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Rational Wellness Podcast

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Rational Wellness Podcast hosted by Dr. Ben Weitz helps you unlock the latest science in functional medicine, nutrition, wellness and health, so you can optimize your body and mind. Weekly interviews with experts in Functional Medicine and Wellness with focus on gut health, hormones, inflammation, wellness, brain health, nutrition, health and longevity. You'll discover evidence-based strategies to reverse chronic disease, balance your biology, and extend your healthspan — from cutting-edge lab testing and nutrition to personalized lifestyle interventions. Past guests include Dr. Dale Bredesen, Dr. Jeffrey Bland, and Dr. Mark Pimentel and many of the most trusted voices in functional and integrative medicine and the wellness world. Subscribe today to learn practical tools you can use right now for better health and wellness.

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episode Cheating Death with Dr. Rand McClain: Rational Wellness Podcast 299 artwork

Cheating Death with Dr. Rand McClain: Rational Wellness Podcast 299

Dr. Rand McClain discusses How to Cheat Death with Dr. Ben Weitz. [If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page [https://www.youtube.com/user/weitzchiro].] Podcast Highlights 3:15Dr. McClain feels that there is a lot of science behind the DNA methylation tests to gauge the rate of biological aging and at this point is the best way to gauge our rate of aging.  He recalls doing a test like this prior to the recently commercialized TruAge version that cost as much as $10,000. Next best to DNA methylation is testing for telomere length.  Dr. McClain has developed an app, the death clock, that is a biological clock evaluation based on biomarkers. 14:35 Dr. McClain had prostate cancer six years ago and was able to cure it with a natural approach by taking specific polyphenols, including green tea extract (EGCG) and cayenne pepper.  He also used Metformin to lower his sugar levels.  Dr. McClain pointed out that while this approach worked for him, he is not recommending it for others with cancer. 20:36Rather than take NAD+ precursors like NR or NMN, as others in the longevity research space recommend, Dr. McClain feels that the best NAD+ stimulator is exercise.  He does recommend sustained release Beta-alanine, which improves your exercise capacity, as an anti-aging supplement.  Another supplement that Dr. McClain recommends is a form of Cat’s Claw herb, AC-11, in order to help repair our DNA.  He also personally takes Rapamycin once per week, which is an mTOR inhibitor for longevity purposes.  While he takes Rapamycin once per week, he will use a peptide that is a growth hormone secretagogue to try and balance out the GH suppressing effects of Rapamycin. Dr. Rand McClain is a leader in alternative and regenerative medical treatments at his Regenerative and Sports Medicine Clinic in Santa Monica, California. Dr. McClain went to medical school late, at age 37, after a career as an accountant and a professional boxer in Argentina.  He utilizes various anti-aging therapies in his practice, including Bioidentical Hormones, stem cells, peptides, hyperbaric oxygen, cryotherapy, and nutritional supplements.  Dr. McClain has a new book Cheating Death [https://www.barnesandnoble.com/w/cheating-death-rand-mcclain/1140960669], the new science of living longer and better, which was recently released.  His website is DrRandMcClain.com [https://drrandmcclain.com/]. Dr. Ben Weitz is available for Functional 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations. Podcast Transcript Dr. Weitz:Hey. This is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast. Hello, Rational Wellness podcasters. Today, we have an in interview with Dr. Rand McClain on cheating death. Dr. Rand McClain is a leader in alternative and regenerative medical treatments at his Regenerative & Sports Medicine clinic in Santa Monica, California, a close neighbor of mine, Dr. McClain, went to medical school late at age 37. After a career as an accountant and a professional boxer in Argentina, is there anything you haven’t done, Rand, he utilizes various anti-aging therapies in his practice, including bioidentical hormones, stem cells, peptides, hyperbaric oxygen, cryotherapy, nutritional supplements, and Dr. McClain has a new book, Cheating Death: The New Science of Living Longer and Better, which is due to be released on March 7th of this year. Rand, thank you so much for joining us. Dr. McClain:No, sir. Thank you for having me. It’s my pleasure. Dr. Weitz:So perhaps you can tell us a little bit about your own health history, which you share in the beginning of the book. Dr. McClain: Yeah, I think it’s probably why, if you look in hindsight why I got into medicine, because I had so many issues myself, I figured might as well… I did so much research, might as well help other people with it too. And I got interested with it for selfish reasons, obviously. But really, to be fair, before I ever got injured, one of the first books I ever pulled off the library that I had at my parents’ house, I say library, they had a bookshelf and they were kind enough to provide us as youngsters with a encyclopedia group and all that. But my mom was one of the early nutritionist before that was even really a phrase. And she had a book on nutrition from Adelle Davis, and I remember thinking, “Wow, this is pretty cool. You can affect your health with what you eat?” Which again, I’m 60 now, so at age 11, that wasn’t really thought of as anything that was real. So that sparked my interest. But then, yeah, I’ve had probably… I say I stopped counting at 30, and that’s true. I’m estimating I’m up to about 30 surgeries now. So I’ve had an- Dr. Weitz:Oh my God. Dr. McClain:… occasion to get into medicine for other reasons than just helping others. Dr. Weitz: Hey, the only one I know who’s had almost as many surgeries is our friend, Phil Goglia. Dr. McClain:He’s been through a few too, right? Dr. Weitz: Yeah. God. Especially some of the mishaps you described that happened, I’m surprised you wanted to go into medicine. Dr. McClain:Well, part of it was there’s got to be a better way, but then you circle back and you realize it’s not all bad, what we call Western medicine, and it has its definite pros along with some of the cons. Dr. Weitz:Right. So your book, Cheating Death, is essentially about longevity and it can be helpful to measure our rate of aging, to know how well our longevity program is going. What do you think are the best tests for gauging our biological aging? Dr. McClain:That’s a great question. We don’t have a consensus because I think the main reason is we haven’t lived long enough to be able to test our theory or assumptions. We can test them, though. And I’d say probably to answer your question with one caveat, I’d like to talk about… Well, it’s not a small difference, but we’ve been talking about longevity, but the new phrase is healthspan. It’s not a phrase, it’s a word, but it encompasses the idea of not just living longer, but living well healthily while you’re around, which all of us want to do. I bet in your practice, you’ve never met anybody who said, “Hey Doc, if I can trade you some quality of life, for give me 10 on the back end, let’s figure that one out.” No. No one wants that. It’s actually the opposite. But there’s a lot of science behind the DNA methylation tests, the whole methodology. Dr. Weitz:Yeah. Have you used the TruAge version from TruDiagnostics? Dr. McClain:Well, yeah. And they’re borrowing from his methodology. Yeah, they found it much cheaper way… When I first did this, it was 10,000 bucks and you’d buy a tray essentially. I think it’s either… I think it might have been a thousand bucks a spot, in other words, but it was a minimum tray of 10. And you got your friends to, “Hey, come on, find out what your biological age is with me here, so you can split the cost.” Now it’s down to, I think those guys you can just refer to, it’s down like 238 a run or something like that. Dr. Weitz:Yeah, maybe a little more. I think it’s more like four, 500, but something like that. Yeah. Dr. McClain:I mean, it’s certainly much better than it was, put it that way. Right? Dr. Weitz:Yeah. Dr. McClain: And I’d say that’s probably the most accurate. Second to that would be maybe the telomere length. Although there’s caveats with that because you want to use a certain technology that doesn’t just give you the mean, but also what we refer to as the median, as opposed to just the average or the mean. And then it gets a little dicey too, because what we would normally consider great, having longer telomeres can actually be horrible because cancer can also show up with longer telomeres. So that one requires maybe a little bit more interpretation. But a quick and easy one is DNA methylation. And I don’t know if you asked me that on purpose or not, but I developed what I call the death clock, a biological age evaluation, an app, and there’s all kinds of other pieces of information that we can use. And using mathematics, regression analysis, basically, multivariate regression analysis, we can come up with a pretty good idea of what your biological age is.  And if I might say also, the purpose is not… I mean, it’d be great if we could come up with a very accurate means, but I say we’re a few lifetimes away from that, just practically speaking.  But from the standpoint of what’s valuable to us, you and I deciding, hey, what we’re doing now in our new regimen is that working to make us younger, precision is most important. So we can say, “It might not be that I’m 60, but I have the age of a 45-year-old or worse, a 65-year-old. Now that I did this, improved what I think is going to improve my health and lower my biological age, I went from 45 to 43, and I have a way to show that’s working in the right direction.”  That’s what we’re looking for. Yeah. Dr. Weitz: Yeah, absolutely. That’s what I’ve been using it for.  But I know there’s some qualms about the DNA methylation test, is possibly being variable with short term changes and diet and stuff.  So not everybody accepts it, but I think it’s the best we have right now. Dr. McClain:Yeah, I would agree. Dr. Weitz:So what do you think are the most important mechanisms of aging? Dr. McClain: That’s a tough one, man. The most important. Well, gosh. I don’t know how you would answer that fairly, to be honest. I mean, if you go through some of the mechanisms, you realize that they all make a difference. I don’t know there… And that’s another one we don’t have a consensus. What is the true source of aging? Is it simply something that is entropy, the breakdown of regularity into chaos in the universe?  I mean, is that the basis of all of it?  Is it cancer? Is it not?  Is it oxidation?  Is it free radicals? I mean, I would say it’s all of them. To what degree one means more than the other I think is open to debate and individuality.  And I don’t think we’re going to have a consensus, really. I think down the line, we’re going to find, it’s going to be some sort of Star Trekking device that takes all these factors into account per the individual and says, “Hey, you need to focus… Your aging is driven more by this, X, versus Y, that.” Dr. Weitz: Yeah, I think it’s probably a combination of avoiding the big killers like heart disease and cancer and some of those.  If you can skirt by those or push those off till much later, and then you can start looking at some of the true biological markers of cell damage and et cetera. Dr. McClain: Well, you hit on really what’s going on right now.  And that’s when we look at these centenarians, we call them, the superagers, that’s what we’re really finding is there’s nothing special about them, and that’s not fair to say, but in the sense that they get the same disease as we do, they just get them later in life, 10, 20 years, even 30 years later than we do.  And that’s different, I think, than what you’re asking originally, what is the real source of aging?  Because the theory is that if we figure that out, whether it’s 10, 20, 30, really it’s going to be never down the line that we felt because that’s what we’re looking for, right? Dr. Weitz: Right. Yeah. No, there’s been all kinds of interesting experiments going on in trying to prolong longevity. I mean, I’m sure you probably heard about the David Sinclair group with that experiment using Naka Machi… What are they called? Naka Machi factors, Yamanaka factors, and reversing the aging of the mice.  And apparently that’s like the fourth or fifth experiment like that that’s been successful. Dr. McClain: And then I am the ultimate optimist, so I’m easy to chime in with you do. So I’ll play the red team for a second and say, the problem we have with a lot of these is we find out, for example, with the caloric restriction, what works in an animal doesn’t work for a human necessarily either. And that’s the problem. So I’m hopeful. I hope he keeps going. I love David Sinclair because I think he’s also an eternal optimist.  And that alone, I side with him.  I hope he keeps going with his research and he gets some private funding and we’ll just keep finding more and more out. But he’s not the only guy either.  Fortunately there’s more guys out there that are studying this sort of thing, and I think we’ll get more answers sooner now than we would’ve thought maybe 10 years ago. Dr. Weitz:Yeah, I guess there’s still a lot of talk about caloric restriction, but Mr. Caloric restriction himself, Dr. Roy Walford, unfortunately, he died at I think 76 of ALS, so. Dr. McClain:Well, he’s the one that was in the… And I’m terrible with names, I beg your pardon, but he was in the biosphere. He was- Dr. Weitz:Yeah, exactly. Exactly. Dr. McClain:And you look at that, I mean, I would say that’s a perfect example of what- Dr. Weitz: No, he came out of that looking horrible. Yeah. Dr. McClain:He was looking horrible. I can’t believe he didn’t feel horrible. That’s one where you go, “Hey, that’s not worth the trade, man. Quality of life includes some fun and not feeling crappy.” But I use that as an example of where theory with animals doesn’t always come into play. And you could argue that with humans, you could argue that because of what went awry with that biosphere, it was a really unintentionally well-designed… Well, a lot of it was well-designed to begin with, but they weren’t supposed to be restricting that severely. They had some problems in biosphere, right? Dr. Weitz:Yeah. His argument was, it was the stress of that situation that probably shortened his life, but… Dr. McClain:Well, again, that’s the problem with all these, these epidemiological studies. And even if you set them up as a prospective, how do you control all the factors that need to be controlled and bring it down to just one thing? And it goes back to your original question to my response, which we’re not going to be able to say it’s just one thing. There’s so many factors that we have to come into play. And I go back to that, and I’m not joking when I think of Star Trek and that the Doc would wave that tricorder or whatever the heck it was, that would pick up on supposedly everything you needed to pick up on. And I think ours will be a version of as much as we can observe combined with artificial intelligence, and it will be a very unique answer for everybody because there’s just too many factors involved. Dr. Weitz:Right. So how can we use nutrition to improve our biological aging? Dr. McClain: Well, the easy answer is fitting the correct nutrition with our individual selves. And that’s why another way of making my point here is if anyone tells you there’s a one diet that fits all, run away, because you and I both know that that doesn’t work. Now, there’s ones that you can start with that might get you in the direction you’re heading, depending upon your goals, what your individual genetics are, et cetera. But throwing into the mix your age, your work life, are you working, or even within that? Are you working 9 to 5 Monday through Friday? And then on the weekends, you’re free to do two or even three-day workouts?So the nutrition that you choose each day is going to be very different. And then the Chinese medicine doctors recognized this 5,000 years ago. That’s going to change also, not just with age, but the season of the year, the latitude at which you reside, all that kind of stuff.  So I don’t think you can say there’s one thing, but certainly… Well, Dean Ornish, right? H e came up with a pretty good strategy in terms of testing the diet.  So in terms of science with the Mediterranean diet or his version of it, sort of an adopted vegan diet, that might be one you could choose where you go, “Hey, I have plaque and arteries. This is a good one to at least start with.” Right? Dr. Weitz: Yeah. I don’t think he would agree that he recommends a Mediterranean diet.  He’s purely, clearly in the vegan camp. Dr. McClain:Well, I thought his last one, he threw in some salmon or something with the last version. Dr. Weitz:Really? Okay. Could be. Dr. McClain:There have been 10 iterations to be fair to you. I just happened to pick up on the last one and he said, “Yeah, you can go throw in some salmon there. And I called that.” Now we switched it. In my mind, that’s a Mediterranean, but to your point, yeah, I think he still calls it a plant-based. Right? Dr. Weitz: Right. Yeah. Yeah. Okay. So let’s talk about the… Let’s see. In your book, you talk about the anti-cancer effects of polyphenols, like green tea extract and curcumin.  Maybe you can talk about this.  Do you take these polyphenols? Dr. McClain:Well, this one’s a personal favorite of mine because I don’t know if I put it in the book or not, but I had prostate cancer. Dr. Weitz:Right. You did mention that. Dr. McClain: I had a PI-Rads 2, which is very early stage, right. Confirmed with an MRI. Not only that, but with a, it’s called an ONCOblot which is not available in the United States anymore, but a test for ENOX2 proteins. And there’s some issues with that because we weren’t really… We’re not getting too far in the weeds. It looks like that’s not exactly what we’re looking for, but the result is the same. We’re getting a diagnosis that’s accurate. Anyway, with the use of the polyphenols in green tea extract, EGCG, and cayenne pepper, which we know the pepper family helps release some of these and increase the potency as it were for these things. I beat it, meaning with no surgical… Dr. Weitz:Oh, you didn’t have surgery? Dr. McClain:No surgery, no radiation, nothing but these polyphenol again from, and it was an encapsulated form that equates to each capsule is the equivalent about 16 cups of green tea and this cayenne pepper without the caffeine, of course, or a theophan or anything that was sympathomimetic. And they made a time release formulation. So you would take during the day, this capsule every four hours, then at night you would take a time release eight hour version. And yeah, I’ve been cancer-free for, I think it’s about six years now, per both the ONCOblot when it was still available. Now the Grail, which is not the best, I think we have about 38% sensitivity with the Grail, but also with an MRI. Dr. Weitz:Did you have a biopsy? Dr. McClain:Heck no. That’s kind of why… We’re trying to avoid that. Yeah, I mean that’s opening up a whole ‘nother can of worm. So I’ll stop because that’s another at least five minutes of a tirade if you want one, boy. There’s so many problems that can come with that. The idea is to try and avoid it, if possible. Dr. Weitz:But I think that’s still considered the standard for diagnosis of prostate cancer? Dr. McClain: Oh, I beg your pardon. If you’re going down that route, yeah, I mean you could argue that… Well, I mean between the ONCOblot and the MRI, I’d say that’s pretty good… I mean, the MRI can come… You can send it off to a place in Holland and get lesion as small as three millimeters identified. And I mean, PI-Rads 2, we had a lesion identified, and the ENOX2 is pretty dog gone accurate. Dr. Moray spent 38 years of his life proving that one. Dr. Weitz:So you took this regimen of green tea extract and cayenne pepper, and you did it for how long? Dr. McClain:90 days was all I needed. Now I have to be fair, that wasn’t the sole treatment. And when you see the C word on your report, cancer, it gets your attention really quick. So I also used metformin, which drives your sugars down, as you know. Dr. Weitz:Okay. Dr. McClain: There might be some other factors involved there with autophagy, et cetera. And before anyone goes any further listening to this and they have cancer jumping on the wagon, know that there are some cancers, not many, but there are some where metformin would actually assist the cancer, where you don’t want the autophagy to be kicked in. But for the most part, and in the case of mine, certainly with prostate cancer in general, that’s a good idea. And then there’s some things that I don’t want to even talk about until I retire, because as you probably well know, Doc, I mean we start talking about, oh, cancer cure, boy, talk about putting a target on your back.  And I’m not saying, guys, that everyone should do this, right?  I’m not recommending it.  I’m just saying what happened to me and what I think [inaudible 00:18:41], right? Dr. Weitz:You got it. Okay. So let’s talk about nutritional supplements for longevity. Dr. McClain:Well, kind of dovetailing off who we just talked about, there are proven properties of certain polyphenols to prevent cancer. I mean, one of the things that I write about in the book is the process by which this does work that’s been documented. And I mentioned my old professor, Doctor… He’s not old, but from the old days when Dr. Melikan who talked about the way it works, I call it chemotherapy light. So it is documented that these things can help us. And of course, you might attribute some of the longevity and the cultures that drink a lot of green tea tubes, some of these properties. Dr. Weitz:What do you think about the Nad+ stimulators, like nicotinamide riboside and NMN? Dr. McClain:Well, this is the only thing where I would pick on David Sinclair just a little bit because, not because he’s got a vested interest in any of this stuff. I don’t even know if he’s got any monetary interest in it. I know his mentor, Lenny Guarente is the one that does that product basis, that has the NAD? Dr. Weitz:Yeah, the nicotinamide riboside, right? Dr. McClain:Oh yeah, he started it. And I think David actually- Dr. Weitz:I think Sinclair might be involved, too. Dr. McClain:Well, and I know he recommends NMN himself. Dr. Weitz:He recommends NMN, okay, then it must be the NMN, okay. Dr. McClain:Well, but anyway, the point is I wish he would be a little bit more clear about how often he uses it and why. Because I think you’ll understand what I’m saying at this way. It’s not clear to me anyway, how much he actually exercises. And he says, “Well, I take metformin and NAD,” certainly metformin on the days he doesn’t exercise. And I think it’s the same for the NAD. But my point is this, what’s the best source of NAD? Exercise. Dr. Weitz:Right. Dr. McClain:So for most of us in our world, Doc, I think people are exercising… To supplement NAD doesn’t necessarily make a lot of sense. That doesn’t mean it’s not going to make a lot of sense for those that either don’t want to or cannot exercise for whatever reason. So I’m definitely not poo-pooing NAD+. But in terms of your supplementation for at least most of the patients I see, I say, “Hey, spend your money on something else.” One of my favorites I think is should ban in the Olympics, for sure, if they’re going to ban all this other stuff, is beta-alanine. A sustained release version of beta-alanine, you’re getting that buffering and that leads to better exercise, which to me is again, your source of NAD+ plus exercise is a great equalizer for all the bad stuff we might do. Plus, you’re getting the L-carnitine, which not only is a buffer in that regard, but that’s an antioxidant in of itself and considered an anti-aging supplement. Yeah. Dr. Weitz: Yeah. I mean, personally, I’m exercising pretty much every day and I’m taking some NR and NMN. I’m hedging my debts. I’m going all in, whatever I can do. Dr. McClain: Oh, you’re fortunate. We’re both blessed that we can afford those. But for those that are trying to tear down- Dr. Weitz:No. Yeah, all these supplements are expensive, there’s no doubt about it. What about some other clinical pearls, nutritional supplements besides beta-alanine? You mentioned in your book cat’s claw extract, AC-11. Dr. McClain: Yeah. I mean, we know about [inaudible 00:22:13] now and booting out the, I use the analogy, the car that just can’t be tuned anymore and is polluting the air not only for the driver, but all those in cars around. That’s one of the great defenses the body has. And if it can be tuned, if we can repair the DNA, then all the better in some cases. So AC-11 has been proven to do that. Dr. Giampapa had some studies done over at least a two-year period where he showed… It was a very small group, but it was pretty well done and pretty clear that the AC-11 was working on as it was purported to do. And I mean, my favorite right now is rapamycin. And even the guys that are very conservative are admitting, “Well, I’m not necessarily recommending it to my patients, but I’m taking it too.” Dr. Weitz:Are you taking it? Dr. McClain:Heck yeah, man. I’m convinced by the evidence and the mechanism of action that we believe right now is the way it works that the problem is, and I do go into this probably too much so in the book for most people’s tastes, but with mTOR 1B, mTOR 2, the rapamycin is going to down-regulate mTOR 1, but also mTOR 2, and it seems to be dose related. So that’s why it looks like the once a week dosing is the way to go rather than consistently using the rapamycin. And I think we’re going to come up with a better drug that allows mTOR 2 to not be affected. Dr. Weitz:Yeah, because the risk areas, you suppress the immune system. Dr. McClain:Well, other… Yeah. I mean- Dr. Weitz:Because rapamycin was originally used for organ transplants to suppress the immune system. Dr. McClain:But what we find now is that in with further research, we’re not necessarily sure that’s exactly the mechanism by which that works, and certainly not with the dose we’re talking about now, it’s more.. Growth hormone is important, we find out, and if you suppress mTOR two for example, too much, that’s not going to work. And that’s one of the solutions that I have been experimenting with is, okay, take rapamycin every Monday, but for certain portions of the week, also take a GH secretagogue to try and balance out. If rapamycin is say, affecting mTOR one a thousand fold, okay, we’re definitely getting that effect. But if we throw GH in, well, we’re going to counter that and make it only 500 fold, but we’re not going to eliminate the effect of mTOR two and therefore rob Peter to pay Paul. And again, I’m probably going into the weeds too much and I try and explain a little bit more in the book. Dr. Weitz:Yeah, so explain for everybody what a GH secretagogue is. Dr. McClain:It’s something that tells your pituitary to make more growth hormone. Dr. Weitz:So is this a peptide that you’re taking? Dr. McClain: Most of them are peptides. There’s one that’s actually my favorite, which is what we call a peptidomimetic. And it’s my favorite for the reason that it tends to, in my experience in practice, create more growth hormone. And with the most recent study is about two months ago, a good size study, well-designed, got better results too. It’s called Ibutamoren. And it’s a capsule so you can ingest it, meaning you can travel with it better. These are practical, but very real considerations to consider when you’re talking about effectiveness, not just efficacy. Imagine a lot of people, end of the day, they’re morning people and “Oh my God, I got to get up. I didn’t take my GH secretagogue. I got to go downstairs, load a syringe. After I get this from the refrigerator, jab myself in the belly.” No, you can leave this next to your bedside. “Oh, I forgot. Well, I have my water and my pill. I’m done. And I don’t have to explain it to any visitors come over, ‘Oh, that’s such a supplement.'” Said, “Hey, what’s this little vial in your refrigerator, pal?” Dr. Weitz:How do you measure the growth hormone release? Are you measuring like IGF-1 levels? Dr. McClain:Absolutely. We know the growth hormone’s only going to be around for about 30 minutes. And so once it hits the liver, your liver’s going to make IGF-1, insulin growth factor one, and that has a half-life somewhere between, depending on who you read, 12 to 16 hours. And therefore, we measure that as a surrogate. And we’re trying to hit… in my practice, I look at treatment failures, anything less than 300 nanograms per milliliter. That’s about what you were producing when you were 20, and that’s what we’re shooting for here. Now the controversy, of course is, well, what about all these people that are living longer that seem to have a lower IGF-1? Dr. Weitz:Right. You know, Valter Longo is a prominent longevity expert who highly recommends that you want to have a lower IGF-1 level. I think he’s recommending under 175. Dr. McClain:But that’s based on observation, which is how we do a lot of things. But I’m not convinced that… When you look deeper, we won’t find that that’s because most people today are writing a desk and not doing much more than sitting there fogging a mirror so that it’s like pouring sugar in a Petri dish full of bacteria. Actually, that’s a bad example, but nutrients for bacteria, it’s going to overwhelm the Petri dish. And too much growth hormone is like leaving a redheaded stepchild alone at home. He’s going to get in trouble. But for someone like you who works out every day, pushes himself and needs the regeneration benefit of a growth hormone, I would argue, no, actually you’re probably doing yourself more harm than good by trying to lower your IGF-1 and growth hormone release. My opinion. Dr. Weitz:Well, interesting. I don’t know if you’ve seen the Fahe study, but that was the first study that was published that showed a reversal of epigenetic aging and the interventions were growth hormone, metformin, DHEA, vitamin D and zinc. Dr. McClain: And again, I should probably state up front that none are convincing one way or the other. My argument versus the gentleman you just mentioned, the Prolon guy over at USC. Dr. Weitz:Valter Longo. Dr. McClain: Yeah, nothing. The studies are just, they’re just too poorly done. There are just too many other factors where you can definitely go, “Oh aha, this is the answer,” because it’s so multifactorial. We’re finding out more and more, and I’m not going to make any more references to the Star Trekking thing, but I think it applies. I think I’m taking it out of context to some degree, so is Longo. So is Fahy. I think we’re all in the game, and we all have our hearts in the right place, but I don’t think we can draw too many conclusions just yet. I think it all becomes individualized. Dr. Weitz:I think to worry about higher growth hormone levels is that it might be associated with higher cancer rates. Dr. McClain:Yes, but I could pick that one apart too. I won’t waste your time with it, but I mean, it sounds silly at first. I’ll just throw one thing out there, but it could be… Well, this is too far afield as a remark, but you have some cancers that are not responsive to many things and they’re slow growing. You may get more results by attacking it with chemo, which works better on fast-growing cancers because they’re replicating faster and throwing in some growth hormone. I know it sounds crazy, but to get that cancer replicating fast, to exaggerate that process where cancer’s growing faster than the normal cell, enough to make the chemo work. I know that sounds too esoteric, but we’ll move on to the next question. Sorry. Dr. Weitz:Okay, no problem. On your section on supplements, I just wanted to comment on one thing that you mentioned, which was you like to use creatine for arthritis, which I thought was interesting. Dr. McClain: Well, there’s some studies showing, and I guess this is important, some anecdotal reports where it works, it might just be because they like to use the word volumizes the cell. We’re putting water back into the cells. Just like with growth hormone, one of the things that I think we forget to take into account, people say, “Oh, it helps build muscle.” To some degree, yes. But particularly in the famous study where it was with older people where they got the 8.8% increase in muscle mass, how much of that was more sarcomeres versus just going from 50% water, which we end up relatively desiccated as we age to back to our original 70% water. It counts as muscle, but is it really new muscle? Creatine is the same in the sense that we’re probably not replacing cartilage or making it new, but we’re hydrating what we have. It’s just, I don’t know if we have any MOAs identified yet, but it seems to work well. The one caveat, I go back to my favorite beta-alanine. In order to avoid problems with the excess acidity that can be created with what you can do with creatine, the extra three to five seconds of activity and you’re building up that lactic acid, it’s important to have the buffer there created with the beta-alanine use to prevent literal chemical damage to the cell. So I always recommend beta-alanine with creatine. Just a little- Dr. Weitz:Interesting. Yeah, I’m more positive than ever about glucosamine sulfate because I know there’s studies showing that there’s some benefit for arthritis and joint pain, but recently there’ve been several studies showing as much as a 30% reduced risk of death from cardiovascular disease with glucosamine and conjoin sulfate. So I’m now recommending as part of the longevity program for that benefit as well as for joints. Dr. McClain:Well, you got one I’m going to have to look up, Doc. I appreciate that. I thought you were going to go with the glycoaminoglycans and the fewer adhesions in the muscle, but I haven’t heard that. Do they know what the MOA is for that? Dr. Weitz:I think it’s keeping the arteries flexible, but I’ll dig up some of the studies and send them to you. It’s pretty robust that there’s a number of pretty good studies showing decreased death from cardiovascular disease with glucosamine and chondroitin. Dr. McClain:30%. Yeah, that’s a pretty big number. Dr. Weitz:Yeah. Yeah. So what about stem cells? What’s the status of stem cells? Are you able to use them in your practice? I know they’re somewhat restricted by the FDA? Dr. McClain:Great question. In the last, I’m terrible with time, but I’ll call it and say three months, the US district, I think it was Central District Court in California, came out with a findings of fact and resolution of law stating that the FDA’s position is no longer tenable. Dr. Berman was taking a lot of the arrows both in the front and the back regarding stem cells because the FDA’s position was anything that involves more than minimally manipulating the cells makes the result considered a drug. And of course, we’re all sitting here going, “Wait a minute, my stem cells, anybody’s stem cells are being called a drug?” First of all, they’re my stem cells. How can you turn around and call it a drug and then regulate it? Right? So anyway, it was written, in my opinion, and that of some of the lawyers I’ve shown it to, the findings of fact and rulings of law very eloquently. And I think the FDA agreed because they had 30 days to appeal and they did not, because I think they have… And look, I’m really, I mean this sincerely, it’s not just CYA, I think the FDA in this case anyway, has its heart in the right place in the sense that it wants to regulate this. I think they just chose the wrong way to do it, and it does need regulating. I think there’s a lot of… just like so many things. I mean, Doc, you’ve been around, there’s good and bad in every profession. There’s people that take advantage. This was just theoretically a bad way of regulating it. And anyway, unfortunately as a side note, Berman died of Covid earlier in the year before the judgment came out. Unfortunately, poor guy. But he did us all some good because now, and you think you hear more about it, it’s really more up to the state. For example, in California, we simply have to state that we are doling out, if you will, a substance that has not been FDA approved. As long as we do that, and of course don’t make any wild claims or anything like that, we can do it. Dr. Weitz:Oh, okay. Interesting. So this is a new development in the last three months. Dr. McClain:Yes, sir. Dr. Weitz:Get your cutting edge information about medical research right here and FDA regulations. So how do you use stem cells in your practice? Dr. McClain:Really for just about anything where we’re opposing degeneration because it’s a regenerative tool for sure. We’re not doing stem cell transplants here. That’s been around since the ’70s to fight leukemia and stuff like that. But like in your practice with sports injuries and stuff, right, it’s fantastic for reducing inflammation without using something like a corticosteroid, which I liken to rubbing compound. Yeah, the paint looks way better. Why? Because you just removed the top coating of it. There’s a pro and a con to the use of corticosteroids. You get the anti-inflammatory effect, but get some regeneration of that, to use the analogy, car paint rather than removal. You can also use it intravenously. And the beauty of this is a monkey could do it because the stem cells, they know where to go. They’re going to hone in on where there’s damage. This is what they’re programmed to do. Dr. Weitz:And where do you get the stem cells from? Dr. McClain:Hopefully, a place that is third party testing their cells. There’s a lot of hoops you should jump through, and you have to jump through to do it legally, to make sure that the stem cells are as risk-free as possible- Dr. Weitz:You get them from a stem cell bank? Some procedures take the stem cells out of the patient’s iliac crest. There’s some people advocate taking it out of the fat cells. Dr. McClain:Yeah. Well, and there’s pros and cons to each. I was just referring to umbilical cord tissue cells where they’re harvesting it from live births and someone, a mom has agreed to let the cord go. It’s all tested before and after, et cetera. But you’re right. Yeah, I mean to me the least favorite of those, least beneficial would be, you mentioned the bone tap, right? The pelvic bone. So you’re going into the marrow. The problem with that is it’ll feel like you fell off your bike pretty hard for about two weeks afterwards and you’re only going to get anywhere from maybe 10 to 20 million cells, and they’re all going to be a mix. So all three of the main ones we’d find in an aspir like that. The beauty of the fat collection, and you’re getting it from the perivasculature of the fat, it involves a liposuction, but we’re only getting one group called mesenchymal stem cells out. And we can take those to a lab and replicate them over and over and over again. So you get more bang for your buck that way. Plus, you’re getting your own cells. So the way we believe it works now is with somebody else’s cells, unless they quite by chance or down the road, will find their way to HLA match them, like you would for any procedure for the old stem cell transplants or current, unless we do that, the odds that those cells actually engrafting, taking the place and becoming the new cell pretty are pretty slim. With your own cells, they will take the place of that damaged heart muscle cell right away, for example. With someone else’s cells, again, let’s say match, they’re kind of like placeholders. In the meantime, a signal goes to your bone marrow if you’re the recipient and they immobilize the cells that are going to eventually replace that. The beauty of the umbilical cord tissue cells though is they tend to be younger. They’re about as brand new as they can get and they come with other factors, exosomes, which carry like RNA growth factors, which are much more potent than say, my 60-year-old cells. And that goes back to if you want to do your own cells, which I would argue is the more bang for the buck method, go ahead and bank them now. Get your liposuction now, so that you have them available for when you’re older and you’ve got the younger ones that are much more potent banked. Now [inaudible 00:39:04]- Dr. Weitz:It’s little late for me to get the younger ones. Dr. McClain:Well, but they still work very well. And you can always use a combination. Dr. Weitz:I appreciate it. I’ll be on Medicare in July, so that tells you what my age is. So how many stem cells do you use per injection typically? Dr. McClain:That’s tough to know and- Dr. Weitz:Estimate. Do you use a way of determining it? Dr. McClain:Again, it depends upon how you harvest them and you grow them. I’m not trying to dodge the question really, because I mean, I used to complain to the group that I use, American CryoStem in the early going, it was too dilute. So I was trying to stuff like 20 mls into some poor guy’s shoulder just to get the requisite number, 100, 150 million cells into his shoulder. So it depends on how they concentrate it. And then of course, unless you put it through cytometry with an umbilical cord tissue cell, you’re not going to know, and again, unless you actually count. But we’re shooting for, okay, anywhere from in a marrow aspir, I said 10 to 20 million to up to 150 million, whether it’s in a joint or intravenously. Typically intravenously, we’re going to go with a higher number. Dr. Weitz:Okay, cool. And have you used it in organs? You mentioned heart. Dr. McClain:No. There are some studies which have injected directly into either the heart muscle or really even the brain, like for Parkinson’s. Those are few and far between, obviously because of the risk. But that’s the beauty of, for example, for the heart because you don’t have to worry about the blood-brain barrier. You can inject them intravenously and they go where they’re needed. Now the one caveat to that is first stop tends to be the lungs. And it’s been shown in some cases that 90% of those cells will go to the lungs before they go elsewhere. But if there’s no damage there, it’ll go on and find the damaged muscle of the heart. And then the other cool thing about this is that you may inject, say, 150 million, but that’s not where it stops. Remember, these are going to replicate many times over to more and more daughter cells. Eventually, they run out and okay, the buck stops here, I’m not replicating anymore. And it becomes a heart muscle cell, for example. But in the meantime, you can have one turn into another genie, which gives you three more wishes that turns into another genie, which you follow? So it might end up with the equivalent of eight times that over the course of anywhere from four to eight weeks. Dr. Weitz:Okay. I know you’re a believer in the use of bioidentical hormones when indicated. Maybe we could talk about that topic next. Dr. McClain:Yeah. No, I’m just going to make fun of that word because yeah, this is science, this is not religion. We know that… Because remember when we were growing up, I mean you say you’re Medicare-bound, you’re older than I am then, but we were always told, “Oh, that’s baloney.” And normally they’re actually, to be fair, referring to anabolic steroids. But we know that the basis from which those are derived, the normally produced steroids like testosterone, have a fantastic effect on your wellbeing. Yeah. I’ll never forget coming into wrestling practice after the summer and the guy who I was dish ragging around the mat prior to summer comes in 30 pounds heavier and is dish ragging me. I said, “Yeah, tell me steroids don’t work, right, anabolic or otherwise.” But yeah, I’d say what I do most is for people who have what we call hypogonadism, whether it’s male or female, their gonads their ovaries or their testicles are not producing as much testosterone. I help get those levels back up to optimal levels and get back to living that healthspan we’re looking for. Dr. Weitz:Now, if you get a man and he has lower testosterone levels, what are the kind of levels you see as low? And then do you do anything to try to bring their levels up naturally before you go to hormones? Dr. McClain:That’s at least a two-prong question in that. First of all, in terms of levels, it can be kind of all over the board. There’s Abraham Morgentaler was one of the original docs that was working with this medicine. He was associated with Harvard, wrote a book called Testosterone for Life, which is great. Also was involved in an international consensus published in 2016, about 20 other urologists and him, nine resolutions, which I won’t bore you with him because I can’t remember them all night anyway, but kind of debunk a lot of the myths about the levels and what testosterone does and doesn’t do. But at one point, I didn’t like him because he drew the line at 450 nanograms per milliliter of total testosterone for a male. I was like, “How do you come up with a number? What if the guy’s at 449?What do you…” “Oh, sorry, you don’t qualify. Missed out by a point. Try again next year.” And finally this international consensus said, Hey, it’s not about the numbers, duh. It’s about the patient and the symptoms, right? Now, obviously a 20-year-old with super low testosterone is more rare than a 60-year-old. And so then you go into a differentiating a factor, which is it primary meaning that testicles themselves aren’t working or is it secondary, meaning here you got a 20-year-old’s testicles, for example. Is he not getting a message from the pituitary in the form of luteinizing hormone in the testicles, say, “Hey, let’s get to work here.” So two different treatments for two different types of hypogonadism. So in the 20-year-old, yeah, we can restore function in the sense that all we really have to do is get the testicles working again. For some reason, sometimes we call a pituitary macro adenoma, a little growth that blocks the signal of luteinizing hormone. We can have it removed or we can just override the system with something that acts like luteinizing hormone and bingo, someone’s natural production has been restored. Guys like you and me, the masters at athletes, the guys that are about to get Medicare, the testicles have long since said, “Hey, we’re done doing our job here and we have to just go to replacement therapy.” Dr. Weitz:Well, not in my case, I just had my levels measured. They’re 900 all natural. Dr. McClain:[inaudible 00:45:41]. And more importantly, really, I can’t say it enough, you treat people, not numbers. Even if you were 300 and you said, “Rand, I feel great, man. I’m not missing out on anything in life,” then why would we mess with it? Dr. Weitz:Right. So what’s the safest, most effective way to administer testosterone, topically, injections, pellets? Dr. McClain:Great question. So with the ladies, because the dosage roughly is about one-10th of a male’s, we can get away with the creams, gels, the topical applications, and they appear to be just as efficacious as well as effective. And that might be a gender thing because… And not to, oh god, at the risk of sounding sexist here. I always joke, I dropped my candy when I didn’t buy stock in Sephora because my wife anyway loves the creams and stuff like that. But I think most of us, I hate shaving. Applying a cream is just not worth it. So effectiveness can sometimes go out the window, but I would argue for males though, even in terms of efficacy, it’s just not as good. We need such a higher amount, and it fluctuates so greatly during the day that it becomes impractical and it’s just not as efficacious. So an injectable form, which essentially means it’s a time release form of an esterified form, works better for guys. You have the option either way with a gal. Pellets, the problem is, first of all, I think it’s fairly barbaric, but for those that say, “Hey, if beats have an inject once a week or apply the cream every day, I only have to do this once every three, maybe four months.” The problem is operator air, it takes a while to figure out the right dose for that individual. And the pellets themselves, I don’t think have been perfected until possibly recently where the slow release is perfected. So you’re not having over the course of three months a huge spike and a patient’s almost manic, and then a missing testosterone level for a month, and they’re begging their doctor for another round. I just think that’s one of the practical problems with the pellets. Dr. Weitz:Do you use peptides in your practice? Dr. McClain:Absolutely. Dr. Weitz:So don’t talk to us about some of the most effective peptides and tides Dr. McClain:They’re so cool because they’re like tinker toys. There’s so many different combinations you can make that each one, you just change one ligan and it might have a totally different feature to it. The beauty of peptides is they’re short-acting now and safe. They’re making them longer acting so they’re still safe and effective. The problem is we just, there’s so many possibilities. We’ve got a lot of research to do. But with the extent peptides, we can deal with things like, again, the masters athlete, we’ve got thymus and beta-4 for example, which helps with actin within the muscle fibers creation of more of that. We’ve got BPC-157 less human research on that, but anecdotally, fantastic for ligaments and tendons as well as GI repair. We already talked about the GH secretagogues as peptides. We’ve got things that work peptides that works as anxiolytics peptides that works as nootropics, helping with cognitive function. I think the sky is going to be the limit, and that’s a huge window of opportunity for us in the next 10 years or so with peptides. But yeah, it really depends upon… I could go on and on. Start with what your goal is or your complaint, and I’ll give you a peptide. Dr. Weitz:What’s the best peptides for joints? Dr. McClain:I always get this one confused because it’s an alphanumeric. I want to say AOE-109, I’m not going to remember this one, but we have a peptide for joints specifically. We also have all kinds of things besides PRP and stem cells that we can include in the joints. We’ve got the hyaluronans, of course, and- Dr. Weitz:Then BPC, and some people even inject BPC. Dr. McClain:I would argue that I wouldn’t use BPC-157 for a joint. I would sooner use, I’m trying to remember the name we used to use and it burned like there was no tomorrow. Dr. Weitz:Oh AOD-9604. That’s from your book. Dr. McClain: Well, didn’t Einstein say why commit to memory anything you can look up or something like that? Yeah, I subscribe to the Henry Ford method of storing things, but yeah, thank you for that. But there are others too, which can be injected. I learned a lot from the world of the strong men competitors. Dr. Weitz:Oh, really? Dr. McClain:Anthony Giva was one of the guys that I remember turned me on to one of these peptides that you would inject. And it’s still out there. It’s just there are better ones that aren’t as painful, but we’ve had them around for a long time, ways to improve, not just the joints, the cartilage, but the tendons too. But I would stick with the ones that are very effective. I mean, there’s alternatives to the peptides. Like I said, the hyaluronic acid bases as well as the PRP and the stems. I think those are no-brainers. Dr. Weitz:Right. Okay. Any other topics you want to talk about on how to cheat death? Dr. McClain:A lot of times, I’m asked, “Okay, what’s the best one or what are the best view?” And it’s oftentimes disappointing. So let me just get it out of the way. It still goes back to the three basics, and I’m as serious as you can get here when I say, no fluff, it’s proper nutrition. Diet makes a big part of your health and longevity. Exercise, I call it the great equalizer. You got to get some. It doesn’t have to be a professional athlete’s mix. As a matter of fact, even if you’re a professional athlete, you need to throw in some of those zone one or even zone zeros for those of us that are doing a lot of cardio where you’re just walking around in your garden or in the woods somewhere for not just physical health but mental health. And then one that probably gets eliminated more easily than the other two in modern life these days, as I see patients, sleep. People do not get enough sleep. It’s got to be… and Matthew Walker, the PhD we stole from UK, who’s now heading up the departments of Berkeley, he’s got a great book that pulls the research and aggregates it in this one place where you go, “Holy moly, sleep does that?” And it’ll convince a lot of people. “Wow, I’m not ditching that anymore.” Remember in the ’80s, we used to brag about how little sleep we used to get at that. That’s how studly I am now. True studs are the ones that boast of getting at least seven to nine hours, and it’s going to vary per person. And it’s got to be not just seven to nine, but seven to nine of quality sleep. That’s the other factor. People go around with sleep apnea. And so I’m a CPA before I’m a doctor, so I’m presumably honest and conservative. I tell you, at least one patient a day has sleep apnea that I see. And you don’t have to be overweight. Whether that means actually fat or just well-muscled, I see ladies as skinny as little Olive oil, the cartoon character that can still have sleep apnea and it goes overlooked because if you think about it, testosterone’s going down and that supports the production of red blood cells and hemoglobin, while age is going up, and you’re more likely to have sleep apnea. So you look at their hemoglobin hematocrit and you go, “Oh, you’re normal.” Well, no, you’re not. You’re suffering from severe sleep apnea sometimes. And this is the other thing I’ll throw in there too, and I promise I’ll shut up after this, but doctors will then look at someone on TRT and go, “Oh, it’s that dog gone testosterone that’s elevating your hemoglobin hematocrit red blood cells. That’s a bad thing.” No, the sleep apnea is, and just now that you have the testosterone back in the system, we’re becoming aware of the sleep apnea and its effect on the body. It’s not the testosterone itself, it’s just leveraging the problem. Dr. Weitz:And for guys who are trying to get their testosterone levels up naturally, make sure you optimize your sleep. That can be a big factor. Dr. McClain:Huge. Huge. Yes. Stress is one of the biggest factors for what I referred to earlier as secondary hypogonadism. And that’s part of how you fix it. Yeah. You say look, you’re 28, but you’re working three jobs and you’re over training, which is, I realize a comparative term, but you’re doing too much for too little repair. And that’s enough to make your testosterone levels, amongst other levels like thyroid included, spiral downward. Absolutely. Dr. Weitz:And of course, during sleep is when growth hormone is released as well. Dr. McClain:That’s the biggest dose you’re going to get during a 24-hour period, and especially that first hour when you’re deep sleep. So if you’re blowing that because you’re eating too late at night or you’re maybe drinking too much, or again, the quality’s not there because of sleep apnea or anything else, man, you’re blowing it big time in a natural way that mother nature provides for you to keep yourself as healthy as you can be. Dr. Weitz:Sounds good. How can listeners and viewers contact you? Dr. McClain:Well, I’ve got an office here in Santa Monica where I spend most of my time. I’m a Malibuian, so it’s only a 35-minute drive for me. We’ve got an office in Houston, an office in Florida, but you can contact all of them through the main line here. And we’ve got a website. Dr. Weitz:What’s your phone number? Dr. McClain:Phone number’s 310-452-3206. Dr. Weitz:Okay. And your website? Dr. McClain:Www.psrmed.com. Dr. Weitz:Psrmed? Dr. McClain:Dot com. Yep. Dr. Weitz:Dot com. Okay. Sounds good. Thanks, Rand. Dr. McClain:Yeah, no, thank you. I appreciate it. Been a pleasure. Thank you. Dr. Weitz:Yes. And I’ll send you links after we publish it. Probably be about five weeks. Dr. McClain:Got it. Thanks so much. Anytime. Dr. Weitz:Excellent. Sounds good. Thanks, Rand. Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way, more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients, so I can see you for a functional medicine consultation, for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.

14 de mar de 2023 - 58 min
episode Discussion on SIBO and IBS with Dr. Sam Rahbar and Dr. Ilana Gurevich: Rational Wellness Podcast 298 artwork

Discussion on SIBO and IBS with Dr. Sam Rahbar and Dr. Ilana Gurevich: Rational Wellness Podcast 298

Dr. Sam Rahbar and Dr. Ilana Gurevich discuss SIBO and IBS and how to treat difficult cases at the Functional Medicine Discussion Group meeting on February 23, 2023 with moderator Dr. Ben Weitz. [If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page [https://www.youtube.com/user/weitzchiro].] Podcast Highlights 4:14: IBS, Irritable Bowel Syndrome, is the most common gastrointestinal condition and it exists in at least 10% of the population.  For many years we had no idea what the real cause of IBS was and it was often considered to be a stress-related condition.  Patients would either be put on antidepressants or if they had constipation, they would get a drug for constipation or if they had diarrhea, they would get a drug to try to control the diarrhea.  Dr. Pimentel pioneered the idea that IBS is caused by an overgrowth of bacteria in the small intestine (SIBO).  When you consume food with fermentable fiber, those bacteria consume that fiber and produce either hydrogen or methane or hydrogen sulfide gas.  By measuring these three gases using a lactulose breath test, we can partition these patients into hydrogen SIBO and methane SIBO and hydrogen sulfide SIBO.  Methane SIBO, which is actually caused by methanogens, which are technically not bacteria but another group of microorganisms known as primitive archaea.  Dr. Pimentel has now changed the name of methane SIBO to IMO both to reflect the fact that the methanogens are not bacteria and that it can exist in the large intestine as well as in the small intestine.  Dr. Pimentel has also pioneered the use of a non-absorbable antibiotic, Rifaximin, for the treatment of SIBO/IBS.  Dr. Pimentel tends to use Rifaximin for hydrogen SIBO, Rifaximin plus Neomycin for methane SIBO (IMO), and Rifaximin plus Bismuth for hydrogen sulfide SIBO. 7:53: Dr. Pimentel has mapped out the microbiome of the small intestine for the first time, so we now know that hydrogen SIBO tends to be caused by E Coli and Klebsiella. IMO is caused by methanogens, including methanobrevibacter smithii. Hydrogen sulfide SIBO tends to be associated with pseudomonas, Fusobacterium, Desulfovibrio, and Bilophila bacteria. Dr. Pimentel has also discovered that there are two bacteria, Ruminococcus and Christensenella, that help to donate the hydrogen to the methanogens.  And Enterobacteriaceae helps to donate the hydrogen to the hydrogen sulfide producers. 10:18 The clinical picture. SIBO is very challenging to treat and the biggest challenges are when you have either a recurrent SIBO or a persistent SIBO or methane SIBO, which is particularly difficult. Dr. Rahbar explained that methane SIBO implies some level of immune dysregulation and he often finds fungal overgrowth concurrent with it. Fungus facilitates the growth of the methanogens because the archaea need an anaerobic environment and the fungus absorbs oxygen and releases nitrogen, creating an anaerobic environment. 13:14While he has performed detailed immunological testing on some patients, Dr. Rahbar does not do this routinely.  He often investigates why this person might have immune dysregulation and he often will look for exposure to toxins in either the urine or the blood and he often finds that the higher the amount of toxins will often correspond with the alterations of the microbiome and the severity of the symptoms. 15:42Dr. Rahbar will usually address the local immune dysfunction with nutritional strategies and part of the immunity has to do with the quality of the mucus layer in the gut and the toxins present in the person will often alter this mucus layer and this makes it easier for the bugs to hang on as they are imbedded in this mucus.  Dr. Rahbar also pointed out that fungus when present will often change their shape into the hyphae form, which is a long branching structure. 18:11Dr. Gurevich finds that by addressing this mucus layer with biofilm busting strategies, that is part of a strategy that is effective at reducing the SIBO. She agrees that with methanogen overgrowth there is often a fungal component and the analogy she uses is that when you look at the forest floor, fungus is literally everywhere.  She uses some aggressive biofilm strategies, starting with Dr. Paul Anderson’s compounded pharmaceutical formulation containing bismuth and DMSA or DMPS.  After a month she will layer in herbal antimicrobials and then pharmaceutical antibiotics if needed.  The results of testing will also inform clinical decisions, including stool testing and blood tests, including running a Candida Immune Complex and Elisa antigen testing for candida IgG, IgA, and IgM from Quest or Labcorp.  To get rid of the fungus, she layers in antifungal herbal and pharmaceutical medications.  If we have a methane patient, she will also use either natural or pharmaceutical prokinetics to make sure that they are moving their bowels. 20:16 Dr. Gurevich uses what she calls her antifungal parade. She starts with pharmaceutical biofilm disruptors as mentioned, then she will use some enzyme biofilm disruptors, including hemicellulose and Serrapeptase, and then she’ll circle through various herbal antifungal agents so patients don’t develop a tolerance for them. There’s some interesting evidence that the herb Gymnema sylvestre prevents the yeast from budding and going into its hyphae form.  She often uses a Gymnema capsule from Wise Woman Herbals three times per day. She will also use Formula SF722 (Undecylenic acid) from Thorne–5 caps twice per day.  Then she’ll switch to oregano oil or to Kolorex and then she will switch to Y arrest from Integrative Therapeutics.  She will have them use natural antifungals for at least three months and sometimes for up to a year.  Dr. Gurevich also likes to use Nystatin, a prescription antifungal and Dr. Rahbar also often uses this medication. 25:52 Diet for SIBO.Neither Dr. Gurevich or Dr. Rahbar advocate strict diets for patients with SIBO. Dr. Gurevich noted that has not found strict anti-Candida diets or low FODMAP diets helpful.  Dr. Rahbar finds that diets that are too restrictive in carbohydrates can lead to mood problems and anxiety. Both Dr. Rahbar and Gurevich want their patients to eat organic, clean diets and avoid junk food and avoid pesticides and herbicides like glyphosate.  Dr. Gurevich emphasizes a vegetable-forward diet and she has seen too many patients develop eating disorders from eating a very strict low FODMAP diet. 30:59SIBO is often difficult to treat because such patients tend to have a complicated picture that besides bacterial overgrowth, they often have gut hypersensitivity, fungal overgrowth, and toxicity. 32:27Dr. Gurevich will often run the Trio SIBO breath test and she will have patients collect breath every 17 minutes instead of 15 minutes, so this will last 3 hours rather than 2 hours. 34:42 Treatment for hydrogen sulfide SIBO.Dr. Gurevich tends to use bismuth and Rifaximin or bismuth and herbs.  As far as herbs, she likes oregano, Allimed, and Chinese herbs like Huang Lian and Huangjiang, Philodendron, Coptis, and Scutellaria. For oregano she will often use oregano oil by Gaia Herbs. Dr. Rahbar tends to use Xifaxan with Bismuth that is compounded without Salicylate. Either bismuth citrate or subnitrate is better to use. Dr. Rahbar also finds Mesalamine is helpful in such patients, which is a medication that is often recommended for treating ulcerative colitis.  He likes the Pentasa brand of Mesalamine and he likes it in the powder form so it opens up in the small intestine. Dr. Sam Rahbar is an Integrative Gastroenterologist in Los Angeles, California, combining conventional gastroenterology, performing colonoscopies, endoscopies, and Heidelberg pH testing, but incorporating anti-aging and Functional Medicine into his unique treatment approach to digestive disorders.  He can be contacted through his website http://www.laintegrativegi.com/ [http://www.laintegrativegi.com/] or by calling his office 310.289.8000. Dr. Ilana Gurevich is a board-certified naturopathic physician and acupuncturist and is currently co-owner of two large integrative medical clinics, one in northwest Portland and one in northeast Portland, Kwan Yin Healing Arts and the website is KwanYinHealingArts.com [https://kwanyinhealingarts.com/].  She runs a very busy private practice specializing in treating inflammatory bowel disease as well as IBS/SIBO and functional GI disorders.  She lectures extensively and teaches about both conventional and natural treatments for inflammatory bowel disease as well as SIBO.  She is one of the foremost experts on the intersection of IBD and IBS and how treating one resolves the other. She can be contacted through her website, naturopathicgastro.com. [https://www.naturopathicgastro.com/]She recently started a new podcast, The Turd Nerds [https://podcasts.apple.com/us/podcast/the-turd-nerds/id1651253399?fbclid=IwAR0gc4vNxDAS_21YIk23tYj6mhiqypMG6ACt6hHs4sLPhZNA26m0MzTcPnI] with Dr. Rebecca Sand and Dr. Ami Kapadia. Dr. Ben Weitz is available for Functional 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations. Podcast Transcript Dr. Weitz:Hey! This is Dr. Ben Weitz, host of the Rational Wellness podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness podcast for weekly updates. To learn more, check out my website drweitz.com. Thanks for joining me and let’s jump into the podcast. Welcome, everybody. If you’re participating in this live event, this is the Functional Medicine Discussion Group of Santa Monica, and we have a special program. We’re going to be discussing SIBO, small intestinal bacterial overgrowth and IBS, and we’re going to have a group discussion with Dr. Sam Rahbar, who’s an integrative gastroenterologist, and Dr. Ilana Gurevich, who’s a naturopathic doctor, who’s an expert on gut health. If you’re listening to this recorded, this is part of my weekly Rational Wellness podcast and I hope you enjoy it. It’s pretty high level science here, and we’ll be discussing some innovative approaches on how to treat patients with these particular conditions. Keep in mind that these are experienced practitioners who often are seeing some of the worst patients who failed some of the basic frontline treatments. For example, a lot of their patients have seen a gastroenterologists or somebody else and have already tried a round of Rifaximin or have tried some of the anti-microbial herbs or have done some of the other strategies that are being promoted out there. They’re seeing some of the most difficult cases. We’re going to have a really high level scientific discussion about how to treat these conditions. I hope you enjoy it and we’ll get started right now. Now, I’d like our two experts who agreed to join us tonight to tell us a little bit about themselves. Alana, can you tell us a little bit about yourself and tell us about your new podcast? Dr. Gurevich: Sure. My name is Dr. Ilana Gurevich, and I am a board-certified naturopathic gastroenterologist and a naturopathic physician who runs a practice out at Portland, Oregon. I am also in the process of launching a new podcast. I teamed up with two other physicians, Dr. Ami Kapadia, who’s a functional medicine medical doctor, and Dr. Rebecca Sand, who has a history of working for the CDC and research and is also a naturopathic physician, and we launched a podcast called The Turd Nerds. It’s just discussing really integrative gastroenterology topics from a research and an anecdotal practice stance. Dr. Weitz:That’s great. I’m not sure about the name. Dr. Gurevich:Either at Google, like tell us it’s offensive. Dr. Weitz:Oh, really? Sam, can you tell everybody about yourself? Dr. Rahbar:I’m a board-certified gastroenterologist, but I practice mainly integrative gastroenterology and I incorporate the traditional with all the alternative method and the functional medicine model into the GI practice. Dr. Weitz:That’s great. I was thinking maybe I could start off talking a little bit to just go into some of the basics about SIBO, in case anybody who’s on the call doesn’t know much about SIBO or IB. Then, I figure we’ll just let the discussion go where it goes and the goal is for all of us to learn from each other and learn a little more about how we can help our patients. The history of IBS is that it is the most common gastrointestinal condition. It’s been around for very long time, probably exists in at least 10% of the population. For many years, we had no idea what was the real cause of IBS. It was often considered to be a stress-related condition. It was that, typically, patients would be either put on anti-depressants or if they had constipation, they would get a drug for constipation, or if they had a diarrhea, they would get a drug to try to control the diarrhea. Unfortunately, IBS is still treated that way in a significant percentage of the conventional medical community. But Dr. Pimentel, who as I mentioned in case you weren’t here at the beginning, wasn’t able to join us tonight, he’s really pioneered that there is this actual cause of IBS and that’s small intestinal bacterial overgrowth. What that means is that there’s an overgrowth of bacteria in the small intestine and that those bacteria, when you consume foods with fermentable fiber, those bacteria consume that fiber and produce gas. Now, we know that there’s three gases, and so we have hydrogen, which was the first gas we discovered, then methane and hydrogen sulfide. Now, the latest data shows that we have the Trio Smart Breath Test, which allows us to measure all three gases for the first time. That allows us to partition SIBO into three different categories. We have hydrogen SIBO, we have hydrogen sulfide SIBO, and then we have … we used to call it methane SIBO and now, Dr. Pimentel has changed the name to IMO, which is Intestinal Methanogen Overgrowth, and I think a couple of reasons for calling it IMO is because it’s produced by methanogens, which are actually not bacteria, and because it doesn’t just exist in the small intestine, it also exists in the large intestine. Dr. Pimentel also pioneered the use of a non-absorbable, supposedly non-absorbable anti-biotic called Rifaximin for the treatment of SIBO. He has shown that it is very effective for, especially hydrogen SIBO. Then, for methane SIBO, he uses a combination of Rifaximin and neomycin. For the new hydrogen sulfide SIBO, as of this point, there are no new approved treatments for that. Dr. Pimentel, my understanding is, he uses Rifaximin plus Bismuth, essentially gives the patients Pepto-Bismol along with the Rifaximin. Dr. Pimentel has been doing a ton of research on mapping the microbiome of the small intestine, so now we know for the first time exactly which particular organisms, particular strains of bacteria are causing these forms of SIBO. We know that with the hydrogen SIBO, maybe you guys can help me out. What are the two bacteria? E-coli- Dr. Rahbar:Klebsiella. Dr. Weitz:Klebsiella, and then with the IMO within methanogen overgrowth, we have Methanobrevibacter. Then recently, Dr. Pimentel has discovered two other bacteria that participate in helping to get hydrogen to the methanogen. The methanogens consume the hydrogen, and then they produce the methane gas. He found two particular bacteria known as Ruminococcus and Christensenella, so these particular bacteria are known as hydrogen donors. He’s also published the paper showing that there are two bacteria that help to donate the hydrogen to the hydrogen sulfide. The bacteria that produce the hydrogen sulfide SIBO are Fusobacterium and Desulfovibrio. Those are the two main ones. Enterobacteriaceae is the bacteria that helps to donate the hydrogen to those. Being able to determine exactly which bacteria is responsible for the SIBO and knowing where they exist in the small intestine is part of allowing us to come up with better treatments and better ways to diagnose and understand it. Sam, where should we go from here? Dr. Rahbar:Let’s go to the clinical stories, I think. I think if the SIBO is easy to treat, we wouldn’t be here. Dr. Weitz:Absolutely. Dr. Rahbar: Okay. Obviously, the challenge is when you have a recurrent SIBO, you have a persistent SIBO or you have methane SIBO. In my experience, when you see methane, it practical involves the entire intestine, the upper part maybe extending all the way to the colon almost, they may have similar numbers for the most part. The question is that, what allows the methanogens to grow in the upper part of the intestine there? I can understand that the colon may be somewhat anaerobic here, but the upper part of the bowel may contain some oxygen and air that we might have swallowed. For these bugs to grow, they probably need an anaerobic environment for this archaea to survive. I think the main question comes up, what has transpired that allows the methanogens to grow in the upper part of the intestine then? Now, I share my own personal experience and observation, this is not all published, but it’s basically our interpretation of what we see and how these might be related there. The presence of methane, to me, generally implies some immune dysregulation. There is something beyond just the SIBO and the body has difficulty keeping the gut clean. We also have to understand at what allows it to have an anaerobic environment without oxygen. Again, when I looked at some of the data as how they actually grow archaea in the laboratory, in the environment, in the methodology that they use, they add the yeast and fungi to be able to absorb the oxygen and release nitrogen and create an anaerobic environment. This is the Journal of Bacteriology Microbiology, and I believe in one of the conferences, I shared the reference on that one. When I see methane excess, I ask two questions, where is the fungus and what has caused immune dysregulation to allow the body for these bug to grow and the body become like a Petri dish? Dr. Weitz: Now Sam, how do we know?  Is there a way to measure this immune dysregulation?  Can we do a stool test that looks at secretory IGA?  Is there a lab test?  Should we use the Lymphocyte Map test?  How can we determine this immune dysfunction? Dr. Rahbar: You can do detailed immunological studies. Okay, I must tell that we have not done that in all patients, but we did it in those that we felt that the problem was more intractable and we had to go further. But we did ask one question that even though there is some immunological dysfunction or body’s inability to deal with this, what would be causing that? That brings us to the question of how that person or that individual has interacted with the universe, and that brings us to the concept of exposure to metals, to toxins, to chemicals, more toxins, many of these either they affect the microbiome directly and they allow an imbalance to remain in the gut or they somehow deal with the immune system. Generally, we just go and investigate that one and see if we can find risk factors. At least, in our observation, we have seen many patients, they have a variety of chemicals or toxins or mold or metals showing up in their urine or sometimes showing in their blood there. Interestingly, it’s not always one item. You cannot just pinpoint one single item, and I think we need to look at this cumulatively and maybe give a score to each of these things that we observe. Practically, the higher the score of abnormality that one can find in a urine toxicity evaluation probably would correspond to the alterations of the microbiome and the symptom presentations that patient come to us. Dr. Weitz:Yeah. When I get a SIBO patient, typically I do a stool test as well as a breath test. If I see low secretory IGA, I’ll use something like SBI Protect to try to help beef up the immune system. Do you try to address the immune system dysfunction in some way? Dr. Rahbar: A hundred percent. We do a variety of things to improve the local immunity at the gut level. That is almost granted that there’s going to be some alterations locally. Part of the defense mechanism that the intestines carry is the quality of the gel and the mucus layer that is sitting on the gut surfaced. When we’re dealing with this dysbiotic fluoride, there is clearly alteration of those mucus layers. Based on what I’ve seen from the literature that exposure to the variety of the chemicals from the environment and detergents, they actually alter that mucus layer and it makes it easier for the bugs to hang on and not be so mobile, if you will. The body has difficulty to push them out and they will get embedded into that mucus layer. My emphasis has generally been on fungal elements because they have an ability to change shape from yeast into HFI format, and HFI has the ability to crack the wall. Those mechanical alterations, they allow bacteria to sometimes remain into those crevices. At least that has been one of my theories, that when we are dealing with recurrent SIBO that, in addition to whatever else is going on, there’s some mechanical changes at the gut level. There’s a whole protocol that we use to deal with that. I’m not going to continue talking as the only person here, see what Dr. Gurevich would like to share. But obviously, dealing with the gut surface and also the immunity locally is going to be crucial to the recovery. Dr. Weitz: I know every time I hear about these bacteria living in the mucus layer, the first thing that I think about is this is a biofilm. That’s probably what’s making it more difficult to get rid of these bacteria, and maybe we need the right biofilm busting agent to help us to do that. I know, like a lot of people who deal with SIBO, we’ve tried various biofilm busting products and strategies and not sure that any of them are all that effective. Dr. Gurevich:I disagree. Dr. Weitz:Oh, okay. Dr. Gurevich:First of all, I could not agree more, I don’t think that meth antigen overgrowth is exclusively an issue with bacteria. I definitely think the more we think about it, the more fungus is one of the key courses of what’s involved. I always put the analogy of looking at the forest floor where the system that the way the forest floor communicates is all of fungus because fungus is literally everywhere, which is why we have such fungal overgrowths. In my experience, very, very intractable methanogen overgrowth is actually pretty resolvable with using some aggressive biofilm strategies. The biofilm strategy that I’m using is, I’ll start with a pharmaceutical compounded medication using bismuth and DMSA or DMPS whatever the pharmacy’s got. Dr. Weitz:Just like Paul Anderson’s strategy? Dr. Gurevich:It is Paul Anderson’s and I’ll start there and then I’ll layer in after a month, I’ll layer in herbal antibiotics and then pharmaceutical antibiotics if needed. Depending on what’s happening with stool tests, blood tests, I’m doing a lot of AMITA antigen testing right now. If I find fungal overgrowth, then I’ll also layer in antifungal both herbal modalities and pharmaceutical modalities. It’s a long protocol, but you can definitely get improvement. Then of course, you can’t ever treat a meth antigen patient without making sure they’re actually eliminating and moving their bowels, and so we’ll use some of our natural or pharmaceutical prokinetics to get it to move as well. Dr. Weitz:What do you use to get rid of the fungus? Dr. Gurevich:I lovingly call it my antifungal parade. I’ll use some pharmaceutical biofilm disruptors, that’s the Paul Anderson one. I’ll use some interesting enzyme biofilm disruptors. There’s some interesting data using Hemicellulose, using Serratiopeptidase, and so I’ll put patients on that, and then I’ll circle them through antifungal herbal agents, so they don’t ever develop a tolerance to it. There is some really interesting data that’s in vitro that shows that using Gymnema prevents the yeast from budding. That’s how I try to- Dr. Weitz:Gymnema is an herb we typically think of as helping with blood sugar problems, right? Dr. Gurevich:Yep. That’s exactly what it is. There’s in vitro data that shows that it prevents the yeast from budding. Dr. Weitz:Can you recommend a product and a dosage for that? Dr. Gurevich: I’m using Wise Woman Herbals. They have a Gymnema capsule and I’ll go one three times a day. I think now also has a really, really affordable product that’s just Gymnema, and so that will be in the protocol.  If I can find candida, I still love Nystatin, and I know it’s not popular anymore, but I think Nystatin is generally very well-tolerated and very safe.  Then, I’ll rotate through that old formulation SF722, they’ve just rebranded it.  I’ll have the patients on that for a bottle, and then I’ll switch them to oregano or I’ll switch them to Kolorex or I’ll switch them to, ITI has a really great formula called yeast arrest or Y arrest, something like that, and I’ll just circle through one product as soon as they finish the bottle, and we’re looking at a minimum three months, but often people were looking at nine months to a year. Dr. Weitz:If you don’t mind, can you give us your entire protocol? Dr. Gurevich: Yeah. Okay. We’re assuming that this patient has both methanogen overgrowth, plus a fungal overgrowth that we found either in stool or more likely a candida immune complex and even possibly candida IGM, IGG or IGA. I don’t do a lot of urine testing, I don’t do the OAT testing, but there are some markers in the OAT test that would also show you fungal overgrowth. What I do is- Dr. Weitz:Let me stop you, sorry. What’s your best test for fungal overgrowth? Dr. Gurevich: I like, Quest and LabCorp have a test called a candida immune complex, which is, this test goes back to I think 1950s or late 1940s, early 1950s, that shows that when that marker is positive, there is actually intestinal candidiasis. I’m going back to way back in the day and I’m using that marker and then I’ll also look for a candida IGM, IGA and IGG. This is an intractable SIBO patient, we’ve tried all the things that should work, they haven’t worked, you’re treating the wrong thing, you start looking. I’ll do that, and I’ll also probably run a stool assay that’s provoked. I try to break down biofilms before they collect their stool, and I see if I can find some fungus in there. If I find fungus, I’ll start them on the BisThiol complex that Paul Anderson came up with, and it’ll take them a month to get up to therapeutic dose. Then, after that month, I’ll introduce the biofilm, the enzyme biofilm disruptors. Right now, I’m using a product called Biofilm X. Enzyme Science also has a pretty interesting enzyme product that has a high dose of Hemicellulose, which also has some data. Dr. Weitz:Do you like Interfase Plus, which is a very popular one? Dr. Gurevich:I use Interfase Plus to provoke. I don’t love the EDTA, is that what’s in there? Dr. Weitz:Yes. Dr. Gurevich: Yeah. I don’t like that long term if I don’t have to, especially if I’m giving them the biofilm disruptor with the BisThiol complex, and so that’s a DM assay, so I kind of will stay away from interface if I’m using the other biofilm agent. Dr. Weitz:The biofilm buster with the bismuth is, how long are you using that for? Because potentially, using a heavy metal like bismuth could be a problem used for a long period of time. Dr. Gurevich: It seems that when you’re making the BisThiol complex, you’re actually protect protecting the body against long-term use of bismuth on its own. It becomes a bigger molecule, and so it doesn’t cross the intestine as easily even with intestinal permeability patients. There is interesting research that says that it’s actually safer. I think Paul talks about it on your podcast actually. Dr. Weitz:Yeah. Dr. Gurevich:I think I heard it from you. I’m using that at a minimum three months, but with these chronic patients, you’re looking nine months to a year easily. I’ll do that and then I’ll introduce the enzymes and the herbs in month two. I’m starting with SF722, which it goes like oleic acid and nucleic acid, they’ve renamed. Dr. Weitz:Right. Is that the Thorne product, I think, yes. Dr. Gurevich:Thorn product, yep. Dr. Weitz:Okay. Dr. Gurevich:They’re little, little gel tabs. You work- Dr. Weitz:I think you have to take almost a whole bottle in five days or something. Dr. Gurevich:They’re like little, little gel tabs, but it’s five- Dr. Weitz:You have to take 12 of them or 15 or something, right? Dr. Gurevich:Ten, yeah, 10 a day. Dr. Weitz:Okay. Dr. Gurevich:Five [inaudible 00:25:24] a day, and then I’ll kind of circle through the herbs as we go. Honestly, usually the first thing that happens, and I don’t know if you guys can see this as well and then I’ll also put a Nystatin, the minute you start Nystatin, generally, their bowel movements start moving. Not always, but it is 70% of the time, they will immediately have better evacuation just by putting in Nystatin if candida or fungus is the underlying cause. Dr. Weitz:Are you addressing diet as part of this program? Dr. Gurevich:I always say, I always have my spiel like, I’m not one of those naturopaths that give people eating disorders, but I am one of those naturopaths that believe that you shouldn’t eat garbage. Your diet can’t be a hundred percent processed, a hundred percent sugar, and I do think the protocol works faster if you’re not eating a ton of processed sugar. Dr. Weitz:Yeah. I would assume some version of an anti-candida diet. Dr. Gurevich:I have a personal story. I was kicking this road trip with my girlfriend when we were in school, and she decided that that was the perfect time while we’re driving to Canada to go on her anti-candida diet, and I have never sat through so many mood swings in all. I’m not a big fan of that restriction. I’m a big fan of eating a really holistic vegetable forward diet that’s not super processed. Sam, do you agree? Dr. Rahbar:Yes. Dr. Weitz:What kind of dietary recommendations do you give to your patients who you see who have SIBO and then especially those who where you think fungus is an issue? Then, somebody also asks, what about restricting fungus in a diet like mushrooms and things and foods that might be … coffee, which might have fungus on it, et cetera? Dr. Rahbar: I’ll try to keep a little bit of balance. It really becomes difficult more than a month to be in such a strict diet. If you keep the carbohydrate too low, occasionally, then mood problems, anxiety and other things start to develop. I generally try not to take coffee away from people. I ask them to use maybe an organic version and something that probably doesn’t have glyphosate. We are all going to have some exposure to fungi. If they use mushroom and other things, I do recommend that those are cooked or highly steamed, so at least those bugs might be killed if they consumed them. As a Libra, I usually try to keep a little balance there, but I’m interested to see what Ilana is going to say. Dr. Gurevich: Basically, when I’m talking to patients with diet, I think pesticides, herbicides, fungicides, all of those need to be, because those are basically just antibiotics that are making the microbiome more deteriorated. On top of that, I think that, as much as you can give me a vegetable-forward diet, I think that’s going to make all the difference. That’s going to give you your fiber, that’s going to increase your biodiversity, that’s also going to help with elimination if you’re getting both soluble and insoluble fibers. Then, I’d say avoid the garbage, which we all eat a little bit too much of as Americans or at this point, the whole world. Avoid all of the processed. I’m not opposed to grains, I think whole grains are super useful. I’m not opposed to proteins, I think any way you can get your proteins, that’s great. Then, just avoid what doesn’t make you feel good. I went through the whole FODMAP where everybody got a FODMAP diet when they had SIBO, and I just witnessed the eating disorders. With all due respect, the minute they stop that diet, they’re having exactly the same symptom picture, they just now have a phobia of food. My goal is not, I don’t actually take very much away, I just try to educate them on what eating a holistic diet looks like and lead them in that direction. I’m a really big fan of meal delivery services. I educate patients where, if you don’t want to do the cooking yourself, let’s get you one of these organic meal delivery services where you can actually eat quality food that tastes good. Dr. Weitz:Now, Dr. Pimentel has been working on using lovastatin for methane SIBO because there’s data showing that lovastatin can block the methane gas as part of the treatment. I wonder if either of you or anybody else who’s on the call has experimented with using something like [inaudible 00:30:03] for methane SIBO? Dr. Gurevich:I thought that- Dr. Rahbar:I don’t have any experience with it. I don’t think he’s strong enough to handle this. Dr. Gurevich:I thought that he had some theories about it, but it didn’t come out in the phase three trials. But I don’t know, I’m not up-to-date. Dr. Weitz:Yeah. As far as I know, so far it has not worked out. He is still talking about developing it. I think the problem with the trial was that they weren’t able to develop a form of Lovastatin that only stayed in the gut. Dr. Gurevich:I’ve never tried it. Dr. Weitz:Yeah. I’ve experimented with red yeast rice. I had a couple of patients where I thought it worked and other patients where I thought I couldn’t tell if it worked or not. Dr. Gurevich:Welcome to SIBO. Dr. Weitz:Well, that’s the thing. The thing about SIBO is it seems like we’ve got this easy disease process, we’ve just got too many bacteria and it should be easy to eradicate except that it’s not, and why is it so hard to eradicate? Is it because we’re not killing the bacteria? We’re not getting to them, they’re difficult to kill. Is it because maybe there’s multiple layers of problems? Maybe the patient who has SIBO, as you guys have both talked about, also has fungal overgrowth.  Maybe there’s other issues with their gut, maybe they have gut hypersensitivity, maybe they have food sensitivities, maybe there’s other issues besides  SIBO. Dr. Gurevich:There is always other issues besides a SIBO, because there is that, there’s like what? A quarter of patients, maybe a fifth of patients, that you give them a round of Rifaximin and it’s like magic and they don’t see you again for a couple of years. There is a subset of people that are very easy to treat. I don’t think they’re coming into our office anymore because they’re getting caught by the regular primary care doc or the regular gastro. I think, unfortunately, I think that our population is just centralized on they have a lot of other things going on. Toxicity is one of them, fungus is one of them, hypersensitivity is one of them. They’re complicated. Dr. Weitz:Right. Now, Ilana, when you do the, I’m assuming you’re using the Trio breath test. I heard Alison Siebecker say that she has her patients do it over a 3-hour period of time, whereas it’s recommended to do it for two hours. What do you do? Dr. Gurevich:I’m having them collect breath every 17 minutes. Dr. Weitz:That makes three hours, right? Because the recommendation is every 15 minutes, right? Dr. Gurevich:Yep. Dr. Weitz:Now, can you explain why? Dr. Gurevich:Because I feel like it’s important to see when they get into the large intestine. I feel like it’s important, that gives us a whole different set of information. Dr. Weitz:Well, explain what that gives us because once it’s past 90 minutes, it’s no longer the small intestine or we assume that’s the case, so then, why do we need to know past 90 minutes? Certainly, why do we need to know past 120? Dr. Gurevich:I think that with intestinal methanogen overgrowth, we can assume that their transit time is greatly delayed. Then, if we’re going through that test too quickly and they’re highly constipated, I feel like we might be missing it, especially if it’s affecting the bottom of the small bowel. That’s why I like to go longer especially with IMO patients. I do like to see that drop and come up again to make sure that I can locate where I am in the bowel. I don’t know if that ever held water, but I think I’ve been doing this too long of a time to not feel comfort with [inaudible 00:33:58]. Dr. Weitz:I wonder if anybody has, I’m going to switch now to hydrogen sulfide SIBO. For years, we didn’t have a hydrogen sulfide breath test, so we used to use a flat line for three hours as indication of hydrogen sulfide. Do we know, at this point, has anybody really done a serious look at patients who had a flat line as compared to patients who test positive for hydrogen sulfide on the new test? Dr. Gurevich:I don’t know. Dr. Weitz:What do you think, Sam? Dr. Rahbar:I’m not sure. Dr. Weitz:Okay. Now, let’s talk about strategies for treating hydrogen sulfide SIBO. Dr. Gurevich:For me, bismuth is king. I think bismuth has to be in that treatment plan no matter what you do. I think bismuth has to be in that treatment plan. Dr. Weitz:Okay. Bismuth plus, I’m using Rifaximin. Dr. Gurevich:I’ll use bismuth and Rifaximin. Well, I’ll use bismuth and herbs depending on cost and patient preference. Dr. Weitz:Okay. What are your favorite herbs for hydrogen sulfide SIBO? Dr. Gurevich:I find that oregano probably works better than anything else. I really, really like Alimed in there too. It’s always a cost thing, but I really love strong, strong Alicin. Then, I’ll play around there some Chinese herbs that I like to play around with that sometime have efficacy. In Chinese medicine, it’s Huang by Huang Leon and Huang Chin. I think Philodendron, Coptis and Scutellaria. Coptis will sometimes flare them a little bit too much, I think it’s high sulfur, but Scutellaria and Philodendron are actually well-tolerated by some. Dr. Weitz:Interesting. Can you give us an oregano product that you like? Do you like the oregano oil? Do you like the dried oregano powder like the ADP? Dr. Gurevich:I’ll use either ADP or I’ll use the oil of oregano by Gaia. Dr. Weitz:Okay. Dr. Gurevich:I’m getting my stuff from fullscript, and something’s on back order every other week. Dr. Weitz:Oh, I know. I know. Dr. Gurevich:Whatever I can get. Yeah. Dr. Weitz:How about you, Sam? What have you found for the most effective strategies for treating hydrogen sulfide SIBO? Dr. Rahbar:I use the combination of Xifaxan and also the Bismuth, but the Bismuth has to be compounded without the Salicylate to avoid any Salicylate issues. Either you can use Bismuth citrate or sub-nitrate. But I also have had some good luck with Mesalamine. Indeed, I know of cases we have had where this was a problem and there was a lot of abdominal symptoms. Even though the patient did not have inflammatory bowel disease, but the Mesalamine was a game changer in that setting. Now, whether it was because of controlling the hydrogen sulfide or something else, it is hard to know, but I know that’s one of the mechanism that it actually works. Dr. Gurevich:Hey, Sam, are you ruling out microscopic colitis with these people first or not necessarily? Dr. Rahbar:Well, I don’t use Mesalamine for microscopic colitis and care. Dr. Gurevich:There’s data. I feel like Mesalamine actually for really complicated microscopic colitis patients, there is data that it has efficacy and I’ve been using it with those patients and I’m wondering if it’s treated, what it’s treating, you know what I mean? There’s a couple of papers, I can send them over to you if you want to see them. Dr. Rahbar:Yeah. Mesalamine has been used for microscopic colitis. It has been used for irritable bowel syndrome. All of these, they have literature out there. But the question, how does it work? I think it may be tweaking the hydrogen sulfide and that’s why I’ve used it. In the few cases we have had, we have had good success with it. Dr. Gurevich:Interesting. Dr. Weitz:Somebody asked Sam for the dosing and the timeline for the use of Mesalamine. Dr. Rahbar:Use equivalent to Pentasa, not other types of Mesalamine. Only Pentasa because it opens up in the small bowel. It also comes in a granule, so you can have the patient to open the capsule. If you buy it from Canada, it comes in a sachet, so it’s actually in a powder format. Because the concern many times with the small bowel, the majority of the Mesalamine products in the market, they deliver to the colon, but you need this thing to open up in the small bowel. If you have patients with unexplained abdominal pain, components of, we can call, bad IBS and some suspicion of inflammation going on that is hard to define, Mesalamine might be an option. If you search, you will actually see it has been used for the setting of “irritable bowel syndrome” with some success there. Dr. Gurevich:How many grams? Four doses a day? Dr. Rahbar:Four. You need to get up to about four grams a day if the patient can tolerate it and they don’t have side effects. Dr. Weitz:Bernie said that he used oregano oil and ended up in the hospital with gut inflammation. Dr. Rahbar:I’m sorry, what is it again? Dr. Weitz:Bernie Bobman mentioned that he used the oregano oil and ended up in the hospital with gut inflammation. Dr. Rahbar:I don’t think we have enough data to understand what the problem was there. Dr. Gurevich:I do think it’s a strong anti-microbial. I think it’s a very strong antibiotic though, oregano, at least in my formulary. Dr. Weitz:Yeah, it depends on the person. I’ve used oregano oil for myself and, for me, it’s a great product. It can be very inflammatory, especially using the oils. That’s why Alana mentioned that she uses ADP, which is a dried form of oregano and it doesn’t have the volatile oils. Some people find that that’s more tolerable, correct? Dr. Gurevich:Yep, and you can go higher doses. Dr. Rahbar:Yeah. I want to make a comment about the use of herbs. Obviously, we all use them. We have had instances where you have a case of evidence of fungal overgrowth and evidence of SIBO and said, “Okay, which one do you think might be the player?” We have used herbal combinations including Allicin, [inaudible 00:41:01], FC-Cidal, Dysbiocide, ADP, and in a few instances, and again this is a small percentage that when you attack the microbiome like this, there may be a predominance as which one of these kingdom they get more affected. In other words, if the bacteria got more affected, you can actually create a fungal predominance. I’ve had cases where people within a few days of taking five herbs, that’s a lot of, they actually felt a lot more bloated, which means that there was a lot more fermentation going on. In those cases, we switched to a pure antifungal with some success. Now, this is a limited observation, but those cases are so prominent in their presentation that you would never forget how would somebody become more bloated while they’re taking five herbs at the same time? The same thing happened in one instance. I think I discussed it the last time, that the patient was an elemental diet and Rifaximin together for SIBO and Fluconazole and Nystatin, all of those and within three days of the elemental diet, the patient became more bloated on elemental diet, so we stopped everything and we switched to Itraconazole, and within few days, the bloating, everything went down again. It was obvious there was resistance of the fungi to those elements and even though there was no more SIBO, but the fungus took over in that setting there. Dr. Weitz:Now, as a chiropractor, I can’t prescribe medications, but when I use herbal products for patients with SIBO, I’m aware of the fact that most of the herbal products that are anti-microbial are also antifungal, so I always feel good about that fact that we’re fighting against the fungal overgrowth as well. Dr. Gurevich:A case like that, I often wonder if there’s a histamine component and especially if the fungus is overgrowing. The way I see it in my practice is, fungal overgrowth will usually lead to a histamine overproduction. If I see something like that, I’ll try to see if I can get some mast cell stabilizers on board to see if that would address some of the side effects. I also wonder, that’s like a big protocol, I’m often wondering, what’s left in there? If we’re getting rid of the bacteria, we’re getting rid of the fungus, then we’ve got viruses left and we’ve got the most resistible species, so I’m like, I wonder what’s left in there. Dr. Weitz:That brings up another question, which is, when is it beneficial to use probiotics? Because as we all know, even using herbal antibiotics or herbal anti-microbials, they could possibly have a negative effect on the microbiome. I haven’t really seen it, but it’s possible. Certainly, we know that using antibiotics can have a negative effect on the microbiome. Is it appropriate to use a probiotic at the same time? A lot of people like to use the analogy that we have a parking lot, we have X amount of parking spaces, and if you leave some of those spaces open, they’ll get filled up by potentially pathogenic bacteria or fungus, so let’s put a car in there, let’s put some probiotics in there. Typically, when I have a patient on a SIBO protocol, I’ll use a spore-based probiotic with the idea that it’s not going to open up in the small intestine supposedly. Dr. Gurevich:I usually hold on probiotics until what I lovingly call phase three. When we’ve done a lot of the treatment, I’ll try to introduce probiotics then. How about you, Sam? When are you using them? Dr. Rahbar:I don’t use probiotics during the treatment and very cautiously after the SIBO is treated. Dr. Gurevich:Because you’ve seen patients flare? Or do they but not strong enough? Dr. Rahbar:Generally, I imply that, if you take probiotics, there’s always a chance you’re going to get more bloated again. It’s not completely predictable as how the body’s going to handle it. Bear in mind that when we give probiotics by mouth, we really mean the probiotic to land in the colon and see the benefits there. What about if it didn’t? What would happen if we put probiotics in our eyes? Sometimes it may behave like a bad thing. Again, I generally go slowly on probiotics, although patients ask us and they want to start early, but I go cautiously there. Dr. Gurevich:Do you avoid fermented food as well? What’s your stance on fermented food? Dr. Rahbar:I use fermented foods and also prebiotics, I liked it. I use the sun fiber, the PhD-G because that’s easy. It generally doesn’t cause gas, it’s interesting there. Then, if they tolerate it, I may add some psyllium slowly in a small amount to see if we can replenish the microbiome in that way after the treatment. During the attack phase, when you’re trying to correct the fermentation process, I think it’s unwise to put probiotics there. Indeed, one of the questions comes up that whether it is wise to use Saccharomyces boulardii. To me, it’s a double-edged sword and if I’m dealing with the fungal clinical picture, I usually do not use S. Boulardii. Okay. Now, I have had people who said it helped them, but that’s not always the case there. Dr. Weitz:Do we think, somebody just asked about soil-based, same thing as spore-based bacillus, do we think that the claims that the spore-based probiotics don’t open up until they get into the large intestine? Do we think that that is the case or do we not know? Dr. Gurevich:I don’t know. Dr. Rahbar:I don’t know the answer to that question, but I can tell you one thing, that about half of the patients who have taken a spore-based probiotics, they will complain of bloating. This is not a magic bullet. I think it’s good to keep it in mind. I definitely will do it down the line after the attack phase, but in a small amounts and you really have to have them experiment with it to see how the body works with that. Dr. Gurevich:I have seen more people flare from this soil-based probiotics or the spore-based than any other probiotic out there. I do think Dr. [inaudible 00:48:00], who’s just an amazing researcher, talks about how it does upregulate the TH17 pathway, and so you are getting upregulation of the immune response or the autoimmune response. If I use it, I’m going to go very, very slow. I’ll start with a quarter cap every other day because I do see people get angry with it. I will also say, from my perspective, I am definitely having a fermented food moment. I feel like when you look back at virtually every culture in history, fermented food has been one of the staples of their diet that is not on accident. Dr. Weitz:What’s your favorite fermented food that you like to recommend? Dr. Gurevich:This week, it’s definitely kimchi. Dr. Weitz:This week? Dr. Gurevich:[inaudible 00:48:42] to the Asian market, next week it might be sauerkraut, maybe yogurt, I don’t know. Dr. Weitz:How about yourself, Sam? Do you ever-? Dr. Rahbar:Kimchi, again, a question that are you aiming for bacterial fermented material or for fungi? I think kimchi has a little bit of both. I don’t think it’s all bacterial. I think it may have some fungal components there. It’s probably safer to use those than to use the pharmaceutical versions. But again, the key is the amount and how one would experiment with it. Dr. Gurevich:And the patient. I also think the key is the patient. If you’re having somebody who’s very, very sick and very, very sensitive, I don’t know if I would jump on the fermented food train. But if you have [inaudible 00:49:35] that’s a little bit more resilient and you feel like the treatment trajectory is going how you expect, that is absolutely going to be in my phase three. I think it’s also, everything that we’re talking about is obviously exceptionally patient-dependent. Dr. Weitz:Right. I would like to point out to everybody who’s listening to this discussion that if we had several other SIBO experts, we would hear several different opinions. A lot of the stuff we’re talking about, people have many different opinions about this. There’s one prominent practitioner out there who treats a lot of SIBO and he feels like probiotics, the first line, that’s what you should give. He feels that there’s enough evidence that probiotics have anti-microbial properties. Dr. Rahbar:I also like the polyphenols. I think those have gotten more attention and we need to think about those more as supporting the local immunity of the gut and the recovery process. Dr. Gurevich:I agree. Dr. Weitz:This is not in the acute phase of SIBO, but have either of you utilized any of the probiotics that are the Akkermansia muciniphila and those other products that are the anaerobic bacteria that are being produced for the first time from, I forgot what the name of the company is. Dr. Gurevich:Pendulum. Dr. Weitz:Pendulum, right. Dr. Gurevich:I’ve never used them. Dr. Weitz:Okay. Dr. Rahbar:What do you mean by anaerobic herb? Talking about the Akkermansia? Dr. Weitz:Yeah, Akkermansia . They have an Akkermansia product and they have a product with Akkermansia and a couple of other similar probiotics that they have a study shows it reduces blood sugar. Dr. Rahbar:Yeah. I actually use Akkermansia when I see it is low. The key is that Akkermansia tends to eat up the mucus layer. There might be a good theory that when there is fungus and the mucus layer becomes quite thick and the fungus gets embedded there, Akkermansia may actually come to the rescue and be able to loosen up that mucus layer and makes it easier to remove the fungus. Having a low Akkermansia and a fungal clinical picture is probably the worst combination. Dr. Weitz:Oh, interesting. Dr. Rahbar:I’m thinking sometimes to see if I can replenish what’s missing here. Dr. Weitz:Yeah, and there’s some data showing, you mentioned polyphenols, certain polyphenols. I know flax seeds, one of them, but berries, the bunch of polyphenols can help to feed Akkermansia. But it might be interesting to try adding Akkermansia probiotic as well. Dr. Rahbar:Do it gently and within in a small amount and be careful because Akkermansia in some literature actually has shown to promote inflammation. It’s not completely clear why that would happen and how you can separate those. One of the things that would actually help to support the growth of Akkermansia is omega 3s. That might be something to keep in mind if a person is on a low omega 3, we can incorporate that as part of the recovery. Dr. Weitz:Okay. I don’t know if either one of you have heard of any practitioners experimenting with removing the anti-Vinculin and the anti-CBT toxins, the antibodies by filtering out the blood. No? I think- Dr. Rahbar:Plasmapheresis? Dr. Weitz:Plasmapheresis, yeah. I believe that Dr. Pimentel is working on doing that. Dr. Rahbar: Risky and very expensive and probably not going to get covered by any insurance company for death. Now that you said those antibodies, we have been looking at antibodies on patients who have had SIBO, especially the persistent ones. How do you explain when these antibodies are not there, they’re negative and somebody has recurrent SIBO. There must be some other sort of either immune dysregulation or physiological alteration that allows the gut for these bugs to grow. As I mentioned earlier, I think the fungi, and I think Ilana pointed out that the fungi are major players and I think they contribute by mechanical disruption means that it’s not only that you have a distorted microbiome, you now have a surface area that is disturbed, is mechanically disturbed. It has cracks, it doesn’t have the smooth, used to be like an ice skating and the bugs can float on it, and now it has cracks in the wall. Dr. Weitz:For anybody who’s not sure what we’re talking about, there is a blood test for SIBO that measures the anti-Vinculin and anti-cytolethal distending toxin antibodies. This comes from Dr. Pimentel’s theory that a significant percentage of patients who have SIBO that it starts with about a food poisoning. Then, the bacteria like Campylobacter that cause the food poisoning, those bacteria secrete an endotoxin, cytolethal distending toxin, the immune system creates antibodies, the cytolethal distending toxin, and then those antibodies cross-react with a protein called Vinculin, which is part of the nervous system of the gut. Then those antibodies attack the nervous system of the gut and that damages the motility of the small intestine and that’s what leads to the SIBO. That brings up the question, how do we best address the motility? Dr. Gurevich:My favorite is always Prucalopride. I think Prucalopride is still magical. I think that there’s definitely a subset of people that it’s not magical for, but a lot of people it’s magical. That’s my pharmaceutical go-to, especially with IMO patients who are just severely constipated. Natural agents, I think artichoke and ginger, there is data on it and it seems to work for a lot of people. That’s my experience. Dr. Weitz:Now, do you use prokinetics for patients with hydrogen and hydrogen sulfide SIBO as well? Dr. Gurevich:Not religiously, and if I do, I really will stay in the ginger area because they’re already moving a lot, so I want to make sure I’m not giving them pharmaceuticals. Dr. Weitz:Right. Now, I know in the past I’ve talked to Dr. Pimentel about this and he distinguishes between the motility of the gut and the MMC, the cleansing waves that happen when you haven’t eaten and that those are controlled by different mechanisms. Therefore, a patient who has hydrogen SIBO, who has increased motility might still lack the migrating motor complex, the cleansing waves that keep the bacteria from building up, so we still might want to use a prokinetic in those cases to make sure that we help clear the SIBO. Dr. Gurevich:I’m very, very cautious about using anything too strong. I think the herbal agents are effective and generally well-tolerated, and I think the pharmaceutical agents are too strong for that population in my experience. Dr. Weitz:What do you think, Sam? Dr. Rahbar:We may have a little bit of a difference of opinion. I use antifungals and pharmaceutical approach at first. Most of the reason is that I like targeted attacks so I understand what am I dealing with. Herbs are good, but they’re broad. They’re too, I understand I’m capturing more bacterial, more fungi is a tradeoff. But as far as a die off, yes, the die off could be stronger, but that we can adjust it by taking less of the medication and less frequently. One patient I had to work with recently, I felt that the chance of [inaudible 00:59:01] was high, I just asked them to maybe use half a tablet of Fluconazole once a week, and if they tolerated that to go to twice a week. You can go slowly and also see what the patient’s comfortable with. If they’re more comfortable with herbal approaches, you can go that way. Dr. Weitz:Do you use prokinetics either during the active treatment or afterwards to reduce recurrence, which is when Dr. Pimentel tends to use them? Dr. Rahbar:I don’t use prokinetics during the treatment. I don’t want to push the drugs out. I want them to hang out in the small bowel, so I would use them afterwards, but not during. Dr. Weitz:Okay, and you? Do you use? I’m sorry. Dr. Gurevich:One of my selling points on the herbs is that they are broad spectrum, that’s one of the things I like about them. They’re less targeted, they’re less specific. The way I think about it is, humans evolve with plant matter for 200,000 years and we’ve had pharmaceuticals that are targeted for about a hundred and our health has significantly declined in that small amount of time, so that’s one of the reasons why I prefer herbs over the pharmaceuticals, if the patient [inaudible 01:00:18]. Dr. Weitz:Oh, I’m sorry. Dr. Rahbar:They’re both good. Dr. Weitz:What do we think about why the patients ended up with SIBO? Do you both think that … ? What percentage of cases do you think are probably related to food poisoning and decreased motility? What do we think are the causes for the SIBO? Also, do we think that hydrogen, do we think that stomach acid reduces the risk for SIBO? Because that seems to be in question now that, at least Dr. Pimentel has talked about the fact that PPI use does not increase the risk for SIBO. Does that mean that stomach acid doesn’t help to reduce bacteria growth in the intestines? Dr. Rahbar:In patients who have low acid and they have SIBO, there may be other mechanisms involved other than just the low acid that is contributing to the SIBO. I am not convinced that the PPIs increase the risk of SIBO, although conceptually that makes sense. It’s just something in practice we have not seen to be a strong association. Dr. Weitz:Yeah. No, Dr. Pimentel has said the opposite. He said that he’s convinced that they don’t increase the risk of SIBO and he seemed to hint that they might be beneficial for use as part of the treatment for patients with methane SIBO. Dr. Rahbar:Right. I don’t know if I’m going to incorporate the PPI in the treatment of SIBO despite that comment. But if I have to use it for somebody who has bad acid reflux and we need some temporary relief, it probably would be okay. Dr. Gurevich:I agree. Dr. Weitz:Let’s see. Anything else we haven’t covered? They did not answer as to, what do you think is the cause of SIBO? Dr. Rahbar:How much time do we have? Dr. Weitz:We can do a couple more. Dr. Rahbar: You should bring Mark back again to discuss that one. Come on, this is going to go on for a long time. I think that, as I said, in our experience, the alterations of the microbiome that we see, I think it has a lot to do with how that individual and the universe were interacting. Obviously, stress, lack of a sleep, late eating, alcohol, use of antibiotics, all of these things are the common ones. We know history of food poisoning, Vinculin antibody being positive. But then there’s a subset of patient that are just exposed to chemicals. We see SIBO and C4 combination is quite commonly people have been exposed to more toxins. This is our own experience looking at a lot of patients that a SIBO that is really high hydrogen or the methane is high. It may very well be associated with the mycotoxin exposure or high level of BPA or Glyphosate or Phthalates. We are seeing these associations and hopefully at one point we can publish this so we can further confirm that. But as an observation, I find that as a subset of patients, they are dealing with this type of problem. Dr. Gurevich:I totally agree and it was beautifully said. Dr. Rahbar:Thank you. Dr. Weitz:Sam, you’ve also published on the fact that there are cases of patients with SIBO who also have Lyme disease and that seems to be a factor. Dr. Rahbar:Right. Back in 2014, I presented the data that if you see somebody with high methane that suggests immune dysregulation and if the clinical picture fits, you must think of Lyme disease or other tickborne diseases. We published this in 2021 in our experience, and the prevalence of SIBO was quite high in the subset of patients who had tickborne disease. But when we compared it with the control group and the people who did not have the tickborne disease, they also had a similar prevalence. However, I want to emphasize in that study we use a cutoff of 80 minutes for SIBO, not 90, not 100, 80 minutes. The reason I did that just to make sure there was no question that if there was SIBO, it was SIBO and it was not the borderline case. Only people who were abnormal at the 80-minutes mark we included in that study. Dr. Weitz:All right. Great. Well, thank you both so much for filling in at the last minute. For anybody who just came in later, Dr. Pimentel wasn’t able to join us, but we hope to have him in a future meeting. Thank you everybody for participating and we hope to see you next month. Dr. Rahbar:I hope so too. Have a nice [inaudible 01:06:06]. Dr. Gurevich:Nice to meet you, Sam. It was lovely hearing you speak. Very nice to meet you. Dr. Rahbar:Yeah. Thank you. All the best. Take care. Dr. Gurevich:Bye, everybody. Dr. Rahbar:Bye. Dr. Weitz:                            Thank you for making it all the way through this episode of the Rational Wellness podcast. For those of you who enjoy listening to the Rational Wellness podcast, I would certainly appreciate it if you could go to Apple Podcast or Spotify and give us a five star ratings and review. That way, more people will be able to discover the Rational Wellness podcast. I wanted to say thank you to all the patients that we’ve been working with at our White Sports Chiropractic and Nutrition clinic who, many of whom, most of whom we’ve been able to help with a range of various health conditions from various types of gut disorders to thyroid and hormonal issues, autoimmune diseases and various other cardiometabolic conditions, and so I very much appreciate you and I’m excited about going forward, helping you to do improve your health on your journey towards optimal health. I wanted to let everybody know that I do have a few openings now for new clients and you can take advantage of that by calling my White Sports Chiropractic and Nutrition, Santa Monica office at 310 395 3111, and we could set you up for a new consultation for functional medicine nutrition and we can get that going as early as the New Year, so give us a call and I’ll talk to you next week.

8 de mar de 2023 - 1 h 7 min
episode Integrative Approach to PCOS with Dr. Fiona McCulloch: Rational Wellness Podcast 297 artwork

Integrative Approach to PCOS with Dr. Fiona McCulloch: Rational Wellness Podcast 297

Dr. Fiona McCulloch discusses An Integrative Approach to Polycystic Ovarian Syndrome (PCOS) with Dr. Ben Weitz. [If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page [https://www.youtube.com/user/weitzchiro].] Podcast Highlights 3:20Even though the name of the condition that we are discussing is Polycystic Ovarian Syndrome, you don’t actually have to have cysts in the ovaries to be diagnosed with it.  And the cysts in question are not actually cysts, but follicles that haven’t really ovulated.  But PCOS is really a condition of androgen (testosterone)  excess, so the name is not really appropriate, but everyone is familiar with the same. 4:29There are two prongs to this condition and one is is androgen excess and the other is insulin resistance.  All PCOS patients have androgen excess, whether they have hair growth on their face, acne or hair loss from the scalp or they test positive for excess androgens, but not all PCOS patients have insulin resistance.  There is a small subset (perhaps 30%) of PCOS patients who are lean and do not have insulin resistance. 6:49 The Adrenal PCOS subtype.This type of patient is often lean and tends to have higher levels of adrenal androgens, like DHEA, though higher DHEA levels usually results in higher testosterone levels, since DHEA is a precursor hormone.  For each patient it is variable how much the DHEA will turn into testosterone.  Patients with the high adrenal androgens are often more symptomatic when they’re younger and they tend to improve when they get older. 8:27 How PCOS develops. PCOS tends to start to develop either in-utero or during early development.  Women with PCOS are more likely to have daughters with PCOS, so we know there are some genetic factors. There are a number of genes that play a role in the development of PCOS, including DENND1a.  The SNP linked to Insulin Resistant PCOS is located on Chromosome 2 *in between* genes: FIGN and KCNH7.  Here is a link to an Instagram post by Dr. McCulloch on this topic: PCOS Genetic Updates [https://www.instagram.com/p/Cm9y-iHuoDQ/]. Two other SNPs (genes) that play a role in the lean PCOS patients are: 1. BMPR1B, a gene that transcribes receptors for AMH, a hormone that often high in patients with PCOS. AMH is critical for the development of the follicles in the ovary and 2. PRDM helps activate the estrogen receptor. It is also involved in the development of the granulosa cells in the process of ovulation. 11:28If an embryo is exposed to too much testosterone at certain windows of development, it can androgenize the ovaries and the brain and along with the genes and we think this is what causes PCOS. What happens during childhood is that there’s a period in which women’s ovaries actually produce more testosterone and normally estrogen takes over at a certain point in time.  But for women with PCOS, they get stuck in this androgen dominance state. And high androgens in women cause visceral fat storage and insulin resistance that is difficult to reverse later.  And such women have higher rates of eating disorders. 14:20 Endocrine disrupting substances in the environment can play a role in the onset of PCOS.  They have found that if you expose any embryo to Bisphenol A plastics, which are endocrine disruptors, that they can develop PCOS. 14:50 Insulin Resistance.It is the insulin resistance that puts PCOS patients at risk for an increase in cardiovascular disease, diabetes, and non-alcoholic fatty liver (NAFLD).  Liver is really the center for insulin resistance.  When the liver gets overloaded with fat because of too many calories being consumed and the fat inside the liver starts to leak out.  The liver starts releasing glucose instead of storing it and this leads to metabolic disease and inflammation. 19:10ALT is the most sensitive indicator of fatty liver and a level of ALT above 19 is associated with Fatty Liver, whereas the normal range is about 40 and for some labs like UCLA the reference range has recently been increased to 70, no doubt because of the decline in metabolic health of Americans during the pandemic. Dr. Fiona McCulloch is a Naturopathic Doctor and founder of White Lotus Integrative Medicine in Toronto Canada, serving thousands of women with hormonal conditions since 2001. Dr. Fiona’s best selling book 8 Steps To Reverse Your PCOS [https://www.barnesandnoble.com/w/8-steps-to-reverse-your-pcos-fiona-mcculloch/1123773772], offers well-researched methods for the natural treatment of Polycystic Ovary Syndrome. Fiona is also a medical advisor to and developed the nutrition methodology for the OpenSourceHealth PCOS project which analyzes molecular, genetic, metabolic and hormonal markers in women with PCOS. As a woman with PCOS herself, Dr. Fiona feels fortunate to serve as a guide, providing trusted information that empowers women to manage their own health.  Her website is DrFionaND.com [https://drfionand.com/]. Dr. Ben Weitz is available for Functional 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations. Podcast Transcript Dr. Weitz:Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast. Hello, rational Wellness podcasters. Today our topic is polycystic ovary syndrome with Dr. Fiona McCulloch. Polycystic ovary syndrome is actually the most common hormonal disorder among women of reproductive age. Some of the most common symptoms are irregular periods, weight gain and difficulty losing weight, fatigue, facial hair, male pattern baldness in women, acne, infertility, mood swings, pelvic pain, headaches, sleep problems. The diagnosis of PCOS for most experts still appears to be based on Rotterdam consensus, which defines the presence of PCOS. If two out of the following three criteria are present, be delayed ovulation or menstrual cycles known as anovulation. Basically, if your cycle lasts 35 days or longer, that qualifies for this. Number two is high levels of androgen and hormones like testosterone and D H E A. And number three is polycystic ovaries seen on ultrasound. On the other hand, the PCOS society sees PCOS as primarily a condition of androgen excess. Insulin resistance is seen as one of the key factors in the pathophysiology of PCOS. I’m thrilled to have the opportunity to speak with Dr. Fiona McCulloch for the third time after appearances on both episodes, 137 and 65, three and four years ago. Dr. Fiona McCulloch is a naturopathic doctor and founder of White Lotus Integrative Medicine in Toronto, Canada, serving thousands of women with hormonal conditions since 2001. Dr. Fiona’s best-selling book, Eight Steps to Reverse Your PCOS, offers well researched methods for the natural treatment of polycystic ovary syndrome. By the way, definitely the best book I’ve read of all the books on PCOS. Dr. Fiona is also a medical advisor and developed a nutrition methodology for the Open Source PCOS Project, which analyzes molecular, genetic, metabolic, and hormonal markers in women for PCOS. As a woman with PCOS herself, Dr. Fiona feels fortunate to serve as a guide providing trusted information that empowers women to manage their own health. Thank you so much for joining us. Dr. McCulloch:Thanks Dr. Weitz. It’s great to be here again. I love your show and I’ve been looking forward to being on it today. Dr. Weitz:That’s great. So let’s start with the diagnosis of polycystic ovary syndrome and what do you consider some of the best ways to diagnose it and what are some of the challenges? And I wanted to say one interesting thing about PCOS is the name is polycystic ovary syndrome, but you actually don’t have to have cysts in the ovaries to be diagnosed with this. Dr. McCulloch:Yeah, that’s right. And there’s a lot of controversy around the diagnosis because this was what it was named many years ago, and what we know is that these cysts are not actually even cysts. They’re just follicles that haven’t really ovulated. So the name, really, it doesn’t make a lot of sense because PCOS is actually conditioned around too much testosterone or hormones like that called androgens. Some people, especially when they’re younger, they do have these cysts in their ovaries, but as patients get older, many don’t, actually. So it’s really important to think of it as a hormonal condition rather than one involving cysts. Dr. Weitz:Well, it really seems like there’s two prongs to this condition, and one is the androgen access, and the other one seems to be insulin resistance, which seems to be the other big concept here. Dr. McCulloch:Yes, a hundred percent. And this is sort of how the center of PCOS works. And what we know is that the way they diagnosed it or do diagnose it still, even if somebody doesn’t qualify for that diagnosis later, they still do have those same tendencies. So it really shouldn’t be undiagnosed, but the tendencies are the androgen excess. So everybody tends to have that, either some clinical signs, they can have hair growth on their face, acne or hair loss from the scalp, or the other one is insulin resistance. In around 70% of patients with PCOS have that, but not everyone. There are patients with PCOS who are quite not insulin resistant. They’re very lean, and actually they think that this might be genetically distinct as a type, even though they both have androgen access. There are definitely differences between these two types, but we still need to learn a bit more about that. Dr. Weitz:Out of curiosity, how many lean PCOS patients are there? Is that a very small percentage? Dr. McCulloch:It’s around 30%, but yeah, technically some of those patients, so they would be considered normal body mass index, and it’s unfortunate they use that as the marker because- Dr. Weitz:You can still have insulin resistance even if you have normal body weight? Dr. McCulloch:Exactly. There’s a whole category of lean patients that actually do have insulin resistance. I would’ve been in that category myself. I wasn’t actually that lean, I had a lot of abdominal fat. I would gain weight very easily. But then there are patients who are actually not at all insulin resistant, and they are very different in that they don’t have this element, which is really powerful. But there are lean patients with normal body mass index who do gain weight around their midsection, and they have all those characteristics too. So yeah, it’s definitely a spectrum. Dr. Weitz:So I guess there’s these different subtypes of PCOS. I’ve also heard you, in one of your articles or in your book, you talk about the adrenal PCOS subtype as well. Dr. McCulloch:Yes. The adrenal type is often lean. And an interesting thing about that, since I’ve written the book, I’ve sort of changed what I think about that a little bit, just observing it over time. Because what we see with the patients with the high adrenal androgens is that this is worse when they’re younger and it improves when they get older, but the level to which that is a problem depends on how much it turns into testosterone. So much of their case is very similar to lean PCOS, but sometimes they do need a lot of additional stress support, that’s quite common in that group. But a lot of the patients who have the adrenal androgens are more in the lean PCOS category as well. Dr. Weitz:So the adrenal androgens, you’re talking about DHEA more so than testosterone? Dr. McCulloch:That’s right, yes. So DHEA is a hormone that comes from the adrenal glands, DHEA-S, and it is used by the ovaries to make testosterone. The brain has to tell it to do that, to take that DHEA and turn that into testosterone. So what we’ll see is that patients who have high DHEA, they usually also have high testosterone. And for each patient, though, sometimes it’s really high and sometimes it’s not that high. So it really depends on what the brain and the ovary are doing with that because it’s really a precursor. And the DHEA-S is not very androgenic compared to testosterone. It’s not very strong. It’s more of a precursor. Dr. Weitz:So in terms of how PCOS develops, it seems as though there’s this in-utero potential and then maybe during early development. And I’ve heard you talk about what happens is that during childhood, there’s a period in which women’s ovaries actually produce more testosterone and they kind of gets stuck in that. Dr. McCulloch:Yeah, exactly. So it’s really interesting. We never knew what caused PCOS, but over the past several years, we’ve really accelerated what we know. And there are genes that are associated with PCOS, they’re still unraveling what those are, so [inaudible 00:09:17] Dr. Weitz:Do we know what some of the key genes are? Dr. McCulloch: Yeah, there’s one that’s called DENND1A. That one actually is involved in the creation of androgens in the ovaries. There’s genes that are correlated to type two diabetes, insulin resistance, the sympathetic nervous system. These ones are actually in between two gene SNPs and they have, if anyone is interested, if you go to my Instagram, I have the RSIDs on there. There’s also some genes for the FSH receptor, which is basically a receptor that takes messages from the pituitary gland to help make estrogen. And then there are some around the estrogen receptor that they found too. So there’s quite a few. There seems to be some differences between the lean and the classic. In the lean PCOS, they also have found a snip that is related to a hormone called anti-mullerian hormone. And that hormone is almost always quite high in PCOS. So they’re actually finding some of these very specific SNPs. And if you’re interested in the names of those, I have them on my Instagram, and you can look them up if you have any raw data. Dr. Weitz:What’s the best panel? Are these contained in a ancestry or 23&Me panel? Dr. McCulloch:So I checked my own because my undergraduate degree is in genetics, so I find it really interesting, and some of them are in the chip I have, but a lot of them are not. And in fact, like the last study they did, it was a genome-wide study, and some of them were new, that they don’t really have a lot of info on, but they were strongly correlated. So they weren’t in those tests, but maybe in the future they will be. Dr. Weitz:So you don’t know of a particular panel that would be appropriate to run for this? Dr. McCulloch:We don’t have anything like that Includes all of those. I have both Ancestry and 23andMe, and each of them have some, but yeah, nothing, not all of it in one. Yeah. Dr. Weitz:And then can you explain, I don’t think most people are aware of the fact that during some part of childhood, women’s ovaries actually produce more androgens than they do estrogen. Dr. McCulloch: Yes. And I should have also answered your other question about the in-utero environment because, so you can have these genes, but then in the in-utero environment, we know that if an embryo’s exposed to too much testosterone at certain windows of development, it can andogenize the ovaries, the brain, and this is what they think actually, along with the genetics, causes PCOS. So basically when that happens, everything’s very quiet during childhood. There’s no hormones. Right before puberty, what happens is our adrenals activate, and this is called adrenarche. This happens before the first period. And in this state actually our cortisol goes up. We begin to gain some weight because that’s required for reproduction. It tends to be around the abdomen and the adrenals start to make androgens. And with PCOS, what happens generally is that that process can start insulin resistance. That weight gain that is happening, that should be happening, really, there’s more androgens than normal. It can actually accelerate the gain of weight around the abdomen called visceral fat. And then when the actual periods begin to start, what happens is, for all girls, there’s a state where the androgens are more dominant for a while, and what normally should happen is that estrogen should take over. And as ovations happen, they should start to be happening more regularly. The androgens become lower over time. But in PCOS, what happens is the androgens that are made are more, there’s too many, and this is related to what happened in the womb, but also genetics and those androgens block ovulation. So then the person gets stuck there in the state where they have high androgens. And high androgens cause visceral fat to be gained, they cause insulin resistance. And in this age group, like adolescents, I remember at that age, I would love to eat all kinds of candy and sugar and all kinds of things and it’s just a recipe where a lot of problems can happen. They can develop eating disorders. All of this is all occurring in those adolescent years, and then the person can either really develop deep insulin resistance, which is harder to undo, or the androgen access just kind of gets stuck like that. So that’s generally how it develops, according to what we know. Dr. Weitz:Right. Okay. And we also think that these endocrine disrupting substances in the environment, these toxins are playing a role in this too. Dr. McCulloch:Yes, absolutely. So I’m really glad you brought that up because they’ve also found that if at those windows in development, if you expose embryos to Bisphenol A plastics endocrine disruptors, they can develop PCOS as well. So that could be, it is involved almost certainly. Dr. Weitz:So let’s talk about insulin resistance, and let’s also talk about the association of fatty liver with PCOS. Dr. McCulloch: Yeah, so this, in my opinion, is something that is the biggest problem because PCOS is still thought of as this fertility condition. Meanwhile, insulin resistance is one of the top health problems generally that anybody can have. And it puts you at risk for cardiovascular disease, diabetes, so many things. And 70% of patients with PCOS have this, and it’s very, very much linked to fatty liver disease. The liver is really the center of insulin resistance. It creates a little cycle where it makes insulin resistance worse. So the liver becomes overloaded with energy, basically overloaded with fat, and the fat inside the liver actually starts to leak out. That creates inflammation, and then that fat actually starts depositing randomly around the body, especially around the organs, but also in areas like the muscle and inside our tissues. And that process basically causes overall inflammation, metabolic dysfunction. We start releasing glucose at the wrong times from the liver when it’s supposed to be storing it, everything just starts going wrong. It’s like the traffic lights are not synced up, and that really is all regulated by the liver. So yeah, this is a really big problem. Dr. Weitz:So not only is fatty liver an indication of this metabolic dysfunction that’s leading to diabetes and heart disease, but fatty liver itself is considered to be one of the growing risks to our health. And we may have a tsunami of people needing liver transplants because of non-alcoholic fatty liver. So this is fatty liver not related to alcohol. Dr. McCulloch:Yes. Dr. Weitz:I see some debate about, I was just listening to somebody else’s podcast and they were talking about, after you eat a high fat meal being a big factor. But my understanding is, it’s really sugar and glucose and high glycemic foods that causes fat buildup in the liver. Dr. McCulloch:Yeah. It is really the energy overload primarily that causes the buildup. But the interesting thing is, if a woman doesn’t have PCOS, if she were to consume extra calories, for example, it goes into subcutaneous fat, which is around the hips and the thighs, and that’s a healthy fat. It’s actually anti-inflammatory. It releases all of these lovely chemicals called adipokines that are really healthy for us, and the estrogen is what does that. So unfortunately in PCOS, the androgens start just pushing all that fat right into the liver, expanding the size of the fat cells and making visceral fat. So it’s like it’s just directed right into that area. And so any excess energy is just stored there so easily. And so it can be any energy, but the problem I find with glucose, definitely glucose is more of a problem because, especially with insulin resistance, it puts people on a glucose roller coaster. They start having hypoglycemia, eating more sugar and carbs. Also, sugar is very inflammatory. Fructose is another big problem for fatty liver. I personally think those are worse. There is also the theory though, that it’s just a total energy overload. And I do agree with certain parts of that also. So yeah, it’s really- Dr. Weitz:It’s kind of interesting, in a functional medicine world, it’s almost a political discussion because we have the vegan party and we have the low carb party, and we have the carnivore party and everybody’s trying to blame somebody else. If you’re in the vegan camp, then you want to blame high fat for the problem because you’re mostly carbs. But anyway. Dr. McCulloch:It’s so true. Dr. Weitz:I saw on Instagram where you said the ALT is the most sensitive indicator, which is interesting because there’s the ALT, there’s the AST, there’s a GGT that sometimes is run. But you say the ALT, and you mentioned that ALT above 19 in women is associated with fatty liver. And the normal range, depending upon the lab, is, say, 40. By the way, UCLA recently raised their reference ranges, and I think it’s now 70. This is a scary thing. People don’t realize that the reference range in the United States and elsewhere. So in the United States, it’s just based on the average American. In fact, the average American that is being measured by that lab, so because of several years of staying home and eating more junk food and drinking more, the average liver enzymes have gone up. And now we’re considering that the reference range, which most people consider good or normal. Dr. McCulloch:It’s shocking. And I think there is more fatty liver disease in children. It’s astronomically rising in children, something we never saw. And I think, yeah, so many people now have fatty liver that they’re flagging everyone. And now they’re like, let’s raise the reference range so it only shows us things like hepatitis ’cause we don’t want to hear about that. But it’s horrible because there’s so many people with fatty liver disease that have no idea they have, it has no symptoms. And if they knew this, they could, because it’s reversible. Dr. Weitz:If everybody was flagged with an ALT above 19, oh my gosh, you’re talking about huge percentage of Americans and probably similar in Canada where you’re located. Dr. McCulloch:For men, I think it’s a little higher at 24, but for women they found it was 19. Dr. Weitz:Wow. Dr. McCulloch:And over that is an indicator. It’s that combined with other signs. I think you see- Dr. Weitz:Sure. Dr. McCulloch:… a higher waist circumference and all of that. But then, yeah, I definitely see that. Dr. Weitz:Higher ferritin, higher triglycerides, lower HDL. Right? Dr. McCulloch:Exactly. Exactly. All those things and the insulin. Dr. Weitz:Yeah, ferritin’s an important marker that’s not always measured. And most people just consider it a marker for iron status, but high ferritin levels is an inflammatory marker. Dr. McCulloch:Yes. And one thing I always like to point out is it’s very unusual in women to not to have high ferritin because women often are irons efficient because of periods, especially reproductive age women, that’s very unusual. So if the ferritin is over a hundred and you’re not eating tons and tons of red meat and iron, that might be fatty liver. Now, ferritin can also be other inflammation very much, but we definitely see it raised in fatty liver. Dr. Weitz:Right. What makes people gain weight so easily with PCOS? I guess the answer is what we just said about insulin resistance, right? Dr. McCulloch:Yeah. There’s so many factors like the insulin resistance, once it sets in for a really long time, you’ll definitely see people who have obesity for many, many, many years. Of course, they can change their diet and lose weight, but what they have trouble with is maintenance. And it’s because we know that the cells actually have a memory of this, of insulin resistance. So once it’s been that way for a long time, you can lose the weight, but your brain and your cells will want to put it back, so it’s very challenging. And one of the big problems I see is that they don’t intervene early enough when it really could be much simpler, and instead just dismiss patients and let them go years. And that whole time they’re just developing more and more insulin resistance. So that’s one part of it. Outside of that too, that androgens themselves just drive this weight gain around the abdomen. And these are the highest when you’re the youngest with PCOS. So it’s just a recipe for insulin resistance in younger years. Dr. Weitz:It’s so interesting how same hormone can have different effects in men and women. Because in men, testosterone tends to make men leaner, whereas testosterone makes women tend to gain weight. Dr. McCulloch:Yes. That’s such an interesting element because it has definitely dimorphic effects in men and women, very different. And in women- Dr. Weitz:That’s a good word, dimorphic effects. Dr. McCulloch:They’ve actually studied that, so I did not come up with that. But yeah, what they find is there’s a sweet spot for women, it’s good if it’s at a certain amount, but when it’s so high that it’s too high and it’s disrupting ovulation, then it starts to drive it into these areas like the liver and the visceral fat. So those androgens are, yeah. But in men, it’s actually quite beneficial to have androgens. In women, as well, low androgens is not good, but in PCOS, they’re just incredibly high. Yeah, big problem. Dr. Weitz:So you mentioned testing for testosterone. Let’s go into lab testing and then we’ll go into treatment. Why don’t we start with the testosterone? I can relate that I’ve had patients, I knew they had PCOS, I could just tell from the presentation. And yet we looked at the testosterone and it was normal on lab testing. And I understand that a lot of times it doesn’t show up. Dr. McCulloch:Oh my goodness. Yes, so true. So basically the reference ranges for androgens are not age adjusted, firstly. So androgens are very high when you’re young and they become very low when you get to about 40 or so, and this is normal, but the reference ranges don’t include that. So what might be high at age 35 would look really normal, but it’s higher than average. So that’s one big problem. There’s also a lot of patients who are right up at the top of that range and they’re not ovulating, and that’s enough that it’s blocking the ovulation process, that’s androgen excess or they have symptoms. So the testing, again, those reference ranges are not very good. Dr. Weitz:So what should we look at for serum levels? Can you give us some ballpark? And we’re talking about total testosterone. Does free testosterone, is that as important as well? Dr. McCulloch:It can be, and I’m going to use Canadian values because I don’t know the US ones. I usually convert them, but I can use what I know and then maybe in the notes it could be converted. Dr. Weitz:You got it. Dr. McCulloch: The total testosterone I use a lot, because this picks up lean PCOS very well. Free testosterone is much better at picking up insulin resistance. So I tend to look at that in a little different way. And the way I test it is, I’ll do total testosterone. In Canada, our reference majors are around two to 2.1, but what I’ll see is that there are some people that are above that. Then as patients get older, they’re kind of up towards the top, 1.8, 1.7. If a woman is 45 years old, for example, and she has a total testosterone of 1.4, that’s very unusual. Even though it’s not even close to the range at the top of the range, it’s not common. So that is one way I look at it. DHEAS is similar, so our range goes up to about 9.7 and around 6.7 in your forties. So anything towards the top might be a problem, it really depends. One of the tests I do a lot is LH and FSH on cycle day two or three because LH makes testosterone. So you’re seeing almost like a leading indicator. If the LH is higher than the FSH, in particular, if it’s double, that is very PCOS-like and will drive androgen excess. So that is another one we can see. Sex hormone binding globulin is another interesting one because this is a hormone that, when you’re insulin resistant, it’s low, and when that’s low, the testosterone can become more powerful and free. So basically, that I like it to be around the middle of the range, so that one wouldn’t necessarily need a unit depending on what the one is there. Dr. Weitz:Oh, interesting. So you need enough SHBG? Yeah, I’m usually concerned, and when I’m working with men, because it gets too high and it blocks the free testosterone. Dr. McCulloch:And it’s the opposite. So when women with the SHBG, it’s very high when there’s high estrogen, and very low when there’s high insulin. And the liver, when it’s insulin resistant, it can’t make SHBG very well. So that’s why the patients who have insulin resistance, they often don’t have enough estrogen either. Sometimes they do and sometimes they don’t. It’s another I misunderstood thing, estrogen dominance, but sometimes their SHBG is so low that even the smallest amount of testosterone is just so powerful in them. Dr. Weitz:I would imagine women with low SHBG probably have trouble with thyroid too, because they don’t have the binding globulin for the thyroid either. Dr. McCulloch:They have so many problems with, definitely, the thyroid, all of the hormones. I just find that those patients, because they have so much insulin resistance, everything starts going off, every hormone basically. Dr. Weitz:And I know sometimes you measure the testosterone in dry urine as well. Dr. McCulloch:Yeah, I don’t do that as much anymore. I’m doing more serum these days. It’s just more efficient, I find. Dr. Weitz:Get it all done in one test. Dr. McCulloch:Yeah, I always want to test insulin, thyroid, all the things that you can’t, and so it’s just easier to do a standard blood lab because I can get the exact panel I want. Dr. Weitz:Right. Okay. So you mentioned FSH and LH, and you mentioned androgens. Total testosterone, free testosterone, DHEAS and androstenedione. Are there a significant number of cases where you might see androstenedione high when the testosterone’s not? Dr. McCulloch:Yes. I actually find the androstenedione is quite sensitive sometimes, so it’s a good one to run. Sometimes it’s a little more expensive, but if it’s unclear, that one is often at the top of the range. Dr. Weitz:Okay. And then what other tests? Do you usually measure the anti-mullerian hormone? Dr. McCulloch:I do that a lot. In particular, if I’m unclear if they might have PCOS and they’re a bit older, I’m like, I don’t know. If I run that and they have a very high egg reserve, it adds to that diagnosis. I will do that sometimes for patients who are seeking fertility treatment as well. And what I find is the lean PCOS patients, sometimes it’s very, very high. So it’s definitely- Dr. Weitz:Technically you can’t have PCOS after menopause, or can you? Dr. McCulloch:You actually can, and it doesn’t go away. But it’s like these diagnostic criteria, technically would be undiagnosed. But what we know from research is the androgen access is still there. They still have it. They have all these risks for cardio, diabetes, so it’s still there, so they need to do something about that. Dr. Weitz:Yeah. And then what other factors? You look at metabolic factors? Dr. McCulloch:Yes. I always really look into insulin resistance. So I’ll do fasting insulin, fasting glucose or an insulin glucose challenge, which is also known as the Kraft test, that’s more detailed, A1C. The lipids are always really important to inflammatory markers. Dr. Weitz:Mention that test for insulin resistance that you just mentioned? Dr. McCulloch:Oh yeah. It’s called the insulin glucose challenge, and it’s also known as the Kraft test. It was created by Dr. Kraft who is quite well known for all of his work on diabetes. And he is a type one diabetic and he created a test involving taking 75 grams of glucose and measuring both glucose and insulin for four hours afterwards at certain increments. And this can show you insulin resistance and its progression towards type two diabetes. So it’s really interesting. Dr. Weitz:I think this was known as the glucose tolerance test and I think it was a six hour test, right? Dr. McCulloch:Yeah. The glucose tolerance test is the one that we do a lot, but this one it’s similar but also includes insulin at each measurement, which- Dr. Weitz:That makes a lot more sense. Dr. McCulloch:So interesting. Dr. Weitz:Insulin is usually often not measured by most doctors and it’s so important because if you are using a lot of insulin to keep your glucose in a normal range, that’s as problematic as having high glucose. Dr. McCulloch:And this is one of the best tests for these lean patients with the insulin resistance because what we’ll see is they’re doing the test, their fasting looks really good, and then they take this sugar, and oh my gosh, they make five times the amount of insulin as another person of the same body mass index. And you can also see hypoglycemia and exactly how it’s happening. So it’s quite a cool test actually. Dr. Weitz:And how do you assess adrenals? Do you do the salivary adrenal testing? Dr. McCulloch:Yeah, I do that a lot. So this is the saliva, four point cortisol is the popular one in our practice. We do also the urinary cortisols. And then sometimes I’ll just do a serum morning cortisol, even though it’s not ideal, sometimes it’s just efficient and it saves on funds. And you can see- Dr. Weitz: I don’t get anything out of that serum cortisol test. Dr. McCulloch:Yeah, it’s sort of a screening, so sometimes it’ll be really high or really low, and that’s really, because not everybody always has, it’s a lot of testing. But if I’m looking, really seeing a problem, I’ll usually run a saliva. Dr. Weitz:So let’s get into treatment. And we all know, the best treatment is to just put all women on birth control, right? Dr. McCulloch:That’s the treatment that’s offered really for everybody. It doesn’t seem to matter. That’s just what you’re getting until you’re ready to have kids, then you can come off it and then we’ll deal with it. So that’s the treatments. And then they also have metformin, that’s the other one, and that’s about it. And metformin isn’t bad, it just doesn’t do all that much. They need to be offering nutrition and exercise. There’s so many things that could be done. Dr. Weitz:Metformin, in and of itself, is not going to do the thing. You’ve got to be doing a diet, the exercise and everything else and then metformin can have a significant effect. But there’s plenty of other natural treatments that can work as well. I understand you will sometimes recommend the use of progesterone. Dr. McCulloch: Yes. This is actually a really interesting treatment. There’s a big clinical trial going on right now at UBC on cyclic progesterone for PCOS. Cyclic progesterone is not the same thing as birth control. A lot of people will think it is because they’re used to that. But what’s in birth control is actually a different substance, it’s called a progestin. And there’s a whole bunch of these progestins, and they all are different in what they do. Some of them actually act like estrogen, some even act like testosterone. And there’s some that have actions that are completely different from progesterone. So it’s totally not the same thing as that. It’s also not the same thing as something called medroxy provera, which is commonly used in PCOS to stimulate a bleed. This is actually natural micronized progesterone. So it’s the same exact type your body makes after ovulation. And progesterone lowers the LH hormone, so when this is done repeatedly for 14 days out of every month, what happens is the LH comes down and it can act as training wheels to teach the ovary to lower the testosterone and let the estrogen be the dominant hormone. So it’s a really interesting treatment, it’s almost like replacing what didn’t happen in the puberty timing and doing it a bit later. Dr. Weitz:Interesting. Are there any other hormones or medications that you use? We’ll go into diet and supplements next. Dr. McCulloch:A lot of the patients have thyroid disease, so I do a lot of natural desiccated thyroid prescribing for PCOS. So I would say these are the top hormones that I would use, that and progesterone. Dr. Weitz:Okay. So let’s talk about the dietary strategy for PCOS. Dr. McCulloch:Yeah, so there’s so much, like you were saying before, all these political sides on each side of it. Every diet is [inaudible 00:37:18]. Dr. Weitz:Eat only meat. Eat only vegetables. Dr. McCulloch:Vegetables are bad. Vegetables are everything. So it’s always personal too. Many different nutrition plans can work for PCOS as long as they’re, if the person has insulin resistance, as long as it’s managing that. But it has to be sustainable. So for most people, of course, doing a very, very low carb diet like keto will lower insulin, but most people can’t do that forever. And there’s many other ways to lower insulin. So I have a way that I generally recommend as a starting point, but it’s very flexible. And this includes four different categories of food. It’s all about balancing blood sugar and stopping spikes of sugar with very healthy anti-inflammatory food and it’s protein. So about 25 to 30 grams of protein in a meal, two or three cups of vegetables, any kind, really, non-starchy. Two servings of healthy fats, so that could be nuts or seeds or avocado, guacamole, healthy oils like olive oil or avocado oil. But a serving of those nuts and seeds is a quarter cup. So pretty significant amount of healthy fats. And the amount of carbs should be variable depending on the person, a half to three quarters of a cup per meal, more of a low glycemic index carbohydrate, something with resistant starch. I find beans and lentils are a great carbohydrate. A lot of people think of them as a protein, but actually, there’s a lot of carbs in there and they’re resistant starch. So that kind of meal is super balancing to the blood sugar. But everyone might need a little tweaking to that, because people are athletic or need certain adjustments. Dr. Weitz:Okay, let’s go into some clinical pearls for treatment with respect to specific nutraceuticals. Dr. McCulloch:And one of the things I’ll say first just before talking about treatment is I see so many of the lean patients doing treatments for insulin resistance and it’s not working for them. So I just want to say firstly, don’t treat insulin resistance excessively if you don’t have it because sometimes people, they’re not even eating enough food and that’s actually making the situation so much worse. Dr. Weitz:So you mean maybe women who are eating almost no carbs and taking a bunch of supplements just for insulin resistance without addressing the androgens and the other aspects of the condition? Dr. McCulloch:That’s right. And they’re lean and they don’t have any insulin resistance and they’re like, oh, I need to do this really, really restrictive diet. I’m not dieting enough. That actually is worse. So firstly, it’s in figuring out what’s going on and what to treat. And so the treatments, one of my favorite supplements is Inositol. Inositol works for both lean and insulin resistant PCOS. It helps with insulin sensitivity, but also helps the ovaries to take messages from the brain, so it’s really important for ovulation. So that’s definitely one of my favorite supplements. Dr. Weitz:And we have the two forms. We got the Myo-inositol and the D-Chiro inositol. Dr. McCulloch:Exactly. Yeah, the myo is what does almost most of it. And then D-Chiro inositol, a small amount of that, seems to be very helpful if the patient has insulin resistance. So a lot of the formulas are in a 40 to one ratio of myo to D-Chiro inositol, but even just Myo-inositol can make a huge difference. Dr. Weitz:So Myo-inositol for any form of PCOS and the combination with D-Chiro specifically when there’s insulin resistance? Dr. McCulloch:Yes, exactly. Dr. Weitz:Okay. Since we’re on insulin resistance, what other supplements do you like for insulin resistance? I use berberine a lot and chromium. Dr. McCulloch:Yeah, I love berberine. It’s definitely one of my favorites. I find you’ll actually see really big changes in the glucose levels on berberine for certain patients. It’s just really effective. I also really like alpha lipoic acid if a patient has a fatty liver disease, especially. Super helpful. Dr. Weitz:What dosage for lipoic acid do you like? Dr. McCulloch:It really depends, but usually I’ll do around 600, something like that range. Dr. Weitz:Any other supplements for insulin resistance? Dr. McCulloch:Yeah, I also really like glucomannan fiber because it basically reduces the spike of sugar after a meal. It helps with fullness and it’s a prebiotic. And so we see a lot of microbiome changes with PCOS. Dr. Weitz:How is that consumed? Dr. McCulloch:They have this in soft gels and in powders, and basically you take it before a meal with a lot of water. If you use the powder, definitely drink it quickly because it becomes a gel and it’s not pleasant. So a lot of people like the soft gels, so it’s usually four soft gels with a big glass of water before the meal. Dr. Weitz:So glucomannan before meals, especially meals where they’re going to have carbohydrates. Dr. McCulloch:And a lot of the time too, if a patient’s like, I’m going out to a party, something like that, and they have that glucomannan, they can enjoy their meal and they don’t really have blood sugar spikes. Often they’re quite full too, but it really just stops the insulin spikes and sugar spikes. Dr. Weitz:What are the best ways to address androgen excess? Dr. McCulloch:So androgen excess, if the person’s insulin resistant, the best way is to deal with the insulin resistance and directly, because that is the biggest trigger for that person. And the reason for that is that low SHBG. So those androgens are just way more powerful, plus insulin makes more androgens and for that category of people. Dr. Weitz:That’s an interesting cycle. I saw you had this one Instagram post where androgens increase insulin resistance. Insulin resistance increases androgens, and on and on. Dr. McCulloch:Yeah, it’s like a really vicious cycle and it just keeps going. So that is really critical. And for the lean patients, we know that doesn’t work for them, so we go right after the androgens. I personally have found the cyclic progesterone to be the most effective direct way to do that. It works extremely well, but there are also the supplements, like inositol will lower LH and androgens. There’s also many herbs that can be helpful, like white peony and licorice, Saw Palmetto, even Reishi mushrooms. So there’s some different herbs that have anti-androgenic effects like this that we use also. Dr. Weitz:Okay. You also mentioned iron as being really important. Dr. McCulloch:So iron is very important generally for women’s health. And with the insulin resistance, we definitely can see sometimes the iron that’s high. In that case, we want to watch and not supplement iron unless we see those levels coming down. As patients start to ovulate and have periods, they start to have lower iron and so it’s sort of a moving target to watch. Sometimes patients, their iron’s really good and then they start having periods and then it starts to go down. So it is something to watch really closely because it has so many effects on health. Dr. Weitz:In your book, you mentioned a few things that could be used topically specifically for the hair loss. Do you still find those things helpful? What do you think for women who are dealing with hair loss, are there some topicals that could be helpful? Dr. McCulloch:Yeah, hair loss is a really interesting area because it is … Topicals can be quite effective because you can access that area very well. So the topicals that I use a lot are melatonin and rosemary. Those two I find to actually be helpful, but hair is very, very slow. And I also find that progesterone topically is actually very helpful for hair loss also. Dr. Weitz:Interesting. So do you just mix all three of those together or how do you administer it? And what about when they do that vampire facelift and you use that thing to make the holes? Would you do that first? Dr. McCulloch:So the progesterone cream, I know some people do apply it on their scalp, but you don’t have to. Most of the time, we just apply it on the wrist and that will deliver to it. It delivers through the capillaries, which is really interesting. But yeah, topically, things like the melatonin and rosemary usually, you can get the spray melatonin or rosemary. I usually suggest to add it to a spray bottle with a little aloe gel to emulsify it, making parts across the hair, just a little spray, massage it in and go across each part all the way, and at bedtime. That is really all you have to do with it. Dr. Weitz:Interesting. Dr. McCulloch:Yeah, it just takes forever because hair is the slowest thing. It’s been studied to be found around the same efficacy as Rogaine. I know there’s not enough- Dr. Weitz:Really? Dr. McCulloch:… to confirm that, but yeah, there’s something- Dr. Weitz:Does that work for men too? Dr. McCulloch:Yeah, men’s hair loss is more challenging too because they just have higher testosterone, so I don’t know how well those will work, but maybe if you catch it early, it’s really important for androgenetic. But yeah, these are antioxidants basically, and the androgens cause oxidative stress around the follicle and that’s what really kills them. Dr. Weitz:Interesting. So you mentioned a category of supplements for inflammation in your book. Dr. McCulloch:Yeah, inflammation is one of the biggest central problems because it actually drives insulin resistance and anyone with insulin resistance has inflammation, and it’s because of all that fat leaking out of the liver, it’s very inflammatory. So for inflammation, we’re always looking at antioxidants that quench that. So things like acetylcysteine has a lot of evidence. Alpha lipoic acid, again, really good as an antioxidant. There are also many anti-inflammatory types of treatments like anti-inflammatory enzymes, for example, like systemic enzyme therapies. Dr. Weitz:Curcumin. Dr. McCulloch:Yeah, curcumin. Exactly. Quercetin. There’s some evidence. There’s basically all of these antioxidants, most of them have shown to be beneficial for inflammation in PCOS. Dr. Weitz:Okay. And what about supplements that are beneficial for women who are trying to get pregnant? Dr. McCulloch:Yeah, that would be the top one is inositol for sure, because our eggs should have a large amount of inositol inside of them. It’s a marker of quality. So inositol actually builds- Dr. Weitz:Now, is that where you just used the myo or do you use the combination and if so, what’s the dosage for that? Dr. McCulloch:You can actually use the combination even in lean patients. If you go higher than that amount, it’s shown to be actually possibly negative, especially if you go really high with that hot D-Chiro. But if you do the 40 to one, it’s actually been shown to be beneficial for all types. The doses are 4,000 grams of myo and 100 of D-Chiro, but you can also skip the D-Chiro and just do the myo. There’s also, they studied some lower doses, but that dose is the most popular dose to use. Dr. Weitz:Cool. Yeah. You also mention- Dr. McCulloch: I should also just mention quickly for egg quality too, other really popular supplements, coenzyme Q10 and PQQ. Both of those are mitochondrial antioxidants and those are really important for egg quality. Dr. Weitz:Somewhere I read you mentioned Vitex as well. I’d be a little nervous because that’s like a hormonal one. Dr. McCulloch:Yeah, Vitex is a little tricky. It’s sort of gotten this reputation of raising progesterone, but it’s never really been shown to do that. Dr. Weitz:Oh, is that right? It has not, huh? Interesting. Dr. McCulloch:No. There’s some studies that show that it can help ovulation and because progesterone is produced by ovulation, they’ve now linked those things, but it’s never been shown to do that. What it does do is lower prolactin and it works on the brain and it has impacts on stress in the brain, the opiate system, and the prolactin system. So a lot of the time, if the patients are having stress-related problems with ovulation, it’s really helpful for that, but it’s not often enough to deal with this androgen excess problem. Dr. Weitz:One more category of supplements I wanted to mention is supplements to help with the adrenal glands. And I guess it’s typically hypercortisolemia that we’re dealing with. Dr. McCulloch:Usually, yes. And then we do have some patients who have low cortisol also just from years of dysregulation. So many different adaptogens, just depending on the situation. Ashwaganda is definitely a favorite. I’ll use Eleuthero, Tribulus. Actually, even though we think of it as raising testosterone, it actually does the opposite in PCOS, it’s been shown to- Dr. Weitz:Interesting. I never heard of that. Dr. McCulloch:Yeah. Dr. Weitz:Oh, cool. Dr. McCulloch:And that’s a really interesting one as well. Dr. Weitz:You mentioned using licorice a lot. Do you use that for hyper or hypo or both? Dr. McCulloch:I would usually use it for someone with low cortisol, but when it’s used for PCOS, it’s also used in a different way, sort of as part of a anti-androgenic formula with peony, but I would tend to only ever prescribe that in somebody that obviously doesn’t have high blood pressure. They generally are more tired. They have that depleted lower cortisol. Dr. Weitz:Great. So I think that’s a wrap. I think we covered it. How can viewers, listeners find out more about you and your book? Dr. McCulloch:Yeah, I practice in Toronto at White Lotus Clinic, so you can find us online there. I’m on Instagram @drfionand. And my book is Eight Steps to Reverse Your PCOS. You can buy that on Amazon or any bookstore as well. Dr. Weitz:Okay, that’s great. And thank you so much. Dr. McCulloch:Thanks. It was great to be here. Dr. Weitz:                            And thank you for making it all the way through this episode of the Rational Wellness Podcast. And for those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcast or Spotify and give us a five star ratings and review, that way more people will be able to discover the Rational Wellness Podcast. And I wanted to say thank you to all the patients that we’ve been working with at our White Sports Chiropractic and Nutrition clinic who, most of whom we’ve been able to help with a range of various health conditions from various types of gut disorders to thyroid and hormonal issues, autoimmune diseases and various other cardiometabolic conditions. And so I very much appreciate you and I’m excited about going forwards, helping you to improve your health on your journey towards optimal health. And I wanted to let everybody know that I do have a few openings now for new clients, and you can take advantage of that by calling my Weitz Sports Chiropractic and Nutrition Santa Monica office at 310-395-3111, and we could set you up for a new consultation for functional medicine nutrition, and we can get that going as early as the new year. So give us a call and I’ll talk to you next week.

1 de mar de 2023 - 53 min
episode Cracking the Longevity Code with Dr. Michael Roizen: Rational Wellness Podcast 296 artwork

Cracking the Longevity Code with Dr. Michael Roizen: Rational Wellness Podcast 296

Dr. Michael Roizen discusses Cracking the Longevity Code with Dr. Ben Weitz. [If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page [https://www.youtube.com/user/weitzchiro].] Podcast Highlights 3:55 The reason Dr. Roizen decided to write this The Great Age Reboot book is that the science related to longevity since he wrote his first book on longevity, Realage: Are You As Young As You Can Be?  has changed enough that the potential to not only slow aging but to reverse it is close.  Dr. Roizen describes 14 different areas of research that are looking at different mechanisms for reversing aging. 8:55 Yamanaka Factors.Six labs have now shown that using all 4 or 3 of the 4 Yamanaka factors are able to reverse aging in mice or other animals.  The most recent study was conducted and published in Cell by Dr. David Sinclair’s Lab at Harvard University: Loss of epigenetic information as a cause of mammalian aging. [https://www.cell.com/cell/fulltext/S0092-8674(22)01570-7?_returnURL=https%3A%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0092867422015707%3Fshowall%3Dtrue] 18:48Yamanaka moved to the Gladstone in San Francisco and they are using a quantum computer to look at the 1,363 drugs that were already approved by the FDA that are generic, meaning $4 per month or less, and they looked at which ones might block the attachment of amyloid and tau to neurons and they found that a diuretic, Bumetadine, blocked the attachment by 70% in cell culture.  We might be able to prevent dementia for $4 per month. 23:33 Brown fat. Mike West was one of the people who worked on the epigenetics of using the Yamanaka factors found that we could regress white fat to pluripotent fat and then turn it into brown fat.  Brown fat is around our organs and it generates heat to keep us warm and it uses a lot of calories.  11 minutes a week of cold exposure will stimulate this metabolically active brown fat. 26:48 Stem Cells. Stem cells hold out hope in the future but you need to have between 30 and 50 million stem cells plus growth factors plus exosomes.  You need to take a bone marrow sample from your iliac crest and grow it in culture till you get to 20-50 million and then inject it back in along with the growth factors. Japan is now testing mass produced stem cells for use in heart failure patients. 29:20 Regenerative Plasma Exchange. You go in and donate blood and you get your red cells back after they are washed along with some fresh albumin and this reversed dementia as we have seen in the AMBAR studies (Alzheimer’s Management by Albumin Replacement):Therapeutic plasma exchange with albumin: a new approach to treat Alzheimer’s disease [https://pubmed.ncbi.nlm.nih.gov/34338566/]. 37:18  TMAO. TMAO is a biomarker for inflammation that is found in the blood that is correlated with heart disease risk.  If you consume the combination of carnitine, lecithin, choline and saturated fat, you change the genome and turn on the genes in the bacteria inside your gut to produce a compound, trimethylamine. If you take L-carnitine pills without saturated fat, then that is not a problem.  If you regularly consume saturated fat, it will change your microbiome, so that the bacteria in your gut produce trimethylamine oxide out of the trimethylamine and this is very inflammatory.  Having some TMAO in your blood from fresh fish is not a problem, since this is a short term situation, as compared to your gut bacteria regularly producing TMAO. Dr. Michael Roizen is the Emeritus Chief Wellness Officer at the Cleveland Clinic, a professor at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, and author of four #1 New York Times best-selling books and 9 top 10 books.  Several of these books he cowrote with Dr. Oz.  He has written more than 190 peer-reviewed scientific articles and has been recognized with an Elle, an Emmy, and the Paul G. Rogers Award from the National Library of Medicine for Best Medical Communicator.  And now we will be talking about his newest book, The Great Age Reboot: Cracking the Longevity Code for a Younger Tomorrow [https://www.barnesandnoble.com/w/the-great-age-reboot-michael-roizen/1139613012].  Dr. Roizen’s website is GreatAgeReboot.com [https://www.greatagereboot.com/]. Dr. Ben Weitz is available for Functional 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations. Podcast Transcript Dr. Weitz: This is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast. Hello, Rational Wellness Podcasters, thank you so much for joining me again today. Today we’re here with Dr. Michael Roizen about his new book, The Great Age Reboot. Dr. Michael Roizen is the Emeritus Chief Wellness Officer at the Cleveland Clinic, a professor at the Cleveland Clinic Lerner College of Medicine and author of five number one bestselling books and a total of like 22 books. I understand several of these books he co-wrote with Dr. Oz. He’s written close to 200 peer review scientific articles. And today we’re going to be talking about his newest book, which is The Great Age Reboot: Cracking the Longevity Code for a Younger Tomorrow. In this book, Dr. Roizen, who co-wrote it with economist Peter Linneman and demographer Albert Ratner, he discusses all this new scientific and medical breakthroughs like stem cells, gene editing, and being able to 3D print new organs that will not only enable us to live longer, so that living to be 120 years old will become increasingly common, but also to reduce our rate of biological aging so that we live younger. Dr. Roizen writes that 90 will be the next 40. Dr. Roizen, thanks so much for joining us. Dr. Roizen:Thank you, Ben, for letting me come on. It’s a privilege. Dr. Weitz:Absolutely. So before we get into the book, since the focus of my podcast is on functional medicine, I’d be curious to get an update on where the Cleveland Functional Medicine Clinic is. I recall being at a Jeffrey Bland seminar maybe like 10 years ago when Mark Hyman announced that he was going to be opening the first functional medicine clinic within a major medical center. Dr. Roizen:It’s thriving. It’s actually in four locations now. The main campus it’s doing well. Mark has returned, he’s basically a part-time consultant here now, and so he’s returned back to his Lennox Hill roots. It’s Lennox, Massachusetts that is, Hill roots. It runs very well and is still thriving. Dr. Weitz:That’s great. Dr. Roizen:I share some space with other people there on Thursdays in our wellness and integrated medicine center, which I showed you a picture of the snow here, winter setting, but it is in Cleveland, and so it showed you the picture of the beautiful, it’s gorgeous here today, but it has a white background in the gorgeousness. But the wellness center is out in Lindhurst, which is about seven miles from our main downtown campus. Dr. Weitz:So Doc, given your long career and accomplishments and all the books and papers you’ve written, why did you feel compelled to write this book? I just wanted to say, I guess it’s easier than trying to run for the Senate. Just kidding. Dr. Roizen: Much easier than that. But the only reason you write a book, at least in my case, the only reason I write a book is because the science has changed enough that you want to help people plan for and motivate them to plan for the future. In this case, what has happened is when we wrote the first book, Realage: Are You As Young As You Can Be? We predicted that 60 would be the new 40, because of the slowing you could do in your rate of aging. That’s come true. Nurses health study, our own data at the Cleveland Clinic for our own employees by motivating them to get healthier, that’s come true. But now it is likely not that we’re going to just be able to slow aging, but reverse it. That is there are 14 mechanisms that we go over in the book that look at the research into the basic mechanism of aging. Research, there are 14 areas that have rebooted at least two animal species, and by rebooted I mean turned back the clock, not just slowed the clock. That is likely to happen. We think with 14 shots on goal, they’re at least an 80% chance that we humans get rebooted. That changes everything. In other words, if you heard in the last couple days, China’s population had decreased, the Japan prime minister said they could no longer function as a society because of the dearth of births. The France individuals protested the increase in the century retirement age from 62 to 64. And the point is the age of 65 in the US as a retirement age was really motivated by a German general in 1858 who said, I want to motivate my employees. Their morale is low. I want to give them a retirement age. What’s the oldest person lived to? And the oldest soldier who had lived at that time in his regimen to 64. So he said, let’s make 65 the retirement age, to increase morale. And it’s stuck since 1858. We’ve had the same retirement age essentially. Dr. Weitz:Interesting. Dr. Roizen: But now we’re going to be, if you’re going to live to 115, which is what the prediction is with one reboot, and it’s going to be as a younger person. It takes a real emotional change. That’s really why we wrote the book, to help people understand the emotional change and plan for it. If you’re going to live to 115, you’re not going to want to retire at 65 and do nothing for 50 years. We expect that people will work, they’re going to live an extra 30 years, they’re going to work an extra 20 years, they’ll still have plenty of time for retirement. But that takes an emotional and a thought process and a planning for it both fiscally and physically to plan for it. And so we go through, and that’s why there’s an economist as a co-author, what happens to the economy and it actually is wonderful if we do this right and what happens, in other words, human capital is the ultimate wealth of nations, the ultimate wealth of ourselves as individuals. If we live, if we’re going to work instead of 40 years, 60 years, we increase our GDP and the amount each of us has as disposable income by about 50%, that gives us an enormous range of extra experiences, extra things that we can use and do and benefit from. To give you the example, if you put 3% of a minimum wage, $15 per hour income away, starting at age 25 and you work to 65, you have about $250,000, assuming it aggregates at about 4% in increase per year. But if you work to 95, it’s 1.4 million. And if your employer matches it, it’s 2.8 million. So the point is this is a tremendous ability to improve society and to improve the quality of every one of our lives if we plan for it. Dr. Weitz: If we plan for it. There’s a number of scientific, medical, technological developments that you mentioned in the book. Stem cells, senolytics, autophagy, gene editing. One of the ones that’s been in the news recently was the Yamanaka factors, which were utilized by David Sinclair’s lab where they just recently published a study in cell that they were able to reverse the aging in mice. Maybe you can comment on that concept. Dr. Roizen:Actually they’re the sixth lab that is able to do this. Dr. Weitz:Is that right? Dr. Roizen:We shouldn’t say, that’s the sixth different lab. Dr. Weitz:Oh wow. Okay. Dr. Roizen:So there’s a private company outside of Davis that did it. Dr. Weitz:Okay. Dr. Roizen:A group at MIT in Harvard, independent of David Sinclair did it as well about four years ago. George Church’s lab. A group in Switzerland has done it. A group at Hopkins repeated that. And a group at Calico, which is the moonshot group of Google, published a paper I think in February of last year on it using three of the four Yamanaka factors. In other words, there are four factors in- Dr. Weitz:Can you explain what those are? Dr. Roizen:Yeah. Yamanaka was a Japanese scientist. He’s now at the Gladstone in San Francisco, but was a Japanese scientist who did 12 million elimination and comparisons with gene editing, turning on and off different genes. So part of this started with the human genome project. We expected to find 300,000 genes. Only 22,000 were found. Only 1500 are on at any one time. The rest of the DNA, initially called junk DNA led to be epigenes or switches. And by turning on those switches to the three of the four, the one that didn’t, I’ll code as c-myc, MYC, but therefore are genes. If you turn on those three and not the c-myc of the Yamanaka factors, the mouse or rat or dog, in the case of George Church’s lab at Harvard becomes younger without losing mental facilities, the organs become younger and they live in the mice’s case someplace between 30 and 80% longer. Dr. Weitz:Wow. That’s amazing. Dr. Roizen:They live as a younger mouse, and if you don’t turn on the c-myc, if you don’t turn on only the three, they don’t develop cancer at any greater rate than the normal mice would develop cancer. So the point is, by turning on all four, the problem was when Yamanaka did this, not only he got the animals to be younger, but they developed cancer and didn’t live any longer. In fact they lived shorter. But by turning on only three of them, you reboot your epigenes. These are genes that correct the DNA abnormalities that we have acquired from the environment and from the sun and from our own choices as we’ve gone along. So you’re rebooting to your original factory settings. And by doing that, and again, David Sinclair’s lab was the sixth as far as I can tell, with the Yamanaka factors of being able to reboot mice or other animals species to a younger age. Dr. Weitz:That’s interesting. How long do you think they are before they start experimenting with humans? Dr. Roizen:I understand they’ve already started. Dr. Weitz:Interesting. Dr. Roizen:Not in the United States because the regulations are a little too tough. But remember, other countries, as I said, Japan already has a declining population. They’ve gone from I think 128 million in 2017 to 125 million last year due to deaths greater than births. And so that’s why their prime minister came out and said this past week that if they don’t change this, if they don’t have more workers, their society won’t function. China reported a decline in population and the whole world has not enough young children so that we need living longer to be able to survive as societies. So we understand this has already started in some other countries. Dr. Weitz:It’s interesting all these developed countries have lower birth rates, that they have less kids as they get more developed. This is a problem in many countries. Dr. Roizen:Well, it’s in every developed country. You can’t find, in other words replacement is 2.1, and without immigration every one of the developed countries, that is the G7, the G20, whatever you want to go to on the limits and until you get to Africa and India, those are the only two societal areas where in fact the replacement rate is now still greater than 2.1. In the US we’re at 1.4, which is the lowest we’ve been including lower than the Great Depression. And without immigration we’d be declining too. We still have a society where people want to come here. But every one of the Koreas at 1.4. Japan I saw. In China are at 1.2. Russia is at 1.1. Dr. Weitz:It’s interesting. You’re making a really good point. I think a lot of people don’t realize that without a growing population, your GDP is going to shrink, your economy’s going to shrink. So it’s an argument for people who are in favor of more immigration, more sensible immigration. And I noticed- Dr. Roizen:And just to make the point, GDP equals population times productivity. It’s a very simple formula. If our population, which has been increasing at around 10% per decade until this last decade, this last decade we were at 7.2%, which is the lowest since the Great Depression, which was 7.4. The congressional budget office predicts even with immigration, we’re going to be at 3%. But they don’t take into account the increased longevity. Longevity, living longer and younger is the solution to the problem, not the cause of the problem. So I want to get people, if we do it, this is going to help America and help the world greatly. Dr. Weitz:Which is great because I think the common sense thought is we’re going to have more people collecting social security and Medicare for longer and therefore it’s going to drain the system. Dr. Roizen: Right. I’m 77 now. I’ve been paying into social security since age about 22 I think. If you will, we need to extend the years when you can collect it slowly, but there’ll be enough money in it. So because I keep paying in, right? The trust fund keeps getting more money from me. That’s the whole point, is if we do this right, if we have a rational plan, Simpson-Bowles had it, but it didn’t get out of, if you will, didn’t get a vote out of the Senate. And that was a bipartisan plan to gradually increase this concurrent with about half of the medical gain in life expectancy. So you’ve heard life expectancy is decreasing in the United States, that’s what we call the war. That’s period life expectancy is if you were born. But life expectancy at any age, what we say cohort. So if you’re 65, your life expectancy was about 15 years, about 20 years ago. It’s now 18 years. Our cohort life expectancy has continued to increase so that the average 65 year old actually, who’s a male, is expected to live to 84. So now and female about 87. We keep extending that cohort life expectancy. That’s a great thing because it also means we have less disability. The key will be to do what we have in the last part of the book, which is how you can slow your rate of aging while you’re waiting for this. This is going to happen. As I said, each one of these 14 areas is moving into human testing. I’ll give you one of my favorites in a second. But each one of these is moving into human testing, which means sometime in the next 10 years we’re likely to have that breakthrough and it’s going to be probably be inexpensive enough. And I’ll give you that example, for us to do it for all of us. And let me give you the example. I told you Yamanaka had moved to the Gladstone in San Francisco. Well, they’ve done a lot of excellent research on aging. Now they used to be focused on cardiovascular disease, but they’ve figured out how and said, we can postpone that cardiovascular disease essentially if people do what’s right in lifestyle changes. And so it’s nonexistent. It kills 40% of the people, but it doesn’t have to kill anyone is what they’ve said. Because we’ve got things that lower blood pressure, that reduce your LDL cholesterol, that reduce inflammation. We’ve got treatments, if you will, or lifestyle choices you can make. So it shouldn’t be the cardiovascular disease. So they went to the basic mechanism of aging, and that’s why Yamanaka is there now.And they actually, using a quantum computer, looked at all 1,363 drugs that had been at that time last year approved by the FDA and were generic, meaning $4 a month or less. And they said, which ones block the attachment of amyloid and tau to neurons?  So that is there any that do that, so that we can block dementia? And they found that a $4 a month water pill, a pill that’s a diuretic. It’s largely been replaced by Lasix or Furosemide now, Bumetanide or Bumex blocked the attachment by at least 70% in cell culture. They did it computer first. They then did it and showed it did in cell culture. They went into a mouse model of Alzheimer’s and it blocked the development of Alzheimer’s by more than 70%. They then went and used two databases, large databases, one from UC San Francisco, had 1.3 million people in it. One with the help of the Cleveland Clinic that had 3.8 million people in it. And they found that those people taking that water pill had a 70 and a 72% reduced rate of dementia compared to those people who were taking other water pills like Hydrochlorothiazide or Lasix. So now they’re doing a randomized study. How expensive would it be to prevent dementia if this really works? $4 a month. Dr. Weitz:I don’t know. I’m kind of skeptical that a water pill is actually going to prevent dementia. I think making life style changes- Dr. Roizen:Remember it isn’t because it’s a water pill, it’s because it has a side effect of its quaternary structure and blocks the attachment of amyloid or tau to neurons. So it’s the side effect that they found, not the main effect. Dr. Weitz:Of course once we get to the root cause, which is inflammation, which is related to diet and lifestyle, that’s really where I think the biggest gains are going to be. Because we have drugs that will remove amyloid and they don’t really reverse it- Dr. Roizen:The reason, remember what amyloid does when amyloid and tau attach their waste products of the neurons, and when they attach that’s what stimulates the inflammation that destroys the neurons. Dr. Weitz:Well, they’re also- Dr. Roizen:They are blocking the attachment, they’re preventing, they’re doing one step before the inflammation. Dr. Weitz:Right. But aren’t they protecting the neurons from damage from the inflammation or the infections that occur? Dr. Roizen:Well, they’re preventing the initial cause of the inflammation. That’s right. The thing that would instigate the inflammation is what they’re stopping with this. Now, we don’t know that it’s going to work perspectively, but if you will, just to give you the example, the example is for $4 a month you would get something on a 26 greater effect, 26 fold greater effect at blocking amyloid and tau than you would by this, I think it’s a $28,000 pill that’s just been I think approved by the FDA, Biogen. It’s a much more potent and much less expensive way of treating you without the side effects that that monoclonal has. Dr. Weitz:Now you mentioned that that group found that we could prevent heart disease if we made the proper diet and lifestyle changes. The problem is, as a country we’re not doing a very good job of that and we’ve seen obesity rates go up, not down. Dr. Roizen:That’s exactly right. But one of the other things that, in fact Mike West who was one of the people who worked on the epigenetics of using the Yamanaka factors, Dr. West did, was he said, could we regress white fat to potent fat, mother fat and then turn it into brown fat? So we have brown fat when we’re born. Brown fat is around our vital organs. It generates heat, it’s brown because it’s got many more mitochondria, which generates the heat to keep us warm. But it uses calories as opposed to, and it comes from mother fat. But as we get older, we lose our brown fat and our fat becomes white fat. So Mike West said, could we regress white fat into mother fat and then turn it into brown fat. And he’s done that as have three other groups. You can do it now by just being exposed to the cold. So the group is- Dr. Weitz:All you need to do is go out in the snow in Cleveland. Dr. Roizen:The group had said 11 minutes of essentially shivering, a week, will activate your brown fat, go back to and use calories. But in fact, West did it by doing an epigenetic change by giving two treatments, if you will. One, to regress it to mother fat, one to turn it into brown fat. And in three species, mice, guinea pigs and sheep, it’s been done at various. Now you say, why did Clemson do it in sheep? Because sheep won’t stop eating either. They developed non-alcoholic fatty liver disease just like humans do in metabolic syndrome and stop producing wool or the quality of beef they normally produce. So from an economic standpoint they didn’t want the sheep to develop it, and they’ve been able to at least experimentally do this in sheep as well. So eliminated obesity may be on the table- Dr. Weitz:Well, it’d be nice to have more brown fat, but I don’t know how much good it’s going to be to have a bunch of brown fat if you’re shoveling in cheeseburgers and fries. Dr. Roizen:Well, no, that’s right. The new drugs, the Mounjaro and semaglutide seem to take away craving and maybe we may be able to get much less expensive versions of those to help people control craving. The side effect of those, I don’t know, I’ve got a couple patients who not only were obese, but were prior opioid addicts and they’ve said it’s taken away the cravings for opioids as well as alcohol for them too. We don’t know whether that’ll prove to be a real benefit, but if that’s true, we can solve a lot of problems with those. Dr. Weitz:You talk about stem cells in your book, and these have been a promising concept for a while, but so far the results haven’t really been there from what I’ve seen. Dr. Roizen: No, that’s exactly right. And that’s because the stem cell research patterns have been, what I would say is inappropriate, not done well. In order to replace an injury in for example, the heart or the brain or a cartilage, you need between 30 and 50 million stem cells plus growth factors. What’s typically been done in experiments is using an extract of blood platelet-rich plasma and growth factors. That gives you between five and 800 stem cells, not 20 to 50 million. And in order to get that much, you have to take out a bone marrow sample from your iliac crest, your bone near your thigh, and grow it in culture till you get 20 to 50 million and then inject it back with the growth factors. Now, the growth factors in platelet-rich plasma and the exosomes, it may be the exosomes that are beneficial because they call for your natural stem cells. But to see the replacement, you’d need to grow this and to do it economically. For me to put it in my own in a culture and grow it is very expensive. But if I could give stem cells, knock out their immunogenicity and grow sheets of them so that I can take my stem cells and inject it to 100 people or someone else’s stem cells and inject it to 1,000 people because I mass produced these stem cells in culture, that makes it much more economic. That started in Japan last year and they’re now testing it with heart failure patients in Japan to inject 20 to 50 million on the heart where there’s no immunogenicity in these stem cells grown in these huge sheets in vats. That’s coming, but we’re not there yet. Dr. Weitz:Okay, that’s interesting. You also mentioned regenerative plasma exchange, and that’s where you donate plasma and then you get some younger plasma put in that was heated, to purify it, and that gets you fresh albumin. I did a podcast where I spoke to Dr David Hussey, who’s been using this on his patients. Dr. Roizen: The AMBAR studies are the real, very good study on this. Six centers, two in Spain, two in Chile, two in the US, University of Pittsburgh and Cleveland Clinic, where they dementia by nine donations of plasma. Literally you donate nine units of blood with the plasma, you get the red cells back after they’re washed. It’s not a very expensive process. People do it. We pay graduate students often to do it to get the albumin, and then they throw away, they actually in this case did four different groups. One group of which they threw away their plasma and gave them saline salt water, very inexpensive again. The group that got had no different results than the group that got the albumin or the albumin and the immunogenicity components.And what they found was just these nine replacements reversed early dementia in every Alzheimer’s patient and has continued to, they published the data in 15 months. I’ve talked to them, they say it’s still improving cognitive function after 24 months, presumably because we take away old signaling proteins. This was nine donations. It wasn’t one, it was nine over a five month period, one per week from five weeks, and then one per month for the next four months. And then they followed them out to 15 months and they’ve now continued to follow them. Well, they’re now starting, that’s a phase 3A at the FDA. It’s got breakthrough designation because it reverses early dementia. And so they’re now doing a 3000 person hundred site center. They’ve started, I think they’re about halfway through an enrollment of the 3000 patients. So in two or three years we’ll know whether that is the breakthrough. Again, not very expensive. We actually pay people to do this. The saline you get back, not very expensive. That is salt water you get back. This would be doable if the Bumex or Bumetanide treatment doesn’t pan out either. But that’s, one is prevention and the other is treatment of early dementia. But that’s AMBAR, A-M-B-A-R, if you want to look at it. And you can donate plasma now if you want. Dr. Weitz:We also have Dale Bredesen’s work showing that using a functional medicine approach that you can reverse Alzheimer’s in a number of patients as well. Dr. Roizen:The data on Bredesen’s work isn’t as convincing, hasn’t been published in a randomized controlled trial like it has for AMBAR. And so I want to see more data before, don’t get me wrong, I think a functional medicine approach is appropriate, that is getting at the cost. And I do think lifestyle changes make a difference. I don’t know that they can reverse it once it started, the way there was early 10 patients that he published- Dr. Weitz:Well, he did publish a study on 25 patients. It wasn’t randomized, but he does have a randomized trial underway right now. Dr. Roizen:In other words I think we’re going to see a lot of these breakthroughs over time. And I think whatever, with all these shots on goal, we’re likely to be able to live when we’re calendar age 90 as if we’re 40 again. So old age won’t be old. That’s the emotional change we have to get over to get more people, I believe, to do things to avoid disability, avoid obesity, avoid osteoarthritis, avoid heart disease and stroke, to do the basic things of getting their blood pressure, et cetera, under control. I think what, if you will, talking about is incredibly important so that we can prepare for it and take advantage of it. Dr. Weitz:You talk a lot about biological aging. What do you think about the new DNA methylation tests to measure biological aging? Dr. Roizen: We need a better test to measure aging. The problem with the methylation test is they’re not consistent and they change too quickly. What do I mean by that? By eating a McDonald’s meal today, you can be on methylation clock 28 years older than you were yesterday. Well, that’s not physiologic. You’re really not 20 years older or 28 years older by one meal. I think the methylation clocks, we need to refine them. We need a biomarker. This has been a good instigation for a biomarker. As of now we came up with real age based on your choices, your lifestyle choices and your biomarkers in 1993 to eight, that’s when we said that 60 was likely to be the new 40. And it’s come to pass. It has a better receiver operating curve for disability and death. Independently verified that UC San Diego than anything, any other test, by a substantial amount. I think it’s going to end up being something like the choices combined with biomarkers. And we don’t know quite the right ratio to get the right formula. But I think, you pray that the epigenetic clocks, the methylation clocks would be better or that some combination of them would work. We haven’t seen the data that they’re accurate yet, a prediction of disability or death. [inaudible 00:36:17]. Dr. Weitz:What about the telomere length, which has been around for a bit? Dr. Roizen:It’s the same problem. The first person, we were excited about that. We did it on a whole bunch of patients in our executive health practice. And the problem was the telomere on white cells versus some other cells or on different white cells or on cells from the spinal cord versus cells from the blood were so different as we didn’t know what to do with the data. And there’s not then there. But there is the fervent to get a biomarker is exactly what we need. Because you’d like it to be able to say to someone, this is what it is now, and you can change that and let them follow it, because that would be very motivating. We hope there will be something or some combination of these that works. Dr. Weitz:Right. Since you’re mentioning biomarkers, I did want to ask you, I was listening to another podcast you did, and I know you mentioned various serum tests. TMAO is a marker for heart disease risk that was pioneered by Cleveland Clinic. And I’ve always had a problem seeing that that is really a good marker, even though I know there’s some data on it. For those who don’t know, you can measure TMAO levels in the blood. And this has been shown to correlate with heart disease risk. And this is correlated with- Dr. Roizen:It’s an inflammatory marker. So let me tell you how it develops and then what you do when you take it, because it’s much more accurate if you take it when you don’t eat fish the night before. And I’ll come back for- Dr. Weitz:That was one of the issues I have with that marker. Because fish is the highest dietary source of TMAO. Dr. Roizen: No, no, but let me go and explain it to you so that it’s clear, Ben. If you have red meat, egg yolks or some cheeses. So the combination of carnitine, lecithin, choline and saturated fat, if you have carnitine pills without saturated fat, no problem. But you change the genome, which genes are on in the bacteria inside your gut. They produce a compound called trimethylamine. And that continually, not once, but continually gets converted to trimethylamine oxide, which is very inflammatory. It’s more inflammatory than, for example, C-reactive protein by a factor of about six. The problem, and it’s been reproduced in 13 different centers now, Mayo, Cedars of Sinai, not just Cleveland Clinic, European centers as well. The key, when you have fish, you get a little TMAO in your food, that shows up as it in your blood, but isn’t a continual production by your bacteria of it. The difference, the fish have it because it’s what that fish smell is. So if you eat old fish, you are getting TMAO, not the precursors of it, you’re getting the metabolic products. It’s the difference of do you have something that manufactures it or do you have just a little. So you don’t want to eat fish the night before, especially old fish. So frozen fish is the best kind. It turns out fresh, frozen right at the source is what you want for fish. And if you have that, doesn’t raise your TMAO at all. If you have fish that’s been aging in a fish market on ice for a few days, you’re going to have a pretty high level of TMAO. But it’s a fake out compared to your bacteria in your gut producing. Dr. Weitz:You made two really interesting points is that even though fish raises TMAO, it doesn’t increase your risk of heart disease. In fact it lowers it, because the TMAO is only there for a short period of time and it’s not being continually produced by U bacteria. And the other thing you mentioned, which was the other problem I had with this TMAO marker, which is that we know that choline, for example, is really beneficial for the brain, for liver health. And we know that L-carnitine is beneficial for fat burning and for heart health, that how could taking an L-carnitine supplement actually increase your risk for heart disease? And you’re saying only if you are consuming something like red meat that has a combination of those along with what you say saturated fat. Dr. Roizen:Right. You need saturated fat plus any one of those three amino acids gets converted. If you don’t have saturated fat, it doesn’t get converted at the same time. So taking L-carnitine pills doesn’t do it. L-carnitine pills plus butter does do it. Dr. Weitz:I see. Interesting. Dr. Roizen:So it’s the two of those together. We don’t know why that changes the gene functioning of your, if you will, the bacteria inside you, but it does. It’s like an epigenetic change that you’re causing in the bacteria. We know that our habits change our epigenes. Well it turns out, one, our habit of red meat changes the epigenes of the bacteria inside us. So when you eat, you’re not only affecting your genes but you’re affecting the bacteria which affect your genes. It’s one of the reasons we think that over the long run we’re going to find out that a lot of the food we eat will affect our mental status, not directly, but through the bacteria with the bacteria produced inside us from our food. Dr. Weitz:That’s interesting because there’s been a big controversy in the dietary world about, how can saturated fat actually increase our risk of heart disease? And there’s looking back at the studies, we really haven’t had that many really good studies and that really correlated that. And there’s really no mechanism by which saturated fat actually increases cholesterol levels. Saturated fat doesn’t turn into cholesterol in the body. Dr. Roizen:You’re exactly right. And in fact in the studies, saturated fat by itself without carnitine lesser than choline doesn’t do it. Just like carnitine lesser than choline don’t do it. Dr. Weitz:Interesting. Interesting. Dr. Roizen:Who would’ve guessed that it works through the bacteria inside us? It’s crazy, right? Dr. Weitz:Well, once again, we got the connection between the gut and the brain. We got the gut and the heart, and this is important gut heart connection. And another reason why it’s so important to have a healthy gastrointestinal tract and microbiome. Dr. Roizen:Right. And you’re into exercise obviously just like I am. But it turns out if you exercise, you actually change, this is crazy and I don’t know the mechanism of this at all, but you again change which genes are on in the bacteria in your gut. There must be a two-way communication system that’s occurring that’s much more sophisticated than any of us thought 20 years ago or 40 years ago. Dr. Weitz:Right. Probably through the vagal nerve. I’m sure we’re going to learn a lot more about that. In terms of diet, what do you think is the healthiest long-term diet for promoting longevity? Dr. Roizen:We know that five food or five food groups are bad. Everything else we think is neutral or good. So the five foods are simple sugars, added syrup, simple carbs, anything that raises your blood sugar level in a glucose version or fructose version quickly. There’s some weirdness, in that trehalose and allulose seem to block the absorption of other sugars. But with those exceptions, simple sugars, added syrup, simple carbs that raise your blood sugar level quickly are bad for you. So are foods that combine carnitine lesser than choline and saturated fat. And that’s basically red meat, processed red meat, egg yolks, and a few hard cheeses. Everything else is fine. So we don’t know the difference between salmon and the same amino acids if you can get them from beans and quinoa. And we think you need, the data look like as you get older, you need more protein to keep your muscles up. I just underwent the rotator cuff surgery because when doing a chest press, I tore muscles, horrible sound. I was amazed that in six weeks being, I’m just now two days out of the cast, out the swing, in six weeks of being in a swing, my muscle, my right arm went down by a third in size. Who would’ve thought that much that quickly? But we need to continue to do resistance activity and get protein as we get older. But basically, so I think you need to make sure you’re getting enough protein and enough of the micronutrients that we know are healthy. But other than that, you want to eat food you love and that loves you back. I love avocados, they love me back. I love salmon, it loves me back. Most of my diet based on the data in the literature is high fiber plant-based with salmon and a rare other fish thrown in. Dr. Weitz:Let’s go through a couple of recommended nutritional supplements as probably our last thing we talk about that might potentially move the needle as far as longevity goes. Dr. Roizen:We have a scientific advisory board and we’ve been presented with 53 of them. That is people have sent into our greatagereboot.com website. What’s the data on this? 53 different ones. And it turns out about 18 of them are beneficial, have substantial benefits greater than risks for those over the age of 45 men and 55 women. I can go through whatever you want, but if people want to ask questions, tell them they can send it or have a different supplement to ask about, they can send it to greatagereboot.com. Dr. Weitz:Let me ask you about one of them that’s one I hadn’t really heard of and I’m pretty familiar with all the supplements. Is this avocado-soybean unsaponifiables. Dr. Roizen:Right. ASU. It’s used in Europe, very prolifically. There’s good data published in the British Medical Journal on lack of side effects and benefit. It is the only disease modifying agent is a supplement we know of for joint health. So for preventing, and by disease modifying I mean it prevents progression. So just like I’ve talked about lifestyle, essentially getting your blood pressure below 120 and below 80 for preventing the progression of cardiovascular disease, for preventing osteoarthritis, ASU seems to do it. Now, you can get it from France or Canada has it as well by ordering ASU, going on the internet and ordering it. The one site and I have no financial relationship at all to it, the one site in the United States that has it is drtheos.com. It’s Dr. Theodosakis, that’s his website. He imports it and has a very good supplier, he believes that has quality ASU from France. He is out of it right now. I speak about it enough that he says I’ve caused a run. In any case, ASU is, I wouldn’t give it to my wife unless it was really good or use it myself. It’s that good, that it is disease modifying. Dr. Weitz:I know we have glucosamine sulfate, which has not only been shown to be helpful potentially for joint pain, but actually I think there’s like a 30% reduced risk of cardiovascular mortality from glucosamine sulfate. Dr. Roizen:Right. It’s an anti-inflammatory, but the ASU complete has ASU plus glucosamine and chondroitin sulfate. Dr. Weitz:Okay. There you go. Dr. Roizen:So you can get ASU complete is what Dr. Theo’s website is sells. Dr. Weitz:Let’s just touch on one more. How about the NAD precursors? You mentioned NR, there’s also NMN and some people take NAD intravenous. Dr. Roizen:I’m going to talk about not intravenous because we don’t have really any outcome data on that as far as I can tell. But the precursors, we know in animal models, they are both safe and reverse a number of neurodegenerative conditions. In humans we also know they are safe with one exception, I’ll come back to that exception in a second. We know they are safe, but we don’t have outcome data showing benefit. That may be due to the fact that they become racemic or something happens in the pill form that doesn’t happen in the intravenous form that we give to animals. It may be that intravenous is different, but as of now we know they’re safe but we don’t have benefit. So you could probably take it. Now, there’s a study from UT Austin of one gentleman, one scientist who looked at it at about 10,000 times the amount you would give to humans in mice, in a mouse model of glioblastoma. Dr. Weitz:I saw that one. Dr. Roizen:He did this because I think it was his wife, it may be his daughter died of glioblastoma and she was taking NAD. But he gave it 10,000 times as much to these mice and it caused the cancer to grow faster. When given in a hundred times as much it didn’t do anything. I think this is an abnormality by, if you will, a dose craziness in that one study. I still think it’s probably safe, we just don’t know whether it’s beneficial or not in the form we take it in. I have at one point in, I guess three or four years ago, I was routinely taking it. About a year ago I stopped taking it routinely as I expected the studies on efficaciousness to come out and none of them have. Although I probably didn’t do any harm, I probably didn’t do any major benefit until at least I wait to be shown the data and efficacy. The efficacy studies are undergoing, but we don’t have the data yet. Dr. Weitz:I guess I’m a bit more of a risk-taker. I’m currently consuming NR and NMN to hedge my bets there on NAD production. Dr. Roizen:I don’t think they’re harmful and they may, you expect them to be beneficial like they were in the animals because multiple animal models, but we just don’t have the data. Dr. Weitz:That’s great doc. So you also have an app and a website that people can go to to monitor their risk factors or get more information, I understand. Dr. Roizen:Right. The website is greatagereboot.com, and you can ask us questions and there’s a free newsletter that we try and get the article of the week. I wrote last week about, I can’t remember, I think it was, one of the ones was compounding a benefit for health. Another one was on red dye. Red food dye has been shown to be harmful to gut performance. I know next week I’ve written that already. Canada came out with a advisory to avoid all alcohol and I go over the benefits and risks of alcohol. And the data that Canada didn’t have is how it improves socialization, improves posse and stress relief. And so I think it has a substantial benefit in getting us to socialize as long as you stay under two drinks a night and only three nights a week. I know that that’s one of the newsletter. But the app is a subscription app. It’s free now, but sometime in the future we’re going to start charging for it. And it’s a rebootyourage.com app. That’s how we expect to be able to pay for the scientific advisory board and the technology that’s in it. But in any case, Reboot Your Age is the app that you can get through the greatagereboot.com site. Dr. Weitz:That’s great. Thank you Dr. Roizen. Dr. Roizen:Ben, thank you. And thank you for all you do. Obviously listeners to this website get a huge benefit from all that you do. So thank you for letting me also, because my passion is helping people live younger. You’ve helped me stay young myself by having the passion. Dr. Weitz:Thank you. And you’ve helped me with the same passion, being able to help others. Dr. Roizen:Thank you. Dr. Weitz:Thank you. And thank you for making it all the way through this episode of the Rational Wellness Podcast. And for those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way more people will be able to discover the Rational Wellness Podcast. I wanted to say thank you to all the patients that we’ve been working with at our Weitz Sports Chiropractic and Nutrition clinic, most of whom we’ve been able to help with a range of various health conditions from various types of gut disorders to thyroid and hormonal issues, autoimmune diseases and various other cardiometabolic conditions. And so I very much appreciate you and I’m excited about going forwards, helping you to do improve your health on your journey towards optimal health. I wanted to let everybody know that I do have a few openings now for new clients and you can take advantage of that by calling my Weitz Sports Chiropractic and Nutrition, Santa Monica office at +1 310-395-3111, and we could set you up for a new consultation for functional medicine nutrition, and we can get that going as early as the new year. So give us a call and I’ll talk to you next week.

16 de feb de 2023 - 58 min
episode Gastrointestinal Disorders Q and A with Dr. Ben Weitz: Rational Wellness Podcast 295 artwork

Gastrointestinal Disorders Q and A with Dr. Ben Weitz: Rational Wellness Podcast 295

Dr. Ben Weitz answers questions on Gastrointestinal Disorders. [If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page [https://www.youtube.com/user/weitzchiro].] Podcast Highlights 0:59The first question is: “I have stomach pain and I went to a gastroenterologist who did a colonoscopy and an endoscopy, and said there was nothing wrong. But then Prilosec was prescribed because that would help with the symptoms. Does that mean that my stomach pain is all in my head?” The answer is absolutely not.  Endoscopy and colonoscopy are ways to look for structural problems like growths, obstructions, pockets, parasites, and inflammation (such as with Inflammatory Bowel Disease).  But the most common gastrointestinal conditions are considered functional rather than structural and the most common condition is Irritable Bowel Syndrome, which occurs in up to 20% of the population. But the small intestinal bacterial overgrowth (SIBO) that is believed to be the most common cause of IBS cannot be seen on a typical endoscopic or colonoscopic exam.  Dr. Pimentel did develop a specialized procedure that allows accurate sampling of the bacteria throughout the small intestine, but this complicated procedure is not typically performed.  Small Intestinal Bacterial Overgrowth (SIBO) can create pain, gas, bloating, and diarrhea or constipation.  When you eat fermentable fiber, the bacteria in the small intestine will produce hydrogen or methane or hydrogen sulfide gas, which results in these symptoms.   SIBO is one form of dysbiosis of which there are other forms, including Large Intestinal bacterial overgrowth, small intestinal fungal overgrowth, candida overgrowth, pathogenic bacteria, parasites such as worms and other microorganisms.  Or you can just have a low amount of healthy bacteria.  Any form of dysbioisis can create various GI symptoms. 9:10Next question, “Dr. Weitz, I have a lot of gas and bloating, especially if I eat broccoli or Brussels sprouts. What do you think is the cause and what can I do about it? And should I take Gas-X?” First we need to try to find the cause of the gas and bloating.  They might just have sensitivity to broccoli and Brussels sprouts or it might be that these foods are high in fermentable fiber and they are suffering with Small Intestinal Bacterial Overgrowth (SIBO).  The best way to diagnose SIBO is with a lactulose SIBO breath test. It is usually also beneficial to do a Functional Medicine oriented stool test like the GI Map and we might want to run an organic acids test to help us to identify Small Intestinal Fungal Overgrowth (SIFO). 13:18The next question is “I have stomach pain, should I take probiotics, fermented foods, or digestive enzymes?”While taking probiotics may be helpful for a number of functional GI disorders and some prominent practitioners use probiotics as their first line therapy for such conditions, for patients with SIBO, taking conventional probiotics may not be appropriate, at least in the beginning of the treatment phase.  There is a problem when citing research studies showing benefits of probiotics, since studies using different formulations of probiotics have been lumped together and this is not appropriate. This would be like lumping studies of various antibiotics together and then stating that antibiotics are effective for treating a particular condition.  Each probiotic product should be tested separately from others. We need to be cautious about using probiotics that might increase bacterial counts in the small intestine when there is already too many bacteria growing there.  This is why it makes more sense to use natural antimicrobials to reduce some of the bacteria, containing ingredients like oregano oil, berberine, allicin, and neem.  It is also important to improve gut motility with natural prokinetics that helps to reduce bacterial counts in the small intestine.  The one probiotic that we tend to use during the active treatment phase is a spore based probiotic, which does not open up until it gets into the large intestine.  Once we reduce the bacteria count in the small intestine, then it makes sense to add in typical probiotics, such as those containing lactobacillus and bifido strains, as well as fermented foods. Digestive enzymes can be very helpful at any phase of treatment for gastrointestinal problems, and digestive enzymes increase your ability to break down the food. And if you don’t properly break down the food, whether it be the carbohydrate component, the fat component, the protein component, you are more likely to react to that food. So for example, if there are certain types of fiber and you can’t break those fibers down, then those fibers might be more problematic. If there are proteins and you can’t break down those proteins, you’re more likely to have an immunological/allergic/sensitivity reaction to those foods. So I like using digestive enzymes and we will not always, but sometimes use them at various points during care, sometimes at the beginning, sometimes in the middle, sometimes in later phases. But adding digestive enzymes can be very helpful. The other way to increase digestive enzymes is to use herbal bitters, which cause your body to increase its own digestive enzymes. 22:06 Question number four for today, “What can I do about constipation? And if I have constipation, should I take fiber?” This depends upon what the cause of the constipation is.  In functional medicine, we always want to get to the root cause.  Now, if you’re constipated because you have intestinal obstruction, that’s a very serious matter. If you haven’t been able to go to the bathroom for days on end, this could be a serious situation and I highly recommend that you see a gastroenterologist, decide how severe it is and decide what is the intervention going to be. It’s possible you might even need emergency surgery, however, that’s rarely the case. And so what are some of the other causes of constipation?Well, eating an unhealthy, low fiber diet with lots of ultraprocessed foods can lead to constipation.  And of course, that’s why increasing your vegetable and fruit and fiber intake can make sense. However, if you’re severely impacted right now and you consume a bunch of fiber, you might get more impacted.  It is better to start with a stool softener like magnesium citrate.  For it to be effective, it has got to be taken at the proper dosage, which can be up to 1,000 – 1,500 milligrams per day.  Magnesium citrate brings more water into the stool, so for magnesium citrate to help with constipation, you’ve got to drink a lot of water. So what are some of the other possible causes of constipation? Well, one of the possible causes of constipation is dysbiosis. And in particular, if you happen to have small intestinal bacterial overgrowth, the methane form, meaning that the microorganisms in your small intestine are secreting methane gas. So when I was talking about the SIBO breath test, what is measured is hydrogen gas, methane gas, and hydrogen sulfide gas, and of those three, methane typically leads to constipation, though sometimes hydrogen or hydrogen sulfide can also cause constipation.  Methane SIBO has also been called intestinal methanogen overgrowth (IMO) because it is called by primitive Archaea, known as methanogens, and this overgrowth can exist in the large intestine as well as in the small intestine. And these Archaea, when they consume fermentable fiber, produce methane gas and methane gas slows the motility of the GI tract. So we have found that using the right antimicrobials that help to reduce the overgrowth of the Archaea using magnesium citrate. Once we’ve gotten the constipation cycle somewhat broken, then adding in some the right forms of fiber can be very beneficial. And the form of fiber that we have found that’s been shown in research to not aggravate the symptoms of SIBO is partially hydrolyzed guar gum, PHGG. That particular form of fiber has been shown to be very helpful for patients with SIBO. And typically when we add in fiber, that’s the when we’ll add in. And then, a lot of times we’ll also use natural prokinetics to try to reset the motility of the digestive track. And in particular, what we’re trying to reset is something called the migrating motor complex. Now, what is the migrating motor complex? This is also known as the cleansing waves. So when you eat food, your digestive track has these peristaltic waves as different parts of the digestive track contract and push the food all the way down and through. However, that motility, those waves, those peristaltic activity occurs not only when you’re digesting food. But also when you have a need for three or four hours and your digestive tract is clear of food, then you’ll get these peristaltic contractions that we refer to as the migrating motor complex or the cleansing waves. And these help to keep too much bacteria from building up in the small intestine. And so when we use natural prokinetics or promotility agents, we are attempting to reset the migrating motor complex and get those cleansing waves going. They’ll reduce the amount of bacteria or fungus that are growing in the small intestine. The other thing that’s important to do to make sure that happens is to make sure that you’re not constantly eating or grazing all day long. You need a period of time of at least three, four hours when you don’t eat anything. Black coffee’s fine, but snacking on anything that has calories, even if it’s healthy things like nuts, et cetera, is going to inhibit the migrating motor complex from kicking in. All right. So I actually have quite a number of other questions, but I think I’m going to take one more question and then we’re going to wrap it up for today. Dr. Ben Weitz is available for Functional 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations. Podcast Transcript Dr. Weitz:Hello, Rational Wellness Podcasters. Today we’re going to do a question and answer session about gut health. As you know, most of my sessions, most of my podcasts are interviews with other practitioners, but I plan to start doing some more solo cast where I talk about particular topics or answer some questions. So today we’re going to talk about gastrointestinal health. 1. So the first question is, “I have stomach pain and I went to a gastroenterologist who did a colonoscopy and an endoscopy, and said there was nothing wrong. But then Prilosec was prescribed because that would help with the symptoms. Does that mean that my stomach pain is all in my head?” The answer is absolutely not. Now, what your gastroenterologist was doing when he did those scopes was he was looking for what we might call structural problems. So when you put a scope either down from the mouth or up from the anus and look through parts of the digestive tract, you’re looking for, in general, specific structural issues like obstructions or pockets. You’re looking for inflammation, you’re looking for damage, you’re looking for polyps, you’re looking for growths. And the most common gastrointestinal problems are what we would call functional gastrointestinal problems.  IBS, irritable bowel syndrome, is the most common of these functional gastrointestinal conditions.  IBS is fairly frequent and occurs in at least 20% of the population.  Now, is it possible to diagnose IBS when doing a scope?  Well, it’s theoretically possible.  You would have to use a special procedure that Dr. Mark Pimentel developed by which he was able to study the microbiome of the small intestine.  Now, normally an endoscope which goes down from the mouth can only get into the first part of the small intestine.  The small intestine is this long tube, fairly narrow tube that is very long and it’s difficult to get a scope down there. But he developed a special procedure where they used balloons to expand, and then ways to get a probe down into that area without collecting any bacteria from up above. And then they are able to sample the juices of the various sections of the small intestine. And by sampling these juices, the liquid that’s there, and then using DNA and or cultural analysis, they can see if there are either pathogenic bacteria or bacterial overgrowth or fungi or parasites. And Dr. Pimentel was able to map out the microbiome of the small intestine and it is possible to see an overgrowth of certain organisms. And we know there’s a certain number of organisms that are considered normal for the small intestine. And if you have more than that amount, that’s considered diagnostic of IBS. However, this particular analysis is rarely done. So this is not to take anything away from your gastroenterologist, it’s just not the standard, and it would be a much longer and more expensive procedure to try to sample the juices of various sections of the small intestine. So at this point in time using no special probe and other equipment and doing it in a way that Dr. Pimentel has done, is not the standard. So when they put a scope down there, if there’s no visible inflammation of the intestinal mucosa as there might be with irritable bowel disease [I intended to say Inflammatory Bowel Disease (IBD)] like Crohn’s, essentially nothing will be seen when scoping it. And so IBS is known to be caused by, in the majority cases, irritable bowel syndrome is known to be caused by small intestinal bacterial overgrowth. Once again, as I was just trying to explain, there are bacteria that line your digestive tract. And they occur throughout your digestive tract from your mouth all the way down to your anus. Now, the large intestine, the colon is where you have the largest concentration of bacteria. And we normally think of the colon as housing our microbiome, but there’s also a microbiome of the small intestine. Now, the small intestine is supposed to have a lower amount of bacterial count because if there are two large an amount of bacteria lining the small intestine, it will interfere with the absorption of nutrients. Remember that lining of your intestine, your intestinal mucosa is only one cell thick, and having a thick layer of bacteria lining that will make it difficult to absorb all those crucial nutrients that allow our bodies to work properly. So if there’s more than a certain amount as occurs in small intestinal bacterial overgrowth, this not only can create nutritional deficiencies, but it can create digestive symptoms. Now, why is that? And a lot of it has to do with the fact that the colon, which is a large and very expandable organ, normally has bacteria that are fermenting and producing gases, and this is actually healthy. The colonic fermentation produces short chain fatty acids like butyrate, which are healthy for the body and healthy for the gut. It produces various nutritional supplements including vitamins, some of the B vitamins, vitamin K2, A number of nutrients are produced in the colon. However, the small intestine is not a super expandable tube. It’s much more narrow. And if you get too many bacteria that ferment fiber, they can produce gas and this can cause gas, bloating, and pain. Now, I would also like to explain that IBS is a subset of what’s called dysbiosis, meaning that there is an imbalance of microorganisms in the intestinal tract. Now, there are other forms of dysbiosis besides SIBO or IBS. This includes large intestinal bacterial overgrowth, small intestinal fungal overgrowth, candida overgrowth, pathogenic bacteria, parasites such as worms and other microorganisms. There are a number of, you can just have a low amount of healthy bacteria. There’s various imbalances that can occur in the microbiome that can all create digestive symptoms. 2. Okay, great. Next question, “Dr. Weitz, I have a lot of gas and bloating, especially if I eat broccoli or Brussels sprouts. What do you think is the cause and what can I do about it? And should I take Gas-X?” Well, first of all, Gas-X is an enzyme that helps you to break down the fiber in beans, and taking a supplement without knowing what the cause of the problem is, is not the best idea. If it helps you symptomatically, fine, it’s not going to harm you. But the most important thing is to try to get a better sense of what either the cause or causes or triggers of your problem are. Now, why would you get a lot of gas and bloating from eating broccoli? Now, you could have a sensitivity to broccoli. Your body just may not tolerate broccoli and/or Brussels sprouts, and that can happen with any food. On the other hand, broccoli and Brussels sprouts are classic examples of foods that contain fermentable fiber. So these would be considered to be high FODMAP foods, and high FODMAP foods are foods that have a lot of fermentable fiber. And when patients are suffering with small intestinal bacterial overgrowth, we often abbreviated as SIBO, which as I just mentioned is the primary cause of irritable bowel syndrome. Eating more high FODMAP foods, foods that have fermentable fiber is liable to make the symptoms worse. So I would recommend that we start to get to the root cause of what’s causing the gas and bloating. And this will depend a course on your history, and we need to know a lot more about exactly what’s going on, what other symptoms you have, and how much broccoli and Brussels sprouts are you eating, and how long has this been occurring on and on. But then we would need to do some specific testing to get a better sense of the diagnosis. The best way to diagnose small intestinal bacterial overgrowth is to do a lactulose breath test. The best way to investigate dysbiosis in general is to do a high quality stool analysis. And functional medicine stool analyses are quite a bit different than the typical stool analysis you might get. If you ask your doctor and he sends you over to Quest, and they basically look for parasites and pathogenic bacteria. That type of stool test is not going to look at the microbiome, it’s not going to look at digestive factors, it’s not going to look for other markers of the overall health of your digestive tract. So SIBO breath test and/or functional medicine oriented stool test, and then sometimes we’ll do an organic acids test if we’re suspecting fungal overgrowth. Because the organic acids test may be the best markers to help us identify fungal overgrowth, which cannot be identified on a breath test and is difficult to identify on a stool test. 3. Okay. The next question is, “I have stomach pain, should I take probiotics, fermented foods, or digestive enzymes?” Well, I certainly know practitioners who are well-respected, who recommend probiotics as a first line treatment for a number of patients with functional gut disorders, and I’m sure some of their patients get great results. And there are quite a number of studies on probiotics. And I have used probiotics in patients with various types of gut disorders and some of the times they’ve worked, some of the times they haven’t worked. But I’d like to say a word about the studies on probiotics, and this is a bit of a problem is probiotics are basically the healthy bacteria put into typically capsules or a powder, and then consumed. And the idea is this will help to build up the healthy bacteria inside your body, what we refer to as the microbiome. And there are individual probiotics like that probiotic might just contain lactobacillus particular strain or it could be a blend of various strains. Typically, lactobacillus strains, bifido strains, sometimes healthy yeast or saccharomyces boulardii will be included. Sometimes the spore-based bacillus strains. There are many, many particular strains of probiotics on the market, and studies have actually shown that there are specific benefits to different strains. And yet when we look at the probiotic research, and then we do a meta-analysis of looking at probiotics. We’re actually merging together a huge number of different products, and nobody would do that while testing antibiotics or any other substances. So if I told you antibiotics are effective because this study use rifaximin, and that study used another antibiotic and this study used a combination of these two different antibiotics, and you’d say, “What are you talking about? These are all different things.” Show me one or multiple studies or a meta-analysis just using one antibiotic like rifaximin at a specific dosage for a particular period of time in a specific patient, and then we’ll consider using that. That would be considered validity. But just lumping all probiotics into a category and seeing that probiotics are effective for a particular condition is not considered the highest level of science. Then we have the whole concept of whether or not it makes sense to consume a probiotic if the person is suffering with IBS or small intestinal bacterial overgrowth. So understand that small intestinal bacterial overgrowth means that we have an excess of bacteria growing in the small intestine. Therefore, does it make sense to consume a capsule that contains more bacteria that might go into the small intestine and add to the bacteria that are already there? Obviously, this doesn’t make a lot of sense. I have worked with patients with IBS who’ve taken probiotics and who have felt worse taking them. We have had a few patients who said they felt better, other patients couldn’t tell the difference. But theoretically, it doesn’t seem to make sense to add more bacteria if there’s already too many bacteria there. It makes more sense to attempt to reduce the amount of bacteria by either using prescription antibiotics. As a chiropractor, we can’t prescribe antibiotics, so those would have to be prescribed by your primary care doctor, your gastroenterologist. So either using prescription antibiotics like rifaximin, which is an antibiotic that’s often used for small intestinal bacterial overgrowth or using natural antimicrobials. And these are products that might contain one or several ingredients that contain things like oregano oil, berberine, Allison, neem, et cetera. And then perhaps later on in the treatment program, after we’ve reduced the bacteria and gotten the gut to heal, improve the gut motility, restoring that gut motility that keeps the bacterial count in the small intestine from being too high, then considering using some probiotics makes a lot of sense. Now during the active phase of care, when we’re trying to reduce the bacterial overgrowth, I have found that a particular type of probiotic. A spore based probiotic that can get all the way down through the small intestine and not open up until it gets into the large intestine. We have found that type of probiotic can be a useful adjunct in the active care of treating IBS and SIBO. However, the typical bifido and lactobacillus combination strains of probiotics I have found not to work as well. What about fermented foods? Well, if what I said about probiotics is correct that we don’t want to add more bacteria while we’re trying to reduce the bacterial count, then we also don’t want to consume fermented foods because these are liable to add to the bacterial overgrowth and make the symptoms worse. Once again, once we’re past that initial phase where that phase takes a month or six months to reduce the bacterial count, adding in fermented foods gradually to tolerance levels can be an excellent way to improve the health of the gastrointestinal tract. What about digestive enzymes? Well, digestive enzymes I find can be very helpful at any phase of treatment for gastrointestinal problems, and digestive enzymes increase your ability to break down the food. And if you don’t properly break down the food, whether it be the carbohydrate component, the fat component, the protein component, you are more likely to react to that food. So for example, if there are certain types of fiber and you can’t break those fibers down, then those fibers might be more problematic. If there are proteins and you can’t break down those proteins, you’re more likely to have an immunological allergic sensitivity reaction to those foods. So I like using digestive enzymes and we will not always, but sometimes use them at various points during care, sometimes at the beginning, sometimes in the middle, sometimes in later phases. But adding digestive enzymes can be very helpful. The other way to increase digestive enzymes is to use herbal bitters, which cause your body to release its own digestive enzymes. 4.   Question number four for today, “What can I do about constipation? And if I have constipation, should I take fiber?” Well, take a guess what my first response is going to be. It depends upon the cause. It depends upon the cause of the constipation. In functional medicine, we always want to get to the root cause. We don’t want to just jump out and treat symptoms. Now, if you’re constipated because you have intestinal obstruction, that’s a very serious matter. If you haven’t been able to go to the bathroom for days on end, this could be a serious situation and I highly recommend that you see a gastroenterologist, decide how severe it is and decide what is the intervention going to be. It’s possible you might even need emergency surgery, however, that’s rarely the case. And so what are some of the other causes of constipation? Well, poor diet can lead to constipation, not eating a lot of foods with enough fiber. And of course, that’s why increasing your fiber intake can make sense. However, if you’re severely impacted right now and you consume a bunch of fiber, you might find things up more and have even more difficulty. So I have found that typically the first answer is to add a stool softener like magnesium citrate. There are other natural stool softeners. There are over-the-counter and prescription stool softeners, but I really like magnesium citrate. However, it is got to be taken at the right dosage, and this could be up to 1,000 – 1,500 milligrams per day. A lot of times I’ll talk to a patient and they said, “Well, I took 100 milligrams, isn’t that enough?” Or, “I took 200. Is it bad to take more?” And that can be a really minimal dose. Now, magnesium citrate brings more water into the stool. So for a magnesium citrate to help with constipation, you’ve got to drink a lot of water. So when you take the magnesium citrate, I recommend one to two glasses of water at that time. And unless it’s late at night to follow it up with a couple of additional glasses of water within the next hour or so. If it’s late at night, you’re going to bed, I don’t want you staying up all night peeing. So what are some of the other possible causes of constipation? Well, one of the possible causes of constipation is dysbiosis. And in particular, if you happen to have small intestinal bacterial overgrowth, the methane form, meaning that the microorganisms in your small intestine are secreting methane gas. So when I was talking about the SIBO breath test, what is measured is hydrogen gas, methane gas, and hydrogen sulfide gas, and of those three methane, typically leads to constipation. Now, this is not always the case. We have patients with hydrogen who get constipation. I’ve even seen patients with hydrogen sulfide who have constipation. But methane is typically associated with constipation. We know that just secreting methane into the intestinal tract will tend to lead to constipation. Now, methane SIBO is now been called intestinal methanogen overgrowth. And so that’s because it can occur in the large intestine and not just in the small intestine. What are methanogens? Well, it turns out that the microorganisms that cause methane SIBO are actually not bacteria, but microorganisms known as primitive Archaea. And these Archaea, when they consume fermentable fiber, produce methane gas and methane gas slows the motility of the GI tract. So we have found that using the right antimicrobials that help to reduce the overgrowth of the Archaea using magnesium citrate. Once we’ve gotten the constipation cycle somewhat broken, then adding in some the right forms of fiber can be very beneficial. And the form of fiber that we have found that’s been shown in research to not aggravate the symptoms of SIBO is partially hydrolyzed guar gum, PHGG. That particular form of fiber has been shown to be very helpful for patients with SIBO. And typically when we add in fiber, that’s the when we’ll add in. And then, a lot of times we’ll also use natural prokinetics to try to reset the motility of the digestive track. And in particular, what we’re trying to reset is something called the migrating motor complex. Now, what is the migrating motor complex? This is also known as the cleansing waves. So when you eat food, your digestive track has these peristaltic waves as different parts of the digestive track contract and push the food all the way down and through. However, that motility, those waves, those peristaltic activity occurs not only when you’re digesting food. But also when you have a need for three or four hours and your digestive tract is clear of food, then you’ll get these peristaltic contractions that we refer to as the migrating motor complex or the cleansing waves. And these help to keep too much bacteria from building up in the small intestine. And so when we use natural prokinetics or promotility agents, we are attempting to reset the migrating motor complex and get those cleansing waves going. They’ll reduce the amount of bacteria or fungus that are growing in the small intestine. The other thing that’s important to do to make sure that happens is to make sure that you’re not constantly eating or grazing all day long. You need a period of time of at least three, four hours when you don’t eat anything. Black coffee’s fine, but snacking on anything that has calories, even if it’s healthy things like nuts, et cetera, is going to inhibit the migrating motor complex from kicking in. All right. So I actually have quite a number of other questions, but I think I’m going to take one more question and then we’re going to wrap it up for today. So, “Dr. Weitz, if I have stomach pain, should I get tested for food sensitivities? Or should I just avoid gluten and dairy?” All right. So food sensitivity testing. I have done a range of food sensitivity tests, some are way more extensive than others, and the more extensive ones are quite a bit more expensive and cost a thousand bucks to get a really high quality panel of all the detailed food sensitivity tests. We can do fruit sensitivity tests for a couple hundred bucks. We can just test the limited number of foods for IGG. Food sensitivity, by the way, is different than food allergies, which are IgE reactions. I’ve run some of these tests and found they were very helpful. They identified a few foods we didn’t really know where on the radar. Oh wow, strawberries, ah, that explained something. Almonds, ah okay, maybe that’s why I was getting those symptoms. And we’ll experiment with taking those foods out for two, three months, and then test them back. If the patients still get symptoms, we’ll keep them out for a longer period of time, and then test them back again at some point in the future. If they continue to have symptoms, we’ll just recommend avoiding those foods forever. But we’ve had other patients where we did food sensitivity testing and all the foods that they tend to eat come back as positive and sometimes it’s dozens and dozens of foods, and limiting all those foods really doesn’t make sense for the overall health of the patient. So I don’t run food sensitivity tests on all of the patients. How about just avoiding gluten and dairy? Actually, not a bad idea as long as you don’t obsess about it too much. But there are a number of reasons to think that the gluten molecule is sufficiently causes enough food sensitivities and other sorts of reactions in the body. We know that the type of wheat is being grown so that it has a much larger gluten molecule that’s harder to break down. This allows the pastry products, the breads, et cetera, to stick together. Gluten’s a sticky protein, and so we have more gluten in our wheat. We have a much longer chain of gluten that’s difficult to digest, and 90% of most wheat products in the United States are sprayed with glyphosate, which is a very dangerous herbicide. And so unless you’re consuming organic and even then there’s a risk. Consuming wheat of any kind is going to increase your potential for consuming glyphosate, which is the active ingredient in Roundup, which is very powerful herbicide and is not known to be good for your health. So we could do a food sensitivity task, we could do an elimination diet and just take out some of the most common foods, keep them out for a period of one to three months, and then test them back one at a time. So it’s another way to do it. So it’s kind of an open question, but yes, food sensitivities can be a problem. Sometimes testing is helpful and sometimes it’s not. So I know that’s not a concrete specific answer, but that’s the answer that makes the most sense. Okay. Thank you so much for sending in your questions. You can send me additional questions to my website, weitzchiro@yahoo.com. Please note that I cannot answer individual questions and if I think the question is worthy, I will include it in a future Q&A podcast. Anyway, thanks so much for joining me today. For everybody who likes listening to this Rational Wellness Podcast, please, please, please go to Apple Podcasts or Spotify. Give us a five star ratings or review and rank us, so more people can find out about the podcast. And for those who need help with digestive disorders, call my office at 310-395-3111, and we’ll get you set up with a consultation to get you on the road to better health. Thank you and we’ll see you next week.

9 de feb de 2023 - 35 min
Muy buenos Podcasts , entretenido y con historias educativas y divertidas depende de lo que cada uno busque. Yo lo suelo usar en el trabajo ya que estoy muchas horas y necesito cancelar el ruido de al rededor , Auriculares y a disfrutar ..!!
Muy buenos Podcasts , entretenido y con historias educativas y divertidas depende de lo que cada uno busque. Yo lo suelo usar en el trabajo ya que estoy muchas horas y necesito cancelar el ruido de al rededor , Auriculares y a disfrutar ..!!
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