forward now, and look at the data out there’s study after study showing probiotics are helpful for a treatment of SIBO. And I think you can’t just have your head in the sand and say, “This doesn’t exist.” And while I agree with Dr. Pimentel that there are issues with meta-analyses, where you just grab all probiotics and shove them together. It’s like saying, “Let’s do a meta-analysis of do drugs treat hypertension?” Well, some do, some don’t. But if you shoved the ones that don’t in there with the ones that do, you’re going to actually get an unclear effect. You’re not going to see anything. And that’s definitely a problem with probiotic meta-analysis, where researchers who are unaware of this fact will just grab all probiotics and shove it together. And listen, some won’t work. If your probiotic strain you’re giving doesn’t have selected antimicrobial properties, or won’t help with motility, then is it going to work with SIBO? Yeah, perhaps not. Whereas ones that actually do have antimicrobial properties do seem to work for SIBO. And I think, again, you look at, there was a meta-analysis in 2017, I think it was, where they took all the probiotic studies for SIBO. And I think they found that… Again which had some issues with methodology because I think it’s grouping all the things together. Which if anything, it precludes beneficial effects, makes it harder to see. But even doing that, there is a 53% eradication rate, clearance of SIBO with probiotics in the studies when they pulled the data together. And since that was published, there’s more and more studies published each year looking at it. Not like 50 studies a year, but there’s a handful of studies published each year supportive of the use of probiotics to effectively treat SIBO, and bring down breath gas with EPI hydrogen, or methane, or both.
Dr. Weitz: Now, is the best way to think about this, some people have described it sort of as a parking lot and here’s only so many parking spaces, and if you park the good bacteria in there, there’s no parking spaces left for the bad bacteria? Almost like if we’re having some elaborate game of musical chairs, and the bad bacteria don’t end up with chairs if there’s enough good bacteria there?
Dr. Hawrelak: That’s definitely a component there. And I think the other additional bit is whether that microbe can produce something that is antimicrobial?
Dr. Weitz: Okay.
Dr. Hawrelak: And I think a good example here is Lactobacillus reuteri DSM 17938, which is sold around the world as BioGaia. There’s a clinical trial giving it to kids with reflux disease, who were given proton pump inhibitors to treat the reflux. And we know that PPIs, that is very consistent around this increased risk of SIBO development. So this study was like, “Okay, what if we give them this probiotic? Will it prevent these kids from getting SIBO?” And they tested, baseline tested, three months later. SIBO developed in, I think, it was 56% of people in the placebo group, 6% of those in the BioGaia group. That’s a massive difference from a prevention perspective.
Dr. Weitz: Yeah. For sure. Absolutely.
Dr. Hawrelak: But what’s unique about this strain, is this strain produces an antimicrobial substance called reuterin. And it may be that is the key reason why it works in that situation. And the dose they’re giving is like a hundred million CFU twice daily, I think was the dose. So relatively small. Yet there was another study, a similar population of kids taking proton pump inhibitors for their reflux, and they gave a combination of Lactobacilli and Bifidobacteria at much higher doses. It did not work, did not prevent SIBO. And it’s like, “Okay, well do those specific strains have any indication they would be helpful in this condition, as in producing antimicrobial substances, et cetera?” No, they don’t have that. So to me it was like, “Oh, okay. Well yeah, if we choose our products wisely, we can get therapeutic benefit.” And if we just use random products with no sort of good rationale for the use, I think we’re going to hit-and-miss more often than we actually hit. Whereas I think when we are actually using stuff that has theoretical rationale for their use, we’re going to get better results. And if we as researchers actually chooses the ones that have theoretical evidence of use through research, we’re going to get better outcomes than just grabbing, “Hey, here’s a random probiotic, let’s see if it works for SIBO prevention.” Versus, let’s choose one that has the traits and qualities we’re after.
Dr. Weitz: Is it possible?
Dr. Hawrelak: We do this in probiotic researchers all the time, they’re looking for how do we choose the best probiotic for treating vaginal bacterial vaginosis? It’s like, let’s see the ones that survive, have the good pH tolerance, produce D-lactic acid, inhibit the growth of those pathogens. And you might get a hundred strains to start with. And you put them through a bit of an obstacle course, and you come up with three or four that actually tick all the right boxes. And then you take them into studies from that point onwards. And I think this also illustrates, I think some of the differences you said initially around do strains matter? Yes, strains do matter. We can clearly see that in that kind of research, where you can have 20 strains of Lactose crispatus for example, and only some will have all the criteria that you need to be like a successful general probiotic. And just like we have numerous strains of Lactobacillus reuteri, only some produce reuterin. So if you’re supplementing with this strain of Lactobacillus reuteri that does not produce reuterin, you cannot expect it to have the same effect as the ones that do produce reuterin, like the BioGaia one that was used in that successful SIBO case. And that same strain have been used in methane cases too, where it actually significantly reduced methane output. And it cleared methane in a number of people in that study as well.
Dr. Weitz: Oh, interesting. Because that was going to be my next question, which is how specific can we get? Can we take the results of a SIBO breath test, find out the patient has hydrogen SIBO, and we know certain organisms tend to cause that? Or is it hydrogen sulfide, or is it methane? And then are there specific strains that you would recommend for each type of SIBO?
Dr. Hawrelak: Yeah. And I think as more research comes to the fore, and we have access to some of those strains, we’ll get better data around this area. And again, I was recently looking at the probiotic SIBO literature, and there’s a number of studies that have been published out of China, where they’re a bit vague in their description of the probiotics that they use in these studies. So it’s hard to necessarily as a clinician take that into clinical practice going, “Okay. Well, this combination of probiotics worked in this Chinese study. Can I use these strains?” Well, they don’t detail the strain they tell you the species. So as each year goes on and we get more research, we will become better at fine-tuning and matching these things up. But currently we know that the reuteri DSM 17938 is helpful for methane. That is clear.
Dr. Weitz: Okay.
Dr. Hawrelak: And then-
Dr. Weitz: Now, is it possible to simply recommend that for a patient with methane SIBO without anything else?
Dr. Hawrelak: Yeah.
Dr. Weitz: Is that something you’ve done?
Dr. Hawrelak: Only in kids.
Dr. Weitz: How would you treat-
Dr. Hawrelak: Only in kids. Yeah.
Dr. Weitz: Only in kids? Okay.
Dr. Hawrelak: Because they can’t necessarily take the foul tasting herbs that I would usually use in adults. Yeah. So certainly they can work brilliantly well on their own in some people.
Dr. Weitz: Okay.
Dr. Hawrelak: But generally I do my best to get the best result as quickly as possible with patients, in a way that doesn’t harm their colonic microbiome in any significant sense. So I’m trying to choose selectively acting antimicrobial herbals, a prebiotic like partially hydrolyzed guar gum. And then for methane, I would use the BioGaia, Lactobacillus reuteri as well.
Dr. Weitz: Okay.
Dr. Hawrelak: Yeah. But for some kids who can’t do the herbs. Well, I might just use BioGaia and partially hydrolyzed guar gum. And yes, you can see results in some of those people with just that simple treatment.
Dr. Weitz: And partially hydrolyzed guar gum you would pick, because unlike a lot of prebiotics or forms of fiber that tend to feed SIBO bacteria, that has been shown not to exacerbate SIBO symptoms, right?
Dr. Hawrelak: Yeah, it’s an interesting fiber, I think. We just did a systematic review of this just recently, actually. But I think there’s nine studies using it for irritable bowel syndrome, and all of them were positive. So that’s what got me excited when I read these studies on IBS, this goes back to 2016 when I first came across it, 2015 or ’14. Not that long ago, but unaware of it before then, do a literature search. I’m like, “Oh, my God. Look at this substance I was completely ignorant of.” And it’s got all these studies showing it not only reduces bloating and distension, and normalizes bowel pattern in patients with IBS. And it works for constipation from IBS or diarrhea from IBS. So we’ve got that data. And then there are studies using it for showing that it decreases methane output in people that have high methane. And then we have studies where they gave it alongside Rifaximin to treat SIBO. And I think from memory, the eradication rate with partially hydrolyzed guar gum was 85, 86% versus 60% with just Rifaximin on its own. So it significantly improved the outcome. And this was hydrogen dominant SIBO. So for me, PHGG is integral whether I’m treating hydrogen dominant SIBO or methane. And it is tolerated by most people with SIBO, not all, there’ll still be some that react to it. But compared to other prebiotic fibers like inulin, FOSS, or galacto-oligosaccharides, it is definitely better tolerated from a gas production perspective.
Dr. Weitz: And do you tend to use that a couple of times a day? And do you tend to use it away from meals, or with meals? Or it doesn’t matter?
Dr. Hawrelak: With the PHGG, it can be with or without meals it doesn’t matter. And generally it’s once a day to ease compliance with that one.
Dr. Weitz: Oh, okay.
Dr. Hawrelak: So it’s six or seven grams, one hit. And it’s easy to work with because you can mix into, unlike some fibers, it mixes beautifully into cold water. And it’s got almost no flavor. So you can mix into a cold drink and it makes the water a bit thicker, but not really much flavor. Easy to mix into smoothies, or easy to add to breakfast cereals, porridge, whatever you might actually have. It’s easy to work with.
Dr. Weitz: Do you know, or can you speculate what is it about PHGG, partially hydrolyzed guar gum, why it has this different quality from many other forms of fiber or prebiotic?
Dr. Hawrelak: Yeah. It’s definitely for most people less gas forming. And I think that’s part of it. And I think we know it also feeds butyrate producing species more so. So if you look at what species utilize substances that we eat, if we have inulin-FOS, then we feed Bifidobacteria, and Faecalibacterium, Akkermansia, for example are three populations that tend to increase. Whereas with partially hydrolyzed guar gum, we need a little bit of Bifidobacteria, but it’s often it’s Roseburia and other-
Dr. Weitz: Akkermansia?
Dr. Hawrelak: Not so much Akkermansia, interestingly enough. But it’s more of a butyrate producing species.
Dr. Weitz: Okay.
Dr. Hawrelak: So it’s kind of feeding a different group of bacteria, that generally perhaps are not overgrowing in the small bowel. We don’t tend to see butyrate producing species don’t really show up on any of the literature looking at what’s overgrowing in the small bowel in patients with SIBO. It’s usually Streptococci or Proteobacteria that show up in the vast majority of studies to date. So they can’t utilize it as a food source so much then. But how exactly to improve the efficacy of Rifaximin in SIBO treatment is an interesting thought. And the researchers initially were doing it because it is a prebiotic like substance, and they were using it that way. We know it does improve efficacy, but the mechanism, I think, is a little bit less clear. Whereas when it comes to methane, I think it’s more clear in that we know that methane producing bacteria, typically Methanobrevibacter smithii is the key one for most people, likes living in a more neutral to alkaline pH. And doesn’t like being bathed in butyrate. So if we ingest a substance that creates more butyrate, we create the conditions that are less conducive to the growth of methane producing bacteria.
Dr. Weitz: What about just adding butyrate as a supplement in such cases of methane SIBO?
Dr. Hawrelak: Yes. You can certainly use that as an adjunct agent too. What you can have though when you use just butyrate, is you can have a… Essentially taking a step back, what does the methane producing bacteria consume? Methanobrevibacter eats hydrogen gas.
Dr. Weitz: Right.
Dr. Hawrelak: If you change the circumstance where you just reduce the levels of methane producing bacteria, the hydrogen gas level can actually increase. So sometimes you can actually have worst bloating or distention from giving butyrate, even though it’s actually dealing with the underlying methane overproduction. But you end up with more hydrogen in the shorter term, which can mean more symptoms as well. So I think I have played a bit with that. And I think it can be useful tool in sometimes, but you just have to be-
Dr. Weitz: So essentially what you’re telling us is anytime you have a patient who has methane SIBO, there may be hydrogen SIBO that’s being masked by the fact that the increased number of methanogens are consuming the hydrogen?
Dr. Hawrelak: Yeah. And this is clearly the case if it’s methane in the small bowel, for sure. Because we’re supposed to have hydrogen produced in the colon, so that’s normal. So if you see a lack of hydrogen rise in the colon, but you see a spike in the rise in methane or breath tests, that clearly shows that’s the case. But in the small bowel, again, if you see that rise in methane at the 20 or 40 minute mark on a breath test, you know there’s hydrogen producers there. Because that’s what’s eating the substance first, they’re eating the lactulose, or the glucose, or the fructose first. They produce hydrogen gas, that’s eaten by the methane producing bacteria very quickly, and you get the spike in methane, not necessarily of hydrogen. So yes, you would actually have hydrogen producers underneath there, that you have to deal with too. And that’s what butyrate itself does not do. So I think it’s arguably better for chronic methane issues than small bowel methane issues.
Dr. Weitz: So in terms of small bowel, large bowel, when we do the SIBO breath test there’s a time cutoff and there’s some controversy about that. Is it 90 minutes? At one point it was a hundred minutes. Is it 120? I’ve talked to some prominent SIBO practitioners who always believe in doing a three-hour test, because they don’t trust that it might only be two hours-
Dr. Hawrelak: Yeah.
Dr. Weitz: … and they want to see what happens.
Dr. Hawrelak: Now, I always do three hour breath tests.
Dr. Weitz: Oh, you do?
Dr. Hawrelak: Always, for extra hydrogen and methane.
Dr. Weitz: Okay.
Dr. Hawrelak: But I always do lactulose and fructose at a minimum. And often lactulose, fructose, and glucose.
Dr. Weitz: Oh, really?
Dr. Hawrelak: Yeah. Yeah.
Dr. Weitz: Are you checking for hydrogen sulfide as well? Is the trio-smart available in Australia?
Dr. Hawrelak: It is. I can arrange it for my North American patients. But I tend not to use trio-smart so much. I tend to stick with the QuinTron based testing for hydrogen and methane for the most part.
Dr. Weitz: Why?
Dr. Hawrelak: Why? I think I’ve seen some results, apparent discrepancies of even some people, the same person a minute apart, sending the breath samples to different labs, or even three. A couple went to the more classic ones that do hydrogen/methane, and one went to the lab that does trio-smart. And the level of hydrogen and methane was the same in the two normal labs. But completely, completely, totally different in the trio-smart one. A hundredfold, a lot different. And I’ve just seen that enough, that I’m just a little bit hesitant to know what to do with that, when the levels of methane and hydrogen are multitudes lower on that test consistently than I see on the other tests. I’m a little bit like [inaudible 00:26:17]-
Dr. Weitz: Interesting. You think that has to do with the way the gases are collected? Or do you know why?
Dr. Hawrelak: Good question. No, I don’t. It is just been enough that I’ve just been hesitant to go, “Okay.” I’m just not fully personally going to trust those results. I’m going to stick with the more conventional labs, because the way that this shows up with the hydrogen and methane seems consistent between them.
Dr. Weitz: Interesting.
Dr. Hawrelak: And I’m comfortable with that. Yeah.
Dr. Weitz: And you might be missing out on hydrogen sulfide though?
Dr. Hawrelak: Well, I am basing that on because I’m testing lactulose, often glucose, and fructose. And if they-
Dr. Weitz: Okay. All three of those?
Dr. Hawrelak: All three.
Dr. Weitz: That’s a lot of testing. You’re talking about, especially if you’re asking everybody do a three-hour test, that’s nine hours of testing?
Dr. Hawrelak: It is. It is. But it’s so much more accurate, the information you get. And this is maybe two years ago now, I went through and said, “Okay, let’s take the last 130 people we’ve suspected of SIBO, and done breath testing for. If we just only did lactulose, only lactulose, how many people would we have picked up with SIBO?” And it was 73% of those people with SIBO we picked up with just lactulose. If we did fructose alone, only fructose, 85% of people. If we did-
Dr. Weitz: Really? Fructose is more accurate than lactulose?
Dr. Hawrelak: I reckon it is. And listen, we need further clear… I don’t have my own hospital setting where I can do aspirate and culture on people to verify things. So what I’m using is essentially that same criteria, rise of 20 parts per million at 90 minutes, whether that be with glucose or fructose. Because for me, why are we defining SIBO by if it eats glucose, it’s SIBO, but if it eats fructose, it’s not SIBO at the 20-minute mark? That’s just stupid to me. It’s like there are bacteria there eating sugar that aren’t supposed to be there.
Dr. Weitz: Right.
Dr. Hawrelak: Whether they’re eating glucose or fructose, it’s still bloody SIBO. I don’t understand where people are like, “Oh, no. It’s only SIBO if it’s a glucose or lactulose.” But if the same bugs are eating lactose, it’s no longer SIBO. It’s like, “Of course it’s SIBO, because it’s defined by the time where the gases are produced. Not by the sugars that are consumed.”
Dr. Weitz: Well, actually when it comes to methane, time doesn’t even matter anymore. Right?
Dr. Hawrelak: No. That’s right.
Dr. Weitz: Because now it’s IMO and it could be in large intestine?
Dr. Hawrelak: That’s right. Yeah.
Dr. Weitz: So are you routinely doing stool testing as well?
Dr. Hawrelak: Yes. Yeah.
Dr. Weitz: To see if there’s methanogens? Okay. You are?
Dr. Hawrelak: Yeah. So we’re looking for methanogens, which don’t always show up on stool tests, I must say.
Dr. Weitz: Right.
Dr. Hawrelak: Breath testing is far better accuracy for picking up methane status, for sure. But also looking for hydrogen sulfide gas producers on stool tests too. So let’s say if I’m suspecting SIBO, and there might be hydrogens sulfide as the background as a possibility, we do lactulose, we do fructose, we do glucose. The glucose and fructose completely normal. No sign of excess. No bump at all, because there shouldn’t be any bumps with hydrogen. And methane’s normal. Lactulose flat lines to three hours. At this point I’m thinking, “Okay, this is possibly hydrogen sulfide SIBO, what does the microbiome picture look like? Do I have elevated levels of hydrogen sulfide gas producers on that? Or do I have-“
Dr. Weitz: So those are the Desulfovibrio, and what-
Dr. Hawrelak: Yeah. And Bilophila, they’re the two classic ones.
Dr. Weitz: Okay. Yep.
Dr. Hawrelak: You can also have those Fusobacterium that would rarely be involved, but can be.
Dr. Weitz: Okay.
Dr. Hawrelak: And Proteobacteria. Some Proteobacteria would overproduce hydrogen sulfide too. So you’d be looking at those. But the classic ones would be Bilophila and the Desulfovibrio. And not all stool tests sadly tests for Bilophila, it’s harder to find. And I think I wouldn’t use a stool test that doesn’t tell me about Bilophila, to be honest. Because it’s such a commonly overgrown hydrogen sulfide gas producer, that if you don’t test for it you would never see it, and you won’t know how prominent it is.
Dr. Weitz: So which stool tests include Bilophila?
Dr. Hawrelak: The ones that do shotgun sequencing, like shotgun metagenomic sequencing. So that would be things like NirvanaBiome, CosmosID in the States, and Microba here in Australia. And Microba sends kits overseas too. They will test for Bilophila and the Desulfovibrio off the top of my head.
Dr. Weitz: I know Desulfovibrio is on the GI-MAP. I’m not sure about-
Dr. Hawrelak: That one is a bit easier to come by, for whatever reason people have gone, “Oh, let’s focus on Desulfovibrio.” Yeah, Bilophila is actually in my experience looking at thousands of stool samples, is more often overgrown than the Desulfovibrio. Because Bilophila, its name gives it away, Bilophila, it loves eating bile, bile’s its thing. So you tend to see a bloom in people who do keto type diets, or high fat diets, high saturated fat diets tend to have these major blooms of Bilophila.
Dr. Weitz: Oh, interesting.
Dr. Hawrelak: And it’s just sad that you can’t see it. Because if you’re doing a stool test that can’t see Bilophila, you have no idea that this diet is feeding, blooming these hydrogen sulfide gas producers in [inaudible 00:31:02]-
Dr. Weitz: And there you are doing a low-carb diet thinking you’re starving your bacteria, and you’re actually feeding some of them?
Dr. Hawrelak: Feeding some of them? Yeah, that’s right. So to me, I would not do any stool test that does not do Bilophila. Because you need to be able to look at that. Yes, so I would look at that. I’d also look for acetogens too. There are certain bacteria that we know that eat hydrogen and convert it through to acetate. So you’re not going to get any breath gases with that. So you have to get them in a stool test too.
Dr. Weitz: Oh, wait a minute, which ones are those?
Dr. Hawrelak: They’re less characterized at this time point.
Dr. Weitz: This is new breaking news.
Dr. Hawrelak: Well, interesting. It’s been around for a long time, but it just hasn’t been discussed even that much for some reason. Listen, even the methane constipation stuff. I moved house recently, and I had to sort through my papers in my garage. I had boxes and boxes of papers that I collected as part of my PhD, and I was painstakingly giving them away.
Dr. Weitz: You know they’re all on the internet now?
Dr. Hawrelak: I know, that’s why I gave them away, most of them. But I came across one paper from the 1980s, and they were looking at methane output in people who were constipated. And they’re like, “Hey, I think there might be a correlation here between people who are constipated and a high methane output.” And not only that, they gave them tons of sulfur as a supplement. And these people shifted their hydrogen dynamics from methane to hydrogen sulfide from the sulfur. And their bowels sped up, and they no longer had constipation. And this is research in the 1980s.
Dr. Weitz: Wow. Ugh.
Dr. Hawrelak: And we forget that stuff like that, people were on it at that point, but some people were.
Dr. Weitz: Wow.
Dr. Hawrelak: Because they were already looking at where does the hydrogen go? It could be methane or hydrogen sulfide, and let’s see if we can shift it between that? And they could, and effectively treat constipation by giving sulfur. So whether that’s an approach we want to be doing? I don’t know, because hydrogen sulfide gas is not particularly great. So I don’t think we want to be shifting people from tons of methane to tons of hydrogen sulfide. But it was interesting they were doing it.
But one of the other pathways that hydrogen can go to, is it can become acetate. So we have a number of groups of bacteria in our colon, hydrogenotrophs who eat hydrogen. So methane producing archaea, hydrogen sulfide gas producing bacteria. And then we have the acetogens, those that eat hydrogen in make acetate. And that’s not a gas, and that’s a lovely short-chain fatty acid with anti-inflammatory effects.
Dr. Weitz: Right.
Dr. Hawrelak: So that’s obviously, which would be great if we could have more of that going on. In fact, I’m on a bit of a tangent here, but I just read a study in Japan recently. And they were looking at methane producing status, and acetogens in this Japanese population. And I think it was only seven percent of the Japanese population had methanogens present. Whereas for Westerners, it’s like 90% of us have got methanogens in our gut.
Dr. Weitz: Right.
Dr. Hawrelak: And Japanese, their rate of constipation is very tiny. And a lot of their hydrogen goes become acetate in Japan. Whereas for Westerners, that’s more of a rare situation. So you could-
Dr. Weitz: What is some of the species that are acetogens?
Dr. Hawrelak: One of the key ones we see is Blautia hydrogenotrophica, I think from memory. Yeah, [inaudible 00:34:05]-
Dr. Weitz: Wow. Never heard of that one.
Dr. Hawrelak: … hydrogenotrophica. No. Again, you need to be using the right stool test to see that one, and that’s where you would have to use shotgun metagenomic sequencing that you can get down to the species level, to look to go what sort of Blautia do you have, and whether you’ve got the acetate, the ones that essentially consume hydrogen to make acetate as a consequence. And the cool thing is too, that particular species can actually cross feed Faecalibacterium. So you now have this beautiful relationship where we have this guy that eats hydrogen and it makes acetate, and it shares some of the acetate with Faecalibacterium prausnitzii who makes butyrate with that shared acetate. So to me it’s a beautiful relationship, and this is why we should be trying to encourage acetogenesis when we possibly can.
But essentially that occurs when the pH in the colon is much lower. So when we have a pH of five and a half or less, we tend to have much more capacity for acetogens to thrive, whereas they don’t live in a neutral pH that we tend to see in Westerners. So you can also be looking at stool pH as one of the markers that can help indicate whether that flat line is hydrogen sulfate or it’s [inaudible 00:35:18]-
Dr. Weitz: Because we’re all drinking our alkaline water to make ourselves healthier?
Dr. Hawrelak: But I think it’s a lack of fiber for the most part.
Dr. Weitz: Oh, okay.
Dr. Hawrelak: Because if you don’t eat plant foods, you don’t eat fiber, you don’t produce short-chain fatty acids, you don’t get the change in pH in water.
Dr. Weitz: So essentially you’re saying that Americans are full of shit?
Dr. Hawrelak: Well, Australians and Canadians too, I’m going to say. And they often are. There’s often days worth of poo inside of those populations. A lot of patients I work with have got days worth of poo that are there. I remember one patient I got them to do the… And this is one test I do for all patients. But I get them to do the bile transit time test, it’s a very low tech test. You eat some corn on the cob or some black quinoa, you don’t chew it, write down exactly when you eat it, you write down when it starts coming out, and when it finishes coming out in your poo. But my champion one is, I think it was 25 days before the corn started coming out.
Dr. Weitz: What?
Dr. Hawrelak: Yeah. And she was only pooing every two or three days. So I knew it was going to be slow, but I had no idea be that slow.
Dr. Weitz: Oh, my gosh. 25 days? Wow.
Dr. Hawrelak: Yeah. And you just think how much fecal matter is loaded in that colon constantly?
Dr. Weitz: Yeah. Wow.
Dr. Hawrelak: And no wonder she was chronically unwell, and felt horrific all the time. It’s like, “Yeah. Well, that explains a lot of it there.”
Dr. Weitz: And how did you treat that?
Dr. Hawrelak: This is a patient maybe 10 years ago. So we’re going back fair while, I can’t recall, but we certainly focused on trying to speed up transit time. And-
Dr. Weitz: Did you ever get her colonic?
Dr. Hawrelak: Listen, I think a colonic would’ve been helpful in the short term. I’m a bit cautious around the potential impact on the colon from a long-term perspective.
Dr. Weitz: Right.
Dr. Hawrelak: But I think as a let’s get week’s worth of poo? Sure, to get you feeling a bit better. But I much prefer working from this way than that way. Although I don’t think the odd enema, I think, is not going to be an issue. But I do think colonics where you’re washing the colon a bit more, you’re likely to have more changes to the microbiome as a consequence.
Dr. Weitz: Do you think that some of the new generation of probiotics like Akkermansia is now available, and I think that fecal bacteria, [inaudible 00:37:26] is starting, I think it’s available?
Dr. Hawrelak: Probably not far of, I would reckon. Yeah.
Dr. Weitz: Not far off. So these are anaerobic strains that hadn’t been available because of the difficulty of producing them?
Dr. Hawrelak: Yes.
Dr. Weitz: And I’ve read some that they may potentially be colonizers of the gut in some cases. What have you seen?
Dr. Hawrelak: Yeah. I can only speak clinically thus far with my patients who’ve taken the Pendulum Akkermansia and Pendulum Glucose Control.
Dr. Weitz: Right. Right. Yep.
Dr. Hawrelak: And I have not seen Akkermansia show up on any stool test yet. When my patients have taken it.
Dr. Weitz: Okay. Okay.
Dr. Hawrelak: When they did have Akkermansia beforehand. I had high hopes. I was excited. I’m like, “Maybe we can, because we’ve tried to revive your Akkermansia population, it is extinct in your gut, you did not have it. Maybe we can recolonize with this supplement.” But thus far, and listen, it’s only been maybe 10 to 15 patients. So I’m not-
Dr. Weitz: Okay.
Dr. Hawrelak: … saying no, it never does it. But I have not seen it do it in any of my patients thus far. And they’ve been taking the supplement at the same time they’re doing the stool test even. And it hasn’t even showed up on the stool test, which I was slightly sad about. Because I thought at least if it showed up when they took it, it’s a bit positive around that. And maybe a chance of it sticking around.
Dr. Weitz: Right.
Dr. Hawrelak: But it haven’t showed up when they’re taking it so far.
Dr. Weitz: Interesting.
Dr. Hawrelak: Yeah. And it’s first generation Akkermansia, so who knows? Maybe wasn’t selected as the core attribute was how good it could colonize. Because I think there’s some discussion around in general our current generation of Lactobacilli and Bifidobacteria do not colonize in any significant degree in kids or adults. Yet, if we gave the same ones to moms when they’re pregnant, they can actually colonize that infant for life. So it’s interesting. There’s a window where-
Dr. Weitz: Oh, really?
Dr. Hawrelak: … they could permanently colonize. Yeah, interesting enough.
Dr. Weitz: Interesting.
Dr. Hawrelak: But it won’t in all the populations. But there’s one study with one type of Bifidobacteria, its code strain was maybe AH2106 or something. I could be a little bit off with that one. It’s been a few years since I read the study. But it did colonize in 30% of people, I think from memory, for up to six months.
So it’s like, “Okay, if a strain is chosen where the main criteria is it can stay, and maybe they’ll screen hundreds of different types of Bifidobacteria to find one with that long-lasting capacity to colonize.” So I would say that in the future we might have Bifidobacteria that can colonize, we might have Akkermansia, or Faecalibacterium that can colonize. I would just say perhaps at the moment, we certainly don’t have that in general with Bifidobacteria. And at least in my experience, we don’t have that with Akkermansia yet.
Dr. Weitz: Do we know specific prebiotics that can make certain bacteria flourish in the gut, especially maybe ones that are really low?
Dr. Hawrelak: Yeah. For sure. And I think this is where prebiotics shine, is where you’re trying to make specific changes to that ecosystem going, “Okay, well you are…” And this is something that I do in my practice all the time, I do analysis. Okay, “You’re low in Bifidobacteria, you’re low in Akkermansia,” let’s say hopefully they’re there.
Dr. Weitz: Right.
Dr. Hawrelak: They’re maybe just a thousandfold less than where you’re happy to be, or a hundredfold less than what they should be.
Dr. Weitz: Right.
Dr. Hawrelak: Then yes, you could go, “Okay, well let’s go inulin-FOS,” or otherwise known as oligofructose-enriched inulin. Very good at feeding both Bifidobacteria, and Akkermansia, as well as Faecalibacterium. So you have this substance that we can generally effectively used to target increased population of those three species, without feeding other things for the most part in most people. And then partially hydrolyzed guar gum, good for a range of butyrate producing species. Then we have galacto-oligosaccharides, which would be Bifidobacteria and Faecalibacterium for the most part. But GOS can also decrease hydrogen sulfide producers like the Desulfovibrio and Bilophila. And inulin-FOS can also decrease Bilophila populations too.
Dr. Weitz: Oh.
Dr. Hawrelak: So we can use these tools to decrease levels of bugs we don’t want, and at the same time encourage levels we do want. And that’s the thing I absolutely love about prebiotics, is that capacity to, let’s say your gut’s overgrown with Proteobacteria, you’ve got large amounts of Proteobacteria? A prebiotic like lactulose, which I think kind of gets a bit of a bad name in the US because it’s the food source in the lactose breath test. But it reduces the levels of Proteobacteria brilliantly well in the colon. It is amazingly effective at doing so.
You’ve got studies showing that. And I can say from 20 years of practice having using lactulose, it effectively reduces Proteobacteria populations in the gut. So you can use something that is increasing levels of good guys, decreasing levels of pathogens, all at the same time. [inaudible 00:42:24]-
Dr. Weitz: So you’re saying for hydrogen sulfide, SIBO, FOS, and GOS combination might be part of an effective strategy?
Dr. Hawrelak: Yeah. You’d have to gauge what their tolerance, because sometimes they will get… One thing that hydrogen sulfide gas does is induces visceral hypersensitivity. So it makes the nerves in the colon more susceptible to gas related pain and discomfort. So you have to gauge where your patient’s at with that. Because if they’ve had H2S overgrowth for a long time, often visceral hypersensitivity can be intense.
So you do anything that increases gas production in the colon such as give GOS or inulin-FOS, that gas discomfort will cause excruciating discomfort and pain. So you have to approach it differently, depending on where they’re at with their symptoms, and how far along they’ve had this H2S issue with. Because if you get them early on, and they don’t have that damage yet? Then yes. Because essentially what we should be getting when we adjust GOS or and inulin-FOS, is farting.
We should just get flatulence. If our gut’s working beautifully, just gas, that’s it. But if we have issues there where we have bloated, distension, pain, cramping, worsening constipation, there’s something else underlying that we need to deal with. And those tools may not be appropriate at this time point. And we might use other strategies.
I think luckily with hydrogen sulfide gas producers, for the most part Bilophila, it eats bile. So you’re just like, “Okay, make sure they’re not taking ox bile supplements.” That can cause a massive bloom in hydrogen sulfide gas producers, that most people again aren’t aware of if you didn’t test for Bilophila. But reduce saturated fat, that’s a very quick and easy way to deal with Bilophila for most people.
Dr. Weitz: Well, but bile helps break down any kind of fats. Why saturated fat?
Dr. Hawrelak: Well, it’s a sulfur compound. When we’re ingesting dairy fat in particular, but also other saturated fats, the sulfur content in our bile is higher for whatever reason.
Dr. Weitz: Oh.
Dr. Hawrelak: And that feeds Bilophila to a far greater degree than if you eat olive oil.
Dr. Weitz: So you want to reduce the bile and the sulfur?
Dr. Hawrelak: Yeah. Yes, both. But particularly it’s about changing the types of fat consumed. But sometimes it’s overall fat too. But certainly you don’t tend to see Bilophila blooms from olive oil, avocados, nuts, and seeds. Even if they’re gorging on them, that does not happen. It is from dairy fat, butter, ghee, coconut oil, palm oil, those are the things that will cause blooms of Bilophila. So it’s often easy to deal with that by changing diet. Now, they can also be encouraged by supplements like chondroitin sulfate or glucosamine sulfate. Again, that aren’t always on people’s radar. And sulfur based preservatives, synthetic ones used in processed foods. So we’ll cut out those.
Dr. Weitz: Oh, you’re saying those, they contain sulfur so they could feed-
Dr. Hawrelak: And they can feed hydrogen sulfide gas producers too. Yeah.
Dr. Weitz: Interesting.
Dr. Hawrelak: So when people take chondroitin sulfate or glucosamine sulfate long term, which is often the case for things like osteoarthritis, we have to be aware that they can negatively impact the colonic ecosystem by encouraging the growth of hydrogen sulfide gas producers over time.
Dr. Weitz: Yeah. There’s studies showing that glucosamine sulfate reduces cardiovascular events by 30%. So it’s real beneficial for cardiovascular as well.
Dr. Hawrelak: Yeah, it’s an interesting substance in that way. And I think it’s just worthwhile keeping tabs on how that individual person’s ecosystem is responding to that dose of sulfur, and whether they’re having a bloom of hydrogen sulfide gas producers or not as a consequence of its use?
Dr. Weitz: Interesting.
Dr. Hawrelak: Mm-hmm.
Dr. Weitz: What do you think about biofilm busting? Is that something that should be done in combating SIBO? Do bacteria that cause SIBO encase themselves in a biofilm? And does that make it… For example, the methane producers tend to grow in the mucus and that’s sort of a biofilm. So does that mean you need to… You know what? I talked to Dr. Barr one time, and he was saying that he thinks that taking Akkermansia, which eats mucus, that that makes it easier to get at the methane SIBOs.
Dr. Hawrelak: Oh, that’s an interesting idea. And certainly Akkermansia is one of the species in the gut that does indeed consume mucus, Faecalibacterium does as well, and others. But an interesting idea, yes.
Dr. Weitz: Right. Now, coming back to what about using agents that supposedly break up biofilms to make it easier to get rid of the gas producing bacteria?
Dr. Hawrelak: Okay. My main concern here is that beneficial bacteria live in biofilm too. Because I think this is conception that some people have-
Dr. Weitz: Okay. Got it.
Dr. Hawrelak: … that bad guys live in biofilm and the good guys are just playing around and don’t. And it’s like, “That’s not true.” They do too. So if we’re giving something that is non-selective, and breaks down biofilm of all bacteria good and bad, then we’re actually harming beneficial species too. Unless you’ve got an agent that can selectively and only break down the biofilm of pathogens and leave the good guys alone. And you could research that before you marketed your product. You could do that research in vitro and go, “Hey. Look, our biofilm busting product doesn’t break down Bifidobacteria, or Faecalibacterium, or Akkermansia biofilm. But it does Klebsiella and E. coli,” wouldn’t that be great? But they don’t do that. Generally it’s like, “It kills bad guys, so therefore it must be fine for everyone to take [inaudible 00:47:49]-“
Dr. Weitz: Is there any biofilm busting agent that you know of where they have done that, looked at that?
Dr. Hawrelak: Not in that kind of sense. But we do know that herbal medicines, well, look at pomegranate husk. So the skin of the pomegranate fruit markedly antibacterial against pathogenic bacteria, leaves Bifidobacteria alone. And would actually leaves lactose alone, and encourages the growth of Bifidobacteria. So you have a selectively acting substance, that can break down the biofilm pathogens. We’ve got clear data around that, both bacterial and fungal pathogens. But actually encourages levels of beneficial species. So for me it’s like, “I’m going to use that, thank you very much. As my tool to try to target overgrowth.”
Dr. Weitz: Where do you get get pomegranate husk from, though?
Dr. Hawrelak: Well, interestingly enough, listen, it’s used in traditional Chinese medicine for 1,800 years.
Dr. Weitz: Okay.
Dr. Hawrelak: It’s been used in Ayurvedic medicine for over 2,000 years. It was used by Western herbalists and European herbalists up until probably about a hundred years ago, widely. It just dropped out in North American and Australian practice in the last maybe 50 years or something like that. You can find old herbalists in the early 1900s talked about using it too.
Dr. Weitz: Huh.
Dr. Hawrelak: I don’t know why it dropped out. But you could do a PubMed search of pomegranate husk. Punica granatum is the botanical name, antimicrobial, or even Google Scholar it, and you’ll get hundreds of papers. It’s so well researched as an antimicrobial agent.
Dr. Weitz: Yeah. But it doesn’t-
Dr. Hawrelak: It kills worms, it kills Giardia, it kills Entamoeba, kills a range of fungi, it kills pathogenic bacteria but leaves good bacteria alone. And for me, I’m just gobsmacked that there aren’t more people in industry who are like, “Oh, my God. Look at this, something that’s got hundreds of research papers on it. Why don’t we make a product with that?” And listen, it is happened here in Australia. I’ve been talking about the wonders of pomegranate husk for 20 years. And now there’s like four or five different products with pomegranate husk on the market for clinicians to access. But in America [inaudible 00:49:45]-
Dr. Weitz: Oh, okay.
Dr. Hawrelak: … to go there. You can buy the powder, you can buy organic pomegranate husk powder.
Dr. Weitz: Oh, really?
Dr. Hawrelak: What I love too is it’s a waste product. It’s like they’re throwing it out anyway, so it’s no ecological concerns about its use. We’re not like finding some rare herb, or something.
Dr. Weitz: Where do you get organic pomegranate husk powder?
Dr. Hawrelak: Well, there’s a brand in the states it’s called eSutras, E-S-U-T-R-A-S, that does organic pomegranate husk, pomegranate skin powder, pomegranate peel. And as more people are aware of it, more people will start requesting it. And then that’ll make a change in terms of how accessible it is.
Dr. Weitz: Interesting.
Dr. Hawrelak: But as I said, unlike some things where we worry about ecological concerns about harvesting Goldenseal, or Coptis, or something like that-
Dr. Weitz: Right.
Dr. Hawrelak: … because they’re these rare slow growing plants. This is the waste product of a huge industry, that we can get bioorganic pomegranates, we can get organic skins, and we can make medicine from that. And we should be given its research base, it’s long use over thousands of years, and its selectivity of action.
Dr. Weitz: Yeah. I know you’ve talked on other podcasts about being worried about some of the antimicrobials as potentially damaging the microbiome as well?
Dr. Hawrelak: Yeah. And that came directly out of my PhD research, where we were looking at the impact of herbs on the microbiome. And I was like, “Oh, look at the herbs that cause harm.” And it just occurred to me, what are these herbs doing to our good guys? And no one had done any research around that back in the early 2000s. So I was like, “Okay, I want to do this in vitro experiment of trying to grow these beneficial bacteria, expose them to a range of different antimicrobial herbs and see the impact.” And it was fascinating to see, because there were some substances like the berberine containing herbs like Goldenseal or Coptis chinensis that were amazingly good at killing Bifidobacteria. They’re good at killing Bifidobacteria, Lactobacilli were more resilient. But there wasn’t a dose that you could kill bad guys without harming beneficial species.
But there are other things like garlic, that could kill Candida and a range of pathogenic bacteria, and completely leave good guys intact. Whereas if you got the dose of garlic up high enough? Yeah, it would harm the good guys as well. So for me, that was a pretty pivotal research project, that really changed my thinking around this stuff. Going, “Okay, well these verbs can cause harm. Maybe we should choose the ones that are acting selectively.” And that’s really been the core of my practice since early 2000s, when I did that research project.
And now we have clear data on some studies looking at long-term berberine use in blood sugar control. And yeah, it does. And it brought down blood lipids and improved blood sugar control. But it hammered Bifidobacteria populations, it decreased butyrate producing species, it decreased diversity of the ecosystem. And perhaps most surprisingly caused blooms of E. coli, Klebsiella, Citrobacter, and a range of Proteobacteria bloomed with long-term use of berberine. Which I think was fascinating, because I was not expecting that. I was expecting Bifidobacteria diversity can go down with its long-term use. And probably butyrate producers with long-term use. The short-term use doesn’t seem to have such a big impact. But I was not expecting blooms of harmful Proteobacteria associated with long term berberine use.
Dr. Weitz: I heard you say something like that. I did a little data searching on berberine. And there were some papers that even showed that it was beneficial for butyrate producers, that it has a beneficial effect?
Dr. Hawrelak: Yeah. And I think short-term versus long-term is one of the factors.
Dr. Weitz: Okay.
Dr. Hawrelak: And there’s a couple of studies out of China, that they used hundreds of participants. They’re actually large studies and with three months of use, versus two weeks of use, or four weeks of use. And then you saw different patterns. We saw the blooms of Proteobacteria, the clear decrease of Bifidobacteria, and clear decrease of butyrate producers. And we may not see that decrease of butyrate producers in the short term studies.
Dr. Weitz: Okay. So when you’re talking about berberine, there are different products on the market. And I was talking to one of the manufacturers. And they said, “Look, when we are trying to use berberine as an antimicrobial, we’re giving you berberine from all these different herbs mixed together. When we’re using berberine as a blood sugar, and actually berberine is one of the few substances that’s been shown to reverse atherosclerotic plaque in arteries, when we’re using it for that purpose, we’re using berberine hydro…” What’s it called?
Dr. Hawrelak: Hydrochloride, probably.
Dr. Weitz: Hydrochloride, yeah. And that has a different action than berberine being derived from herbs. Do you think that makes a difference?
Dr. Hawrelak: No. I think it’s got to do with absorption. I think that’s what’s key is that berberine derived from Coptis, I think, it’s going to be same as berberine hydrochloride from an action standpoint. I think it’s whether it’s absorbed or not? And berberine, the challenge with berberine is it’s very poorly absorbed for the most part. Because our peak glycoprotein pump doesn’t like it. So it’s gets into the cell, and your enterocyte’s like, “Oh, I don’t want this thing,” and spit it back out into the lumen of the gut. So because of that, most of the berberine you ingest stays in the colon, where it interacts with the ecosystem. And long-term causes harm to that ecosystem. Now, there are ways of probably trying to enhance the absorption of berberine. And there are some companies that have focused on that, where they can combine it with Phosphocholine, the same way they do with turmeric or Boswellia, they combine.
Dr. Weitz: Right.
Dr. Hawrelak: Or green tea extract, they can combine it with Phosphocholine which increase absorption. Clinically I’ve used black pepper or piperine to improve the absorption of berberine as well, to get it out of the gut into the bloodstream. For me, I’m using it to treat dental abscess infections, where I want the antimicrobial action of berberine, but I don’t want it in the gut, I want it in the bloodstream. And piperine turns off peak glycoprotein pumps and enterocytes. So you actually end up with a ton more berberine in your bloodstream if you take it with piperine. So there are ways of modulating it, so you can increase the absorption and decrease colonic damage with its use. But I think it’s imperative we’re aware of the fact that it does harm the microbiome with long-term use too. Because we might have options, like if we go, “All right, berberine is one way of controlling blood sugar. But so is Nigella sativa, black seed.” Tons of studies on that showing very similar results. And you don’t get the microbiome harm with black seed.
So I’m like, there’s often, often choices. With atherosclerosis, I came across a study that used, I think it was Pycnogenol and Gotu kola, showing clearance of artery plaque with long-term use. And again, I’m much more comfortable using that for months to years than I am berberine. I don’t mind using berberine for two weeks, no issue at all for just treating Giardia as something, I don’t mind using it for two weeks. Or I don’t mind again, treating a dental abscess where I’m giving it with, or other systemic infection, with black pepper to enhance the absorption for 10 to 14 days. But I’m really cautious with any more than 14 days use. And we don’t necessarily know at what point we get that more substantive microbiome harm with berberine. We can just say the studies that looked at three months, definitely showed the damage that was done. So for me, I’d certainly be cautious that it’s something to recommend on a daily basis for years, such as substance.
Dr. Weitz: Yeah, I haven’t seen that. But… Yeah. Yeah.
Dr. Hawrelak: Yeah, it would be interesting if you did shotgun metagenomic sequencing with all your patients pre and post.
Dr. Weitz: Oh, okay. Yeah.
Dr. Hawrelak: So you do that beforehand, do it after three months, and see the impact. I can just say that I’ve seen it with my patients.
Dr. Weitz: Right.
Dr. Hawrelak: And I’ve seen the research is clear with long-term use, there are certain patterns that you start seeing with it that are not positive.
Dr. Weitz: You just mentioned turmeric. I’ve been using curcumin, a highly absorbed form of curcumin to help some patients with visceral hypersensitivity.
Dr. Hawrelak: Yeah.
Dr. Weitz: I’ve seen a couple of papers on that. What do you think about that?
Dr. Hawrelak: Yep. Love it. I love it. And I use it heaps for that same purpose too. I use Iberogast lots for that.
Dr. Weitz: Okay.
Dr. Hawrelak: Iberogast, it’s a herbal combination.
Dr. Weitz: Right.
Dr. Hawrelak: For whatever reason it’s hard to come by in the US. But in Australia and in Europe it’s much easier to find.
Dr. Weitz: Yes. Somehow for a while it wasn’t available at all.
Dr. Hawrelak: Yeah.
Dr. Weitz: And something happened with the manufacturer, or I don’t know.
Dr. Hawrelak: Yeah, I’m not sure. We had constant access to it here, so I’m not sure what happened overseas. But it’s something that effectively decreases visceral hypersensitivity with patients. Because I think I’ve got some patients who have IBS and they go, “Oh, I’ve tried Iberogast for two weeks and it didn’t decrease my symptoms.” I’m like, “Well, yeah.” We’re lucky if it decreases the symptoms, and a lot of people it will decrease bloating, and distention, and abdominal pain, and cramping for sure. But we’re using it to decrease visceral hypersensitivity. And that takes three plus months of use to see that kind of benefit. And I use it all the time with a well-absorbed turmeric phytosome extract, so that they’re… And usually within three to six months there’s a massive improvement in their visceral hypersensitivity. Which means that their diet can be expanded, they can have more onions, and garlic, and legumes, and other things that nurture a wide range of beneficial microbes they may have had to cut out, because their gut was so sensitive to gas pressure.
Dr. Weitz: Interesting. So some people might be able to tolerate a much lower level of gas, if so, it’s not just about getting the gas down?
Dr. Hawrelak: Oh, totally.
Dr. Weitz: It’s… Yeah.
Dr. Hawrelak: Yeah. That’s very clear from the IBS research that, yeah, there is some research showing that people with IBS have produced more gas. But there’s more research showing that they’re sensitive to the gas being produced. And I always tell this example to my patients, but they put these special balloons up their butts and they pump up those balloons, and people with IBS will complain of pain when the balloon is this full, whereas normal people would when the balloon is that full, before they get the same degree of pain and discomforted.
Dr. Weitz: Right.
Dr. Hawrelak: Because the nerves are just hypersensitive. And that can be pretty extreme in some cases.
Dr. Weitz: It depends if you take the population from West Hollywood or not. I’m just kidding. So what do you think about soil-based probiotics?
Dr. Hawrelak: Ah. Listen, I’ve been organic gardening for over 30 years. I love it. And I organic garden all the time. I’m with nature, and I’m drinking creek water, and exposing myself to lots of wild microbes. And I think that’s important.
Dr. Weitz: Are you drinking creek water?
Dr. Hawrelak: I do drink. Well, not from a dirty source obviously. But if I’m out in the rainforest and it looks clean? Yes, I’ll drink creek water. I was out in Canada up in the highland Rocky Mountains where again, I don’t think people were peeing and pooing upstream. And I’m happy drinking creek water. And I wouldn’t even worry if it was like healthy people peeing or pooing to be honest. It’s just like people who don’t have such healthy gut ecosystems or are have Giardia or something, I don’t want to drink their downstream water. But it is an interesting way of picking up microbes from the environment, anyway. And I think we even know that interestingly though, even having a more diverse garden, if you have a wider diversity of plants growing in your garden, you have a more diverse gut ecosystem as well. So we are certainly always picking up microbes from the environment. Generally it’s temporary, usually.
Dr. Weitz: Oh, so I’m really referring to spore-based probiotics?
Dr. Hawrelak: Well, you are talking about soil-based ones too. But I suppose I’m just taking the conversation a bit further. Yeah.
Dr. Weitz: I think spore-based are often referred to as soil-based?
Dr. Hawrelak: Yeah.
Dr. Weitz: Right?
Dr. Hawrelak: Yeah. And I think that-
Dr. Weitz: And are they the same or not?
Dr. Hawrelak: Well, I don’t think all soil-based ones will be spore formers, for sure not.
Dr. Weitz: Okay. Not. But spore are soil-based? Okay, I see.
Dr. Hawrelak: But certainly the ones that people are often marketing, they are spore based. And originally probably derived from soil as well.
Dr. Weitz: Okay.
Dr. Hawrelak: Yeah. I think there’s a growing body of evidence building around the use, which I’m really happy to see. I think they were over hyped initially compared to the evidence base. And I think that’s changing is more evidence comes onboard. So for me it’s always around evidence, if there’s evidence that this product is safe and efficacious, whether it comes from soil, or it comes from the skin of litchis, or it came from some healthy Swedish person’s gut, or another Swedish person’s breast milk? Like the reuteri DSM 17938 came from someone’s breast milk, for example. I’m totally happy to use it if it’s safe and efficacious. And again, I don’t mind if it’s coming from soil or whatnot. I just think that the evidence base for them as class compared to Bifidobacteria, or Lactobacilli, or even Saccharomyces is just a lot less at the moment.
Dr. Weitz: Right.
Dr. Hawrelak: But there’s research on Bacillus coagulans. GBI306086, I think from memory is its code name, strain name, that for rheumatoid arthritis. And there’s no other probiotic with good data for rheumatoid arthritis. So I will definitely use that in that condition for sure. So I think if it has something that’s unique or better evidence based, I would totally use them irrespective of where they came from.
Dr. Weitz: Right.
Dr. Hawrelak: Yeah. And I think just sometimes the generalizations out there sometimes are a bit much, of like, “Oh, coming from the soil, therefore we should all be ingesting it.” It’s like, “Well, what soil? Where, which part of the world?” Soil would be different elsewhere. The assumption that something that lived in garden soil is going to be a happy in your gut growing at 37 degrees in quite a different environment than soil is a bit much too, if you’re expecting it to permanently colonize.
But we know that sometimes you can pick up bugs from soil, and have them stay for long periods of time. And we know that people who are active gardeners in summer, they can have a tremendous number of increased microbes. Some people, compared to what it’s in winter when they’re not actively gardening, where you have temporary visitors of these soil derived microbes as well.
Dr. Weitz: You mentioned a specific probiotic that helps with rheumatoid arthritis. The GI-MAP stool test which we tend to do a lot, has a section where they have bacteria that may be correlated with autoimmune conditions. And there’s a certain amount of data showing that those specific bacteria, that there’s a certain level of correlation with specific autoimmune conditions. And so if those bacteria are overgrown, the idea is maybe if I could reduce that bacteria, maybe we could have some benefit. What do you think? Where are we? Is it still pretty speculative?
Dr. Hawrelak: Oh, I think it’s a bit speculative. But we see disease associations [inaudible 01:04:14] certain patterns with certain disease states all the time. And I can say I’m a clinician too. So I’m a researcher clinician, I see patients. So I see what works and what doesn’t work. And I’m happy to prescribe things that work clinically too, that haven’t even been researched necessarily yet either. So I’m okay with some relatively novel stuff of going, “Okay, there’s a study that shows that low Akkermansia or low Bifidobacteria in eczema seems to be a common pattern.” And I go, “Okay. Well, I will increase Bifidobacteria in my eczema population.” And clinically you see good results by doing that in terms of decreased allergies and decreased reactivity. So I’ll base my decisions along that too. So I think yes, there’ll be a degree of speculative that’s there, but you might have to again trace that back. I’m not familiar with all the microbes that they associate with increased risk of autoimmunity.
Dr. Weitz: Right.
Dr. Hawrelak: And you might just want to double check that. And going, “Okay. Well, do I concur by my view of the connection between those ones?”
Dr. Weitz: Sure. Yeah.
Dr. Hawrelak: But I’m open to that approach in general, of the different disease associations, associate diseases with different microbiotic patterns. And how we can modify that to change the disease process. Because that’s something I do every day in clinical practice, and see the results of.
Dr. Weitz: Cool. Great. Awesome discussion. Jason, thank you so much. I could ask you a hundred more questions. But I appreciate your time and I respect it. So tell our listeners and viewers about the things you have to offer, the Probiotic Advisor, your courses, where can they go?
Dr. Hawrelak: Yeah. So we set up the Probiotic Advisor as an independent, evidence-based, accessible information around probiotics. So you can take industry out of the way, out of the equation and go, “What does the evidence say about this probiotic strain for this condition?” So it’s a searchable database, where you can type in a condition or a product, and you can work out what the research says it should be used for. And that’s been going for a number of years. And that’s one of my babies that came out again, of wanting people to be as evidence-based when possible, in choosing… We really wanted to improve outcomes with patients, that’s what it boils down to. And if we can do that by using evidence to go, “Okay, this product chain works for this condition, this one doesn’t?” Use the one that works, don’t use the one that doesn’t. And don’t even just guess, maybe it’ll work. Just use the one that works. And I also offer a range of courses through the Microbiome Restoration Center as well. And I’m mostly targeting clinicians, because I love teaching clinicians around gut health and microbiome restorations. So we have two general courses, natural and functional medicine approaches to gastrointestinal conditions.
And then another 10 week course, which is Advanced Microbiome Manipulation. Which is all about some of the concepts we talked about today. But about different testing approaches in different labs and interpretations. But also how to modify ecosystems in beneficial ways. In a way that, for me, the thing that came out of my PhD looking at the wonders of the microbiome, I’ve been indoctrinated in the wonders of the microbiome from the late ’90s when I started my first reading around the microbiome, is choosing therapeutic approaches that minimize harm from the microbiome perspective. Which is an old naturopathic concept of first to no harm.
And I think if we have choices of tools, we can choose berberine or we can choose pomegranate husk? I’m going to choose pomegranate husk. If I can get the same outcomes, without the negative outcomes on microbiome perspective, I will choose that first. So that underlying philosophy that runs through my teaching, is to optimize ecosystem and minimize agents that cause harm, or interventions that cause harm as much as we can. And also being aware. Like I had a patient last week who, a ketogenic curated diet for child epilepsy made a huge difference, huge difference to having daily seizures that were uncontrollable, to having mild seizures daily from doing a ketogenic diet. But our focus will be on how do we maintain your ecosystem health, when you’re on this diet that you need to be on because it’s really helpful for you? How do we make sure you’re still feeding your beneficial bacteria? And how do we prevent the bloom of harmful species, that over the long term could potentially actually be counterproductive to what we’re trying to achieve in terms of neurological inflammation? So I think always having that, as how do we optimize microbiome health for this person? And how do we choose agents that are most likely to do that, at the forefront of our minds as clinicians.
Dr. Weitz: That’s great. And if listeners want to work with you?
Dr. Hawrelak: Yeah. I do see patients through Gould’s Natural Medicine, which is my clinic down in Hobart, although I’m not in Hobart now. But I see patients internationally, I’m completely online these days.
Dr. Weitz: Right.
Dr. Hawrelak: Yeah.
Dr. Weitz: Okay. Great. Thank you so much. Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify, and give us a five star ratings and review. That way more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients. So I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions. Or for an executive health screen to help you promote longevity, and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing. And we’re going to look at a lot more details to get a better picture of your overall health, from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition Office at 310-395-31-11. And we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
https://drweitz.com/wp-content/uploads/2023/10/rwp-329-website.jpg350785drweitzhttps://www.drweitz.com/wp-content/uploads/2017/06/drweitzdsamplelogo-withtext.pngdrweitz2023-10-11 21:08:212023-10-24 04:45:27Probiotics & SIBO with Dr. Jason Hawrelak: Rational Wellness Podcast 329
Dr. Peter Bongiorno discusses An Integrative Approach to Depression and Anxiety at the Functional Medicine Discussion Group meeting on September 28, 2023 with moderator Dr. Weitz.
[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.]
Podcast Highlights
9:27 The Neurotransmitter Theory of Depression and Anxiety. This theory is that specific neurotransmitters are responsible for mood disorders. For example, this theory includes the idea that depression is caused by a deficiency of serotonin. In 2008 the New England Journal of Medicine published a paper suggesting that maybe this whole serotonin theory wasn’t true, and a lot more people who took SSRIs actually didn’t have as positive effect. [Belmaker RH, Agam G. Major Depressive Disorder. N Engl J Med 2008; 358:55-68.] Then Fournier in JAMA published a paper showing that SSRIs had no better effect than placebo for mild to moderate depression, though they are beneficial for severe depression. In 2020 a paper discussed that the evidence is that “The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations.” [Moncrieff, J., Cooper, R.E., Stockmann, T. et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry (2022).] Some studies show that a medication, Stablon, which lowers serotonin, is equally effective as SSRI drugs that raise serotonin levels. This is not to say that serotonin has no effect but only 27 to 35% of patients who take an antidepressant have a positive response. Even if serotonin is a factor, there may be other factors that affect whether that antidepressant can be effective, such as do they have enough amino acids in their diet to make neurotransmitters? It could also be because estrogen or other hormones are low or their adrenals or thyroid are off. Even if depression or anxiety are related to a neurotransmitter issue, we should be trying to figure out what caused this dysregulation of neurotransmitters. Those reasons can include physiology, nutrients, hormones, inflammation, digestion, lack of sleep, not enough exercise, too much exercise, mitochondrial dysfunction, toxicity, mold.
16:02SSRIs. Drugs that potentially modulate serotonin and the other neurotransmitters, like the Selective Serotonin Reuptake Inhibitors (SSRI) even when they do work, tend to stop working after a period of time. And there are many problems with these drugs, including that they are very difficult to get off of these drugs when you want to stop taking them and they have significant side effects, including a significant increase in all-cause mortality. Dr. John Neustadt spoke at the Connecticut Naturopathic Conference about how SSRIs increase the risk of osteoporosis by changing osteoblastic and osteoclastic activity. Also when you place someone on these SSRI medications, it does change the function of the HPA axis and does change the ability and the balance of how the body regulates things like circadian rhythm, how it regulates the production of neurotransmitters, how it regulates the production of receptors.
23:35 Blood Sugar. Blood sugar is especially important for anxiety. Kids who have anxiety often have high blood insulin and low blood sugar from eating highly processed, high carbohydrate foods, which stresses out the primitive brain. Dr. Bongiorno will sometimes see kids who are eating poorly and will have high insulin, low blood sugar, and low iron (ferritin) and that is a recipe for anxiety. A patient like this may have multiple nutritional deficiencies. Such patients often have trouble focusing, so they may get put on medications for focus and ADHD, which ramps up the dopamine and this makes the anxiety worse. We may now have a young girl who other than her poor diet is otherwise healthy and now she finds herself on medication for focus and several medications for anxiety and we still haven’t fixed the underlying issues yet. This patient is likely not eating enough protein to give her brain enough of the amino acids and other nutrients needed to produce the serotonin that she is taking medication to try to increase, so this approach is likely to fail. Or they may have poor digestion or low stomach acid or they may not be chewing their food well because they are anxious and in a rush, which means they are not breaking down their proteins. Or their microbiome may be out of balance and this may affect neurotransmitter production and hormone production, etc. A good recommendation for such patients is to make sure to have a good breakfast in the morning when their digestion is its strongest. While intermittent fasting can be beneficial for a number of reasons, for the patient who is anxious and undernourished and has low blood sugar, it may make more sense to have smaller, more frequent meals. On the other hand, for a postmenopausal woman who is having trouble taking weight off, intermittent fasting and detoxification may be beneficial.
30:54Coffee. Coffee can be healthy and beneficial, especially for those with depression, and its a good way to get the bowels moving. On the other hand, depending upon the person, it could increase anxiety. It depends upon how well that person processes caffeine. It should be organic and we should avoid putting sugar and dairy in it.
32:58Alcohol. We used to think that a modest amount of alcohol was healthy, but now the studies seem to be showing that for cancer, no amount of alcohol is good. It may have a slight benefit for heart health in raising HDL levels. Alcohol has a relaxing effect, so that may have some benefit, esp. for anxiety. Dr. Bongiorno told how his parents used to drink a Manhattan before dinner, which they placed gentian bitters in, which they would do while his mom was making dinner. The alcohol relaxed them and the bitters promoted the release of digestive enzymes, promotes better digestion.
36:17 Sleep. Sleep is crucial to good health and mood. During sleep is when we detoxify our brains and where our mitochondria build back up.
38:19Exercise. Exercise is crucial for mental health and if you are feeling stressed and you don’t move your body, the stress hormones tend to affect your brain more. When we are under stress, we are in a fight or flight mode and we need to move to equalize that stress, while we work on creating better balance in our nervous system. Exercise helps us build better mitochondria, which we need for our nervous system to work really well. In the short term, exercise increases gut permeability, but when we exercise regularly, we have less gut permeability and we have better digestion. People who exercise regularly feel better and live longer.
47:04 Labs. Dr. Bongiorno likes to run labs for mental health, whether the problem is anxiety, depression, schizophrenia, or bipolar disorder. But first we should take a good history and make sure the basics are there, including sleep, exercise, eating green vegetables and consuming essential fats. Then he will usually run the basics like a CBC, blood sugar, insulin, A1c, a full thyroid panel with antibodies, vitamin D and an iron panel, incl. ferritin for iron storage. And then looking at some of the vitamins, magnesium, zinc, zinc-to-copper ratio, B12. Depending upon the patient, he will also run sex hormones and then look at adrenal cortisol testing, melatonin and glutathione levels, and mycotoxin testing can be helpful. Stool testing can also be beneficial to look at the microbiome. He will try to work through Quest and LabCorp when possible for the basic lab work in order to have them covered by insurance and then he relies on specialty labs like the DUTCH panel, Genova for adrenal testing, Diagnostic Solutions for genetic profiles and stool testing, RealTime Labs and MyMycoLab for mycotoxin testing.
Dr. Weitzis 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. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. 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. Okay. Hello everybody. I’m Dr. Weitz, in case you don’t know. Thank you for joining our functional medicine discussion group meeting tonight with Dr. Peter Bongiorno on an integrative approach to depression and anxiety. I hope you’ll consider joining some of our other upcoming meetings. October 26th, we’ll be discussing integrative cardiology with Dr. Howard Elkin, and this will be our first in-person meetings since 2019. November 16th, we’re going to meet again. Topic is most likely going to be long COVID, though I still have to confirm it. December, we’re going to be off, and then January 25th, we’ll start off the year with Dr. Vojdani. I encourage you to participate in the discussion by typing your question into the chat box, and then I’ll either call on you or ask Dr. Bongiorno your question when it’s appropriate. If you’re not aware, we have a closed Facebook page, the Functional Medicine Discussion Group of Santa Monica. This is for practitioners that you should join, so we can continue the conversation when this evening’s over. I’m recording the event and it’ll be included in my weekly Rational Wellness podcast. The Rational Wellness Podcast is available on Apple Podcast, Spotify. There’s a video version on YouTube. If you don’t listen to it regularly, please check it out. If you do listen to it regularly, please give me a five star review on Apple or Spotify. And I’d like to thank our sponsor now, which is Integrative Therapeutics, and we have Steve Snyder on the line to tell us about a few Integrative Therapeutic products. Steve?
Steve Snyder: If I can unmute. I always hate talking at these things because I know that everybody’s waiting for the speaker to talk and they’re way more interesting, but this one happens to be kind of right up our alley, and we have a few products that I just want to remind people about. The big one is Lavela, which is our lavender oral essential oil, essentially for anxiety. This is one of the products that we grow ourselves and market in Europe. So there’s about 25 clinical studies on it showing significant reduction in symptoms and similar efficacy to pharma products. It’s the real deal. Really the only side effect to it, and Dr. Bongiorno, you might be able to … people burp lavender. It’s not the worst thing in the world. It’s better than fish oil, but we also have a product called Neurologix that includes saffron, citicoline, and a unique spearmint extract that’s mostly for kind of a cognitive improvement, but it does also have a serious impact on mood, and we feel like those are sort of connected. And then… Yeah.
Dr. Weitz: Hey, Steve, can you just address the concern that some people have about using lavender? There’s this thought out there that’s going to decrease testosterone levels.
Steve Snyder: So this is one of those urban legends that we can’t get to go away, and thanks for letting me throw this one out there, too. Sort of like black pepper and curcumin. The lavender issue is related sort of, if you do a little Google searching, it all comes back to one doctor who had one patient, it was a kid who used to bathe in lavender and he got gynecomastia. It went away when they stopped bathing him in lavender. But there’s really nothing to that other than that sort of snowballed into all of these references that basically go back to that same thing. We have a warning on it to not use it in prepubescent men or males, but it’s literally one of our top five selling products, and we’ve never had any report of it. So if you know us, you know how conservative we are on labeling stuff. If there was any kind of worry about it, we would have it plastered all over the product and we don’t. And literally, this is one of the most heavily studied nutritional supplements out there. It’s over 20 studies now, so it’s not something we’re worried about. And if we’re not worried about it, I’m fairly certain you shouldn’t be worried about it. So does that help?
Dr. Weitz: Okay. Great. Yeah, thanks Steve.
Dr. Bongiorno: And then the Theracurmin, the curcumin supplement, that’s a big one for mood and memory as well, all kinds of cognitive stuff. We actually have a new one that’s better than Theracurmin called Curalieve. There’s no clinical studies on anxiety and depression yet, but there’s a great one on memory and mood. And then Cortisol Manager, that’s everybody’s favorite for everything, so we always say that one. So I’ll throw some links into the chat and if anybody [practitioners] wants to know more about them or sample any of these, we can make that happen.
Dr. Weitz: That’s great. Thanks, Steve.
Steve Snyder: Yeah.
Dr. Weitz: So, let me just quickly introduce the topic and then we’ll introduce our speaker and we’ll get started. So we’re going to talk about mood disorders. Depression is a mood disorder characterized by a persistent feeling of sadness and hopelessness and a loss of interest or pleasure in previously enjoyed activities. Gallup research found in 2023 that the percentage of US adults who report having been diagnosed with depression at some point in their lifetime has reached 29%, the all-time high and 10 points higher than in 2015. Anxiety is characterized by feelings of worry, nervousness, or fear that are strong enough to interfere with one’s daily activities. In 2023, 28% of US adults reported symptoms of anxiety disorder in the past two weeks, though this was lower than the all time high in 2021.
Dr. Peter Bongiorno is a naturopathic doctor and acupuncturist in New York City, and he also works with clients via phone and Skype. He’s written a number of books including Healing Depression, Holistic Solutions for Anxiety & Depression, which is an incredible book, and I’m reading it again for the third time. And there’s just so many great clinical pearls, especially for functional medicine practitioners. And he also wrote How Come They’re Happy and I’m Not?, and Put Anxiety Behind You: The Complete Drug-Free Program. Both of these are for patients. His website is drpeterbongiorno.com. Peter, thank you so much for joining us.
Dr. Bongiorno: Thank you, Dr. Ben. Thank you for that introduction, and thank you for bringing people together and spreading good energy. Really appreciate it.
Dr. Weitz: Absolutely. Yes, it’s my mission. So it sounds like anxiety levels were highest during COVID, which I guess is understandable, but it sounds like maybe depression has resulted from all this, and I wonder if this might even be a untalked about symptom of long COVID.
Dr. Bongiorno: Yeah. Well, I mean, I think there are a lot of similar underlying factors that contribute to long COVID, and a lot of those factors and mechanisms also play a very strong role in depression as well. So it makes a lot of sense to me that we’re going to see this clinical and subclinical long COVID syndrome. And along with that, we’re going to see more depression, too.
Dr. Weitz: Right. So let’s start by talking about the neurotransmitter theory of depression and anxiety for those who aren’t … I’m sure we must all be familiar with it, but the concept is that somehow depression, for example, is caused by a deficiency of serotonin, and that specific neurotransmitters are responsible for these mood disorders, and that’s somehow we can modulate this by taking medications that increase serotonin or norepinephrine. Where are we in terms of this theory? Have we learned? Is there more evidence for this concept, or is it even more in doubt?
Dr. Bongiorno: Yeah. Well, I mean, in the end, it really depends on the patient, right? But if you look at the literature, the New England Journal of Medicine in the early aughts, I think it was maybe 2008 or nine had published a paper suggesting that maybe this whole serotonin theory wasn’t true, and a lot more people who took SSRIs actually didn’t have as positive effect. And then a few years later, a fellow named Fournier in JAMA, right?
Dr. Weitz: Yeah.
Dr. Bongiorno: The Journal of the American Medical Association, published a paper looking at all the studies that supposedly weren’t looked at. Some people felt they were hidden, and that’s why we didn’t see them. And when he looked at them all, what he noticed was that SSRIs really for mild to moderate depression, really didn’t have a better effect than using a placebo. In severe depression, there was a beneficial effect, but not in mild to moderate. And then really about a year and a half ago, another paper came out of strongly suggesting that serotonin itself might not be as strong a player in depression as they thought originally. And it’s interesting because again, maybe about 10, 15 years ago, there are some studies on another medication called Stablon, which is the opposite of an SSRI. It’s a serotonin…it actually helps keep less serotonin around. And they found that about 30% of people did well with that drug, about the same amount that did well with the SSRIs. And so, kind of people scratching their heads going, “Wait a second. One drug that does the exact opposite has as good effect as the drug that’s supposed to keep the serotonin around.” And in my opinion, that’s not to say that serotonin has no effect. What we need to understand is that neurotransmitters are real. If you think about disease, very typical metaphor, the disease is like an iceberg, right? So neurotransmitters are the tip of that iceberg. So the question is, and there are maybe 27 to 35% of people when they take an antidepressant, they do feel better. And I believe that’s true. I’ve seen that clinically. So it’s not that no one does well with it, but it’s not, unfortunately, the high rates that originally that were being told to us. And the reason is is because there’s many, many other factors in depression besides serotonin, and maybe for 25, 30% of people, that is a major piece of it, but for many people it’s not. And then for the people that serotonin is a major factor then we have to ask, well, why is serotonin low that when we use the drug, it does work?
And that could be so many other reasons. It could be not enough amino acids in their diet. It could be because estrogen is low or other hormones are low or adrenals are off, or thyroid. I mean, so there’s a whole lot of reasons. So that’s the question that we need to ask, not whether neurotransmitters themselves are the only reason. And that’s unfortunately where I think modern psychiatry has been for a long time. And when you think about psychiatry, I’ve worked with many psychiatrists over the years, and the ways explained to me was that before there were psychiatric meds, psychiatrists themselves weren’t looked at as, quote, “Real doctors,” because they didn’t have drugs. So they themselves felt like they weren’t real doctors because when somebody got sick, there wasn’t a drug to use. And then as the years went on, they developed all these different drugs. They accidentally, they were unearthed that they had some benefits. It was actually in the beginning, it was studying TB is actually how they started isoniazid. And they started figuring out this whole idea of mono means and the blocking of those. And anyway, that’s another story.
But the point is then psychiatry started having drugs that they did notice having an effect, especially for patients who were originally put in sanitariums and locked away. And so, like the magic pill for so many other things, that seemed like the approach to take. And unfortunately, that’s still the approach that’s being taken. And we’re not getting to the point where we’re saying, “Okay, this human being has a lot of physiology going on.” And there’s a lot of different reasons in that physiology, nutrients, hormones, inflammation, digestion, lack of sleep, not enough exercise, too much exercise, mitochondrial dysfunction, toxicity, mold, all of these things that are going to play a role in why neurotransmitters change. So that’s what I’m hoping, as the years go on, that we’re going to start to understand is we have to really treat that whole person and all of those issues. And maybe it is a neurotransmitter issue, but we don’t want to just focus on trying to regulate a neurotransmitter. We want to figure out what the underlying cause of that dysregulation is if it is a neurotransmitter.
Dr. Weitz: Absolutely. And it also sounds like there’s a large number of neurotransmitters that have a number of different complex roles, and it sounds like it’s not as simple as just serotonin for depression and just another neurotransmitter to make you happy. There’s this complex symphony of various neurotransmitters that play various roles that we probably only scratching the surface on. And then of course, we have the problems with these drugs, which are number one, that even when they do work after a while, they tend to stop working. They’re very difficult to get off of, and they have significant side effects, including a significant increase in all-cause mortality.
Dr. Bongiorno: Yeah. I recently went to the Connecticut Naturopathic Conference and I gave a talk there, and one of my colleagues, Dr. John Neustad, he was speaking about SSRIs and the effect on osteoporosis, for example. And that was something that I’d heard a little bit about, but I didn’t know too much, and I didn’t realize how deeply those mechanisms lied and how they changed osteoclastic and osteoblastic formation. And so, that was something kind of new for me in the world of SSRIs, which I always think about them even from a hypothermic pituitary adrenal access standpoint, how they really do change function. And I do find when patients are put on these medications, which sometimes in an urgent care situation where somebody might hurt themselves or somebody else, sometimes it can be lifesaving. So I’m not trying to say that they should never be used, but I think at this point, the prescriptions way outnumber the need for it by a factor of many.
And unfortunately, when you place someone on these medications, it does change the function of the HPA axis and does change the ability and the balance of how the body regulates things like circadian rhythm, how it regulates the production of neurotransmitters, how it regulates the production of receptors. And especially in younger people, I see that sometimes can make it much harder to actually treat them because even if they feel better for a while with the medication, it still becomes more of a challenge to work on the underlying issues because now you have this HPA axis that’s now been manipulated and changed a bit, and that sometimes can make it a little more challenging to really treat the underlying causes.
Dr. Weitz: Interesting, interesting. So our challenge from a functional medicine approach is more difficult.
Dr. Bongiorno: Yeah. And look, like I said, if you have somebody who can’t get out of bed, is thinking of hurting themselves-
Dr. Weitz: Absolutely.
Dr. Bongiorno: .. when you want them to do all this nice testing and go to Whole Foods and buy some salmon, if anyone’s ever gone through it, you know. It’s nice to think about these things, but you feel awful and there’s nothing. So sometimes medication can get you out of that place and bless it if it can, but it is a challenge once it’s there to figure out how to help the body rebalance. Not impossible, but it’s definitely, I think as functional medicine, naturopathic, holistic practitioners, and especially those of us who are working with the conventional psychiatry world, we have to create a process and maybe a flow that allows us to question like, “Okay, do we need this medication in the beginning? Is it safe to start with that one? Can we start by working on more of the basics? Does this person monitored properly and in a safe place? And are they a single mom who needs to take care of a child and isn’t taking care of this child?” We have to ask all these questions to find out whether, be a little more judicious when we start using medications and see if there’s an opportunity to not use it because I think that allows the functional medicine to work even better once we bring it in.
Dr. Weitz: Right. Especially as you’re describing in a case where somebody has mild to moderate depression-
Dr. Bongiorno: Exactly.
Dr. Weitz: … they’re not suicidal, they’re not in a situation where they’re an air traffic controller or taking care of young kids that they might not otherwise be able to take care of. Certainly in those situations, whatever you can do, medication, anything else to get that person doing better is the most important thing.
Dr. Bongiorno: Absolutely. Yep.
Dr. Weitz: So what are some of the most important dietary factors that play a role in triggering depression and anxiety? Is there a best diet? What sorts of things should we be thinking about?
Dr. Bongiorno: Yeah. Well, when I think about working with someone who has any condition, but especially mental health, I think about two things. Are they sleeping and are they pooping? So as far as pooping, the first thing I think about is are the bowels moving enough? Because if the bowels aren’t moving preferably every day, it is hard to create balance with inflammation in the body, with toxicity, with hormones, with nutrition absorption. All of those things really rely on bowel movements and the bowels moving every day. So I find that that’s critical, and we need to do our best, whether it’s to add fiber, to add water. Sometimes when anxiety is so high, that can be a reason the bowels shut down because, of course, when you’re running from a bear, you’re not going to be sitting down to eat a meal. So the body, the perimeter brain naturally shuts the gut down. So sometimes doing things more acutely to help lower anxiety can be useful, whether it’s through supplements or acupuncture, just to kind of calm things down a little bit to get the bowels moving. So getting the bowels moving is my first order of business. In a sense, I don’t even get as concerned with what a person’s eating unless I think it’s constipating them too, because we just want them moving. The body’s so resilient, and we all know this. We know people who can eat absolute junk and stay really healthy because the body just wants to be healthy. And sometimes with the right genetics, it could do it even with poor food, not that I’m recommending that.
And then the next step would be sit down and say, “Okay, what are we eating here and what can we change for the better?” And I would say without knowing a person or knowing their sensitivities or their preferences, if I had to pick a diet, I’d probably start with some version of the Mediterranean diet. Sánchez and Villegas in Spain started studying the Mediterranean diet in the early aughts, probably about 2003 or four were the first papers that came out. And so many papers have come out since then. And they’ve really shown how the Mediterranean diet works on that endothelial lining of the blood vessels. And it really helps with inflammation. It really calms inflammatory markers, the benefits it has on anxiety and depression to both prevent and treat the condition. When you really look at even studies on longevity and the blue zones, people are pretty much eating some geographical version of the Mediterranean diet. So that would be a place I would start in terms of foods.
Dr. Weitz: What are some of the other important dietary factors? Blood sugar we know is super important.
Dr. Bongiorno: Yeah. So blood sugar is definitely, especially with anxiety, I find blood sugar regulation is a key. I was working with a young girl who came in 17 with her mom and very severe OCD and anxiety, and we talked a little bit and it was so clear that her blood sugar was so low. And then when I looked at her blood work, her blood sugar was around 62, her fasting blood sugar-
Dr. Weitz: Wow!
Dr. Bongiorno: … which is pretty low, not the lowest I’ve seen, but pretty low for a fasting blood sugar. And because it wasn’t high, no doctors really talked about it that much. No one had mentioned it to her. No one looked at an A1c, but I bet you the A1c is probably around four, and no one really looked at insulin. And sometimes now in young people, you see these very high insulins because of all the highly processed carby foods we’re eating, it spikes all this insulin and then it drops their blood sugar. So you have kids who really don’t eat much nutritionally, and they’re still eating a lot of sugar. So you get this high insulin, low blood sugar, and if you want to get the primitive brain stressed out and create an anxiety response, just keep the blood sugar low. And then in this particular case, one of the other things that I noticed was that the ferritin was very, very low. And I see this also because you get these young women who are menstruating typically earlier and earlier, they’re not really eating nutritional food, not getting iron in, blood sugar is low, iron is low, and that’s a recipe for anxiety. By the time they’re 17, 18, now they’re starting to get really anxious and they don’t know why.
Dr. Weitz: Yeah, this is somebody who’s undernourished and probably has a huge amount of nutritional deficiencies.
Dr. Bongiorno: Yeah. And then because they feel that way, they’re not focusing well. And then guess what happens. They get put on medications for focus, ADHD medication. What does that do? That ramps up the dopamine so they focus a little better, but now the anxiety’s getting worse, and now we’re in this cycle, and I tell you, and you see this pattern over and over, and I think to myself, “Gosh, we have to work on the underlying issues here. We can’t just keep this ongoing,” because now you have a young girl who’s otherwise healthy and is now being told you have anxiety and focus issues, and you have these diagnoses. Now they’re on a couple of medications for anxiety, and we haven’t fixed the underlying issues yet.
Dr. Weitz: Right. You were talking about the need for amino acids to be able to produce neurotransmitters. And of course, that could be one reason why some of these medications are not effective in some cases because you take a serotonin reuptake inhibitor, which is supposed to keep serotonin around longer in the brain, but if the body doesn’t have the right precursors, amino acids and other nutrients to make the serotonin in the first place-
Dr. Bongiorno: Absolutely.
Dr. Weitz: … it’s doomed to fail.
Dr. Bongiorno: Right, absolutely. So then the question is is the person not taking them in or are they taking them in and the digestive tract isn’t absorbing them? If stomach acid is very low, you’ll see people with SIBO, small intestinal bowel overgrowth, their stomach enzymes are very low, their hydrochloric acid is low. They’re not really breaking down their protein. They might not even be chewing their food very well because they eat in a rush and they’re so anxious. And so, how is a person supposed to get enough protein digested for a good amino acid intake to make these neurotransmitters?
Dr. Weitz: Absolutely. And they may have H. pylori infection, and that’s usually associated with lower hydrochloric acid secretion. So maybe you can talk about the microbiome and its importance for the health.
Dr. Bongiorno: Yeah. And the microbiome, so that’s the other side of the gut. So we have the stomach acid being produced in the upper gut and then down in the lower gut, we have … all these bacterias that are so important, and the microbiome and the microbiota is just such a key to keep in balance, to help produce neurotransmitters in the brain, to help keep inflammation balanced, to help process hormones in the gut. The liver, yes, processes a lot of hormones, but a lot of hormones get processed and get absorbed through the gut, and the microbiome has a lot to do with that. Plus the microbiome, that good bacteria also creates a lot of short-chain fatty acids, which has also a very important role in helping keep the brain in balance, too.
Dr. Weitz: And of course, to make sure you get enough amino acids, you’ve got to make sure you’re eating good quality protein.
Dr. Bongiorno: Yeah. So yeah, protein is a key. And I tell my patients, especially first thing in the morning when your digestion is its strongest, it’s a really good idea, have a good breakfast, have good protein. But so many patients who come in, their cortisol levels are so high in the morning and they feel so awful. And I’ve been through it myself during a very stressful time where my cortisol levels are very high and I didn’t want to eat in the morning either. So I know exactly what that feels like. So it kind of sets up the day where you’re not eating in the morning, that your blood sugar is going to bounce around all day because you didn’t get the foods you needed first thing in the morning.
Dr. Weitz: And now, of course, a lot of people who are trying to promote their health are doing intermittent fasting, and a lot of them are instituting that by skipping breakfast.
Dr. Bongiorno: Yeah. And for some people, it’s fine. If their blood sugar’s balanced and they’re getting their macronutrients in and their digestion’s good, then that could work for them because it does make sense. You give your liver a little bit of a break and it can clean out and do a little more in terms of detoxification. But for people who have that kind of blood sugar imbalance and their sugar gets really low, I do tell them the opposite. Usually using that example of the 17 year old with that OCD and anxiety, she probably needs less detoxification. She just needs more nourishment. So for her, small frequent meals are better, but maybe for someone, let’s say a perimenopausal woman in her forties, maybe for her a little more intermittent fasting and detoxification would be good for her liver, might help balance her hormones. So there’s almost nothing that’s really good and bad anymore. It’s like, well, what’s going to be appropriate for an individual patient that’s going to really work for them? And that’s really the key.
Dr. Weitz: Personalized care, which is one of the keys to functional medicine. Yeah.
Dr. Bongiorno: Absolutely. So yes, intermittent fasting could be very, very beneficial. It just depends who we’re using it for.
Dr. Weitz: Is coffee good or bad for mood disorders?
Dr. Bongiorno: Yeah, so coffee could be pretty good. No, again, it depends on the person. So I always think about … My father’s going to be 90 and my mom’s going to be 86, right? They’re immigrants from Sicily. And my father can have four espressos and he’ll go right to bed and no problem. I don’t think he’s had a day of sleep problems in his life. My mother can drink decaf and be awake for two days. It depends on you. Some people, their liver, and now we know there’s certain genetic polymorphisms that will make us more or less able to process caffeine in a proper way through phase I of liver detoxification. And so, coffee has definitely been shown to be helpful in terms of cardiovascular health, in terms of liver health, it certainly gets the bowels moving in a natural non-addictive kind of way. So I ask my patients, as long as the bowel movements aren’t too loose, as long as they don’t have a lot of anxiety or sleeping problems, then I think coffee’s good. I always make sure my coffee is organic because there are a lot of pesticides in coffee. And I do drink it black to make sure there’s no sugar, there’s no dairy in it. And so, for me, I feel like it’s healthy.
Dr. Weitz: Do you do the low mold coffee as well?
Dr. Bongiorno: I haven’t gotten there yet. No.
Dr. Weitz: Me neither.
Dr. Bongiorno: But look, it makes sense to me and especially for people who are sensitive, that might be a good idea. Look, I have patients, that’s something maybe in the beginning I might’ve said, “Oh, what’s the use of that?” But now I think about, I have patients who are celiac, if they use a shampoo that has gluten, their antibodies go up and I’ve seen it. So some people are that sensitive and they need that level of care, so yeah. So it might be a good idea for some people who are really mold sensitive.
Dr. Weitz: Right. What about alcohol?
Dr. Bongiorno: Alcohol? Well, look, again, if you look at the literature, the studies keep bouncing up and down about how beneficial. We used to think that generally a little bit was fine and beneficial, and now it seems like it’s landing in such a way that for cancer, any amount of alcohol is not good, that any amount, depending on the person can help promote cancer. And that for heart disease, there doesn’t seem to be much benefit, but there might be a small benefit because alcohol is one of the few things that raises HDL levels. So that’s my understanding right now. I also understand that alcohol has a relaxing effect for people, and I think that might have some benefit.
Again, I’ll bring up my parents. I grew up, my parents always had a little bit of Manhattan before dinner, not enough to get drunk or even buzzed, but just a little bit. And when I think about that, I think now my father would come home from work. He worked hard all day. He was a bricklayer. My mom would be making dinner and you’d smell the food in the air. They would make the Manhattan with a little bit of bitters in it. They had the gentian bitters, they sip their Manhattan, they talk a little bit. They listened to some music. Then we sat down and we ate. Nobody does that anymore. So think about the role the alcohol played, it relaxed them. They got the bitters, the digestive juices were flowing. They smelled the food that they were cooking. That promotes good digestion. Those are just all things we’re not doing anymore. So whether the alcohol is tremendously healthy for them, I’m not sure. But the overall ritual and effect I think was. And that’s what I think is missing in our lives today. We’re all so busy. We’re not sitting down having a little aperitif, cooking our food, smelling our food, our digestions getting ready, what do we do? We order food. We’re eating in the car. It’s a quick meal. “We got to go. Who’s got to go to practice?” And so, I think there’s a lot to be learned from the way we used to live.
Dr. Weitz: Absolutely. And herbal bitters is a great way to stimulate digestion.
Dr. Bongiorno: Absolutely. So good to the liver.
Dr. Weitz: Stimulates pancreatic enzymes, stimulates hydrochloric acids, stimulates bile production.
Dr. Bongiorno: Yeah. And the other thing it does is it helps promote our interest in non-sweet foods.
Dr. Weitz: Ah! Interesting.
Dr. Bongiorno: We’re so used to sweet, sweet sweets, and a lot of us now don’t like bitter food because we’re so used to sweet because the primitive brain wants sugar because sugar, you pack fat and you make it through the winter. So if you have a winter where there isn’t enough food in a primitive world, you’re the one who’s going to live. So we’re so programmed for sugar, but the truth is the bitters are just so, like you’re saying, it has so many beneficial effects on our digestive system. And the more people can eat those bitters, the more they’re going to be inclined to eat more bitters and eat less sweet.
Dr. Weitz: How important is sleep and circadian rhythm?
Dr. Bongiorno: Yeah. So sleep is basically the first chapter of all the books I write. Like I said, if we’re not sleeping and we’re not pooping, it’s hard to fix anything else. So no matter what any patient comes in with, it’s really important. I ask them about sleep and how they’re pooping. And if they’re not sleeping, then we want to work on that because sleep is where we detoxify. It’s where our mitochondria breakdown and build back up and build better mitochondria. It’s where our lymph system cleans out. It’s where our gut lining fixes itself. It’s where the liver fixes itself. It’s where the kidneys do most of their work because when we power down for the night, our body says, “Okay, now we can use our energy to do things we need to do for maintenance.” For years, nobody really understood why we slept, but now we know. We have all this great information and research teaching us why we need to sleep.
Dr. Weitz: Do you get into analyzing sleep? Do you have your patients use a Oura Ring or some other device to look at quality of sleep and REM and deep sleep and et cetera?
Dr. Bongiorno: I do sometimes. Usually a good patient intake will tell me what’s going. I mean, a patient knows if they’re sleeping or not. A great question is when you wake up in the morning, do you feel rested? So oftentimes they know if they’re not sleeping. But yeah, I do think it helps and I find patients do like to see the data to see what their REM and non-REM sleep is, and if they’re getting into deep sleep long enough. So I do think it’s helpful. And I do find those things for the most part correlate with what we’re hearing clinically. I can’t say from my perspective it’s changed too much what we do, but I think it’s valuable. And I think if it helps a patient motivate to make the changes we need to make, then I’m all for it. Yeah.
Dr. Weitz: What about the role of exercise in helping them manage mood disorders?
Dr. Bongiorno: Yeah. So exercise is definitely a key. If we’re not moving our body … One time somebody asked me the question, I had to think about it, “If you could only do one thing, exercise or eat well, which would it be?” And I had to think about that. And when I thought about it, I don’t even remember what I said as the answer, but when I thought about it over a couple of days, and I thought to myself, “Well, if I ate well and just sat in bed all day, I would die,” right?
Dr. Weitz: Right.
Dr. Bongiorno: But if I ate crappy and moved my body, I think I had a chance. So now I’m starting to think, “Okay, well maybe exercise is more important.” I mean, neither is more important. We need both of them, obviously. But exercise, the point is that exercise is crucial and it’s absolutely important for mental health. There’s no question about it. When you get stressed out, you want to run. It’s fight or flight. You want to run, you need to move your body. So when we have all these stress hormones and we’re not moving our body, what happens is these stress hormones affect our brain. And our brain starts to look around and our brain doesn’t realize that there isn’t a bear coming at us. Our brain just knows that there’s stress hormones up and that there’s something wrong. So if you have an average person who’s just going to work and doing the normal things of a day, but those stress hormones are high, now the brain is going to start conjuring things. And that’s where anxiety comes from and obsessive thoughts and impulsive and all these things come from because there’s something not right. The level of stress hormones in our body does not make sense with what our brain is seeing on the outside.
And so, exercise is a brilliant way to try to equalize that while we’re working on the underlying reasons we are that stressed out. Exercise helps us build better mitochondria, which we need for our nervous system to work really well. Exercise. It’s interesting, there’s studies that show how exercise in the short term actually creates more gut permeability. While you’re exercising, there’s a little inflammation and you get this transient permeability. But people who exercise regularly, what’s been shown is they actually have less gut permeability because now the body reacts by healing it and creating a better gut. And we actually have better digestion as a result and less leaky gut.
So many good reasons to exercise. There’s a study out of the University of Copenhagen that came out of a few years ago and showed that people who exercised moderately by running or some kind of cardio work, the men live 6.2 years longer. The women 5.6, something like that, years longer. I mean, if there was a drug that somebody could sell to you and say, “Hey, you spend $2 a day on this drug, you’ll live six years longer, no side effects, and you’ll feel better, wouldn’t you take it?
Dr. Weitz: Absolutely.
Dr. Bongiorno: I would take it. I would take it. I would buy it.
Dr. Weitz: The longevity benefits of exercise are just so many, it’s incredible.
Dr. Bongiorno: Unbelievable.
Dr. Weitz: Maintain bone density, as you mentioned before, maintaining your muscle mass, your balance, because as you get older, that’s crucial for longevity.
Dr. Bongiorno: Yeah, it’s amazing. And you know what’s amazing to me too is that I never heard of that study in the media. No one ever mentioned it. I never saw it on the news. Five to six years live longer. Why wouldn’t somebody want to talk about that?
Dr. Weitz: Well, because there’s no pharmaceutical company that patented exercise and hired a PR firm to get the word out about it.
Dr. Bongiorno: Yeah, it’s just not right. I don’t know what else to say about that.
Dr. Weitz: No, I know. It’s incredible.
Dr. Bongiorno: It’s why we have a job, right? I mean, in a way, that’s it.
Dr. Weitz: Yeah. No, absolutely. It’s good they did the study though, because not enough research is being done on nutrition and exercise and these natural things because it’s not easy to make a lot of money out of it. And that’s who’s paying for most of the research.
Dr. Bongiorno: Right. And a lot of the studies we see on natural medicines come from other countries because there are other governments who at least see some value in it, and the money’s put in. And if you notice, very few actually come from the United States because it’s just not a priority.
Dr. Weitz: No, I know. It’s amazing. I interviewed Dr. Terry Wahls, and you probably know about her.
Dr. Bongiorno: Yeah, of course.
Dr. Weitz: Her story’s incredible reversing MS, and almost all the money coming for her research studies is coming from private donors.
Dr. Bongiorno: Right, exactly. Yeah. People who care and are interested in making a difference. Yeah.
Dr. Weitz: Because the NIH is just not really funding a lot of that type of research on using diet and exercise and natural methods for combating chronic degenerative diseases.
Dr. Bongiorno: Right. That’s right. Yeah.
Dr. Weitz: So what about in today’s world with electronics and social media? Is that something you address with patients with mood disorders?
Dr. Bongiorno: Yeah, absolutely. Especially patients with focus issues and attention issues, and especially younger people. I mean, these bright screens, and, I mean, look at what I’m doing right now. It’s 10:18 in New York, and I’m staring at a bright blue light screen. I mean, yeah. We’re laughing, but that’s the truth, right?
Dr. Weitz: Yeah. No, absolutely.
Dr. Bongiorno: Right now my melatonin wants to come up, but it can’t because I’m doing [inaudible 00:44:28]. And yeah. And that’s an issue. Plus a lot of screens there’s a lot of fast moving things. When you take kids out into nature, nature’s very slow. It doesn’t move the way a video game moves. And so, they start to get anxious about it because they’re waiting for the next dopamine hit because that’s really what it is. It’s getting addicted to dopamine and producing dopamine quickly, and it feels really good. And then when it goes away, things don’t seem as fun. Things seem bored, and then you kind of looking around for the next dopamine hit, and that’s the problem. And some kids are more susceptible than others. There are some kids, there’s interesting studies during the pandemic that showed how kids, because they had to isolate and be home, that that isolation and having to do things virtually really affected young women very heavily. And they tended to get more depressed and a lot more anxious.
They found for young boys, too much was no good as well, but they found that some was actually more helpful and that some of the gaming and stuff actually kind of kept them up enough where otherwise they wouldn’t have been. So every kid is different, and certainly gender can affect it as well, but there’s no question that we’re all doing too much screen time and that’s not great for our brain.
Dr. Weitz: And you mentioned going out in the forest. Forest bathing is a wonderful therapy.
Dr. Bongiorno: Yeah. Yeah, I talk about that in my books, too. It’s called shinrin-yoku, right?
Dr. Weitz: Yep.
Dr. Bongiorno: And that the forest itself, the trees actually emit something called phytoncides, and that we breathe them in, it gets into our bloodstream, and it affects our nervous system in a very healthy way. It’s very calming. Inflammatory markers go down. Yeah. I mean, we’re made to be in nature. I remember when I was in naturopathic school, one of the advice, Dr. Mitchell, one of the founders of Bastyr University, used to tell us, he used to say, “I want you to go outside and just find your favorite tree and sit and look at it, talk to it, listen to it, get to know it.” And it’s really powerful. If you’ve never tried it, sit with a tree and just talk to it a little bit and listen to what it has to say. It’s pretty interesting.
Dr. Weitz: Cool. So let’s go into lab testing. Tell us about what kinds of labs you like to run with your patients with mood disorders?
Dr. Bongiorno: Yeah. So I’m a big fan of running labs. I think there’s so many, for mental health, like we were talking about earlier, there’s so many factors involved in why someone’s mood might not be right, whether it’s anxiety, depression, schizophrenia, bipolar disorder. There’s so many possibilities. And so, we want to run some labs to figure out what we need to work on. So there’s some basics that I like to run with everybody, like a CBC, blood sugar, insulin, A1c, a full thyroid panel with antibodies, vitamin D and iron panels, critical and ferritin for iron storage. And then looking at some of the vitamins, magnesium, zinc, zinc-to-copper ratio, B12. Sometimes you can’t run everything on everybody because it’s just too many vials. But what you can do is get a really good history and then start to narrow down.
And then usually depending on the patient, I’ll run hormonal tests. I’ll run tests to look at cortisol and adrenal function, take a look at melatonin levels, glutathione levels, mycotoxin testing could be very important as well. And then looking at stool testing in some patients, too. Looking at the microbiome a little further. Sometimes if I hear some basics are very off, again, we were talking about that 17-year-old girl with anxiety and OCD, if there’s some basics that just aren’t there, then sometimes I won’t run a lot of testing because we know we need to get those basics in. Maybe a person needs to get to bed earlier, they need to start moving their body, they need to eat green vegetables, make sure they’re getting essential fats in their body. So if there are a lot of basics not there, then sometimes it’s not worth running a lot of tests because we know we have to get these in, and then if they’re not better, then we could also run additional testing, too. So everybody’s different.
Dr. Weitz: What are some of the favorite lab testing companies you like to use? Do you send patients to Labcorp and Quest, or do you use-
Dr. Bongiorno: Yeah, I mean, I use, if we can work through their insurance and Labcorp and Quest usually that gets the job done for a lot of the basic blood work. There are a couple of specialty labs I tend to rely on. I do the Dutch panel, which is very good, but Genova also has some very good adrenal testing, too. I love Diagnostic Solutions Laboratory. I think they do a good job, especially with the genetics and using the Opus23-powered genetic profiles. So that’s very helpful, too. The GI-MAP testing is excellent. RealTime Labs has their mycotoxin testing. Dr. Campbell has their mycotoxin. I think they all have benefits as well. So, yeah. So there’s a number of different good ones out there. Those are probably the ones I tend to use and rely on the most.
Dr. Weitz: For nutrients, are you running serum levels? Are you doing some of the specialty micronutrient testing?
Dr. Bongiorno: Yeah, I don’t do too much of those. Not that I don’t believe in them, but just that there’s already so many tests. And usually with a blood panel, it’s almost like you can’t run them all. But I get an idea from the ones we do run, and then we just make sure we cover them all with our intake. And as long as I think somebody’s absorbing, then we’ll do, but I could see some benefits of running specialty labs as well.
Dr. Weitz: Give us some insights on some of those labs that are helpful in how you approach patients.
Dr. Bongiorno: Yeah. So you have somebody who can come in who could be very fatigued, and there are people who have very high cortisol, and that could fatigue them because when cortisol’s very high, it bathes the brain. And especially if DHEA is low, then you’ll see a brain that people feel really tired and almost like this kind of floaty effect at the same time. And then you have other people that are tired and their adrenals are just flat. They’re not making any cortisol, and they can have very similar clinical presentation. So running a test that looks at adrenal function, looks at cortisol could be very, very helpful because it can differentiate between those two things.
Dr. Weitz: That’s really interesting because we typically think of cortisol being high as the person has trouble sleeping and they’re overstimulated rather than showing fatigue.
Dr. Bongiorno: Yeah. And I would say the majority of the time that’s true, but not all the time. So that’s why the tests are so nice. And then, yeah, for nighttime, when people aren’t sleeping, it is nice to see, is cortisol super high at night and is that the problem? Or is cortisol really normal, but they’re not making enough melatonin, or maybe they’re making enough melatonin and their cortisol is normal and it’s completely something else. So that helps differentiate. And what I’ve noticed is it kind of gets me there a little faster to help create a treatment plan that’s effective. So that’s why I like using tests like that because it can help to differentiate
Dr. Weitz: And hormones. Do you sometimes recommend hormones when their hormones are low?
Dr. Bongiorno: Yeah, absolutely. I mean, hormones from pregnenolone, which helps make both cortisol and progesterone through one pathway and DHEA and testosterone, and then into estrogen in another pathway, all of those different steroidal compounds will affect the brain and the receptors that the brain makes for neurotransmitters and the metabolism of the neurotransmitters themselves. So for example, if a woman or a man has low estrogen, that’s going to affect their production of serotonin and affect the ability of the serotonin receptors to be produced, too. So yeah, we’d want to look at that.
Testosterone, of course, is very important as well. In fact, I wanted to talk to Steve about that. Steve, there’s one test. We were talking about lavender and testosterone. They did this test on animals. I’ll have to pull it up, but I remembered while you were talking that they looked at, I think it was rats who were given formaldehyde poisoning to affect their liver and their testes, and they found that these rats that were treated with the formaldehyde, testosterone levels went down. But when they were given lavender, it actually protected the testicles and they didn’t see the decreases in testosterone so I thought that was kind of interesting.
Dr. Weitz: Really, really interesting. Yeah.
Dr. Bongiorno: Something to think about.
Dr. Weitz: So you mentioned men with low estrogen that they can have trouble making serotonin. How do you address that?
Dr. Bongiorno: Yeah, so men have have actually more estrogen in their brain than women does. So estrogen’s important, and that’s why the panels look at estrogen in men. We don’t see progesterone in those panels. We use the estrogen.
Dr. Weitz: So what do you do with men with low estrogen?
Dr. Bongiorno: Well, so the next thing you want to check is are they making testosterone because testosterone gets made into estrogen. So sometimes if that’s low or really flagging, then that could be a reason. And then you want to look down the line. Are they making DHEA? Are they making pregnenolone? Are they making cholesterol? Cholesterol’s the first one that everything else is made from.
Dr. Weitz: Or are they taking heavy statins and trying to get their cholesterol as low as possible.
Dr. Bongiorno: Exactly. Right. That could be an issue. It could be an issue that they don’t have enough fat tissue, that maybe they need … It’s not common, but sometimes that happens, too. So we see that as well.
Dr. Weitz: So you’re saying your body fat is too low?
Dr. Bongiorno: Possibly. Yeah, possibly. So not common, but it’s possible. So then-
Dr. Weitz: Right. So then-
Dr. Bongiorno: I’m sorry. Go ahead.
Dr. Weitz: No, I was going to say let’s go into supplements that are beneficial for depression and anxiety. And I wanted to maybe start with NAC. I was going through some of the literature, and there’s amazing research on NAC. There’s studies showing it can be used as an acute intervention for patients who are suicidal. It can be effective for severe depression, not just mild or moderate.
Dr. Bongiorno: Yeah. Also for bipolar, there’s strong research for bipolar, for trichotillomania, which is hair pulling, which is basically an obsessive kind of [inaudible 00:56:09]-
Dr. Weitz: What was that term?
Dr. Bongiorno: Trichotillomania.
Dr. Weitz: Great word.
Dr. Bongiorno: Yeah, that’s the word of the day, trichotillomania. And so yeah, no, NAC, N-acetyl cysteine, it’s a precursor for glutathione, basically. And in its own right, it’s a very good mucolytic. So the perfect patient is someone who has some mood issues and are all stuffed up all the time. So maybe we get them off of dairy, do some nasal rinses, and take some NAC for all of that, and it could be very helpful. Yeah, I love N-acetyl cysteine, and unfortunately, it’s something that’s been threatened on and off for the past couple of years to be taken off the shelves.
Dr. Weitz: Right. Yes. Yeah. Apparently what happened is that it was originally studied as a drug.
Dr. Bongiorno: Mm-hmm. That’s right.
Dr. Weitz: So there was some thought that the FDA might ban it because of that, and so Amazon stopped selling it, but it’s still being made and it’s still being sold.
Dr. Bongiorno: Yeah. Interestingly, Amazon doesn’t also sell CBD, right?
Dr. Weitz: Oh, really?
Dr. Bongiorno: You can’t even get CBD on Amazon. And I noticed also Fullscript doesn’t sell, Amazon doesn’t sell CBD as well.
Dr. Weitz: Really?
Dr. Bongiorno: Yeah, yeah. Try to get it on those. You’re not going to find it.
Dr. Weitz: Oh, interesting.
Dr. Bongiorno: Yeah. So, there’s still some-
Dr. Weitz: [inaudible 00:57:40].
Dr. Bongiorno: Yeah. Well, it seems like there’s still-
Dr. Weitz: Is it the marijuana thing, you mean?
Dr. Bongiorno: Yeah, I think there’s still some residual regulatory issues about that. I know of cases where PayPal, when people have stores, practitioners have stores, PayPal will shut it down if they’re selling CBD. So there’s still a lot of things like that going on.
Dr. Weitz: Oh, wow.
Dr. Bongiorno: Yeah. We’re not there yet. But that’s an interesting thing too, because we see all this legalization of marijuana, which I’m not necessarily against, but I think the powers that be should have really taken a look at the literature and shown that people who take marijuana every day, especially young people before the age of 25, 26, when the nervous system and the brain is fully formed, it really does affect in a negative way things like the HPA axis. And I do wish, even though I think marijuana clearly has medicinal use along with CBD, I think it should have been regulated to be legal after that age, because I’m very worried about people. I have a daughter who’s 15. In a couple years, she’s going to go to college, and most likely the college she goes to, marijuana is going to be legal for her age. And I really am very concerned about kids and young people using marijuana every day. And the problem is now marijuana is not the marijuana from the ’60s. It wasn’t like, oh, indica or sativa and sativa’s a little bit stronger. Now. It’s this very, very high THC content, low CBD content. So now we’re getting something that we’re seeing, I’m seeing it now in my practice, a lot more cannabis overuse syndrome, because people are smoking what they think is reasonable amounts, and now they’re getting addicted to it, and now they’re starting to get these syndromes, these cyclic vomiting issues, these digestive. So this is something that’s coming, and it’s going to be a big concern, too. So something that I think has a lot of benefit can also be an issue.
Dr. Weitz: Interesting. So what is some of the other most impactful supplements for mood disorders?
Dr. Bongiorno: Oh, yeah. Sorry. I got sidetracked.
Dr. Weitz: That’s okay.
Dr. Bongiorno: So if you look at the literature and you say, “Okay, just from meta-analysis,” for example, probably the top ones are St. John’s wort, SAMe, curcumin, and I would say Rhodiola, St. John’s wort, Hypericum, is probably the most studied herb of all time. There are meta-analysis of meta-analysis now on St. John’s wort, meaning that meta-analysis is a study of studies. Now, there’s studies of the studies of studies, and so thousands and thousands and thousands of people, and what’s been shown is that St. John’s wort clearly for mild to moderate depression works just as well as SSRIs with less side effects. So we want to be careful with St. John’s wort because if people are on a number of drugs, it can affect the activity of those drugs through the liver. It affects the cytochrome system. So you always have to be a little more careful with St. John’s wort than maybe a few other things because of that processing issue.
But there’s studies that also show, for example, if people are taking Plavix, which is a drug for blood clouding to help protect the cardiovascular system, what they’ve shown is that when people take Plavix and can’t take more because of side effects, and they take some St. John’s wort, they can actually get the effect they need from the Plavix without having to increase the drug. So as much as we’re worried about negative interactions, we need to study more of these positive interactions because now we know there’s benefit there.
Dr. Weitz: Exactly. So I’m assuming it’s inhibiting part of the cytochrome P450 liver detox.
Dr. Bongiorno: Exactly. Yep, exactly. And sometimes we can use that to our advantage.
Dr. Weitz: Absolutely.
Dr. Bongiorno: As long as we know the medications patients are taking, how the drugs work, how the cytochrome system works, then we can make actually good decisions and use them together.
Dr. Weitz: Right. You can use grapefruit juice also as a way to modulate.
Dr. Bongiorno: Exactly. Very strong. Yep.
Dr. Weitz: Yeah. Fish oil.
Dr. Bongiorno: Fish oil, yeah. I mean, absolute favorite. No question about it. Studies keep coming out about fish oil. Fish oil just supports healthy cell membranes, and when you have a healthy cell membrane, you’re going to be able to get nutrients in a cell, you’re going to be able to get toxins out of a cell. You’re going to get tempered, balanced immune reactions because a cell membrane breaks when immune reactions need to happen. And that keeps it a much more tempered immune system. Probably about a year and a half or two. Yeah, it’s probably two Augusts ago, so over two years ago now. There’s a study that came out in, I forget which journal, I apologize. One of the psychiatry journals showing how in patients who are treatment resistant to antidepressants, when they take fish oil, then the antidepressants work better. Which also made me wonder, did they need the antidepressant or did they were really just low in fish oil? Actually, one of the tests I probably started using more and more in the past couple of years is an omega check, a fish oil, basically looking at essential fatty acids in the bloodstream. And that’s very helpful to see.
Dr. Weitz: Yeah. So what were those herbs you mentioned besides St. John’s wort that you said? [inaudible 01:03:37].
Dr. Bongiorno: Oh, yeah. So the other ones I think are pretty clear from a meta-analysis standpoint, showing benefits at least as equal as the medications. And I want to qualify that because I said earlier that medications for depression work maybe 25 to 35% of the time for depression. So I’m not even suggesting that the supplements work better. They work probably around the same. So it still tells us we have a lot of other work to do. But I would say, someone with mild to moderate depression who isn’t at risk of hurting themselves or someone else, why would we start with a medication with more side effects? Why not start with something more natural to the body that can work just as well with less side effects?
Dr. Weitz: So yes, SAMe, which is S-adenosyl-L-methionine, can help the body move some of the cycles that help create better neurotransmitters, especially if people have poor methylation. Sometimes we’ll see people with things like high homocysteine and they have MTHFR polymorphism and we know maybe if we support the methylation with things like SAMe, you need methylation even to make CoQ10. It’s hard to make proper amounts of CoQ10 without that. So that’s a very good choice for some patients.
Dr. Weitz: And then of course, methylated B vitamins to go along with that.
Dr. Bongiorno: Yeah. And in the right patients, methylated B vitamins can be very helpful, too, to help move those as well and lower the homocysteine. And then I mentioned Rhodiola. Rhodiola has a rich history starting in Russia when it was first studied, and that definitely is something that can be very, very helpful. It’s considered a natural COMT inhibitor. COMT is one of the genes that’s important for how we break down neurotransmitters. So sometimes people who are very depressed, you can use Rhodiola as a way to help keep neurotransmitters at a higher level. So it’s very supportive that way. And then curcumin. There’s forms of curcumin that have been studied that have very good antidepressant quality and that makes sense because it’s a very potent anti-inflammatory. But there’s a fellow named Aggarwal who’s done a lot of studies on curcumin and he shows that there’s so many more mechanisms than just the pure anti-inflammatory effect that creates some of the benefits.
Dr. Weitz: Yeah, curcumin’s an amazing herb. I’ve seen some of the anti-cancer effects and one doctor showed a chart that showed just affecting 20-
Dr. Bongiorno: Yeah, exactly.
Dr. Weitz: … different pathways that all potentially could decrease your risk for cancer growth.
Dr. Bongiorno: Yeah, absolutely. Yeah, it might’ve been that same fellow. I don’t know because I know he’s someone who’s studied at a high level and it’s just amazing. And I remember him saying in this conference, it was a number of years ago, he said, “There’s no drug that did this, and if there was a drug, it would be an absolute blockbuster cancer drug.”
Dr. Weitz: Right.
Dr. Bongiorno: So I remember those words.
Dr. Weitz: Yeah. What about saffron? Steve mentioned saffron. That seems to be a newer herb that seems to have some benefits.
Dr. Bongiorno: Mm-hmm. Yeah, it’s interesting. A number of years ago I did some formulations for Douglas Labs and the formula I created was actually the first formula for mood to have saffron in it. So it’s something I’ve been interested in for many years. I first caught wind of it when I was looking for something to help patients who had libido issues with SSRI drugs, and, albeit small, there are studies in men and women that show benefits for libido when they’re taking SSRIs. So sometimes I have a patient either can’t get off a medication or really don’t want to, but they want help with libido and there’s some research there. I mean, of course we want to work on all the other underlying factors that contributed to libido, but when you see that clear SSRI-induced change in libido, that’s a reasonable choice to try.
Dr. Weitz: Right. Lithium, I know you wrote a paper about lithium.
Dr. Bongiorno: Yeah, so lithium orotate also known as nutritional lithium, so not lithium carbamate the drug. Is it just very small amounts, milligrams, usually between five and 20 milligrams is helpful. I use it to help people with typically anxiousness, impulsivity, even in children, a milligram, two milligrams up to five can be helpful, too. And it’s known as a way to just help calm the amygdala, help calm that fear center of the brain, help it work better. You can check it with hair analyses and see if levels are low or just start on low levels. I personally have never seen it affect kidney function or thyroid function the way the drug does. I think it’s still a good idea to check those before and during just to make sure. But I’ve been using it for years and I haven’t seen any issues like that, thank goodness.
In fact, I was on a group today, I was teaching nurse practitioners and functional psychiatrists, and one of the fellows, I think it was a psychiatrist, had told me that he saw somebody go up to 30 milligrams and do quite well with it with no issues as well. So I hadn’t actually used it at that high. Usually I don’t go past 20, but he said 30 milligrams wasn’t a problem, at least in the one patient he saw. So yeah, definitely very, very helpful. I actually like combining it with CBD. I find they work really nicely together. So supporting the endocannabinoid system, calming the amygdala seems very helpful.
Dr. Weitz: And then there’s specific amino acids and other nutrients to help support the various neurotransmitters. So we have 5-HTP, we have Mucuna for L-dopa, we have GABA. What about some of those supplements?
Dr. Bongiorno: Yeah, I mean, if you hear that when patients tell you that, “Oh, I took a drug, it raises dopamine like Wellbutrin,” for example, which is very good at raising things like dopamine, then yeah, then it makes sense. Well, why not support the dopamine pathways more naturally if we can? And Mucuna, which is a natural amount of low levels of L-dopa can be useful along with some tyrosine, which helps support the pathway to make dopamine. Of course, we always want the co-factors in there. We want vitamin B6, vitamin D levels, zinc levels appropriate as well, because those are going to be really important for the body’s ability to use those materials to make the eventual neurotransmitters, too.
But yeah, those are great, 5-HTP to support serotonin. Sometimes I use tryptophan, sometimes I’ll use 5-HTP. I find tryptophan helps people stay asleep better at night, so sometimes I’ll use tryptophan at night, but 5-HTP during the day. I know some practitioners from a theoretical standpoint feel that if there’s a lot of inflammation and they’re going through that quinolinic acid pathway, then maybe 5-HTP is a better choice. I find this really interesting, even though theoretically and it makes sense. I’ve seen in practice that hasn’t necessarily affected it, so I just try to use what’s best and what I think is working for a patient.
Dr. Weitz: Interesting. Which company do you get the tryptophan from?
Dr. Bongiorno: I’ve been using tryptophan from Douglas Labs typically. Yeah. They have a little bit of B6 in there, so it’s nice if a patient isn’t taking B6 or doesn’t have enough level, then that’s helpful.
Dr. Weitz: Okay, good. Yeah. I think most of the functional medicine supplement, professional supplement companies are carrying 5-HTP, but not so much tryptophan.
Dr. Bongiorno: Right? Yeah. I know tryptophan’s a little bit old, but I don’t know. They took=
Dr. Weitz: Well, you took it off the market.
Dr. Bongiorno: I’m a little bit old. Well, that was a mistake. That was purely because the company had introduced the bacteria there. In fact, it was interesting. When I did research when I was in my twenties, right out of college at the National Institutes of Health was, it was like this sort of predoctoral fellowship, and there was a doc in one of the labs I worked in. Her name was Esther Sternberg, and she was actually one of the people who testified because she was a well-known tryptophan researcher. So they brought her in to talk about tryptophan. And so, she was one of the people that helped them understand that tryptophan itself doesn’t cause eosinophilia-myalgia syndrome, this EMS, which about 30 or 40 people unfortunately die from. But it was actually just the bacteria that was introduced by the company who I guess shouldn’t have been making that they didn’t know exactly what they were doing.
Dr. Weitz: Right. Okay.
Dr. Bongiorno: Yeah. Very unfortunate.
Dr. Weitz: Excellent. Any final thoughts you want to leave us with?
Dr. Bongiorno: No. Well, what I would say is if you’re listening out there and you have mood issues, and I know what they feel like because I’ve had some myself and I’ve been through a little bit, unfortunately, too. When you’re going through it, it just feels like nothing can help you. It almost feels like this monster from the outside who just comes and goes as he or she pleases and doesn’t let you live the life you want to live. It’s always worth looking for a practitioner who will sit and listen to you and help look at these underlying issues. And I can tell you that there are things that can be done and it’s always worth searching for them. And of course, if for at any time you feel like you want to hurt yourself or something, please call a loved one. There’s wonderful hotlines, people who really want to listen and who care and who are there to help.
Dr. Weitz: Anybody on the call right now who wants to ask Peter a question, you feel free to unmute yourself or type it into the chat box. Okay. And then how can folks who listen to this get ahold of you?
Dr. Bongiorno: Oh, yeah. Thank you. So yeah, so my website is drpeterbongiorno.com. That’s D-R-P-E-T-E-R-B-O-N-G-I-O-R-N-O dot com. It’s a very long name, drpeterbongiorno.com. Yeah, so feel free to. All my contact information is there.
Dr. Weitz: Excellent. Thank you so much.
Dr. Bongiorno: Oh, thank you. And thank you for all the work you do and just having me on. And it’s really an honor and I appreciate everything you’re doing, all the good information you’re putting out there.
Dr. Weitz: Thank you, thank you.
Dr. Bongiorno: Thank you, Dr. Ben.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way, more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
https://drweitz.com/wp-content/uploads/2023/10/rwp-328-website.jpg350785drweitzhttps://www.drweitz.com/wp-content/uploads/2017/06/drweitzdsamplelogo-withtext.pngdrweitz2023-10-03 17:51:422023-10-14 07:39:06An Integrative Approach to Depression & Anxiety with Dr. Ben Weitz: Rational Wellness Podcast 328
