Archive for category: Rational Wellness Podcast

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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.] 

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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 practice since 1989.  His website is LAFunctionalNeurology.com.

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

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

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Dr. Jill Carnahan discusses her Unexpected Health Challenges with Dr. Ben Weitz.

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Dr. Jill Carnahan is a 

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

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Dr. Maggie Ney discusses Bioidentical Hormone Replacement 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.] 

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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.

8:46  The 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) 

16:24  Relative 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 Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. 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.

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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.

16:02  SSRIs.  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.

20:32  Dietary Factors.  Two of the most important factors are the patient sleeping and pooping?  It is critical that the patient is having a good bowel movement daily.  We need to facilitate that whether it is adding fiber, water, magnesium, etc. If the patient has a lot of anxiety, that tends to put them into sympathetic mode, which shuts down the bowels. So we need to calm their anxiety, whether that is through supplements or acupuncture. Then the next step is to look at their diet and see what we can change to get them eating better.  The best diet is probably some version of the Mediterranean diet, which Professor Almudena Sanchez-Villegas showed in several papers how it improves the endothelial lining of the blood vessels and reduces inflammation and also that this diet both prevents and helps to treat anxiety and depression. [Sánchez-Villegas A, Henríquez P, Bes-Rastrollo M, Doreste J. Mediterranean diet and depression. Public Health Nutr. 2006 Dec;9(8A):1104-9.]  [Sánchez-Villegas A, Delgado-Rodríguez M, Alonso A, Schlatter J, Lahortiga F, Serra Majem L, Martínez-González MA. Association of the Mediterranean dietary pattern with the incidence of depression: the Seguimiento Universidad de Navarra/University of Navarra follow-up (SUN) cohort. Arch Gen Psychiatry. 2009 Oct;66(10):1090-8.]  [Sánchez-Villegas, A., Martínez-González, M.A., Estruch, R. et al. Mediterranean dietary pattern and depression: the PREDIMED randomized trial. BMC Med 11, 208 (2013). https://doi.org/10.1186/1741-7015-11-208] 

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.

30:54  Coffee.  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.

32:58  Alcohol.  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.

38:19  Exercise.  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.

55:25  Nutritional Supplements. NAC has some impressive research findings for its benefits of depression, including severe depression and even as an acute intervention for patients who are suicidal. [Hans D, Rengel A, Hans J, Bassett D, Hood S. N-Acetylcysteine as a novel rapidly acting anti-suicidal agent: A pilot naturalistic study in the emergency setting. PLoS One. 2022 Jan 28;17(1):e0263149.] It’s beneficial for bipolar disorder and for trichotillomania or hair pulling, which can be part of an obsessive compulsive disorder. [Nery FG, Li W, DelBello MP, Welge JA. N-acetylcysteine as an adjunctive treatment for bipolar depression: A systematic review and meta-analysis of randomized controlled trials. Bipolar Disord. 2021 Nov;23(7):707-714.]  NAC is a precursor for glutathione and its a good mucolytic.  Some of the other most effective supplements supported by research for mood disorders are St. John’s wort, SAMe, curcumin, and Rhodiola.  St. John’s wort is supported by many studies and meta-analyses but some are concerned about the fact that it affects the metabolism of certain drugs, such as blood thinners like Plavix. [Canenguez Benitez JS, Hernandez TE, Sundararajan R, Sarwar S, Arriaga AJ, Khan AT, Matayoshi A, Quintanilla HA, Kochhar H, Alam M, Mago A, Hans A, Benitez GA. Advantages and Disadvantages of Using St. John’s Wort as a Treatment for Depression. Cureus. 2022 Sep 22;14(9):e29468.] Fish oil supports healthy cell membranes, which facilitates the flow of nutrients into cells and ability to remove toxins from the cells.  Dr. Bongiorno likes using the omega check to measure essential fatty acids is helpful.  Fish oil helps the anti-depressants to work better. S-adenosyl-L-methionine, can help the body move some of the cycles that help create better neurotransmitters, especially if people have poor methylation.  This is also needed to make CoQ10.  Methylated B vitamins can also be very helpful.  Rhodiola is a natural COMT inhibitor and it can work synergistically to keep neurotransmitters at a higher level.  Curcumin is also a natural anti-depressant as well as an anti-inflammatory.  Saffron has been shown to have benefits for libido for patients with libido problems when taking SSRI drugs.  Lithium orotate, aka nutritional lithium, is effective in helping to calm anxiousness and impulsivity. It helps to calm the amygdala. You can check on lithium levels with hair analysis to make sure you don’t end up having too high a level.  The dosage is usually between 5 and 20 mg.  It also works well combined with CBD.  [Hamstra SI, Roy BD, Tiidus P, MacNeil AJ, Klentrou P, MacPherson REK, Fajardo VA. Beyond its Psychiatric Use: The Benefits of Low-dose Lithium Supplementation. Curr Neuropharmacol. 2023;21(4):891-910.]  Specific amino acids can help to support the production of various neurotransmitters, including 5-HTP for serotonin, Mucuna and tyrosine for dopamine, GABA, etc.  Vitamins B6, Vitamin D, and zinc are important co-factors.  Dr. Bongiorno likes to use 5-HTP for daytime and tryptophan at night for sleep.                                        

Dr. Peter Bongiorno is a Naturopathic Doctor and Acupuncturist and he is the co-director of InnerSource Natural Health and Acupuncture, with offices in New York City and on Long Island.  He also works with clients around the world via phone and Skype.  He did research at the National Institutes of Health in the department of Neuroimmunology and then went to Bastyr University to study naturopathic medicine and acupuncture.  He wrote a number of books, including Healing Depression in 2010 and Holistic Solutions for Anxiety and Depression in Therapy: Combining Natural Therapies with Conventional Care in 2015, both targeted for physicians, as well as How Come They’re Happy and I’m Not, and Put Anxiety Behind You: The Complete Drug Free Program. 

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