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Toxic Mold with Dr. Jill Carnahan: Rational Wellness Podcast 87
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Dr. Jill Carnahan discusses Toxic Mold with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

2:52  Dr. Carnahan explained that she suffered with mold toxicity in 2013 after there was a big flood in Boulder, Colorado and they found Stachybotrys mold in the basement of the building where her office was. Dr. Carnahan started to have symptoms, including shortness of breath and exercise intolerance.  She would get brain fog and was having trouble finding words and it would take her twice as long to write an article. She had skin rashes and burning eyes and eczema on her scalp.  Dr. Carnahan tested her urine and found Trichothecenes, which are mycotoxins that are very toxic. She left her office with her patient charts and never set foot in that office again. Even the paper patient charts were bothering her, so she needed to scan them in and throw them out as well. 

6:54  When Dr. Carnahan is taking a patient’s history, her intuition can help her connect various bits of data and give her a sense of what’s going on with the patient. She will ask when the patient first got sick. Was it after a move to a new home? She asks about allergies, asthma, respiratory immune issues. Did multiple family members all get ill with some unexplained illness?  Was there water damage in their home? If you just ask people if there is mold in their home, most people will say no because they don’t know that it’s there.  Did they feel better when they went on vacation and got out of their home?  Dr. Carnahan asks about washers, dryers, dishwashers, flat roofs, leaks in the basement, the sump pump, the crawl spaces, window condensation, etc. The mold can be behind the walls or under the floors.  It can be in the schools.  Musty smells are often VOCs from mold. And there can also be other toxins in their environment for chronic illness besides mold, like radon and heavy metals.

10:37  When it comes to testing, Dr. Carnahan will start with a questionnaire, the cluster symptom analysis for CIRS. If 8 out of 13 symptom clusters are present, it is considered positive.

 

Dr. Carnahan will also do a visual contrast study in her office that tests retinal acuity between darkened and light lines.  If this is impaired, there is likely a biotoxin exposure.  If either the questionnaire or the visual contrast study are positive, then she will do further testing.  She will do chronic inflammatory response labs, which you can do through any major lab, like LabCorp or Quest, which will include TGF Beta, MSH, melanocyte stimulating hormone, and VEGF.  She may also look at genetics, though she has been finding genetics testing less reliable for predicting outcomes. Dr. Carnahan will also do urinary mycotoxin testing, which measures mycotoxins being excreted from the body in the urine. The controversy here is could they be from food, but usually we can see a pattern if there’s a lot of different micro toxins in a person that has mold related illness, it’s more likely the environment than foods.  Dr. Carnahan started out using Real Time Labs, which does Elisa testing, but she has been using Great Plains Labs, since it uses mass spectroscopy, which is more sensitive. She will usually have her patients take glutathione or use an infrared sauna or both to help mobilize the mold prior to the urine test.  She will recommend that her patient take 500 mg liposomal glutathione twice per day for five days prior to the urine test.

15:33  For Functional Medicine practitioners who would like to get more training about treating patients with toxic mold, Dr. Carnahan explained that Dr. Richie Shoemaker has been at the forefront in this training for years, but he was reprimanded from the Maryland State Board of Physicians in 2013 and he closed his practice then, and there has been a lot of controversy over his methods. From my perspective, Dr. Shoemaker is clearly an innovator and has pushed the limits with his testing and protocols, including the use of various prescription drugs off label.  But Dr. Shoemaker has set up protocols and some basic treatment protocols that are very helpful today. Dr. Carnahan is now on the board of a new group, known as International Society for Environmentally Acquired IllnessISEAI.org. This is a non-profit group that is devoted to bringing science to the field of mold and toxic exposure and they will be having their first conference May 3-5, 2019 in Phoenix, Arizona entitled Healing Complex Patients in a Toxic World.

16:57  Treatment for patients with mold toxicity must involve first removing yourself from further exposure to mold, whether that be proper removal or remediation of the mold or moving out of the home or office that is contaminated with mold.  Second, treatment should involve either taking liposomal or IV glutathione or the glutathione precursors, vitamin C, glycine, and NAC. Third, treatment should include binders, including bile acid binders, like cholestyramine.  We can also use clay, charcoal, zeolite and other binders, depending upon which mycotoxin you are trying to bind. For example, okra toxin is probably best bound by cholestyramine, whereas aphlatoxin is better bound by clay and charcoal.  Binders need to be taken away from food or supplements, either an hour before a meal or two hours after. They can be taken all at once or twice a day is usually sufficient.  Supporting the gut, treating dysbiosis, and making sure their GI tract is moving is also very important.  Due to weakened immune systems, many of these patients will also have viral and fungal infections. You also have to check the sinuses for colonization by antibiotic resistant strep infection known as MARCONS (Multiple Antibiotic Resistant Coagulase Negative Staphylococci).  She also recommends vitamin D, a probiotic, fish oil, Alpha Lipoic acid, NAC, milk thistle, green veggies to alkalinize the body, infrared sauna, and epsom salt baths.  Dr. Carnahan recommends going slow with binders since as these toxins are leaving the body, the patient is getting re-exposed to the toxins and can get very sick.

24:45  Dr. Carnahan recommends her patients who have been exposed to mold to follow a low mold diet and it should also be low in carbs and sugar, since they feed fungus. This diet should avoid grains, legumes, and dried fruits. Coffee and chocolate tend to have a higher mold content. You should also avoid fermented foods and mushrooms.

 

 



Dr. Jill Carnahan is a Medical Doctor who runs the Flatiron Functional Medicine clinic in Louisville, Colorado and has a specialty in treating patients with chronic diseases, including with mold related toxicity. Dr. Carnahan speaks around the world and lectures for the Institute of Functional Medicine.  Dr. Carnahan can be reached at JillCarnahan.com.  Here is a link to a free guide to mold toxicity for Rational Wellness listeners from Dr. Carnahan: https://www.jillcarnahan.com/exposed-to-mold-now-what/

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

Podcast Transcripts

Dr. Weitz:                            This is Dr. Ben Weitz with the Rational Wellness podcast bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the rational wellness podcast on Itunes and YouTube and sign up for my free e-book on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy the rational wellness podcast, please go to iTunes and give us a ratings and review. That way more people will find out about the rational wellness podcast.

Our topic for today is toxic mold, it’s effect on our bodies and how to get rid of it with Dr. Jill Carnahan. Exposure to mold and micro toxins affects many people and often is an undiagnosed underlying trigger for many other symptoms and conditions. Many people are unwittingly living or working in water damaged buildings.  This exposure may be causing many negative effects on their health. Not only can mold and micro toxin exposure cause a host of symptoms that we will go into, but it can also be an underlying trigger or root cause for many other serious health problems, including affecting our sex hormones, thyroid, adrenals, fibromyalgia, hypertension, heart disease, autoimmune diseases, Alzheimer’s, and even cancer. When looking at a patient from a Functional Medicine perspective, we usually focus on underlying triggers and root causes of their health condition. Mold may be one that is frequently overlooked. Research indicates that mycotoxins can bind to DNA and RNA and cause damage, alter protein synthesis, increase oxidative stress, deplete antioxidants, alter cell memory, function, act as potent mitochondrial toxins, and alter apoptosis, which is important for killing off cancer and other cells that we don’t want in the body.

Dr. Jill Carnahan is an MD who runs the Flat Iron Functional Medicine clinic in Louisville, Colorado. Dr. Carnahan is one of the first hundred doctors certified by the Institute of Functional Medicine. She’s a survivor of breast cancer and Crohn’s Disease and she’s a sought after speaker and she loves teaching other healthcare practitioners the Functional Medicine approach, which is to look for the root case and underlying triggers for chronic illness. Thank you Dr. Carnahan for joining us today.

Dr. Carnahan:                    Thanks. Excited to be here.

Dr. Weitz:                          Thank you. So how did you become interested in studying mold and patients suffering with mold toxicity?

Dr. Carnahan:                    Well like things in my life, there’s a happenstance. In fact, in 2013 was the big flood in Boulder. There’s been a lot of this lately with climate change. We had a massive epidemic –

Dr. Weitz:                          Fake news. Fake news.

Dr. Carnahan:                    Yeah. We had a massive epidemic flood in Boulder in 2013 and ever since as a physician who knows mold, I’ve been picking up the pieces. But it hit me very personally because my office basement was flooded. I think the office itself maybe had some minor issues even before the flood and the flood just took it over the edge. I was two stories up above the basement where there was water damage and Stachybotrys mold which is a really nasty, toxic black mold in the outside of a crawl space right under my office that in hindsight was probably really toxic, as well. There was probably water sitting in there.

So bottom line is I started to have symptoms. Shortness of breath, exercise intolerance. I used to be able to run a 5k no trouble and then I was having trouble running and breathing. So my respiratory system was affected. I would have brain fog in the sense of I could still do my work, but I would have difficulty finding words. I would misplace words and say the wrong words when I meant something else and it was kind of strange. Focus concentration was affected, so instead of being able to write an article in an hour, it would maybe take me twice that time. My skin was affected, so I had rashes. Red, itchy, burning eyes, eczema on my scalp. Just all kinds of things as far as on the body and skin.

Mold, one of the things it does is create a lot of histamine response.  So a lot of the symptoms we see with mold exposure are histamine, or mass cell related.  All this to say I kind of knew there was something going on.  And I have such compassion for my patients who go through this because I myself ignored it for about six months.  I thought no, this can’t be mold. If it were mold, it would affect my office or workplace or home and I didn’t want to deal with it.  I kind of put my head in the sand.  But finally, it got bad enough that I knew I had to check it out.  I actually was diagnosed with an immune deficiency, so it was significantly impairing my health.

So I did my own testing of my urine and found Trichothecenes, which is some of the mycotoxins you talked about. Trichothecenes are used, they’re actually being studied as chemical warfare agents. They’re so toxic. They are neurologically toxic, immune toxic brain toxic, so very, very toxic to the body. I had this actually in my body from the exposure. Then we found the Stachybotrys in the basement and I literally, this was at the very end of 2014, the day after Christmas. And I never set foot again in that office. I left everything. I ended up getting my paper charts because obviously for patient care I needed those, but every single book, desk, everything else I left and walked out and started over.

It was one of the hardest and best things I’ve ever done because now I’m completely well, but it took really getting rid of all those things and getting out of that office in that time. Even my paper charts ended up bothering me quite a bit until I scanned them in a few months later. So even that paper. Now we know that those mycotoxins and VOCs can actually attach to course materials. If someone’s exposed, they don’t always have to leave everything. It’s not all catastrophic. But in my case, it just made sense. I wanted to get well and I didn’t want to be exposed at all. But it was quite an experience. And then over the following year or two, I really dove in because I wanted to heal from this exposure and I learned how it all connected.  I just, understanding it from that level as an experience gives me a whole different level of understanding. Now when I hear patient’s histories in front of me, there’s so often clues in their history that remind me of a likely mold exposure. Then I ask more questions and do more testing.  But because I’ve lived it and overcome it, I really have a greater understanding of what it looks like and I can see it.  And once you know this, a lot of practitioners don’t know mold illness, it’s very, very prevalent.  It’s very prevalent.  Surprisingly so.  So that’s my story.

Dr. Weitz:                          What are some of those things that make you suspect mold?

Dr. Carnahan:                    Yeah, so history is huge. Before you spend a penny on testing, I would say 99% of the time, I have a really good idea just from the questions I ask, the patient may have a mold exposure and I’ll tell you some of those things.  But you don’t always, if you’re a good clinician and a good detective, history can tell you so much.  I know you understand this well.  My staff actually jokes because literally when I go to test for mold or some of these other infections really, some of the diagnoses that I think might be there to prove it, I’m pretty much batting 100%.  If I think it’s there, it’s almost always confirmed.  That’s just because of the history and really knowing what to ask.

So what questions-

Dr. Weitz:                          Yeah. I think a good clinician really does testing to confirm what they already suspect.

Dr. Carnahan:                    Yes. And you know, I just have to stop here because, at least in my training, there was so much emphasis on objective science which I love. I’m all about science. But I kind of lost my intuition for several years.  I put it aside and felt like it wasn’t valid. I feel like now, I’m really, really embracing that intuitive sense that tapes together millions of pieces of data much more quickly than my brain could do.  Then I confirm it with the science, but my intuition is right on.  And most of the time and most of us in this field, we have a very strong intuitive sense.  And we actually rely on that and then prove it out.  It’s probably the best tool that we have.  Yeah, you’re nodding. I know you understand this. Back to the question. I’ll ask for the history.  When did you get sick?  What happened?  Was it after a move?  So a couple of things that would be … a new move to a new home and then the next year or so, lots of different autoimmunity, allergies, asthma, respiratory immune issues, all kinds of things crashing.  If there’s a family and multiple family members are all ill with unexplained illness, that’s guaranteed there’s some environmental trigger, especially if they’re all pretty healthy, they all move into a new home and within a year they all have issues.  That’s classic for an environmental trigger.

I ask about water damage because if you ask point blank have you had mold in your home, most people would say no. They don’t know it, they don’t see it. Musty smells, because people don’t understand that those are VOCs from mold, so if there is a musty, kind of bad smell, that probably means there’s mold growing somewhere.  Again, just them moving to a new environment. If they have maybe gone on vacation for 10 or 14 days and started to feel better out of that environment, that could be a trigger. And mold is one thing. There’s other things in the environment that could be issues. Like radon, heavy metals, chemicals. But typically mold is a real clear thing as far as a new home or water damage.  I’ll ask about washers, dryers, dishwashers, flat roofs, leaks in the basement, the sump pump, the crawl spaces, window condensation, all of these.  I’m kind of becoming a building expert too even though that’s not my expertise because you really have to understand how the envelope of the building and intrusion of water can create a mold illness.  And most of the people, I’d say 90%, you don’t see this.  You don’t really see it.  You don’t know it’s there.  It’s behind the walls, it’s under the floors.  I just found out this last month that in many of the schools that uses vinyl tile, there’s actually a huge problem, there’s this variegated system that goes under to hold the tile in place and it actually has these ridges where when they flood the tile with water, it’s porous. It goes into these ridges and just sits there in this dark, warm, damp space.  And it’s going to be an epidemic like the asbestos stuff for school systems because it’s a really big deal and no one knows about it.  So things like that where you can’t see it, you can’t smell it, but it is causing illness. And I see school systems as probably being the number one areas, kids and teachers that are affected by mold, it’s epidemic.

Dr. Weitz:                          Wow. You mentioned testing. What kinds of testing do you find are helpful once you suspect that a patient has mold?

Dr. Carnahan:                    Yeah. I just want to emphasize history because I get a ton with history, asking the right questions.

Dr. Weitz:                          Right.

Dr. Carnahan:                    There’s a symptom cluster analysis that I do that’s been validated. So I’ll give them that questionnaire.

Dr. Weitz:                          Oh yeah, good. What is the name of that questionnaire?

Dr. Carnahan:                    It’s just called cluster symptom analysis for CERES and I’m happy to share that with you or your listeners.

Dr. Weitz:                          That would be great. We’ll put it on there.

Dr. Carnahan:                    You got it. Basically, there’s 13 different categories and if you have any one symptom in each category, eight or more out of those 13 are positive. It includes things from brain fog, focus concentration, memory issues to trouble breathing, cough, shortness of breath, sinus pressure, congestion, numbness, tingling, something called “ice pick pain” where you have these sharp, stabbing pains, digestive issues like diarrhea, constipation, heartburn are really common. The skin, the rashes. The brain fog. Fatigue is incredibly common. Weight gain or weight loss. Just all systems are affected. So symptom analysis is free. I do that to every patient that I suspect. Then I also do a visual contrast study in office. This test, retinal acuity between darkened and light lines and if this is impaired, there is likely a biotoxin exposure. They used this in the 1940’s, years ago in the armed services for their armed service people exposure to chemicals.  So it’s not just mold, but it tells you if you have kind of a toxic exposure that affects the retinal blood vessels that are so small that it’s one way you can actually test for that capillary cytokine damage in an easy way in the office. So those two things are free and I always start there. Then of course if they’re positive, I go further. Testing wise, doctors, people I work with, always want to know what’s the one test. Unfortunately, this is a very complex field and there is no one test. You really cannot rely on one thing. History is huge. I just cannot emphasize that enough. But testing wise, there’s about three different things that you can do. One is chronic inflammatory response labs, which you can do through any major lab, like Lab Corps, Quest, or your hospital lab. The most common ones to check are TGF Beta, MSH, melanocyte stimulating hormone, VEGF, and then you can check genetics.  Genetics we’re finding are less and less reliable for really predicting outcomes.  So while there is a stratified risk, it’s not that … they used to call the set of genes a dreaded gene and that really is not valid.

So people who thought they were dreaded and they never get well, it just doesn’t prove out in science. So while I do look at the genetics to follow that, I don’t rely nearly so much on the genetics as I used to. That’s kind of new in this field to not rely on those. Often, we’ll do urinary mycotoxin testing, so testing for the mycotoxins coming out of the body in the urine. The controversy here is could they be from food, especially okra toxin and that answer is yes. So while we don’t always know, usually we can see a pattern if there’s a lot of different micro toxins in a person that has mold related illness, it’s more likely the environment than foods.

Dr. Weitz:                          By the way, do you use a glutathione ahead of time to increase the likelihood that they’ll be excreting mycotoxins?

Dr. Carnahan:                    Yes, great point. So four or five days prior, I like to instruct them to use either infrared sauna or glutathione or both because what you want to have … years ago, I did a couple of these mycotoxin tests in the early days and I had patients that I was sure there was mold issues and they came back completely negative. Really sick people, mold issues and I was so puzzled. I thought how in the world are these people negative? But what I realized is our very sickest people are so toxic, they’re not excreting anything. So you just hit the nail on the head in the sense that some of those really sick people, you will get false negatives if you don’t pre-treat them with something to push those toxins a little bit. Now you still, even if someone is very toxic, you still might get a false negative, so you just have to know that is a possibility, but you’re going to be less likely if you pre-treat with glutathione or infrared sauna.

Dr. Weitz:                          How much glutathione?

Dr. Carnahan:                    Yeah, I do 500 BID for five days.

Dr. Weitz:                          Great. Do you find the Real Time labs, or Great Plains, one more reliable than the other?

Dr. Carnahan:                    Yes. The first one that came out was Real Time Labs and they do Elisa testing and they’re fantastic. They have a really large panel. That was who I, when I first got sick, used. Then Great Plains came along and their technology is a little bit more sensitive with mass spectroscopy.  So we pick up more detail.  It’s more sensitive.  The downside is you may pick up foods more quickly than you would environmental.  So there’s pros and cons of both.  I probably use Great Plains more now because of the sensitivity.  But every once in a while I’ll go back to the Real Time just because they really both are valid.  They’re both great tests.

Dr. Weitz:                          Related question for those Functional Medicine practitioners who might be listening to this conversation, what’s the best training or learning program for them to become more knowledgeable about treating patients with mold?

Dr. Carnahan:                    Yeah. Dr. Shoemaker’s been at the forefront in this training. He really set a lot of the foundation in place. The newest group that I would highly recommend is ISEAI, it’s International Society for Environmentally Acquired Illness, so ISEAI.org.  It’s non-profit.  I’m on the board, so I’ll disclose that, but other than that it’s completely non-profit. The real push there is literally I don’t get paid by them at all. I just want to bring the science to this field and so does everybody else who’s there. So a lot of the docs who have been doing this the longest and really understand all the nuances have created this organization.  They’re bringing, in fact in May there’s going to be the first conference so stay tuned for that. But I really think the best and most scientific data will come from that organization. So most of my colleagues and friends who ask how can I learn more? I would say join the ISEAI group because you’re going to stay in touch with the latest scientific. There was a lot of politics historically in this field, and I won’t go into that, but I feel this is really free from those biases and really the people who are in charge are trying to bring great science to a very difficult and changing field.

Dr. Weitz:                          Great. Let’s get right into treatment.  How do we treat patients who are sick from mold or mycotoxin exposure?

Dr. Carnahan:                    Yeah. This is … if you’ve ever heard me lecture on toxic exposure and environmental toxicity, it’s all about toxic load.  So I always talk about the bucket capacity. We are born, some of us genetically have a very small bucket, but that’s our capacity to hold onto toxins and to actually get rid of them and deal with life.  What we should have is a nice little margin at the top and that allows us to take in and get out every day.  Most people should actually do a daily detox, whether it’s making sure they’re eating clean, incorporating infrared sauna or Epsom salt baths.  There’s all kinds of ways, but just a 21 day detox once a year is probably not going to cut it in our toxic environment.

Most people, including myself that I see at least, have a smaller bucket and they’ve completely reached capacity. They’re spilling over the top. That’s when they present with us with illness. Commonly with environmental toxicity, it’s neurological illness, it’s autoimmunity and it’s cancers. So these things we see are all epidemics. But back to treatment. Thinking about the toxic load, the first thing you want to do is start to decrease that load. So you cannot really … you can give them glutathione or binders which I’ll talk about specifically. But if you don’t get them out of that exposure, you’re not going to get very far and you may not make any progress at all. So the hardest thing is to find where this exposure is coming from and get out, because it could involve selling, losing a house, losing your job. There’s some really big ramifications of this illness. It’s like a tornado or fire sometimes when people lose a lot of stuff. But, the bottom line is your health is the most valuable asset you have. For me, I was worth walking away from probably hundreds of thousands of dollars of things that it didn’t matter because my health really did matter.

All of that is replaceable. So when patients finally get that, they get it and they’ll do anything. And I don’t mean to be fatalistic, because not everybody has to give up everything. You can move and keep your stuff, no problem. But it is a big deal to make sure that you’re in a pretty clean environment because you will not be able to get well without that piece. I always just have to emphasize because people think they can take a bunch of stuff and stay in their home and that will not work. So once you find the culprit, get it out. And again, it could take a few months or a few weeks. You do what you can in the meantime. But, when you get out, or even while you’re getting out, glutathione is really powerful because when you have a mold exposure, you tank.

You basically use up your glutathione, especially if you have any SNPs for glutathione synthase, or any of those which a lot of our patients have. They will be impaired. Now, I will say not everyone tolerates glutathione for reasons that they can cause oxidation. So there are people who need precursors like glycine, vitamin C and maybe NAC and they do better with those than glutathione.  I’m one of those. I’ve never done well with glutathione, but I can take all the Vitamin C and glycine in the world and I do fine as long as I take the precursors.  So everybody is different, but you need to be producing glutathione and you need to give your body all the raw materials or the liposomal or IV forms.

Second would be binders. The way these mycotoxins and molds are detoxed from our body, one of the main pathways is the liver-gallbladder transformation there. What happens is phase one, makes an intermediate that’s very toxic. Then phase two takes it into a more water soluble form. It’s excreted into the bile and stored in the gallbladder.  So our bile excretion is actually one method of elimination of these toxins.  What you’ll find is bile acid binders, or sequestrins, are very powerful ways to pull those toxins through the bile out of the body. If we do not do that, about 95% of the bile is intrahepatically recirculated.  It just is like a merry go round and those toxins go right with it and they never really get out of the body.  So we can use clay, charcoal, zeolite, a cholestyramine, Welchol, these are all substances that have affinities for toxins. I like to combine binders because each of them have a different affinity to different mycotoxins and even endotoxins from the gut. So we’re getting a much bigger, broader spectrum when we combine. I will say that for example, okra toxin is probably best bound by cholestyramine, whereas aphlatoxin is better bound by clay and charcoal.

So there is differences to the types of mycotoxins and based on the results, I can pick and choose the binders to use. But, it’s probably best to use a multiple. People can take them all at once and usually twice a day is sufficient. They need to be taken an hour away from food or supplements, either an hour before a meal or two hours after.  So it’s a little tricky.  In the old days, we used four times a day, but I find that just to be incredibly difficult and people can get well at a little bit lower dosing.

Dr. Weitz:                          That’s great. Let’s see. Do you also support liver detoxification as part of the program?

Dr. Carnahan:                    Yeah. That’s just scratching the surface because surely as you do, I do a complete Functional Medicine approach.

Dr. Weitz:                          Yeah.

Dr. Carnahan:                    You have to get the bowels moving. You have to treat dysbiosis, which is really common. A lot of these patients because of weakened immune system will have viral or fungal burdens, very commonly fungal burdens and also viral. So you have to treat those in the gut or in the body. You have to check sinuses for colonization of MARCONs, which is a methicillin resistant bacteria or also fungal and treat that as well. So you’re really treating the whole body for infections and toxic load. There’s a lot more things I put people on. The very basics would be a Vitamin D, a probiotic, fish oil. Fish oil actually helps with the detox and the reactions people have. 

Then, making sure they have all the Alpha Lipoic acid and the N-Acetyl cysteine; milk thistle, glutathione, all the good liver support. And you sometimes have to go very slowly because as you bind, I think of it as if you have a magnet and metal filings on your desk and you pull that magnet and most of the metal filings stick, but there’s a little trailing along. It’s very similar when you’re binding mycotoxins out of the body with these binders. They don’t have an iron grip. They’re pulling gently with a small affinity, but you’re actually often in the beginning getting re exposed on the way out. So when you start binders, if you start too heavy, often people will feel more sick, they’ll have more symptoms because they’re actually kind of getting re-exposed to this toxin on the way out. That’s super common.  My best tips for that would be mineral water or alkalinization of the body with greens and things. Infrared sauna is super powerful. Epsom salt baths are amazing. And go slow. So all those things can be helpful in the process.

Dr. Weitz:                          What’s the typical length of treatment?

Dr. Carnahan:                    Yeah, I would say six to 18 months is pretty typical. Sick people are pretty resilient and sometimes longer. Again, in that period, they become hyper sensitive. There’s an unmasking. So when they’re in the moldy house or the moldy office, they don’t feel well.  But they don’t even notice the mold as far as smell or how they feel.  As they start to detox, what’ll happen is they’ll become super sensitive and they’ll notice if they walk into a building or somewhere with mold.  So they think they’re getting worse.  It’s actually a really good sign because all of a sudden, the water… sensitive. Some develop multiple chemical sensitivities.

Dr. Weitz:                          Okay, great. I don’t know if you’ve noticed, but consumer products with charcoal are really hitting the market big time these days.

Dr. Carnahan:                    Yeah, you find it … in the airport the other day, I saw lemonade charcoal for post hangover.  I’m like gosh, they’re really getting into this. Just a travel tip; I always, always travel with charcoal and I pretty much take it every day when I’m on the road because it’s a great binder for bad food.  I don’t drink, but too much alcohol if someone were a drinker.  It’s also a binder for just environmental toxins.  I find I feel much better when I travel to take that charcoal.

Dr. Weitz:                          Maybe in the last few minutes we have, we could talk a little bit about a low mold diet, which I know you recommend.

Dr. Carnahan:                    Yeah. When patients are in the midst of this detox, often getting mold out of the diet can be a really helpful thing. Also, like I said, some of them are colonized with fungal species like candida or even they could have aspergillus in their sinuses or lungs as well. All of these things feed on refined carbs and sugars. So at the very core, it’s eliminating … like a paleo-style diet tends to be fairly close, because it’s grain free and legume free, especially the flours and the sugars. Those just have to be out. Dried fruits are notorious for not only mold, but high sugar, so dried fruits should be out.  Coffee and chocolate tend to have a higher mold content unless you’re really sure about the clean.  So those are better to avoid or be cautious. Then anything that’s … your blue cheese, fermented foods, things that are either fermented or moldy by nature are a problem.  Mushrooms are usually a problem. So temporarily, patients can get all of these things out of their diet and then start to add them back in as they get better. It’s just most patients who have mold related illness are incredibly sensitive to both alcohol and sugar. Those are probably the two biggest things to avoid.

Dr. Weitz:                          That’s great. So for listeners who’d like to get a hold of you, what’s the best way for them to contact you and find out about your programs?

Dr. Carnahan:                    Thank you. Yeah, my website is just a plethora of information, all free. So I hope you visit. It’s just my name, JillCarnahan.com. I do have a free mold guide. I’ve updated it just this last year. A lot of patients, I get all the time emails from patients how have just read the guide and started to get well. I can’t sere them, but it’s free. And it is out there for your listeners. I’ll be sure and send you the link, but if you have trouble, if you just Google Dr. Jill mold guide, you will get it right there up on Google and it’s free. I hope you’ll download that. [Here is the link to the mold guide: https://www.jillcarnahan.com/exposed-to-mold-now-what/ ]

Dr. Weitz:                          Excellent. Thank you so much Dr. Carnahan for joining us today.

Dr. Carnahan:                    You’re welcome. Thank you for the interview.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Histamine Intolerance in Patients with SIBO with Dr. Nirala Jacobi: Rational Wellness Podcast 86
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Dr. Nirala Jacobi talks about Histamine Intolerance in Patients with SIBO with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

0:53  Histamine intolerance sometimes occurs in patients who are also suffering with Small intestinal bacterial overgrowth. Histamine is a neurotransmitter that signals your immune system to launch an inflammatory response in your gut, your lungs, your skin, your brain, or your cardiovascular system. When dust makes you sneeze or you get a skin rash from eating gluten, this is a histamine-mediated response.  Most of the histamine is generated in mast cells, but it is also produced in the enterochromaffin-like cells in the stomach that are involved in the production of hydrochloric acid for digesting your food.  Histamine is produced from the amino acid histidine, with the help of the histidine decarboxylase enzyme. Histamine is usually broken down by the enzyme histamine N-methyltransferase or the enzyme diamine oxidase, with diamine oxidase being the most important one.  If you’re deficient in diamine oxidase, you’ll likely have histamine intolerance, since the histamine does not get broken down and it builds up. There are various causes of low diamine oxidase, including gluten intolerance, leaky gut, small intestinal bacterial overgrowth. There are certain foods that tend to block diamine oxidase like alcohol and energy drinks. Inflammation blocks diamine oxidase. And a number of medications also reduce diamine oxidase. 

4:30  Histamine is involved in a lot of functions in the body and it can present with classic allergy symptoms, but it can also present with digestive symptoms like bloating or cramping, and more systemic symptoms like fatigue and headaches. Dr. Jacobi explained that when she is treating a patient with digestive conditions like SIBO and she doesn’t get the expected response, then she will see if their symptoms might indicate histamine intolerance.  Sometimes she can pick out histamine intolerance patients early on.  Extreme histamine intolerance can be mast cell activation syndrome.  Histamine can stimulate hydrochloric acid production, so reflux can be caused by histamine intolerance. 

6:39  Dr. Jacobi explains that you have to break down histamine problems into exogenous histamine production found in foods we are eating, like spinach, canned fish, and cured meats and then you have endogenous histamine production where histamine is either over produced by the body or not being cleared. Histamine intolerance can result from a lack of diamine oxidase because of microvilli destruction due to SIBO or Celiac Disease. 

8:32  If Dr. Jacobi suspects a patient may have histamine intolerance she might test serum histamine, chromogranin A and a host of other urine measures that are more specific for mast cell activation syndrome. Lately, she has been running the Dunwoody Intestinal Barrier Function test, which measures histamine and diamine oxidase levels, though measuring serum histamine levels is not that reliable since it has a very short half life.  If diamine oxidase levels are low, she will prescribe a product containing pure diamine oxidase called Umbrellux. 

12:28  Dr. Jacobi has developed a SIBO histamine biphasic diet for SIBO patients in collaboration with dietician Heidi Turner. It’s a variation on her biphasic diet for SIBO patients and for the first two weeks you avoid histamine liberating foods, like lime and citrus, and histamine containing foods. If you’re improved after two weeks, then you can start adding back in the histamine liberators. You remain on the histamine avoidance foods and then you phase into the biphasic diet for SIBO (her version of a low FODMAP diet) starting with phase two.

14:51  Sometimes it is easy to suspect that histamine is a problem for SIBO patients, such as when they tell you that they eat tuna every day for lunch and get bloating. You can just have them remove canned fish and the other high histamine foods right off the bat.  Fresh fish does not have a lot of histamine until it is allowed to age in the can or in the refrigerator. In fact, any protein food that is allowed to age will develop histamine, such as leftovers.  Now there is another reason not to eat tuna besides histamine, which is because it is so high in mercury.  The exception is the baby tuna in a can sold by Vital Choice, which is much lower in mercury.

19:28  There is probably not much need for supplements to promote diamine oxidase production, even though it is supported by B6 and copper.  It is more beneficial to heal the gut and the microvilli.  So gut healing formulas can be helpful and folate and methylation factors can also be beneficial.  Using a supplement of diamine oxidase for a month or two and treating the SIBO or the other underlying cause is the most beneficial treatment for histamine intolerance.  If they have mast cell activation, which means they have a large pool of endogenous histamine, they will need mast cell stabilization, such as by taking quercetin or other mast cell stabilizers. Here is a paper on the effectiveness of quercetin: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0033805

22:49  Some probiotics have been shown to be beneficial for patients with histamine intolerance, including Lactobacillus plantarum strain 299V, lactobacillus ramnosus, bifido infantis, and bifido longum have all been shown to help degrade histamine.  But Dr. Jacobi said that she has not seen much benefit just using probiotics in these patients, though she often does include them in her protocol.  And histamine is a bioactive amine can actually be produced in the microbiota in the large intestine.  Here is a paper on lactobacillus plantarum degrading biogenic amines like histamine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3316997/  Here is a paper that discusses how bifidobacterium infantis and longum suppress histamine signalling: https://www.jstage.jst.go.jp/article/jphs/107/2/107_08028FP/_article/-char/ja

 

 



Dr. Nirala Jacobi is a Naturopathic Doctor who specializes in treating patients with functional gastrointestinal disorders like SIBO and she directs the Biome Clinic in Australia.  Dr. Jacobi runs the SIBO test online breath-testing and educational service. She is also the host of the popular SIBO Doctor podcast on Itunes

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.



 

Podcast Transcripts

Dr. Weitz:  This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition. From the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness podcast on iTunes and YouTube. And sign up for my free eBook on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello, Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy the Rational Wellness, please give us a ratings and review on iTunes. That way more people can find out about the Rational Wellness Podcast.

Today we are going to talk about histamine intolerance, especially in patients who are also suffering with small intestinal bacterial overgrowth. SIBO is the underlying cause of IBS in the majority of cases.  First of all, what is histamine? And what is histamine intolerance? Histamine is a neurotransmitter that signals your immune system to launch an inflammatory response in your gut, your lungs, your skin, your brain, or your cardiovascular system. When dust makes you sneeze or you get a skin rash from eating gluten, this is a histamine-mediated response. Most of the histamine is generated in mast cells, but it is also produced in the enterochromaffin-like cells in the stomach that are involved in the production of hydrochloric acid for digesting your food.

Histamine is the chemical involved in common allergies, which is why drugs that block histamines are often prescribed for patients with allergies. We have H1 receptor blocking agents, like Benadryl, Zyrtec, Claritin, and Allegra. We also have H2 receptor blocking agents, like Tagamet, PEPCID, and Zantac. And as you can tell those are drugs that help in the GI tract. There are also quite a number of foods and nutritional supplements that can modulate histamine levels, which we’ll probably get a chance to talk about today.

Histamine is produced from the amino acid histidine, with the help of the histidine decarboxylase enzyme. Histamine is usually broken down by the enzyme histamine N-methyltransferase or the enzyme diamine oxidase, with diamine oxidase being the most important one.  If you’re deficient in diamine oxidase, you’ll likely have histamine intolerance. There are various causes of low diamine oxidase, including gluten intolerance, leaky gut, small intestinal bacterial overgrowth. There are certain foods that tend to block diamine oxidase like alcohol and energy drinks. Inflammation blocks diamine oxidase. And a number of medications also reduce diamine oxidase.

I’m so happy that Nirala Jacobi will be joining us today to help give us some clarity on what do to about histamine intolerance, especially in patients suffering from small intestinal bacterial overgrowth. Dr. Jacobi is a naturopathic doctor who graduated from Bastyr University in 1998. She’s now the director of the Biome clinic in Australia, where she takes care of patients with functional gastrointestinal disorders.  Dr. Jacobi is the host of The SIBO Doctor Podcast. She runs the SIBO test online breath-testing and educational service. And she develops courses for training functional medicine practitioners. Dr. Jacobi has developed her version of the low FODMAP diet, the biphasic diet for patients with SIBO, and recently she developed the SIBO histamine biphasic diet.  Dr. Jacobi, thank you so much for joining me today.

Dr. Jacobi:  My pleasure. Thanks for inviting me.

Dr. Weitz:  So when you’re working with a patient with small intestinal bacterial overgrowth, what we call SIBO, when do you suspect that histamine intolerance may also be a problem?

Dr. Jacobi:  Well, as you so aptly pointed out, histamine is involved in a lot of different functions in the body. And it’s a really important molecule, a biogenic amine. And it can sort of present with pretty classic symptoms. As you mentioned, allergies, but also what we see are a lot of digestive disorders like bloating, cramping, more systemic symptoms like fatigue and headaches and so forth. And what happens is … I usually start my treatment out and if I don’t get the expected response, or if people have sort of dysautonomia symptoms that are more classic along the spectrum of histamine intolerance all the way to mast cell activation syndrome … That’s a real spectrum. So you could have simple histamine intolerance all the way to mast cell activation syndrome. So wherever they are on the spectrum, and I sometimes suspect it fairly early on. But mainly-

Dr. Weitz:  What are some of the symptoms of histamine intolerance?

Dr. Jacobi: Well, some of the symptoms of just plain histamine intolerance is bloating after meals. It can even be reflux because of this histamine actually stimulating hydrochloric acid production. Cramping is pretty common, abdominal cramping or hypersensitivity. Those are pretty classic. Diarrhea or constipation, but more predominantly diarrhea, which of course all those are SIBO symptoms as well.  So after treatment and if the patient tests clear after treatment and they still continue to have symptoms, I start to suspect this.

Dr. Weitz:  Okay. What about if you get a patient and you work them up for SIBO and they have some of the histamine symptoms outside the gut? Do you change your-

Dr. Jacobi: Do you mean like rashes … I mean, the thing is-

Dr. Weitz:  Yeah, skin rashes or other allergy symptoms, respiratory, et cetera?

Dr. Jacobi:  So the way I think about histamine, because I really did a pretty deep dive into histamine intolerance, and the way to understand it is that you have exogenous histamine production, which is found in food that we’re eating. Histamine can be found in things like spinach or canned fish, all canned products, cured meats, that type of thing. And then you have also conditions where histamine is endogenously over-produced or not cleared. So those two are very separate conditions that I wouldn’t class them necessarily all in one ball of histamine intolerance.  I usually think of histamine intolerance as a lack of diamine oxidase, which could be because of microvilli destruction due to SIBO or, as you mentioned, celiacs, those types of conditions, where really the main enzyme that breaks down food-based histamine is destroyed.

Dr. Weitz:  Okay. If you suspect a patient of having histamine intolerance, do you do any specific testing? Do you do serum testing? Or how do you try to work them up?

Dr. Jacobi: It’s a good question, because it is woefully inadequate is what I would say in terms of how to really get a good grasp of what’s going on with histamine. Because it has a very, very short half-life, so typically serum testing of histamine is not all that reliable. But there are a battery of tests that … I usually do that if I suspect mast cell activation syndrome, which include things like serum histamine but also chromogranin A and a host of other urine measure or markers that are more specific for mast cell activation syndrome.  But for simple histamine intolerance, there are some tests like I’ve been using the Dunwoody Intestinal Barrier Function test. That’s what it is. And it does measure histamine and diamine oxidase levels just on a … it’s a blood test. Like I said, the histamine I’m always a little bit iffy with, but with diamine oxidase that can be helpful. And then I prescribe a product called Umbrellux, which is a diamine oxidase, which is difficult to find pure diamine oxidase, but that’s one of the ones I use.

Dr. Weitz:  Oh, okay. Have you read about the connection between H. pylori and histamine intolerance?

Dr. Jacobi: So, H. pylori has so may different triggers in the upper gut, in terms of hydrogen sulfide production and so forth. But, yeah, there are some connections. When you have H. pylori, it’s sort of like it’s one of those ancient species that have been with us for so long, that it doesn’t always cause a problem and it only is a problem when you’re actually symptomatic for those things.  But I haven’t particularly noticed that my H. pylori patients are particularly histamine intolerant. I can’t say that clinically, no.

Dr. Weitz:  Right. Okay. I guess I saw a paper where H. pylori can increase histidine carboxylase, which is the enzyme that helps promote formation of it.

Dr. Jacobi: Yeah, which is interesting and I would kind of want more research on that. Because as we know, H. pylori lives in the stomach and it sort of survives these extreme conditions by creating an alkaline cloud around it. So by increasing histamine, it effectively would increase stomach acid, which would be a real surprise to me actually. Because it is a bug that lives there but it doesn’t thrive in stomach acid.

Dr. Weitz:  Yeah. Interesting. Maybe it just happens as a result of having H. pylori and maybe they just saw an association.

Dr. Jacobi: Yeah. Perhaps.

Dr. Weitz:  I just interviewed Jill Carnahan this morning and she was mentioning how mold toxins can result in histamine intolerance. Have you seen this…

Dr. Jacobi: Yeah, mold toxicity is not my specialty. I know that mold toxicity, obviously, because of its connection to a rampant, innate immune system, can have a lot of different causes of lots of different systemic issues. I haven’t seen the connection specifically to histamine. I know that there is a very specific connection to SIBO, simply because of the vasoactive intestinal peptide that’s often an issue with mold toxicity. And so if you have SIBO as a result of mold toxicity, that could be a very easy explanation as to why your patient is histamine intolerant.

Dr. Weitz:  Interesting. So can you tell us about your SIBO histamine biphasic diet for SIBO patients?

Dr. Jacobi: It’s a mouthful, I know. It’s a real mouthful, the name of it. So because I’m a SIBO specialist and I came across actually quite a few papers that mentioned the prevalence of histamine intolerance in a number of digestive disorders which are fairly benign. But the authors of these studies suggested that histamine is actually very often the culprit in terms of digestive symptoms.  So I looked into this a lot deeper and collaborated with Heidi Turner, who’s a fantastic dietician in Seattle. She gave a very riveting presentation at one of the SIBO symposiums about rheumatoid arthritis and SIBO, but also mentioned histamine in that whole process. And she was on my podcast talking about mast cell activation syndrome.

So we collaborated and came up with a fairly straightforward but quite restrictive approach. And anyone who’s listening who’s heard of a biphasic diet, it’s really a staged approach to SIBO treatment. And so we wanted to take that same blueprint and have a staged approach to histamine intolerance. And the way we did that is, rather than just remove pretty much all foods, which would be the case if you’re treating SIBO and histamine intolerance at the same time, we’ve sort of used the histamine intolerance diet as a starting point before you go into the straight biphasic diet.

So what we did is we staged the histamine liberators and histamine foods. So histamine liberators are foods that actually, just as the name implies, liberate histamine from foods. Such as lime and citrus, et cetera. So the first part is where you’re avoiding all histamine liberators and histamine foods, which is about two weeks. And if you’re improved then you can start adding in the histamine liberators. Then you remain on the histamine avoidant foods and then you sort of phase into the biphasic diet stage two, or phase two.

So it’s a great way to manage symptoms really quickly for people where you really suspect they have histamine intolerance. And sometimes people will be really obvious. They say, for example, they eat a can of tuna every day for lunch. You and I know that’s not a good practice, besides histamine. But it is something that people do a lot and they have a lot of bloating, they have a lot of issues. And so you just can start with saying, look, just remove that food and remove all the main heavy hitters and see if there’s any improvement.  And I often do that with my SIBO patients, sort of like a histamine intolerance 101, kind of a light version of the histamine biphasic diet.

Dr. Weitz:  Yeah, so you brought up tuna fish. So from what I understand, fish, if it’s really fresh, is going to be very low in histamines. But as it sets, whether it’s sitting in your fridge or whether it’s in a can, right, that’s when it starts developing higher histamine levels?

Dr. Jacobi: Yeah. Yeah, fish tends to be very high. There’s actually a condition called … I think it’s scombroid poisoning. Some kind of crazy name.

Dr. Weitz:  Yeah…

Dr. Jacobi: I actually have a patient where I very much suspected that it was a triggering event for him, of subsequent histamine intolerance. And he had a lot of systemic symptoms. But anyways, yes, tuna fish or any tinned or canned fish, any protein, really, that’s allowed to age. And so sometimes people are so sensitive that they can’t even do leftovers. They have to eat their meals very fresh, freeze them fresh. Those would be suspect. Also, in terms of … if people come in and they just have a ton of sensitivities, you have to suspect histamine as your first priority.

Dr. Weitz:  So what about fish that’s frozen? Is that going to prevent the histamine formation?

Dr. Jacobi: Yeah, you’d want to really check the label that it says flash frozen on the ship or on the boat. That’s a good practice. The reason I mentioned why it’s not such a good practice to eat tuna, really, anymore is because of mercury levels, right?

Dr. Weitz:  Right. Yes.

Dr. Jacobi: Which is a whole nother kettle of fish in another way. But yeah-

Dr. Weitz:  Except that one company that makes the baby tuna. You know about that one?

Dr. Jacobi: That they … isn’t that horrible? That they’re using that, it’s now a thing? Yeah. Where are we going to stop destroying the planet?

Dr. Weitz:  It’s not going to stop, unfortunately. There’s not going to be any wild fish soon, so …

Dr. Jacobi: That’s right. So I usually promote companies like Vital Choice, which is an Alaskan fishermen cooperative-

Dr. Weitz:  I think that’s the one that has the baby tuna.

Dr. Jacobi: Oh, really? That would surprise me. I mean, I’ve talked to the main guy. But look, I don’t know this. I haven’t actually come across this-

Dr. Weitz:  So I think what they said is the baby tuna accidentally get caught up in the nets with the bigger tuna, and the fishermen used to throw them away. And then they realized that the baby tuna actually have very low levels of mercury, so…

Dr. Jacobi: Yeah, they do. They do.

Dr. Weitz:  … they buy them up from the other fishermen … that’s what-

Dr. Jacobi: Oh, I see what you’re saying, right. Well, that’s a whole new thing. I thought that they’re specifically targeting tuna day care centers.

Dr. Weitz:  Yeah. We separate the baby tuna from their mothers when they cross the border.

Dr. Jacobi: Oh, God. We shouldn’t laugh about that but it’s pretty funny.  Well, Vital Choice, the reason I like them is because they do, according to my own research, they do very sustainable practices. And so that’s really the way forward with all this. It’s like, we can’t possibly expect things to be sustainable the way we’re doing it now. And so I like to promote or support companies that have much better sustainable practices.

Dr. Weitz:  Right. Yeah, absolutely. I think it’s important where you get your fish oil from too, because some of them-

Dr. Jacobi: Exactly, yeah.

Dr. Weitz:  … you get them from the small fish that the whales eat, the krill, that’s going to be a problem because that’s going to deplete the whales, right?

Dr. Jacobi:  Well, actually Antarctic levels of … I mean, this is way off the topic, Ben, but … krill levels. I’m quite close to Antarctica, you know close, how close I don’t know.

Dr. Weitz:  That’s true, that’s true, yeah.

Dr. Jacobi: But we do have plenty of krill down there. We have great thriving humpback migration routes here.

Dr. Weitz:  Okay, so anyway, so, getting back to the topic of histamine… So what about foods and nutritional supplements that can promote diamine oxidase production?

Dr. Jacobi: So it’s supported by B-6 and copper. So that’s one thing. But it’s a rare patient that’s really depleted in copper in my experience. So I don’t usually use precursors or supplements to promote the replenishment. It’s really about healing the gut. Because as soon as the microvilli return, you should have ample amounts of diamine oxidase. And it’s a protective mechanism for all of us to have this in our microvilli, because all of us have a certain tolerance to histamine after which it gets really overloaded.

So if you’re somebody who’s listening and reacts a lot to green smoothies, thing like that where you eat a lot of spinach, and you have reactions, I would suspect histamine intolerance. But really it’s about healing the microvilli, and that is take your gut-healing formula of choice to really regrow that. Which requires a lot of folic acid. Actually if we think about that we have this gut lining that’s one-layer thick from mouth to anus, more or less. Well, it’s actually in the small intestine where it’s one-layer thick. And all the way through the large intestine.  And that cellular turnover to renew itself occurs every 48 to 72 hours. And so for that DNA replication you require a lot of folate and methylation cofactors, which is … I go easy on them. I always start very easy on them. Because a lot of people react to B-vitamins, especially if they still have SIBO, because it’s like a food for the bacteria. So you gotta be easy on that. But I just wanted to make that point that folic acid is really important in cellular replication.

Dr. Weitz:  Right. You ever use natural agents that are … like natural histamine blockers like quercetin in the short term to help modulate symptoms?

Dr. Jacobi: Yeah, so it’s not really a histamine blocker, quercetin. It’s more of a mast cell stabilizer. And it does a really good job. Really, really good job in doing that. You gotta go up high. And it does do that. But remember that if we’re talking about histamine intolerance, where it’s not a mast cell problem. It’s actually more of an issue of where you’ve destroyed the very enzyme that breaks down histamine at the very get-go.  So I usually find that using Umbrellux or something like that for about a month or two is really helpful. And then treating SIBO if that’s the underlying cause, or treating whatever other underlying cause.  Crohn’s disease, celiacs, that type of thing.  And really healing the gut lining is my primary objective then. But if they’re moving on this spectrum where in other words, it’s not just exogenous or outside histamine that’s the problem that’s coming in from food, but they have an aberrant mast cell response where that was triggered by stealth infection, by mold, by a number of insults, then they actually have an endogenous pool of histamine that’s very high. And for that they’re going to need a lot of mast cell stabilization.

Dr. Weitz:  Right. Yeah. There’s also some genes that could predispose them. What about probiotics?

Dr. Jacobi: So I often get asked about probiotics, and I’m a single-strain kind of person.  Or no more than a few strains.  Sometimes I go above that and I use research strains. We don’t really know enough yet about which strains … there are conditions in which your microbiome actually produces histamine. That does occur. And it is a biogenic amine. So that often happens in the large intestine where we see further degradation of histidine into histamine.  So that does happen. And so I sometimes recommend probiotics like lactobacillus plantarum and lactobacillus rhamnosus gg, specifically. But to be honest, I haven’t seen a great deal of relief with just probiotics.  And I do a lot with probiotics.  So I’m a little underwhelmed as it is right now with just using probiotics.  And there’s very little research.  I’m hoping it’s coming very soon, but there’s very little research on even the strains that I’ve mentioned.  But there is some.  So I do use it for those instances.

Dr. Weitz:  I did see a few papers that show that certain strains of probiotics, bifido infantis, longum, and bifido plantarum helped to degrade histamine.

Dr. Jacobi: You mean lactobacillus plantarum?

Dr. Weitz:  Yeah, lactobacillus plantarum.

Dr. Jacobi: Yeah. That’s the one I mentioned that’s a really well researched strain, it’s usually 299v. And it’s the one in sauerkraut, which is kind of mean because sauerkraut’s full of histamine. But it is in the fermented vegetables. And so, yeah, that’s a very well researched strain for a lot of different things. Also for hydrogen sulfide. So I use it for a lot of purposes.

Dr. Weitz:  Okay. Let’s see. So your biphasic diet involves testing back in some histamine-liberating foods.

Dr. Jacobi: Yeah, so, the SIBO histamine bisphasic is … like I said, it’s sort of like the entry point into the biphasic SIBO diet.  Which is really about minimizing die-off symptoms and having a very streamlined approach to SIBO treatment.  But the histamine was a very specific part of this process for those that are very, very sensitive.  I don’t know about you, Ben, but I’m seeing increasingly people that are eating only five different foods or so.  Extremely sensitive.  Very reactive patients.  And I mean, I specialize in digestive disorders, so that’s not a surprise.  But still it seems to be getting quite, quite intense for people out there.

So really this diet was necessary for me as a starting point for many of my patients that are super sensitive. So yes, once again the first part is histamine liberators and histamine foods are to be avoided. And the second part is where you can introduce the histamine liberators again and then still remain off of the histamine foods. And then the third part is you transition into the phase two of the biphasic diet, of the SIBO diet.  So it took us a long time to produce this diet, because we had to juggle these two conditions, SIBO and histamine intolerance.  And if you combine them … you’re left with hardly any food.  And so we had to have this staged approach to treatment.

Dr. Weitz:  And that happens a lot, especially in patients that are treating themselves and they go on the internet and they find another list and another restrictive list. And you start layering these lists, there’s no foods to eat anymore.  I’ve been amazed with patients with gut problems that I’ve treated. And when they start to feel better I would have thought that they would be very anxious to have a much broader diet and they would be bored with eating those foods.  But I’m shocked a lot of times when they say, no, I’m okay.  I’ll just keep eating this way the rest of my life. I finally feel okay.  And as you mentioned, it’s not that healthy to have a very limited diet, so …

Dr. Jacobi: It’s not healthy at all, and there is a lot of food fear out there. And to some extent … I mean, people feeling sick, of course, they have to find a way to feel better. But that often creates a situation where they are very fearful to reintroduce foods. And so we have to really counsel them around that. And what I usually say is, look, you’ve basically selectively fed a very small number of bacteria. Whatever food you’re going to start eating after your two-year stint of just chicken breasts, Brussels sprouts, and maybe white rice … whatever you’re going to start putting back in will cause you some reaction. I fully expect that.

So if you actually preface that by saying that, I think that makes a big difference for people. Like, oh, okay. I’m not going to relapse all the way; I’m just going to have a few reactions, maybe, but I’ll be okay. So that’s important for practitioners to really understand, is like if they’ve painted themselves in a corner, they will have some reactions. And you just mitigate that by reducing doses and very small amounts.  I’m a big fan of collaboration as a practitioner, so I have a team of people around me that I can delegate stuff to. So I have a nutritionist that I work with that does a great job with food reintroduction, again. So I highly recommend that to anyone that has any food issues, is go to a really qualified nutritionist or dietician like Heidi Turner, for example. She’s fantastic with things like that.

Dr. Weitz:  That’s great. I think that’s pretty much all the questions I had about histamine intolerance in SIBO patients.

Dr. Jacobi:  It’s a big deal.  Do you see a lot of them?  Do you have a lot of people with histamine intolerance?

Dr. Weitz:  I have some. I have a lot of patients with SIBO and I’m not always sure if they have histamine intolerance.  It’s always tricky to figure out, so …

Dr. Jacobi:  Well, one of the things that was interesting … I belong to quite a few professional forums and one of my colleagues … Because I kept saying, look, I sound like a broken record. But if somebody was posting, I’m treating them for SIBO, they’re not improving, I said, try removing histamine food.  And I was sounding like a broken record and a colleague was saying, I finally did it and these patients that were not improving had a miraculous turnaround.  So really don’t underestimate the power of histamine intolerance in patients that have very tough-to-treat SIBO or not so much frequent relapses … it’s not really a cause of a relapse.  But people that are just borderline on a test, not really terrible fermentation but still have really pretty tremendous symptoms, I would put that at the top of my list.

Dr. Weitz:  Does anything show up on stool tests with histamine intolerance? No …

Dr. Jacobi:  No. No. Not at all. Stool testing really is … I think in the future maybe … only this Dunwoody lab that I … it’s a new one, I can’t really fully endorse it yet. I’ve had it maybe with 20 people. But so far, it’s holding its weight. So it’s looking promising.

Dr. Weitz:  That’s the one where you’re measuring the diamine oxidase levels?

Dr. Jacobi: Yeah. Yeah. And they also have histamine levels. They actually also do LPS antibodies. So that’s interesting, and zonulin, of course, and things like that.

Dr. Weitz:  Yeah, yeah, yeah. Okay. Great. So how can listeners and viewers get a hold of you and find out about your programs?

Dr. Jacobi: So I’ve created thesibodoctor.com, which is an educational portal for practitioners and also soon to be patients. I have a clinic in northern New South Wales in Australia called The Biome Clinic, and you can just find that at thebiomeclinic.com. And I have a breath-testing company, but if you’re listening to this podcast in America I say, look, just go with a local breath-testing company to reduce the carbon footprint of sending test kits.  I take that stuff very seriously. We’re soon to be 100 percent solar-powered company, so that makes us all very happy and doing our part.

But yeah, you can find us on Facebook. The SIBO Doctor is our main page, where we talk pretty much everything related to SIBO. I’m just about to launch a gut-healing program for patients that will be also great for practitioners to recommend to their patients. And I intend to cover topics like histamine intolerance and how people can really help themselves. And I teach people how to do enemas, how to do hydrotherapeutic treatments at home, how to do a carminative tea, how to really help themselves and empower themselves again with healing their digestive tract. So it kind of is a good adjunct to the practitioner treatment plan. So that’s kind of what I’m working on right now.

Dr. Weitz:  Great. And your podcast?

Dr. Jacobi: The podcast is called The SIBO Doctor Podcast. It’s on iTunes as well. We just finished our second year. So it’s a really popular podcast for practitioners. It’s not just about SIBO. It’s really about the entire universe that is the digestive tract. And it’s fantastic. As you know, it’s just so wonderful to be talking to experts and have very lively, stimulating conversations with other practitioners and experts and researchers.  Just did one on lactic acidosis that just was very interesting, with Dr. Satish Rao. So, yeah. You can find us on iTunes. It is definitely more geared towards practitioners, but as you know, patients are becoming a lot more educated and want to learn more about their own health, which is great.

Dr. Weitz:  Yeah. It’s definitely on my list of favorite podcasts. So thank you.

Dr. Jacobi: Well, thanks, Ben. Appreciate it.

Dr. Weitz:  Okay. I’ll talk to you soon, Nirala.

Dr. Jacobi: All right. Take care.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Histamine Intolerance in Patients with SIBO with Dr. Nirala Jacobi: Rational Wellness Podcast 86
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Dr. Nirala Jacobi talks about Histamine Intolerance in Patients with SIBO with Dr. Ben Weitz.

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Podcast Highlights

Weitz Sports Chiropractic and Nutrition
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24-Hour Urine Testing for Hormones: Rational Wellness Podcast 85
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Dr. Frank Nordt discusses 24 Hour Urine Testing for Hormones with Dr. Ben Weitz.

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Podcast Highlights

1:07   My goal for this podcast is to gain some insights in what we can learn from 24 hour urine hormone testing that can help guide patients to feel better and be healthier.  Hormones can be testing using serum, urine, saliva, blood spot, or dried urine. Serum testing is the most common method since it’s easy and is usually covered by insurance. But urine testing also allows you to be able to test not only hormones but their metabolites, which can be helpful, esp. with estrogen metabolism. Dr. David Zava from ZRT Labs has argued that the best way to monitor hormones administered topically is to use saliva testing. And the dried urine testing from DUTCH has recently become one of the more popular methods with the Functional Medicine community. 

6:00  Dr. Frank Nordt, the CEO and director of Rhein Labs explained that there are various methods of hormone testing today, including blood, blood spot, 24 hour urine, and dried urine testing. With regard to dried urine testing, while it is convenient to do, since all you have to do is urinate on a piece of filter paper and send it in the envelope, but there is not one published study that supports the validity of dried urine spots.  Therefore, according to Dr. Nordt, it is junk science. 

7:28  Let’s start by talking about 24 hour urine testing for hormones. It provides insight into the metabolism and turnover of hormones in the body. Dr. Nordt believes it provides the best measure of hormone levels in the tissues.  You cannot directly assess hormones in the tissues without taking a biopsy, but that can’t be done on an outpatient basis. So while urine is measuring the levels of hormones that have been excreted versus serum which is measuring hormones in the blood, the key is to find out what levels are in the target tissues of the body.

9:12  Dr. Nordt divides the Rhein Labs 24 hour urine hormone report into estrogens, androgens, and corticosteroids. Estrone (E1) is the storage form of estradiol (E2) and the Estrone:Estradiol ratio should be 2:1, though in the case of estrogen dominance, this can be 4:1. The reference ranges that are reported are divided by decade and include plus or minus one standard deviation from the mean. Some doctors like to look at an ideal reference range, though they may have different ideas what this is. Some feel ideal is what a woman’s levels are in their 20s and other feel it is what hormone levels a woman in her 30s would have. 

15:10  When we look at the estrogen metabolites, it appeared a number of years ago from the literature that an increased amount of the 16 hyroxyestrone and looking at the 2:16 ratio would indicate a higher risk of breast cancer. But the more recent research has not really panned out.  With respect to oncogenesis, the 4-hydroxyestrone appears to be the better indicator of higher risk than the 16. If the 2 hyroxyestrone is especially high and the 2 methoxyestrone is unusually low, then the person is not methylating properly.

24:02  When we look at testosterone and the other androgens, we can see what is up and down regulated. For example, in men, 5-alpha-reductase upregulation leads to an increase in DHT levels. Or 5-alpha-reductase can be downregulated by drugs like Finasteride, which completely knocks out the 5-alpha-reductase and this can lead to impaired sexual function.  If a patient is taking DHEA we can see if it is converted into androstendione and it can then be converted into testosterone or into estrone.  For men, DHEA typically does not raise testosterone levels to any substantial level, though it can do this in women.

39:21  Progesterone cannot be measured directly in urine, but we measure the metabolite, pregnanediol, which is a very sensitive indicator for progesterone. 

40:14   Dr. Nordt explained that when you measure hormones with either saliva or blood spots, you are only measuring hormones at one spot in time, when hormones are produced in a pulsatile fashion. What if you measure testosterone in the morning and it is normal in the morning but it is low later in the day?  You will miss that. One of the problems with saliva testing is that many people have buccal microbleeds, or bleeding from the gums, which will contaminate the samples. Another problem is that saliva testing uses immunologically based assays and these antibodies can have cross-reactivity, which can alter the results.  Also, as we age, we have less saliva, so salivary testing gets more difficult to do.  If you have difficulty generating enough saliva, then this can create stress and raise cortisol levels.

46:12  Dr. Nordt talked about some of the issues with blood spot testing for hormones, where you prick your finger and drip some blood onto a piece of cardboard. In such a situation, blood often gets contaminated with interstitial fluid and therefore the results are not as reproducible. With respect to the dried urine testing, the results collected at different times during the day are normalized by using an algorithm an algorithm should have no place in a clinical lab.  All the results are normalized to creatinine, but to accurately measure creatinine, you need a 24 hour collection. Dr. Nordt’s 24 hour urine collection testing is not available for direct testing to patients but must be ordered by a clinician. Rhein Labs can be contacted through their web site, RheinLabs.com  or by calling 503-292-1988.

 

 



Dr. Frank Nordt has a PhD chemistry and is the CEO and the Laboratory Director of Rhein Consulting Labs, which offers quality 24 hour urine testing for hormones for both men and women and you can call 503-292-1988

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

Podcast Transcripts

Dr. Weitz:            This is Dr. Ben Weitz with the Rational Wellness podcast, bringing you the cutting-edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness podcast on iTunes and YouTube and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello, Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness podcast, please go to iTunes and give us a ratings and reviews so more people can find out about the Rational Wellness podcast. Today, our topic is to look into 24-hour urine testing for hormones and what we can learn from looking, not only at hormone level but at the hormone metabolites that are also excreted in the urine. My goal for this podcast is to gain some insights in what we can learn from this type of hormone testing that can help guide patients to feel better and be healthier.

To analyze our hormones like estrogen, progesterone, and testosterone, there are various testing methods available today, serum, urine, saliva, blood spot, and dried urine. Serum hormone testing is the most commonly employed method by doctors in the US, especially conventional MDs. It’s certainly the easiest testing requiring only a blood draw on the part of the patients and it’s often the cheapest since it is more likely to be covered by insurance.  Many Functional Medicine doctors like urine testing since it allows the measurement of the metabolites of estrogen, which are important for assessing the risks for breast and other estrogen-related cancers. On the other hand, urine testing is not directly measuring hormone levels in the bloodstream or in the tissues, but instead, is measuring hormones and metabolites that have been excreted.

Besides serum and 24-hour urine collection for hormones, there is also saliva, blood spot, and dried urine testing. David Zava from ZRT Labs has published a number of widely read articles that have been published in the Townsend Letter.  And he argues that serum, urine, and saliva can all reliably measure our natural hormones, though there is a difference when measuring hormones that patients are taking. He argues that saliva is the best way to monitor hormones that have been administered topically. I’ve read articles by and spoken to other prominent functional medicine doctors who’ve told me that saliva is very unreliable. I also know there are very successful clinicians who use serum, urine, and saliva. They all use different methods, and they all claim to get good results.

The newest method is to use dried urine testing, which is quite popular now with the Functional Medicine community.  And it was the most popular form of hormone testing in an informal poll that I gave to 1,300 Functional Medicine practitioners on our closed Facebook page.

So what is the most effective method for testing hormones, both for looking at natural hormones, and to monitor hormones that patients are taking?  To sort out this controversy, I’ve asked Dr. Frank Nordt, the president and lab director of Rhein Consulting Laboratories in Portland, Oregon to join us. Dr. Nordt has a PhD in biochemistry and he’s published extensively on hormone testing methodologies. Rhein Labs is a small boutique lab that was the first to develop a reproducible, accurate, and clinically relevant hormone profile for both men and women in 24-hour urine, long before the entry of Genova and others into this arena. Dr. Nordt, thank you for joining us today. And can you tell us about your background and how you came to start Rhein Consulting Labs?

Dr. Nordt:            Yes.  First of all, I appreciate the opportunity to speak with you and your audience today and I hope to clear up a few or throw some fire on, some controversies that have arisen over the years.  My background, as you said, I received a PhD in biochemistry and biophysics at the Oregon Health Sciences University, after which I did a postdoc at the Max Planck Institute in Munich. I went on into industry and worked in pre-clinical research. I was primarily interested in blood flow properties and I worked in the area of stroke. I came back to academia at the medical school and worked in neurology.  And to be quite frank, no pun intended, I got sick and tired of academic politics and decided that my skills and interests were in the private sector.  And I like to innovate.  I continue to collaborate with academia and continue to publish.  I’ve been doing this since 1991, and I’ve been doing hormone testing since then using various modalities, primarily serum and then the 24-hour urines.

You’re right, there are various matrices, blood, venous blood, blood spots, 24-hour urine, and as you said, the dried urine testing, which has gained popularity in the last five years or so. I will be quite direct with regard to the dried urine testing. It is convenient, certainly. All one has to do is urinate on a piece of filter paper, basically, and send it in in an envelope and hopefully, get results that are meaningful. I can tell you that there is not one published study that supports the validity of dried urine spots. I have been asked by people to collaborate in regard to this, but I won’t because, quite frankly, it is junk science and I will stand by that. And I will elaborate on that a little bit later.

So why don’t we, first of all, talk a little bit about the 24-hour urines and then I will go into what I think of the other modalities, including blood. As you say, it’s convenient. It’s the most widely used. But let’s go and first look at what I think a profile should look like. And a profile is not just a “panel”, but it’s a well thought out, I think, profile, which, again, provides insight into the metabolism and turnover of the hormones in the body. You mentioned that it’s what is excreted, you’re absolutely right. It is excreted, but I think it provides the best measure of hormones and hormone levels in the tissues. You can’t directly assess hormones in the tissues without taking a biopsy. There have been studies that have actually done that, looked at, for example, breast biopsies, looked at local concentrations of estrogens, androgens, et cetera. But, obviously, that’s not an approach that can be used on an outpatient basis.

Let me throw up a … Can you see that?

Dr. Weitz:            Yeah, we can see that.

Dr. Nordt:            Okay. First of all, I divide the report into estrogens, androgens, and corticosteroids. On the following page, this is an example of a graphic format. Some people like it, some people don’t. Patients tend to like it because it’s colorful. Frankly, for me, it’s attractive, but not that easy to look at. So mostly what we do is we stick to our old format. This is kind of difficult because I can’t see the sharing. Oh, here it is. I’m sorry. I found it. I’m working with more than one monitor here. So anyway, here we go.  So what I want to do is go through what I call the tabular format. These are the same results and as I said, we have estrogens, androgens, and corticosteroids.  Starting with the estrogens, we look at estrone. This is an example of a premenopausal patient that is menstruating regularly, and it’s an example of a typical, let’s say 30 to 40 year old. We have all of our reference ranges divided into age by decade. So from 30 to 39, 40, to 49, et cetera. So this is a typical reference range for a 38-year-old in this case, and we see her estrone at 9, estradiol is about half of that.

The importance of looking at ratios, the estrone is the storage form for estradiol and there is an equilibrium between estrone and estradiol. And in aberrant cases, the estrone, for example, in estrogen dominant women, the ratio of estrone to estradiol will be much higher. And we look at that, for example, down here, what I call the potent estrogen ratio, which varies between approximately one and four. Ideally, that ratio is around two. In the graphic format, we have what I call ideal reference ranges. I’m not exactly sure what ideal means, but a lot of the functional medicine people would like to see something idea, an ideal reference range where, for example, a 20 to 30 would be … Some people think we should adjust hormones in postmenopausal women to what they were for a woman in their 20s, some people feel it in their 30s.

As I say, I’m not exactly sure what people mean by an ideal reference range. What we’ve done is taken it from, basically, plus or minus two standard deviations of the mean. We’ve taken it down to plus or minus one standard deviation approximately. What ideal is, is oftentimes in the eyes of the beholder.

Dr. Weitz:            I think it’s common in the Functional Medicine world for there to be labs to have normal ranges. And we often consider normal meaning like for example, you measure vitamin D and if it’s above 30, that’s considered normal. But most people in the Functional Medicine community feel that, based on the research, you have the least risk of chronic diseases if you get that level up between 50 and 70. So that’s what we consider an ideal range versus a normal range from a lab.

Dr. Nordt:            Right. Now, the problem with hormones is that the research in terms of what is ideal is lacking. And I think there is also a lot of misinformation out there regarding how one should, for example, adjust the postmenopausal woman. As I say, some people think it should be where hormones were in their 20s to 30, others 30s to 40s. Other people feel that, and this is quite controversial and I don’t agree with it. There are what I call high estrogen protocols where women who are postmenopausal actually start menstruating again.

Dr. Weitz:            Yeah, that’s because they cycle the progesterone for two week periods to sort of duplicate.

Dr. Nordt:            Correct.

Dr. Weitz:            Basically, the idea is, or the theory is, that you’re duplicating the hormone levels and the sequence of a woman in her 20s.

Dr. Nordt:            Exactly. Again, it’s in the eyes of the physician what they feel is ideal for their patients. As a laboratory, quite frankly, I don’t think it’s my place to prescribe what various practitioners should do.

Dr. Weitz:            So let’s go into some of these estrogen metabolites like the 2-hyroxyestrone, the 16-hydroxyestrone, and the 4-hydroxyestrone.

Dr. Nordt:            Right. Now, let’s, first of all, talk about the two. Normal metabolism of, for example, estrone, and we use the metabolites of estrone because it is the most abundant if you will estrogen that is active. In other words, the two active ones are estrone and estradiol. There’s more estrone, so we use the metabolites of estrone because the fidelity of the measurement is better than it would be with estradiol. The estradiol actually mimics the estrone, so I’ve never found much point, and we’ve done some work in this regard, I’ve never put a lot of emphasis on measuring the metabolites of estradiol because they, basically, mimic those of estrone. Having said that, there has been controversy about the two to sixteen ratio. Some people continue to feel that it’s a valid marker for-

Dr. Weitz:            Breast cancer.

Dr. Nordt:            And frankly, a review of the literature would indicate that it isn’t what it was cracked up to be. We continue providing those levels for those people who continue to feel that it is important. And there are people and there is literature that would indicate that it is, so what we do is we provide the information and let the practitioner deem and interpret it how they wish to.  I think in terms of oncogenesis, a more current hypothesis revolves around the metabolite that are what we call depurinating adducts leading to apurinic sites leading to errors in DNA repair and mutations and then leading to breast, and in males prostate cancer.  Also, the role of catechol estrogens, the estrogen quinones, specifically the oxidation, unfortunately. And catechol estrogen quinones, the oxidation of 4-hydroxyestrone, they act as carcinogens that damage DNA leading to again, cancers of the breast and prostate.

Dr. Weitz:            So what you’re saying is that the 4-hydroxyestrone may be a better measure of potential breast cancer risk than the 2:16 ratio.

Dr. Nordt:            Correct. And then, following from there is the final metabolism, the hydroxyestrones, it leads to the methoxyestrones, namely 2-methoxy and 4-methoxyestrone. We can get an idea of the efficacy of methylation by looking at those levels. Now, the 4-catechol estrogens in animal models are carcinogenic. The two 2-catechol estrogens are not. There haven’t really been any studies that I’m aware of in humans, but again, like I say, the hypothesis is that it’s the 4-hydroxy and 4-methoxy, if the individual is methylating that those are the “carcinogenic” if you will, estrogens.

Dr. Weitz:            Yeah, I interviewed Dr. Lindsey Berkson, and she actually takes the 2-methoxyestrone and she had a whole series of cancers prior to doing this. And she feels that is really significant in helping reduce cancer in her body and I know she was working on possibly trying to get that approved for use.

Dr. Nordt:            Yeah. Again I think the evidence is sketchy. I think that we have hints as to what is going on. And to be at the forefront, I think it’s important to measure these and if they are way out of range, if the person is not methylating by, for example, looking at the relationship between the estrone and the 2-hydroxy and 2-methoxyestrones, if the 2-hydroxyestrones are inordinately high and the 2-methoxyestrone is inordinately low, that is an indication that the person is not methylating. I will tell you that the 4-2-methoxy and the 4-hydroxyestrones are relatively low in most individuals. And in most cases, you cannot detect with any degree of certainty that the levels of 4-methoxyestrone in urine. They will be, quite frankly, mostly on the low side and we take the 2-hydroxyestrone and the 2-methoxyestrone to be the indicator of methylation.

Dr. Weitz:            By the way, I wanted to mention to the listeners that if you’re listening to this on your phone or in your car, if you want to see the slides that Dr. Nordt is putting up, go to the YouTube page, the Weitz Chiro YouTube page and the video version of the podcast will be there.

Dr. Nordt:            Good.

Dr. Weitz:            I noticed that you have a separate reference range for women who are taking hormone replacement.

Dr. Nordt:            Correct. Because we divide the reference ranges for the estrogens by decade, women who are on hormone replacement are going to have somewhat different levels of estrogens. And most practitioners feel that they do not have to replace the estrogens to the levels of premenopausal women, but should replace them to the point where the patient has no symptoms. And those reference ranges tend to be lower. And again, we provide those reference ranges and they’re taken, basically, from a cohort of patients who are on hormone replacement.

Dr. Weitz:            Would it matter what for of estrogen that they’re taking though?

Dr. Nordt:            Most people these days are on topical estrogens. If they are on oral estrogens, which I think most people have gotten away from because of the significant first pass effect which occurs. These estrogen levels are primarily from topicals whether they be topical creams or, for example, the patch. I will tell you that with the patch, you can get away with lower doses of estrogen using the patch because it tends to be more efficacious in getting through the skin and into the circulation. And we find that with these lower levels, patients will be without climacteric symptoms. We look at the androgens also and the androgen metabolites of testosterone. There are many women who are on testosterone replacement. The does there generally vary between one and four milligrams per day. Generally, you can get away with one to two milligrams and get adequate levels.  The metabolites become important, and I should point this out, metabolites become important in looking at the … Let me bring up another slide here.

Dr. Weitz:            Well, right now you’re talking about the metabolites of testosterone, which, if we’re not doing 24-hour urine or dried urine, we are not testing. So what are some of the benefits of looking at these? What can these tell us?

Dr. Nordt:            These tell us, I think, if you can see, this is a flow chart. What we can look at and infer are the enzymatic activities which lead to these metabolites, and what is up and downregulated. As an example, 5-alpha-reductase metabolism in women is less important than in men. In men, 5-alpha-reductase upregulation leads to increase in DHT. And the downregulation of 5-alpha-reductase, for example, by drugs such as Finasteride, which completely knocks out the 5-alpha-reductase. And in some men, it cannot recover, which is referred to as the Finasteride syndrome. Oftentimes, these people will probably never have prostate cancer, but sexual function is impaired.  Finasteride, the commercial name, if it’s for BPH is Proscar. If it’s for hair growth for the follicularly impaired, it’s known as-

Dr. Weitz:            I see that you’re scratching your bald head there Dr. Nordt, for those who are listening and not watching.

Dr. Nordt:            Yeah. I’m a little follicularly impaired, yes. In any case, even at low doses of Finasteride, which is, as I said, known as Propecia commercially, it does lead to knocking out, basically, the 5-alpha-reductase. We can look at other enzyme systems. I’ll go back to the profile and-

Dr. Weitz:            Yeah, so what do we learn out of looking at these metabolites? So we’ve got the DHT and so the benefit there is we can look at that for prostate health and hair loss. Right?

Dr. Nordt:            Correct.

Dr. Weitz:            What do we get out of these other metabolites? What can they tell us?

Dr. Nordt:            Well, we’ve gone a little bit through the estrogens as far as looking at the various estrogen metabolites and the risk in breast cancer, et cetera. With the androgens, primarily, for example, taking DHEA, DHEA is preferentially metabolized to the other 5-beta-reductase to etiocholanolone down here. Again, the relationship between androsterone and etiocholanolone is 5-alpha and 5-beta-reductase. When we go to the corticosteroids, these metabolites … The corticosteroids starting here with cortisone, again we have the THF and 5-allo-THF, 5-alpha and 5-beta-reductase. But then there’s also an equilibrium between cortisol and cortisone, which is a 17-beta-hydroxysteroid dehydrogenase. And there are two forms of this enzyme.

Dr. Weitz:            Hang on one second, Doc. Let’s just finish with the testosterone stuff. So you mentioned DHEA, which converts into androstenedione into testosterone and then into etiocholanolone.

Dr. Nordt:            Etiocholanolone and-

Dr. Weitz:            What’s the benefit of looking at that? What does that tell us?

Dr. Nordt:            Okay. Androsterone, for example, has androgenic activity, whereas the etiocholanolone does not.

Dr. Weitz:            Okay.

Dr. Nordt:            Eating a lot of DHEA, for example, you can see, by looking at a profile, you can see if there is significant conversion of DHEA into estrogen. These are things that you’re not going to gather from any kind of blood test. You’re not going to be able to see that in any kind of saliva testing because they do not measure the metabolites.

Dr. Weitz:            I got it. So you have a patient, they’re low in testosterone and they’re low in DHEA, and you give them supplements of DHEA hoping that’ll boost their testosterone levels, but it may get pushed over into forming more estrogen.

Dr. Nordt:            Correct. And that’s especially true in men who oftentimes eat DHEA like candy and end up with mild forms of gynecomastia.

Dr. Weitz:            What does eating DHEA like candy mean?

Dr. Nordt:            What I mean by that is higher than 50 milligrams.

Dr. Weitz:            Okay.

Dr. Nordt:            We see people taking 25, 50, 100 milligrams of DHEA. In men, you can never eat enough DHEA to raise testosterone levels in a clinically significant way.

Dr. Weitz:            Okay, so you’re putting an end to the thought that some clinicians have and patients who are trying to boost their testosterone levels, you’re saying that taking DHEA in no way is going to meaningfully boost testosterone levels.

Dr. Nordt:            That’s correct. In women, in some cases, you can because the testosterone levels in women are much lower than in men. You can raise, in some cases, the testosterone levels in women in a clinically significant way.

Dr. Weitz:            On the other hand, I have male patients who when we’ve given them a modest dosage DHEA, like 25 or 50 milligrams, notice significant difference in the way they feel in terms of energy levels and things like that.

Dr. Nordt:            Correct. But again, if you look at the testosterone levels per se, and I think in some cases when you look at DHEA, DHEA, as you say, there are some physical effects that people tend to feel better. This is true in women also. But you have to watch it in terms of the aromatase activity, which is oftentimes upregulated.

Dr. Weitz:            Which would convert it into estrogen instead of testosterone.

Dr. Nordt:            Correct. So they may feel a little bit better, but again, looking at their testosterone levels, per se, you’re not going to see an increase as a result of the DHEA. Some people use 7-Keto-DHEA because they feel that it is not converted to estrone and so we measured-

Dr. Weitz:            Is that true?

Dr. Nordt:            First of all, if you take 7-Keto-DHEA, it is always going to be outside of the “references range”. The supplementation will lead to higher levels than for example what we call here, the 45 micrograms per day. I’ve seen indications that this is probably a misnomer that 7-Keto does not lead to. Although, chemically, it should not revert to DHEA, so I don’t quite see how it ends up as estrone because once the ketone group has been added at the 7 position, it is then oxidized to the hydroxy and I just don’t see a way of it getting back to estrone. I don’t know what your experience is. I just talked to someone who felt that giving 7-Keto has no advantage in terms of they see that estrone levels are increased by giving 7-Keto. I don’t have enough data.

Dr. Weitz:            Okay. So let’s move onto the cortisone and cortisol, and maybe you could start by explaining what’s the difference between cortisol and cortisone.

Dr. Nordt:            Okay. Just like estrone is the storage form for estradiol, cortisone, in essence, is the storage form for cortisol. There is an equilibrium between cortisol and cortisone. And in cases where cortisol is needed, there is the reverse direction going from cortisone to cortisol. And there are, basically, three metabolites that I look at in terms of corticosteroid metabolism. That’s the THE, which is tetrahydrocortisone, the THF, tetrahydrocortisols.

Dr. Weitz:            So what can that tell us, looking at THE?

Dr. Nordt:            Okay. There are two things to look at. One is, if the enzyme is upregulated to metabolize cortisol leading to a depletion of cortisol to cortisone, then that cortisone, in order to get rid of it, it is metabolized at the THE.

Dr. Weitz:            Okay.

Dr. Nordt:            If you look at the sum of the three metabolites, and I think that’s probably the most important thing that we can say, the THE plus THF plus 5-allo-THF, if that is elevated in men greater than about 6,000 to 7,000 micrograms per day, you can almost bet that individual is insulin resistant, has metabolic syndrome, is pre-diabetic, or frankly, diabetic. We have found, I’d say, over a dozen cases where these enzymes with the THE, THF, and 5-allo-THF rise to levels greater than about 15,000, you can almost bet that individual has most likely an adrenal adenoma. And the cortisol levels continued to be normal. What happens is the body compensates for the increases in cortisol by upregulating the enzymes, metabolizing cortisone and cortisol, and until, basically, there is no more headroom and you end up with very high levels of these metabolites.

At which point, when you do run out of headroom, it’s at that point that the cortisol levels actually elevate. And we’ve had, like I say, around a dozen, a little bit more, about fifteen of these kinds of cases where the surgeon then remarked, when imaging these individuals, “How did you ever find this?” These people end up in the physician’s office. They measure 24-hour urinary cortisols and they are perfectly normal. They’re sent home but they know that something is wrong.

 So there are two advantages to measuring these metabolites. One is an early warning indicator for insulin resistance. And the second one, like I say, which is relatively rare, but nevertheless, you can catch these adenomas at a very early stage, and at least watch them until they become clinically significant and need to be surgically removed.  There are a couple of other metabolites, the 11-beta-OHAN, which is the androsterone.  Again, the relationship there is 5-alpha and 5-beta-reductase metabolism. The same kind of thing the corticosterones, THA, THB, and 5-allo-THB. Some people ascribe significance to those in terms of their metabolism toward aldosterone.  We have clients that want those. I don’t personally ascribe that much significance to these other than, again, an indicator of 5-alpha and 5-beta-reductase metabolism.  But again, like I say, we try to cover the bases if you will.

Dr. Weitz:            Okay.  That’s good.  I don’t want to get too much into the weeds on some of this stuff.  We may lose some of the viewers and listeners.

Dr. Nordt:            Right. This is the problem and some of this stuff, certainly for lay individuals, gets to be pretty technical. And as you say, especially for lay people, I tend to stay out of the …let me put it this way, over interpretation.  I do want to say something about progesterone. Progesterone cannot be measured directly in urine. We use the metabolite, which is pregnanediol. It is a very sensitive indicator for progesterone and there is a lot of fidelity to the measurement. If you’ve ever looked at progesterone in serum, in premenopausal as well as postmenopausal women who are on replacement, serum levels are oftentimes quite low. The reason for that is the progesterone is rapidly compartmentalized taken out of the serum. But if you look at the target tissue and you look at the urine where you actually are looking at turnover, you can get very nice measurements of progesterone.

I do want to say something about both the saliva testing and blood spots, as well as urine spots. The major drawback of any kind of spot testing, in other words, it’s a single point in time. Hormones are produced in a pulsatile fashion. And in serum, for example, testosterone is a good example, testosterone measurements in serum should be taken in the morning. That’s convention. What happens after the morning is oftentimes not looked at at all. And we have lots of indications that testosterone levels may be perfectly normal in the morning, but decrease over the day and become quite low in the afternoon and evening.

The issue there is that if you look at a spot test, whether a blood spot of a saliva test, and I should say that saliva tests for the sex hormones are controversial because of the relatively low levels, and all of the saliva measurements and this is where I think some people find them to be useful. Some people say well, I get different levels all the time testing the same patient. All of the saliva testing is done using immunologically based assays. In other words, they involve using an antibody to the hormone which is being measured. The steroids and again, this gets technical, but the steroids to an antibody tend to look the same. And there is a considerable cross-reactivity. In the case of testosterone in women, for example, using an immunologically based assay, and there’s a serious paper out there, you can guess better than you can measure because the measurements tend to be all over the place.

The other problem with saliva testing, there are two issues. One is buccal microbleeds. The hormone levels in serum or in blood are approximately 1,000 times higher than they are in the saliva. Depending on the oral health of that individual and all of us have buccal microbleeds to one extent or another.

Dr. Weitz:            You’re talking about tiny bits of blood in your mouth.

Dr. Nordt:            Correct.

Dr. Weitz:            From your nose or something like that.

Dr. Nordt:            Yeah. From the gums. Some people who have oral health that is somewhat compromised, you crush your teeth and all of a sudden you have some blood on the toothbrush. If you contaminate the saliva, even to a level where you cannot see the blood, that measurement in the saliva will be compromised. The other issue with saliva is the lack thereof. People, as they grow older, the amount of saliva that is secreted decreases significantly depending on stress levels. We’ve all experienced this. So you get a dry mouth syndrome. Dry mouth syndrome is also an issue in people who are on certain medications. Saliva testing becomes really problematic and unless done under very rigorously controlled circumstances, these measurements on an outpatient basis are oftentimes not particularly efficacious.

So to summarize there, a contaminated saliva sample is a compromised sample. If you stimulate saliva flow using chewing on cotton. Some labs have you try to stimulate saliva flow. That also becomes a compromised sample. I work with the primate center here, the Regional Primate Center here in Oregon where cortisol measurements are taken from monkeys in order to evaluate stress levels. They are very, very careful not to stress these monkeys before taking the saliva sample because even the act of collection, and this is true in human also, the act of collection can change the cortisol levels.

Dr. Weitz:            But, Doc, living in the modern world, I feel like we’re all a bunch of stressed-out monkeys.

Dr. Nordt:            You have a point. Right now, to be honest with you, I’m a little stressed talking about all of this and I have a dry mouth. People who will sit for 30, 45 minutes trying to collect an adequate specimen. It’s problematic.

Dr. Weitz:            Hey, let’s go back to full screen view for the last few minutes here.

Dr. Nordt:            Are we back?

Dr. Weitz:            Yeah, that’s good.

Dr. Nordt:            Let me then talk a little bit about blood spots.

Dr. Weitz:            Okay.

Dr. Nordt:            And I’ve asked this question and I’ve never gotten an adequate answer.

Dr. Weitz:            This is where you prick your finger like you would do to check your blood glucose.

Dr. Nordt:            Correct.

Dr. Weitz:            Some practitioners like this form of testing as do patients because you don’t have to go into a lab to have it done and you can just put the blood on a little piece of cardboard and mail it in.

Dr. Nordt:            Correct. I hope and I don’t know how many people in your audience are aware of the Theranos Labs.

Dr. Weitz:            Yeah, but I think that’s not really comparable to-

Dr. Nordt:            Well, no it’s not.

Dr. Weitz:            I mean that was a big scam. They were claiming that they had this machine that you could just put the blood in. Meanwhile, somebody took the blood, brought it in the back, had a bunch of lab technicians using the normal testing everybody else is using and it was just a big show for the investors.

Dr. Nordt:            Correct. It goes beyond that. I asked the question what is the difference between a blood spot taken from a finger prick on a piece of filter paper and a blood spot in a nanotainer. The issue here is every time you take a finger prick, that blood is contaminated with interstitial fluid. This goes back to my days in graduate school. Much of my work was done on the red blood cell membrane. If you did a finger prick and you looked at, for example, the surface properties of red cells from a finger prick, they will be different every time, and it’s because of the absorption of proteins from the interstitial fluid. One of the hypotheses of why the nanotainer didn’t work is because of the contamination. And there were some really good editorials in the Wall Street Journal from experts in this field that feel that finger pricks, and I certainly share that, that finger pricks lead to blood samples which cannot be tested adequately and reproducibly. Having said that, blood spots the same problem, you have a point in time. Getting to-

Dr. Weitz:            Of course, there could be benefits to having a point in time too. Like, for example, when we do the salivary cortisol testing, we don’t just learn what the total cortisol level is, but we learn is it low or high in the morning as opposed to the evening, if it’s supposed to be higher in the morning and then it’s supposed to drop in the evening. If it’s lower in the morning and then it’s higher in the evening, that interferes with sleep. So there could be benefits to knowing where hormones are at a certain point in time during the day.

Dr. Nordt:            Yeah, the issue again gets back to adequate collection of the samples. And we actually did a study in conjunction with the University of Washington, the Fred Hutchinson Cancer Research Institute, on cortisol levels in shift workers. And quite frankly, there are very few people who work a normal shift, in other words, a day shift, who have abnormal cortisol rhythms. They may have low cortisol. You will discover low cortisol and at the 24-hour urinary cortisol is still the gold standard in that regard. If you have low cortisol overall, you will see that in the 24-hour urine. If you have high cortisol levels in the morning, for example, you will see that in the 24-hour urine.

Dr. Weitz:            Right.

Dr. Nordt:            The rhythm is very rarely an issue per se.

Dr. Weitz:            I would say just to give you a little argument, pushback on that. Would say that most of us in the Functional Medicine community, myself included, feel that the majority of our patients are stressed out and we do see that the cortisol tends to be lower in the morning and it’s not unusual to get a spike in the evening when they’re not supposed to.

Dr. Nordt:            Yeah. The evening spike, oftentimes, and this I st problem, you don’t really know how to interpret it because you don’t know under what circumstances that sample was collected. Let’s say that individual is, in the evening, they normally don’t collect their saliva in the evening, they sit there, they have a little bit of trouble producing enough saliva. And then, all of a sudden, that cortisol level is artificially increased in the evening. It’s true in some people, not true in others. How do you know when?

Dr. Weitz:            You mean they’re so stressed out from having to spit into the tube that their cortisol level goes up?

Dr. Nordt:            Absolutely, absolutely.  This is exactly what I’m getting at.  Not in all cases, but if you don’t know and you see the spike in the evening, is it due to stress.

Dr. Weitz:            Well, you know, I would say that I’ve seen enough patients with that sort of effect who report having trouble with sleep.  And then we use adaptogenic herbs that help to calm out the adrenal levels and sometimes glandulars.  And we often find that those patients feel better.  I think that there’s some truth in that.

Dr. Nordt:            I think this is really important because, as you mentioned, the urine spots have become very popular.

Dr. Weitz:            Yeah.

Dr. Nordt:            As I indicated, there is not one publication out there that supports the validity of this type of testing.

Dr. Weitz:            Okay.

Dr. Nordt:            Number one. Number two, there are different modalities that are being promulgated, but a urine sample collected at 8:00 in the morning is, if you’ve gone to the bathroom at 5:00 in the morning, that 8:00 sample is going to be different if you didn’t urinate at 5:00 in the morning. The attempt is made to normalize these results by using “over several samples throughout the day”, the attempt is made to normalize these results and approximate the total production using an algorithm. An algorithm infers information that isn’t there. And I think an algorithm has no place in a clinical laboratory. If we can measure it, measure it.

And a third issue is that all of the results are normalized to creatinine. The creatinine levels that are reported as being the normal range are in these urine spots differ by a factor of ten. In other words, from low to high is a tenfold difference. In urine, in the 24-hour urine, that factor is roughly four, so it’s twice as much. Why do they have such a broad range for creatinine is to try to get relatively “normal” results. Creatinine varies with age, it varies with diet, it varies on the basis of genetics. Why do we take a 24-hour urinary creatinine level to measure kidney function? We don’t use a spot creatinine.  We don’t use a serum creatinine.  No, we use a 24-hour urinary creatinine.

Dr. Weitz:            Okay.  I got it, Doc.  Yeah.  You made some good points there.  So we need to wrap.

Dr. Nordt:            Okay.

Dr. Weitz:            So why don’t you tell us how we get a hold of your lab testing and how do we sign up as providers? Is it available just through providers? Can patients-

Dr. Nordt:            There is a law in the state of Oregon and I agree with it, that it can only be ordered on the basis of a provider.

Dr. Weitz:            How do providers sign up?

Dr. Nordt:            They give us a call at 503-292-1988. As you mentioned at the beginning, we are a small lab. We specialize in this. We do bill insurance. 24-hour urinary profiles are reimbursable by most insurance companies. We are preferred providers for a number of insurance companies. Even if we are not preferred providers, we oftentimes are successful at getting full, or at least partial reimbursement, usually somewhere around 80%. Our pricing is such that it is the same for all practitioners and patients. We bill insurance companies the same amount that we bill a patient without insurance. In that sense, and we pride ourselves in this, we do have transparent pricing. We don’t, like I say, charge an insurance company a different price than we charge a patient. The pricing is presently $280 for the full profile. I think that’s quite reasonable.  I am available to help with interpretation. If you do one, two, or three of these and give me a call, you will become an expert in interpretation. The profile, like I say, is a profile you oftentimes have to take a little bit of a step back and not just look at each individual value, you look at it sort of like an impressionist painting. If you get too close all you see are dots. Step back and you get the complete picture.

Dr. Weitz:            Sounds good, Doc. And what’s the website for your company?

Dr. Nordt:            Www.rhein labs, that’s spelled R-H-E-I-N, as in November, R-H-E-I-N L-A-B-S.com.

Dr. Weitz:            Excellent.

Dr. Nordt:            We’re available and if you have more questions, if you want to talk about some of these things a little bit more in terms of the matrices, saliva, blood, whatever, give us a call, I’m available.  We do answer our phones and you do get to talk to me also.

Dr. Weitz:            Excellent. Thank you so much, Doc.

Dr. Nordt:            You’re welcome.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Homeopathy with Ananda More: Rational Wellness Podcast 84
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Ananda More discusses Homeopathy with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

7:58  The majority of the scientific studies about homeopathy are either positive or inconclusive.  Only 5% are negative. There are over 1000 published studies and close to 200 randomized clinical trials.  On the other hand, quite a number of studies on drugs that were negative were never published and, in fact, the pharmaceutical industry had a history of doing a study over and over many times till they got three that were positive, that they would then pass on to the FDA for approval.  Ananda said that she has “heard many stories throughout my life with my friends and family who are doctors in research where they’ve been asked to change their results for specific studies, because the results didn’t quite line up with the expectations of the funders. I had a friend who was told that if she published her results, she wouldn’t be allowed to get her PhD, for example.” We also have to consider that these medical journals are being funded by advertising from big pharma.

12:47  Mainstream medical journals like the New England Journal of Medicine, rarely ever publish papers on homeopathy.  Ananda said that when the word homeopathy is in the abstract and the result is positive, the study isn’t even sent out for review. Also, there is very little funding for research on homeopathy.  Homeopathic medicines can’t be patented and they are easy to replicate.  So you don’t have the same possibility of profits that you do with other forms of medicine.

14:19  In the Magic Pills documentary there’s a section where there was an outbreak of leptospirosis in Cuba due to some severe hurricanes in 2007. They only had enough leptospirosis vaccine for 1% of the population and besides the vaccine requires two separate dosages to incur immunity. So they decided to do a homeopathic intervention, which they distributed to 2 and a half million people.  It completely stopped the epidemic and the levels of this disease dropped far below the historical averages for years afterward. But when these scientists (immunologists and epidemiologists) tried to publish their results, they were turned down by all the medical journals. They did eventually publish their results, but only in a homeopathic journal, Homeopathy. The paper is:  Large-scale application of highly-diluted bacteria for Leptospirosis epidemic control. The lead author, Dr. Bracho, started receiving death threats after publishing this paper. 

18:05  How can Homeopathy be effective when the active ingredient is is so diluted?  Homeopathy is an energy medicine and not only do you need to dilute the active ingredient, but there is this process of producing the formula that includes hitting the glass vials that the formula is in very hard against a surface, known as succussion. This creates high temperatures in the bottles and it creates nano particles of the active ingredient within the vial. It also sloughs off nano particles from the glass and silica is a conductor. 

22:38  Ananda was at a conference and Dr. Bracho from Cuba came and told this story about the homeopathic intervention that was so effective and long lasting and she wanted to get this story out there to help change people’s attitude about homeopathy, which is why she decided to make Magic Pills.

24:04  The Australian National Health and Medical Research Council released a report in 2015 that has been very influential and has led to a shift in public policy and opinion against homeopathy in a number of countries around the world, including in Australia. In both Australia and the United Kingdom homeopathy was covered by the national health system and now it is not due to the influence of this report.  This report was supposed to be a review of the research on homeopathy, but in the end they cherry picked the data and only included five studies, four of which were negative and one of which was positive, and they concluded that there is no evidence that homeopathy is effective for any condition. But this review had serious methodology problems, including using an arbitrary criteria that excluded any study with less than 150 subjects. NHMRC’s own guidelines are that a good study is over 20 subjects. Their methodology was so poor that they were refused for peer review publication. When the Australian Homeopathic Association did a freedom of information request they found out that there had been a previous study done by a well respected scientist, but they refused to release that first report. The speculation is that first report concluded that homeopathy was effective for certain conditions, so there is a global movement to release the first report, where you can sign a petition. 

28:28  Homeopathy has a long history in the United States and in fact, the senator who brought the bill that created the FDA, Royal S. Copeland, was an MD who practiced homeopathy.  There are homeopathic hospitals, which still exist today, including Hahnemann Hospital in Philadelphia, and there is a statue of Samuel Hahnemann and a memorial to homeopathy in Washington, DC, that was endorsed by President McKinley. But now the FDA has decided that they wanted to change the oversight on homeopathy and they have created a draft document that is creating some oversight over homeopathy but might be setting themselves up to make homeopathy illegal, since in order to go through a new drug application process, it requires a minimum of $300 million and homeopathy has thousands of medicines and which medicine is used is individualized for each person. The homeopathic industry isn’t big enough to be able to afford this process, so this could be setting the stage for removing homeopathy in the US.  And we know that in the US, the ability to lobby congress is what allows you to get favorable legislation, and homeopathy is a threat to the pharmaceutical industry, which spent $240 million to lobby congress in 2015 alone. 

35:16  The other problem with this draft document is that it is removing the FDA guidelines for manufacturing a homeopathic product, the CPG Sec. 400.400, which outlines proper manufacturing guidelines. By getting rid of these guidelines, it will be more difficult to assess if a homeopathic product is being properly manufactured.  Based on what has happened in other countries, this has created a worry that this document is part of a process that will limit or make homeopathy illegal in the US. 

36:24  There’s a group of mothers that depend upon homeopathy that have created this organization, Americans for Homeopathy Choice, to lobby for homeopathy and they have already delayed the passing of this draft document. You can go to Homeopathychoice.org and learn more, sign up, and write letters.  According to Ananda, “Even if you don’t believe in homeopathy, I think this is about protecting our rights to freedom of choice. It’s a basic human right to decide how you want to treat your body and how you want to medicate yourself. If you want to try other options first in a safe manner, I think that’s absolutely a human right.” 

39:48  Ananda has made this documentary about homeopathy, Magic Pills, which she if inviting people to screen with groups of people in their homes, coffee shops, churches, theaters, etc. which you can learn about by going to the website, magicpillsmovie.com or by going to the Magic Pills Movie Facebook page.

 



Ananda More is a Homeopath in Toronto, Canada at Riverdale Homeopathy, where she sees patients and teaches educational programs for homeopathy and she made an incredible documentary on homeopathy called Magic Pills that has not been released in the US yet but you can screen with groups of people in your home or in other public places.  She is dedicated to spreading the word about homeopathy. 

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

Podcast Transcripts

Dr. Weitz:                            This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello, Rational Wellness Podcasters. Thank you so much for joining me again today. For those of you who enjoy the Rational Wellness Podcast, please go to iTunes and give us a ratings and review, that way more people will find out about the Rational Wellness Podcast. Today, our topic is homeopathy, and we’ll be joined by homeopath Ananda More.

For those of you who are not familiar, what exactly is homeopathy? Well, according to Wikipedia, the source of all knowledge, skepticism, sarcasm there, homeopathy is a system of alternative medicine created in 1796 by Samuel Hahnemann based on his doctrine of like cures like, a claim that a substance that causes the symptoms of a disease in a healthy person would cure similar symptoms in a sick person.  

There are quite a number of studies that show the effectiveness of homeopathy, while quite a number of other studies show no benefit. Scientists and mainstream doctors tend to be skeptical, because some of the theories behind homeopathy don’t line up with the general accepted principals of chemistry and physics. For example, the concept that by diluting a homeopathic formulation more, it gets stronger. Goes against the principle that you need a minimum of the active ingredient to create an effect in the body, and having less than this amount will tend to be less effective or have no therapeutic effect.  This skepticism, combined with a report produced in 2015 in Australia by the National Health and Medical Research Council that declared that there are no health conditions for which there is reliable evidence that homeopathy is effective. Homeopathy, in other words, according to them, is no better than placebo. They stated that homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness.

Yet over 5 million adults and over a million children in the US and many more million around the world use homeopathy on a yearly basis. Many get positive results with very few side effects. We have asked Ananda More, a homeopathic practitioner from Toronto, Canada, and a filmmaker to help sort out the truth about homeopathy. Ananda wrote, directed, and produced an incredible documentary on homeopathy called Magic Pills that includes some amazing footage on how homeopathy is saving lives in Africa, India, South America, and Cuba, among other countries. Homeopathy can be delivered at a fraction of the cost of traditional medicine and medical care, which some of these people don’t have access to in these developing countries because of their poverty levels.  Ananda, thank you so much for joining us today.

Ananda More:                   Hi, Ben. Thanks so much for inviting me on.

Dr. Weitz:                         That’s great.

Ananda More:                   Wow, you started with a challenge there.

Dr. Weitz:                         Ananda, can you tell us how you came to become a homeopath?

Ananda More:                   Sure. So I was very, very skeptical of homeopathy. I did this course in university on witchcraft and the occult.  One of the things we studied under witchcraft and the occult was homeopathy. Were were taught that the idea is that they’re giving you highly diluted substances-

Dr. Weitz:                         Is that a broom in the back? Oh no, I’m kidding.

Ananda More:                   Probably.  So we were taught that it’s a medicine that believes that there’s these highly diluted substances, and they dilute them and dilute them and dilute them until there’s nothing there. Then we’d give this to people to treat whatever is ailing them. We’ve decided that this is medicine. To me, it just sounded preposterous. The way it was taught as well with that perspective also made it sound preposterous. I was very skeptical.  I was willing to open my mind up to traditional Chinese medicine, herbology, even Reiki, like the idea of energy medicine appealed to me, but this, I just couldn’t wrap my head around.

Then I found myself in India very sick. I was in this place called Pune, and I was traveling with a friend of mine, who’s German, which is where homeopathy originates. Her mom was a homeopath, and she had her nice little first aid homeopathic kit with her. I was, to be graphic, throwing up and everything going out both ends. It was really bad.  She comes along and goes, “Hey, want to try one of my little sugar pills?” I was delirious. I was like, “Whatever. I’ll make you happy. I’ll take your little placebo pill.”  When 15 minutes I felt absolutely fine, I was kind of floored.  In a way, there was a control, because other people in the place where we were staying had the same illness and were sick for days.  Not very scientific, but I had a nice way to compare what had happened.  I was kind of surprised.

At that point, I decided to go see a homeopath in India. That homeopath gave me some remedies. I’d been dealing with and struggling with depression most of my life. I think it’s genetic. It runs in my family. The depression that I had been dealing with, but that’s how I knew the world, that’s how my filters worked, that’s how I perceived everything around me, suddenly changed and my perception of life changed. It wasn’t sudden. It was gradual over a couple of months, but it really changed my life. At this point, I was heading to law school. I was all gung ho about doing human rights work. I realized that I thought I could help a lot of people with homeopathy, if it really did work for others the way it worked for me.  That’s when I decided to go study homeopathy, and my aspirations of being a lawyer went down the drain. Sometimes when I see what I pay my lawyers, I’m a little disappointed in my choices, but not really. It’s been an incredible journey really.

Dr. Weitz:                         That’s great. Let’s talk about homeopathy. Is there a science that proves that homeopathy is effective?

Ananda More:                   The majority of the science either shows that it’s effective or the study couldn’t tell. In a very equivalent manner to what you see in conventional medicine, you get about 40, 45% of studies have positive results for homeopathy. You get around 40% that are inconclusive, and around 5% that are negative. If you really look at the scientific literature, you’re getting more of a positive overview rather than a negative one.  We have over 1,000 clinical trials. We have almost 200 randomized controlled clinical trials that have been published. In terms of basic science, there’s thousands of studies that have been done as well. By basic, I mean working in vitro with cell lines, with plants, sometimes with animals. Many of those studies have been replicated. Again, they often more often than not show a positive result for homeopathy.  There’s something there definitely. This idea that homeopathy is unscientific I don’t think is true. Science is a way of studying things. We can set up appropriate ways of studying the effects of homeopathic medicine. Now as more and more science, particularly in physics, and our technology improves and we have more ways of looking at water molecules, at what’s going on in these solutions, we have a better understanding that what may be the basis for how homeopathy works.

Dr. Weitz:                         I’d like to point out a lot of people don’t realize this, but quite a number of studies on drugs that end up with negative results end up never getting published, whereas they tend to only cherry pick the studies that are positive and publish those.

Ananda More:                   Right. So there was this history in the pharmaceutical industry of doing a study over and over again until they were able to get enough positive studies to pass onto the FDA. I think they need three studies for the FDA. So they could do 900 studies and only three of them are positive, cherry pick those three studies and use those to defend their case. There’s more controls put in place against that now, but I know it’s still happening. But technically what’s supposed to happen is the study is supposed to register before it’s done in a way to kind of control that aspect of things.

Dr. Weitz:                         Do you think that’s actually being done?

Ananda More:                   I think it’s improving. Is it being done 100% of the time? I doubt it. I’m not one of the keepers of that process, so I can’t speak to that, quite honestly, in a good way. But the honesty is too that a lot of studies, they’re manipulating the data set. They’re finding ways to get the results they want. We see a lot of research is being funded by the pharmaceutical industry, and they have ulterior motives. I’ve heard many stories throughout my life with my friends and family who are doctors in research where they’ve been asked to change their results for specific studies, because the results didn’t quite line up with the expectations of the funders. I had a friend who was told that if she published her results, she wouldn’t be allowed to get her PhD, for example.

Dr. Weitz:                         Wow.

Ananda More:                   There’s a lot of research going on where people have created false studies and delivered them, submitted them to journals, only to have them accepted and published. This has been a matter of exposing the weaknesses of the peer review system. There’s also a lot of publishing bias, because who is it that’s actually funding these medical journals? It’s advertising dollars from the pharmaceutical industry. That really affects what we see as our evidence base. We’re talking so much about evidence based medicine, and yet how do we know we can trust that evidence base? We don’t. That’s very problematic.

Dr. Weitz:                         Yeah, that’s really important to point out. Have you found that mainstream medical journals, like the New England Journal of Medicine, you don’t see many papers on homeopathy in those journals.

Ananda More:                   I think there’s two issues going on there. One is that publishing bias that we discussed. A lot of the people I interviewed for my film, top scientists in their fields, said that as soon as the word homeopathy is in the abstract and the result is positive, the study isn’t even sent out for peer review. It’s rejected at the editorial stage. Another issue is that we don’t really have a ton of funding for homeopathic research, because there isn’t a lot of money in homeopathy. You can’t patent our medicines. They’re very easy to replicate. They’re very cheap to make. So you don’t have the same possibility of profits that you do with other forms of medicine.  Who funds most of the medical research? It’s the pharmaceutical and the medical industry. They’re not going to be funding homeopathic research. We depend on very few grants. A friend of mine, Dr. Alex Tournier, who’s a physicist in Heidelberg, he’s been struggling to raise enough money to maintain his lab, which is dedicated to homeopathic research. You’ve got both of those things, a profound publishing bias, along with a lack of funding for research.

Dr. Weitz:                         In your Magic Pills documentary, there’s a section where some doctors submitted a paper about their experience in Cuba after the hurricanes where they didn’t have enough money for medication or vaccines for leptospirosis, which commonly occurs after flooding and other types of water damage. Homeopathy was incredibly effective at reducing the rates of leptospirosis, but they were turned down for publication.

Ananda More:                   Yeah. So I just want to, just to get a few listeners up to date, what they did was there’s this disease, leptospirosis, which in North America is relatively unknown, but in tropical countries, it’s a pretty significant problem. It’s hard to diagnose, because it looks a lot like dengue and has some very generalized symptoms that are hard to specifically assign to a disease. It’s fatal up to 10% of the time, and it’s spread through water.  In Cuba in 2007, they had severe hurricanes that left the eastern coast of Cuba quite decimated. Homes were destroyed. There was no clean water, and flooding was everywhere. The Finlay Institute, which is a pharmaceutical company in Cuba that actually makes vaccines and is the only company on the planet that makes vaccines for leptospirosis, the issue wasn’t that they didn’t have the money. The issue was that they didn’t have enough vaccine on hand to take to those areas. They only had enough vaccine for 1% of the population.

The other issue is that that vaccine takes two doses and months to incur immunity. It’s not an instant fix. It takes a long time. In order to get it out there, it’s an injection. You’re dealing with cold chain, you need to be able to get to that area and maintain the vaccines cold. There’s a lot of issues with trying to get something like that to people in a fast manner.

They decided to attempt a homeopathic intervention instead, which they got out to 2 and a half million people. In the course of two weeks, they completely stopped the epidemic. Not only that, but the levels of the disease were far below their historical averages for years afterwards. Yeah, when these guys, who are immunologists, epidemiologists, they were scientists, they were not homeopaths, they have never had issues getting their work published, they got their work published all the time, and they even have their own vaccine journal that they’re the editors of. Suddenly they send it out for publication, and they were shocked, because in Cuba, they’re more isolated, they didn’t realize that there was this bias against homeopathy, and everyone refused to publish these results. They would get excuses like, “Well, we need a signature from all two and a half million people involved.” That sort of thing they’d never been asked for before. It was ridiculous.  So it was quite evident to them the level of bias that existed. They did eventually publish their results in a homeopathic journal called Homeopathy. When they did, Dr. Bracho told me he stopped reading his email because of the death threats that he was receiving.

Dr. Weitz:                         Wow.

Ananda More:                   He didn’t leave the country for over two years of fear of being attacked.

Dr. Weitz:                         Wow. Can you explain to the skeptics out there how can it be that by diluting the active ingredient that … Well, to begin with, everything we’ve learned about other forms of medicine is you need to find the right amount of the active ingredient and give that in an effective dosage. In some cases, if it’s not effective, then you give it more frequently or you give an additional dosage. That’s how we use herbs. That’s how medications are typically used. How can it be in homeopathy that by first of all diluting it so much that you’re going to have any effect at all, and then how can it be that by diluting it more, it makes it stronger?

Ananda More:                   Well, so I don’t want to say that diluting it more actually makes it stronger. We think homeopathy is an energy medicine. By diluting it more, you’re changing its signal. For one person, a higher dilution may be more effective. For another person, a lower dilution may be more effective. But in terms of this idea of dilution, what’s important isn’t just the dilution, but rather this process that we call succussion, which is we have machines or we do it by hand, and we hit these glass vials very hard against a surface. This actually causes very high temperatures to happen in those bottles for microscopic moments in time.  We believe what’s happening is it creates nano particles as it breaks down the material within the vial. It also sloughs off nano particles from the glass as well, and silica is a conductor. There’s a lot of things that are happening that isn’t just diluting a substance until it disappears.

We don’t have exact clear answers at this point, but we have several theories. We have discovered that there are nano particles of source material and very highly diluted remedies. This has been seen over and over. They’ve done this with metals like gold. They’ve done this with organic substances now too. What they do is they put the remedy under an electron microscope and look for the nano particles and see if there’s any trace. Then they have special ways using spectrography to understand what that source material is that they’re looking at.  This has been replicated dozens of times. We know for a fact now that there are nano particles in these solutions of the source material. How that relates to the mechanism, we’re not sure. How are those nano particles maintained in that solution? We don’t know, but they are there. They’re observable.

There’s ideas around now nano clusters, so actual formation of the water molecules and various … I have a cat that’s trying to get on my keyboard. He likes the keyboard. We can see these nano structures of the actual water molecules where they take on specific structures. Those have been observed. We can measure a difference in electromagnetic resonances or fields from remedies that have been actual just water to homeopathically prepared water. We have, what was it? Polar dyes. Studies have been done using polar dyes where they bring the remedies to very low temperatures. As they rise, these dyes change color and respond to usually material in the water. But what they’re doing is they’re actually responding as they should in the homeopathic remedies, if that substance was in the water, where they don’t with the plain water.  We can actually measure and see differences within those preparations. There’s still a lot to understand where it’s just at the infancy of the science, but it’s not because it’s unscientific. It’s because the technology’s just catching up that’s allowing us to look at these models. The funding is lacking.

Dr. Weitz:                            How did you come to make this documentary, Magic Pills?

Ananda More:                   So the story about Cuba that I just told, I was sitting at a conference, and Dr. Bracho from Cuba came and presented their results. I thought to myself, “Everybody needs to know about this. If this was a vaccine that had no adverse reactions, that could be prepared within minutes, or not minutes, but could be prepared within a manner of days, enough doses to reach two and a half million people, you don’t need cold chain, and it’s that effective and long lasting? Wouldn’t everybody know about it? Wouldn’t this be headline news?” But nobody heard about it.  I was racking my brain as to what do we, as a homeopathic community or scientific community need to do to get that data out there to let people know what’s going on, because in my view, this was all being suppressed. That’s where the idea of a film was born. I’d seen movies have incredible results in terms of changing how we respond to things like black fish and our responses to Sea World and how we raise animals, or rather marine mammals and how we keep them. Things like that. I was hoping that we could have a larger influence through a film and reach more people.

Dr. Weitz:                            Cool. Can you talk about the Australian National Health and Medical Research Council report that found that their conclusion was that there’s no good scientific evidence that homeopathy is effective?

Ananda More:                   Yeah. So this has been a very, very influential study. They’ve really shifted policy in Australia, according to what the study has said. They’ve done the same in the United Kingdom where homeopathy has been part of the culture there for a long time. The royal family, themselves mostly use only homeopathy, and they have these incredible homeopathic hospitals across the country. Homeopathy was covered by the national health system there and it was part of your public healthcare plan. Suddenly with the use of the study and some other commissioned reports, they decided that, “Oh, there’s no evidence that homeopathy works, so therefore we shouldn’t fund it anymore.” But the study is very problematic. From the point in time where they reached out to other scientists to say, “Can you look at our methodology and give us some feedback?” They got a lot of feedback, because their methodology was very poor, but they didn’t respond to those criticisms, and they didn’t change how they were doing the study.

When the report came out, it’s supposed to be a review of all of the literature out there, but their final data is based on five and only five studies, because they created a, in a way, very arbitrary data set that they decided was what qualified a good study versus a bad study. Part of that data set was a study that was over 150 people. That may sound reasonable, but if you look at the NHMRC’s guidelines, what they think is a good study is over 20 people. When they really cherry pick the data down to five studies, four of which were negative, one of which is one of our best studies showing that homeopathy works, which is a study on diarrhea in children, and they, based on these five studies, they didn’t even address the one study that was positive and didn’t look at it. They just said there is no evidence for any disease to say that homeopathy works. Also, yeah, just the rabbit hole just keeps going and going and going around why didn’t they look at these studies? Why didn’t they look at those studies?

When the Australian Homeopathic Association reached out and tried to get … Well, they did a freedom of information request to learn more about the study, they learned that there had been a previous study that had been done. That previous study had been done by a very well respected scientist. They’d seen the feedback on that study, which said that the methodology was of very high quality, and yet that study was buried. The lead scientist on that study was fired, and they decided to make a whole new study. They’re refusing to release that first report.

Dr. Weitz:                         Wow.

Ananda More:                   On top of that, this current report was rejected for peer review because its methodology was so poor.

Dr. Weitz:                         Wow.

Ananda More:                   So now we’re using this to uphold that homeopathy doesn’t work, and yet it couldn’t even get published, an anti-homeopathy study that couldn’t get published. I think that’s very meaningful. Now there’s a campaign, and it’s a global campaign, so I invite everyone who’s listening to this to go and sign this petition to release that first report. That could be a game-changer. People can go to releasethefirstreport.com. There’s tons of information, a real in-depth analysis of what is wrong with this study. Other people won’t say it, but I’m willing to say that I think the study is quite fraudulent and had something to prove that they couldn’t prove the first time. Yeah, I invite everyone to go there, learn more, sign, share. I think it’s really important.

Dr. Weitz:                         So how about in the United States? I understand the FDA has taken note of this report and issued some sort of a warning or something.

Ananda More:                   So homeopathy has been, in a sense, accepted by the FDA since its inception. Homeopathy was grandfathered in. The senator who brought in the bill to create the FDA was actually a homeopath himself.

Dr. Weitz:                         Really?

Ananda More:                   Yeah. So there’s a long-

Dr. Weitz:                         What was his name?

Ananda More:                   Pardon?

Dr. Weitz:                         What was the name of the senator?

Ananda More:                   I can’t remember his name. I’ll have to look it up.

Dr. Weitz:                         Wow. Interesting.

Ananda More:                   Quick Google search. But homeopathy has a long history in the US. We’ve had homeopathic hospitals, which still exist today. They’re just not homeopathic anymore, like the Hahnemann Hospital in Philadelphia. There is a memorial to homeopathy that was built by a president in Washington, DC.

Dr. Weitz:                         Really?

Ananda More:                   Yeah.

Dr. Weitz:                         Which president built it?

Ananda More:                   Again, I can’t remember his name. I’m not very helpful there, am I?

Dr. Weitz:                         You Canadians, you don’t know anything about American history.

Ananda More:                   It wasn’t a major president whose name was burning in my ears.

Dr. Weitz:                         That’s okay.

Ananda More:                   Resonate. But now the FDA has decided out of nowhere that they wanted to change how homeopathy is the oversight, how it’s overseen. They created this draft document which basically in a sense states that homeopathy is legal. It stated that we brought homeopathy in, but these remedies haven’t gone through the new drug application process. Therefore, we’re going to pursue this on a risk basis, on a high risk basis.  To the industry, they were saying, “Don’t worry. We’re only going to address remedies that are going to people that are immunocompromised and babies and things like this where there may be a risk to them using these remedies.” But in all honesty, what’s the risk if there’s no active ingredient in it? It’s not going to hurt anyone. It’s non-toxic, and in many situations, it’s the only medicines available to pregnant women and compromised individuals, people like that.

The other issue is that they’re basically setting themselves up to make homeopathy illegal with this document. In order to go through a new drug application process, it’s at minimum around $300 million. We have thousands of medicines. There’s a level of individualization to homeopathy, so you could have one remedy that could be good for 50 different ailments in 50 different individuals in different ways, and the kind of research that the FDA requires is very pathologically centered and per drug rather than homeopathy as a whole, which does not allow for individualization and using homeopathy as it’s actually used in practice.  Being able to pass those requirements are very doubtful, and our industry isn’t big enough to be able to afford that kind of money to pass every medicine for every possible indication. It really complicates things, and it’s basically setting the stage for the removal of homeopathy in the United States.

Dr. Weitz:                            Yeah. No, I can totally understand that. On the one hand, I saw a recent report where the FDA stopped the use of a particular brand of homeopathy, because they found bacteria or something in some of their products, and that sounded totally reasonable and sounded like what they were talking about. On the other hand, we have to understand in the United States especially, and I don’t know how many other countries follow this, but our government is increasingly controlled by big corporations and even the heads of the FDA and these other agencies are often lobbyists or people who work for these big corporations because of the way that the government is set up with the lobbying and everything.  For example in California, where I practice as a chiropractor, all the individual healthcare plans include no chiropractic coverage. How can that be in a liberal state like California where people use chiropractic and other alternative medicine quite readily?  It came down to lobbying, and the chiropractic profession didn’t do a good job of lobbying to make sure that chiropractic, which is relatively inexpensive, was going to be included in the new healthcare plans.  They wanted to cut something, and that was a low-hanging fruit they could cut.  It was based on lobbying. That’s I think one of the risks for homeopathy in the future is that everything seems to be based on influences based on the amount of funding.

Ananda More:                   Mm-hmm (affirmative). Yeah, and like what you’re talking about, there’s been a few situations recently where they have found bacteria in remedies. There is a story of Highland’s Teething Tablets, which garnered a lot of news because of their belladonna content, or deadly nightshade. Again, there was a freedom of information request done on that data, and it was so arbitrary. These supposed cases of death attributed to this remedy had nothing that was very hard to attribute the death to the remedy. You’d see cases like a child born without kidneys or who then had a dose of this remedy and died three months later. They were just completely … It just looked like falsified data. A lot of the data had been doubled as well. So they had to do a lot of filtering, and they claimed it was hundreds of thousands of complaints when you really looked at it, half of them you didn’t know what the complaint was about. Half of them were replicated from other things. Half of them had nothing to do … I keep saying half, but it dwindled down to almost nothing, in terms of complaints.  If you really took those teething tablets, in order to intake enough to have the minimum level for toxicity, you’re looking at taking hundreds of boxes or consuming hundreds of boxes of this medication. It really feels like there’s a witch hunt out there.

The other problem around that with this document is that if it passes, they’re actually removing the manufacturing guidelines for these remedies. There’s a document called the CPG 400.400. Within that document, it outlines proper manufacturing practices. The FDA has every right to go after these manufacturers who aren’t maintaining the purity of their remedies. What they’re doing is they’re getting rid of that. Suddenly you can’t even go after them with proper manufacturing, and we can’t even assess whether they’re selling a product that they say is what it is, because there’s no manufacturing guidelines.

Dr. Weitz:                         Wow, so you can’t go after the big pharma companies are having this stuff made in China that has all kinds of proven toxins.

Ananda More:                   But that’s very specific to homeopathy. That’s what they’re removing, the guidelines for manufacturing a homeopathy, which makes no sense.

Dr. Weitz:                         Right.

Ananda More:                   There is this fantastic group of mothers that formed in the United States headed by this very vibrant woman named Paula Brown. These were all moms who depend on homeopathy on a daily basis. It really amazed me, because we have public healthcare here. I can go to the hospital, and it doesn’t cost me anything out of pocket. But a lot of these-

Dr. Weitz:                         What a concept? You socialists.

Ananda More:                   Yeah, I highly recommend it. But these women were either didn’t have access to healthcare, couldn’t afford these hospital visits.

Dr. Weitz:                         We’ve got the greatest system in the world where a simple emergency room visit for a flu can cost you $3,000.

Ananda More:                   Yeah. I can’t wrap my head around that in any way, shape, or form, because I’ve never experienced that. But you see these women who were dependent on drugs and suddenly lost their plans and couldn’t get their thousands of dollars worth of medications anymore. They couldn’t afford to take their kid to the hospital. They saw miracles happen with homeopathy, so they really stand behind it. You hear these stories. They’re just astounding. They were so terrified of losing access to homeopathy that they formed this organization called Americans for Homeopathy Choice.  These women have been a powerhouse in the US, in terms of lobbying for homeopathy. This document that the FDA, this draft would have passed already if it wasn’t for them. They’ve put in place a petition and were asking for people to write letters to the FDA to support this petition. It’s not the kind of petition that everyone signs. It’s a petition specifically for them that’s clogged up the passing of this document. People can go to homeopathychoice.org and learn more, sign up, and write their letters. There’s all the instructions there as to what needs to be done.

Even if you don’t believe in homeopathy, I think this is about protecting our rights to freedom of choice. It’s a basic human right to decide how you want to treat your body and how you want to medicate yourself. If you want to try other options first in a safe manner, I think that’s absolutely a human right.

Dr. Weitz:                            I totally agree with you on that. There’s many cases now in the United States where those options are being taken away, where vaccines are being made mandatory to send your kids to school, and there’s a lot more things, a lot more cases where those individual choices for choosing your own healthcare, making your own healthcare decisions are being taken away.

Ananda More:                   Mm-hmm (affirmative).

Dr. Weitz:                            Well, this has been a very interesting interview, Ananda. Thank you so much for joining us.

Ananda More:                   Thanks so much for letting me talk and spread the word. I appreciate it.

Dr. Weitz:                            So how can listeners get a hold of you, if they want to talk with you or if they want to get more information about homeopathy? I’ll put links in the show notes, of course?

Ananda More:                   Brilliant. Well, we have made this … I think it’s a fantastic documentary called Magic Pills. We’re inviting people to screen it all over the US. We have a goal of 1,000 screenings. It’s actually been screening all over the world. It’s been in a bunch of film festivals. But what we want to do is bring it into people’s homes. There’s this model of you can screen the film in your own living room, invite your friends and family to come watch it. Or you can screen it in the church, a theater, all kinds of different places are being used. Coffee shops, museums. But we want to make it really accessible, and we want people to come together so there could be a really great discussion afterwards and a building of community around the issues presented.  We invite you to go to the website, magicpillsmovie.com. There’s lots of information there on how to make that happen. Through the contact us link there page, you’ll definitely reach out and you’ll hit me. Could also check us out on Facebook, which is Magic Pills Movie. We’re pretty active there as well. Those are the two excellent ways to reach us.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Men's Health with Dr. Myles Spar: Rational Wellness Podcast 83
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Dr. Myles Spar discusses Men’s Health with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

1:22  Some of the ways in which men’s health is different than women’s, is that men die younger. They have higher rates of heart disease. They may have issues with erectile dysfunction, prostate problems, and low testosterone especially as they age. Men, on average, die five years younger than women.  According to the Harvard Health Blog, the reasons why men die younger are that: 1. men tend to take bigger risks, 2. have more dangerous jobs, 3. die of heart disease more often, 4. are larger than women, 5. commit suicide more often than women, 6. are less socially connected, and 7. tend to avoid doctors.

3:45  Dr. Spar said it appears to be masculinity that results in men dying younger than women. In countries where the masculine machismo is more prevalent and they engage even less in the behaviors we know contribute to longer life and healthier living, are countries where men’s health is actually worse.  Dr. Spar said that we need to figure out how to message wellness to men so that they respond, which is what his professional mission has been about.

4:31  Dr. Spar said that the five factors that most contribute to premature death in men are 1. lack of exercise, 2. drinking too much, 3. engaging in risky behaviors, 4. smoking, and 5. being overweight.

5:29  We need to message in a way that men will tend to respond. Talking about a prevention and wellness approach means a lot to us as practitioners, but it only resonates to someone who is fairly abstract thinking, while guys tend to be more specific results oriented. Dr. Spar explained that we need to message to what matters to that person, such as performance at work, losing weight, getting cholesterol down, sexual function, etc. Men tend to respond to a more performance oriented message. but there are also lots of women who also think in this goal oriented way of thinking. 

7:11  When working with men to lose weight it is important to measure not just weight but bodyfat percentage and setting goals and holding men accountable.  Dr. Spar finds that apps like Strava are helpful in using technology that helps with accountability and tracking improvement or not. 

9:25  Dr. Spar prefers to look at genetics to see if his patients have trouble with detoxification. He uses either Pathway Genomics or PureGenomics from Pure Encapsulations that allows you to put your 23and me raw data through. But he is concerned about a report that such programs that analyse genetic data tend to have up to 20% errors when reporting on the SNPs of these genes.

12:17  To help men reduce their risk of heart disease, men need to have an advanced lipid profile, since the tests that are run with the annual physical exam are inadeguate in assessing the risk for heart disease. Dr. Spar likes to use the Cardiometabolic Profile from Spectracell, which looks at LDL particle size and number and also at inflammatory markers like CRP. We also need to look at Lp(a), which is a huge risk factor for heart disease.  Take the case of Bob Harper, the trainer from Biggest Loser who appears to be in great shape, and had no risk factors except that he had a high Lp(a) and had a near fatal heart attack.  It will also look at homocysteine, which is a risk factor for heart disease and is easy to lower with the right supplements. And homocysteine is also an indication that you don’t methylate well, if you haven’t had genetic testing. Your primary MD will usually not order such an advanced lipid profile because it’s usually not covered by insurance and they usually avoid such conversations.  Dr. Spar also likes some of his patients to get a coronary calcium score to see directly if there is any plaque in their arteries, which is another useful test that is not covered by insurance. But despite some patients’ concerns, there is very little radiation associated with such a limited scan and there is no radioactive dye.  If he has a patient who has cholesterol problems and he has them on fish oil and plant sterols and he is deciding whether to place them on a statin, the coronary calcium scan can help him and his patient make that decision. 

17:08  Men tend to have lower testosterone levels today because of 1. stress and anxiety, since our bodies shut down reproductive drive if we are under stress, 2. environmental toxicity, which especially seems to affect free testosterone, and even lowers sperm count, and 3. opioids, which have been correlated with lower testosterone levels.  Testosterone should ideally be in an optimal range betweeen 350 and 900. Too much and too low can both be risks for heart health. Men should also have an optimal range of estrogen with an ideal estradial range of 15-30. Men who are taking a lot of estrogen blockers can be causing themselves harm with respect heart and bone health if they drive their estrogen down too low.

23:50  Natural ways to raise testosterone levels include: 1. zinc and chrysin are both natural aromatase inhibitors and will block the conversion of testosterone to estrogen. When you take zinc you should also take 1/10 as much copper. 2. Chinese panax ginseng, 3. Tribulus, 4. Maca root, 5. stress management techniques, including meditation, yoga, Tai chi, journaling, prayer, some breath work, 6. 7-9 hours of sleep per night is very important 

26:45  Free testosterone levels seem to be often very low, even more so than the total testosterone.  Some of this can be due to thyroid and liver problems, but most of this is probably related to increases in SHBG (sex hormone binding globulin), which may be related to environmental toxins.  Dr. Spar noted that when tracking men whom he has placed on topical estrogen supplements, he will track them with saliva free testosterone levels, which is more sensitive for this than serum. This is part of his tack180.com program.

31:57  Dr. Spar does measure PSA levels in men, especially if he has placed them on testosterone.  We do know from the work of Dr. Abraham Morgentaler that testosterone does not cause prostate cancer, though if someone has prostate cancer, we don’t want to give them testosterone.  Dr. Spar will do a digital exam and if the prostate is enlarged he will also check a free PSA. If the PSA is elevated, will have the patient get a prostate MRI. If that is positive, only then he will recommend a biopsy.  This reduces unnecessary biopsies.

                                                                                          

 



Dr. Myles Spar is a Medical Doctor who practices in Hollywood, California and he is a leading authority on men’s health. He is a co-author and editor of a comprehensive book on men’s health, Integrative Men’s Health. Dr. Spar provides a lot of useful information on his website, MDSpar.com where he offers his Tack180 program of comprehensive men’s care.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

Podcast Transcripts

Dr. Weitz:            This is Dr. Ben Weitz with The Rational Wellness Podcast. Bringing you the cutting edge information on health and nutrition, from the latest scientific research and by interviewing the top experts in the field. Please subscribe to The Rational Wellness Podcast on iTunes and YouTube, and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health.

Hello Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and leave us a ratings and review. That way more people will find out about the Rational Wellness Podcast. Today we are going to focus our discussion on men’s health, with our special guest, Dr. Miles Spar. We’ve talked in prior episodes about prostate health, and libido, with Dr. Geo Espinoza in episodes eight and number 48. These are important issues for men. But today, we’re going to talk about these and other factors in an overall approach to improving men’s health.

Some of the ways in which men’s health is different than women’s, is that men die younger. They have higher rates of heart disease. They may have issues with erectile dysfunction, prostate problems, and low testosterone especially as they age. Men, on average, die five years younger than women. What are some of the reasons for this? According to the Harvard Health Blog, men tend to take bigger risks, have more dangerous jobs, die of heart disease more often, are larger than women, commit suicide more often than women, are less socially connected, and tend to avoid doctors. As a chiropractor, I can definitely endorse this, because my practice, like most chiropractors, is 60% women, and a lot of the men who come in are only there because their wives or girlfriends pushed them to come in.

I’m happy that Dr. Miles Spar will be joining us today. He’s a medical doctor in Hollywood, California. He practices Functional Medicine, and he also directs the integrated medicine program at the Venice Family Clinics, Simms/Mann Health and Wellness Center. Dr. Spar is a leading authority on men’s health. His comprehensive book on integrated men’s health was published in 2014. When Dr. Spar sees patients, his consultations usually include an analysis of genetics, nutrient levels, hormones, and advanced cardiovascular testing. Dr. Spar is also an iron man athlete, and he works both with Hollywood celebrities, and professional athletes, including being a medical advisor for the NBA. I’m honored that you’ll be joining our podcast Miles, to speak about men’s health.

Dr. Spar:              Thank you. Thanks Ben. It’s great to be here.

Dr. Weitz:            Absolutely. So, do you agree with those reasons the author of the Harvard Health Blog wrote about why men tend to die younger?

Dr. Spar:              Yeah I do. I think it’s definitely proven at this point, that it’s not genetic, it’s not biologic. There’s differences in life expectancy between men and women, but those differences change over time, and across cultures. If there’s really biology, it would be a fixed difference or more close to a fixed difference. It really just seems to be, it’s more like masculinity is killing us, as opposed to being male. There’s a really interesting report, just a couple of weeks ago, the World Health Organization put out on the status of men’s health in Europe saying very similar things to what you quoted from that Harvard blog, that the countries where the masculine machismo is more prevalent, are countries where men’s health is actually worse. There are countries where they are engaging even less in behaviors we know contribute to longer life and healthier living.  Absolutely, I think it’s coming upon us to really try and figure out what are we doing wrong, and messaging wellness towards men. Why aren’t they responding? What can we do differently. That’s really what my professional mission has been all about.

Dr. Weitz:            Of those factors we mentioned, which ones do you think are the most important?

Dr. Spar:              Basically I think there are five that are most important. There are five that are most likely to contribute to the decrease in mortality, the decrease in life expectancy, because they contribute most to the preventive causes of premature mortality. That’s basically lack of exercise. It’s a lot of what you mentioned, but I think … I can’t narrow it down to one. I think it’s lack of exercise. It’s drinking too much or not moderating alcohol. It’s taking risky behaviors. It’s smoking. I have a little thing here. It’s also maintaining a healthy weight. Men are more likely to be obese than women, and I think that may be the most important cause of it right there.

Dr. Weitz:            Yeah great. How do you address some of these issues in your practice?

Dr. Spar:              I think, first of all, like I kind of refer to we don’t message what we’re trying to do to men very well. We’ve been using this prevention and wellness approach, which is great, and it means a lot to us as practitioners, but it only resonates to someone who is fairly abstract thinking, able to put off things now for future benefit. By and large, guys are a little more result oriented. “What do I need to do now, and how is it going to impact me now?” It’s more about results, outcomes, specific goals, as opposed to broad ideas of wellness or prevention. I think part of what we need to is really think about messaging that’s directed at what matters to the person that you’re in front of. Is it about performance at work? Is it about losing weight? Is it about being more on mentally? Is it about getting cholesterol down? Is it about sexual function? Then making very specific recommendations that will impact that particular goal that’s of concern to that person. I call it a men’s approach, that it’s really about performance oriented, but it’s really not just for men.

I think that would help us in general, because there are a lot of people who think in this more stereotypical masculine way that’s result oriented, goal oriented that is more abstract and wellness orientated. By and large, that’s more men than women, but this is a caveat to our whole conversation today. When we talk about men, I really mean anyone who thinks in a stereotypical male way. It doesn’t have to be a person who’s a male in gender. That’s the first step, is really more goal results oriented way of talking about why it’s important to make behavior change.

Dr. Weitz:            You mentioned weight gain and obesity. How do you specifically deal with that with men, and how do you come up with more … How do you approach it in a way that’s more impactful than just making general recommendations, “You should lose some weight”?

Dr. Spar:               Yeah. Good question. I think it’s about measuring and holding patients accountable and having real milestones. As opposed to a general grid. “I have this great anti-inflammatory diet. Here’s what you eat. Here’s what you shouldn’t eat.” That doesn’t work as well as, “Okay, let’s look at specifically what you’re eating, meet with a nutritionist, and then let’s measure not just weight because with guys oftentimes they’re working out and then they don’t lose weight because they’re building muscle mass, so let’s look at waist circumference or let’s put you in a DEXA scan, which you can do now pretty inexpensively and check your body fat percentages. Whatever single measure can really be important to that guy, find that, and then check it periodically because guys like to compete even if it’s against themselves or against other people.  That’s the other part of that. I think physical activity is as important as diet. With guys especially trying to get them to engage. I love Strava, which is an app that’s like a social media/competition app or Weight Watchers even now has a great app. They’re using some kind of technology that helps have accountable measures. It’s all about having a measurement that you track and being able to show improvement or lack thereof and then figuring out where do we need to change our tactics.

Dr. Weitz:            Yeah, we use bioimpedance in our office, and that’s helpful.

Dr. Spar:              That’s great. Something that you use the same one each time, then it really is good. It’s showing changes, and then you know if you’re going the right direction or not. I think guys especially, everybody, especially guys like to feel like you’re holding yourself accountable. As a practitioner you’re going to say, “Look, I know this is going to work, and we’re going to show it’s working. If it isn’t, we’re going to change things. Then they like to see that they’re making improvements in black and white.

Dr. Weitz:            Do you ever look at toxins as a factor in having trouble losing weight or so many other health issues?

Dr. Spar:              Yeah. I like to do both looking at toxins and looking at genetics because sometimes people have genetics where they’re not detoxifying as well, so I like to do genetic testing to see if they need issues with detoxifying because it may be that they’re being exposed to the same amount as everybody else, but their hormones are getting messed up because they’re not clearing them out. Even if you do measure their testosterone, TSH and all that, it’s kind of okay, but their hormones aren’t operating as maximally because there’s so many toxins. Some of that is determined I think by how good their liver is at clearing things out. We can measure that through some of the genetic tests. They can tell us, “Oh, okay. This person really does have a propensity to not clearing stuff out, so let’s give him supplements that help boost whatever phase of detoxification they might need help with.”

Dr. Weitz:            What’s your favorite genetic panel?

Dr. Spar:              That’s a really good question. I play with all of them. Right now I’m using Pathway Genomics. It’s not really my favorite, but I like it for right now in terms of price and availability. I also like Pure Encapsulations products. It has this free if you’re one of their clients. It has this thing called PureGenomics, which is great. You can run 23andMe data for free through there. You get a great report.

Now the caveat is I’m concerned because I’m hearing that there is concern with some of these secondary data analyses from 23andMe data, that there have been found to be quite a bit of misinterpretation. I take it all as one piece of evidence. None of them is going to be a sole decision maker for me. It’s just if someone comes in with symptoms that could be relating to, let’s say, detoxification, then I look to see how are they detoxifying. How is their SOD? How is there MTHFR or some of these other genes? To see, okay, that could explain it or, “You know what? This doesn’t even make sense. I don’t really think this is significant.”  I mean I think hopefully whole genome sequencing will become more affordable, and that’s going to be a lot more reliable than any of these tests that look at individual SNPs.

Dr. Weitz:            What was that concern about the 23andMe?

Dr. Spar:              There are some just some studies that are showing that these Promethease and PureGenomics and some of these other programs that basically do secondary data analysis, they basically take the raw data from 23andMe and run it through their systems, that there’s a lot of error.  I forget the numbers now. I wish I could tell you. It was 20% or more were recording genes that were just inaccurate, that patients didn’t have those genes as it said they had.

Dr. Weitz:            Oh, wow.

Dr. Spar:              Yeah. It was really high rate of error. It definitely gave me some pause.

Dr. Weitz:            Interesting. Yeah, we’ve been utilizing that service as well. How do you deal with the heart disease risk that men have?

Dr. Spar:              Well, I think it’s important number one to look beyond just the general annual physical lipid panel. That’s a big thing. I think that just plain old cholesterol and LDL cholesterol is one part of the picture. You need to really look at these advanced VAP panels like Berkeley Heart Lab or I use SpectraCell, one of these advanced panels that looks, A, at things that go beyond the plain lipid panel. So they look at lipid particle number and particle size. Do they have a bad pattern of LDL or bad kind of cholesterol. You can have the worst pattern or the not as bad pattern.  Then especially looking at other markers because we know that heart disease number one is plaque and inflammation. Those are the two essential parts, right? We know that cholesterol can increase risk for plaque, but if their inflammation markers like CRP are really low, I’m less concerned. It’s really important to measure that. Then we know things like Lp(a), separate from cholesterol, a huge risk factor for heart disease. Bob Harper made that famous. He’s the guy that is a trainer on Biggest Loser, really in shape guy, had a heart attack or at least needed a stent placed emergently, and I think it was a heart attack.  Then there was a big article in the New York Times about the fact that his only risk was his high Lp(a) back in January or February of this year, your listeners can look that up, by this really good science writer for the New York Times. It really brought to light how important that marker is, which unfortunately isn’t always covered by insurance, but it’s a really important mostly genetically based risk.

Dr. Weitz:            I think that’s one of the big factors why when someone goes for their typical annual physical and they get this very limited number of blood tests, especially today, which when it comes to lipids is maybe going to be like LDL and HDL, total cholesterol, and triglycerides and sometimes even less because that’s what the insurance is going to pay. Unfortunately, most primary MDs are trying to stick with the insurance guidelines, and so unfortunately I think short changing the patients.

Dr. Spar:              Yeah. I mean there have been studies showing the annual physical as it’s currently done literally is a waste of time. It doesn’t provide any change in mortality or morbidity. There have been articles in the New England Journal of Medicine and JAMA and in very prestigious, very conservative journals about that. It’s because it’s all based on what insurance says as opposed to what is really optimal in terms of preventative medicine and evaluating risk, which is unfortunate because then it puts us in this position of saying, “You know, you really do need this test and this is how much it’s going to cost, and I’m not making money off of it, but you really need this.”  Patients who are low income, it’s not fair.

Dr. Weitz:            MDs rarely even offer patients that choice, though.

Dr. Spar:              Right because it’s a whole discussion that they don’t feel like to have. Either they don’t know about it because they don’t learn about it.  It kind of goes down they only learn about what’s in the annual physical or they’re like, “Okay, I know he needs this, but I got three patients waiting. Do I really want to go into ‘Well, you need this. This is why. Is it covered or not covered.'” They’re just like, “No, I’m just going to check off the lipid panel.”  It’s really unfortunate.

Dr. Weitz:            Yeah.

Dr. Spar:              Then the other marker I would say in there that I didn’t mention is homocysteine. That’s if someone can’t afford genetic testing that’s kind of a hint that they might have like an MTHFR, a gene where they don’t methylate their B vitamins well and don’t clear homocysteine.  Homocysteine is easy to lower, and it’s a very known risk factor for heart disease.  That’s part of it. And then imaging, I really think again is not covered by insurance but is not that expensive.  It’s like $200 for a coronary calcium score.

Dr. Weitz:            Right.

Dr. Spar:              To me, I love those because if somebody does have high cholesterol, but they don’t really want to go on a statin and I don’t really want to put them on a statin, we’re trying fish oil, we’re trying plant sterols. They’re watching their diet. The thing that will help me decide, “Okay, do we really need a statin or not?” is something like a phenotypic test. Is that risk translating into real disease? The way to look at that is something like a coronary calcium CT scan, which is only a few cuts, a couple inner bugs, and we can see do they have plaque or not, and if they don’t, then I know, “You know what? Don’t worry about it. You have some cholesterol, but it’s not really manifesting as plaque,” versus, “Ooo, you have a high calcium score of 100, we’re putting you on a statin.”

Dr. Weitz:            I think the reason why you mentioned that it’s just a few cuts is to point out that it’s not a lot of radiation.

Dr. Spar:              Right. Exactly. Some people get scared of having too much CAT scanning. This one, there’s no contrast dye that they’re injecting in you. It’s really limited to just looking at the arteries around your heart.

Dr. Weitz:            Right. Good. Yeah. Let’s bring up the testosterone topic.

Dr. Spar:              Yes.

Dr. Weitz:            First of all, we’re seeing lower levels of testosterone in men over the last several decades. Why is that?

Dr. Spar:              Good question. I don’t know that we know. I mean, I think the hypotheses that seem most likely are number one, anxiety and stress. There’s just more stress. There’s less time to do what we need to do. There’s less people unplugging and relaxing. We know that reproductive drive is completely directly correlated with or inversely related with stress. Women stop menstruating when they’re really stressed. Men stop making testosterone. It’s literally evolution protecting our progeny because if our bodies sense stress or crisis, and that can be emotional stress from work or from relationships just as much as being under attack from a saber tooth tiger, it’s going to say, “Whoa, we need to protect the home front. We can’t make progeny that we may not be able to protect. Let’s shut down reproductive drive and just focus on survival.”  It’s kind of hard where it ends. Stress lowers testosterone. I think that’s a lot of it.

I think some of it is environmental toxicity. We see that in to some degree this difference between total testosterone and free testosterone, which I know you were going to ask about anyway. Basically, some guys like their total testosterone is okay, but they have so much of this binding up protein called sex hormone binding globulin that their amount of testosterone available to really work is low. Some of that, I think, is due to environmental toxins that affect the liver and then the liver makes more of that protein.  I think between the stress and the toxins, those are probably the most likely. We see fertility going down. We see sperm counts going down. There’s something really affecting reproduction in general in men and women, but you can see a direct correlation in men.

Then opioids as well I guess would be the third one. We hear a lot of this opioid epidemic. Opioids are very directly correlated with lower testosterone, completely, even if you’re just appropriately taking them for a couple of weeks after having surgery or something. Your testosterone is going to go down while you’re on them.

Dr. Weitz:            Yeah. Opioids have all sorts of negative effects on the gut, every system of the body really. When it comes to testosterone levels, it’s interesting that really high levels of testosterone like professional body builders have will increase their risk of heart disease, while really low levels also increase their risk of heart disease. Then, yes, testosterone levels lower. A lot of times there’s higher estrogen levels, and it’s interesting that that’s a negative for men.  For women, higher estrogen levels are very protective for heart disease, which is one of the reasons why women have lower risk of heart disease.

Dr. Spar:              Yeah. I mean, I think there’s this whole controversy about testosterone, but it shouldn’t be a surprise that it’s not good if it’s too high or too low. I mean, we know with thyroid for example if it’s too high you can have problems. You can have palpitations and a risk of heart attack. If it’s too low, you get a wheeze and constipated, and you can even have all sorts of skin and other immune system conditions. All hormones are very finely tuned. They affect each other. It’s the same with testosterone. There’s definitely evidence too low testosterone affects increased risk for heart disease, increased risk for obviously osteoporosis and bone problems, and too high of testosterone increases it as well.  Really, it does need to be in the optimal range. I think that’s part of the issue with guys like bodybuilders that are taking too much of it. It’s not like … I don’t know if there’s any good example, but it’s not like more is better. You know? I mean, more is better if they’re low and they’re just getting it to the upper 25% of the normal range.  If they’re taking it over the normal range, it’s not good.

Dr. Weitz:            Yeah, what bodybuilders are taking though is nowhere close to the normal range, you know?

Dr. Spar:              No, no.

Dr. Weitz:            They’re taking thousands of times above what the normal range is.

Dr. Spar:              Exactly. They get results in terms of muscle mass, but they also get dangerous side effects, liver, heart disease, all sorts of issues. I think the estrogen is the same thing. You want it in that what’s normal for men. That’s the other thing bodybuilders and some guys do. They’ll read it in Men’s Health magazine or these magazines to take all these estrogen blockers, and then they take too much, and their estrogen is unmeasurable. They think that’s great, but that actually puts them at risk for osteoporosis because you want between 15 and 30, if you’re measuring your estradiol level. If it’s much higher than that, no it’s not good. You can get breast tenderness and issues if you do maybe take a blocker a couple of days a week.  These guys who are taking blockers like every day, and they feel great that their estrogen is unmeasurable, are really in trouble.

Dr. Weitz:            You think 15 to 30 is the sweet spot for estrogen for men?

Dr. Spar:              Yeah, for estradiol specifically. Yes.

Dr. Weitz:            Estradiol. Yes. What about for testosterone? When you look at these testosterone tests, let’s start with the total testosterone. The range on some of these labs is 150 to 900, which is a big range.

Dr. Spar:              Yeah. I know. I think for a total really if it’s under 350, they’re likely to have symptoms.  First of all, with testosterone I rarely just treat the number. If it’s in the 100s, I will treat the number.  Even if they don’t have symptoms, that’s dangerous for bone and heart health and even diabetes risk. If it’s in the 300s, likely they’re going to have symptoms if it’s under 350. So the symptoms that a guy can have, they may not report sexual function issues, but they could have depression. They could even be put on antidepressants because nobody checked testosterone, but really they’re depressed because their testosterone is low.  They can have low energy.  They can just have lack of muscle mass or losing muscle mass or losing weight. Sometimes guys won’t talk about having issues with sexual function, but they’ll talk about these other things.  Those all can be improved if you get the testosterone normal.  I would say probably 350 is the lower limits of normal, optimal, and up to maybe 900, probably much above that you risk the blood count getting too high. You risk acne. You risk getting that kind of road rage kind of feeling.  There’s probably no extra benefit of getting it to 1,100 versus 900.

Dr. Weitz:            What are some of the strategies for helping to normalize or elevate testosterone levels besides taking testosterone?

Dr. Spar:              A couple of things. Number one, you can take some things that naturally do block some of that conversion of testosterone to estrogen, like zinc for example or there’s a natural herb called chrysin which you can even put into a topical thing. Those help a lot.  The conversion, you know we all convert testosterone to estrogen via this enzyme aromatase.  Those are natural aromatase inhibitors, so they will naturally boost testosterone a little bit.

Whenever you take zinc, you want to take a little bit of cooper with it in a ratio of about ten to one zinc to copper because they go together, so they are supplements that will have those combined. Those are kind of natural ways.  Other than that, there are other things that help boost libido and male energy, but they don’t boost testosterone per se.  Still, I think they’re worth using if testosterone is mildly low and somebody has symptoms.  For example, in Chinese medicine the ginsengs, we all know about, right? Especially Panax ginseng. In Indian medicine there’s Tribulus, which is kind of like the Ayurvedic form of ginseng. In South America, there’s Maca root, which is what they call Peruvian ginseng. Every culture kind of has their own male energy formula.  I really like Tribulus.  Maca has been really well shown to help with mood changes. There is a good study showing men on I forget if it was Celexa, Prozac, one of those SSRIs, which are known to cause sexual side effects taking Maca I think it was about two grams a day.  This was like a very well peer reviewed study.  They had a decrease in those side effects after they started the Maca, those sexual side effects.  I think that’s a great thing to try.  Those don’t raise T per se, but they do help some of the symptoms of low T.

Dr. Weitz:            Right. Tongkat Ali, have you tried that herb?

Dr. Spar:              No, I haven’t.

Dr. Weitz:            Yeah, check that one out. Look into the research on it.

Dr. Spar:              Okay. Great. Yeah, I definitely will. Obviously the other things we talked about that are real important. We talked about how stress lowers testosterone, so one of the most important interventions to increase testosterone is to find some stress management approach, whether it’s meditation, yoga, Tai chi, journaling, prayer, some breath work. I counseled a guy to do every day to really help decrease the impact stress has on the body. That’s probably the most powerful thing.

Dr. Weitz:            I found sleep to be really impactful as well. So many of us are sleeping four, five, or six hours a day.

Dr. Spar:              Yeah. That’s true. Most people do need seven to nine on average. You can get away with one or two less than that, but over time that absolutely decreases your ability to deal with the stress of life and then that’s going to cause a cascade of events. Yeah, that’s a really good point.

Dr. Weitz:            To bring up the free testosterone thing, I’ve noticed a huge percentage of men with low free testosterone levels. Even if their total testosterone level has sort of been normal or mid-range.

Dr. Spar:              Yes. Yeah, I don’t know that we know exactly why. Like I said some of that is from this increase in this binding protein, HDGN. We don’t know why that’s raised. We know thyroid disease and liver disease affects it, but it seems like more and more guys are getting a lot of testosterone gunked up with this SHBG, and I suspect myself, and I don’t have a lot of scientific basis for it, that it is part of this environmental toxicity affecting the liver and liver manufacturing more of this.

Dr. Weitz:            A lot of these environmental toxins are estrogenic substances.

Dr. Spar:              Exactly. The program I do called Tack 180, and in the show notes I’m sure you’ll have a link to that, it’s tack180.com that does a lot of this testing like we’ve talked about. I do saliva testing in addition to the blood. The blood is good for checking total, and you can check free as well, but the saliva is really good because it only checks the free really available testosterone and especially if I’m using topical testosterone replacement for a guy. Sometimes that salivary will really help me hone it in better because you can kind of overdose pretty easily a patient on topical testosterone just checking serum levels. The saliva will help you catch if you’re using too much or not.

Dr. Weitz:            Just in conversations with some patients who have used topical, they often feel like it doesn’t do much especially that AndroGel stuff.

Dr. Spar:              Yeah, it’s funny. You know, I think it’s like 50/50. I don’t know the percentage, but some guys it absolutely works, and it’s great. Some guys it does nothing. A, they don’t feel anything, and, B, it doesn’t even raise the level much. It must have something to do with the carrier and whether it gets absorbed or not. Just so your listeners know, bioidentical testosterone, it’s all the same. It’s much less complicated than with women, right? With women you can have all these nonbioidentical estrogens and progesterones, but, man, it’s all the same testosterone compound. It’s all pretty much bioidentical.

Dr. Weitz:            Yeah, there’s no testosterone coming from horses.

Dr. Spar:              Right. That would be right. I guess if they would take like stallions maybe they could get some or something.

Dr. Weitz:            Actually, that could be a big seller.

Dr. Spar:              As opposed to the mares, yeah. Okay. Let’s delete that. It’s going to be my patented thing. I don’t know how we’re going to collect it, but we’ll figure it out. Yeah, it is all the same. That’s why sometimes I like to go with compounded because you can put it in a carrier that might work better than whatever AndroGel uses. You can put it in a cream instead of a gel so it’s a little less sticky. You can use less volume and make it more concentrated so it’s less done. I’m using more and more of clomiphene, which is a pill so it’s easier, but it is off label. It’s not FDA approved for men. It’s approved for women. It’s safe. Urologists started using it a lot a few years ago, and so those of us doing men’s health started looking at that. It’s been out for a long time, so it’s available generically. It’s not that expensive.  It especially is good because it helps get the testosterone to be made by the patient themselves, so it stimulates their own testicle production so you’re not taking over completely the testosterone by putting it in either injecting it or topically. You’re just kind of fooling the pituitary gland into telling the testicles to make more testosterone.

Dr. Weitz:            Yeah. Dr. Elkin who’s in my office on Tuesdays, he’s an integrative cardiologist, he likes to use that in combination with HCG.

Dr. Spar:              Yeah. They work in a similar way, so it’s working on the level of the pituitary and hypothalamus. The other thing people don’t talk about when you use testosterone testicles shrink because you’re really taking over production. I don’t care with doctors say. You are taking over production unless you’re adding in HCG or clomiphene. As soon as the body senses you’re taking much higher doses of testosterone than you would make on your own, they’re like, all right we’re good. You’re just going to handle it through the shot or the topical. And the testicles stop producing and do shrink. That’s a concern for a lot of guys.

Dr. Weitz:            Over a period of time if men stay on that they may lose the ability to product their own testosterone, right?

Dr. Spar:              I don’t know if that’s true. I don’t think we know that.

Dr. Weitz:            I know it’s the case with former body builders because I used to treat a lot of these guys, and that was pretty common. They would take them in crazy excessive amounts.

Dr. Spar:              Right. Yeah, definitely if you’re using high doses like that. If you’re using just kind of therapeutic doses, I don’t know because the reality is guys are guys, right? No offense. They don’t use it all the time. Even guys on it for years are missing a lot of doses that are going on. They run out. They forgot how they felt off of it, so then they stop. It really ends up not being an issue. Most guys are not on it day in and day out for years unless they’re like you said body builders or something.

Dr. Weitz:            Do you use PSA to screen for prostate problems? I just recently had a physical with my primary care doctor, and he said, “I don’t believe in PSA anymore.”

Dr. Spar:              Yeah. No, I definitely do if they’re on testosterone. You have to. I do believe in annual exams.

Dr. Weitz:            But even if they’re not?

Dr. Spar:              Yeah. I mean, it’s really important. I mean, we know testosterone treatment does not increase risk for prostate cancer. That’s been proven. Abraham Morgantelar from NYU or Columbia proved that. If somebody gets prostate cancer, you don’t want to keep giving them testosterone. Yeah, I do screen for it with PSA. You know, in the other patients it’s tough. I will have the discussion. Basically I always do a digital exam and feel the prostate. If it’s enlarged, I will check it. I usually try and also check a free PSA. I think on one hand, yes, it’s like what do you do if the PSA is elevated. Half the time it’s just causing stress and worry, and it’s nothing, but the good thing is nowadays most men have access to a prostate MRI. That can really make the need to jump from a high PSA to biopsy much less likely.  They can instead have an MRI if the PSA is a little high, and if the MRI is fine, they don’t need to have the biopsy. If the MRI is not fine, they know exactly where to go for the biopsy so they’re not just doing a ton of random punches. The MRI helps me feel better about ordering a PSA.

Dr. Weitz:            Unfortunately, once again, we have another situation where you’ve got a procedure that’s not always covered by insurance.

Dr. Spar:              Right, right. Usually if the PSA is over 4, at least in my patients who are mostly PPO kind of insured, they’ve had it covered. Sometimes you have to go through the urologists, but usually they can get it covered.

Dr. Weitz:            Right. I think the big issue with the PSA test is that men who have positive PSA who show elevated PSA levels sometimes jump to biopsy and then just jump to surgery and then have a lot of side effects when maybe it was a slow growing prostate cancer that they could’ve monitored for years without any problems.

Dr. Spar:              Exactly. It’s heartbreaking. It really is. We’re trying to figure out. We need better tests to know which ones are just there and will never cause problems and which ones are scary.

Dr. Weitz:            Yeah. I think we’re doing a disservice though to not do the PSA. We just need to make sure that when they get it that they don’t panic and rush out and get a procedure that can cause incontinence and impotency when they might not need it.

Dr. Spar:              Right. Exactly. Yep. The free PSA even if there’s not access to the MRI it’s a little bit helpful. It kind of breaks out if someone has an elevated PSA into the percentage that is what’s called free, and that correlates with the likelihood that that elevated PSA is just enlarged prostate versus cancer.

Dr. Weitz:            Right. I think those are most of the questions that I had. Is there any other issue you’d like to raise?

Dr. Spar:              No, not really. I think it’s just important for listeners to know that, number one, there are ways to help men make behavior change, and I think it’s really, really important whether you’re a practitioner or patient to do that. It’s Movember right now. I’m not sure when this is going to air, but this is men’s health month. It’s literally life and death. I mean, it sounds like a hyperbole, but men are dying because they’re not resonating with the message you are giving. I just encourage listeners to really think about one step at a time. Don’t talk about big global prevention messages. Talk about one thing you or your patient can do to decrease the risk of getting some kind of problem. Make sure they understand how it affects something they’re concerned about. Make it goal oriented.

My whole tag line is when you’re healthy you can win. When you’re not healthy, there’s that saying, I forgot who said it. Somebody who is healthy has a thousand dreams. Somebody who’s unhealthy has one. That’s really something to think about.

Dr. Weitz:            That’s great. That’s a great note to end on. How can listeners get a hold of you and find out about what you offer?

Dr. Spar:               Sure. My website and blog and everything is at drspar.com. D-R-S-P-A-R dot com, and then the program I have for optimal men’s health is called Tack180, T-A-C-K 1-8-0, so Tack180.com. Really, I encourage you to sign up for my newsletter. It’s very brief. It’s once a week, just three nuggets of information that are germane to men’s health, and you can sign onto that right on the website.

Dr. Weitz:            That’s great. I’ll put links to that in the show notes. Thank you, Miles.

Dr. Spar:               Thank you. Appreciate it. It was a pleasure.

Dr. Weitz:            Yeah, excellent.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Breathing with Emma Ferris: Rational Wellness Podcast 82
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Emma Ferris discusses proper breathing with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

5:20  Most of us come out as belly breathing babies, but then either trauma or infections or stress lead to bad breathing habits that we get stuck with.  So then we need to retrain these people to use proper breathing techniques. 

6:17  Emma explains that when you feel stress, your sympathetic nervous system takes over and results in faster, shallower breathing through our mouth, rather than slower, deeper, belly breathing.  This shallow, fast breathing tends to recruit our neck muscles, like our scalenes, SCMs, and our upper trapezius muscles and can contribute to neck pain.  We should be using our diaphragm as our primary breathing muscle.  Activating our diaphragm helps to support our back. Taking a longer exhale will tend to activate the parasympathetic system, that teaches the body that it can go into the rest, digest, and recovery mode.

10:11 When you’re breathing too fast, you breath out too much carbon dioxide and your blood chemistry shifts, making your body more alkaline.  When your body becomes more alkaline, you get more anxious and you may have trouble sleeping.  This reduces blood flow to the brain and also to the fingers and toes. 

13:45  The importance of deep, belly breathing is that you use your diaphragm to breath. If you breath fast and shallow through your chest, you’ll end with tightness and trigger points in your scalene, SCM, upper trapezius and your other neck muscles. Your diaphragm on the other hand has several roles, including respiration, speech, and stability. Using your diaphragm helps to stabilize your lower back by building up the intra-abdominal pressure. Manual therapy and chiropractic manipulation can be helpful for reducing trigger points in these neck muscles, the ribcage, and the diaphragm. 

18:40  When you are in sympathetic, stress mode it tends to shut down three systems in the body: 1. Hormones, which results in more infertility, 2. Immune system, so you tend to get more colds and flus, etc., 3. Digestion, so IBS is more common. If you are running away from a lion, it is no time for digestion.  This is a result of our inability to handle stress. Breathing is a strategy that can help.

29:30  When Emma works with athletes she will often have them use a device called a PowerBreathe, which is an inspiratory muscle training device. It is like dumbbells for your diaphragm and it makes it harder to take a breath in.

 

 



Emma Ferris is a physical therapist and acupuncturist from New Zealand who created an online breathing hub called The Butterfly Effect and The Big Exhale breathing course to help patients recover from dysfunctional breathing patterns.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

Podcast Transcripts

Dr. Weitz:                            This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube and sign up for my free eBook on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello Rational Wellness Podcasters, Dr. Ben Weitz here. Thank you so much for joining me again today. For those of you who are enjoying listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and reviews, so more people can find out about the Rational Wellness Podcast.

Our topic for today is breathing. How important is breathing, what proper breathing is, why breathing properly is important for our health, and how improper breathing can lead to the following health consequences: neck and back pain, the inability to recover from injuries, fatigue, depression and anxiety, stress, concentration and memory problems, reduced performance for athletes and the inability to work through emotional trauma or grief.  While there are a large number of different breathing techniques out there, especially when you start looking at all the different forms of breathing coming out of the yoga tradition, but when it comes to the more therapeutic forms of breathing, breathing through your nose and deep, slow belly breathing, rapid and shallow rapid mouth breathing seemed to be two of the more important concepts I’ve come across.

Today, our special guest is Emma Ferris. She’s an acupuncturist, a Pilates instructor, a registered physio therapist, and a public speaker, and she’s joining us all the way from New Zealand. Emma created an online breathing hub called the Butterfly Effect, and she offers the Big Exhale Breathing Course to help patients recover from dysfunctional breathing patterns. Emma, thanks so much for joining us today.

Emma Ferris:                      Thank you Ben for having me.

Dr. Weitz:                            Good. So, can you explain how you became so interested in breathing as a form of therapy?

Emma Ferris:                      Well, breathing kept coming up in my life with my experiences, both with my patients as a physical therapist, but my first exposure to learning about breathing was when I was around 12 years old. I struggled with a speech impediment and a stutter. And so for me, I started at a very early age getting some speech and drama and therapy for that. And, one of the most important things for that was learning to breathe. I particularly learned to breathe into my belly. So I learned that, but I never connected the dots as I went through my physical therapy training; we often put things in silos, which they often do in medicine and healthcare. Cardio, respiratory was over here, and neuro or the brain work was over here, and then muscular, which I was really fascinated with by fixing necks, back pain, all that sort of stuff; that was what I loved.

But, what really changed for me was the patients that I couldn’t fix, and it frustrated with me. You know, the neck pain and back pain that kept coming back. People that struggled with the multiple symptoms that when with it, the fatigue, anxiety, the poor sleep, and I guess in my training and in my life experiences, it wasn’t really explained how key that was until I began to dig a bit deeper and look at what the underlying causes and what the wires, and that’s obviously what you’re all about here too, Ben, is finding out what the why behind people getting to that place of dysfunction.

So, definitely in my patients, it began to show up for me. Then, I had my own life crisis when I was around 28 when I got pregnant with a condition called hyperthermesthesia. So, it’s extreme morning sickness. I realized that all the things I’d done before that point with my life; I had a busy physio practice, I was teaching, I was running workshops, and my body was running on empty before I even started to carry this little baby, little human being. I ate okay. I did a bit of exercise, but the reality was that’s not good enough, and my nervous system was just shot.  So, I learned then that what I’d been doing beforehand wasn’t good enough, and so I went into this process of researching and trying to formulate my own thesis, and I became a bit of a mongrel with breathing. So, I got all these different ideas from yoga and Pilates and Butyeko and Greycliff breathing, all these different versions. And, what really stuck with me for learning about breathing was it’s actually the story about why we connect with every person, why that’s important and why breathing as it makes a difference, but the reason they got here in the first place. You know, what was the stress and trauma, what was the environment that got them to learn to need to change?

And, I think that’s so important because most of us come out breathing like babies that are beautiful belly glorious breathing. So, we don’t come out sometimes when people don’t come out screaming and yelling and appraising very well, but most of the time we’re naturally belly breathers. So, things happened along that process, whether it’s trauma, illness, infections, stress, and then the habit gets stuck, and so I’m all about looking at the why, but retaining the habit and looking at the science behind it and the muscles because it, as a physical therapist, that’s what I treat a lot of, you know, motor patterns, dysfunction, and that actually has a huge trouble with breathing retraining. Yeah.

Dr. Weitz:                           So, that’s interesting. So, we start out as mouth breathers. Is that what you said?

Emma Ferris:                      No, we start as nose breathers.

Dr. Weitz:                           Oh, okay.

Emma Ferris:                      But, belly breathing. Sorry, so we start out as beautiful, slow belly breathing. Watch a baby sleep. It’s just glorious. And, they do it so naturally.

Dr. Weitz:                           Right. So, can you go into some of the details about what’s proper breathing is and, and why is it so important to breathe through your nose rather than your mouth?

Emma Ferris:                      Yep. Well, I’ll go into the nose and the mouth breathing constantly mistaken, but a lot of it’s all about the reaction to stress and how our body’s nervous system gets overridden with breathing. So, breathing is both under conscious and unconscious control. And, that’s a really powerful point because we have the power to actually override our autonomic nervous system, which more often than not gets pushed with our busy modern day lives or the stresses we have in it, and that changes us to push into what we call your sympathetic nervous system, much of which I know you’ve talked about before on the podcast, and the reaction to stress, whatever it is, whether it’s past, present or future, drives us to change our breathing. So, if you imagine that lions are chasing us, we take a big breath in, we inhale, and we use our neck and shoulder muscles.  We prepare our hip flexor muscles that like to get us out of danger, and we use those muscles to mobilize and get more air in. Now, that’s really important for that stress with danger that’s coming after us, but if that danger is a relationship issue or a problem with somebody at work or you’ve had back and neck pain for a long time, and even the thought process behind that keeps you stuck in that space of going, oh, this is dangerous. I’m sore. I’m going to get sore if I do this. In a response to a dangerous activates that fierce into our brain to trigger that reaction, and so the problem is we get stuck in that cycle, and one of the main things that changed is our breathing. So, we become faster or begin to breathe through our mouth because that’s a fast way of getting air in and getting more oxygen. which again is important for exercise, in and times of stress, to get us out of danger, but not all the time. So, as learning why we use it, people say to me, “Should we be using our nose all the time?” And, it’s like, well no, that’s not practical because when you walk up a hill, your body’s going to need to get more oxygen in, so you need to be able to go to mouth, but it’s as soon as possible going back to that nose breathing and reconnecting with it.

So, the reason why the nose is important is because it’s got two holes versus one for the mouth, and so it slows the air down. Like, it’s simple concepts, but if you can use that, it slows the air down, which is really important for your diaphragm, and the diaphragm is your main breathing muscle, and that sits between your rib cage and your stomach, so to say, and your lungs, and learning to use your diaphragm in the right way is really what for me, changes people’s perception and understanding of breathing, so it’s not about taking big breaths, and that’s the content I want people to be aware of as well.  When you say take a big breath, it’ll calm you, that doesn’t actually work always. That can actually stimulate you more. So, for me, it’s about low, slow belly breathing and long exhale, which is why my program is called the big exhale, so then you need to get out of that fight or flight inhale mode and learning to drop the chest down, and that’s really important for neck and back pain, which we can talk about it a bit more later on.

Dr. Weitz:                           Why is it more important to have a longer exhale?

Emma Ferris:                      Well, that’s one of the easiest ways to activate that parasympathetic nervous system, so activating that teaches the body that it can go into that rest, digest, and recovery mode. And, that’s why in Yoga and pranayama and all the techniques like Tai Chi work on lengthening the exhale, free diving, Pilates, meditation; naturally they’re getting your comps of your breathing, which is activating that parasympathetic nervous system.  That’s why people feel good doing those activities that you don’t always know why. So, and the other reason is that we’re not meant to be driven into that fight or flight response. And, we do, when our blood chemistry changes over time, when we’re breathing too fast. And, I know you’ve talked about this before with Rosalba Courtney, who I’m a really big fan of; she’s a wonderful breathing teacher around the world, an osteopath from Australia. Now, the blood chemistry shifts when you’re breathing too fast. What it does is your, by breathing out too much carbon dioxide, which is way more important than oxygen, you end up increasing your pH and making it more alkaline. So, over time that if your body stays in that state, it thinks that that’s normal, that new level of CO2 balance is what you’re supposed to go to and keeps you driven physiologically to breathe in that vast state.

So learning to lengthen your exhale also overrides that new level of normal or what you think is normal, and that’s really important for anxiety, patients who struggle with anxiety, with a shortness of breath and a suffocation response. And, so a lot of the techniques that are out there are great, like Butyeko, which gets you to lengthen your exhale to increase that CO2 liberal response, so that your brain goes, okay, I can now hold for longer. I don’t feel that fear and danger response of suffocation, which means I need to take a big breath in and gets you stuck on the inhale mode.

Dr. Weitz:                            Most of us think that the whole purpose of breathing is just to get oxygen. So, can you talk about why getting enough carbon dioxide is important?

Emma Ferris:                      Well, CO2 has a really big impact onto both the pH, like I say, because it actually shifts the … By breathing out too much CO2, you shift the pH, and then your body’s going to try and replace that acidic component, and it’s going to start leaking bicarbonate into the blood. So it has a bit of a knock-on effect and disseminates systems. One of the other impacts is the brain, so when you change that pH and the CO2 depletes, you actually reduce the blood flow to the brain, which is why there’s a connection with memory and concentration, brain fog, or whatever you want to call it, processing and cognition, and for learning, that’s a really important part for children and for adults. And, one of the things that I find really powerful was when people get stuck in that fastest stressed breathing and our habits contribute to that, like caffeine or alcohol that can shift our breathing. But, stimulants we don’t realize then that our body will be shifting its blood chemistry, and it takes a while to recover. And, even those habits and stimulants can actually then create a shift in the blood chemistry, which then creates more anxiety and other components of poor sleep that gets you stuck in that cycle.

So, the pH is pretty powerful. One of the other things is it actually causes, with that shift in pH, your blood is going to go from our limbs and our extremities because we don’t, we’re not worrying about feeding the blood into the limbs and the hands when you are in that stressed state, and this is important for athletes as well, so it’s going to divert blood flow to areas that need it, like our organs. And, so we can get cold fingers and toes. This is one of the signs of breathing dysfunction. I get tingling in fingers and as well. And, so there’s a change even in blood flow and our brain and our organs. We just divert things around because of that physiological push.

Dr. Weitz:                            What’s the importance of deep belly breathing as opposed to, I guess more shallow chest breathing?

Emma Ferris:                      Yeah, one thing is that as changing the right breathing muscles to work, so most of the breathing, like 70 to 80 percent of our breathing should come from our diaphragm, our big belly breathing muscle. So, what happens when you’re stressed and you start to use the inhale?  You’ll get stuck with what we call breath stacking, where you breathe in and you hold, and then you might do that a little bit, but then your brain goes, oh, I feel like I’m suffocating. I’ll take another breath in. Then, you get stuck in that mode and using our backup breathing muscles and what I call your parachute reserve.  And these are your neck muscles, your scalenes on the side of your neck, your sternocleidomastoid from the front of your neck all back up into your head and your skull down into your sternum and your upper traps, those muscles that get really sore and tight on the back of your shoulder.

Now, we’ve seen them all the time. Clinically, I know you do too, Ben, with our patients. I gave you a cue there, and this is a really important point because we’re using those muscles between, depending on your breathing, that breathing frequency between 17,000 and 210,00 times a day, the amount of breaths we take. So, if you’re using the wrong muscles in the first place, you’re going to cause more trigger points, those achy, knotty spots that can become active and referred to be trigger point index or trigger front for zero down the arms. So, that’s one of the main ones is that you’re actually using the wrong muscle all the time, and it’s like a reverse drug when you start using the top part and not the bottom part. So, teaching them how to use the diaphragm is really important, but also what I talk about is 360 degree breathing.  So that diaphragm has attachments right from the front of your stomach all the way around the ribs down the sides because it’s like a dome and all the way into your lower back into by your L1, L2, your lower vertebrate, and your hip flexor, your fight or flight stress muscle, and it has that neural connection through the ear, which is pretty powerful. So, learning to activate the diaphragm is really important for both intraabdominal pressure, and there’s a lot of research now looking at diaphragm function and dysfunction with back pain, and when someone has an episode of back pain, one of the first things we’re going to do is inhale and protect, and they actually lose that activation of the diaphragm, which actually is needed to actually stabilize. So, you get in this vicious cycle because of not breathing right, and they create more trigger points because the physiologic physiology changes, and then they also feel more stressed and anxious about being in pain. And, so when I go to bend or twist, they go, “This is how I injured my back last time; I’d better protect.”

So, from the point of view of the diaphragm, it has several roles: respiration’s king, speech is queen. And, I guess the next one is stability. So, if you’re walking up a hill, first thing that’s going to go is stability. You start to not stabilize very well. And, then you speak each, and then respiration. So, that’s always going to be the key thing. So, you start to recruit from other muscles. So, it’s really important to look at that role of diaphragm, but to understand that it actually, it’s a one way muscle, and that only works on the inhale, and then if you learn to lengthen your exhale and relax as a diaphragm recoils back up, then you can activate that parasympathetic nervous system.  But, a lot of time, when I’m looking at people that have been training yoga or training other techniques, they’re actually forcing the air out and causing that CO2 balance to actually be shifted just by the way they’re breathing, so a lot of it’s just conscious retraining and moments.  You know, I had to lie down for 20 minutes. It can be I’m going to stop right now on my drive around LA or New Zealand and just cause an exhale. You know, simple things add up.

Dr. Weitz:                            You’ve refined restrictions in the diaphragm and have to use manual techniques to free those up. Yeah.

Emma Ferris:                      Absolutely, and, all of those breathing, so scalenes, verse ribs, upper traps, and I use a lot of dry needling or I think … What do you guys call it over there? Trigger point needling, and that’s really effective for releasing the result of the poor breathing pattern, but unless you change the breathing pattern, the driver on the why it comes back. So I love the manual therapy for that.

Dr. Weitz:                            Yeah. We find chiropractic manipulation also beneficial in those cases as well.

Emma Ferris:                      And, particularly for thoracic because if you’re not getting thoracic mobility and ribcage, you’re not going to get that lower stability. So, I 100 percent agree because that also goes into that parasympathetic loop, automatic nervous system.

Dr. Weitz:                            Yeah.

Emma Ferris:                      So I love manual therapy. There’s so many ways of getting somebody into a calm state. That’s why I love acupuncture as well to go look, what is the right formula for a person in front of you?

Dr. Weitz:                            Yeah. One of the things, one of the conditions we didn’t talk about or I didn’t mention, which comes to mind when you talk about rest and digest, is IBS or CBO, and I could see how breathing be really super important for those patients because if they’re always in this sympathetic mode, they’re never going to properly digest their food, and it’s going to increase all their digestive symptoms.

Emma Ferris:                      Absolutely, and the same stress mode … If you’re stacking stress on that sympathetic thing, they usually change the bacteria in your stomach in the first place. So, one of the great things with learning to use a diaphragm and is that you’re actually going to pop through, you get the empty stomachs to actually work in the right way, get the blood flow, and when you are in a stressed state, blood flow is diverted from your bowel and your stomach because when you’re running away from that lion, you’re not worried about processing food. There are three areas that get shut down hormones, so particularly females, and we’re seeing that a lot with infertility problems these days, but that cycle and upset from that by being stuck into the sympathetic drive and immunity, so we get colds and flues, we’re rundown, or we’re stressed and particularly the digestive system.

So, there’s so many more problems these days all because of our inability to manage stress, and that comes in so many forms, and there’s a lot of pressures and by society that drives us, and I just think as the more that we can get this understanding out because people are hungry. There’s a groundswell of looking at techniques that are focused on holistic treatments like the manual therapy, like acupuncture, like yoga, because it makes you feel good in a way that is not a pill in a bottle. It’s very hard to override that nervous system.

Dr. Weitz:                            Yeah. When it comes to nose breathing, when I talked to clients there’re so many people that have problems with allergies and with you know, issues not being able to breathe properly. How do you deal with some of those issues if you’re trying to get them to breathe through their nose, and their sinus passages are partially clogged, or they have deviated septum, or they have allergies, or they have, you know, some of these chronic respiratory problems?

Emma Ferris:                      They’re huge problems, and that can be the driver in the first place for getting stuck in the habits, but then also that habit of mouth breathing gets them stuck with the sinus problems as well because they’re not actually using that nose as a filter and keeping the blood flow through there. So, it’s really problem solving for the individual. And, so one of my first steps for someone struggling, getting them back to the doctor and check for any polyps and any problems in teeth. And, then there’s simple things that you can do, like sinus rinses for instance. Have you done them, Ben, a sinus rinse?

Dr. Weitz:                            Yeah.

Emma Ferris:                      People don’t always like them, but they’re so satisfied, and that’s a really good way of cleaning out the nose and allowing it to get that filter through. And, one of them is learning to breathe through both nostrils because you actually switch nostrils through the day that you break through. Do you know that?

Dr. Weitz:                            No.

Emma Ferris:                      So, every one to four hours, you’re switching nostrils, so one side becomes the one you’re breathing through. And, the other side is the cleaning system. So, if you have one side that is actually blocked, you have a deviated septum, then even in your sleep, you’ll be switching through the mouth breathing because you’re short of air. So, getting that correct is very important, and during those steps, before you try anything like mouth taping, because that’s not for everybody. You’ve got to check people’s saturation and stuff as well, but you know, I use it myself. I use it on different patients, and it’s very successful. So again, it’s not a one size fits all model for nose breathing but learning to-

Dr. Weitz:                            How do you decide when somebody, when it’s appropriate for somebody to do mouth taping, and can you explain what mouth taping is? This is where you use special tape to shut your mouth while you’re sleeping, right? To keep it closed.

Emma Ferris:                      Yeah, absolutely, and you don’t need to have much on it because a lot of people can even open your mouth. People go, “Oh, that feels really scary. I don’t like the idea of that.” And, it’s always a bit of a jug of patients, you know, they keep them quiet, and I said, look, you can say goodnight to your partner and husband then rollover and then take your mouth up. I have to see it, but it’s actually really effective in getting that diaphragm to actually activate when you’re sleeping in the first place instead of going to that mouth breathing, but really what people got to think about is … I’ll come back to nose taping in a second, but you’re breathing at night is a consequence of what you’ve been doing with your habits in the day. So, if you have been caffeinated, if you have, which is very strong culture we have, and you’ve been pushing your body hard and driving it hard, and you’re basically running a marathon through the day with your breathing, then when you go to sleep, your body’s not going to go, oh, I’m going to go calm and relax. It’s going to go really fast, be fast, be fast. And, so you’re not going to sleep well; you’re not gonna get into that nice delta wave when you’re sleeping. You’re gonna keep that mouth breathing.

So, taping is again as dependent on to make sure that people can breathe through here. So, I do a test to check that they can put like a knife or a spatula under there, and we can say if they’re breathing through both nostrils. I can check the nozzle sides. I usually get an EMT to check or a Dr. to check to make sure there’s no polyps or anything else, and we checked saturation as well, so make sure when you do practice, that’s a practice that before you go to sleep, have a lie down and see how that feels and that I get too anxious or short of breath with that and that saturation levels don’t drop down.  So, it’s kind of a looking at the why behind that person. It’s used really commonly, but again, don’t use it for just everybody. I have a lot of athletes because they have already been breathing too much mouth breathing too much in the daytime, and what they try, and they don’t realize that that’s still contributing to the recovery at night. And, so when they start doing that, they sleep in the muscles, at least teens. They don’t need as much magnesium, which is to relax muscles and help with recovery.

Dr. Weitz:                            Interesting. Can everybody change their breathing? Or, are some people just stuck with mouth breathing?

Emma Ferris:                      Well, there’s some physiological reasons which will be driving you to breath faster. And, so there could be. It’s really important to get checked out by your doctor. What we find is that breathing dysfunction is often the last thing that gets diagnosed, and for reasons like diabetes, that can be a real reason why you’re driving faster. I have a lot of patients. I work with a lot of people with Parkinson’s as well, and the anxiety behind that also drives you to breathe faster within the breathing faster drives you to have more anxiety. And, so that has low dopamine as a big part of it. So, there are some people that need even medical support to help shift and get them into a good space. Like, I don’t say that this is going to cure everybody, like there’s not a one size fits all model, but learning to use breathing as an adjunct like with asthma, it’s a really important part. It’s like 40 percent of people that are asthmatic also breathing dysfunction in them, so you can use breathing alongside your other tools into that you can wean off or get the support and work with the respiratory physio to help get that under control.

So, there’s lots of conditions that also benefit highly from training your breathing, become a conscious of it, but anybody can do it, and in regards to how long it takes, it depends how long you’ve been stuck in that fight or flight mode. And, I have a patient that I worked with recently or the last last year really, and he’s a good example of someone that he came into his doctor with several factors, not sleeping well. He’s 40. He was going through a cardiac experience. So, he went to the emergency room thinking he was having an anxiety … Sorry, having a cardiac, a heart attack, and he was getting tingling in fingers and arms, and so many symptoms, the body, stomach problems, erection dysfunction, which is also a sexual dysfunction can be also linked to breathing function because you’ve got to be able to get arousal both sympathetic and parasympathetic with your breathing. So that’s an important area to look at all aspects.

So this guy, because Dr Stefanie was very switched on and went, “I think your breathing’s part of it,” and sent them him to see me, and over three or four sessions, that stress dropped down dramatically, and it was a huge shift for him. And, so he’d basically been, the why behind it though was he was going through a huge a court case trying to get custody of his children through a big divorce, and that had been driven him, and he was really PTSD; he was posttraumatic stress given his marriage, struggling with balancing business and life, and it wasn’t until he got those tolls he can recover, but there was a lot more behind the scenes for that too with family experiences, and so you’ve got to dig deeper and not go there’s not just a habit. There was the driver and the why behind it.

And, when he started to see that his breathing pattern was actually linked to emotions, so when he came in, I’ll be like I, “Okay, so what’s the fear today, mate?” Because, he’d be out here and holding that upper chest, breathing in, and beholding and be like, “Okay, no, this is what’s happening in my life.” And, when we actually talked about and expressed it, it dropped away and belly breathing, they need to do actually to activate the diaphragm is also linked in with your emotions with happiness and joy. So, that’s one of the powerful things I find too is that it’s not just about breathe through your nose and breathe through your belly and actually has an impact on our emotions. And, the research for me that has changed it was a few years ago now, in 2011. It was a guy called Pierre Philpot, and he did this research study. And, I love it because for me, emotions is important in life; we connect; we interact with people. Relationships are huge. So, what it showed was he had this group A, and it looked at four emotions: sadness, joy, fear, and anger. And, he asked that first group to think of those emotions and then look at their breathing patterns.  And, each emotion had a separate breathing pattern. So, I look at it clinically; we see that fear and anger is upper chest breathing. We see. Sorry, fear is upper chest breathing, anger as bracing and holding through our stomachs and obliques, which has a big impact onto a stomach and digestive system. Sadness is often that depressive, a posture that slumped down teenagers, posture that impacts, again, the way we breathe. And so, and the joy breathing is that belly breathing opening up into their stomach. So, what he found in the other group, group b, who knew nothing about group a, once he said, “Breathe in these four patterns, and then what emotion do you feel? The top summary of it.” And it was either the joy, sadness, fear, or anger. So, we have the power to change our emotions by the way we breathe, and we have the power to change our breathing by the way, our emotions, which is why coming back to the simple practices like gratitude, which, you know, hard to put the science behind that, but it’s getting there, you know, and mindset and our shifts behind that has a huge physiological impact onto our body and the way that we breathe in and breathing has a huge impact onto the way we sleep, the way we play, they way we love. That’s huge.

Dr. Weitz:                            Cool. So, you work with people in a one on one basis as well as offering group classes, right?

Emma Ferris:                      Yes, absolutely.

Dr. Weitz:                            So, when you’re working with a professional athlete, how is that different and do have them try to breathe through their nose while they’re running or doing their athletic performance?

Emma Ferris:                      Yeah, so it depends on the athlete and what their sport is. Many athletes need to train specifically for what they’re doing, like swimmers and rowers and cyclists all have different aspects, and many of the sports that actually impact diaphragm position like rowing and cycling ’cause they’re bent forward have more breathing dysfunction in the first place, so they’ve got to work harder to control that, and that one is a high link with back pain and neck pain because of that, because they’re having to switch between. So, the reality is when I look at training somebody, it goes back to breathing pattern first. So, how are they breathing? Have they got the right control? Can I activate the diaphragm? And, you might have to train them for a while to get that right in the first place. Once you’ve got pattern right, then you go to strengthening, and I use a great device called a power breathe. Have you heard of that before?

Dr. Weitz:                            No.

Emma Ferris:                      So power breathe is a … So, I’ve talked about exhaling being really important in that first phase, it really is getting that long exhale and activating because if you can’t exhale, you can’t inhale. It sounds really silly again, but if you don’t get that diaphragm to lift up and exhale, you can actually get the power into it to actually get the right inhale into the base. So, for that second stage, particularly for athletes, though I do use this to people that got anxiety, neck pain, back pain, COPD problems as well. We use a device called power breathe and that is inspiratory muscle training. So, it’s training your diaphragm to actually be strong for the activity. And, it’s pretty powerful. It’s only the science behind it, the research shows 30 breaths twice a day using this inspiration master trainer is enough to get the same results as a … So, there was one research study that showed over six weeks, I think it was, four to six weeks later the research.  And, one group was using the inspiratory trainer, and the other group was using, was running 45 minutes five times a week, and they had the same changes in the respiratory function from doing the diaphragm strengthening. So, it’s, you know, it’s a lot, a lovely adjuncts to training for people because they can actually get really good changes in physiology because the diaphragm is getting thicker, and it also shows after six weeks of using that, that your diaphragm thickens up to around 13 percent, which is quite a lot for work-

Dr. Weitz:                            Well, how does this device work? Does it wrap around you or something like that?

Emma Ferris:                      I actually brought one from the clinic I was going to show, you know, it’s in your mouth, so you put in your mouth, and you’re going a quick breath into using a diaphragm and to get in there. So, it’s a quick, breath in, fast and hard. You’ve got to work at least 50 percent resistance to get the diaphragm. So, they learned from the research as well that you can’t go at like resistance training for like 30 percent on your one rep maximum isn’t actually enough to get the changes in your diaphragm strength. I think it needs to be that 50 percent to 60 percent mark, and so I teach people in the clinic that you can work at it to sort of feel what that energy is or that level is for you when you train it. There’s a company out of UK that’s created them, and there’s a wonderful respiratory physiologists, and she is Allison Connell I want to her say name is that’s loved a lot of this research, and there’s great research now even in New Zealand, physio, and Aukland is looking has led to the break of breathing at the diaphragm, changing the strengthening and the dysfunction that occurs, people with anxiety, with back pain, and looking at that under ultrasounds, which is pretty cool seeing those changes.

Dr. Weitz:                            I’ve seen people in the gym with these things, so it’s some sort of a mouthpiece. And what does it do exactly, makes it harder to get a breath in?

Emma Ferris:                      Absolutely. I mean it’s like breathing through lots of straws. So it kind of risk for respiratory through there, so it’s like dumbbells for your diaphragm. And, so if that’s targeting that breathing muscle, you still want the pattern to be right though. Some of the research I went and saw a respiratory researcher in Canada about two years ago who was researching the respiratory training with athletes. And, what they noticed was the pattern store. If you don’t breathe in the right pattern, all your training is the upper chest breathing muscles, and what he wants to do is that diaphragm, so it might mean you turn the resistance down, and you work on the pattern, but then that diaphragm strengthens to actually help pay for working in a high level when you go and run or when you go and lift something, it’s going to naturally activate and do its job, so it doesn’t fatigue faster. And, what I loved about the research there as well, another, I think it was in the UK, they looked at the blood flow and the limbs.  So, they’re looking at when you were doing your exercise and training. So, I think this is cycling athletes; they looked at the blood flow in your veins and the legs, and what they found is after six weeks of doing the the inspiratory master training with the power breath thing, it was a device they used, they reduced the … The blood flow stayed in the limbs for longer. So, what it showed was the body’s stress response was better. So, the body didn’t go all right, I can train harder, and then when I get fatigued I had to pull the blood in, and it could actually keep the blood and the limbs for longer, which is really important for athletes, for endurance and for training. So, lots of consequences with using something like that. 

Dr. Weitz:                            How do you tell if they’re using their diaphragm? Do you put your hand on their diaphragm?

Emma Ferris:                      Yeah, I’m very manual with that. So, very much feeling that, you can see it. You can get them to put hands on their chest while I’ve got one hand here, and they don’t all use a mirror, biofeedback in any way that you’ve got. Posture’s a huge part of that, so if you slumped down and then you’d try and breathe, your diaphragm is going to start recruiting somewhere else. If you lift up too much, you’re gonna use your upper chest. So, even teaching people when your choose is like good simple habits add up, and that’s like a modeler for me is small changes make a big impact with what we’re doing.

Dr. Weitz:                           We work a lot with posture, and that’s super important, and it goes hand in hand with the breathing.

Emma Ferris:                      Yeah, absolutely. So using that posturing, raising that with your breathing is a very powerful tool, and then add some credit to it that you’re doing really well.

Dr. Weitz:                           Great. So, any other final thoughts you want to have for our audience? I think we got some good information to help folks with their breathing.

Emma Ferris:                      I think my take-home and something that I really like people just to be aware of is just take a moment and enter the day as many times you can is just to exhale, and the one thing I can say is you can do it out the mouth just once. Do it for me now, Ben. Breathe out the mouth, go uh, noticing your chest drops down, so that’s like a little valve release, then go back to nose breathing, but that little we exhale just drops you bit more into that calm part of that nervous system that needs a bit of love and attention. So, do it when you had the kids, when something’s winding you up, when you’ve got a traffic, wherever you are. I don’t have much traffic in my small town in New Zealand where I live, but you never know in LA and around the world.

Dr. Weitz:                           Oh yeah, LA traffic is brutal all the time. Yep.

Emma Ferris:                      Take moments. Take moments and use it to change that breathing. And, when you think about that, a lot of conscious drop, see what emotion you can bring up. Can you create joy? Can you shift your mindset, which will then impact your nervous system? Okay, take power back.

Dr. Weitz:                           I’ll be using it on the drive home because I’ll be hitting the 4:00 traffic. And then I’m going to go vote after that. So, I’ll need some stress reduction there too.

Emma Ferris:                      And, the next few days, good luck in New York is all I can say.

Dr. Weitz:                           God help the world.

Emma Ferris:                      And, please help us out over here.

Dr. Weitz:                           So how can listeners get a hold of you and find out about your programs?

Emma Ferris:                      Well, there’s a few ways. I have my online breathing hub called thebutterflyeffect.online. So, if you go through or search the “big exhale” or my name “Emma Ferris.” I’m not related to Tim Ferriss. I’ve got only one s at the end of my name. You can find me there, and there’s lots of ways. I have a free online Pilates video, 15 minutes that you can do, which helps work through some of the stretches that I do because what I find is if you can’t get the neck muscles and chest muscles and the hip flexor to release in the breath flow dropdown. So, that’s the place to sign up and join in and watch that. I also have my online breathing course called the big exhale, and that’s a 30 day program, but you can do it over a whole year. And, the first five days of it are free, so if you want to sign up for the big exhale, you can do that. Or join me on a workshop, come to New Zealand’s, come on my retreats, or meet me around the world in Malaysia or wherever the next one’s gonna be I have tour retreats in the states, so I can fly over and change the way that we breathe in the states post election.

Dr. Weitz:                           Sounds good.

Emma Ferris:                      Yeah.

Dr. Weitz:                           Emma, I really enjoyed this.

Emma Ferris:                      Thank you. I appreciate you having me on.

Dr. Weitz:                           Okay. I’ll talk to you soon.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Autoimmune Gastritis as a cause of SIBO with Angela Pifer: Rational Wellness Podcast 81
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 Angela Pifer discusses how Hypochlorhydria can lead to SIBO and IBS with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

6:26  Low stomach acid or hypochlorhydria can result in Small Intestinal Bacterial Overgrowth (SIBO), which is the cause of IBS in the majority of cases.  Low stomach acid can be caused by chronic stress or hypothyroidism. There are pathogens that come into the digestive tract through your food and we need hydrochloric acid and a pH of 3 to kill such pathogens. Such acidity also signals gastric emptying, a release of digestive enzymes, and a release of bile, all of which help to reduce bacteria in the small intestine. And when it comes to treating SIBO, it is easy to just think that we have to kill the bacteria. However, to really fix the gut, we need to help reset and rebalance and reseed to cure SIBO and get someone to a negative breath test. 

12:17  There are certain symptoms that might make you suspect that your SIBO patient has low stomach acid, such as when they feel that food is just sitting there and does not move through their stomach normally of if they say that they’re not breaking down their food. You might also suspect low stomach acid if there are intact pieces of food in their stool or if they have peanut butter stool that is very sticky and requires multiple wipes. We can also look at a Spectracell Micronutrient test and look at nutritional deficiencies like iron or B12, which might be trending lower if they have low stomach acid.

13:38  Once you suspect a patient may have low stomach acid, Angela will rule out H. pylori as a cause and she recommends looking at the urea breath test for H. Pylori and she also likes to order a GI Effects stool test and include a stool H. pylori antigen test.  She finds that more sensitive than the blood antigen test for H. pylori.  Interestingly, if H. pylori grows in the antrum or lower portion of the stomach, H. pylori can cause increased hydrochoric acid production and ulcers.  But if the H. pylori grows in the fundus or upper portion of the stomach or in the body, or corpus, the areas where the parietal cells are that make the hydrochloric acid, it can lead to decreased acid production.  If there is chronic burping or you have any kind of burning or warmth in the stomach or a sense of fullness, we need to rule out H. Pylori.  If you suspect it is a chronic case of hypochlorhydria, then Angela will look at advanced markers, like anti-parietal cell or anti-intrinsic factor antibodies to see if it is a case of atrophic autoimmune gastritis. If there is no H. pylori, then we should see what can be done with diet, lifestyle, and supplements. If they are stressed and in sympathetic mode, then we need to work on stress reduction and this could include the Wim Hof breathing technique. 

18:55  When Gastroenterologists do an endoscopy and biopsy for H. Pylori they usually biopsy the antrum and the duodenum to look for celiac.  They will miss H. pylori in the fundus or the body of the stomach.

20:33  When it comes to Atrophic Gastritis, one cause is H. Pylori and the other cause is autoimmmune gastritis, in which you get antibody production against the parietal cells. We routinely check of celiac, despite the fact there is only a prevalence in the US of .5 to 1%, whereas autoimmune atrophic gastritis has a prevalence of 2 to 8% and we hardly ever screen for this and the rate is going up.  These parietal cells that produce stomach acid also produce intrinsic factor, which is required to absorb B12.  And if they are not making stomach acid, then they will not be breaking down their proteins to be able to absorb B12.  If you suspect a patient of having low stomach acid you can send them for a Heidelberg test.

27:26  When you are treating a patient who has low stomach acid because they have been on PPIs, Angela will work with their MD to slowly wean them off the PPIs.  Angela likes to add in bitters, like Bitters 9 or Bitters X from Quicksilver Scientific, to stimulate their own production of digestive enzymes and hydrochloric acid production. She has them use the Bitters X and do one or two pumps and hold it in their mouth for 90 seconds, swishing it around, before swallowing it.  She will also have them cook all their vegetables and eat smaller, more frequent meals, and chew their food three times more than they think they need to. She will also sometimes add digestive enzymes. She will have them use a little baking soda in water if they need to to take the edge off.

31:10  Angela treats autoimmune atrophic gastritis by treating both the gastritis and also by treating the underlying autoimmune condition.  We have to look for the triggers for the autoimmune condition, whether they are stress, environmental toxins, food sensitivities, etc. We need to treat the nutritional deficiencies that result, including vitamin B12 and iron.  They may initially need iron and B12 injections.  Such patients may need hydrochloric acid supplementation for life.

 

 



Angela Pifer is one of nation’s foremost Functional Medicine nutritionists in Seattle, Washington with a focus on Gastrointestinal Disorders like SIBO and IBS. Angela is known as the SIBO Guru. Her website is SIBO Gurushe has launched a gut prescription recipe site, Gut Rx Gurus and a FODMAP-free line of bone broths, Gut Rx Gurus Bone Broth.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

Podcast Transcripts

Dr. Weitz:                          This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to Rational Wellness Podcast on iTunes and YouTube, and sign up for my free e-book on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello Rational Wellness podcasters. Thank you so much for joining me again today. And for those of you who enjoy the Rational Wellness Podcast, please go to iTunes and give us a ratings and review so more people can find out about the Rational Wellness Podcast.

So on this episode of the Rational Wellness Podcast, we are going to focus on low stomach acid as a cause of SIBO. Small Intestinal Bacterial Overgrowth, abbreviated as SIBO, is the cause of irritable bowel syndrome in the majority of cases. While the large intestine or colon is lined with trillions and trillions of bacteria, the small intestine is relatively free of bacteria. This is because this is where most of the absorption of nutrients from our food occurs, and if there were a lot of bacteria lining the small intestine, it would interfere with that important function.

There are a number of mechanisms that prevent more than a small amount of bacteria from growing in the small intestine. These include the migrating motor complex, which are the peristaltic waves that occur when you haven’t eaten for more than three or four hours, when you hear your stomach gurgling. These help to sweep out any bacteria out of the small intestine. There’s also the GALT, or GI-Associated Lymphoid Tissue, which is the immune system that surrounds the digestive tract. This tends to remove pathogens that enter our body with the food. Then there is the hydrochloric acid secretion from the stomach, and this also serves to kill unnecessary bacteria as well as help us digest our protein. Bile, which is secreted by the liver and stored in the gall bladder, which not only helps us digest fat, but has an antiseptic function, and stands to scrub away bacteria from the small intestine. You also have digestive enzymes, which besides helping us digest our food, have an antimicrobial function. And then we also have the ileocecal valve, which is a protective barrier to stop bacteria from migrating from the colon back up into the small intestine.  When any of these processes and structures fail, it can facilitate the growth of SIBO. Today, we’re going to focus on what happens when you have inadequate amounts of hydrochloric acid produced by the stomach.

Our special guest is one of the nation’s foremost functional medicine nutritionists, Angela Pifer, who practices in Seattle, Washington. Angela specializes in treating patients with functional gastrointestinal disorders like SIBO and IBS, and she’s known as the SIBO guru. She lectures around the world on such topics, and has launched a gut prescription recipe site, Gut RX Gurus, and a FODMAP free line of bone broths, Gut RX Guru Bone Broth. Angela, thank you so much for taking time out of your busy schedule to speak to me and our listeners.

Angela Pifer:                      Thank you, Ben. Thanks for having me.

Dr. Weitz:                          Great. So how did you get interested in treating patients with gastrointestinal disorders?

Angela Pifer:                      Gosh, you know, I’ve been in practice about 13 years, and it was just out of the gate, the gut has always fascinated me. There was never anything else. It wasn’t even a thought, and I loved it. To me, there’s some other things going on with the body. We can look at the brain and everything, but we start with the gut in so many cases, don’t we? Like you know, how we’re digesting, how are bowel movements moving along, is digestion working from top down? Like we have to look at all of that to see how we can then support the body and the system with almost everything else. So it’s really kind of this hub, and working with people with functional or chronic gut presentations has always just fascinated me.  And honestly, I think that population as a whole, my lovely patients and anyone out there who’s listening who has a functional gut disorder being in that chronic state, they need help. They need support. They need hand-holding, and they really need someone to sometimes step in and be that hub between all their other specialists, because everyone seems to be going off in a different direction sometimes when they’re seeing different specialists, and to have somebody pull everything together is really really helpful.

Dr. Weitz:                          Yeah, absolutely. You know, if you deal with Functional Medicine, the gut has got to be one of the starting places for almost everything. I just saw a patient this week, and her big complaint is that she’s having unexplained seizures, one after the other, and she’d been to the neurologist and nobody could figure anything out. So we did some stool tests, and she’s got all kinds of things going on in her gut. You can’t even believe the things happening there. Layers and layers. And it turns out, she’s had all these gut symptoms which she was really sort of used to and not even complaining about, and now she’s doing so much better just by fixing her gut.

Angela Pifer:                      Yeah. And I say the word complacency with so much love and respect and empathy for a person, but I think they have this known sense of norm. “This is what I deal with day in and day out, this is just how it is,” and over time, they adapt to it.  Never liking it, but adapt to it, and it isn’t until you show them what it really feels like to not have to sit with that, it’s mind-blowing sometimes what they’ve had to deal with, right?

Dr. Weitz:                          Yeah, no, absolutely.

Angela Pifer:                      Yeah.

Dr. Weitz:                          Yeah, they don’t know what it’s like not to be constipated or not to have gas.

Angela Pifer:                      Yep. Yeah yeah.

Dr. Weitz:                          So can you explain how low stomach acid can be a cause of SIBO, which is the cause of IBS in a majority of cases?

Angela Pifer:                      Yeah, absolutely. So when we look at SIBO, we really have to always consider that SIBO is a secondary condition. It’s never a primary condition. It was set up because something else has happened, some other thing or things have happened. And so we have to try to get at the root of what is setting this up for the person. You know, SIBO needs to be addressed, but we have to look at everything else as well to fix that root cause. So SIBO doesn’t continue or come right back or be reoccurring because you’re not fixing the real correct thing here.  So one of the very big contributors can be low stomach acid.  Low stomach acid can be caused by a few different things.  Low stomach acid could be caused by really really really chronic stress, it could be caused by hypothyroidism as well.  So it’s this spiderweb of connections that we have to get in and try to figure out this root cause for people.  And we’re starting to look at low stomach acid, I mean this is, you know, it’s like not chewing your food. This is like a major component and stuck within the digestive tract, and if you can’t use low stomach acid to actually break your food down properly … And really the main thing is we’re talking about SIBO is to clear up pathogens that are coming in.  You know, we need that proper really acidic pH that’s under three pH to actually clear everything off, otherwise we’re just gonna get bombarded with things that we’re taking in by mouth multiple times a day.  We want that first step, it’s a really big line of protection there.

We also have to look at, we’ve got a pH at that acidity for a reason, and it signals gastric emptying properly, it signals the proper release bile, it signals the proper release of digestive enzymes. So as you were talking about in your intro, bile being needed as well to clear out the intestinal tract. We have a lot of conjugated bile with our intestinal tract. It actually acts as a detergent. And every time we eat some fat, your gall bladder goes squish squish. It’s like a stress ball, squish squish. And it’s gonna release some bile, and with that, that will help your emulsify your fats. Then it’s also coming through as a detergent and clearing out that small intestine. And it also happens in between meals, so it doesn’t just happen that you get a bile release with your meals, you also get it in between meals, and that’s gonna piggyback the migrating motor complex and those cleansing waves that come down.

So in your intro, I’m going to disagree just a little bit here because I think it plays into the conversation we have about what the heck to do with SIBO. I think if we start to compare the trillions of organisms that are in the large intestine, there’s so many massive amounts of organisms in the large intestine that when you look at the small intestine, it seems quite minuscule. And yet if we look at the small intestine just by itself, we’re looking at millions and upwards of billions of microorganisms per milliliter, per teaspoon of fluid. So it’s not sterile by any means, there’s lots of organisms there. But we also have forward-moving matter. Everything’s moving forward, it’s not hanging out like it does in the large intestine where everything hangs out there and ferments and we get all this beautiful relationship with our microbiota in that area. Things are moving through a lot faster, so we don’t get this big buildup of organisms in the small intestine. And we’ve got bile moving through, like there’s lots of mechanisms to help keep the organism load at a specific load.

When one of those mechanisms, or multiple mechanisms, goes wrong, of course, then we get a buildup. And then we get fermentation happening in the small intestine and lots of other things that could come with SIBO that’s quite debilitating, because that small intestine is not meant to stretch, and that causes a lot of pain. And we don’t get as much gas movement of course, out or just spilling across the intestinal lining.  So why I say that is so many people think SIBO, “I gotta kill it.” And we can’t Drano that small intestine, we want to look at this as a re-balancing. Really fixing the underlying issue, getting on the mechanisms and what’s going on there, but then re-balancing and just taking the person to that level. Not “kill kill kill,” and then stepping back, because that’s not gonna work either. We’ve got to help reset and re-balance and reseed, affect change with the immune system, and there’s so much that goes into play with this even once you get somebody to a negative breath test. There’s so much healing on the other side to make all this beautiful work that you’ve just done stick.

Dr. Weitz:                          Do you sort of use the four R or five R program as kind of a backbone of your approach?

Angela Pifer:                      Yeah, you know, I don’t. Not with SIBO specifically. There’s so many other things I do. I mean as we start to look at autoimmune and others, I know we’re gonna talk about an autoimmune condition as we talk here. But in terms of SIBO, I don’t … There’s so many beautiful things that that four R program does, and there’s bits and pieces filled in along the work that is done, that really it’s more, you know, stabilize the patient and whatever that means. We’ve gotta evoke change with the diet, oftentimes. We don’t always have to go drastically low, but we wanna adjust the diet to make sure they’re nourished, adjust it to how they’re digesting and absorbing, adjust it to make sure their symptoms are somewhat calmed down so they can hang out in this period of time as we treat properly, you know. So there’s a lot of change that happens with the diet.  And in terms of kind of that whole repletion, we’ve got to get on the other side of actually treating SIBO to get to that point where we can start to work on more of that reseeding of the gut, a lot of immunoregulatory support at that point. And it’s bits and pieces, but not the perfect four R.

Dr. Weitz:                          Okay. Sounds good. So when would you suspect low stomach acid as a cause for a patient with SIBO?

Angela Pifer:                      You know, I would say that I actually assess that with every patient. It kind of comes out of the gate when you’re doing the intake with the patient, and they start to talk about different symptoms that they have, 

Dr. Weitz:                          What symptoms would make you think about low stomach acid?

Angela Pifer:                      Yeah, absolutely. Food just feels like it’s just sitting there and not moving through their stomach.  A little bit bit of food makes them feel full fast.  It could be that we start to look at, you know, they’re not breaking down their food, they see a lot of intact pieces of food in the stool, or even peanut butter stool, I call it.  So it’s really sticky stool, it takes a lot of wipes.  They’re probably not breaking their proteins down, so then we would look back upstream and figure out what’s going on there, which low stomach acid is oftentimes a culprit at that point.  I would say what I see with a lot of patients is a lot of burping.  Food just feels like it’s a heavy weight in their stomach.  They need to space their food out because they don’t feel like they’re digesting at a quick enough clip that they can eat a little bit more consistently than that. And then as we step back and look at labs, you know, Spectracell and nutritional markers, we can look at different things to see if their iron is trending lower or B12 is trending lower, and we would see that if they have low stomach acid.

Dr. Weitz:                          Okay. Once you suspect that a patient has low stomach acid, how would you figure out what is causing the low stomach acid, whether it be a H. pylori infection or autoimmune-related or something else?

Angela Pifer:                      Yeah. I think we always are gonna start with the basics, I mean unless somebody presents with a really chronic case where they’ve had just chronic low B12 over time, I’m gonna start to step into some of those advance markers, looking for anti-parietal cell or anti-intrinsic factor antibodies to see if there’s actually something going on more as an autoimmune front.  But once we start to look at this, you know, how are they digesting their food, what is their diet presenting like, can we correct this with supplements, and then what is also going on in terms of their lifestyle?  If they’re, you know, really in a sympathetic state, we work a lot on stress reduction because a sympathetic state, being more stressed chronically over time, is really gonna drive digestive chemicals away from the digestion, from top-down. So there’s a lot of lifestyle effect that we can have as we start to see people move away from that. But really, and again, I say this with great love for the patient that is sitting there feeling like this is just … ‘Cause chronic presentation, and they deal with this all the time. Most people with functional gut disorders like this feed forward cycle, stress is always gonna contribute to that, but then once it’s present, they’re having to deal with these symptoms all the time. And so stress is almost always some sort of factor that’s adding to that, and so I think there’s a lot of … You know, I introduce people to the Wim Hof breathing method, I have them make sure they’re walking an hour a day …

Dr. Weitz:                          Wim Hof is when you take a cold shower?

Angela Pifer:                      No, Wim Hof is actually … So that’s more contrast hydrotherapy. Wim Hof is actually a breathing technique. You should look him up on YouTube, he’d be interesting to have on your podcast. I don’t even know if I’ll explain it correctly. It’s this beautiful way of actually really taking in almost this hyper amount of oxygen into your blood, and huge diaphragmatic breathing technique, and then you actually ride that out a little bit. But in terms of oxygenation and capacity, people aren’t using the full lung that they have, or lungs, and moving it up. And so it’s a really interesting breathing technique to get them to use that entire space and diaphragm. Yeah, it’s very very cool.  So yeah. So I think there’s a lot that we can do in terms of just the stress piece, you know, to really help people out. So as we’re starting to look at the low stomach acid piece, you know, we’ve gotta really listen to the patient, and SIBO is going to contribute. Once SIBO is set up in terms of … And where SIBO is at the small intestine. So the further SIBO is up, and the worse SIBO is with all those contributing factors, it can start to break down digestive enzymes in that brush border, uncoupled bile. It can really interfere with a lot of nutritional absorption that we’re doing in that area. So it just depends on the patient as we’re working on, to what degree we need to come in and do any kind of intervention at that point.

Dr. Weitz:                          So how would you rule out H. pylori?  What tests do you like to use for H. pylori?

Angela Pifer:                      Yeah. I actually prefer the breath test for H. Pylori.  I really do.  The urea breath test.

Dr. Weitz:                          Okay. Why is that?

Angela Pifer:                      That’s my favorite one. Oftentimes I want to see a GI Effects so I’ll add that on, as we look at a stool antigen for that.

Dr. Weitz:                          Yeah.

Angela Pifer:                      You know, if they’ve never been diagnosed with H. Pylori, then we’ll do a blood antigen, but I really like the breath test. I know there’s a like controversy on SIBO’s presence, sometimes you’ll get a false positive. I’ve not seen that line up.  And of course we have endoscopy, right, is where rather referring over to the GI doctor. But I think the urea breath test is really pretty straightforward to me. I think the antigen test with the stool antigen actually misses it a lot more than when we see that breath test.

Dr. Weitz:                          So the notes you sent me over before we did this podcast, it was really interesting that you talked about how if H. Pylori grows in one part of the stomach, it’s associated with increased hydrochloric acid. For those of you who aren’t aware, H. Pylori is often an undiagnosed cause of ulcers because you get this bacteria that burrows into the wall of the stomach, and then the stomach produces more and more acid to try and get rid of it, and so it can often be the true cause of ulcers. On the other hand, if that H. Pylori grows in another part of the stomach where the cells that make the hydrochloric acid are, it actually destroys those parietal cells, and you end up with less hydrochloric acid from H. Pylori.

Angela Pifer:                      Yeah. So you really can’t go off of … There’s some symptoms that are present that we need to investigate if H. Pylori is present. I mean to me, if any kind of burping, if they’re chronic burping, I think H. Pylori should be ruled out. But any kind of burning, any kind of warmth in the stomach, a really early sense of fullness, we really should be ruling out H. Pylori and stepping through the sequence from there.

Dr. Weitz:                          And you also mentioned in your notes that GI docs, when they do an endoscope, they’re often looking in at that part of the GI tract where H. Pylori leads to ulcers, but not the … What’s the other part of the stomach where …?

Angela Pifer:                      Yeah, so if you think about the stomach like a kidney bean, like up on it’s end, you’ve got the fundus is up top, the body is kind of in the middle, and then the antrum is on the bottom. When we start to look at parietal cells, which produce stomach acid, they’re in the fundus and the body, so in this upper two thirds part. And then in the bottom part is the antrum, and if you look on almost every single endoscopy, they’re doing biopsies on the antrum. They’re looking for H. Pylori, and they’re gonna miss if there’s an autoimmune issue with parietal cells. And they’re also doing biopsies in the duodenum to see if there’s celiac.  So I feel like, especially as we’re gonna get into it here, we really should be assessing the whole stomach and looking a little bit beyond this. But it’s interesting that even when recommended that, it doesn’t come back as the biopsy in that area. I think they’re just on … And I say it with great respect, they do things none of us can, but that’s just where they’re looking, and they’re not looking in the fundus or the body.

Dr. Weitz:                          Yeah, interesting. Yeah, you have to try to develop a relationship. There’s not many integrative GI docs around.

Angela Pifer:                      Yeah.

Dr. Weitz:                          Fortunately we have Dr. Rhabar in LA, so …

Angela Pifer:                      Yeah. Yeah, and Dr. Mullen. Yep.

Dr. Weitz:                          Yeah. Is he in LA?

Angela Pifer:                      No, Dr. Mullen, Jerry Mullen up in …

Dr. Weitz:                          Yeah yeah yeah yeah.

Angela Pifer:                      Yeah.

Dr. Weitz:                          Yeah. So let’s talk about autoimmune atrophic gastritis. What are some of the symptoms associated with that in particular, and how do we assess for that?

Angela Pifer:                      Yeah, absolutely. Well I think when we start to look at autoimmune, there’s a lot of conversation around the CDTB toxin and autoimmunity coming from that, and that being a cause of this IBS-C or SIBO.  What we have to look at is that’s definitely a percent, that can set SIBO up, but when we’re starting to look at the population that has low stomach acid and trying to get to the root of what’s going on with SIBO, there’s going to be a small percentage there that we really do have to have, you know, a keen eye on to see if any of those people have autoimmune atrophic gastritis.  And basically what that is is you’ve got some atrophy of the stomach, and you have gastritis, which is inflammation.  So we’ve got atrophy and inflammation, and then you’ve got this autoimmune involvement.  So atrophic gastritis, there’s two types.  One is caused by H. Pylori, and the other is autoimmune atrophic gastritis.  And so basically you’ve got the autoimmune involvement and you’ve got antibody production against the parietal cells.  And so as we start to tuck deeper into low stomach acid and its implications, when we start to look at autoimmune atrophic gastritis, this is everything that we’ve just talked about tenfold because this isn’t simply more stress induced or a bit of hyperthyroid pushed in in terms of setting that metabolic rate and how much stomach acid you’re producing, or you’ve got a zinc deficiency.  All of those can be recovered fairly easily, depending on the case.  But what we’re really talking about is an autoimmune connection here with low stomach acid.

I think to discuss this, we kind of have to talk first about prevalence, because I think it seems like kind of a foreign term, and yet when we start to look at prevalence, everyone’s pretty much heard about celiac.  Almost everything is screened for celiac, especially if there’s digestive stuff going on. So even as practitioners, we’re so quick to jump on that. But when we look at celiac disease, it’s .5 to 1% prevalence in the U.S.  Very, very small percent of people, and if you have it, it’s a very big deal.  But it’s a small percent of people, and yet, as practitioners, we’re fairly quick to rule that out.  When we look at autoimmune atrophic gastritis, we’re actually looking at a 2 to 8% prevalence.  So even if we just take the 2%, it’s 2 to 4 times more likely present than celiac.  And so we really have to kind of stand up and pay attention to this.

When we look at atrophic gastritis caused by H. Pylori, that’s actually going down in America because it’s being screened for.  But when we look at autoimmune atrophic gastritis, it’s going up. It’s starting to increase as are a lot of the autoimmune conditions, right?  People are becoming more susceptible, and we can have a whole ten shows over why we think that is, right?  But when we’re starting to look at the autoimmune atrophic gastritis, basically what we’re looking at is, we’ve got inflammation of the stomach, atrophy of the stomach, we see a breakdown of the parietal cells because you’re making antibodies against those.  And when we look at the parietal cells, those make stomach acid, and they also make intrinsic factor.  And intrinsic factor is what binds to your vitamin B12, and that coupling, as it moves through the intestines, is absorbed together.  If you’re not making intrinsic factor, you’re not gonna absorb your B12, and if you’re not making stomach acid, you’re not gonna break down your proteins to get to your B12 in the first place.

So as we start to look at this patient population … This isn’t everyone that needs to be screened for this, but we have to start to look at if there’s a chronic digestive presentation here. And we really want to start to key into this is if somebody’s taking massive handfuls of HCl Betaine and they’ve been doing that for a really long time or they don’t digest their food, this is something that we should be screening them for.  When we start to look at this, you know, we kind of have this …

Dr. Weitz:                          By the way, do you ever use that HCl challenge test as a way to screen for this?

Angela Pifer:                      You know, I don’t as a way to screen for this. I refer people over for the Heidelberg test if we’re suspecting low stomach acid, especially if I see them on this level of HCl Betaine.

Dr. Weitz:                          Okay.

Angela Pifer:                      I feel for a time, that was really working for me. So setting aside autoimmune atrophic gastritis, it was working for me in terms of getting people on a certain load, and it was making a difference, and then I feel like it just didn’t work as well anymore.

Dr. Weitz:                          Right. By the way, for people that aren’t aware of what we’re talking about, this is where you give a patient one HCl tablet taken before a meal, and then you give them two or take it after a meal, and then three, and you keep increasing it until they get a burning sensation, and then you back off.

Angela Pifer:                      Yeah. Or a warming sensation, but yes.

Dr. Weitz:                          Warming, yeah.

Angela Pifer:                      Yeah. So I’ve seen that work for some people. I’ve seen other people … A lot of times when people come to me, they’ve been to quite a few practitioners, and they’ve already done that test in the past, so you know, we just kind of learn from what they’ve already been working through.

Dr. Weitz:                          Yeah.

Angela Pifer:                      Yeah. So it’s pretty interesting. So I would just go off more symptoms of what we would expect. Again, you know, total protein’s low in a lab. You’ve got B12 that’s chronically low.  Iron is low with no really good cause for it, and when you’re recovering.  You know, they’re kind of the slight, not life-long, but say for the last few years at least this has kicked in at some point, they’ve been trending more towards meat, yeah, they’re not quite getting it recovered.

Dr. Weitz:                          What tests do you like for B12 and for iron?

Angela Pifer:                      I do serum B12. And then when we’re looking at iron, it’s just the full panel.  Serum, TIBC, saturation, ferritin.  And then of course looking at all the rest of the CBC, looking up, you know… 

Dr. Weitz:                          You don’t find the need to do like methylmalonic acid or homocysteine for B12 status?

Angela Pifer:                      I actually like both of those when looking at folate and B12.

Dr. Weitz:                          Okay.

Angela Pifer:                      Yes yes. I look a little bit more at that, and of course it depends on what I see in terms of supplementation that they’ve been on, you know, for a really long time. I’m also looking at that more for folate and B12 status, and methylating. Yeah.

Dr. Weitz:                          Okay, cool. So let’s talk about treating a patient with low stomach acid.  How do you approach that?

Angela Pifer:                      Yeah, absolutely.  Well I think low stomach acid and autoimmune atrophic gastritis are gonna be really two different things in terms of approaching that.

Dr. Weitz:                          Okay, so let’s start with a few different cases.  With somebody who’s got low stomach acid because they’ve been taking proton pump inhibitors for years, how do you handle that?

Angela Pifer:                      Yes, absolutely. So with their doctors approval for coming off of medication, of course, I actually will start to add in bitters. I’ll have them cook all their vegetables.  I’ll have them eat more frequent meals just to start, and then we’re really gonna work on stress management, setting the tone for the meal, and chewing their food three times more than they think they need to.  We might need to address fat load a bit, just depending on how well their gastric emptying is going.  We might need to adjust things that way.  I work a lot with that.  I love bitters, I love them.

Dr. Weitz:                          And bitters are designed to stimulate your own digestive enzymes and acid secretion, right?

Angela Pifer:                      Yeah, absolutely. Our food, I mean it’s kind of crazy to think about, even our broccoli and brussel sprouts are bred for sweetness.  All of like the bitterness, the different species within those, they’re all bred more sweet. We’re like setting aside anything that has more bitter because the masses don’t trend towards that, right, in terms of what we’re choosing at the supermarket.  So when we give somebody bitters, it literally is bitter.  Your mouth has these beautiful taste receptors back here that just light up when you give somebody bitters, and if you even think about it if you’ve done it, it makes your mouth water. Like it’s really stimulating digestion from the top down. So I have people … I like Quicksilver Scientific, their Bitters 9.

Dr. Weitz:                          Oh, okay.

Angela Pifer:                      And their Bitters X is fantastic, and I just have them do one or two pumps 15 minutes before a meal. They hold it in their mouth for 90 seconds, swishing it around, trying to get it to the back, and then they swallow. We’ve got bitter receptors in our stomach as well, so it’s wonderful. It’s a great way to kind of help stimulate digestion there.  In terms of digestive enzymes, one of my favorites is Panplex 2-Phase by Integrative Therapeutics.  It has a low-level digestive enzyme, low-level bio-support, and just a little bit of HCl Betaine.  So I think less is more.  I wanna kind of just start with these lower levels and work up from there.  So that’s my way to approach it.  I would try to set the tone for the meal, really look at your food, smell your food, think about where it came from, what it’s gonna taste like, put that first bite in your mouth and really set your fork down and taste it.  And to me, that sets the tone for the meal and really slows people down.

Dr. Weitz:                          When you’re weaning patients off of PPIs, you have to be careful about sort of a rebound, right?

Angela Pifer:                      Yeah, you do. You know, I’ve had really great luck again with, you know, Dr’s approval on this, and really great luck in weaning people off of proton pump inhibitors. There hasn’t really been a case that I haven’t been able to do because we set everything else up first, and then depending on the medication, we might be able to halve that medication, or we just start to slowly take that every other day. And I’ll always aim that around a weekend, because if you’ve ever really watched people’s food journals over the course of a week, like year after year like I have, you realize that hunger is much more increased during the week. Like there’s just more stress going on. So I start to wean them over a weekend, and you know, have just a little bit of baking soda on hand if they need to do like a half teaspoon of baking soda and water just to take the edge off. And then they have the medication. If something comes up, nobody is asking them to sit in misery with heartburn.  It’s usually pretty good. I think most people just try to stop cold turkey, and then they realize that didn’t go well, so they feel like they’re really chained to it. So you just have to work with them to get them set up.

Dr. Weitz:                          Okay. And then how do you treat patients with atrophic gastritis, and is it the same treatment if it’s autoimmune origin or H. Pylori?

Angela Pifer:                      Yeah, so atrophic gastritis is caused by H. Pylori, and so there’s some great treatments out there for H. Pylori. What we’re talking about is the autoimmune atrophic gastritis, and that’s gonna be more from an autoimmune perspective. So you know, just as if there’s autoimmune thyroid, you’re going to treat the thyroid, but you’re also going to treat the autoimmune condition. So with autoimmune atrophic gastritis, you’re going to treat the autoimmune condition in that you’ve got to work on the whole stress cycle with everybody, getting them sleeping well, calming down the body’s reason for ramping everything up and attacking.  You want to calm down and figure out triggers, you know, where triggers are coming from, whether it’s stress, environmental, internal in terms of food and all.

And then we really want to look at treating nutritional deficiencies, making sure that they’re recovering their B12, recovering their iron. So when we look at autoimmune atrophic gastritis, the vast majority of cases aren’t even diagnosed until they’re completely at this end stage of pernicious anemia, and that pernicious anemia is basically you’ve got anemia because you can’t absorb your vitamin B12, and you need B12 along the iron pathway.  And then you’ve got this autoimmune component causing this.  So pernicious anemia is also an autoimmune condition, but it’s this end stage of autoimmune atrophic gastritis.  So most people aren’t diagnosed ’til that point, so we want to catch them before that. We want to catch them when they consistently have B12 levels of under 500, that we see indications of pancreatic insufficiency.  So they’ve got this low stomach acid and signaling of the pancreas, you know, we don’t see that and that connection. We wanna look for vitamin B12 deficiency symptoms like peripheral neuropathy.  We want to look for even restless leg syndrome, which is strongly connected to this.  That you know, again, at that beginning they’re going to have poor gastric emptying, they’re gonna feel full, they’ve got this excessive burping, sometimes they feel a little nauseous ’cause food is sitting there, and all of this has been kind of chronically presenting.  We’ve got a store of iron in our system, you know, in our body. It isn’t until we really start to see this very big shift, and same thing with B12, this really big shift with this autoimmune attack. We don’t usually start to see this rear up for a good year and a half, two years, so we wanna catch this earlier on, and it might be that chronic presentation that we get to see that with.

So again, first rule out H. Pylori. Absolutely let’s rule that out, but then let’s start to look at, you know, do we start to see B12 levels dipping down? Which is kind of hard sometimes because everyone’s taking B12. And serum B12 is a really great indication that you’re taking good supplements sometimes, so maybe we need to take people off of things for a couple of weeks to get a better read on that serum level. But we wanna look at that, we want to investigate gastroparesis if that’s there, or again, if gastritis is present, we’re going to look for H. Pylori and then start to look at iron and B12 and start to recover those.

If somebody’s gotten to the point of pernicious anemia, they might need iron shots, they might need intramuscular B12 shots, you know, the supplementation may not do it. And this population of course is interesting because they’ve got lower stomach acid and poor signaling, and oftentimes they’re gonna have slower motility. So if you’re trying to recover iron on a consistent basis, you know, you can really slow things down more because iron can be quite constipating. And iron isn’t necessarily … It can be toxic to the colonocytes as well, so you know, sometimes iron shots are gonna be a better choice depending on that patient and what’s going on there.

Dr. Weitz:                          Interesting. And of course, trying to heal the gut as well, right?

Angela Pifer:                      Mm-hmm (affirmative). Absolutely, absolutely. I think that’s going to come with it, and I think that comes with a lot of conditions after as well.

Dr. Weitz:                          And those patients are going to need HCl supplementation probably for the rest of their lives, right?

Angela Pifer:                      They probably will, and you know, I think it’s again, if somebody has an autoimmune condition, we need to be able to tell them that they have an autoimmune condition, because autoimmune comes in pairs. And also, I would say that autoimmune, you know, as we start to look at this, we need to be able to say like there is a reason that you might need ongoing supplementation, in terms of HCl Betaine, in terms of B12 support, in terms of iron support. There’s a connection to be made there with the patient, because sometimes I think, you know, patients might go from practitioner to practitioner and they’ve got these long laundry lists of supplements, and we don’t know which are necessary and which aren’t. But if we’ve got an autoimmune condition set up for this, they’re going to need to really support their system long-term because of the autoimmune condition that’s present.  And the more stressed out they get from wherever this is coming at, the worse the autoimmune cycle can get. And then you get more degradation and targeting of those parietal cells which makes everything downstream worse. So the stress management piece can’t be talked about enough with this population, but then we also have to start to look at how else are we gonna support them, and they’re gonna need supplementation lifelong. They’re going to need it, like absolutely. So they need to know that and be able to connect with that because I think people can fall in and out of favor with supplements, or you know, “I don’t know if these are even doing anything for me” kind of thing. In this case, this is really something that needs to be looked at.

Dr. Weitz:                          So can you monitor those anti-parietal cell antibodies the way you monitor like TPO antibodies with patients with Hashimoto’s to see to what extent their autoimmune component is active, or?

Angela Pifer:                      Yeah. You really can, but I think we have to be careful to say, you know, parietal cell antibodies are at 82 and they go to 72, it doesn’t mean that they’re necessarily getting better. You know, antibodies are volatile. They don’t just go up a ladder and down a ladder depending on two things. If we are in a very stressful situation, we can see a shift there. If we are fighting off a cold, we can see a shift. If we …

Dr. Weitz:                          Right, but maybe are there bigger shifts? Like with TPO, you know, antibodies for thyroid, if they have 500 and it goes up to a thousand, that’s significant, or it’s 1,200 and it goes down to 150, you still have elevated antibodies, but that’s a significant shift, whereas if it goes from 100 to 400, maybe it’s insignificant.

Angela Pifer:                      I agree. I completely agree, yeah. When there’s 

Dr. Weitz:                          Is there a similar sort of range with the anti-parietal cells?

Angela Pifer:                      You know, I think it’s going to be based on the person and what we’re looking at with both of those and where they kind of fall into. I think as we start to look at the progression and how long this has been there for people and how advanced they are, they might not be able to get those fully recovered like we’d like.  But for the anti-parietal cells, the anti-intrinsic factor antibodies, you know, we’d look at both of those, and of course if there’s a positive test, we’re gonna refer over to a GI doc to get a biopsy. But in the right place, they’ve got to biopsy the fundus or the body of the stomach to be able to actually confirm that.

Dr. Weitz:                          Cool.  Okay, that’s good.  Very interesting information.  Thank you for informing us about a condition I think most patients and even a lot of practitioners are not aware of, which is autoimmune atrophic gastritis as a cause of low stomach acid leading to SIBO.

Angela Pifer:                      Yep.

Dr. Weitz:                          So how can listeners and practitioners get a hold of you if they want to contact you, sign up for your courses, get your bone broth?

Angela Pifer:                      Yeah, absolutely. So my practice site is siboguru.com, and I’d love to have everybody visit me there.  And then GutRxGurus.com is a beautiful collection of practitioners and chefs that are in the low-FODMAP realm. And there’s a SIBO-specific category in there, and everything is low-FODMAP.  And I’ll say it really quick, I don’t as a whole put every single person that’s ever even, you know, SIBO glaring, on a low-FODMAP diet, but there’s going to have to be some adjustments, and so to be able to have a recipe set that you can go to to really fill in the gaps and give people ideas … Because we’re so used to eating what we eat, and then when we can’t eat that anymore, it’s like chicken on a plate. Like what do you do? So it’s nice to be able to have all these beautiful recipes for sauces and sweets if you need them, and the foods just really tasty. So that’s a subscription site for recipes, gutrxgurus.com.

And then GutRxBoneBroth, the first low FODMAP bone broth to hit the market, and people can order that online. It just ships directly to their door, and we actually ship beautiful high-protein, high-gelling bone broth that tastes absolutely amazing. We’ve got a big plant here in Seattle, and we sell beef and we sell chicken, and it is just absolutely delicious, so it’s just nice to have that to kind of fill in the gaps and have that as a base of a soup, because you can’t just go to a store and get a garlic-free, onion-free anything, right? Everything has it in it. So it’s nice to have a broth that people can really connect to there.

Dr. Weitz:                          Cool, great. Thank you so much for spending time with us.

Angela Pifer:                      Of course, thank you!

Dr. Weitz:                          Okay, I’ll talk to you soon, Angela.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Best Diet for IBS with Dr. Norm Robillard: Rational Wellness Podcast 80
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Dr. Norm Robillard discusses what is the best diet for patients with Irritable Bowel Syndrome with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

 

Podcast Highlights

6:47  When you look at studies on IBS, there is a wide range as to what percentage of patients are caused by Small Intestinal Bacterial Overgrowth (SIBO), in one meta-analysis from 4 up to 78%.  This has made some doctors and researchers to question what relationship SIBO has to IBS. Dr. Robillard explained that there are some issues with test methodology, including whether you use lactulose or glucose as the substrate and glucose is less sensitive since it will miss SIBO in the distal part of the small intestine, since it is absorbed in the proximal portion of the small intestine. Lactulose should be a preferred substrate, since it is not digested by humans. There are some potential issues with the 24 hour test preparation, which requires strictly following essentially an intervention diet and then an overnight fast and if these procedures are not strictly followed, it can affect the test results.  Also, this test is only one snapshot in time and there is a constantly changing situation in your gut where if you eat a lot of fermentable carbohydrates, the likelihood of SIBO will go up, while there are a number of mechanisms that work to prevent it from developing, including the Migrating Motor Complex, bile, hydrochloric acid from the stomach, digestive enzymes, and your Gastrointestinal Associated Lymphoid Tissue (GALT), the immune system clustered around your digestive tract. Dr. Robillard thinks the correct number is somewhere in the range of 45-65% of people with IBS who have SIBO. 

11:48  Dr. Robillard has coined the term LIBO for large intestinal bacterial overgrowth because he believes that some of the time the gastrointestinal symptoms are coming from an overgrowth of bacteria or archaea in the large intestine. When bacteria ferment carbohydrates they produce short-chain fatty acids, which are acidic. They did a study at John’s Hopkins that looked at 47 patients with IBS and they had them swallow a SmartPill that could detect pH changes.  They did not see any pH changes till they got to the large intestine, which they interpreted as bacteria in the large intestine, not the small intestine.  Dr. Robillard believes that when you have methane SIBO it is likely caused by archaea not in the small intestine but the large intestine, because the methane gas slows down motility, which causes constipation. This is why you get methane showing an elevated methane even in the zero time point in the breath test. He thinks that the archaea in the large intestine can overgrow and produces so much gas that if forces open the ileocecal valve leading to the gas getting into the small intestine. Evidence has shown that when researchers placed a pressure sensitive instrument in the ileocecal valve it was weaker, which could be because it is being forced open by back pressure from gas being produced in the colon.  Dr. Robillard also mentioned that he has written a book about reflux and his theory that reflux is caused by pressure from the gases being produced by the overgrown bacteria pushing up into the stomach pushing the acid up into the throat.  He found that a low carb diet made his reflux go away. 

25:37  If the archaea are really overgrown in the large intestine instead of the small intestine, this might explain why treating methane SIBO is more difficult and why Rifaximin is not as effective for the archaea, since it acts mainly in the small intestine.

27:18  The causes of SIBO can include the motility of the intestinal tract related to the migrating motor complex and the iliocecal valve. Hypochlorhydria or low stomach acid can also be a factor, since the acid helps to keep the bad bacteria out of the small intestine and from moving up to your throat, lungs and sinuses.  Low stomach acid can result from the use of Proton Pump Inhibitors (PPIs). It can also come from H. pylori infection, which is a corkscrew like spirochete bacteria that burrows through the mucosa into the lining of the stomach. If H. pylori grows in lower part of the stomach, the antrum, it can result in increased hydrochloric acid.  But if it grows in the upper part of the stomach, the fundus, where the parietal cells are, it can damage these parietal cells and results in decreased hydrochloric acid secretion. Low stomach acid both increases the risk of SIBO and also stomach cancer. Patients with liver problems like cirrhosis will produce less bile and are at increased risk for SIBO. Also patients with pancreatitis, since they may have decreased production of pancreatic enzymes. Kids with cystic fibrosis have a high instance of SIBO and GERD and have to be on digestive enzymes. Pain medications can slow motility and cause SIBO.  There’s an increased risk of SIBO with Celiac and Crohn’s disease. Diabetes can lead to nerve damage and predispose to SIBO.  Surgery and other adhesions in the intestines can lead to SIBO.  Scleroderma is also risk factor for SIBO.  Simply eating too many fermentable carbohydrates in your diet, esp. as we age since our digestion may not work quite as well as we get older.

33:18  Dr. Robillard has developed a special diet, the Fast Tract Diet, and the Fermentation Potential (FP) point system to easily keep track of how to eat less fermentable carbs. Dr. Robillard has also found that a super low carb diet like the ketogenic diet works well with GERD and SIBO. The Fast Tract diet limits lactose, fructose (and polymers of fructose), resistant starch fiber, and sugar alcohol.  The FP calculation uses the glycemic index, which measures how quickly carbohydrates are broken down and converted into blood sugar. For diabetes you want low glycemic foods, but for gut issues you want higher glycemic foods that digest more easily.  After you take the glycemic index you add in fiber and sugar alcohols to do the calculation and Dr. Robillard has developed an app for your phone that does this for you, the Fast Tract Diet Mobile App.

47:50  Wine and light beer are surprisingly low on FP points because foods that are fermented have less carbohydrate in them because the carbs are being converted into alcohol.

50:19  It is common in the Functional Medicine world that after the patient has been placed on a treatment protocol for SIBO that involves a restricted diet, such as a low FODMAP diet, along with herbal antimicrobials or other supplements for a number of months, once the patient feels better, that we try to broaden their diet as much as possible.  But Dr. Robillard does not really agree with this concept.  He does not feel it is helpful or necessary to add back in a lot of fermentable carbohydrates and fiber. He likes to see people diversify their diet by adding more low FP vegetables, fresh herbs, and small servings of fermentable foods, like pickles, kimchi, sauerkraut, and maybe a little bit of yogurt. If you have an animal-based diet with some fatty fish, plenty of green leafy vegetables, and some nuts, there is no reason to add grains and beans and other fermentable carbohydrates.  If you need some fiber, you can use psyllium or cellulose, or something like that’s not very fermentable.  Rather than supplement with prebiotics, Norm would rather have someone have an organic garden and compost pile, which will inhance your micobiota. Studies on compost piles show that they are similar to the microbes in your gut.  Dr. Robillard is also not a big fan of antibiotics for SIBO, given the harm they cause to our microbiota as well as other side effects.

 

 



Dr. Norm Robillard has a PhD in microbiology and he is the founder of the Digestive Health Institute and he is a gut health expert and author. He is the creator of the Fast Tract Diet and the Fermentation Potential (FP) System, the author of the Fast Tract Digestion book series and the publisher of the Fast Tract Diet mobile app. He also consults directly with patients.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

Podcast Transcripts

Dr. Weitz:                            This is Dr. Ben Weitz with the Rational Wellness podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top expert in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free eBook on my website by going to DrWeitz.com. Let’s get started on your road to better health.  Hello Rational Wellness podcasters. Thank you so much for joining me again today. This is Dr. Ben Weitz. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and review.

For those of you who’d like to see Dr. Robillard’s face, as well as listen to him, you can always go to our YouTube page and watch the video version of the Rational Wellness Podcast. Anyway, our topic for today is Irritable Bowel Disorder, or syndrome, and small intestinal bacterial overgrowth, and then how to treat it. Irritable Bowel Syndrome is a condition marked by gas in the intestines, bloating, abdominal discomfort, constipation, diarrhea, alternating one and the other, as well as a series of other symptoms. IBS, Irritable Bowel Syndrome, is the most common gastrointestinal disorder and occurs in up to 20% of the U.S. population.

For many years, IBS was considered a stress-related condition with no known cause, and this is partially because IBS was most common in women. Traditional medical treatment has been generally composed of medications for controlling symptoms, such as medication to reduce constipation, another medication to control diarrhea, et cetera, et cetera, but in functional medicine, we don’t wanna just treat symptoms, we’re trying to get to the underlying cause of our health conditions. Dr. Mark Pimentel, from Cedars-Sinai, was really the first one to discover that small intestinal bacterial overgrowth, or SIBO, is the cause of IBS in up to 84% of cases. SIBO consists of bacteria that normally grow in the large intestine or colon that then start to grow into the small intestine, which normally has relatively small amounts of bacteria.

When you eat certain types of carbohydrate foods that contain fermentable fiber, our gut bacteria eat the carbs and they produce various types of gases, like hydrogen and methane. When this occurs in the colon, this is not a problem, since the colon’s very expandable and there’s a valve, the ileocecal valve, to keep this gas from going back up into the rest of the digestive tract, but the small intestine is a relatively narrow tube and it’s not really expandable in a way that the large intestine is. If there are bacteria there that are eating fermentable carbs, they’ll produce gas, and this gas, likely, will cause discomfort, a feeling of gas and bloating, and many of the other symptoms of IBS or SIBO. The gold standard for diagnosing SIBO is finding more than a tiny amount of bacteria upon jejunal aspirate, which means that when putting a scope down into the intestines, you scoop a small amount of the liquid in the proximal jejunum, which is the lower part of the intestine, and then analyze it via culture, or PCR.

Unfortunately, this test is very invasive and it’s not typically done on a regular basis in clinical practice. What we have is a somewhat imperfect but fairly useful test, which is known as lactulose hydrogen-methane prep test to diagnose SIBO. Dr. Pimentel also found that SIBO often results from a bout of food poisoning, where the bacteria that causes food poisoning give off an endotoxin referred to as cytolethal distending toxin. The immune system reacts to this toxin and attacks this cytolethal distending toxin, but then, because the cytolethal distending toxin is similar to some of the structural proteins in the intestinal wall, the immune system cross-reacts and ends up attacking the intestinal wall. By this understanding, SIBO is really an autoimmune condition.  This can be diagnosed via a blood test that Dr. Pimentel developed called the IBS check test, and now Cyrex Labs has Array 22, that’s a more sophisticated way of trying to measure these antibodies produced by the immune system in this attack on these toxins, as well as the antibodies to the structural proteins in the intestinal wall, in order to be able to diagnose SIBO. This is all, obviously, a very complicated and confusing condition, and that’s why I’ve asked Dr. Norm Robillard to join us today. Dr. Robillard’s an expert at IBS and SIBO. He has a PhD in microbiology from the University of Massachusets where he studied Bacillus species of bacteria, which are the spore-based bacteria.  He’s the founder of the Digestive Health Institute, and he’s also a gut health expert, author, and microbiologist. He’s the creator of the Fast Tract Diet and the Fermentation Potential system. The author of the Fast Tract Digestion book series and the publisher of the Fast Tract Diet mobile app. Thank you for joining us, Dr. Robillard.

Dr. Robillard:                      Thanks for having me on, Ben.

Dr. Weitz:                            When you look at the studies on IBS, there’s a big range as to what percentage of patients with IBS are actually positive for SIBO, and so there’s one review paper that says it ranges from as little as 4% all the way up to 78%. This has led some practitioners and doctors and researchers to even wonder if there really is a relationship with SIBO and IBS and what percentage it is. On the other hand, Dr. Pimentel did a study in which he found that 84% of patients with IBS tested positive for SIBO.  Why do you think there’s such a wide variation in these results and what percentage of patients with IBS do you think are really caused by SIBO?

Dr. Robillard:                      Yeah, that’s a good question. Of course, there’s basic test methodologies. I used to run an analytics testing laboratory, and so there’ll always be precision, accuracy, intermediate precision, which is how closely different laboratories get the same result, so it requires a lot of training and a lot of calibration to get these labs on the same page. Of course, the test for SIBO, there are different techniques used.  Some people, you mentioned lactulose sugar, which is really, I would think, the preferred method, because lactulose is not digested by humans, so it passes through the intestines until it runs into bacteria that can break it down and produce hydrogen.  When you use lactulose, you can detect bacteria all the way through the small intestine.  But a lot of labs use glucose, which is quickly absorbed, and so if the bacteria are not up in the proximal or early part of the small intestine, you may not even see them with that test, so it’s less sensitive, however, it’s more specific.

There are some test methodology issues.  Before we went live, you and I were just talking about the test preparation, which I think is also important and, potentially, a flaw or an imperfection in this testing, because before people take the breath test, there’s a 24-hour preparation period where you’re, essentially, on an intervention diet, and so you’re avoiding legumes. You can still have some fish and chicken, no fruit juice, and you mentioned they can have some rice, and some rice is worse than others, as we’ll get to in a little bit, but nevertheless, they’re on an intervention diet for 24 hours and then they fast overnight before taking the test.

You, obviously, follow Dr. Pimentel’s work, and those folks down there have really worked a lot on this migrating motor complex, so SIBO is a snapshot in time. If these bacteria move their way up into the small intestine, your body, stomach acid, a lot of these mechanisms we’ll be talking about today, motility, it’s always trying to move these bacteria out, bile, antimicrobial factors, your immune system, and so the more chance you give it to not be either fed more with carbs, things like fasting, the more of a chance you have of being negative. On the other hand, if you feed everybody a lot of fermentable material, you’re going to see the number of people with SIBO go way up. Again, it’s a snapshot in time.

The last point I wanted to make is, and I hope we get a chance to talk about this a little bit today, I had coined the term LIBO in an article I wrote a few years ago on resistant starch, it’s to stand for Large Intestinal Bacterial Overgrowth. In your introduction, you mentioned, well, as long as all this fermentation happens in the large bowel, you can accommodate that all, bacterial growth and a lot of gas, but if you have too much, that could be problematic as well. People would come in with symptoms and test negative for SIBO, and they still have excess bacterial fermentation, that’s what I believe. The second part of your number was what’s a number, right? What should it be–87% or 4%?  Again, from being analytics testing all of these years, I do know that if you test something enough, the answer gets closer and closer to the accurate value. Dr. Pimentel had put together a meta-analysis of a whole variety of studies and really validated the finding of SIBO and connecting it to IBS, and I thought that was pretty powerful. When you look at enough data, you’re going to get a better answer. Is it 45% or 65%? I don’t know, but it’s probably somewhere in there, again, fluctuates.

Dr. Weitz:                            Right. Yeah, that’s interesting, you talk about LIBO, or bacterial overgrowth in the large intestine, I wonder if you could use the SIBO breath test to diagnose that if you just look at the rise in gases after 120 minutes or beyond.

Dr. Robillard:                      Probably not, because when you go from even somebody with SIBO, they have greater than 100,000 bacteria per mill in the small intestine, which anybody that works with bacteria will tell you, that’s such a tiny, tiny amount, and then you get to the large bowel, and the large intestine contains 100 trillion bacteria, so much more, so basically, this lactulose would be just rapidly consumed and produce a lot of gas, even if somebody didn’t have “LIBO”.

Dr. Weitz:                            Oh, okay.

Dr. Robillard:                      However, there was a study done, jumping into this LIBO thing a little bit, by a group that looked at, I think they were out of John’s Hopkins, looked at 47 patients with IBS, and some controlled, so it’s pretty good end for statistical analysis, and they had them swallow a wireless motility capsule, kind of a SmartPill, and this pill could detect pH differences, so it’s going through the stomach, small intestine, and into the large intestine, and it was measuring acidity. What they found was really interesting, they didn’t see any pH change, no increased acidity in the small intestine. Just to back up for a minute, when bacteria ferment carbohydrates, they produce short-chain fatty acids, right? They’re fats and they’re acids, and that’s where the acidity comes from, but they didn’t see any increased acidity in the small bowel of people with IBS, but when the SmartPill got to the large bowel, they did see an increase in acidity, and they indicated that they interpreted that as the bacteria in the large bowel.

For IBS patients who were very active, producing more of these short-chain fatty acids and more of the acid, they were questioning SIBO. While we’re on that topic of questioning SIBO, there was another lab up in Canada that used a radioactive tracer molecule when they gave people, and again, it was a pretty good sized study, I think it was about 40 people with IBS and some controls, when they gave them the lactulose breath test, at the same time, gave them the lactulose, they gave them this radioactive tracer probe. They could literally follow this probe on somebody’s body, and they had mapped out, here’s the end of the small intestine, the ileocecal valve should be right here, and they were literally following this radioactive probe through the small intestine. What they found was that by the time people were registering as hydrogen-positive within 90 minutes indicative of SIBO, that that dye had already reached the ileocecal valve and was entering at the large bowel.  Again, they were saying that they think that people that test positive with SIBO, perhaps, have faster motility, and that’s what they’re measuring, not the actual SIBO. I thought about both of these studies and I really think the answer is that both LIBO and SIBO exist. For instance, in this radioactive probe study, yes, as people were recording a positive breath test, some of this dye, for at least 5%, had reached the large bowel, but a lot of the dye was still back in the large intestine, small intestine, and a lot of the lactulose was still back in the small intestine, so I don’t think it debunks SIBO so much as it suggests, both of these studies, that we need to look at LIBO and SIBO. While we’re on that topic, again, with the SmartPill and the acidity, they found that they had no change in acidity in the small intestine, but they did in the large bowel, but again, getting back to the numbers, even if you have 100,000 or 500,000 bacteria in the small intestine, is that enough bacteria to meaningfully change the PH, especially when the small bowel adds bicarbonate and it neutralizes the acidity from the stomach, and all of that?  I think SIBO could exist, easily exist, and that it’s not debunked by these methods, but I do think it is a good reason for us to look at it in a different way and think maybe it’s a combination.

Dr. Weitz:                            Yeah. A thought I also have about that, and then I think maybe I should ask you to explain what the SIBO breath test is for those listeners who are not familiar with it, is some of the real acid-loving bacteria, like the lactobacillus, is they’re typically not part of the SIBO equation, whereas primitive archaea are, and I wonder, if they’re not really as acid producing as some of the bacteria, so that could be a factor as well.

Dr. Robillard:                      Well, in SIBO, so we’ve been talking about breath testing, but you also mentioned the gold standard, which is taking an endoscope that can sample the small intestine, aseptically as possible, pull these bacteria out and try to culture them. Some of those studies have been done and they’re not perfect studies because, first of all, 80 or 90% of the bacteria in your gut will not grow and culture. They haven’t figured out how to grow them, and that’s why they use the 16S rRNA gene sequencing to look at these strands molecularly. They have done some culture work and they find that SIBO is comprised of an overgrowth of some bacteria that are from the small intestine, so there’s your lactobacillus and some staph and strep, but also, bacteria that are more associated with the large bowel, some Firmicutes, some clostridium species, some bacteroides, like bacteroides fragilis and several other Gram-negative and Gram-positive strains, so bacteria in the large bowel and from the small bowel are overgrowing there, so that-

Dr. Weitz:                            Also the archaea, right?

Dr. Robillard:                      Well, okay, some people may have thought that early on, because in some of these breath tests, the people have high levels of methane and they’re like, “Wow, okay, must be the archaea,” they’re not bacteria. These other micros called archaea take the hydrogen and they use it to reduce carbon dioxide to methane. That’s the little molecular food chain there, and so where are these archaea? Because wow, even in the first sample, they have high methane and they just continually have high methane, but remember, with these breath tests, they have you blowing in these tubes, right, so that if any hydrogen’s being produced by bacteria in your gut gets absorbed into your bloodstream, exhaled through your breath and you capture it in this tube.

You blow in that first tube, it’s called times zero, put the cap on, put a label on it. That’s times zero, that’s before you drink the sugar solution, then you set that aside, then you drink the lactulose sugar solution, and then every 15 minutes, 20 minutes, depends on the test, usually about every 15 minutes, you blow in a new tube and put the cap on. With hydrogen, you can see a real kind of time course there if you plot it out. Zero sample is hardly any hydrogen in it, and then all of a sudden, starts to come up, and it may be 40 minutes, and 60 minutes comes up, then it starts to, maybe, go down a little bit, and then it hits the large bowel past 90 or 120 minutes and it goes through the ceiling.  You can get a profile like that with hydrogen, but with methane, you almost always just see that it’s high in the zero time point, so that’s telling us that it has no dependence on the lactulose sugar. It’s doing its thing, taking the hydrogen and CO2 and combining that to make methane. There has been some work on it, I’m not sure I can cite any particular studies at the moment, but that shows that these archaea are in the large bowel and that they’re just churning away. Some people may not know this, people with IBS-C, or constipation-predominant IBS, almost always have these really high levels of methane because methane, there’s been good work on this, you can inject methane into the intestines of animals and it slows down the transit.  There’s just such a tight corelation with people that are high methane having slow transit and constipation. There is a strong belief that these archaea organisms are doing that in the large bowel.

Dr. Weitz:                            I thought that they had grown into the small intestine, and that was one of the theories, I talked about Dr. Pimentel’s theory about the autoimmune component, but to follow up on that, what that meant is by damaging the structural proteins in the small intestine, it caused decreased motility, and he describes it as like a stream that stops running quickly and starts backing up and that allows the bacteria from the large intestine to grow into the small intestine, so I thought that’s where the archaea-

Dr. Robillard:                      Well, right. This whole story, and it’s a great story, by the way, they worked out with Cytolethal Distending Toxin and the autoimmune reaction with Vinculin, which slows down motility, hits the nerves and so forth, causes constipation. Slowing everything down, whether that causes archaea organisms to back up all the way into the small intestine, I’m not sure. I do have my own theory about connections between the LIBO and SIBO. Something we’re not talking about today, but it’s just relevant in this discussion, is when I first got into nutrition and dieting, it was only because I had chronic acid reflux myself, and I had found that a super low carbohydrate diet caused my symptoms to just go away, and so I was so amazed by this.  I was playing around with this idea, and I started following the food groups through the digestive process and came up with this new theory that, what was happening, I believed, was that I was consuming too many carbohydrates, too many were getting malabsorbed, feeding blooms of gas-producing bacteria, right? As a microbiologist who grew these bacteria, right? You mentioned I worked in a Bacillus lab for my graduate work, but I also worked as a post-doctorate fellow on bacteroides fragilis, that’s 10% of the gut bacteria, and E. coli. I was actually the first one to be able to move genes between E. coli and this strict anaerobe bacteroides through this conjugative process.

One thing I knew about these bacteria, they produced a lot of gas. They were saccharolytic, they loved carbohydrates, they produced a lot of gas, and I came up with a theory that all this gas produced too many carbs, was pressurizing my stomach, it was translating into my stomach, and they do know people with GERD, acid reflux, have much higher pressure in their stomach, and the theory was it was pushing reflux, opening this valve instead of the original theory that stood for 60 years. We’re saying that this valve was dysfunctional or it was weaker, or it was relaxing spontaneous, and so there’s a lot more evidence for this gas-producing bacteria driving reflux, and so I’ve written a couple of books on that. Now, to this new discussion on SIBO versus LIBO, these guys with the PH SmartPill, they found all this acidity past the ileocecal valve in the early part of the large bowel.

How could that relate? Suppose you had SIBO and LIBO, how’s the SIBO getting there? I have a theory that it might work the same way as my acid reflux theory, that these bacteria are producing a lot of gas in the early part, the ascending colon, just past the ileocecal valve, a lot of growth, a lot of gas, and maybe this same gas pressure is pushing back on the ileocecal valve. It’s interesting, it ties into another study done out of John’s Hopkins as well, I think, where they found that people with SIBO, was it a SIBO population or an IBS population? I think it was SIBO, but one or the other, but probably people with SIBO, they found their ileocecal valve pressure and they measured it like a colonoscopy tube going right up to the valve.  They put a pressured, sensitive, like a manometry instrument, position it right in the ileocecal valve, and it was weaker, there was less pressure, people that had SIBO. It could be the same thing, if you have gas pressure from bacteria pushing back on that valve and pushing it open, if you have a pressure-sensitive tube in there, it’s going to look like it’s weaker, but really, it’s being forced open by back pressure. Anyway, something to think about.

Dr. Weitz:                            That’s interesting. If the archaea are really in the large intestine, that could be one of the reasons why it’s difficult to correct methane SIBO and kill or cut back the archaea if Rifaximin, which is what gastroenterologists often use when they treat this, is basically acts in the small intestine, so it might not be acting in the large intestine where, under your theory, the archaea really are.

Dr. Robillard:                      Yeah. Well, it probably explains why Rifaximin alone is not efficacious for IBS-C.

Dr. Weitz:                            Right, that’s why they usually recommend Rifaximin plus Neomycin, or another antibiotic.

Dr. Robillard:                      Yes, and both are nonabsorbable. If you’ve seen my other work, you know I’m not a big fan of antibiotics, but at least these two are nonabsorbable. You can eliminate some of the systemic problems.

Dr. Weitz:                            Right.

Dr. Robillard:                      They use both. The Rifaximin is probably, by their own estimations, not very useful in the large bowel, right?  There’s a whole story about, well, it won’t upset your microbiome because it requires bile for its most efficient inhibition, and 95% or more of the bile is reabsorbed at the end of the small intestine, so the Rifaximin is probably not a big factor. It would be, really, what’s the Neomycin doing?

Dr. Weitz:                            Interesting. We’ve talked about a couple other things that could cause SIBO, we’ve talked about the damage to the motility of the intestinal tract, and you mentioned the migrating motor complex, and you also talked about the ileocecal valve. What are some of the other causes of SIBO?

Dr. Robillard:                      Yeah. Motility is big, and Pimentel thinks it’s really probably one of the biggest. Low acid is another one, people with hypochlorhydria, achlorhydria. The acid not only is it important for digestion, but it’s important for keeping the bad bacteria out of your gut, keeping the bacteria in your gut from moving up to your throat, lungs, and sinuses, so acid’s important. By the way, on the acid, there is an autoimmune disease that will lead to atrophic gastritis and hypochlorhydria, but it’s quite rare, actually, so unless somebody has a lot of other autoimmune conditions, you might not have to look at that one, but definitely PPIs, that’s what they do, they knock down your stomach acid.

Dr. Robillard:                      The other big one is a prolonged infection with Helicobacter pylori, bacteria that infects the stomach, it’s a corkscrew shape, like a spirochete, and it burrows down through the mucus and anchors on the stomach lining and it makes these colonies. Depending on where those colonies are in your stomach, that’s where the damage happens and that’s where the gastritis and atrophic gastritis happens. For some people, it effects the hormones that regulate stomach acid and they can have too much stomach acid, and they’re very susceptible to duodenal and stomach ulcers. People that have these bacterial colonies of H. pylori near the parietal cells that produce the acid, those are the ones you have to worry about having low stomach acid, so that’s a big one, too, I think, in a subset of people. Any kind of-

Dr. Weitz:                            That’s really interesting because most people think of H. pylori as automatically associated with increased acid production, but you’re saying if the H. pylori grows in a certain part of the stomach, it can be associated with decreased hydrochloric acid secretion?

Dr. Robillard:                      Absolutely. Right. The two doctors down in Australia, one of them gave himself an H. pylori infection and got gastritis.

Dr. Weitz:                            Yeah, Marshall, right.

Dr. Robillard:                      Wow, that was a great story, but they were focused on the ulcers, with the cause of ulcers, but they can also cause the opposite.

Dr. Weitz:                            Interesting.

Dr. Robillard:                      The people that have low stomach acid, not only will it really mess with your digestion, can still have symptoms, but they also are at higher risk for stomach cancer with the low stomach acid, which caused me to wonder, if they studied PPIs, if they would see there was also a gastric cancer risk with PPIs. No one’s been reported so far, but it also really knocks down your stomach acid. Just to cover a couple more quick ones, any kind of liver issues, we talked about liver and it produces the bile and that’s antimicrobial, people with cirrhosis, any kind of liver problems, they can have SIBO, a lot of problems, anything with your pancreas, pancreatitis, the pancreas produces amylase, protease and lipase, right? If you have any kind of problem with your pancreas, you won’t be digesting food as well, especially if you’re deficient in the amylase.

Even kids with cystic fibrosis, while they don’t have a pancreas problem, per se, they do have a lot of mucus in the ducts where the enzymes are released from, so kids with CF have a very high instance of SIBO and GERD, for that matter, right? There’s another link there, and they have to be on digestive enzymes. Problems with drugs, we talked about PPIs, pain medicines, man, there’s a whole story about MSDS, it’s just unbelievable. Too many pain meds, especially narcotics on the motility front, Pimentel, in one of his interviews, was talking about anybody on morphine has SIBO. You don’t even have to ask, so they really do slow down the motility.  We talked about GI infections already, and not just bacterial. Gastroenteritis from food or water-born illnesses, bacteria, yes, but also protozoa, viruses, anything that causes gastroenteritis.

Dr. Weitz:                            You mean even fungal infections, and you can have what’s called a SIFO, or a Small Intestinal Fungal Overgrowth?

Dr. Robillard:                      Certainly, sure. We talked about the ileocecal, other genetic-based diseases, celiac and Crohn’s, it’s huge, diabetes, it might be a nerve damage issue going on, surgery and adhesion’s, I’ve heard Pimentel talk about that. I cover all of these in the Fast Tract Digestion books, by the way. I have a whole chapter on this. Speaking of scarring, scleroderma is a big problem for a lot of people with SIBO.

Here’s one that never gets any attention, and I’m not sure why, too many fermentable carbohydrates in your diet. Now, I learned that the hard way myself. When I was in my early 40s, I was having a terrible time eating all these carbs and having all these symptoms, took the carbs out of the equation and no problem, so I really think that some people, maybe as we get a little bit older, a lot of these functional GI issues start in our mid 30s and 40s, our digestion just may not work quite as well. You might not be able to put your finger on exactly what it is, but if you’re not digesting and processing carbohydrates well, digesting these things is a real finely tuned collaboration between our own digestive powers and the ability to use bacteria to help us out. If we overwhelm them and then throw in a couple of these other potential underlying causes, I mean, you’re in real trouble.  There’s a handful. I have a whole chapter on this if people want to read more.

Dr. Weitz:                            Yeah. It’s interesting, I think a lot of us in the functional medicine world, when we are putting patients on treatment protocols, I know myself, we usually use a diet that’s designed to have less fermentable carbohydrates. I typically use the Low-FODMAP Diet. Now, you’ve looked at some of these diets, like the Low-FODMAP Diet, specific carbohydrate diets, some of these other diets that are popular, and you found some problems with those diets and so you came up with your system. Maybe you could tell us about your Fast Tract Diet and your fermentation-potential figure for being able to analyze, quantitatively, which foods to include.

Dr. Robillard:                      Sure. This story goes back quite a few years, 15 years ago is when I really found that very low carbohydrate helped my GERD symptoms, started looking into this, and so that’s not on your list, right? You mentioned FODMAP and specific carb diet, but just a low carb, even a ketogenic diet, I use ketogenic diet in my own consultation practice as a troubleshooting tool. We’ll get into the Fast Tract Diet in a minute, but it allows some carbohydrates, kind of a flexible approach for people with different dietary preferences. Jasmine rice is better than basmati rice, for instance, for reasons we can talk about, but what happens if, well, even the jasmine rice I’m having IBS symptoms or heartburn symptoms”? Okay, well, there may be a problem for you even digesting the easier to digest starch.

For instance, jasmine rice has amylopectin, an easier to breakdown starch, some people have trouble even with that, so I’ll go to a ketogenic diet just as a troubleshooting method to say, well, let’s take all the starches out and see how you do. Why did I come up with this diet? Well, initially, I had just found low-carb diet works, but when I came up with this theory about the underlying cause of reflux, linking it to bacterial overgrowth, similar to what Pimentel was doing at the same time with IBS, I was doing with acid reflux, when you limit all of the carbs that seem to be okay, so I had written a book on just this mechanism. I just wanted to get out there, it’s a new theory, new way to look at acid reflux.

I was living not too far away from you at the time in Thousand Oaks California, and I was pretty close to Dr. Mike Eades who was living down in Santa Barbara, he and Mary Dan, his wife, also an M.D. who wrote Protein Power, their book was the first time I ever read about any kind of diet ever, and it was to go on this low-carb diet. I noticed, in his book, which he had written in the mid-90s, he said, “Oh, by the way, we have patients that their heartburn improves on a low-carb diet,” and I’m like, “Ah, that guy speaks my language,” so I sent him my book on the mechanism. Well, actually, I didn’t just send it to him, I was going to send it to him, but when I had him on the phone, I said, “Gee, I’m gonna be at the farmer’s market down in Santa Barbara,” we agreed to meet and I gave him a copy. We became friends, drank some wine together, and we’re talking about this stuff, and he was the one that really asked a key question, he said, “Well, low carbs is helping heartburn, we know that, and now we know there’s a mechanism for it,” and he bought in fully into my theory.

He thought it made sense, and there’s a lot of evidence for it, but he said, “You know, which types of carbohydrates are the most problematic?” That one question sent me on my way for another couple of years of research. I wasn’t really aware much of the FODMAP and the specific carb diet. I think I had, at some point, read Elaine Gotschall’s book Breaking the Vicious Cycle, I can’t remember exactly when, so I was aware of that, but I was just thinking about which of these carbs are hard to digest? I didn’t have any specific lenses on except just look at these, so I came up with lactose, fructose, and, of course, polymers of fructose, those are actually dietary fibers, resistant-starch fiber and sugar alcohol, so there’s five.

The next step was to come up with a way to quantitatively measure these in foods because you pick up a pear, how much of these five things are in that pear? Who knows. Give it to the best dietitian in the world, she might not know either, or he. I was thinking about this problem, and by the way, the specific carb diet, it limits disaccharides, it limits grains and starches but not honey. That didn’t cover these five that I was interested in, and the same with the FODMAP diet, which, right, Fermentable Oligo-, Di-, Mono-saccharides and Polyols, so some of the monosaccharides like fructose, polymers are fructose, sugar alcohols, polymers of galactose, for that matter, too, but not fiber or resistant starch.  I think the reason not all these diets cover it is because they either just don’t think some of these are very fermentable or they just think they’re so darn healthy for our gut that we need to include them. I came up with the five, I came up with the FP calculation to quantitatively measure them, but many years after I wrote the first Fast Tract Digestion book, I came across this textbook, can you see that?

Dr. Weitz:                            Yeah.

Dr. Robillard:                      Textbook of Primary and Acute Care Medicine, it’s fat.

Dr. Weitz:                            Wow.

Dr. Robillard:                      A lot of good stuff in there, but this book was published in 2004. It’s used to train doctors, but I think some doctors might have skipped the chapter on intestinal gases because when you go to page 1192 and open it up and read it, there’s those five carbohydrates that the Fast Tract Diet restricts, so it’s not that far out there. It’s aligned with this Textbook of Primary and Acute Care Medicine, that’s why I chose those five and why I developed my own diet that was low-carb keto is a great approach. The other ones, I think they’re missing a couple, and I think that can be challenging for some people if they’re having problems.  There’s so many different types of fibers and we know some of those are very fermentable, stachyose, ravinose, various other polymers of sugars. I think you need to limit all five, and then the other thing was I needed to find a way to do it quantitatively, so I could make the diet something people could use. In the books, in the mobile app, the Fast Tract Diet mobile app, there’s all these tables of all these foods with these FP values. The FP calculation, it took me a long time to figure it out because I didn’t know how I was gonna measure the five carbohydrates in a way that you could just look at any food and say is there a lot of fermentable material in this or not?

I struggled with that issue, and for a while, I started thinking about the glycemic index instead of thinking, well, that measures how quickly carbohydrates go into the bloodstream, must be some way to use that. I was just, I don’t know, kind of dense thinking about it at first, but as I thought about it more and more, eventually I realized that it wouldn’t be that hard to modify that equation, flip it around and modify it because instead of measuring carbohydrates going into the bloodstream, I wanted to measure how many carbohydrates were persisting in the small intestine and not being absorbed. I turned the equation around, but because the glycemic index equation does not measure fibers or sugar alcohols, I needed to add those back after, so I flipped the equation around. Then, after that first part of the calculation, you add dietary fiber and any added sugar-alcohols, and so all you need is the glycemic index and the nutritional facts for any food and you can do this calculation.  Of course, the app has a calculator for this, but also, it has tons of table sets. We’re releasing a new version in the next month, we’re about 10 months behind releasing this, but it’s going to have over 1,000 foods in it now. It’s got voice recognition on it, so if you just open it up, I have it opened up now, search. Whoops, I pushed on the happy face instead of the other thing.  Carrots.  You can bring up carrots raw, and you can cook them after, by the way, but it will just tell you what the fermentation points are for any given serving size.  And if the points are too high and you still like carrots, just use a few less. Use half the number of carrots, it will cut the servings, it will cut the points in half. That’s how it works, in a nutshell.

Dr. Weitz:                            Is there a quantitative amount of FP points somebody’s supposed to have in the course of a day or is that related to their total caloric intake, or how does that work?

Dr. Robillard:                      No, that’s a good question, it does matter a great deal.  In fact, we’re listening to our readers on this one.  We had initially set a flexible range between 25 and 35 points, and just to put that into perspective, 30 grams of undigested carbohydrates that are fermented by bacteria can allow bacteria to produce 10 liters of gas, so just an ounce of these carbs can drive a whole bunch of gas production, that’s why you do need to limit these.  Typical western diet may have 150 or more FP points a day, so that’s 50 liters of gas, that’s a lot. We wanna get that level down, and so we recommend somewhere between 25 and 45, depending on if you have a lot of severe symptoms, you want to go to the lower end, and as you get better and start improving, you can increase up to more than 45, but you’ll probably never really be eating 150 a day again if you’re somebody that suffers with these functional issues.

We have a Facebook group, Fast Tract Diet Official Facebook Group, people should join. There’s about 8500 members on there right now sharing recipes and talking about all this stuff. We have a lot of groups of people with these different conditions, not only IBS and SIBO, acid reflux, we have people with laryngo-pharyngeal reflux, real subtle irritation in the throat and vocal chords, it’s linked to reflux but it’s subtle, but it’s also persistent and it’s hard to get rid of. We’ve had people on the page, many of them, saying, “Well, this irritation’s persistent, subtle, but you know what?  If I really was diligent with my points, I had to go less than 20, down to 15, and I had to do it for weeks,” and some people months, and finally their throat symptoms would get better when nothing else worked.  They were driving this with us and they were saying, “You know what?  You’re not cutting the points enough, you have to cut more,” so we’re learning from them.  We’re involved in a clinical study where we’ve actually reduced the points based on what people on our Facebook group are telling us.

Dr. Weitz:                            Interesting.  I wonder if there’s an issue with pre-diabetic or diabetic patients, because your program is actually promoting consumption of foods that have a higher glycemic index, right?

Dr. Robillard:                      I never thought about it as promoting.  It is a flexible eating plan, right?

Dr. Weitz:                            Right.

Dr. Robillard:                      Yes, if you were going to have rice, rather than Uncle Ben’s or basmati white rice, because a small bowl of those is going to give you a whole lot of points, maybe 10, 20 points, depending on how big the serving size is.

Dr. Weitz:                            Partly because those foods are digested slowly, right?

Dr. Robillard:                      Yeah, yes.

Dr. Weitz:                            It makes them more preventable.

Dr. Robillard:                      So far, I’m making your point for you, yeah, versus a jasmine or sushi rice has a higher glycemic index, hence a lower FP.  They’re more easily digested, more will go into your bloodstream, less will stay behind, so you’ll have less GI symptoms.  Now, what happens, though, your blood sugar increases, and so in the book we’re cautious to warn people about prediabetes metabolic disorders and diabetes, and people have to be responsible for their own blood sugar levels.  Somebody that doesn’t have an issue, or they’re an athlete, or they’re carb loading, or they’re a construction worker, so this book, a lot of different people are going to use this book.  Other people may have to really watch their carbohydrates, so a low GI, low GI carbs is one way to do it, but it is going to feed the bacteria a lot, so that’s the downside.

If you’ve got functional GI issues, your solution, in the end, will probably be a lower carbohydrate diet. That way you’ll have less blood sugar, you’ll also feel less of the bad guys in your guts, the overgrowing bacteria. We’re not telling people to load up on sugars, even if you look at our tables and the serving sizes.  I mean, there’s different categories on this app, so let’s just go down to rices, right?  Well, here’s the one we just talked about.  I’m gonna click on jasmine rice.  Cooked jasmine rice, all right.  What’s the total serving size?  I don’t know if you can see it there, but it’s a half a cup.  People with blood sugar issues, chances are they’re wolfing down a lot more rice than that, so we purposely, even though it’s low in FP points, we purposely tell people that, really, small serving sizes are better, lower carb is better, and eat slowly and chew well, which will also help digest these starches and some of these carbs better.

Dr. Weitz:                            I was surprised to see wine and beer, or light beer, on your list because these are fermented, but I guess there’s a difference between foods that are fermented and are fermentable, is that the case?

Dr. Robillard:                      Okay. Yeah, you’re bringing up a couple of points there. Foods that are fermented, right, there’s less carbohydrate in those foods when you consume them because the fermentation happens in a vessel, in a vat or a tank or a mason jar, right? The lactic acid bacteria, in the case of pickles, the yeast in the case of beer and wine, they’re using the sugars and they’re producing alcohol, right? Well, not in the lacto-fermented, they’re producing short-chain fatty acids and so forth, but in the beer and wine, they’re producing alcohol and they’re consuming the carbohydrates, so when you consume those foods, there’s less carbohydrates than there otherwise would be in there.  However, when it comes to beer, a light beer has many fewer points. I think it’s somewhere around six or something for a bottle of light beer, four to six maybe. No, I’m sorry, maybe three or four, but when you have a heavier beer, like one of my favorites, IPA, it has a lot more points because there are a lot more carbohydrates in there. Regardless of the fermentation process, you still have to look at, anyway, it’s gonna take me too long to find the drinks and open up the beers, but-

Dr. Weitz:                            Yeah, I got it.

Dr. Robillard:                      Yeah. I purposely watch my points on days when I’m going out with my buddies because I want to have a couple of IPAs, but they have more points, and so if I’m also eating french fries, and something like that, and I have a couple of these beers, it’s kind of like death from a thousand cuts. These points add up and then they really get you, and then you need a couple of days, two or three days, to unwind it. You have to pick your poison. Distilled liquors are fine because they have no carbohydrates at all.  Dry wines, red or white, are pretty low in points, and light beer is pretty low on points. From there you just have to conserve your points and pick your poison.

Dr. Weitz:                            Now, it’s common in the Functional Medicine community to put a patient on one of these restricted diets along with using some other protocols to try to get rid of the SIBO, and yet, once we’re done with the treatment period, whether that be one month, two months, six months, whatever that period is, it’s usually recommended that we try to broaden the person’s diet as much as possible. This is to make sure that we are bringing back in some of the fibers that are necessary to have a healthy microbiome and also to make sure we’re getting all of the phytonutrients from having that diverse diet, but you have a little bit different take on using your Fast Tract Diet, don’t you?

Dr. Robillard:                      Well, I do. I’ve been doing this for 15 years myself, and my own, which was terrible, chronic acid reflux, it was horrible.  I was choking in the middle of the night, reflux entering my lungs and all-day heartburn, it was a terrible situation, so I’ve been doing this for 15 years. I don’t worry so much about encouraging people to add back fermentable material. I find that when people get better, and the more you do stay lower FP or you control these fermentable carbs or focus on identifying and addressing all of these underlying conditions, like a lot of people with H. Pylori, they will say, “Well, I’m just not gonna do anything about it. I heard it’s not that big of a deal,” maybe when you’re younger, but in time, gastritis, loss of stomach acid, and you might need some help.  We have a consultation program where we really work on this, what are these things and what are the risk factors and what are your symptoms?  How do we mostly throw things out, but the things that are remaining, the few things that are remaining, we have to confirm and address those.  Of course, I’m a microbiologist, I’m not a doctor, so I give them my notes.  I’m a consultant microbiologist to them, they take my notes to their doctor and we work through these things.  You have to identify and address potential underlying causes, that’s one thing.  

As you reduce the fermentable carbs, work on the underlying causes, you’re going to have less fermentation, less bacteria there that make proteases that damage the enzymes and the tips of your villi, toxins, you may actually damage the microvilli and villi themselves, kind of like a mini version of celiac disease where you get some blunting, does occur with SIBO. As you have less inflammation, control your diet, look at these causes, your digestion will improve.  I do like to encourage people I work with to broaden their diet, in terms of three food groups, low FP vegetables, and there’s a lot of those.  If you look at the vegetable lists and apps, there’s, I don’t know 180 vegetables, fresh herbs, but low FP, fresh herbs, low FP fresh vegetables with the idea of a diverse diet.  They do have some fiber and some fermentable material, just not as much, but diversifying it will diversify your gut microbiota.  Fresh vegetables, fresh herbs, and then also some small servings of some fermented foods, lacto-fermented pickles, kimchi, sauerkraut, that kind of thing, maybe a little bit of yogurt, just don’t go overboard.  That’s a nice mix, but this thing about immediately feeling like you have to come back with a ton of fiber, I think that’s misguided. I think I might be one of the only ones out there, at this point, arguing against too much fiber. Everybody just seems to think we’re starving our microbiota.  I just don’t believe it, especially if you have an animal-based diet with some fatty fish and you still have plenty of green leafy vegetables and you’re consuming some nuts, to me, that is an ancestral diet and a healthy one.

I feel like people, when they get better, they can be the best judge of what they can tolerate.  I feel like I don’t have to ram fiber down their throat.  On that topic, I was reading a review by, his name’s William Chad, I haven’t met him yet, a gastroenterologist up in Michigan who I hope to meet at this upcoming SIBO conference because he’s a GI guy doing work on diet, it’s just great to see.  He wrote a review, co-authored it with, I think, one of the Australian folks that works on these diets, on fiber, and they are on the same page with me.  They recognized there’s so many different types of fiber and their fermentability is so different, and so they worked, well, what’s the fermentability of all of these diets?  I have a chapter on that in the Fast Tract Digestion books where I do the same thing, and they reach the same conclusion, psyllium, cellulose, something like that’s less fermentable, and if you’re gonna play around with anything, maybe start there, that’s the less invasive of all of these other ones because some of the other ones are very fermentable. There’s papers on using these.  People that had GERD, they gave them fructooligosaccharide, right?  A polymer fructose, but it’s a mini dietary fiber, and their reflux, they were measuring it with probes.  The reflux occurred much more frequently, it was much more severe, and they had terrible symptoms, so that’s a prebiotic.  They gave people with GERD a prebiotic and they really almost killed them.  I mean, it was terrible symptoms and terrible reflux.

Dr. Weitz:                            That’s very common in the Functional Medicine world right now, is prebiotic supplements.  You even see doctors saying, rather than use probiotics, it’s much more important to use prebiotics, and it’s definitely very popular right now.

Dr. Robillard:                      Yeah, it is.  I’m not against prebiotics in very small amounts or a little bit of experimentation.  Some people are worried about taking a probiotic because some of these probiotic contain a prebiotic with the idea that it’ll help get these bacteria going once you swallow them and they get into your intestines, but if you look at the label closely on those, they typically add about 50 milligrams of one of these prebiotics, which is really a tiny amount.  It’s less than a 10th of an FP point because an FP point is a gram.  One FP is one gram of fermentable material.

Dr. Weitz:                            Yeah. I think part of this putting the prebiotics in afterwards, also, after your treatment period is part of the 4-R or 5-R program that’s been so prominent in the functional medicine world and pretty much accepted as one of the few biblical versus in the functional medicine world, which is that first you get rid of the bad bacteria and then you replace and repopulate with bacteria and prebiotics with probiotics and prebiotics.

Dr. Robillard:                      Yeah. I mean, my favorite way to repopulate is just to have an organic garden and a compost pile. That’s what I’ve been doing my entire adult life, flipping the compost and growing my own garden so I get away from the chemicals for a lot of the year. We’re harvesting some squash right now, we’ll put them in a basement, they’ll still be good next spring. If you make some pickles, those will last you another winter. There are ways to eat less chemicals.  Also, when you eat some of your vegetables raw, I mean not all of them, cooked vegetables are little bit easier to digest, but at least some of them raw, some grains. We grow a lot of dill and parsley and basil, then you are repopulating your gut with bacteria from your environment. By the way, they’ve done studies on compost piles. There’s a lot of similarities between the microbes in our gut and what’s in a compost pile. A lot of the same groupings of bacteria.  That would be my preference, yeah.  I’m not a real nut for the prebiotics unless they’re in limited amounts.

Dr. Weitz:                            Right. I’d like to ask you one more question because I know we need to wrap up soon. From reading some of your articles, you’re generally not recommending a lot of nutritional supplements. You do recommend digestive enzymes and ox bile and probiotics, but you don’t particularly like herbal antimicrobials, and I think these are a common part of many functional medicine protocols for SIBO. I know myself, we typically put the patients on one of these restricted diets and include these antimicrobials, and the thought is first we’re gonna starve the bacteria and then we’re gonna try to kill them using natural agents like berberine and oregano oil, et cetera, et cetera, but you’re not a big fan of these?

Dr. Robillard:                      Yeah. I mean, I could see why there’s a temptation to do that. I’m not totally against it. I spent 10 years working on and developing antibiotics. I worked on the development of Cipro, I’ve studied a mechanism of action of antibiotics, I’ve studied mechanisms resistance and the genetics of antibiotics, so I’ve worked on them for along time, they can be lifesavers.  I mean, they’re very important. I’m against the loose use, I guess, of antibiotics because of resistance and a lot of problems. I really want to see diets continue to be improved and refined, and a lot of people have eating disorders or preferences and it’s hard for them to change their diet, I understand that. “I’m a foody,” I hear that a lot, “I wanna eat what I wanna eat.” I get it, but I have more of an ancestral health perspective and I’ve been reading more and more about this over the years and it just makes so much sense, that the more we can eat like our ancient ancestors, that’s really the way we evolved, but of course, it’s not exactly the same today. The foods not the same.

The Western diet is just not only terrible but also the availability of all of these snack foods, it’s just too easy to eat these things, and so it’s harder to change your diet. Also, our microbiota is changing, especially since the invention of antibiotics and the clinical development of antibiotics in the 40s, that’s only been, what, 60 years, it’s having a huge impact on our gut. Also chemicals and preservatives, so our gut bacteria are not the same, they’re not nearly as diverse. If you go back and look, and Jeff Leech has done some great work living with and eating like and sampling the guts of the Hadza in South Africa. Their guts are much more diverse and much more in touch with the biosphere than we are.

We’ve got this gut microbiome that’s gotten used to eating more processed foods, more easy to digest food, and then, all of a sudden, we’re getting all this advice, well, if you wanna be like the Hadza, you better throw some of this fiber at it, but your gut microbiota and your digestive tract is not handling it well. You can keep fighting it or you can just say, “Well, I have to go with it a little bit, but I still wanna eat healthy, green-leafy veggies,” occasionally maybe a half of a sweet potato or a half a cup of rice, for some people. You also have to consider, you mentioned diabetes, but also, how about cardiovascular risk? It’s huge. I don’t know if you follow the work of Ivor Cummins and Jeffery Gerber, but they just came out with a new book that’s super, and follow their lectures.

Dr. Weitz:                            What’s the name of the book?

Dr. Robillard:                      Eat Rich, Live Long, I believe. Yeah. I just started reading it myself, but yeah, you can also google Ivor Cummins lectures, just phenomenal stuff.

Dr. Weitz:                            Okay.

Dr. Robillard:                      Really looking at things, starting out from the basics and saying, “What’s important? Is LDL really that important?” Turns out, actually, it correlates very poorly with cardiovascular risk, but you know what all correlates really well? Insulin. It’s just fascinating lectures, I can’t say enough for their work.

Dr. Weitz:                            I’m not sure if you’re distinguishing between antibiotics, which are prescription medicines, and oregano oil. I totally agree that antibiotics, especially broad spectrum antibiotics, have a negative effect on the microbiota and can have harmful effects, but generally speaking, my understanding and my reading of the research is that these herbal antimicrobials don’t have a negative effect on the microbiota.

Dr. Robillard:                      Yeah. Okay, so I didn’t cover that, let’s cover that. First of all, when you look at the history of antibiotics, most of them came from other living things, back in the day, anyway, from bacteria, from fungi, and then the Germans started to figure out how to use chemistry and sulfur drug, came up with sulfur drugs and so forth, and then it grew from there. A lot of regular commercial antibiotics come from other organisms, so do these herbal antibiotics, and while I would say you could put them, maybe, on a less invasive scale than some of these more powerful pharmaceutical antibiotics, every antibiotic is going to kill or inhibit, right? Some are cidal, some are bacteria static, are going to kill or inhibit a certain variety of bacterial types, and they’re also going to have a certain potency, right?

What is the concentration of antibiotics you need to get to to kill those particular microorganisms? With herbals, and there is that one study, is that also, I think that was John’s Hopkins as well. It’s funny, all these study’s from John’s Hopkins, talking about using berberine, some other herbals, and they were as good as Rifaximin, so I think that’s interesting and it’s good to look at. Maybe they’re not as bad, but we don’t really know that much about it.

A lot of the work for those has been done on the side, outside of the mainstream, and I do think we need to learn more. By the way, when you say something as good as Rifaximin for treating SIBO, you’re basically saying, if you look at the target studies, that’s 10% better than placebo. I think diet, behaviors, and identifying and addressing underlying issues, those three things should be front and center. If you don’t do that, I think you’re dead in the water. After that, then you can start to look at supplements, digestive enzymes, absolutely.  If there could be a stomach acidity issue, betaine, right, some vinegar, work your way down. Somewhere, herbals are in there as something to try, but for me, at least, and for people that I work with, I just don’t know enough about it to really be too gung-ho.

Dr. Weitz:                            Have you used motility agents like ginger and 5-HTP, things like that?

Dr. Robillard:                      Yeah. I think, again, there’s a whole thought that motility is slow because something’s wrong, right? That could be, and yes, with the vinculin and then the gastroenteritis, absolutely. There may also be an adaptation too, depending on what you’re consuming, right, because bacteria want to help us get all of those calories out of the food. Our bodies are collaborating with the bacteria, so depending on what you’re eating, your motility could speed up or slow down for a whole variety of reasons, it doesn’t really mean something’s absolutely wrong.  Also, you do have to look at the extremes of diet, as well. I was reading a study the other day that, in anorexics, they found that they had a spike or an increase in these archaea organisms, Methanobrevibacter smithiii, that produces the methane, so it makes me wonder, under extreme caloric deprivation, is this a mechanism to make sure you ring every last calorie out of any kind of vegetative matter you consume by these archaea going up and motility slowing down? I first try to look at everything in terms of what could the natural mechanisms be here. Am I smarter than 50 million years of evolution? No.  I just have a little more of a cautious approach. I try to really understand before I just jump to try this and try that.

Dr. Weitz:                            Awesome. Thank you Dr. Robillard. This has been an amazing podcast, gives us a lot to think about. How can listeners get a hold of you and get your books and your programs?

Dr. Robillard:                      Sure. Well, you can find us at DigestiveHealthInstitute.org, and I would also encourage people to join the Fast Tract Diet Official Facebook Group. I’m on there most days, poking in here and there and answering a few questions, but there’s a lot of people that have become real experts on the diet, and they’re very helpful as well. I think those are the two main places to find us. If you wanna specifically look at the mobile app, you can go to FastTract, T-R-A-C-T, Diet.com. You can find those on iTunes and Android store, as well.

Dr. Weitz:                            That’s great.

Dr. Robillard:                      Thanks for having me, Ben. It’s great talking.

Dr. Weitz:                            Thank you Norm. Yeah, I really enjoyed the conversation.

Dr. Robillard:                      Me too.

 

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Toxic Mold with Dr. Jessica Tran: Rational Wellness Podcast 79
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Dr. Jessica Tran discusses how to avoid and correct Mold Toxicity with Dr. Ben Weitz.

[If you enjoy this podcast, please give us a rating and review on Itunes, so more people will find The Rational Wellness Podcast]

 

Podcast Highlights

6:05  The diagnosis of mold toxicity is difficulty to make, since the symptoms like fatigue, joint pain, skin rashes, respiratory problems, cognitive and neurological issues, fatigue, and headaches could be indicative of many other conditions.  Mold may be a diagnosis of exclusion, after other causes have been ruled out.  Patients with dementia or Alzheimer’s may have mold toxicity as a trigger.  In fact, Dr. Tran said that she has seen a handful of patients with triple negative breast cancer who have all had tremendous mold exposure.  Patients who have multiple chronic illnesses, say somebody who has hypothyroidism, Lyme infection, allergies, etc. will often have a mold allergy or mold sensitivity or a mycotoxin issue.  We can get mycotoxins from our food, which most people will eliminate on their own.  But these patients may have a compromised ability to eliminate mycotoxins.  The key is to take a good, detailed history.

14:12  Dr. Tran likes to screen patients who she suspects of having mold toxicity with a urine test through either RealTime Labs or Great Plains but she likes to have them take either liposomal oral glutathione 500 mg three times per day the day before or an IV Glutathione drip or push the day before collecting the urine.  This will increase mold excretion.  Without doing the glutathione challenge, you can have someone who has been exposed to mold and is reacting to it, but they may be a poor excreter.  It may be stored or stuck in their body and not coming out.  It’s the same concept when you test for heavy metals and do an oral chelator challenge and then test the urine. Dr. Tran talked about the Autism study when they looked at the baby’s first haircuts looking for mercury to see if mercury was related to autism. But they found the opposite–those with autism had lower levels of mercury. But what this study really showed was that the autistic kids were poor mercury excreters.

20:25  The best ways to test your home for mold is to contact a mold expert to come and impect your home or office.  If you want to test it yourself, the ERMI kit is better than the HERTSMI, since the ERMI looks at more forms of mold and is more extensive than the HERTSMI.  If your budget is very limited, you can get a petri dish from Home Depot or Amazon and just leave it in your home for a couple of days and then mail it in and they send you a report.

21:57  A Functional Medicine approach to treating mold problems should include looking at the whole person and also look at food allergies and other environmental allergies. For the mold component, treatment should start with glutathione, either liposomal or intravenous. You should also add phosphatidylcholine, which helps improve the lipid membrane. Dr. Tran says she may also use binders like psyllium, bentonite clay, and/or activated charcoal.  She finds that cholestyramine is fairly harsh, so she does not use it.  Dr. Tran will also look at the gut, esp. since mold has a relationship with candida overgrowth. 

 



Dr. Jessica Tran is a board-certified Naturopathic Doctor who is practicing Functional Medicine at the Wellness Integrative Naturopathic Center in Irvine, California, where she practices with Dr. Darin Ingels. The website is WellnessIntegrative.com and she can also be found at DrJessicaTran.com   Dr. Tran’s office phone is 949-551-8751 where she sees patients in office or remotely. 

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

Podcast Transcripts

Dr. Weitz:            This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting-edge information on health and nutrition from the latest, scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health. Hello Rational Wellness Podcasters. Dr. Ben Weitz here. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and leave us a ratings and review. That way, more people can find out about the Rational Wellness Podcast.

Our topic for today is toxic mold, its effect on our bodies, and how to get rid of it, with Dr. Jessica Tran. Exposure to mold and mold toxins, known as mycotoxins, affects many people and often is an undiagnosed underlying trigger for many other symptoms and conditions.  Many people are unwittingly living or working in water-damaged buildings, and this exposure may be causing many negative effects on their health including skin rashes, respiratory problems, cognitive, neurological issues, fatigue, headaches, joint pain, even increased urinary frequency, and a list of other symptoms. When looking at a patient from a functional medicine perspective, we usually focus on likely underlying triggers and root causes of their health condition, and mold may be one that is sometimes overlooked.  Research indicates that mycotoxins can bind to DNA and RNA and cause damage, alter protein synthesis, increase oxidative stress, deplete antioxidants, alter cell membrane function, act as potent mitochondrial toxins, and alter apoptosis, which is important for killing off cancer and other cells that we don’t want in the body. Molds and mycotoxins can negatively affect our hormones including our sex hormones, thyroid, and adrenal function. In some cases, POTS, postural orthostatic tachycardia syndrome, fibromyalgia, chronic fatigue, and a bunch of other conditions can be caused by mold exposure.  Other conditions that may have a mycotoxin component include various cancers, diabetes, atherosclerosis, heart disease, hypertension, autism, rheumatoid arthritis, lipid problems, Crohn’s disease, Sjögren’s syndrome, MS, Alzheimer’s disease, et cetera. 

This is why we’ve asked Dr. Jessica Tran to join us today. Dr. Tran is a board-certified naturopathic doctor having completed her naturopathic degree from Bastyr University. She also completed a three-year specialty environmental medicine fellowship, and she also recently completed an MBA in health care from UC Irvine.  Dr. Tran is extremely knowledgeable about mold and mycotoxins and environmental conditions, and this is why we’ve asked her to join us to share some pearls of wisdom with us today. Dr. Tran, thank you so much for joining us.

Dr. Tran:              Thank you so much for having me. I’m excited to be here.

Dr. Weitz:            Excellent. How did you become interested in environmental medicine and studying mold and patients suffering with mold toxicity?

Dr. Tran:              It was through my fellowship program at Southwest that I became more familiar with mold. It was never on my radar. It wasn’t anything I ever learned in undergrad or even living in Seattle where it’s very moldy and damp. I rarely had encountered anyone or any patients that came in for us with symptoms that remotely resembles mold, toxicity or mold allergy. I was probably seeing them, but it wasn’t anything that was exposed to me at that time.

Dr. Tran:              In my fellowship program, because I was at the Center of Environmental Excellence there, we saw patients from around the globe, and it was there that I had patients come in, and it was through my mentor and faculty director who through our history uncovered that patients who were living in water-damaged homes or had exposure to mold had chronic illnesses that after seeing 40 or many, many different doctors, their symptoms and condition wasn’t resolved.

One of the things that really fascinated me was that you can have mold exposure and not even see it in your home because it could be behind the drywall of the home, and patients would usually have a history of, “Yeah, we had water damage. We cleaned it up,” or, “The toilet overflowed,” but we then … Part of the fellowship program, you learn about building practices and how to ask certain questions. We have our patients or a home inspector go in, take a look, and lo and behold, sometimes people would have black mold behind their shower wall or in their bathroom or even in their home or kitchen sink, roof leak, and that was really where I learned a ton about patients who were exposed to mold and having mycotoxin issues.

Dr. Weitz:            Cool. So, what would make you suspect that a patient that you’re dealing with may have an underlying mold problem that’s part of their health struggles, especially when symptoms of mold toxicity could also be caused by a number of other things?

Dr. Tran:              That’s the hardest aspect. It’s usually for most … As a general practitioner, it’s really hard to know because patients are coming with fatigue, joint pain, and all these other things that are so many different things that you can have value … they have … For me, sometimes, I’m one of the last people that patients see, and it’s a diagnosis of exclusion. If it’s something that a doctor hasn’t looked at, it’s something that I usually ask. One of the things that are strange, rare, peculiar, or that patients will come and being overlooked is patients with dementia or Alzheimer’s.  To this date, I’ve had a handful of patients who have triple negative breast cancer, and hands down, every single person has had a tremendous mold exposure. So there’s certain cancers that I believe-

Dr. Weitz:            Wow.

Dr. Tran:              Wait. We don’t know if it’s the culprit, but it’s definitely an association that we see. It’s definitely something that’s, for me, just my bias is strongly correlated that I see in my practice. We take an environmental perspective, environmental history, and part of the history, somebody who has many chronic illnesses, I would say three or four conditions, like hypothyroidism, Lyme infection or other allergies. Most of them will struggle with a mold intolerance, and that could be mold allergy or a mycotoxin issue.  The mycotoxin issue, we get mycotoxins from our food, right? So we’re all exposed to mycotoxins to some degree. Our body naturally will eliminate mycotoxins on its own. But as you know, people who struggle with metal issues, their ability to eliminate may be slowed based on their genetics. So they may have a compromised ability to eliminate. Even though, naturally, we all have the ability to eliminate it, some people eliminate slower than others, and because it’s slower there’s a buildup that occurs, and we develop this toxic burden, and it’s not just with mold, it’s with other things like metals in the environment, glyphosate, like different herbicides. You know, pesticides we’re exposed to also.  So it’s the totality of everything that we have to look at. But definitely, the mold mycotoxin issue is huge, and it’s hard to really know if it’s how big a factor it is.  I’m always asking a patient about whether they have water damage in their home, and most patients who are mold-sensitive will know because through their history, with their itchy eyes, runny nose. When they walk into a damp room, they’ll know. Others may not. So it’s a good history, is what I’d say.

Dr. Weitz:            So what percentage of patients that have symptoms of mold toxicity or that do have mold toxicity know that their home or office has mold that they’re getting exposed to?

Dr. Tran:              Surprisingly, I believe, and maybe my patients are more educated. They will say to me, “I think my home … ” Maybe I’m mold-sensitive because I’ve read about it online. But for most patients, I don’t think … They don’t suspect because it’s never anything that they’re clued into.

Dr. Weitz:            Right.

Dr. Tran:              So I actually believe it may be more diagnosed than we ever realized it to be because it’s something, but it’s not really talked about or taught in conventional medicine. Most conventional practitioners will send a patient to an allergist. The allergist will do a skin scratch test. It may not even show up because the mold, allergy is not IgE-mediated–it may be a delayed response. So we may-

Dr. Weitz:            An IgE or IgM reaction.

Dr. Tran:              Yeah, so there are patients who are immune-compromised that are more susceptible to getting certain mold infections, especially in their lungs. When patients are immune compromised, that’s recognizing how much medicine. But for people who have a low-level toxin exposure with mold accumulation, it may be overlooked.

Dr. Weitz:            You mentioned triple negative breast cancer, and we’ve had a few patients with that over the years, and that’s really a grim prognosis, very hard cancer to treat. Do you find that treating the mold increases their prognosis?

Dr. Tran:               It’s hard to say. But in my experience caring for these patients, with triple negative, their prognosis is better, and I think it’s because we’re doing everything else, right? We’re changing their diet. We’re helping them change … decrease stress. I think it’s everything together. But I say that with the triple negative breast cancer because there isn’t anything … The prognosis is terrible. Some patients go around different chemotherapy agents, which usually have no evidence, which blows my mind because it’s supposed to be a research … science-based.

Dr. Tran:               But I know they’re doing their best. They’re trying to find the best regiment for patients.  I find a lot of my patients with the triple negative breast cancer and comparing to people who decide to go conventional versus integrating Functional Medicine, alternative medicine aspect, they do better because of everything they’re doing, the diet, lifestyle, supplements and hormonal balance. Even though estrogen/progesterone isn’t playing a role, there’s cortisol, the adrenal glands, right? So that plays a role too. We have to address that.

Dr. Weitz:            Yeah, and I’m not convinced. Even though they’re estrogen-receptor negative that estrogen metabolism still isn’t important in these women.

Dr. Tran:              Oh, and it’s gut, right? Gut function?

Dr. Weitz:            Right, yep.

Dr. Tran:              Gut function’s essential, right?

Dr. Weitz:            Right.

Dr. Tran:             Our microbiome is very important. How our gut … You know, B vitamins are important. If the patient has dysbiosis, they’re most likely to have an altered level of beads. I mean, we know that there’s so many different co-factors in our body that we need for metabolism, essential detoxification. I really believe for triple negative and certain types of cancer, it’s the depletion of essential nutrients that leads to altered or uncontrolled growth of cells, right?  So that’s why when we see patients with certain cancers, we’re always looking at nutrient levels. How can we support them from that?  And food is medicine.  We start there first and look at how will they absorb.  We can see that we go through higher levels of intervention.  We may need like IV nutrient therapy.

Dr. Weitz:             Right. Do you find any tests useful for screening patients for mold toxicity? Such as, say, some of the urine tests?

Dr. Tran:              They can be useful, yes. So the caveat for that is that when you do these urine tests, it doesn’t tell you what your burden is. It tells you your level of exposure, and it tells you you’re able to excrete. Similar to toxic metals, so we … There are some people who are non-excreters. They don’t excrete well. What I do find in the patients who are poor excreters, they’re not going to have a high level of mycotoxins in their urine. It’s going to actually show a low level. It’s counterintuitive, but then what I learned, and I learned this through Dr. Tim Guilford that glutathione binds to mycotoxins.

So what I’ve done in patients where I know they’re living in a water-damaged home. I know they’re … They have every classic symptom that the urine test shows that it’s negative. I do a glutathione challenge. So the day before, I will either dose with liposomal glutathione throughout the day, with 500 milligrams three times a day. Or I’ll do an IV bolus of glutathione drip or push and then collect the next morning first urine void. Then you’ll see it.

Dr. Weitz:             Cool.

Dr. Tran:              I do have a case. I can show you with the lab results at the presentation. So whole family has exposure living in the moldy home, and there’s one … The mom has very high levels of leukotoxin, and of fragilis in the home, from air samples in the home. Her urine test shows that she’s exposed. Her friend who has developmental delays and issues, his levels showed very little, like nothing. Nothing excreted out. The interesting thing is that the son saw my colleague in the office, Dr. Ingle. I recommended the tests. He saw the results. He’s like, “Oh, okay. No exposure.”

Dr. Tran:              But when you look at … because they’re exposed. The kid has to have some excretion.  But what it tells me is that this kid is a poor excreter.  He’s probably very, very burdened but he’s not excreting well.

Dr. Weitz:            Did you do the glutathione and retest with him?

Dr. Tran:              Yeah, and so you will see when you do the glutathione and then you retest. You see a greater level of excretion, maybe not a ton. I have a handful of cases where that’s the case, where toxic mold exposure. Their practitioners will do … I see them. They will see other practitioners around town. They have a test. It’s negative, and I’m like, “Let’s try this. Let’s try a glutathione challenge test,” and then lo and behold you see a greater expression of mycotoxins, and I believe it’s because it’s stuck, stored or what not in the body, and not excreted well. We see that with metals. So it’s my experience in metal toxicology with the chelaters. I drew from that to apply in this situation.

Dr. Weitz:            Meaning when somebody comes in, you suspect might have heavy metal toxicity. Instead of just measuring their urine, you give them a oral chelater, and then you measure their urine the next day with the idea that the chelater is pulling the metals out that then will get excreted?

Dr. Tran:               Exactly. That’s the exact concept because we don’t really … When we’re doing a first morning urine challenge test either for mold or heavy metals, just first … No chelater. First morning void just shows us what the patient is exposed to and how well they’re able to eliminate. It doesn’t tell us what’s bound … For metals, we know this from metals really well, is that certain metals will bind very strong to proteins and make certain enzymes non-functional. It’s the affinity of these metals that bind it so strongly when you have a chelating agent on board, it pulls it off and then freeze it up, and then you excrete it out through the urine.

Dr. Tran:               So, same concept. I don’t know if you’re … Are you familiar with the autism study When they looked at the baby’s first haircuts and looking at mercury?

Dr. Weitz:            No.

Dr. Tran:               There’s a study looking … because we had believed that mercury was implicated in developing autism. So there’s a study that looked at babies’ first haircuts, and we expected to see a higher level of mercury excretion in kids on the spectrum. But the opposite was what the studies showed. It was in fact the neurotypical kids. The control’s had high levels of mercury versus the autistic kids, and that study demonstrates and illustrates the fact that the autistic kids are poor excreters since their genetics doesn’t allow them to excrete. That’s the takeaway from that study.

Dr. Weitz:            I see.

Dr. Tran:               We have a study similar, which I’ll talk about. Same thing with children on the spectrum do not excrete ochratoxin very well either. So you’ll see the control group will excrete really well, but the children on the autistic spectrum will not excrete ochratoxin very well. The study doesn’t take the leap to do a glutathione challenge test or anything. They hopefully one day will get there. But the research does show that there are people who just do not excrete very well.

Dr. Weitz:            Cool. So what’s the best way to test your home for a mold or mycotoxins?

Dr. Tran:               There’s different ways to test. So you can do a spore trap analysis. You have somebody come to the home, measure the spores in the home. You could do … The inexpensive way to do it is … I tell some of my patients. You can get a petri dish. You go to Home Depot or buy on Amazon online a petri dish mold, you know, test. Just put it in the home, and if you just leave it in there, in the home for a couple days, then you send it back and you get a report. It’s not very expensive.

Dr. Tran:               I usually recommend patients to get it evaluated by a mold expert or somebody who comes in the home. They can do the moisture test testing, looking at indoor mold samples and outdoor mold quality. There’s some people who will talk about the ERMI and the HERTSMI. So we’ll go over that at the presentation, the pros and cons. But in a nutshell, the ERMI is a more extensive evaluation. The HERTSMI is looking at the five molds, mycotoxins, like producing molds that Shoemaker believes are most … has the most adverse effects on our health. So those are the differences in a nutshell.

Dr. Weitz:            Okay, so let’s get into treating. So how do you treat a patient that we believe strongly or is confirmed from testing are sick from mold or mycotoxin exposure?

Dr. Tran:               For treating a patient, you also have to not only look at the molds. You look at the whole entire person. You have to look at the food allergies and there are other environmental allergies to get the best resolution. There’s some people who will just treat in isolation, like feel like we will do a disservice if you just do that. But there’s some people who just want just the mold component. If you look at just the mold component, what the evidence shows is that liposomal glutathione, IV glutathione does bind into the mycotoxins.  If we’re talking about mycotoxins alone, you know, glutathione, in conjunction with phosphatidylcholine, because it helps improve the lipid membrane, is essential because we know it impairs cellular … a lipid bilayer. So phosphatidylcholine is another oral or IV. It’s something that can be used. Looking at the gut microbiome is really important.

Dr. Weitz:            So it’s interesting. You talk about liposomal glutathione is something that binds to the mold. I’ve been hear people talking about liposomal glutathione or the forms of glutathione as a way to push the mold out and then using clay and charcoal and pectins and things like that to bind it.

Dr. Tran:              Yes.

Dr. Weitz:            One of the experts calls it the push-catch strategy.

Dr. Tran:              In my experience, if we had to pick one, glutathione’s my favorite.

Dr. Weitz:            Okay.

Dr. Tran:              The binders, yes. Some people like to use cholestyramine. I find that it’s really harsh. So there are other binders that are good like psyllium, bentonite clay, that’s good. It’s hard to find a good source of it too. It’s fairly inexpensive. Some people will take activated charcoal at nights.

Dr. Weitz:            Right.

Dr. Tran:              I think it’s essential for us to know how to schedule it so patients don’t deplete their nutrients more than they are depleting their nutrients.

Dr. Weitz:            Right, because those binders if they’re consumed at the same time with foods that have a lot of nutrients or nutritional supplements, they’ll bind with those two and take them out.

Dr. Tran:              Yes, yeah, absolutely. We’ll do a lot of gut work too when patients are exposed to mold. Some patients are like, “Why do I have to look … Why are you making me do a stool test?” I’m like, “It’s part of the evaluation,” because it’s not just … because mold has a relationship with patients with candida too.  Some people who have an overgrowth of candida will just experience symptoms of mold, allergy, and toxicity to a greater degree.  So we want to make sure we evaluate it, and we treat it appropriately.  That’s why I like the sensitivity testing, our functional comprehensive stool analysis, because we can actually treat with the correct nutraceutical.

Dr. Weitz:            Cool. Of all those binders, I’ve seen clay, charcoal, cholestyramine, chlorella, zeolite, modified citrus pectin, beta-sitosterol, glucomannan, diatomaceous earth. Can you sort those out? Or what are your two favorites? Or do you like to use some in certain cases?

Dr. Tran:              I would say my favorite would probably be the bentonite clay and activated charcoal.

Dr. Weitz:            Okay.

Dr. Tran:              And there are super soluble fiber products that I like to use too. I think fiber’s important because it also helps, and it really depends on the patient’s budget too. So, activated charcoal is relatively really expensive, and it is something that’s put on board for just to help. If they can do with different fibers, and we rotate the fibers, that’s something that I like. Some people can’t tolerate one fiber over the others. That’s why you have to understand what theIr intolerances are too.

Dr. Weitz:            Okay, interesting. Hey, have you noticed that we seem to be in this charcoal phase of consumer products? I mean, in fact, in my household, my wife had brought home a toothpaste with charcoal, a facial mask with charcoal. Occasionally, we have a treat of ice cream made from coconut, and they have a flavor that is charcoal ice cream.

Dr. Tran:             I think that’s a new trend and fad.

Dr. Weitz:           I mean, it’s … Everywhere is charcoal.

Dr. Tran:             I was with a friend this weekend, and I ordered a lemonade charcoal, and she was like, “What is this?” I’m like, “It’s lemonade charcoal. It’s a trendsetter.” We went and had an amazing bowl in Los Angeles, and it had charcoal, and she was like, “I can’t … Why is there charcoal in everything?” I’m like, “Just wait. In a couple of months, six months from now, it’s going to … support everyone there. But it’s trending here in LA. Yeah, it’s every … lemonade, yeah.

Dr. Weitz:           Yeah, I guess we haven’t had a new fruit that only grows in the Amazon that’s the new super antioxidants. So we got charcoal now.

Dr. Tran:             I could tell you about other exotic fruits that hasn’t been well talked about.

Dr. Weitz:           Oh okay. Maybe we could start a trend right here on the Rational Wellness Podcast.

Dr. Tran:             I’ll bring that to you next time, other botanicals and nutrients that aren’t trending yet that that we can tell about, yeah.

Dr. Weitz:           Okay. We’ll be the trendsetters. So when you’re treating a patient for mold or mycotoxin toxicity, do you have them avoid foods that may contain mold or … And do you have them avoid eating mushrooms, by the way, which is another trend is foods that have dried mushrooms in them, like reishi and chaga and whatever the latest trendy medicinal mushroom is-

Dr. Tran:             Cordycep.

Dr. Weitz:           … that’s put in coffee and tea and everything else?

Dr. Tran:             Yeah, so, it really depends on the patient’s tolerance, and that’s of the other thing is making sure we understand the patient’s food intolerances. In general, most providers who are treating patients with molds, they avoid all of it. Even avoid the mushrooms. Avoid cheese, everything. I find that some patients will be able to tolerate taking cordyceps or reishi for adrenal support when they’re mold sensitive, but there are other patients who cannot tolerate it. So it’s patient specific. You really have to identify their needs, yeah.

So as a blanket statement, I think, in general, sure, you can avoid. But I think mushrooms have such beneficial uses, and I also there are good uses of mold. Not all molds are bad.

Dr. Weitz:           But we could very easily say since these are common foods that have mushrooms, and they’re also very common allergen, say, avoid wheat, corn, cheese. There’s a few other common foods that also are probably irritating to the gut. You could easily take those out as part of your program and improve their overall health. Take out alcoholic beverages.

Dr. Tran:             Yes, yeah, you can.

Dr. Weitz:           Should we be using an air filter?

Dr. Tran:             Well, in Orange County, LA area, I think we should … air filter.

Dr. Weitz:           What’s the best kind of air filter to get?

Dr. Tran:             It depends on what you’re trying to eliminate. So what I tell patients-

Dr. Weitz:           Mycotoxins.

Dr. Tran:             So if you’re looking to get rid of mycotoxins and mold spores, you want to look for an air filter that has a MERV 8 rating at least. Each filter will have a different rating. I’ll show that to you in the presentation. There’s different types of air filters and qualities, and the issues of the air filter is … You can have charcoal, carbon filter, air filter, or you can have one with ozone. Then people will say that certain air filters will emit too much EMF. So you have to look at the EMF excretion. You know, the emission of EMF.

Dr. Weitz:           Yeah, I just did a podcast with Oram Miller, and he’s the EMF guy. He spoke in our last Functional Medicine meeting as well.

Dr. Tran:             One of my favorites air filter, which is the IQAir Air … You know, he and other people will say, “It emits too much EMF for certain patients.” So I like the IQAir, Blueair or the Austin Air are the three top air filters that … It was just passed down from me … I’m just regurgitating that information … and in our industry is what we recommend to patients. There are other ones like-

Dr. Weitz:           So what are those three again real quick?

Dr. Tran:             The IQAir.

Dr. Weitz:           IQAir.

Dr. Tran:            IQAir is big and bulky, but it’s beautiful. It’s quite expensive. The Blueair is nice and sleek.

Dr. Weitz:          So we can turn our home into a blue zone with the Blueair filter.

Dr. Tran:            Yeah. The Molekule, which is newer. I have one in my office. It’s-

Dr. Weitz:          Could you repeat that last one because you broke up a little bit.

Dr. Tran:            Oh, I apologize. My internet. I am hardwired, though. Is the Molekule. The Molekule is the last one that a lot of you were … or a lot of people have been talking about. I actually have three in my office. I love it.

Dr. Weitz:            Oh, wow.

Dr. Tran:               I have every single one in my office. I have the Blueair, Austin Air, just so that I can show patients the different types of air filters they can pick for their home. I think honestly, like anything at Costco is good too. If they want to go Target, most products at Target are sufficient too.

Dr. Weitz:             Yeah, but don’t buy your fish oil at Costco.

Dr. Tran:               I know. I don’t get that. But yeah, it’s interesting. But yeah, but quality of Costco fish oil is just …

Dr. Weitz:             Oh my God.

Dr. Tran:               We’ll talk about … I don’t know. Do you talk about that on your podcast because I don’t think the consumer, the public knows about the quality of their own fish oils.

Dr. Weitz:             I haven’t done a podcast just on that, but it’s definitely something I’m passionate about, but I definitely should.

Dr. Tran:               I have lab results for patients who take my supplement, and then they want to go to Costco to get it for less expensive, and their numbers change, and I’m like, “Well … ” I just don’t pay attention because my staff deals with the dispensary side. I mean, dispensing supplements, and I’m like, “Well, what supplement are you taking?” They show me this Costco bottle. I’m like I cringe.

Dr. Weitz:             Oh, I know, and it’s the size of a garbage can, and it costs $20, and you go, “What do you think?” You think you’re going to get caught?

Dr. Tran:              They’re like titanium dioxide. I mean, which is more than a lot of supplements and more patients can be safe. But there’s a lot of coloring and fillers, and I haven’t even … Yeah, you read the label, and you’re like, “Wow.”

Dr. Weitz:            I know.

Dr. Tran:              But it is something, and if it’s what they can afford, something is better than … But I don’t know. It depends on the situation.

Dr. Weitz:            Okay, Jessica. So thank you for providing us with some very interesting, useful information about mold. How can listeners and viewers get ahold of you? How can they contact you?

Dr. Tran:              At my office or through Gmail?

Dr. Weitz:            Yeah, yeah. Well, I mean, what’s your website? And you can give out your office phone number, and you do consultations in person, and do you also do them remotely?

Dr. Tran:              I do for certain situations, yes. So my website is wellnessintegrative.com. My office number is 949-551-8751, and I’m on drjessicatran.com. Instagram is Dr. Jessica Tran. I also have a Facebook page, I guess. People message me through that, my Facebook.

Dr. Weitz:            Okay, good.

Dr. Tran:              That’s Dr. Jessica Tran-Naturopathic Doctor.